Central Venous Access Devices (Nursing)

00:00 Hi! My name is Jill Beavers-Kirby, and today we're going to be talking about central venous access devices. So, why do we need these types of devices? Well, they're great. As a nurse, you're going to love them because they allow you to do a lot of things. They allow you to give certain types of fluids, certain types of toxic fluids. They allow you to monitor somebody's heart rhythms, heart pressures, and they also allow multiple blood draws. So now we're going to talk about the different types of central venous access devices. You might also hear these called central lines. So that's a group of all the different types of devices that we're going to talk about. The first one is called a PICC line, for a peripherally inserted central catheter. So, a PICC line is usually inserted in the upper arm of someone, either their right arm or their left arm. And this is great because a specially trained registered nurse can put these types of lines in. They can be left in for a long amount of time, usually, a few months.

01:08 They are about 24 inches long and they can have either one, two, or three ports. So, as a nurse, when you're looking at somebody's PICC line in their arm, you want to measure the circumference of their upper arm because these lines can get infected.

01:25 And if the circumference of their upper arm becomes large, then you might have an infection or a clog going on.

01:33 You'll also want to measure the length of the line that you can see left out of the patient. So, you're going to have part of the line hanging out of the patient.

01:42 It's usually about six inches long. It will be in centimetres because centimetres is marked on the tubes. But you'll want to document how much of the tube you can see with each nursing assessment. That way you know if the line has become dislodged or has migrated further in or has migrated further out.

02:02 The next type of central line that we're going to talk about is an implanted port. These are also great when it comes to the patient and the nurse because these are surgically implanted under somebody's skin. They are usually in the right upper chest or the left upper chest. They have a covering of skin over them so they're like in a little pocket. They look great because you can't see them, and it is really nice because once again, you can use these to access patient's central venous system and to do blood draws. The downside of this is that sometimes they do hurt when you go to access them just a little bit because you're just poke in the skin a little bit. Patients usually can get over that when they use something called EMLA cream which is lidocaine cream. So, implanted ports will usually have one lumen or two lumens, and we call those a double lumen. As I stated previously, the advantages are the very aesthetically pleasing to the patient because you have no lines hanging out, they don't cause any problems for patients when they want to shower or go swimming.

03:11 However, the disadvantages are is that they do sometimes pinch just a little when you go to access them with a needle. An implanted port can be open-ended or close-ended. A close-ended port will have a valve on the end. An open-ended port doesn't have any valve on the end, so you have to put a little bit of a heparin solution in those lines so they don't clot off. The next type of central line we'll talk about is a nontunneled line. This will be something like a triple lumen, three lumen, central venous catheter, CVC, or something like a Swan-Ganz catheter which is a pulmonary arterial catheter. These usually also go in the upper chest or in the neck.

03:59 They can go in on either side. You'll see this put in usually during emergency situations, usually at a patient's bedside because a patient is probably not stable enough to go to an OR to have this inserted. They will have two lumens or three lumens. These are nice, but they're temporary. They're usually only left in for one week, maybe two weeks at the most, and then they have to be changed out. There's a high risk of infection with these lines or displacement because they are put in up here on the skin.

04:33 Patients can accidentally get them pulled on things. The patient can't shower with them.

04:40 There's a lot of manoeuvring with these lines because you're touching the area, the patient is touching the area so they can become dislodged pretty easy.

04:49 So, there's also a risk for a pneumothorax when you go to put these lines in. These lines are put in by a physician, but there you can poke the lung and get a small pneumothorax when you're trying to insert these lines. So some other types of lines are open-ended valved catheters. Some brand names you're going to hear are Hickmans or Broviacs.

05:13 Hickmans have one, two, or three lumens. Broviacs only have one lumen, and you'll generally see these in the pediatric population. But these can be either open-ended or valved. For example, a Groshong, which is another brand name, is an example of a valved catheter and has two lumens. You'll see things like Hickmans, Broviacs, and Groshong is used frequently in the oncology population because these lines go to the central system very quickly.

05:41 They can be left in for a long time, a month or two.

05:46 They're pretty easy to take care of. They are sutured a little bit and they do have a little balloon on the end that helps keep them in place. And because of the type of IV that they are, they can tolerate the caustic medicines of chemotherapies. Dialysis catheters are also sometimes seen in the hospital setting. And these can be external in the chest, in the arm, in the groins. These are large bore double lumen central lines.

