VASCULAR ACCESS DEVICES

CLINICAL SIGNIFICANCE 151

CLINICAL SIGNIFICANCE • A chest X-ray should be performed immediately for the internal jugular and subclavian lines to ensure proper placement and absence of an iatrogenic pneumothorax • Be sure you are withdrawing venous blood before dilation and cannulation of the vessel https://www.accjournal.org/m/journal/view.php? • If internal jugular CVL attempt is number=1156 unsuccessful, move to the ipsilateral subclavian vein. Never attempt the opposite side without a chest X-ray or ultrasound first to avoid bilateral pneumothoraces 152 CENTRAL VENOUS CATHETERIZATION

CLINICAL SIGNIFICANCE • Never let go of the guidewire as it may migrate distally into the vessel • Never force the wire on insertion because it may cause damage to the vessel or surrounding structures • Always place your finger over the open hub of the needle to prevent an air embolism • Always confirm placement with ultrasound 153 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CENTRAL CATHETER DRESSING 154

NON-TUNNELED LINE DRESSING • Wash your hands for 15 seconds with liquid soap and water. Dry them well. • Gather all supplies o Transparent or gauze bandage 155 o Anti-germ scrubber o Anti-germ patch o Securing device or tape • o mask Wear mask and open the bandage kit • Put mask on patient and turn patient’s head away from the site to keep them from breathing or coughing on it to help prevent infection CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED LINE DRESSING • Remove the old bandage towards the insertion site to help • keep from accidentally pulling the line out Remove the securing device if present and throw them • away Look where the line enters the skin for signs of infection: redness, puffiness, or drainage • Remove your clean gloves and wash your hands • Open your sterile dressing change kit in sterile fashion and • put on sterile gloves Scrub in a 2-inch circle around the point where the line enters the skin for 30 seconds with anti-germ scrubber 156 CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED LINE DRESSING 157 • Allow the area to air dry. This may take a full minute. Do not fan or blow on the area • Put on the anti-germ patch (slit facing down, print facing out). If you have a securing device, put it on • Put on the bandage • Change a clear bandage every 7 days. Change a gauze bandage every other day. Also, change the bandage when it’s loose, wet or dirty CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED CENTRAL CATHETER FLUSHING 158

NON-TUNNELED LINE FLUSHING 159 • Gather equipment o 2 saline syringes o 2 heparin syringes o 2 alcohol wipes • o A pair of gloves Wash your hand and put on gloves • Using a twisting motion, scrub the end cap with alcohol wipes for 15 seconds and allow cap to dry • Prepare one saline syringe • Point the syringe cap up and remove the cap and carefully remove the air bubbles CENTRAL VENOUS CATHETERIZATION

NON-TUNNELED LINE FLUSHING • Without touching the tip of the end cap, insert the saline syringe into the center of the cap. Once inserted, turn clockwise • Unclamp the central line • Slowly begin flushing with saline, starting and stopping as you flush • Clamp the central line, keeping your thumb on the plunger end of the syringe • Remove the syringe, holding the end cap and not the • line Repeat steps using heparin syringe ( as ordered) 160 CENTRAL VENOUS CATHETERIZATION

TUNNELED CENTRAL CATHETER 161

TUNNELED CENTRAL CATHETER • Tunneled central venous catheters are VADs that have a portion of the catheter lying in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin • This separation is intended to prevent the organisms on the skin from reaching the bloodstream 162 CENTRAL VENOUS CATHETERIZATION

TUNNELED CENTRAL CATHETER • Tunneled lines can be used for long-term infusional therapy for periods ranging from months to years • The tip of the catheter is inserted directly into the jugular or subclavian vein (as with non-tunneled lines) and is then threaded through to end up in the superior vena cava • The catheter may be round or flat, and catheter sizes can range from 2.7 to 12.5 F. Single-, dual-, and triple- lumens are available • These catheters were originally named for the physicians who designed them, including Broviac, Hickman, and Leonard catheters 163 CENTRAL VENOUS CATHETERIZATION

