Historia.

Los primeros intentos a principios del siglo XX. Accediendo a la circulación central utilizando las venas
cubitales y femorales. En 1929, Forssmann introdujo un catéter ureteral 4 F en su propio corazón a través de
una aguja en su fosa cubital izquierda, documentándolo por radiología. En 1956, recibió el Nobel de
Medicina.

Aubaniac utilizó catéteres subclavios para la infusión rápida de fluidos de reanimación en víctimas militares
en 1952. 10 años después Wilson et al informaron sobre las ventajas de la medición de la presión venosa
central en el mantenimiento de Volumen de sangre óptimo. Dudrick et al describió el valor de la nutrición
parenteral total lo que reforzó su uso.

Indicaciones para CVC.

Dispositivos de acceso

s Administración rápida de líquidos, por ejemplo, en casos de: - trauma múltiple

- quemaduras

- cirugía abdominal extensa

- sepsis

s Administración de fluidos IV que requieren dilución dentro de

La circulación central para evitar el daño vascular (es decir,

quimioterapia, nutrición parenteral total)

s Administración de fármacos vasoactivos y / o incompatibles.

s Muestreo frecuente de sangre (en pacientes sin una línea arterial)

y / o terapias de administración de sangre

s Pacientes con enfermedades crónicas en los que el acceso periférico IV es limitado. s Control de la presión
venosa central (CVP) para evaluar

estado del líquido intravascular

s Medición de los niveles de saturación de oxígeno en la sangre que regresa a

el corazón (SsvcO2)

s Monitoreo y acceso para arteria pre o post pulmonar

inserción del catéter (mismo sitio de inserción)1

OVERVIEW

Indications for Use – Central Venous

Access Devices

Contraindications include patients with:

s Recurrent sepsis
s Hypercoaguable state where catheter could serve as a focus for

septic or bland thrombus formation

Types of Central Venous Access Devices

A central venous catheter is, by definition, a catheter whose tip resides in the central circulation. There are
various types of these catheters, but, for the purpose of this guide, we will focus on the short-term (< 30
days) IV access catheters that are made by various manufacturers, including Edwards Lifesciences.

Single-lumen or double-lumen catheters are often inserted for intermittent or continuous infusion of
medication or fluid. They are applicable for the administration of a particular solution (i.e., chemotherapy,
antibiotic, and/or nutritional therapies) in the hospital or home setting. single-lumen catheters may lend
themselves to administration of total peripheral nutrition (TPN) through a dedicated line.

Multi-lumen catheters allow for multiple therapies to be performed through a single venous access site and
are often seen in the critical care environment. These catheters, although designed for short-term access,
generally see much use during this period.

Introducers are used to direct and place intravascular catheters, especially pulmonary artery catheters
(PAC), within a designated blood vessel. They may be left in place to serve as a central venous access after
removal of the PAC.

Advanced Venous Access (AVA) devices combine the ability to insert PACs and to infuse multiple fluids in
one multipurpose device.

Central Venous Catheters Catheter Specifics

Polyurethane (commonly used for catheter body)

s Tensile strength, which allows for thinner wall construction

and smaller external diameter

s High degree of biocompatibility, kink and thrombus resistance s Ability to soften within the body

(continued)

OVERVIEW

Central Venous Catheters

Catheter Specifics

Number of Lumens

s More than one lumen increases the functionality of a single site (benefit)
s Multilumem catheters may be more prone to infection because of increased trauma at the insertion site or
because multiple ports increase the frequency of manipulation

(continued)

Nursing Note

Acetone and isopropyl alcohol should be avoided when caring for these catheters.

CDC Guideline (1996)

Use a single-lumen central venous catheter, unless multiple ports are essential for the management of the
patient.

Although one study showed that only a single port is often used in one half of the triple lumens placed,
triple- lumen CVCs appear to be the most commonly placed central line in ICU.

Practical Point

Critically ill patients may need more IV access than that obtained with a single multi-lumen CVC. Two triple-
lumen CVCs or an introducer and a CVC may be placed in the same vein or in two different veins. This
procedure is referred to as a double stick.

Flow Characteristics

s Primarily determined by a catheter’s internal diameter and length, not by the size of the blood vessel into
which the catheter is inserted

s Is often incorrectly assumed to be proportional to the catheter’s outside dimension

Flow rates are usually calculated with normal saline at a head

height of 40" (101.6cm).

OVERVIEW

Central Venous Catheters

Catheter Specifics

Length
Various studies have shown that the average safe insertion

depth for central venous catheterization from the left or right internal jugular or subclavian vein is 16.5 cm
for the majority of adult patients.1 (This assumes correct tip placement above the right atrium.2)

Coatings

Catheter coatings may include the bonding of the catheter surface with antimicrobial and/or antiseptic
agents to decrease catheter-related infection and thrombotic complications. Heparin-bonding process is one
example; other agents reported in the literature include antibiotics such as minocycline and rifampin, or
antiseptic agents like chlorhexidine and silver sulfadiazine. Materials, in particular metals, that are
antimicrobial in minute amounts are called oligodynamic.
One of the most potent of these is silver, with the antimicrobial form being silver ions. The bactericidal
action of silver ions is effective against a broad spectrum of bacteria, including the common strains which
cause infection and the more virulent antibiotic-resistant strains. Silver has been in medical use for decades
and was used in systemic drugs before the advent of antibiotics. Today, silver is used routinely in
antibacterial salves (silver sulfadiazine), to prevent infection and blindness in newborns (silver nitrate), and
in medical devices and catheters.

Antibiotic- and antiseptic-coated catheters have demonstrated reduced rates of catheter colonization and
associated blood stream infection in some clinical trials, but it is important to remember that heparin-
induced thrombocytopenia and/or allergy to the antibiotic used on a catheter could result in patient
morbidity. Additionally, there is always the possibility that antibiotic-resistant microorganisms may develop
or that the catheter site becomes infected with other organisms,

such as Candida.

(continued)

OVERVIEW

Central Venous Catheters Catheter Specifics (continued)

Nursing Note

Heparin-induced thrombocytopenia is a reduction in platelets caused by antiplatelet antibodies. It occurs in

approximately 0.4% of patients with heparin-coated catheters and has a high mortality and morbidity.
Patients so afflicted must not receive any more heparin, in any form, until the heparin-associated
antiplatelet antibodies are no longer detectable.

Timely Tip

Twelve patients in Japan who had a silver sulfadiazine- chlorhexidine catheter in situ developed anaphylactic
shock. This was related to possible pre-exposure to chlorhexidine in skin creams.5

Other Considerations

s Soft tip to avoid injury or perforation

s Radiopaque
s Depth markings on all catheters and guidewires

Technical Tip

Catheter softness is a function not only of the material, but also of the specific formulation of that material
(often proprietary information). Triple lumen catheters need to be stiffer because more septations and a
firmer plastic are needed to extrude a multi-lumen catheter.

OVERVIEW
CVC Port Designation

Blood administration TPN or Medications

High volume fluids
Colloid fluid administration
Drug therapy
whit
Proximal white
e
Medial (1) blue blue
Medial (2)

DISTAL (OR LARGEST GAUGE)

CVP monitoring
These are suggestions only.

MEDIAL

PROXIMAL

Medication administration

Blood sampling Drug therapy

CVC Port Color Designation

PORT DOUBLE TRIPLE

Distal brown brown

Introducers as a Central Line

QUAD

white blue gray brown

Sometimes an introducer is used for central venous access or is left in place following the removal of a
pulmonary artery catheter. Components of the introducer system usually include:

s Flexible polyurethane sheath s Guidewire and dilator

s Side port
s Hemostasis valve

After insertion, the guidewire and dilator are removed, leaving the sheath in place. Fluids may be
administered through the side port, while the hemostasis valve prevents bleedback and/or air embolization.

A single-lumen infusion catheter can be used with the introducer, placed through the hemostasis valve (after
swabbing the valve with Betadine), to convert to a double-lumen access. An obturator should be used to
safely occlude the lumen as well as to prevent air entry when the catheter is not in use.

OVERVIEW
French Catheter Size Conversion
7

OVERVIEW

French Catheter Size Conversion (continued)

8

OVERVIEW
Insertion Sites

Typically, central venous catheters are inserted via the subclavian or internal jugular (IJ) veins. The
subclavian vein begins at the lateral border of the first rib and arches through the space between the first rib
and clavicle. It joins the internal jugular to become the innominate (or brachiocephalic) vein, which then
flows into the superior vena cava to the heart. The subclavian vein can be approached either
infraclavicularly (below the clavicle) or supraclavicularly (above the clavicle). Alternative sites include the
external jugular and femoral veins.

RELATIONSHIP OF CLAVICULAR LANDMARKS TO VASCULAR ANATOMY

Note the natural “windows” for supraclavicular venipuncture: 1) supraclavicular triangle formed by the
clavicle, trapezius, and sternocleidomastoid muscles, 2) clavicular sternocleidomastoid triangle formed by
the two bellies of the sternocleidomastoid muscle and the clavicle.

(Reproduced with permission from Novak RA, Venus B: Clavicular approaches for central vein cannulation.
Probl Crit Care 2:242, 1988.)

INSERTION AND REMOVAL

Insertion Sites (continued)

ANATOMIC ILLUSTRATION OF SIDE PREFERENCE RATIONALE FOR CLAVICULAR APPROACHES

Right IJ, supraclavicular procedures and left infraclavicular pro- cedures are preferred. Note the close
proximity of arterial and venous structures. Venipunctures in the lateral region of the clavicle are more
prone to arterial puncture, brachial plexus injury, and pneumothorax. Note the prominent thoracic duct and
higher apex of the lung on the left and the perpendicular entry of the left IJ into the left subclavian vein.

(Reproduced with permission from Novak RA, Venus B: Clavicular approaches for central vein cannulation.
Probl Crit Care 2:242, 1988.)

Sites for Central Venous Catheterization: Advantages and Disadvantages

INTERNAL JUGULAR (58 - 99% SUCCESS RATE)

ADVANTAGES

Relatively short and direct pathway to heart (right IJ)

High success rate

Easy access from head of bed Pneumothorax rare

Easier control of bleeding

DISADVANTAGES

Not ideal for prolonged cannulation

Uncomfortable for patient Dressings difficult to maintain

Left IJ increases risk of thoracic duct injury

Poor landmarks in obese or edematous patients

10

INSERTION AND REMOVAL

Sites for Central Venous Catheterization:

Advantages and Disadvantages

INTERNAL JUGULAR (58 - 99% SUCCESS RATE)

ADVANTAGES

Continued chest compression during CPR possible

DISADVANTAGES

Difficult access with tracheostomies

More prone to collapse with volume depletion or shock

Difficult access during emergencies when airway control is being established

Carotid artery puncture relatively frequent

Contraindications for patients with intracranial hypertension

INFRACLAVICULAR (85-99% SUCCESS RATE)

ADVANTAGES

Easier to maintain dressings More comfortable for patient

Better landmarks in obesity

Large vein less collapsible during hypovolemia

DISADVANTAGES

Higher risk of pneumothorax

Compression of bleeding site difficult

Long pass from skin to vein

SUPRACLAVICULAR (85-99% SUCCESS RATE)

ADVANTAGES

Low incidence of pneumothorax High success rate

Easier to pass catheter Accessible from head of bed Good landmarks

No interference with chest compression

Anatomic landmarks constant Short path from skin to vein

DISADVANTAGES

Control of bleeding difficult

Pneumothorax possible

Uncomfortable for patient

Not ideal for prolonged access

Dressing and catheter maintenance difficult

Thoracic duct puncture possible

Not ideal approach when airway control is being established

Not ideal for temporary hemodialysis

(continued)

11

INSERTION AND REMOVAL

Sites for Central Venous Catheterization:

Advantages and Disadvantages

EXTERNAL JUGULAR (60-90% SUCCESS RATE)

ADVANTAGES

Part of surface anatomy

Clotting abnormalities not prohibitive Pneumothorax avoided
Access from head of table
Prominent in elderly

DISADVANTAGES

High failure rate

Not ideal for prolonged access

Uncomfortable for patient

Dressing maintenance difficult

Poor landmarks in obese and edematous patients

Unsuccessful in young patients

Difficult for threading central catheters

(Reproduced with permission from Novak RA, Venus B: Clavicular approaches for central vein cannulation.
Probl Crit Care 2:242, 1988.)

(continued)
Practical Point

Catheters inserted in the femoral vein and advanced into the inferior vena cava may be utilized as a second
alterna- tive to the superior vena cava, except for emergency IV fluid resuscitation or for superior vena cava
injuries. Cannulation of this vein usually has a high success rate. This approach may, however, have the
disadvantage of requiring longer catheters; the catheter tip should lie in the inferior vena cava for infusions
and should reach the level of the diaphragm for the purpose of central venous pressure monitoring.

Research Riches

In a study of anesthetized, mechanically ventilated patients who were in a 10o head down position and
receiving fluid loading, an inverse relationship between a large external jugular vein (as measured with an
ultrasound imaging machine) and a small internal jugular vein was found. Mean IJV diameter was 17.4 mm
(range 4-30 mm). There was no correlation between weight, height, or neck size and IJV diameter. A

12

INSERTION AND REMOVAL

Sites for Central Venous Catheterization:

Advantages and Disadvantages

(continued)

CDC Guideline (1996)

s Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications
against the risk of mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian
vein laceration, hemothorax, thrombosis, air embolism, catheter misplacement).

s Use subclavian, rather than jugular or femoral, sites for central venous catheter placement unless
medically contraindicated (e.g., coagulopathy, anatomic deformity).

Central Venous Catheterization via the

Seldinger Technique

ONE

s Enter vessel with 22 gauge locating needle and attached

5ml syringe

s Upon aspiration of dark venous blood, remove needle and syringe

TWO

s Attach 5ml syringe to 18 gauge catheter over 20 gauge

needle assembly

s Insert needle
and relocate vein previously entered
s Upon aspiration of
venous blood, remove
needle and syringe, leaving the 18 gauge catheter in place.

s Insert guidewire into already placed 18 gauge catheter

Catheter over needle inserted together

wire in - needle out

13

INSERTION AND REMOVAL

Central Venous Catheterization via the

Seldinger Technique

THREE

s Remove catheter, leaving the guidewire in place FOUR

s Enlarge puncture site, if necessary with small scalpel

FIVE

s Further enlarge the insertion site and vessel by threading a dilator over the guidewire

s Leaving the guidewire in place, remove the dilator

SIX

s Thread central venous catheter over the guidewire.

s Remove guidewire

Reproduced with permission from Darovic, GO: Hemodynamic Monitoring Invasive and Non-invasive Clinical
Application, 1987.

Patient Preparation

Catheters can be inserted in a variety of settings under various conditions. Recently, it has been shown that
the setting of catheter placement may not be as critical a factor in minimizing infection risk as the use of
maximal barrier precautions.

Two studies have shown the use of maximal barrier precautions (cap, mask, gown, gloves, and large drape)
decrease the colonization of the catheter surface at the time of insertion, thereby decreasing the risk for
catheter-related sepsis.

(continued)

wire out
CDC Guideline (1996)

Use sterile technique, including a sterile gown and gloves, a mask, and a large sterile drape (i.e., maximal
barrier precautions), for the insertion of central venous and arterial catheters. Use these precautions even if
the catheter is inserted in the operating room.

14

INSERTION AND REMOVAL

Patient Preparation (continued)

The skin should be cleaned before insertion using an antiseptic agent to kill or inhibit growth of
microorganisms. Popular antiseptics include:

70% ALCOHOL

ADVANTAGES

Fast kill

Very effective against gram-negative and gram-positive bacteria

Effective fat solvent

2% TINCTURE OF IODINE

ADVANTAGES

Effective against the same organisms as 70% alcohol

Prolonged contact may even kill certain fungi and spores

DISADVANTAGES
Not effective against spores

Must rub the site vigorously for at least one minute

Drying nature of alcohol.

DISADVANTAGES

May cause skin irritation

Must be removed from skin before catheter is placed

10% POVIDONE-IODINE (IODINE SOLUTION)

ADVANTAGES

Reduced toxicity

Less skin irritation than iodine tincture

CHLORHEXIDINE

ADVANTAGES

Active against gram-positive and gram-negative organisms and viruses

Residual activity up to 6 hours Patient Position

15 - 30 DEGREES TRENDELENBURG

DISADVANTAGES

Contact time of 2 minutes necessary for optimal microbial kill

Neutralized in presence of blood and pus

DISADVANTAGES

Can be inactivated by compounds found in hard water and soap

Allergic reactions reported

s Increases venous return by approximately 37% s Increases intrathoracic pressure

s Helps prevent inadvertent air embolization
s Not always well tolerated by cardiac patients

s Not necessary when jugular venous distention (JVD) present in supine position (right-sided failure)

15

INSERTION AND REMOVAL

Patient Position (continued)
VALSALVA MANEUVER (FORCED EXPIRATION AGAINST

CLOSED GLOTTIS)

s Increases cross-sectional area of jugular vein by approximately 25%

s May be accomplished in ventilated patients by causing a forced inflation via an Ambu bag

“BUMP” POSITION

Head turned to the contralateral side and a rolled towel placed in the back.

INFRACLAVICULAR APPROACH TO THE RIGHT SUBCLAVIAN VEIN

The patient is positioned with a rolled towel between the scapulae to increase the distance between the
clavicle and the first rib.

16

INSERTION AND REMOVAL

Catheter Tip Placement

Triple-lumen catheters should be inserted so that the tip

is approximately 2 cm proximal to the right atrium (for right-sided approaches) and similarly placed or well
within the innominate vein (for left-sided approaches), with the tip parallel with the vessel wall. A chest x-
ray must be done post insertion, as it provides the only definitive evidence for catheter tip location.

Probably the most important factor in the prevention of complications is the location of the catheter’s tip.
The pericardium extends for some distance cephalad along the ascending aorta and superior vena cava. In
order to guarantee an extrapericardial location, the catheter’s tip should not be advanced beyond the
innominate vein or the initial segment of the superior vena cava. (It is important to note that a portion of
the superior vena cava lies within the pericardium.)

Some practitioners may prefer a deep SVC placement (within the lower third of the SVC), but nearly half the
length of the SVC is covered by pericardial reflection that slopes downward toward its lateral edge. To avoid
the risk of arrhythmias and tamponade, the tip of a CVC should lie above this reflection and not in the right
atrium.

Clinical Concern

It should be noted that even x-ray confirmation of the catheter in a location above the pericardial reflection
does not guarantee against possible tamponade. Cases of perforation with hydromediastinum and cardiac
tampon- ade have been reported, with the site of extravasation being as distal as the subclavian vein. One
concern with the multi-lumen catheter is the necessity of advancing it somewhat further than a normal
catheter to ensure that the proximal opening is within a central vein.

Tips to assure catheter tip not extravascular or against a wall might include:
s Syringe aspiration yields blood freely
s Venous pressure fluctuates with respiration

s Advancement of the catheter is unhindered

17

INSERTION AND REMOVAL

The Circulation System

Right subclavian vein

Right lung

Right atrium

Pulmonary veins

Superior vena cava

Brochiocephalic vein

Right ventricle Inferior vena cava

Left ventricle

Abdominal aorta

Carotid artery
Clinical Considerations: Insertion

RECOMMENDED EQUIPMENT

Central venous catheter insertion kit:

- Multi-lumen CVC
- 22 gauge locator needle
- 18 gauge catheter over 20 gauge needle assembly - Guidewire

- Dilator
- 5 cc syringes
- Scalpel
- Lidocaine with needle and syringe - Needleless injection caps
- Suture material/needle
- Gauze
- Sterile drapes (large)
- Antiseptic

Left internal jugular Left subclavian vein

Aorta

Pulmonary artery

Left atrium

Left lung

18

INSERTION AND REMOVAL

Clinical Considerations: Insertion (continued)

Additional items:
- Sterile gloves, sterile gowns, masks and caps for everyone

in room

 - Dressing materials (dressing per hospital policy,

nonallergenic tape)

 - Heparin flush solution

 - Pressure monitoring setup for CVP determination, if

desired (flush solution, pressure bag, pressure tubing, trans- ducer and holder, stopcocks, monitor
cable, leveling device)

CLINICAL RESPONSIBILITIES

s Confirm orders
s Obtain informed consent from patient or designated power of

attorney

s Provide further information as requested by patient or family members

s Check equipment to monitor patient (EKG, blood pressure, pulse oximetry, etc)

s Assemble equipment and move into patient room

s Position the patient and provide privacy
s Assist with insertion of catheter under aseptic technique s Monitor patient vital signs during insertion
s Assess patient comfort and intervene appropriately
s Protect the patient by:

 - Assuring compliance with maximal barrier precautions

 - Calling in support personnel (i.e., respiratory therapy) as

necessary

 - Recording vital signs, rhythm strips or waveform traces, SaO2

values, etc.

