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Central line best practice
This document provides information and best practices for central and peripherally inserted central catheters (PICCs). It discusses indications for central lines, types of central lines including non-tunneled and PICCs, catheter placement and tips, dressing changes, flushing procedures, and documentation standards. The document emphasizes following Centers for Disease Control and Prevention guidelines to prevent infections, including using sterile technique and chlorhexidine for dressing changes and site access. It also stresses the importance of daily site assessments and prompt removal of unnecessary lines.
In this document
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Overview of central lines and PICC lines' care practices; presenter details and educational background.
Definition, indications, and placements of central venous access; importance of chest X-ray for placement confirmation.
Differences between non-tunneled central venous catheters and PICC lines; clinical applications and length specifications.
Detailing the function of lumens in central and PICC lines; specifications for medication and fluid administration.
CDC recommendations on catheter dressing; procedures for dressing changes and skin cleansing protocols.
Guidelines for maintaining needleless access devices, flushing techniques, and precautions for catheter care.
Strategies to prevent blood reflux; daily assessments of catheter insertion sites and the need for lines.
Key elements to document in patient charts; ensuring proper records for catheter management and care.
Citing sources used in the presentation; concluding with a Q&A session and post-quiz for evaluation.
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Central line best practice
- 1. Central and PICCLines Care and Best Practices Mary Larson, SN St. Cloud State University
- 2. Mary Larson Hometown: Atwater, MN St. Cloud State University Nursing Program: December 21st Capstone Semester Preceptor: Jamie Daniel 180 Direct Patient Care Hours, 90 Leadership Hours (40 at Meeker Memorial) Leadership Project- Teaching
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- 4. Central Venous Access Catheters inserted into large veins in central circulation Tip of catheter threaded to reside in lower third of the vena cava Chest X-ray to confirm correct placement
- 5. Central Venous Access Indications: Patients requiring multiple sites for IV access Patients lacking useable peripheral IV sites Patients requiring central venous pressure monitoring Patients requiring total parenteral nutrition Patients receiving incompatible medications Patients requiring multiple infusions of fluids, medications, or chemotherapy Patients requiring long term antibiotic therapy Patients subject to frequent blood sampling or receiving blood transfusions Patients requiring a temporary access site for hemodialysis Patients receiving infusions that are hypertonic, hyperosmolar or infusions that have divergent pH value
- 6. Non-Tunneled Percutaneous Central Venous Catheter AKA Central Line Inserted by physician Subclavian vein of upper chest or internal jugular veins in the neck Occasionally femoral – higher rates of infection Measure 7-10 inches (18-25 cm) 1 to 5 Lumens Used most common: Trauma, critical care, surgery No recommended dwell time: used for short term, not the catheter of choice for home care or ambulatory clinic settings
- 7. Peripherally Inserted CentralVenous Catheters (PICC) Long catheter, inserted in vein of antecubital fossa or middle of upper arm Basilic vein preferred, cephalic used if necessary Inserted by physicians or specially trained nurses Length 18-29 inches (45-72 cm), 1-3 Lumens Optimal dwell time unknown: reported to dwell successfully for months or even years Lower rate of Central Line Assoc. Bloodstream Infections (CLABSI) than Central Lines Patients requiring lengthy antibiotics, chemotherapy, parenteral nutrition, or vasopressor agents – benefit from PICC line.
