Guideline for the Insertion, Management, Replacement and ...



|Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children |

|Guideline Detail |

|Ownership Lorna Johnson |

|Publication date April 2012 |

|Next Review date April 2015 |

|Status |

Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children

1 Background 5

1.1 Key Changes from previous policies 5

1.2 Aim 5

1.3 Objectives 5

1.4 Definitions 6

1.5 Abbreviations used in this document 6

2 Before inserting a catheter 6

2.1 Warnings 6

2.2 Emergencies 7

2.3 Competent personnel 7

2.4 Indications 8

2.5 Choice of catheter 8

2.5.1 Number of lumens 8

2.5.2 Antimicrobial-impregnated catheters 8

2.5.3 Tunnelled/non tunnelled 8

2.5.4 Implantable access devices (Ports) 9

2.5.5 Choice of entry site 9

2.6 Consent 9

3 Insertion 9

3.1 Hand hygiene 9

3.2 Minimum aseptic precautions 9

3.3 Personal protective equipment 9

3.4 Environment 9

3.5 Insertion procedure 10

3.6 Skin decontamination 10

3.7 Insertion problems 10

3.8 If asepsis is breached 10

3.9 Ultrasound 11

3.10 Landmark method 11

3.11 Securing the catheter 11

3.12 Dressing the newly inserted CVC 11

3.13 Needle-free devices 12

3.14 Three-way taps 12

3.15 Extensions 12

3.16 Sharps disposal 12

3.17 Confirmation of placement 12

4 Ongoing care of catheter 13

4.1 Key points 13

4.2 Dressings 13

4.2.1 Impregnated dressings 14

4.3 Accessing the CVC 15

4.3.1 Key points 15

4.3.2 Hand hygiene 15

4.3.3 Personal protective equipment 16

4.3.4 Asepsis 16

4.3.5 Giving sets 16

4.3.6 Flushing 16

4.3.7 Three way taps, extensions and needle-free devices ……………….18

4.3.8 Blood sampling…………………………………………………………..18

4.4 TPN 19

4.5 Medications 19

4.6 Infusions 19

4.7 Line associated infection indications………………………………….20

4.8 Site inspection 20

4.8.1 Visual inspection of CVC entry site. 20

4.9 Removal or replacement of catheter 21

4.9.1 Key points 21

4.9.2 Routine replacement 22

4.9.3 Microbiology 22

4.9.4 Management of damanaged cathethers…………………………….. 22

4.9.5 Guidewire-assisted catheter replacement ………………………...…22

4.10 Catheter related thrombosis……………………………………………24

4.10.1 Symptoms………………………………………………………………..24

4.10.2 Diagnosis………………………………………………………………...24

4.10.3 Management…………………………………………………………….24

4.11 Management of complications…………………………………………24

4.11.1 Infection 25

4.11.2 Occlusion 26

4.11.3 How to use urokinase to unblock occlusions 27

4.11.4 Management of a blocked central venous line 29

4.11.5 Management of persistent withdrawal occulsion in central venous catheters………………………………………………………………...30

4.11.6 Dislodgement……………………………………………………………31

4.11.7 Damaged CVC 31

4.11.8 Breach of asepsis 31

5 Documentation……………………………………………………………….31

5.1 Key points ……………………………………………………………….31

6 Appendix……………………………………………………………………...33

6.1 Procedure for removal of a non-tunnelled CVC 33

6.2 Vascular access device seclection guide……………………………..35

6.3 Different types of venous access devices…………………………….36

6.4 Central Line Entry Site Score (for use in adults)……………………..38

6.5 Catheter selection for oncology patients……………………………...39

6.6 Central venous access catheter selection for chemotherapy patients……………………………………………………………………40

6.7 Manufacturer guidance for central catheters used across the Yorkshire Cancer Network……………………………………………...41

6.8 A Quick reference guide for managing problems with CVAD’s ….. 43

6.9 VYGON vascular access devices flushing guidance………………...46

6.10 Central venous access devices used within oncology………………………………………………..…………….…..47

6.11 Guidelines for the selection of central venous access devices; portacath or hickman line in paediactric and adolescent haematology and oncology……………………………………………………………..48

6.12 Central venous access device insertion and removal…………………………………...……………………………….50

7 Consultation group 51

8 Glossary………………………………………………………………………..53

9 References 55

10 CHECKLIST 56

11 EQUALITY IMPACT 60

Background

1 Key Changes from previous guidelines

This guideline supersedes the previous policy ‘Prevention of Infection Associated with Central Venous Catheters (CVCs)’, and updates sections from the now expired ‘Insertion of Central Venous Catheters using the Landmark Technique’. These guidelines incorporate the YCN Chemotherapy Nurses Group: Guidance for the Management of Central Venous Access Devices and Yorkshire and Humber Children and Young People’s

Cancer Network Guidance for the Management of Central Venous Access Devices in children and Young People with Cancer.

It should be read in conjunction with ‘Guideline for management of infected "temporary" central venous catheters (CVC) and arterial catheters in adults’.

Key changes include

• Guidance on the replacement of CVCs that were placed in sub-optimal conditions (section 2.2).

• A recommendation favouring the use of sutureless catheter securement devices over sutures (section 3.11).

• Guidance on dealing with breaches of asepsis (section 4.11.6).

• Guidance on the use of needle-free devices (section 3.13).

• Guidance on flushing (section 4.3.6).

• The requirement to consider, and document, the need for short term CVCs on a daily basis (section 5).

• Guidance that allows for rational risk assessments when considering whether to attempt to salvage potentially infected catheters (section 4.9.1).

• An assessment tool to allow for quick and quantifiable regular inspection of the CVC entry site (section 4.8).

• YCN Chemotherapy Nurses Group: Guidance for the Management of Central Venous Access Devices and Yorkshire and Humber Children and Young People’s Cancer Network Guidance for the Management of Central Venous Access Devices in children and Young People with Cancer have been incorporated into these guidelines.

2 Aim

To minimise the risk of CVC-related complications by ensuring that:

a. Intravenous access is accomplished by using the optimal venous access device for that patient.

b. Insertions are performed with minimal delay using the optimal technique via the safest route.

c. Catheters are managed according to best practice and removed as soon as indicated.

d. Complications are recognised and managed as soon as they arise.

3 Objectives

• Reduction in catheter-related bloodstream infections.

• Reduction in numbers of unnecessary CVCs.

• All CVCs inserted and managed according to these guidelines.

• Reduce patient suffering and delays in treatments.

• Provide cost effective, safe, timely intravenous therapy for patients.

4 Definitions

|Central Venous Catheter |A venous catheter that terminates in the great veins near the |

| |heart, with one or more lumens for infusion, blood withdrawal |

| |and monitoring functions. |

|Aseptic Non-Touch Technique |A technique for minimising the opportunity for contamination by|

| |never touching key parts or key sites and by minimising the |

| |time that key parts or sites are exposed. |

|Midline catheter |A peripherally inserted venous catheter, typically 8-20cm long,|

| |inserted near the antecubital fossa and terminating in the |

| |peripheral vasculature in the upper arm. |

5 Abbreviations used in this document

• ANTT - Aseptic Non-Touch Technique

• BSI - Bloodstream Infection

• CHG - Chlorhexidine Gluconate

• CVAD - Central Venous Access Device

• CVC - Central Venous Catheter

• CVP - Central Venous Pressure

• HDU - High Dependency Unit

• ICU - Intensive Care unit

• KVO - Keep Vein Open

• PICC - Peripherally Inserted Central (venous) Catheter

• PPE - Personal Protective Equipment

Before inserting a catheter

1 Warnings

All routes of access for CVCs are associated with risks to the patient.

Careful selection of an appropriate CVC should be made, taking into consideration the size of the patient, the intended route of insertion and predicted use for the device.

The use of real time ultrasound guidance will reduce the risk of complications associated with needle entry into the vessel. It does not eliminate the risk of early vein perforation by the wire, dilator or catheter nor does it eliminate the risk of delayed complications. Ultrasound should be used whenever accessing the internal jugular, subclavian, axillary or femoral veins unless there are specific reasons why it is impractical (NICE 2002).

In order to minimise complications associated with the use of guide wires and dilators:

• Guidewires should only be inserted as far as the position required for the catheter tip, unless X-ray screening is used.

