In general, peripheral catheters are preferred when IV access is required for shorter periods, when direct access to the central circulation is. The veins in your arms are called peripheral veins. That simply means they're not in the center part of your body. A catheter inserted into a. A central venous catheter (CVC) is a large diameter catheter that can be placed in the jugular or peripheral vein. CVCs can be indicated for various. USPS BUSINESS CLASS CSGO BETTING

Central venous catheters may be used for the following reason: To give medicines for treatment of pain, infection, or other medical issues e. To help conduct certain medical tests. What types of central venous catheters are there There are several types of central venous catheters. A peripherally inserted central catheter PICC line is placed into a vein in the arm. A tunneled catheter is surgically placed into a vein in the chest or neck and then passed under the skin. One end of the catheter comes out through the skin so medicines can be given right into the catheter.

An implanted port is similar to a tunneled catheter, but an implanted port is placed entirely under the skin. Medicines are given by a needle placed through the skin into the catheter. Where are central venous catheters used? We use a wide prep to prepare for a right central venous catheter insertion. After the prep dries we will place a wide sterile barrier. The sterile drape should cover the entire lower half of the body including the bed between the patient and the operator.

We're now using a sterile sheath to grasp the ultrasound probe that has had a non-sterile ultrasound gel applied to the top. You grasp the ultrasound probe and then carefully pull the sterile sheath over the probe so that you can have a sterile probe to do real time ultrasound. Now we're going to prepare the catheter. We're applying needleless caps on to the blue port and the white port of the catheter and we're going to use sterile saline to flush each of the ports.

Here we're flushing the white and the blue port of the catheter that have the caps in place. And with the brown port which is the distal port the wire will be coming out of that port so we do not have a cap in place but after we flush that port we'll have to clip the line before removing the sterile saline syringe. Now with the 1 percent lidocaine we're applying a sterile label so that all the syringes can have sterile identification. Sterile ultrasound gel is then use on the skin and now we're looking at the right femoral artery and the femoral vein in transverse orientation.

The femoral artery is on the top left-hand side. With compression you can see that the right femoral vein compresses but that the right femoral artery which is more superficial and to the left does not compress. We're using 1 percent lidocaine for local anesthesia of the skin and the underlying soft tissue. Now we're introducing a introducer needle at about a 45 degree angle inserted the same depth away from the probe as the vein is deep to the probe.

We are inserting so that we gradually can see the needle advance into the vein and now we have return of venous blood. We're going to grasp the hub of the needle and withdraw the syringe to confirm that it is nonpulsatile blood.

Now we're going to insert the sterile wire through the sheath and through the needle. We are going to rotate the probe into the longitudinal orientation and we can see that the wire is threading into the vein as the wire is advanced through the needle. In the femoral location the wire can be advanced even as deep as 30 centimeters. Now the sheath is removed and the wire is left in place.

The needle is now withdrawn and leaving the wire in place you can still see that the wire is in the vein on the ultrasound image. And now the probe can be dropped and sterile gauze can be used to identify the insertion site clearly, and then a scalpel could be used to nick the skin over the wire. Now a dilator is inserted over the wire and the wire is grasped on the opposite side of the dilator.

The dilator is advanced with a twisting motion to dilate a tract through the subcutaneous tissue and into the femoral vein. Now the dilator is withdrawn leaving the wire in place. The wire is then threaded back through the central venous catheter until you can grasp the wire on the opposite end of the brown or distal port of the catheter.

Now the wire is grasped on the distal end of the catheter and then the catheter is advanced all the way to the end of the catheter. And now the wire is withdrawn back into its sterile sheath and completely withdrawn out of the body. Once the wire is completely withdrawn the brown port is clipped.

Now we're introducing the last needleless cap onto the brown port and then it will be unclipped and then you will withdraw the blood into the syringe and then the whole line is flushed, care being taken not to inject any air into the port. Now the white and the blue ports of the central venous catheter are flushed with sterile saline. Now some local anesthesia is used to numb up the skin adjacent to the central venous catheter, a bio-patch is applied at the insertion site with the blue side angled towards the ceiling.

This is a patch that's impregnated with chlorhexidine to minimize the risk of catheter related bloodstream infections. And now suture is used to secure the catheter in place in two locations. After this is secured, a sterile occlusive dressing will be applied over the central line to complete the procedure.