 - Securing the catheter and dressing the site per hospital

protocol

 - Ordering chest x-ray post-insertion

 - Running fluids at TKO until chest x-ray results available
 - Contacting clinician to read chest x-ray or to inform of

abnormal findings

 - Documenting site, depth of insertion, and the patient’s response to the procedure on
progress/nursing notes

19
INSERTION AND REMOVAL

Clinical Considerations: Insertion (continued)

CDC Guideline (1996)

s Wear non-latex or latex gloves when inserting an intravascular device as required by the Occupational
Safety and Health Administration (OSHA) Bloodborne Pathogens Standard.

s Do not routinely use cutdown procedures as a method to insert catheters.

s Cleanse the skin site with an appropriate antiseptic, including 70% alcohol, 10% povidone-iodine, or 2%
tincture of iodine, before catheter insertion. Allow
the antiseptic to remain on the insertion site for an appropriate length of time before inserting the catheter.

s When tincture of iodine is used for skin antisepsis before catheter insertion, it should be removed with
alcohol.

s Do not palpate the insertion site after the skin has been cleansed with the antiseptic (this does not apply to
maximum barrier precautions during which the operator is working in a sterile field).

s Record the date and time of catheter insertion in an obvious location near the catheter insertion site (e.g.,
on the dressing or on the bed).

Insertion Complications

Mechanical complication rates range from 1% to 10%, although rates as high as 15% have been reported
when the access is placed emergently. Complications related to insertion can manifest themselves within
minutes following insertion or may not be obvious for several days.

Research Riches

One study shows, the strongest predictor of a complica- tion is a failed catheterization attempt. Many
clinicians feel that three attempts are enough,6 and then it is time to ask another clinician to attempt
catheterization from another site.

20

INSERTION AND REMOVAL

Insertion Complications (continued) Complications of Central Venous Catheterization

Air Embolism

s May be associated with insertion process

s Patient positioning (Trendelenburg)

s Often related to disconnection of tubing or at catheter removal

s Valsalva maneuver (forced exhalation)

s Patients who are hypovolemic or snore are at highest risk

s Can occur after removal, if subcutaneous tract made by catheter has failed to close

s Sudden onset tachycardia, pulmonary hyper-, or systemic hypo-tension

s Neurologic deficit or potentially fatal position; aspirate air if CVC still in place

s Place patient in left lateral decubitus

Arterial Puncture

s Arterial and venous proximity

s Local pressure may be enough to stop bleed s Variable venous anatomy
s Appearance of bright red, pulsatile blood

s Hematoma may resolve or evolve into false aneurysm or arteriovenous fistula

Clinical Concern

The rare complication of tracheal puncture may also occur with internal jugular cannulation attempts,
especial- ly in patients with endotracheal tubes, since the inflated cuff brings the tracheal wall closer to the
adjacent veins.

21

INSERTION AND REMOVAL

Insertion Complications (continued) Arrhythmias

s Transient atrial/ventricular arrhythmias

s Usually related to over insertion of guidewire or catheter, with impingement of the tips of these devices in
the region of the right bundle branch

Cardiac Tamponade/Pericardial Effusion/Hydromediastinum

s Fluid in pericardial cavity due to perforation of structures by catheter

s Cardiovascular collapse once critical volume reached s Infusion of fluid through catheter prior to
placement

confirmation
s Immediate pericardiocentesis

Pneumothorax/Hydrothorax

s Puncture of lung tissue

s Diminished breath sounds, tachypnea

s Atmospheric pressure causes air to enter and collapse portion of lung

s Not clinically detectable if < 20%
s May heal itself or require chest tube

Malpositioned Catheters

s Arrhythmia, venous thrombosis

s Cardiac tamponade
s Falsely elevated pressure measurements s Delivery of infusate into thoracic cavity s Vascular erosion and
perforation

Physiologic Fact

The most common malposition occurs when a catheter inserted via the infraclavicular route goes into the
homolateral internal jugular vein with the tip of the catheter facing oncoming blood flow. Other vessels in
which a catheter might become malpositioned include the internal mammary, axillary, vertebral, and the
greater azygos veins.

22

INSERTION AND REMOVAL

Insertion Complications (continued)

CARDIAC TAMPONADE
Pericardial tamponade caused by central venous catheter perforation of the heart is a catastrophic
complication that can be prevented by attention to proper positioning of the catheter tip proximal to the
cardiac silhouette. In a recent study7 (1998), it was determined that only 31% of the physicians studied who
insert central venous catheters were aware that cardiac tamponade is a potential complication, and only
10% recalled ever seeing or reading the package inserts

that warned of cardiac tamponade. This is in spite of the fact that in 1993 the Food and Drug Administration
(FDA) sent a three-volume video entitled “Central Venous Catheter Complications” to all hospitals where
central venous catheters were inserted. This same study detailed 25 previously unreported cases of cardiac
tamponade after placement of central venous catheters in a nineteen-month period. Eighty percent of the
patients died and 12% remain in a persistent vegetative state. Post-insertion chest x-rays were available in
23 cases. All post-insertion chest x-rays showed the tip of the catheter to be with- in the pericardial
silhouette.

Next, thirty local radiologists were interviewed. Ninety percent of them were not aware that the tip of the
central venous catheter should be located outside
of the pericardial silhouette on the radiograph. None of the inserting physicians believed that it was his or

her responsibility to check the chest x-ray for catheter placement.

Pulmonary symptoms were common, with 8 patients complaining of chest tightness, 12 of shortness of
breath, and 15 were noted to have air hunger up to 6 hours
prior to significant changes in vital signs occurring. Fourteen patients developed tachycardia and 8 were
noted to be bradycardic. All patients developed significant, unexplained hypotension as a result of cardiac
tamponade. Many of these patients were intubated as part of their resuscitation. Seven patients developed
EKG changes consistent with inferior wall ischemia or injury.

23

INSERTION AND REMOVAL

Insertion Complications (continued)

CARDIAC TAMPONADE (CONTINUED)

In all cases, the clinicians treated the patient for myocar- dial ischemia and did not suspect cardiac
tamponade. Ten patients developed new or different non-specific ST- and T-wave changes. Five developed
worsening of their hypotension when nitrates were administered.

This study is particularly discouraging, because the FDA and catheter companies have attempted to warn
physicians of the danger of cardiac tamponade through the use of talks, posters, videos and package insets.
However, this survey and surveys done previously have shown that a minority of physicians were aware of
this potential complication. More importantly, few physicians are aware that cardiac tamponade is
preventable if the tip of the central venous catheter is outside the pericardial shadow on the chest
radiograph. Any patient with a CVC

in place who develops unexplained hypotension, chest tightness, or shortness of breath should have an
emergency echocardiogram to rule out cardiac tamponade.

Clinical Responsibilities

s Observe patient for any signs of cardiopulmonary distress

s Auscultate lungs every 2-4 hours; record findings on nursing flow sheet/progress notes

s Observe daily chest x-ray and record interpretation as to catheter position in the nursing notes/progress
notes

s Include depth of catheter insertion daily in nursing notes/progress notes

s Observe and record any change in neurological status. s Report any change in patient condition to the
clinician,

as appropriate

s Maintain emergency cart, including thoracentesis, pericardiocentesis, and chest tube insertion trays

24

INSERTION AND REMOVAL

Delayed Complications

The most common delayed complications of vascular access device insertion are thrombosis and infection.
These two complications are somewhat related, as thrombotic complications are common in catheterized
veins and are often associated with catheter sepsis.

Thrombosis
All catheters are thrombogenic. Within seconds after

insertion, much of the catheter body is coated with body fluids and proteins. Platelets adhere and thrombus
forms.
Catheters can become encased within 5-7 days, forming a fibrin sheath. Some investigators state that a
fibrin sleeve is found on 100% of subclavian catheters in postmortem examinations and in patients studied
with cinefluoroscopy.

Clinical Concern

Three common organisms causing catheter-related infections (S epidermidis, S aureus, C albicans) adhere
well to fibrin and fibronectin found in fibrin sheaths. These organisms also produce a coagulase enzyme
(slime) that further enhances their adherence on the vascular catheter as well as protects them from the
action of antibiotics.

Mural (wall) thrombi may form on the catheter and/or on the wall of the vessel. They may develop within 48
hours of cannulation, and there have been many case reports of such thrombi breaking off and resulting in
pulmonary emboli. Some of these cases have resulted in mortality 4-5 days after insertion. Additionally,
catheter removal may precipitate dislodgement of such thrombi.

Mangano found that the use of catheters with heparin-bonding offers considerable protection from
thrombosis for 24 hours or longer.8 Thus the use of such catheters may be efficacious in minimizing the risks
of embolism, infarction, and occlusive thrombosis over prolonged periods.

The use of prophylactic anticoagulants is variable. In a recent (1998) review of the literature, it was found
that prophylac- tic use of heparin significantly decreases central venous catheter- related thrombosis,
decreases bacterial colonization of the catheter, and may decrease catheter-related bacteremia. Low
molecular weight heparin seems to have lesspropensity for caus- ing heparin-induced thrombocytopenia
and is 99% bioavailable.

25

INSERTION AND REMOVAL

Delayed Complications (continued) Therapies may include:

s Mix heparin with TPN solution (3U/mL)

s Give heparin IV every 6 or 12 hours (5,000 U)
s Give low molecular weight heparin subcutaneously every day

(2,500 U)

Catheter Occlusion

Catheter occlusion may be a result of fibrin sheath formation and/or thrombus at the tip of the catheter but
has also been associated with blood clots, lipid deposits or precipitates within the catheter lumen. Fibrin
sheath formation is significant in that the sheath may eventually totally encase the catheter

and affect the functional ability of the catheter. Withdrawal occlusion may occur if the fibrin sheath acts as a
flap which blocks the tip of the catheter when blood withdrawal is attempted, and then opens up with
injection.

There is also evidence that partial occlusion is related to a residue of blood products deposited within some
access devices each time blood is aspirated or infused.

Other theories include drug precipitation. These occlusions may result from:
s Inadequate flushing between incompatible medications
s Simultaneous administration of incompatible medications
s Medications administered in a concentration exceeding that

required for stability

Attempts to clear catheter occlusions include the use of

fibrinolytic agents. Catheter patency can often be restored

if the solubility of the fluid components is changed by altering the pH through the use of 0.1 N hydrochloric
acid and sodium bicarbonate.

Clinical Concern

The use of lipid-containing TPN, commonly referred

to as three-in-one, has been shown to be responsible
for a unique type of catheter precipitate occlusion. An aggregation that occurs with lipid/parenteral
nutrition admixtures causes the development of deposits that result in sludging in the catheter lumen and
eventual occlusion. The use of an ethanol (70% ethyl alcohol) solution as a means of dissolving fat (the main
component of the occlusion) has been reported.

26

INSERTION AND REMOVAL

Delayed Complications (continued) Infection

It is estimated that 200,000 nosocomial (hospital-acquired) bloodstream infections occur each year; most of
these infections are related to the use of an intravascular device. These infections are associated with
increased mortality and morbidity, prolonged hospitalization and extended intensive care unit stays, and
greater hospital costs. It has been estimated that each bloodstream infection costs the hospital
approximately $6,000- $40,000 and increases the length of stay by an additional 24 days per survivor.9

Catheter-related bloodstream infection – isolation of the same organism by a semiquantitative technique

from a removed catheter associated in time with the recovery of the same organism from properly collected
blood cultures (preferably drawn from a peripheral vein) in a patient with accompanying clinical symptoms
and no other apparent source of infection.

Practical Point

There are rarely more than 50-100 colony-forming

units (CFU) at the site of insertion of a peripheral venous catheter on the arm or wrist. On CVC sites located
on the chest or neck, there are as many as 1000 to 10,000 CFU/site, especially in long-term ICU patients. 10

Research Riches

All other factors being equal, the general feeling is that the longer the line stays in place, the more likely the
pos- sibility of infection. However, more recent data suggest that the daily risk of infection remains
constant.11

27

INSERTION AND REMOVAL

Delayed Complications (continued)

Over the past two decades, there has been a marked change in the distribution of pathogens reported to
cause bloodstream infections (BSIs). Since the mid-1980s, an increasing portion of nosocomial BSIs have
been due to gram-positive, rather than gram-negative, species. The increase in nosocomial BSIs during the
past decade is largely due to significant increases in four pathogens:

s Coagulase negative staphylococci (CoNS), including Staphylococcus epidermidis

s Candida species
s Enterococci
s Staphylococcus aureus
(N.B. Coagulase-negative organisms are gram-positive organisms.)

Prior to 1986, S aureus was the most frequently reported pathogen causing nosocomial BSIs. Currently,
coagulase negative staphylococci, particularly S. epidermidis,
have become the most frequently isolated pathogens in catheter-related infections. The prevalence of these
organisms also shows that the hands of healthcare workers and the flora of patients’ skin are likely to be the
predominant sources of pathogens for most catheter-related infections.

The pathogenesis of central venous catheter colonization and related bloodstream infection is not
completely understood. The leading theories include:

s Migration of skin organisms through the cutaneous catheter tract

s Contamination of the hub

s Hematogenous seeding (from pneumonia, urinary tract infections, etc)

s Contaminated infusate

(Reproduced with permission

from Maki DG: Infections due to infusion therapy. (Chapter 40) in Hospital Infections (Bennett JV, Brachman
PS, eds) Boston: Little, Brown and Co, 1992.)

28

INSERTION AND REMOVAL

Delayed Complications (continued)

Research Riches
Recent findings suggest that duration of catheteriza- tion influences which of the mechanisms predominate.
Hub contamination is the more likely mechanism for infection for long-term catheters (i.e., in place > 30
days) while skin contamination is the most likely cause for short-term catheters (i.e., <10 days).12

Timely Tip

Manipulations of the delivery system, especially the administration set, appear to provide a highly effective
means for access of microorganisms to in-use infusate. This was illustrated by a spate of nosocomial
outbreaks across the US traced to in-use contamination of a newly released intravenous anesthetic, propofol
(Diprivan). The solution provides an almost uniquely rich medium for rapid microbial growth. (It is a lipid
formulation, like intralipids administered with TPN.)

Timely Tip

A recent (1998) editorial left this “take home” message.

“Antibiotic- and antiseptic-coated catheters have demonstrated reduced rates of catheter colonization and
associated blood stream infection. However, if all other measures are optimized, their value remains to be
proven.” “...these devices may best serve high-risk populations... patients undergoing change of a central
venous catheter over a guidewire and patients for whom the consequence of infection is great... or when the
duration of CVC use is anticipated to exceed 5 days.” 13

CDC Guideline (1996)

In adults, consider use of a silver-impregnated collagen cuff or an antimicrobial- or antiseptic-impregnated

central venous catheter if, after full adherence to other catheter infection control measures (e.g., maximal
barrier precau- tions), there is still an unacceptably high rate of infection.

Diagnosis
The best tests for venous access device infection are direct

specimens of the device itself and any attached material or organisms, and these tests are possible only after
the catheter is removed. Otherwise, there is no identified gold standard for diagnosing catheter-related
infections.

29

INSERTION AND REMOVAL

Delayed Complications (continued) DIAGNOSIS OF CATHETER-RELATED INFECTION

Semi-quantitative catheter culture (Maki)

s Catheter removed after skin is cleaned

s Most widely used, best studied

s At least 5 cm of tip and the catheter segment beginning 1-2 mm inside the point of the skin-catheter
junction are cultured

s Cutaneous segment may be better predictor than tip s Only outside of catheter cultured
s Only determines catheter colonization
s Catheter segments are rolled on agar plate
s Catheter must be removed

Quantitative catheter culture

s Catheter segment flushed with broth s Most sensitive
s Segment then immersed in broth
s Both luminal and external surfaces
s Sonicated to release organisms
s Catheter must be removed

Quantitative blood cultures

s Blood cultures simultaneously drawn from catheter and

peripheral IV sample
s Positive = catheter blood sample colonies > 5x peripheral s Compares concentration of organisms
s Does not require removing CVC

Catheter exchange
s Change catheter over wire
s Remove new catheter if positive culture obtained s Culture catheter

s The critical step in the treatment of central line infections is to remove the involved catheter. Antimicrobial
therapy usually is given adjunctively, but is no substitute for catheter removal.

30

INSERTION AND REMOVAL

Delayed Complications (continued)

Clinical Responsibilities: Delayed Complications

s Monitor patient temperature frequently

s Monitor WBC levels (with differential) at least on a daily basis

s Administer medications, as ordered, to prevent thrombosis and infection

s Collect blood or tip cultures as ordered, using sterile technique

s Monitor coagulation parameters as ordered s Report abnormal findings to the clinician

Catheter Exchange

There are a wide variety of practices concerning the changing of short-term percutaneously-inserted CVCs.
Policies run the gamut from routine changes every 3-4 days to leaving the catheter in place until a
complication develops or it is no longer needed.

CDC Guideline (1996)

Do not routinely perform surveillance cultures of patients or of devices used for intravascular access.

Research Riches
A recent controlled study showed that routine replace- ment of CVCs every three days does not prevent
infection. A prospective, randomized trial concluded that routine 72-hour catheter exchange does not confer
an advantage over 7-day catheter exchange in the prediction of central venous infection in a critically ill
patient requiring multi- ple lumen central venous access. 14

Central venous catheters can be exchanged for a variety of reasons. Replacement of these catheters can be
achieved by using de novo (in a new site) percutaneous placement or by using the Seldinger technique to
change the catheter over a guide- wire in the same site. In general, exchanging catheters over
a guidewire may be associated with fewer mechanical complications and no increased risk of infection,
compared to new-site venipuncture.

31

INSERTION AND REMOVAL

Catheter Exchange (continued)

However, these findings have not been consistently document- ed, and complications may relate to
clinician experience.

Research Riches

Exchanging catheters over guidewires or at new sites every three days is not beneficial in reducing
infections, compared with catheter replacement on an as-needed basis.15

CDC Guideline(1996)

s Do not routinely replace non-tunneled central venous catheters as a method to prevent catheter-related
infections.

s Use guidewire assisted catheter exchange to replace a malfunctioning catheter or to convert an existing
catheter if there is no evidence of infection at the catheter site.

s If catheter-related infection is suspected, but there is

no evidence of local catheter-related infection (e.g., purulent drainage, erythema, tenderness), remove the
existing catheter and insert a new catheter over a guide- wire. Send the removed catheter for
semiquantitative or quantitative culture. Leave the newly inserted catheter in place if the catheter culture
result is negative. If the catheter culture indicates colonization or infection, remove the newly-inserted
catheter, and insert a new catheter at a different site.

s Do not use guidewire assisted catheter exchange whenever catheter-related infection is documented. If
the patient requires continued vascular access, remove the implicated catheter and replace it with another
catheter at a different insertion site.

It has been a common practice to obtain a chest x-ray after catheter exchanges over a guidewire.

32

INSERTION AND REMOVAL

Catheter Exchange (continued)

However, there has recently been controversy concern- ing this policy. Some clinicians now feel that chest x-
rays are unwarranted after uncomplicated guidewire exchanges in hemodynamically stable, monitored
patients. Rationale includes:
s The results of several studies showing no complications

s The feeling that many complications would be picked up by clinical signs

s Patients requiring CVC generally have routine chest x-rays, usually within 48 hours of exchange

Clinical Responsibilities: Catheter Exchange s Assist with catheter exchanges, as per insertion

responsibilities

s Assist with regloving and redraping the site between removal and reinsertion

CVC Removal

Central venous catheters may be removed for a variety of reasons, including discontinuation of therapy and
transfer to a subacute environment. Removal of the CVC generally is performed by house staff or nurses. It
should precede the patient’s transfer, as this removal is ideally performed in a monitored situation.

Research Riches

The removal of a central venous catheter can be complicated by a rare but potentially life-threatening
neurocardiopulmonary distress, according to one recent (1998) study. The clinical courses of eight patients
who had CVCs removed were studied. The major complica- tions were: neurologic paresis or coma (4
patients), respiratory failure (4 patients), and shock (2 patients). One patient died from pulmonary sepsis.
The overall mortality rate was 12.5%. The authors felt this syndrome to be an unappreciated complication of
central venous catheter removal. 16

33

INSERTION AND REMOVAL

CVC Removal (continued)

CDC Guideline (1996)

s Remove any intravascular device as soon as its use is no longer clinically indicated

s No recommendation for removal of central catheters inserted under emergency conditions where breaks
in aseptic technique are likely to have occurred

Clinical Considerations: Removal

RECOMMENDED EQUIPMENT

- Sterile gloves
- Suture removal set
- Sterile dressing material
- Antibiotic/antiseptic ointment - Non-allergenic tape
- Appropriate waste container
- Culture container
CLINICIAN RESPONSIBILITIES

s Confirm order

s Explain procedure to the patient and/or family members

s Remove existing dressing material and dispose of it in the appropriate waste container. Clip any sutures

s Discontinue existing IV solutions running through CVC; switch to alternate site

s Position the patient in a head-down position, if tolerated; at least keep as flat as possible

Clinical Concern

This is especially important if the patient is dehydrated, as a low CVP may generate a sucking force of air into
the systemic circulation.

s Observe careful aseptic technique as you remove the catheter. Change gloves

s Slowly and continuously remove catheter while the patient holds his/her breath to prevent air
embolization

34

INSERTION AND REMOVAL

CVC Removal (continued)

Clinical Concern

If patient is intubated, have respiratory therapist provide a forced inspiration via Ambu bag.

