1 Castroviejo needle holder

2 Right-angle retractors

2 Chops retractors

1 Set of Garrett dilators, nine pieces (sizes 1, 1.5, 2, 2.5, 3, 3.5,

4, 4.5, 5)

String the following instruments from left to right on two 9-inch sponge

sticks or instrument stringer. Then place on top of a rolled Huck towel.

4 9-inch sponge stick

1 Tonsil clamp (bleeder)

1 6.5-inch Crile

1 5.75-inch Crile

1 Baby right-angle clamp

4 Straight mosquitoes

6 Curved mosquitoes

3 Fine curved mosquitoes

2 Tubing clamp with guard

1 Ryder needle holder

1 Webster needle holder

1 Straight mayo scissor

1 5.75-inch Metzenbaum scissor

1 Curved Steven scissor

1 Straight Iris scissor

4 Small towel clips (nonpenetrating)

1 Baby Satinsky clamp

1 Curved bulldog clamp

1 Straight bulldog clamp

1 Disposable ECMO tray (Table 33.2)

ECMO, extracorporeal membrane oxygenation. For information on suture material,

see Appendix B2.

Fig. 33.2. Infant positioned for cannulation with shoulder roll

present and head extended to the left. Position of neck incision is

indicated.

Table 33.2 Contents of Disposable

ECMO Tray

Number Item

2 1-mL syringe

1 20-mL syringe

1 6-mL syringe

1 3-mL syringe

1 Needle adapter

3 Single-cavity tray

2 Gauze packages

1 Betadine ointment

1 Surgical blade no. 15 carbon

2 Semipermeable transparent dressings

1 Handle, suction Frazier, 8 Fr

1 Xylocaine insert

1 Mini yellow vessel loops

1 Hand-control cautery

1 Suture, 4-0 Vicryl

1 Suture, 2-0 silk

1 Suture, 6-0 Prolene

4 Forceps, sponge

1 25-gauge needle

1 NaCl, 5-mL amp

1 3-g foil package of Surgilube

1 Surgical blade, no. 11 carbon

2 Steri-Drapes

2 Connectors, straight 0.25 × 0.25 inch

1 Xylocaine 1%

1 Suction tubing, 3/16 inch × 10 ft

1 Package sterile towels (14)

9. At the point of incision, infiltrate the skin with lidocaine (0.25%, with epinephrine) (Fig. 33.2).

10. Wait at least 3 minutes for anesthesia to be effective.

11. Make a 1- to 2-cm vertical incision over the right sternocleidomastoid muscle, starting approximately 1 cm

above the right clavicular head, using the electrocautery set on cutting current (Fig. 33.3).

 

a. A physician trained in management of ECMO

patients and cannulation techniques, who will

administer anesthetic agents and manage the infant

medically during the procedure

b. A bedside intensive care (neonatal or pediatric

intensive care unit) nurse, who will monitor vital

signs, record events, and draw up medications as

needed by the ECMO physician

c. A respiratory therapist, who will change ventilator

settings as necessary

3. Circuit specialists

a. A cardiovascular perfusionist, nurse, or respiratory

therapist specially trained in this procedure, who

will prime the pump

b. A bedside ECMO specialist (nurse, respiratory therapist, or cardiovascular perfusionist with special

training in ECMO management), who will manage

the ECMO system after the patient is on ECMO

Equipment (Fig. 33.1)

Sterile

1. Arterial and venous catheters (9)

a. Arterial

(1) The size of the arterial catheter determines the

resistance of the ECMO circuit because it is the

part of the ECMO circuit with the smallest internal diameter and thus the highest resistance.

(2) This catheter should be as short as possible, with

a thin wall and a large internal diameter (resistance is related directly to the length of the

catheter and inversely proportional to the diameter). An example of a suitable catheter is

the Bio-Medicus Extracorporeal Circulation

Cannula, 8 to 10 French (Fr) (Bio-Medicus,

Minneapolis, Minnesota).

b. Venous

(1) Venous catheter with

(a) As large an internal diameter as possible, to

allow maximal blood flow (the patient’s oxygenation is related directly to the rate of

blood flow).

(b) A thin wall/large internal diameter. An example of a suitable catheter is the Bio-Medicus

Extracorporeal Circulation Cannula, 8 to 14

Fr. (Bio-Medicus, Minneapolis, Minnesota).

2. Surgical instruments required are listed in Tables 33.1

and 33.2.

