CENTRAL VENOUS ACCESS DEVICES (CVAD) I. II. III. Description Were introduced in 1982.

uced in 1982. A device designed and used for long-term administration of medication and fluids into central veins. Are small, flexible tubes placed in large veins for people who require frequent access to the bloodstream. Referred to as venous access ports or catheters Usually in one of the large veins of the chest or neck Purpose Frequent access to the veins without deep needle sticks. Administration of medications - Antibiotics, chemotherapy drugs, other IV drugs Administration of fluids and nutritional compounds (hyperalimentation) Transfusion of blood products Multiple blood draws for diagnostic testing Advantages over regular IV lines Avoid problems that result over time from administering strong medications through small veins with regular IV lines, namely irritation of the vein and blood clots in the vein. Avoids the inflammation and scarring that can occur in a vein after multiple needle sticks. Increases comfort and reduces anxiety for people who require frequent venous access.

IV. Four Types 1. Nontunneled (or percutaneous) central catheter - For short-term (less than 6 weeks) IV therapy in acute care setting. - Common used: Subclavian vein provides a stable insertion site to which the catheter can be anchored. Advantage: 1. Is easy compressible (facilitating control of hemorrhage) 2. Allows the patient freedom from movement 3. Easy access to the dressing site. Last resort: Jugular Vein (Only for 1-2 days) Available for central lines: Single, Double and Triple Lumen

CDC Recommends: Single Lumen- used for CPN whenever practicable Triple Lumen- for a patient with limited IV access a. Distal Lumen- infuse blood or other viscous fluids b. Middle Lumen- reserved for PN infusion c. Proximal Port/Lumen administration of blood or medication

2. Peripherally inserted central catheter - For intermediate term (several days to months) IV therapy in the hospital, long term care or home setting. - Accessed: Basilic or Cephalic Vein above the antecubital space Threaded: Superior Vena Cava - Avoid: Taking BLOOD PRESSURE and BLOOD SPECIMENS from the extremity with the PICC. 3. Tunneled catheter For long-term use and remain in place for many years. - Are cuffed and can have a single or double lumens (e.g hickman, groshong and permacath), inserted surgically. - Threaded under skin reduce the risk for ascending infection from the subclavian to vena cava. 4. Implanted ports - Used for long-term IV therapy (e.g. Port-A-Cath, Mediport, Hickman Port, and P.A.S Port) - End of catheter is attached to a small chamber, placed in Subcutaneous pocket (either on Chest wall or on forearm) - Require minimal care and complete freedom of activity - More expensive than the external catheters, and access requires passing a special noncoring needle (Huber-tipped) through the skin into the chamber to initiate IV therapy. V. Risks

Problems that can occur during or after placement of a central venous access device include the following:

Pneumothorax - Collapse of the lung because of injury from the needle used to insert the device into the subclavianorjugular 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 from the device, causing a life-threatening infection (This often results from an infection of the device or from not using sterile techniques when using the device.) Mechanical problems - A device breaks or does not function correctly.

Venous thrombosis - A blood clot in the vein that can cause swelling of the involved extremity (This is often called deep venous thrombosis or deep venous thrombophlebitis. This is dangerous because pieces of the clot may break off and travel to the lung, which can be life threatening.) Endocarditis - Bacteria or fungi from the device travel through the bloodstream to the heart valves, where they form an infection that can destroy the valve. VI. When to Seek Medical Care

Call or visit a health care provider right away if a central venous access device is inserted and any of the following symptoms occur:

Swelling of an arm or the area around the device Shortness of breath or chest pain Redness, pain, or tenderness around the device Redness or tenderness along the vein in the upper arm (especially if it is a PICC line) Unexplained fever Device malfunction Pain with injection/infusion into the device Difficulties with concentration, memory, reasoning, or staying awake (mental status changes) Excessive tiredness Unexplained weight loss Go directly to the nearest hospital emergency department in any of the following circumstances:

Inability to reach the health care provider Symptoms worsening or new symptoms appearing In particular, shortness of breath, chest pain, or sudden changes in mental status may indicate a direct emergency, and the person with the venous access device should go to an emergency department immediately. VII. Examination and Test

If a central venous access device is present, the health care provider, whether a primary care provider, specialist, or emergency provider, will have a heightened awareness of the problems that can occur. The provider will ask about symptoms and perform a physical examination. Some of the following tests may be performed:

Chest x-ray - Evaluates for improper device placement or complications such as pneumothorax or hemothorax. Blood draw - Checks for infection. Ultrasound exam of the arm vein - Performed if a clot is suspected.

