VASCULAR ACCESS DEVICES

HOW TO ACCESS A PORT You will need: • Needless Connector • 90 degree, Non-Coring Port • Port Access Kit needle or PowerLoc needle o Sterile gloves for PowerPort o CHG cleanser o Central line dressing • Sterile Normal Saline • Syringe for flushing kit • o Skin protectant A Biopatch • Masks for yourself and the patient 201 CENTRAL VENOUS CATHETERIZATION

HOW TO ACCESS A PORT 1. Explain the procedure to the patient. Ask the patient if they use a particular needle size or if they have a PowerPort 2. Perform hand hygiene and apply clean gloves 3. Locate and palpate the port 4. Place a mask on the patient and nurse 5. Perform hand hygiene again 6. Open the sterile port access kit and PALPATE PORT create a sterile field. Add your non- coring needle, Biopatch, and sterile 10cc https://www.elsevier.com/__data/asse syringe to the field ts/pdf_file/0018/271062/ch0084.pdf 7. Apply sterile gloves 202 CENTRAL VENOUS CATHETERIZATION

HOW TO ACCESS A PORT 8. Attach the flush to the non-coring needle and purge the 203 air by priming the line until you see the saline drip from the needle tip 9. Scrub the site clean with CHG from the kit using a back and forth/up and down motion for the amount of time indicated on the directions, typically 30 seconds to 1 minute in each direction 10. Allow the antiseptic to dry on the skin 11. Stabilize the port with the index finger and thumb of your non-dominant hand 12. You may apply anesthetic cream to numb the skin CENTRAL VENOUS CATHETERIZATION

HOW TO ACCESS A PORT 13. With the needle at a 90 degree https://veins.wales/information/portacath/ angle from the skin, insert the needle into the center of the portal chamber until you feel the needle hit resistance at the back of the chamber 14. Aspirate the syringe to assess for blood return and verify placement 15. Once blood return is verified, flush the tubing and clamp. Connect the needleless connector 16. Apply the Biopatch around the needle with the blue side up 204 CENTRAL VENOUS CATHETERIZATION

HOW TO ACCESS A PORT 17. Apply skin protectant around the site 18. Cover the entire site with a transparent dressing. All sides should be occlusive. If patients have sensitivity to Tegaderm, Opsite may be used 19. Label the site with date, time, and nurse’s initials 20. Re-access the site and change the dressing according to hospital policy 205 CENTRAL VENOUS CATHETERIZATION

HOW TO DEACCESS A PORT 1. Use clean non-sterile gloves when deaccessing a port 206 2. Flush catheter with 0.9% sodium chloride to clear it of blood, IV solution, or medication 3. Because of potential resistance, the port should be stabilized in place with gloved, non-dominant hand during needle removal 4. To reduce the potential for blood backflow into the catheter tip of a port, after clamping the infusion set and stabilizing the port, the non-coring needle should be removed slowly straight upward by the clinician 5. After needle removal, apply a small sterile dressing over the site for approximately one hour CENTRAL VENOUS CATHETERIZATION

FLUSHING AND LOCKING OF IMPLANTABLE PORTS 207

FLUSHING OF PORT 1. Flushing is recommended to https://fineartamerica.com/featured/1- promote and maintain patency flushing-implanted-port-science-photo- and prevent the mixing of library.html?product=metal-print incompatible medications and solutions 208 2. Sterile 0.9% sodium chloride for injection should be used by clinicians to flush a port unless the manufacturer recommends flushing with heparin sodium solution CENTRAL VENOUS CATHETERIZATION

FLUSHING OF PORT 209 3. Ports should be flushed by clinicians immediately: • After placement • Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection • Prior to and after blood drawing 4. The flush solution and flushing intervals should be documented by the clinician in the patient record CENTRAL VENOUS CATHETERIZATION

LOCKING OF PORT 1. Locking involves instilling a solution to prevent occlusion 210 when the device is not in use. • Heparinized saline has been used primarily due to the antithrombotic properties of heparin • However, complications such as heparin-induced thrombocytopenia (HIT), altered coagulation studies and bleeding have been reported, particularly if other general anticoagulant therapy is administered • Additionally, heparin is incompatible with certain substances in solution e.g. gentamicin sulphate CENTRAL VENOUS CATHETERIZATION

