Which action would the nurse perform to best ensure effective insertion of venous access device into a patients arm?

Central Venous Catheter is a catheter line that ends in a large vein, either the Superior Vena Cava (SVC), which is just above the heart, or the Inferior Vena Cava (IVC), which is just below the heart.  Central Venous Catheter is placed in a vein for access in either the upper arm, chest, neck, or mid-thigh and these venous access sites correspond to these central lines; PICC Lines, Axillary Lines, Internal Jugular Lines, and Femoral Lines, respectively. Central Venous Catheter lines provide treatment options for medications that are caustic or require longer infusion times that would be contraindicated using a basic IV, extended Dwell PIV, or a Midline and the larger veins near the heart allow the medication to be diluted and delivered throughout the body quickly. A Central Venous Catheter also enables easier blood draws and can be used as one of the most accurate ways to measure central venous blood pressure. Additionally, Central Venous Catheters include large bore lines such as Vas Caths for Dialysis. A Central Venous Catheter provides tremendous flexibility when screening a patient in need of a central line.

Central Venous Access Device

| CVAD

Central Venous Access Device, often abbreviated as CVAD, is either a standard central line, such as a PICC, or advanced central lines, such as Internal Jugular Lines, Axillary Lines, and Femoral Lines, and the various lines provide additional access options for patients who may have a complicated medical history or other medical concerns that must be taken into account.  The least intrusive Central Venous Access Device is the PICC as it is placed in the upper arm.  When vascular access through the upper arm is limited such as due to poor vasculature or must be preserved for other uses, the PICC is no longer clinically appropriate and another CVAD must be chosen.  The Axillary Line, placed in the chest in either the Axillary or Subclavian vein, provides an effective option when there is limited access to the upper arm. When vascular access is contraindicated to the chest or arm areas such as for those who survived Breast Cancer or those with risk of Lymphedema, Deep Vein Thrombosis (DVT), Chronic Kidney Disease, or Upper Arm Cellulitis, the Internal Jugular Line, placed in the neck, is an appropriate CVAD. Lastly, the Femoral line, placed in the mid-thigh area avoiding the inguinal fold as this can be a potential source of infection, is used in cases when the patient has limited mobility, Superior Vena Cava Syndrome (blocked SVC), or a new placed cardiac pacer.  For additional flexibility, Central Venous Access Devices are available in multiple lumens (in other words, tubing, and cap) including single, double, triple, and quad, enabling them to be used for delivering multiple medications separately.

Central Venous Access Device placement is usually performed using an Ultrasound as a reliable way to visualize and guide the needle. The Modified Seldinger Technique (MST) is mostly used as the standard approach, which helps ensure correct placement and some CVAD Nurses use needle guides and others use the preferred needle visualization.  Needle visualization is preferred as this can help obtain vascular access in more patients such as in difficult cases.  Central Venous Access Device insertion can be confirmed via Electrocardiogram (ECG) Tip Confirmation technology or X-Ray. ECG, which requires additional training, is more convenient and efficient as, when clinically available, it often removes the need to wait for the X-Ray to be completed and evaluated enabling faster therapy.

Central Venous Catheter Care

| Central Venous Catheter Nursing Care

Central Venous Catheter Care is a critical part of line maintenance to help mitigate the risk of infection and other line complications and thus enable the catheter to stay clean and to continue working to deliver medications and therapies.  Central Venous Catheter Care includes changing the bandage (dressing), flushing the catheter with fluids, and changing the cap on the end of the catheter and this is the best way to prevent infections or complications that would prevent treatment completion.  In such situations where there are infections or other complications that could require the line to be removed before treatment is completed, a new line may need to be placed increasing costs and delaying treatment. Infection risks include Central Line Associated Bloodstream Infections (CLABSIs) which are bloodstream infections via central lines when bacteria from the skin accesses the body at the Central Venous Catheter insertion site.  As per the best practice recommendations, this is a main reason for avoiding the groin and bend areas such as the elbow area when inserting lines including Femoral Lines and PICC Lines, respectively.

Central Venous Catheter Nursing Care is similar to Central Venous Catheter Care as much of the care and maintenance can be performed by nurses at any level or most caregivers without medical training.  Similar to the above paragraph, this care generally includes the practice of changing the dressing, flushing the catheter with fluids, and changing the cap on the end of the catheter.  With respect to Central Venous Catheter Nursing Care, nurses are trained in the care and maintenance as part of the specialized and focused training on Central Venous Catheter lines or as part of general nurse training, as care and maintenance are usually performed by general or bedside nurses.  Central Venous Catheter Nursing Care included in the training on Central Venous Catheter lines consists of specific training topics such as flushing guidelines, troubleshooting clogged or clotted lines, determining and addressing catheter positioning, and assessing symptoms of CLABSIs.  Other training includes how to develop and implement the Centers for Disease Control (CDC) recommended Central Line Care Bundles, select products for optimal Central Line Care, and how to reduce accidental pullouts.  This kind of training can be attained from Vascular Access Companies such as Vascular Wellness, and in the case of Vascular Wellness, can be customized to address specific concerns and conditions.  Training from a specialized Vascular Access Company tends to be more effective as many times, the trainers are the actual, practicing nurses who place central lines regularly.

