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www.arrowintl.com

Arrow CVC Poster PLUS

TRUSTED. COMPREHENSIVE. PROVEN.

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References: Larson, E. "Guideline for Use of Topical Antimicrobial Agents." American Journal of Infection Control, December 1988, Vol. 16, pp. 253­266. Bryce, E.A., Spence, D., Roberts, F. J. "An In-Use Evaluation of an Alcohol-Based Pre-Surgical Hand Disinfectant," Infection Control and Hospital Epidemiology, October 2001, Vol. 22, Issue 10, pp. 635­639. Strand, C.L., Wajsbort, R.R., Sturmann, K. "Effect of Iodopher vs. Iodine Tincture Skin Preparation on Blood Culture Contamination Rate." Journal of the American Medical Association, 1993, Vol. 269, pp. 1004­1006. LeVeen, H.H., LeVeen, R.F., LeVeen, E.G. "The Mythology of Povidone-iodine and the Development of Self-Sterilizing Plastics." Surgery, Gynecology & Obstetrics, 1993, Vol. 176, pp. 183­190. Birnbach, D.J., Stain, D.J., Murray, O., Thys, D.J., Sordillo, E.M. "Povidone-iodine and Skin Disinfection Before Initiation of Epidural Anesthesia," Anesthesia, March 1998, Vol. 88, Issue 3, pp. 668­672. Craven, D.E., et al. "Contamination of Povidone-iodine Solution With Psuedomonas Aerginosa," Morbidity and Mortality Weekly Report, 1981. O'Rourke, E., et al. "Contaminated Iodophor in the Operating Room," American Journal of Infection Control, June 2003, Volume 31, Issue 4, pp. 255­256. Maki, D., Ringer, M., Alvarado, C.J. "Prospective Randomized Trial of Povidoneiodine, Alcohol, and Chlorhexidine for Prevention of Infection Associated With Central Venous and Arterial Catheters." Lancet, August 1991, Vol. 338, pp. 339­343. Denton, G.W. Chlorhexidine. Disinfection, Sterilization, and Preservation. Edited by S.S. Block, 4th edition, (Philadelphia: Lea & Feabiger, 1991). "Guidelines for the Prevention of Intravascular Catheter-Related Infections," Morbidity and Mortality Weekly Report, 2002, Vol. 51 (RR10), pp. 1­26. Available at: http://www.dcd.gov/incidod/hip/iv/iv.htm. Accessed March 10, 2004. Bar-Joseph G., Galvis, A.G. "Perforation of the Heart by Central Venous Catheters in Infants: Guidelines to Diagnosis and Management." Journal of Pediatric Surgery, 1983, Vol. 18, pp. 284­287. Blitt C.D., ed. "Central Venous Pressure Monitoring." Monitoring in Anesthesia and Critical Care Medicine, New York, NY, Churchill Livingstone, 1985, pp. 121­165. Brandt, R.L., Foley, W.J., Fink, G.H., Regan, W.J. "Mechanism of Perforation of the Heart With Production of Hydropericardium by a Venous Catheter and Its Prevention." American Journal of Surgery, 1970, Vol. 119, pp. 311­316. Collier, P.E., Ryan, J.J., Diamond, D.L. "Cardiac Tamponade From Central Venous Catheters--Report of a Case and Review of the English Literature." Angiology, September 1984, Vol. 35, pp. 595­600.

