CENTRAL VENOUS ACCESS

DEVICES (CVADs) and Angioplasty

CENTRAL VENOUS ACCESS
DEVICES (CVADs)
DEFINITION
A short or long term intravenous
catheter inserted into a centrally
located vein with the tip residing in
the lower 1/3rd of the Superior Vena
Cava (SVC)
(Infusion Nurses Society (INS)
Standards of Practice, 2006).
CVADs are usually used
Peripherally Inserted Central Catheter
(referred to as a PICC)
Hickman skin tunneled catheter
Central Venous Catheter (short term non-
tunneled referred to as CVC)
Port-a-cath implanted port and Power
Port(power injectable)
Dialysis & Apheresis catheters which are
procedure specific
Antibiotic and antimicrobial coated
catheters
PatientsTHE
CHOOSING disease and
ACCESS DEVICE status
Number and type of
solutions,
osmolality
Flow required
Frequency accessed
Duration of use- days vs
months
 DURATION
> 7 days - PICC Line
1- 12 Weeks - PICC line /
tunneled
catheter
12 weeks - 6 months or
greater
tunneled catheter
> 6 months - Port
Although there are many veins in the
body only a few are suitable for CVADs.

The most commonly used insertion

sites are:
Neck (internal jugular vein)
recommended
Upper chest (subclavian vein)
Mid upper arm (basilic vein)
Femoral vein
Commonly used catheter insertion sites
Commonly used port
insertion sites
CENTRAL VENOUS ACCESS:
1. Long term IV
INDICATIONS
therapy:
-Chemo
-Antibiotics
-TPN
-Blood products
2. Recurrent blood
draws
3.
CVADs are used for the infusion of:

Hypotonic and hypertonic solutions

Solutions with extremes of pH and osmolality
Vesicant and irritant medications and solutions
e.g. cytotoxic therapy or antibiotics
Complex drug therapy regimes
Rapid hydration of fluid or blood /blood
products
Parenteral Nutrition(PN)
CVP monitoring
Blood sampling
Therapeutic procedures
Long term antibiotics
IV therapy in the community
Dialysis catheter
No kink

Tip of cath
PICC line
IR or Bedside
Ultrasound guided
1 week to 1 year dwell
Sutured or secured
with special anchor
tape
Easy to insert, easy to
remove
Newer power PICCs
and triple lumen PICCs
Tip in SVC
PICC
Implanted Venous Ports
Placed in IR or OR
May be used for chemo same
day it is inserted
Need huber non-coring
needle to access
Sterile procedure for access
2,000 punctures
Nice VAD for patients; low
care and maintenance, low
infection rate
Needs a flush once a month
when not in use
Newer power ports, regular
and low profile
PORT
Power Ports

May be used for CT scans and power

injectors
Need to use special power huber
needle for CT scan
Otherwise regular huber needle can
be used for routine IVs/chemo/blood
Groshong Tunneled
Special valve at tip
No clamp
NS flushes
If valve
malfunctions, may
need to switch to
heparin flushes
HICKMAN CATHETER
Hickman Tunneled
1,2 or 3 lumens
Silicone material
Use large lumen for
blood draws
Clamp on reinforced
area
Temporary stitches
Broviac is smaller
peds
May be repaired
Do not force flush,
easy to rupture
ANATOMY AND PHYSIOLOGY REVIEW

Knowledge of
anatomy and
physiology, and the
principles of blood
flow is essential for
safe management of
all Central Venous
Access Devices.
Anatomy

Basilic v
Cephalic v
Veins and Valves

Reservoir vessel
+/- 65% of total blood volume
Distend 6-10x > arterial wall.
The veins also have what is referred
to as a muscle or venous pump.
This action can specifically affect
PICCs causing them to migrate
 Muscle action is also responsible
for reflux of blood into the tips of
CVADs. Pressure from the
contracting muscle forces the
locking fluid out of the catheter
lumen allowing blood to reflux into
the CVAD when the muscle
relaxes. The vein and catheter are
two distinct flow systems, each
vulnerable to occlusion (Hadaway,
2005).
Veins have three layers and
each plays an important role in
catheter placement and dwell:

Tunica Intima - inner lining

Tunica Media - middle layer
Tunica Adventitia - outer layer
 Three layers of vein

Tunica Intima
VALVE
TUNICA INTIMA-------------

Tunica media -

nica adventitia ----

The Tunica Intima is the delicate
inner lining of the vein which can
become damaged by mechanical,
chemical or bacterial means.

