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Infusion Therapy: 5 Things Nurses Should Know About CVAD’s

 Central Venous Access Devices (CVAD's)

 

First the nurse must know what a CVAD is and where it will be placed in the patient.  A CVAD is a Central Venous Access Device.  This may be a PICC line, Triple lumen, Groshong, or other type of centrally located vascular access device.  CVAD’s are an essential part of Infusion Therapy and the nurse must learn and understand the differences in the types and locations of the devices as well as the infusates that will be administered through the devices.


The following are 5 important topics that Nurses should be aware in relationship to their CVAD:
1.  Nurses must get an order for a chest  XRAY or use an alternative device to confirm Placement of the Distal Tip of the CVAD
The distal tip of the PICC line is best positioned in the Lower one thoird of the SVC
2.  Ensure that if using a CVAD that the health care team and facility implements the Central Line Bundle Protocol
Using the Central line Bundles have be shown to saignificantly reduce CRBSI's
3.  The health care provider should changes the administration tubing every 72-96 hours according to the INS standards and or hospital policy.
All nurses are encouraged to obtain a copy of the INS standards and use them in their daily practice
4.  Nurses MUST wipe the Access Ports each and every time they are accessed
Access Port contamination is the #1 cause of central line blood stream infections
5.  ALL Central line dressings should be changed every 7 days or PRN is dressing becomes visibly soiled or falls off.


To learn more about Vascular Access and Infusion Therapy Join Central Valley Medical and CVAN at the 25th Annual Scientific Meeting held by the AVA in San Jose California on October 3rd.
Also visit our website and enroll in one of our courses.

Infusion Therapy | Vascular Access Devices | BD Medical

How Things Have Changed

Over the past two years I have taught a lot of students; both RN and LVN's.  I have taught in the classroom and on the job.  I have seen a lot of new equipment that has made our lives easy; however, this is so simple and I dumb founded that I did not think of it. 
Before the BD Autogard Insyte and the B. Braun Introcan angiocatheter devices; we used straight 18 gauge and 20 gauge over-the-catheter needles without any safety device.  There were not even safety shields.  We were taught to stick the patient and throw the needle away immediately.  We were to have the sharps container at the bedside or with close reach so you could dispose of the needle promptly. 
However, statistics have shown us that this was not good practice and that as professionals we still left needles lying around or threw them in the trash by accident.  Then the CDC and NIOSH decided to enact the 2001 Needlestick Safety Act that mandates that all employers provide a needless system and or devices with a safety feature built into it.
Today, it is probably safe to say that most facilities use either the BD Autogard Insyte or the B. Braun Introcan.  Both devices are nice; however, here at Central Valley Medical we are particularly found to the BD Autogard Insyte as it is easy to use, it is made from polyurethane, and it has a sharp bevel with the patented "insta-flash" technology.  The only probably I have ever had is in the following figure.

Well, BD has solved this issue with the BD Autogard Inyte with Blood Control

If the hospital or providers will choose the BD Autogard Insyte with Blood Flow Control; the nurse can remove the needle and not have to worry about holding pressure, spilling, blood, or even bending the catheter.  Using this device solves that issue with a small device inside the hub.
However, once the hub is used by either connecting intravenous tubing or a syringe; it will no longer control the backwards blood flow.  It will only work at the initial intravenous puncture.

An alternate choice is the

BD Nexiva Closed IV Catheter System

 This peripheral catheter is a closed system device and will soon become the preferred choice by most facilities.  It will take some nurses a little while to get use too; especially if the nurse is left handed.  This device is very nice in that the needle is remove from the device in one complete component and it is covered to prevent accidental needlestick injuries. Also, even if you forget to close the clamp you can see from the figure above it has a small, clear, cap that is inserted into the end of the extension tubing and thus it will not leak out.

This new closed system will eliminate the need for both catheter, j-loop tubing, and a clave. The medical provider can either attach the intravenous tubing directly to the extension tubing or add a clave to the end as well.

In either case; both devices handle well, are safe to use, and the cost is average or even better than most of its competitors.  For more information visit:
http://www.bd.com/infusion/products/ivcatheters/iagbc/videos/

Infusion Therapy without Vascular Access might be Impossible

This year the Association for Vascular Access (AVA) celebrated its 25th Anniversary in San Jose, CA.  The AVA plus the Infusion Nurses Society equal a perfect marriage for infusion therapy as well a good thing for patients and health care professionals alike.
 