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Curelaru, J., Linder, L.E., Gustavsson, B. "Displacement of Catheters Inserted Through Internal Jugular Veins With Neck Flexion and Extension." Intensive Care Medicine, 1980, Vol. 6, pp. 179­183. Maschke, S.P., Rogove, H.J. "Cardiac Tamponade Associated With a Multilumen Central Venous Catheter." Critical Care Medicine, 1984, Vol. 12, pp. 611­612. Peters, J.L., ed. A Manual of Central Venous Catheterization and Parenteral Nutrition. Boston, MA: John Wright PSG, 1983, pp. 58­61, 155­157. Sheep, R.E., Guiney, W.B. Jr. "Fatal Cardiac Tamponade." JAMA, 1982, Vol. 248, pp. 1632­1635. Sherertz, R.G. Presented as a poster presentation at the 37th IDSA: Philadelphia, PA, 1999. Alexander, J.W., Fischer, J.E., Boyajian, M., Palmquist, J., Morris, M.J. "The Influence of Hair-Removal Methods on Wound Infections." Archives of Surgery, 1983, Vol. 118, p. 347. Ibert, T.J., Katz, L.B., Reiner, M.A., Brownie, T., Kwun, K.B. "Hydrothorax as a Late Complication of Central Venous Indwelling Catheters." Surgery, November 1983, pp. 842­846. Eissa, N.T., Kvetan, V. "Guidewire as a Cause of Complete Heart Block in Patients With Preexisting Left Bundle Branch Block." Anesthesiology, 1990, Vol. 73, pp. 772­774. Andrews, R.T., Bova, D.A., Venbrux, A.C. "How Much Guidewire Is Too Much? Direct Measurement of the Distance From Subclavian and Internal Jugular Vein Access Sites to the Superior Vena Cava-Atrial Junction During Central Venous Catheter Placement." Critical Care Medicine, January 2001. Thielen, J.B., Nyquist, J., "Subclavian Catheter Removal." Journal of Intravenous Nursing, March/April 1991, Vol. 14, pp. 114­118. Conn, C. "The Importance of Syringe Size When Using Implanted Vascular Access Devices." Journal of Vascular Access Nursing, Winter 1993, Vol. 3, pp. 11­18. Patents: Arrow Raulerson Syringe: U.S. Patent Nos. 4,813,938 and 5,045,065 Japanese Patent No. 2,135,570 Arrow Advancer: U.S. Patent Nos. 5,484,419 and 6,477,402 ARROWg+ard®/ARROWg+ard Blue PLUS®: U.S. Patent Nos. 5,019,096, 6,706,024 and 6,872,195

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Insertion procedure and usage references

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Caution: U.S. federal law limits this device to sale by or on order of a physician. Contents of unopened, undamaged package are sterile. Disposable. Refer to package insert for current warnings, indications, contraindications, precautions and instructions for use. For additional reference information contact Arrow International, Inc. ARROWg+ard Blue PLUS not for sale in European Union.

Distribution Worldwide: Arrow offices are located in Belgium, Canada, Czech Republic, France, Germany, Greece, India, Italy, Japan, Mexico, Netherlands, Slovakia, South Africa, Spain and the United States. Arrow International, Inc., 2400 Bernville Road, Reading, PA 19605 U.S.A. Tel: 610.378.0131 www.arrowintl.com

CVC-P 12/05 6M CRB-05-0347 © 2005 Arrow International, Inc. All rights reserved. Printed in the U.S.A.

VENOUS ACCESS

ARROW MULTI-LUMEN CATHETERS

FLOW RATES AND PRIMING VOLUMES

Arrow CVC Poster PLUS

INSERTION PROCEDURE

Seldinger Technique (S.)**/Modified Seldinger (M.S.) Technique

Priming volumes are done without the injection cap (priming volume = 0.17 cc). Flow rates are done with normal saline, room temperature and 40" head height, and represent approximate flow capabilities.

www.arrowintl.com

Description 7 Fr. x 16 cm (6") 7 Fr. x 16 cm (6") 7 Fr. x 20 cm (8") 8 Fr. x 16 cm (6") 8 Fr. x 20 cm (8") 7 Fr. x 16 cm (6")

Lumens Volume (cc) Dist. (16 Ga.) Prox. (16 Ga.) Dist. (18 Ga.) Prox. (14 Ga.) Dist. (14 Ga.) Prox. (18 Ga.) Dist. (14 Ga.) Prox. (14 Ga.) Dist. (14 Ga.) Prox. (14 Ga.) Dist. (16 Ga.) Med. (18 Ga.) Prox. (18 Ga.)

