By Jean McCaslin, RN, IgCN.

In our last blog, the types of central catheters typically used for the infusion of IVIG were discussed. Also reviewed, was the assessment of these ports as it relates to IVIG therapy. In this blog, the care of central lines (herein called VADs; Vascular Access Devices) and potential complications will be covered. This discussion will be limited to the intermittent use of VADs for IVIG therapy being given between 1-5 days monthly. For more detailed information regarding continuous VAD use, or the administration of other medications, please refer to the INS standards published on their website.

CARE OF VASCULAR ACCESS DEVICES:

Each healthcare entity (including hospitals, home care agencies, nursing agencies, infusion suites, and specialty pharmacies) are tasked with the development of policies and/or protocols for the insertion, care, and maintenance of VADs. Some items for consideration include, but are not limited to, the following:

1. Administration sets:
1. Administration sets and any add-on devices (extension tubing, claves, filters, and needleless devices) should be of luer-lock design to ensure secure connections.
2. These items should be primed just prior to use. Each device should be labeled with time, date, and RN initials while VAD is accessed.
3. Disinfect needless connectors prior to each access, using aseptic no-touch technique. Scrubbing times and disinfecting agents vary depending on manufacturer; they range between 5 and 60 seconds. Check workplace policies for specifics.
4. Needleless connectors should be changed when the primary access line/extension is changed; no more often than 96 hours to avoid unnecessary breaks in system.
5. For IVIG administration, new tubing should be used at the start of each day of therapy. A dedicated infusion set should be used; IVIG should not be piggy-backed into a Y-connector.
2. Filtration:
1. Filtration of IVIG solution is rarely needed as most IVIG products have moved away from the lyophilization process. Some products state in their package inserts that IVIG may be filtered, but it is not necessary.
2. Today, only Gammagard SD (lyophilized) still requires filtration.
3. Stabilization devices:
1. Stabilization/securement devices are recommended to avoid unintentional loss of access. Dressings and tape should not be relied upon alone for securement.
4. Patency, flushing:
1. VADs are flushed and aspirated for blood return prior to each infusion in order to confirm functionality and to avoid complications.
2. A 10 ml syringe should be used to assess patency in order to maintain catheter integrity.
5. VAD locking:
1. VADs are flushed at the completion of infusion to clear residual IVIG solution and avoid occlusion.
2. Only single use pre-filled syringes should be used and if resistance is met, never be forcibly flushed.
3. The volume of flush solution should be equal to the volume of VAD system times 2.
4. VADs fluid-lock solutions vary by catheter type; either heparin (10 or 100 U/ml, as ordered) or NS is used. Always ascertain catheter type and follow manufacturer guidelines and those of your workplace.
PICC locking:  PICC fluid-locking solution is typically Heparin 10 U/ml; variable by brand.

Midline locking:  Midline catheters may be flushed with either Heparin 10 U/ml or NS; again based on manufacturer recommendations.


6. Site/dressing care basics:
1. All VADs in use, and midline catheter sites require site care and dressing changes at pre-determined intervals, and when integrity of the dressing is compromised.
2. Gauze dressings are changed every 2 days unless moist; transparent dressings are changed every 5 - 7 days.
3. Chlorhexidine 2% (e.g., Chloraprep) is the preferred skin antiseptic agent; tincture of iodine, 70% alcohol, or povidone-iodine may be substituted. Tincture of benzoin should be avoided to reduce the possibility of skin injury.
4. For sensitive skin, a skin barrier solution may be applied.
7. Supplies; VAD or midline catheter dressing:
1. Masks (for RN and patient).
2. VAD/central line dressing kit if available, gloves (sterile and non-sterile), antiseptic solution, securement device, skin barrier solution, antimicrobial dressing, gauze pads, tape, transparent dressing, label.
8. Dressing change procedure:
1. Wash hands, gather supplies, explain procedure.
2. Apply mask to RN and patient, assemble supplies on sterile field.
3. Apply non-sterile gloves, remove dressing, assess site (covered in Part One of Two. Types of Central Catheters used for IVIG, Assessment, Care, and Complications), remove securement device, remove gloves.
4. Wash hands, apply sterile gloves, cleanse skin with antiseptic and allow to dry completely.
5. Apply antimicrobial dressing, apply skin barrier solution, apply securement device, apply transparent dressing, discard waste appropriately, remove and discard gloves, wash hands.
6. Label, date, initial.
9. Patient education:
1. Patient education is a critical component of infection prevention. Patients must be instructed to keep the dressing over the Huber needle insertion site clean and dry.
2. Patient may not swim or shower over the 1 - 5 day course of IVIG therapy with their VAD accessed.

POTENTIAL COMPLICATIONS ASSOCIATED WITH VASCULAR ACCESS DEVICES:

Many of the potential complications associated with the use of Vascular Access Devices may be prevented through education, proficient insertion and access technique, strict policy adherence, astute assessment skills, and aseptically performed technique. As discussed, patient education is a critical component as well.

Some Potential Complications with the use of a VAD are:

1. Infection: Hand-washing adherence, aseptic technique, and education are all effective preventative measures. It is important to limit the number of times an accessed device is penetrated when possible and to be diligent when performing assessments.
2. Mechanical occlusion: VADs may become kinked or lay against a vessel wall either during insertion or over time. There also may occasionally be manufacturing defects that cause partial occlusions.
3. Thrombin sheath occlusion: Over time, the tip of any indwelling catheter may become occluded due to fibrin sheath formation.
4. Emboli (blood clot or air): VADs are at risk for the formation of blood clots along the inside or outside wall of a catheter; these clots could potentially break loose and travel into a limb, lungs, brain, or heart. Air emboli can occur at any time during routine use of a VAD. It is important to have patients perform a Valsalva maneuver and hold breath during access and tubing change procedures.
5. Catheter migration: PICC lines in particular are at risk for catheter migration. Patient education and astute assessment skills are critical in preventing migration.
6. Pain: On occasion, patients experience discomfort from VADs. This can be caused by inconvenient placement, bruising at Huber-needle or PICC insertion site, infection, or poorly applied securement device.
7. MARSI (Medical Adhesive-Related Skin Injury): Many patients with thin, fragile skin experience irritation to their skin at or surrounding their VADs. An added irritant may be either the antiseptic, adhesive, or dressing components. Over time, these areas with fragile skin may experience painful redness or skin tears. There are now many available products to prevent such injuries.
8. Port-inversion: Port-a-caths are typically held securely in place under the skin with sutures. Some very slim patients have less available tissue to suture port onto. Patients who lose excessive amounts of weight are also at risk for their port to slide laterally or to flip partially or completely.

Documentation and follow-up: It is important to document the specifics of care surrounding VADs. Oftentimes, there are many healthcare professionals involved in the care of each individual patient. In order to relay important information to each caregiver, a thorough note must be written. Detailed descriptions of what is being seen by the RN or experienced by the patient should be documented.

It is also very important to report abnormal findings to the physician, specialty pharmacy, and nursing personnel so that all information is shared with, and acted upon by each member of the care team as needed.