• The dilator should only be inserted far enough to open the vessel puncture site, and NOT pushed to its full length. It is vital that excessive force is not used.

In the event of cardiovascular collapse in a patient with an in-situ or recently removed CVC the possibilities of venous or arterial perforation and haemorrhage, pericardial tamponade, air embolism, arrhythmia, haemothorax or pneumothorax must always be considered.

Central venous access is not usually an emergency procedure. It can and should be abandoned early if difficulties ensue.

2 Emergencies

An emergency is defined as a situation that is immediately life-threatening to the patient. Examples include cardio-respiratory arrest, near-arrest situations and severe trauma. During an emergency, inserting or using a CVC may be an essential aspect of that patient’s immediate treatment, and adhering to all the precautions outlined in this document might result in increased risk to the patient.

It is recognised that it may be rational to deviate from these guidelines in an emergency situation. For example, if the sterile field is compromised during the final stages of catheter insertion during an emergency it may not be in the patient’s best interests to restart the procedure.

Such deviations from guidelines, and their rationale, must be clearly documented retrospectively in the patient’s medical notes. If the patient is then transferred to another area, these deviations must be communicated to the receiving staff.

Central venous access devices that have been placed in sub-optimal conditions should be removed, and replaced if needed, as soon as possible. Usually this will mean following admission to ICU/HDU and a period of stabilisation and the presence of a competent operator with the time and expertise to replace the catheter in optimal circumstances.

3 Competent personnel

Operators should only undertake CVC insertion using a technique or route in which they are recognised to be competent, and that is suitable for the type of catheter being used. Operators who are not competent in the employed technique may insert CVCs but this must be under the direct supervision and control of a competent individual. The responsibility for insertion and troubleshooting of the CVC will remain with the competent individual at all times.

4 Indications

Indications for placing a CVC include

• The need for IV access lasting longer than a week where a midline catheter is considered inappropriate.

• Repeated collection of blood specimens in the absence of good peripheral veins.

• Intravenous nutrition.

• Haemodialysis.

• The need for IV access when peripheral venous access is poor.

• Administration of vesicants

• Administration of preparations with extremes of pH or high osmolarity.

• Administration of vasoactive drugs.

• Monitoring of central venous pressure.

• Certain cardiac procedures.

5 Choice of catheter

1 Number of lumens

Each extra lumen may increase the opportunity for microbial contamination of the system so the number of lumens should be kept to a minimum, ensuring that the device has sufficient access ports to achieve therapeutic goals, and avoids the mixing of non compatible fluids and medications.

Use a single lumen CVC unless multiple lumens are essential for the management of the patient (CVAD 7 epic2 Class A).

If it is known that TPN will be given to the patient then a dedicated lumen should be allocated and not used for any other purpose (CVAD 8 epic2 Class D/GPP).

A multiple lumen CVC will be necessary for the management of most patients undergoing major surgery or who are critically ill.

2 Antimicrobial-impregnated catheters

Catheters impregnated with antimicrobials are not currently recommended for routine use in this Trust.

3 Tunnelled/non tunnelled

If the need for central venous access is expected to last for less than 3-4 weeks then a non-tunnelled catheter should be used. Tunnelled catheters should be considered if access is needed for longer than 3-4 weeks, particularly for continuous access or long infusions (CVAD 9 epic2 Class A).

4 Implantable access devices (Ports)

An implantable access device should be considered if IV therapy will be long term, particularly if the patient has difficulty in accepting or safely managing the external portion of an IV device. An implantable device is suitable for intermittent access, but less suitable than a tunnelled device for continuous access or access for long infusions (epic2 CVAD 13 Class C).

5 Choice of entry site

Because of the risk of contamination and subsequent bacteraemia the femoral site should be avoided if possible (epic2 CVAD 12 Class C). It is also thought to have higher risks of thrombosis.

The risk of infection is lower from a non-tunnelled subclavian catheter when compared with a non-tunnelled jugular catheter (epic2 CVAD 12 Class C).

Patients tend to report finding PICCs and subclavian catheters more tolerable than jugular catheters.

6 Consent

Informed consent must be obtained from the patient in accordance with LTHT (DOH) Policy for Consent to Examination or Treatment.

Insertion

1 Hand hygiene

Hands must be decontaminated immediately prior to the procedure in accordance with LTHT hand hygiene policy.

2 Minimum aseptic precautions

The patient should be covered with a body-length sterile drape, fenestrated to allow access to the entry site (epic2 CVAD 14). The operator should wear a sterile gown, sterile gloves, head cap and facemask for every CVC insertion (Hu 2004).

3 Personal protective equipment

Eye protection should be available for the operator. It is advisable to use eye protection for inserting a CVC and the operator is under no obligation to continue with insertion if eye protection is not available.

4 Environment

The environment must be clean, free from extraneous items and be easy to clean in the event of a spillage. There should be sufficient space for the operator and operator’s assistant when considering the most appropriate clinical area for insertion.

5 Insertion procedure

CVCs must be inserted by experienced clinicians with accepted expertise in this area. Clinicians who are not competent may insert CVCs but this must be under the direct supervision and control of a competent individual.

6 Skin decontamination

In patients without an allergy to any of the contents, skin should be decontaminated using a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol with tint. It should be applied over the proposed entry site using repeated strokes in a cross-hatching pattern for thirty seconds before moving outwards until an area significantly wider than that which will be visible through the fenestration of the drape has been covered.

If an allergy to chlorhexidine is known or suspected then Povidone iodine 10% is the second line cleaning agent. Povidone iodine is available in alcohol or water-based solutions. The water-based formulation should only be used if the patient is sensitive to alcohol.

The cleaning agent must be left to air dry completely before draping. Drying is a vital step in the decontamination process, and alcohol fumes beneath a drape are at risk of igniting.

7 Insertion problems

Referral to a senior colleague prior to attempting insertion should be considered in all situations / patients where difficult cannulation can be predicted e.g. previous difficult cannulation or complication, morbid obesity, significant co-morbidity.

The operator should consider the warnings in section 2.1. Before beginning the procedure the operator must ensure they are aware of how to get senior help should the need arise.

8 If asepsis is breached

It is the duty of all LTHT employees involved in the procedure to immediately report breaches of asepsis to the practitioner inserting the CVC.

If asepsis is breached during insertion of a CVC then it is the responsibility of the practitioner inserting the catheter to ensure that all potentially contaminated parts are discarded and the procedure restarted from a point before the breach occurred with new equipment.

All breaches of asepsis need to be documented in the patient’s medical notes together with the rationale for subsequent action.

9 Ultrasound

In this context, ultrasound refers to 2-D ultrasound imaging. Audio-guided Doppler ultrasound is not recommended to assist in CVC placement (NICE 2002).

Access at all the commonly used sites for CVCs (jugular, axillary/subclavian, femoral, peripheral upper arm) is safer and faster overall with the use of 2-D ultrasound. Ultrasound should be used both to ensure the presence of a suitable patent vein, and to establish correct needle placement in the target vein (NICE 2002).

At more peripheral sites ultrasound is useful to find veins not easily externally visible or palpable, and to allow placement at sites away from limb flexures.

In order to maintain asepsis a single-use sterile long probe cover should be used, along with single-use sterile ultrasound gel.

10 Landmark method

Landmark techniques should be reserved for true emergency use or the very rare situations where ultrasound guidance is impractical e.g. massive subcutaneous air emphysema.

11 Securing the catheter

Sutures should not be routinely used for the stabilisation of CVCs (CDC 2002, Maki 2002, RCN 2003). A dedicated sutureless catheter securement device should be used as it is less invasive, less painful and quicker to apply, facilitates cleaning around the entry site, and eliminates the risk of suture-related needlestick injury to the operator.

Sutures should only be used if the use of a sutureless catheter securement device is ruled out on clinical grounds.

Sutureless catheter securement devices are contraindicated in patients with known adhesive or tape allergies. As these devices are adhesive-based they may not be sufficiently effective in patients with very greasy, sweaty or flaky skin.

Fragile skin need not be a contraindication to the use of a sutureless device, provided sufficient alcohol is used in its removal.

12 Dressing the newly inserted CVC

The catheter should be dressed as soon as it is secure.

