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100% will be able to operate a CVC or A-Line.
Contact hours for LPNs in any state are earned by completing this course. This is part of a series of 24 contact hours of courses to prepare for LPN IV Certification in Florida. Florida certification participants must schedule a 6 hour live presentation and return demonstration to complete IV Certification. The live presentation is not provided by CEUFast.com.
After completing this continuing education course, the participant will be able to meet the following objectives:
Central venous and arterial catheters are a major component in the treatment of critically ill patients and patients that require long-term IV treatment. It is estimated that in the US, 300 million catheters are used each year. These have big risks. If you see bleeding or air in the line, clamp the line. Otherwise, do not touch unless you have been orientated.
Central venous catheters (CVC) are inserted into a vein in the arm, chest, or leg, and the tip ends in a large vein near the heart. These catheters may also be called a central line. Based on the type of insertion the terms centrally inserted central catheter (CICC) and peripherally inserted central catheters (PICC) may be used. The term vascular access device (VAD) may also be used.
Central venous catheters (CVC) are inserted into a vein in the arm, chest, or leg, and the tip ends in a large vein near the heart. These catheters may also be called a central line. Based on the type of insertion the terms centrally inserted central catheter (CICC) and peripherally inserted central catheters (PICC) may be used. The term vascular access device (VAD) may also be used.CVCs can be single, double, triple, or quadruple lumen. The different lumens have slits and a terminal hole that empty the contents of each lumen at different levels along the catheter; so, the fluids infused do not mix. This means you can infuse medications, fluids, blood and (PN) at the same time. The most distal opening is the most reliable for blood draws because it is less likely to be suctioned against the vein wall during aspiration.1
Catheters with antibiotic and antiseptic impregnation are available and may reduce infection rates.
The more lumens, the thicker the catheter. The more lumens, lumen diameter decreases, maximum infusion rate is lowered, and the rate of thrombosis increases. More lumens in a catheter increases the risk of deep vein thrombosis (DVT) and bloodstream infections.1
Indications for a central venous catheter include1,2:
Contraindications to CVC are relative and depend upon the urgency and alternatives for venous access. Contraindication to consider are2:
Nontunneled catheters are easier to monitor for bleeding if a CVC is needed in patients with coagulopathy. A subclavian insertion should be avoided in these patients because the site is not easily compressed to stop bleeding.2
Non-tunneled CVCs are inserted percutaneously with the catheter exiting the skin in the area of the cannulation site. These are usually for emergency or temporary access.
Peripherally inserted central catheters (PICCs) are relatively easy to insert into peripheral veins in the upper extremity. The include Brachial and basilic veins. PICCs have a lower risk of insertion complication and are tolerated well by the patient. A PICC is inserted into a smaller vein than other PICCs.
For patients with chronic kidney disease (glomerular filtration rates <45 mL/minute; stage IIIb kidney disease or higher) requiring central venous access other than for hemodialysis, a small-bore, tunneled PICC can be used.1 PICCS should be avoided in patients with chronic kidney disease. The risk of PICC related DVT or central vein stenosis can complicate future access for hemodialysis.
Implanted catheters are meant to be semipermanent. They should only be removed due to complication or if the catheter is no longer needed. Implanted catheters can be tunneled catheters or totally implantable venous access devices.
Tunneled central venous catheters are put through a tunnel in the subcutaneous tissue between the skin insertion site and the place where the vein is punctured. Any catheter can be tunneled. The tunneled catheters have a lower rate of infection compared to non-tunneled catheters.
Chronic hemodialysis and apheresis catheters are specialized, tunneled, large diameter, double lumen catheters. They are used to exchange a large volume of blood or high flow rates. Brands are Tesio, Hickman, Quinton-Mahurkar, and MedComp.
Subcutaneously implanted venous access devices are commonly known as ports. Brands are Port-a-Cath, BardPort, PowerPort, Infuse-a-Port, passport, and Mediport. This device is a catheter that connects an implanted access device in a subcutaneous pocket to a catheter that is inserted into the vein. Ports are accessed with a special non-coring needle called a Huber needle. Using a regular needle causes damage to the membrane.
