What Are Those Tubes For?

     Responding to a call, you find an 87-year-old female lying on the floor. Her husband says she fell while walking to the bathroom. He also reports that she has end-stage pancreatic cancer and has been taking a lot of narcotics for pain. After performing a complete assessment, you determine that she has no traumatic injuries, but has a blood pressure of 70/40, heart rate of 88, respiratory rate of 16, and clear and equal lung sounds. She is disoriented and has pinpoint pupils. You apply high-flow oxygen, cardiac monitor (showing regular sinus rhythm at 88), and determine her pulse oximetery is 95%. You apply a tourniquet to start an IV, and no veins are visible or palpable. Her husband says she has a Groshong catheter that is used regularly for chemotherapy treatments. You stare blankly at the husband, attempt two unsuccessful peripheral IV insertions, and transport without IV access. You administer naloxone intramuscularly but are unable to administer fluids for her low BP.

     When confronted with a patient with a central venous access device (CVAD), many providers hesitate before using the device, due to concerns about misuse, infection and dislodgement. The reality is that providers' familiarity with the various devices and techniques used to access patients can make their ability to provide complete ALS care much easier.

     You may have already encountered these devices, as healthcare provisions allow (and sometimes mandate) earlier discharge of patients with implanted devices previously only seen in the hospital environment. Don't assume that these patients will always be critically ill, as the devices are used by people in extended care facilities, private homes, working, at the beach, driving their cars or in nearly any location. Yet, the patient with a CVAD does have a medical condition warranting the use and implantation of such a device, and your medical history-taking should aim at determining the reason for its presence and use.

What Are the Devices Used For?
     Central venous access devices are used for patients who require long-term medication therapies like antibiotics, patients who require multiple blood draws on a regular basis, or patients who receive medication therapy that may cause peripheral vein necrosis (such as chemotherapy agents). CVADs are also used to administer total parenteral nutrition (TPN) to patients unable to eat normally. Additionally, CVADs are often used for dialysis in patients with poor venous access or when using a shunt is impractical.

     CVADs can be used to draw blood samples and to administer IV fluids and/or medications. Any medication that can be administered through a traditional peripheral IV can be administered through a CVAD. The dose and speed of administration remain the same.

CVAD Precautions
     Always maintain sterility by using fresh sterile gloves for each administration of medication.

     Never use a syringe smaller than 10cc, as smaller syringes produce significant pressure and may rupture the tubing.

     Always withdraw at least 10cc before administering anything through the tubing.

     Never use a regular needle on an implanted catheter—use only a Huber needle.

     To prevent a backflow of blood into the tip of the catheter, always inject the last 0.5 ml of saline flush at the same time you are withdrawing the syringe through the end cap.

Types of Devices
     Generally grouped into two types, CVADs may be described as tunneled or implanted. The rationale for the type selected varies from infection concerns, patient's age and intended usage to external appearance and patient comfort.

Tunneled catheters
     Tunneled catheters are implanted through one or two surgical openings in the skin, generally in the chest or neck area, but the groin may be used as well. The catheter is inserted under the skin into a large vein, such as the subclavian, jugular or femoral vein. The catheter inserted into the vein is threaded until the tip sits just inside the superior vena cava, above the right atrium. This placement allows for rapid infusion of medication and fluids into the circulatory system. Types of tunneled catheters include the Groshong, Hickman, Broviac and PICC lines.

     The Groshong central venous catheter is made of silicone and has a three-position valve at the end of each lumen that can allow liquids in or out, but remains closed when not in use. It may have a single lumen (tube) or be multi-lumen (dual, triple, or even four or five lumens). Each lumen in a multi-lumen is considered a separate intravenous line. The Groshong is inserted into the subclavian vein, with the tip resting at the junction of the superior vena cava and the right atrium. Just below the surface of the skin is a small cuff that helps hold the device in place and provides a barrier to infectious agents. The exterior portion of the tubing has a dressing and may be taped and/or sutured to the chest wall. Take care to not pull on the Groshong, as pulling may dislodge it. With its three-way valve, the Groshong does not have or need a clamp, but patients are instructed to have a clamp on hand in case the tubing or end cap is damaged.

