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Managing venous Catheters

IV Therapy At Home - Outside the Body or Central Line Access

IV’s at Home are Common 

   Going home with an IV (venous catheter) is a common occurrence these days.  Whether you have external access (i.e., an IV placed in your vein in your arm) or internal access (i.e., like a PICC line), you go home with an order for instructions for medication management by Home Health, IV supplies, training on IV infusion equipment, and supplies (lots of supplies).   

Many Types of Central Line Devices    

 Multiple types of central line devices exist. However, they all have common features. 

  • You must use sterile techniques whenever you access them. 
  • Unintentionally introducing anything into the central line can threaten the care receiver’s life.
  • You must constantly pay attention to your every move. If you accidently contaminate yourself and introduce bacteria into the central line, you allow bacteria to directly access the heart. 
Review Preventing Infection Here

     Review the section on Preventing Infections to refresh your memory on sterile technique and on putting on sterile gloves!

Home IV Therapy

Occasionally a family member may be sent home for short term IV therapy. The process is much the same as that used for a central line. The YouTube Video,

How to Administer Home IV Fluids

describes the steps required to start an IV.

  1. Wash your hands using liquid soap humming the Happy Birthday song twice
  2. Put on non-sterile gloves
  3. Remove air bubbles from all syringes by pushing plunger upwards.
  4. Return caps to end of syringes. Set aside
  5. Pull plug from IV bag. Insert spike into the IV bag till IV starts to flow through the tubing.
  6. Clamp the tubing. Hang the bag.
  7. Fill the chamber of the tubing about 1/3-1/2.
  8. Slowing open clamp to allow remove air from rest of tubing. Re-clamp when all air bubbles removed.
  9. Remove cap from end of PIC line and set aside. Scrub end 10 sec. with alcohol wipe.
  10. Apply Saline flush Syringe, unclamp tubing, inject saline using push/stop technique until all saline is infused.
  11. Remove syringe and re-apply green cap to IV line, if anything touched it, clean with alcohol first.
  12. Attach tubing and dial-a flow rate device.
  13. Undo clamp; confirm it’s dripping and that everything is working.
  14. Monitor Infusion till complete.
  15. Disconnect IV tubing from PIC line,
  16. Scrub IV line and attach saline syringe to flush line.
  17. Flush with saline using push/stop method.
  18. Inject Heparin
  19. Clamp, Re-cap, Cover.
  • Apply a tourniquet
  • Keep the limb dangling lower than the heart
  • Apply light heat, wrap the area in a blanket
  • Stay away from lumpy areas (those are valves that block the needle’s progress)
  • For veins that roll, tighten the fist or skin area before attempting to insert the needle to anchor the vein.
  • Angle the needle at a shallow rather than steep angle to avoid going through the vein as easily.
  • When starting IV’s, they must start inserting needles at the farthest point from the heart and work their way upward or the veins above the insertion point will leak from previous missed attempts.
  • No more than three attempts by the same person in one sitting; then someone with more experience has to come try.

YouTube Video demonstrating how to find a vein and start and IV:

How to Find A Vein 

  1. Gather necessary supplies
  2. Wearing sterile gloves, remove old dressing careful not to dislodge IV
  3. Carefully remove statlock (alcohol may help to remove it)
  4. Change gloves
  5. Using swabs to clean site. Use to of swab to clean one side of PICC, flip swab and clean other side; throw swab away.
  6. Use another swab and clean sides around site, again flipping swab as different quadrants are cleaned. Always clean inner most to outer most directions  
  7. Change gloves
  8. Apply stat statlock
  9. Apply new clear dressing (date dressing so you remember when you changed it)

Central Venous Access Catheters

     Central Venous Catheters provide access to large veins in the body.  The two primarily accessed are the subclavian and the internal jugular veins, which lead directly into the superior vena cava of the heart. While there are many advantages to using large veins, central venous therapy increases the risk of life-threatening complications such as:

  • pneumothorax (hole in the lung),
  • sepsis (whole-body infection),
  • thrombus formations (blood clot), and
  • vessel and adjacent organ perforation (punching hole in the blood vessel or organ nearby).

     Therefore, if you are managing a central line catheter at home, extreme care must be used whenever you are accessing or handling the catheter. Any contamination to the line could have life-threatening consequences. Strict Sterile technique is required to prevent bloodstream infections.

Central Venous Line Care Instructions

     The following are key points to keep in mind related to lab work.