Occlude catheter lumen or exit wound immediately, again to prevent air entry.

Be careful applying pressure to neck sites as this could:

s Dislodge arteriosclerotic plaques or thrombus in the carotid artery, causing a stroke and/or

s Cause a vasovagal reflex, leading to acute onset bradycardia and hypotension

Apply antibiotic ointment to the exit wound to seal the track opening.

Apply air-tight occlusive dressing; leave in place for at least 12 hours, preferably 24-72 hours.

Research Riches

The literature report cases of air embolization after line removal due to a long-standing catheter track.17

Collect appropriate cultures. (This may require a second person to cut the tip while the first secures the site.)

Patient should remain lying flat in bed for 30 minutes after CVC removal.
Note: a suture may be needed to close a large and long-standing catheter track.

Chart patient’s response to the procedure, any untoward complications, and the type of culture sent.

Physiologic Fact

Any patient that has an opening between the right and left sides of the heart is especially at risk if air enters
the venous system. Although the blood flow through an opening is usually left-to-right since pressures are
higher on the left side, it is possible for the air to enter the left side of the heart through a patent foramen
ovale (the hole in the atrial septum that normally closes at birth) or through shunts in the pulmonary
circulation. A very small amount of air is necessary to cause neurologic symptoms as the air enters the right
carotid artery and goes to the brain. This causes left-sided weakness. The only reason the right carotid is
usually involved is that it is the first upward artery off the aortic arch.

35

INSERTION AND REMOVAL

Site Care

Care of the catheter site is considered to be of primary importance and is believed to play a critical role in
decreasing the risk for catheter-related sepsis. Universal standards for care of the catheter site have not
been established. Unresolved issues include use of ointments and antiseptic agents, dressing type, and
frequency of dressing changes.

Although exact protocols for site care vary from institution to institution, they all call for:
s Removal of the old dressing
s Inspection of the site and surrounding area

s Cleansing of the site

s Covering the site with a sterile dressing

Sterile gloves and masks should be worn during dressing changes.

CDC Guideline (1996)

s Wash hands before and after palpating, inserting, replacing, or dressing any intravascular device

s Wear non-latex or latex gloves when changing the dressings on intravascular devices

s No recommendation for the use of sterile versus non-sterile clean gloves during dressing changes

Site Inspection

Any signs or symptoms that might indicate an infection should be reported at once. However, these signs
are not always indicative of infection. Signs of infection may include redness or exudate. However, many
catheters exhibit slight erythema at the site without necessarily being infected. Conversely, the
immunosuppressed patient may shown no signs of infection even when infection is present. Fever, however,
in a patient with a CVC is usually attributable to the catheter until proven otherwise.

36

SITE MAINTENANCE
Site Inspection (continued)

CDC Guideline (1996)

s Palpate the catheter insertion site for tenderness daily through the intact dressing

s Visually inspect the catheter site if the patient has development of tenderness at the insertion site, fever
without obvious source, or symptoms of local or bloodstream infection

s In patients who have large, bulky dressings that prevent palpation or direct visualization of the catheter
insertion site, remove the dressing, visually inspect the catheter site at least daily, and apply a new dressing

Site Cleansing

The catheter exit site should be cleansed with an appropriate antiseptic agent that includes 70% alcohol and
10% povidone-iodine. (Povidone-iodine has replaced iodine for use in the clinical setting.)

Cleansing with an appropriate antiseptic solution should proceed in a circular pattern, working outward from
the insertion site. Typically, cleansing begins with the application of 70% isopropyl alcohol to remove skin
oils and cells, exposing the lower skin layers to the antimicrobial activity. Alcohol needs to remain wet on the
skin for at least 1 minute. Although alcohol provides the most rapid and greatest reduction in microbial
counts on the skin, it does not have any residual antimicrobial activity.

Research Riches

One study by Maki found no significant antimicrobial benefit for defatting the skin during dressing change.18

Technical Tip

Acetone, alcohol and ether have been shown to weaken polyurethane and silicone materials.

After the alcohol (if used), the insertion site is usually prepped with povidone-iodine. This material must
remain in contact with the skin for at least 2-5 minutes before the procedure in order to achieve adequate
microbial count reductions.

37

SITE MAINTENANCE

Site Cleansing (continued)

The sustained release of free iodine from povidone-iodine has an antibacterial effect. The antimicrobial
activity of povidone-iodine is significantly reduced by the presence of blood, mucous, and other organic
matter.

CDC Guideline (1966)

s Wash hands before and after palpating, inserting, replacing, or dressing any intravascular device

s Cleanse the skin site with an appropriate antiseptic, including 70% alcohol, 10% povidone-iodine, or
2% tincture of iodine. Allow antiseptic to remain on the insertion site for an appropriate length of time
Chlorhexidine 0.5% in 70% isopropyl alcohol has recently been promoted for use as a skin disinfectant.
Chlorhexidine leads to residual antibacterial activity that persists for hours after application, and it is not
affected by protein.

Research Riches

In a prospective, randomized study by Maki, in which he looked at the efficacy of several solutions, 2%
chlorhexi- dine before insertion and for post-insertion site care sub- stantially decreased the incidence of
catheter-related infection.19

FDA Alert! Chlorhexidine allergy resulting in anaphylactic shock has been reported.

The use of ointments in the care of CVCs is controver- sial. Although it would appear that the use of an
antimi- crobial ointment would be beneficial, clinical trials have not conclusively confirmed the benefit of
such ointments. Their use has been further complicated in that an increase in frequency of Candida
infections has been shown. It has been recommended that in patients who are considered to be at increased
risk, an antimicrobial agent such as povi- done-iodine ointment be used at the insertion site of cen- tral
venous catheters placed for the administration of par- enteral nutrition. However, routine use of ointments
is not recommended.

CDC Guideline (1996)

Do not routinely apply antimicrobial ointment to central venous catheter insertion sites.

38

SITE MAINTENANCE

Dressings

The ideal frequency of dressing changes and the type

of dressing to use has not been established. Current recommendations by the Centers for Disease Control
(1996) did not include a recommendation as to the frequency of dressing change. The types of dressings
used for CVCs include gauze and tape and transparent semi-permeable membrane (TSM) dressings. With all
types of dressings, it is preferable to change the dressing:

s In conjunction with any tubing change

s When it becomes damp, loosened, or soiled

CDC Guideline (1996)

s Replace catheter site dressings when the device is replaced, when the dressing becomes damp, loosened,
or soiled, or when inspection of the site is necessary

s No recommendation for the frequency of routine replacement of dressings used on central catheter sites

The traditional gauze and tape dressings have been used for years. Adhesive material should be applied over
the entire gauze surface to ensure that the dressing is closed and intact. These dressings may be preferred
for a diaphoretic patients or those with fragile or inflamed skin. Unfortunately, there is no way to observe
the site without manipulating the dressing.

Transparent semi-permeable dressings are currently popular because they:

s Allow for continuous inspection of the site
s Adhere well to dry skin
s Provide protection against external moisture
s Are usually more comfortable
s May also assist in stabilizing and securing the catheter

The concern with these dressings is moisture retention occurring underneath the dressing. Moisture, of
course, can lead to increased colonization of the site and increased risk of catheter-related infection.

39

SITE MAINTENANCE

Dressings (continued)

Research Riches

Another study by Maki found that, if the transparent dressing was left on for up to 5-7 days, there was more
than a ten-fold increase in the density of cutaneous flora, which was then associated with a 50% increased
risk of catheter-related infection.20

Newer dressing materials are available that allow for improved vapor transmission rate. Opsite IV 3000, for
instance, is reported to move 3-8 times more moisture away from the site than other transparent dressings.

Other Considerations
Studies have shown that the use of special intravenous

therapy teams consisting of trained nurses or technicians has been associated with substantially lower rates
of catheter-related infection. However, even without a dedicated team, institutions can greatly reduce their
rate of catheter-related sepsis by scrutinizing catheter care protocols and more intensively educating and
training their clinicians.

Research Riches

A recent study by Maki showed that, when this new dressing was used, there was no difference in infection
or colonization rates when compared to gauze dressings.21

Research Riches

In a study of cost effectiveness, Tomford and Hershey reported that such a team reduced the costs of
complica- tions of infusion therapy nearly ten-fold.22

Current trends in healthcare may also influence the infection rate associated with CVCs. Downsizing can
result in inexperienced or insufficient personnel, and such trends maybe associated with increasing infection
rates. Conversely, education and experience with

the insertion and use of CVCs may reduce or prevent infections.

40

SITE MAINTENANCE
Dressings (continued)

CDC Guideline (1966)

Conduct ongoing education and training of health

care workers regarding indications for the use of and procedures for the insertion and maintenance of
intravas- cular devices and appropriate infection control measures to prevent intravascular device-related
infections. Audiovisuals can serve as a useful adjunct to standard educational effects.

Clinical Considerations: Dressing Change

RECOMMENDED EQUIPMENT

- Sterile gloves
- Mask
- Sterile drape
- Sterile gauze sponges and/or transparent dressings - Sterile applicators

- Non-allergenic tape - Solutions, ointments

CLINICIAN RESPONSIBILITIES

s Observe strict aseptic technique; change gloves between removal of old dressing and application of new
one

s Position patient with head turned away from the dressing site or have patient wear a mask

s Remove old dressing and dispose of materials appropriately s Inspect site for unusual warmth, erythema,
edema, drainage,

tenderness or pain

s Drape catheter insertion site

s Cleanse area, working in a circular path from the catheter to the periphery. Include the area under the hub

s Apply ointment, if appropriate. Check for patient allergies. s Dress site with appropriate dressing material.
Dressing

should be occlusive

s Indicate date, time, and initial the dressing

s Chart procedure, site inspection, and any complications in the nursing/progress notes

41

SITE MAINTENANCE

Needlestick Injury

It is estimated that 600,000 to 1,000,000 workers are stuck by needles each year. In a one-year study
conducted in 199423, 24% of the healthcare workers who drew blood were stuck by a needle. Over 1,000
healthcare workers contract a serious infection from needlestick injuries annually. The lab work and
treatment of workers injured by needle stick cost $600 - $1,000 per incident. This does not include the cost
of loss of work and treatment from complications.

Of all the bloodborne diseases transmitted by used needles, the HIV virus has the most notorious
reputation. However, as dreaded as the HIV virus can be, there are up to 20 other bloodborne diseases that
can be transmitted to healthcare workers as a result of exposure to blood on the job. Of these, the diseases
that pose the most serious threat to healthcare workers are Hepatitis B and Hepatitis C. Experts now
estimate that more healthcare workers will eventually die due to complications from occupational exposure
to Hepatitis C than from occupational exposure to HIV.

HEPATITIS B HEPATITIS C
Percent of infections which More than 85% (70% of all infections lead to
result in chronic (long-term) Less than 10% chronic
infection. liver disease).
Number of people in U.S. with
1 to 1.25 million 3.9 million
chronic infection.
Contact with infected blood. Contact with infected blood (transmission via
This infection is transmitted to
Sexual contact. Perinatal sexual contact and perinatally occurs but is
others in the following ways.
(mother to child). much less frequent).
There is an effective vaccine
Vaccine that can keep you from THERE IS NO VACCINE.
getting this disease.
Cure None None
Treatment

Treatment with Interferon alpha produces a positive response in 35%

of cases. Some people with HBV should not receive this treatment.

Interferon alpha, taken for one year, can help 15 to 25% of patients. A new combination drug therapy has
reduced viral levels in 46% of cases.

42

NEEDLESTICK INJURY

Needlestick Injury (continued)

VIRUS

HIV
Hepatitis C (HCV) Hepatitis B (HBV)

CHANCE OF INFECTION IF EXPOSED

Very Low – there is a 0.3% (1 in 333) chance of being infected.

Higher – there is a 5% (1 in 20) chance of being infected.

Highest – there is a 6 to 30% (between 1 in 16 and 1 in 3) chance of being infected.

Reproduced with permission from SEIU’s Guide to Preventing Needlestick Injuries. SEIU, Third Edition, 1998.)

Safe Needles/Needleless Systems

Federally funded research has shown that most needlestick injuries can be prevented by switching to
needleless IV connectors and using devices with incorporated safety features. In 1992, the FDA published a
“Needleless Systems” safety alert warning about the risk of needlestick injuries from the use of hypodermic
needles as a connection between two pieces of IV equipment. This alert was based on research that
demonstrated that secondary IV tubing with connector needles was associated with the highest risk of
needlestick injury.

EXAMPLE OF SAFE NEEDLE

This is an example of an “active” safety mechanism, requiring the healthcare worker to pull the sheath over
the needle after use

After use

Before use

43

NEEDLESTICK INJURY

Safe Needles/Needleless Systems (continued) EXAMPLE OF NEEDLELESS SYSTEM

With the advent of needleless systems, it is now most common for each lumen to be capped off with an
injection cap. These caps need not be removed to allow the withdrawal of blood. This allows for a
completely closed system, decreasing the chance of infection. Additionally, the use of stopcocks can

also increase the risk of infection secondary to manipulation; however, the use of injection caps keeps the
system closed. The needleless factor also contributes to patient and clinician safety.

Timely Tip

Several states have mandated the use of safe needles and needleless systems to reduce the risks of sharps
injury
and resultant transmission of blood borne diseases.

Technical Tip
Today it is estimated by the FDA that more than 50% of all hospitals use needleless IV connection systems.

44

NEEDLESTICK INJURY

Blood Sampling

Blood sampling for various laboratory tests can be accomplished through central venous catheters.
Generally,
this procedure involves catheters with multiple lumens, but could also apply to single-lumen devices. When
using the triple- lumen CVC, blood withdrawal may be done via the designated lumen, usually the proximal
or distal lumen. The designation of these two lumens is arbitrary but is a result of the middle lumen usually
being reserved for TPN administration. If the patient is not receiving TPN, any lumen will suffice.

Any laboratory test that does not require arterial blood can usually be drawn through the CVC. These tests
may include:

s Chemistries
s Hematolgy studies
s Blood levels of drugs s Coagulation studies s Blood culture
s Cardiac enzymes

Blood Conservation

Studies have shown that patients in ICUs with an arterial line in place had a mean blood volume of 944 mL
withdrawn and were phlebotomized a mean of 4 times daily during their ICU stay.24 This amount does not
account for withdrawal and discard of flush solution mixed with blood; i.e., “clearing” volume. Additionally,
this blood loss associated with diagnostic phlebotomy is superimposed on blood loss from other causes,
such as gastrointestinal hemorrhage or surgery.

It is no wonder the terms iatrogenic or nosocomial anemia have appeared. Blood loss from phlebotomy
alone can make a big impact on ICU patients, especially critically ill pediatric and neonatal patients, and
certain adult patients with chronic renal failure, and those whose religious beliefs do not permit blood
transfusions.

Draw Methods

There are three methods to obtain blood from a central line; direct, indirect or through a blood conservation
device.

Vacutainer devices can be connected directly to the injection cap attached to the appropriate lumen of the
CVC. The vacuum within the collection tube draws out precisely the amount of blood needed for the specific
laboratory test.

45
BLOOD SAMPLING

Draw Methods (continued)

When using this system, the initial blood tube container drawn will represent the discard. It is necessary to
use an appropriately colored blood tube that corresponds to the amount of discard fluid desired.

In the indirect method, the syringe is inserted into the injection cap, and the appropriate volume of fluid is
drawn
and discarded. Then the volume of blood necessary for the particular laboratory test is withdrawn and then
transferred into the blood collection tube. Although this procedure involves an extra step, it is often
necessary to employ this method as the amount of suction generated in withdrawing the blood sample is
controlled by the clinician.
46

BLOOD SAMPLING

Blood Sampling (continued)

When using a blood conservation device, the discard amount is withdrawn into a closed system and then
reinfused following blood collection. (Although this line may attach directly through a luer lock to the central
venous catheter, the system remains closed and is needleless.)

Research Riches

Studies have shown that results do not differ as a function of the method used to collect the sample if the
samples are collected appropriately.25

Discard Volume

A certain amount of blood is discarded prior to blood sampling (the discard volume) to avoid contamination
of laboratory samples with heparin or saline. The amount of blood drawn back to clear the line is dependent
on several factors, including:

s Tubing size and length

s Amount of heparin in the line
s Line from which blood is to be drawn s Type of study to be performed

This volume is often expressed as multiples of the dead space within the catheter to be utilized for the blood
draw. This is a function of the volume contained in the catheter from the tip of the catheter to the port from
which the sample is to be drawn. Anywhere from two to ten times the dead space have been advocated.
Some clinicians merely recommend a discard volume of 5-10 mL with smaller waste volumes in neonatal

and pediatric patients. However, hospital policies and procedures generally dictate the dead space specific
to a particular institution.

47

BLOOD SAMPLING

Discard Volume (continued)

Sample of CVC Catheter Lumen Volumes (mL)

7F Double Lumen

Proximal Distal

Proximal Medial Distal

Proximal Distal

Proximal Medial 1 Medial 2 Distal

0.62 0.62

0.52 0.47 0.60

0.78 0.80

0.39 0.36 0.38

0.65 0.88

7F Triple Lumen
8.5F Double Lumen
8.5F Quad Lumen

16cm

0.59

0.57

0.47

0.45

0.56

0.71

0.73
0.31

0.29
0.30

Practical Point

An alternative to drawing a waste is to flush the catheter with 0.9% sodium chloride and then aspirate/flush
back and forth multiple times to clear the catheter.

Chemistry Studies

Errors in potassium concentration may be related to the draw procedure. Blood cells may be damaged
(hemolysis) during the procedure by:
s Drawing too fast

s Drawing through too small a lumen

s Excessive turbulence during the transfer procedure
20cm

48

BLOOD SAMPLING

Chemistry Studies (continued)

Practical Point

Always hold the blood sample level with the vacutainer during transfer of blood, and never push blood into
collection device.

Additionally, errors in potassium measurements have been identified in specimens obtained from newly
inserted central catheters, secondary to the presence
of benzalkonium salts and the sensitivity of certain analyzers to them.26

Accurate determination of sodium or glucose concentrations might be of concern, since 0.9% sodium
chloride is often used to flush catheters, and IV fluids usually contain glucose. However, studies have shown
that accurate results can be obtained if the dead space plus two milliliters is withdrawn as the discard
volume. 27

Practical Point

It is interesting to note that, in spite of CDC guidelines, heparin mixed in dextrose solution is sometimes used
to keep intravascular lines patent. In this instance, special care would need to be exercised. Even venous
blood samples drawn via venipuncture from an extremity infused with D5W are not reliable, even when they
are drawn from below the site of entry or even from a site remote from the glucose infusion. 28

Hematology Studies

These studies usually include determination of hemoglobin, hematocrit and white blood cell count. If the
laboratory specimen were to contain flush fluid, the hematocrit determination could be falsely low due to
the dilutional effect. The hemoglobin and white cell counts would be unaffected.

Blood Cultures

Blood cultures can be drawn from central lines. There is always the concern that any culture drawn from an
indwelling intravascular catheter might show contamination that is related to the device rather than the
patient. Of course, in some cases that is precisely the point. Generally, however, blood cultures are ordered
in a series, each drawn from separate sites.

49

BLOOD SAMPLING

Blood Cultures (continued)

Research Riches
Most studies comparing the results of blood cultures drawn from arterial and central venous lines versus
direct venipuncture found no significant differences. One study found a 93.5% incidence of identical results
in 92 blood cultures simultaneously drawn from central venous pressure catheters and venipunctures. 29

CDC Guideline (1996)

No recommendation for obtaining blood samples for cultures through central venous or central arterial
lines.

Coagulation Studies

Perhaps the one type of laboratory test that would be most seriously affected by heparin flush fluid
incorporated into the sample would be coagulation studies. Some hospitals might require all coagulation
studies to be done by venipuncture to eliminate such concern.

Research Riches

However, studies have found no significant differences between samples obtained from arterial catheters
and those obtained from venipuncture. Studies show reliable results on activated clotting time (ACT),
prothrombin time (PT), activated partial thromboplastin time (aPTT), and thrombin time (TT) after sufficient
discard volumes have been used. 30

Research Riches

Confidence that six times the dead space volume is adequate for discard in the nonsystemically heparinized
adult patient is supported in published literature. Results of two studies on heparinized patients indicated
that this discard volume may be adequate for this population as well, but due to small sample size and
exclusive use of the femoral site in these studies, further research is indicated. These results should not be
generalized to systematically heparinized patients, pediatric patients, or other types of heparized lines such
as pulmonary artery, central venous or Hickman catheters.31

50

BLOOD SAMPLING

Coagulation Studies (continued)

Practical Point

A practical approach is to draw all other laboratory sam- ples first, saving the coagulation studies for last.

