VASCULAR ACCESS DEVICES

COMPLICATIONS 4. OCCLUSION • Occlusion occurs when fluid or medication cannot enter the vein • S/SX: The IV flow is interrupted and blood may be backed up in the tubing or heparin or saline lock • TREATMENT: flush with mild pressure. If the catheter does not flush with mild flush, do not force it. Remove the IV and start a new one in a new site 51

COMPLICATIONS 5. VEIN IRRITATION • S/SX: pain at the site, possible blanching, red skin over the vein during infusion, and quickly developing signs of phlebitis • CAUSE: occurs due to solutions with high or low pH and high osmolarity (such as potassium chloride, phenytoin, vancomycin, erythromycin, and nafcillin) • TREATMENT: decreasing the flow rate and diluting the infusions 52

COMPLICATIONS 6. THROMBOSIS • S/SX: The vein will appear painful, red and swollen. The IV infusate will not run quickly • CAUSE: Thrombosis occurs when the platelets adhere to the tunica intima of the vein due to vessel injury during venipuncture • TREATMENT: Remove the IV catheter and restart the IV in the opposite arm if at all possible. Warm soaks can also be applied 53

COMPLICATIONS 7. CIRCULATORY OVERLOAD • S/SX: The patient may be anxious, experience respiratory distress, crackles in the lung bases, increased blood pressure and neck engorgement • CAUSE: Occur when the IV roller clamp is loosened and the infusate is allowed to run into the vein quickly • TREATMENT: Treatment includes raising the head of the bed, administering oxygen and IV furosemide as ordered, and prompt notification of the physician 54

COMPLICATIONS 8. INFECTION • S/SX: Localized infection : may include erythema, exudate, warmth at the site, induration, pain, palpable venous cord, or venous thrombosis Systemic infection : may include malaise, fever, headache, tachycardia, nausea, vomiting, and chills https://www.havedummy.co m/iv-therapy-after-the-battle/ 55

COMPLICATIONS 8. INFECTION • CAUSE: Localized infection, systemic infection or bacteremia can occur as a result of phlebitis, poor taping that allows the venipuncture device to move in and out of the vein, prolonged dwell time of the catheter, and failure to maintain aseptic technique during insertion or site care • TREATMENT: Treatment includes contacting the physician, culturing the site and device, administering antibiotics and hemodynamic support 56

COMPLICATIONS 9. AIR EMBOLISM • S/SX : Respiratory distress, unequal breath sounds, a weak pulse, increased central venous pressure, decreased blood pressure, and loss of consciousness • CAUSE: Air embolism occurs when the solution container runs empty and the added container pushes air down the line into the patient • TREATMENT: Discontinue the infusion, place the patient in Trendelenburg, administer oxygen, and notify the physician 57

2. MIDLINE PERIPHERAL CATHETERIZATION 58

DEFINITION • A midline catheter is a vascular access device intended for placement into a peripheral vein in the upper arm; basilic, cephalic, or one of the two brachial veins, with the internal tip located level at or near the level of the axilla and distal to the shoulder • Standard midlines can range from 10 to 20 centimeters in length and can have a single lumen or double lumen • Midlines are 3 to 5 French in diameter https://edu.cdhb.health.nz/Hospitals- Services/Health-Professionals/CDHB- Policies/Fluid-Medication- Manual/Documents/Midline-Catheter.pdf 59

INDICATION Midline use is clinically appropriate as follows: • Unable to obtain Peripheral IV • Extended therapy requiring 29 days of IV access • Exhausted or diminished lower arm Access Insertion Sites • Dehydration or poor peripheral venous volume Midlines uses vary and are very effective and efficient in bridging the gap between an IV and a central line such as a PICC. 60

CONTRAINDICATION • Therapies not appropriate include continuous vesicant chemotherapy, parenteral nutrition medications /solutions with pH less than 5 or greater than 9 and a final osmolarity of less than 600 mOsm/L o The pH and osmolarity outside these parameters increase the risk for complications like phlebitis and thrombosis • Midline catheters should not be placed in extremities affected by mastectomy with lymphedema, paralysis, or dialysis grafts and fistulas 61

CONTRAINDICATION • When using a double-lumen midline catheter, do not administer incompatible drugs simultaneously administered through both lumens because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein • Tourniquets or blood pressure cuffs must not be used on the arm where the Midline is indwelling 62

SITES OF INSERTION Basilic vein Cephalic vein Brachial vein Nursing Standard https://journals.rcni.com/nursing- standard/how-to-undertake- venepuncture-to-obtain-venous-blood- samples-ns.2018.e10531 63

