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Central Lines — Transcript

by Trinity Pullam · 7,010 words · 999 segments · language en · Watch on YouTube

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0:04hello everyone this is your PowerPoint
0:06on Central
0:08Line uh so first of all there's several
0:11different reasons why a patient might
0:12need Central lines um maybe the patient
0:16needs multiple IV sites and in order to
0:20maintain adequate access they may need
0:22to put in a central line uh maybe they
0:25have poor peripheral IV site Choice I've
0:28had this with multiple clients that were
0:29just not able to get an adequate or
0:32large enough catheter peripherally so a
0:34central line needs to be placed in uh
0:38the client uh they may need Central
0:40Venus pressure monitoring and central
0:42line can um offer us that
0:45option the patient may require tpn and
0:49as a tpn has a hyper um osmolar presence
0:54it can cause irritation to the
0:55peripheral vein so we always want to
0:57make sure that we're using a um central
1:00line with that um maybe the patient has
1:03multiple incompatible medications and
1:05the use of the central line allows us to
1:08administer those medications at the same
1:10time because they will not be inter um
1:13intertwining or interacting with each
1:15other in that way um if they just have a
1:18lot of fluids medicines um different
1:21things that they need to require or
1:23patients that are on chemotherapy a
1:25central line can be used for that um
1:27Central lines are often used for
1:28patients that need on going antibiotic
1:30therapy because you can put um a line in
1:33and it can be maintained way more or for
1:37way more time than a peripheral line can
1:38be maintained um and some of them can be
1:41maintained for years even if a patient
1:43gets frequent lab draws this is going to
1:46save them from sticks um frequent blood
1:48transfusion that gives us an access that
1:51is always uh large enough and available
1:54and then they can be used temporarily
1:56for hemodialysis access as well and some
1:59of you have probably seen um some
2:01clients that have some
2:02temporary um access um where it'll be
2:07like do not touch because it they're
2:08going to go to dialysis with that and
2:10then um eventually they will put in the
2:13The
2:17graft so um when you hear the term
2:21central line a non tunnel percutaneous
2:24Central Venus catheter is what you are
2:26typically thinking of these are the
2:28lines that are put in at the bedside um
2:31non- tunnel just means they insert it
2:34directly into that vein they don't
2:36tunnel tunnel it underneath the skin at
2:38all so the insertion site is open to air
2:41at that point um a physician must put in
2:45the central line and that can be i' I've
2:47seen um General
2:49Practitioners um er doctors surgeons so
2:52a lot of different types of Physicians
2:53as long as they're trained in it can
2:55insert it um there is a measurement
2:57usually it's 7 to 10 in um and you can
3:01have one to five lumens you want to use
3:05the least amount of lumens um that is
3:08necessary but you will find a lot of
3:10facilities only carry one or two types
3:12of central lines so often uh when you
3:15work at one you're like oh it's going to
3:16have three lumens because that is really
3:18what that facility carries most
3:20often uh you'll see them used a lot in
3:22trauma Critical Care patients that need
3:25surgery um just so that they can have
3:27that um available access are more short
3:30term they should only be in for a couple
3:32of weeks um so it's longer than a
3:36peripheral line but um after a few weeks
3:38the patient becomes at that very
3:40increased risk for of infection because
3:42remember we have this access site
3:44basically open to air to this very large
3:48vein um and so that vein you've had a
3:52catheter in there tunneling it causing
3:54irritation and then we have um that
3:57access and so we just put at a lot of
3:58increased risk for in infection the
4:00longer that would stay uh typically the
4:03one we they try to get them in the um
4:06internal jugular vein subclavian vein
4:08and then if they're um if they need an
4:11access that they can't get into those
4:13you may see in the femoral vein um the
4:15femoral veins are going to put you at a
4:17little bit higher risk of infection
4:18though because um just because of the
4:22area where the P where the the uh it's
4:26in the grind so just because of the area
4:28we're going to be
4:30um at risk for
4:33contamination so uh with the
4:35non-tunneled insertion uh these are once
4:39again going to be inserted by a
4:40physician not a nurse but the nurse will
4:42be at the bedside assisting so prior to
4:46any insertion we need informed consent
4:48it is a considered it is considered a
4:50surgical procedure even though it's at
4:52the bedside it's still a surgical
4:53procedure so the patient needs informed
4:55consent there are risk involved um
4:58specifically the two major ones that
5:00come to mind or the risk for an air
5:02embolism because we are um inserting
5:05something into a very large vein and the
5:09uh risk
5:10for