Priming Volume (cc) 0.35 0.38 0.32 0.47 0.57 0.40 0.70 0.71 0.75 0.80 0.39 0.35 0.37

Gravity (standard tubing) 5110 Units 4700 Units 1500 Units 5000 Units 5000 Units 1500 Units 6200 Units 6000 Units 5600 Units 5100 Units 3400 Units 1800 Units 1900 Units

VENOUS ACCESS

(S.) After administering local anesthetic, locate vein using thin-wall introducer needle. Vessel may be prelocated with a smaller needle. (M.S.) Catheter/Needle assembly may be used in place of the thin-wall introducer needle.

(S.) Remove syringe. Confirm venous placement by using hemodynamic monitoring or checking for pulsatile blood flow. Warning: The color of blood is not always an accurate indication of venous entry.* (M.S.) Remove needle and syringe, leaving catheter in vessel. Warning: To avoid possible catheter embolus, do not reinsert needle into catheter.

(S.) Immediately occlude needle lumen to prevent air embolism or bleeding. (M.S.) Immediately occlude catheter lumen to prevent air embolism or bleeding.

(S.) Using a straightening tube, straighten J tip of Spring-Wire guide, if used, and advance into vessel through needle. Warning: To avoid severing or damaging wire, do not cut Spring-Wire guide to alter length, nor withdraw Spring-Wire guide against needle bevel. (M.S.) Advance wire through IV catheter. Warning: Do not cut Spring-Wire guide.

(S.) Hold Spring-Wire guide in place and remove needle. Precaution: Maintain a firm grip on Spring-Wire guide at all times. (M.S.) Hold Spring-Wire guide in place and remove IV catheter. Precaution: Maintain a firm grip on Spring-Wire guide at all times.

(S. + M.S.) If making skin-nick, enlarge cutaneous puncture site with cutting edge of scalpel positioned away from Spring-Wire guide.

(S. + M.S.) If using tissue dilator, pass it over Spring-Wire guide to enlarge site as needed. Warning: To avoid possible vessel wall perforation, do not leave tissue dilator in place as an indwelling catheter.

(S. + M.S.) Thread tip of catheter into vessel using Spring-Wire guide. Grasping catheter near skin, advance into vein with a slight twisting motion.

(S. + M.S.) Advance catheter into final indwelling position. Hold catheter and remove Spring-Wire guide. Check lumen placement by aspirating through pigtails. Apply dressing per hospital protocol. Verify catheter tip position by X-ray (or other method in compliance with hospital protocol).

(continued on back)

INFECTION PROTECTION CHECKLIST

To help you protect your patients from catheter-related bloodstream infection (CRBSI), we've created this checklist. It consists of key recommendations from the CDC 1A Guidelines, the 100K Lives Campaign and the Keystone Project. Bolded steps pertain specifically to catheter selection, insertion and site maintenance.

Educate and train healthcare workers on infectioncontrol practices. Select the optimal catheter site; subclavian vein is the preferred site for non-tunneled catheters. Use clinically proven antiseptic-impregnated catheters. Follow hand hygiene and aseptic technique. Use 2% chlorhexidine for skin antisepsis. Follow maximal sterile barrier precautions and maintain a sterile field. Review line daily; promptly remove unnecessary lines. Avoid routine replacement of catheters. Create a policy that an observer will supervise and assist with central line insertion and use a checklist to ensure compliance with CDC guidelines for inserting central lines. Have caregivers ask daily whether central venous catheters could be removed. Frequent review of compliance with checklist and bloodstream infection data. Provide feedback to staff on infection rates.

Modified Seldinger Technique Using Arrow® Raulerson Syringe***

After administering local anesthetic, locate vein using thin-wall introducer needle attached to Arrow Raulerson syringe. The vessel may be prelocated with a smaller needle.