Huber needles come in gauge 20 and 22. Available lengths are from ½ inch to 1 ½ inch. If the needle size has not been determined for that patient, start with a 22 gauge 1 ½ inch. Ideally, the hub of the needle should rest flat, as close to the skin as possible. If the Huber needle is more than ¼ inches above the insertion site, use a shorter needle next time.3 Use an aseptic technique to access and remove the needle from the port.
| Access needs | Type of catheter |
| Emergency | Nontunneled single-lumen |
| Short-term <14 days | Nontunnelede CVCs or PICC |
Mid-term ≥ 14 days – 3 months | Tunneled CVC or PICC |
Long Term ≥ 3 months | Tunneled CVC or port |
If a catheter or connection is damaged or dislodged, immediately clamp the catheter with a catheter clamp or kink and tape the line.
Use aseptic technique during the insertion and maintenance of the catheter. Use aseptic technique when the catheter lumen is opened or connected to other devices. Chlorohexidine is recommended, but Povidone iodine can be used. Acetone and tincture of iodine may adversely affect the catheter or connectors.4
Closely observe the catheter after insertion for catheter damage or patient injury. A damaged catheter may cause rupture or fragmentation that may lead to embolism or surgical removal.
Confirm CVC catheter tip placement by chest x-ray before initial use. Also, confirm placement if a patient is admitted with an existing PICC or undocumented CVC.5 To find out information about an existing CVC, you can look at chest x-rays, CT scan, interventional radiology report, operative note, discharge summary, referring doctors note, outside hospital transfer note, or patient provided documentation.
Use leur lock connections with a CVC.
Hickman, Leonard and Broviac Central Venous Catheters are a type of central venous catheters. The catheter is inserted into a large central vein and progressed to the point that the tip is in the superior vena cava above the right atrium. The catheter is tunneled subcutaneously. The Surecuff allows tissue to grow into a cuff that is attached to the catheter. The cuff secures the catheter in place. The Surecuff is placed 3-5 cm below the skin exit site in the tunnel.4
These catheters are for long-term vascular access for the patient that lacks adequate peripheral access. The catheter can be used for IV infusion of fluids, medications, blood products, and parenteral nutrition. It can also be used to withdraw blood samples; however, small catheters will increase the changes of the sample clotting. The catheter may have single, dual, and triple lumen catheters.
Vitacuff is an Antimicrobial cuff that may be used to help prevent central line infections. It is a concentric layer of material attached to the catheter that is to be placed just subcutaneously at the insertion site. The antimicrobial cuff absorbs fluids at the insertion site and works for 4-6 weeks. The antimicrobial cuff may help prevent infection at the insertion site but does not work against infection that may be introduced into the catheter system when accessing or replacing tubing.4
Hickman Trifusion is a triple lumen long-term catheter. It has 3 equally sized lumens.
Groshong catheters have a closed tip. The valves are on the side of the catheter. The valve is a three position, pressure sensitive valve. Negative pressure opens the valve inward to allow blood draws. Positive pressure opens the valve outward to allow infusion. When not in use, the valve is closed. This restricts backflow, bleed back and air emboli. This catheter reduces the need for clamping or hepranization.6
Cordis catheter is a CVC with one lumen and a less flexible tube to improve ease of insertion. It is used in emergency situations.7
PowerHickman and PowerLine are catheters that allow power injections of contrast media. Otherwise, this catheter functions as other central line catheters.
Infusion pressure greater than 25 psi may damage blood vessels. Never us a syringe smaller than 10 mL for a CVC.4
Follow your facilities policy regarding flushing CVC. The following are recommendations for the adult patient.7 Flushing should be done after completion of infusion or blood sampling.
| Type of catheter | Flushing solution | Flushing frequency in not in use |
| Implanted ports | Heparin 100 units/mL. flush with 5 mL (500 u) | Monthly |
Hickman tunneled | Heparin 10 units/mL flush with 5 mL (50 u) | 1-2 times a week |
Multiple lumen nontunneled, PICCs | Heparin 10 units/mL flush with 5 mL (50 u) | Every 24 hours |
Groshong, Saline only PICCs and valved catheters (Vaxcel, Bard powerPICC SOLO) | Preservative-free normal saline 20 mL after blood sampling or stopping PN, 10 mL after meds or routine flush May use heparin | Every 7 days Use push-pause technique when flushing with saline |
Hohn | Heparin 10 units/mL flush with 5 mL (50 u) | Every 7 days |
When using push-pause technique of flushing, maintain positive pressure by clamping the line while injecting the last of the flush. Do not clamp while injecting if you are using a system that has a positive pressure feature (max-Plus). Clamp these only after removing the flushing syring.5
Follow your hospital policy about how much blood to discard when drawing blood from a CVC.
