{"id":3537,"date":"2015-06-15T18:17:24","date_gmt":"2015-06-15T18:17:24","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&#038;p=3537"},"modified":"2021-05-20T21:45:41","modified_gmt":"2021-05-20T21:45:41","slug":"intravenous-therapy-peripheral-and-central-venous-catheters","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/intravenous-therapy-peripheral-and-central-venous-catheters\/","title":{"raw":"8.2 Intravenous Fluid Therapy","rendered":"8.2 Intravenous Fluid Therapy"},"content":{"raw":"<strong>Intravenous therapy<\/strong> is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein (Perry, Potter, &amp; Ostendorf, 2014).<b>\u00a0<\/b>Intravenous therapy is an effective and fast-acting way to administer fluid or medication treatment in an emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous therapy.\r\n\r\nThe most common reasons for IV therapy (Waitt, Waitt, &amp; Pirmohamed, 2004) include:\r\n<ol>\r\n \t<li>To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body's fluid balance is regulated through hormones and is affected by fluid volumes, distribution of fluids in the body, and the concentration of solutes in the fluid. If a patient is ill and has fluid loss related to decreased intake, surgery, vomiting, diarrhea, or diaphoresis, the patient may require IV therapy.<\/li>\r\n \t<li>To administer medications, including chemotherapy, anesthetics, and diagnostic reagants: About 40% of all antibiotics are given intravenously.<\/li>\r\n \t<li>To administer blood or blood products: The donated blood from another individual can be used in surgery, to treat medical conditions such as\u00a0shock or trauma, or to treat a failure in the production of red blood cells. The infusion restores circulating volumes, improving the ability to carry oxygen and replace blood components that are deficient in the body.<\/li>\r\n \t<li>To deliver nutrients and nutritional supplements: IV therapy can deliver some or all of the nutritional requirements for patients unable to obtain adequate amounts orally or by other routes.<\/li>\r\n<\/ol>\r\n<h2>Guidelines Related to Intravenous Therapy<\/h2>\r\nThe following are general guidelines for peripheral IV therapy:\r\n<ul>\r\n \t<li>IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of solution or medication, rate of infusion, duration, date, and time. IV therapy may be for short or long duration, depending on the needs of the patient (Perry et al, 2014).<\/li>\r\n \t<li>IV therapy is an invasive procedure, and therefore significant complications can occur if the wrong amount of IV fluids or the incorrect medication is given.<\/li>\r\n \t<li>Aseptic technique must be maintained throughout all IV therapy procedures, including initiation of IV therapy, preparing and maintaining equipment, and discontinuing an IV system.\u00a0Always perform hand hygiene before handling all IV equipment.\u00a0If an administration set or solution becomes contaminated with a non-sterile surface, it should be replaced with a new one to prevent introducing bacteria or other contaminants into the system (Centers for Disease Control [CDC], 2011).<\/li>\r\n \t<li>Understand the indications and duration for IV therapy for each patient. Practice guidelines recommend that patients receiving IV therapy for more than six\u00a0days should be assessed for an intermediate or long-term device (CDC, 2011).<\/li>\r\n \t<li>If a patient has an order to keep a vein open, or \"TKVO,\" the usual rate of infusion is 20 to 50 ml per hour (Fraser Health Authority, 2014).<\/li>\r\n \t<li>Complications may occur with IV therapy, including but not limited to localized infection, catheter-related bloodstream infection (CR-BSI), fluid overload, and complications related to the type and amount of solution or medication given (Perry et al., 2014).<\/li>\r\n \t<li>For an infusing peripheral IV, the site must be assessed every 2 hours and p.r.n.<\/li>\r\n \t<li>A saline lock site must be assessed every 12 hours and p.r.n.<\/li>\r\n<\/ul>\r\n<h2>Types of Venous Access<\/h2>\r\nSafe and reliable venous access for infusions is a critical component of patient care in the acute and community health setting. There are a variety of options available, and a venous access device must be selected based on the duration of IV therapy, type of medication or solution to be infused, and the needs of the patient.\u00a0In practice, it is important to understand the options of appropriate devices available. This section will describe two types of venous access: peripheral IV access and central venous catheters.\r\n<h3>Peripheral IV<\/h3>\r\nA peripheral IV\u00a0is a common, preferred method for short-term IV therapy in the hospital setting. A <strong>peripheral IV (PIV)<\/strong>\u00a0(see Figure 8.1) is a short intravenous catheter inserted by percutaneous venipuncture into a peripheral vein, held in place with a sterile transparent dressing to keep the site sterile and prevent accidental dislodgement (CDC, 2011). Upper extremities (hands and arms) are the preferred sites for insertion by a specially trained health care provider. If a lower extremity is used, remove the peripheral IV and re-site in the upper extremities as soon as possible (CDC, 2011; McCallum &amp; Higgins, 2012). The hub of a short intravenous catheter is usually attached to IV extension tubing with a positive pressure cap (Fraser Health Authority, 2014).\r\n\r\nPIVs are used for infusions under six days and for solutions that are iso-osmotic or near iso-osmotic (CDC, 2011). They are easy to monitor and can be inserted at the bedside. CDC (2011) recommends that PIVs be replaced every 72 to\u00a096 hours to prevent infection and phlebitis in adults. Most agencies require training to initiate IV therapy, but the care and preparation of equipment, and the maintenance of an IV system can be completed each shift by the trained health care provider. For more information on how to initiate IV therapy, see the resources at the end of the chapter.\r\n\r\n[caption id=\"attachment_6161\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902.jpg\"><img class=\"wp-image-6161 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-300x199.jpg\" alt=\"Saline lock\" width=\"300\" height=\"199\" \/><\/a> Figure 8.1 Peripheral intravenous (IV) catheter (PIV)[\/caption]\r\n\r\nPIVs are prone to phlebitis and infection, and should be removed (CDC, 2011) as follows:\r\n<ul>\r\n \t<li>Every 72 to 96 hours and\u00a0p.r.n.<\/li>\r\n \t<li>As soon as the patient is stable and no longer requires IV fluid therapy<\/li>\r\n \t<li>As soon as the patient is stable following insertion of a cannula in an area of flexion<\/li>\r\n \t<li>Immediately if tenderness, swelling, redness, or purulent drainage occurs at the insertion site<\/li>\r\n \t<li>When the administration set is changed (IV tubing)<\/li>\r\n<\/ul>\r\nSeveral potential complications may arise from peripheral intravenous therapy. It is the responsibility of the health care provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health Authority, 2014; McCallum &amp; Higgins, 2012). Table 8.1 lists the potential local and complications and treatment.\r\n<table style=\"height: 571px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.1 Potential Local Complications of Peripheral IV Therapy<\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><strong>\u00a0Signs, Symptoms, and Treatment<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Phlebitis<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Phlebitis<\/strong> is the inflammation of the vein's inner lining, the tunica intima. Clinical indications are localized redness, pain, heat, and swelling, which can track up the vein leading to a palpable venous cord.\r\n\r\n<strong>Mechanical causes<\/strong>: Inflammation of the vein's inner lining can be caused by the cannula rubbing and irritating the vein.\u00a0It is recommended to use the smallest gauge possible to deliver the medication or required fluids.\r\n\r\n<strong>Chemical causes<\/strong>: Inflammation of the vein's inner lining can be caused by medications with a high alkaline, acidic, or hypertonic solutions. To avoid chemical phlebitis, follow the <em>Parenteral Drug Therapy Manual<\/em> (PDTM) guidelines for administering IV medications for the appropriate amount of solution and rate of infusion.\r\n\r\nTreatment: Immediately remove cannula. May elevate arm or apply a warm compress. Document findings in chart. Initiate a new peripheral IV if necessary.