Chapter 17, Central Venus Access Device from the Lewis textbook and this is a review from class. Central Venus access devices are catheters that are placed in large blood vessels like the subclavian vein or jugular vein and this is for people who require frequent or special access to the vascular system. There are three main types of central lines. Centrally inserted catheters, peripherally inserted central catheterss and implanted ports. Now a physician can place any of these devices but a nurse with specialized training can insert a pickline which is the peripheral inserted central catheter. A central catheter can permit frequent continuous rapid or even intermittent administration of fluids and drugs. It allows for giving medications that are potentially vesicants and is used to administer blood or blood products, parental nutrition, and can provide a means to perform hemodynamic monitoring and obtain venus blood samples. Central lines are useful with patients who have limited peripheral vascular access, who have a projected need for long-term vascular access. Central lines can be inserted in the neck or the chest. and the chest you could look at the subclavian or the jugular or in the groin the femoral with the tip resting in the distal end of the superior vennea. The other end of the catheter is either non-tunnled or tunnled through the subcutaneous tissue and exit through a separate incision on the chest or abdominal wall. A dayron cuff on the catheter serves to stabilize a catheter and may decrease the incidence of infection by preventing bacteria migration along the catheter beyond the cuff. The advantages of a central venus access device is immediate access to the central venus system and a reduced need for multiple venopunctures and decreased risk of extravisation injury. The disadvantages are increased risk of systemic infection and the invasiveness of the procedure itself. Extravisation can still occur if there's displacement or damage to the device. Multiluin catheters are used in the critically ill patient because each lumen can provide different therapies simultaneously. An example is incompatible drugs can infuse in separate lumens without mixing while a third lumen provides access for blood sampling. Specific types of long-term central catheterss are Hickman catheters which do require clamps to make sure the valve is closed and a gshon catheter which have a valve that opens as fluid is withdrawn or infused and remains closed when it's not in use. Peripherally inserted central catheterss, otherwise known as pick lines, are central venus catheters inserted into a vein in the arm rather than a vein in the neck or the chest. They're inserted at or just above the anicubital fossa, which is usually either the syphalic or basillic vein, and it's advanced to a position with the tip ending in the distal 1/3 of the superior vennea. Picks are single or multiluin non- tunnled and up to 60 centimeters in length with gauges that range anywhere from 24 to 16. They're used in patients who need vascular access for a week to up to 6 months, but they can be in place longer. If a patient has a pick, do not use that arm to do blood pressures or blood draws. The advantages of a pick over a central venus catheter are lower infection rate, fewer insertion related complications, decreased costs, and it can be inserted at the bedside or an outpatient area. Complications usually include catheter occlusion and phobitis. If flabitis occurs, it usually appears within 7 to 10 days following the insertion. Implanted infusion ports consist of a central venus catheter connected to an implanted single or double subcutaneous injection port. The catheter tip lies in the vein and other end is connected to a port that is surgically implanted in a subcutaneous pocket on the chest wall. The port consists of a metal sheath with a self-sealing silicone septum. Drugs are then placed in the port reservoir either by direct injection or through injection into an already established IV line. After it's filled, the reservoir will slowly release the medicine into the bloodstream. Implanted ports are good for long-term therapy and have a low risk of infection. The hidden port offers cosmetic advantages. Plus, there's less maintenance compared to other types of central venus access devices. Regular flushing is required though to avoid the formation of a sludge, which is an accumulation of clotted blood and drug precipitate that can happen within the port septum. To access these devices, a special Huber needle with a deflected tip is used to prevent damage to the rubber septum that could make the port useless. Huber needles are also available with the tip at a 90° angle for longer infusions. IV infusion techniques. Flush the catheter with normal saline to check for resistance. Palpate the site before and during the flush and look to see did the patient complain of any discomfort when palpated. Check to see if you feel any temperature change at the site or feel the solution moving through the vein or feel fluid accumulating at the catheter tip. Finally, listen to everything a patient tells you about how the entire area feels. Flushing a central venus catheter whose tip is migrated to the jugular vein will cause the patient to hear a gurgling