- 8. Lumens CentralLine: 1-5 PICC Line: 1-3 Port Designation: (with 3 Lumens) Proximal Blood Sampling Medications Blood Administration Medial TPN Medications (Only if TPN use in not anticipated) Distal CVP monitoring Blood Admin High Volume or Viscous Fluids Colloids Medications
- 9. Catheter Dressings Center for Disease Control and Prevention (CDC) Recommendations: Use either sterile gauze or sterile transparent semipermeable dressing If pt is diaphoretic or site is bleeding or oozing, use gauze until resolved Replace dressing if damp, loosened, or visibly soiled Do not use antibiotic ointments or creams Dressing changes: Short-term CVC sites q 2 days for gauze and at least q 7 days for transparent PICC-24 hours post insertion, then transparent dressings q 5-7 days unless soiled or loose, gauze q 2 days unless wet, soiled, or non-occlusive >5% Chlorhexidine to cleanse skin during dressing changes
- 10. Dressing Changes Dressing Removal: Stabilize catheter and Luerlock hub to prevent dislodgement Separate dressing away from Luerlock hub and toward insertion site Chlorhexidine should be used to swab in a back and forth pattern for 30 seconds to ensure the skin is clean and disinfected If patient is diaphoretic with a great deal of fluid present on skin, area should be scrubbed for 2 minutes to ensure bactericidal activity During dressing change- assess external catheter length to determine if migration had displaced catheter tip Sterile occlusive dressing should cover entire insertion site, suture wing and at least 2.5 cm of the extension tubing is recommended
- 11. Dressing Change Procedure Gather supplies Hand hygiene Don clean gloves and mask (patient) Remove old dressing (toward insertion site) and discard Remove gloves, perform hand hygiene, and don sterile gloves Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck Cleanse site (chlorhexidine) back and forth motion Allow to air dry Secure catheter in place Apply sterile dressing to site Document date, time, and initials on new dressing Document the procedure, any complications, and external catheter length to patient’s chart
- 12. Caps: Needleless AccessDevices CDC recommends changing caps at least as frequently as administration sets No benefit to changing these more frequently than every 72 hours TPN/Lipids (enhance microbial growth) Accessing: “Scrub the Hub” for 15 seconds Types: Negative Displacement Device Neutral Displacement Device Positive Displacement Device At Meeker Memorial: Baxter Clearlink System (Negative Displacement)
- 13. Flushing Lines A single use syringe should never be used more than once 10 mL syringes should not be divided into several doses and used for multiple lumens Never use a syringe smaller than 10 mL The pressure created by smaller syringes could damage the catheter Volume: Minimum of twice the volume of the catheter should be used to flush In general for adults 10 ml is sufficient 0.9% NaCl solution should be used Frequency: If being used a minimum of q 8 hours, flush with 10 mL NS before and after every use and for lines in maintenance mode flush with 10 mL NS every 24 hours. Flush using a pulsative or “stop-start” technique Creates turbulence within the catheter to adequately flush medications from the line
- 14. Preventing: Blood Reflux Major problem Catheters are deep in the body, reflux cannot be seen when it occurs Caused by inadequate flushing, also b/t flushes caused by increased intravascular pressure (ex: coughing, vomiting) leading to biofilm formation and buildup, occlusion, and even infection Prevention Strategy: Know which type of needleless connector is being used. Negative Displacement (Meeker Memorial – Baxter Clearlink System) Catheter must be clamped BEFORE syringe is removed Neutral Displacement Fluid should remain neutral, therefore clamping can be done before or after syringe removal Positive Displacement Important to clamp the catheter AFTER the syringe is removed in order to get displacement https://www.youtube.com/watch?v=X5wIhmR0SIE
- 15. Assessment Visuallyexamine insertion site daily for erythema, drainage, tenderness, suture integrity, and catheter position Routine IV site assessments Routinely assess dressings (change if necessary) Daily assessment of need for Central Line and promptly discontinue lines which are no longer indicated Nursing staff should be encouraged to notify physicians of Central Lines which are unnecessary
- 16. Documentation Thefollowing should be included in the patient’s chart: Product Name Date of insertion, inserter Anatomical location Catheter depth according to catheter reference markings X-ray confirmation of catheter tip location Port designation for infusions/measurements, e.g. TPN, CVP, Medications Ensures uniform use of lumens Amount, type, and frequency of flush solution Dressing and tubing changes Document exposed catheter length with dressing changes Site assessments Every shift Complications Catheter removal and application of air-impermeable dressing
- 17. References Angiodynamics(2014). Bioflo picc with endexo technology: Directions for use. Marlborough, MA: Navilyst Medical, Inc. Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow International, Inc. Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan for outpatient oncology settings. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan- 2011/central-venous-catheters.html Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheter-related infections. Retrieved from http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders. Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive care unit (non-icu) settings toolkit. Atlanta, GA: Centers for Disease Control and Prevention. Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based practice and technologies: A continuing educational activity for pharmacists and nurses. Irving, TX: VHA, Inc. The Nebraska Medical Center (2012). Standardizing central venous catheter care: Hospital to home (2nd ed.). Omaha, NE: The Nebraska Medical Center.
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Editor's Notes
- #15 0-1:38, 2:42-4:40