Care And Maintenance - Bard Access Equistream Mode D'emploi

C (INSERTION TECHNIQUE (1): PERCUTANEOUS PLACEMENT)
1. Unlock, remove, and discard stylet.
CAUTION: Stylet is intended for use over a guidewire to aid in placement.
Inserting the stylet into the venotomy without tracking over a guidewire could
result in vessel damage including perforation.
2. Fill the catheter lumens with heparinized saline solution.
3. Advance the dilator sheath introducer assembly over the exposed guidewire into
the vessel.
CAUTION: Care should be taken NOT to force the dilator sheath introducer
assembly into the vessel during insertion as vessel damage including
perforation could result. As reported in literature, left sided catheter placement
may provide unique challenges due to the right angles formed by the innominate
vein and at the left brachiocephalic junction with the SVC.
WARNING: Cardiac arrhythmias may result if the guidewire is allowed to touch
the walls of the right atrium.
4. Withdraw the vessel dilator and guidewire, leaving the introducer sheath in
place.
CAUTION: Care should be taken not to advance the split sheath too far into
vessel as a potential kink would create an impasse to the catheter.
WARNING: To prevent air embolism and/or blood loss, place thumb over the
exposed orifi ce of the sheath introducer.
5. Remove thumb and feed distal section of catheter into the sheath introducer.
Advance the catheter tip. Catheter tip placement, tip orientation and proper
length selection is left to the discretion of the physician. However, routine x-ray
should always follow the initial insertion to confi rm proper placement of the
catheter tips prior to use. The recommended tip location is at the junction of
the superior vena cava/right atrium (SVC/RA) or in the mid right atrium.
placements should be confi rmed by fl uoroscopy.
6. With the catheter advanced, peel away the sheath by gripping the "T" handle
and breaking it apart with a downward and outward motion to initiate separation
and withdrawal of the sheath.
CAUTION: Ensure that the introducer sheath is only torn externally. Catheter
may need to be further pushed into the vessel as sheath is torn.
CAUTION: For optimal product performance, do not insert any portion of the
cuff into the vein.
7. D (Common Steps).
D (COMMON STEPS)
1. Confi rm catheter patency by releasing clamp and aspirating blood through each
lumen.
2. Flush each lumen with 10 mL sterile saline using a 10 mL or larger syringe.
WARNING: To avoid damage to vessels and viscus, infusion pressures
should not exceed 25 psi (172 kPa). The use of a 10 mL or larger syringe is
recommended because smaller syringes generate more pressure than larger
syringes
3. Inject heparin solution into each lumen in amounts equal to the priming volumes
as printed on the catheter clamps. Be sure to clamp each lumen immediately.
WARNING: Failure to clamp extensions when not in use may lead to air
embolism.
4. For additional security, suture the entire entry site, or use a Statlock* Catheter
Stabilization device to anchor the catheter.
5. Follow your hospital protocol for dressing change and exit site care. Allow
alcohol-containing agents (e.g., Chloraprep* solution) to air dry completely
before dressing catheter.
WARNING: Acetone and PEG-containing ointments can cause failure of this
device and should not be used with polyurethane catheters. Chlorhexidine
patches or bacitracin zinc ointments (e.g., Polysporin* ointment) are the
preferred alternative.
6. Verify the catheter tip location with x-ray or fl uoroscopy.
Recommended Dressing Technique
1. Secure the catheter to the skin using one or two sterile tape
strips.
Optional: Place a pre-cut gauze dressing over the exit site,
fi tting it snugly around the catheter. Place a 2 in. x 2 in. (5 cm x
5 cm) gauze over the pre-cut gauze and catheter.
2. Apply a cover dressing, leaving the extension legs exposed.
If using a sterile, transparent, semipermeable dressing, the
following is recommended:
2a. Cut a 1-2 inch (3 - 5 cm) slit in the short side of the dressing
using sterile scissors. Remove the backing sheet.
2b. Viewing catheter site through the dressing on the skin so that
the slit is over the catheter hub. Press one side of dressing into
place while holding the other side off the skin.
2c. Partially remove the frame portion of the dressing near the
catheter hub which is already secured to the skin.
2d. Overlap the unsecured side of the dressing slightly over the
secured side to seal dressing under catheter hub. Carefully
remove the frame from the dressing while fi rmly smoothing
down the edges. Smooth down the entire dressing.
WARNING: Acetone and PEG-containing ointments can
cause failure of this device and should not be used with
polyurethane catheters. Chlorhexidine patches or bacitracin
zinc ointments (e.g., Polysporin* ointment) are the preferred alternative.
INSERTION TECHNIQUE (2) Surgical Cutdown Procedure:
The catheter may be inserted into the superior vena cava via the subclavian vein,
external jugular vein or the internal jugular vein
(standard operating room procedure). For surgical cutdown procedure, the patient
should be placed in Trendelenburg position with the head turned to the opposite side
of the entry site.
1. Go to A (Common Steps).
2. Skip B (Common Steps).
3. Skip C (Insertion Technique (1) Percutaneous Placement).
4. Locate the desired vessel for insertion of the catheter with a small incision.
NOTE: If performing a jugular insertion and external vein is not of adequate
size to accommodate the catheter, the internal vein may be used. A purse string
suture may be used to secure catheter in the internal vein.
5. Make a small incision at the desired exit site of the catheter, in the area between
the nipple and right sternal border. Make the incision just large enough to
accommodate the implantable cuff.
6. Go to B (Common Steps).
7. If not using a stylet, the proximal end of the guidewire must be inserted into the