The AVA Scientific Meeting was a great experience and it provided a great deal of information as well as a preview of future technology in Infusion Therapy and Vascular Access.

During this years meeting there were several nurses that presented their stories in regards to blood exposure from attempting to gain a vascular access device or blood for lab values.  The following are some of those health care workers.

• Cheryll, BSN, RN, OCN
• Edie, BSN, RN, Emergency/Trauma

Healthcare personnel are at risk for blood exposure from bloodborne pathogens,
that include hepatitis B virus (HBV), hepatitis C virus (HCV), and human
immunodefi ciency virus (HIV). Exposures may occur through needlesticks or cuts
from other sharp instruments contaminated with an infected patient's blood.  Exposure may also occur through contact via the eyes, nose, mouth, or skin.  
"An estimated 385,000 percutaneous injuries (i.e., needlesticks, cuts, punctures and other injuries with sharp objects) occur in U.S. hospitals each year." (CDC) Prevention of bloodborne exposures requires healthcare personnel to use safer vascular access devices, improved work practices,and the use of personal protective equipment (PPE).  One type of device that is great is the new BD Autogard Insyte with Blood Control.

This new vascular access device allows the healthcare professional to access the patients vein without the concern of blood flowing through the catheter and makes it easy for the nurse to attached the injection port or extension tubing. 
Changes in peripheral intravenous catheter technology have us moving away from catheters that spills blood out of the hub to using cathetrs with blood flow technology and even closed system devices. 

Remember to Always Wear your PPE

 3 for $36! 100mL Hand Therapies at Crabtree & Evelyn Today!

 

References

1. BD Medical
2. Association for Vascular Access
3. Center for Disease Control
4. Infusion Nurses Society

 

Vascular Access Devices-So many to choose from with infusion therapy

Vascular Access Devices

Think about this for a while; at any given time; more than half to three quarters of all patients receive some form of intravenous care or medication during their hospital stay.  Intravenous therapy can range from normal saline to total parenteral nutrition, chemotherapy, electrolytes, antibiotics, narcotics or a combination of these parenteral therapies. Nurses are currently infusing several hundred various types of medications, intravenous solutions, and/or blood products.  Patient venous access may vary from poor vascular integrity, poor circulation, good vascular integrity, and excellent blood flow or a combination of each the aforementioned.
Nurses must have a good understanding of why everyday peripheral intravenous therapy fails.   It is often that the characteristics of the intravenous medications and/or solutions provided to the patient and through their given vascular access device that the primary factor venous access devices do not last longer than 24-48 hours in most cases; specifically peripheral venous access devices (PIV). The drug compositions in a lot of medications we are infusing today have a high osmolarity as well as high Ph level.  What does that mean for you, the everyday floor/staff nurse?  It means a lot for you and the patient.   It is important, to evaluate and understand the drug pH and osmolality when selecting a venous access device to complete patient’s intravenous therapy as this can help prevent complications and as well as extend the lifetime of the catheter.

Types of Peripheral Venous Access Devices (PVAD) or (PIV)

Peripheral IV Catheters (PIV)

There are a couple of main companies that provide peripheral intravenous catheters; BD Medical and B Braun.

BD Medical

(BD Medical Nexiva)
BD Medical provides the BD Autogard Insyte over-the-needle catheters which range in gauges 14g to 24g and lengths of 0.75 to 1.88 inches. The Autogard Insytes 18g to 22g catheters are suitable for use with power injectors rated for a maximum of 300 psi.”(BD)
Materials: BD Vialon biomaterial-“BD Vialon biomaterial is a unique, proprietary biomaterial, developed especially for vascular access” (BD) and it softens as it sits in the vessel. (BD)

B Braun

B Braun provides “B Braun Introcan Safety IV Catheter” (B Braun).  The Introcan ranges in size from a 14g to 24g as well as the lengths range from 0.55in-2.5in. 

