Major Veins Used

Internal and External Jugulars

Subclavians
Femorals

Vein vein vein vein vein vein vein vein

TUBES GO INTO VEIN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Central Vein Therapies Requiring Central Catheters
Fluids at high-volume
TPN
Vesicant Chemotherapy
Caustic or irritating medications
Hemodynamic monitoring
Prolonged venous access
Uses
Inaccessible peripheral veins
Infusion of irritating or vesicant fluids
Rapid or large volume infusions
TPN: hypertonic solutions, need larger vein
Long term IV access, only area that can be used for a long time
Central Venous Pressure measurements: tells us what the circulating volume is in the
body, intravscularily
Blood draws, thick solution moves slower, central line quick, no more sticking through
periphery!
Why?
Need to put in larger volumes of drugs
Hypertonic solutions, such as TPN, need larger veins
Dopamine, will cause damage to arm if infiltrated in periphery
Lines must always remain PATENT! Follow policy for flushing ect...
Have meds that can be inserted into catheter to "eat away" clot and make them
functioning again
Central catheter device insertion techniqes
"Through the introducer"
"Over the wire" technique-aka-"guide wire" or Seldinger technique
Types of central catheter devices
Non-tunneled catheter
PICC-peripherally inserted central catheter
Tunneled silastic catheter- ex: Hickman, Broviac, Groshong, Leonard
Implanted infusion port-ex: Port-A-Cath, Infus-A-Port, Mediport
Categories of central catheter devices
Length of dwell time
short term-swans ganz
mid term-PICC
long term-surgically implanted port or tunneled catheter
Method of placement
Central venous catheter care and maintinance
cath with tip in SVC or IVC or Right atrium, must be on pump

give here so it doesn't harm peripheral veins

2000ml/hr (central) vs 10ml/hr (periphery)
Inserted: subclavian, PICC line, internal/external jugular, femoral

maintain patency-CRITICAL. Check your institution's policy for flush protocol. some may
require periodic flushes with NS and heparin, while others may require NS only.
Use sterile technique when changing dressing. Check your institution's policy for
dressing change protocol.
More catheter care and maintinance
Yuck!
Catheter sutured in place, lots of redness, some drainage, old blood
Clean using sterile technique
Document: redness, sutures in tact, drainage at site (type, smell, color, amount),
pseudomonas?, ask patient about pain, call the doctor

Most frequent side effect infection

Take out: send tip for culture (when ordered, or when suspected), sterile procedure
(gloves, cup, sterile scissors), 2 people
Cardiac Catheterization
Invasive procedure: it is! Measures heart pressures, injection fraction...
Measures cardiac chamber pressures & assess coronary arteries patency:
Requires ECG and hemodynamic monitoring; emergency equipment must be available
Interventions: like stents, need open heart surgery available

Assessment prior to test; allergies, blood work: pretreat with Decradon/Benadryl to

prevent
BUN and Creatinine for kidneys!
Kidney problems: give fluids, to wake up kidneys
Risk of overload
Aceytylcistine: for Tylenol overdose, protective medicine for kidneys for dye studies (off
market)

Activity restrictions and voiding concerns

KNOWING WHAT YOU'RE GETTING INTO IS HUGE: HIGH RISK

Assessment of patient after procedure
Circulation: look at limb, pink and warm, q15 minutes for 1-2 hours
potential for bleeding: high risk, look at dressing
potential for dysrhythmias: tubes and injection in the heart! Part of report, outpatient
care and recovery,
contrast-agent induced nephropathy : why we flush with NS, don't use too much! Use
Aceytylcistine
Look at labs: renal failure!
Patient education before & after procedure
informed consent, no matter how much you educate about lying still and flat, they "have
never heard that", lock out bed
Pre-op
Consent:
Do you understand why you are getting this device?
Do: witness signature
Don't: call the doctor!

Prep:
Sterile procedure "O.R.", even when changing a dressing
"prevent infection at all costs", dont want bugs in there!