5:12um aumo thorax because if if that um
5:17catheter were to um puncture an area of
5:21the lung then we could have a
5:23pneumothorax that has occurred and I've
5:24actually seen that happen before um with
5:27the patient and they had the
5:28subcutaneous empys
5:30um that you could F underneath it and
5:32also of course the risk for infection
5:34that comes along with it for all
5:37clients it can be performed at the
5:39bedside when a patient is getting the
5:42procedure you want their head down for
5:44the insertion that's going to decrease
5:46our risk for that air embolism so you
5:49want their head down or their
5:51sepine um it
5:53is obviously you can do it at the
5:55bedside but it is a sterile technique so
5:58anyone that's in the room room will
6:00perform surgical scrub um and then they
6:03will wear a surgical gown uh sterile
6:06gloves a mask and a hat to cover any
6:10hair uh the patient themselves will be
6:13draped from head to toe with sterile
6:16drapes so that um only the area that
6:19we're working on is what is left open
6:22and actually before you drape them
6:24because you have to prep it um you would
6:26prep the skin with chlorexidine uh
6:28gluconate solution
6:30which is just like a chlorexidine mixed
6:32with 70% alcohol solution um D or Duro
6:37prep um and you would just prep that
6:39area and then you would make sure that
6:40you allow that to dry before the
6:42physician inserts because that allowing
6:44it to dry is what's killing off all of
6:47the organisms and then so after you
6:49would prep it that's when you would
6:51actually put the drapes on um so once
6:54that's inserted The Physician will
6:56either suture the site down onto the
6:58chest area or they will use a sutus
7:01device and then that sutus device um is
7:04taped down to um or is taped on the skin
7:06and holds it in place um the most common
7:09one that we see is a stat
7:11lock the uh site should be covered in a
7:14transparent moisture permeable sterile
7:16dressing so it does allow the moisture
7:19to get out so you don't get a fungus or
7:21something underneath there but it's
7:23transparent so we can actually visualize
7:25the site and look for the signs of
7:26infection that can
7:28occur um
7:30the site cannot be used until a chest
7:33x-ray has been completed and confirms
7:35the placement so once we get that chess
7:37x-ray they'll confirm the placement and
7:39then we'll be able to give uh whatever
7:42medications um in the case where it's
7:44not quite in the right place sometimes
7:47uh The Physician will come in and like
7:48pull it out a a certain centimeters
7:51based on what the radiologist tells them
7:53or um you know sometimes they have to be
7:56redone um but typically it's a pretty
7:58easy fit because um it it will be there
8:02it just may have be like a little bit
8:04far or something um and then make sure
8:07that once this is done the insertion
8:08date insertion type the type of this
8:11device and the lot number is recorded in
8:13the patient's medical
8:16record so that was a central line
8:19non-tunneled central line that we were
8:21talking about that has to be inserted by
8:23um The phys Physician but now we're
8:26going to talk about a peripherally
8:28inserted Central C ceter or a pick line
8:31so I'm sure a lot of you have seen these
8:32pick lines um these can actually be
8:35inserted by physicians or specially
8:37trained nurses um so they have to go
8:39through a certification in order to
8:41insert it but it can be a registered
8:43nurse it is a long catheter that gets
8:46inserted into the anticubital area of
8:49the arm and either the basilic vein or
8:51the calic vein um the uh length of it is
8:57deter they do some measurements where
9:00they actually pull it up your arm and
9:02they look at your I don't even have
9:03those as um a requirement for you but
9:06they do a special measurement before
9:09they put it in that tells them how much
9:11length uh to basically aim for um the
9:15pick lines are 1 to three lumens so once
9:17again it just depends on the provider
9:20but you want to use the least amount of
9:22lumens necessary because if you have
9:23more lumens you have more access site
9:26you have an increased risk for infection
9:29um um these because they're peripherally
9:31inserted because it's are we're going
9:33into a smaller vein and not straight
9:36into that large vein because it gets
9:37inserted and threaded through you have a
9:40lot a decreased level or risk for
9:43infection for these so um months or even
9:46years these can be left into place as
9:48long as uh we're not seeing signs of
9:50infection and they're working
9:52properly
9:54um oh and then once again it's the lower
9:57rate of a central line associate
9:59bloodstream infections than you would
10:01see with the non- tunnel Central
10:05lines um for the pick insertion again
10:09it's a surgical procedure even though
10:10it's done at the bedside you still need
10:12your written consent um those
10:14measurements would be taken prior to
10:17beginning um the actual catheter
10:19placement you don't take the catheter
10:20out and measure you actually do a
10:22measurement with the measuring tape um