If laboratory values obtained from central venous catheters are markedly different in a previously stable
patient, the test results should always be repeated before treating the patient.

There are not a lot of studies relating directly to drawing blood from central venous lines. Generally, the gold
stan- dard is direct venipuncture. Many studies discussed here relate to arterial lines as the source of blood
that is com- pared to the venipuncture sample. However, central venous catheters have some similarities,
especially in terms of flush solution to keep the line patent. Therefore, the assumption is that, if it can be
declared reliable with arterial line draws, then it can also be accurate with CVC draws. Whenever possible,
studies relating directly to cen- tral venous draws are discussed.

Clinical Considerations: Blood Sampling

RECOMMENDED EQUIPMENT

- Syringes/Vacutainers
- Heparin flush syringe with needleless cannula - Sterile gloves
- Blood collection tubes
- Antiseptic swabs

CLINICAL RESPONSIBILITIES

s Review orders and check with the Laboratory if any concerns s Inform patient of what procedure will entail
and answer

questions
s Use aseptic technique and meticulous handwashing s Avoid opening the system as much as possible
s Utilize safety precautions such as needleless access s Utilize strategies to minimize blood loss

51

BLOOD SAMPLING

Coagulation Studies (continued)

s Consider lumen choice based on drugs/fluids being infused

Consider turning off infusions for 2-3 minutes, if appropriate

s Follow hospital policy and procedure as to appropriate discard volumes

s Ascertain that correct volume of blood is placed in the appropriate lab collection container

Practical Point

The volume of blood cultured is critical to maximize the yield of cultures. In adults, obtaining at least 20 mL,
but ideally 30 mL, per drawing, with each specimen containing 10-15 mL, is recommended. 32

s Flush lumen after sample withdrawn

s Appropriately label specimen and send to laboratory
s Evaluate laboratory results and communicate them to clinician

s Go to resource personnel in event of technique-related questions

52

BLOOD SAMPLING

Coagulation Studies (continued)

Normal Reference Ranges for Laboratory

Blood Tests

BLOOD CHEMISTRY STUDIES

Sodium (Na) Potassium (K) Chloride (Cl)
Carbon dioxide (CO2) Glucose (BS)

Blood Urea Nitrogen (BUN) Creatinine

Calcium (Ca)
Magnesium (Mg) Osmolality

Bilirubin (direct) (indirect)

(total) Amalyse

Lipase Anion Gap Lactate

HEMATOLOGY STUDIES

Red Blood Cells (RBC)

White Blood Cells (WBC) Hemoglobin (Hgb)

Hematocrit (Hct)

COAGULATION STUDIES

Platelets

Prothrombin Time (PT)

Plasma Thrombin Time (PTT)

Activated Partial Thromboplastin Time (aPPT)

Activated Clotting Time (ACT)

136-145 mEq/L 3.5-5.0 mEq/L 98-106 mEq/L 21-30 mEq/L 75-115 mg/dL 10-20 mg/dL
<1.5 mg/dL 8.5-10.5 mEq/L 1.3-2.1 mEq/L 275-295 mOsm/kg

0-0.3 mg/dl 0.2-0.7 mg/dl 0.2-1.0 mg/dl

25-125 U/L 23-208 U/L 8-16 mEq/L 0.5-2.2 mEq/L

4.25-5.5 x 106/μL (males) 3.6-5.0 x 106/μL (females)

5-10 x 103/μL

13.5-17.5 g/dL (males) 12-16 g/dL (females)

40-54% (males) 37-47% (female

150-350 x 103/uμL 10-14 sec

30-45 sec
16-25 sec

92-128 sec
Normal value ranges depend upon specific laboratory determinations.

53

BLOOD SAMPLING

Flushing (Intermittent)

Although current practice mandates a flush procedure to maintain patency and prevent complications, the
type, concentration, and volume of the solution vary widely from institution to institution and sometimes
from unit to unit within the same institution.

Positive Pressure Flushing

Regardless of the amount and frequency of flush used,

it is important to use a positive pressure flushing technique.
A proper positive pressure flushing technique creates positive pressure within the lumen of the catheter and
is thought to minimize reflux of blood into the tip of the catheter, and thus prevent clotting. This flush can
best be performed by clos- ing the catheter or extension clamp while flushing before the syringe completely
empties. Another way to accomplish this would be to maintain pressure on the syringe plunger while
withdrawing the syringe from the injection cap.

Consideration must also be given to the syringe size used to flush. The smaller the syringe size, the greater
the pressure generated. Catheters are designed to withstand various infusion pressures; however, infusion
pressures should never exceed 25-40 pounds per square inch (psi). Smaller-sized syringes will generate
pressures in excess of this amount and may cause damage to catheters, especially if an obstruction is
present.

A 10mL syringe is advocated by many for use with CVCs.

Saline vs. Heparin

The anticoagulant properties of heparin have led clinicians to use heparin flushes to fill the lumens of central
venous catheters locked between uses in an attempt to prevent throm- bus formation and to prolong the
duration of catheter patency. The efficacy of this practice is unproven.

There is a large amount of research indicating that peripheral intravenous catheters may be kept patent
with intermittent saline flushes. Can the same be said for central venous lines? Much of the literature on
CVCs is hard to interpret, because some long-term CVCs have been maintained with weekly saline flushes.
However, these catheters do not see anywhere near the use involved in the care of critically ill patients.

54

FLUSHING (INTERMITTENT)

Saline vs. Heparin (continued)

There is some literature dealing with arterial and pulmonary artery line patency. Most of the literature
supports the use of heparinized flush solutions delivered continuously (on average, 3-5mL/hour) under 300
mmHg pressure. But what about the frequent but intermittently utilized CVCs? So far there are no clear-cut
answers.

Research Riches

Conclusions of the AACN Thunder Project are probably applicable to CVCs: “....heparin does significantly
affect patency of arterial pressure lines over time. However, lines can be kept patent without heparin, and
other factors also significantly affect patency of arterial monitoring lines. Furthermore, the flush solution
does not guarantee patency of the line.”33

Research Riches

Recent in vitro studies suggest that the growth of CoNS on catheters may be enhanced in the presence of
heparin.34

Concentration
Various concentrations of heparinized saline from 5 to

1,000 USP units/ml are commonly used to flush CVCs.

A questionnaire was distributed to a sample of persons attending the annual conference of the National
Association of Vascular Access Networks in 1992. Heparin flushes were still used by 97% to maintain
patency. The most commonly used concentra- tion of heparin to maintain non-infusing CVCs was 100
units/mL. The Intravenous Nursing Standards recommends that the lowest possible concentration of heparin
be used.

Research Riches

Stern et al hypothesized that the daily amount of heparinized saline solution injected via a heparin lock was
20 ml or approximately 2 ml of 1,000 U/ml heparin sodium – a total of 2,000 U/day.35

55

FLUSHING (INTERMITTENT)

Saline vs. Heparin (continued)

Clinical Concern

Administration of low-dose heparinized saline solution has been associated with hypersensitivity reaction,
transient increases in activated partial thromboplastin time, delayed fibrinolysis with platelet aggregation,

and thrombocytopenia. Drug interactions occur with diazepam, meperidine, promethazine, hydroxyzine,
tetracylcine, penicillin G, methicillin, erythromycin gluceptate, gentamicin, and dacarbazine. At least one
case of iatrogenic hemorrhage has resulted from the flushing of multiple catheters.36

Flush Volume

It has been accepted that the volume of the heparinized saline flush be equal to two times the volume
capacity of the cannula. (See previous for catheter lumen volumes.) Typical flush volumes range from 1-5
mL.

Clinical Considerations: Flushing

RECOMMENDED EQUIPMENT

- Antiseptic swabs
- 10mL syringe with needleless cannula
- Heparin flush solution (concentration per hospital policy)

CLINICAL RESPONSIBILITIES

s Cleanse injection site with approved antiseptic solution s Use a 10 mL syringe

s Maintain positive pressure during flushing
s Monitor coagulation parameters

56

FLUSHING (INTERMITTENT)

Infusion Therapy

One of the major indications for the percutaneous placement of a short-term polyurethane multi-lumen
central venous catheter is to allow for the delivery of various therapies through a single venipuncture.
Solutions that are infused through multi-lumen catheters in the critical care area may include maintenance
or replacement fluids, medications, blood products or total parenteral nutrition (TPN).

Fluid Administration

With appropriate catheter tip placement within the central circulation, large volumes of fluid can be
administered and diluted rapidly. Most fluids can be administered safely. However, solutions/medications
containing high concentrations of alcohol should not be infused through polyurethane catheters due to
alcohol’s weakening effect on the material.

CONCENTRATIONS IN FREQUENTLY USED INTRAVENOUS SOLUTIONS (MEQ/L)

FLUID

D5W

D10W

D50W

1/2 NS (0.45%NS)

NS
(0.9% NS)

D51/4NS D5 1/2NS D5 NS LR

GLUCOSE

NA+

K+

CL- MOSM/L KCAL/L

50g 0 00 252
100
0 00 505
g
500
0 00 2520
g
0 77 0 77 154
0 154 0 154 308
50g 38 0 38 329
50g 77 0 77 406
50g 154 0 154 560

IV Delivery System

130

4 110 272
170

340 1700

0
170
170
170
10

Many policies have advocated routinely replacing the entire infusion delivery system at certain intervals to
reduce the risk of sepsis from extrinsically contaminated fluid. If an infusion runs continuously for an
extended period, the cumulative risk of contamination increases, and there is increased risk that the con-
taminants could grow to dangerously high concentrations, result- ing in septicemia.

57

INFUSION THERAPY

IV Delivery System (continued)

However, contaminated infusion is not a common cause of most catheter-related bacteremias.

Contaminated infusate can result from intrinsic (introduced during its manufacture) or extrinsic (introduced
during its preparation or administration in the hospital) contamination. Microorganisms can be introduced
extrinsically into the fluid being infused from entry points into the administration set (during injections into
the line or aspiration of blood specimens from the intravascular device through the line) or at the junction
between the administration set and the catheter hub. However, the majority of introduced contaminants
are rapidly cleared from running infusion by continuous flow.

Most studies indicate that intravenous delivery systems do not need to be replaced more frequently than
every 72 hours.

CDC Guideline (1996)

s Replace extension tubing when the vascular device is replaced

s Replace IV tubing, including piggyback tubing and stopcocks, no more frequently than at 72-hour intervals,
unless clinically indicated

s No recommendation for the hang time of IV fluids, including non-lipid containing parenteral nutrition fluids

In-Line Filters

The use of filters continues to be advocated as a means of reducing the hazard of contaminated infusate.
However, filters must be changed at periodic intervals and can become blocked, leading to added
manipulations of the system, and, paradoxically, greater potential for infection.

Additionally, the use of filters:

s May permit the passage of endotoxin s Are expensive
s May not be justified as a control method for prevention of rare sporadic septicemias deriving from
extrinsic contamination of infusate

58

INFUSION THERAPY

In-Line Filters (continued)

CDC Guideline (1996)

Do not use filters routinely for infection control purposes.

Stopcocks

Stopcocks used for injection of medications, administration of IV infusions, or collection of blood samples,
may represent a source of entry for microorganisms. Although stopcock contamination is common (45-50%),
the relative contribution of stopcock contamination to intravascular catheter or IV fluid contamination is
unclear. Few studies have been able to demonstrate that the organism colonizing the stopcock is the same
one responsible for catheter-related infection.

Even if stopcocks are used, injection caps may be placed on each port to keep the system as closed as
possible.

CDC Guideline (1996)

s Clean injection ports with 70% alcohol or povidone- iodine before accessing the system

s No recommendation for use, maintenance, or frequency of replacement of needleless IV devices

Piggyback Systems

Piggyback systems may be used as an alternative to stopcocks. They pose a risk for contamination of the
intravascular fluid if the needleless cannula entering the injection port is partially exposed to air and/or
subject to repeated connections and disconnections as might occur with intermittent administration of
antibiotics. The use of a closed piggyback system in which the piggyback line is never detached from the
primary line would seem to decrease the chance of infection.

Research Riches

Modified piggyback systems appear to prevent contami- nation at these sites and reduce the incidence of
catheter- related BSI six-fold when compared with conventional stopcock and piggyback systems. 37

59

INFUSION THERAPY

Piggyback Systems (continued)

Practical Point
One piggyback line can be used for multiple intermittent infusions, even if the medications are incompatible,
as long as all medications to be piggybacked are compatible with the primary solution. When one
medication is fin- ished, the line is back-flushed to fill the short line with primary solution. Another partial-fill
can then be spiked and administered.

CDC Guideline (1996)

No recommendation for frequency of replacement IV tubing used for intermittent infusions.

Medication Administration

Drug administration is an important therapeutic intervention

in the care of the critically ill patient and is, therefore, a concern for the critical care clinician. As a basic
principle, only one drug should be added to an infusion fluid, and no drugs should be co-administered in the
same line. Hence, the rationale for multi-lumen catheters in the critically ill population.

However, these patients often require several intravenous medications administered simultaneously, in
excess of the amount of lumens available. This may be accomplished via three-way stopcocks, multiple y-
sites, or manifolds attached to multi-lumen catheters. Therefore, more than one medication may be
administered through a portion of a single line.

When using such devices, the clinician must be aware of several factors in order to safely administer drugs
to the critically ill patient. Are the drugs compatible with each other? Compatible with the catheter
material? Will the desired effect be achieved? There are various charts available that attempt to delineated
drug compatibilities/incompatibilities for the clinician; however, these are considered as guidelines only.

It is always recommended that instructions provided by intravenous drug suppliers and/or device
manufacturers be read carefully.

60

INFUSION THERAPY

Medication Administration (continued)

Drug Incompatibility

A drug incompatibility is defined as failure of a drug or drug mixture to combine with another drug, diluent,
or infusion device system in an expected or desired manner. Drugs are assumed to be compatible when
mixed if there is no sign of physical or chemical incompatibility.

Physical incompatibility – combination of two or more drugs resulting in a change in the appearance of the
solution (precipitation, color change, or cloudiness)

Chemical incompatibility – significant drug degradation (usually a > 10% loss of potency) occurring with or
without a change in the appearance of the solution

(Physical compatibility does not imply chemical compatibility) Due to the larger vessel size and flow velocity
surrounding

the catheter lumen exit sites in the central venous system,

simultaneous administration of incompatible medications

has been practiced. However, few studies have evaluated the safety and efficacy of this in clinical practice.

Grillo et al38 looked at the chemical compatibility of inotropic and vasoactive agents delivered via a multiple
line infusion system. They studied three different triple-drug admixtures diluted with either 5% dextrose in
water or 0.9% sodium chloride solution. The triple drug admixtures were combinations of dobutamine,
dopamine, norepinephrine, nitroglycerin, and sodium nitroprusside. All triple-drug admixtures were
chemically stable when placed in single containers. Dobutamine, norepinephrine, and sodium nitroprusside
showed chemical stability when delivered
via a multiple-line infusion system. Therefore, these drugs should be able to be administered through the
same line in a multi-lumen central venous catheter.

Other Considerations

Although infusion of incompatible medications through various lumens is possible through multi-lumen
catheters, studies have shown that blood volume and the configuration of the lumen exit sites at the distal
end of the catheter may be important factors to consider. One recent study39 attempted to evaluate the
simultaneous administration of incompatible medications

by using an in vitro venous flow model system designed to mimic an in vivo clinical situation.

61
INFUSION THERAPY

Medication Administration (continued)

The study looked at the physiochemical phenomena that occur when two known incompatible drugs,
phenytoin and TPN, were simultaneously administered through a multi-lumen CVC.

This study showed that the design of the catheter might have an impact on precipitate formation. Catheters
designed with adjacent exit sites (ports) at the tip of the double-lumen catheter appeared to permit
interaction of the two infusing incompatible drugs. Staggered orifices (exit ports), on the other hand,
reduced this interaction. This study concluded that the clinical significance of this phenomenon has yet to be
assessed.
Nitroglycerin Administration

Consideration must be given to the effects that certain medications have upon the catheter as well as on
other simulta- neous infusions. The problem of the adsorption of nitroglycerin onto some catheter
materials, namely polyvinyl chloride, has been reported in the literature. Adsorption is the adhesion of
a gas or liquid to the surface of a solid; i.e., the medication is “leached” out into the tubing or catheter
material instead of being delivered to the patient. Polyurethane, the material used to make most central
venous catheters, does not contribute to leaching of this drug.

This effect of adsorption is more prominent if agents are administered in small quantities or at low
concentrations and in the initial phase of administration. This is a particularly significant point to remember
when starting a vasoactive drug that will be titrated. After this initial phase, adsorption contin- ues, but at a
lower rate. In consequence, the dose
administered to the patient may increase with time, although the infusion rate is kept constant. This may
require adjustments in the rate of infusion.

The clinical significance of the adsorption is controversial, however, since the drug is often titrated to effect.
Nitroglycerin is usually mixed in glass bottles to minimize the leaching effect of the container. Some
institutions use non-PVC tubing when administering nitroglycerin; others do not. Some “saturate” the tubing
initially by flushing it rapidly with the medication to be infused. Follow the institution’s policy when it comes
to nitroglycerin administration.

62

INFUSION THERAPY

Medication Administration (continued)

Clinical Consideration

Low dose dopamine (for renal perfusion, for instance) may be administered through a peripheral line in
some cases. However, titratable doses for vasoactive purposes need to go through a central line for several
reasons. The dosages are greater and the action of the drug needs to be central, rather than local. Also, local
vasoconstriction from higher dosages of dopamine might limit the amount of drug that could get into the
central circulation – as well as potentially injure the surrounding tissues.

Blood Administration

Another indication for the placement of a central venous catheter is for frequent administration of blood or
blood products. According to the Core Curriculum for Critical Care Nursing by the American Association of
Critical-Care Nurses, peripheral IV sites may be used for this purpose as long as

at least a 20 gauge access (to prevent hemolysis) is used. However, central venous catheters, with their
larger lumens and more stable access, may be preferable.

Administration of TPN

Although enteral feeding is preferred, a substantial number

of critically ill patients receive parenteral nutrition. The risk of bloodstream infection remains one of the
most important complications associated with TPN therapy. This is due to the fact that dextrose, amino
acids, or lipid emulsions are more likely than conventional IV fluids to support microbial growth.

CDC Guideline (1996)

Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours of initiating the
infusion.

63

INFUSION THERAPY

Administration of TPN (continued)

Research Riches

Studies randomizing trauma patients to TPN or enteral feedings have continued to show increased infection
rates in the TPN groups.40

Special precautions need to be taken with TPN. Experienced pharmacists use an aseptic technique when
mixing solutions under a laminar flow hood. Total parenteral nutrition should ideally be delivered in a
dedicated line that should be left unbroken in order to reduce the possibility of infection. No sec- ondary (or
piggyback) tubings, except lipids, are permitted into this line. Nearly all septicemias linked to contaminated
infusate have been gram-negative bacilli. However, microbial growth in most parenteral solutions, with the
exception of lipid emulsion, is actually very limited.

Lipid emulsions, however, are particularly suited for growth of specific bacteria and yeasts, including
Candida species. Microbial growth occurs as early as 6 hours, with clinically significant levels being reached
within 24 hours.

Nurses Notes

Combined TPN solutions (3-in-1), which use glucose, amino acids, lipid emulsion, and additives in one multi-
liter bag, do not appear to support greater microbial growth than non-lipid containing TPN fluids.41

Clinical Consideration

TPN may be administered peripherally as long as the dextrose content is low enough not to irritate the
vessel. However, peripheral TPN does not provide the nutritional benefit of central TPN solutions.