TUNNELED CENTRAL CATHETER • Tunneled CVCs are equipped DACRON with a fibrous (Dacron) cuff, CUFF which sits in the skin tunnel https://lavascular.com/hickman-catheter/ • This enables the patient’s tissue to bond with the line, to create a secure fix, and will act as a mechanical barrier to stop infection travelling down the line into the patient’s bloodstream to cause sepsis 164 CENTRAL VENOUS CATHETERIZATION

TUNNELED CENTRAL CATHETER INSERTION 165

TUNNELED CENTRAL CATHETER A. GATHER EQUIPMENT ••• Chlorhexidine Sterile dressing • Central line kit Ultrasound machine o Puncture Needle (21G) o Guidewire with probe o 5 Fr sheath with Dilator •• Fluoroscopy o Tunneled central catheter Heparinized saline o Metal tunneler o Anesthetic o Scalpel •• Sterile drape Sterile gown, cap, gloves and mask 166 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION B. PERFORM INITIAL PATIENT ASSESSMENT • Take a detailed access history • Assess risk for complications: • Bleeding • Difficulty of vein puncture • Pre-op blood test as per institutional policy • Informed consent 167 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION C. PATIENT PREPARATION • Patients should be positioned supine; the neck may be turned away from the side of vein puncture • Scan both the internal jugular vein and assess for: o Size 168 o Overlap with artery o Compressibility o Respiratory variations in size and doppler • Use coinntteinrruooguastEioCnG monitoring, BP and saturation monitoring CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Clean the skin with chlorhexidine or povidone-iodine solution from the mandible to the nipple, including the angle of the mandible, chin, and axilla, to the opposite sternal border • Perform ultrasonography (US), with a sterile probe cover, to choose a point on the skin above the vein • Infiltrate 3-5 mL of local anesthetic, and make a small (≤ 1 cm) horizontal skin incision 169 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Under US guidance, puncture the internal jugular vein (IJV) with an access needle. A lateral approach may give the catheter a smoother course, which is less likely to kink • Advance the guide wire. Use fluoroscopy to guide the wire into the inferior vena cava so as to minimize the risk of arrhythmia • Choose a skin exit site about 7.5-10 https://emedicine.medscape.com/articl cm (3-4 in.) below the clavicle but e/1375734-technique away from breast tissue and any prominent veins 170 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Infiltrate the remaining 15 mL of local anesthetic, starting at this point and continuing along the full length of the expected tunnel • Make a skin incision, and use either the metal or plastic tunneler to make a tunnel from the skin exit site on the chest to the venotomy site, ensuring that the tunneler is angled upward • Attach the catheter to the tunneler, and pull it through the tract until the cuff enters the tract https://www.semanticscholar.org/paper/Ultrasound- assessment-of-thrombotic-complications- Tomaszewski- CENTRAL VENOUS CATHETERIZATIONiKgousriea/k0/46dd5d0e567beee25afdb0eacf5fec185dd23cdf/1f 71

TUNNELED CATHETER INSERTION D. INSERTION • To reduce the risk of infection, ensure that the cuff is at least 1-3 cm (commonly ~2 cm) from the skin exit site • Detach the tunneler • Cut the catheter to a suitable length, which is measured by advancing a guide wire through the jugular sheath to the superior RA or by placing the line over the chest and cutting below the right main bronchus after fluoroscopy 172 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Pre Dilate the tract in the neck, if necessary, over the previously inserted guide wire, then introduce the peel- away sheath pre-mounted over a dilator • Ask the patient to hold his breath • Remove the inner dilator and wire, closing the opening in the sheath with a finger. (Note that some current dialysis lines come with a pneumostatic valve) 173 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Feed the line into the peel-away sheath, and peel the sheath. Tilt the table 10º lower at the head to prevent air embolism • Anchor the line with 2-0 nonabsorbable sutures, and close the skin incision in the neck with 4-0 absorbable sutures, Steri-Strips, or skin glue • Flush all the lumina of the lines with heparinized saline after aspirating blood (a higher heparin concentration is used for dialysis catheters) 174 CENTRAL VENOUS CATHETERIZATION

TUNNELED CATHETER INSERTION D. INSERTION • Perform radiography of the chest to assess for proper line positioning and exclude pneumothorax • The retention stitch may be removed once the cuff is secured (~3-4 weeks) 175 CENTRAL VENOUS CATHETERIZATION