The preferred dressing will be sterile, transparent, semi-permeable polyurethane (epic2 CVAD 19 Class D).

If the entry site is oozing or bleeding a sterile gauze dressing should be used.

13 Needle-free devices

Needle-free access devices reduce the risk of CVC-BSI (Yebenes 2004). All ports on a CVC should be covered with a needle-free device to ensure that the system remains closed (or closed screw on bung as short term measure to stop bleeding or air entry). The one exception to this requirement is in areas that find CVP monitoring is inaccurate through a needle-free device. If this is the case then the needle-free device may be omitted from the pressure-transduced lumen.

14 Three-way taps

The number of access ports should be kept to the minimum needed to provide therapy. The use of three-way taps is acceptable, provided that this does not result in unnecessary, unused ports.

If three-way taps are necessary, use them with needle-free connectors. These should be available within the CVC insertion pack and separately.

15 Extensions

The use of extension lines on CVCs is discouraged because they increase the dead space in the system and they make misidentification of lines more likely, increasing the risk of incompatible drugs on the same line and inadvertent boluses.

If more ports are needed, consider three-way taps before considering an extension line.

Extension lines may occasionally be used to make longer-term CVCs more tolerable to the patient.

16 Sharps disposal

Sharps must be disposed of by the operator at the point of use as soon as practically possible.

17 Confirmation of placement

Confirmation of placement requires both of the following:

1. Confirmation that the catheter is intravenous;

On placement, free aspiration of dark venous blood should occur at a low pressure not exceeding 15-20 cm of water (1.5-2 kPa, 11-15 mmHg) via all lumens. If in doubt the catheter lumens can be checked with a column of fluid (e.g. IV administration set) or by connection to a pressure transducer and monitor to measure pressures and observe the waveform. Blood gas analysis can be used to demonstrate oxygenated blood as seen in arteries.

2. Confirmation that the catheter is centrally placed;

A Chest X-ray is needed to demonstrate central passage of the catheter. It does not, however, confirm that the catheter is intravenous. Close proximity of major arteries, mediastinal structures and the pleura means that the catheter can lie in these and appear to be in the correct position radiologically.

3. If any doubt exists seek specialist advice to confirm position radiologically via contrast injection or CT imaging, and to seek the safest option in terms of removal.

Ongoing care of catheter

1 Key points

Ongoing care of the CVC has three aims:

• Minimising the opportunity for complications.

• Prolonging the life of the device.

• Frequent consideration of the utility of the device.

Needle-free devices should be used on nearly all CVCs as detailed in section 3.13.

For specific guidance on the management of complications see section 4.11.

2 Dressings

A sterile, transparent, semi-permeable polyurethane dressing is the dressing of choice for CVAD’s when required (epic2 CVAD 19 Class D). This type of dressing can remain in place for a maximum of 7 days, providing it remains secure and appears clean.

If the entry site is oozing or bleeding then the preferred dressing is one that contains sterile gauze. A gauze dressing should be removed at least every 24 hrs, or sooner if it is visibly soiled, and the site inspected and cleaned. If the site continues to ooze or bleed then it should be re-dressed with another sterile gauze; if oozing has stopped then use a sterile, transparent, semi-permeable polyurethane dressing. Continued bleeding can often be stopped by a fine (5/0) purse string suture around the exit site.

The catheter insertion site should be decontaminated during each dressing change. In patients without an allergy to any of the contents, skin should be decontaminated using a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol. If an allergy to chlorhexidine is known or suspected then Povidone iodine in alcohol single-use application10%, is the second line cleaning agent. Povidone iodine is available in alcohol or water-based solutions. The water-based formulation should only be used if the patient is sensitive to alcohol.

The decontaminated area should extend beyond the edges of the dressing.

The cleaning agent must be left to air dry completely before redressing.

It should be noted there may be two dressings in place after insertion of a tunnelled line, entry site and exit site. The entry site dressing is generally removed within 48 hours and the suture is left exposed. The exit site dressing generally stays in place until the wound has healed.

In general, within LTHT, buried absorbable sutures are used for skin closure for Hickman lines and ports, if the patients’ skin and tissues are suitable. If not traditional external sutures will be present and should be removed 7-10 days post insertion. If a suture wing is used for external anchorage (rather than a statlock type device) then these sutures should be left in for 3 weeks and then removed to allow time for the cuff to anchor in the tissues.

Dressings can be removed from tunnelled lines when the exit sutures have been removed/dissolved and the site is healed. The line should be looped and secured to prevent pulling in both adults and children.

PICC lines must always have a statlock device to secure the line and it is recommended that it is changed weekly. A semi permeable polyurethane dressing is also applied to secure the line to the skin minimising movement which leads to fracture and the risk of mechanical phlebitis.

Ensure that catheter site care is compatible with the manufacturer’s recommendations (see Appendix 6.7). An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendations prohibit the use of alcohol with their product (EPIC2 2007).

Fully healed tunnelled catheters may not need a dressing (epic2 CVAD 23). All other types of CVC must remain dressed for the full duration of their use.

1 Impregnated dressings

Impregnated dressings (eg. chlorhexidine) may be of use if the incidence of CVC-BSI remains high in a patient group despite assurance these guidelines have been robustly implemented and are routinely followed.

When considering the use of an impregnated dressing, one should be chosen that allows undisturbed visualisation of the entry site to allow for regular inspection.

4.3 Accessing the CVC

Prior to flushing, the exit site should be checked for any signs of infection and possible line migration. Assess the patient for;

Pain in tunnel site, neck, shoulder or chest

Swelling of chest wall, arm, neck

Shortness of breath

Line migration (i.e. line longer at exit site than it was on insertion)

• Signs of redness, swelling or extudate

4.3.1 Key points

• Hands must be cleaned before accessing the CVC.

• An ANTT must be used for catheter site care and for accessing the system (CVAD 3 epic2 Class B).

• Before accessing the catheter the end of the needle-free device should be decontaminated by a vigorous scrubbing for 30 seconds with a sterile single-use swab impregnated with chlorhexidine 2% in 70% isopropyl alcohol. The solution must be given time to dry (CVAD 33 epic 2 Class C, GCP).

• After accessing the catheter it should again be decontaminated by a vigorous scrubbing for 30 seconds with a sterile single-use swab impregnated with chlorhexidine 2% in 70% isopropyl alcohol (CVAD 33 epic 2 Class C, GCP). This will prevent leaving any residues on the needle-free device which may prove impossible to shift once dry.

A port system can be used on the first post operative day, assuming there are no complications. If the port needs to be accessed the same day as insertion, it is recommended that the CVAD insertion operator is informed. The port can therefore be accessed in theatres and the gripper needle left in place, this will reduce discomfort for the patient. However, care needs to be taken with the adjacent wound, until this is well healed. It is recommended that the port is not accessed near to the incision, until it is healed. It takes about a week for the port site to settle and tenderness on palpation to disappear.

4.3.2 Hand hygiene

Hands must be decontaminated before accessing or dressing a central venous access device. Antimicrobial liquid soap, (eg. Hibiscrub) is available for this purpose in certain designated areas such as operating theatres.

Due to safety concerns, most areas of the trust do not (and should not) routinely stock antimicrobial liquid soap. Hand decontamination is achieved in these areas by using alcohol handrub on clean hands. If hands are not clean, (visibly soiled or contaminated with dirt or organic material) soap and water must be used before the alcohol handrub.

Soap and water cannot be relied upon to decontaminate hands and must always be followed with alcohol handrub.

(CVAD 4 and 5 epic 2 Class A).

4.3.3 Personal protective equipment

Clean gloves and apron must be donned before accessing the CVC.

4.3.4 Asepsis

An aseptic non-touch technique must be used when accessing the CVC (epic 2 CVAD 3 class B).

4.3.5 Giving sets

If a CVC is replaced, ensure that all giving sets are replaced at the same time. Do not connect an old giving set to the new CVC (epic2 CVAD 45 Class A).

If a giving set is detached from the CVC then it should be discarded and replaced with a new, sterile set. Do not re-attach a detached giving set to a CVC (epic2 CVAD 45 Class A).

If a giving set is used to allow the administration of a slow bolus of a drug, for example giving an antibiotic over 1-2 hours then once the bolus is finished the set should be discarded and the catheter flushed. Leaving unused giving sets attached increases the risk of catheter occlusion.