CDC Guideline (1996)

s Do not use single-lumen parenteral nutrition catheters for purposes other than hyperalimentation (e.g.,
adminis- tration of fluids, blood, or blood products)

s If a multi-lumen catheter is used to administer parenter- al nutrition, designate one port for
hyperalimentation. Do not use the designated hyperalimentation port for other purposes (e.g.,
administration of fluids, blood, or blood products)

64

INFUSION THERAPY

Administration of TPN (continued)

s Complete infusions of lipid-containing parenteral nutrition fluids (e.g., 3-in-1 solutions) within 24 hours of
hanging the fluid

s When lipid emulsions are given alone, complete the infusion within 12 hours of hanging the emulsion

Clinical Considerations: IV Administration

RECOMMENDED EQUIPMENT

- Volumetric infusion pump

- IV fluid and appropriate tubing

CLINICAL RESPONSIBILITIES

s Review orders

s Identify patient

s Dedicate one lumen for TPN administration

s Do not infuse solutions with a high concentration of alcohol through polyurethane catheters or tubing

s Flush after medication administration to deliver any residual portion of the dosage to the patient

s Do not push IV medications through lumen containing vasoactive drugs (since this may precipitate serious
cardiovascular events)

s Consult compatibility tables or pharmacist when administering more than one drug through a lumen

Practical Point

If in doubt as to compatibility of an intermittent push medication, flush the intended line with a known
compati- ble solution, follow push with similar flush.

s Observe tubing and IV solution for precipitation or any other signs of incompatibility

s Follow specific guidelines for blood administration

65

INFUSION THERAPY

Frequently Used Drugs in Critical Care

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS
Adenosine ↓ sinus rate. ↓ Conversion of Initial bolus = Side effects
conduction supraventricular tachycardia 6 mg rapid IV but transient
Trade Name: to a regular sinus rhythm, bolus over 1-3 and usually resolve
Adenocard through AV node. including PSVT associated seconds followed spon- taneously
with accessory bypass tracts by a 20 ml saline within 1-2 minutes –
Class: Can interrupt that involve the AV node (as flush. Wait 1-2 flushing, dyspnea, chest
 minutes. pain.

seen in WPW) that is Consider ↑ dose

If no response
refractory to vagal in patients on
observed, admin-
maneuvers. theophylline since
ister 12 mg (may
repeat the 12 mg methylxanthines
Wide-complex tachycardia of dose once in the prevent binding of
reentrant path- uncertain type after lidocaine 1-2 minutes). adenosine at receptor
ways through the administration. sites.
AV node.
Due to extremely
If the dysrhythmia is not due short half-life, Consider ↓ dose
Endogenous
Has a direct effect to reentry involving the AV start IV line as in patients on
chemical,
on node or sinus node (atrial proximal to the dipyridamole
Antidysrhy-
supraventricular fibrillation, atrial flutter, atrial heart as possible, (Persantine) because
thmic
tissue. or ventricular tachycardias), such as the adenosine potentiates
adenosine will antecubital fossa. its effects.
Half-life is less
than 5 seconds. not terminate the Onset: Seconds. Relatively high
dysrhythmia but may incidence of recurrence
produce transient AV block of the tachycardia after
Peak: Seconds.
that may clarify the 6 mg dose; 92%
diagnosis. conversion to a sinus
Duration: 10-12 rhythm after 12 mg
seconds. bolus.
Amrinone

Trade Name: Inocor

Class:
Non- adrenergic, non-ß-agonist

Potent inotropic effect.

↑ cardiac function.

Induces vasodilation.

Severe CHF that has not responded to diuretics, vasodilators and conventional inotropic agents.

0.75 mg/kg over 2-3 minutes followed by an infusion @ 5-15 μg/kg/min, titrated to effect.

s Incompatible with furosemide. s May exacerbate myocardial ischemia.

s May worsen ventricular ectopy.
s Should be administered via an infusion pump. s Hemodynamic monitoring is suggested for optimal use.

66

INFUSION THERAPY

Administration of TPN (continued)

MECHANISM
OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS

ß-Adrenegic Blockers

Atenolol (Tenormin)

Esmolol (Brevibloc)

Metoprolol (Lopressor)

Propranolo (Inderal)

ß-adrenergic blockade.

↓ rate of discharge of sinus node.

↓ myocardial contractility.

↓ blood pressure.

↓ myocardial oxygen consumption.

↓ incidence of VF in post-MI patients who did not receive thrombolytic agents.

When used within 4 hours after ad- ministration of thrombolytic therapy, may ↓ rate of nonfatal rein-
farction and recurrent ischemia.

In thrombolytic treated patients, may ↓ mortality and recurrent MI if administered within 2 hours of
symptom onset.

Atenolol: 5 mg IV over 5 min, may repeat in 10 min.

Esmolo: 500 μ/kg over 1 minute (loading dose) followed by a main- tenance infusion

at 50 μ/kg/min over 4 minutes.

Metoprolo: 5 mg slow IV push at

5 min intervals to total of 15 mg.

Propranolol: Total dose of 0.1 mg/kg slow IV push divided into 3 equal doses at

2-3 intervals.

Should be avoided in:

s bradycardia. s second or third-degree AV block.
s hypotension. s overt CHF.
s lung disease associated with bronchospasm.

Bretylium Tosylate

Trade Name: Bretylol

Class: Ventricular antidys- rhythmic, Adrenegic blocker

Initial sympath- omimetic effects due to release of norepinephrine:

s ↑ heart rate.
s ↑ peripheral vasoconstriction.
s ↑ blood pressure. s ↑ cardiac output.

Subsequent sympatholytic response after 15-20 minutes (adrenergic block):

s ↓ blood pressure s Suppresses. ventricular ectopy. s ↑ VF threshold.

Not a first-line antidysrhythmic.

After defibrillation, epinephrine and lidocaine have failed to

convert VF.

VF has recurred despite epineph- rine and lidocaine.

Lidocaine and procainamide have failed to control VT associated with a pulse.

Lidocaine and adenosine have failed to control wide-complex tachycardias.

Refractory VF/ pulseless VT:

5 mg/kg rapid IV bolus followed by defibrillation.

If VF persists, ↑ dose to 10 mg/kg and repeat every

5 min to maximum dose 30-35 mg/kg.

If conversion
occurs to a perfusing rhythm after bolus therapy, initate a continuous infusion at 1-2 mg/min.

To mix drip:
1 gram in 250 ml
or 2 grams in 500 ml. Using a microdrip (60 gtts/ml) administration set:
1 mg/min = 15 gtts/min 2 mg/min = 30 gtts/min

Persistently recurring VT
(with a pulse):
(IV infusion)
5-10 mg/kg diluted in 50 ml and infused over 8-10 min to avoid nausea/ vomiting. If conver- sion occurs,
initiate a continuos mg/min. infusion at 1-2

Postural hypotension.

Nausea/vomiting with rapid IV administration.

Contraindicated in digitalis toxicity.

Additive effects with sympath- omimetics.

67
INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS
Calcium Chloride

Diltiazem

↑ myocardial contractile function.

Slows conduction and increases refractoriness in the AV node.

Probably helpful (Class IIa) in:

s Hyperkalemia.
s Hypocalcemia.
s Calcium channel blocker toxicity.

May also be used to pretreat patients with PSVT prior to administration of verapamil.

Multifocal atrial tachycardia, atrial fibrillation or atrial flutter with a rapid ventricular response.
2-4 mg/kg (usually 500 mg – 1 gram) of 10% calcium chloride solution slow IV bolus

and repeated as necessary at

10 minute intervals.

0.25 mg/kg (20 mg) IV over 2 minutes followed 15 minutes later by 0.35 mg/kg (25 mg) IV over

2 minutes.

In atrial fibrillation with a rapid ventricular response, diltiazem may be used as a mainten- ance infusion of 5-
15 mg/hour.

s Bradycardia with rapid IV injection.

s Use with caution in digitalized patients.

s Precipitates with bicarb.

s Produces less myocardial depression than verapamil.

s Avoid or use with caution in left ventricular dysfunction.

s Common side effects include hypotension and flushing.

s Avoid in patients with

AV block, sinus node dysfunction or severe cardiac failure.
s Do not admin- ister to patients with WPW – may worsen dysrhythmia.
s Not effective in VT.

Dobutamine

Trade Name: Dobutrex

Class: Sympathom- imetic

ß-adrenergic stimulator.

Potent inotropic effect (↑ myocardial contractility → ↑ stroke volume → ↑ cardiac output).

Less chrono- tropic effect (heart rate).

Stimulates ß-2 receptors at doses > 10 μg/kg/min → peripheral vasodila- tion → ↓ systemic vascular
resistance.

Refractory congestive heart failure (systolic BP > 100 mm Hg with normal diastolic BP).

Cardiogenic shock.

2-20 μg/kg/min (usual dose 2.5-10 μg/kg/min).

To prepare infusion: Mix 250 mg in

250 ml (1000 μg/ml) and titrated to desired response.

s ↑ of heart rate of more than 10% may induce or exacerbate myocardial ischemia (common at doses > 20
μg/kg/min). s Less likely
to induce tachycardia than isoproterenol or dopamine.
s Best admin- istered via an infusion pump.
s Do not mix with sodium bicarbonate – inactivates dobutamine.
s Correct hypo- volemia before administration of dobutamine.
s Do not discon- tinue abruptly – taper gradually.

68
INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS
Dopamine

Trade Name: Intropin, Dopastat

Class: Sympathom- imetic Natural cate- cholamine

Precursor of epinephrine that has dopaminegic, a and ß-adrenergic receptor stimu- lating actions.

Dose-related effects:

Low dose
(1-5 μg/kg/min): s Dopaminergic effectdilates renal and mesenteric vessels.
s May not ↑ heart rate or blood pressure at
this dose range.

5-10 μg/kg/min: s Predominant ß-adrenergic stimulanting properties → ↑ force of contract- ion, minimal ↑
in heart rate → ↑ cardiac output.

> 10-20 μg/kg/min: s a effects domin- ate → renal, mes- enteric, peripheral arterial and venous
vasoconstriction → ↑ systemic vascular resistance and preload, ↑ heart rate.

Hypotension that occurs with sympto- matic bradycardia.

Hypotension that occurs after return of spontaneous circulation.

Cardiogenic shock.
Only administered by IV infusion, never as a bolus.

5-20 μg/kg/min, titrated to desired effect.

To mix infusion:
400 mg dopamine in 250 ml (or 800 mg dopamine in 500 ml) → 1600 μg/ml concentration.

MAO inhibitors potentiate effects of dopamine.

May induce tachycardia necessitating

↓ dosage or discontinuation of infusion.

Extravasation may result in tissue sloughing or necrosis – monitor IV site closely.

Should not be administered with alkaline solutions – inactivates dopamine.

Do not discontinue abruptly – taper gradually.

Should be infused via an infusion pump.

Should be infused via a central vein –

if central venous access not possible, use a large peripheral vein (antecubital vein).

Correct hypo- volemia before administration of dopamine.

69

INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS

Epinephrine

Trade Name: Adrenalin

Class: Sympatho- mimetic, Natural Catecho- lamine

Produces bene- ficial effects in patients during cardiac arrest primarily because of its a-adrenergic
stimulating properties.
a-adrenergic effects:
↑ systemic vascu- lar resistance (vasoconstriction) → ↑ diastolic pressure → ↑ myocardial and cerebral
blood flow during CPR.

ß-adrenergic effects:
↑ heart rate (+ chronotropy)
↑ myocardial contractility
(+ inotropy) Results in ↑ myocardial oxygen demand.

First agent in cardiac arrest:

IV Bolus:
s VF.
s Pulseless VT.
s Pulseless. electrical activity. s Asystole.

Infusion:
s VF.
s Pulseless VT.
s Vasopressor agent for patients with symptomatic bradycardia (not a firstline agent).

1 mg of 1:10,000 solution IV bolus every 3-5 min.

Intermediate dose: 2-5 mg IV bolus every 3-5 min.

Escalating dose:
1 mg, 3 mg, 5 mg IV bolus (3 min apart).

High dose:
0.1 mg/kg IV bolus every 3-5 min.

Epinephrine infusion: start at 1 μg/min and titrate to desired response

(2-10 μg/min).

To prepare infusion: mix 1 mg in 250 ml (4 μg/ml) or 1 mg in 500 ml (2 μg/ml).

-Endotracheal dose 2-21/2 times IV dose (prepare 2-21/2 mg of epinephrine 1:1000 solution, add normal
saline for total volume of 10 ml

and administer).

Continuous IV infusions of epinephrine should be administered via a central vein to the

↓ risk of extravasation.

Should not
be administered in the same IV line as alkaline solutions – inactivates epinephrine.

Epinephrine infusion should be administered via an infusion pump.

Isoproterenol

Trade Name: Isuprel

Class: Sympatho- mimetic, Beta-Agonist, Synthetic Catecholar- mine

Pure ß-adrenergic stimulator (ß-1 and ß-2).

Potent chrono- tropic effect (heart rate) (primary effect).

Inotropic effect (↑ force of contraction).

↑ cardiac output.

↑ myocardial O2 consumption → ↑ myocardial ischemia.

Vasodilation.

Class IIa (probably helpful) Refractory torsades de pointes (overdrives the ventricular rate – “chemical” over-
drive pacing.

Class IIb (possibly helpful) in low doses for sympto- matic bradycardia (after atropine, pacing, dopamine and
epinephrine).

Class III (may be harmful) in higher doses for sympto- matic bradycardia.

2-10 μg/min titrated to desired response (for bradycardia, usually titrated to

a heart rate of 60 beats/minute).

To mix drip: 1 mg in 250 ml (4 μg/ml).

If used for symptomatic bradycardia, should be used with extreme caution.

Not indicated in patients with cardiac arrest or hypotension.

Excessive tachycardia.

Dysrhythmias.

↑ myocardial O2 consumption.

70
INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS
Lidocaine Hydrochloride

Trade Name: Xylocaine

Class: Ventricular antidys- rhythmic

Suppresses ventricular ectopy.

↑ VF threshold. Decreases

excitability in ischemic tissue.

Does not signif- cantly affect myocardial contractility in therapeutic doses.

Significant ventric- ular ectopy (runs of VT, “R on T” PVCs) seen in the setting of acute MI/ischemia.

VT/VF that persist after defibrillation and administration of epinephrine.

VT with a pulse.

Wide-complex tachycardia of uncertain origin.

Routine prophy- lactic use in uncomplicated MI orischemiawithout PVCs is no longer recommended.

VF/Pulseless VT: 1-1.5 mg/kg repeated in 3-5 min to maximum dose

of 3 mg/kg.

VT with pulse/Wide- complex tachycardia of uncertain origin, significant ventricular ectopy (PVCs): 1-1.5
mg/kg repeated every 5-10 min as needed with 0.5-0.75 mg/kg to total dose of

3 mg/kg.

Only bolus therapy used in cardiac arrest. After return of pulse, continuous infusion (IVdrip):

after 1 mg/kg → drip 2 mg/kg

after 11/2-2 mg/kg → drip 3 mg/kg

after 21/2-3 mg/kg → drip 4 mg/kg

To mix drip:
1 gram in 250 ml or
2 grams in 500 ml. Using a microdrip (60 gtts/ml) administration set:
1 mg/min = 15 gtts/min 2 mg/min = 30 gtts/min 3 mg/min = 45 gtts/min 4 mg/min = 60 gtts/min

Endotracheal dose 2-21/2 times IV dose diluted in 10 ml normal saline or distilled water.

Indications of toxicity are usually CNS related:

s Muscle twitching.
s Seizures.
s Slurred speech. s Altered LOC. s Respiratory arrest.

Because lidocaine is metabolized in the liver, reduce dose in:

s Decreased cardiac output (acute MI, CHF, shock).

s Elderly patients (>70years).

s Hepatic dysfunction.
In these patients, the normal bolus dose should be administered first, followed by 1/2 the normal
maintenance infusion.

Do not treat ventricular ectopy first if the heart rate is < 60 beats/ minute – treat the bradycardia.

Lidocaine may be lethal in a brady- cardia with a ventricular escape rhythm (second degree AV

block, type II, third-degree (complete) AV block with a wide-QRS.1

71

INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS

Magnesium Sulfate

May ↓ early MI mortality.

May ↓ incidence of dysrhythmias that often occur in survivors of MI.

Mechanism of action not completely understood. May ↓

due to:
s Systemic vasodilation → ↓ myocardial oxygen demand. s ↓ platelet aggregation.
s Coronary vasodilation.
s Improved myocardial metabolism.
s ↓ myocardial infract size.
s Protection against catechola- mine induced myocardial necrosis.

Torsades de Pointes.

Pulseless VT/VF.

Acute MI with known or suspected hypomagnesemia.

Pulseless VT/VF: 1-2 grams IV (2-4 ml of 50% solution) diluted in 10 ml and administered over 1-2 minutes.

Acute MI, Hypomagnesemia. Loading dose of 1-2 grams mixed in 50-100 ml of NS and administered over 5-
60 minutes.

Torsades de Pointes 1-2 grams IV (2-4 ml of 50% solution) diluted in 10 ml administered over 1-2 minutes
followed by the same amount (mixed in 50-100 ml of NS) infused over 1 hour.

Magnesium deficiency is associated with cardiac dysrhyth- mias, symptoms of cardiac insuf- ficiency and
sudden cardiac death.

Signs/symptoms of magnesium overdose include ↓ respiratory rate, hypotension, hyporeflexia.

Calcium chloride should be on hand for IV administration

if signs of magnesium overdose develop.

Norepine- phrine

Trade Name: Levophed

Class: Sympatho- mimetic, Natural cate- cholamine

Naturally occurring potent vasocons- trictor (a-receptor stimulating agent) and inotropic (ß-1 receptor
stimula- tor) agent.

90% a, 10% ß.
a activity usually

dominant.

Usually causes renal and mesenteric vasoconstriction.

Cardiogenic shock.

Severe hypotension (systolic BP < 70).

0.5-30 μg/min titrated to effect.

To prepare infusion: Mix 4 mg in 250ml (16 μg/ml). Titrate to desired effect.

Relatively contraindicated in hypovolemic patients.

Should not be administered in the same IV line as alkaline solutions.

Use with caution in patients with ischemic heart disease as myocardial O2 requirements may ↑.

Extravasation may result in tissue sloughing or necrosis.

72

INFUSION THERAPY
Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS

Procainamide

Trade Name: Pronestyl

Class: Antidys- rhythmic

Suppresses ventricular ectopy.

↑ VF threshold.

Shortens effective refractory period of the AV node.

Prolongs effective refractory period and duration of the action potential in the His-Purkinje system.

Recommended when lidocaine is contraindicated or has failed to sup- press ventricular ectopy.

Wide-complex tachycardias that cannot be distin- guished from VT (not a first-line drug).

Atrial fibrillation with a rapid ventricular response (not a first-line drug).

Suppression of recurrent VT that cannot be controlled with lidocain.

Refractory pulseless VT/VF.

IV infusion of
100 mg over 5 min (20 mg/min) until one of the following occurs:
s Dysrhythmia is suppressed.
s QRS widens by 50% of its original width.
s Hypotension develops.
s Total of 17 mg/kg has been adminis- tered (1.2 gm for a 70 kg patient).

Note: Up to
30 mg/min may be administered in urgent situations.

To prepare infusion: Mix 1 gram/250 ml or 2 grams/500 ml (4 mg/ml).

Maintenance infus- ion is 1-4 mg/min.

↓ maintenance infusion in renal failure, CHF or liver dysfunction.

Hypotension may occur if injected too rapidly –

use caution in patients with acute MI.

Avoid in patients with pre-existing QT prolongation and torsades

de pointes.

Observe ECG for ↑ PR and QT intervals, widening QRS and heart block.

Sodium Nitroprusside

Trade Name: Nipride

Potent, rapid- acting peripheral vasodilator (arterial and venous) → ↓ preload and afterload.

↑ cardiac output.

↓ myocardial. oxygen consumption.

Heart failure. Hypertension.

Add 50 mg to 250 ml (200 μg/ml).

0.1-5.0 μg/kg/min but higher doses (up to 10 μg/kg/min) may be needed.

IV and tubing should be wrapped in aluminum foil (deteriorates when exposed to light); use an infusion
pump.

Nitroglycerin preferred vasodilator in acute MI, especially when complicated

by CHF.

Primary - complication is hypotension.

Other side effects: s Headaches.

s Nausea/vomiting. s Abdominal cramps.

s Palpitations. s Dizziness.

Watch for thiocya- nate toxicity:

s Confusion.
s Hyperreflexia. s Convulsions.

s Tinnitus.

73

INFUSION THERAPY

Administration of TPN (continued)

MECHANISM

OF ACTION/
DRUG EFFECTS INDICATIONS DOSAGE PRECAUTIONS
Verapamil

TradeName(s): Isoptin, Calan

Class: Calcium channel blocker

Slows conduction and ↑ refractoriness intheAVnode.

May terminate reentrant dysrhyth- mias that require AV nodal conduc- tion for their continuation.

May control ven- tricular response in patients with atrial fibrillation, atrial flutter or multifocal atrial
tachycardia.

May ↓ myocardial contractility.

May exacerbate CHF in patients with severe left ventricular dysfunction.

Narrow-complex PSVT (adenosine drugofchoice).

Atrial fibrillation or atrial flutter with a rapid ventricular response.

Wide-complex tachycardia KNOWN WITH CERTAINTY to be supraventri- cular in origin.

2.5-5.0 mg slow IV bolus over 2 minutes.

If no response, may repeat with 5-10 mg every 15-30 minutes to a maximum of 20 mg (if blood pressure
normal or elevated).

Administer over 3-4 minutes when treating the elderly or when the BP is within the lower range of normal.

Avoid or use with caution in left ventricular dysfunction.

Observe for hypotension.

Avoid in patients with AV block, sinus node dysfunction or severe cardiac failure.

Do not use in WPW with atrial fibrillation/flutter.

Use cautiously in patients who receive long-term beta-blocker therapy.

Reproduced with permission Aehlert B: ACLS Quick Review Study Guide, 1994.
74

INFUSION THERAPY

Monitoring Central Venous Pressure

Central venous pressure (CVP) measurements are widely used in both medical and surgical patients as a
simple and easily available guide to fluid therapy after hemorrhage, accidental and surgical trauma, sepsis
and emergency conditions associated with blood volume deficits.

