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Managing Venous Catheters

Managing Venous Catheters at Home

Caregivers frequently receive responsibility for managing venous catheters (IVs) at home a few days prior to patient discharge from the hospital.  Whether the catheter enters the bloodstream from outside the body or internally using a long catheter that ends close to the heart, family caregivers receive training in the hospital and go home to care for alone.

Usually, a nurse shows them what to do, lets them do it a few times, and once home, they have materials sent home with them from the hospital to use as reference in case anything goes wrong. Home health usually comes by the day of or the day after discharge to check on them, but their visit only lasts about an hour at most, the rest of the time they do all the care themselves.

Most people do not realize that the procedure these family members do at home is one of the most strictly controlled procedures performed in the hospital for infection and safety precautions. It’s very risky. Not doing it correctly opens places the patient at risk of acquiring a blood infection.  Blood infections mean any organ of the body can also become infected.  

Furthermore, failure to properly secure the clamp on the tubing could allow air to enter the tube leading to an air embolus (clot) resulting in a stroke or death or allowing massive blood loss from the line through hemorrhage. As you can see, knowing what to do and how to do it safely is critical to the life of the person with the central line. Adequate training and access to quick and knowledgeable resources during emergencies are essential.

Many Types of Central Line Devices    

Multiple types of central line devices exist. Central line catheters access the major blood vessels inside the body and are the riskiest. Though there are many types, common features exist among them.

  • Using a sterile technique is mandatory every time.
  • Unintentionally letting anything get into the central line can threaten the family member’s life.
  • You must constantly pay attention to your every move. If you accidentally allow bacteria to get into the central line, it goes directly to the heart.
review Prevent Wash Your Hands

Knowing how to wash your hands correctly is the #1 defense against fighting infection. I encourage you to review handwashing techniques even if you think you know it all.  Wash Your Hands is an excellent resource to review concerning germ-free work areas and sterile techniques.

Managing Venous Catheters When Providing Home IV Therapy

Occasionally a family member receives short-term IV therapy while home. Managing home venous catheter IV therapy is much the same as home central line care. Here’s an example to show you how from YouTube.

How to Administer Home IV Fluids

Wash your hands using liquid soap humming the Happy Birthday song twice

  1. Put on non-sterile gloves
  2. Remove air bubbles from all syringes by pushing the plunger upwards.
  3. Return caps to the end of syringes. Set aside
  4. Pull the plug from the IV bag. Insert spike into the IV bag till the IV starts to flow through the tubing.
  5. Clamp the tubing. Hang the bag.
  6. Fill the chamber of the tubing about 1/3-1/2.
  7. Slowing open clamp to allow remove air from rest of tubing. Re-clamp when all air bubbles are removed.
  8. Remove the cap from the end of the PIC line and set it aside. Scrub end 10 sec. with an alcohol wipe.
  9. Apply Saline flush Syringe, unclamp tubing, and inject saline using the push/stop technique until all saline is infused.
  10. Remove the syringe and re-apply the green cap to an IV line, if anything touched it, clean with alcohol first.
  11. Attach tubing and dial-a flow rate device.
  12. Undo clamp; confirm it’s dripping and that everything is working.
  13. Monitor Infusion till complete.
  14. Disconnect IV tubing from the PIC line,
  15. Scrub IV line and attach the saline syringe to flush line.
  16. Flush with saline using the push/stop method.
  17. Inject Heparin
  18. Clamp, Re-cap, Cover.

How to Find A Vein 

Note:  Most Caregivers do NOT start their own IVs. However, knowing how to perform the technique may be helpful in preparing your family member for the procedure.

  • Apply a tourniquet
  • Keep the limb dangling lower than the heart
  • Apply light heat, wrap the area in a blanket
  • Stay away from lumpy areas (those are valves that block the needle’s progress)
  • For veins that roll, tighten the fist or skin area before attempting to insert the needle to anchor the vein.
  • Angle the needle at a shallow rather than steep angle to avoid going through the vein as easily.
  • When starting IVs, they must start inserting needles at the farthest point from the heart and work their way upward or the veins above the insertion point will leak from previous missed attempts.
Steps for IV Dressing Change- No Touch Sterile Technique

Note:  Caregivers usually do change the IV site because that is usually done by home health; however, in some cases, it may be necessary due to the frequency required. If venous access is needed on a regular basis, usually a porta cath is inserted instead.