Retractable Technologies, Inc

 

Retractable Technologies, Inc states that their product the VanishPoint IV Catheter:

• minimizes exposure to the contaminated needle
• allows for one-handed activation
• integrated safety mechanism
• once activated, the needle is safely retracted through disposal
• easy to use

 

 To learn more about this and other topics download our vascular access information kit today. Central Valley Medical, LLC, would like to thank you for downloading our E-Book (Vascular Access Devices and Infusion Therapy are a Perfect Match).  At the end of this E-Book is a course evaluation.  Please fill it out with your NAME and License number and you will receive 1 CE Contact hour free.  Just Fax it back to (559) 354-0991 or email it to Onlinecampus@central-valley-med.com

References

1. Vascular Solutions. http://www.vascularsolutions.com/
2. IV-Therapy.net. “Micro-Introducer Technique for PICC Insertion A Sample Policy with Competency Checklist.” http://www.ivtherapy.net/
3. Galt Medical. “Microintroducer Kits.”  http://www.galtmedical.com/.
4. Bard Access. “PowerGroshong* PICC.”  http://www.bardaccess.com/.
5. Bard Access. “PowerPICC* Catheter.” http://www.bardaccess.com/.
6. Bard Access. “Maximum Barrier Kit.”  http://www.bardaccess.com/.
7. Cook Medical. “Cook Spectrum® Central Venous Catheter.” http://www.cookmedical.com/.
8. Cook Medical. “Triple Lumen Polyurethane Central Venous Catheter.” http://www.cookmedical.com/.
9. Retractable Technologies, Inc. http://www.vanishpoint.com/Simple4.aspx?PageID=175

Infection Control is just as important in Infusion Therapy

CHLORA-PREP  ™ for infection Control

Every year, a lot of lives are lost due to the spread of infections in hospitals. Health care workers can take precautions to prevent the spread of infectious diseases. This is a vital part of nursing and as patient advocates it is our duty to follow these steps as a part of infection control.
Proper hand washing is the single most effective method to prevent the spread of infections in our hospitals. If you were a patient or one of your family members was a patient would you not be concerned then?
Don't be afraid to remind friends, family and other health care providers to wash their hands before getting close, performing a procedure, or touching the patient before starting an IV.

DONT FORGET

• Cover the coughs and sneezes
• Using gloves, masks and protective clothing
• Making tissues and hand cleaners available to everyone
• Following hospital policies and procedures when working with paitents in regards to blood, body fluids, or other possible contaminated items
  
  
  
  
  
  ChloraPrep ™ is an antiseptic cleanser that contains 2% chlorhexidine gluconate in a 70% isopropyl alcohol solution. The solution is sterile and contained within a glass ampoule which is housed within a plastic applicator is produced in a varity if styles and shapes.
  ChloraPrep is available in a range of applicators containing either 0.67ml, 1.5ml, 3ml, 10.5ml or 26ml of solution and is indicated for the disinfection of skin prior to invasive procedures.
  
  ChloraPrep Sepp^® 0.67 mL Applicator
  
• 260449 ChloraPrep Sepp 0.67 mL Applicator

ChloraPrep Frepp^® 1.5 mL Applicator

• 260299 ChloraPrep Frepp 1.5 mL Applicator

ChloraPrep Swabstick 1.75 mL and 5.25 mL Applicators

• 260100 ChloraPrep Swabstick 1.75 mL Applicator (single)
• 260103 ChloraPrep Swabstick 5.25 mL Applicator (triple)

ChloraPrep 3 mL Applicator

• 260415 Hi-Lite Orange^® Tint
• 260400 Clear

ChloraPrep 10.5 mL Applicator

• 260715 Hi-Lite OrangeTint
• 260725 Scrub Teal^®Tint
• 260700 Clear

ChloraPrep 26 mL Applicator

• 260815 Hi-Lite Orange Tint
• 260825 Scrub Teal Tint
• 260800 Clear

Central vascular access device (CVAD) site care and dressing changes should include the following:

1. removal of the existing dressing
2. cleansing of the catheter where it meets the skin
3. Use the appropriate antiseptic solution(s),
4. replacement of the stabilization device if used
5. application of a sterile dressing
6. Chlorhexidine solution is preferred for skin antisepsis

These are the recommendation of the Infusion Nurses Society and have been set in the 2011 INS Infusion Therapy Standards of practice.
For More information of this type of cleanser visit Carefusion.com; also following us on Facebook.

References

1. Carefusion
2. CDC.gov
3. IHI
4. INS

Intravenous Mucomyst (Acetylcysteine) for Acetaminophen Overdose

Remember the days in the Intensive Care Unit (ICU) when giving patient Mucomyst to help break up that thick , yucky, stuff?  Or working in the emergency room (ER) and maybe the night shift receives an aecatminophen overdose.  They would pull out the Mucomyst and give the patient some orally to help protect the liver.

