Name: a protocol to set up needle-free connector with positive displacement on central venous catheter in intensive care unit
Uploaded: 2019-07-13T15:00:00.000+00:00
Duration: 9 min 57 s
Description: Watch this Scientific Journal Video about A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit at JoVE.com

The authors are grateful to Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript. The authors would like to thank the communication department of Rouen University Hospital and the teams of the Medical Training Center for their participation in the video shoot.

1. Preparation of connectors and infusion lines
<ol>
	<li>Sterilely retrieve the connectors.</li>
	<li>On the 3-way extension stopcock, screw 1 connector into each socket of the stopcock and 1 connector into the end of the extension line. Take 0.9% NaCl with a 50 mL syringe to purge the extension and the lines. Purge each 3-way extension with 0.9% NaCl through the 2 connectors of the stopcock.</li>
	<li>Take the infusion manifold. Unscrew each single-use cap. Screw 1 connector into each socket of the manifold to replace the caps. Purge the infusion line through each connector by turning each stopcock sequentially. 
	NOTE: At the end of this step, there are 3 extensions with 3-way stopcock with purged connectors and an infusion manifold with purged connectors.</li>
</ol>
2. Placement of the catheter
<ol>
	<li>Place the central venous catheter sterilely according to usual practice in the unit or a previously described protocol9.</li>
	<li>Check the permeability of each line by aspiration of blood and then reinjection of 0.9% NaCl serum. Clamp the lines.</li>
</ol>
3. Installation of the connectors
<ol>
	<li>Screw the extension&#8217;s connector of each 3-way extension stopcock into each catheter line. These connectors, directly connected to the lines of the catheter, are the &#34;proximal connectors&#34;. Unclamp the lines.</li>
	<li>Connect the infusion manifold line to one of the connectors of the 3-way stopcock of the distal line. 
	NOTE: There is no need to place a vein guard on the manifold or extensions.</li>
</ol>
4. Use of connectors and infusion lines
<ol>
	<li>Before each infusion, disinfect the end of the connector for 3 s with a sterile compress soaked in 70% isopropyl alcohol. Connect the syringe or tubing directly to the connector by screwing and injecting. After injection or infusion, unscrew the device. Do not remove the connector.</li>
	<li>If needed, rinse an unused line with 3 mL of saline. There is no need to clamp or infuse an unused line with a vein guard. Leave the proximal valve in place even if the line is not perfused.</li>
</ol>
5. Replacement and maintenance of connectors and infusion lines
<ol>
	<li>Always change the connectors every 7 days except for the proximal connectors. Thus, every week, the nurse prepares the extensions with 3-way stopcock and the infusion manifold in sterile conditions (see step 1).</li>
	<li>Unscrew the used extensions at the proximal valve and screw the new sterile and purged extensions to the catheter on the proximal connector (see step 3).</li>
	<li>Only change a proximal connector if it is soiled (to maintain the catheter in a &#34;closed&#34;&#160;system).</li>
	<li>In case of macroscopic contamination, rinse the connector with 10 mL of 0.9% NaCl. If there is still contamination, replace the connector. In the event of transfusion, infusion of lipid solution (e.g. propofol) or parenteral nutrition, change the tubing and connectors of the line concerned every 24 hours.</li>
	<li>Change other infusion lines and tubing according to the practices and protocols of each unit.</li>
</ol>

