CENTRAL VENOUS CATHETER (CVC) - BASIC CARE AND MAINTENANCE ADULT

Transcription

1 POLICY Principles for Care The recommended and optimal CVC tip position is the distal (lower third) superior vena cava (SVC) and the cavo atrial junction. Physician orders are required for the following practices: o Chest x-ray (CXR) for tip confirmation o Tip confirmation prior to use Tip position is documented in the patient s health record. Review the need for invasive lines daily. Remove unnecessary lines promptly. Review the CVC entry site for inflammation daily and with every dressing change. All solutions are infused via an infusion pump, at a rate of not less than 15 ml/hour. 10 ml is the smallest-sized syringe to be used with non-tunneled CVCs One atraumatic clamp (e.g. bulldog clamp) per lumen must accompany the patient with a CVC at all times for emergency clamping in case built-in clamp fails. Always use a positive pressure cap on the end of each lumen.. A CVC is clamped (with the built-in clamp on the catheter lumen) when not in use. Need to Know Each lumen is an independent lumen. A CVC has a clamp on the permanent extension tubing. Recommended Uses for each Lumen: Triple Lumen Catheter o Any lumen can be used for the administration of IV crystalloid and colloid fluids, the administration of blood products, medication administration, and blood sampling. o The distal lumen is required for CVP monitoring and preferred for rapid volume administration. Priming volumes and flow rate are written on the outside of the CVC kit Management of Complications - see Appendix A. Flow Rates and Priming Volumes - see Appendix B Site Applicability BC Women s Hospital Maternal/Gyne Program Page 1 of 26

2 Competencies and Skills Required High Acuity RN: Successful completion of the relevant skills assessment program is required for CVC line care and maintenance. This includes a formalized instruction program that is compliant with evidence based data and national standards. The first time an RN performs any new CVC skill, care and/or maintenance procedure (e.g. dressing change, catheter removal, and blood withdrawal); the RN is encouraged to be observed by an experienced RN, if possible. RNs are encouraged to bring a partner to the bedside to read step-by-step instructions aloud for CVC care, if preferred. Specific education and skill evaluation assessment is required for all aspects of CVC care. This includes: Care and Maintenance Site assessment Flushing Tubing change Cap change Dressing change Obtaining a blood sample Removal Assisting Physician with Insertion PROCEDURES Part 1: Site Assessment Part 2: Positive Pressure Cap (PPC) Use/Flushing A - Flushing B - Cap Change C - Using Capped Lumen to Administer a Continuous Infusion D - Discontinuing a Continuous Infusion from a Capped Lumen Part 3: Tubing change Part 4: Dressing Change Part 5: Obtaining a Blood Sample Part 6: Removal Part 7: Assisting the physician with CVC insertion Page 2 of 26

3 Part 1: Site Assessment Policy Statements: 1. CVC lines are assessed at the beginning of each shift and PRN. Procedure: Immediately post insertion, measure the amount of catheter visible from the exit site up to the built in extension tubing (one black dot equals one cm) and document it in the chart with the insertion details. Document the total catheter length (i.e. 16 cm). Each assessment should include: 1. Line placement a. Measure amount of catheter visible from the exit site up to the built in extension tubing (one black dot equals one cm) and confirm that it matches with the documented insertion length. b. Ensure intactness of the stabilization wing, and presence of an intact suture. c. Ensure all connections are secured. d. Ensure unused lumens are clamped. 2. Dressing a. Ensure dressing is dry and intact. 3. Infection a. Assess exit site for redness, edema, tenderness, discharge, or pain. Assess patient for signs and symptoms of systemic infection. 4. Thrombus a. Assess color, warmth, sensation, movement and check for edema of CVC site/side comparing to opposite site/side. b. Assess for visible collateral chest/facial veins, neck swelling or redness. Page 3 of 26

