Question: I was just wondering how CVAD access should be documented on the ACR? There is no specific code for CVAD. Is it ok to document using the Normal Saline code (345) and just specify that it was via CVAD in remarks? Should I always get blood when I aspirate? (I didn’t but it seemed to flow well).
Answer: Great question! Thanks for asking it. We have checked with our Professional Standards staff and thanks for bringing it to our attention- there is indeed no code on the eACR for CVAD. Your strategy as above would be reasonable in the interim. Unfortunately this does not allow us to track CVAD access readily so we are going to make some inquiries about adding a code specific for this procedure. The short answer to your second question however is “YES”. You should always confirm blood flow back on the line to ensure patency and also in order to aspirate and discard the contents of the proximal lumen as often it may contain a significant amount of heparin to prevent clotting. Failure to aspirate and discard may result in an inadvertent heparin bolus which could have harmful effects. Perhaps this may be a great time to actually review the procedure entirely. We have included the procedure below Procedure as below for CVAD access.. Notes:
When IV access is required, proceed with the following steps:
a. Identify the type of Central Venous Access Device. (CVAD)
b. Have available an empty 10 cc syringe and also draw up a second 10 cc syringe with sterile NS,
c. Ensure lumen to be accessed is clamped*
d. Remove prn adapter from lumen exposing luer lock end
e. Connect the empty syringe to the lumen, unclamp the lumen
f. Using sterile technique, aspirate 3-5 cc of blood from the lumen you wish to use (to remove instilled heparin), keeping a closed system
g. Clamp the lumen and connect the 10 cc saline syringe, then unclamp the lumen
h. Inject approx. 2 cc of NS, then withdraw 1-2 cc and visualize blood return to ensure the line is patent. Then flush remaining NS – if resistance is met, assume the lumen is obstructed and repeat procedure on the second lumen (if a 2nd lumen exists).
i. Once lumen patency has been confirmed, re-clamp lumen and remove syringe
j. Attach IV bag and flushed tubing to lumen, unclamp lumen and run IV at appropriate rate. Ensuring there are no air bubbles in the syringe, IV tubing or CVAD is imperative
k. Ensure IV tubing is well secured to CVAD lumen
1. Except in emergent situation, other IV access should be sought first 2. Risks of complications – either dangerous for patient (heparin bolus from heparin that is instilled in each lumen post-dialysis, infection, air embolus or jeopardizing catheter by blockage or infection)