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Care for all percutaneous central venous catheters is the same regardless of the insertion site. So your policies for dressing and flushing would remain the same. The issues with IJ placement is neck motion and hair making it very difficult to keep the dressing intact. So you may find that you have to do more frequent dressing changes. Educate the patient and family about how to watch for non-intaqct dressing, what to do if they find it coming loose and when to call you. I would not teach them to change this dressing. So this would indicate that the risk of infection may be greater with this site. Always use some type of skin protectant solution as this also helps the dressing adhere more easily. After the first week of dwell the risk is not considered to be the skin, but the catheter hub. So use all your standard ways to scrub the needleless connector, change the needleless connector every 4 days, and the intermittent tubing every 24 hours, making sure that the tip of the set is covered with a new sterile end cap after each use. Assess tip location for being in the lower SVC near the cavoartial junction. If not there and the patient will require a lengthy course of IV meds (longer than a few more days) you may want to recommend that this catheter be replaced with a PICC before you accept the patient.

Hi Patty,

I recently had probably one of my most challenging cases in my whole career come through our ER doors. 60ish lady with a hx of bilateral mastectomies with lymph removal, hx of factor V deficiency with multiple hospitalizations for clotting problems including a thrombus in her right subclavian vein. Presented with symptoms of lower extrem DVT,s, an osteomyelitis in her spine , on long term IV Vancomycin. She had a Hickman catherter placed in her left subclavian vein that had no blood return and was difficult to flush. IV Nurses nightmare right? When I saw this lady she was terrified, in pain, had no IV access and was poked about 12 times in the ER. Took me about a 1/2 hour to even get her to agree to let me look for a periph site. I was able to place one but knew I had to make a plan for her and pronto! I called our interventional radiologist and we decided to work together and place one of my Solo PICC's into her right jugular vein under flouroscopy. I was able to assist him with the procedure and it was really awesome! Thank goodness I had been to AVA and attended a seminar on the subject.

She was in the hospital for a week, I saw her every day and did her dressing change with a tegaderm CHG before she was to be discharged. I also was able to inservice the homecare nurses and follow this lady for her 6 week course of Vancomycin. The homecare nurses were uncomfortable changing the dressing so I was able to have her come in weekly where I was able to assess the site, the patency and do the dressing change myself. (I have a few tricks and hints if interested) We only had to Cathflo once in a 6 week period and her insertion site remained free from evidence of infection the whole time. Our patient couldn't express how grateful she was for the whole team's effort. She was so distraught after having so many complications and didn't think ANYTHING would ever go right for her again. She told me that our team collaberation restored her faith in the healthcare system. It will probably be a long time before we have another patient that requires this type of line, but now I know that our team can provide the best quality of care for all of our patients!

                                         Sincerley,

                              Cherylanne Perry RN,CRNI  Clinical Coordinator, IV Therapy St Joseph Hospital, Nashua NH

I am in a constant disagreement with the surgeons in my facility who place Central Lines. According to the Standards of Practice the correct tip placement is SVC or Cavo-Atrial Junction.  If they place a line that is malpositioned in the jugular, contralateral or any  vessel other than SVC, they claim it's perfectly ok for use.  Does anyone know of any literature to explain why this is not best practice and what consequences can arise?  I have read the standard on this but can not find any literature that says you cannot use this line.  Also I would like to know what is the nurses responsibility regarding placement?  Is the physicians order "okay to use" sufficient?   Can she be held liable if there is a unfavorable outcome and exactly what really could happen?  I appreciate any input into this neverending topic.