4 Part 2: Positive Pressure Cap (PPC) Use/Flushing Policy Statements: CVC lumen ends are covered with positive pressure caps (PPCs), which are used to access the CVC, in order to maintain a closed system. 1. Access positive pressure cap (PPC) with a Luer-lock connection only. Do not use a needle to access PPC ml is the smallest-sized syringe to be used with CVCs. 3. Replace PPC every 6-7 days and PRN if complication noted. 4. Accessing of lumens is done using aseptic technique using appropriate cleaning technique of cap. Scrub cap for 30 seconds and allow to dry completely (minimum 60 seconds) prior to accessing. 5. Check for patency when accessing by aspirating blood into mid extension tubing using a 10 ml syringe. Following aspiration, flush with ml normal saline. 6. Flush with 10mL NS every 24 hours when not in use, and after each time it is accessed. 7. Flush with minimum 2 x 10 ml NS syringes after blood product administration and blood sampling. 8. Flush using a turbulent, stop-start technique to facilitate thorough flushing of catheter. 9. If resistance is met with flushing, or in the absence of blood return when aspirating, ensure further assessment and interventions are considered and done according to Appendix A. 10. IV direct medication may be given into a capped CVC. A Flushing Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) 2% Chlorhexidine(CHG)/70% alcohol swabs Clean gloves 1 x 10 ml syringe pre-filled with NS (one for each lumen to be flushed) Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Put on clean gloves. 5. Scrub top of cap with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 6. Attach pre-filled NS syringe to PPC 7. Unclamp lumen. 8. Check lumen for patency by aspirating blood into mid extension tubing. (If unable to aspirate blood, click here to view Troubleshooting Appendix A #4 Partial Occlusion) 9. Following aspiration, flush with 10 ml NS, using turbulent, stop-start technique. 10. Remove syringe 11. Clamp lumen. 8. Wipe top of PPC with CHG/alcohol swab to remove fluid residue. 9. Document procedure. Page 4 of 26

5 B - Cap Change Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Clean gloves 2% Chlorhexidine(CHG)/70% alcohol swabs Sterile MaxPlus Positive Pressure Cap (PPC) 10 ml pre-filled syringes with NS (one per lumen to be flushed) Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Open new PPC and NS pre-filled syringe and leave in package. 5. Clamp lumen. 6. Wash hands thoroughly for 30 seconds using alcohol-based hand sanitizer. 7. Put on clean gloves. 8. Attach 10 ml pre-filled NS syringe to PPC using no touch technique, prime cap with cap inverted to allow air to escape first, leave attached and place in syringe package. 9. Scrub CVC and PPC connection with CHG/alcohol swab using friction x 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 10. Remove old PPC. 11. Attach new PPC. 12. Unclamp lumen. 13. Check lumen for patency when accessing by aspirating blood into mid extension tubing. (If unable to aspirate blood, click here to view Troubleshooting Appendix A #4 Partial Occlusion). a. For a capped lumen: i. Flush with 10 ml of NS using a rapid stop-start or push-pause technique to facilitate thorough flushing of catheter and reduce PPC and lumen occlusion. ii. Remove syringe. iii. Wipe top of PPC with alcohol swab to remove fluid residue. iv. Clamp lumen. b. For continuous infusions: i. Flush with 10mL of NS using a turbulent, stop-start technique to facilitate thorough flushing of catheter. ii. Remove syringe. iii. Attach IV infusion set into PPC using no touch technique. iv. Initiate infusion. 14. Document procedure. Page 5 of 26

6 C- Using Capped Lumen to Administer Continuous Infusion Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Clean gloves 2% Chlorhexidine(CHG)/70% alcohol swabs Alaris IV Pump and cassette IV solution IV tubing 10 ml pre-filled syringes with NS (one per lumen) Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Prime IV tubing. 5. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 6. Put on clean gloves. 7. Scrub top of PPC with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 8. Attach 10 ml NS syringe. 9. Unclamp lumen. 10. Check lumen for patency when accessing by aspirating blood into mid extension tubing. (If unable to aspirate blood, click here to view Troubleshooting Appendix A #4 Partial Occlusion). 11. Flush with 10mL pre-filled NS syringes using turbulent, stop-start technique. 12. Remove syringe. 13. Connect IV tubing to positive pressure cap (PPC) using no touch technique. 14. Initiate IV infusion. 15. Secure tubing. 16. Document procedure. Page 6 of 26

