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.
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.
And if the circumference of their upper arm
becomes large, then you might have
an infection or a clog going on.
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.
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
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.
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.
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.
Patients can accidentally get them pulled
on things. The patient can't
shower with them.
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.
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.
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.
They can be left in for a long time,
a month or two.
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.
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.
All central lines, the placement has to be
verified by an X-ray before you use it.
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.
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.
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.
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.
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.
Another potential complication of inserting
a central line is infection.
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.
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.
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.
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.
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.
You know, they will be like,
"I can't breathe.
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.
Thank you. This has been Jill Beavers-Kirby
discussing central venous lines.