<ol>
	<li>Worth, L. J., McLaws, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+it+possible+to+achieve+a+target+of+zero+central+line+associated+bloodstream+infections.">Is it possible to achieve a target of zero central line associated bloodstream infections.</a> Current Opinion in Infectious Diseases. 25 (6), 650-657 (2012).</li><li>Kelly, L. J., Jones, T., Kirkham, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Needle-free+devices:+keeping+the+system+closed.">Needle-free devices: keeping the system closed.</a> British Journal of Nursing (Mark Allen Publishing). 26 (2), 14-19 (2017).</li><li>Casey, A. L., Karpanen, T. J., Nightingale, P., Elliott, T. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+risk+of+microbial+contamination+associated+with+six+different+needle-free+connectors.">The risk of microbial contamination associated with six different needle-free connectors.</a> British Journal of Nursing (Mark Allen Publishing). 27 (2), 18-26 (2018).</li><li>Salgado, C. D., Chinnes, L., Paczesny, T. H., Cantey, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Increased+rate+of+catheter-related+bloodstream+infection+associated+with+use+of+a+needleless+mechanical+valve+device+at+a+long-term+acute+care+hospital.">Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital.</a> Infection Control and Hospital Epidemiology. 28 (6), 684-688 (2007).</li><li>Jarvis, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+care-associated+bloodstream+infections+associated+with+negative-+or+positive-pressure+or+displacement+mechanical+valve+needleless+connectors.">Health care-associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors.</a> Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 49 (12), 1821-1827 (2009).</li><li>Btaiche, I. F., Kovacevich, D. S., Khalidi, N., Papke, L. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+needleless+connectors+on+catheter-related+bloodstream+infections.">The effects of needleless connectors on catheter-related bloodstream infections.</a> American Journal of Infection Control. 39 (4), 277-283 (2011).</li><li>Chernecky, C., Waller, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+evaluation+of+five+needleless+intravenous+connectors.">Comparative evaluation of five needleless intravenous connectors.</a> Journal of Advanced Nursing. 67 (7), 1601-1613 (2011).</li><li>. Infusion Resource Library - BD Available from: <a target="_blank" href="https://www.bd.com/en-us/offerings/capabilities/infusion/infusion-resource-library?contenttype=22_productline=115">https://www.bd.com/en-us/offerings/capabilities/infusion/infusion-resource-library?contenttype=22_productline=115</a> (2019)</li><li>Kim, S. C., Klebach, C., Heinze, I., Hoeft, A., Baumgarten, G., Weber, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraclavicular+fossa+ultrasound+view+for+central+venous+catheter+placement+and+catheter+change+over+guidewire.">The supraclavicular fossa ultrasound view for central venous catheter placement and catheter change over guidewire.</a> Journal of Visualized Experiments. (94), 52160 (2014).</li><li>Clavier, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+MaxZeroTM+needle-free+connector+on+the+incidence+of+central+venous+catheter-related+infections+in+surgical+intensive+care+unit.">Impact of MaxZeroTM needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit.</a> Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses. , (2018).</li><li>Lehn, R. A., Gross, J. B., McIsaac, J. H., Gipson, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Needleless+connectors+substantially+reduce+flow+of+crystalloid+and+red+blood+cells+during+rapid+infusion.">Needleless connectors substantially reduce flow of crystalloid and red blood cells during rapid infusion.</a> Anesthesia and Analgesia. 120 (4), 801-804 (2015).</li><li>Ferroni, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pulsative+flushing+as+a+strategy+to+prevent+bacterial+colonization+of+vascular+access+devices.">Pulsative flushing as a strategy to prevent bacterial colonization of vascular access devices.</a> Medical Devices (Auckland, N.Z). 7, 379-383 (2014).</li><li>Flynn, J. M., Keogh, S. J., Gavin, N. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sterile+v+aseptic+non-touch+technique+for+needle-less+connector+care+on+central+venous+access+devices+in+a+bone+marrow+transplant+population:+A+comparative+study.">Sterile v aseptic non-touch technique for needle-less connector care on central venous access devices in a bone marrow transplant population: A comparative study.</a> European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society. 19 (6), 694-700 (2015).</li><li>Merrill, K. C., Sumner, S., Linford, L., Taylor, C., Macintosh, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+universal+disinfectant+cap+implementation+on+central+line-associated+bloodstream+infections.">Impact of universal disinfectant cap implementation on central line-associated bloodstream infections.</a> American Journal of Infection Control. 42 (12), 1274-1277 (2014).</li><li>Mermel, L. A., Bert, A., Chapin, K. C., LeBlanc, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+stopcock+and+manifold+colonization+of+newly+inserted+peripheral+intravenous+catheters.">Intraoperative stopcock and manifold colonization of newly inserted peripheral intravenous catheters.</a> Infection Control and Hospital Epidemiology. 35 (9), 1187-1189 (2014).</li><li>Rosenthal, V. D., Maki, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+study+of+the+impact+of+open+and+closed+infusion+systems+on+rates+of+central+venous+catheter-associated+bacteremia.">Prospective study of the impact of open and closed infusion systems on rates of central venous catheter-associated bacteremia.</a> American Journal of Infection Control. 32 (3), 135-141 (2004).</li><li>Bouza, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+needleless+closed+system+device+(CLAVE)+protects+from+intravascular+catheter+tip+and+hub+colonization:+a+prospective+randomized+study.">A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study.</a> The Journal of Hospital Infection. 54 (4), 279-287 (2003).</li><li>Tabak, Y. P., Jarvis, W. R., Sun, X., Crosby, C. T., Johannes, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+on+central+line-associated+bloodstream+infections+associated+with+a+needleless+intravenous+connector+with+a+new+engineering+design.">Meta-analysis on central line-associated bloodstream infections associated with a needleless intravenous connector with a new engineering design.</a> American Journal of Infection Control. 42 (12), 1278-1284 (2014).</li><li>Wallace, M. C., Macy, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+Central+Line-Associated+Bloodstream+Infection+Rates+in+Patients+in+the+Adult+Intensive+Care+Unit.">Reduction of Central Line-Associated Bloodstream Infection Rates in Patients in the Adult Intensive Care Unit.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 39 (1), 47-55 (2016).</li><li>Btaiche, I. F., Kovacevich, D. S., Khalidi, N., Papke, L. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+needleless+connectors+on+catheter-related+thrombotic+occlusions.">The effects of needleless connectors on catheter-related thrombotic occlusions.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 34 (2), 89-96 (2011).</li><li>Williams, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+Occlusion+in+Home+Infusion:+The+Influence+of+Needleless+Connector+Design+on+Central+Catheter+Occlusion.">Catheter Occlusion in Home Infusion: The Influence of Needleless Connector Design on Central Catheter Occlusion.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 41 (1), 52-57 (2018).</li></ol>