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Infiltration<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Infiltration<\/strong> occurs when a non-vesicant solution (IV solution) is inadvertently administered into surrounding tissue. Signs and symptoms include pain, swelling, redness, skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV site, and frequent alarms on the IV pump.\r\n\r\nTreatment: Stop infusion and remove cannula. Follow agency policy related to infiltration. Always secure peripheral catheter with tape or IV stabilization device to avoid accidental dislodgement. Avoid areas of flexion and always assess IV site prior to giving IV fluids or IV medications.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Extravasation<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Extravasation<\/strong> occurs when vesicant solution (medication) is administered and inadvertently leaks into surrounding tissue, causing damage to surrounding tissue. Characterized by the same signs and symptoms as infiltration but also includes burning, stinging, redness, blistering, or necrosis of the tissue.\r\n\r\nTreatment: Stop infusion and remove cannula. Follow agency policy for extravasation for specific medications. For example, toxic medications have a specific treatment plan.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hemorrhage<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hemorrhage is defined as bleeding from the puncture site.\r\n\r\nTreatment: Apply gauze to the site until the bleeding stops, then apply a sterile transparent dressing.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Local infection at IV site<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Local infection is indicated by purulent drainage from site, usually two to three\u00a0days after an IV site is started.\r\n\r\nTreatment: Remove cannula and clean site using sterile technique. Monitor for signs and symptoms of systemic infection.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fraser Health Authority, 2014; McCallum &amp; Higgins, 2012<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nSystemic complications can occur apart from chemical\u00a0or mechanical complications. To review the systemic complications of IV therapy, see Table 8.2.\r\n<table style=\"height: 571px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.2 Systemic Complications of Peripheral IV Therapy<\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"4\">\r\n<h5>Safety considerations:<\/h5>\r\n<ul>\r\n \t<li>Cardiac and renal patients have increased risk of systemic complications.<\/li>\r\n \t<li>Pediatric patients, neonates, and elderly people\u00a0have increased risk of systemic complications.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\r\n<p style=\"text-align: center;\"><strong>\u00a0Signs, Symptoms and Treatment<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Pulmonary edema<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Pulmonary edema<\/strong>, also known as fluid overload or circulatory overload, is a condition caused by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system. It is characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, and coughing up pinky frothy sputum. Pulmonary edema requires prompt medical attention and treatment. If pulmonary edema is suspected, raise the head of the bed, apply oxygen, take vital signs, complete a cardiovascular assessment, and notify the physician.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Air embolism<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><b>Air embolism<\/b>\u00a0refers to the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and\/or pulmonary circulation. An air embolism is reported to occur more frequently during catheter removal than during insertion, and the administration of up to 10 ml of air has been proven to have serious and fatal effects. Small air bubbles are tolerated by most patients.\r\n\r\nSigns and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension.\r\n\r\nTreatment: Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly.\r\n\r\nTo avoid air embolisms, ensure drip chamber is one-third\u00a0to one-half filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter embolism<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A <strong>catheter embolism<\/strong> occurs when a small part of the cannula breaks off and flows into the vascular system. When removing a peripheral IV cannula, inspect tip to ensure end is intact.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter-related bloodstream infection<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Catheter-related bloodstream infection (CR-BSI)<\/strong> is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial preventable infection and an adverse event.\r\n\r\nCR-BSI is confirmed\u00a0in a patient with a vascular device (or a patient who had such a device in the last 48 hours before the infection) and no apparent source for the infection other than the vascular access device\u00a0with one positive blood culture.\r\n\r\nTreatment: IV antibiotic therapy\r\n\r\nTo avoid CR-BSI, perform hand hygiene prior to care and maintenance of an IV system, and use strict aseptic technique for care and maintenance of all IV therapy procedures.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fraser Health Authority, 2014; Fulcher &amp; Frazier, 2007; McCallum &amp; Higgins, 2012; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3>Central Venous Catheters<\/h3>\r\nA <strong>central venous catheter <\/strong>(CVC) (see Figure 8.2), also known as a central line or central venous access device, is an intravenous catheter that is inserted into a large vein in the central circulation system, where the tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right atrium. CVCs have become common in health care settings for patients who require IV medication administration and other IV treatment requirements. CVCs can remain in place for more than one year. Some CVC devices may be inserted at the bedside, while other central lines are inserted surgically. Central lines are inserted by a physician or specially trained health care provider, and the use of ultrasound guided placement is recommended to reduce time of insertion and complications (Safer Healthcare Now, 2012).\r\n\r\nA CVC has many advantages over a peripheral IV line, including\u00a0the ability to deliver fluids or medications that would be overly irritating to peripheral veins, and the ability to access multiple lumens to deliver multiple medications at the same time (Fraser Health Authority, 2014). Central venous catheters can be inserted percutaneously or surgically through the jugular, subclavian, or femoral veins, or via the chest or upper arm peripheral veins (Perry et al., 2014). Femoral veins are not recommended, as the rate of infection is increased in adults (CDC, 2011; Safer Healthcare Now, 2012).\u00a0To have a CVC inserted or removed, an order by a physician or nurse practitioner must be obtained. Site selection for a CVC may be based on numerous factors, such as the condition of the patient, patient's age, and type and duration of IV therapy.\r\n\r\nThe majority of patients in an ICU will have a CVC to receive fluids and medications. A chest X-ray is given to determine correct placement before inserting, or to confirm a suspected dislodgement (Fraser Health Authority, 2014). An IV pump must be used with all CVCs to prevent complications.\r\n\r\nCVCs are typically inserted for patients requiring more than six\u00a0days of intravenous therapy or who:\r\n<ul>\r\n \t<li>Require antineoplastic medications<\/li>\r\n \t<li>Are seriously or chronically ill<\/li>\r\n \t<li>Require vesicant or irritant medications<\/li>\r\n \t<li>Require\u00a0toxic medications or multiple medications<\/li>\r\n \t<li>Require central venous pressure monitoring<\/li>\r\n \t<li>Require long-term venous access or dialysis<\/li>\r\n \t<li>Require\u00a0total parenteral nutrition<\/li>\r\n \t<li>Require medications with a pH greater than 9 or less than 5, or osmolality of greater than 600mOsm\/L<\/li>\r\n \t<li>Have poor vasculature<\/li>\r\n \t<li>Have had\u00a0multiple PIV insertions\/attempts (e.g., two attempts by two different IV therapy practitioners)<\/li>\r\n<\/ul>\r\n[caption id=\"attachment_6520\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002.jpg\"><img class=\"size-medium wp-image-6520\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-300x199.jpg\" alt=\"Central venous catheter (CVC) prior to insertion\" width=\"300\" height=\"199\" \/><\/a> Figure 8.2 Central venous catheter (CVC) with three lumens[\/caption]\r\n\r\n[caption id=\"attachment_6519\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001.jpg\"><img class=\"size-medium wp-image-6519\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-300x199.jpg\" alt=\"Peripherally inserted central catheter (PICC)\" width=\"300\" height=\"199\" \/><\/a> Figure 8.3 Peripherally inserted central catheter (PICC) with one lumen[\/caption]\r\n\r\nA central line is made up of lumens. A <strong>lumen<\/strong>\u00a0is a small hollow channel within the CVC tube. A CVC may have single, double, triple, or quadruple lumens (Perry et al., 2014). Depending on the type of CVC, it may be internally or externally inserted, and may have an open-ended or valved tip.