10:24and that gives you basically your aim uh
10:26sometimes ultrasounds can be used if
10:28they are needing assistance in
10:30determining the best vein to use and
10:32that the veins are large enough uh to
10:35hold the
10:36catheter and you again sterile attire is
10:39going to be used you want to surgically
10:40scrub you will be wearing a gown mask um
10:45hat or cap whatever to keep your hair in
10:48place and sterile gloves the patient
10:50will be drap from head to toe they don't
10:52necessarily need to be placed in Seine
10:55position though uh they can you just
10:57want to in a position position that's
10:59comfortable and that they can stay
11:01draped without any problems um the skin
11:05is going to be prepped again with the
11:06chlorexidine
11:07solution you want to make sure that you
11:09allow it to dry properly and then you
11:11would apply the drapes leaving only the
11:13area that you were working on
11:16open um the pick line will typically be
11:20secured with a statlock type sutur list
11:23securement
11:24device um and then it is also covered
11:27with a transparent moisture permeable
11:29sterile dressing and you also have to
11:32have the confirmation by x-ray that the
11:34tip is in the correct place before you
11:36can use
11:37it and so now we're kind of looking at
11:40the tunnel devices so tunnel device is
11:42very similar to a central line now
11:45they're not going to be in the groin
11:46they're always going to be in the chest
11:47area The Physician will insert the
11:51central line um typically this is either
11:54going to be done in a surgical Suite or
11:56in a radiology and they would insert the
11:59central line into the large vein um and
12:02then what happens is they take that
12:05insertion where it's inserted and they
12:07actually thread that line underneath the
12:10Skin So then the the port or the the the
12:14part that we actually see of the central
12:17line um comes out in a different area
12:19and because we don't have that access
12:21directly over that large vein it's going
12:24to give us less risk of infection so
12:26that's why you can use those for long
12:28long term so those are going to be a
12:30much better choice if you're doing
12:32long-term therapy um than a non- tunnel
12:36device because they can stay in longer
12:38and they have less risk um the devices
12:40themselves are almost always made of a
12:42silicone and there are multiple
12:44different devices out here these are
12:46some common ones Hickman broak Leonard
12:49and gang um and you can see there's
12:51different reasons why someone might
12:53choose one over another for example a
12:56Hickman has a larger Lumen than a
12:57broviac so if you need a larger Lumen
13:00for giving like massive transfusions or
13:02things like that you may choose a
13:04Hickman broviac are usually things that
13:06you'll see in pediatric patient you also
13:10because of the smaller Lumen you're not
13:11going to be able to get blood sampling
13:13as e as easily um and then you know gr
13:16shs uh are not heiz and they don't
13:20require clamping so these are the ones
13:22that don't have the glamp on them um and
13:24then the uh decron cuff on Tunnel
13:27catheters will be in the subc
13:29tunnel um and it kind of anchors it and
13:32prevents the spread of organisms along
13:35the
13:38catheter so for inflatable ports
13:40implantable ports are going to be placed
13:42in a surgical Suite or the radiology
13:44department um the most common site that
13:48we're going to see is going to be the
13:50anterior chest just below the clavicle
13:53I've seen it nowhere else in my life
13:55they they've been in the anterior chest
13:57right below the clavicle everyone that
13:58I've seen in the last 20 years but you
14:00know that there's going to be one that's
14:02in a different spot sometime um you can
14:04have a single or double Lumen um
14:07implantable Port I think most of them
14:10are going to be single but there will be
14:12some that are a little bit
14:13different um the port itself has this
14:16self-sealing silicone septum so the part
14:18that's over the very top of it that gets
14:21punctured is self-sealing so once that
14:23needle comes out it seals itself um and
14:26keeps itself closed but then you can
14:28puncture through it with a needle
14:29whenever you need to access there's a
14:32metal or a plastic Reservoir that's
14:34underneath it um so it's kind of like a
14:36little bowl that sits there with the
14:38silicone covering it think of it like a
14:40little tupperware
14:42bowl um the catheter itself itself uh or
14:46not the catheter the port itself also
14:47has a catheter um that connects the port
14:51to a central vein which is typically
14:53going to be your Superior vnea so it's
14:55kind of like you got this little bowl
14:57it's covered completely and at the end
14:59of it you've got this line that that
15:01threads into the
15:02vnea um the SES are completely covered
15:05with skin so they're not visible other
15:09than sometimes you can see the outline
15:11of them thinner people it's going to be
15:13more easy to see some people you have to
15:15just feel for it um so patients will