When the Tunica Intima is damaged,

bleeding occurs into the interstitial
compartments of the basement
membrane. The Tunica Adventitia,
rich in nerves provides the pain
pathway.
The superior vena cava is on average
20 mm in diameter and has a high
blood flow of approximately
2000mL/min, far greater than in a
peripheral vein (refer to table below).

This means that irritant drugs and

fluids, those with concentrations of
solutions with extremes of pH or
osmolality can be infused without
damaging the SVC vein wall due to
this increased haemodilution.
 Vein flow
VEIN DIAMETER FLOW RATE LENGTH

Cephalic 6 mm 40-60 ml/min 38 cm

Basilic 8 mm 60-95 ml/min 24 cm

Axillary 16 mm 13 cm

Subclavian 19 mm 150 ml/min 2.5 cm

Innominate 19 mm 800 ml/min 6 cm

Superior Vena 20 mm 2000 ml/min 7 cm

Cava
Complication
Failure to draw blood from port could
possibly be due to:
the presence of a fibrin sheath.
tumor growth at catheter site.
sludge inside port.
vessel wall drawn up into the catheter
tip.
Blocked catheter
Failure to draw blood and infuse fluids
could be caused by:
thrombus formation as a result of damage
to the venous intima by the catheter.
inadequate flushing technique
intermittent positive pressure should be applied
when flushing catheter
catheter malposition.
mechanical failure of catheter.
accumulation of fibrin tail or sheath at
internal catheter tip.
Occlusions
Inability to draw blood or flush
catheter) are:
dislodgment of port and/or needle.
kinking or coiling of external catheter.
kinking or coiling of internal catheter.
precipitation of a drug within the length
of a catheter.
presence of a fibrin tail or sheath at
catheter tip.
thrombus formation.
SIGNS OF OCCLUSION
Ability to flush but not aspirate blood is
called a persistent withdrawal occlusion
(PWO)
Ability to aspirate but not flush is called a
reverse ball occlusion(Ports)
Resistance to flushing
Sluggish infusion
Complete inability to flush or infuse
Increasing alarm occlusion with electronic
infusion devices
Fibrin formation
As early as 24 hours
after catheter
placement
Infusion is possible, but
prevents the withdrawal
of blood
acts as a valve
Treatment option is
catheter replacement
Costly
Fluroscopic removal of
fibrin sheath
Not available in all centre
Expert interventional radiologist
Types of Occlusion
FIBRIN SHEATH
Fibrin Sheath-Retrograde
flow
Fibrin sleeve can
cause retrograde
flow and potential
extravasation
Patient c/o pain
and pressure with
flushing and there
was no blood
return
FIBRIN SHEATH-PTA
Catheter Migration
Causes of catheter migration
Forceful flushing
Changes in the intrathoracic pressure
from:
o vomiting
o coughing
o constipation
o sneezing
o heavy lifting
Heart failure
Presence of tumors
Mechanical ventilation
The cuff in tunneled catheters dislodges or
fails to adhere to the tissue after insertion
Signs and Symptoms of catheter migration

Inability to flush, infuse, aspirate may

be a
sign the tip is no longer in the SVC
Leaking of IV solutions/flushes at
insertion
site
Loss of CVP trace or arrhythmia if
catheter
has migrated into the right atrium
Changes in the external catheter
Signs and Symptoms of catheter
migration