\u00a0Open-ended devices are those in which the catheter tip is open like a \u201cstraw.\u201d These have a higher risk for complications, such as hemorrhage, air embolism, and occlusion from fibrin or clots. Valved\u00a0devices are those in which the tip is configured with a three-way pressure-activated valve (Perry et al., 2014). It is important to know what type of central line is being used, as this will impact how to care for and manage the equipment for\u00a0specific procedures.\u00a0Table 8.3 lists various types of central lines.\r\n<table style=\"height: 955px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.3 Types of Central Venous Catheters (CVCs)<strong>\u00a0<\/strong><\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"4\">\r\n<h5>Safety considerations:<\/h5>\r\n<ul>\r\n \t<li>CVC care and maintenance requires specialized training to prevent complications.<\/li>\r\n \t<li>Central lines heighten the risk for patients to develop a nosocomial infection. Strict adherence to aseptic technique is required for all CVC care.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td colspan=\"2\">\r\n<h4>Type<\/h4>\r\n<\/td>\r\n<td colspan=\"2\">\r\n<h4>Location and Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Percutaneous central venous catheter (CVC)<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Tip location: The tip of the catheter is located in the SVC. The entry site is the exit site.\r\n\r\nCan be inserted at the bedside by specially trained physician or nurse. The <strong>percutaneous CVC<\/strong> is inserted directly through the skin. The internal or external jugular, subclavian, or femoral vein is used.\r\n\r\nMost commonly used in critically ill patients. Can be used for days to weeks, and the patient must remain in the hospital. Usually held in place with sutures or a manufactured securement device.\r\n\r\n&nbsp;\r\n\r\n[caption id=\"attachment_6789\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter.png\"><img class=\"size-medium wp-image-6789\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-300x231.png\" alt=\"Central venous catheters\" width=\"300\" height=\"231\" \/><\/a> Central venous catheters[\/caption]\r\n\r\n[caption id=\"attachment_6788\" align=\"aligncenter\" width=\"186\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-065-e1443923824140.jpg\"><img class=\"wp-image-6788 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-065-186x300.jpg\" alt=\"Central venous catheter\" width=\"186\" height=\"300\" \/><\/a> Internal jugular venous catheter (upper CVC)[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Peripherally inserted central catheter (PICC)<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Tip location: The tip is located in the SVC.\r\n\r\nA<strong> PICC<\/strong>\u00a0(see Figure 8.3) may be inserted at the bedside, in a home or radiology setting. The line is inserted through the antecubital fossa or upper arm (basilic or cephalic vein) and is threaded the full length until the tip reaches the SVC. Can provide venous access for up to one year. The patient may go home with a PICC. PICCs can easily occlude and may not be used with dilantin IV. It is h<span class=\"item\">eld in place with sutures or a manufactured securement device.<\/span>\r\n\r\n[caption id=\"attachment_6965\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc.png\"><img class=\"wp-image-6965 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-300x247.png\" alt=\"picc\" width=\"300\" height=\"247\" \/><\/a> PICC line inserted in the upper arm (through the basilic vein)[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Subcutaneous or tunnelled central venous catheter<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A<strong> tunnelled CVC<\/strong>, also known as a Hickman, Broviac, or Groshong, is a long-term CVC with a proximal end tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site. Insertion is a surgical procedure, in which the catheter is tunnelled subcutaneously under the skin in the chest area before it enters the SVC. A tunnelled catheter may remain inserted for months to years. These CVCs have a low infection rate due to a<strong>\u00a0Dacron cuff<\/strong>,\u00a0an antimicrobial cuff surrounding the catheter near the entry site, which is coated in antimicrobial solution and holds the catheter in place after two to three\u00a0weeks of insertion.\r\n\r\n[caption id=\"attachment_6873\" align=\"aligncenter\" width=\"225\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device.png\"><img class=\"wp-image-6873\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-290x300.png\" alt=\"tunneled-venous-access-device\" width=\"225\" height=\"233\" \/><\/a> Tunnelled CVC[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Implanted central venous catheter (ICVC, port a cath)<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The <strong>implanted central venous catheter (ICVC)\u00a0<\/strong>is inserted into a vessel, body cavity, or organ and is attached to a reservoir or \"port,\" located under the skin. The ICVC\u00a0is also referred to as a <strong>port a catheter<\/strong> or <strong>port a cath<\/strong>. A surgical procedure is required to insert the device, which is considered permanent. The device may be placed in the chest, abdomen, or inner aspect of the forearms. It is often better for body image. The ICVC\u00a0can be accessed using a non-coring needle. A patient may return home with this type of CVC.\r\n\r\n[caption id=\"attachment_6790\" align=\"aligncenter\" width=\"190\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062.jpg\"><img class=\"size-medium wp-image-6790\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-190x300.jpg\" alt=\"IVAD inserted under the skin\" width=\"190\" height=\"300\" \/><\/a> Chest with ICVC\u00a0inserted[\/caption]\r\n\r\n[caption id=\"attachment_6791\" align=\"aligncenter\" width=\"221\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063.jpg\"><img class=\"size-medium wp-image-6791\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-221x300.jpg\" alt=\"IVAD under the skin\" width=\"221\" height=\"300\" \/><\/a> ICVC\u00a0under the skin[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fulcher &amp; Frazier, 2011; Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nCVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All health care providers require specialized training to care for, manage complications related to, and maintain CVCs as per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For more information on CVC care and maintenance, see the suggested online reference list at the end of this chapter.\r\n\r\nHealth care providers should assess a patient with a central line at the beginning and the end of every shift, and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is functioning correctly. Each assessment should include:\r\n<ul>\r\n \t<li>Type of CVC and insertion date: reason for CVC<\/li>\r\n \t<li>Dressing: is it dry and intact?<\/li>\r\n \t<li>Lines: secure with stat-lock, sutures, or Steri-Strips?<\/li>\r\n \t<li>Review: patient still requires a CVC?<\/li>\r\n \t<li>Insertion site: free from redness, pain, swelling?<\/li>\r\n \t<li>Positive pressure cap: attached securely?<\/li>\r\n \t<li>IV fluids: running through an IV pump?<\/li>\r\n \t<li>Lumens: number of lumens and type of fluids running through each?<\/li>\r\n \t<li>Vital signs: fever?<\/li>\r\n \t<li>Respiratory\/cardiovascular check: any signs and symptoms of fluid overload?<\/li>\r\n<\/ul>\r\nSee Table 8.4 for a list of complications, signs and symptoms, and interventions.\r\n<table style=\"height: 571px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 8.4 Potential Complications with Central Venous Catheters<\/caption>\r\n<tbody>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">\r\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">\r\n<p style=\"text-align: center;\"><strong>\u00a0Signs and Symptoms<\/strong><\/p>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"9\">\u00a0<b>Interventions<\/b><\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Pulmonary edema<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Also known as fluid overload (circulatory overload); characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, coughing up pinky frothy sputum.