Central Catheter Maintenance

Definition

Central venous therapy involves placing a catheter into one of the patient's central veins, with the tip situated in the superior vena cava. Central catheter maintenance includes those actions performed by a nurse or other health care professional to keep the catheter functioning properly and to minimize any negative effects on the patient.

Purpose

There are a number of reasons for a patient to require a central catheter. Sometimes a person's peripheral venous access is inadequate for the type or duration of intravenous therapy planned. In other cases, a central line allows central venous pressure to be measured and monitored.

Precautions

Several factors should be considered when deciding which type of central catheter is appropriate for a patient. The duration of therapy and the types of medications ordered, the setting in which the client will receive intra- venous therapy, and the client's activity level and lifestyle will all help to determine the catheter the patient has inserted.

Description

There are several types of central catheters, which are divided into two categories: nontunnelled and tunnelled. They are made from a variety of materials: Teflon, polyurethane, silicone, polyvinyl chloride, and a silicone/elastomer blend called silastic. Each type has advantages and disadvantages, and each type requires specific maintenance.

Nontunnelled catheters are used primarily for short- term intravenous therapy, and when quick venous access is required to administer life-saving drugs or fluids. They may be inserted at the client's bedside by the physician. One type of nontunnelled catheter is the peripherally inserted central catheter (PICC). Specially trained nurses can insert the PICC, which is suitable for the administration of any intravenous therapy in any setting. Nontunnelled central catheters are easily inserted, cost- effective, and easily removed. On the other hand, they can easily be dislodged by the patient's movements, require sterile dressing changes, and must be flushed by heparin when not used continually.

Tunnelled central venous catheters include the Broviac, Hickman, and Groshong. These are made from either polyurethane or silicone and can be distinguished from each other by the inside gauge of lumen and the type of catheter tips. Each of these catheters has their advantages and disadvantages.

• Broviac: This is a smaller-bore catheter that is anchored to the chest wall so a patient's movement is not restricted. Its small lumen makes it suitable for children and the elderly. Its disadvantages are that it requires surgical insertion, tears and kinks easily, must be removed by a physician, and is difficult to repair. Because it has a smaller gauge, it is not suitable for many patients. It also requires routine flushing with saline and heparin to maintain its patency.
• Hickman: This catheter is also anchored to the chest wall, and it may have multiple lumens allowing multiple uses. However, it also requires surgical insertion, is difficult to repair, and the ports must be capped and clean at all times. Routine flushing is required for the Hickman with saline and heparin.
• Groshong: The Groshong has some of the same advantages as the Broviac and Hickman. In addition, because of its valve at the tip, the need for daily Heparin flushes is eliminated. Instead the line can be flushed weekly with 0.9% saline solution. The Groshong is also easy to repair, and generally requires less time and cost for maintenance than the Broviac or Hickman. It too has disadvantages, however. The Groshong tears and kinks easily and must be surgically inserted and removed by a physician.

In addition to flushing, all central catheters require routine sterile dressing changes. The frequency of with which the dressing must be changed depends upon whether the patient is hospitalized or in the home environment.

Another type of central catheter is an implanted port, which consists of a portal body, a septum, a reservoir, and a catheter. The port is inserted surgically into a subcutaneous pocket in the patient's trunk, and the catheter is then threaded into the central vascular system. The septum consists of a self-sealing silicone, which is accessed by the nurse using a special noncoring needle. One of its primary advantages is that is does not require frequent flushing when not in use, and since it is implanted beneath the skin, it aids in maintaining the patient's body image.

Preparation

The patient should be told why a central catheter is being placed, what care it may require afterwards, and, if possible, should consent to the procedure before it is performed. Tunnelled catheters are usually placed surgically by the physician. Prior to the procedure, a sedative is often ordered to relax the patient.

Aftercare

After the catheter is placed, the placement must be confirmed by x ray prior to use.

Complications

The two primary complications with central catheters are infection and occlusion. Infections can be decreased with strict sterile technique when changing dressings, and monitoring the patient closely for any signs of infection, including fever, redness or soreness at the site of insertion, and drainage from the insertion site.

Occlusions are the most common noninfectious complication seen with central venous access devices. Thrombotic, or blood clot, occlusions can be prevented with regular flushing using the proper technique. A positive-pressure technique prevents blood reflux after the flushing. Some thrombotic occlusions may require flushing with an agent like urokinase.

Mechanical occlusions can also occur if the catheter develops a kink, or if the suture holding the catheter in place is too tight. In addition, if the catheter was positioned with the tip touching the vessel wall, a partial occlusion could result that would allow infusion, but not the aspiration of blood. These types of occlusions may require the replacement of the catheter.

Results

Ideally the central catheter will stay in place for as long as it is needed without complications developing. After it is no longer needed, the catheter is removed.

Health care team roles

With the exception of PICC lines, most central catheters are inserted by a physician. These lines are normally maintained and cared for by nurses.

KEY TERMS

Central catheter—A catheter placed into a central vein for the purpose of administering drugs, fluids, nutrients, and blood products. It may also be used to withdraw blood for laboratory testing.

Noncoring needle—Also known as a Huber needle, this special type of needle has a hole on its side rather than at the tip, and may be either straight or angled. Its special shape slices rather than punctures in the septum, reducing the chance of leakage through the opening.

Patency—Degree of openness; once inserted, catheters can become clogged unless they are flushed with heparin and/or saline to keep them clear.

Urokinase—A kidney enzyme found in urine used to dissolve blood clots.

BOOKS

Ignatavicius, Donna D., et al. Medical-Surgical Nursing across the Health Care Continuum. Philadelphia: W.B. Saunders Company, 1999.

PERIODICALS

Andris, Deborah A., and Elizabeth A. Krzywda. "Central Venous Catheter Occlusion: Successful Management Strategies." MedSurg Nursing 8 (August 1999): 229.

"Comparing Central Venous Catheters." Nursing 31 (February 2001): 17.

Deanna M. Swartout-Corbeil, R.N.