CENTRAL VENOUS MONITORING:
STANDARDS OF NURSING CARE IN CCTC (SONC)


  1. Set-Up Hemodynamic Circuit
  2. Maintain Accuracy
  3. Maintain Closed System
  4. Obtain Blood Samples
  5. Change Dressings
  6. Monitor Site
  1. Prevention of Air Entry
  2. Analyze CVP
  3. Document
  4. Obtain Chest Xray
  5. Obtain Access for Central TPN
  6. Introducers (pacemakers, CVCs, PAs)
  7. Remove Central Line

Infection Control

All vascular devices (peripheral, central venous or arterial) can be a source for blood stream infection and be become the nidus for a central venous infection. Stict aseptic technqiue should be maintained at all times during insertion, dressing changes, medication administration and accessing of intravascular devices. .  

 

All central venous and arterial lines that are inserted without strict adherence to sterile techniques/established safety bundles should be changed as soon as possible. Lines inserted during any resuscitation (e.g., trauma resuscusitation, during a crash OR or in another hospital) should be evaluated and considered for replacement. Unless there is clear documentation in the chart to confirm that insertion techniques were maintained, lines should be considered at risk and changed as soon as possible using a new site whenever possible. 

 

All peripheral IVs should be inserted using aseptic technique. Site should not be touched unless wearing sterile gloves after prepping. Peripheral IVs should be removed if insertion technique is unknown or within 96 hours.

 

The insertion of all arterial and central venous lines should adhere to the Central Venous and Arterial Line Safety Checklist and Procedure Note. These forms should be completed and placed in the Progress Note of the Clinical Records. Separate insertion trays are available for arterial and central venous lines.

Arterial and central venous dressing changes are done using aseptic technique. Special dressing trays for "Arterial and Central Venous Dressing Trays" are available.

 

Maintain Safety Bundle Standards for Insertion, Maintenance, Dressing Changes and Removal:

Safety Bundles

 

STANDARD OF NURSING CARE

RATIONALE FOR STANDARD

Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment.

 Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.

 1.

Set-Up Hemodynamic Circuit

RNs in CCTC are responsible for the priming, zeroing, leveling, and maintenance of hemodynamic pressure monitoring circuits and for the assessment and monitoring of hemodynamic pressures and waveforms.

RNs in CCTC may flush hemodynamic monitoring circuits as required to maintain patency.

Use the distal port of a multi-lumen catheter for monitoring pressure, unless the quality of the waveform is better from one of the other lumens.

All central venous lines, including femoral venous lines must be connected to a closed pressure monitoring system at the time of line insertion, and have pressure and waveform monitored.

 1.



RNs in CCTC have received additional education in the care of invasive monitoring circuits. Refer to Procedure for Hemodynamic Monitoring Circuits.

Waveform assessment is important to confirm that the line is venous versus arterial. Although CVP monitoring from a femoral venous line may not reflect the right atrial pressure, it can still be used to guide fluid therapy by following the trend.

Waveform assessment is also used to rule out interstitial central venous placement and to identify central venous lines that have been advanced too far with the tip in the right ventricle.

The most common reason for placement of a central venous catheter into the RV is the use of a 20 cm versus 15-16 cm catheter.

 2.

Maintain Accuracy

Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line.

Transducer levels should be validated at the beginning of each shift, prior to each PWP or CVP measurement, following patient repositioning and prn to validate hemodynamic pressures.

Document level confirmation in the graphic record. Documentation is required at the start of each shift and q6h, prior to each CVP and PWP measurement, and following transducer repositioning.  PICC lines do not require routine pressure monitoring.  Valveless PICCs can be used for CVP monitoring if required and an adequate waveform can be obtained.

 2.



Zeroing eliminates the effect of atmospheric pressure on measured hemodyamic values.

Leveling eliminates the influence of hydrostatic pressure on the transducer. A transducer that is positioned below the patient's heart will produce falsely elevated pressures and a transducer positioned above the patient's heart will produce falsely low pressures.

PICC lines are not inserted for hemodynamic monitoring and are placed under fluoroscopy.