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Accurate fluid balance assessments, monitor electrolytes and vital signs, provide chest auscultation, elevate head of bed, administer oxygen and diuretic therapy<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Mechanical complications<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">A mechanical complication that mainly occurs during insertion of the CVC due to\u00a0failure to correctly place the catheter, which may lead to asystolic cardiac arrest, bleeding, subcutaneous hematoma, hemothorax, catheter mal-position, or pneumothorax. These complications are usually detected at the time of insertion.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Treatment will be specific to the complication.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter-related bloodstream infection<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Infection is a common complication of indwelling CVCs in patients with a vascular device and no apparent source for the bloodstream infection other than the device.\u00a0Confirmed with one positive blood culture in patients who have had a vascular device implanted within the last 48 hours.\r\n\r\nCatheter-related bloodstream infection (CR-BSI) is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis.\u00a0A CR-BSI is a nosocomial preventable infection and an adverse event.\r\n\r\nSystemic: elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing and cap changes, blood cultures as required, IV antibiotic therapy, remove\/replace catheter, prevent contamination of hub<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Infection at insertion site<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Insertion site may become red, tender, swollen, or have purulent drainage. Monitor blood work and temperature.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Notify physician, clean area using strict aseptic technique, send <strong>C &amp; S swab<\/strong> (swab for bacterial wound culture) as per policy<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter-related thrombosis<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\"><strong>Catheter-related thrombosis (CRT)<\/strong>\u00a0is the development of a blood clot related to long-term CVC use. It mostly occurs in the upper extremities and can lead to further complications, such as pulmonary embolism, post-thrombotic syndrome, and vascular compromise. Symptoms include pain, tenderness to palpation, swelling, edema, warmth, erythema, and development of collateral vessels in the surrounding area.\u00a0Most CRTs are asymptomatic, and prior catheter infections increase the risk for developing a CRT.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Routine flushing with positive pressure, vital signs, repositioning, IV bolus, notify physician, venogram\/X-rays likely; will require anticoagulant therapy and possible removal of the CVC<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Air embolism<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">An air embolism is the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and\/or pulmonary circulation. An air embolism can occur during CVC insertion, while catheter is in place, or at time of removal.\u00a0Administration of up to 10 ml of air has been proven to have serious effects, and is sometimes fatal. Tiny air bubbles are tolerated by most patients.\r\n\r\nSigns and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension. The effects of air embolism depend on the rate and volume of air introduced.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly.\r\n\r\nTo avoid an air embolism, ensure drip chamber is one-third\u00a0to one-half\u00a0filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Occlusions of CVC (mechanical or thrombus)<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Occlusions may be mechanical (<strong>pinch-off syndrome<\/strong>, due to an internal pinching of the central line between the first rib and clavicle), caused by medication (unplanned\/accidental precipitation in the IV line), or from parenteral nutrition (may leave a lipid residue inside the catheter). Thrombus formation (fibrin sheath around the tip of the catheter) may occur as soon as 24 hours after CVC is inserted. Thrombotic occlusions are responsible for approximately 58% of all occlusions. In addition to causing catheter dysfunction, thrombotic occlusions can lead to catheter-related thrombosis. Signs include sluggish flow rate, inability to flush or infuse medications, and frequent downstream occlusion alarms on the EID.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Follow agency-specific guidelines for managing various types of occlusions. Thrombolytic therapy may be initiated.\r\n\r\nDo not flush against resistance, flush well between medications, and always flush using positive pressure through a positive pressure cap.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Damage to CVC line<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">CVCs may become broken or cracked. Assess for pinholes, cracks, or tears during routine care. Assess for drainage after routine care.\r\n\r\nAvoid using sharp objects around CVCs, and only use a needleless device when accessing a central line.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Clamp immediately and seal with a sterile, occlusive dressing to prevent an air embolism, bleeding, or a CR-BSI. The CVC may be repaired or replaced. Notify health care provider promptly. Repair should only be completed by a trained CVC specialist.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter migration<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Patient may experience dysrhythmias caused by tip of the catheter moving from original position to an unwanted position.\u00a0Migration may occur due to increased intrathoracic pressure due to coughing, change in body position, or physical movement (of the arms), sneezing, or weightlifting.<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Call physician and stop all fluid infusions. You may need to pull back on tubing and X-ray CVC again for placement confirmation.\r\n\r\nTape catheter securely using tape and devices.\r\n\r\nDo not pull on central lines; prevent IV lines from being caught on other equipment.<\/td>\r\n<\/tr>\r\n<tr style=\"border: 1px solid #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"18\">Data source: Baskin et al., 2009; BCIT, 2015a; Brunce, 2003; Fraser Health Authority, 2014; Perry et al., 2014; Prabaharan &amp; Thomas, 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<ol>\r\n \t<li>What is the difference between a non-tunnelled (percutaneous) catheter and a tunnelled catheter?<\/li>\r\n \t<li>Name three advantages and three disadvantages of a central line.<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>","rendered":"<p><strong>Intravenous therapy<\/strong> is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein (Perry, Potter, &amp; Ostendorf, 2014).<b>\u00a0<\/b>Intravenous therapy is an effective and fast-acting way to administer fluid or medication treatment in an emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous therapy.<\/p>\n<p>The most common reasons for IV therapy (Waitt, Waitt, &amp; Pirmohamed, 2004) include:<\/p>\n<ol>\n<li>To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body&#8217;s fluid balance is regulated through hormones and is affected by fluid volumes, distribution of fluids in the body, and the concentration of solutes in the fluid. If a patient is ill and has fluid loss related to decreased intake, surgery, vomiting, diarrhea, or diaphoresis, the patient may require IV therapy.<\/li>\n<li>To administer medications, including chemotherapy, anesthetics, and diagnostic reagants: About 40% of all antibiotics are given intravenously.<\/li>\n<li>To administer blood or blood products: The donated blood from another individual can be used in surgery, to treat medical conditions such as\u00a0shock or trauma, or to treat a failure in the production of red blood cells. The infusion restores circulating volumes, improving the ability to carry oxygen and replace blood components that are deficient in the body.<\/li>\n<li>To deliver nutrients and nutritional supplements: IV therapy can deliver some or all of the nutritional requirements for patients unable to obtain adequate amounts orally or by other routes.