Crossing the line

Competency Framework: CD2.7

Central Venous Catheter (CVC): insertion & care in A&E

Hello! Welcome to A&E in the depths of winter. You’ve become well acquainted with the art of corridor care and doorway triage, and now it’s time to see critical care overflow from the ICU!

You take handover in a busy resus room and are introduced to a young woman suffering from septic shock – an A&E Registrar is currently referring and discussing her with critical care – your initial assessment is as follows…

Airway:Patent with nil adjuncts.
Breathing:Tachypnoeic. Self-ventilating via 15lpm O2 non-rebreathe mask. Noted use of accessory muscles. Speaking in short sentences.
Circulation:Sinus tachycardia 129BPM. Weak radial pulse. Arterial line in situ, persistently hypotensive. Catheterised, though anuric. Bilateral 18G peripheral cannulas in situ.
Disability:V-AVPU scale. Orientated when roused. Blood glucose 5.2mmol/l. Pupils are equal and reactive to light, 4mm.
Exposure:Pyrexic at 39 degrees Celsius. Diaphoretic, cold to touch.

The A&E Registrar returns to explain to you that the ICU is full, and wont be accepting transfers for another couple of hours. The critical care team has recommended the commencement of vaopressors through a central line, and they shall come to review shortly… are you ready to prepare and care for this patient!?

WHAT?

• Generally referred to in practice as central lines, a CVC is a form of venous access placed specifically into larger, more “central” veins for a number of clinical reasons.
• Normally appearing in practice with a number of lumens to facilitate multiple infusions and processes at once, you should familiarise yourself with the packs and products you have in your resuscitation room!

• It is important to recognise that central access may also appear in a number of variables: implanted ports, PICC and Hickman lines etc. Patients may also present to A&E with these already in situ! Always refer to your seniors, critical care or venous access specialists for advice!

A “non-tunnelled” central line: likely commonly seen in your resus room!

WHY?

• Inability to obtain peripheral access in the critically unwell patient.
• Administration of specific medications (e.g. adrenaline, noradrenaline), and multiple infusions simultaneously
• Central venous pressure monitoring and fluid status of the patient
• Administration of parenteral nutrition (unlikely in a resus situation)
• Fluid resuscitation is NOT a sole indication for central line insertion; wide bore access peripheral lines are adequate.

• It’s important to note that peripheral administration of inotropes/vasopressors is currently a topic of much debate! Some departments may hold certain criteria or a policy… please get reading! (4)

WHY NOT?

• Less invasive forms of venous access are possible and appropriate.
• Agitated or uncooperative patient.
• Uncorrected clotting pathologies, risk of bleeding.
• Overlying skin conditions or pathologies: lesions, burns, cellulitis etc.
• Obstruction of intended vein by tumour, mass or thrombosis.
• Agitated or uncooperative patient.

WHERE?

Common placement sites of a central venous catheter in emergencies:

– Internal jugular vein (IJV)
– Subclavian vein
– Femoral vein

Nursing considerations during CVC insertion

1. Your patient –if appropriate, should provide consent, receive an explanation of the process, and reassurance.
2. Transducer lines should be COMPLETELY primed with normal saline, to mitigate risk of air embolus – never prime a single half in double transducers for arterial/central line insertion. (1)
3. The patient should be supine for insertion, with continuous cardiac monitoring, spo2 and cycling non-invasive blood pressure in situ as minimum.
4. The head of the bed may be lowered – reverse trendelenburg – to the discretion of the practitioner inserting the central line.
5. Ultrasound machine should be accessible at the bedside, as is now the standard of care for insertion of a central venous catheter.
6. As a sterile field is maintained, it is important for the practitioner performing the procedure to have someone able to assist at the bedside throughout – likely one of the nursing team.

CVC use and care

The transducer & CVC from the DISTAL lumen should be labeled as such. This confirms location and safety for use – PRIOR TO ADMINISTRATION OF DRUGS – in IJV and subclavian lines, a chest x-ray should be undertaken however this is hospital dependant and remember chest X-ray doesn’t confirm placement only the absence of a pneumothorax.

Perform POCT blood sampling to confirm venous placement.

Reassess ECG to confirm no arrhythmia has been caused. (3)

CVC access should ALWAYS be sutured in place, ensure this with practitioner performing the insertion; if any doubt with regards to the security of central access or a line that may have “traveled”, have placement reconfirmed before continuing infusions. Make sure the line insertion is documented as per your local policy; the practitioner who carried it out, any complications encountered etc.

A transparent and occlusive dressing should remain over the insertion site for early identification of phlebitis or other infusion complications. Always ensure compatibility of infusions “sharing” CVC lumen through intranet, local policy or the commonly used medusa system.

A rare occurrence in A&E, the removal of a CVC should only be performed by a practitioner competent in doing so – due to the high risk of fatal complications e.g. air embolus.

Central Venous Pressure (CVP) gives an indication of the pressure in the right atrium of the heart.

The transducer must be zero’d to atmospheric pressure and kept at the height of the patient’s heart to give consistently adequate measurement. Loss or abnormalities in waveform may indicate incorrect placement. Normal CVP range is 3-10mmHg (5-12cmH20). (5)

Potential complications in CVC insertion and care

– Arterial puncture – caused by incorrect insertion or placement.

– Pneumothorax – due to trauma to the chest wall during insertion.

– Arrhythmia – in “overshooting” subclavian or IJV guidewire insertion.

– Air embolus – in incorrect removal technique (2)

We should all acknowledge that the central line is a vastly invasive piece of kit, and strict asepsis is key in avoiding infection related complications.

RCNCurriculum and Competency Framework for Emergency Nursing: CD2.7

References:

1. Arterial Line and Pressure Transducer (2017). Chris Nickson, LITFL
2. Central Venous Cannulation (2017). Mike Cadogan, LITFL
3. Central Venous Catheters (2017). Chris Nickson, LITFL
4. Peripheral Vasopressors: Safe or Dangerous?(2017). Salim Rezaie, Rebel EM
5. Central Venous Lines (2003). The Nursing Times

Need a reminder of how to prime, flush and transduce your central line circuit? Watch Vicky here… Sample principles apply!