     Hickman lines are the most frequently seen CVAD in the adult population. The main difference between a Hickman and Broviac catheter is that the Broviac has a smaller lumen and thus smaller catheter size. Broviac catheters are often used for pediatric patients. Otherwise, each catheter is made from silicone and may be single or multi-lumen (although dual-lumen is the most common). Hickman and Broviac catheters are also inserted into the subclavian or jugular vein, with the tip resting in the superior vena cava, directly above the right atrium. A cuff located underneath the skin helps hold the catheter in place and decrease infections. Both the Hickman and Broviac catheters have attached clamps on each lumen that are used when the port is not in use or if the end cap needs to be changed.

     A peripherally inserted central catheter (PICC) is similar to other CVADs in that the tip is placed into the superior vena cava; however, the PICC line is inserted into a peripheral vein, usually the cephalic, brachial or basilic. PICC lines may be single or multi-lumen, and the size of each lumen may vary in its diameter. The exterior tubing is sutured and/or taped to the arm, with a clear dressing over the insertion site. Generally, the tubing is marked with its equivalent IV catheter size (20g, 16g, etc.) and the location of its opening on the tubing (mid, distal, proximal). The lumen may also be marked with its maximum flow rate through the tubing. The type of lumen used is not as important as choosing the largest size to administer medications or fluid, or withdraw blood samples. Clamps on each lumen of the PICC line are used when not in use or when the end cap needs to be changed. Before withdrawal or administration of anything through the lumen, ensure the clamp is open.

Implanted catheters
     Known as a Mediport, Port-A-Cath, BardPort, PassPort or Infuse-A-Port, an implanted port is a catheter that is surgically implanted completely beneath the skin. Shaped like a quarter-sized disk, it consists of a self-sealing silicone bubble that rests in a shallow metal cup. The sides and bottom of the cup are thick metal and are strong enough to prevent the access needle from penetrating through the back or sides of the bubble. The bubble is attached to a silicone tube that enters the jugular or subclavian vein, with the tip resting in the superior vena cava, similar to the other CVADs. Implanted catheters are less prone to infection, dislodgement and damage. Patients are allowed to swim and comfortably shower, which generally makes them less self-conscious about their appearance (compared to the visible external tubing of tunneled catheters).

     Implanted ports require the use of the special non-coring Huber needle. Using any other needle may core a piece of silicone from the bubble and allow it to float directly into the circulatory system, causing an embolism. This will also disrupt the ability of the bubble to self-seal and cause an internal hemorrhage with rapid blood loss. Never use anything other than a non-coring needle. Huber needles come in a variety of sizes and gauges, and may be straight for use with a syringe or at a 90º angle for use with IV drip sets. Once a drip set is attached, normal needles can be used on the drip set.

How Do I Use These Devices?
     Perhaps of greatest importance is ensuring through your medical director that your EMS protocols allow use of these various devices. In some jurisdictions, only paramedics may use the CVAD. In others, advanced courses like UMBC's CCEMT-P program are required. Some may not allow their use at all. In some cases, you must have specialized equipment, along with medical authorization, to use a particular CVAD.

     Another important step is maintaining sterility of the tubing and ports. Providers should use sterile gloves during every medication administration and when handling the tubing. This, along with proper cleaning of the port, will minimize any infectious agents entering the tubing. The cleaning agent of choice for CVAD ports and the skin covering an implanted port is 2% chlorhexidine. If not available, use povidone, with alcohol wipes as a last choice. Two percent chlorhexidine has been shown to reduce infectious colonization by nearly 50%, as compared with povidone and alcohol wipes. Each port, or the skin surface for implanted ports, should be cleaned twice, using a new wipe each time.