15:18like them because they they just look
15:20better they don't they're not as uh
15:23conspicuous um the infection rate is
15:27going to be much lower because once
15:28again we have this completely covered we
15:30do not have an open site unless we are
15:33using it actively so when it's not
15:35necessary it can be completely closed
15:37off and not covered so the risk of
15:40infection is the lowest on an
15:41implantable Port of all the central
15:43lines uh patients can bathe shower
15:46continue with their activities uh
15:48because they don't have a tube that they
15:50have to worry about and then there's not
15:53exit site care you don't have to worry
15:55about the exit site because it's closed
15:57off um the main problem with the
16:00implantable port other than having to go
16:02through a surgical procedure is that
16:04accessing it at time can be um painful
16:07it shouldn't be extremely painful um you
16:10can see up here in this middle picture
16:12this is a Huber needle which is a
16:15noncing needle it is a metal needle and
16:18it just pops directly in the middle of
16:20that site um that needle when it goes
16:23through most patients just have mild
16:26discomfort because there are going to be
16:27some neres over it um but sometimes if
16:31the PK gets kind of moved sometimes they
16:33kind of switch positions slightly and
16:36they will have a little bit more pain
16:38with the insertion um but usually not
16:41usually way less than like a um
16:44periperal line would
16:46hurt so this Huber needle you would put
16:49this in using um a sterile
16:52technique um and or sterile equipment
16:55anyways and then you would just insert
16:56the hubber needle and then you would
16:58cover that with the um uh the clear uh
17:03semi-permeable dressing um and then you
17:05would be
17:07um you would leave it like that anytime
17:10you needed it for Access so like if you
17:12had a patient they entered the hospital
17:15you could um add the Huber needle and it
17:18could continue access for seven days um
17:22and then when you remove you just remove
17:24the entire um area and they the cool
17:27thing is they don't bleed very much you
17:29just remove it and then you would cover
17:30it with a uh sterile gauze and a
17:33dressing uh the most popular brand name
17:36is porath U metaport is another name
17:38that I've seen uh pretty
17:41frequently so this is just some
17:44information about uh kind of comparison
17:48about the central types um just for your
17:52kind of information to look
17:55at so anytime that we are in seting a
17:59central line and when I'm talking about
18:00inserting and
18:02removing mostly I'm talking about the
18:05non- tunnel central
18:06line but anytime you're inserting any
18:09Central lines it's still going to be um
18:11a sterile procedure so you need to make
18:14sure that the P that everyone that is
18:17working on the client is wearing sterile
18:19gowns sterile gloves mask and a cap um
18:22the patient needs to be under full body
18:23drape the prep needs to dry completely
18:26before access
18:30and then because you do these things
18:32obviously it's going to decrease your
18:33risk of
18:37infection okay so there are you'll hear
18:41some of this terminology multiple times
18:43especially clapsy which is a central
18:45line Associated bloodstream infection so
18:49anytime a patient has a central line in
18:52place for at least 48 hours before they
18:55have a bloodstream infection um that
18:58they cannot relate to an infection
19:00elsewhere so like if I have pneumonia I
19:02have an organism and then that gets into
19:04my blood that would be related to the
19:06pneumonia but if I do not have an
19:09infection and I've had a central line in
19:11for 48 hours and then all of a sudden I
19:13have this new onset that is a clapsy or
19:15a central unassociated bloodstream
19:17infection now um catheter related
19:21bloodstream infection you don't hear it
19:23quite as often um but that would be you
19:26would have to actually culture the of
19:28the cath to identify the same organism
19:30that's in the blood so it requires just
19:33a little bit more um rigorous definition
19:36where they're actually able to identify
19:38an organism from the catheter that
19:40caused the
19:44infection so reducing infection is a big
19:47thing on your central line uh first of
19:49all hand hygiene you want to wash your
19:52hands with soap and water or use an
19:53alcohol hand rub before the care of uh
19:58the central line in any way before and
20:00after the care and any Drug
20:03Administration uh you wanted to was them
20:05before and after you palpate the sides
20:07and you would be doing that if you were
20:08looking for signs of tenderness or pain
20:12before after you insert the catheter so
20:14whenever the catheter is being placed
20:16that hand hygiene of course is going to
20:18be um included and then that just got
20:21repeated somehow and you always want to
20:23use a non-touch technique or sterile
20:26gloves but even if you use sterile
20:27gloves want to use that non-touch
20:29technique as much as possible which just
20:31means that all of the parts that would