Nuclear imaging study - Confirms that the device is properly placed and still working and/or excludes blood clots in the lungs. VIII. Follow-up / Prevention

The venous access device can be removed when it is no longer needed, such as when the medical problem for which it was inserted has resolved. Proper home care of a venous access device involves regular irrigation with a drug called HEPARIN to prevent clotting (except with Groshong-type catheters) and attention to a sterile technique to keep the device free of infection. IX. Question and Answer

1. Central venous access devices are beneficial in pediatric therapy because: a. They dont frighten children. b. Use of the arms is not restricted. c. They cannot be dislodged. d. They are difficult to see. Rationale: Answer B. The child can move his extremities and function in a normal fashion. This lessens stress associated with position restriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheters can be readily seen. 2. How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who has stomatitis and severe diarrhea? a. The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve. b. Crystalloid can be administered to prevent dehydration. c. Concentrated hyperalimentation fluid can be administered through the CVAD. d. The chemotherapy dose can be reduced. Rationale: Answer C. In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support. High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affected with options a and d. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation can provide free water and considerable nutritional benefits. 3. Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters: a. Have an increased risk of infiltration. b. Only work a short while because the small bore clots off. c. Are beneficial to patient care but are prohibitively expensive. d. Allow different medications or solutions to be administered simultaneously. Rationale: Answer D. A multilumen catheter contains separate ports and means to administer

agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously. 4. A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can be inserted without going to the operating room. He mentions that, at least the doctor wont be wearing surgical garb, will he? How will the nurse answer the patient? a. You are correct. It is a minor procedure performed on the unit and does not necessitate surgical attire. b. To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves. c. It depends on the doctors preference. d. Most doctors only wear sterile gloves, not a cap, mask, or sterile gown. Rationale: Answer B. Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a central venous line including a PICC. Options A, C, and D are incorrect statements. They increase the risk of infection. 5. A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply? a. You will have general anesthesia so you wont feel anything. b. It will be inserted rapidly, and any discomfort is fleeting. c. The insertion site will be anesthetized. Threading the catheter through the vein is not painful. d. You will receive sedation prior to the procedure. Rationale: Answer C. Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented. 6. What volume of air can safely be infused into a patient with a central venous access device (CVAD)? a. It is dependent on the patients weight and height. b. Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed and cause no problems. c. It is dependent on comorbidities such as asthma or chronic obstructive lung disease. d. None. Rationale: Answer D. Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venous lines; none should enter the patient. 7. Kent a new staff nurse asks her preceptor nurse how to obtain a blood sample from a patient with a portacath device. The preceptor nurse teaches the new staff nurse: a. The sample will be withdrawn into a syringe attached to the portacath needle and then placed into a vacutainer. b. Portacath devices are not used to obtain blood samples because of the risk of clot formation. c. The vacutainer will be attached to the portacath needle to obtain a direct sample. d. Any needle and syringe may be utilized to obtain the sample.

Rationale: Answer A. A special portacath needle is used to access the portacath device. A syringe is attached and the sample is obtained. One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. A vacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needles should be used to access the portacath device. 8. What is the purpose of tunneling (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling:

a. Increases the patients comfort level. b. Decreases the risk of infection. c. Prevents the patients clothes from having contact with the catheter d. Makes the catheter less visible to other people. Rationale: Answer B. The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection. 9. The primary complication of a central venous access device (CVAD) is: a. Thrombus formation in the vein. b. Pain and discomfort. c. Infection. d. Occlusion of the catheter as the result of an intra-lumen clot. Rationale: Answer C. A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an even higher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not cause pain and discomfort. 10. Nurse Blessy is doing some patient education related to a patients central venous access device. Which of the following statements will the nurse make to the patient? a. These type of devices are essentially risk free. b. These devices seldom work for more than a week or two necessitating replacement. c. The dressing should only the changed by your doctor. d. Heparin in instilled into the lumen of the catheter to decrease the risk of clotting. Rationale: Answer D. A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparin used depends on the patients age, comorbidities, and the frequency of catheter access/flushing. Although patients have few complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevity of central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how to perform dressing changes at home.