TC, PG and BV previously conducted a study on PPNC valves. BD provided the connectors for this previous work but had no role in the trial initiation, study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit. The other authors have nothing to disclose. The drafting of this protocol was formalized in 2013 with validation by Carefusion consultants.

Setting up the connectors slightly increases the total time required to place the catheter. However, their use has several advantages: no need to maintain a continuous saline perfusion for non-infused lines, rapid stopping of infusion of the lines if necessary (in case of urgent transport of the patient for example), no need to use single-use caps several times a day to close the infusion lines. The use of connectors simplifies the daily use of catheter infusion lines without any particular complications. It should be noted that during our four year experience of these PPNC connectors there have been no complications with rapid fluid administration while this has been described with other types of connectors11. It is essential to maintain complete asepsis when installing the connectors in order to keep the infusion system closed. In addition, regular examination of the connectors for contamination is essential to be able to rinse or change the implicated connectors and avoid bacterial growth. A recent work reports the in vitro efficacy of a pulsative flushing technique to prevent bacterial colonization of vascular access devices but this technique has not been evaluated directly on needleless connectors12. Due to the technical aspect of this kind of connector, nurses must be trained before using these connectors in everyday practice. In this context, the use of Aseptic Non Touch Technique, which is a safe method for managing intravascular devices, is very relevant13. Thus, even after the connectors are set up, direct contact with the connectors should be minimized as much as possible to minimize the risk of contamination. In this context, the use of a disinfectant cap on needleless connectors can help to limit the contact with connectors and is effective in reducing central line-associated bloodstream infections14.
The inclusion of extension tubing, stopcocks and manifolds increase the complexity of the system and expose it to a risk of contamination of stopcocks and manifolds15. Our choice of extensions and infusion lines is the result of a reflection on the balance between patient safety and infectious risk. In the ICU, continuous uninterrupted infusion of certain drugs is essential (e.g., catecholamine, sedation). In our protocol, the use of a 3-way extension stopcock allows medication relays to be easily made without ever interrupting the infusion, which is a guarantee of safety for the patient. The use of a unique 4-port manifold with a perfusion line allows the infusion of several drugs simultaneously (e.g., antibiotics, analgesics, insulin) but the number of these manifolds should be limited to prevent the risk of infection.
Some studies have shown interest in a closed system to prevent colonization and catheter infections16,17. Additionally, several studies have reported a decrease in catheter infection after using PPNCs10,18,19. It is also possible that these connectors may decrease thrombotic catheter occlusions, but there is insufficient evidence to conclude a direct causal link between needleless connectors and catheter occlusions20,21. Moreover, data in the literature support the safe and prolonged use of these devices10,16,19. However, different department may sometimes use different methods to mount connectors on infusion lines and most studies do not describe the method used to install connectors on catheters. It could appear interesting that studies on connectors report their installation protocol to better assess potential differences of practice between teams.