06:16 These also go directly to the central circulation. So your nursing assessment must include assessing the site for any redness, pain, erythema, tenderness, any drainage of fluids from the site. If you notice any of these, you need to notify your physician right away. So, what are some complications of central lines? Well, one is malposition. They can migrate. So just with the flow of blood, the tips of the catheter can kind of like the wave of an ocean get caught up in that forward motion, and they can migrate in a little further. So for example, when I was talking about the PICC line, you want to make sure you're noting how far out that catheter is each and every time you look at it. If the catheter looks like it's too far in or too far out, you need to notify the physician right away.

07:14 All central lines, the placement has to be verified by an X-ray before you use it.

07:19 So before you instil any type of fluid into a central line, you have to get an X-ray. This can be a portable chest X-ray done at the bedside or you can send the patient to the radiology department for the X-ray. But I can't stress enough.

07:35 You have to have an X-ray before you use that line for the very first time. So, kind of as we talked about a little earlier, a pneumothorax which is air in the pleural space can also happen when these lines are being put in. I have never seen a pneumothorax occur after a line has been inserted. Most times, the majority of time it's going to be when the line is going in. That's because the physician is using a large needle to poke the skin. And they can sometimes set the apices of the lungs which are all the way up here around your collarbone. So, if somebody has hit the lung and caused a pneumothorax where the air enters the pleural space, the patient will start coughing or complain of being short of breath. Or if they're hooked up to an oxygen monitor, you might notice that their oxygen saturations are decreasing. You'll want to notify the physician right away.

08:29 You'll probably end up removing the central line. And sometimes, if the pneumothorax is big enough, the patient might even require a chest tube. Another common complication of these lines is occlusion. This can occur from a blood clot, a clot of medicine like sticky medications like dextrose solutions can cause these lines to clog up. Or maybe when the physician was putting in the line, he dislodged a little piece of plaque that caused the area of the line to clog off. You'll notice this right away because your IV pump will be at high pressure. One way to prevent this is to flush your lines per your institution's policy. It's different at whatever institution. So just as long as you know your policy, follow those guidelines.

09:22 Some medications, for example, IV Dilantin, can have precipitates in it. Precipitates can be little white flecks in the medicine. Like I said, Dilantin is known to have precipitates in it. So when you give IV Dilantin, you always, always, always always have to give it with a filter to filter out those precipitates, because if not, those precipitates will clog off your line, they'll clump together and clog off your line. You'll also want to remember to change your IV tubing if it does become occluded. And you also want to change your IV tubing per your institution's policy.

10:01 Some institutions will say to change your IV tubing every 48 hours. Some places change it every 72 hours, and for example, if you're running in total parenteral nutrition, TPN, you have to change that tubing every 24 hours.

10:17 Another potential complication of inserting a central line is infection.

10:21 This can be caused from a dirty catheter site before the line was inserted, so the area wasn't cleaned off well, or somehow the line got contaminated during insertion, or strict sterile technique is not used during dressing changes.

10:40 So in order to prevent infection, you want to make sure that you are following the sterile technique as outlined by your institution, frequent assessment of the site, and always monitor your hand hygiene. So you want to make sure you're wearing your gloves, washing your hands, or using some alcohol-based hand cleaner. So, what do you do if you have an infected line? Well, you're going to have to take out the central line. You're going to have to notify the physician. And the patient also might be required to have IV antibiotics.

11:13 This can be a serious complication because the central line is going straight to the central bloodstream. The person can become highly septic very quickly.

11:23 An air embolism is when air gets in the tubing and then goes into the central circulation. This can happen when you're setting up the tubing to be connected to the central line and you don't get all of the air out of the line. This is called priming the line. It can also happen if you're connecting something to the tubing and you don't connect it well enough and that allows air to get in.

11:47 These air embolisms can be deadly in a patient if the air embolism is large enough. So the patient will complain a shortness of breath. It will be sudden.

11:56 You know, they will be like, "I can't breathe.

12:01 Help me, I can't breathe." It's not a gradual shortness of breath. They might wheeze, they might turn a little cyanotic which is blue, they might feel like their heart is jumping out of their chest, and their blood pressure might drop. So to prevent this, we want to make sure we prime those lines, all of them. We want to make sure that we have tight connections. What do we do if we notice or if we think somebody has an air embolus? One, notify the physician immediately. You'll want to place the patient on their left side or in Trendelenburg position, that's with their head lower than their feet. They're going to have to have supplemental oxygen and you're going to want to monitor their vital signs.

12:43 Thank you. This has been Jill Beavers-Kirby discussing central venous lines.