A surgically created arteriovenous connection used for hemodialysis. A subcutaneous fistula may be accessed in critical patients requiring immediate medication administration in life-threatening situations only.
- Discontinue any current IV solution.
- Use caution when discontinuing a continuous IV infusion containing chemotherapy to minimize exposure.
- Use clean gloves.
- Prepare 10 mL syringe, IV administration set and IV solution.
- Prep injection port with alcohol swab. If clamped, unclamp catheter.
- Slowly inject 5 mL NS into port. If resistance is met, re-clamp catheter and do not use. (see dialysis catheter).
- Aspirate for blood. (For dialysis catheters only: Aspirate 3 - 5 mL blood and discard prior to injection of saline).
- If unable to get a blood return, re-clamp catheter and do not use.
- If no resistance is met, inject remaining 5 ml NS into catheter.
- If resistance is met, re-clamp catheter and do not use.
Accessing Hemodialysis Fistula:
- Check site for bruits and thrills.
- Access fistula on the venous side (side with weaker thrill in patient with a pulse).
- Inflate BP cuff around IV bag to just above patient’s systolic BP to maintain flow of IV.
- If unsuccessful in accessing site, hold direct pressure over site for 10 minutes.
Administering IV fluids / medications:
- Prepare IV solution, IV administration set.
- Prep injection port with alcohol swab.
- Puncture injectable cap with appropriate device. (Most home care injection caps are needle-less.)
- Tape needle to catheter. Administer medications IVP via main line.
- Flush well with NS after each medication administered.
- Acute status patients.
- Cardiopulmonary arrest.
- For hemodialysis fistula - life-threatening condition requiring immediate vascular access.
- Medications - All medications approved for venous administration.
Types of Catheters:
External Silastic Indwelling Catheter/Devices:
- Broviac, Hickman and others: Silicone tube inserted in the chest; Heparinized and protected by injectable cap.
- Midline catheter: Enters the arm via vein near the AC area. Commonly used for long-term antibiotic admin.
- PICC Line: Peripherally inserted central catheter inserted into right atrium via peripheral arm vein.
- Hemodialysis catheter: Large tube inserted into distal superior vena cava via the subclavian vein. Usually a higher concentration of heparin is in the tube, which must be aspirated prior to use.
Internal Subcutaneous Infusion Ports: NOT approved for access by prehospital personnel.
A pre-existing vascular access device (PVAD): is an indwelling catheter/device placed into one of the central veins, to
provide vascular access for patients requiring long term intravenous therapy or hemodialysis.
- Infection: Use clean gloves. Prep injection port. Obtain new supplies if equipment becomes contaminated.
- Air Embolism: The PVAD provides a direct line into the circulation. Introduction of air into these devices is hazardous.
- Do not remove injection cap from catheter.
- Do not allow IV fluids to run dry.
- Always expel air from preload/syringe prior to administration.
- Thrombosis: improper handling and maintenance of the PVAD can cause a blood clot within the vascular system.
- Dislodging a clot can cause a PE or vascular damage. Follow medications with 10 mL normal saline.
- Do not inject medications or fluids if resistance is met when establishing patency.
- Catheter Damage: Clamp immediately between skin exit site and damaged area to prevent air embolism or blood loss.
- Use patient’s clamp or padded hemostats if available or fold and tape tubing to clamp.
- Always use a minimum of a 10 mL syringe to prevent catheter damage from excess infusion pressure.