  • If you have lab work ordered and someone unfamiliar is about to draw labs, remind them not to draw blood from the same line used for giving medication if two lines are available.
  • Draw only the smallest amount of discard blood allowed to keep all access limited to only essential draws.
  • Try to group lab tests so that one stick can get blood for multiple tests.
  • Flush the site very well after lab draws to decrease the rest of the blood clots and possible blockage.

     Blood has a natural tendency to clot.  If any build-up gets on the inside of the catheter, blood will begin to stick to it, and the opening will close off. To prevent that from happening, using a heparin flush solution after each use helps to prevent clots from forming.

 

     The general rule is that during the time the catheter is not in use, a weekly flush is customary.  During times the catheter is in use, follow this procedure:

  1. Check the catheter to make sure the line is open by pulling back and checking for blood flow before use each time,
  2. Use saline flush between doses of medications or injections of anything else to prevent incompatibility reactions, and
  3. Give Heparin flush to prevent clots from forming as the last step.

     It’s essential to keep an airtight dressing over the site where the catheter enters the body. The reason why is to prevent germs from entering the body around the catheter at that opening. Remember, that catheter is taking blood, and whatever else has touched that catheter straight into the heart.  Therefore, the strictest of sterile technique must be used to do dressing changes, tube changes, anything that goes with that catheter.

 

     See-through (transparent) semipermeable (breathable) dressings should be changed every 5-7 days and gauze dressings every two days. If you see signs of infection, if the dressing comes loose, gets dirty, contaminated, or messed up in any way, CHANGE IT.

     Don’t. Never pull that catheter out. Only nurse practitioners or doctors can remove them. If you feel it must come out, go to the emergency room to have a doctor pull it out. If it accidentally comes out, hold pressure on the insertion site to prevent bleeding in transport to the hospital.

Peripherally Inserted Central Venous Catheter - PICC Lines

     A Peripherally Inserted Central Catheter (or PICC for short) is a long, flexible tube used to deliver fluids and/or medication into your body through a vein in your arm. Using a needle and local anesthetic, a radiologist or certified nurse inserts a thin wire to guide the catheter into a large vein leading to your heart. Once inserted, the PICC catheter allows direct delivery of medication or fluids for several weeks without having to use a needle or IV each time. Regular care must be taken to ensure the catheter is working correctly and the dressings remain dry and clean. For example, PICC catheters require a flush of saline or other fluids at least once a week to ensure proper flow.

   

PICC (Peripherally Inserted Central Venous Catheter (PICC) 

  1. Assemble your supplies
  2.      Wash your hands
  3. Open supplies for access while you have on sterile gloves 
  4. Remove air bubbles from saline and heparin
  5. Put on your sterile gloves
  6. Scrub hub of the central line for 15 seconds
  7. Clamp line and attach saline flush.
  8. Unclamp line and flush.
  9. Clamp line, remove syringe and scrub-hub with alcohol again for 15 seconds.
  10. Attach heparin syringe, unclamp line and inject heparin. 
  11. Remove the heparin syringe, recap the end of the line.

If you would like to see an example of a Central Line being flushed and the cap being changed, here is a YouTube video that you might find interesting to watch. This patient had a Hickman Catheter. 

How to Flush Your Central Line and Change the Cap. 

The following YouTube Video, Changing the Caps on a Central Line, does an excellent job of demonstrating proper technique in changing central line caps. If you use a central line, this video is a great way to check your own technique to make sure you haven’t developed any bad habits (which is easy to do overtime).

Changing Caps on a Central Line 

Instructions for how to perform the task:

  • Caps are changed every seven days.
  • Masks must be worn during line cap changes since the line is completely open.
  • The cap is primed with saline prior to being applied to the line. 
  • Attach the cap to the syringe by twisting clockwise.
  • Before changing the clamp, clamp the line.
  • Remove the old cap by twisting it off counterclockwise.
  • Scrub the end of the line with alcohol for 15 seconds.
  • Take off the blue end of the primed cap, insert the new cap into the line and twist it into the line to tighten it.
  • Remove the syringe.
  • Unclamp the line.
The most common complications for PICC lines include the following:
 

Catheter migration symptoms (i.e., the catheter moved out of place):  change in catheter function, change in external length of the catheter, chest pain, difficulty breathing, and irregular heart rates

Catheter Becomes Clogged or Blocked (Occluded line): inability to flush the line or give medication through it.  Medicines won’t flow through the line or they are running very slow.