7 D- Discontinuing a Continuous Infusion from a Capped Lumen Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Clean gloves 2% Chlorhexidine(CHG)/70% alcohol swabs Dead end cap 10 ml pre-filled syringe with NS (one per lumen to be discontinued) Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Stop IV infusion and clamp lumen. 5. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 6. Put on clean gloves. 7. Scrub tubing and positive pressure cap connection with an alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 8. Disconnect IV tubing from positive pressure cap. 9. Cap IV tubing with sterile dead ender if IV tubing will be re-connected for later infusion. 10. Scrub top of PPC with a CHG/alcohol swab using friction for 30 seconds. Allow to dry completely (Approx. 60 seconds). 11. Attach NS syringe and unclamp lumen. 12. Check lumen for patency when accessing by aspirating blood into mid extension tubing. (If unable to aspirate blood, click here to view Troubleshooting Appendix A #4 Partial Occlusion). 13. Flush PPC with 10 ml NS using turbulent, stop-start technique. 14. Remove syringe. 15. Wipe top of PPC with CHG/alcohol swab to remove fluid residue. 16. Clamp lumen. 17. Document procedure. Page 7 of 26

8 Part 3: Tubing Change Policy Statements: 1. Luer-Lock IV tubing is used for all CVC infusions. 2. Do not use or interchange peripheral IV tubing with any central venous access. 3. Primary IV solutions/bags are changed: a) every 24 hours b) with routine tubing change (refer to table below) c) when bag is empty. Frequency of Tubing Change (as needed and not less than) Item Frequency With new insertion site Continuous infusion Intermittent infusion Secondary medication and Y connectors Blood and blood product infusion See Transfusion Medicine Policies for more information New tubing Every 96 hours Every 96 hours When the primary tubing is changed Every 4 hours or 2 units (whichever comes first); change between products (e.g. red cells and platelets) Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Clean gloves 2% Chlorhexidine(CHG)/70% alcohol swabs IV solution IV tubing 5 x 5 cm sterile gauze, if required to use around connection site if difficult to disconnect. Alaris IV Pump and cassette Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Prime tubing. 5. Stop IV infusion and clamp lumen. 6. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 7. Put on clean gloves. 8. Scrub tubing and positive pressure cap connection with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 9. Disconnect IV tubing from positive pressure cap 10. Scrub positive pressure cap with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRYCOMPLETELY (Approx. 60 seconds). 11. Connect new IV tubing to positive pressure cap using no touch technique. 12. Unclamp lumen. 13. Initiate IV infusion. Page 8 of 26

9 14. Secure tubing. 15. Document procedure. Page 9 of 26

10 Part 4: Dressing Change Policy Statements: 1. The CVC insertion site must be assessed daily and with every dressing change (see Site Assessment). 2. All CVCs are sutured via the stabilization wing. If sutures are not present, notify the physician. 3. The first dressing change must be done 24 hours post insertion. 4. A routine dressing change is required every 6-7 days and PRN if complication noted (e.g. the dressing is loose, wet, or drainage is noted). 5. A transparent, semi-permeable adhesive dressing is required for routine dressing as visualization of site is necessary (e.g. Tegaderm 1655 (small) for jugular /femoral insertion site or 1650 (large) for subclavian insertion site or large neck). 6. Gauze dressing (i.e. Sterile Mepore ) is used if patient bleeding at the site, diaphoretic or allergic to transparent dressing. Gauze dressing is changed q48hours and PRN if complication noted (i.e. the dressing is loose, wet, or drainage is noted). 7. Strict aseptic technique is required for dressing change procedure including dressing tray, mask and sterile gloves. 8. Untinted 2% Chlorhexidine Gluconate (CHG) with 70% alcohol is used as the skin cleansing in swab stick and swab/wipe application. CHG 2% without alcohol (available as a swab stick only) is to be used when skin irritation is related to an interaction between the adhesive in the dressing, and the alcohol of the prep. Betadine (Povidone Iodine 10%) is used as an alternative to CHG in cases of contact dermatitis or allergy. To prevent development of sensitivities, Betadine must be cleaned off with NS after it is dry. CHG may be inactivated if used with normal saline. If there is a lot of blood under the CVC dressing, use the CHG to remove the blood not saline. This will require the use of extra CHG swab sticks/swabs/wipes. Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Mask Clean gloves Sterile gloves Dressing tray Transparent dressing (e.g. Tegaderm ) or sterile dry gauze dressing (e.g. Sterile Mepore ) 4 - CHG 2% with 70% alcohol swab sticks 3 - CHG 2% with 70% alcohol large wipes Protective skin barrier (e.g. Cavilon ) for patients who are sensitive to tape, to protect skin from adhesive trauma. Tape measure Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Position patient. 5. Put on mask. Page 10 of 26