Giving sets being used for continuous infusions must be replaced as detailed in the following table.

|Product |Replace giving set: |

|Blood or blood products |After 2 units have been given or between different types of |

| |product. |

|Solutions containing lipid emulsions - eg. Propofol or TPN. |Before 24 hours |

|Solutions that do not contain blood products or lipids |Before 72 hours |

There may also be pharmacological reasons why particular solutions require more frequent giving set changes.

Giving sets should be clearly labelled at the end nearest to the patient with date, time and infusion contents.

4.3.6 Flushing

There is little consensus and limited convincing evidence regarding the frequency and composition of flushes.

Each episode of catheter access should follow the same steps:

1. Decontaminate port.

2. Verify that the catheter is located in a vein.

3. Flush.

4. Give therapy.

5. Flush.

6. Clean port.

No CVC should ever be left unattended with any medication other than a connected infusion or the flush occupying the lumen.

If the rate of administration of a medication needs to be limited then the post medication flush should be given at the same rate until the catheter is clear. This will prevent inadvertent bolus.

Protocols regarding the frequency of flushing of unused lumens are particularly contentious. Practice may differ in specific areas provided that local protocols are in place. The RCN Standards for Infusion Therapy (2010) recommendations should be followed unless local protocol or manufacturers’ recommendations dictate otherwise:

o Short term CVC: 8 hourly

o PICC: weekly

o Long-term tunnelled CVCs: weekly.

o Ports : monthly

Please refer to 6.10 for local guidance within Oncology and Physics.

Central lines should be flushed with 5-10mls of 0.9% sodium chloride, using a pulsated flush. On discharge tunnelled lines should be flushed with 5mls of heparin sodium flushing solution 10 units/ml and implanted devices flushed with 4-6mls of heparin sodium 100 units/ml.

• The needle-free device must be decontaminated by giving a 30 second scrub with a sterile, single-use swab of 2% chlorhexidine in 70% isopropyl alcohol and allowed to dry.

• The patency and placement of the catheter must be checked before administering a drug by aspirating and checking for blood return unless a locally agreed protocol states otherwise. There is no need to discard this blood for routine flushing to maintain patency, aspiration of blood is not necessary (Dougherty and Lamb 2010, RCN 2010).

• Flushes and IV medications should be stored, prescribed, dispensed and prepared appropriately.

• ANTT should be used when drawing up and giving a flush.

• The catheter must be flushed between incompatible medications.

• The catheter must be flushed after giving medications.

• If sodium chloride is compatible with the medication previously administered then 0.9% sodium chloride is the preferred flush solution. Heparin-based solutions should not be routinely used. Practices may differ in specific areas if locally agreed. However, manufacturers of open-ended catheter lumens or implanted ports may recommend heparin flushes when not in regular use.

• Sodium chloride is not compatible with all medications. In the event of incompatibility an alternative flush solution must be used. Consult the IV Monographs (Medusa) () for medication-specific information.

• The volume of flush should be twice that of the catheter; 5-10mls saline 0.9% is usually sufficient.

• Repeated flushes in children may make a significant contribution to their total fluid intake and to avoid fluid overload it may be necessary to calculate the amount of flush needed. The flush volume should be at least double the volume of the catheter (RCN 2007). A paediatric CVC typically has a volume of less than 1ml (Dougherty 2008 p428).

• Except where very small flushes would make it impractical, the syringe used for flushing must have a capacity of 10ml or greater to reduce the possibility of pressure-related lumen failure.

• Flushing lines should be performed within manufacturers recommended maximum pressure limits in pounds per square inch (PSI). Extensive pressure can cause catheter rupture. Smaller syringes exert a greater PSI than when the same force is applied to a larger syringe.

• If withdrawing blood, the opposite applies, the larger the syringe the greater the force required to withdraw fluid, without creating a vacuum. So if there is difficulty in aspirating blood, using a smaller syringe may result in success.

• The catheter is ready for use once its patency and placement have been established and it has been flushed.

• Any agents used to unblock lines should adhere to the central line manufacturer guidance (RCN 2003).

• The flush should be administered using a stop-start technique of rapid small boluses. This technique promotes a turbulent flow, reducing the possibility of precipitates or other residues adhering to the internal lumen of the catheter.

• If the catheter is not going to be immediately used after a flush then the following two steps need to be followed:

o Inject the last 10% of the flush slowly, and clamp the lumen before this 10% is finished in order to minimise the possibility of backflow of blood into the lumen during disconnection of the syringe.

o Disconnect the syringe and decontaminate the needle-free device.

4.3.7 Three way taps, extensions and needle-free devices

Ongoing issues regarding the use of taps, extensions and needle-free devices are dealt with in the section on catheter insertion.

4.3.8 Blood sampling

1. When sampling a line for routine blood a discard of at least twice the line volume should take place (approximately 5-10ml).

2. If obtaining blood for cultures, the initial blood withdrawn from the CVAD gives important microbiological information and therefore should not be discarded. For further information please see SOP for obtaining blood cultures.

4. The catheter should be flushed after the sample has been taken (see below Maintaining Catheter Patency).

5. Blood samples should not be taken from a CVAD which has recently been used for the administration of drugs or fluids, as this could result in an inaccurate biochemical analysis or drug level analysis. If this is the only route the infusion should be stopped for a minimum of 10 and up to 20 minutes and flushed with 0.9% saline. Twice the prime volume of the CVAD should then be discarded before aspirating the blood sample (RCN 2005, Dougherty & Lamb 2008)

4.4 TPN

If a multilumen catheter is used then identify, designate and label one port for the use of TPN if at all possible (CVAD 8 epic2 Class D/GPP). Document the rationale for deviations in the patient’s medical notes.

4.5 Medications

Medications should be prepared using Aseptic Non Touch Technique.

The injection port must be flushed before and after administration of a medication.

4.6 Infusions

Incompatible products must not be given simultaneously via the same lumen. Compatibility information may be found on the intranet at .

The injection port must be flushed (see section 4.3.6) prior to connecting an infusion, and immediately after disconnection. Unless there is a possibility that an infusion may need to be restarted quickly (for example during the titration of inotropes or during a sedation hold) then the infusion should be taken down and the catheter flushed as soon as possible.

Do not leave empty gravity infusions connected as backflow of blood may lead to occlusion of the lumen. A gravity infusion should be disconnected as soon as it is finished. Volumetric pumps should be used in areas where it cannot be guaranteed that a gravity infusion can be immediately disconnected once finished.

PICCs are particularly prone to occlusion and gravity infusions should not be used. If a volumetric pump is required and cannot be obtained an incident report (IR1) should be filed. The volumetric pump will only prevent occlusion if it is either running an infusion or has switched to KVO mode. A volumetric pump that is switched off is not protecting the PICC from occlusion.

The administration set for a volumetric pump may contain as much as 25ml of fluid. This should be accounted for when giving infusions, particularly small volume infusions of 250ml or less, otherwise the patient may receive significantly less medication than was prescribed. When the infusion appears to have finished it may be necessary to flush the contents of the administration set by attaching a small bag of a suitable fluid and delivering an appropriate volume via the pump.

4.7 Line-associated infection indications

Typical warning signs include;

1. Inflammation or discharge at exit site, with or without tracking up the line

2. Fever, rigors, sepsis, especially those related to line flushing

Blood cultures which grow bacteria frequently associated with line infection, such as coagulase-negative staphylococci and diphtheroids, may indicate infection of a line, as can cultures positive for other types of bacteria or yeasts where there is no immediately recognisable focus of infection. (see 4.9.3)

3. Resolution of signs or symptoms of infection following line removal provides circumstantial evidence of a line-related infection; however culture of the tip following removal of the device may give a definitive answer.

A line infection should be considered in cancer patients with possible signs of infection and a CVAD where there is no other obvious source.

A high index of suspicion of line-associated infection should be maintained in patients with a line and a fever but without an obvious source, especially if the patient does not respond to apparently appropriate antimicrobial therapy.

Line salvage may be possible using antibiotic or alcohol locks. Senior expert microbiology advice should be sought. Local protocols should be agreed for management of line infections.

