Fonte: Madeline Lassche, MSNEd, RN e Katie Baraki, MSN, RN, College of Nursing, Università dello Utah, UT
I dispositivi di accesso venoso centrale (CVAD), comunemente noti come linee centrali o cateteri centrali, sono cateteri endovenosi (IV) di grandi dimensioni che vengono introdotti nella circolazione centrale. Tipicamente, i CVAD terminano nella vena cava superiore, appena fuori dall’atrio destro del cuore, ma possono anche terminare in una qualsiasi delle grandi vene(cioè aorta, vena cava inferiore, vena brachiocefalia, arteria polmonare, vena iliaca interna o vena femorale comune). I pazienti possono aver bisogno di un CVAD per una serie di motivi. I CVAD consentono la rapida infusione di liquidi per trattare l’ipovolemia o lo shock significativi. Sono anche utili quando si somministrano farmaci vasoattivi, farmaci altamente concentrati, nutrizione parenterale totale (TPN) o chemioterapia, perché l’aumento del volume del sangue in queste aree consente l’emodiluizione di questi agenti potenzialmente caustici o reattivi. I pazienti che devono ricevere più farmaci IV non compatibili, quelli che richiedono farmaci IV a lungo termine o quelli con accesso vascolare limitato possono anche richiedere il posizionamento di un CVAD. Questi dispositivi possono essere tunnelati(cioè inseriti in una vena in una posizione e tunnelati sotto la pelle per emergere attraverso la pelle in un altro sito) o non tunnel(cioè inseriti attraverso la pelle e direttamente in una vena). Esempi di CVAD includono cateteri venosi centrali multi-lumen, cateteri per arteria polmonare, cateteri per dialisi, port-a-cath e cateteri centrali inseriti perifericamente (PICC).
Poiché i CVAD vengono introdotti nella circolazione centrale, è importante che siano curati utilizzando una rigorosa tecnica asettica per prevenire le infezioni del sangue associate alla linea centrale (CLABSI). Gli standard infermieristici di cura impongono l’uso di “tecnica sterile” quando si cambiano le medicazioni CVAD. I Centers for Disease Control raccomandano di cambiare le medicazioni CVAD almeno ogni 2 giorni per le medicazioni di garza e almeno ogni 7 giorni per le medicazioni trasparenti sui pazienti adulti. Per i pazienti pediatrici, il CDC raccomanda di utilizzare il giudizio clinico per determinare i tempi appropriati dei cambiamenti di medicazione CVAD, poiché il rischio di rimozione della linea durante il cambio di medicazione può superare i benefici.
Questo video presenta il processo di modifica delle medicazioni CVAD utilizzando tecniche sterili.
This video details the process of changing a dressing from a CVAD using sterile technique. While it is important to maintain an aseptic approach, the most critical component of the process is to recognize when sterility has been compromised. This requires focus and awareness, as well as being sure not to turn your back on the sterile field. Common mistakes during CVAD dressing changes are failure to recognize when sterility has been compromised, when new supplies are needed, or when the process needs to be restarted. Another mistake is failing to secure the catheter, causing the catheter to inadvertently dislodge from the insertion site. If the catheter becomes dislodged, sterility should be maintained, and the catheter should be secured in place. The CVAD should not be used (i.e., stop all infusions), the primary care provider should be notified immediately, and an x-ray should be obtained to determine the viability of the catheter. The catheter should never be pushed back into the site, as this can result in damage to the vessel or the introduction of pathogens into the site.
Central venous access devices, abbreviated as “CVADs,” are commonly called central lines or central catheters and are introduced into a patient’s central circulation system. Examples of CVADs include multi-lumen central venous catheters; pulmonary artery catheters; dialysis catheters; port-a-cath; and peripherally inserted central catheters, or PICC.
Because CVADs are introduced into central circulation, it is important that they are cared for using strict aseptic technique to prevent central line associated blood infections, or CLABSI. The Centers for Disease Control recommends changing CVAD dressings in adult patients at least every 2 days for gauze dressings and at least every 7 days for transparent dressings. When caring for pediatric patients, nurses are advised to use their clinical judgment to avoid the risk of accidental line removal during dressing changes.
Nursing standards of care mandate using sterile technique when changing the dressings of CVADs, and this video will illustrate this entire process in detail.
Patients may need a CVAD for any number of reasons. To review these reasons, please see the text protocol below.
To begin, first perform hand hygiene by either washing hands or using hand sanitizer.
At the bedside computer, log into the patient’s electronic health record and review the patient’s medical history and documentation of previous CVAD dressing changes. Discuss with the patient any preferences or complications experienced during previous dressing changes. Assess the CVAD insertion site and dressing. The considerations are similar to the assessment performed on a peripheral intravenous line, covered in another video of this collection. Leave the patient’s room and perform hand hygiene.
Now, gather the supplies needed to change the CVAD. The supplies may be included in a CVAD dressing change kit. In addition, obtain an extra pair of sterile gloves in case of contamination, clean exam gloves for dressing removal procedure, and an extra face mask for patient use.
If a kit is not available, needed supplies include sterile gloves, clean gloves, 2 face masks, 2% chlorhexidine wand, presoaked antimicrobial disc, alcohol swab, 1-inch cloth tape, and a transparent dressing. If institutional policy requires central line anchoring device, retrieve this item if not included in the CVAD dressing change kit. Assess all packages for sterility. Packages that are damaged, wet, soiled, stained, or past the expiration date should not be used.
Now, take the gathered supplies and walk to the patient’s room. Set the supplies down on a clean, dry surface and perform hand hygiene. Inform the patient that you will be changing the central line dressing. If tolerated by the patient, assist them to occupy a semi-Fowler’s position. Give a facemask to the patient and instruct them to turn their head away from the insertion site during the dressing change to prevent site contamination.
