Slide 1

Alternative Access & Complications
Catherine Luksic, BSN RN
Alternative access routes
 1. Central Venous Lines - percutaneous
-<60 days, subclavian or internal jugular veins
- Single, double, triple, quad-lumen
- Sutured in place, Sterile dressing change q.7 days
*check policy….may be q 48-72 hr.
- May require daily heparin flush
**check policy
 2. Tunneled catheters – Hickman, Broviac, Groshong
- Percutaneous, tunnelled under skin
- Single, double, or triple lumen
- Long term use 1-2 years
 3. PICC lines - Peripherally Inserted Central Catheter
- placed peripherally, longer term use
Alternative Access Routes
 4. Implantable Ports
Single or double lumen
Single or double port
Metal chamber connected to silicone catheter
POC (port-a-cath)
Requires huber needle to access
Change needle q. 5-7 days
*check policy first
5. Tesio Catheter
 For hemodialysis use ONLY
 Do NOT access, flush, aspirate or administer meds via Tesio
 For dialysis staff only !
 Require heparin
Central Venous Line
 Most common use = hospital
 Usually have multiple lumens
 Advantages:
 Can be inserted at bedside.
 Easy to use
 Multi-lumen
 Disadvantages:
Requires sterile dressing changes (check policy)
Risk of infection
May require daily heparin flush (if not used continuously)
Requires activity restrictions
Triple Lumen Catheter (TLC)
Central Venous Line (CVL)
Central Venous Lines
Tunneled Catheters
 Placed surgically in OR
 Tunnel is made from surgical site near the subclavian to an
exit wound further down on chest. (2 surgical wounds)
 Cuff forms a barrier under the skin - stabilizes catheter and
prevents bacterial migration into bloodstream
 examples : Broviac, Hickman, Groshong
Groshong Catheter
Implanted Ports
 Relatively common
 Placed and removed in OR
 Common use = chemo
 Port is placed in a surgically made “pocket” and sutured in
place. Catheter extends into vein from this port/reservoir.
 Must be “accessed” for use w/ huber needle
 *LPN may NOT access POC
Port a Cath (POC)
PICC Lines
 Can be 20x longer than peripheral cath
 Can be used up to 1 year (usually less)
 Common use = long term antibiotic therapy; TPN
 Must be confirmed by xray before use
 Advantages:
 Can be inserted by specially trained nurse at bedside
 Low infection rate
 Disadvantages:
 Requires daily flush
 Limits activity (external catheter)
 Cannot use for high pressure infusions
PICC Lines
 FLUSHING – used to maintain patency of the line.
 Dictated by agency policy.
 Most commonly normal saline, followed by heparin. (Volume
determined by manufacturer, usually 5-10cc).
 Check for allergies, incompatability, bleeding, etc.
 Check policy re: heparin use
 EXTERNAL CATH LENGTH – measure, check markings
Central Lines
 15 seconds
Central line dressing change
 Change as needed and according to institution policy
 q 48-72 hr for CVC or….
 Q 7 days for CVC
**check policy !
 Q 7 days for PICC
 Must be performed as sterile procedure
 Inspect site at each change
Central Line Dressing Change
 Cleanse from insertion site outward for 4-6 in area
 Cleanse site well with alcohol first, then chlorhexadine or
povidine-iodine (betadine)
Clean in a circular motion, allow to dry
Apply transparent dressing, reinforce with tape, and LABEL.
 Legal, ethical , and professional responsibility
 Includes:
 Insertion procedure
 Proper infusion and maintenance
 Monitoring of site and infusion
 Direct care given (i.e. dressings, tubing changes, patient
education, etc.)
 Systemic - problem involving the entire body, related to IV
 Local - adverse reaction or trauma to the surrounding
venipuncture site.
 Hypersensitivity - can be systemic or local
Systemic Complications
 Circulatory overload - usually infused too fast, or with
hepatic, cardiac, renal disease
 Dyspnea, cough, edema, wt. gain, rales or crackles
 Decrease IV rate, elevate HOB, obtain vitals & assess the patient,
notify physician
 Infection (septicemia) - microorganisms in circulatory system
 Fever, chills, tachycardia, tachypnea, headache
 ? IV contaminated, break in aseptic technique
 Notify physician, treat symptoms, blood cultures, remove IV
 Establish another IV site
Systemic Complications
 Venous Air Embolism - rare, but lethal
 Air trapped in Rt. Ventricle lodges against pulmonary valve
Blocks flow of blood to pulmonary artery
Right heart overfills
Small bubbles may enter pulmonary circulation
 Tachycardia, SOB, shoulder pain, JVD, hypotension, weak
pulse, lightheadedness
 Immediately – pt. on left side, trendelenburg, notify physician
 Causes air to rise in right atrium, prevents air from entering
pulmonary artery
 Obtain vitals and pulse oximetry, administer oxygen
Systemic Complications
 Speed Shock - foreign substance (usually medication) is
rapidly introduced into circulation
 Usually results in hypertension
 Slow infusion rate, notify physician
 Vancomycin = “red man syndrome”
 Incompatibility
 Drug interactions
 Allergic reaction
Local Complications
*Common area for nursing malpractice
 Phlebitis - Inflammation of the vein, common
 Redness, pain, swelling, induration
 *symptoms worse w/ thrombophlebitis = clot
 Remove IV and relocate
 Tx: Warm compresses
 Prevention = rotate sites every 72 hours
 ASSESS site hourly !
Local Complications
 Infiltration - seeping of fluid into surrounding tissue
 Site is cool with dependent edema, and often painful.
 Tx: Discontinue IV solution, remove catheter, apply warm
compresses, elevate extremity
 Prevention = hourly IV site checks !
Local Complications
 Infection - related to microbial contamination of the catheter
or the infusate
 Extravasation - infiltration of a vesicant medication, can cause
blisters and subsequent sloughing of tissues
 Chemo
 IV potassium at higher concentration (over 40meq)
 Dopamine
 Dilantin
 Flagyl
Local Complications
 Hematoma – infiltration of blood into extravascular tissues
 SQ hematoma is a localized collection of blood and is the
most common local complication.
May see discoloration of skin
Usually related to nursing skills
Higher risk in pts. on anticoagulants
Higher risk in elderly
Preventing Complications
 Use aseptic technique
 Inspect all fluids & equipment before use
 Be alert to signs of circulatory overload
 JVD, elevated BP, elevated RR, moist crackles, edema
weight gain
 Anchor IV cannula well to prevent motion
 Do not use veins over area of joint flexion
PN Scope of Practice
 Must complete state approved infusion course
 Must attend annual review (CEU’s) to maintain skills
 May not administer meds which require titration (insulin,
heparin, cardizem, etc.)
 May not administer blood products
 May administer saline flushes & heparin flushes
 May administer TPN & lipids
PN Scope of Practice
 Peripheral Line: may insert & D/C, flush, change tubing,
site care
 PICC Line: may not insert or D/C; ok to flush, change
tubing, site care, draw blood
 ?? Check hospital policy !
 Central Line: may not D/C; ok to flush, draw blood, change
tubing and perform site care
 ?? Check hospital policy !
 POC: may NOT flush or access, may not draw blood, may
change tubing and administer IVPB
 ?? Check hospital policy !
PN Scope of Practice
 Guidelines are provided by State Board of Nursing
 MUST always follow institution policy – this may vary from
state guidelines
INS Standard
 The nurse shall educate the patient, caregiver, or legally
authorized representative:
 Prescribed infusion therapy
 Plan of care
 Potential complications associated with therapy
 Peripheral or Central
 Risks
 Benefits

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