20:34go um that could introduce anything
20:38directly to the client we try not to
20:40touch them at all so for example if we
20:42were flushing a um central line we're
20:46not going to put our finger on the end
20:48of the catheter Hub we're going to hold
20:51the uh catheter Hub by the part that
20:54does not um connect to the actual inside
20:58so you would hold that on the outside
21:00and you would scrub it still not
21:02touching it with your hands and then
21:04when you put your C when you put your
21:06syringe on you're not touching anything
21:07for your hand so that's really what that
21:09non-touch technique means and even if
21:12you're doing something like a procedure
21:14where you're doing a dressing change you
21:17still try not to touch the insertion
21:19site even if you have sterile gloves you
21:21don't want to touch those directly
21:23because occasionally you will have
21:27contaminants
21:28um for once again this is going to talk
21:31about the prep um anytime we're we're
21:35prepping a patient for insertion you
21:36want to make sure that you uh cleanse
21:39their skin with the chlorexidine or Duro
21:42prep you want to you want to make sure
21:43that it dries completely before
21:45insertion 30 seconds is pretty quick um
21:48some places will tell you 2 minutes some
21:50will be 30 you want to follow the
21:52directions on um whatever prep you're
21:54using but the the goal is it has to dry
21:57completely before for you use it uh when
21:59you're selecting a
22:01catheter um site subclavian veins are
22:05going to be the lowest risk of infection
22:08and once again if we're um entering That
22:10central line in Emeral area because of
22:12the fact that it's near the groin we're
22:14going to have a higher risk of
22:17infection um if we have long-term
22:20therapy greater than a month and really
22:22greater than two weeks usually we would
22:24say this you want to either use a pick a
22:27tunnel Cal line or imp plantable Port um
22:30if it's shortterm a non- tunnel would be
22:34fine um and then when you're selecting
22:38your catheters make sure that you use
22:41the least amount of lumens
22:43necessary um and then you know it says
22:45consider a coded impregnated catheter if
22:47the patient is high risk for infection
22:49most of your catheters are going to be
22:52coated or impregnated I would um
22:55recommend that if you're ever you know
22:57choosing
22:58you choose something that's going to
22:59decrease the risk of infection so coated
23:02or impregnated cath to use in your
23:03general population would be very nice to
23:05have on
23:09hand when you uh place the dressing so
23:12you will have a uh sterile transparent
23:15semi-permeable polyurethane dressing um
23:18this will be placed over the uh Central
23:20lines and this will also be placed over
23:23your pick line well it's a central line
23:26your um chest Central lines your pick
23:28lines or really the the lines in the
23:29groin as well you want to change them
23:31every 7 days unless you need it earlier
23:34so if you see that the dressing is um
23:38you know peeling up if you see moisture
23:40if you see blood coming through whatever
23:43you see that's causing you to say it
23:44needs to be changed you would go ahead
23:46and change it earlier and then you would
23:47wait another 7 days from there if for
23:50some reason they needed to place a Gau
23:51dressing typically only see that if
23:54there's extra bleeding um you would need
23:56to change that at least every 2 days and
23:58usually what happens is after the
24:00initial change they'll switch that over
24:02into the semi-permeable you want to
24:04inspect it at least once a day I would
24:06suggest every shift you're looking for
24:09the signs of infection is there redness
24:11is there uh pain or discomfort
24:13tenderness are we seeing um edema at the
24:17side
24:19um is there any kind of um unusual
24:22drainage you you don't use a topical
24:24oinkment or anything at the insertion
24:26site um
24:30and then this is channeled or implanted
24:32Central Venus uh catheters change
24:34dressing once a week it's basically the
24:36same thing we just
24:37said so um you want to
24:41not manipulate the hubs of a catheter
24:45more than is absolutely necessary if
24:47you're going to manipulate it more the
24:49more you access it the more you risk
24:51contaminating it the increase risk of
24:53infection so decrease manipulation of
24:55your catheter hubs as much as possible
24:59anytime that you are um
25:02accessing the site you want to make sure
25:05that you scrub the hub for 15 to 30
25:07seconds with an approved solution which
25:09is usually a a chlorexidine with alcohol
25:13solution or um an Al 70% alcohol
25:16solution or um po povidine iodine
25:19solution we don't see that used very
25:22often and it takes a very long dry time
25:25as well and you must allow that solution
25:27to dry before accessing um and depending
25:30on which solution you have that can be
25:33anywhere from 5 to 15 seconds I believe
25:36it may even be 30 seconds the povidine
25:38iodine I think takes a couple minutes so
25:40you can see why we don't use it but you