3. Gowns and gloves

4. Saline for injection

5. Syringes (1 to 20 mL) and needles (19 to 26 gauge)

6. Povidone–iodine solution

7. Povidone–iodine ointment

8. Semipermeable transparent membrane-type dressing

9. Absorbable gelatin sponge, for example, Gelfoam

(Upjohn, Kalamazoo, Michigan)

10. Surgical lubricant, bacteriostatic

Nonsterile

1. Surgical head covers and mask

2. Pulse oximeter

3. Surgical head light

4. Electrocautery

5. Wall suction

6. Shoulder roll, for example, a small blanket, to place

under infant’s shoulders

7. Tubing clamps

Medications

1. A long-acting paralyzing agent, for example, pancuronium bromide (0.1 mg/kg)

2. Fentanyl citrate (10 to 20 μg/kg)

3. Sodium heparin (75 to 150 U/kg)

4. Topical thrombin/Gelfoam

5. Lidocaine, 0.25%, with epinephrine

6. Lidocaine, 1%, plain (without epinephrine)

7. Cryoprecipitate, thawed, or commercially available

fibrin sealant (optional)

E. Technique—Preparation for

Cannulation

1. Place infant with head to “foot” of overhead warmer

bed.

2. Anesthetize the patient with fentanyl (10 to 20 μg/

kg).

Fig. 33.1. Schematic diagram of VA ECMO circuit, showing

the drainage from the right atrium into the bladder of the circuit,

with flow through the membrane lung, heat exchanger, and return

flow to the arch of the aorta via the carotid artery catheter. (From

Polin RA, Fox WC, eds. Fetal and Neonatal Physiology, Vol. 1.

Philadelphia: WB Saunders; 1992:933, with permission.)

Chapter 33 ■ Extracorporeal Membrane Oxygenation Cannulation and Decannulation 215

3. Paralyze the patient with pancuronium (0.1 mg/kg).

4. Hyperextend the patient’s neck with a shoulder roll,

and turn the head to the left (Fig. 33.2). Make sure that

the Bovie ground pad is placed at this time.

Observe closely for hypotension.

5. Monitor vital signs and give additional fentanyl and/or

pancuronium as needed (see Chapter 6).

6. Clean a wide area of the right neck, chest, and ear with

Betadine solution.

7. Drape the infant and entire bed with sterile towels.

8. Use Steri-Drapes (3M Health Care, St. Paul,

Minnesota) to secure the towels to the skin.

Table 33.1 Surgical Instruments for

ECMO Cannulation

Number Item

Place in a 12- × 18-inch mayo tray with a Huck towel on the bottom of the

tray.

2 Custard cup (place on inside of other cup with a 3- × 4-inch

sponge)

1 Medicine cup (place inside of custard cup with a 3- × 4-inch

sponge)

2 Straight bulldog clamps

1 Sauer eye retractor

1 Alm retractor

1 Mastoid Jansen retractor

2 Vein retractors

2 Octagonal forceps

2 7-inch Gerald forceps

2 6-inch DeBakey forceps

1 Adson forceps, plain

2 Adson forceps with teeth

2 No. 3 knife handles

 

213

Khodayar Rais-Bahrami

Gary E. Hartman

Billie Lou Short

Extracorporeal Membrane

Oxygenation Cannulation and

Decannulation

33

Extracorporeal membrane oxygenation (ECMO) is

defined as the use of a modified heart–lung machine combined with an oxygenator to provide cardiopulmonary support for patients with reversible pulmonary and/or cardiac

insufficiency in whom maximal conventional therapies

have failed (1–3). After decades of laboratory and clinical

research, ECMO is well accepted as a standard treatment

for neonatal respiratory failure refractory to conventional

techniques of pulmonary support (4–7). Most causes of

neonatal respiratory failure are self-limited, and ECMO

allows time for the lung to recover from the underlying disease process and for reversal of pulmonary hypertension,

which frequently accompanies respiratory failure in the

newborn.

Venoarterial Extracorporeal Membrane

Oxygenation—Cannulation

A. Indications

Placement of carotid arterial and internal jugular venous

catheters for use in venoarterial (VA) ECMO. VA ECMO

should be used in patients with significant cardiovascular

instability.

B. Relative Contraindications for

ECMO in the Neonatal Period (5,7)

1. Gestational age <34 weeks

2. Birthweight <2,000 g

3. Uncontrolled coagulopathy or bleeding disorders

4. Congenital heart disease without lung disease.

Exception: Postoperative cardiac patients, a topic that

will not be covered in this chapter.