<\/li>\n<\/ol>\n<h2>Guidelines Related to Intravenous Therapy<\/h2>\n<p>The following are general guidelines for peripheral IV therapy:<\/p>\n<ul>\n<li>IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of solution or medication, rate of infusion, duration, date, and time. IV therapy may be for short or long duration, depending on the needs of the patient (Perry et al, 2014).<\/li>\n<li>IV therapy is an invasive procedure, and therefore significant complications can occur if the wrong amount of IV fluids or the incorrect medication is given.<\/li>\n<li>Aseptic technique must be maintained throughout all IV therapy procedures, including initiation of IV therapy, preparing and maintaining equipment, and discontinuing an IV system.\u00a0Always perform hand hygiene before handling all IV equipment.\u00a0If an administration set or solution becomes contaminated with a non-sterile surface, it should be replaced with a new one to prevent introducing bacteria or other contaminants into the system (Centers for Disease Control [CDC], 2011).<\/li>\n<li>Understand the indications and duration for IV therapy for each patient. Practice guidelines recommend that patients receiving IV therapy for more than six\u00a0days should be assessed for an intermediate or long-term device (CDC, 2011).<\/li>\n<li>If a patient has an order to keep a vein open, or &#8220;TKVO,&#8221; the usual rate of infusion is 20 to 50 ml per hour (Fraser Health Authority, 2014).<\/li>\n<li>Complications may occur with IV therapy, including but not limited to localized infection, catheter-related bloodstream infection (CR-BSI), fluid overload, and complications related to the type and amount of solution or medication given (Perry et al., 2014).<\/li>\n<li>For an infusing peripheral IV, the site must be assessed every 2 hours and p.r.n.<\/li>\n<li>A saline lock site must be assessed every 12 hours and p.r.n.<\/li>\n<\/ul>\n<h2>Types of Venous Access<\/h2>\n<p>Safe and reliable venous access for infusions is a critical component of patient care in the acute and community health setting. There are a variety of options available, and a venous access device must be selected based on the duration of IV therapy, type of medication or solution to be infused, and the needs of the patient.\u00a0In practice, it is important to understand the options of appropriate devices available. This section will describe two types of venous access: peripheral IV access and central venous catheters.<\/p>\n<h3>Peripheral IV<\/h3>\n<p>A peripheral IV\u00a0is a common, preferred method for short-term IV therapy in the hospital setting. A <strong>peripheral IV (PIV)<\/strong>\u00a0(see Figure 8.1) is a short intravenous catheter inserted by percutaneous venipuncture into a peripheral vein, held in place with a sterile transparent dressing to keep the site sterile and prevent accidental dislodgement (CDC, 2011). Upper extremities (hands and arms) are the preferred sites for insertion by a specially trained health care provider. If a lower extremity is used, remove the peripheral IV and re-site in the upper extremities as soon as possible (CDC, 2011; McCallum &amp; Higgins, 2012). The hub of a short intravenous catheter is usually attached to IV extension tubing with a positive pressure cap (Fraser Health Authority, 2014).<\/p>\n<p>PIVs are used for infusions under six days and for solutions that are iso-osmotic or near iso-osmotic (CDC, 2011). They are easy to monitor and can be inserted at the bedside. CDC (2011) recommends that PIVs be replaced every 72 to\u00a096 hours to prevent infection and phlebitis in adults. Most agencies require training to initiate IV therapy, but the care and preparation of equipment, and the maintenance of an IV system can be completed each shift by the trained health care provider. For more information on how to initiate IV therapy, see the resources at the end of the chapter.<\/p>\n<figure id=\"attachment_6161\" aria-describedby=\"caption-attachment-6161\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6161 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-300x199.jpg\" alt=\"Saline lock\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0902-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6161\" class=\"wp-caption-text\">Figure 8.1 Peripheral intravenous (IV) catheter (PIV)<\/figcaption><\/figure>\n<p>PIVs are prone to phlebitis and infection, and should be removed (CDC, 2011) as follows:<\/p>\n<ul>\n<li>Every 72 to 96 hours and\u00a0p.r.n.<\/li>\n<li>As soon as the patient is stable and no longer requires IV fluid therapy<\/li>\n<li>As soon as the patient is stable following insertion of a cannula in an area of flexion<\/li>\n<li>Immediately if tenderness, swelling, redness, or purulent drainage occurs at the insertion site<\/li>\n<li>When the administration set is changed (IV tubing)<\/li>\n<\/ul>\n<p>Several potential complications may arise from peripheral intravenous therapy. It is the responsibility of the health care provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health Authority, 2014; McCallum &amp; Higgins, 2012). Table 8.1 lists the potential local and complications and treatment.<\/p>\n<table style=\"height: 571px; width: 100%;\">\n<caption>Table 8.1 Potential Local Complications of Peripheral IV Therapy<\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><strong>\u00a0Signs, Symptoms, and Treatment<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Phlebitis<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Phlebitis<\/strong> is the inflammation of the vein&#8217;s inner lining, the tunica intima. Clinical indications are localized redness, pain, heat, and swelling, which can track up the vein leading to a palpable venous cord.<\/p>\n<p><strong>Mechanical causes<\/strong>: Inflammation of the vein&#8217;s inner lining can be caused by the cannula rubbing and irritating the vein.\u00a0It is recommended to use the smallest gauge possible to deliver the medication or required fluids.<\/p>\n<p><strong>Chemical causes<\/strong>: Inflammation of the vein&#8217;s inner lining can be caused by medications with a high alkaline, acidic, or hypertonic solutions. To avoid chemical phlebitis, follow the <em>Parenteral Drug Therapy Manual<\/em> (PDTM) guidelines for administering IV medications for the appropriate amount of solution and rate of infusion.<\/p>\n<p>Treatment: Immediately remove cannula. May elevate arm or apply a warm compress. Document findings in chart. Initiate a new peripheral IV if necessary.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Infiltration<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Infiltration<\/strong> occurs when a non-vesicant solution (IV solution) is inadvertently administered into surrounding tissue. Signs and symptoms include pain, swelling, redness, skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV site, and frequent alarms on the IV pump.<\/p>\n<p>Treatment: Stop infusion and remove cannula. Follow agency policy related to infiltration. Always secure peripheral catheter with tape or IV stabilization device to avoid accidental dislodgement. Avoid areas of flexion and always assess IV site prior to giving IV fluids or IV medications.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Extravasation<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Extravasation<\/strong> occurs when vesicant solution (medication) is administered and inadvertently leaks into surrounding tissue, causing damage to surrounding tissue. Characterized by the same signs and symptoms as infiltration but also includes burning, stinging, redness, blistering, or necrosis of the tissue.<\/p>\n<p>Treatment: Stop infusion and remove cannula. Follow agency policy for extravasation for specific medications. For example, toxic medications have a specific treatment plan.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hemorrhage<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Hemorrhage is defined as bleeding from the puncture site.<\/p>\n<p>Treatment: Apply gauze to the site until the bleeding stops, then apply a sterile transparent dressing.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Local infection at IV site<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Local infection is indicated by purulent drainage from site, usually two to three\u00a0days after an IV site is started.<\/p>\n<p>Treatment: Remove cannula and clean site using sterile technique. Monitor for signs and symptoms of systemic infection.