LOCKING OF PORT 1. Locking involves instilling a solution to prevent occlusion when the device is not in use. • Until there is further evidence, clinicians should use 5 mL of sterile heparinized saline (10 Units in 1mL) to lock a port that is no longer used for continuous infusions in preparation for future use; unless the manufacturer recommends catheter lumens be locked with an alternate solution 211 CENTRAL VENOUS CATHETERIZATION

LOCKING OF PORT 2. Ports not being accessed should be flushed and locked every four weeks by a clinician 3. Some CVCs integrate valve technology which restricts blood backflow and air embolism by remaining closed when not in use therefore eliminating the need for heparin flushing to maintain patency 212 CENTRAL VENOUS CATHETERIZATION

VASCULAR ACCESS DEVICE DURATION DEVICE Epic3 GUIDANCE MAGIC STUDY PIVC Up to 7 to 10 Michigan Appropriateness MIDLINE days Guide for Intravenous PICC 1 to 4 weeks Catheters NON-TUNNELLED 4 weeks to 6 CVAD months Up to 5 days TUNNELLED CVAD Up to 7 to 10 6 to 14 days IMPLANTED PORT days More than 6 days Months or years Up to 14 days Months or years More than 15 days More than 30 days https://www.nursingtimes.net/clinical-archive/infection-control/vessel-health-and-preservation-1-minimising-the-risks-of- 213 vascular-access-30-04-2020/ CENTRAL VENOUS CATHETERIZATION

PROS AND CONS OF CVADs NON PICC TUNNELLED PORT TUNNELLED Insertion No No Yes Yes under general anesthetic How long will Days to Weeks to Months to Years it last? weeks months years Needle No No No Yes access Dressing Yes, changed Yes, No No, only weekly changed when in use weekly Participation No Some with Some with Most in sport caution caution Able to go No No No Yes swimming 214 CENTRAL VENOUS CATHETERIZATION

DIFFICULT INTRAVENOUS ACCESS PATHWAY AFTER 2 FAILED ATTEMPTS CHOOSE THE RIGHT DEVICE FOR PATIENT’S TREATMENT PIVC MIDLINE PICC CVC/TUNELLED VASCATH Insitu: < 12 months Insitu: 72 to 96 hours Insitu: < 4 weeks Insitu: < 6 weeks Inserted centrally via Or as clinically indicated Midline length approx. PICC trimmed to length subclavian, jugular or for removal 10-20 cm long on insertion femoral veins • Maintain PIVC if • Chest x-ray not • Chest x-ray • Chest x-ray required therapy access <7 required required (exclude femoral days • Use like PIVC • Tip terminates on CVC) • Consider MIDLINE if • Not suitable for TPN, • Tip terminates on therapy access >7 distal superior vena distal Superior vena days vesicant cava cava (exclude • DIVA PIVC may medications or • Suitable for TPN, femoral CVC) remain in situ up to Inotropes vesicant • Suitable for TPN, 7 days, must be • If Power injectable, medications and vesicant reviewed daily suitable for CT Inotropes medications and contrast Inotropes https://www.researchgate.net/figure/Difficult-intravenous-access-pathway-The-flow-diagram-illustrates-the-process- 215 of_fig3_321138707

INTRAVENOUS CANNULATION DEVICE SELECTION • Medication or solution not listed as irritant or • Medication or solution listed as irritant or vesicant vesicant (can be administered through peripheral (can’t be administered through peripheral veins) veins) • Osmolality of solution greater than 500 • Osmolality of solution less than 500 mOsm/liter mOsm/liter (TPN) (0.9%NaCl, 5% glucose) PERIPHERAL ACCESS GOOD? NO POOR IV ACCESS? Patient requires central (3 suitable sites or more) • Two suitable sites or less venous access device (CVAD) • No veins visible or palpable YES • Multiple failed cannulation EXPECTED DURATION EXPECTED DURATION attempts • DIVA Less than 7 Greater than 7 If less than 7 days Up to 3 months Greater than 3 days? days? duration, consider PICC or central line months Maintain by Between 7 days to 4 Ultrasound guided If greater than 6 intravenous weeks? weeks, consider consider tunnelled peripheral Consider midline peripheral tunnelled catheter catheter or cannula catheter or PICC intravenous cannula. or implanted port implanted port Duration greater than 4 to 6 weeks? Refer to DIVA Consider tunnelled catheter or implanted port https://www.researchgate.net/figure/Access-Vascular-Device- Decision-Tree-The-clinical-pathway-illustrates-best-choice- of_fig2_321138707