5. Irreversible lung pathology

6. Intracranial hemorrhage more than grade II

7. Major lethal congenital anomaly

8. Duration of maximum ventilatory support, >10 to

14 days

9. Responding to ventilator management and/or inhaled

nitric oxide

C. Precautions

1. Ensure that the patient is paralyzed before placing the

venous catheter to prevent air embolus.

2. Recognize that

a. Internal jugular lines placed for IV access prior to

ECMO may cause clot formation, resulting in the

need for thrombectomy before placement of the

venous ECMO catheter.

b. Excessive manipulation of the internal jugular vein

may cause spasm and inability to place a catheter of

appropriate gauge.

c. A lacerated vessel may result in the need for a sternotomy for vessel retrieval.

Appropriate instruments should be on the bedside tray or cart.

A backup unit of blood should be available in the

blood bank.

d. Blood loss sufficient to produce hypotension can

occur during a difficult cannulation.

Emergency blood should be available at the bedside (10 to 20 mL/kg).

e. The vagus nerve is located next to the neck vessels,

and may be injured or manipulated during isolation

of the vessels. Manipulation can cause bradycardia

or other arrhythmias.

f. Vital signs and pulse oximetry values must be monitored at all times because clinical observation of the

infant is prevented by the surgical drapes.

g. If the patient has been hand bag–ventilated for stabilization, do not place the Ambu bag on the bedside when surgical drapes are placed. The bag may

entrap oxygen, which can result in a fire when electrocautery is used.

D. Personnel, Equipment, and

Medications (8)

Personnel

1. Surgical team

a. A senior surgeon (pediatric, cardiovascular, or thoracic)

with assistant

b. A surgical scrub nurse and a circulating nurse

214 Section V ■ Vascular Access

2. Medical team

 

212 Section V ■ Vascular Access

15. Wong EC, Schreiber S, Criss V, et al. Feasibility of red blood cell

transfusions through small bore central venous catheters in neonates. Pediatr Res. 2001;49:322A.

16. Vegunta RK, Loethen P, Wallace LJ, et al. Differences in the outcome of surgically placed long-term central venous catheters in

neonates: neck vs groin placement. J Pediatr Surg. 2005;40:47.

17. Murai DT. Are femoral Broviac catheters effective and safe? A

prospective comparison of femoral and jugular venous Broviac

catheters in newborn infants. Chest. 2002;121:1527.

18. Benjamin DK, Miller W, Garges H, et al. Bacteremia, central

catheters, and neonates: when to pull the line. Pediatrics.

2001;107:1272.

19. Vasudevan C, McGuire W. Early removal versus expectant management of central venous catheters in neonates with bloodstream

infection. Cochrane Database Syst Rev. 2011;10:CD008436.

20. Ramasethu J. Complications of vascular catheters in the neonatal

intensive care unit. Clin Perinatol. 2008;35:199.

21. Rastogi S, Bhutada A, Sahni R, et al. Spontaneous correction of

the malpositioned percutaneous central venous line in infants.

Pediatr Radiol. 1998;28:694.

22. Doellman D. Prevention, assessment and treatment of central

venous catheter occlusions in neonatal and young pediatric

patients. J Infus Nurs. 2011;34:251.

23. Soylu H, Brandao LR, Lee KS. Efficacy of local instillation of

recombinant tissue plasminogen activator for restoring occluded

central venous catheters in neonates. J Pediatr. 2010;156:197.

24. Monagle P, Chalmers E, Chan A, et al. Antithrombotic therapy

for neonates and children: American College of Chest Physicians

Evidence Based Clinical Practice Guidelines (8th Edition).

Chest. 2008;133:887S.

25. Svoboda P, Barton RP, Barbarash OL, et al. Recombinant urokinase is safe and effective in restoring patency to occluded central

venous access devices: a multiple-center, international trial. Crit

Care Med. 2004;32:1990.

26. Beardsley DS. Venous thromboembolism in the neonatal period.

Semin Perinatol. 2007;31:250.

27. Chiang MC, Chou YH, Chiang CC, et al. Successful removal of

a ruptured silastic percutaneous central venous catheter in a tiny

premature infant. Chang Gung Med J. 2006;29:603.