4.8 Site inspection

The entry site should be inspected at least twice daily (with the exception of tunnelled lines which should be inspected daily) and its score documented.

4.8.1 Visual inspection of CVC entry site.

All CVCs less than four weeks old should have the entry site visually inspected twice daily (with the exception of tunnelled lines which should be inspected daily). If a CVC is removed, twice daily inspection of the site should continue for three days or until fully healed, whichever is longer. Visual inspections should be appropriately documented.

The Central Line Entry Site Score (Appendix 6.4) is adapted from the commonly used Visual Infusion Phlebitis score (Jackson 1998). It should be remembered that the entry site is only one possible factor in the development of CR-BSI and that a low score does not rule out the possibility of CR-BSI and other CVC-related problems.

It is important for the user to be careful with the score in people with dark skin. Heavily pigmented skin is less prone to developing erythema in the presence of an irritant, and any erythema that has developed is more difficult to visualise. The score for those with dark skin is therefore less accurate and liable to under-report.

The following table provides guidance for management of a CVC according to its score. The score can be used as an aid to CVC management decisions, but must be used sensibly and in consideration of other factors.

|CLESS |Recommendation |

|0 |A score of zero offers little reassurance as it does not rule out CR-BSI. Continue to care for the |

| |catheter as described in the CVC care guidelines, and remove if no longer needed. |

|1 |A medical review should be done to assess for likelihood of systemic infection. If there are |

| |signs/symptoms of systemic infection then take paired blood cultures and consider replacement of |

| |catheter. |

|2 |A medical review should be done to assess for likelihood of systemic infection. If obtaining |

| |replacement central venous access is high risk, and central venous access is essential for the |

| |patient’s management, then the catheter should be immediately removed (and if necessary replaced at |

| |a different site) and the site inspected twice daily until inflammation is resolved. Paired blood |

| |cultures should be taken. See 0 for further guidance. |

4.9 Removal or replacement of catheter

4.9.1 Key points

It is easy to overlook the presence of a CVC and leave it in for longer than necessary. Failure to remove or replace unused or potentially infected CVCs in a timely manner has been found to be the root cause of several bacteraemias in LTHT.

The need for short-term IV fluids is rarely an indication for using central venous access, nor is the need for regular phlebotomy in the presence of adequate peripheral veins.

The team responsible for the care of the patient with a non-tunnelled CVC must, on a daily basis:

• Consider and document the rationale for continuing to use the CVC.

• Ensure that the CVC is removed if it is decided that there is no rationale for continuing its use. CVCs should be removed within four hours of the decision to remove and before any transfers to other areas.

• Identify potential barriers to the removal of a CVC at the time of the decision to remove and ensure that a plan is in place to address these barriers. A common finding is that there is a delay in removing a CVC because the patient has no alternative IV access. This should be addressed and a plan made at the time of the decision to remove.

4.9.2 Routine replacement

There is no evidence that routine catheter replacement reduces. CRBI rates. However short term centrally inserted central venous catheters are known to be associated with a higher infection risk than long term catheters.

4.9.3 Microbiology

If a patient has a CVC and a bloodstream infection then CVC-BSI should be suspected. If CVC-BSI is suspected then paired cultures should be taken - ie blood cultures should be taken from the suspected catheter and from a peripheral stab with no delay between them. The microbiology laboratory will use a differential time to positivity (DTP) test to establish the likelihood that the catheter is a source of infection. The test relies upon the cultures being taken at the same time and it is important to document the time on the request form. The test also requires the same volume of blood in each bottle. Blood cultures should be taken in accordance with the ‘LTHT guidance for blood culture sampling in adults’.

If the catheter is removed and CVC-BSI is suspected then the catheter tip should be sent to microbiology.

If exit site infection is diagnosed clinically then a swab or sample of pus may be sent to microbiology for identification of the pathogen.

4.9.4 Management of damaged catheters

When the external portion of a CVAD is damaged, the device may be repaired according to the manufacturer’s guidelines, using aseptic technique and observing universal precautions (Reed and Philips 1996; Gabriel 1999)

Vascular catheters that can be repaired include mid line catheters, PICC’s and tunnelled central catheters (Reed and Philips 1996, Gabriel 1999). All damaged catheters should be referred immediately for expert advice.

1. Immediate management of damaged line…

clamp between the break and skin to avoid back bleeding and air entry into the negative pressure central veins. If clamp unavailable kink the catheter or use other device eg paper clip.

2. Establish what fluid is leaking. If cytotoxic follow local guidance (hazardous waste/ spillage policy) to manage the spillage. Take all necessary measures to protect the patient, carer and yourself.

3. If the line has a clamp, clamp the line above the point of leakage.

4. Switch off and disconnect any infusion device.

5. In general, patients with damaged lines should not be discharged home with some sort of temporary clamp in place due to risks of bleeding or air embolism.

6. Document incident in patient’s notes

4.9.5 Guidewire-assisted catheter replacement

Catheters do not need to be routinely replaced as a method to reduce the risk of CVC-BSI (epic2 CVAD 28 Class A). If a catheter needs to be replaced there are certain circumstances where this may be achieved by passing a new guidewire through the old CVC, removing the old CVC and passing a new one over the wire. Although rewiring a CVC can lead to quicker and safer replacement, it carries a higher risk of early microbial contamination of the new catheter.

Epic 2 guidelines illustrate when guidewire-assisted catheter replacement should be performed.

[pic]

4.10 Catheter related thrombosis

The presence of a CVAD in a vein can result in damage to the lining and thrombosis formation.

Thrombi form on CVADs in the first few hours following placement. This can encourage microbial colonisation (Pratt et al 2007). Thrombus occurs in large vessels after long term catheterisation in 35-65% of patients.

4.10.1 Symptoms

Pain, swelling and oedema in the neck and ipsilateral upper limb.

Distension of peripheral, neck and chest veins.

4.10.2 Diagnosis

Doppler ultrasound or contrast venography.

4.10.3 Management

Optimal management is not clear in the literature. There are no randomised controlled trials. Immediate removal of the catheter and treatment with low molecular weight heparin (LMWH) is recommended by some professionals. Others argue that in cases where the CVAD is needed, removal will expose the patient to risks associated with reinsertion, including another thrombosis. Kenney et al (1996) report a 78% success rate in resolving the symptoms of CVAD thrombosis by means of anticoagulation without catheter removal. Lee and Levine (200) also advocate leaving the catheter in situ but state that many questions still remain about optimal anticoagulation treatment.

Prophylactic heparin and warfarin have been used widely to prevent catheter thrombus formation and catheter related complications such as deep vein thrombosis (DVT) (CDC 2002).

Young et al (2009) found that prophylactic warfarin compared with no warfarin is not associated with a reduction in symptomatic catheter-related or other thromboses in patients with cancer and therefore we should consider newer treatments.

Patients with more severe signs of limb thrombosis, SVC thrombosis or other problems should be considered for systemic thrombolysis, discuss with vascular radiology to reduce longer term vascular problems and pulmonary embolism.

A clinical judgement should be made in each case.

4.11 Management of complications

Complications are common and may occur even if great care is taken with insertion and management of a CVC. Many of these complications require senior expert help and their management is too dependent upon individual circumstances to be detailed in these guidelines.

Complications may include

• Pneumothorax

• Air embolism

• Pleural effusion

• Arterial puncture/catheterisation

• Great vein perforation

• Damage to neighbouring structures

• Cardiac arrhythmias

• Infection and/or sepsis

• Thrombosis

• Mechanical phlebitis

• Incorrect catheter tip position

• Embolised, fractured or irretrievable guidewires or catheter parts

• Extravasation injury

• Catheter occlusion

Adapted from Bodenham and Simcock (2009).

The management of common complications is detailed in the rest of this section.

4.11.1 Infection

For treatment of infections in temporary CVCs in adults see ‘Guideline for management of infected “temporary” central venous catheters (CVC) and arterial catheters in adults’. For children and adolescents, this advice should be read in conjunction with the ‘Guidelines for management of infection in paediatric and adolescent oncology patients’.

Attempting to salvage a potentially infected catheter carries a significant risk of harm to the patient. Removing or replacing a catheter is also not without risk.

In most cases this risk assessment weighs heavily towards removal of the catheter.