25:42want to make sure that you scub that hub
25:44for uh 15 to 30 seconds depending on the
25:47manufacturer's recommendations and your
25:49facility policies but for our purposes
25:53it's going to be 15 to 30 seconds um so
25:56the tubing is going to be changing for
25:58your facility policy typically if it's
25:59just regular tubing it's going to be the
26:013 to 4 days that is typical of all of
26:04your tubing changes um blood tubing you
26:06can ignore that I don't know why it says
26:08every 12 hours you change it just like
26:10you do regular every 4 hours or every
26:13two transfusions um and if you're given
26:15tpn you need to change it every 24
26:22hours um when you're flushing you will
26:26only use the syringe one time so you
26:28wouldn't take a syringe push half of it
26:30take it off and then reintroduce that
26:32syringe to flush more so you need a new
26:35a brand new sterile sterile saline um
26:40flush syringe every time that you um
26:45need to flush uh when you are beginning
26:48the access or you're checking for
26:50patency you can never use a syringe
26:52smaller than 10 milliliters because if
26:55you have to press that hard
26:58um that's going to cause potential um
27:01increased pressure in there and it could
27:02damage the
27:04catheter um usually 10 mL flush is what
27:07we use it's always going to be normal
27:10saline um and it's going to be minimum
27:13of every 8 hours and you'll give 10 Mill
27:1610 ms of normal sailing um to flush it
27:19and and to identify patency you can give
27:22your medication following this you would
27:24use the smallest size syringe for that
27:27and then you would flush it again with
27:28your with your new syringe of saine if
27:31you need Hein that is based on the
27:34manufacturer's recommendation so a lot
27:36of times a flesh will be followed with
27:39heprin um and that just keeps the line
27:41from um clotting up uh but a lot of them
27:46no longer require the use of Hein so we
27:48don't see it as frequently but it still
27:50is uh common in some when you're giving
27:53a flush especially when you're doing
27:55your well at any time you want to use a
27:58pulsative or a start stop technique
28:00because that's going to create some
28:01turbulence inside of that catheter and
28:03it's going to make sure that it flushes
28:04all that medication out of the
28:08line so blood reflex is a major problem
28:11that can cause basically the inability
28:14to use the ports um can happen if you
28:17don't flush the line very well and so
28:21the blood is still in the line um and it
28:24can happen due to some increased
28:26intravascular pressure like if patient
28:27has a lot of coughing or vomiting that
28:29can cause that um blood that pressure to
28:33move blood into the light as well so
28:35there are uh different strategies there
28:37are different type of needleless
28:40connectors that we see on these
28:42catheters and they're based on what the
28:44manufacturer recommends or
28:47provides so if you have what's known as
28:50a negative displacement catheter that
28:52means that that blood it's kind of like
28:54a negative pressure it it's going to to
28:58um keep that
29:00blood in the syringe so if you don't
29:04clamp that before you remove your
29:07syringe then if you remove your syringe
29:09some blood May reflux and then if you
29:11clamp it you're just sitting there with
29:13the blood so you always want to clamp a
29:15negative
29:16displacement um if they have a negative
29:19displacement connector you want to clamp
29:21that before you remove your syringe if
29:23it's neutral it can be done before or
29:24after cuz we're not really the blood
29:26should just kind of remain neutral not
29:28moving in out if it's positive it has
29:31positive pressure that's pushing the air
29:33in or pushing the air in sorry pushing
29:36the blood in and so it should keep it
29:39out of the line and you want to actually
29:40clamp that after you remove your
29:44syringe so when we're obtaining blood
29:46specimens there's multiple ways that we
29:48can do this it's going to depend on what
29:50your facility's policies are so you
29:52always want to follow your facility's
29:54policy
29:56um there are a lot of um studies out
30:00there that you know kind of question the
30:02use of central lines for blood draws
30:05because it can cause an increase um risk
30:08of infection of course we're
30:10manipulating we're inserting things so
30:13any times we're using it's going to
30:14increase the um the use also if you're
30:18drawing blood because there needs to be
30:20some sort of waste um we can have some
30:23blood loss especially if we we have
30:26continuous blood draws
30:28um so there's different ways to do this
30:30I'm going to talk specifically about the
30:32Dead Space um and the discard method
30:35I'll talk about them all but those all
30:37those are the most common ones that we
30:39see uh the Dead Space is what is
30:44um typically the recommended by the
30:47literature so a pushpull method you
30:50would be giving blood you would aspirate
30:52three to five time you flush flush your
30:55syringe you would aspirate three to five