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fraser Health Authority, 2014; McCallum &amp; Higgins, 2012<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Systemic complications can occur apart from chemical\u00a0or mechanical complications. To review the systemic complications of IV therapy, see Table 8.2.<\/p>\n<table style=\"height: 571px; width: 100%;\">\n<caption>Table 8.2 Systemic Complications of Peripheral IV Therapy<\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"4\">\n<h5>Safety considerations:<\/h5>\n<ul>\n<li>Cardiac and renal patients have increased risk of systemic complications.<\/li>\n<li>Pediatric patients, neonates, and elderly people\u00a0have increased risk of systemic complications.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">\n<p style=\"text-align: center;\"><strong>\u00a0Signs, Symptoms and Treatment<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Pulmonary edema<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Pulmonary edema<\/strong>, also known as fluid overload or circulatory overload, is a condition caused by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system. It is characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, and coughing up pinky frothy sputum. Pulmonary edema requires prompt medical attention and treatment. If pulmonary edema is suspected, raise the head of the bed, apply oxygen, take vital signs, complete a cardiovascular assessment, and notify the physician.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Air embolism<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><b>Air embolism<\/b>\u00a0refers to the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and\/or pulmonary circulation. An air embolism is reported to occur more frequently during catheter removal than during insertion, and the administration of up to 10 ml of air has been proven to have serious and fatal effects. Small air bubbles are tolerated by most patients.<\/p>\n<p>Signs and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension.<\/p>\n<p>Treatment: Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly.<\/p>\n<p>To avoid air embolisms, ensure drip chamber is one-third\u00a0to one-half filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter embolism<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A <strong>catheter embolism<\/strong> occurs when a small part of the cannula breaks off and flows into the vascular system. When removing a peripheral IV cannula, inspect tip to ensure end is intact.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Catheter-related bloodstream infection<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\"><strong>Catheter-related bloodstream infection (CR-BSI)<\/strong> is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial preventable infection and an adverse event.<\/p>\n<p>CR-BSI is confirmed\u00a0in a patient with a vascular device (or a patient who had such a device in the last 48 hours before the infection) and no apparent source for the infection other than the vascular access device\u00a0with one positive blood culture.<\/p>\n<p>Treatment: IV antibiotic therapy<\/p>\n<p>To avoid CR-BSI, perform hand hygiene prior to care and maintenance of an IV system, and use strict aseptic technique for care and maintenance of all IV therapy procedures.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fraser Health Authority, 2014; Fulcher &amp; Frazier, 2007; McCallum &amp; Higgins, 2012; Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>Central Venous Catheters<\/h3>\n<p>A <strong>central venous catheter <\/strong>(CVC) (see Figure 8.2), also known as a central line or central venous access device, is an intravenous catheter that is inserted into a large vein in the central circulation system, where the tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right atrium. CVCs have become common in health care settings for patients who require IV medication administration and other IV treatment requirements. CVCs can remain in place for more than one year. Some CVC devices may be inserted at the bedside, while other central lines are inserted surgically. Central lines are inserted by a physician or specially trained health care provider, and the use of ultrasound guided placement is recommended to reduce time of insertion and complications (Safer Healthcare Now, 2012).<\/p>\n<p>A CVC has many advantages over a peripheral IV line, including\u00a0the ability to deliver fluids or medications that would be overly irritating to peripheral veins, and the ability to access multiple lumens to deliver multiple medications at the same time (Fraser Health Authority, 2014). Central venous catheters can be inserted percutaneously or surgically through the jugular, subclavian, or femoral veins, or via the chest or upper arm peripheral veins (Perry et al., 2014). Femoral veins are not recommended, as the rate of infection is increased in adults (CDC, 2011; Safer Healthcare Now, 2012).\u00a0To have a CVC inserted or removed, an order by a physician or nurse practitioner must be obtained. Site selection for a CVC may be based on numerous factors, such as the condition of the patient, patient&#8217;s age, and type and duration of IV therapy.<\/p>\n<p>The majority of patients in an ICU will have a CVC to receive fluids and medications. A chest X-ray is given to determine correct placement before inserting, or to confirm a suspected dislodgement (Fraser Health Authority, 2014). An IV pump must be used with all CVCs to prevent complications.<\/p>\n<p>CVCs are typically inserted for patients requiring more than six\u00a0days of intravenous therapy or who:<\/p>\n<ul>\n<li>Require antineoplastic medications<\/li>\n<li>Are seriously or chronically ill<\/li>\n<li>Require vesicant or irritant medications<\/li>\n<li>Require\u00a0toxic medications or multiple medications<\/li>\n<li>Require central venous pressure monitoring<\/li>\n<li>Require long-term venous access or dialysis<\/li>\n<li>Require\u00a0total parenteral nutrition<\/li>\n<li>Require medications with a pH greater than 9 or less than 5, or osmolality of greater than 600mOsm\/L<\/li>\n<li>Have poor vasculature<\/li>\n<li>Have had\u00a0multiple PIV insertions\/attempts (e.g., two attempts by two different IV therapy practitioners)<\/li>\n<\/ul>\n<figure id=\"attachment_6520\" aria-describedby=\"caption-attachment-6520\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6520\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-300x199.jpg\" alt=\"Central venous catheter (CVC) prior to insertion\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-002-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6520\" class=\"wp-caption-text\">Figure 8.2 Central venous catheter (CVC) with three lumens<\/figcaption><\/figure>\n<figure id=\"attachment_6519\" aria-describedby=\"caption-attachment-6519\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6519\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-300x199.jpg\" alt=\"Peripherally inserted central catheter (PICC)\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-001-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6519\" class=\"wp-caption-text\">Figure 8.3 Peripherally inserted central catheter (PICC) with one lumen<\/figcaption><\/figure>\n<p>A central line is made up of lumens. A <strong>lumen<\/strong>\u00a0is a small hollow channel within the CVC tube. A CVC may have single, double, triple, or quadruple lumens (Perry et al., 2014). Depending on the type of CVC, it may be internally or externally inserted, and may have an open-ended or valved tip.\u00a0Open-ended devices are those in which the catheter tip is open like a \u201cstraw.\u201d These have a higher risk for complications, such as hemorrhage, air embolism, and occlusion from fibrin or clots. Valved\u00a0devices are those in which the tip is configured with a three-way pressure-activated valve (Perry et al., 2014). It is important to know what type of central line is being used, as this will impact how to care for and manage the equipment for\u00a0specific procedures.\u00a0Table 8.3 lists various types of central lines.<\/p>\n<table style=\"height: 955px; width: 100%;\">\n<caption>Table 8.3 Types of Central Venous Catheters (CVCs)<strong>\u00a0<\/strong><\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"4\">\n<h5>Safety considerations:<\/h5>\n<ul>\n<li>CVC care and maintenance requires specialized training to prevent complications.<\/li>\n<li>Central lines heighten the risk for patients to develop a nosocomial infection. Strict adherence to aseptic technique is required for all CVC care.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td colspan=\"2\">\n<h4>Type<\/h4>\n<\/td>\n<td colspan=\"2\">\n<h4>Location and Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Percutaneous central venous catheter (CVC)<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Tip location: The tip of the catheter is located in the SVC. The entry site is the exit site.