Vascular Access Midlines, Cent ral Lines & PICC Lines 2019 VCNE S eries Erin Haak, RN, PCCN Erin.haak@ avera.org
Powerglides / Midlines *Placed asept ically at bedside wit h ult rasound guidance – t ypically in t he upper arm. *S ingle Lumen Only – 18 gauge –8 or 10 cm lengt h *Used for difficult IV access, ext ended hospit al st ay, infusion t herapy < 4 weeks –depending on t he medicat ion *Power inj ect able for CT scan *May be used for blood draws *Benefit (not requirement ) of cat het er – NO TP A* *Not specifically designed for blood draws*
Midline Care & Maint enance Flush daily with saline Weekly aseptic dressing change –Do not need to change the saline lock tubing or cap (bonded) Guardiva disc around insertion site (CHG) **NO wrong dressings** - Keep the site clean, dry, and covered *S ecure with S tatlock* (Picture at right) McKennan currently trialing different securement devices and dressings. More to come in the future!
Cent ral Venous Cat het er/ Central Line/ PICC Line Placed in lower 1/ 3 of superior vena cava (S VC) 2L of blood / minut e Dilution of drugs Vein preservation
Dilut ion
Types of Cent ral Lines- Acut e Care Cat het ers Internal Jugular S ubclavian
Indicat ions for Acut e Care Cat het ers *Unst able pat ient s requiring hemodynamic monit oring, mult iple medicat ions, large fluid infusions, blood or blood product s, or cont inuous parent eral nut rit ion *Short – t erm access for up t o 14 days *Inabilit y t o obt ain peripheral access in crit ically ill pat ient s MAGIC Guidelines
Dialysis Cat het ers Tunneled Dialysis Line Temporary Dialysis Line
Indicat ions for Dialysis Cat het ers *Short – t erm hemodialysis (Temporary Line) *Long –Term Hemodialysis (T unneled Line) If in place for an ext ended t ime (mont hs – years) and int ernal cuff has adhered t o skin, may be left open t o air wit h no dressing if pat ient is not immunocompromised.
Tunneled Cent ral Lines (Non – Dialysis) PowerLine –Placed in chest – Looks like a PICC S omet imes called Hohn Cat het er
Indicat ions for Tunneled Cent ral Lines (Non – Dialysis) *Inabilit y t o place PICC *No venous access, Mast ect omy, DVT , AV Fist ula, Infect ion, Recent Fract ure, Implant ed device in arm (birt h cont rol) *Dwell t ime up t o 6 mont hs (Single or Dual Lumen)
Trifusion Cat het ers Trifusion –Used for long term intravenous access (Bone marrow transplantation, hematology) Tunnelled with dacron cuff –allows tissue to adhere Used for long term therapy such as: Chemotherapy, chronic parenteral nutrition, & apheresis procedures Flush daily with heparin 100 units/ ml (3 mls) and clamped Available as single, dual, or triple lumen Cover with CHG dressing and use max plus valves Other types: Groshong & Hickman –cannot be used for apheresis
PICC Lines (Peripherally Insert ed Cent ral Cat het er)
Indicat ions for PICC Lines *Infusion of solut ions requiring cent ral access in clinically st able pat ient s *Infusion of medicat ions considered irrit ant s or vesicant s *Infusion of medicat ions wit h pH<5 or >9 and/ or osmolalit y >500 *Infusion t herapy for great er t han 4 weeks – Indefinit e dwell t ime barring any complicat ions *Difficult IV access and need for mult iple IV medicat ions simult aneously *Hemodynamic Monit oring
Care & Maint enance of Cent ral Lines Dressing & cap change every 7 days – writ e dat e on dressing and change dat e in comput er Tubing changed every 24 hours (int ermit t ent ) or 96 hours (cont inuous) –AND wit h new line placement (May keep IV Fluids) Lines may be left in unt il complet ion of t reat ment or clinically indicat ed for new sit e Flush lines DAIL Y wit h saline ( Heparin for P AC and Dialysis cat het ers/ t rifusions) Be PROACTIVE NOT REACTIVE
Care & Maint enance of Cent ral Lines Curos Caps Use curos caps on ALL IV sit es and ALL Y-sit es on t ubing Disinfect in 60 seconds One t ime use- discard when removed from IV or t ubing
PICC Dressing Applicat ion
Cent ral Venous Cat het er Cap Change
CHG Dressing Tips Allow CHG & S kin prep t o dry before placing dressing Use all 3 part s of dressing (Taco shell met hod) DO NOT S TRETCH Use firm pressure t o enhance adhesion along edges for approximat ely 7 seconds
CHG Dressing Tips Change if act ive bleeding or blood out side gel pad Use S urgicel 1x2 gauze t o help st op act ive bleeding Change if insert ion sit e is not visible Change dressing if loose, soiled, or compromised Change after 48 hours if has gauze pad If allergic t o CHG use alcohol/ bet adine t o cleanse sit e IV 3000 dressings may be used for sensit ive skin
IV Sit e & Line Assessment Every 1-4 hours depending on unit and pat ient Monit or for infilt rat ion and phlebit is – document appropriat ely Monit or for infect ion –A Red IV is NOT bet t er t han NO IV! Assess ext ernal measurement s of PICC/ cent ral lines Always assess for blood ret urn on cent ral lines/ PICCs 3mls/ 3 seconds Fibrin sheat h may have formed
Occluded Line – What t o do? Consider posit ion changes for pat ient TP A – Follow Nursing policy – Must have order from Physician Chest X-Ray t o verify placement Call PICC t eam
Admit / Discharge wit h Cent ral Line in Place Admit -Physician order for X-Ray t o check placement -Change dressing, caps, and needle (if P AC) Discharge -Educat e pat ient on possible complicat ions and line care -Inst ruct t o keep lines clean and dry (Cover for showers)
PICC Removal
Cent ral Line / PICC Removal Follow Facilit y Policy Have pat ient hold breat h t o prevent air embolus Hold pressure approximat ely 5 minut es Ensure cat het er is int act Place occlusive dressing over sit e for 48 hours Bet adine oint ment , gauze, and t egaderm
What is What ?
What is What ?
Quest ions? ? ? ? ? ? Avera McKennan PICC Team 605-322-2055 Pager 605-322-0478 Voalte erin.haak@ avera.org References INS S tandards of Practice Center for Disease Control R ecommendat ions MAGIC Guidelines https:/ / annals.org/ aim/ fullarticle/ 2436759/ michigan-appropriateness- guide-intravenous-catheters-magic-results-from-mult ispecialty-panel Facility Policies
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