3.

Maintain Closed System

All stopcocks must have dead-end (non-vented) luer lock caps or luer lock connected infusions. This includes stopcocks located on transducers.

Alcohol impregnated sampling port caps should be maintained on all sampling ports.Caps with visible blood soilage should be replaced.

Hemodynamic circuits are changed with each new line and prn.

3.



To prevent accidental entry of air or contaminants. Accidental movement of a stopcock that does not have a dead end luer lock cap can result in hemorrhage/air embolus.

4.

Obtain Blood Samples

RNs in CCTC may draw blood from indwelling venous lines using a stopcock technique.

RNs in CCTC may draw central venous gases to determine Central Venous Oxygen Saturation (ScvO2), from central lines inserted via the subclavian or jugular sites.

Venous blood gases must be obtained at the time of central line insertion or upon admission of a patient with an established central line (including femoral venous lines) and as an endpoint to resuscitation or titration of vasoactive drugs.

ScvO2 should be monitored until it is > 70% or until a new ordered target has been achieved or vasoactive drugs are no longer required.

 

Flush thoroughly after blood sampling and maintain adequate counter pressure to prevent thrombus formation. Reconfirm waveform after flushing.


4.



See Procedure for Blood Withdrawal and Blood Gases Venous. Remember, that when you draw a blood sample from a central line with one or multiple infusions running through it, you must stop all infusions to draw the blood sample(s) to avoid contamination and inaccurate results.

Patients requiring vasoactive drugs are still in shock. Venous gases can be used to identify the adequacy of the cardiac output. Although femoral venous gases may not reflect the right atrial values, they can be used for trending.

Central venous lines should be secured to avoid movement. Catheter movement can lead to inflammation at the site and migration of pathogens along the catheter tract.

Thrombosis increases the risk for infection, compromised limb perfusion/compartment syndrome and VTE events.

5.

Maintain and Change Dressings

Central venousl line dressings are changed q 7 days and PRN when using CHG transparent dressings, or Q 24 H when using gauze.

Dressings should be changed prn if occlusivity is disrupted or if the CHG pad becomes boggy.

Maintain all arterial and venous vascular devices as per Safety Bundle for Central Venous and Arterial Line Insertion and Central and Venous Arterial Line Maintanance.

Ensure that endotracheal securement devices do not disrupt IJ dressing.

Record any redness or abnormal findings in the AI record and report to the physician. Change dressings as per Central and Arterial Line Dressing Change

Non-sterile cap, gown and mask with face shield plus sterile gloves are required.


5.


Dressings of tape and gauze are change q 2 days and prn in critically ill patients to allow site inspection and to reduce bacterial colonization Skin condition, diaphoresis and site oozing necessitates more frequent dressing changes in critically ill patients.

It is acceptable and prefered LHSC Infection Control practice to use a Tegaderm TM dressing that can be changed q7days as per general hospital policy, as long as occlusivity is maintained.

The Centre for Disease Control does not recommend routine line changes.

6.

Monitor Site

Monitor site q 15 minutes following insertion, then q 1 h. Monitor for bleeding, IV connections and occlusivity of dressing. Monitor distal extremity for color, sensation, swelling and movement q 1 h. Document any finding not within normal limits in AI record.


6.



Bulky dressings can mask bleeding. Pressure dressings will not stop arterial bleeding.

Venous thrombosis or hematoma can compromise circulation to distal limb.

7.

Prevent Air Embolism

Maintain luer-lock con
nections on all central venous devices.

Clamp lumens/lines before disconnecting IVs or accessing a port.

Avoid piggybacking infusions that are not running on another infusion pump into Y sites that are located below the air detection devices.

Infusions pumps have air detectors up to the level of the pump.  Patients with intracardiac shunts are at increased risk for venous to arterial air embolization.  TPN tubing includes an air elimination filter than can be used if additional support is needed.

Trendelenburg positioning and breath holding techniques are used during insertion and removal of central venous catheters to prevent air entry.

If air inadvertently enters a central venous catheter, immediately aspirate from the line and place the patient left side down in a trendelenburg position.