Central venous catheter-related infections (CRI) are a severe complication of central venous catheters in intensive care unit (ICU). The decline in CRI remains an ever-present objective, with a final goal of &#34;zero catheter related infection&#34;1. Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. There are two main designs of connectors: split septum (no internal moving parts) and closed valve systems (internal moving components) but both designs can be combined in one connector2. Needle-free connectors are categorized according to the type of fluid displacement that occurs after disconnection of a male Luer valve: negative (blood reflux into the catheter), neutral, and positive (with a push of blood out of the catheter lumen)2,3.
Some connectors have been described as a cause of catheter-related infections, in particular in the intensive care unit (ICU)4,5,6. A new generation of needle-free connectors with minimal internal complexity, a reduction or elimination of interstitial or dead space, a visible fluid path to help assess proper flushing technique, and a flat access surface, etc. has been designed to lower the risk of infection. In vitro, these connectors have shown low bacterial colonization7. There are global recommendations from the laboratory manufacturing these connectors; however, there is no practical description of how to install them on catheters8. Hence, it is possible that each team uses them differently. Therefore, we propose a formalized protocol for the installation of these connectors on central venous lines in the ICU.
We present the installation of a positive pressure needleless connector (PPNC) with an internal silicone piston in our ICU but this protocol is applicable with any positive displacement valve. This valve is a mechanical needle-free connector with positive displacement.

<table><tbody><tr><td>BD MaxZero&amp;trade;&amp;nbsp;needle-free connector</td><td>Becton Dickinson</td><td>MZ1000-07</td><td>we present the installation of the connector with MaxZero but this protocol is applicable with any positive displacement valve.</td></tr><tr><td>4-port mannifold with PE/PVC extension</td><td>Cair-LGL</td><td>RPB4310A</td><td></td></tr><tr><td>PE/PVC extension line with 3-way stopcock</td><td>Cair-LGL</td><td>PE3302M</td><td></td></tr><tr><td>NaCl 0.9% 250 ml</td><td>Baxter</td><td>2B1322</td><td></td></tr><tr><td>BD&amp;nbsp;Plastipak&amp;trade; 50mL Luer-Lock Syringe</td><td>BECTON DICKINSON MEDICAL</td><td>613-3925</td><td></td></tr></tbody></table>

a protocol to set up needle-free connector with positive displacement on central venous catheter in intensive care unit

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from &#34;opening&#34; once it has been sterilely installed.