11 6. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 7. Set up dressing tray. 8. Put on clean gloves. 9. Measure amount of catheter visible from the exit site up to the built in extension tubing (one black dot equals one cm) and confirm that it matches with the documented insertion length 10. Remove dressing toward catheter insertion site avoiding catheter dislodgment and skin tearing. 11. Inspect the catheter site. If there are any signs of infection, swab the site for C&S and notify the physician. 12. Remove clean gloves. 13. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 14. Put on sterile gloves. 15. Clean catheter and insertion site with LARGE CHG/ alcohol swab/ wipe: a. Squeeze excess solution from LARGE CHG wipe onto catheter insertion site and clean. b. Wrap 2 nd large CHG wipe around catheter. Clean the catheter moving away from the insertion site up to the permanent stabilization wing. 16. Clean the insertion site, sutures and skin with CHG 2% with alcohol 70% non-tinted swab stick, ensuring skin contact with CHG scrub is a total of 40 seconds: a. Starting at the insertion site clean insertion site, sutures and along one side of catheter, using friction rub technique. (Friction rub technique involves cleaning back and forth on skin moving outwards until 10x10 cm area has been cleaned). Avoid crossing over the catheter. b. Using 2 nd swab stick repeat step (16a.) on the other side of the catheter. c. Using 3 rd swab stick, clean from the insertion site outwards in a circular clockwise motion to a radius of 10 cm. Avoid crossing over the catheter. d. Using 4 th swab stick repeat step (16c.) going in the opposite direction counterclockwise. e. Allow skin to dry completely (approximately 3 minutes) to prevent skin irritation. RATIONALE FOR FRICTION RUB TECHNIQUE: The application of friction allows the solution to penetrate the lower layers of the epidermis thus killing a greater number of skin organisms. 17. While waiting for the skin to dry use a LARGE CHG wipe to clean all lumens from the permanent sutured stabilization wing up to the PPC. Clean in one direction moving away from the insertion site. 18. Allow CHG to dry completely before applying the dressing to prevent skin irritation and chemical burns. 19. Apply skin prep (e.g. Cavilon ) to area where dressing to be applied. 20. Apply transparent sterile dressing to site. a. Ensure catheter site is visible near center of dressing window. b. Ensure dressing covers up to 2-3 cm below insertion site and beyond second built-in stabilization wing. c. Ensure that all lumens are not twisted or kinked. 21. Label dressing with date and initials. 22. Remove gloves, mask, and wash hands thoroughly for 30 seconds using an antimicrobial hand wash. 23. Document procedure. Page 11 of 26