Upright positioning and hypotension increases the risk for air entry into central venous lines.

During removal, catheter tract must be immediately occluded to prevent air entrying the tract.

See Procedure for Removal of Central Venous Line.



7.



Bulky dressings can mask bleeding. Pressure dressings will not stop arterial bleeding.

Venous thrombosis or hematoma can compromise circulation to distal limb.

Venous air embolism can create an "air lock" that blocks the flow of blood from the right side to the left side of the heart, leading to cardiorespiratory collapse.  CPR can break air into smaller bubbles to restore circultation.

If venous air is broken into smaller bubbles or there is a persistent formen ovale, air can enter the left side and embolize to the brain or other organs.

Careful technique to avoid the entry of air in to the circuit is essential.

Left lateral trendelenburg positioning may trap air bubbles within the right ventricle in an emergency.

Strategies that increase cardiac pressures above atmospheric pressure reduce the gradient for air to move into the central venous catheter (e.g. breath holding or head down positioning).  Conversely, condition that lower intracardiac pressures in relation to atmospheric pressure increase the gradient for air entry into the catheter site (upright positioing or hypotension).

8.

Analyze/Interpret CVP Waveform

Measure right atrial and femoral venous pressures from a waveforms that is printed and analyzed to identify the pressure at end-expiration and the downslope base of the "V" wave.

Waveform analysis is identified on a paper recording for each right atrial pressure measurement. Place paper recording in the clinical record with the CVP measurement point identified on the printout.

If CVP is measured more frequently than q4h AND the CVP pressure has remained unchanged, CVP printouts may be posted q 4 h. If the CVP value has changed by > 3 mmHg or the waveform has changed from the last measurement, post the waveform in the clinical record.

8.



CVP measurements are obtained from a right atrial waveform. Femoral venous pressures do not reflect the right atrial pressure, but should have a waveform that is similar to a CVP. The pressures from the femoral vein will be different, however, pressure trends from the femoral vein can provide guidance reqarding fluid resuscitation.

The goal for right atrial pressure monitoring is to identify the pressure during end-expiration and end-diastole. Although the pre-C wave best reflects the end-diastolic pressure, it is often difficult to identify, reducing inter-rater reliability. For consistency, we measure the pressure during mid-diastole (during diastasis) because it is easy to find and reflects a pressure that is similar to the pressure at end-diastole.

Posting the waveform in the clinical record allows other members of the team to compare multiple pressure readings with better precision, allowing for more accurate interpretation of trends and signficance.

9.

Document

Document all newly inserted peripheral and central venous and arterial lines in the Line Tracking Section of the 24 hour CCTC Flowsheet.  Refer to documentation standards.

Identify CVP as per item #8 and document pressure in the graphic record. Post a printed waveform to the chart.

Record venous oxygen saturation in the hemodyanmic section of the graphic record.

Assess catheter patency and document in the intravascular line section of the flow sheet at the start of each shift and q 4 h.

Document the type of solution infusing into each IV site/lumen in the AI record.

Sign for all medications and infusions in the MAR.

Record IV infusion volumes in the fluid balance record.

Record vasoactive drug doses in mcg/kg/hr or mcg/min in the graphic record section of the flow sheet.

Document dressing changes in flow sheet and * and DAR abnormal findings.

9.



As per hospital policy.

10.

Obtain Chest Xray

Obtain chest xray upon insertion an as ordered.

10.



To identify complications including: pneumothorax, hemothorax, hydrothorax, catheter kinking, catheter placement (e.g. right atrial placement of CVP catheters or distal placement of right heart catheter), pulmonary infarction or hemorrhage.

11.

Obtain Access for Central TPN

New lines should be inserted for initiation of central TPN (vs using an existing line). Exceptions may be made by the CCTC Consultant if the risk of line insertion exceeds the risk of infection.

11.



Central TPN supports the growth of infection, particularly fungemias.

12.

Introducers

Use:

Introducers are used as stand alone IVs (e.g., for rapid infusions) or to facilitate the insertion of a temporary transvenous pacemaker, pulmonary artery catheter or central venous catheter.

