1. INTRODUCTION

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1. INTRODUCTION
2
Acknowledgements
This project is an initiative of Nurse
Education Workforce Strategy Gippsland Content
supplied by Gippsland Oncology Nurses Group
(GONG)- an initiative of Gippsland Region
Integrated Cancer Services (GRICS) Special
thanks Anny Byrne (Gippsland Regional
Integrated Cancer Services) Anne Maree Day (West
Gippsland HealthCare Group) Dianne Fahy (Nurse
Education Workforce Strategy) Anne Johnson
(Latrobe Regional Hospital) Linda Langskaill
(Central Gippsland Health Service) Melanie Regan
(Gippsland Regional Integrated Cancer
Services) See other sources and references at
the end of this presentation. Further reading is
encouraged to complement these tutorials.
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CVAD Tutorials

• Introduction to Central Venous Access Devices
• Hickman Catheters
• Implantable Ports
• PICCs

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Scope of this tutorial

• What is a Central Venous Access Device (CVAD)?
• Name three different types of CVADs
• Name 5 indications for CVADs
• What is a clean technique?
• When is it used?
• What is a sterile technique?
• When is it used?
• What is a pulsatile flushing technique and why is
  it used?

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Central Venous Access Devices

• In Central Venous Access Devices (CVADs), the tip
  of the catheter resides in a central vessel in
  the chest that immediately connects with the
  right atrium. This is usually the Superior Vena
  Cava (SVC)
• Examples are Hickman Catheters, Central Venous
  Catheters, Implantable PORTS and Peripherally
  Inserted Central Catheters (PICCs)

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Types of CVADs

• CVADs can be for short term (approximately 10
  days to 6 weeks), intermediate term (2 weeks to 6
  months) or long term (6 weeks to years) therapy.
• Central Venous Catheter - for short term therapy,
  often used in the ICU setting
• Hickman Catheter - for intermediate and long term
  therapies. Often used in the haematology setting
• Implantable Ports - for long term therapies. Most
  often used in the chemotherapy setting
• PICC - for intermediate and long term therapies,
  IV antibiotics, continuous chemotherapy

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Choice of Venous Access Device

• Consider the following
• Length of treatment
• Type of treatment
• Frequency of treatment
• Geographic location of the patient
• Age of patient
• Anatomical factors
• Social setting i.e. impact on body image,
  workforce issues

Hickman Catheter
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Indications for CVADs

• Difficult venous access
• Multiple infusions eg long term chemotherapy,
  antibiotics
• Continuous infusions of chemotherapy via a
  Continuous Ambulatory Delivery Device (CADD) pump
• Infusions of vesicant drugs, that may cause
  damage and/or pain if infused peripherally
• Bone marrow / stem cell transplants
• ICU setting
• Total Parenteral Nutrition infusion

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Key Principles of Care (1)

• Confirmation of placement Always confirm
  placement before commencing treatment and ensure
  there is a written x-ray report confirming the
  placement of the device
• Access - Always ensure a blood return before
  infusing any fluids or drugs
• Syringe size Only use syringes 10 mls or
  larger, smaller syringes increase the pressure in
  the catheter wall and increase the risk of
  rupture of the catheter
• Pulsatile flushing - always use a pulsatile
  (stop/start) flushing technique, to create
  turbulence in the lumen of the catheter, remove
  debris and avoid blockage of the catheter

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Key Principles of Care (2)

• Aseptic technique sterile tray and sterile
  gloves for accessing an open system (when
  cap/bung is removed)
• Clean technique - Wash hands, clean gloves and
  clean bung with 3 alcohol swabs. Allow bung to
  air dry before proceeding to access a closed
  system (when cap/bung is in situ)
• Heparin Lock (Heparinization) weak versus
  strong
• Strong Heparin Lock (1000u/s in 9ml Normal Saline
  - give 5ml )
• Weak Heparin Lock (50u/s in 5ml)

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References (1/4)
More References

• Arrow International. (2000). Peripherally
  Inserted Central Catheters. Continuing Education
  Program. Arrow, Reading, PA, USA.
• Brown, J.D., Moss, H.A. Elliott, T.S.J. (1997).
  The potential for catheter microbial
  contamination from a needleless connector.
  Journal of Hospital Infection. 36, 181-189.
• Cancer Nursing website. (2005).
  http//www.cancernursing.org
• Dougherty, L. (2000). Central Venous Access
  devices. Nursing Standard. 14(43)45-55.
• Farley, K. (1998). Peripherally Inserted Central
  Catheters Patient selection, insertion and
  maintenance. Johnson Johnson Medical, USA.
• Hadaway, L. Catheter related infections. Nursing
  2002. 32(9), 46-48

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References (2/4)
More References

• ICU Medical. (2003). Extended Use Microbial
  Challenge and Disinfection Study of the CLC2000.
  ICU Medical. http//www.icumed.com/CLC2000.asp
• Intravenous Nurses Society. (2005). Infusion
  nursing standards of practice. Journal of
  intravenous nursing. 23(6S).
• Catheter Care. Best Practice Statement.
  www.joannabriggs.edu.au
• Latrobe Regional Hospital. (2004). Central Venous
  Catheter- PICC Management Policy protocol.
  Latrobe Regional Hospital-Policies and Protocols,
  pp.1-4.
• Lenhart, C. (2001). Preventing central venous
  access device occlusions with saline only flush
  by use of an adapter. Journal of Vascular Access
  Devices. Summer 2001.
• Luptak, P. (2000). Prevention of PICC and midline
  occlusions with the CLC2000. Abbott Laboratories.

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References (3/4)
More References

• Masoorli, S. Angeles, T. (2002). Getting a line
  on central venous access devices. Nursing 2002.
  32(4), 36-43.
• NSW Cancer Institute. (2005). http//www.cancerins
  titute.org.au
• Oncology Nursing Society. (1997). Access device
  guidelines Recommendations for nursing practice
  and education. Pp. 2-7, 40-46. Pittsburgh, PA,
  USA.
• OGrady, N., Alexander, M., Patchen-Dellinger,
  E., Gerberding, J., OHeard, S., Maki, D., Masur,
  H., McCormick, R., Mermel, L., Pearson, M., Raad,
  I., Randolph, A. Weinstein, R. (2002).
  Guidelines for the Prevention of Intravascular
  catheter Related Infections. Infection Control
  and Hospital Epidemiology. 23(12)759-769.

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References (4/4)
End References

• Pearson, M., The hospital Infection Control
  Practices Advisory Committee. (1995). Guidelines
  for prevention of intravascular device-related
  infections. National Center for Infectious
  Diseases Centers for Disease Control and
  Prevention. 17438-473.
• Peter MacCallum Cancer Centre. (2005). Principles
  of care of central venous access devices. Peter
  MacCallum Cancer Centre Policies and Procedures
  31.1, pp. 1-4.
• Pratt, R., Pellowe, C., Harper, P., Loveday, H
  Robinson, N. (2001). Preventing infections
  associated with central venous catheters. Nursing
  Times. 97(15)38-39.
• Rummel, M., Donnelly, P. Fortenbaugh, C.
  (2001). Clinical evaluation of a positive
  pressure device to prevent central venous
  catheter occlusion results of a pilot study.
  Clinical Journal of Oncology Nursing.
  5(6)261-265.
• Welker, D. (2004). Troubleshooting Vascular
  Access Devices. Smiths Medical MD. Michigan, USA.

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GONG Products

• www.gha.net.au/grics