| Patient | Blood discard amount |
| Adult | 6 mL |
| Neonate | 1 mL max |
| Infant | 2 mL max |
| Child | 5-10 mL max |
| Adolescents and older children | 3 mL tunneled catheter 3-5 mL implanted port |
Site care should be done according to your facility policy.
CDC recommends the use of Chlorhexidine gluconate 2% for site disinfection. Povidone iodine is an alternative.5
Other CDC CVC catheter site dressing recommendations are listed below.8 Some of these recommendations contradict each other. That is because both are correct, and the facility or provider makes a choice.
The following is a recommended procedure4:
It is very important to use the correct catheter clamp. The wrong clamp can damage the catheter. The clamp should be smooth. Clamp the catheter of over the reinforced clamping sleeve or tape tab. Never clamp over the reinforced segment directly adjacent to the connector.
Clamp the catheter whenever4:
CVCs have an advantage to the patient because there are fewer needle sticks during treatment, but a CVC can change the patient’s body image. In addition, the patient must be able to comply with care and handling of CVC. The best complication prevention is to remove the catheter as soon as it is not needed.
| Infiltration | Infiltration is caused by dislodgement of the catheter from the vein with unintentional infusion into the surrounding tissue | |
Prevention | Signs and symptoms | Intervention |
Select the best catheter and insertion site Secure catheter and tubing Assess catheter for patency prior to use | Discomfort or pain Swelling Coolness of surrounding tissue Slows or quits flowing Absence of blood backflow | Stop infusion Disconnect tubing Remove catheter If severe, apply warm compress and elevate site |
Vesicant Extravasation | Extravasation is the infiltration of vesicant solutions into the surrounding tissue. Vesicants include chemotherapy, hyperosmolar solutions, parenteral nutrition, and KCL | |
| Prevention | Signs and symptoms | Intervention |
| Same as infiltration | Same as infiltration Infusing a vesicant solution | Stop infusion Disconnect tubing Do not remove catheter Apply dry cold compress Contact provider |
Phlebitis | Caused by
| |
| Prevention | Signs and symptoms | Intervention |
Secure catheter and tubing Splint site Assess catheter for patency prior to use Use large vein for irritating infusion Adequately dilute irritating medications | Discomfort and pain that will progress along the path of the catheter and vein Redness, swelling, warmth, induration Purulence Red streak above site Palpable venous cord | Apply warm compress Elevate site Consider removing the catheter Consider pharmacological interventions (analgesic, anti-inflammatory, corticosteroids) |
Catheter-associated bloodstream infection | Caused by
| |
| Prevention | Signs and symptoms | Intervention |
Adhere to hand hygiene Use aseptic technique, maximum sterile barrier precautions during insertion, mask, cap, sterile gown and sterile gloves Clean site appropriately Chlorhexidine use instead of povidone-iodine Change tubing as recommended Maintain integrity of the administration system Use dressing that allows visualization of the site Avoid insertion into the femoral vein Use best practices checklists for insertion and maintenance Remove unnecessary CVC Antibiotic-impregnated catheters Vigilant catheter care | Signs of local infection Fever, chills Nausea, vomiting Elevated WBC Malaise, tachycardia Backache, headache May progress to septic shock with profound hypotension | Stop infusion Consider removing the catheter Get a sample of any exudate for possible culture When removing catheter, cut off the tip of with sterile scissors and place in sterile dry container for possible culture Start appropriate antibiotic therapy |
Circulatory overload | Fluid overload is caused by the infusion of excessive IV fluids. The elderly, infants and patients with cardiac or renal failure are at greater risk. | |
| Prevention | Signs and symptoms | Intervention |
Assess for cardiac or kidney conditions Be vigilant in high-risk patients Monitor infusion rate Use electronic infusion device in high-risk patients Keep accurate intake and output Splint the site if the flow rate fluctuates too widely with movement | Increased BP and pulse Increased CVP, venous distention, engorged jugular veins Headache Anxiety Shortness of breath, tachypnea, coughing Pulmonary crackles Chest pain | Notify the provider Sit the patient up to ease breathing Reduce IV infusion rate Monitor for worsening condition |
Air Embolism |
| |
| Prevention | Signs and symptoms | Intervention |