12 Part 5: Obtaining a Blood Sample Policy Statements: 1. Blood sampling can be done from triple lumen CVC. Use the proximal lumen for blood samples. If multi-lumen, clamp other lumens during blood draw. If other lumens (multi-lumen) are capped, flush all lumens after blood sampling. A discard sample is taken prior to obtaining blood work. Flush with 20 ml NS syringes post blood draw. Whether continuing with IV infusion or capping the lumen, follow the guidelines for flushing. Blood sampling may be done using the Vacutainer method Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Clean gloves 4-5 2% Chlorhexidine(CHG)/70% alcohol swabs Vacutainer and Vacutainer adapter Lab blood tubes Biohazard Sharps container ml pre-filled syringes with NS Dead end cap if reconnecting existing IV tubing. Additional supplies required to flush all capped lumens after blood sampling Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Turn off IV infusion if present. For multi lumen, ensure all IV infusions are turned off prior to blood sampling. 5. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 6. Put on clean gloves. 7. Scrub tubing and positive pressure cap connection with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRYCOMPLETELY (Approx. 60 seconds). 8. Disconnect IV tubing from positive pressure cap. 9. Cap IV tubing with dead ender to maintain sterility of IV tubing end. 10. Clamp all lumens excluding the lumen you are drawing blood from. 11. Scrub top of PPC with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). 12. Attach 10 ml syringe 13. Check lumen for patency when accessing by aspirating blood into mid extension tubing. (If unable to aspirate blood, click here to view Troubleshooting Appendix A #4 Partial Occlusion). 14. Flush catheter with 5 ml NS. Page 12 of 26

13 15. Slowly aspirate 5 ml of blood as the discard sample. 16. Remove discard sample syringe. 17. Clamp lumen. 18. Scrub CVC and PPC connection with alcohol swab using friction x 30 sections. ALLOW TO DRY COMPLETELY (Approx. 6 0 seconds.) 19. Remove PPC. 20. Attach male adapter/tube holder (vacutainer holder) using no-touch technique. 21. Unclamp lumen. 22. Insert blood tubes into barrel of device and push down to allow blood to flow into the tube. Continue until all tubes have been collected (if blood flow slows or stops see troubleshooting guide above). Insert blood tubes in this order: 23. Clamp lumen once all samples are collected. 24. Remove the male adapter/holder (vacutainer) and discard into the sharps container. 25. Attach new PPC. 26. Unclamp lumen. 27. Scrub positive pressure cap with an alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 sec). 28. Attach NS syringe and flush immediately using turbulence (stop/start) with 20mL NS. 29. Remove syringe. 30. a. If reconnecting IV tubing: Scrub top of PPC with a CHG/alcohol swab using friction for 30 seconds. ALLOW TO DRY COMPLETELY (Approx. 60 seconds). Connect IV tubing and resume IV infusions. b. If capping lumen: Remove syringe. Wipe top of PPC with a CHG/alcohol swab to remove fluid residue. Clamp lumen. 31. Unclamp all other lumens as necessary and reinitiate any stopped IV infusions. 32. Flush all capped lumens with 20cc NS after blood sampling. 33. Label collected specimens, and send to the Lab as per lab guidelines. 34. Remove gloves and wash hands thoroughly for 30 seconds using an antimicrobial hand wash. 35. Document procedure. Note: If unable to draw blood using the vacutainer method, use the peripheral method. Troubleshooting If blood flow slows or stops: Check lumens for any kinks. Have patient cough, do Valsalva maneuver, turn head to opposite side, raise arms or change position. Change blood collection tube. Use syringe to withdraw blood through the PPC. Change PPC. Flush lumen with 5 ml NS solution and if resistance to flush is felt, stop and contact physician. Page 13 of 26

