Central Lines: Patient Safety Considerations - PowerPoint PPT Presentation

Loading...

PPT – Central Lines: Patient Safety Considerations PowerPoint presentation | free to download - id: 3b21a0-YjEzZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Central Lines: Patient Safety Considerations

Description:

Central Lines: Patient Safety Considerations Reviewed & Updated By Tom DiDonna And Rob Bennington December 2011 * * * * * * * * * * * * Phlebitis Grading Phlebitis ... – PowerPoint PPT presentation

Number of Views:354
Avg rating:3.0/5.0
Slides: 40
Provided by: masoncoun
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Central Lines: Patient Safety Considerations


1
Central Lines Patient Safety Considerations
Reviewed Updated By Tom DiDonna And Rob
Bennington December 2011
2
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 superior vena cava
  • Used for long-term IV Fluid administration,
    total parenteral nutrition, vasopressors,
    antibiotics, or primary vascular access

3
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

4
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

5
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

6
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

7
TYPES OF CENTRAL LINES
  • Groshong - 3 way pressure sensitive slit at the
    catheter tip
  • doesnt 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

8
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

9
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

10
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

11
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.

12
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.

13
Power Port
  • The Power Port
  • Designed for power injections when used with a
    PowerLoc safety infusion set
  • Withstands injections of 5ml/sec _at_ 300 psi
  • The unique triangular shape and palpation points
    makes it easy to distinguish the Power Port from
    ordinary Mediports
  • Requires Heparin flush

14
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.

15
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
    doctors 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.

16
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.

17
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.

18
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

19
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

20
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

21
Dressings
  • Procedure
  • Change dressing 24 hours after insertion and then
    every 7 days and PRN
  • Confirm patients 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.

22
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.

23
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.

24
Dressing Change
  • Carefully remove old dressing pulling from edges
    toward the center
  • Maintains catheter positioning
  • Decreases risk of insertion site contamination

25
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.

26
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.

27
Dressing Change
  • Apply steri-strips
  • Note cm marking on catheter at insertion site
  • Center the Tegaderm over the insertion site

28
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.
29
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.

30
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

31
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

32
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

33
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

34
Phlebitis Grading
  • Phlebitis Scale - Clinical Criteria Notify
    Infection Control and physician for grade gt 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 gt1 inch
    in length, purulent drainage.

35
Complications
  • Immediate
  • Hemothorax
  • Pneumothorax
  • Arterial puncture
  • Nerve Injury
  • Dysrhythmias
  • Catheter malplacement
  • Catheter rupture
  • Embolus
  • Cardiac tamponade

36
Complications
  • Delayed
  • Dysrhythmias
  • Catheter malplacement
  • Catheter rupture
  • Embolus
  • Cardiac tamponade
  • Catheter related infection
  • Thrombosis
  • Hydrothorax

37
Implantable Device Video
  • http//www.bardaccess.com/infusion-powerloc.php?se
    ctionVideo
  • After video is complete, return to presentation
    and complete.

38
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_F
    requently_Asked_Questions.pdf Accessed July 5,
    2009.
  • Mermel LA. Prevention of intravascular
    catheter-related infections. Ann Intern Med.
    2000132391-402. 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. 199920396-401. Abstract
  • CDC. Central Line-Associated Bloodstream
    Infection (CLABSI) Event. Available at
    http//www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABSc
    urrent.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. 2002511-26.
  • Pittet D, Tarara D, Wenzel RP. Nosocomial
    bloodstream infection in critically ill patients.
    Excess length of stay, extra costs, and
    attributable mortality. JAMA. 19942711598-1601.
    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.
    200829s12-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. 200829s22-s30.
    Abstract
  • Klevens RM, Morrison MA, Nadle J, et al. Invasive
    methicllin-resistant Staphylococcus aureus
    infections in the United States. JAMA.
    20072981763-1771. Abstract

39
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. 200836609-626. Abstract
  • Rosenthal VD, Maki DG, Mehta A, et al.
    International nosocomial infection control
    consortium report, Data summary for 2002-2007. Am
    J Infect Control. 200836627-637. Abstract
  • Yamamoto AJ, Solomon JA, Soulen MC, et al.
    Sutureless securement device reduces
    complications of peripherally inserted central
    venous catheters. J Vasc Interv Radiol.
    20021377-81. 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.
    20093011231-1241. 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.
    200862809-615. 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.
    2006811159-1171. Abstract
  • Institute for Healthcare Improvement. Implement
    the central line bundle. Available at
    http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
    veCare/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.
    20063552725-2732. Abstract
About PowerShow.com