28. Evans M, Lentsch D. Percutaneously inserted polyurethane central catheters in the NICU: one unit’s experience. Neonatal

Network. 1999;18:37.

29. Nguyen ST, Lund CH, Durand DJ. Thrombolytic therapy for

adhesions of percutaneous central venous catheters to vein intima

associated with Malassezia furfur infection. J Perinatol. 2001;

21:331.

 

2. U.S. Department of Health and Human Services. Centers for

Disease Control and Prevention. Guideline for prevention of

intravascular catheter related infections; 2011:1. Available at:

http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

3. Schulman J, Stricof R, Stevens TP, et al. Statewide NICU central

line associated bloodstream infection rates decline after bundles

and checklists. Pediatrics. 2011;127:436.

4. Nowlen TT, Rosenthal GL, Johnson GL, et al. Pericardial effusion and tamponade in infants with central catheters. Pediatrics.

2002;110:137.

5. Beardsall K, White DK, Pinto EM, et al. Pericardial effusion and

cardiac tamponade as complications of neonatal long lines: are

they really a problem? Arch Dis Child Fetal Neonatal Ed.

2003;88:292.

6. Pezzati M, Filippi L, Chiti G, et al. Central venous catheters and

cardiac tamponade in preterm infants. Intensive Care Med.

2004;30:2253.

7. Cartwright DW. Central venous lines in neonates: a study of 2186

catheters. Arch Dis Child Fetal Neonatal Ed. 2004;89:504.

8. Webster NJ, Page B, Kuschel CA, et al. Digital imaging does not

improve localization of percutaneously inserted central lines in

neonates. J Paediatr Child Health. 2005;41:256.

9. Coit AK, Kamitsuka MD. Peripherally inserted central catheter

using the saphenous vein: importance of two-view radiographs to

determine the tip location. J Perinatol. 2005;25:674.

10. Odd DE, Page B, Battin MR, et al. Does radio-opaque contrast

improve radiographic localisation of percutaneous central venous

lines? Arch Dis Child Fetal Neonatal Ed. 2004;89:41.

11. Brissaud O, Harper L, Lamireau D, et al. Sonographaphy guided

positioning of intravenous long lines in neonates. Eur J Radiol.

2010;74:e18.

12. Primhak RH, Gathercole N, Reiter H. Pressures used to flush

venous catheter. Arch Dis Child Fetal Neonatal Ed. 1998;78:

F234.

13. Aly H, Herson V, Duncan A, et al. Is bloodstream infection preventable among premature infants? A tale of two cities. Pediatrics.

2005;115:1513.

14. Shah PS, Shah VS. Continuous heparin infusion to prevent

thrombosis and catheter occlusion in neonates with peripherally

placed percutaneous central venous catheters. Cochrane

Database Syst Rev. 2008;16:CD002772.

Fig. 32.16. Emergency catheter repair using butterfly needle (46). (From Neonatal Network, Santa

Rosa, CA, with permission.)

 

Chapter 32 ■ Central Venous Catheterization 211

b. In the event of catheter breakage, immediately grasp

and secure the extravascular portion of the broken

catheter to prevent migration.

c. If the catheter is not visible outside the baby, apply

pressure over the venous tract above the insertion

site to prevent the catheter from advancing.

Immobilize the infant, and obtain a radiograph

immediately to localize the catheter.

d. Surgical and/or cardiothoracic intervention may be

required if the catheter is not visible externally (27).

e. Damaged or broken catheters must be removed and

replaced. Repaired catheters and catheter replacement over a guidewire place the patient at risk for

infection or embolization. If no other options exist

owing to limited venous access, the catheter can

sometimes be repaired, utilizing meticulous aseptic

technique. Repaired PICCs should be considered

temporary, and a new catheter should be placed as

soon as possible. Some manufacturers offer repair

kits and instructions. A butterfly or blunt needle

may be used in an emergency (28) (Fig. 32.16).

9. Tethered catheter

a. Difficulty in removing catheter may be due to the

formation of a fibrin sheath or secondary to sepsis.

b. Management

(1) Place warm compresses on skin along the vein.

(2) Use gradual, gentle traction on the catheter.

(3) Thrombolytic therapy (29)

(4) Surgical removal through a peripheral incision

References

1. Ainsworth SB, Clerihew L, McGuire W. Percutaneous central

venous catheters versus peripheral cannulae for delivery of parenteral nutrition in newborns. Cochrane Database Syst Rev.

2007;CD004219.