30:57times time so you would pull up and you
30:58would um aspirate aspirate aspirate um
31:02and then as you aspirate you move it
31:04back in so it's kind of like mixing that
31:06back and forth so that you're not going
31:08to have whatever the flush was in there
31:10the problem is because you're moving
31:12that blood in and out of the line you
31:14can cause that hemolysis and that can
31:16cause some um abnormal
31:19um Labs um so it's cool because we don't
31:22have the blood loss but because we can
31:25damage our blood you know it might not
31:27be great um so for the reinfusion method
31:31um you
31:34would sorry you would um do your saline
31:38flush then you would draw out the same
31:40amount usually six milliliters or
31:41greater um and then you with withdraw
31:44whatever you need for the
31:46sample then you would take that initial
31:48blood draw drawn out and you would
31:50introduce it so this could be nice that
31:52you're not having
31:54um you're not uh um having that blood
31:59loss but once again you're taking
32:01something removing it and then
32:02reinserting it and so you're going to
32:04have an increased risk of
32:07infection so the discard method was the
32:09one that I was always taught in school
32:11and it's still used in a lot of places
32:13so you would flush this flush the um
32:17Center Line and then you would withdraw
32:18that same same amount usually six Ms or
32:21greater um and then you would take that
32:23and you would just get rid of it then
32:25you would draw your specimen that's
32:27needed it's very easy to learn a very
32:30easy procedure the risk of infection um
32:34is relatively low because we're not
32:37putting things back in but we are going
32:39to lose some of our blood because of
32:41that withdrawal and
32:43disc so with the Dead Space method um
32:47you would flush and then you would just
32:48withdraw until you start seeing blood
32:50enter the syringe and then you would
32:52remove it so at that point you're like
32:54blood is in the syringe so we are no
32:56longer dealing with normal sailing you
32:58would discard that syringe then you
33:00would just draw what you needed and then
33:02that way you have that decreased blood
33:04loss it's also very simple um technique
33:07as
33:09well um okay so the flushy I think we
33:11talked a little bit about this but you
33:13want to make sure um oh that you flush
33:16after you draw any specimen any lab draw
33:20specimen of 10 MERS once again you will
33:22only use heprin if the um manufacturer
33:26recomm comms it you will only want to
33:28use a 10 mil syringe when you initially
33:32access the IV site because you're you
33:35don't want to damage it we want to use
33:37the push pause method or the turbulent
33:40technique um and you want to use um a
33:44positive pressure
33:46flush if you have a nonv valved
33:50catheter that is the same as the
33:52negative pressure uh needleless ports um
33:55so you want to make sure that you clamp
33:58before um the syringe is removed um if
34:03you have a valve device um you don't
34:06necessarily have to have a clamp because
34:07you're going to have that positive
34:09pressure that will prevent any air from
34:10entering the Venus circulation and uh
34:13keep the blood out of the
34:18catheter um so if you have a central
34:20line um in place and all of a sudden
34:23you're not able to to um obtain p see
34:27you're not getting blood um there may be
34:29a few things that are happening but the
34:30very first thing that you want to do if
34:32you're not able to flush your um
34:35aspirate blood is you want to make sure
34:36that it's not clamped and I cannot tell
34:38you how many times that it being clamped
34:41is the culprit so always make sure that
34:43you double check that it's
34:44unclamped um and then you want to look
34:46and make sure that the tubing isn't
34:48kinked somewhere um and then if we still
34:53are having issues then we often have to
34:55move into some secondary interventions
34:58um you can see Pony loss due to a blood
35:01clot or fibrin sheath we'll talk about
35:03that here in a bit uh you may want to uh
35:06or may want you may need uh to use uh
35:09Radiology where they use a radioopaque
35:11die um where they can evaluate like
35:14where the problem is happening um and
35:16then they can also um you can get an
35:20order where you provide urokinase or
35:22tissue plasminogen activator um to break
35:25up any clots or fibrin sheets that might
35:27be
35:28there so you can have um occlusions
35:33inside or outside of the actual catheter
35:35so inter luminal inside of the catheter
35:38uh typically what we're going to see is
35:40either precipitate or thrombus so if
35:43blood is remaining in that line for even
35:46short times because if the blood's just
35:48sitting there it's stagnant you can
35:50start seeing clotting occur which then
35:52would be able to olude the line um the
35:55larger gauges are going to decrease that
35:57potential if you have a smaller one you
35:59have less room so the clotting is going
36:01to be easier to happen um but large
36:05gauge devices may still remain patent
36:08for quite a while as a thrombus is