Mucomyst

USES: can be give by inhalation, acetylcysteine is used to help thin and loosen mucus in the airways due to certain lung diseases (such as emphysema, bronchitis, cystic fibrosis, pneumonia). This effect helps you to clear the mucus from your lungs so that you can breath easier.
May also be given by mouth (orally), used to prevent liver damage from acetaminophen overdose.
Working in the Emergency room (ER), nurses must be familiar with intravenous medications. One medication that stands out is intravenous (IV) Acetadote.  This medication is also given orally for acetaminophen overdose as well; however, oral medications can take longer to take effect and often these patients may not have the time.

What is Acetylcysteine(Acetadote)?

Acetylcysteine(Acetadote) is currently the only FDA-approved IV acetylcysteine for acetaminophen overdose.
Acetadote, was introduced into the United States in 2004 and is used in more than 3,000 emergency rooms across the U.S.  It has been proven to be a safe and effective treatment for acetaminophen overdose when administered within 8-10 hours post-ingestion

Acetaminophen Overdose

According to the data provided by the American Association of Poison Control Centers (AAPCC), acetaminophen was involved in more than 187,000 poisoning exposures in the United States in 2009, including more than 100,000 cases of acetaminophen in combination with other medications.²

CONTRAINDICATIONS

Patients who may have had a previous anaphylactic reaction to acetylcysteine should avoid this medication.

WARNINGS AND PRECAUTIONS

• Acute flushing and erythema of the skin and serious anaphylactoid reactions may occur

• Use with caution in patients with asthma or history of bronchospasm

• Adjust total volume for patients less than 40 kg and for those requiring fluid restriction

Acetadote should be used with caution in patients with asthma or where there is a history of bronchospasm.

Indications for Use

View Webcast on IV Acetadote

Intravenous Acetadote, should be administered intravenously within 8 to 10 hours after the known ingestion of a potentially hepatotoxic quantity of acetaminophen.  This treatment is indicated to prevent or lessen the injury to the patients liver.
For best results it is important to administer the first intravenous dose within 8 hours.  The longer the time frame from ingestion the less likely the treatment will work effectively.

Safety Information

Acetadote should be used with extreme caution in patients who may suffer from asthma, COPD, or where there is a history of bronchospasm. "In the literature, the most frequently reported adverse reactions attributed to IV acetylcysteine administration were rash, urticaria and pruritus. The frequency of adverse reactions has been reported to be between 0.2% and 20.8%, and they most commonly occur during the initial loading dose of acetylcysteine."²

 References

1. Bronstein AC, Spyker DA, Cantilena JR, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Tox 2010; 48:979-1178.
2. Acetadote (Acetylcysteine). http://www.acetadote.net/home.php
3. Cumberland Pharmaceuticals.http://www.cumberlandpharma.com/

 

Central Venous Access Device (CVAD) In the Emergency Room

Over the past two to three decades we have really grown in the health care industry in the fact that we have developed and advanced the infusion and vascular therapy industry by leaps and bounds with the PICC line, Mid-line, and peripheral intravenous catheters.  However, as nurses we have not kept us with the pace of technology in regards to our education and skills sets.  This may seem harsh yet numbers do not lie and with this in mind it is a simple fix. 

Practice, Practice, Practice.

Still many years later we continue to have one in four medications errors in our hospitals as well as approximately 45 000-164 000¹ patients get an infection in their central venous access devices (CVAD). 

(CDC.gov)

Most of the infections in our patients CVAD’s occur the intensive care units (ICU).

 Who is responsible for these infections and errors? We are as nurses.  Whether you are a new graduate nurse or a nurse with a lot of experience it is still our duty and calling to advocate and protect our patients even if that means from us.  Our patients deserve better and we must be diligent in perfecting our skills to the best of our ability by continuing our training and education, practicing, and ensuring we follow the standards of care.