TYPES OF TUNNELED CENTRAL CATHETER 176

TYPES OF TUNNELED CENTRAL CATHETER LINES CUT TO LENGTH INCLUDE THE FOLLOWING: • BROVIAC CATHETER o This is a 6-french single-lumen catheter (a 2.7-french version is available for neonates) o It is tunneled forward and cut to length o This type of catheter is usually used for antibiotics or parenteral nutrition o Transdiaphragmatic tunneled broviac catheters appear to be cost-effective for central venous access in infants undergoing cardiac surgery 177 CENTRAL VENOUS CATHETERIZATION

TYPES OF TUNNELED CENTRAL 178 CATHETER LINES CUT TO LENGTH INCLUDE THE FOLLOWING: • HICKMAN CATHETER o Hickman lines are essentially the same as Broviac lines, but with a larger internal lumen o This is a 9-French dual-lumen (6 + 3 or 4.5 + 4.5) catheter with or without antibiotic impregnation; it is tunneled forward, and the line is cut to the required length; this type of catheter is used for chemotherapy but works for other indications as well CENTRAL VENOUS CATHETERIZATION

TYPES OF TUNNELED CENTRAL 179 CATHETER FIXED-LENGTH LINES INCLUDE THE FOLLOWING: • GROSHONG CATHETER o Groshong catheters have a formed blunt end with a slit-like orifice just proximal to distal end o This acts as a valve with the following functions: ⮚ It stops back-bleeding ⮚ It prevents air entry and embolism from negative intrathoracic pressure ⮚ It obviates the need for a heparin lock as saline can be used instead CENTRAL VENOUS CATHETERIZATION

TYPES OF TUNNELED CENTRAL CATHETER FIXED-LENGTH LINES INCLUDE THE FOLLOWING: • GROSHONG CATHETER o External clamping of the catheter is not required o A pressure difference must be generated by either suction or positive pressure to open the distal valvular slit 180 CENTRAL VENOUS CATHETERIZATION

TYPES OF TUNNELED CENTRAL 181 CATHETER FIXED-LENGTH LINES INCLUDE THE FOLLOWING: • TESIO CATHETER o This is a 6.5F and 10F single-lumen line, that is tunneled backward from neck to chest after line positioning o Two lines are usually inserted for dialysis o Allows vascular access in adult patients requiring hemodialysis or apheresis who do not have functional permanent vascular access or are not candidates for permanent vascular access CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS 182

IMPLANTABLE PORTS • An implantable port is a catheter https://portal.pedagogyeducation.com/De with a small reservoir (port) attached mo/Content/106/2.aspx to it 183 • Ports are similar to tunneled catheters in many ways, however, they are entirely placed under the skin with the catheter portion of the port is tunneled from the reservoir site on the chest to the neck or upper chest where it enters into the central veins much like a tunneled catheter CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS • Implantable ports are sometimes called port-a-caths, subcutaneous ports, mediport, powerport or smart port • Ports consist of : o Portal body ⮚ Houses the reservoir ⮚ Has bumps that can be palpated under the skin o Septum (diaphragm) ⮚ Made of self-sealing silicone and is located in the center of the port body over the reservoir ⮚ Punctured through the skin to access the port 184 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS • Ports consist of : o Catheter ⮚ Inserted into the vein and attached to the portal body o Huber needle ⮚ A special non-coring needle used to access the port under the skin 185 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS HUBER NEEDLE IMPLANTABLE SEPTUM PORT PALPATION BUMPS https://www.ciamedical.com/cr-bard- CATHETER 0652010-case-powerloc-safety- CONNECTOR infusion-set-without-y-injection-site- 20-gauge-x-1-20-cs CENTRAL VENOUS CATHETERIZATION 186