sound or a running stream. Complaints of pain or discomfort in strange locations of the chest, the neck, or upper abdomen could be related to the catheter. If the IV is running too slow, don't play catch-up. Assess the patient for any respiratory distress secondary to a fluid overload. So then start thinking about, well, what are signs of circulatory overload? That would be like increased blood pressure, shortness of breath, even anxiety. And the cause could be from a rapid infusion, reduce kidney function, or impaired heart contractions. So, as a nurse, your first action is to assess for respiratory distress, do vital signs, then decrease the flow rate, put the patient in a fowler's position, and call the physician. How do you know the IV is infiltrated? Well, there's swelling at the site, burning, coldness, slow or no rate, and it could be because the solution is escaping into the subcutaneous tissue. So, the IV needs to be deceeded, restart a new one, and put warm compresses times 20 minutes on the one that you desc. If you suspect a thrombus because the patient has pain and swelling, it could be because the canula point has traumatized the wall of the vein and a thrombi can form on the vein in the tip of the canula. This traps bacteria. So that needs to be desced and then called the physician. If you look at the subclavian vein insertion, you'll see the catheter is pinched between the clavicle and the first rib. The bottom one, you'll see a collapsed peripheral vein wall that's oluding the blood return. A central venus catheter can be oluded secondary to clamping or kinking the catheter, the tip coming in contact with the vessel wall, thrombosis, or precipitate buildup in the lumen. Clinical symptoms of catheter occlusion include a sluggish infusion or aspiration or being unable to infuse or aspirate. Management includes instructing the patient to change position and raise their arm and cough. Assess for and alleviate clamping or kinking. Flush with normal saline using a 10ml syringe. Do not force it. And fluoroscopy can determine a cause in the site and may need installation of anti-coagulant or thrombolytic agents. Another complication is an embolism and this can occur secondary to a catheter breakage, dislodgement of the thrombus or entry of air into the circulation. The clinical symptoms include chest pain, respiratory distress, hypotension, tacocardia. Preventative measures to avoid an air embolism. Clear all air from the tubing before attaching it to the patient. Monitor solutions carefully and change the bag before it becomes empty. frequently check to make sure that all connections are secure. Symptoms of an air embolism could be shortness of breath, anxiety, sudden chest pain, rapid heart rate with a drop in blood pressure. The cause could be movement of a previously stationary blood clot. So, it's important that you as a nurse that you'll stay with the patient and you'll call for help. Immediately place the patient on their left side with the feet elevated and this helps the pulmonary artery to absorb small air bubbles. administer oxygen and notify the physician immediately. So, a quick review, management of the embolism, administer oxygen, clamp the catheter, place the patient on their left side with their head down, especially if it's an air emblei, and notify the physician. Infection. The longer the duration of infusion, the more likely complications are going to occur. Solutions and meds are irritating to the vein, and a canula can irritate and pierce venus walls that cause complications. Small veins are more likely to be irritated. Veins in the lower extremity are a factor when there's pulling or stagnant blood. You know, poor technique can cause inflammation and infection. Phabitis is inflammation of the wall of the vein and phabitis with sepsis is associated with the insertion technique. Properly secure the catheter hub to a limb. Stabilize the extremity and use by applying an armboard if necessary. Frequent assessment of the IV site. Keep the flow rate at a prescribed rate. Change the IV site and tubing per hospital policy and avoid areas where flexion occurs like the anacubital fausa. Thrombophobitis is when there's presence of a blood clot and vein inflammation. Treatment is the same as infiltration amphabitis. The symptoms are pain along the length of the vein and the vein becomes increasingly painful and hard. Watch for septasemia and acute bacterial endocarditis. DC the IV and notify the physician and the IV should be discontinued and restarted at the first sign of pain, edema, redness and stopped and remove the IV catheter. Elevate the extremity and if noticed within 30 minutes of onset, apply ice to the site because this will help decrease the inflammation. If it's noted after 30 minutes of onset, apply warm compresses as this will encourage absorption. Notify the physician per the hospital policy. document the findings and the actions and then restart an IV in an alternative location opposite extremity if possible. If you suspect that a patient has a pumothorax, your job is to make sure that you are assessing the patient, particularly if they had a central line insertion because they're at risk for an embolism and a numoththorax. An enumathorax can occur if the plura is