CONSIDERATIONS: 1. Does prescribed therapy requires central venous infusion: continuous vesicant chemotherapy hypertonic (osmolarity > 500 mOsm/L) extremes of pH (pH 9), TPN with >10% dextrose or >5% protein 2. Expected therapy duration 2.Age 3.Medical history 4.Vein status 5.Weight 0 to 6 days 6 to 14 10 days to 2 Months to days months years Therapy Therapy CF tune Therapy CVC can be Surgical Lines - tunnelled cuffed requires suitable for up requires replaced devices (eg central peripheral central after 10-14 venous infusion venous days with HICKMAN®, infusion ultrasound age 8yo = infusion another CVC BROVIAC® or (US) guided midline in mid if treatment Port/Portacath) CVC upper arm if duration is 2- can tolerate awake/N2O & 3 weeks Therapy No visible IV midline PICC if needs suitable for sites catheter if peripheral appropriate GA or going vein available to HITH >1 infusion Call for early hour away CVC [PICCs age>2yo = PICC line anesthetic and child are rarely or age Adequate assessment >8yo and not inserted for Or sites for IV going home treatment rotation duration ] Age>2yo, <15kg = Short term or CVC anesthetic, non peripheral IV cuffed tunneled CVC cannula or consider surgical CVC cuffed tunneled line Or US guided extended dwell or midline catheter if appropriate vein https://www.rch.org.au/uploadedFiles/Main/Content/anaes/venous_access_decision_path_Feb_2011.pd f

4 DIALYSIS VASCULAR ACCESS 218

INTRODUCTION DIALYSIS https://smart.servier.com/smart _image/dialysis/ • Dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally • Typically, dialysis is ordered when kidney function declines to 10–15% of normal function 219 DIALYSIS ACCESS DEVICE

INTRODUCTION 220 INDICATIONS: • “AEIOU” o Acid-base problems o Electrolyte problems o Intoxications o Overload, fluid o Uremic symptoms DIALYSIS ACCESS DEVICE

INTRODUCTION TYPES OF DIALYSIS • HEMODIALYSIS o In hemodialysis, the patient's blood is pumped through an artificial kidney machine (dialyzer) o Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane o The cleansed blood is then returned via the circuit back to the body 221 DIALYSIS ACCESS DEVICE

HEMODIALYSIS BLOOD BLOOD Dialysis fluid Dialysis fluid PUMP THINNER with treated waste drain ADDED TO water BLOOD Arterial side DIALYZER Venous BLOOD FROM BLOOD BACK TO ARM side ARM BUBBLE TRAP https://www.news- 222 medical.net/health/Benefits-and- DIALYSIS ACCESS DEVICE Disadvantages-of-Dialysis.aspx

INTRODUCTION • PERITONEAL DIALTYYSPISES OF DIALYSIS o In peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run through a tube into the peritoneal cavity o The abdominal body cavity around the intestine, where the peritoneal membrane acts as a partially permeable membrane o Peritoneal dialysis is carried out at home by the patient, often without help 223 DIALYSIS ACCESS DEVICE

PERITONEAL DIALYSIS SOLUTION BAG PD SYSTEM CONNECT CATHETER DRAINAGE BAG OR PERITONEAL DIALYSIS SOLUTION https://nephcure.org/peritoneal-dialysis/ 224 DIALYSIS ACCESS DEVICE

DIALYSIS ACCESS DEVICES 225

DIALYSIS ACCESS DEVICES There are 3 types of dialysis vascular access: • Arteriovenous (AV) graft • Arteriovenous (AV) fistula • Central venous catheter (CVC) 226 DIALYSIS ACCESS DEVICE

DIALYSIS ACCESS DEVICES 227 These accesses can also be categorized as “Temporary” & “Permanent” Vascular Accesses. • TEMPORARY o Internal Jugular Access (a type of CVC) o Femoral Access (a type of CVC) o Permanent Catheter (a type of CVC) • PERMANENT o Arteriovenous (AV) fistula o Arteriovenous (AV) graft DIALYSIS ACCESS DEVICE

