Chapter 17: Vascular access devices: insertion and management
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Pre‐procedural considerations
Equipment
Catheters
Most catheters are made of polyurethane and may be single or multi‐lumen (up to five) devices (Figure 17.34). There is a variety of lumen gauges and the catheters vary in length. They are usually open‐ended but lumens can exit at staggered points along the catheter (Figure 17.35) (Dougherty [123], Ives [225]). Multilumen catheters may carry a higher risk of infection than single‐lumen ones (Smith and Nolan [418]), which has resulted in the manufacture of coated and impregnated catheters, which may have antimicrobial agents such as chlorhexidine, silver sulphadiazine or antibiotics bonded onto the surface (Hill et al. [211], Monzillo et al. [323]). It has been shown that this can reduce the incidence of catheter‐related bloodstream infections, and the use of such devices is strongly recommended by the Department of Health (Bassetti et al. [23], Loveday et al. [278], RCN [381], Sampath et al. [397]). Care must be taken as patients have been known to develop sensitivity to chlorhexidine (MHRA [314]) or the medications impregnated in the catheter (Lai et al. [258]).
Figure 17.34 Non‐tunnelled multilumen central venous catheter.
Figure 17.35 Types of catheter tip. (a) Open‐ended catheter (single and double lumen). (b) Staggered‐exit open‐ended catheter.
Pharmacological support
Since these devices are usually in constant use, 0.9% sodium chloride is the flushing solution of choice to reduce the risk of occlusion (Loveday et al. [278], RCN [381]). It may be appropriate to use continuous infusions to keep the vein open. 1% lidocaine is often used to provide anaesthesia prior to cannulation and advancement of the introducer.
Specific patient preparation
Prior to inserting the catheter, the following should be carried out (Hamilton [198]):
- assessment of allergies
- physical examination, for example of physique, weight (e.g. obesity or cachexia) and relevant physical features (e.g. bull neck, lymphoedema or tracheostomy)
- vascular assessment
- assessment of respiratory, cardiovascular and neurological function
- assessment for fractures, arthritis and shape of sternum
- assessment for infection issues
- radiological assessment (e.g. to check for thrombosis)
- laboratory assessment (e.g. biochemistry, coagulation and platelets).
In general, the nurse's responsibilities when assisting another practitioner include the following:
- ensuring, where possible, that the patient understands and has been given a full explanation of the procedure and had the opportunity to discuss any aspects of it that they wish (DH [116], NMC [356], RCN [382])
- explaining any specific pre‐ and post‐procedure instructions and the appearance and function of the catheter
- teaching the patient techniques that may be required during insertion (e.g. the Valsalva manoeuvre) and explaining that they may be placed in the Trendelenburg position (where the patient lies flat with the head lower than the feet, potentially with their knees bent) (Dougherty [123], Weinstein and Hagle [465]) (Figure 17.36)
- assembling the equipment requested
- preparing local anaesthesia and dressing materials
- ensuring the correct positioning of the patient during insertion (i.e. in the supine or Trendelenburg position)
- attending to the physical and psychological comfort of the patient during and immediately following the procedure
- ensuring that no fluid or medication is infused before the correct position of the catheter has been confirmed on X‐ray by an appropriate clinician and the tip location has been documented in the patient's notes.
Figure 17.36 One way to achieve the Trendelenburg position.
Table 17.6 Prevention and resolution (Procedure guideline 17.9)
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| Unable to advance wire, dilator or catheter |
Anatomical deviation
Valves |
Use ultrasound prior to insertion.
Ensure good history taking and physical examination prior to commencing the procedure. |
Do not force the wire, dilator or catheter as this may rupture a vessel.
Remove the wire/catheter and reposition the patient.
If problems persist, remove the wire/catheter and change site or contact a more experienced colleague. |
| Unable to achieve blood flashback |
Vein may be transfixed
Vein missed | Use ultrasound to visualize the vein. |
Only aspirate blood on withdrawal, not on insertion.
Withdraw the needle slowly, aspirating gently until flashback is seen. |
| Arterial blood aspirated | Arterial puncture | Ensure accurate use of ultrasound and steep needle insertion to avoid past pointing. | Withdraw the needle and press on the site firmly for at least 5 minutes to prevent major haematoma formation. |
| Occurrence of arrhythmias on inserting the wire | Wire inserted too far | Assess likely distance to the heart prior to insertion. | Withdraw the wire 2–3 cm. |
| Air aspirated from needle | Pleural space entered during insertion | Ensure accurate use of ultrasound. | Abandon the procedure. Contact the medical team urgently to request insertion of a chest drain. |
| Pneumothorax on post‐procedure chest X‐ray | Pleural space entered during insertion | Ensure accurate use of ultrasound. | Contact the medical team urgently to request insertion of a chest drain. |