perforated during insertion and symptoms would be decreased or absent breast sounds, respiratory distress, you know they have cyanosis, dysmnia, tipnia, chest pain or distended unilateral chest. Management includes oxygen administration, semifaler's position and chest tube insertion. Catheter migration or displacement could also happen. And the clinical symptoms would be sluggish infusion or aspiration, edema of the chest or neck during the infusion, patient complaining of gurgling sound in the ear or disriythmias. The central venus access device will need to be removed and it may be replaced. Extravisation injury usually refers to the damage caused by leakage of solutions from the vein to the surrounding tissue spaces during IV administration. Once an extravisation has occurred, damage can continue for months and involve the nerves, the tendons, and the joints. If treatment is delayed, surgical debriement, skin grafting, and even amputation may be a consequence. Catheter insertion site assessment includes inspection of the site for redness, edema, warmth, drainage, tenderness, or pain. Observation of the catheter for misplacement or slippage is important. performing a comprehensive pain assessment, particularly noting any complaints of chest or neck discomfort, arm pain, or pain at the insertion site. Performing dressing changes and cleansing of the catheter insertion site using strict sterile technique is required. Typical dressings include transparent semi-permeable dressings or gauze and tape. If the site's bleeding, a gauze dressing is preferable. Otherwise, transparent dressings are preferred. Transparent dressings allow for observation of the site without having to remove the dressing, and they can be left in place for up to a week if they're clean, dry, and intact. Change any dressing immediately if they become damp, loose, or visibly soiled. A chlorohhexodine based preparation is a cleansing agent of choice. It lasts longer than other providone, iodine, or isopropyl alcohol, offering improved killing of bacteria. When using chlorohhexodine, cleansing the skin with friction is critical to infection prevention. When applying a new dressing, the area needs to be allowed to air dry completely before chlorohhexedine application is effective. Secure the lumen ports to the skin above the dressing site and then document a time and date of the dressing change and initial the dressing. Change injection caps at regular intervals are done according to the institutional policy. Use strict sterile technique and turn the patient's head to the side opposite of the central valve insertion during any cap changes. If the catheter cannot be clamped, instruct the patient to lie flat in bed and perform the valva maneuver. To decrease infection risk, friction should be used when cleaning the central VAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. Flushing is one of the most effective ways to maintain lumen patency and to prevent occlusion of the central VAD device. The push pause technique creates turbulence within a catheter lumen and promotes the removal of debris that aderes to the catheter lumen. This technique involves injecting saline with rapid alternating push pause motion instilling 1 to 2 mls with each push on the syringe plunger and it's done after giving medication. It also decreases the risk for clotting. A central venus access device if it's a multiluin can also keep incompatible drugs or fluids from mixing. using a normal sailing solution in a syringe that has a barrel capacity of 10 mls or more to avoid excessive pressure on the catheter. Remember, if you feel resistance, do not apply force. This could result in a ruptured catheter or create an embolism if a thrombus is present. Because of the risk of contamination and infection, pre-filled syringes or single dose vials are preferred over multiple dose vials. If using a negative pressure cap, clamp the catheter while maintaining positive pressure. If the mechanical valve has negative displacement, fluid flows through the middle of the centerpiece. If a positive pressure valve cap is present, it works to prevent the reflux of blood and resultant catheter lumin occlusion. If it has a positive displacement, fluid flows between the outer housing and the movable centerpiece. Some mechanical valves are said to have neutral displacement contain a reverse internal blunt canula that connects with the male lure of the IV setter syringe and allowing fluid to flow through its center. However, not all neutral displacement connectors have this design. Removal of a central venus access device is done according to the institutional policy and the RN scope of practice. In many agencies, nurses with demonstrated competencies can remove PICSS and non-tunnled centravenous catheterss. The procedures involves removing any sutures and then gently withdrawing the catheter while instructing the patient to perform the vala maneuver as the last 5 to 10 centimeters of the catheter is withdrawn. Pressure should be immediately applied to the site with sterile gauze to prevent air from entering and to control bleeding. Be sure to inspect the catheter tip to determine that it's intact. And after the bleeding has stopped, apply an aneseptic ointment and sterile dressing to the site.