 

4. Infection

a. Infection is the most common complication of central

venous catheters, with the smallest and most immature infants being at greatest risk. Catheter-related sepsis (CRS) rates range from 0% to 29% of lines placed

and from 0.4 to 17 per 1,000 catheter days (2,3).

b. Strict protocols for central line care and a methodology of surveillance with a data feedback mechanism

are recommended to decrease CRS (2,3,13).

c. Management of catheter-related sepsis: Remove

central venous line if possible. Prompt removal of

the line is recommended for Staphylococcus

aureus, gram-negative, or Candida sepsis.

Treatment with appropriate antibiotics without

removal of the line may be attempted in infants

with coagulase-negative Staphylococcus sepsis, but

repeated positive cultures mandate removal of the

line (18,19).

5. Catheter dysfunction

a. Obstruction of the catheter is characterized by

increased pump pressures, or inability to infuse fluids or withdraw blood.

b. Dysfunction may be due to malposition, fibrin

thrombosis, precipitates caused by minerals or

drugs, or lipid deposits (22).

c. Management

(1) Check catheter position on chest radiograph.

(2) If malposition is ruled out, review history of fluids and drugs administered through the catheter

to determine probable cause of occlusion.

A C

B D

Fig. 32.14. Various venous malpositions of PICCs. A: Jugular. B: Tip in right atrium C: PICC from left

arm, through superior vena cava and right atrium, into inferior vena cava. D: PICC from saphenous vein

in leg entering vertebral venous plexus via ascending lumbar vein.

 

8. Dress with small, self-adhesive bandage or gauze pad

and inspect daily until healing occurs.

Complications of Central Venous

Lines (20)

1. Damage to other vessels and organs during insertion

a. Possible during both percutaneous and surgical

placement of central venous catheters

b. Complications include bleeding, pneumothorax,

pneumomediastinum, hemothorax, arterial puncture, and brachial plexus injury.

2. Phlebitis

a. Mechanical phlebitis may occur in the first 24 hours

after line placement as a normal response of the

body to the irritation of the catheter in the vein.

b. Management of mild phlebitis (mild erythema and/

or edema): Apply moist, warm compress, and elevate extremity.

c. Remove the catheter if symptoms do not improve, if

phlebitis is severe (streak formation, palpable venous

cord, and/or purulent drainage), or if there are signs

of a catheter-related infection.

3. Catheter migration/malposition (Fig. 32.14)

a. Can occur during insertion or at any point during

the dwell time of the catheter (possibly as a consequence of poor catheter fixation at the skin surface

and movement of the joints). The catheter can enter

a venous tributary during insertion or can reverse

direction, causing it to loop back.

b. Sites of misplacement include the cardiac chambers, internal jugular vein, contralateral subclavian vein, ascending lumbar vein (which communicates with the vertebral venous plexus),

superficial abdominal vein, renal vein, and others.

Consequences include pericardial effusion or

pleural effusion, cardiac arrhythmias, tissue

extravasation/infiltration, neurological complications such as seizures or paraplegia, thrombosis,

and death.

c. The decision to remove the catheter or attempt to

correct the position is based on the location of the

tip. Although PICCs are intended to be placed in

central veins (See Section E, page 195), occasionally, the tip is in a noncentral location (e.g., in the

subclavian vein). These noncentral PICCs may be

used, provided the fluids administered through them

are isotonic, but the care of the catheters must be as

stringent as for centrally placed catheters.

d. The catheter should be pulled back into an appropriate position if the tip is in the heart, as serious

consequences such as cardiac arrhythmia, perforation, or pericardial effusion can occur.

e. Catheters in the ascending lumbar vein or vertebral

venous plexus must be removed, since the infusion

of parenteral alimentation fluids in this area may

lead to severe CNS damage, manifesting as seizures,

paraplegia or death (Figs. 29.3, 32.14D) (20).

f. Spontaneous correction of malpositioned lines has

been demonstrated in some cases (21). If the tip of

the catheter is looped into the internal jugular or in

the contralateral brachiocephalic vein, the catheter

may be used temporarily (using isotonic fluids that

are suitable for peripheral venous cannulae) and reevaluated radiologically in 24 hours. If the catheter

Chapter 32 ■ Central Venous Catheterization 209

has not moved spontaneously into the desired location, it should be removed.