Phlebitis (inflammation) of the Vein: tenderness, redness, heat or swelling at the site where the line enters the blood vessel or anywhere along the length of the blood vessel.

Infection at the Infusion Site: redness, swelling, heat, hardness, pain, or drainage at the insertion site.  May also have a fever or a fast heart rate.

Air Embolism (i.e., an air clot that blocks off blood flow): lightheadedness, anxiety, confusion, fast heart rate, low blood pressure, sharp chest pain, and severe difficulty breathing.

PICC Complications      

This is a video tutorial on how change a PICC dressing. The PICC in this video is a double lumen PICC with a stat lock.  No-touch sterile technique and sterile gloved sterile technique is used.  Wearing a mask and hat to cover the hair and face is recommended to decrease the risks of infection. Depending on the type of PICC line in use, a Heparin flush may be required to keep the line open.  If so, the flush is often done at the same time as the dressing change.

How to Change a PICC Dressing 

 

A portacath is another type of implanted central line access device often used for chemotherapy patients or those who frequently receive IV fluids. It’s a small round hub implanted under the skin accessed by a needle.  The following YouTube Video, Accessing Implanted Port, shows you how it’s accessed and flushed.

Accessing Implanted Port 

  1. Locate Port and gather supplies
  2. Prime syringes so that fluids to be injected are at tip in each.
  3. For Saline syringe, attach positive pressure cap to tip of syringe.
  4. Push enough saline through filter to fully prime the pressure cap.
  5. Open extension tubing and while it’s still in the package, attach Huber needle (if not already attached).
  6. Attach all of it to the end of filter.
  7. Flush the tubing keeping the syringe/filter/tubing all together in the package.
  8. Put on your mask and sterile gloves
  9. Scrub porta cath site for 30 seconds with alcohol. Let air dry for 60 seconds.
  10. Retrieve extension tubing with attached Huber needle on end.
  11. Locate port, hold it firmly while inserting needle into the center of the port until the needle hits the back of the reservoir. Aspirate to determine placement.
  12. Flush the port with 10 ml saline using push/pause method.
  13. Give medication next if ordered.
  14. Complete process with Heparin.
  15. Put transparent dressing over needle site. Label with date.

Boston Children's Hospital YouTube Video Series

Video Series Produced by Boston Children’s Hospital October 2013

Careing Fora A Central Line At Home

 

Children with certain medical conditions may require a central line to deliver medications or liquid nutrition. Although maintaining the central line requires special care, parents can manage it within the comforts of their home.  This video introduces the topic on in home care of a central line. It goes over the topic of having the right supplies, being organized and how to pull it all together.

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Handwashing 

 

Careful hand washing is very important to prevent central line infections in children and teens on home parenteral nutrition or cancer treatment.

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Hand Sanitizer  

 

Hand sanitizer is also a great way to clean your hands instead of soap and water before doing line care for your child or teen on home parenteral nutrition or getting cancer treatment. 

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Making a Clean Workspace  

 

Creating a safe, clean workspace is important for proper central line care. When you are working on sterile medications, you want to know that you are not introducing germs or missing steps.  Work somewhere that you won’t be distracted or that your work area won’t become contaminated by the wind blowing something into it or a cat jumping into it. Always wipe it down before it.  A solution I use is a bleach solution of 1 part bleach to 10 parts water for my routine disinfected cleaning for anything medical. Spray it on and let it dry. 

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Putting on a Mask 

Germs can be transmitted through our mouths, so wearing a mask while working with central lines is recommended. Here is the proper way to put on a medical mask to prevent germs from being transmitted during line cap changes and dressing changes for your child or teen.

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Putting on Sterile Gloves   

It’s important to put of sterile gloves properly, so you can prevent passing on germs during line cap changes and dressing changes.

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Scrubbing the Hub  

When connecting anything to the central line, like home parenteral nutrition, IV hydration or IV medicines, it’s essential to clean the line with alcohol for 15 seconds.  After cleaning the hub, allow it to air dry. 

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Flushing the Central Line  

Flushing the central line is important to prevent anything from blocking the catheter and to prevent infections.

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Connecting Tubing  

 

You need to connect tubing to the central line, so you can give home parenteral nutrition, IV hydration or IV medicines. To safely connect any tubing to your child’s central line, follow these instructions carefully. 

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