14 Part 6: Removal Policy Statements: 1. An RN who has completed the relevant skills assessment program may remove CVC s. 2. Assess daily the need for CVC if it is not being used obtain an order for removal. 3. If a complication or thrombus is identified, consult physician (removal by physician may be indicated). 4. If patient is being anticoagulated, discuss with physician whether IV infusion of anticoagulant needs to be stopped prior to removal of CVC. It is recommended that IV anticoagulant therapy be discontinued min prior to removal. 5. Check blood work for coagulation abnormality (i.e. platelets, INR) consult with physician if abnormalities identified. 6. If CVC infection suspected then send tip for culture and sensitivity. Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Sterile dressing tray Clean gloves Sterile gloves Mask / Goggles Sterile suture scissors (x 2 if culturing CVC tip) 10 x 12 cm transparent dressing (e.g. Tegaderm ) 4-CHG 2% in 70% alcohol swab sticks C & S container if sending tip for culture Procedure: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Position patient in Trendelenberg for jugular or subclavian line removal and supine for femoral removal. 5. Put on mask. 6. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 7. Set up dressing tray. 8. Put on clean gloves. 9. Remove dressing toward catheter insertion site avoiding catheter dislodgment and skin tearing. 10. Inspect the catheter site. If there are any signs of infection, swab the site for C&S and notify the physician. 11. Remove clean gloves. 12. Wash hands thoroughly for 30 seconds or use alcohol-based hand sanitizer. 13. Put on sterile gloves. 14. Clean the insertion site, sutures and skin with CHG 2% with alcohol 70% non-tinted swab stick. a. Starting at the insertion site clean insertion site, sutures and along one side of catheter, using friction rub technique. (Friction rub technique involves cleaning back and forth on skin moving outwards until 10x10 cm area has been cleaned). Avoid crossing over the catheter. b. Using 2 nd swab stick, repeat step (14 a.) on the other side of the catheter. c. Using 3 rd swab stick, clean from the insertion site outwards in a circular motion to a radius of 10 cm. Avoid crossing over the catheter. d. Using 4 th swab stick repeat step (14 c.) going in the opposite direction counterclockwise. e. Allow skin to dry completely (approximately 30 seconds) to prevent skin irritation. Page 14 of 26

15 15. Cut suture using sterile scissors. 16. Have the patient perform the Valsalva maneuver if the patient s condition allows. If the patient is mechanically ventilated, wait for the end of inspiration. If Valsalva is contraindicated, remove the catheter while the patient exhales. 17. Hold folded 4x4 gauze in non-dominant hand while removing the catheter with the dominant hand in one straight motion. Occlude site with sterile gauze immediately upon CVC removal. Avoid wiping catheter on gauze during removal to prevent site contamination. 18. Apply pressure to the site for minimum of 5 minutes or until no further bleeding, especially if the patient is anticoagulated or has a coagulation abnormality. 19. After removal inspect distal tip of CVC noting condition and length to ensure complete removal. 20. Apply a dressing consisting of 4-2x2 sterile gauze covered with transparent dressing. Options for Practice: Sending the catheter tip for C&S may be indicated if the patient is febrile or if the CVC is suspected as a source of infection. 21. Do vital signs post removal q15 x2 then q30 x1 and document. 22. Instruct patient to remain in bed supine or flat if possible for 15 minutes post removal. This position maintains a positive intra-thoracic pressure and allows time for the tissue tract to seal 23. Post removal, observe patient for bleeding, air emboli and or other removal complications for 60 minutes. Refer to Appendix A: Management of Complications. 24. Remove dressing 24 hours post CVC removal, if site is not epithelialized apply new dressing and assess every 24 hours until skin is epithelialized. 25. Document procedure. Page 15 of 26

16 Part 7: Assisting the physician with CVC insertion Policy Statements: 1. At any point before and during the placement of the line the observer and /or the assistant should feel empowered to halt the procedure if there is a break in sterile technique or patient safety is at risk. 2. Recommended and optimal tip position is the lower third (distal) superior vena cava (SVC) and or cavo atrial junction. 3. Tip position is documented in the patient s health record and must be assured of appropriate use. 4. Tip placement must be confirmed by chest x-ray, though x-ray can be delayed under emergent or urgent circumstances. A nurse must confirm x-ray results with the inserter prior to use. 5. Ensure daily review of line necessity and prompt removal of unnecessary lines. The CVC insertion procedure is done using maximal barrier precautions including: Proper hand hygiene, preferably with 2% CHG solution Use of Chloroprep (tinted Chlorhexidine Gluconate (CHG) 2% with alcohol 70%) Large sterile drape Sterile gown and gloves Head cover and protective eyewear Mask Indication Resuscitation Short term IV therapy Infusion of IV fluids Medication administration Blood products Blood sampling Central Venous Pressure monitoring Need for IV access when peripheral access not available Contraindication Coagulopathy, a relative contraindication but one requiring extreme care during insertion (INR>2, platelets<50,000). Infection over target vein Thrombosis over target vein Scarring over target vein Erythema or open wound over targeted site Equipment: Hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) Head cover for inserter and assistant(s) Mask for inserter and assistant(s) Clean gloves Sterile gown Sterile gloves (for RN and inserter) CVC kit - Choose catheter size that will accommodate client size and required therapy Positive Pressure Cap (PPC) i.e. Max Plus 1 per lumen Transparent dressing impregnated with Chlorhexidine CHG 2% with alcohol 70% tinted bottled solution or swab stick x ml pre-filled syringes with NS Clipper with disposable blade Anesthetic ultrasound machine with sterile probe cover Page 16 of 26

