STANDARD OF CARE CENTRAL VENOUS MONITORING

Ensure that patient and health care provider safety standards are met during this procedure including:

• Risk assessment and appropriate PPE
• 4 Moments of Hand Hygiene
• Procedural Safety Pause is performed
• Two patient identification
• Safe patient handling practices
• Biomedical waste disposal policies
• Safe Handling of Intravenous Bag and Tubing Set-up on Articulating Arms

1. Set-Up Hemodynamic Circuit
2. Maintain Accuracy
3. Maintain Closed System
4. Obtain Blood Samples
5. Change Dressings
6. Monitor Site
7. Prevention of Air Entry
8. Analyze CVP
9. Document
10. Obtain Chest Xray
11. Obtain Access for Central TPN
12. Introducers (pacemakers, CVCs, PAs)
13. 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

• Procedural Safety Pause
• Central and Arterial Line Insertion
• Central and Arterial Line Maintenance
• Central and Arterial Line Dressing Change
• Procedure for Removal of Central Venous Catheter

STANDARD OF NURSING CARE

 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. Refer to Procedure for Hemodynamic Monitoring Circuits.

RNs in CCTC may flush hemodynamic monitoring circuits as required to maintain patency.  Do not flush with syringes smaller than 5 mL as these may cause excessive resistance and damage the catheter or dislodge a clot.

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. Measure pressure by direct connection (not through a needleless access connection).

Ensure that pressurized flush solutions are maintained on an IV pole that is not attached to the articulating arm, and placed at least 1 meter from an electrical outlet.

Insertion Standard

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. 

Prepare hemodynamic monitoring circuit prior to central venous line insertion. Connect central line immediately to pressure monitoring, before initiation of any medications or infusions.

Upon confirmation of a venous waveform, a central venous catheter can be immediately use for the administration of vasopressors, massive transfusion protocol or medications.  

Do not use the catheter if an arterial waveform is displayed. Do not remove a CVC if inadvertently placed into an artery if the vessel has been dilated. Leave an iatrogenic arterial catheter in place, and connect it to a pressurized hemodynamic circuit to maintain patency and prevent thrombus formation (do not flush manually).

A Chest Xray is still required to rule out pulmonary complications (e.g. pneumothorax) for catheters inserted via the IJ or SC site, and to confirm that the catheter is located in an appropriate vein (e.g. has not migrated up the jugular vein toward the head).

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

At the start of every shift and PRN if central venous pressure waveform becomes dampened, blood backs up or the catheter is difficult to aspirate or flush:

Confirm that there is at least 250 mL of saline in the 500 mL flush bag

Confirm that the bag is pressurized to at least 300 mmHg

Confirm that the pressurized bag is on an IV pole not attached to the articulating arm and at least 1 meter away from the electrical outets.

Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line. Zeroing eliminates the effect of atmospheric pressure on measured hemodyamic values.

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

At the start of every shift and PRN for dampened waveforms or difficulty flushing/aspirating:

Select an appropriate scale for waveform assessment (recommended to use a defined scale with "zero" as the base pressure - this is essential when measuring pulmonary artery and right atrial pressures from a PA catheter)

Relevel and rezero the transducer

Flush the transducer dome through the venting stopcock to ensure there are no small bubbles that may interfere with the pressure reading

Perform a Dynamic Response Test (square wave test) to evaluate the waveform.

Document level confirmation in the Device Band. Documentation is required at the start of each shift and q6h, prior to each CVP and PWP measurement, and following transducer repositioning. 

PICC lines and temporary dialysis catheters do not require pressure monitoring confirmation. Confirmation of venous placement for dialysis catheters should be done by venous blood gas prior to the initial dialysis run.

*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.

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. Accidental movement of a stopcock that does not have a dead end luer lock cap can result in hemorrhage/air embolus.

Alcohol impregnated sampling port caps should be maintained on all sampling ports. Caps with visibly soiled should be replaced.

Hemodynamic circuits are changed with each new line and prn.

Obtain Blood Samples

RNs in CCTC may draw blood from indwelling venous lines using a stopcock technique. When drawing 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. See Procedure for Blood Withdrawal and Blood Gases Venous.

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 (30-60 second pull of the flush device) and maintain adequate counter pressure to prevent thrombus formation. Back flush through sampling port and replace needleless access device if there is visible blood.  Reconfirm waveform after flushing. 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.

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.

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.

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 connections 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. When air venting is required for intracardiac shunt, ensure that air vent filters are placed below the most distal Y injection port.

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 and require 0.2 micron filters (see Tubing and filters for venting of vascular lines for patients with Intracardiac shunt).

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.

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.

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 CVP in IView in the vital signs section.

Create a Dynamic Group under Device Band in the EHR for the central venous line. Under activity field, select "inserted" to document the insertion date and time.

Assess site, patency, CCM, dressing appearance and waveform quality at the start of each shift and Q1H. Document assessment at the start of each shift, Q4H and PRN in the Device Band.

Document abnormal findings or significant changes/interventions in the assess/reassess section.

Print a waveform upon insertion and at the start of each shift to confirm venous placement, and to interpret CVP reading as in #8.  Post this to the paper-based portion of the patient's health record.

Document Record venous oxygen saturation in the 

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

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

Sign for all medications and infusions in the MAR and record the hourly dose of medications.

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 the Devise Band and identify abnormal findings in the assess/reassess section.

Update "date due" for dressing changes and IV tubing in the Actions and Situational Awareness section in Nurse View of the EHR.

10.

Obtain Chest Xray

Obtain chest xray upon insertion an as ordered or by Medical Directive.

Ensure provider reviews film.

11.

Obtain Access for Central TPN

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

Central TPN supports the growth of infection, particularly fungemia.

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.

The insertion of a double/triple lumen catheter into a previously established introducer should be avoided due to the increased risk for infection. Only introducers that have been inserted with full barrier precautions AND where the access cap has been maintained with a sterile cap and covered with a sterile dressing should be considered.

If a central venous catheter is inserted into an established introducer, full barrier central line insertion techniques (with gowning and draping) are required.

Size:

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 transvenous pacing catheters require a continuous flow of IV fluid via infusion pump (5 ml per hour is sufficient, or they can be used for any central line infusion).  Saline lock should not be used (increased risk for thrombosis).

Any patent introducer with confirmed placement can be used for the administration of medications 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. 

13.

Remove Central Line

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

See Procedure for Removal of Central Venous Line.