Here an instrument tie is being used to secure the central line using suture which is done in two locations. Video created by Hospital Procedures Consultants at www. Ultrasound-Guided Cannulation of the Subclavian Vein The patient is placed in Trendelenburg [ph ] position and then chlorhexidine swab is used to prep the left anterior chest wall all the way up, half way up the neck and then also broadly to cover the left shoulder.

The chlorhexidine has to be allowed at least two minutes to fully dry for good antisepsis. Now a sterile wide drape is being applied with the hole centered on the insertion site. This sterile drape should cover the head and almost all of the bed. Now we're drawing up 1 percent lidocaine which we'll use for local anesthesia.

Since all of the fluid in a sterile field must be labeled after the syringe is full of the lidocaine, a sterile label with 1 percent lidocaine will be added onto the syringe.

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Electronic search strategies will be as sensitive as possible, with no limits of language, date, or publication status. Table 1 Open in a separate window 3. Hand search and other search resources We will also search for RCTs in the reference lists of all included studies to avoid missing important studies that may not have been indexed in electronic databases.

Selection of studies Using the electronic tool covidence. We will resolve disagreements by discussion with the author team. We will read the full text of the relevant trials and identify studies for inclusion. Moreover, we will identify and exclude duplicates and collate multiple reports of the same study so that each study, rather than each report, is the unit of interest in the review. If a trial does not meet the eligibility criteria, we will document the reasons for exclusion.

The data extraction will include: 1. General features of the studies: author, year of publication, country, number of participants, age, sex of participants, and associated clinical conditions. Specific features of the studies: intervention, comparison, primary and secondary outcomes, blinding, inclusion and exclusion criteria. Each component of the risk of bias tool in the included studies will be judged as a low, high, or unclear risk of bias. We will resolve disagreements by discussion within the review team.

The risk difference will be obtained with Review Manager 5 software. Unit of analysis issues We will use an intention-to-treat approach and we will consider the participant as the unit of analysis for all outcomes. Dealing with missing data We will analyze the available data and intend to contact the trial authors to request missing data eg, when a study is identified as an abstract only.

Where possible, we will use the RevMan calculator to calculate missing standard deviations using other data from the trial eg, CI. Where this is not possible, and the missing data are thought to introduce serious bias, we will explore the impact of including such studies in the overall assessment of results by a sensitivity analysis.

Assessment of heterogeneity We will inspect forest plots visually to consider the direction and magnitude of effects and the degree of overlap between CIs. We will use the I2 statistic to measure heterogeneity among the trials in each analysis but acknowledge that there is substantial uncertainty in the value of I2 when there is only a small number of studies.

If we identify substantial heterogeneity, we will report it and explore possible causes by prespecified subgroup analysis. We will use these ranges to guide our interpretation of the I2 statistic according to section Data Synthesis We will synthesize the data using RevMan 5.

If there is substantial heterogeneity, we will use a random-effect model. If it is not appropriate to combine in a meta-analysis, we will not undertake a meta-analysis but will describe the data narratively. We plan to extract study data, format our comparisons in data tables, and prepare a summary of findings table before writing the results and conclusions of the review.

Table 2 Open in a separate window 3. We will use the 5 GRADE domains study limitations, consistency of effect, imprecision, indirectness, and publication bias to assess the certainty of evidence relating to the studies which contribute data to the meta-analyses for the prespecified outcomes. Subgroup analysis and investigation of heterogeneity Where there are sufficient data available, we will perform subgroup analyses for the following: 1.

Table 2 Continued Open in a separate window 2. Table 3 Open in a separate window Since we are planning to explore possible causes of substantial heterogeneity with subgroup analysis assessment of heterogeneity , we will use all outcomes in subgroup analyses. We will use the formal test for subgroup differences in RevMan 5. Sensitivity analysis We plan to carry out the following sensitivity analyses, to test whether key methodological factors or decisions have affected the main result: We will consider the overall risk of bias of an included study as low if there are no high-risk judgments in the 4 domains of random sequence, allocation concealment, incomplete outcome data, and selective reporting.