<\/p>\n<p>Can be inserted at the bedside by specially trained physician or nurse. The <strong>percutaneous CVC<\/strong> is inserted directly through the skin. The internal or external jugular, subclavian, or femoral vein is used.<\/p>\n<p>Most commonly used in critically ill patients. Can be used for days to weeks, and the patient must remain in the hospital. Usually held in place with sutures or a manufactured securement device.<\/p>\n<p>&nbsp;<\/p>\n<figure id=\"attachment_6789\" aria-describedby=\"caption-attachment-6789\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter.png\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6789\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-300x231.png\" alt=\"Central venous catheters\" width=\"300\" height=\"231\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-300x231.png 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-65x50.png 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-225x173.png 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter-350x269.png 350w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/central-venous-catheter.png 927w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6789\" class=\"wp-caption-text\">Central venous catheters<\/figcaption><\/figure>\n<figure id=\"attachment_6788\" aria-describedby=\"caption-attachment-6788\" style=\"width: 186px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-065-e1443923824140.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6788 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-065-186x300.jpg\" alt=\"Central venous catheter\" width=\"186\" height=\"300\" \/><\/a><figcaption id=\"caption-attachment-6788\" class=\"wp-caption-text\">Internal jugular venous catheter (upper CVC)<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Peripherally inserted central catheter (PICC)<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Tip location: The tip is located in the SVC.<\/p>\n<p>A<strong> PICC<\/strong>\u00a0(see Figure 8.3) may be inserted at the bedside, in a home or radiology setting. The line is inserted through the antecubital fossa or upper arm (basilic or cephalic vein) and is threaded the full length until the tip reaches the SVC. Can provide venous access for up to one year. The patient may go home with a PICC. PICCs can easily occlude and may not be used with dilantin IV. It is h<span class=\"item\">eld in place with sutures or a manufactured securement device.<\/span><\/p>\n<figure id=\"attachment_6965\" aria-describedby=\"caption-attachment-6965\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6965 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-300x247.png\" alt=\"picc\" width=\"300\" height=\"247\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-300x247.png 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-65x54.png 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-225x185.png 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc-350x288.png 350w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/picc.png 811w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6965\" class=\"wp-caption-text\">PICC line inserted in the upper arm (through the basilic vein)<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Subcutaneous or tunnelled central venous catheter<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">A<strong> tunnelled CVC<\/strong>, also known as a Hickman, Broviac, or Groshong, is a long-term CVC with a proximal end tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site. Insertion is a surgical procedure, in which the catheter is tunnelled subcutaneously under the skin in the chest area before it enters the SVC. A tunnelled catheter may remain inserted for months to years. These CVCs have a low infection rate due to a<strong>\u00a0Dacron cuff<\/strong>,\u00a0an antimicrobial cuff surrounding the catheter near the entry site, which is coated in antimicrobial solution and holds the catheter in place after two to three\u00a0weeks of insertion.<\/p>\n<figure id=\"attachment_6873\" aria-describedby=\"caption-attachment-6873\" style=\"width: 225px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6873\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-290x300.png\" alt=\"tunneled-venous-access-device\" width=\"225\" height=\"233\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-290x300.png 290w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-65x67.png 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-225x233.png 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device-350x362.png 350w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/tunneled-venous-access-device.png 646w\" sizes=\"auto, (max-width: 225px) 100vw, 225px\" \/><\/a><figcaption id=\"caption-attachment-6873\" class=\"wp-caption-text\">Tunnelled CVC<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Implanted central venous catheter (ICVC, port a cath)<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The <strong>implanted central venous catheter (ICVC)\u00a0<\/strong>is inserted into a vessel, body cavity, or organ and is attached to a reservoir or &#8220;port,&#8221; located under the skin. The ICVC\u00a0is also referred to as a <strong>port a catheter<\/strong> or <strong>port a cath<\/strong>. A surgical procedure is required to insert the device, which is considered permanent. The device may be placed in the chest, abdomen, or inner aspect of the forearms. It is often better for body image. The ICVC\u00a0can be accessed using a non-coring needle. A patient may return home with this type of CVC.<\/p>\n<figure id=\"attachment_6790\" aria-describedby=\"caption-attachment-6790\" style=\"width: 190px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6790\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-190x300.jpg\" alt=\"IVAD inserted under the skin\" width=\"190\" height=\"300\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-190x300.jpg 190w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062.jpg 650w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-65x102.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-225x354.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-062-350x551.jpg 350w\" sizes=\"auto, (max-width: 190px) 100vw, 190px\" \/><\/a><figcaption id=\"caption-attachment-6790\" class=\"wp-caption-text\">Chest with ICVC\u00a0inserted<\/figcaption><\/figure>\n<figure id=\"attachment_6791\" aria-describedby=\"caption-attachment-6791\" style=\"width: 221px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6791\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-221x300.jpg\" alt=\"IVAD under the skin\" width=\"221\" height=\"300\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-221x300.jpg 221w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063.jpg 753w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-65x88.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-225x306.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Oct-2-2015-063-350x476.jpg 350w\" sizes=\"auto, (max-width: 221px) 100vw, 221px\" \/><\/a><figcaption id=\"caption-attachment-6791\" class=\"wp-caption-text\">ICVC\u00a0under the skin<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Data source: Fulcher &amp; Frazier, 2011; Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>CVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All health care providers require specialized training to care for, manage complications related to, and maintain CVCs as per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For more information on CVC care and maintenance, see the suggested online reference list at the end of this chapter.<\/p>\n<p>Health care providers should assess a patient with a central line at the beginning and the end of every shift, and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is functioning correctly. Each assessment should include:<\/p>\n<ul>\n<li>Type of CVC and insertion date: reason for CVC<\/li>\n<li>Dressing: is it dry and intact?<\/li>\n<li>Lines: secure with stat-lock, sutures, or Steri-Strips?<\/li>\n<li>Review: patient still requires a CVC?<\/li>\n<li>Insertion site: free from redness, pain, swelling?<\/li>\n<li>Positive pressure cap: attached securely?<\/li>\n<li>IV fluids: running through an IV pump?<\/li>\n<li>Lumens: number of lumens and type of fluids running through each?<\/li>\n<li>Vital signs: fever?<\/li>\n<li>Respiratory\/cardiovascular check: any signs and symptoms of fluid overload?