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Nursing

Venous Access Devices

Peripheral Intravenous (PIV)

The PIV is the most commonly used device to administer intravenous fluids and medications. PIVs are placed in peripheral veins using an intravenous catheter. The PIV can be left insitu as long as necessary, in the presence of proper site care and careful attention to any signs of complications.

Advantages

Disadvantages

  • Easiest vascular access device to insert

  • Lowest risk of device-related systemic infection

  • Least invasive device for children with good peripheral vein access

  • No blood sampling capabilities

  • Peripheral veins are readily irritated by some medications and Total Parenteral Nutrition (TPN)

When to remove a PIV

  • Catheter will not flush with gentle pressure (e.g. blockage)
  • Site or vein is very painful for child
  • Course of IV therapy complete
  • Infiltration into surrounding tissues
  • Mechanical Failure
  • Leakage of IV fluid at site

Midlines

  • inserted in a vein of the arm and the tip lies just below the axilla; therefore, midlines are NOT central lines, although they look very similar to PICCs (see below) when viewed externally
  • insertion of a midline catheter is a sterile procedure
  • used for mid-term therapy; up to six weeks (e.g., antibiotics)
  • inserted by the IV team

Central Venous Catheters (CVC's)

CVC's provide access to the central venous system via the superior vena cava (SVC) or the inferior vena cava (IVC). CVC's are intended for both short term (acute) and long term (chronic) use.

The benefits of Central Venous Catheters over Peripheral IV's include:

Stability

depending on the device, CVC's can remain in place for weeks to years

Rapid haemodilution

due to large blood flow through the SVC, medications and solutions are rapidly diluted and distributed throughout the body, thus inabling the administration of all infusates (e.g., IV solutions, medications, TPN, blood products)

Safety

drugs that are vesicants or vessel irritants are more safely administered via a CVC as there is less risk of extravasation (the inadvertent delivery of drug into surrounding tissue)

Blood sampling

most CVC's allow for blood sampling decreasing the amount of venipunctures for those requiring frequent blood monitoring

Multilumen configuration

available as single or multi-lumen which allow incompatible infusions to take place simultaneously

Home IV therapy

CVC's allow patients who are medically able to receive treatment at home

Peripherally Inserted Central Catheters (PICC's)

  • inserted in the same place as the Midline in the basilic or cephalic vein
  • tip is advanced to the central venous system at the SVC and right atrium junction
  • may be inserted using topical/local freezing, sedation or general anesthetic
  • most PICC's have cuffs or sutures which help to keep the line in place
  • used for mid to long-term therapy (e.g., bowel rest, TPN) or irritant/vesicant agents (e.g., antibiotics, antivirals, chemotherapy)
  • usually restricted to therapies up to six months in duration
  • require ongoing care for heparinization, cap change, dressing change
  • must be protected from water; should not swim or immerse limb while bathing
  • sometimes used for children with poor/difficult peripheral venous access

Tunneled External Catheters

  • commonly referred to as CVL's
  • surgically tunnelled through subcutaneous tissue from exit site on anterior chest - improves stability of catheter
  • tip of catheter is usually advanced to the internal jugular vein
  • requires full general anesthesia for insertion
  • used for all long-term IV therapy (e.g., chemotherapy, TPN, hemodialysis, bone marrow transplant)
  • require ongoing care for heparinization, cap change, dressing change
  • must be protected from water; should not swim or immerse limb while bathing

Subcutaneous Ports

  • totally implanted venous access device
  • portal body is implanted in subcutaneous tissue of anterior chest
  • catheter tunnelled to internal jugular vein and tip rests in the SVC
  • requires full general anesthesia for all insertions and removals
  • accessing requires needle insertion
  • lowest risk of infection among all CVC's as there is no external portion when not in use
  • good for long term, intermittent therapy (e.g., chemotherapy) and for conditions with intermittent access requirements (e.g., haemophilia)
  • when not in use requires only monthly heparinization
  • when not accessed, no daily care required and no restrictions on most activities (e.g., swimming, sports) as entire catheter internalized (e.g., Port-O-Cath)

General CVC Care

Dressing changes

semi-permeable transparent membrane dressings (e.g., Tegaderm) should be changed routinely every seven days and prn. Gauze and Hypafix dressings (used for patients with sensitivity to transparent dressing or when there is exudate at site) should be changed two times per week and prn.

Cap changes

 interlink caps are to be changed every three days

Tubing changes

tubing used for continuous infusions are to be changed every three days. Some medications and blood products require more frequent tubing changes and new tubing must be initiated if solution/tubing left stagnant (i.e., not running) for more than four hours.

Securing CVC's

Ensuring CVC's are properly secured helps prevent accidental dislodgement of the catheter and damage caused from repeated twisting or kinking of the catheter. The "dacon cuff" that exists on most of the tunneled external catheters and many of the PICC's used at SickKids is usually the only internal securing device for these lines. It is very important to remember that this cuff is not enough on its own to prevent dislodgement of the catheter. All CVC's must be well secured externally to the patient's body.

Important Points

  • Do not measure blood pressure on the arm in which a Midline or PICC catheter is placed as this may damage the catheter
  • Do not draw blood from the arm in which a catheter is placed
  • Never push the catheter back inside the insertion site – this can cause infection

CVC Resources

  • SickKids Policies & Procedures: IV & Vascular Access (via Lotus Notes)
  • Policies and Drug Information for Nurses manual (PDIN)
  • IV Medication Administration Guidelines (available online)
  • Formulary
  • Clinical Support Nurse
  • Clinical Leader
  • Nurse Educator
  • 8A RN's
  • Vascular Access Resource Nurses
  • IV team