After that, we will perform analysis including only studies with a low risk of bias. We will examine both the fixed-effect model and random-effects model meta-analyses, and we will explore any differences between the 2 estimates. These results will be presented and compared with the overall findings. Conclusions We will base our conclusions only on findings from the quantitative or narrative synthesis of included studies for this review.

We will avoid making recommendations for practice and our implications for research will suggest priorities for future research and outline what the remaining uncertainties are in the area. Discussion Although there are a great number of techniques for central intravenous access, there is a lack of high-quality evidence to decide which one is better in terms of cost-effectiveness.

Johansson et al[ 14 ] proposed that PICC is more related to deep venous thrombosis and less related to catheter occlusion than traditional CVC. However, this statement is not consensual in the literature. Therefore, this SR is particularly important and will attempt to address this lack of robust evidence. Peripherally inserted central catheter versus central venous catheter for intravenous access: A protocol for systematic review and meta-analysis. The authors report no conflicts of interest.

Complications of central venous access devices: a systematic review. Pediatrics ;e— Central venous catheters in home infusion care: outcomes analysis in 50, patients. J Vasc Interv Radiol ;— Guidelines for the prevention of intravascular catheter-related infections: recommendations relevant to interventional radiology.

J Vasc Interv Radiol ;14 2 pt 1 —6. Peripherally inserted central venous catheters and central venous catheters in burn patients: a comparative review. J Burn Care Res ;—5. Reducing blood stream infections during catheter insertion. A patient with a tunneled catheter can continue to receive intravenous therapy even after leaving the hospital.

Nontunneled CVC A nontunneled catheter is designed to be temporary and may be inserted into a large vein in the neck, chest, or groin. Often a nontunneled CVC is used when urgent or emergent access is needed, for example hemodialysis in the event of renal failure, or resuscitation.

Implantable ports An implantable port is shaped like a disk and is connected to a flexible tube that has been placed into a vein in the chest during surgery. Implantable ports can remain in place for years, until a provider determines it is no longer needed. Ports can be used for giving IV intravenous medicines, fluids, food, or taking blood samples. PICC lines A PICC line peripherally inserted central catheter is a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart.

Sometimes rarely the PICC line may be placed in a person's leg. A PICC line is generally used to give medications or liquid nutrition. Nursing care of CVCs There are a number of protocols to follow when working with a central venous catheter. Then, continue to change the dressing on a weekly basis or as timed per facility policy. Perform a complete dressing change over the insertion site using the aseptic technique.

How to access implantable ports Access implantable ports with a non-coring Huber needle, which provides a strict aseptic no-touch technique during vascular access procedures. This is to reduce the risk of catheter-related infection. This is a job that requires skill and experience — it is advisable to reach out to a mentor nurse or charge nurse for help showing how to do this the first time.

Flush the line with normal saline, or depending on the facility, use heparin. Always flush with a 10ml syringe or bigger. Using a smaller syringe can put too much pressure on the catheter. This is because the pressure of the cuff might cause bleeding at the insertion site.

It also increases the risk of thrombus clot formation or can cause retrograde blood flow, which raises the risk of catheter occlusion. How to remove a CVC Place the patient in supine position when removing a central venous catheter. Also, instruct the patient to perform the Valsalva maneuver bearing down as if having a bowel movement during removal.

Full Transcript Hi. In this video, we are going to talk about the IV route medication administration. At the end of the video, I'm going to give you guys a quiz, test your knowledge of some of the concepts I will be covering in this video. So definitely stay tuned for that. Let's start off by talking about best practices for IV insertion. In terms of catheter size, we're going to want to use a bigger catheter, so a smaller gauge for trauma patients.

So for trauma patients, we would use a gauge catheter. If we're talking about a surgery, then an gauge would be appropriate. And for medical patients, we can use a , , or a gauge catheter. When we are attempting insertion of an IV, we want to place the patient's arm in a dependent position to really encourage blood flow down into that arm. We would place a tourniquet about 5 to 6 inches above the insertion site, and we use a blood pressure cuff instead of a tourniquet for older patients. You want to try using veins or inserting the catheter in a vein distally on the arm first.