Verify venous access by inserting fluidprimed transduction probe into rear of Arrow Raulerson syringe and through syringe valves. Observe for venous placement via wave form obtained by a calibrated pressure transducer. Remove transduction probe.

Using the Arrow AdvancerTM, straighten J tip of Spring-Wire guide, if used, and advance through rear of syringe plunger. Warning: To avoid severing or damaging wire, do not cut Spring-Wire guide to alter length, nor withdraw Spring-Wire guide against needle bevel.

Hold Spring-Wire guide in place and remove Arrow Raulerson syringe. Precaution: Maintain a firm grip on Spring-Wire guide at all times.

If making skin-nick, enlarge cutaneous puncture site with cutting edge of scalpel positioned away from Spring-Wire guide.

If using tissue dilator, pass it over Spring-Wire guide to enlarge site as needed. Warning: To avoid possible vessel wall perforation, do not leave tissue dilator in place as an indwelling catheter.

Thread tip of catheter into vessel using Spring-Wire guide. Grasping catheter near skin, advance into vein with a slight twisting motion.

Advance catheter into final indwelling position. Hold catheter and remove Spring-Wire guide. Check lumen placement by aspirating through pigtails. Apply dressing per hospital protocol. Verify catheter tip position by X-ray (or other method in compliance with hospital protocol).

There are two key benefits to using the Raulerson syringe. First, it lessens the exposure to blood and can lower the risk of air embolism. Second, it enables you to place the catheter in fewer steps, with less risk of dislodging needle from vessel.

References:

CDC 1A Guidelines: www.cdc.gov 100K Lives Campaign: www.ihi.org/NR/rdonlyres/BF4CC102-C564-4436-AC3A0C57B1202872/0/CentralLinesHowtoGuideFINAL720.pdf Keystone Project: www.mha.org/mha/keystone/icu/projectoverview.jsp

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PORT DESIGNATIONS

Port designations are assigned to ensure uniform use of the catheter lumens by healthcare personnel. Label ports of a multiple-lumen CVC (MLC) for designated use. Enter the information into the chart and onto the patient's information sheet. Note: There is a lack of scientific data to support many of the designation protocols currently in use. Most choices have been made using deductive reasoning. Always confirm hospital protocol from port designations, as standards can differ.

INSERTION SITES, LANDMARKS AND INSERTION ORIENTATION

ANATOMY OVERVIEW

thoracic duct parotid gland left brachiocephalic carotid artery external jugular vein right brachiocephalic internal jugular vagus nerve pulmonary apex phrenic nerve subclavian artery and vein first rib axillary cephalic superior vena cava brachial basilic suprasternal notch manubrium subclavian vein clavicle

EXTERNAL JUGULAR

sternocleidomastoid muscle external jugular vein superficial cervical fascia

INTERNAL JUGULAR

trachea anterior jugular vein internal jugular vein external jugular vein clavicle

EXTERNAL JUGULAR

Landmarks > Vessel is part of surface anatomy Insertion Orientation > Needle can be inserted into vessel as visualized on neck surface Advantages > Easy to locate, visible Disadvantages > Difficult to cannulate (vessel rolling, valves, tortuous path) > Higher complication rate compared with other sites > Problematic in patients with tracheostomies > Difficult dressing maintenance Adjacent Anatomy > Carotid artery > Phrenic and vagus nerves > Pulmonary apex > Thoracic duct (left side only) Potential Complications > Arterial puncture > Variable extent of nerve damage > Pneumothorax > Pleural effusion > Chylothorax (Thoracic duct)