small venous end hole of the distal-most tip, and threaded into the end hole
of the arterial tip, passing through the arterial lumen until it extends out the
arterial Luer-lock connector (red). If using stylet, thread the proximal end of the
guidewire through the distal tip of the stylet until the guidewire extends out the
stylet Luer-lock connector.
8. Insert the catheter through a small venotomy in the selected vein. Advance the
catheter tip. Catheter tip placement, tip orientation and proper length selection
is left to the discretion of the physician. However, routine x-ray should always
follow the initial insertion to confi rm proper placement of the catheter tips prior to
use. The recommended tip location is at the junction of the superior vena cava/
right atrium (SVC/RA) or in the mid right atrium.
confi rmed by fl uoroscopy.
CAUTION: For optimal product performance, do not insert any portion of the
5,8
All tip
6
All tip placements should be
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cuff into the vein.
WARNING: Cardiac arrhythmias may result if the guidewire and/or stylet is
allowed to touch the walls of the right atrium.
9. Remove the guidewire and stylet while applying forward pressure on the catheter
so it does not withdraw.
CAUTION: Ensure that the catheter does not move out of the vein while
removing the insertion stylet.
10. Go to D (Common Steps)
INSERTION TECHNIQUE (3) Sheathless Procedure
For sheathless placement, the catheter is preferably inserted into the internal jugular
vein. For the sheathless procedure, the patient should be placed in Trendelenburg
position with the head turned to the opposite side of the entry site.
1. Go to A (Common Steps).
2. Go to B (Common Steps).
3. Skip C (Insertion Technique (1) Percutaneous Placement).
4. Sequentially dilate (guiding dilators over the guidewire), the venous puncture
site to accommodate the catheter (dilate vessel to at least the same French size
as the catheter, and preferably to 1.5 F larger).
5. After removing the dilator, keep the guidewire in the venous system while
applying digital compression at the puncture site to maintain hemostasis.
6. If not using a stylet, the proximal end of the guidewire
must be inserted into the small venous end hole of
the distal-most tip, and threaded into the end hole
of the arterial tip, passing through the arterial lumen
until it extends out the arterial Luer-lock connector
(red). If using stylet, thread the proximal end of the
guidewire through the distal tip of the stylet until the guidewire extends out the
stylet Luer-lock connector.
7. To minimize the risk of air embolism, clamp the venous extension leg (indicated
by the blue Luer-lock connector).
8. Advance the catheter over the wire, until the tip reaches the desired location.
Note that some resistance may be experienced when passing the catheter
through the soft tissues, but this should subside once the catheter tip is
intravascular.
CAUTION: For optimal product performance, do not insert any portion of the
cuff into the vein.
WARNING: Cardiac arrhythmias may result if the guidewire and/or stylet is
allowed to touch the walls of the right atrium.
9. Remove the guidewire and stylet (if applicable) while applying forward pressure
on the catheter so it does not withdraw.
CAUTION: Ensure that the catheter does not move out of the vein while
removing the insertion stylet.
10. Go to D (Common Steps).
INSERTION TECHNIQUE (4) Femoral Vein Placement Procedure:
For femoral placement, the patient should be positioned supine, and the catheter
tip should be inserted to the junction of the iliac vein and inferior vena cava
WARNING: The risk of infection is increased with femoral vein insertion.
Note: Catheters greater than 40 cm are intended for femoral vein insertion.
1. Assess the right and left femoral areas for suitability for catheter placement.
Ultrasound may be helpful.
2. On the same side as the insertion site, the patient's knee should be fl exed, and
the thigh abducted with the foot placed across the opposing leg.
3. Locate the femoral vein, posterior/medial to the femoral artery.
4. Go to A (Common Steps).
5. Go to B (Common Steps), directing tunnel laterally to decrease the risk of
infection.
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6. Go to C (Insertion Technique (1) Percutaneous Placement).
14.5 F Equistream* Catheter Venous and Arterial Pressures •
250
200
150
100
50
0
300 mL/min 350 mL/min
-50
-100
-150
-200
-250
42 cm Venous
• As suggested by in
19 cm Venous
vitro data, using a blood
simulate approximating the
19 cm Arterial
viscosity of whole blood.
42 cm Arterial
16 F Equistream* XK Catheter Venous and Arterial Pressures •
250
200
150
100
50
0
300 mL/min 350 mL/min
-50
-100
-150
-200
-250
42 cm Venous
• As suggested by in
19 cm Venous
vitro data, using a blood
simulate approximating the
19 cm Arterial
viscosity of whole blood.
42 cm Arterial

CARE AND MAINTENANCE

The care and maintenance of the catheter requires well trained, skilled personnel
following a detailed protocol. The protocol should include a directive that the catheter
is not to be used for any purpose other than the prescribed therapy.
Accessing Catheter, Cap Changes, Dressing Changes
• Experienced personnel
• Use aseptic technique
• Proper hand hygiene
• Clean gloves to access catheter and remove dressing and sterile gloves for
dressing changes
• Surgical mask (1 for the patient and 1 for the healthcare professional)
• Catheter exit site should be examined for signs of infection and dressings should
be changed at each dialysis treatment.
2
:
2
6.
3 .
400 mL/min 450 mL/min 500 mL/min
Reverse Flow Rate vs Venous Pressures •
42 cm Straight Catheter -
Reverse Flow
300 mL/min 400 mL/min
140 mmHg 159 mmHg
400 mL/min 450 mL/min 500 mL/min
Reverse Flow Rate vs Venous Pressures •
42 cm Straight Catheter -
Reverse Flow
300 mL/min 500 mL/min
97 mmHg 117 mmHg
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