Position:
Trendelenburg
Need to see and feel vessels
Procedure "cell dinger" can be scary for patient

Procedure:
Make opening in skin, put needle into vessel, hit vessel, take wire, thread through
needle, leave wire, take catheter (large)(dialater), push through skin and vessel, make
hole bigger, to put large catheter in, when inserting hold wire so it doesn't advance,
push to biforcation,
LAC
going into the artery to look at the coronary arteries, femoral artery, see heart, inject dye
see where it goes
RAC
in the vein
Swan ganz
femoral to IVC to RA (ICU), only put it in for those pressures, after calculation take out!

kept in the body 10-14 days at most, put in in critical care area, goes into sublcavian,
through the right atrium into right ventricle, tip sits in pulmonary artery, hooked up to
monitoring, tells us how heart is working, only see in ICU

Pull out, see the path that it has taken, because it looks like a heart
Advantage: see pressures in different chambers
Can draw blood
Give meds
Measure CVP
Systolic and Diastolic pressure
Take a core temperature
Pacer wires in heart to help heart function
True cardiac patients, nurse must use the one the doctor says (regular temp or core)
Continuous CO
Central venous oxygenation

Diagnostic
finding source of problem
not all cardiologists can fix a damaged area
After taking them out
need to apply pressure upwards of 30 minutes, lay flat, no getting up for 6 hours hand
hold, 2-3 hours sealed, BUT USUALLY 6
Central Venous Pressure (CVP)
get from smaller central line VENUS LINE
Pulmonary artery pressure
swan ganz, needs to get to artery, inflate balloon, will travel far with blood flow, as close
to the left sided heart pressure as we can get VENUS LINE

Pulmonary artery catheter: to the heart

temp, pacer, fluids
must be in critical care
it is a central VENUS catheter
Balloon-tipped, Swan-Ganz catheter
measuring pulmonary capillary wedge pressure (PCWP)

Balloon flows with blood gets stuck in pulmonary capillary area

See change in wave form
Read the number
Number of pressures on left side
Deflate: 1 ½ mLs,
They will become SOB, producing sputum
Only in for a few seconds
Wave form, goes flat, read that number, deflate, pull back, plug up

each lumen has its own canal

Intra-arterial BP monitoring
ARTERIAL LINE, who pokes arteries best: respiratory, may use brachial, to determine
patency: occlude ulnar and radial (turn white), release one side (turn pink), release
other (turn pink), if only one was patent, and tube the patent, arm will die. The ALLEN
TEST! Insert arterial line if we need very close BP monitoring, internal BP,
hemodynamic monitoring, real time, constant

pulmonary arteries carry deoxygenated blood to lungs to be oxygenated

arteries carry oxygenated blood to arterioles to tissues

Non tunneled----"triple lumen"
temporary dialysis, put in under normal method, short term, 10-14 days, "single, double,
triple", more is better always

also called "Triple Lumen" as it often has 3 lumens to use!!! (The patient cannot go
home with this one!!! Can be used in critical care units and on Medical/Surgical units)

Each tail tells the gauge

Important: looks like you have one lumen, but there are 3 tunnels in the one catheter,
tunnels don't touch, 1000 ml/minute infusing, 3 exit spots for each lumen, don't have to
worry about compatibility, "hard concept"
Practice: flush different ports to see where fluids come out

Distal Non-tunneled
16 gauge
furthest away
tip
measure/monitor CVP
infusing blood
infusing medications
Medial Non-tunneled
18 gauge
large
reserved for TPN
infusing TPN
infusing medications
possibility for TPN: leave open

Can have meds in medial and change it to TPN

But cant have TPN going and stop it for meds: too much sugar!
Proximal Non-tunneled
18 gauge
closest to patient,
Drawing blood samples
infusing medications
Tunneled---ie: Hickman, Broviac, Leonard
wont see very often, oncology, tunnel catheter, inserted in one area, tunneled through
skin, enters subclavian in another area, allows for decreased infection rate, puts up a
"road block"