Central Venous Catheter Dialysis

| Dialysis Catheter Insertion

Central Venous Catheter Dialysis is a Large Bore Central Venous Catheter line such as a Vas Cath that is placed in the jugular or femoral vein and can be used as a temporary hemodialysis catheter allowing kidney function to be restored or maintained.  A Central Venous Catheter Dialysis is often referred to as a Vas Cath for Dialysis, which is typically a dual lumen catheter.  A Vas Cath for Dialysis is appropriate for a patient needing dialysis such as who is in acute kidney failure and needs temporary dialysis to help the kidneys recover; has pending cultures but needs emergency dialysis, or is wait-listed for a Permacath but needs urgent dialysis. A Vas Cath can be used instead of a more complicated surgical procedure, such as the AV Fistula or AV Graft, to enable dialysis or to enable temporary dialysis if an AV Fistula or AV Graft becomes infected and needs to be removed to allow the infection to fully heal.  A Central Venous Catheter Dialysis can also be a trialysis catheter that contains a triple lumen.

At a high level, Dialysis Catheter Insertion is similar to the placement of a Small Bore Central Venous Catheter, although additional training is needed above and beyond Small Bore training.  Vascular Wellness places these lines using UltraSound (US) guidance needle visualization and the Seldinger Technique, as compared to using the Modified Seldinger Technique for other lines, with placement confirmed by X-Ray.  Proper Dialysis Catheter insertion can lead to less bleeding along with fewer blood transfusions, and lower rates of infection due to the ability to place large bore lines in the Internal Jugular vein closer to the base of the neck and, as noted, in the Femoral vein in the mid-thigh area away from the groin.

Vascular Wellness is one of a few select companies that has received approval from a state (NC) Board of Nursing and has instituted a large bore line placement program including nurse placement or insertion of Vas Caths for Dialysis.  Vascular Wellness has seen the benefits of clinicians placing Vas Caths as patients can have swift dialysis at the bedside, even after-hours or on weekends, and can avoid the need to undergo a more complicated surgical procedure.  Medical facilities can have cost savings from the reduction of the need to use more costly medical specialists and from the elimination of transportation expenses.  In addition, at this time Vascular Wellness has not had any bleeding or infections rates.

Vascular Access Specialists

| Vascular Wellness

Vascular Wellness is a team consisting of Vascular Access Specialists that have elevated the role of nurses in the placement of the Central Venous Access Device. Clinicians skilled in the insertion and placement of Central Venous Catheters have tremendously effective options when Midlines and PIVs are not clinically indicated.  Vascular Wellness specializes in all aspects of CVAD placement including assessment, insertion, maintenance, difficult placements, and removal.  Vascular Wellness clinicians are W2 employees who complete comprehensive training that can involve placing 50 to 100 lines per procedure type, follow best practices for line placement for vein preservation and to prevent side effects, and utilize the best equipment and supplies from Bard/BD, a leading supplier to hospitals. Vascular Wellness clinicians can place Ultrasound-Guided Extended Dwell PIVs, Midlines, and PICCs, and many clinicians can place advanced devices including Small Bore Central Catheter Lines (such as Internal Jugular Lines and Femoral Lines) and Large Bore Central Catheter Lines (such as Vas Caths for Dialysis and Quad Lumens). Vascular Wellness also provides vascular access training, infection control, and comprehensive administrative support including quality reports and detailed patient records for The Joint Commission surveyors.  Vascular Wellness clinicians are Vascular Access Specialists.

To learn more about the care and maintenance of PICCs and Midlines, see our PICC and Midline Catheter Care page

If you require Vascular Access or want to learn more about our services, speak to the team at Vascular Wellness today. For the latest articles and insights, follow us on LinkedIn, Facebook, Twitter, YouTube, and Instagram.

Vascular Wellness Serves North Carolina, South Carolina, and Virginia and expanding to Georgia, Kentucky, Ohio, Tennessee, and West Virginia.

Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion?

Which procedure is used to verify placement of a newly inserted central venous access?

What would the nurse do to assess a patients risk for embolus when removing a venous access device?

Which action will the nurse take to minimize the patient's risk for injury when applying a dressing to an infusion site?