Central Lines: Patient Safety Considerations Reviewed & Updated By Tom DiDonna And Rob Bennington December 2011
CENTRAL LINES • A Central line is an IV whose catheter tip resides in central circulation where the veins are large and the blood flow rate is high • The tip of a central line should be in the lower 1/3 of the superiorvena cava • Used for long-term IV Fluid administration, total parenteral nutrition, vasopressors, antibiotics, or primary vascular access
CENTRAL LINES • Placement can be made directly into a jugular, subclavian, femoral, basilic, cephalic, or antecubital vein • Catheter can be tunneled. • Hickman, Broviac, and Leonard catheters are placed surgically and threaded under the skin
TYPES OF CENTRAL LINES • Central venous catheters may have 1, 2, or 3 lumens • TPN is given through a dedicated port • Blood products are given through an 18-20 gauge or larger infusion port • Dual Lumen Lines • Some dual lumen catheters have both lumens open at the distal end of the catheter • Be cautious with incompatible medications • Be aware of possible contamination of blood sample if drawing blood from one port while the other supports infusion of IV fluid, blood, or medication
TYPES OF CENTRAL LINES • Triple Lumen Lines • Staggered lumen openings • Incompatible medications may be given at the same time • Blood sampling should be through the proximal port to avoid contamination by fluids and medications from the other ports • CVP monitoring is measured at the distal port
TYPES OF CENTRAL LINES • PICC – Peripherally Inserted Central IV Catheter • Usually inserted in the upper arm • Catheter tip is in the distal superior vena cava like all other central lines • Midlines are NOT central lines
TYPES OF CENTRAL LINES • Groshong - 3 way pressure sensitive slit at the catheter tip • doesn’t require clamping or heparin flush • flushed with saline q week • Groshong tip catheters are usually blue • Design used in tunneled catheters and some PICC lines
TYPES OF CENTRAL LINES • Hickman/Broviac/Leonard – Open-ended, no valve • Inserted surgically and threaded under the skin • Usually inserted in the subclavian vein with the tip 2-3 cm from the right atrium • Flush with Saline and Heparin after use & every day
TYPES OF CENTRAL LINES • Hickman, Broviac, and Leonard Catheters – Open-ended, tunneled central lines • Hickman catheters can be 1, 2, or 3 lumen • The lumens may all be identically sized, or • The lumens may be of different sizes • Broviac catheters are all single lumen catheters • Leonard catheters have 2 lumens of identical size
IMPLANTABLE DEVICES • Implanted subcutaneously instead of patient having a port outside of body • Mediport and Portacaths are the most common • No dressing is required • Accessed by a Huber needle • Flushed with Heparin • More expensive
Mediport or Portacath • A portacath or "port" is comprised of two components, a self-sealing injection port and a catheter that enters the vein. The port and catheter are placed entirely under the skin using a small incision.
Mediport or Portacath • There will be a bump on the chest wall where the injection port is located. This is the site where the access Huber needle is placed. • If no solutions running, extension tubing is capped off like a regular Heparin lock and 5 ml of Heparin flush solution (10 units/ml) is instilled q shift per facility protocol. • Once port is deaccessed, it needs a MONTHLY flush with 5ml of heparin (100 units/ml) to keep it patent.
Power Port • The Power Port • Designed for power injections when used with a PowerLoc safety infusion set • Withstands injections of 5ml/sec @ 300 psi • The unique triangular shape and palpation points makes it easy to distinguish the Power Port from ordinary Mediports • Requires Heparin flush
USING THE CENTRAL LINE • Flush Groshong tip catheters q shift, before and after use with NS. Open ended catheters also require heparin flush. • Close clamps when not is use. • Fluids are changed every 24 hours • Tubing is changed every 72 hours. • Dressing is usually changed every 7 days. • Line can be used for blood drawing - withdraw and waste 6 ml, then withdraw blood for samples.