SITES OF INSERTION • The basilic and brachial are preferred over the cephalic vein as their higher flow ensures lower complication rates. Basilic vein also has larger diameter and straighter path • Avoid the cephalic vein as flow rate is usually lower, and it gets narrower proximally • Avoid the cubital fossa as catheters inserted here are associated with higher infection and thrombosis rates due • to friction with movement The ideal insertion site is proximal enough to the elbow to ensure easy elbow flexion distal enough form the axilla to ensure an 8 or 12 cm midline will not cross the axilla 64

MIDLINE CATHETER Arrow CG+ 15 cm Midline Catheter https://www.teleflexvascular.com/pro ducts/cdc-41552-mpk1a Bard PowerGlide 20g x 10 cm Midline Catheter Midline IV Catheter https://rebelem.com/midline-iv- catheters/ PowerGlide Pro Midline Catheter 65 https://www.bd.com/en- us/products-and- solutions/products/product- page.f122088pt

MIDLINE CATHETER Needle hold Finger Securement rest wings Forward Insertion wings lever Bullpup Midline Catheter https://bullpupscientific.com/the- 66 solution/

MIDLINE CATHETER INSERTION 67

MIDLINE CATHETER INSERTION A. GATHER EQUIPMENT • •Catheter-insertion kit • •Midline catheter of choice 30-mL vial of normal saline • Single-use tourniquet Needleless connector with/without • •Sterile and nonsterile measuring tape short extension tubing • •Waterproof underpad/linen saver syringes • •Mask Gauze • •sterile gloves Sterile, transparent, dressing • Sterile drapes and towels Bedside ultrasound machine with • •Antiseptic solution (e.g., 2% vascular probe Sterile ultrasound probe cover •chlorhexidine–based preparation) Sterile ultrasound gel • •10-ml vial of heparin Catheter securement device 68 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION B. POSITION AND ATTACH MONITORING • Position with chosen arm outstretched on arm board • Locate the ultrasound machine to ensure a good view of the screen • Attach monitoring if sedation is being used https://www.acepnow.com/article/10-tips-ultrasound- guided-peripheral-venous- access/?singlepage=1&theme=print-friendly 69 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION C. PERFORM A BILATERAL ULTRASOUND ARM SCAN IDENTIFYING ANATOMY • Apply the tourniquet • Scan BOTH arms and identify the basilic vein, the brachial veins (usually paired and on either side of the brachial artery) and the median nerve on each arm https://www.rch.org.au/uploadedFiles/Main/Con tent/anaes/a_procedural_guide_to_midline_ins ertion.pdf 70 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION D. CHOOSE THE BEST VEIN AND INSERTION SITE • Chose the largest vein, ensuring it is far enough from the brachial artery to avoid it. • The best vein is usually the basilic vein • Marking the puncture site with the needle hub is recommended • Release the tourniquet until the sterile set up on the chosen arm is undertaken. 71 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION E. BARRIER PRECAUTIONS https://www.istockphoto.com/s earch/2/image?phrase=ppe+go • Wear sterile gown, and mask, one minute wn hand scrub sterile gloves • Prep the whole upper arm for 30 seconds with alcoholic chlorhexidine • Apply large fenestrated drape covering arm and upper body • Insert ultrasound probe into the sterile cover 72 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION F. PERFORM REAL-TIME ULTRASOUND GUIDED VENIPUNCTURE • Re-apply the tourniquet to distend the vein • To avoid any painful sensation during midline insertion, skin should be infiltrated with local anesthetic using ultrasound guidance. Small amount of anesthetic is recommended to prevent vein constriction • With ultrasound guidance and the vein in a short axis view, transfix the vein with the introducer needle or a 22 gauge needle until a flush of venous blood is obtained 73 MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION 74 G. PERFORM THE MODIFIED SELDINGER TECHNIQUE • A modified Seldinger technique entails advancing a fine catheter over a needle into the vessel and withdrawing the needle • The fine catheter rather than the needle can then be used as a conduit for inserting the guide wire MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION 75 G. PERFORM THE MODIFIED SELDINGER TECHNIQUE • Insert the guidewire at least 10 cm into the microintroducer needle, not to exceed a position beyond the axillary line • Rescan to ensure the wire and cannula are in the correct vein • Remove the cannula leaving the wire insitu and remove the tourniquet MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION 76 G. PERFORM THE MODIFIED SELDINGER TECHNIQUE • Make a small superficial incision at the entry point of the wire to facilitate the passage of the line • Slowly insert the peelable sheath introducer using a rotating motion while slowly withdrawing the wire • Once wire is withdrawn, remove dilator from the peelable sheath and insert the distal tip of the catheter through the sheath until catheter tip is correctly positioned in the target vein MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION 77 H. SECURE THE MIDLINE CATHETER • Attach syringe to extension and open clamp. Blood should be aspirated easily • Once adequate aspiration has been achieved, lumen should be irrigated with saline. Do the same on the second lumen • Proceed to remove the tear away sheath by slowly pulling it out of the vessel while simultaneously splitting the sheath by grasping the tabs and pulling them apart MIDLINE PERIPHERAL CATHETERIZATION