PERMANENT DIALYSIS ACCESS DEVICES 228

ARTERIOVENOUS FISTULA • An AV fistula is a connection, made by https://www.bmj.com/content/349/bmj.g6 a vascular surgeon, of an artery to a 262 vein 229 • This creates a large robust blood vessel that can be needled regularly for use during hemodialysis • Kidney and hemodialysis experts, including consider the fistula the “gold standard” access choice DIALYSIS ACCESS DEVICE

ARTERIOVENOUS FISTULA • A fistula is usually created in the non-dominant hand • Some people may not be able to have a fistula created due to weak arteries, veins or other medical conditions • An AV fistula frequently requires 2 to 3 months to develop, or mature, before the patient can use it for hemodialysis • If an AV fistula does not mature, an AV graft is the second choice for a long-lasting vascular access 230 DIALYSIS ACCESS DEVICE

ARTERIOVENOUS FISTULA Why the AV Fistula is considered the “gold standard” access? • It a lower risk of infections than other access types • It has a lower risk of forming clots than other access types • It allows for greater blood flow • It lasts longer than the other access types • It can last many years, even decades with proper care 231 DIALYSIS ACCESS DEVICE

ARTERIOVENOUS FISTULA Disadvantages of Arteriovenous fistula? https://www.sunwaymedical.com/blogpo st/arteriovenous-fistula • The appearance of bulging veins at the access site • Taking several months for a new one to mature • Maturation may be delayed, or it may fail to mature • Needles are required to access the AV fistula for hemodialysis 232 DIALYSIS ACCESS DEVICE

ARTERIOVENOUS FISTULA SITES BRACHIOCEPHALIC VEIN CEPHALIC VEIN BRACHIAL ARTERY BASILIC VEIN RADIAL ARTERY 233 DIALYSIS ACCESS DEVICE

ARTERIOVENOUS FISTULA SITES RADIOCEPHALIC BRACHIOCEPHALIC TRANSPOSITION FISTUcLrAeated by FISTUcLrAeated by BRACHIOBASILIC BasFilIiScTvUeLinA is anastomosing the anastomosing the transposed into a more cephalic vein to the https://docctoer.fpsehtyat.cloicm/avreteirniovtenooutsh-fiestula/ superficial and latera2l34 radial artery brachial artery

ARTERIOVENOUS GRAFT • The AV graft is similar to a fistula, in that it is also an under-the-skin connection of an artery and vein, except that with a graft, a biologic or prosthetic tubing connects the artery and vein • A soft, plastic-like tube, about one-half inch in diameter and is made from a type of Teflon or Gore-Tex material is used for prosthetic graft • Donated cadaver arteries or veins can also be used as biologic graft https://cjasn.asnjournals.org/content/10/1 2/2255 235 DIALYSIS ACCESS DEVICE

ARTERIOVENOUS GRAFT ADVANTAGES • Grafts do not require as much time to mature as fistulas. It may be ready for use in days to 3 to 4 weeks • An AV graft provides a solution for small or weak veins DISA•DVBAeNcTaAusGeEgSrafts are created from materials outside of the body, they tend to have more problems than fistulas due to clotting and infections • Grafts may not last as long as a fistula and could need to be repaired or replaced each year 236 DIALYSIS ACCESS DEVICE

DIALYSIS NEEDLES 237

DIALYSIS NEEDLE TYPES METAL NEEDLE PLASTIC NEEDLE PLASTIC CANNULA BEVEL WINGS INTRODUCER NEEDLE Red and black markers on hub show the exact position of the bevel at first glance SHAFT BACK EYE https://www.researchgate.net/fi DIALYSIS ACCESS DEVICE https://www.researchgate.net/fi gure/Features-of-plastic- cannulae-Picture-with-the- gure/Features-of-plastic- courtesy-of-Nipro-Europe- NV_fig2_305488959 cannulae-Picture-with-the- 238 courtesy-of-Nipro-Europe-

DIALYSIS NEEDLE TYPE 239 • METAL NEEDLES o Metal needles are made of stainless steel, and are either sharp or blunt ⮚ UsSeHdAfoRrPthe rope ladder technique, have a sharp cutting edge BLUNT ⮚ Designed for the buttonhole technique, are rounded on top and do not have a sharp edge. DIALYSIS ACCESS DEVICE