INTERNAL JUGULAR

Landmarks > Angle of mandible > Two heads of sternocleidomastoid muscle > Clavicle > External jugular vein > Trachea Insertion Orientation > Central: Insert needle at apex of triangle formed by the two bodies of the sternocleidomastoid muscle and the clavicle. Insertion depth 3 cm­5 cm. > Anterior: Insert needle at midpoint of sternal head of the sternocleidomastoid muscle approximately 5 cm from the angle of the mandible aiming toward the feet and ipsilateral nipple. Insertion depth 2 cm­4 cm. > Posterior: Insert needle approximately 1 cm dorsal to the place where the external jugular vein crosses the posterior border of the sternocleidomastoid muscle. Insertion depth 5 cm­7 cm. Advantages > Large vessel size > Easy to locate > Easy access > Short, straight path to superior vena cava (right side) > Low complication rate Disadvantages > Close proximity to carotid artery > Higher infection rate compared with other sites > Problematic in patients with tracheostomies > Uncomfortable to patient > Difficult dressing maintenance Adjacent Anatomy > Carotid artery > Phrenic and vagus nerves > Pulmonary apex > Thoracic duct Potential Complications > Arterial puncture > Variable extent of nerve damage > Pneumothorax > Pleural effusion > Chylothorax

SUBCLAVIAN

Landmarks > Clavicle > Two bodies of sternocleidomastoid muscle > Suprasternal notch > Manubriosternal junction Insertion Orientation > Infraclavicular: Insert needle 2 cm­3 cm caudal to midpoint of the clavicle at the point where the clavicle slants toward the manubrium. Insertion depth may extend to 10 cm. > Supraclavicular: Insert needle at 45-degree angle into the angle formed by the clavicle and the sternocleidomastoid muscle. Insertion depth 1 cm­4 cm. Advantages > Large vessel with high flow rate > Lower infection rate compared with other sites > Easy to maintain dressing > Less restricting for patient Disadvantages > Lies close to the lung apex (pneumothorax risk) > Close proximity to subclavian artery > Difficult to control bleeding (noncompressible vessel) > Potential for pinch-off phenomenon Adjacent Anatomy > Subclavian artery > Pulmonary apex > Right lymphatic duct > Costoclavicular ligament, first rib Potential Complications > Arterial puncture > Pneumothorax, pleural effusion > Chylothorax > Pinch-off phenomenon

Proximal port

> Blood sampling > Medications > Blood

Medial port

> Total parenteral

Distal port

> CVP monitoring > Blood

Additional lumen(s)

> Infusion > Medication

nutrition (TPN)

> Medications

administration

> High-volume or

administration

(if TPN use is anticipated, use distal port instead)

viscous fluids

> Colloids > Medication

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SUBCLAVIAN

EXTERNAL JUGULAR INSERTION

ASSESSING AND MANAGING

OCCLUDED LONG-TERM CVCS

Can you manually irrigate catheter with 10 ml syringe?

YES NO

Have medications been administered?

NO YES

Can you aspirate?

YES NO

Can you aspirate?

YES NO

Was TPN administered?

YES NO

Did medication precipitate?

NO YES

No problem

Is catheter tip in distal SVC?

NO YES

Is catheter kinked?

NO YES

Was TPN a TNA?

YES NO

Phamacologic intervention not indicated

Will change in pH solubilize precipitate?

NO YES

Practitioners must become familiar with the signs, symptoms, interventions and preventive measures for catheter-related complications at all insertion sites.

Reposition or replace catheter

Is a thrombus suspected?

YES NO

Reposition patient or straighten catheter

Is lipid occlusion suspected?

YES NO

Is CaPO4 precipitation suspected?

YES NO

Is a thrombus present?

NO

Did blood back up or were blood products administered?

YES NO

Replace Increase pH catheter with NaHCO3 or decrease pH with HCI

Ethyl alcohol

HCI

YES

VENOUS ACCESS

Consider empiric thrombolytic therapy

Thrombolytic therapy

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Arrow CVC Poster PLUS

To help medical professionals provide the highest-quality patient care, we've provided the following information on insertion techniques, antiseptic procedures and infection prevention. Carefully organized and clearly presented, the CVC Poster PLUS is designed to serve either as a poster or as a quick visual reference. ANTISEPTIC SOLUTIONS: PRO/CON

