Central Venous Access Devices

Section 9 - Procedure Guidelines

9.34 CENTRAL VENOUS ACCESS DEVICES

Central Venous Access Devices (CVAD) or central venous catheters are used as the mainstay of treatment for patients requiring long term administration of medications or providing medical treatments such as antibiotics, chemotherapy or dialysis. These devices may be maintained with normal saline or heparin to prevent clotting or occluding the catheter.

When to use:

• Seminole County Paramedics are authorized to access only Peripherally Inserted Central Catheters (PICC) and central venous catheters under the following conditions:
  • After two peripheral IV attempts have been unsuccessful.
  • Life-threatening event requiring immediate medication or fluid administration.
  • Major trauma.
  • Cardiac arrest.
• SCEMS Paramedics are not authorized to access dialysis shunts or implanted ports.

How to identify:

• Central venous access devices come in a variety of styles. Always inquire, if possible, from the patient or family what type of access device is implanted on the patient.
  • PICC lines are usually single or double lumen (port) with a smaller size tubing inserted into the forearm or upper arm of the patient.
  • Central venous catheters may have from one to three lumens (ports) and are usually inserted near the neck and into the subclavian vein.
  • Implanted ports are located in the chest wall and they resemble a triangular or round device under the skin of the patient. These have no exposed ports or lines and must be accessed with a special needle.
  • Dialysis catheters are usually large caliber lines with one venous (blue) and one arterial port (red).

Procedure:

• Identify the location of the central venous access device.
• Cleanse the access port with alcohol or betadine.
• Central lines have clamps on each access port. Keep all clamps secured except the one being used for infusion.
• Any time the central line port is accessed and line or CLAVE type port being connected, the clamp must be secured to prevent air from entering the line. An open line can aspirate air into it causing an air embolus.
• Use a large syringe (12-20 ml) with a luer adapter to connect to the central line port.
• ASPIRATE the line gently and withdraw 10-15 ml of fluid and blood until you have only blood on the line.
  • This is done to aspirate the saline or heparin that was previously infused to maintain the line.
• DO NOT PUSH/FLUSH the contents of the catheter into the bloodstream!
  • If the catheter is heparinized it will cause coagulation changes and may be detrimental to the patient.
• Discard the syringe used to aspirate the contents of the catheter.
• Cleanse the access port again before inserting a new saline filled syringe.
• Using a new 12-20 ml syringe filled with normal saline, gently flush the line in and assess for patency.
  • The line should flow smoothly without resistance.
  • If the line is difficult to flush or you are unable to flush – DO NOT USE!
    • In the event the line cannot be flushed look for another IV site or gain access using an IO device.
• Once the line is accessed, connect IV tubing and infuse normal saline at the appropriate rate.
  • Central lines and PICCs, once accessed must have continuous fluid infusion at a minimum of a KVO rate.
• SCEMS Paramedics are not authorized to discontinue the infusion once it is started and the line is flowing patent.
  • Hospital staff must evaluate infusion before disconnecting or removing access based on their policies.

Contraindications:

• Central Venous Access Devices must not be used:
  • If a peripheral IV access can be easily attained
  • As a preventative measure – prophylactic IV line
  • The device is known to be occluded
  • It is suspected to be infected or be the source of infection
  • If other medications are already infusing through the line (compatibility problem)

WARNING
Central Venous Access Devices should be utilized ONLY if no other IV access can be obtained rapidly and before intraosseous access is performed during a LIFE-THREATENING emergency. SCEMS Paramedics must consider the RISK vs. BENEFIT of accessing these types of devices and use only when it is in the best interest of the patient.