Central venous access devices all you need to know

Central venous access devices

1. Central Venous Access Devices By Dr. Mohamed Ramadan

2. DEFINITION: A central venous access device is defined as a catheter placed into a thoracic central vein (e.g., superior vena cava, brachiocephalic vein, subclavian vein, internal jugular vein) or the iliocaval venous system (e.g., inferior vena cava, iliac vein, common femoral vein)

3. INDICATIONS: Inadequate peripheral venous access: Unable to obtain peripheral access or complex infusion regimen Peripherally incompatible infusions: Medications such as vasopressors, hyperosmolar solutions, chemotherapy agents, and TPN are typically administered into a central vein, as they can cause vein inflammation (phlebitis) when given through a peripheral intravenous catheter.

4. Hemodynamic monitoring: Central venous access permits measurement of central venous pressure, venous oxyhemoglobin saturation (ScvO 2 ), and cardiac parameters (via pulmonary artery catheter).

5. Extracorporeal therapies: Renal replacement therapy (i.e., hemodialysis, hemofiltration), plasmapheresis, and extracorporeal membrane oxygenation. Large-bore venous access to support the high-volume flow.

6. TYPES OF CENTRAL VENOUS CATHETERS: A variety of central venous access devices are available, each with its own risks and benefits. Central venous access devices are generally classified based on duration of catheter use (i.e., dwell time; short-term, mid-term, long-term), location of insertion (e.g., jugular, brachial), number of lumens (i.e., single, double, triple), as well as whether the catheter is implanted or not, and to what extent (e.g., tunneled, totally implanted [i.e., port]).

7. Nontunneled Placed percutaneously Usually temporary access Single or multiple lumens Variety of lengths (15 to 30 cm) Made of polyurethane Higher risk of infection Tunneled Surgically inserted Longer time of therapy Single or multiple lumens Variety of lengths up to 40 cm and 16 F Made of polyurethane or silicone Lower risk of infection

8. Peripherally inserted central venous catheters (PICCs) another type of commonly used central venous access device. Inserted percutaneously, intermediate to long therapy, single or double lumen, made of polyurethane or silicone and up to 40-60 cm long. Advantages: Can remain for several weeks to a year Can be easily removed Low infection rate Disadvantages: Low flow Higher risk of thrombosis

9. CONTRAINDICATIONS : Infection at insertion site Severe coagulopathy Thrombosis at selected vein Trauma at insertion site e.g. clavicle fracture Burn SCV in CKD patient at risk of hemodialysis Uncooperative awake patient

10. ACCESS SITE SELECTION Preferred site for non hemodialysis catheters is the subclavian vein over internal jugular especially in tracheostomized patients. Avoid femoral vein cannulation as possible. Avoid SCV hemodialysis catheter insertion in CKD due to increased risk of central vein stenosis.

11. PREPROCEDURAL PREPARATION: Consent: Central venous access is an invasive procedure and informed consent should be obtained unless emergency situation. Monitoring: Continuous cardiac rhythm and pulse oximetry. Supplemental oxygen should be immediately available. Anesthesia: Awake patients typically needs local anesthesia. Some times you may need some degree of sedation. As for every procedure, perform “ time out ”. Pre-cannulation vein assessment: Before cannulation, routine bedside ultrasound by the provider placing the access aims to evaluate the vein location, size, and patency and aids in selecting the most appropriate site of access.

12. Ultrasound preparation: Turn on the machine and enter the patient data and choose the appropriate machine program examination. Transducers: A high-frequency (5 to 15 MHz) linear transducer is usually best. Mode: B-mode (brightness mode), the standard 2D grayscale image of the tissue. Doppler mode used in assessment pre-cannulation. Transducer orientation and view: Transverse (short axis) or longitudinal (Long axis). Adjust the gain, depth and focus.

13. ASEPTIC TECHNIQUE

14. Hand hygiene technique Using water, wet your hands and forearms up to the elbows. Your hands must be held above the elbows at all times. Clean your nails with the file found inside your surgical scrub brush box. Use the sponge to rub your hands and forearms. To get the foam, you need to wet the sponge and wring it out. Only use the brush to rub your nails, cuticles and the areas between your fingers. Finally, drop the brush and file into a designated bin and rinse your hands first, followed by your forearms (keeping your hands above your forearms). Dry your hands and forearms with a sterile drape, starting with your fingers (one at a time), then the palm/back, wrist and finally the forearms up to the elbow joint.

15. PICC line insertion

16. Bed side CVCs Removal Correct any coagulopathy if present Prepare removal kit Perform hand hygiene Wear PPE Remove the old dressing using non-sterile gloves then discard Use chlorhexidine 2% with alcohol 70% unless contraindicated Don sterile gloves and apply CHG and wait until dry Remove statures

17. Remove the catheter using the following steps: Lower the head of the bed. Position insertion site below the patient’s heart level or use Trendelenburg position if tolerated. Ask the patient to hold breath during catheter removal, or remove at the end of inspiration if the patient is mechanically ventilated. Pull the catheter in slow but steady withdrawal motion, applying immediate and direct pressure slightly above the insertion site upon removal. Apply direct and continuous pressure for a minimum of 7 minutes before assessing of bleeding. Assess for bleeding or hematoma every 5 minutes for the first 15 minutes, then every 15 minutes for one hour, then every 1 hour for 4 hours.