Use an antiseptic solution to kill or inhibit the growth of microorganisms prior to inserting a CVC, and for routine follow-up care of the insertion site. Choose the antiseptic by referring to the following facts and your hospital's own protocols and available literature, as well as the patient profile prepared by your healthcare facility. The three antiseptic solutions used most frequently are alcohol, iodine/iodophor and chlorhexidine.1 Alcohol Very effective against gram-negative and gram-positive bacteria, fungi and viruses. Also effective as a fat solvent. Two common alcohols are used in medical practice for skin antisepsis: isopropyl alcohol and ethanol/ethyl alcohol. There are minimal differences in the antimicrobial effects of these two alcohols.2 Dilute alcohol before use; 70% and 90% (v/v) are the most effective concentrations. To achieve maximum kill, apply alcohol to the insertion site with a vigorous rub lasting one minute. Keep the site wet with solution the entire time. Disadvantages: Ineffective against spores. Repeated applications can dry skin. No residual property is left on the skin. Flammable when wet. Tincture of Iodine/Iodophor Solutions Effective against gram-positive and gram-negative bacteria, M. tuberculosis, viruses and fungi (prolonged contact may be needed to kill certain fungi and spores). The most common iodophor is Povidone-iodine, a combination of iodine and polyvinylpyrolidine. Povidone-iodine reduces toxicity and skin irritation. With either tinctures or iodophor solutions, two minutes of contact time are necessary for optimum microbial kill.3 Iodophors have approximately a two-hour residual property. Disadvantages: Iodine and iodophors can irritate skin and cause allergic or toxic effects in sensitive individuals. Proteinaceous fluids such as blood and pus can neutralize iodophors' antimicrobial properties. There have been reports of microbial growth in certain iodophor solutions, prompting careful attention to the proper dilution and container.4, 5, 6, 7 The available concentrations are .5%, 2%, 7.5% and 10%, and should be provided in a single-use bottle, swabstick or applicator. Chlorhexidine Very active against gram-positive organisms, gram-negative organisms and viruses. Chlorhexidine binds to the skin surface and provides a residual antimicrobial property on the skin surface. The residual property for aqueous chlorhexidine solutions is effective up to six hours; chlorhexidine combined with alcohol is effective for a minimum of 48 hours. Chlorhexidine is active in the presence of organic matter (i.e., blood). In at least one study, a 2% solution has been found to be superior to a 70% isopropyl alcohol solution and 10% Povidone-iodine for preventing IV-related infections.8 Few side effects were noted. Disadvantages: Less active against fungi; minimally effective against M. tuberculosis. Chlorhexidine's action is optimum at a pH between 5.5 and 7, which corresponds to body surfaces and tissues; it can be inactivated by compounds found in hard water and soap.9 Combination Solutions These contain at least two active agents. Benefits include compliance and convenience. The most common combination products include chlorhexidine and alcohol (CHG-IPA), PVP-I and alcohol, and tincture of iodine (iodine and alcohol). Arrow recommends investigating the claims made by the manufacturer of the combination products. The "CDC Guidelines for Prevention of Intravascular Catheter-Related Infection" prefer a 2% chlorhexidine-based solution for skin antisepsis prior to insertion and for maintenance of intravascular catheters. This is a Category IA recommendation that is strongly advised for implementation in clinical practice. This directive is based on well-designed experimental, clinical or epidemiological studies.10 Disadvantages: The number of patients who might experience a skin reaction with a skin antiseptic agent (i.e., chlorhexidine, Povidone-iodine, tincture of iodine, alcohol, etc.) is low compared with the risk of catheter-related bloodstream infection (CRBSI), especially when evaluating the morbidity and mortality associated with these infections. Disadvantages stated previously for other solutions also apply.

WARNINGS AND PRECAUTIONS

Clinicians should be familiar with the following issues in order to recognize them early and intervene to minimize potential negative effects. Read all product instructions thoroughly prior to inserting a central venous catheter (CVC), and seek clarification on any issues. In addition, before using any company's infection-protection CVC, review the patient's health history for potential allergies to the relevant antimicrobials.