DIALYSIS NEEDLE TYPE • PLASTIC NEEDLES (fistula cannula, fistula catheter) o The basic design is a sharp metal needle housed within a flexible plastic sheath o The metal needle is used to access an AVF and to also guide the insertion of the plastic sheath into the vessel o After the sheath is deployed into the vessel, the metal needle is removed, and only the flexible blunt sheath is left within the vessel o Plastic fistula cannulas/catheters may allow patients greater mobility with a decreased risk for infiltration due to the blunt and flexible lumen that lies within the vessel 240 DIALYSIS ACCESS DEVICE

DIALYSIS NEEDLE GAUGE • Small gauge needles (17G) are recommended for at least the first few cannulations of a new fistula • Thereafter, the gauge can be BLOOD FLOW RECOMMENDE increased incrementally as the RATE D NEEDLE fistula matures, and if prior GAUGE cannulations have gone smoothly <300 ml/min 17 gauge 300-350 16 gauge • Except for the initial cannulation, ml/min most guidelines do not >350-450 15 gauge recommend a specific gauge, but ml/min 14 gauge rather that the needle gauge match the blood flow rate >450 ml/min 241 DIALYSIS ACCESS DEVICE

BACK EYE • The arterial needle should always have a back eye to maximize flow from the access • Back eye prevents suction of the needle to the inner vessel wall and reduces the need for rotating the needle • Needle with back eye can be used as arterial and venous needle • Non-back eye needle is for venous use only 242 DIALYSIS ACCESS DEVICE

PLACEMENT OF NEEDLES • 4 – 5 cm (1.5 to 2 inches) apart, hub to hub, if needles are in the same direction • 2.5 cm ( 1 inch) apart, hub to hub, if needles in opposite direction • Insertion site, or needle tip, once inserted, 4 cm (1.5 inch) away from the anastomosis 243 DIALYSIS ACCESS DEVICE

NEEDLE DIRECTION • The venous needle should be inserted in the direction of blood flow. • •The arterial needle can point in the two directions. ANTEGRADE cannulation: the arterial needle points to direction of blood flow • RETROGRADE cannulation: the needle points to the arteriovenous anastomosis. 244 DIALYSIS ACCESS DEVICE

CANNULATION TECHNIQUE 245

CANNULATION TECHNIQUE 246 • ROPE LADDER PUNCTURE (Rotating sites) o This describes the systematic use of the entire length of the vessel o Each needle is inserted at approximately 2 cm above the last site and back again, resulting in a uniform use of the vessel o This has demonstrated less aneurysm formation as the punctures per area are reduced o However, care must be taken to ensure that an area puncture technique is not undertaken in the belief that the nurse is following the rope ladder technique DIALYSIS ACCESS DEVICE

CANNULATION TECHNIQUE 247 • ROPE LADDER PUNCTURE (Rotating sites) DISADVANTAGE: o Small dilatations over the whole fistula o Concerns of “one-site-it is” (causes aneurysm and stenosis formation) ADVANTAGE: o Low rate of infection o Help expand the lifespan of the fistula o Changing cannulation site gives the previous needle site time to heal and decrease the chance of formation of aneurysm DIALYSIS ACCESS DEVICE

CANNULATION TECHNIQUE 248 • AREA PUNCTURE o This describes the development and use of one or two areas of the fistula that are regularly used o This may result in increased aneurysm formation related to the number of repeated punctures over a small area causing increased tissue elongation and aneurysm formation o As a consequence of the increased risk of long term damage to the vascular system, area puncture is not advocated DIALYSIS ACCESS DEVICE

CANNULATION TECHNIQUE 249 • BUTTONHOLE PUNCTURE o This describes the repeated puncture of exactly the same site at exactly the same angle into exactly the same hole each dialysis o Over time cylindrical scar tissue develops, guiding the needle into the right place. (about 10 cannulations) o Buttonhole cannulation has also been associated with less pain associated with cannulation, and a reduction in hemostasis post dialysis DIALYSIS ACCESS DEVICE

CANNULATION TECHNIQUE 250 • BUTTONHOLE PUNCTURE ADVANTAGES: o May prolong AVF lifespan o Reduce needling attempts o Reduces pain o Reduces bleeding and hematoma o Reduces infiltration o Reduces aneurysm formation o Promotes self-care and self-dialysis o Use of blunt needles after a buttonhole is created require no safety device DIALYSIS ACCESS DEVICE