IMPLANTABLE PORTS • Implantable ports allow for repeated intravenous access • without the need of peripheral IVs The insertion of a port allows a patient to have minimal body image change owing to the implanted nature of the device • with minimal visibly Physical activity is not impaired with ports; swimming is • allowed when the port is not accessed The disadvantages of ports include some anxiety and discomfort associated when port is accessed with a Huber • needle Ports have a minimal maintenance when not in use; monthly flushing is all that is recommended to maintain patency 187 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS 188 TYPES OF IMPLANTABLE P•OSRiTnSgle lumen port o A port with 1 access point o Most people will get a single lumen port • Double lumen port o A port with 2 access points o You can put a needle in each access point. o Two ports are helpful if you need to get more than one medication at the same time CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS TYPES OF IMPLANTABLE P•OPRoTwS er-injectable ports o Power-injectable ports are made to be used during imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), to allow for high speed injections (shots) of contrast 189 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORT INSERTION 190

IMPLANTABLE PORTS A. PRE-PROCEDURE PREPARATION • Bleeding Risk o INR : Correct to 1.5 o Low molecular weight Heparin: Hold 1 dose prior to procedure o Clopidogrel : Hold for 5 days o Aspirin : Do not hold o Platelet : Transfuse if < 50,000 191 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS B. GATHER SUPPLIES •• Sterile drape Sterile gown, cap, • Implantable port kit gloves and mask o Port ••• Chlorhexidine o Puncture Needle (21G) Sterile dressing o Introducer needle Ultrasound machine o Guidewire with probe o 5 Fr sheath with Dilator •• Fluoroscopy o Central catheter Heparinized saline o Metal tunneler o Anesthetic o Scalpel 192 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS C. PATIENT PREPARATION • Patients should be positioned supine; the neck may be turned away from the side of vein puncture • Prepare the upper portion of the chest and neck in a sterile fashion using the sterile solution, sterile gauze, • and sterile drapes Place sterile probe cover on the ultrasound probe • Use your finger to snug the probe cover against the probe, removing any folds and air bubbles 193 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS D. ACCESS • Re-identify vein using ultrasound • Infiltrate the skin with 1% lidocaine for local anesthesia around the site of the needle insertion • Using the scalpel, create small nick at insertion site • Insert the introducer needle under ultrasound guidance • Advance the guide wire with fluoroscopy. Deep inspiration • and breath hold may help access IVC Secure wire; flow switch can be used 194 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS E. CREATE PORT POCKET • Infraclavicular region a few centimeters below the clavicle. Some operators use 2 to 4 finger breadths below clavicle ⮚ Ideal port pockets have reservoir positioned over 2nd • anterior rib without interaction with mammary tissue Anesthetize pocket and planned tunnel with 1% lidocaine with epinephrine. • Make incision long enough to allow insertion of the port 195 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS 196 E. CREATE PORT POCKET • Dissect port pocket by blunt dissection with a Kelly hemostat and small retractors or simply with the operator’s finger IDEAL POCKET: ⮚ Large enough to allow the easy port insertion ⮚ Incision can be closed without tension on the skin ⮚ Incision does not overlie the diaphragm of the port reservoir CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS F. ASSEMBLE CHEST PORT • Connect catheter to reservoir stem • Connector/locking ring slides over catheter to secure catheter to port reservoir stem • Test junction of the port reservoir and catheter by accessing the port with a Huber needle, flushing the catheter, and pinching off the distal end of the catheter to challenge the catheter/port junction (confirming absence of a leak) • Attach tunneler to catheter tip 197 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS G. INSERT CHEST PORT AND TUNNEL ••• Place port into pocket Tunnel catheter over clavicle to neck venous entry site Cut catheter to desired length H. INSERT CATHETER • • Remove micropuncture sheath • Dilate tract if needed • Place peel-away sheath • Remove wire and inner dilator Advance catheter through sheath and remove peel-away 198 CENTRAL VENOUS CATHETERIZATION

IMPLANTABLE PORTS I. CLOSE POCKET • Confirm final position with fluoroscopy • Confirm function/patency with aspiration of blood followed by flushing with normal saline; use Huber needle • Lock with 5 mL heparin 100 U/mL • Close pocket with sutures • Approximate skin edges with steri-strips or glue • Close venous entry site with glue 199 CENTRAL VENOUS CATHETERIZATION

ACCESSING AND DE- ACCESSING IMPLANTABLE PORTS 200