The purpose of this video is to provide general information and education about the care of
a critically ill child. It is in no way a substitute for the independent decision-making
and judgment by a qualified health care professional. The information contained in this video should
not be used to make a diagnosis or to overrule the advice of a qualified healthcare provider,
not should it be used to provide advice for emergency medical treatment.
Accessing a Central Venous Catheter by Mary- Jeanne Manning, please note that in this video
we will be following the guidelines used at Boston Children’s Hospital. Some of this
information may need to be modified based on the equipment, guidelines, and practices
in place in your institution.
Introduction.
Hello, my name is Mary Jeanne Manning; I’m a Clinical Nurse Specialist in Pediatric Critical
Care of the Critical Care Department at Children’s Hospital Boston. In this segment, I will be
reviewing access of a central line and drawing blood specimens.
Indications.
You would want to perform this procedure in order to draw blood from a patient, or to
administer medications, fluids, or blood products in a patient with a central venous catheter
in place, to provide long-term infusion therapy when peripheral access is unavailable, to
provide vesicant or hyperosmolar infusions or to provide complex infusion therapies.
You would also want to perform this procedure in order to check the patency of a central
venous catheter that is not in use.
Contraindications.
Some healthcare providers would refrain from performing this procedure if they suspect
the presence of a thrombus or an infection in the central line, which may manifest itself
as an excess amount of fluid and/or discharge at the insertion site of the central line.
A fracture or disruption of the central line would also prompt healthcare providers to
refrain from performing this procedure.
Equipment.
You will need the following equipment to perform the procedure: A 3 mL syringe, shown here
on the left, and a 10 mL syringe, shown on the right,
Point of Clarification:
Syringe Sizes and Uses.
Note: That two different sizes of syringes are generally used for this procedure. A larger
10mL syringe is used for flushing the catheter and checking for a blood return. A smaller
3mL syringe is used when collecting blood to perform blood tests.
Saline flush, Blood specimen containers, Antiseptic wipes, 2-by-2 gauze, Clean gloves, Hand sanitizer
Procedure.
So to begin, we always begin by explaining to the patient, if it’s age-appropriate,
and cleaning our hands. I am using an antiseptic sanitizer; if my hands are soiled, I would
use soap and water scrub. After explaining to the patient, we would get our equipment
ready, and I would start with gloves. This is not a sterile procedure, so clean gloves
are adequate, and there is no need for a mask. Next, I will open my 2-by-2 gauze sponge,
a Chloroprep or antiseptic wipe that your institution uses – we place that right on
top of the 2-by-2 gauze. I pick up the appropriate tube ending and take my antiseptic swab and
2-by-2 gauze, wrap it firmly around the end, and scrub. Here, in the MSICU at Children’s
Hospital Boston, we scrub for 30 seconds. We have found this reduces our chance of central
line infections. Other institutions in other areas may use less time to scrub, for instance
10 or 15 seconds. Please go by your own institution’s policy. Once we have scrubbed for 30 seconds,
we let it dry for 30 seconds. We have found that letting it dry prevents stickiness from
forming around the site. Therefore, if tubing or a syringe is attached, it will be easier
and won’t stick when we discard it from the device. So once that is dry, we will take
a normal saline-filled syringe, empty the air out of the syringe, and directly attach.
Again, this is equipment that we use at Children’s Hospital Boston; please use the proper equipment
as per your institution.
First we will flush slightly to make sure the tubing is patent. Always pull back to
make sure you have a blood return as well; this manikin does not have a blood return
at this time. Showing a blood return and flushing to note resistance will tell you if your line
is patent. Once I know that I have good flow and blood draw, I can prepare to draw blood.
If at all you meet resistance when flushing and cannot get a blood return, please refer
to the appropriate personnel. Once clean and dry and flushed, I now can draw my blood,
whatever size syringe is needed depending on the amount of blood to be drawn. Once the
specimen is drawn, it should be prepared and placed in the appropriate blood specimen tubing.
A second 2-by-2 gauze and antiseptic wipe should be prepared at this time to cleanse
the line one more time. It is not necessary to scrub for another 30 seconds; 10 seconds
should be fine. Again, you should check for patency and flush your line, as to prevent
any clotting. So with a sterile saline syringe, I will flush and make sure I don’t meet
any resistance. This cleans blood out of the end of the line to prevent clotting.
Complications
The complications that you may observe include: Infection, Air embolism, Dislodgment of a
thrombus, Dislodgement of the central line catheter itself. Please note that you may
or may not observe any of these complications during or following this procedure. I encourage
you to monitor your patient closely for signs or symptoms of complications, and to be prepared
to manage them, which includes having the necessary equipment available to treat the
complications should any arise.
Assessment and Monitoring
First of all, it is important to monitor the ease or difficultly with obtaining a blood
return. You will also want to assess the ease or difficulty when flushing the catheter with
normal saline. Lastly, if placement is in or near the right atrium, be sure to monitor
for any arrhythmias.
Documentation
Following central line access, you should document the following information in the
patient’s medical record: The indication for the procedure, The date and time of the
procedure, Type, size, and position of the central venous line, Appearance of the insertion
site, The ease or difficulty with obtaining a blood return when flushing the catheter,
Any medications that are administered through the central line during this procedure, Any
adverse outcomes
And that’s the end of this segment.
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