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Emergency Management of the Hi-Tech Patient in Acute and Critical Care


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Anatomy

Schematic illustration of CVC anatomy. (a) Externalized indwelling CVC and (b) implanted port.

      (Source: ©2020 The Children’s Hospital of Philadelphia, CHOP Family Information Line Drawing w/anatomy, (a): https://www.chop.edu/treatments/tunneled‐catheter‐placement; (b): https://www.chop.edu/treatments/implantable‐venous‐port.)

Schematic illustration of externalized indwelling CVC. Schematic illustration of fully implanted CVC.

      (Source: Image courtesy of Macmillan Cancer Support, UK.)

Identify the patient and explain the procedure to the patient and family.Position the patient safely. Supine positioning is preferred; women and adolescent girls should have their brassiere removed on the side of the catheter.Perform hand hygiene and don sterile gloves. Some institutions will also require practitioners to wear a mask and/or sterile gown.Prime all tubing and connectors to be used in the procedure to purge them of air.Place a sterile towel or drape under the externalized portion of the catheter.If the patient's CVC does not have its own clamp, clamp the line at least 3 in. proximal to the cap using forceps without teeth.Remove the catheter cap and scrub the hub with alcohol, allowing it to dry fully (at least 5–10 seconds).Attach a 10 cc syringe of normal saline; unclamp the catheter and slowly inject up to 5 cc of saline. If the line flushes easily, aspirate the instilled fluid and check for blood return.If there is resistance to fluid infusion or no blood return with aspiration, the line is likely occluded (see the section on troubleshooting an occluded CVC). Recap the line and do not inject fluids or medications into the occluded line.If there is successful blood return with aspiration, instill the remaining saline in the syringe. Clamp the line and remove the syringe.If the line is needed for blood drawing, aspirate 3–5 cc from the line prior to clamping, as in Step 10. Discard this saline‐and‐blood mixture, and attach a new, empty syringe to the catheter cap. Unclamp the catheter and withdraw the needed volume of blood. Reclamp the catheter, attach a second 10 cc syringe of saline, unclamp the catheter, and flush the line to clear blood from the line. Clamp the catheter after flushing and remove the syringe.If the line is needed for infusion of medications or fluids, connect primed IV tubing to the catheter hub, unclamp the catheter, and administer fluids or medications as care dictates.