36:10occurring um so you may start noticing
36:13that it's still patent um but you don't
36:15get an aspiration of blood or it feels
36:18like uh the line doesn't there feels
36:21like there's pressure against you when
36:22you're trying to flush so that also
36:24needs to be addressed and discussed with
36:25a physician if you start filling that um
36:28and then if you have medications that
36:32cause a precipitate when mixed together
36:34that precipitate can get in the line and
36:36then that can cause an occlusion
36:39as so then extra luminal occlusion means
36:42that we have an out we have something
36:43outside of the catheter itself uh so one
36:46of the common things that we see is a
36:47fiber and sheet so it like forms
36:49basically at the end of the catheter um
36:52this little fibrant till um at the um at
36:56at the bottom of it um kind of forms
37:00underneath it so a lot of times what
37:01you'll see at the beginning is you lose
37:04the ability to aspirate blood but the
37:05catheter works fine because we're able
37:08to like push past that fiber Intel but
37:10then as it builds up and builds up you
37:11can lose complete you can get a
37:13completely uded um
37:16catheter and then another thing that
37:19were happening were happening that could
37:20happen is the pinch off syndrome so this
37:22really just kind of like a positional
37:24issue that happens um you usually we see
37:27between the clavicle and the first rib
37:29is where uh the line itself gets
37:31positioned and with different movements
37:34um it can include that so uh if you have
37:37a patient
37:39that has um a catheter that's secluded
37:44that's another thing that you want to
37:45try before you start looking to that is
37:47moving um and positioning especially
37:49with that arm up and down um but it
37:52still needs to be addressed because if
37:54there is a pinch off syndrome even if
37:56you can move their arm and use it
37:57properly that means that they're having
38:00that pressure repeatedly over the
38:02catheter so um it's something to watch
38:04carefully because the catheter itself
38:06could break because of
38:09that so when we remove a catheter and we
38:13nurses can remove the non-tunneled or
38:16the pick lines um the nurse will do the
38:19whole procedure themselves so this is
38:21specifically going to be talking about a
38:23non-tunneled central Venus access device
38:26uh you want to make sure that if there's
38:27any infusions that that is turned off
38:29the IV tubing is removed um the supplies
38:32will be
38:33sterile but you can just wear clean
38:35gloves with this uh you want to position
38:38the patient aine um or head down if
38:41tolerated remember lower we are it's
38:44going to decrease uh our ability to get
38:46air into the
38:48vein you're going to take the old
38:50dressing off you're going to clean the
38:51site with your solution usually it's a
38:53chlorexidine alcohol solution um you're
38:57going to remove any sutures using a
38:59suture removal kit or open the sutur
39:02stabilization device if it's uh locked
39:05into place that
39:06way you're going to take usually 4x4s
39:09and you're going to hold it light
39:12pressure over the S so you're not like
39:13shoving it down at this point because
39:15we're going to have to have enough
39:16ability to pull out the line so as we're
39:20pulling out the line you want to ask the
39:22patient to Exhale during that or Bear
39:27Down performing that Val Salva maneuver
39:29this is once again going to decrease our
39:32risk of getting an air embolism because
39:34we're having this pressure pushing air
39:36outwards instead of in um so you would
39:38say you know um if the patient can
39:42perform Val Salva that's probably going
39:43to be your best but otherwise you would
39:45you know say I need you to Bear Down on
39:49three one two three and then keep
39:51bearing down keep bearing down and then
39:52when it's pulled you you're good um if
39:55they can't perform that you would say I
39:57need you to take a deep breath in and
39:59then I need you to Exhale slowly while I
40:02remove this and so you take a deep
40:03breath in now exhale slowly you would
40:06remove it while it exhales now you don't
40:08yank it out but it can come out
40:09relatively quickly you just kind of a
40:11nice steady movement and you just pull
40:14it directly out then you take that same
40:17sterile gauze and you just keep that
40:19over the sight applying firm pressure
40:21for at least 2 minutes so if a patient
40:23is on anti-coagulants or any other medic
40:26that could cause them to bleed you want
40:28to make sure that you hold that um at
40:31least 5
40:32minutes um because they're going to be
40:35at an increased risk for bleeding
40:36obviously and then after that pressure
40:39is held for the right amount of time
40:41you're going to cover it with a
40:42transparent airtight dressing um and
40:45then if this was taken out because we
40:47were suspecting a um an infection was
40:50happening you want to make sure that you
40:52send that uh catheter tip to lab so they
40:55can test it
41:00that

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