An introducer is a central venous catheter and should be treated with the same central line insertion, maintenance and removal precautions (e.g., risk for air, central line infection, thrombosis).

Dressing occlusivity is more difficult to maintain when a central venous catheter is inserted through an introducer, especially at the jugular site. A "waterfall technique" where each lumen of the central venous catheter is taped separately may reduce the dressing "pull down" effect.  See Procedure for Central Line Dressing.

Consideration should be given to limit the duration of time when an IJ introducer-CVC is used or to utilize a multilumen central line catheter (> 3 lumens if possible).

 

Infection Risk:

Introducers inserted during any resuscitation should be considered "potentially contaminated".  This includes lines inserted in ED, CCTC or OR for patients undergoing emergency OR, trauma/cardiac arrest resuscitation or massive transfusion.. Lines should be replaced within 24 to 48 hours.

Introducers are usually quite large (e.g., 9F). These require additional pressure/diligence during removal to prevent bleeding, hematoma development or the entry of air into the large tract.

A 6F is the usual size for a 5F tranvenous pacing wire or Swan Ganz Pacemaker. A Swan Ganz Pacemaker consists of two pacemaker electrodes and a balloon for flow directed insertion. This catheter is inserted into an introducer to facilitate advancement, but the pacemaker does not have any vascular lumens.  The introducer provides vascular access but the actual pacemaker does not have any vascular lumens.

 

Patency/IV Therapy:

Introducers with pulmonary artery, central venous or tranvenous pacing catheters require a continuous flow of IV fluid via infusion pump (5 ml per hour is sufficient).  Saline lock should not be used (increased risk for thrombosis).

Any patent introducer with confirmed placement can be used for the administration of medication that requires central venous access, including vasopressors. 

Vasopressors and PA Catheter:

When a pulmonary artery catheter is in place, the introducer is the preferred location for the administration of vasoactive agents. 

 

12.

 

Introducers are central venous catheters that carry the same risk and benefit as other central venous catheters.

The larger bore size of a 9 F introducer can increase the risk for complications and leave a larger potential tract following removal.

When a catheter is inserted through an introducer the flow rates are decreased and the potential for thrombosis around the catheter tip increased.

The introducer is independent of the pulmonary artery catheter. If a pulmonary artery catheter is advanced or withdrawn, infusions that are being administered via the blue (proximal injectate), white (proximal infusion) or orange (right ventricle port of Paceport(TM) model) lumens must be stopped to prevent inadvertend administration of fluid into the sleeve or disruption of life-supporting medication.

Administration of life supporting medication via the introducer ensures uninterupted administration during advanacement, withdrawal or removal of the pulmonary artery catheter.

It is often not possible to maintain full barrier precautions or achieve optimal dry time of skin preparations when lines are placed during life-saving resuscitations (including lines inserted in the OR during a crash case).  Lines placed during resuscitation carry a higher risk for central line infection.

.

13.

Remove Central Line

RNs in CCTC may remove central venous lines, with an order from a physician. Document removal in the intravascular device section of the graphic record.

See Procedure for Removal of Central Venous Line.

 

13.

 

 

Last Update: January 20, 2017, October 10, 2017

 

References:

Bpwdoe. A. (2014). Vascular complications of central venous catheter placement: Evidence-based methods for prevention and treatment. Journal of Cardiothoracic and Vascular Anaesthesia. 28(2), 358-368.

 

Center for Disease Control (2011). Guidelines for Prevention of Intravascular Infections. http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

Canadian Patient Safety Institute. Central Line Infection Reduciton.

http://www.patientsafetyinstitute.ca/en/Topic/Pages/Central-Line-Infections-(CLI).aspx

Kornbau, C., et al. (2015). Central line complications. Int J Crit Illn Inj Sci. 5(3): 170-178.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613416/

LHSC Procedure for Care, Use and Maintenance of Central Intravascular devices. (2012).

 

 

 

 

 

LHSCHealth Professionals

Last Updated October 10, 2017 | © 2007, LHSC, London Ontario Canada