However, some areas that use long-term catheters in very vulnerable patients may encounter significant risks when replacing a catheter. For example, in paediatric oncology, replacing an infected catheter may involve a general anaesthetic to enable removal, a period of unreliable IV access, and another general anaesthetic during the insertion of the new catheter. It is currently common in some areas to adopt a default position where attempting to salvage an infected catheter is almost always the initial management approach.

It is difficult to conduct a risk assessment when an immediate risk (such as a general anaesthetic) is balanced against a more long-term risk (of bacteraemia) particularly when information about longer-term risks is not routinely available.

Suspected infection in long term lines should ideally be established via microbiological diagnosis through blood cultures, obtained aseptically from each lumen and from a peripheral vein. Exit site swabs can be beneficial if there are localised signs of infection i.e. erythema or discharge at the exit site.

Removal of CVC should be considered when

1. A definitive microbiological diagnosis has not been achieved and line infection cannot be excluded

2. There is a tunnel infection or

3. In cases of infection with particular microorganisms such as Pseudomonas aeruginosa, Bacillus spp., fungi and mycobacteria.

It is recommended that routine surveillance of outcomes from CVCs is conducted, particularly in areas where it is common to attempt to salvage infected catheters.

4.11.2 Occlusion

Occluded lumens predispose the patient to an increased risk of developing subsequent bacteraemia and venous thrombosis. A CVC with an occluded lumen should not be left in place without considering and documenting a management strategy.

Occlusion may be partial (where it is difficult or impossible to aspirate the lumen but where it is still possible to infuse fluids) or total, where there is no flow in either direction through the lumen.

Catheter occlusion is usually a result of:

1. The formation of a precipitate caused by inadequate flushing between incompatible medications.

2. Clot formation following a delay between an infusion finishing and a flush being given.

3. Mechanical causes such as kinking or pinch-off syndrome.

4. Longer term formation of a fibrin sleeve along the length of the catheter.

Dougherty and Lamb 2008

Catheter occlusion can be mostly avoided using good flushing technique (see section 4.3.6).

There are three strategies for managing an occluded lumen, all of which should be considered.

.

1. The possibility of manoeuvres to unblock the lumen.

2. Removal of the CVC, with or without subsequent replacement of the device (see 4.9)

3. In a multi-lumen device, to continue to use the non-occluded lumens.

The third strategy is undesirable and should only be used if the first two cannot be followed. Responsibility for using a catheter with an occluded lumen should be taken by a senior member of the team and the rationale for doing so must be clearly documented in the patient’s medical notes.

A broad strategy for attempting to unblock a catheter is outlined below:

1. Consider malposition - find out if repositioning the patient, lifting arms in the air or coughing relieves the occlusion. If the occlusion is relieved in this manner then the tip position should be checked with X-ray. A malpositioned catheter should be removed or repositioned.

2. Consider the possibility of precipitation of incompatible drugs and if necessary discuss with pharmacy the possibility of attempting to instil a suitable solute. Dissolution of precipitate is unlikely to be successful.

3. If step 1 is unsuccessful and step 2 is unsuccessful (or the possibility of precipitation is low) then the occlusion should be treated as an intraluminal clot or a fibrin sheath. Urokinase is licensed for unblocking central venous catheters and can be used (in accordance with a locally agreed protocol). It is generally only used in the context of long term catheters.

4.11.3 How to use urokinase to unblock occlusions

Urokinase should be prepared at a concentration of 5000 units per ml. It is important to only use sufficient to fill the catheter without administering it to the patient unnecessarily ie avoid a systemic dose.

The urokinase must not simply be pushed into the occluded catheter because excessive force could rupture the catheter or push the clot into the patient. Giving it as a simple bolus could also cause inadvertent and unnecessary administration of urokinase to the patient. For these reasons a ‘negative pressure’ technique should be used.

Do not attempt a negative pressure instillation of urokinase unless you understand how to do it correctly.

A negative pressure technique involves creating a vacuum in the catheter and allowing this vacuum to ‘suck’ urokinase from a syringe to fill the catheter. It requires a three-way tap attached to the occluded lumen and two 10ml Luer-lock syringes. Syringe A should contain 2ml of urokinase 5000 units/ml. Syringe B should be empty, with the plunger fully depressed.

1. Attach both syringes to the three-way tap.

2. Turn the tap so that it is open to the catheter, open to syringe B and closed to syringe A.

3. Withdraw the plunger on syringe B to around the 8ml mark. Because the lumen is occluded, very little liquid will be seen in the syringe. This will create a partial vacuum between the plunger of the syringe and the clot in the lumen.

4. Maintaining this vacuum, turn the three-way tap so that it is open to the catheter, open to syringe A and closed to syringe B. This will draw the contents of syringe A into the lumen, allowing the urokinase to come into contact with the clot.

5. Close the three way tap to the ports and seal with obturators if no needlefree devices are present. Wait 60-90 minutes before attempting to flush the catheter.

6. Steps 1-5 may be repeated several times if necessary.

[pic]

[pic]

4.11.6 Dislodgement

The optimal placement of the catheter tip is in the superior or inferior vena cava or the upper right atrium, with the distal section and tip parallel to the vein, and with no kinks or pinching of the catheter. Tip migration may have occurred if the external portion of the catheter was inadvertently moved after being snagged, pulled by a confused patient or mishandled. Dislodgement may also occur spontaneously or following seemingly innocuous activity such as coughing or the Valsalva manoeuvre.

Dislodgement is obviously present if the external portion of the catheter changes in length.

Tip migration or kinking may be suspected if any of the following issues arise: patency problems, discomfort during flushing, venous thrombosis, change in CVP trace.

A catheter that may be dislodged must have its position checked with X-Ray and expert advice sought. The consequences of continuing to use a dislodged catheter include DVT/PE and great vein perforation.

4.11.7 Damaged CVC

If a CVC is damaged and leaking it should be clamped, or folded over if it has no clamp, to stop the leak and prevent air entrainment and embolus (see above).

The majority of CVCs should then be removed as soon as possible.

In some specialist areas such as paediatric oncology certain catheters may be repaired if the external portion is damaged and a risk analysis may indicate that repair is the better option. See manufacturer’s instructions.

4.11.8 Breach of asepsis

If these guidelines are followed correctly and carefully then there should not be a breach of asepsis during routine use. If, however, asepsis is breached during care of the catheter this must be documented in the patient’s notes, and in an incident report form (IR1). It should also be communicated to a senior member of the team and serious consideration should be made to the possibility of replacing the catheter. If the catheter is not replaced the rationale for this decision should be documented by the person responsible.

It is important that breaches in asepsis are correctly documented so that common themes can be identified to allow practice to improve.

5 Documentation

5.1 Key points

Full documentation of the insertion procedure should appear in the patient case notes, and unless locally agreed, an insertion checklist should be completed. Documentation should include (as a minimum):

• the site(s) of insertion or attempted insertion

• the number of needle passes

• attempts at different sites

• any local or systemic medications used

• the technique followed

• infection prevention and control precautions

• ALL complications or difficulties encountered

• any checks made to ensure correct catheter placement

• any deviations from these guidelines and the rationale for these deviations

The rationale for continuing with a non-tunnelled short-term CVC should be documented on a daily basis in the medical notes. This documentation should include a statement that either there is no suspicion of a catheter infection, or that there is suspicion/confirmation of infection and the reason for its continuation.

6 Appendices

6.1 Procedure for removal of a non-tunnelled CVC

This procedure assumes that all infusions have already been disconnected. Cuffed, tunnelled catheters (eg. Hickman) will need surgical cutdown.

1. Equipment needed:

i. Clean trolley

ii. Sterile dressing pack

iii. Sterile scissors/stitch cutter if stitch present

iv. Sterile gloves

v. Container for microbiology if indicated

vi. Microbiology swab if indicated

vii. Swab containing chlorhexidine 2% (or alternative if patient allergic - see section 3.6)

viii. Sterile, clear dressing

ix. Sterile gauze

2. Explain the procedure to the patient.

3. Clean trolley surfaces with disinfectant wipes.

4. Place patient in a supine/head down position to increase venous pressure and reduce risk of air entry down skin tract.