USING THE CENTRAL LINE • After blood draws, catheters require 20 ml NS flush • If port becomes clotted, do not use - sometimes ports can be opened up with Alteplase (requires a doctor’s order). • Keep catheter hub/needle manipulation to a minimum. • Luer-lock all tubing connections and assure all connections are secure. • When flushing, use at least 2 times the volume of the catheter (see attached) and any add-ons.
USING THE CENTRAL LINE • Never use smaller than 10cc syringe for flushing or rapid medication administration. Catheter may be damaged by the higher pressure of smaller syringes. • Change peripheral- short catheter IV site as soon as possible if IV was started in the field where aseptic technique may have been compromised, no later than 48 hours.
USING THE CENTRAL LINE • Observe for signs of extravasation during flushing, medication injection, or IV fluid flow (swelling and leakage). • Record intake and output on all patients receiving IV fluids. • Use alcohol and Betadine (use alcohol first), or chlorahexadine for cleansing the skin. • Blood pressure cuffs or tourniquets should not be applied over peripherally inserted catheters, but may be placed distally.
YOUR ROLE AFTER THE INSERTION Place an occlusive sterile dressing • Flush lumens to maintain patency • Monitor site for bleeding • Assess breath sounds • Assess circulation • Assess for hematoma • Document insertion, site, dressing and flushing
Risks • Pneumothorax - Collapse of the lung because of injury from the needle used to insert the device into the subclavian or jugular veins • Hemothorax - Bleeding into the chest because of injury to the blood vessels from the needle at insertion into the subclavian or jugular veins • Cellulitis - Infection of the skin around the catheter or port • Catheter infection - An actual infection of the device itself inside the vein • Sepsis - Release of bacteria into the bloodstream
Dressings • Equipment needed: • Sterile transparent dressing • Sterile gloves • Mask • Sterile drapes • Chlorhexidine swabs • Steristrips • Statlock if Statlock is being used **Do Not Use Gauze or Antibiotic Ointment
Dressings • Procedure: • Change dressing 24 hours after insertion and then every 7 days and PRN • Confirm patient’s identification • Explain procedure • Wash hands thoroughly and put on clean gloves and mask. Wear cap if hair is longer then shoulder length. • Carefully remove the old dressing and discard it in a red biohazard bag. Avoid tugging on the catheter or using scissors while removing the dressing.
Dressings • Procedure: • Inspect exit site for erythema or induration, catheter migration. Palpate the vein proximal to the IV site and inspect for any signs of phlebitis (see phlebitis scale) • Measure exit site to hub if migration is suspected. • Put on sterile gloves. • Using Chlorhexidine swabs, begin at insertion site of central line and, working outward, vigorously scrub the insertion site and surrounding area. Take care to remove old blood from the skin, catheter and hub.
Dressings • Procedure: • After cleaning, allow to dry. • Apply Stat-lock and steri-strips as needed to secure the catheter • Apply Tegaderm to area over central line. Center the tegaderm over the insertion site. • Loop catheter or IV tubing and tape securely to dressing or skin to prevent tension on the catheter or implanted port access needle. • Label dressing with next dressing change date, catheter type, insertion depth, date, time, and nurses initials.
Dressing Change • Carefully remove old dressing pulling from edges toward the center • Maintains catheter positioning • Decreases risk of insertion site contamination
Dressing Change • Vigorously scrub the insertion site with chlorhexidine swabstick starting from the center and working outwards. • Swab the portion of exposed line that will be under the tegaderm.
Dressing Change • The hub has holes in the wings that line up with stat-lock clasps. • Remove stat-lock backing to adhere stat-lock in a location that does not apply traction to line with patient movement and feels comfortable to the patient.
Dressing Change • Apply steri-strips • Note cm marking on catheter at insertion site • Center the Tegaderm over the insertion site
Dressing Change • Label Central line dressing with: External catheter length is determined by counting the centimeter dots visible on the catheter from the insertion site to the zero mark.