The Infusion Nurses Society (INS) Standards of Infusion Care states that “infection prevention and surveillance protocols shall be in accordance with organizational policies, procedures, and/or practice guidelines and local, state, and federal rules and regulations.²”

 (photo Courtesy of Free Digital Photos.net and Renjith Krishnan)
 The INS continues on the say that health care works should also use personal protective equipment (PPE) during all infusion procedures that may potentially expose the health care worker  to blood and body fluids as well as protect the patient from the same.
In order to help prevent a CVAD infection the health care provider should use “Maximal sterile barrier” protections.  Appropriate hand hygiene is also essential as hand hygiene is the single most effective method in preventing infections.
Nurses in the emergency room (ER) should also understand how to care and provide maintenance for CVAD's as they are becoming more prevalent as well  as more and more hospitals are contemplating using PICC teams including for patients in the ER.  ER nurses are under a lot of stress and work often at a fast pace; however, this is not reason not to follow procedures as best of your ability as possible.
To learn more about CVAD's and care and maintenance as an ER nurse stayed tuned for Central Valley Medical's articles,classes, and webinars on caring for patients in the ER with Peripheral Venous Access Device (PVAD's) and CVAD's.
 

References

1. Center for Disease Control. http://www.cdc.gov/. 2011
2. Infusion Nurses Society. SOC. http://www.ins1.org/. 2011.
3. Free Digital Photos.Net. http://freedigitalphotos.net/. 2011
4. Cath Matters. Catheter Education. http://www.cathmatters.com/. 2011

Legal Matters Regarding Infusion and Vascular Access Therapy

Nurses have long been charged with caring for patients in different settings.  Some work in the ICU, ER, LTC, or even doctors’ offices.  What is so puzzling is that some nurses seem to fail to realize that no matter what setting they are in; a patient is still a patient.  Standard procedures, tasks, skills, and critical thinking do not change much from area to area. 

Granted there are more advanced skill sets and the need for higher critical thinking in the specialty areas; however, if the nurse will remember the “5 Medication Administration Rights.” As well as the fact that every patient may at some point need the nurse to perform life saving skills such as cardiopulmonary resuscitation (CPR). 
Rule #1:  DON’T PANIC 
If you Panic you will forget everything that you have learned and the patient will suffer.
A senior investigator with the Department of Consumer Affairs testified at a hearing on a complaint that the board of registered nursing received in regards to a patient injured by a nurse who was performing a task related to infusion therapy. 
Patient A
Patient A was admitted to the ICU with a diagnosis of hypokalemia, (low potassium) with a serum potassium level of 3.0 mmol/L.  A normal serum potassium level is typically between 3.5 to 4.5 mmol/L.   On December 19, 2007, at 6:39 a.m., Patient A's physician ordered four doses of  intravenous (IV) potassium supplementation which was to be administered over one hour increments starting at 7:30 a.m.  The nurse caring for Patient A was aware of the physician's order of Potassium Supplementation; however, the healthcare provider did not administer the IV medication to Patient A's until 11:10AM.  This is almost four hours later.
 At approximately 10:30 a.m.; the PYXIS system used by the nurse and hospital system had flagged Patient A's MAR because the Potassium Supplementation had not been administered on time.  When asked why the medication was not given, the nurse stated that the medication was not yet available and he had not contacted the pharmacy.   The nurse also informed his supervisor that he checked for the Potassium in the refrigerator; however, it was not available.   The nurse then went on to tell a DPH surveyor he was going to wait to administer the dose because the peripherally inserted central catheter line (PICC line) had not been inserted and that he was aware that Potassium Supplementation was an important medication, but did not believe that the medication was an emergency, nor was it necessary to rush since the doctor did not write in his order; “give stat.”  The nurse went on to state that another reason the infusion was not started was due to the fact that the patient’s peripheral intravenous catheter (PIV) had infiltrated causing an extravasation.
The issues here are too many to count.  However, the important questions to ask in this type of situation are:

1.  Why did the nurse fail to contact the ordering physician in regards to the infiltration, extravasation, as well as the need for a central line in order to administer the medication correctly and in a timely manner?
2. Why did the provider not call the pharmacy right away?
3. Did the nurse attempt another viable route to give the medication needed for the patient?

Caring for patients is a noble and courageous undertaking.  On the other hand the nurse should use critical thinking skills as well as common sense in order to protect the patient.  To learn more about this case and others visit us here at Central Valley Medical as well as the BRN.

 California Code of Regulations, title 16, section 1442, states:

As used in Section 2761 of the code, 'gross negligence' ·includes an extreme departure from the standard of care which, under similar circumstances, would have ordinarily been exercised by a competent registered nurse. Such an extreme departure means the repeated failure to provide nursing care as required or failure to provide care or to exercise ordinary precaution in a single situation which the nurse knew, or should have known,cou1d have jeopardized the client's health or life...'