Читать книгу Emergency Management of the Hi-Tech Patient in Acute and Critical Care - Группа авторов - Страница 79

The overarching principles of routine management for CVCs in the ED is similar for all devices. As none of these indwelling catheters is initially placed in the ED, routine CVC use in the emergent setting consists primarily of accessing and de‐accessing the device for blood drawing and/or medication infusion. In all cases, a sterile field and meticulous sterile technique should be maintained when accessing or caring for a CVC. Forceps with teeth should not be used to clamp externalized lines, as these increase the risk of catheter breakage; if only toothed forceps are available, the teeth should be wrapped in sterile gauze prior to using the forceps to clamp the line. While povidone‐iodine may be used to sterilize both externalized catheter hubs and the skin overlying implanted CVCs, neither tincture of iodine nor acetone should be used to clean an externalized line, as it may dry the catheter and increase the risk of line breakage. When flushing fluids or drawing back blood from a CVC, a 10 cc syringe or larger should be used; smaller syringes may cause excessive pressure in the catheter, leading to rupture. Practitioners should have all specimen tubes for blood‐drawing, all fluids to be infused, and all heparin and saline flushes ready prior to accessing the line. Fluids should never be infused into a line that does not draw back blood after flushing. To avoid instilling an air embolus, externalized catheters should always be clamped whenever a cap, syringe, or intravenous (IV) tubing is not attached to the distal end of the device. The specifics of accessing and de‐accessing each device type are described below.

Figure 5.1 Schematic 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.)

Figure 5.2 Schematic of externalized indwelling CVC.

Figure 5.3 Schematic of fully implanted CVC.

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