<\/li>\n<\/ul>\n<p>See Table 8.4 for a list of complications, signs and symptoms, and interventions.<\/p>\n<table style=\"height: 571px; width: 100%;\">\n<caption>Table 8.4 Potential Complications with Central Venous Catheters<\/caption>\n<tbody>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">\n<p style=\"text-align: center;\"><b>Complication<\/b><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">\n<p style=\"text-align: center;\"><strong>\u00a0Signs and Symptoms<\/strong><\/p>\n<\/td>\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"9\">\u00a0<b>Interventions<\/b><\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Pulmonary edema<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Also known as fluid overload (circulatory overload); characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, coughing up pinky frothy sputum.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Accurate fluid balance assessments, monitor electrolytes and vital signs, provide chest auscultation, elevate head of bed, administer oxygen and diuretic therapy<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Mechanical complications<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">A mechanical complication that mainly occurs during insertion of the CVC due to\u00a0failure to correctly place the catheter, which may lead to asystolic cardiac arrest, bleeding, subcutaneous hematoma, hemothorax, catheter mal-position, or pneumothorax. These complications are usually detected at the time of insertion.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Treatment will be specific to the complication.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter-related bloodstream infection<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Infection is a common complication of indwelling CVCs in patients with a vascular device and no apparent source for the bloodstream infection other than the device.\u00a0Confirmed with one positive blood culture in patients who have had a vascular device implanted within the last 48 hours.<\/p>\n<p>Catheter-related bloodstream infection (CR-BSI) is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis.\u00a0A CR-BSI is a nosocomial preventable infection and an adverse event.<\/p>\n<p>Systemic: elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing and cap changes, blood cultures as required, IV antibiotic therapy, remove\/replace catheter, prevent contamination of hub<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Infection at insertion site<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Insertion site may become red, tender, swollen, or have purulent drainage. Monitor blood work and temperature.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Notify physician, clean area using strict aseptic technique, send <strong>C &amp; S swab<\/strong> (swab for bacterial wound culture) as per policy<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter-related thrombosis<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\"><strong>Catheter-related thrombosis (CRT)<\/strong>\u00a0is the development of a blood clot related to long-term CVC use. It mostly occurs in the upper extremities and can lead to further complications, such as pulmonary embolism, post-thrombotic syndrome, and vascular compromise. Symptoms include pain, tenderness to palpation, swelling, edema, warmth, erythema, and development of collateral vessels in the surrounding area.\u00a0Most CRTs are asymptomatic, and prior catheter infections increase the risk for developing a CRT.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Routine flushing with positive pressure, vital signs, repositioning, IV bolus, notify physician, venogram\/X-rays likely; will require anticoagulant therapy and possible removal of the CVC<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Air embolism<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">An air embolism is the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and\/or pulmonary circulation. An air embolism can occur during CVC insertion, while catheter is in place, or at time of removal.\u00a0Administration of up to 10 ml of air has been proven to have serious effects, and is sometimes fatal. Tiny air bubbles are tolerated by most patients.<\/p>\n<p>Signs and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension. The effects of air embolism depend on the rate and volume of air introduced.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly.<\/p>\n<p>To avoid an air embolism, ensure drip chamber is one-third\u00a0to one-half\u00a0filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Occlusions of CVC (mechanical or thrombus)<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Occlusions may be mechanical (<strong>pinch-off syndrome<\/strong>, due to an internal pinching of the central line between the first rib and clavicle), caused by medication (unplanned\/accidental precipitation in the IV line), or from parenteral nutrition (may leave a lipid residue inside the catheter). Thrombus formation (fibrin sheath around the tip of the catheter) may occur as soon as 24 hours after CVC is inserted. Thrombotic occlusions are responsible for approximately 58% of all occlusions. In addition to causing catheter dysfunction, thrombotic occlusions can lead to catheter-related thrombosis. Signs include sluggish flow rate, inability to flush or infuse medications, and frequent downstream occlusion alarms on the EID.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Follow agency-specific guidelines for managing various types of occlusions. Thrombolytic therapy may be initiated.<\/p>\n<p>Do not flush against resistance, flush well between medications, and always flush using positive pressure through a positive pressure cap.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Damage to CVC line<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">CVCs may become broken or cracked. Assess for pinholes, cracks, or tears during routine care. Assess for drainage after routine care.<\/p>\n<p>Avoid using sharp objects around CVCs, and only use a needleless device when accessing a central line.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Clamp immediately and seal with a sterile, occlusive dressing to prevent an air embolism, bleeding, or a CR-BSI. The CVC may be repaired or replaced. Notify health care provider promptly. Repair should only be completed by a trained CVC specialist.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"4\">Catheter migration<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">Patient may experience dysrhythmias caused by tip of the catheter moving from original position to an unwanted position.\u00a0Migration may occur due to increased intrathoracic pressure due to coughing, change in body position, or physical movement (of the arms), sneezing, or weightlifting.<\/td>\n<td style=\"border: 1px solid #000000; text-align: left;\" colspan=\"9\">Call physician and stop all fluid infusions. You may need to pull back on tubing and X-ray CVC again for placement confirmation.<\/p>\n<p>Tape catheter securely using tape and devices.<\/p>\n<p>Do not pull on central lines; prevent IV lines from being caught on other equipment.<\/td>\n<\/tr>\n<tr style=\"border: 1px solid #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"18\">Data source: Baskin et al., 2009; BCIT, 2015a; Brunce, 2003; Fraser Health Authority, 2014; Perry et al., 2014; Prabaharan &amp; Thomas, 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\n<\/header>\n<div class=\"textbox__content\">\n<ol>\n<li>What is the difference between a non-tunnelled (percutaneous) catheter and a tunnelled catheter?<\/li>\n<li>Name three advantages and three disadvantages of a central line.<\/li>\n<\/ol>\n<\/div>\n<\/div>\n","protected":false},"author":5,"menu_order":2,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3537","chapter","type-chapter","status-publish","hentry"],"part":3534,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3537","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":30,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3537\/revisions"}],"predecessor-version":[{"id":10163,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3537\/revisions\/10163"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/3534"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3537\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=3537"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=3537"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=3537"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=3537"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}