MIDLINE CATHETER INSERTION I. DRESSING • Secure the catheter at the insertion site by applying an alternate catheter securement device • Apply a chlorhexidine impregnated gel dressing or sponge to the site • Cover the area with a large Tegaderm or any sterile, transparent, occlusive dressing https://multimedia.3m.com/mws/media/447983 78 O/tegaderm-transparent-film-dressing- brochure.pdf MIDLINE PERIPHERAL CATHETERIZATION

PATIENT MONITORING AND CARE 79

MONITORING AND CARE 80 A. Observe the dressing and insertion site every 30 minutes for the first 4 hours after insertion. B. Assess the insertion site and upper extremity every shift for signs and symptoms of phlebitis, thrombophlebitis, or infiltration. Tangent Medical https://twitter.com/TangentMedical MIDLINE PERIPHERAL CATHETERIZATION

MONITORING AND CARE 81 C. Assess the catheter for venous blood return and patency before initiating infusions. • Connect a 10-mL syringe filled with 10 mL of normal saline to the extension tubing Do not use a syringe smaller than 10 ml to flush and confirm • patency Release the clamp and aspirate slowly to verify blood return • Flush with 10 mL of NS (with a push/pause technique) and then administer the infusion MIDLINE PERIPHERAL CATHETERIZATION

MONITORING AND CARE 82 D. Assess the catheter for dislodgement or migration by measuring the length of the external catheter. E. If there was insertional bleeding, the initial dressing should be left in place for 24 hours. After this: • Transparent, semipermeable dressings should be changed at least weekly • Sterile gauze dressings should be changed every 48 hours • Dressings should be changed if they become damp, loosened, or visibly soiled MIDLINE PERIPHERAL CATHETERIZATION

MONITORING AND CARE F. Monitor the insertion site and the patient for signs and symptoms of local or systemic infection. G. Avoid measuring blood pressure, performing venipuncture, or administering injections in the extremity with a midline catheter. Consider placing a sign at the patient's bedside to alert clinicians to avoid use of the extremity with the midline catheter. H. Follow institutional standards for assessing pain. Administer analgesia as prescribed. 83 MIDLINE PERIPHERAL CATHETERIZATION

3. CENTRAL VENOUS CATHETERIZATION 84

DEFINITION 85 • In central venous catheterization, a thin, flexible tube is inserted into a vein, and guided ( threaded) into a large vein above the right side of the heart called superior vena cava • The catheter can remain in place either temporarily (days) or long- term (weeks to years) so that it can be easily and repeatedly accessed over the necessary period of time without the need for repeat skin punctures to the patient CENTRAL VENOUS CATHETERIZATION

DEFINITION • Central lines are classified as either centrally- inserted where the skin entry point is on the trunk of the patient or peripherally- inserted where the line is inserted through the limb vein 86 CENTRAL VENOUS CATHETERIZATION

INDICATION A central line would be considered with: 87 • Difficult peripheral venous access • Parenteral nutrition • Medications that would be incompatible through a single lumen • Multiple infusion of fluids, medications or chemotherapy • Temporary access for hemodialysis • Solutions that are hypertonic or cannot be given peripherally for other reasons • Invasive monitoring • Long term access CENTRAL VENOUS CATHETERIZATION

CONTRAINDICATION • Uncooperative patient and those who are unable to tolerate Trendelenburg positioning • Coagulopathy • Infection over site of insertion • Distortion of anatomic landmarks • Pneumothorax or hemothorax on the collateral side • Positive end-expiratory pressure mechanical ventilation • Only one functioning lung 88 CENTRAL VENOUS CATHETERIZATION