Once all the elements are in place, the catheter has connectors on almost all the junctions between two infusion lines (Figure 1). Thus, it has proximal connectors on each line and two connectors on the sockets of the 3-way extensions (Figure 2). Each infusion line has connectors at all its female sockets (Figure 3). Once the assembly is in place, any injection or infusion (continuous or discontinuous) must be made, after disinfection, through one of the connectors of the infusion lines or extensions (Figure 4).
Maintaining the connectors in place keeps the infusion system closed as well as sterile mounted and minimizes the risk of bacterial contamination. One of our previous works, the first study that prospectively analyzed these devices over several years, showed a significant decrease in CRI incidence during the six-year period framing the introduction of the connectors (Figure 5)10. In this work, the incidence of CRI before using connectors was 6.2 CRI/1000 catheter-day vs. 2.7 CRI/1000 catheter-days after using connectors10. Moreover, we did not find any increase of CRI after the beginning of connector use (Figure 5) and there was no significant difference concerning the kind of bacteria species involved in CRI10. We have not identified any specific complications associated with the use of these connectors during these years of use.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/59801/59801fig01.jpg" /> 
Figure 1: Global view of the catheter once the connectors have been placed. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/59801/59801fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/59801/59801fig02.jpg" /> 
Figure 2: Proximal part of the catheter with proximal connectors (A) and connectors on the 3-way extension stopcock (B). <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/59801/59801fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/59801/59801fig03.jpg" /> 
Figure 3: 4-port manifold with connectors. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/59801/59801fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/59801/59801fig04.jpg" /> 
Figure 4: Steps of injection through a connector.&#160;(A) Disinfect the surface of the connector for 3 seconds with 70% isopropyl alcohol. Wait until the connector is dry. (B) Insert the tip of the syringe or infuser into the connector. (C) Inject or infuse the medication. (D) Remove the syringe or infuser. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/59801/59801fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/59801/59801fig05.jpg" /> 
Figure 5: Evolution of catheter-related infection incidence before and after the use of connectors.&#160;Figure taken from Clavier et al.10 <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/59801/59801fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit at JoVE.com

A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit

We present a protocol to show the installation of a needle-free connector with positive displacement on a central venous catheter.

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest ...

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12.1K Views.  Rouen University Hospital. We present a protocol to show the installation of a needle-free connector with positive displacement on a central venous catheter.

Video: A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit

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COVID-19 / Coronavirus Outbreak: Hemodynamic monitoring with PiCCO artery

During pandemics, medical staff become a key resource in treating and managing patients with these infectious diseases. To achieve the best medical care, relevant techniques and procedures must be taught to medical staff which minimize the risk of work-related transmission of infection. When carrying out hemodynamic monitoring in cardiovascularly unstable patients, it is possible to utilize a Pulse Contour Cardiac Output (PiCCO) catheter. This system utilizes a thermodilution method to analyze a patient&#8217;s cardiovascular status. This video highlights&#160;the placement and setup of a PiCCO catheter and system, including both the practical component and analysis of the thermodilution method, whilst taking into account important personal protection measures.

COVID-19 / Coronavirus Outbreak: Hemodynamic Monitoring with PiCCO artery

During pandemics, medical staff become a key resource in treating and managing patients with these infectious diseases. To achieve the best medical care, ...

Peripheral Intravenous Catheter Insertion

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
The purpose of peripheral intravenous catheter (PIV) insertion is to infuse medications, perform intravenous (IV) fluid therapy, or inject radioactive tracers for special examination procedures. Placing a PIV is an invasive procedure and requires the use of an aseptic, no-touch technique. 
Common IV venipuncture sites are the arms and hands in adults and the feet in children. According to the Intravenous Nurses Society (INS), the feet should be avoided in the adult population because of the risk of thrombophlebitis. Venipuncture sites should be carefully assessed for contraindications, such as pain, wounds, decreased circulation, a previous cerebral vascular accident (CVA), dialysis fistulas, or a mastectomy on the same side. The median cubital vein and the cephalic vein in the wrist area should be avoided when possible. The cephalic vein has been associated with nerve damage when used for IV placements. The most distal site available on the hand or arm is preferred so that future venipuncture sites may be used if infiltration or extravasation occurs.
This video will demonstrate the insertion of a PIV, including the preparation and attachment of an IV extension set. Although a PIV securement device is used here to stabilize the IV catheter, according to INS recommendations, some facilities may not elect to purchase these devices, and the alternate chevron or U-shaped taping method may also be used.