So you don't want to start up high because if you mess up and blow out that vein, then you're not going to be able to use that vein down lower from that injury site. So you want to start lower on the patient's arm, and if you don't hit it, you can kind of work your way up. You want to avoid any hardened veins, and we also want to avoid veins in the hand for older patients because there's a lot of nerve endings there, so it can be really painful, and also those veins tend to be kind of wiggly and difficult to hit with an IV.

You want to avoid veins in flexion areas as well, such as the antecubital fossa. So those veins there in the AC are pretty easy to see and to hit and, obviously, for dealing with an emergency situation, you want to get that IV in as fast as possible, so the AC would be appropriate in that case. But if we're talking about a stable patient who's going to be admitted to the hospital, then really it makes sense to choose a different area that is not in the AC or any flexion area because if you put the IV in there, then when the patient is eating or doing other things, they're bending their arm and that's going to cause the IV to be become occluded, and that's going to cause the IV pump to start alarming, and you're going to be in that patient's room every two minutes resetting the alarm until you really bite the bullet and move their IV to a better spot.

So it's just better to start off with a better spot than to put it in the AC and then have to move it later. You also never want to put an IV on the same side as the patient has had a mastectomy, or where a patient has an AV fistula, which they would use for dialysis. So in terms of inserting the catheter, you want to insert it at a to degree angle, and you need to use a new sterile needle for each insertion attempt.

So if you're trying to insert the IV and you're not hitting it, and it's not going well, and you pull it out, you can't just stick it back into another spot. You need to go get another kit. So when I used to be a floor nurse-- I don't do a lot of IV insertions now.

But when I was a floor nurse, I would always bring two or three kits with me because I wasn't the best at IVs right out of the gate. So again, you need to use a new sterile needle for each insertion attempt. Once we've successfully inserted our IV line, we need to take measures to maintain the patency of that line.

So if the patient is not getting continuous IV fluids through that line, then we're going to want to flush that line every 8 to 12 hours with normal saline, or per facility policy, in terms of the timing. And then every 24 hours, we're going to want to change all the IV tubing out. And any time we connect a syringe or line to that IV access site, we want to scrub the port down with an alcohol swab for 15 seconds. And any time we're giving medication, we always want to check the compatibility of that medication with the IV fluids that the patient is receiving.

So we are not going to administer any kind of medication through that line. We need to use a separate line to give the patient their IV medication. And then we always want to flush before and after the administration of any IV medications. So when you come in the patient's room, you want to bring a couple of flushes along with the medication syringe.

You want to attach one of the normal saline flushes to the port, and you want to aspirate and check for that blood return to make sure that the IV line is patent, that there's no clotting or other issues. Once you see that blood return, you can flush the line with the normal saline, disconnect that saline flush, attach the medication syringe, push the medication at the prescribed rate, disconnect that syringe, and then flush again with another normal saline syringe.

So again, we're always flushing before and after medication administration. So peripheral IVs are fine for short-term use. However, if your patient requires long-term antibiotic therapy or chemotherapy or total parenteral nutrition, then they really need to have a central venous catheter or a CVC. So no matter the type of CVC that your patient has, the catheter tip will terminate in the superior vena cava right above the right atrium. And that vein there is nice and fat, and it's able to accommodate harsher medications such as vancomycin or chemotherapy, as opposed to your peripheral vein which is kind of skinny and delicate and would not hold up well to a medication such as vancomycin over the long term or chemotherapy.

So in terms of the nursing care of a CVC, 24 hours after your patient has the CVC inserted, you're going to want to do a complete dressing change over the insertion site using aseptic technique. And then going forward, you will need to perform dressing changes weekly or per facility policy, again, using aseptic technique.

If you need to access your patient's implantable port, you need to do so using a non-coring Huber needle. And if you've never used this before, then definitely reach out to your mentor nurse or your charge nurse for help showing you how to do that the first time.

And we would flush these with normal saline. Or sometimes at certain facilities, they would flush using heparin. And we always want to flush with a milliliter syringe or bigger. So if we use a smaller syringe, it puts too much pressure on that catheter, so you always want to use a bigger syringe, at least 10 milliliters or bigger. And then lastly, you never want to take blood pressure on a patient's arm where they have a PICC line. So you definitely want to make sure you use the other arm instead.

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Routes of administration: Peripheral IVs, Central Venous Catheters - Pharmacology Basics

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