5. Clean hands as indicated (Soap and water or handrub).

6. Prepare sterile field and open supplies onto trolley.

7. Using clean gloves remove old dressing and dispose in biohazard container.

8. Decontaminate hands with alcohol rub.

9. Don sterile gloves.

10. Inspect the area for signs of infection. If indicated swab insertion site for culture.

11. Clean the catheter site with chlorhexidine or alternative.

12. Free the catheter of any securement device.

13. Instruct patient on how to perform Valsalva manoeuvre (to raise venous pressure).

14. Place sterile gauze dressing over the insertion site.

15. Whilst patient is performing valsalva manoeuvre, use gentle traction to withdraw the catheter.

16. If any resistance is encountered do not force the catheter and seek senior advice.

17. Apply pressure to gauze over site, using free hand.

18. Avoid any contamination of the catheter tip during removal, if culture is to be obtained

19. If the catheter tip is to be cultured have a colleague assist by cutting off approx 3 cm of the catheter at tip into a sterile container, using a pair of sterile scissors.

20. As soon as the catheter is free, apply firm steady pressure to the exit site.

21. Hold pressure for a minimum of 5 minutes, keeping patient lying flat if they can tolerate it. If patient cannot remain flat, sit up at 45 degree angle.

22. If bleeding stops, dress the site with a sterile transparent bio-occlusive dressing ( to keep clean and stop air entry)

23. Inspect the catheter to make sure the tip was removed intact. Suspect catheter embolus if tip is not intact.

24. If the site bleeds, maintain pressure for a further 15 minutes. Do not release pressure until the site stops bleeding.

Ongoing care/observation

1. Instruct patient to:

a. Avoid lifting, stooping, squatting, or any strenuous activity for 24-72 hours

b. Avoid getting dressing wet or soiled

c. Leave dressing in place for 24 hours

2. Signs and symptoms to report:

a. Bleeding.

b. Shortness of breath.

c. Fever.

d. Swelling of the site, (face, neck, arm or groin depending on site of catheter).

e. Drainage from the site.

3. Continue with Central Line Entry Site Score until any inflammation is no longer seen, or for three days, whichever is longer.

6.2 Vascular Access Device Selection Guide

Ask the following questions before you select a Device:

• How long will IV access be required?

• What type of therapy will be administered via the device?

• How suitable are the patient’s peripheral veins?

• Will the line be used for TPN? (must have a dedicated lumen).

• Consider relevant contra-indications/co-morbidities, e.g. Obesity, previous vascular surgery.

Also consider:

• Will blood sampling from line be required? (NB. ONLY use device for sampling if access is poor).

• How many lumens will be required? Avoid multiple lumen catheters wherever possible.

• Make plans for removal/review of device rotation/replacement dependant on patient need.

• Will hemodynamic monitoring be required

6.3 Different Types of Venous Access Devices

|Catheter Type |Tip location |Indication for use |

|Peripheral |Peripheral vein |Device rotation/replacement every 72 hours |

| | |Isotonic fluids and medicine only |

| | |Not suitable for blood sampling |

| |Axillary/ |Mid term access < 30 days or as per manufactures guidance |

|Midline |Subclavian vein |Isotonic fluids and medicine only |

| | |Not suitable for blood sampling |

| | |Short term access |

|Short term Central Venous Catheter (CVC) | |Not suitable for long-term access, at 7 days plan for longer term device |

| |SVC |Suitable for irritating/vesicant solution that require greater haemodilution |

| | |Can provide multiple access ports for critically ill patients |

| | |Hemodynamic monitoring |

| | |Blood sampling possible |

| | |Account for majority of CRBSI |

| |SVC |No routine replacement |

|PICC (Peripherally Inserted Central Venous Catheter) | |Longer term access, usually for 2-12 weeks. |

| | |Suitable for irritating/vesicant solution that require greater haemodilution |

| | |Multiple lumen devices available |

| | |Blood sampling possible |

| |SVC |No routine replacement |

|Skin Tunnelled Central Venous Catheters (Hickman Lines) | |Long term access (several months- year) |

| | |Particularly suited to frequent access |

| | |Suitable for Irritating/vesicant solution that require greater haemodilution |

| | |Blood sampling possible |

| |SVC |Long term access, may dwell indefinitely |

|Ports | |Good for long term intermittent therapy |

| | |May be inserted in chest or arm |

| | |No permanent external device |

|For Haemodialysis Patients |

|Arteriovenous fistula |In arm |Haemodialysis |

|(1st choice) | |NO OTHER USE ACCEPTABLE |

|Arteriovenous synthetic graft |In arm or leg |Haemodialysis |

|(2nd choice)_ | |NO OTHER USE ACCEPTABLE |

|Tunnelled venous catheter Tesio/Permcath |SVC |No rotational schedule |

|(3rd choice) | |For haemodialysis only |

| | |Temporary access (several months- year) |

|Sort term non tunnelled CVC |SVC or IVC if |For haemodialysis |

|(4th choice) |femoral |Dual lumen some have additional third lumen for IVI / TPN |

| | |Remove femoral lines by day 7 |

| | |Remove jugular lines by day 14. |

General consideration

• All Vascular Access Devices are associated with risk and must be inserted and cared for by competent practitioners

• All Vascular Access Devices should be inserted using a sterile technique as per LTHT guidelines

• All Vascular Access Devices must be accessed using an Aseptic Non-Touch Technique (ANTT) as per LTHT guidelines

• Because of the risk of contamination and subsequent bacteraemia the femoral site should be avoided if possible (EPIC2). It is also thought to have higher risks of thrombosis.

• For haemodialysis patients, femoral CVC insertion is preferable due to the risk of central venous stenosis with IJ / SC lines and the need for patent central veins to allow fistula formation. They must be removed by day 7 due to the high risk of infection.

• The risk of infection is lower from a non-tunnelled subclavian catheter when compared with a non-tunnelled jugular catheter (EPIC2). Patients with renal failure ideally should not have subclavian punctures.

• Patients tend to report finding PICCs and subclavian catheters more comfortable than jugular catheters.

• Use a single-lumen catheter unless multiple ports are essential for the management of the patient.

6.4 Central Line Entry Site Score (for use in adults)

[pic]

6.5 Catheter Selection FOR LONG TERM ACCESS

There are 3 types of CVAD

Tunnelled line (e.g. Hickman)

Peripherally inserted line (PICC)

Implanted port (e.g. Portacath)

6.6 Central Venous Access Catheter Selection for Chemotherapy Patients

6.7 Manufacturer Guidance for Central Catheters Used Across the Yorkshire Cancer Network

|Commercial name of |Cleaning solution recommended |Line can be flushed with/ |Dressings recommended and |Use of Line Connectors |

|line/ company | |Frequency of flushing |duration to remain in situ |Bungs e.g. bionectors |

|Hickman line – (Bard)|Alcohol based products can be |Syringe size limited to | |Luer caps should be |

| |used on line made of silicone |25psi/ 10ml syringe or larger| |changed every 7 days or |

| | | | |as necessary i.e. if |

|Material - silicone | |Refer to heparin lock- 2.5cc | |removed |

| | |of heparin injected. No |7 days for transparent semi| |

| | |reference to frequency 24-48 |permeable dressing or as | |

| | |hours for gauze dressing as |necessary |Vygon Bionectors must be |

| | |needed | |changed every 7days (MHRA|

| | | | |2004) |

| | | | | |

|Leonard/ Broviac |Alcohol based products can be |Syringe size limited to |24-48 hours for gauze |Luer caps should be |

|(Bard) |used on line made of silicone |25psi/ 10ml syringe or larger|dressing as needed |changed every 7 days or |

| | | | |as necessary i.e. if |

| | | |7 days for transparent semi|removed |

|Material - Silicone | | |permeable dressing or as | |

| | | |necessary | |

| | | | |Vygon Bionectors must be |

| | | | |changed every 7days (MHRA|

| | | | |2004) |

|Groschong line (Bard)|Alcohol based products can be |Saline |24-48 hours for gauze |Luer caps should be |

|Dual Lumen catheter |used on line made of silicone |5ml Routine flush |dressing as needed |changed every 7 days or |

| | |10mls if blood in line | |as necessary i.e. if |

| | |20ml post blood aspiration or| |removed |

| | |TPN | | |

| | | |7 days for transparent semi| |

|Material - silicone | |Syringe size limited to |permeable dressing or as |Vygon Bionectors must be |