Peripheral Intravenous Catheter Insertion: No Touch Technique

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
The purpose of peripheral intravenous catheter ...

Nursing Skills

Peripheral Venous Cannulation

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
Placement of an intravenous (IV) catheter is one of the key procedures in medicine. The IV catheter allows patients to receive critical medications, including pain medicine, insulin, antibiotics, blood products, and fluids for rehydration. Additionally, placing an IV catheter allows for blood samples to be obtained, which can be sent to the laboratory for testing and evaluation. A majority of peripheral IV lines are placed in the superficially located veins of the upper extremities. IV catheters can be placed in any superficial vein from the upper arm to the hand (though the veins in the antecubital fossa are larger than those in the hand). IV catheters can be placed in the lower extremities as well; however, this procedure should be performed with caution in patients with a history of diabetes or poor peripheral circulation.

Peripheral Venous Cannulation and Catheter Insertion

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
Placement of an intravenous (IV) ...

Emergency Medicine and Critical Care

Central Venous Catheter Insertion: Internal Jugular

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, intravascular device delivery (pacing wires, Swann-Ganz catheters), volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy.
Safe reliable placement of a central venous catheter (CVC) in the internal jugular (IJ) vein using ultrasound guidance has become the standard of care. It is therefore imperative to understand the anatomy, the relationship between the IJ and the carotid artery, and their appearance on ultrasound. It is also necessary to have the psychomotor skills of vessel cannulation under ultrasound guidance.
Seldinger technique is an introduction of a device into the body over a guide wire, which is inserted through a thin-walled needle. In the case of CVC insertion, the device is an intravascular catheter and the target vessel is a central vein. First, the target vessel is cannulated with an 18 gauge thin-walled needle. A guide wire is then passed thought the needle until it is appropriately positioned within the vessel. The needle is removed, and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. The dilator is then removed, and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed.
Successful placement of a CVC using ultrasound consists of a working understanding of the target anatomy, facility with procedural ultrasound, and fluidity in Seldinger technique. An IJ CVC can be placed in either the right or the left IJ vein. In general, however, the right IJ vein is preferred because of its straight route to the superior vena cava (SVC), which makes malposition of the catheter less likely.
There are several types of CVC kits commonly available marketed by different manufacturers. CVCs may a single lumen, a double lumen, or a triple lumen. For purposes of this discussion, we will place a triple-lumen CVC, as this is commonly needed when multiple different medications need to be delivered simultaneously. The procedure for placing any type of CVC is the same.

Catheter Insertion in Internal Jugular: the Seldinger Technique

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of ...

Central Venous Catheter Insertion: Femoral Vein

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the femoral. Each of these vessels has distinct advantages and disadvantages with unique anatomical considerations. 
Femoral vein cannulation can be easily performed both under ultrasound guidance and using the surface landmarks; therefore, femoral access is often used when emergent placement of a central venous catheter (CVC) is needed (such as in the case of medical codes and trauma resuscitations). In addition, cannulation of the femoral artery allows one to simultaneously perform other procedures needed for stabilization, such as cardiopulmonary resuscitation (CPR) and intubation.
Successful placement of a femoral CVC requires working understanding of the target anatomy, access to with procedural ultrasound, and fluidity in the Seldinger technique.
Seldinger technique is the introduction of a device into the body over a guide wire, which is placed through a thin-walled needle. In the case of CVC insertion, the device is an intravascular catheter and the target vessel is a central vein. First, the target vessel is cannulated with an 18-gauge thin-walled needle. A guide wire is then passed through the needle until it is appropriately positioned within the vessel. The needle is removed and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. The dilator is then removed and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed.
The main disadvantage of a femoral CVC is the high incidence of infection due to proximity to the groin (and often as a result of the quasi-sterile nature under which emergent CVCs are placed). Femoral lines should be replaced early on in the patient's hospital course if sustained central access is needed. A line placed with minimal sterility should be replaced as soon as the patient is stable.