Dressings • Documentation of site/dressing: • Procedure • Date and time • Site assessment • Reason for dressing change • Problems, if any and care given, and who was notified (see phlebitis and infiltration scales.) • External exit to hub measurement if indicated. • Initial blood return.
Accessing Ports • Ports should be accessed only with Huber or noncoring needles • Ports should never be forcibly flushed if resistance is felt • Malposition of the catheter tip should be suspected when difficulty in blood aspiration is resolved with a patient's cough, Valsalva maneuver, or change in body position
Accessing Ports • Access needles usually are removed after every IV infusion • The port should not be accessed for more than 7 days without changing the needle • Aseptic technique is required when accessing Mediports
Complications • Phlebitis-red, hot, swollen, painful insertion site • Treat with K-pad and Ibuprofen • May lead to thrombophlebitis if not treated • Occluded catheter- • May be corrected with Alteplase • Infected line-purulent drainage, painful, hot insertion site, red, febrile patient • Contact physician
Complications • Extravasation-swelling and IV fluid leakage at insertion site • Usually caused by fibrin sheath diverting IV fluids from catheter tip down the length of the catheter to the insertion site • May be caused by catheter breakage • Contact physician
Phlebitis Grading Phlebitis Scale - Clinical Criteria Notify Infection Control and physician for grade > 2 0 No symptoms. 1 Erythema at access site with or without pain. 2 Pain at access site with erythema and/or edema. 3 Pain at access site with erythema and/or edema, streak formation, palpable venous cord. 4 Pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch in length, purulent drainage.
Complications • Immediate • Hemothorax • Pneumothorax • Arterial puncture • Nerve Injury • Dysrhythmias • Catheter malplacement • Catheter rupture • Embolus • Cardiac tamponade
Complications • Delayed • Dysrhythmias • Catheter malplacement • Catheter rupture • Embolus • Cardiac tamponade • Catheter related infection • Thrombosis • Hydrothorax
Implantable Device Video • http://www.bardaccess.com/infusion-powerloc.php?section=Video • After video is complete, return to presentation and complete.
References • MHA Keystone Center for Patient Safety & Quality. Frequently asked questions (FAQs) on central line-associated bloodstream infections (CLABSI). Available at: http://www.msic-online.org/pdf/BSI_Frequently_Asked_Questions.pdf Accessed July 5, 2009. • Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132:391-402. Abstract • Soufir L, Timsit JF, Mahe C, et al. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol. 1999;20:396-401. Abstract • CDC. Central Line-Associated Bloodstream Infection (CLABSI) Event. Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf Date accessed: June 22, 2009. • O'Grady NP, Alexander M, Dellinger EP, et al. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR. 2002;51:1-26. • Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601. Abstract • Yokoe DS, Mermel LA, Andersen DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:s12-s21. Abstract • Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:s22-s30. Abstract • Klevens RM, Morrison MA, Nadle J, et al. Invasive methicllin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298:1763-1771. Abstract
References • Edwards JR, Peterson KD, Andrus ML, et al. National Healthcare Safety Network (NHSN) report, data summary for 2006 through 2007. Am J Infect Control. 2008;36:609-626. Abstract • Rosenthal VD, Maki DG, Mehta A, et al. International nosocomial infection control consortium report, Data summary for 2002-2007. Am J Infect Control. 2008;36:627-637. Abstract • Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol. 2002;13:77-81. Abstract • Timsit J-F, Schwebel C, Bouardma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults. A randomized controlled trial. JAMA. 2009;301:1231-1241. Abstract • Sanders J, Pithie A, Ganly P, et al. A prospective double-blind randomized trial comparing intraluminal ethanol with heparinized saline for the prevention of catheter-associated bloodstream infection in immunosuppressed haematology patients. J Antimicrob Chemother. 2008;62:809-615. Abstract • Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81:1159-1171. Abstract • Institute for Healthcare Improvement. Implement the central line bundle. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm. Accessed July 7, 2009 • Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. Abstract