CENTRAL LINE CATHETER DEPTH MARKINGS DISTAL TIP PROXIMAL CATHETER JUNCTURE HUB LUMEN MEDIAL LUMEN SLIDE CLAMP DISTAL LUMEN SUBPNG: MEDICINE CARTOON LUER CONNECTOR TRANSPARENT INJECTION CAP https://www.subpng.com/png- wy62s1/ CENTRAL VENOUS CATHETERIZATION 89

CENTRAL LINE CATHETER • There may be a single or multiple lumens on a central line (1 to 5 in number) • Each lumen of a multiple lumen catheter will open at a certain point along the catheter length and is named according to this position PROXIMAL LUMEN EXIT MEDIAL LUMEN PROXIMAL EXIT LUMEN DISTAL LUMEN MEDIAL LUMEN EXIT DISTAL LUMEN 90 CENTRAL VENOUS CATHETERIZATION

CENTRAL LINE CATHETER CROSS SECTION OF CATHETER LUMEN SINGLE DOUBLE TRIPLE QUAD LUMEN LUMEN LUMEN LUMEN D https://www.pinterest.ph/ pin/242209286182486372/ 91 CENTRAL VENOUS CATHETERIZATION

SITES OF INSERTION SUBCLAVIAN INTERNALJUGU VEIN LAR VEIN PERIPHERAL SUPERIOR VENA VEIN (basilic) CAVA FEMORAL VEIN RESEARCH GATE 92 https://www.researchgate.net/figure/Cent ral-venous-access-sites_fig1_334584348 CENTRAL VENOUS CATHETERIZATION

SITES OF INSERTION SUBCLAVIAPNRVOESIN CONS • Not compressible ( worst central insertion site if increased hemorrhage risk) • Subclavian artery injury • Most suitable long-term • Greatest risk of site to lower infection risk pneumothorax • Subclavian stenosis may • Easy to dress and maintain limit options for creation of dialysis fistula • Potential for thoracic duct injury 93 CENTRAL VENOUS CATHETERIZATION

SITES OF INSERTION JUGULAR VPERINOS CONS • Compressible • Infection rate higher than • Less risk of subclavian pneumothorax than • Carotid artery injury subclavian • Potential for thoracic duct • Preferred site for pulmonary artery injury (on left side) catheters • Difficult to dress and maintain (Especially when tracheostomy is present) • Patient discomfort due to decreased neck mobility 94 CENTRAL VENOUS CATHETERIZATION

SITES OF INSERTION FEMORAL VEPRINOS CONS • Compressible • Infection rate highest of the • NO risk of pneumothorax central insertion sites of other thoracic injury • Mobility is restricted and • Easier to place if patient agitated or restless behavior cannot tolerate being compromises line head-down • IVC filters may become entangled with cannula • Potential injury to femoral artery and peritoneal structures • Thrombosis and phlebitis risk • Difficult to dress and maintain 95 CENTRAL VENOUS CATHETERIZATION

SITES OF INSERTION PERIPHERBAALSVILEIICN CEPHALIC • Insertion via the cephalic vein is more difficult than the basilic vein due to the sharp turns • Generally easier to made by the vein as it divides advance the catheter by into clavipectoral fascia and at this route than by the its junction with the axillary vein cephalic vein • There are valves in the cephalic system near its termination at the axillary vein • There is a greater risk of phlebitis than the basilic vein 96 CENTRAL VENOUS CATHETERIZATION

CENTRAL VASCULAR ACCESS DEVICES 97

TYPES OF CENTRAL VENOUS ACCESS DEVICES 1. Non-tunneled central catheter 2. Peripherally-inserted central catheter 3. Tunneled central catheter 4. Implantable ports 98 CENTRAL VENOUS CATHETERIZATION

CENTRAL VENOUS ACCESS DEVICE CONSIDERATIONS IN CHOOSING CVAD Therapeutic purpose Infusates/medications requiring central venous access include: • Continuous vesicant chemotherapy • Hypertonic solutions (osmolarity > 500 mOsm/L) • Extremes of pH (pH <5, >9) • TPN Estimated length of Any patient requiring more than 7 days treatment of intravenous therapy should be assessed for insertion of CVAD Medical history Including any cardiac anomalies, hematological disorders, and previous history of line complications (such as 99 thrombosis). CENTRAL VENOUS CATHETERIZATION

CENTRAL VENOUS ACCESS DEVICE CONSIDERATIONS IN CHOOSING CVAD Vein status Difficult peripheral IV access should be a flag for early insertion of a CVAD Patient weight and size PICC insertion is technically difficult and has a high failure rate in patients < 15kg or 2 years old Urgency of venous access 100 CENTRAL VENOUS CATHETERIZATION