Catheter Insertion in Femoral Vein: FV CVC Placement

Central Venous Access Device Dressing Change

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
Central venous access devices (CVAD), commonly known as central lines or central catheters, are large-bore intravenous (IV) catheters that are introduced into the central circulation. Typically, CVADs terminate in the superior vena cava, just outside of the right atrium of the heart, but they may also terminate in any one of the great veins (i.e., aorta, inferior vena cava, brachiocephalic vein, pulmonary artery, internal iliac vein, or common femoral vein). Patients may need a CVAD for any number of reasons. CVADs allow for the rapid infusion of fluids to treat significant hypovolemia or shock. They are also beneficial when administering vasoactive medications, highly concentrated medications, total parenteral nutrition (TPN), or chemotherapy, because the increased blood volume in these areas allows for the hemodilution of these potentially caustic or reactive agents. Patients who must receive multiple non-compatible IV medications, those that require long-term IV medications, or those with limited vascular access may also require the placement of a CVAD. These devices may be tunneled (i.e., inserted into a vein at one location and tunneled under the skin to emerge through the skin at another site) or non-tunneled (i.e., inserted through the skin and directly into a vein). Examples of CVADs include multi-lumen central venous catheters, pulmonary artery catheters, dialysis catheters, port-a-cath, and peripherally inserted central catheters (PICC). 
Because CVADs are introduced into the central circulation, it is important that they are cared for using strict aseptic technique to prevent central line associated blood infections (CLABSI). Nursing standards of care mandate using "sterile technique" when changing CVAD dressings. The Centers for Disease Control recommends changing CVAD dressings at least every 2 days for gauze dressings and at least every 7 days for transparent dressings on adult patients. For pediatric patients, the CDC recommends using clinical judgment to determine the appropriate timing of CVAD dressing changes, as the risk of line removal during the dressing change may outweigh the benefits. 
This video presents the process of changing CVAD dressings using sterile techniques.

Source: Madeline Lassche, MSNEd, RN and Katie Baraki, MSN, RN, College of Nursing, University of Utah, UT
Central venous access devices (CVAD), commonly ...

Central Venous Catheter Insertion: Subclavian Vein

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of clinical situations for hemodynamic monitoring, medication delivery, and blood sampling. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the femoral vein.
Central venous access via the subclavian vein has several advantages over other possible locations. The subclavian central venous catheter (CVC) placement is associated with lower infection and thrombosis rate than internal jugular and femoral CVC. Subclavian line can be placed quickly using anatomic landmarks and are often performed in trauma settings when cervical collars obliterate the access to the internal jugular (IJ) vein. The most significant disadvantage of the subclavian access is the risk of pneumothorax due to the anatomic proximity to the dome of the lung, which lies just superficial to the subclavian vein. In addition, in the event of an inadvertent arterial puncture, the access to the subclavian artery is impeded by the clavicle, which makes it difficult to effectively compress the vessel.
Successful placement of the subclavian CVC requires good working understanding of the target vessel anatomy as well as fluidity in performing the Seldinger procedure (an introduction of the catheter into a vessel over the guide wire, which is inserted through a thin-walled needle). First, the subclavian vein is cannulated with an 18-gauge thin-walled needle. A guide wire is then passed thought the needle until it is appropriately positioned within the vessel. Next, the needle is removed, a dilator is passed over the wire to dilate the skin and soft tissue, and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed, and the catheter is sutured in place.
There are several types of CVC kits commonly available marketed by different manufacturers. CVCs may have a single lumen, a double lumen, or a triple lumen. For purposes of this discussion, we will place a triple-lumen CVC, as this is commonly needed when multiple different medications need to be delivered simultaneously. The procedure for placing any type of CVC is the same.