Gurgling in ear during flushing indicates

the tip has migrated to the internal
jugular
Headache; pain; swelling; redness;
shoulder, arm or neck discomfort
Coldness felt in middle of back on
flushing (tip migration into the azygos
vein)
Tunneled catheters - coiling of catheter
in tunnel, able to palpate coil in tunnel
Catheter Migration

Patient complains of the sound of a

waterfall
or rushing water
tip may have moved up the internal jugular
May require radiographic evaluation with
contrast injection
ascertain the location of the catheter tip
The catheter tip positioned deeply in
theSVC/atrial junction is less likely to
migrate
Management of catheter migration
Good catheter assessment
Avoid forceful flushing
Secure external catheter using a
securement device (or sutures) and a
dressing
Palpate for correct cuff position with
tunneled catheters
X-ray to verify tip location and
repositioning under fluoroscopy
Removal and replacement may be
necessary
Pinch-off syndrome
Exclusively in Percutaneous method
Subcutaneous extra-vascular course of
the catheter between the clavicle and
first rib
When the point of insertion into the vessel was
too medial
can be avoided by using the
jugular venous approach
PINCH OFF SYNDROME
Catheter fracture
Port Thrombus

Inadequate
flushing can cause
a buildup of blood
in port
chamber/catheter
After drawing blood
from port flush with
2 syringes of NS
then heparin or
start infusion
 10mL 0.9% pre-filled sodium chloride
Saline pre-flush syringe

Medication
Administer

10mL 0.9% pre-filled sodium chloride

Saline Post flush syringe using pulsating flush (use 20mL
following blood sampling or transfusion)

Heparin Lock Appropriate dose using positive

displacement device to activate positive
pressure in Port
Malpositioning
Catheter is wedged
against the wall
if detected intra-
operatively, redirect or
reposition
redirected by replacing
the catheter over a
guidewire
redirecting the tip by
using a snare from a
femoral venous
approach
FALSE ROUTE
Thrombosis
Collaterals from PICC
related thrombosis.
Worse type of PICC removed,
occlusion. Blood anticoagulant therapy
flow in vessel
impaired
Pain, swelling,
collaterals, loss of
blood return,
difficulty flushing
SVC clot causes
head and neck
swelling, pain, may
be life threatening
Air Embolism from VAD
VADs that exit above
the heart can cause
an air embolism
Prevent these by
making sure VADs are
clamped before
changing caps
Prime all tubing
Use luer-lock
connections
Anchor catheters well
and teach patients not
to use scissors near
Infection
Infection along catheter tract or in
port
Redness or exudate along catheter tract
evidence of slight erythema may not signal
infection.
Immuno-compromised patients may
show no external sign of infection.
The organism that causes infection is
believed to colonize the I.P. by two routes
migration along the catheter tunnel
introduced upon port access
Port Pocket Infections
Chest Port (top) Arm Port (bottom)
Warm, red, tender
port site
Possible elevated
WBC, fever
Prevent by using
sterile technique
to access ports
Treat with
antibiotics, might
require port
removal
EXIT SITE INFECTION
Purulent fluid
collection under the
dressing suggestive of
infection.

Purulent secretion,
erythema over the
tunnel and skin
changes secondary to
infection in the
subcutaneous tunnel.
Sources of infection
CATHETER EXIT SITE
INFECTION
Catheter related blood stream infection (CRBSI)

85% OF BACTERIA FOUND ON THE

SKIN ARE RESPONSIBLE FOR CRBSI
(Maki)
CVAD insertion bundle
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection
Extravasation
Possible cause
Needle dislodgment
Catheter tip displacement
Inadequate needle stabilization
Catheter damage
Before administering a vesicant, the
port should be flushed and checked
for positive blood return.
When there is no blood return, the
catheter may require radiographic
evaluation with contrast injection.
Chemo Extravasation
 CARE AND
MAINTENENCE OF
ACCESS PORT
CVAD insertion principles