Clear all air from tubing before infusion Change solution containers before they run empty Ensure all connections are secure Use Luer-lock connections or administration sets with air-eliminating filters unless contraindicated Use correct technique when removing central venous access devices When removing central venous device, place the patient in supine or Trendelenburg, unless contraindicated, so the insertion site is at or below the level of the heart Instruct the patient to bear down (Valsalva maneuver) during catheter removal | Sudden onset of dyspnea, breathlessness, and tachypnea Chest pain, hypotension tachycardia Altered mental status, altered speech Change in facial appearance, paralysis | Immediately prevent additional air from entering the bloodstream by closing, kinking, clamping, or covering the existing device or insertion site with an air occlusive dressing Immediately turn the patient on the left side and lower the head of the bed. This will trap air in the right side of the heart Notify the provider immediately |
Occlusion or sluggish flow | Caused by:
| |
| Prevention | Signs and symptoms | Intervention |
Assess the functionality of the vascular access device routinely Use appropriate flushing procedures Secure the IV with tape and armboard if needed | Unable to withdraw blood or sluggish blood return Sluggish flow or frequent occlusion alarms Signs of infiltration or extravasation | Assess for mechanical causes of occlusion Reposition the catheter by pulling back slightly on the cannula in case the cannula is against a wall or valve Lower the solution container below the patient heart and observe for blood backflow Assess the functionality of the electronic infusion device Consider removing the device |
Venous thrombosis | Caused by:
| |
| Prevention | Signs and symptoms | Intervention |
Select appropriate vascular access device and site location Ensure proper dilution of irritating substances Ensure proper placement of vascular access device Institute nonpharmacological strategies for thrombosis prevention if possible (early mobility, adequate hydration) Anticoagulant prophylaxis if ordered | Swelling and pain around the IV or in the extremity proximal to the insertion site Slowing of IV infusion or inability to draw blood from the central line Palpable lump in the cannulated vessel | Notify provider Anticipate therapeutic anticoagulant dose |
Insertion or migration injury |
| |
| Prevention | Signs and symptoms | Intervention |
Experienced operator Ultrasound-guided insertion | Specific to the injury | Specific to injury and symptoms Notify the practitioner |
CVCs are the most frequent cause of healthcare-associated bloodstream infections.10 Central line-associated bloodstream infection (CLABSI) are a major concern identified by the Joint Commission (JC). An estimated 80,000 CLABSIs occur in US ICUs every year. When other treatment areas are counted, there are an estimated 250,000 CLABSIs per year. The mortality rate due to CLABSIs is 12.3%. These infections are mostly preventable. That means the nurse has a major impact in preventing CLABSIs.10
Prophylactic antibiotics are not recommended.2
Do not routinely replace PICCs and PICCs. Do not remove PICCs and PICCs based on fever alone.8
The tissue will grow into the Surecuff within 2-3 weeks.4 Use the method of removal determined by the physician and your facility. This may include traction of the catheter to surgical removal.
Traction removal procedure4:
Arterial catheters are also called intra-arterial catheters or A-lines. These catheter tips are positioned into the pulmonary artery. If in doubt, don’t touch.
A-lines are used in critical care to obtain arterial blood for laboratory testing, and for direct measurement of blood pressure and cardiac output. When central venous lines are not available, the A-line can be used to obtain blood samples.
A-lines are indicated when7,11:
Close blood pressure monitoring is needed when the pressure is acute and labile can occur with shock, major surgery, hypertensive emergency, or vasopressor therapy.
A-line blood pressure monitoring is the gold standard. The mean arterial pressure generally correlates will with sphygmomanometry in healthy patients. The sphygmomanometry is not as accurate when the patient has calcified arteries, shock, cardiac arrhythmias or is on vasoconstrictor drugs. Noninvasive finger artery blood pressure correlates well with radial artery blood pressure monitoring in ambulatory patients but is not reliable when the patient is hemodynamically unstable.11
Technical problems with the pressure transducer make the measurements invalid. Follow hospital policy and manufacturer directions in use and checking of the transducer position. Calibrating the monitor and transducer are no longer necessary because current disposable transducers are standardized.11 Be thankful. Frequent calibrating use to drive me crazy.