Cardiac Tamponade > Placement of indwelling catheters in the right atrium is a dangerous practice that may lead to cardiac perforation and tamponade.11, 12, 13, 15, 16, 17 > High mortality rate is associated with cardiac tamponade secondary to pericardial effusion.18 > Advancing the catheter too far relative to patient size may cause cardiac tamponade. > No particular route or catheter type is exempt.17 > Confirm catheter tip position by X-ray (or other method in compliance with hospital protocol) after insertion.11, 12, 14, 16, 17, 19 > Central venous catheters should be placed in the superior vena cava:11, 12, 13, 14, 15, 16, 24 · Above junction with the right atrium · Parallel to the vessel wall21, 24 · Distal tip positioned at a level above the azygos vein or the carina of the trachea, whichever is better visualized Other complications > Cardiac tamponade secondary to vessel wall erosion > Septicemia > Atrial or ventricular perforation > Thrombosis > Pleural and mediastinal injuries > Inadvertent arterial puncture > Air embolism > Nerve damage > Catheter embolism > Hematoma > Catheter occlusion > Hemorrhage > Thoracic duct laceration > Dysrhythmias > Bacteremia > To lessen risk of disconnects, use only securely tightened Luer-Lock connections. > To guard against air embolism, follow hospital protocols for all catheter maintenance procedures. > Passage of the guidewire into the right heart can cause dysrhythmias, bundle branch block22 and a perforation of the wall, atrial or ventricular. > There is a potential for the guidewire to be entrapped by an implanted device in the circulatory system (e.g., vena cava filters or stents). Review patient's history before catheterization procedure to assess for possible implants. And take care regarding the length of Spring-Wire guide inserted. · Catheter procedure should be done under direct visualization to minimize the risk of guidewire entrapment.23 > Five-lumen catheter, the catheter clamp and fastener should not be placed proximal to 20 cm marking to ensure lumen placement within the vessel. Safety, Sharps Due to the risk of exposure to HIV (Human Immunodeficiency Virus) or other blood-borne pathogens, healthcare workers should routinely use universal blood and body-fluid precautions in the care of all patients. Take care to follow your institution's sharps safety procedures, and utilize all sharps safety products and instruments provided. Care and maintenance issues > Indwelling catheters should be routinely inspected for desired flow rate, security of dressing, correct catheter position and secure Luer-Lock connection. > Use centimeter markings to identify when the catheter position has changed. > X-ray (or other method in compliance with hospital protocol) examination of the catheter placement can ensure that the catheter tip has not entered the heart or no longer lies parallel to the vessel wall. > If catheter has shifted, immediately perform chest X-ray examination to confirm catheter tip position. > For blood sampling, temporarily shut off remaining port(s) through which solutions are being infused. > Use of a syringe smaller than 10 ml to irrigate or declot an occluded catheter may cause intraluminal leakage or catheter rupture.25 Use of disinfectants and solvents (some disinfectants contain solvents that can attack the catheter material) > Check ingredients of prep sprays and swabs for acetone and alcohol content. > Alcohol and acetone can weaken the structure of polyurethane materials. > Always allow alcohol or any disinfectant to dry completely before applying dressing. > Acetone may be applied to skin but must be allowed to dry completely prior to applying dressing. > Do not use alcohol to soak catheter surface or to restore catheter patency. > Take care when instilling drugs containing high concentrations of alcohol.

Procedural technique warnings and precautions > Do not use excessive force to remove a guidewire or catheter. > If removing the guidewire becomes difficult, obtain a chest X-ray for further assessment. > There is a potential for air embolism from: · Leaving intravascularly inserted needle open to air. · Leaving catheters open in central venous puncture sites · Inadvertent disconnects

Warning:

Do not place the catheter into or allow it to remain in the right atrium or right ventricle. Read instructions!