Fluid Challenge Guideline Chart Baseline Values:

CHALLENGE VOLUME
PAWP* MMHG AMOUNT/10 MINUTES CVP* MMHG
< 12 mmHg
12 - 16 - 18 mmHg > 16 - 18 mmHg

200 ml or 20 cc/minute 100 ml or 10 cc/minute 50 ml or 5 cc/ minute

< 8 mmHg
8 - 13 mmHg > 13 mmHg

s Re-profile at the end of 10 minutes or fluid challenge

s Discontinue challenge if PAWP increased > 7 mmHg or CVP

increased > 4 mmHg

s Repeat challenge if PAWP increased < 3 mmHg or CVP increased < 2 mmHg

s Observe patient for 10 minutes and re-profile if PAWP increased > 3 mmHg but < 7 mmHg or CVP
increased > 2 mmHg or < 4 mmHg

s Observe SVI and RVEDVI if RV volume values are available

s Discontinue challenge if: SVI fails to increase by at least 10 % and RVEDVI increases by 25% or RVEDVI is >
140 ml/m2 and PAWP increases > 7 mmHg

OPTIONAL BASELINE RVEDVI VALUE GUIDELINES:

s If RVEDVI < 90 ml/m2 or mid range 90- 140 ml/m2, administer fluid challenge

s If RVEDVI > 140 ml/m2, do not administer fluid * References differ on PAWP and CVC ranges

75

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale

Central venous catheters are used to measure the pressure under which the blood is returned to the right
atrium and to give an assessment of the intravascular volume and right heart function. The CVP is a useful
monitor if the factors affecting it are recognized and its limitations are understood. Serial measurements are
more useful than individual values, and the response of the CVP to a volume infusion is a useful test of right
ventricular function. The CVP does not give any direct indication of left heart filling but may be used as a
crude estimate of left-sided pressures in patients with good left ventricular function.

Research Riches

Mangano demonstrated that CVP could be used to predict pulmonary artery wedge pressure in patients
prior to, during, and after coronary artery surgery as long as the patients had ejection fractions greater than
0.50 with no angiographically demonstrable ventricular dyssynergy preoperatively.42

Essentially, CVP measurements reflect events in the

cardiac cycle and, in so doing, depict cardiac function. During ventricular diastole, the AV valves are open,
and each side of the heart is essentially unichambered. The pressure created by blood volume in the
ventricles now extends back into the atria so that pressure measured in the right atrium indirectly mirrors
the volume status of the right ventricle. Preload, or the volume status of the heart, has been measured as
CVP or PAWP, for the right and left ventricles, respectively.

76

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued) Mechanical Cardiac Cycle Phases

SYSTOLE

Isovolumetric Phase

Follows QRS of ECG

All valves are closed
Majority of oxygen consumed

Rapid Ventricular Ejection

Occurs during ST segment

80% to 85% of blood volume ejected

Reduced Ventricular Ejection

Occurs during “T” wave

Atria are in diastole
Produces “v” wave in atrial tracing

DIASTOLE

Isovolumetric Relaxation

Follows “T” wave

All valves closed
Ventricular pressure declines further Ends in the ventricular “diastolic dip”

Rapid Ventricular Filling

AV valves open
Approximately two-thirds of blood volume goes into ventricle

Slow Filling Phase: End-Diastole

“Atrial Kick”
Follows “P” wave during sinus rhythms Atrial systole occurs
Produces “a” wave on atrial tracings Remaining volume goes into ventricle

77

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

Simplistically, by applying the principles expressed in Starling’s Law of the Heart, it can be deduced that if a
patient’s CVP is low or normal, blood volume expanders may
be given safely. This would serve to increase the presystolic
(or end-diastolic) volume and therefore the ventricular muscle fibers, resulting in increased cardiac output.
Conversely, as the CVP rises to higher levels, cardiac reserve decreases, and further blood volume
administration becomes progressively more hazardous and less effective in increasing the work of the heart.

However, despite the apparent relationship between CVP and blood volume, it is incorrect to assess blood
volume status from CVP. There are many factors that influence CVP values, not the least of which are cardiac
performance, blood volume and vascular tone, intrinsic venous tone, increased intraabdominal or
intrathoracic pressures and vasopressor therapy.

Sheldon and Leonard43 showed that, contrary to what one might expect clinically, arterial pressure and
central venous pressure are relatively well maintained due to compensatory mechanisms until
approximately 20-30% of the estimated blood volume has been extracted. Only then do these values begin
to fall in a meaningful way.

78

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

Upon resuscitation, CVP rises linearly but comes to baseline values prematurely. On the average, CVP
returns to baseline after only 50% of the hemorrhage volume has been reinfused.

Clinical studies have shown that, in the presence of normal right heart function, severe deterioration of left
ventricular function is not reflected in changes in CVP. Buchbinder,44 in 1976, demonstrated a wide range of
pulmonary wedge pressures (left ventricular preload) obtained from patients in the presence of normal
central venous pressure.

40 30 20

10 0

Figure 1. Data from 33 patients, showing the wide range of pulmonary capillary wedge pressure valves
measured in the presence of normal central venous pressure (1-5 mm Hg).

HEMODYNAMIC MONITORING: INVASIVE TECHNIQUES

Neil Buchbinder, M.D. and William Ganz, M.D.

Prompt recognition and accurate assessment of serious circulatory changes in patients gravely ill
or undergoing major surgical interventions is of critical importance. Although monitoring heart rate, arterial
blood pressure, and central venous pressure has been a valuable guide, these values do not provide a
sufficient basis for accurate diagnosis and proper management.

79
PULMONARY WEDGE PRESSURE (mmHg)

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

The value of central venous pressure is limited by the fact that it basically reflects the functional state of the
right ventricle, which frequently does not parallel that of the left ventricle.
Information about the function of the left heart is, however, often essential for proper evaluation. In recent
years, techniques that allow easy monitoring and analysis of the function of both ventricles have become
available. This paper describes these techniques and demonstrates how their use enables proper diag- nosis
and therapy of commonly encountered clinical situations.
Monitoring Techniques

Systemic Arterial Blood Pressure

In most situations, the sphygmomanometer accurately deter- mines blood pressure. However, in some low-
cardiac-output states,pulses may be poorly palpable, and Korotkoff sounds hard to hear while the intra-
arterial pressure may be only moderately reduced. Monitoring of intra-arterial pressure is readily
accomplished by percutaneous insertion of an 18- or 20-gauge sheath into a radial, brachial or femoral
artery. With appropriate display systems, continuous pressure monitoring is obtained. Long-term patency is
facilitated by intermittent flushing with 2-5 ml of heparinized 5% dextrose in water.

Right Heart and Pulmonary Vascular Pressures

While the right atrial (central venous) pressure can easily

be measured at the bedside, catheterization of the pulmonary artery with semirigid catheters requires
fluoroscopic guidance and substantial skill. Even in experienced hands, a risk of serious complications exists
when severely ill patients are catheterized. These problems have been largely overcome
by the introduction of balloon flotation catheters, which allow for rapid and relatively safe catheterization of
the pulmonary artery without fluoroscopy.

Catheterization with Balloon Flotation Catheters

Catheterization can be performed in any hospital location where appropriate support devices are available
for effective detection and therapy of arrhythmias and for recording hemody- namic data. Catheterization is
performed during continuous electrocardiographic monitoring. The basilic, brachial, femoral, subclavian and
internal jugular veins are used as insertion sites, the latter two being particularly preferred by
anesthesiologists and surgeons.

80
MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

After entry into the selected vein, the catheter is advanced until the tip is in or near the right atrium. This
usually occurs after advancement for approximately 15 cm when the jugular or sub- clavian vein is used,
after 40 cm with use of a vein in the right antecubital fossa, after 50 cm with use of a vein in the left ante-
cubital fossa, and after about 30 cm when a femoral vein is used. Increase in respiratory fluctuation confirms
that the catheter tip is in the thorax. At this time, the balloon is inflated to the rec- ommended volume and
the catheter advanced further. The catheter tip pressure is continuously recorded as the catheter proceeds
from the right atrium into the right ventricle, pul- monary artery, and finally into a “wedge” position.
At this point, the diameter of the balloon (11 or 13 mm) slightly exceeds that of the pulmonary artery. In the
“wedge” position the tip senses the pressure transmitted with some delay and damping from the left atrium
retrograde through the pulmonary veins and capillaries. With deflation of the balloon, pulmonary arterial
pressure will reappear. Reinflation will cause the balloon to float into “wedge” position again.

As the catheter material (polyvinylchloride) softens with time, the transcardiac catheter loop tends to
diminish, and this may result in migration of the catheter tip into smaller branches and into “wedge”
position. Continuous or frequent (every 15 to 30 minutes) monitoring of pulmonary arterial pressure is,
therefore, recommended. Inflation of the balloon to full capacity when the catheter tip is in a small branch
of the pulmonary artery will result in a spuriously high pulmonary wedge pressure reading, caused by
compression of the catheter lumen. Reinflation of the balloon should, therefore, be performed slowly,
adding incre- ments of 0.1 to 0.2 ml air until a change in pressure contour from pulmonary arterial to
pulmonary wedge pressure is seen. If the pulmonary wedge pressure is obtained at a volume substantively
less than the recommended inflation volume, the catheter should be gradually withdrawn (several cm) until
the volume required for wedging is equal or nearly equal to the full inflation volume. When the balloon is
deflated, the ideal catheter posi- tion is with the tip in one of the primary branches of the pul- monary
artery.

One of the most important applications of the balloon flotation catheter is in the recording of the pulmonary
capillary wedge pressure obtained when the inflated balloon impacts into a slightly smaller branch of the
pulmonary artery. The pulmonary

81
MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

capillary wedge pressure is of great significance in clinical practice in that it provides information about two
important determinants of cardiopulmonary function. First, the level of this pressure is a basic factor in
pulmonary congestion and in the shift of fluid from the pulmonary capillaries into the interstitial tissue and
alveoli. Second, the pulmonary capillary wedge pressure closely reflects left atrial pressure and can,
therefore, serve as an index of left ventricular filling pressure.

The mean pulmonary capillary wedge and left atrial pressures closely approximate left ventricular end-
diastolic pressure in patients who have normal left ventricular and mitral valve func- tion. In left ventricular
failure, the elevated left ventricular end- diastolic pressure may significantly exceed the mean left atrial and
accordingly, pulmonary capillary wedge pressure. Nevertheless, in clinical practice the mean pulmonary
capillary wedge pressure has proved to be a reliable and useful index of left ventricular filling, and as such
provides highly relevant information on the function of the left ventricle.

Since the pulmonary vasculature is a low-resistance circuit, the pulmonary arterial end-diastolic pressure is
normally only slightly higher (1 to 3 mm Hg) than the mean pulmonary capillary wedge pressure and can,
therefore, be used as an index of left ventricu- lar filling, when the pulmonary capillary wedge pressure is
not obtainable. However, in states associated with high pulmonary vascular resistance, the pulmonary
arterial end-diastolic pressure may markedly exceed the mean pulmonary capillary wedge pressure.

* Associate Director, Cardiac Catheterization Laboratory, Cedars-Sinai Medical Center; Assistant Professor of
Medicine, UCLA.

** Research Scientist, Cedars-Sinai Medical Center, Los Angeles, and the Department of Medicine, UCLA
School of Medicine, Los Angeles, California.

Address reprint requests to Dr. Ganz: Division of Cardiology, Cedars-Sinai Medical Center, 4833 Fountain
Ave., Los Angeles, California 90029.

(Reproduced with permission from Buchbinder N, Ganz W: Hemodynamic Monitoring: Invasive Techniques.
Anesth 45:2,1976.

82

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

Additionally, central venous pressure is a pressure-based measurement used to assess volume. The
relationship of pressure to volume is not a linear one. Actually this relationship is expressed by a family of
compliance curves that change in response to various clinical situations and/or therapeutic interventions.
For further information on this technology, please refer to literature on Edwards’ Right Ventricular Ejection
Fraction (REF) catheter.

PRESSURE

CB

VOLUME

COMPLIANCE REDUCED
• MYOCARDIAL ISCHEMIA • RV DILATION/OVERLOAD • SHOCK
• PEEP

• PERICARDIAL EFFUSION • INOTROPIC DRUGS

COMPLIANCE INCREASED

• RELIEF OF ISCHEMIA
• CARDIOMYOPATHY
• DRUGS (TNG. NITROPRUSSIDE)
(Reproduced with permission from Sibbald WJ, Driedger AA: Right ventricular function in acute disease
states: Pathophysiologic considerations. Crit Care Med 11:5,1983.)

CAVEATS

1. CVP only indicates the relationship between circulating blood volume and the capacity of the heart
to handle it at any particular time.
2. A low CVP may indicate hypovolemia while a high CVP may indicate hypervolemia: however, a high
CVP may also indicate a need for positive inotropes to pump the existing fluid volume more
effectively.
3. The trend of the venous pressure and the response to therapy is often more significant than the
actual level of an isolated venous pressure determination.

83

MONITORING CENTRAL VENOUS PRESSURE

Physiologic Rationale (continued)

CVP Interpretation (CVP Range 2-6 mm Hg)

INCREASED CVP DECREASED CVP

Increased venous return from conditions that cause hypervolemia

Depressed cardiac function

Cardiac tamponade Pulmonary hypertension PEEP

Vasoconstriction

Clinical Assessment

Decreased venous return and hypovolemia

Loss of vascular tone caused by vasodilation (sepsis) which contributes to venous pooling and reduced
blood return to the heart
Various studies have documented that it is unreliable to assess central venous pressure by clinical
assessment alone. In 1983, Connors et al45 prospectively evaluated 62 right heart catheteriza- tions
performed on critically ill patients with no evidence of a recent acute myocardial infarction to determine
whether the hemodynamic measurements obtained could have been predict- ed by physical examination
and review of the chest x-ray. Additionally, they looked at whether the procedure led to changes in therapy.
They found that estimates of the patient’s hemodynamic status based on physical examination were
frequently in error and that catheterization often prompted a change in therapy.

Specifically, in each medical intensive care unit, a team of physicians consisting of an attending physician, a
critical-care fellow, a third-year resident, an intern, and frequently a fourth-year medical student
determined the need for catheterization and the current therapy and formulated theoretical plans for
therapy to be followed if catheterization data were not available. In 48.4% of all the cases studied,
information obtained through catheterization prompted a change in therapy.

84

MONITORING CENTRAL VENOUS PRESSURE

Clinical Assessment (continued)

(Reproduced with permission from Connors AF, McCaffree DR, Gray BA: Evaluation of Right-Heart
Catheterization in the Critically Ill Patient without Myocardial Infarction. NE Jour Med 308:263-267,1983.)

Research Riches

Eisenberg et al examined 97 ICU patients to

determine the accuracy of clinical diagnosis compared
to measurement by pulmonary artery catheterization. Clinical assessment correctly predicted right atrial
pressure approximately 50% of the time. Overall, planned therapy was altered by the information obtained
from catheteriza- tion in 58% of all the cases. In 30%, a new (unanticipated) therapy was added after
catheterization.46
Research Riches

In 1990, Cook examined 50 consecutive intensive care patients with right internal jugular catheters. She also
found considerable disagreement and inaccuracy in the clinical assessment of central venous pressure in
critically ill patients.47

Research Riches

Cook noted that the predictions of attending physicians and critical care fellows were no more accurate than
those of house staff and medical students. Cook also noted that physicians are better at identifying low CVP
and more accurate when ventilated patients are excluded from

the study.

85

MONITORING CENTRAL VENOUS PRESSURE

Manometric versus Electronic Measurement

The use of water manometers for the measurement of central venous pressure has been surpassed by use
of the disposable pressure transducer. Two studies48 in the mid-1980s reported that manometric values of
central venous pressure differed from those obtained electronically. Despite correct position of the catheter
tips and adequate respiratory oscillations, manometric measurements differed considerably from right atrial
mean pressure determinations. Both investigators recommended that water manometry for the
measurement of central venous pressure not be used in the critical care environment.

CVP Monitoring Set-Up

Pressure Monitoring System

The typical invasive pressure monitoring system consists of: s Noncompliant tubing – to accurately transmit
pressure

waveforms to the transducer

s Disposable transducer – to accurately amplify the signal

s Monitor cable – to accurately transmit the amplified signal to the monitor

86

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued) Additional components include:

s Pressurized solution – pressurized to at least 300 mm Hg

s Integral flush device with a restrictor – to limit flow rate to

approximately 3 to 5mL/hr for adults

s Heparinized solution – 0.9% NS with Heparin 0.5-2 U/mL

CATHETER TUBING COMPONENT

This system, incorporating the catheter, tubing, and associated stopcocks, must be fluid-filled for the
waveform to be reproduced accurately. Fluid is essentially non-compressible and allows the waveform signal
to be transmitted across relatively long distances.

One factor likely to alter the waveform signal is the length

of the tubing. The longer the tubing, the more likely the waveform will be distorted. As a general rule, the
tubing should be kept as short as possible to obtain accurate waveforms.

The top trace represents a valid arterial waveform. The bottom trace represents the same waveform
distorted by increased length of tubing.

Air bubbles are compressible and will, therefore, also distort the waveform signal. Blood in the tubing will
also absorb more of the waveform signal than normal saline.

The top trace represents a valid arterial waveform. The bottom trace represents the same trace when
distorted by an air bubble in the line.

87

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued)

Nursing Note
Although the difference in pressures recorded may not be clinically significant in these examples of arterial
lines, mean CVP values range between 2-6 mm Hg; even a small difference (related to air bubbles or length
of tubing) may appear clinically significant.

Overdamping results in a waveform losing its definition. Systolic pressure decreases and diastolic pressure
increases. Several factors could cause damping:
s Fibrin at catheter tip

s Catheter tip against wall of vessel s Air bubbles or blood in the system

FREQUENCY RESPONSE

Frequency response and damping coefficient measure the overall system’s ability to accurately reproduce a
signal; in this case, a pressure tracing. The square wave test is an easy one to perform and interpret at the
bedside. Most commercial fast flush systems, once activated, produce a rapid rise in pressure that goes off
the scale of the monitoring system. This squares off the tracing. Upon release of the flush device, the
pressure waveform then rapidly returns to baseline.

Nursing Note

If a clot is suspected, aspirate first; then flush gently.

88

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued) SQUARE WAVE TESTING

1. Activate snap or pull tab on flush device.

2. Observe square wave generated on bedside monitor. 3. Count oscillations after square wave.
4. Observe distance between the oscillations.

Optimally Damped:

1 - 2 oscillations before returning to tracing. Values obtained are accurate.

Underdamped:

> 2 oscillations. Overestimated systolic pressure, diastolic pressures may be underestimated.

Overdamped:
< 1 1/2 oscillations. Underestimation of systolic pressures, diastolic may not be affected.

CALIBRATION

It is no longer important to calibrate the transducer, as the disposable transducer systems currently in use
today have an accuracy rate of 1-2%. If inaccuracy is suspected, the transducer is usually replaced after the
monitoring cable has been replaced and found not at fault.

ZERO REFERENCE

The accuracy of the CVP is determined, in part, by transducer placement relative to an external reference
point on the patient’s body representing the location of the right atrium. Since its identification in 1945, the
phlebostatic axis has been repeatedly confirmed as a valid external reference point for CVP, LAP and PAP
measurements. It has been anatomically shown to be a true external point for identifying the right atrium
when the patient is supine.

89

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued)

(Reproduced with permission from

Woods SL, et. al.: Cardiac Nursing. J.B. Lippincott Co., Third Edition.)

The method to zero reference the pressure monitoring system requires placement of the air-fluid interface
at the level of the phlebostatic axis. The stopcock located at the designated air-fluid interface is then opened
to air, allowing for the influence of atmospheric

pressure to be eliminated. Usually, this stopcock is located at the transducer but may be located anywhere
within the line itself. Once the leveling has been accomplished, the patient and transducer must remain in
the same position. If the head of the patient’s bed is elevated, then re-leveling needs to be repeated in the
new position.
(Reproduced with permission from Woods SL, et. al.: Cardiac Nursing. J.B. Lippincott Co., Third Edition.)

90

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued)

Practical Point

The only exception to re-zeroing with patient movement is to mount the transducer on the patient. When
patient-mounted, the transducer will not lose its relationship to the phlebostatic axis as long as the
movement is in the same plane (i.e., the patient cannot be turned laterally).

Patient Position

The literature suggest that accurate CVP measurements can be obtained with the adult and pediatric patient
in the supine position in various degrees of backrest up to 30 degrees. Additionally, the effect of tilting on
CVP measurement has been investigated and accuracy maintained with the use of the phlebostatic axis as
the zero reference point.

Physiology Fact

Actually, it is sometimes suggested that, in the assess- ment of circulatory volume depletion, CVP should be
measured with the patient at 45 degrees as measurement of CVP in the supine position may not detect or
may severely underestimate circulatory volume depletion.49

The evidence supporting use of the phlebostatic axis to yield accurate CVP values in the lateral position is
less clear. In
the studies on pressure measurement in patients in the lateral position, the phlebostatic axis yielded more
reproducible values between the supine and lateral positions than other postulated reference levels.