Other errors due to dynamic response can be checked by testing at the bedside using a rapid-flush test. Problems may be caused in an under-damped system by excessive tubing length, connecting with stopcocks, or patient factors (tachycardia, high output states). Over-damped systems are usually air bubbles in the connecting tubing.11
When considering an insertion site, collateral flow should be assessed prior to insertion in the smaller arteries. Inadequate collateral flow can cause ischemic complications leading to necrosis.7 No particular A-line insertion site is supported by data, but the following are arteries are common sites11:
In pediatric patients, the temporal and umbilical arteries can also be used.
Insertion of an arterial line is done under sterile conditions.
Ultrasound should be used to identify and guide catheter placement for patients in whom vessel palpation is difficult (e.g., small vessels, obesity).11
Transducers, tubing, flush solutions, and flush devices should be replaced every 96 hours.
Arterial catheters have all the complications of venous catheters plus11:
Catheter functionality is improved, and the incidence of thrombosis with A-lines can be reduced by using a heparin flush instead of normal saline.7,11 Sodium citrate may be used as an alternative flushing agent if heparin is contraindicated.
A-line air embolism causes much more ischemic damage to end organs than central line air embolisms. Air introduced into a central venous line travels to the capillaries and can be filtered out. A-lines deliver the air directly into an organ.
A-line infections increase with lines in place for over four days, but routinely changing A-line sites is not recommended.11 Instead, strict aseptic technique is required.
Arterial catheters should be discontinued as soon as they are not critical to patient care. Femoral catheters should not be in for more than 5 days. A-lines at other sites should not be in for more than 7 days.
Keep all components of the pressure monitoring system sterile. Minimize the number of manipulations and entries into the monitoring system. Use a closed flush system rather than an open system (syringe and stopcock).8
Do not administer dextrose-containing solution or PN through the pressure monitoring system.
Iatrogenic blood loss due to withdrawal of blood for can be minimized using intra-arterial ABG monitoring. This technique uses a fluorescent optode to measure arterial pH, PaCO2 , and PaO2 measurements as needed without removing blood from the patient. Fiber optic continuous sensor systems (e.g., Paratrend 7+; Philips Medical Systems) are also available, which may offer an advantage if monitoring is needed over a prolonged period of time.11
Removal of an A-line is guided by hospital policies. In general, physicians or physician extenders are authorized to remove catheters in patients with coagulopathies, thrombocytopenia, or platelet dysfunction.7
Before removing an A-line, international normalized ratio (INR), PTT, and platelet counts should be checked, and medications that affect coagulation and platelet function noted. If any of these are abnormal, or if the patient is on antiplatelet therapy, extended compression times will be needed.7
Aseptic technique is used during removal of arterial catheters. After hand washing, put on nonsterile gloves, a protective gown, and face mask with shield regardless of catheter location. The catheter should be flushed prior to removal, or alternatively, blood can be drawn back into the catheter to prepare it for removal.11
Because of the angle of entry, the arterial puncture site is usually 1 to 2 cm proximal to the skin puncture site for radial arterial lines and 2 to 3 cm proximal for femoral lines. To remove the catheter, clean the catheter site according to hospital policy. Place dressing and apply pressure over the arterial puncture site, then slowly pull the catheter out maintaining pressure at both the artery and skin puncture sites.11 The catheter should be inspected to ensure it is intact.
NOTE: If the catheter has fragmented, pressure should be applied distal to the catheter. Embolization of the catheter fragment can occlude the distal extremity circulation, and urgent surgical referral should be obtained.11
After catheter removal, hold pressure on the site for at least 5 minutes over the radial artery and 10 minutes over a femoral artery. If the site continues to bleed, apply pressure and recheck every 5 minutes. Larger diameter catheters will require more time. If the patient has coagulation problems, increase the pressure time by 50-100%.11 Watch your patient closely after removal. Seeing an arterial removal site break open is one of those situations that make you realize how few times you have truly been afraid.
This course is applicable for the following professions:
Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
Topics:
LPN IV Series