Next, pull the bedside table and trashcan toward the head of the patient’s bed, on the side of the CVAD dressing and perform hand hygiene again. At this point, don clean gloves and wipe the table clean using an institutionally approved wipe. Next, dry the surface with a paper towel. Now you are ready to remove the central line dressing.
To begin, discard the worn gloves, wash hands, and don a new pair of clean gloves. Using your non-dominant hand, gently hold the CVAD in place while peeling back any tape that is anchoring the CVAD lines outside of the transparent dressing. Discard in a trash receptacle.
Now, gently peel back a small portion of the corner of the old dressing, pulling toward the insertion site. With your non-dominant hand, hold the skin near the site that you are pulling to ease the removal of the dressing and decrease tissue damage and pain. Continue to peel the corner back until you are within about 2 cm from the insertion site.
Using this same process, peel back the other three corners of the dressing. During this whole process, hold the CVAD tubing with your non-dominant hand, to avoid accidental dislodgement during the removal of the dressing. Next, grasp a corner at the bottom of the dressing and remove it by pulling towards the insertion site and out and away. This approach will help to prevent accidentally dislodging the central catheter. Drop the old dressing into the trash receptacle, remove and discard the gloves, and perform hand hygiene.
Now that the old dressing has been removed, prepare the sterile field before applying the new dressing. Open the outer packaging of the sterile field and gently remove the contents. Place the packaging on the center of the bedside table and unfold the packaging once. With both hands, grasp the edges of the center seam of the packaging and gently pull the packaging outward. Crease the packaging if necessary to ensure the packaging stays open. Avoid touching more than the very edges of the packaging. The outer one inch of the package edges should be considered non-sterile, as well as any portion of the package that hangs over the table edge.
Next, add other supplies one by one to the sterile field. Hold the package and contents securely and, with your non-dominant hand, gently peel back the wrapper. Then hold the package a few inches above the sterile field and gently drop the item out of the package and onto the sterile field. Take care not to touch the sterile field with the supply package. Do not allow your arms to cross over the sterile field, and always drop the item near the center of the field. If the item falls in the one-inch border, a new item must be obtained. Repeat the same steps until all items have been removed from packaging and are on the sterile field.
Next, don the sterile gloves. With your non-dominant hand, gently grasp the inner cuff of the glove for your dominant hand. Insert the fingers of your dominant hand into the glove. Gently pull the glove cuff until it is completely applied. Take care not to touch any external surfaces of the glove. Now, with your sterile-gloved dominant hand, rearrange supplies on your sterile field if necessary to access the remaining glove. Insert the fingers of your non-dominant hand into the glove, taking care not to contaminate sterile surfaces. Gently push the glove cuff with the other hand until it is secure in place. Rearrange the gloves as needed until they fit securely and snuggly, taking care to avoid touching any exposed skin.
Now, clean the insertion site before applying the new dressing. To start, grasp the chlorohexidine wand and gently squeeze the wings toward the wand to release the fluid. Gently press the chlorohexidine wand at the CVAD insertion site to start the fluid flowing.
Grasp the CVAD tubing between the pinky and ring fingers of your non-dominant hand. This will allow you to move the tubing as you clean the insertion site. These two fingers are now considered non-sterile and should not touch any sterile items henceforth. Clean the insertion site for at least 30 seconds, using a back-and-forth motion and friction. Finish cleaning by gently moving up the catheter tubing.
All surfaces should be allowed to dry completely. For some products, this may take up to two minutes. Do not fan the site to promote drying. In some cases, institutional policy may require an antimicrobial disc at the insertion site for up to 72 hours. If so, place the disc under and around the catheter tubing.
Next, using the dominant hand, pick up the transparent dressing and remove the backing using your non-dominant hand. Hold the dressing just above the CVAD insertion site using both hands. Center the dressing over the site and then place it on the skin. Gently push down on the dressing to remove any air bubbles and secure the dressing to the site.
Next, remove the center window packaging from the front of the transparent dressing. This packaging often includes a sticker for labeling; do not discard the labeling sticker. If a second anchoring strip with a small cutout is included in the CVAD kit, remove the backing and place it under the CVAD lines and just over the transparent dressing.
Now, write the date and time of the dressing change on the sticker and place it on any outer edge of the transparent dressing. Next, place the external anchoring device, if required by institutional policy. Then remove and dispose sterile gloves, personal and patient facemasks. Discard supply packaging and perform hand hygiene.
Finally, go to the electronic health record and document the dressing change. Be sure to include the date, time, location, and site of the dressing change. Also, record your assessment of the site and how the patient tolerated the dressing change. Leave the patient’s room and wash hands thoroughly.
“Caring for these CVADs requires sterile technique to prevent the potential for central line associated blood infections. While it is important to maintain an aseptic approach, the most critical component of the process is to recognize when sterility has been compromised. This requires focus and awareness and ensuring that you do not turn your back on the sterile field.”
“Common mistakes during CVAD dressing changes are failure to recognize when sterility has been compromised and when new supplies are needed or the process needs to be restarted. Another mistake is failing to secure the catheter, and the catheter is inadvertently dislodged from the insertion site.”
“If the catheter becomes dislodged, be careful to maintain sterility. Secure the catheter in place, don’t use the CVAD, and stop all infusions. Also, notify the primary care provider immediately and obtain an x-ray to determine if the catheter can be used. The catheter should never be pushed back into the site, because this can result in vessel damage or contamination with pathogens.”
You’ve just watched JoVE’s video on changing a dressing for a central venous access device using sterile technique. You should now understand the different types of CVADs and the importance of utilizing sterile technique in the process of changing the CVAD dressing for a patient. As always, thanks for watching!