Needs daily care to maintain patency and prevent infection

Has a Dacron sheath that holds it in place for years
Not used much anymore (newer types are easier)
Implanted Port---Medi-Port
REALLY COOL, surgically, long term, circular device, "pad" with a diaphragm, under
skin, against bony prominence, easy access, 90 degree need "Huber needle", use the
port if they have a port!, visible from surface, plastic or metal, DO SEE A LOT, pt. taught
to say "I have a port"
going into jugular to the SVC, catheter attaches to port

A venous catheter with one end located in the Central Venous Circulation and the other
attached to a port which is surgically implanted in a subcutaneous pocket

Huber needle with implant

"Non coring tip" ,90 degree angle
Beveled to not take out chunks
Important to know

Subcutaneous insertion
Initial access in O.R. under anesthesia, swelling, pain
Follow up visits/treatments, accessed then de-accessed before they leave
De-access to remove needle and maintain patency on catheter
Use heparin in catheter itself
Know ahead of time what the catheter can hold "milliliters"
Accessed next time withdraw heparin
Accessed at least once a month if not being used

Peripherally inserted----PICC
single, double, triple lumen, fast infusion, compatible to go down to x-ray under
pressure, have to use a minimum 10cc volume syringe in a central line to not cause too
much pressure!, power PICC is more sturdy and CAN withstand more pressure, but as
a nurse I will always use the 10cc rule!!!

usually either cephalic or basilic and with the tip residing in the central circulation

confirmed with x-ray, cant use until confirmation

10cc Rule
no matter what your administering minimally 10cc syringe, 1cc will apply more PSI,
need to convert 1cc to 10cc syringe, too much pressure could lead to embolism

power PICC is more sturdy and CAN withstand more pressure, but as a nurse I will
always use the 10cc rule!!!

Patient Education: BIG BIG BIG BIG BIG

Rational for PICC
Need for Assessment: measure circumference (everyday) of arm to see if there is
swelling "baseline"
Sterile Technique
Possible Complications: infection, bleeding, embolism (red, swelling, heat, pain)
Reason for X-Ray
Dressing Changes: don't pull out catheter! (students don't change dressings)
Routine Care: flushing, observing, documenting, infection, bleeding (sometimes)
assessment: Measure Arm Circumference
Look for:
Redness; Tenderness; Edema
Note any Drainage from site
Measure External Catheter Length
Make sure Dressing is Dry & Intact
dressing change once a week
Routine Care
All Central Lines
Site Assessment
Catheter Flushes: daily
Cap/Injection Port Changes: changed 72-96 hours, make sure they are screwed on
tight, require 15 second alcohol prep "scrub the hub", going straight to heart!
Dressing Changes: weekly, PRN
Nurses will leave catheter clamped if not in use or connected to anything
Hospital policy
Initiating Therapy
Dressing
If gauze - make occlusive: may see under clear dressing, but don't see very often, want
to visualize site
Ointment per protocol: betadine, but rarely see, now use chlorhexidine (decreases
infection rate) scrub
Flushes: hospital protocol, every shift, minimum of 10 ml of NS
Normal Saline - Heparin (dependent on equipment and hospital protocol): some
catheters may have in them, r/t policy, patient, situation, push/pause method: causes
turbulence in catheter, "better cleaning", TPN discontinued-use push/pause to release
glucose stuck inside
-- Use Push Pause method to give flushes
Infusion: any infusion in a central line
Isotonic Keep-Vein-Open (20cc/hr (480cc/day) not all patients can abide by this rule,
minimum 7): use isotonic (just like the body), intermitent administration, need isotonic
KVO, safer to have NS KVO, makes job easier, don't need to have a flush, critical care:
10cc/hr
Electronic Controller/ Pump: everything on a central line is on a pump

tested on central line dressing change, variations at facility, packages to clean

Management of Infusions
Monitor extremely closely
Rate appropriate "rights"
Patency
Site
Central lines folluw rules of other tubing
TPN tubing changed every 24 hours!!!!! NEW BAG NEW TUBING NEW LABEL!!!!!
Piggy back, policy
IVP use 10cc and larger! KNOW KNOW KNOW KNOW
Fluid Administration
Initiating fluids
Changing solution and tubing
Medication Administration
Piggyback Medications
I.V. Push Medications
COMPLICATIONS--insertion related
Pneumothorax: symptom: SOB, anxious
Hemothorax: punctured vessel, leaking, accumulation at base of lungs, same
symptoms, blood taking up space
Chylothorax: fat particle occludes lungs
Intravascular tip malposition: what we take the X-ray for! "didn't do a twirly bird
somewhere and go to the head"