Potger and Elliott50 studied the lateral position when the trans- ducer was leveled at the supine phlebostatic
axis and was not re- leveled when the patient was turned 30 degrees to the right or left lateral position with
the head of the bed elevated
20 degrees. Although there was no statistical significance, there were clinically significant changes. They
suggested an alternative approach involving the identification of the transducer placement in the patient in
the lateral position that yielded the same CVP reading as that obtained in the supine position.

91

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued)

If there is any doubt about the CVP value obtained in the patient in the lateral position, the patient should
be returned to the supine position for re-measurement.

An interesting point to consider is the minimum stabilization period after patient repositioning.
Unfortunately, this has not been determined. However, it is prudent not to determine pressure
measurements immediately after repositioning. It should also be remembered that, in elderly and critically
ill patients, the change in position may have a greater contri- bution to variations in pressure than the
position itself.

Port Site

Measurement of CVP is usually performed through one of the ports of a triple-lumen central venous
catheter. In a study by Scott et al,51 measurements of CVP in 48 adult intensive care patients were obtained
via each of the three ports of a triple- lumen CVC. Catheters were placed in either the right or left subclavian
vein or the right or left internal jugular vein. The data showed significant differences across port sites. There
were significant differences between the proximal and distal ports and between the medial and distal ports.
In some patients, the difference between CVP obtained from the distal port and pressure obtained from the
proximal or the medial port could have been clinically significant. It would make sense to assure that CVP
readings be standardized to a specific port to enhance validity of data and that the port utilized

is documented in the clinical notes.

Respiratory Influences
During spontaneous breathing, inspiration causes a decrease

in intrathoracic pressure that is transmitted in part to the right atrium and produces a decline in CVP. The
opposite is true when the patient is receiving mechanical ventilation. Most clinicians measure end-
expiratory values for cardiac filling pressures, because both pleural and pericardial pressures approach
atmospheric pressure under these conditions, whether the patient is breathing spontaneously or receiving
positive pressure mechanical ventilation. These pressure values can be determined by visual inspection of
the CVP waveform on a calibrated monitor screen or digital printout.

92

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued) PAP TO PAWP TRACING

Physiology Fact

Ventilatory support with positive pressure usually elevates the central venous pressure only slightly
(0-2 mm Hg). However, if more effective ventilation and oxygenation improve pump function, the CVP may
decrease as a result of the positive pressure ventilation.

93

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued) Infection Control for Pressure Lines

It is interesting to note that gram-negative microorganisms account for the majority of catheter-related
infections associated with the use of pressure monitoring systems. Apparently,
such systems are considerably more vulnerable to becoming con- taminated during use. This may stem from
the presence of a stagnant column of fluid subjected to frequent manipulations. Studies suggest that if the
infusion for hemodynamic monitoring is set up so that it flows continuously, it may not be necessary to
routinely change out at 24-48 hour intervals. With the use of dis- posable transducers, there appears to be
no need to replace the transducer and other components of the delivery system more frequently than every
four days.

CDC Guideline (1996)

s Use disposable, rather than reusable, transducer assemblies whenever possible.

s Replace disposable or reusable transducers at 96 hour intervals. Replace other components of the system,
including the tubing, continuous flush device, and flush solution, at the time the transducer is replaced.
s Keep sterile all components of the pressure monitoring circuit (including calibration devices and flush
solution).

s Minimize the number of manipulations and entries into the pressure monitoring system. Use a closed-flush
(i.e., continuous flush), rather than an open system (i.e., one than requires a syringe and stopcock), to
maintain patency of the pressure monitoring catheters. If stopcocks are used, treat them as a sterile field,
and cover them with a cap or syringe when not in use.

s When the pressure monitoring system is accessed through a rubber diaphragm rather than a stopcock,
wipe the diaphragm with appropriate antiseptic before access- ing the system.

s Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure
monitoring circuit.

s Do not routinely use pressure monitoring devices to obtain blood samples that do not require arterial
blood.

94

MONITORING CENTRAL VENOUS PRESSURE

CVP Monitoring Set-Up (continued) TROUBLESHOOTING PRESSURE MONITORING SYSTEMS

PROBLEM

No Waveform

POSSIBLE CAUSES/SOLUTIONS

s Check power supply.

s Check the pressure range setting on the

monitoring equipment.
s Check balancing and calibration of the equipment. s Check for loose connection in the IV pressure line. s
Check to be certain that Stopcocks are not turned

off to the patient.

s It is possible that the catheter is occluded or has moved out

of the vessel. If this is suspected, try to aspirate blood from the line. NOTE: Fast-flushing the line may
dislodge a clot. Never apply pressure to the irrigating syringe greater than that used for a standard IM
injection.

s Check for electrical interference.

s Check for patient movement.
s Catheter whip may be the problem.

s Temperature change of IV solution (new flush bag hung) or environment.

s Be certain the electrical monitoring cable is not kinked or compressed.

s Check stopcocks and tubing for kinks.

s Check to see that the pressure bag is inflated to the
appropriate level.

s Check balance and calibration.

s Check to see if the transducer is located at the

appropriate level.
s Check stopcocks to make certain they are open to

the patient.
s Suspect failure of the automatic flush device (flow too fast).

s Check to see if the transducer is located at the appropriate level.

s Check for loose connections

s Check for air bubbles in the system.

s Check for kinks in the tubing.
s Suspect possible occlusion at the catheter tip (ie, thrombus)

or the catheter tip may be resting against the vessel wall. NOTE: A term sometimes used is “high pressure
damping.” This refers to a baseline that elevates and remains elevated – usually at the upper limit of the
pressure monitoring range. This is invariably caused either by an electrical failure of the monitor/amplifier or
by total occlusion at some point in the fluid-filled line. Check stop- cocks, tubing and catheter patency.

Artifact
Waveform Drifting

Unable to Flush Line

Reading Too High

Reading Too Low

Dampened Waveform

(Reproduced with permission from Darovic GO: Hemodynamic Monitoring, Invasive and Noninvasive Clinical
Application. W.B. Saunders)

95

MONITORING CENTRAL VENOUS PRESSURE

Normal CVP Waveform

Waveforms seen on the monitor merely reflect the intracardiac events. The normal CVP waveform consists
of three peaks
(a, c and v waves) and two descents (x and y). The a wave represents atrial contraction and follows the P
wave on the EKG trace. This is the atrial kick that loads the right ventricle just prior to contraction. As atrial
pressure decreases, a c wave, resulting from closure of the tricuspid valve, may be seen.

The x descent represents the continually decreasing atrial pressure. The v wave represents the atrial events
during ventricular contraction – passive atrial filling – and follows the T wave on the EKG. When the atrial
pressure is sufficient, the tricuspid valve opens, and the y descent occurs. Then the cycle repeats.
Accurate recognition of these waves requires that they be aligned with an EKG trace. As mechanical events
follow electrical events, the waveforms can be identified by lining them up with the EKG events. Although
the arterial pressure trace can be used for timing, this may be confusing due to the time delay involved in
transmitting the aortic pressure to the radial artery.

96

WAVEFORM ANALYSIS

Normal CVP Waveform (continued)

ELECTRICAL – MECHANICAL CARDIAC CYCLE

(Reproduced with permission from Ahrens TS, Taylor LA: Hemodynamic Waveform Analysis) Abnormal
Waveform Analysis

Arrhythmias

Since electrical events determine the mechanical, there will be no a waves in atrial fibrillation. Occasionally,
fibrillation waves may be seen in the CVP trace when the atrial fibrillation is coarse and the rate is slow.
Atrioventricular dissociation or junctional rhythm results in cannon a waves. This is due to atri- al
contraction occurring during ventricular systole when the tri- cuspid valve is closed. Ventricular pacing can
be identified in similar fashion by searching for cannon waves in the venous pressure trace.
97

WAVEFORM ANALYSIS
98
Abnormal Waveform Analysis (continued)
These three conditions may cause arterial hypotension due to

loss of atrial kick, and the venous trace may help with diagnosis.

This patient, with atrial fibrillation, has no identifiable a waves. Small flutter or fibrilla- tion waves may be
evident. Only v waves can be seen following each QRS complex on the EKG.
Key: 1 = v wave

2 = y descent

This patient has

AV dissociation with a demand pacemaker.
The underlying atrial activity (p waves) is indicated by arrows. When p waves occur caus- ing the atria to
contract against a
closed tricuspid valve, cannon a waves occur. Key: 1 = a wave

2 = v wave
3 = cannon a wave

In this CVP tracing, there are normal a and v waves. Following a PVC, a large v wave is noted. As the AV valve
was open during the premature beat, blood goes back into the right atrium during early contraction.

Key: 1 = a wave 2 = v wave

3 = large v wave

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

Tricuspid Valve Disease

Tricuspid regurgitation produces giant v waves as abnormal

systolic filling of the right atrium through the incompetent valve occurs during ventricular systole. Right
ventricular end diastolic pressure is overestimated by the numeric readout on the bedside monitor that
reports a single mean value for CVP. Reading the waveform at the top of the a wave might prove a better
indicator of right ventricular filling.

In this CVP trace, both a and v waves are elevat- ed. However, the v wave is dominant and reflects tricuspid
insufficiency. The elevated a wave demonstrates a degree of right ventricular failure as well.
Key: 1 = a wave

2 = c wave

3 = v wave Tricuspid stenosis usually presents with an increased a wave

that represents the increased force of atrial contraction to push blood across the stenotic valve. In this
instance, CVP readings will be falsely elevated. Right ventricular filling may actually be decreased due to the
valvular obstruction.

Right Ventricular Infarction

This condition causes a disproportionate elevation of CVP compared to PAWP. Often the CVP will exceed
wedge pressure and display prominent a and v waves, the former suggesting atrial contraction into a stiff or
incompletely relaxed right ventricle, and the latter suggesting tricuspid valve regurgitation, which is often
associated with this condition.
99

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

In this patient with a right ventricular infarc- tion, right ventricular compliance is decreased due to
myocardial injury. The right atrium must generate a much higher pressure during systole to pump blood into
the compromised right

ventricle, resulting in a dominant a wave. The v wave is somewhat elevated due to right ventricular failure.
Key 1=awave 2=vwave (NotethatthePAWPtraceisnor- mal.)

Pericardial Constriction/Cardiac Tamponade

In these conditions, the pericardium or an increase in pericardial fluid limits venous return to the heart. This,
in turn, reduces stroke volume and cardiac output. Central venous pressure is elevated, and there is end-
diastolic pressure equalization in all cardiac chambers. Characteristic of the pressure trace is an M or W
configuration secondary to

prominent a and v waves and steep x or y descents.

In this patient with cardiac tamponade,
both a and v waves are elevated reflecting the elevated diastolic filling pressures in all cardiac chambers.
This diastolic plateau results from dias-

tolic compression of the heart by the blood or fluid in the peri- cardial sac. There is a prominent x descent
and a very short y descent.
Key 1=awave 2=cwave 3=vwave

Please see Edwards slide module Waveform Analysis for further information.

100

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

Abnormal Waveform Chart

RIGHT ATRIAL WAVEFORMS

Decreased mean pressure

- Hypovolemia
- Transducer zero level too high

Elevated mean pressure

- Fluid overload states

- Right ventricular failure
- Left ventricular failure causing right ventricular failure - Tricuspid stenosis or regurgitation
- Pulmonic stenosis or regurgitation
- Pulmonary hypertension

Elevated “a” wave: atrial systole, increased resistance to ventricular filling

- Tricuspid stenosis
- Decreased right ventricular compliance - Right ventricular failure
- Pulmonic stenosis
- Pulmonary hypertension

Absent “a” wave

- Atrial fibrillation
- Atrial flutter
- Junctional rhythms: cannon “a” waves
Elevated “v” wave: atrial filling, regurgitant flow
- Tricuspid regurgitation
- Functional regurgitation from right ventricular failure

Elevated “a” and “v” waves

- Cardiac tamponade
- Constrictive pericardial disease - Hypervolemia
- Right ventricular failure

101

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

Abnormal Waveform Chart (continued)

RIGHT VENTRICULAR WAVEFORMS

Elevated systolic pressure

- Pulmonary hypertension
- Pulmonic valve stenosis
- Factors that increase pulmonary vascular resistance

Decreased systolic pressure

- Hypovolemia
- Cardiogenic shock - Cardiac tamponade

Increased diastolic pressure

- Hypervolemia
- Congestive heart failure - Cardiac tamponade
- Pericardial constriction

Decreased diastolic pressure

- Hypovolemia

PULMONARY ARTERY WAVEFORMS

Elevated systolic pressure

- Pulmonary disease
- Increased pulmonary vascular resistance - Mitral stenosis or regurgitation
- Left heart failure
- Increased blood flow; left to right shunt

Reduced systolic pressure

- Hypovolemia
- Pulmonic stenosis - Tricuspid stenosis
102

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued) CASE STUDY

Patient Profile

A 72-year-old male with a history of arteriosclerotic heart disease and chronic obstructive lung disease was
admitted to the intensive care unit following coronary artery bypass grafting of the left anterior descending
and circumflex arteries.
The following data are obtained four hours postoperatively:

B/P (S/D/M) 90/60/73 mm Hg 100 bpm

17 mm Hg

10 mL/hr
The patient is receiving Dopamine at 5 mcg/kg/min.

Diagnosis

The decreased blood pressure, elevated heart rate, and decreased urinary output might point to pump
failure.
The high CVP seems to support this diagnosis. Remember the patient is already receiving inotropic support.

Does this patient have right heart failure secondary to his chronic lung disease and/or being on
cardiopulmonary bypass?

Analysis

One might think that the diagnosis of right heart failure is justified based on these findings, and an increase
in inotropic support might be indicated. However, what additional hemodynamic information can be
gleaned from this patient?

The RAP/CVP waveform can be recorded and analyzed for any clues. The waveform is characterized by:

s Elevated mean pressure s Prominent a and v waves s Exaggerated x descent

This waveform is suggestive of cardiac tamponade – or a dry heart unable to fill secondary to compression.

If a pulmonary artery catheter were inserted, the following hemodynamic data would be obtained:

CO 3.0 L/min 1.5 L/min

18 mm Hg 50/20 mm Hg

HR
RAP/CVP
Urine Output
CI
PAWP
PAP

103

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

The elevated wedge pressure and decreased cardiac output are indicative of both heart failure
(biventricular) and cardiac tam- ponade. However, whenever the PAWP and RAP equalize (dias- tolic
plateau), cardiac tamponade should at least be suspected.

Results

The patient did indeed have cardiac tamponade and was returned to the operating room for evacuation of a
clot.

Summary

The original treatment of increasing inotropic support would not have been appropriate. The patient
actually needed fluid administration (contrary to what might be anticipated by the increased CVP). Analysis
of the right atrial waveform would have provided increased impetus to obtain an echocardiogram for
definitive diagnosis.

This is not an abstract scenario. Collier’s work on previously unrecognized cardiac tamponade secondary to
central line placement should be reviewed. He stated that significant diagnostic clues might be:

s Worsening of hypotension after the administration of nitrates. The nitrates reduce the venous return and
worsen the physiology of cardiac tamponade; i.e., an already dry heart
is now made drier.

s Worsening of hypotension shortly after intubation. The negative intrathoracic pressure during normal
respiration pulls blood back into the heart as a compensatory mechanism for the tamponade. Intubation
converts this negative pressure
to positive pressure. This dramatically reduces the venous return to the heart, and the cardiac output falls,
usually
leading to a precipitous drop in blood pressure.
Waveform analysis to differentiate right ventricular

infarction, constrictive pericarditis and cardiac tamponade can be very specific.

104

WAVEFORM ANALYSIS

Abnormal Waveform Analysis (continued)

Additionally, the use of a right heart ejection fraction catheter (RHEF) would have provided the following
data: RVEF 50% normal range 30-40% contractility OK
RVedv 60 mL normal range 100-160 mL hypovolemia

105

WAVEFORM ANALYSIS

Advanced Venous Access (AVA) Devices

AVA High Flow (HF)

The AVA HF device integrates

the capabilities of an introducer and multi-lumen central venous access into one device. Unlike standard
introduc- ers, the AVA HF device

incorporates three independent lumens that function similar to multi-lumen lines. The AVA HF device may
eliminate the need to place both a central venous catheter and a pulmonary artery catheter in the high-risk
surgical patient. Similarly, a pulmonary artery catheter can be quickly inserted through the

introducer lumen when more invasive cardiac monitoring is required.

The AVA HF (9F) incorporates a tri-lumen sheath design with inner flexi- ble walls so that the individual
lumen size can vary. The cross section increas-

es from a 15 gauge lumen under standard gravity (101.6cm head height), to 12 gauge when infusing fluids
under pressure at 300 mm Hg (without a catheter through the distal lumen).

AVA HF DEVICE – FLOW RATES GRAVITY UNDER PRESSURE (WITHOUT PAC) (300 MM HG)

Proximal 1 and 2 combined 161 mL/min 1,202 mL/min

Distal lumen only 555 mL/min 1,293 mL/min
All 3 lumens simultaneously 1,492 mL/min
GRAVITY
AVA HF DEVICE – FLOW RATES (WITH 8F PAC) UNDER PRESSURE (300 MM HG)
Proximal 1 and 2 combined 161 mL/min 560 mL/min
Distal lumen only 60 mL/min 169 mL/min
Flow rates shown using normal saline, room temperature.

106

DIST AL 9F

P15RGOAXIMAL1

P15RGOAXIMAL2
EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Advanced Venous Access (AVA)

Devices

(continued)

Practical Point

AVA HF may replace the need for a double-stick, discussed earlier. Only one site to manage!

AVA 3Xi
The AVA 3Xi device is a true multifunctional access device –

a triple lumen device and introducer combined. Designed with the needs of the routine and fast-track
cardiac surgery patient in mind, the AVA 3Xi incorporates three independent lumens with flexible walls and
staggered infusion exit ports. The addition

of a detachable introducer valve allows the introduction of a pulmonary artery catheter through the existing
triple lumen device at any time. This is made possible through the anti-bleedback septum (ABS) that is
permanently attached to the distal lumen. This septum ensures that the distal lumen remains sealed when
not in use and allows for access with any male luer connection.

107

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Advanced Venous Access (AVA)

Devices

FEATURE

(continued)

Detachable introducer valve Anti-bleedback septum

Locking contamination shield

BENEFIT

Provides flexibility for evolving central venous access requirements

Maintains hemostasis when not in use

Allows patient transfer to stepdown or telemetry unit when introducer is removed

Compatible with any male luer connection (IV tubing, pressure tubing or syringe)

Secures PA catheter at both proximal and distal locations

Helpful Hints

Flush all 3 lumens with heparinized saline pior to inser- tion. Be sure that the introducer is attached to the
anti-bleedback septum on the distal lumen before inserting dilator. (Do not insert dilator directly into anti-
bleedback septum.)

To ensure proper attachment to introducer valve or any male luer to the ABS, follow these steps.

1. AligndesiredmaleluerwithABS
2. PushmaleluerintoABS(straight-notatanangle). 3. Rotatemaleluerdeviceclockwisetotighten.
4. Ensurethatconnectionissecure.

Insert the pulmonary artery catheter at least 25 cm before inflating the balloon to be sure that the PAC has
exited the tip of the introducer sheath.

Do not pierce anti-bleedback septum with a needle. Use a luer syringe to attach directly to the anti-
bleedback septum.

Draw blood samples from the distal lumen.

108

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Advanced Venous Access (AVA)

Devices

COMPARISON OF ADVANCED VENOUS ACCESS DEVICES AVA HF AVA 3XI

(continued)
High-risk medical/ surgical
patients Fast-track and routine cardiac surgical patients
Patient Type
involving multiple access lines
High infusion/ volume need
Introducer Lumen Size 9F 8.5F
PAC French Size Up to 8F PAC Up to 7.5F PAC
Distal Proximal 1 Proximal 2 Distal Medial Proximal
Lumen Volumes
2.7 mL 1.6 mL 1.6 mL 1.5 mL 0.5 mL 0.5 mL
AVA Port Color Distal – Brown Proximal 1 – Blue
Distal – ABS Medial – Blue Proximal – White
Designation Proximal 2 – Grey
AVA Port Exit Locations (from Distal tip)

Distal – tip Proximal 1 – 1.5 cm Proximal 2 – 1.5 cm

Distal – tip Medial – 1.0 cm Proximal – 2 cm

Advanced Venous Access devices (both AVA HF and AVA 3Xi) are available with or without AMC
THROMBOSHIELD (an Antimicrobial* Heparin Coating) and Interlink components, in basic set or expanded
kit trays.

*Decreases viable microbe count on surface of catheter during handling and placement. Antimicrobial
activity associated with AMC THROMBOSHIELD has been demonstrated using in vitro agar diffusion assays
against the following organisms: Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus faecalis,
Candida albicans, Escherichia coli, Serratia marcescens and Acinetobacter calcoaceticus.