 

208 Section V ■ Vascular Access

from flowing back into catheter. Positive-pressure

injection caps are available to prevent backflow.

f. Changing IV catheter injection cap: Most manufacturers recommend changing injection caps every 3

to 7 days, after blood product administration, or

when they appear damaged (see specific manufacturer’s instructions).

Catheter Removal

A. Indications

1. Patient’s condition no longer necessitates use.

2. Occluded catheter

3. Local infection/phlebitis

4. Sepsis and/or positive blood cultures obtained through

the catheter (catheter colonization). There are rare

clinical circumstances when a catheter is left in place

despite sepsis and antibiotic or antifungal therapy is

administered through it in an attempt to clear the infection, but this may be associated with an increased risk

of morbidity and mortality (18,19).

B. Technique

Surgically implanted central venous catheters should be

removed by a physician or other person specifically trained

to remove cuffed and/or tunneled catheters.

1. Remove dressing.

2. Make sure that the patient is in the Trendelenburg

position (or reverse Trendelenburg position if the catheter is in the lower extremity) to minimize the risk of an

air embolism.

3. Pull catheter from vessel slowly over 2 to 3 minutes.

Avoid excessive traction if catheter is tethered, because

the catheter may snap (see Complications).

4. Apply continuous pressure to the catheter insertion site

for 5 to 10 minutes, until no bleeding is noted.

5. Inspect catheter (without contaminating tip) to ensure

that entire length has been removed.

6. The cuff on the tunneled catheter should be dissected

out under local anesthesia with IV sedation. If cuffs are

retained, they rarely cause more than a persistent small

subcutaneous lump, although they can occasionally

extrude through the skin.

7. If desired, antibiotic ointment may be placed over site.

(4) Cover gauze with tape.

(5) Label dressing with initials and date.

(6) Secure IV tubing with tape to prevent tension

on the center (a stress loop can decrease tension

on the catheter).

F. Care of the Catheter When Not in Use for

Continuous Infusion

Indications

To maintain patency and prevent clotting of the catheter

when the line is used intermittently. Only large-bore catheters (2.5 Fr or larger) may be kept patent by this technique.

PICC lines that are 2 Fr or smaller tend to clot easily if continuous infusions are interrupted.

Equipment

1. 3 mL of heparin–saline solution (10 unit Heparin /mL)

in a 10-mL syringe (follow manufacturer’s guidelines

for syringe sizes)

2. Alcohol wipes

3. Catheter clamps (must have no teeth or be padded), or

use clamp provided on catheter (Fig. 32.10)

4. Clean gloves

5. IV injection cap (needleless is recommended)

Chapter 32 ■ Central Venous Catheterization 207

Technique

1. Converting to a heparin lock

a. Wash hands thoroughly.

b. Don clean or sterile gloves.

c. Prepare sterile work area.

d. Using aseptic technique, open sterile injection cap

package and prefill injection cap with heparinized

saline.

e. Clean the outside of the hub–IV tubing connection

with an antiseptic such as alcohol wipes. Work outward in both directions. Allow to dry.

f. Clamp catheter with padded hemostat, or close

catheter clamp.

g. Holding hub with alcohol swab, disconnect catheter

hub from IV tubing.

h. Connect preflushed injection cap into hub of catheter (gently flushing during connecting can prevent

air from entering catheter).

i. Release clamp and flush line with 1 to 3 mL of heparinized saline (depending on size of catheter).

Fig. 32.13. Occlusive dressing for a central venous

line using presplit gauze. A: Placing split gauze over

the skin entry site. B: Covering split gauze and the

catheter with sterile gauze. Entire dressing is then covered with adhesive tape or clear dressing.

j. Reclamp catheter while plunger of heparin syringe

is depressed to prevent blood from backing into

catheter (positive pressure).

k. Secure catheter and tape to chest or abdomen.

l. Flush catheter with heparinized solution every 6 to

12 hours (per institution policy).

2. Flushing catheters

Equipment is same as for heparin lock.

a. Wash hands thoroughly.

b. Put on gloves and prepare sterile work area.

c. Prepare IV injection cap with antiseptic solution.

Allow to dry.

d. If injection cap is part of a needleless system (recommended), connect flush syringe to cap. If the cap is

not a needleless device, insert needle into IV catheter

plug. Always use a 1-inch or smaller needle. A longer

needle can puncture the catheter.

e. Unclamp catheter and slowly inject 1 to 2 mL of heparinized saline (depending on catheter size). Reclamp

catheter while injecting solution to prevent blood

A

B