DURING INSERTION
Know the terms!
Xray afterwards to make sure these problems didn't happen!
COMPLICATIONS-----post insertion
Infection/Sepsis: in the blood, remove catheter, culture tip, after new one is put in,
cultures before IV antibiotics
Thrombus Formation: get clot around catheter, look for swelling of extremity closest to
insertion site, thrombus can occur by NOT doing push/pause
Tip migration: can move
Catheter occlusion: clogs up, must take care of it! cath-flow solution "mini pack man",
put in (what tube can hold) and then extract, doesn't go into patient just into the
catheter, or call IV team to preform this task
Air Embolism: make sure there's no air in syringe or tubing! Use clamp

AFTER INSERTION
Got it in, what can happen now
"Ruggedness" during push/pause rather than smooth push like usual
Pre-flush all tubes with saline! Individually!
Miscellaneous stuff:
Groshong Valve------A central catheter with a 3-way slit valve opening, Can be found on
any long term central catheter or PICC, needs only saline flushes due to its design.

Nice to know info

Probably wont see
Has valve that doesn't allow back flow
Kept positive pressure in catheter
Didn't have to use heparin!
Blood draw through a central line
Turn off running IV fluids
Aspirate and discard first 5cc withdrawn
Withdraw enough for all lab tubes
Fill tubes for lab tests and label
Flush central catheter or re-start IV

Take from the right port (proximal)

Turn off solution that may be infusing (no back pulll into area)
Attach syringe, pull back at least 5 mls (waste in catheter), throw away
Take new syringe, pull back what you need (5-20mls...)
After pulling blood, minimum 20 ml flush of saline, push/pause!
Discard in red bag

Extravasation
The inadvertent administration of a vesicant solution and / or medication into the
surrounding tissues.

Signs / Symptoms:
Tissue Sloughing (from necrosis)can involve a small or large area, including connective
tissue, muscles, tendons, and bone
****Usually avoided with the use of a Central Venous Catheter.

Swelling redness hurts red line necrotic tissue sloughs off (dopamine, or dilantin)
Regitine is antidote for dopamine!
"nice to know"
Inject direct to save the tissue
SC injections all around tissue site
Hopefully will save!

Nursing Interventions
Discontinue infusate immediately: infiltrate: STOP, peripherally-new line, centrally-call
doctor
Follow Institutional Policies and Procedures (varies):

Leave cannula in place - aspirate residual medication

Instill antidote per protocol
Remove cannula/ catheter
Infiltrate affected area with antidote
Apply dry sterile dressing
Elevate extremity
Apply warm or cold compress as indicated (dependent upon medication infiltrated):
need to have an order!
Notify physician and continue to observe area
Restart an IV infusion site as soon as possible:
Use opposite arm
Preferably - initiate a central line for infusing vesicants
Central Catheter Removal
Confirm if hospital P & P allows nurse to perform this procedure!!!!!!!!!

Scrub Hands, ID PATIENT, foam in foam out, EXPLAIN "it wont hurt"
Assist Patient to Lie Flat or Trendelenberg
Apply Sterile Gloves
Remove Tape and Dressing
Assess Insertion Site
Clip and Remove Sutures (prn) (sterile)
Cleanse around site with alcohol
Instruct pt. in Valsalva Maneuver: bare down, don't want to suck in air, and have
embolis, cough, hold breath...
Gently Pull Catheter to Remove
Apply Occlusive Dressing-----antiseptic ointment
Assess Catheter Integrity-----inspect tip, measure catheter
Document
Document
Check policy!!
Document: in tact
Catheter was removed
Intact
Toleration "no pain" "no SOB"...
Position
Measure catheter
Tip is there and intact!

PICC lines are cut based on length they are needed, may not have defined "tip"