     In all cases, explain the procedure to patients, letting them know you have been trained to use their CVAD. Patients may be apprehensive, as damage to the CVAD may result in further surgeries to repair or replace it. Confirm with medical control and stop all fluids being infused into any of the ports. Check the catheter to ensure there is no damage or visible leakage from the tubing or around the insertion site. Any tear or leakage of the tubing could lead to rapid blood loss, and thus damaged tubes should not be used. If any damage occurs, clamp the external tubing below the damage (closest to the patient). The clamp should be smooth and not serrated or with teeth, as this may also tear the tubing.

Tunneled catheters
     Wearing sterile gloves, clean the port to be used with two separate 2% chlorhexidine wipes. Attach a sterile 10cc syringe and withdraw at least 5cc of fluid (10cc if a PICC line). If TPN is being administered, withdraw 10cc of fluid (20cc if a PICC line). Properly discard the syringe used to withdraw fluid. If the catheter does not withdraw easily, do not flush, as an occlusion or clot formation may have occurred and flushing may force this into the bloodstream, likely causing a pulmonary embolism. Use another port if available, or establish a peripheral IV. Label the port that will not flush as unusable. Once able to withdraw the minimum 5cc of fluid, providers can withdraw any blood samples needed with a syringe or Vacutainer.

Implanted catheters
     To access an implanted port, prepare an empty 10cc syringe, a 10cc syringe with sterile saline, and a Huber needle attached to a saline-flushed extension set or IV fluid bag and drip set. Palpate the upper chest area on both sides for a small bulge (although implanted ports can be placed nearly anywhere on the chest, abdomen and sides of the chest, most are placed over the clavicle or sternum). Cleanse the area in a circular motion with two separate 2% chlorhexidine wipes. Wearing sterile gloves, stabilize the port with one hand and use the Huber needle to pierce the skin and center of the silicone bubble with a straight, downward motion until firm resistance is felt. Attach the empty syringe and withdraw 10cc of fluid, discarding the syringe properly afterward. If unable to withdraw fluid, do not use the port; establish a peripheral IV. If fluid is withdrawn, take blood samples as needed, then flush with 10cc of sterile saline.

     Once blood samples are drawn, or if none are required, any medication or IV fluid can be administered. If blood is withdrawn for testing, or a medication is administered but no fluid is infused, flush the tubing with 10–20cc of saline to ensure that no blood remains in the tubing to potentially cause a clot. Likewise, if a medication has been instilled, flush after administration with 10–20cc of saline to ensure all of the medication is properly delivered to the patient.

     If the device is multi-lumen, follow this procedure for each different port.

Summary
     Prehospital providers who are trained to access and utilize existing CVADs, including Groshong, Hickman, Broviac, PICC lines and implanted ports, will be able to establish rapid IVs. The CVADs, which should be used in critical scenarios like shock, cardiac arrest and critical medical conditions, will allow EMS to administer medications and fluids to patients in whom IV access may otherwise be impossible. Providers should review with their medical directors the feasibility and practical application of using these devices, ensuring they have the correct training and equipment to use these potentially lifesaving devices.

Bibliography
Bard Access Systems. Groshong C.V. Catheters Nursing Procedure Manual. Salt Lake City, UT, 1994.
Bard Access Systems. Hickman, Leonard and Broviac Catheters Nursing Procedure Manual. Salt Lake City, UT, 1994.
Bard Access Systems. Power PICC Nursing Guide. Salt Lake City, UT, 2004.
Cook Medical Inc. Peripherally Inserted Central Venous Catheters. Bloomington, IN, 2006.
Mimoz S, Villeminey S, Ragot S, et al. Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care. Arch Intern Med 167(19):2066–2072, 2007.
O'Grady NP, Alexander M, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR 51(RR10):1–26, Aug 9, 2002.

Marc A. Minkler, NREMT-P, CCEMT-P, is a paramedic/firefighter with the Portland (ME) Fire Department and has been a student of EMS for over 19 years. He is the author of several internationally published EMS instructor programs. Reach him at pfd225@roadrunner.com.