  1. Gather necessary supplies
  2. Wearing sterile gloves, remove old dressing careful not to dislodge IV
  3. Carefully remove stat lock (alcohol may help to remove it)
  4. Change gloves
  5. Using swabs to clean the site. Use of swab to clean one side of PICC, flip swab and clean another side; throw swab away.
  6. Use another swab and clean sides around the site, again flipping the swab as different quadrants are cleaned. Always clean innermost to outermost directions
  7. Change gloves
  8. Apply stat lock
  9. Apply new clear dressing (date dressing so you remember when you changed it)
Managing Venous Catheters with Central Access

Central Venous Catheters provide access to large veins in the body.  The two primarily accessed are the subclavian and the internal jugular veins, which lead directly into the heart’s superior vena cava. While there are many advantages to using large veins, managing venous catheters carefully is very important. Central venous catheter therapy increases the risk of life-threatening complications such as:

  • pneumothorax (hole in the lung),
  • sepsis (whole-body infection),
  • thrombus formations (blood clots), and
  • vessel and adjacent organ perforation (punching hole in the blood vessel or organ nearby).

Therefore, if you manage a venous catheter (central line) at home, extreme care must be used whenever you access or handle the catheter. Any contamination of the line could have life-threatening consequences. A strict sterile technique is required to prevent bloodstream infections.

Central Venous Line Care Instructions

Lab Work
The following are key points to keep in mind related to lab work.

  • If you have lab work ordered and someone unfamiliar is about to draw labs, remind them not to draw blood from the same line used for giving medication if two lines are available.
  • Draw only the smallest amount of discarded blood allowed to keep all access limited to only essential draws.
  • Try to group lab tests so that one stick can get blood for multiple tests.
  • Flush the site very well after lab draws to decrease the risk of blood clots and possible blockage.

Flushing and Locking a Catheter
Blood has a natural tendency to clot.  If any build-up gets on the inside of the catheter, blood will begin to stick to it, and the opening will close off. To prevent that from happening, using a heparin flush solution after each use helps to prevent clots from forming.

The general rule is that during the time the catheter is not in use, a weekly flush is customary.  During times the catheter is in use, follow this procedure:

  1. Check the catheter to make sure the line is open by pulling back and checking for blood flow before use each time,
  2. Use saline flush between doses of medications or injections of anything else to prevent incompatibility reactions, and
  3. Give Heparin flush to prevent clots from forming as the last step.
Keep a Dressing Over the Entry Site into the Body

It’s essential to keep an airtight dressing over the site where the catheter enters the body. The reason why is to prevent germs from entering the body around the catheter at that opening. Remember, that catheter is taking blood, and whatever else has touched that catheter straight into the heart.  Therefore, the strictest sterile technique must be used to do dressing changes, tube changes, and anything that goes with that catheter.
See-through (transparent) semipermeable (breathable) dressings should be changed every 5-7 days and gauze dressings every two days. If you see signs of infection, if the dressing comes loose, gets dirty, contaminated, or messed up in any way, CHANGE IT.
NEVER Remove the Catheter Yourself. Don’t. Never pull that catheter out. Only nurse practitioners or doctors can remove them. If you feel it must come out, go to the emergency room to have a doctor pull it out. If it accidentally comes out, hold pressure on the insertion site to prevent bleeding in transport to the hospital.

Peripherally Inserted Central Line Access – PICC Lines

A Peripherally Inserted Central Venous Catheter (or PICC for short) is a long, flexible tube used to deliver fluids and/or medication into your body through a vein in your arm. Using a needle and local anesthetic, a radiologist or certified nurse inserts a thin wire to guide the catheter into a large vein leading to your heart. Once inserted, the PICC catheter allows direct delivery of medication or fluids for several weeks without using a needle or IV each time.

Managing venous catheter care after placement includes ensuring that the catheter is working correctly, and the dressings remain dry and clean. For example, PICC catheters require a flush of saline or other fluids at least once a week so that lines do not get clogged preventing blood flow through them.

PICC (Peripherally Inserted Central Venous Catheter (PICC) 
Flushing the Central Line

  1. Assemble your supplies
  2.  Wash your hands
  3. Open supplies for access while you have on sterile gloves
  4. Remove air bubbles from saline and heparin
  5. Put on your sterile gloves
  6. Scrub hub of the central line for 15 seconds
  7. Clamp line and attach saline flush.
  8. Unclamp line and flush.
  9. Clamp line, remove syringe and scrub hub with alcohol again for 15 seconds.
  10. Attach heparin syringe, unclamp line and inject heparin.
  11. Remove the heparin syringe, and recap the end of the line.

If you would like to see an example of a Central Line being flushed and the cap being changed, here is a YouTube video that you might find interesting to watch. This patient had a Hickman Catheter.
How to Flush Your Central Line and Change the Cap. 

The following YouTube Video, Changing Caps on a Central Line, does an excellent job of demonstrating the proper technique for changing central line caps. If you use a central line, this video is a great way to check your own technique to make sure you haven’t developed any bad habits (which is easy to do overtime).