| | |25psi/ 10ml syringe or larger|necessary |changed every 7days (MHRA|

| | | | |2004) |

|Lifecath |Aqueous chlorhexidine is |For Vygon lines see attached |Do not specify specific |Vygon Bionectors must be |

|(Long term cuffed |recommended |table |dressing or duration time |changed every 7days (MHRA|

|silicone catheter) | | | |2004) |

| |Do not use acetone or alcohol | | | |

|Material - silicone |based iodine solutions on any | | | |

| |part of the catheter tubing or| | | |

| |hub | | | |

|PICC line (Bard) |Isopropyl alcohol and povidine|Syringe size limited to |7 days for transparent semi|Luer caps should be |

|Single/ Double lumen |iodine |25psi/ 10ml syringe or larger|permeable dressing or as |changed every 7 days or |

| | | |necessary |as necessary i.e. if |

| | | | |removed |

|Material - Silicone | | | |Vygon Bionectors must be |

| | | | |changed every 7days (MHRA|

| | | | |2004) |

|Lifecath (Vygon) PICC|Aqueous chlorhexidine is |For Vygon lines see attached |Do not specify specific |Vygon Bionectors must be |

| |recommended |table |dressing or duration time |changed every 7days (MHRA|

|Single/double lumen | | | |2004) |

| |Do not use acetone or alcohol | | | |

|Material: |based iodine solutions on any | | | |

|Polyurethane |part of the catheter tubing or| | | |

| |hub. | | | |

|Porta cath (Bard) |N/A internal device |Should be flushed every four |N/A internal device |Gripper needle |

| | |weeks when not in use | | |

|Portacath (Braun) |N/A internal device |Should be flushed every four |N/A internal device |Gripper needle |

|Leeds Children’s | |weeks when not in use | | |

|services | | | | |

6.8 A Quick Reference Guide for Managing Problems with CVAD’s

|Presenting symptom/s |Potential problem |Possible cause |Recommended actions |

|Chest pain |Air embolism or Atrial |Air entering the venous system |Seek urgent medical advice/emergency|

|Dyspnoea Tachycardia/ irregular pulse|fibrillation |during insertion or catheter use |admission |

|Hypotension |Pulmonary embolism |Catheter stimulating the heart | |

|Hypoxia | |muscle | |

| | |Clot breaks off catheter and | |

| | |embolises to lungs | |

|Pain on inspiration and expiration, |Pneumothorax |Air entering the space between the |Seek urgent medical advice/ |

|dyspnoea | |pleural lining and the lung |emergency admission |

|Hypoxia | | | |

|Tingling |Nerve injury |Damage to the nerves in the local |Contact the cancer centre/unit for |

|Loss of movement down part or all of | |area can occur |medical advice |

|the affected limb Shooting pain | | | |

|Coughing |Catheter malposition |Catheter in the wrong place |Contact the cancer centre/unit |

|Ear/ neck pain on the side of | | |x-ray may be required |

|insertion/ palpitations or | | | |

|arrhythmia’s | | | |

|Inability or difficulty aspirating | | | |

|blood (See flow chart 1) Swelling of | | | |

|neck, chest arm or leg. Shoulder tip | | | |

|pain | | | |

|Swelling of neck, chest, arm or leg |Thrombosis in vein |Thought to be caused by damage to |Seek urgent medical advice/ |

|Skin discoloration | |vein wall causing the release of |emergency admission |

|Skin temperature changes | |thromboplastic substances that cause| |

|Infusion difficulties | |platelets to collect at injury site.| |

|Inability to aspirate blood | |These may grow into a larger | |

| | |thrombus or small bits break away | |

| | |and cause occlusion of a vessel | |

| | |elsewhere | |

| |Mechanical phlebitis/ |Irritation of the vein due to |Ensure the line is appropriately |

|Pain redness along the vein, tracking|infection |movement of the catheter in the vein|secured. If less than 10 days ensure|

|and swelling: | |(not associated with tunnelled |the patient is applying heat packs |

|For PICC lines – if post 10days | |CVAD’s but can occur with PICC’s) |as advised. |

|insertion consider whether chemical | | | |

|phlebitis or infection. Mechanical | | |Refer to Cancer centre/unit for |

|phlebitis less likely after 10 days | | |advice, may require anti |

|insertion | | |inflammatory or antibiotic |

| | | |medication |

|Continuous back flow of blood into |Blood present in the |Fault in catheter, or line flushed |Flush the line using correct |

|the catheter |lumen of the catheter |incorrectly |technique. If back flow continue |

| | | |seek advice from the Cancer |

| | | |Centre/unit |

|Inability to flush the line |Catheter occlusion |Line adhered together near clamp. |Follow flow chart 1 and 2 |

| | |Line kinked or twisted. | |

| | |Clot within or fibrin sheath on | |

| | |catheter. | |

| | |Drug precipitate blocking catheter | |

| | |Lipids from TPN feed blocking | |

| | |catheter. | |

| |Pinch off syndrome |When the catheter is compressed |Refer to the Cancer centre/unit who |

| | |between the clavicle and the first |will assess |

| | |rib | |

|Difficulty in aspirating blood |Catheter occlusion |Line adhered together near clamp. |Refer to the Cancer centre/unit |

| | |Clot or fibrin sheath in catheter. | |

| | |Line kinked or twisted. | |

| | |Drug precipitate blocking catheter | |

| | |Lipids from TPN feed blocking | |

| | |catheter. | |

| |Pinch off syndrome |When the catheter is compressed |Refer to the Cancer centre/unit who |

| | |between the clavicle and the first |will assess |

| | |rib. | |

| |Fibrin sheath formation |Sheath has formed around the |Cancer centre/unit to consider |

| | |catheter tip. |venogram to confirm patency |

| | | |dependant on the chemotherapy |

| | | |regimen. Medical consultation |

| | | |required. |

|Redness and tracking at site. |Infection at insertion |Infection at insertion site. |Refer to the Cancer Centre/unit, |

|Purulent discharge at site. |site | | |

|Pyrexia of unknown origin, rigors. |Infection associated with|Infection |Refer to the cancer centre/unit. |

|These may occur up to one hour after |the catheter | |Inform the theatre where the line |

|line has been flushed and should be | | |was placed. |

|investigated | | | |

|Leakage from the catheter when used. |Damage to catheter |Use of a sharp object near the |Refer to the cancer centre/unit for |

| | |catheter or movement twisting of the|advice. |

|Damage visible | |catheter (PICC’s are vulnerable to | |

| | |fracture). High pressure on the |(NB Many CVAD’s can be repaired by |

| | |syringe as injecting into the |cancer centre/ unit) |

| | |catheter. | |

|Line appears longer at the exit site |Line migration |Can occur with general activity, |Refer to the cancer centre/unit for |

|or the cuff is visible. On |(Common problem for |caution should be taken when |advice. |

|measurement the length is on longer |PICC’s) |removing dressings specifically | |

|than upon insertion. | |PICC’s not to pull the line. |X- ray to confirm the catheter tip |

| | | |may be required. |

|Skin changes at insertion site - |Skin over granulation |Unknown - possibly due to |Discuss with the cancer unit/ |

|thickening of skin at point of | |inflammatory response of injured |centre. |

|insertion pink/ red in colour. | |tissue, as prolonged and excessive | |

| | |inflammation can lead to over |A change of dressing may be |

| | |granulation (Dunford et al 1999) The|indicated. Polyurethane foam |

| | |presence of a foreign body |dressings e.g. Lyofoam are suggested|

| | |interfering with healing may also |for over granulation (Harris and |

| | |contribute (Harris and Rolstad 1994 |Rolstad 1994). |

6.9 VYGON Vascular Access Devices Flushing Guidance

|Nursing Responsibilities |VYGON VASCULAR ACCESS DEVICES ONLY |

| |Peripheral |Central |Specialty |

| |Peripheral short catheter ( 1 yr | | |

|AML12 Acute Myeloid Leukaemia |Double Hickman |Portacath by discussion with consultant |

| | |haematologist |

| | |All definite Bone Marrow Transplant |

| | |recipients must have Hickman |

|Baby Brain-infant brain tumours ................
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