> CVCs should not be placed in the right atrium unless specifically required for special, relatively short-term procedures, e.g., aspiration of air emboli during neurosurgery. Such procedures should be closely monitored and controlled.

ARROW MULTI-LUMEN CATHETERS

FLOW RATES AND PRIMING VOLUMES (continued )

Description 7 Fr. x 20 cm (8") Lumens Volume (cc) Dist. (16 Ga.) Med. (18 Ga.) Prox. (18 Ga.) Dist. (16 Ga.) Med. (18 Ga.) Prox. (18 Ga.) Dist. (14 Ga.) Med. (16 Ga.) Prox. (16 Ga.) Dist. (16 Ga.) Med. 1 (14 Ga.) Med. 2 (18 Ga.) Prox. (18 Ga.) Priming Volume (cc) 0.44 0.39 0.39 0.49 0.40 0.44 0.49 0.88 0.50 0.43 0.36 0.54 0.41 Gravity (standard tubing) 3100 Units 1500 Units 1600 Units 2300 Units 1000 Units 1100 Units 4400 Units 8650 Units 3800 Units 3200 Units 5400 Units 1600 Units 1800 Units

7 Fr. x 30 cm (12")

8.5 Fr. x 20 cm (8")

8.5 Fr. x 16 cm (6")

Please note: This chart lists examples of commonly used catheter sizes. For capacities and performance specifications of a specific Arrow

catheter, please contact Arrow International, Inc. Capacities and performance specifications are also provided with each Arrow catheter package.

VENOUS ACCESS

ARROWg+ard BLUE® TECHNOLOGY

Over 30 randomized, controlled trials, meta-analyses and case-control studies have proven the efficacy of ARROWg+ard® antiseptic technology. In particular, ARROWg+ard reduces bacterial colonization of the catheter by 60 percent and catheter-related bacteremia by an even greater 80 percent.1 And it's effective against a wide array of grampositive bacteria, including S. epidermidis, MRSA and S. aureus; gram-negative bacteria, including Enterococci and Pseudomonas strains; and fungi, including C. albicans.2

References:

1

Maki, D.G., Stolz, S.M., Wheeler, S., Mermel, L.A. "Prevention of Central Venous Catheter-Related Bloodstream Infection With an Antiseptic-Impregnated Catheter: A Randomized, Controlled Trial," Annals of Internal Medicine, August 15, 1997, Vol. 127, Issue 4, pp. 257­266.

2

References include but are not limited to Maki 1997, Sampath 1995 and Bach 1994.

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SITE PREPARATION GUIDELINES

1 Don't remove hair at the site unless it interferes with dressing adherence. Clipping is preferable to shaving; it minimizes skin lacerations and disruption of the epidermal barrier that can lead to infection.1 2 Check for patient sensitivity to the prepping solution by requesting known allergy information or testing on a small area of skin away from the proposed insertion site. 3 Physically clean the skin prior to applying antiseptic solution and inserting the catheter. Take care to remove all soap residue. 4 Apply the antiseptic following the specific antiseptic manufacturer's packaging instructions. 5 Allow the antiseptic solution to air dry prior to inserting the catheter.

Reference:

1

Alexander, J.W., Fischer, J.E., Boyajian, M., Palmquist, J., Morris, M.J. "The Influence of Hair-Removal Methods on Wound Infections." Archives of Surgery, 1983, Vol. 118, p. 347.

VENOUS ACCESS

DECLOTTING PROCEDURE

> Verify catheter tip placement by chest X-ray. > Rule out mechanical occlusion. > Evaluate medications being infused to assess the possible nature of the occlusion. > Use a 10 cc syringe or larger to avoid excessive pressure.1 > Do not use excessive force during the declotting procedure. > Use gentle aspiration to dislodge any occlusion. > Do not exceed catheter's lumen-filling volume.

Reference:

1

Conn, C. "The Importance of Syringe Size When Using Implanted Vascular Access Devices," Journal of Vascular Access Nursing, 1993, Issue 3, Winter, pp. 11­18.

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