Instructions for how to Changing Caps on a Central Line :

  • Caps are changed every seven days.
  • Masks must be worn during line cap changes since the line is completely open.
  • The cap is primed with saline prior to being applied to the line.
  • Attach the cap to the syringe by twisting clockwise.
  • Before changing the clamp, clamp the line.
  • Remove the old cap by twisting it off counterclockwise.
  • Scrub the end of the line with alcohol for 15 seconds.
  • Take off the blue end of the primed cap, insert the new cap into the line, and twist it into the line to tighten it.
  • Remove the syringe.
  • Unclamp the line.

PICC Complications 
The most common complications for PICC lines include the following:

Catheter migration symptoms (i.e., the catheter moved out of place): 

Change in catheter function, change in external length of the catheter, chest pain, difficulty breathing, and irregular heart rates

Catheter Becomes Clogged or Blocked (Occluded line):

Inability to flush the line or give medication through it.  Medicines won’t flow through the line or they are running very slow.

Phlebitis (inflammation) of the Vein:

Tenderness, redness, heat, or swelling at the site where the line enters the blood vessel or anywhere along the length of the blood vessel.

Infection at the Infusion Site:

Redness, swelling, heat, hardness, pain, or drainage at the insertion site.  May also have a fever or a fast heart rate.

Air Embolism (i.e., an air clot that blocks off blood flow):

Lightheadedness, anxiety, confusion, fast heart rate, low blood pressure, sharp chest pain, and severe difficulty breathing.

 PICC Dressing Change

Accessing Implanted Port 
A porta cath is another type of implanted central line access device often used for chemotherapy patients or those who frequently receive IV fluids. It’s a small round hub implanted under the skin and accessed by a needle.  This YouTube video shows how it’s accessed and flushed.

Locate Port and gather supplies

  1. Prime syringes so that fluids to be injected are at the tip of each.
  2. For the Saline syringe, attach a positive pressure cap to the tip of the syringe.
  3. Push enough saline through the filter to fully prime the pressure cap.
  4. Open extension tubing and while it’s still in the package, attach the Huber needle (if not already attached).
  5. Attach all of it to the end of the filter.
  6. Flush the tubing keeping the syringe/filter/tubing all together in the package.
  7. Put on your mask and sterile gloves
  8. Scrub porta cath site for 30 seconds with alcohol. Let air dry for 60 seconds.
  9. Retrieve extension tubing with attached Huber needle on end.
  10. Locate the port, and hold it firmly while inserting a needle into the center of the port until the needle hits the back of the reservoir. Aspirate to determine placement.
  11. Flush the port with 10 ml saline using the push/pause method.
  12. Give medication next if ordered.
  13. The complete process with Heparin.
  14. Put transparent dressing over the needle site. Label with date.

Boston Children’s Hospital YouTube Video Series

Video Series Produced by Boston Children’s Hospital October 2013

Caring For A Central Line At Home

Children with certain medical conditions may require a central line to deliver medications or liquid nutrition. Although maintaining the central line requires special care, parents can manage it within their home.  This video introduces the topic of in-home care of a central line. It goes over having the right supplies, being organized, and pulling it all together.
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Handwashing 

Careful hand washing is very important to prevent central line infections in children and teens on home parenteral nutrition or cancer treatment.
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Hand Sanitizer  

Hand sanitizer is also a great way to clean your hands instead of soap and water before line care for your child or teen on home parenteral nutrition or getting cancer treatment.
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Making a Clean Workspace  

Creating a safe, clean workspace is important for proper central line care. When working on sterile medications, you want to know that you are not introducing germs or missing steps.  Work somewhere that you won’t be distracted or that your work area won’t become contaminated by the wind blowing something into it or a cat jumping into it. Always wipe it down before it.  I use a bleach solution of 1 part bleach to 10 parts of water for my routine disinfected cleaning for anything medical. Spray it on and let it dry.
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Putting on a Mask 

Germs can be transmitted through our mouths, so wearing a mask while working with central lines is recommended. Here is the proper way to put on a medical mask to prevent germs from being transmitted during line cap changes and dressing changes for your child or teen.
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Putting on Sterile Gloves   

It’s important to put on sterile gloves properly so that you can prevent passing on germs during line cap changes and dressing changes.
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Scrubbing the Hub  

When connecting anything to the central line, like home parenteral nutrition, IV hydration, or IV medicines, it’s essential to clean the line with alcohol for 15 seconds.  After cleaning the hub, allow it to air dry.
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Flushing the Central Line  

Flushing the central line is important to prevent anything from blocking the catheter and to prevent infections.
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Connecting Tubing  

You need to connect tubing to the central line so that you can give home parenteral nutrition, IV hydration, or IV medicines. To safely connect any tubing to your child’s central line, follow these instructions carefully.
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