Central Venous Catheters (CVC)

Vantex Central Venous Catheters

with Oligon Material
Vantex CVCs provide antimicrobial protection through the use of a new material called Oligon. Silver,
platinum and carbon are combined with a base material of polyurethane. When the catheter is inserted,
body fluids interact with the silver and platinum particles in the material, causing a release of silver ions the
catheter. Antimicrobial activity on the Oligon surface and inner lumens of the catheter during handling and
placement has been demonstrated through in vitro testing against organisms commonly associated with
nosocomial infections.

109

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued)

The activity ofthe antimicrobial agents is localized at the catheter surfaces and is not intended for treatment
of systemic infections.

In vitro testing demonstrated that the Oligon material provided broad spectrum effectiveness (≥ 3 log
reduction from initial concentration within 48 hours) against the organisms tested: Staphylococcus aureus,
Staphylococcus epidermidis, Klebsiella pneumoniae, Enterococcus faecalis, Candida albicans, Escherichia coli,
Serratia marcescens, Acinetobacter calcoaceticus, Corynebacterium diptheriae, Enterobacter aerogenes,
GMRSa, and Pseudomonas aeruginosa. The impact of Oligon material on infection
rates has not been demonstrated.
SIZE GAUGE
7F 16/16
7F 16/16
SIZE GAUGE
DOUBLE LUMEN

Available as catheter only, basic sets and expanded kit trays, with and without heparin coating, Interlink:

8.5F 14/15 8.5F 14/15

TRIPLE LUMEN

LENGTH

16 cm 20 cm 16 cm 20 cm

Available as catheter only, basic sets and expanded kit trays, with and without heparin coating, Interlink:

LENGTH

7F 18/18/16 16 cm 7F 18/18/16 20 cm

110

15

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued) QUAD LUMEN

Available as catheter only, basic sets and expanded kit trays, with and without heparin coating, Interlink:

SIZE

8.5F 8.5F
GAUGE

15/18/18/18

LENGTH

16 cm 20 cm

15/18/18/18

Commercial Comment

Since Edwards’ Vantex CVC with Oligon material does not contain chlorhexidine, the potential risk
associated with chlorhexidine is avoided.

VANTEX CVC WITH OLIGON MATERIAL – AVERAGE FLOW RATES IN ML/HR

7F DOUBLE LUMEN

Distal Proximal

7F TRIPLE LUMEN

Distal Medial Proximal

8.5F DOUBLE LUMEN

Distal Proximal

8.5F QUAD LUMEN

Distal Medial 1 Medial 2 Proximal

16CM LONG CATHETER

20CM LONG GAUGE CATHETER SIZE

16 16

16 18 18

14 15

15 18 18

1,566 18

3,781 3,481
3,601 3,416
3,593 3,535
1,569 1,488
1,754 1,628
6,190 5,900
4,964 4,594
4,990 4,732
1,544 1,394
1,640 1,442

1,784

Flow rates shown using normal saline, room temperature, at 40" (101.6cm) head height

111

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued) VANTEX CVC WITH OLIGON MATERIAL – AVERAGE LUMEN

VOLUME (ML)
7F DOUBLE LUMEN

16CM 20CM

0.65 0.66

0.63 0.52 0.53

0.80 0.78

0.71 0.30 0.31

0.31 0.33

0.59
Distal
Proximal
0.61
7F TRIPLE LUMEN
Distal 0.52
Medial 0.45
Proximal
0.48
8.5F DOUBLE LUMEN
Distal 0.72
Proximal
0.71
8.5F QUAD LUMEN
Distal 0.64
Medial 1 0.28
Medial 2 0.29
Proximal

Multi-Med Central Venous Catheters

Edwards MULTI-MED 7F 20cm

Multi-Med “High-Flow” Central Venous Catheters

(CVCs) are constructed of soft polyurethane with a soft tip. Polyurethane material contributes to excellent
handling, flexibility and kink-resistance. The Multi-Med CVC features optimized lumen and backform design,
providing optimal flow characteristics, up to 50% faster than standard CVCs. Edwards CVCs are either 16cm
or 20cm long to prevent the complications associated with over-insertion of the catheter, (i.e., perforation
and cardiac tamponade.)

112

PROXIMAL/5 CM 18 GA

DASTAL 16 GA

MEDIAL/2cm 18 GA.

15

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued) SINGLE-LUMEN

Available as catheter only, basic sets, and expanded kit trays, with and without AMC THROMBOSHIELD,
Interlink:

SIZE GAUGE

3F
5F
6F 14

DOUBLE LUMEN

LENGTH

13 cm 20 cm 20 cm

20
16

Available as catheter only, basic sets, and expanded kit trays, with and without AMC THROMBOSHIELD,
Interlink:

SIZE GAUGE

7F
7F
8.5F
8.5F 14/15
TRIPLE LUMEN

LENGTH

16 cm 20 cm 16 cm 20 cm

16/16
16/16
14/15

Available as catheter only, basic sets, and expanded kit trays, with and without AMC THROMBOSHIELD,
Interlink:

SIZE

7F 7F

GAUGE

16/18/18

LENGTH

16 cm 20 cm

QUAD LUMEN

16/18/18
Available as catheter only, basic sets, and expanded kit trays, with and without AMC THROMBOSHIELD,
Interlink:

SIZE

8.5F 8.5F

GAUGE

15/18/18/18

LENGTH

16 cm 20 cm

15/18/18/18

113

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued)

AMC THROMBOSHIELD is a proprietary antimicrobial heparin coating that is coated on both the inner and
outer surfaces of the catheter. Decreased antimicrobial activity associ- ated with AMC THROMBOSHIELD has
been demonstrated using in vitro agar diffusion assays against the following organ- isms: Staphylococcus
epidermidis, Staphylococcus aureus, Enterococcus faecalis, Candida albicans, Escherichia coli, Serratia
marcescens, and Acinetobacter calcoaceticus. AMC THROMBOSHIELD decreases viable microbe count on
surface of catheter during handling and placement.

MULTI-MED CVC – AVERAGE FLOW RATES IN ML/HR

SINGLE-LUMEN

7F DOUBLE LUMEN

Distal Proximal

7F TRIPLE LUMEN

Distal Medial Proximal

8.5F DOUBLE LUMEN

Distal Proximal

8.5F QUAD LUMEN

Distal Medial 1 Medial 2 Proximal

16CM LONG CATHETER

20CM LONG CATHETER

GAUGE SIZE

20 16 14

16 16

16 18 18

14 15

15 18 18 18

1,362
3,483
6,210
3,608 3,292
3,620 3,200
3,510 3,160
1,500 1,300
1,670 1,420
6,126 5,886
5,130 4,716
4,812 4,564
1,538 1,349
1,623 1,412
1,741

1,471

Flow rates shown using normal saline, room temperature, at 40" (101.6cm) head height.

114

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

20ga —
16ga —
14ga —

7F DOUBLE LUMEN
Distal 0.57
Proximal 0.59

7F TRIPLE LUMEN
Distal 0.56
Medial 0.45
Proximal 0.47

8.5F DOUBLE LUMEN

Distal 0.73
Proximal 0.71

8.5F QUAD LUMEN

Distal 0.65
Medial 1 0.29
Medial 2 0.30

Proximal (1)

Proximal (2)

Medial (1)

Medial (2)

white

blue

white

blue

Distal brown brown brown brown brown

white
blue

gray

gray

blue

blue

white

115
Central Venous Catheters (CVC) (continued) MULTI-MED CVC – AVERAGE LUMEN VOLUMES (ML)

SINGLE-LUMEN

16CM 20CM

0.41 0.25 0.09

0.62 0.62

0.60 0.47 0.52

0.80 0.78

0.69 0.30 0.30

0.31 0.32

Proximal

Markings on the catheter body of Edwards Lifesciences’ CVCs (except for the single-lumen) are calibrated in
1cm intervals, starting at 10cm. The 15cm depth is clearly marked. Guidewires are also marked at 10, 20 and
30cm depths. These markings aid the clinician in correctly assessing the amount of catheter or guidewire
inserted. Catheter depth should be routinely documented in the insertion and clinical notes.

PORT COLOR DESIGNATION

PORT DOUBLE TRIPLE QUAD AVA HF AVA 3XI
EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Central Venous Catheters (CVC) (continued)

Practical Point

With Edwards’ devices, the distal lumen is always the largest. Look at the hub to see both catheter gauge
and distance of lumen from tip.

SUTURE LOOP/BOX CLAMP

If desired, the optional suture loop/box clamp can be placed on the catheter and sutured to the skin.

s Place the optional suture loop onto the catheter by spreading the suture loop wings and pressing onto the
catheter.
(See Figure 1)

s Snap the box clamp over the optional suture loop to secure both components to the catheter. (See Figure
2)
s Suture the optional suture loop and box clamp together to the patient to prevent catheter migration. (See
Figure 3) Precaution: The box clamp must be removed from the

catheter before attempting guidewire passage prior to catheter exchange.

116

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Intro-Flex Percutaneous Sheath Introducers

Important: Insertion depths will vary according to the inser- tion site and the size of the patient.

1. Remove the guidewire and assure that venous blood can

be freely aspirated through the distal lumen. Begin fluid infusion.

For continuous infusion, attach infusion set luer connector to desired lumen hub and infuse per
hospital protocol. Precaution: To avoid damage to the extension lumen, the slide clamp must be
opened before infusing through the lumen.

2. Under continuous pressure monitoring, and fluoroscopy if desired, gently advance the catheter into
the superior vena cava, stopping above the junction of the right atrium and the superior vena cava.

Precaution: Positioning the distal tip of the catheter in the right atrium or ventricle is NOT
recommended (see Complications).

3. Once in position, secure the catheter by suturing the suture wings to the skin. Note the
approximate insertion depth of the catheter by observing the 5 cm depth markings on the catheter
body.
4. If desired, the optional suture loop/box clamp can be placed on the catheter and sutured to the
skin.
a. Once the catheter has been inserted to the appropriate position and the guidewire has been
removed, place the preslit optional suture loop onto the catheter by spreading the suture loop
wings and pressing onto the catheter (see Figure 1).
 b. Snap the box clamp over the optional suture loop to secure both components to the catheter
(see Figure 2).
c. Suture the optional suture loop and box clamp together to the patient to prevent catheter
migration (see Figure 3). Periodically check catheter placement to confirm tip has

not migrated.

Precaution: The box clamp must be removed from the catheter before attempting guidewire
passage prior to catheter exchange.

117

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Intro-Flex Percutaneous

Sheath Introducers

5. Verify catheter tip position in the superior vena cava by chest X-ray film immediately after insertion.
Note: The chest X-ray film should confirm that the catheter tip is in the superior vena cava, above the
superior vena cava and right atrial junction, with the catheter tip parallel to the vessel wall (Refs. 8, 11 & 16).

MAINTENANCE AND USE IN SITU

1. Adequate maintenance is required to avoid catheter occlu- sion. Keep pressure monitoring and infusion
lumens patent by intermittent flush, continuous, slow infusion with heparinized saline solution, or use of a
heparin lock using the provided injection caps or Interlink injection sites in con- junction with heparinized
saline solution (Ref. 20).

To use injection caps:

a. Disinfect injection caps before entry with syringe needle (see Complications).
b. Use a small bore needle (22 gauge or smaller) to puncture and inject through the injection caps.

To use Interlink injection sites:

a. Ensure that the injection sites are securely connected to the lumen hubs.
b. Grasp finger flange to stabilize injection site (Figure 4).
c. Swab septum with preferred antiseptic.
d. Insert Interlink cannula, attach to an appropriate device directly through the center of the septum.
Precaution: If a conventional needle must be used, insert a small gauge needle into the perimeter of the sep-
tum to avoid fluid leakage while the needle is in place.
e. Engage locking features if applicable.

2. For blood sampling, attach blood sampling device to desired lumen hub and draw blood sample per
hospital protocol.

(continued)

118

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

Intro-Flex Percutaneous

Sheath Introducers

Intro-Flex Percutaneous Sheath Introducers feature the following design characteristics:

s High infusion capability

s Tapered tip to dilator interface
s Choice of hemostasis valves
s V-shaped sidearm
s Optional infusion catheter with lock-in adapter s Optional obturator - short or long versions
s Optional locking contamination shield

The Intro-Flex introducers are available with two valve options, either in an Automatic hemostasis valve, or
Adjustable hemostasis valve that accommodates varying catheter sizes and helps prevent catheter
migration. The v-shaped sidearm permits unobstructed path for fluid delivery, with or without a catheter in
place. AMC THROMBOSHIELD coating is available on selected models.

A single-lumen infusion catheter is available for use with the Intro-Flex introducers to be placed through the
hemostasis valve (after swabbing the valve with Betadine) to convert to a double lumen access. It has a
lock-in adapter to safely secure the fitting between introducer and infusion catheter. The infusion catheter
extends beyond the sheath to allow unobstructed fluid flow. An obturator is available to safely occlude the
lumen as well as to prevent air entry when the catheter is not in use.

The obturator is available in a short (cap) version or long 13cm option.

INTRO-FLEX PERCUTANEOUS SHEATH INTRODUCERS

FRENCH SIZE CATHETER SIZE

INTRODUCER (INFUSION CATHETER) PAC SIZE

(continued)
5F 4F
6F 5F 5F
7F 5F 6F
8F 7F 7F
8.5F 7F 7F - 7.5F
9F 7F 7.5F - 8F

119

EDWARDS LIFESCIENCES CENTRAL VENOUS ACCESS PRODUCTS

CDC Guideline for the Prevention of Intravascular Device-Related Infections (1996) Central Venous Catheters

INSERTION

s Use a single-lumen central venous catheter, unless multiple ports are essential for the management of the
patient.

s In adults, consider use of a silver-impregnated collagen cuff or an antimicrobial- or antiseptic-impregnated

central venous catheter if, after full adherence to other catheter infection control measures (e.g., maximal
barrier precautions), there is still an unacceptably high rate of infection.
s Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications
against the risk of mechanical complications (e.g., pneumotho- rax, subclavian artery puncture, subclavian
vein laceration, hemothorax, thrombosis, air embolism, catheter misplacement).

s Use subclavian, rather than jugular or femoral, sites for central venous catheter placement unless
medically contraindicated (e.g., coagulopathy, anatomic deformity).

s Use sterile technique, including a sterile gown and gloves, a mask, and a large sterile drape (i.e., maximal
barrier precautions), for the insertion of central venous and arterial catheters. Use these precautions even if
the catheter is inserted in the operating room.

s Wear non-latex or latex gloves when inserting an intravascular device as required by the Occupational
Safety and Health Administration (OSHA) Bloodborne Pathogens Standard.

s Cleanse the skin site with an appropriate antiseptic, including 70% alcohol, 10% povidone-iodine, or 2%
tincture of iodine, before catheter insertion. Allow the antiseptic to remain on the insertion site for an
appropriate length of time before inserting the catheter.

s When tincture of iodine is used for skin antisepsis before catheter insertion, it should be removed with
alcohol.

s Do not palpate the insertion site after the skin has been cleansed with antiseptic (this does not apply to
maximum barrier precautions during which the operator is working in a sterile field).

120

CDC GUIDELINE

CDC Guideline for the Prevention of Intravascular Device-Related Infections

(1996) Central Venous Catheters

s Do not routinely replace non-tunneled central venous catheters as a method to prevent catheter-related
infections.

s Record the date and time of catheter insertion in an obvious location near the catheter-insertion site (e.g.,
on the dressing or on the bed).

GUIDEWIRE EXCHANGE

s Use guidewire assisted catheter exchange to replace a malfunctioning catheter or to convert an existing
catheter if there is no evidence of infection at the catheter site.

s If catheter-related infection is suspected, but there is no evidence of local catheter-related infection (e.g.,
purulent drainage, erythema, tenderness), remove the existing catheter and insert a new catheter over a
guidewire. Send the removed catheter for semiquantitative or quantitative culture. Leave the newly inserted
catheter in place if the catheter culture result is negative. If the catheter culture indicates colonization or
infection, remove the newly inserted catheter, and insert a new catheter at a different site.

s Do not use guidewire assisted catheter exchange whenever catheter-related infection is documented. If
the patient requires continued vascular access, remove the implicated catheter and replace it with another
catheter at a different insertion site.

IV INFUSION
s In general, administration sets include the area from the spike of tubing entering the fluid container to the
hub of the vascu- lar device. However, a short extension tube may be connected to the vascular device and
may be considered a portion of

the device to facilitate aseptic technique when changing administration sets. Replace extension tubing when
the vascular device is replaced.

s Wipe the catheter hub with an appropriate antiseptic before accessing the system.

s Replace extension tubing when the vascular device is replaced.

s Replace IV tubing, including piggyback tubing and stopcocks, no more frequently than at 72-hour intervals,
unless clinically indicated.

(continued)

121

CDC GUIDELINE

CDC Guideline for the Prevention of Intravascular Device-Related Infections

(1996) Central Venous Catheters

s Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours of initiating
the infusion.

s Clean injection ports with 70% alcohol or povidone-iodine before accessing the system.

s Do not use filters routinely for infection control purposes. TPN

s Do not use single-lumen parenteral nutrition catheters for purposes other than hyperalimentation (e.g.,
administration of fluids, blood, or blood products).

s If a multi-lumen catheter is used to administer parenteral nutrition, designate one port for
hyperalimentation. Do not use the designated hyperalimentation port for other purposes (e.g.,
administration of fluids, blood, or blood products).

s Complete infusions of lipid-containing parenteral nutrition fluids (e.g., 3-in-1 solutions) within 24 hours of
hanging the fluid.

s When lipid emulsions are given alone, complete the infusion within 12 hours of hanging the emulsion.

SITE CARE

s Wash hands before and after palpating, inserting, replacing, or dressing any intravascular device.

s Wear non-latex or latex gloves when changing the dressings on intravascular devices.

s Palpate the catheter insertion site for tenderness daily through the intact dressing.

s Visually inspect the catheter site if the patient has develop- ment of tenderness at the insertion site, fever
without obvious source, or symptoms of local or bloodstream infection.
s In patients who have large, bulky dressings that prevent palpation or direct visualization of the catheter
insertion site, remove the dressing, visually inspect the catheter site at least daily, and apply a new dressing.

s Use either a sterile gauze or transparent dressing to cover the catheter site.

(continued)

122

CDC GUIDELINE

CDC Guideline for the Prevention of Intravascular Device-Related Infections

(1996) Central Venous Catheters

s Replace catheter site dressings when the device is removed or replaced, or when the dressing becomes
damp, loosened, or soiled. Change dressings more frequently in diaphoretic patients.

s Avoid touch contamination of the catheter insertion site when the dressing is replaced.

s Do not routinely apply antimicrobial ointment to central venous catheter insertion sites.

s Do not apply organic solvents (e.g., acetone or ether) to the skin before insertion of parenteral nutrition
catheters.

s Replace catheter site dressings when the device is replaced, when the dressing becomes damp, loosened,
or soiled, or when inspection of the site is necessary.

PRESSURE MONITORING SYSTEMS

s Use disposable rather than reusable transducer assemblies whenever possible.

s Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system,
including the tubing, continuous flush device, and flush solution, at the time the transducer is replaced.

s Keep sterile all components of the pressure monitoring circuit (including calibration devices and flush
solution).

s Minimize the number of manipulations and entries into

the pressure monitoring system. Use a closed-flush (i.e., continuous flush), rather than an open system (i.e.,
one than requires a syringe and stopcock), to maintain patency of the pressure monitoring catheters. If
stopcocks are used, treat them as a sterile field, and cover them with a cap or syringe when not in use.

s When the pressure monitoring system is accessed through a rubber diaphragm rather than a stopcock,
wipe the diaphragm with appropriate antiseptic before accessing the system.

s Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure
monitoring circuit.

s Do not routinely use pressure monitoring devices to obtain blood samples that do not require arterial
blood.

(continued)
123

CDC GUIDELINE

CDC Guideline for the Prevention of Intravascular Device-Related Infections

(1996) Central Venous Catheters

MISCELLANEOUS

s Conduct ongoing education and training of health care workers regarding indications for the use of and
procedures for the insertion and maintenance of intravascular devices and appropriate infection control
measures to prevent intravascular device-related infections. Audiovisuals can serve as a useful adjunct to
standard educational efforts.

s Designate trained personnel for the insertion and maintenance of intravascular devices.

NO RECOMMENDATION

s For the use of sterile versus non-sterile clean gloves during dressing changes.

s For removal of central catheters inserted under emergency conditions, where breaks in aseptic technique
are likely to have occurred.

s For obtaining blood samples for culture through central venous or central arterial lines.

s For the frequency of routine replacement of dressings used on central catheter sites.

s For frequency of replacement IV tubing used for intermittent infusions.

s For the hang time of IV fluids, including non-lipid containing parenteral nutrition fluids.

s For use, maintenance, or frequency of replacement of needleless IV devices.

These are selected guidelines only.