17 Procedure: Pre-insertion: 1. Clean work surface with hospital-grade cleaner/surface disinfectant (e.g. Caviwipes ) following manufacturer s guidelines for contact times. 2. Perform hand hygiene (If hands are visibly soiled, wash hands thoroughly for 30 seconds with soap and water, or use alcohol-based hand rub). 3. Gather equipment. 4. Provide the inserter with head cover, mask, sterile gown, and sterile gloves. 5. For internal jugular and subclavian placement, place client in Trendelenberg (15 ) position. For femoral insertion, place client in supine position. 6. Remove pillow and place a protective pad under the patient s head and shoulders or pelvic /lower hips. 7. Remove hair over targeted insertion area with clippers, if necessary. 8. Continuously monitor patient s oxygen saturation throughout procedure 9. Assist inserter as needed. 10. Provide support to client. Post-insertion: 11. Physician aspirates blood from each lumen and flushes each lumen with 20 cc NS using a start-stop or turbulent method. 12. Ensure positive pressure caps are attached to each lumen. 13. Ensure extension tubing is clamped if lumen is not in use. 14. If inserter didn t apply the dressing post insertion then follow the dressing change procedure. DOCUMENTATION Document on Central Venous Access Flowsheet, High Acuity Flow Sheet, and on Interprofessional Notes as needed. REFERENCES Canadian Patient Safety Institute. (2016.). Central Line Infections. Retrieved from Centers for Disease Control and Prevention. (2011.). Guidelines for the prevention of intravascular catheter-related infections. Retrieved from html Intravenous Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing. 29(Suppl. 1S). Fraser Health Authority. (2015, May 15.). Clinical practice guideline: Intravenous therapy. Retrieved from ID=916 Vancouver Coastal Health. (2014, July 8.). Non-tunneled central venous catheter (NT-CVC) single and multilumen basic care and maintenance adult. Retrieved from ase/general%20medicine/cpd_c-000.cfm Registered Nurses Association of Ontario (RNAO). (2005). Care and Maintenance to Reduce Vascular Access Complications. Toronto, Canada: Registered Nurses Association of Ontario. Retrieved from Page 17 of 26

18 DEVELOPED BY Date of Creation/Review/Revision : Posted: January 2010, Revised: July 8 th, 2014 Modified for BCWH Maternal Gyne Program: February 23, 2016 by Karen Pike, Perinatal Clinical Educator Page 18 of 26

19 Appendix A - Management of Complications For CVC Complications Signs & Symptoms Management Prevention 1. Air Embolism: Air is drawn up through the catheter into the patient s vascular system. Air embolism can occur during insertion and or removal of CVC. 2. Pneumothorax A collapse of the lung caused by the presence of air between the lungs and the chest wall, caused by improper insertion. Most common in subclavian site. Light-headedness Restlessness anxiety Chest pain A sense of impending doom Nausea Tachycardia Hypotension Dyspnea, tachypnea Cyanosis, changes in mental state, confusion, seizures Unresponsiveness Rales or wheezing in the presence of pulmonary edema Dyspnea Cyanosis Shock Decreased SpO2 Sharp pain in chest and/or shoulder Coughing Decreased breath sounds Clamp the open/cracked lumen/catheter and apply an occlusive dressing to a dislodged, cracked or disconnected lumen. Place patient on left side, head down (this permits the air bubble to rise to upper part of the Right Atrium). Call a code. Vital signs every 5 minutes. Administer oxygen. Position patient in Fowler s Apply O2 Call anesthesia STAT Assess vital signs Observe for unequal chest movement Assess bilateral breath sounds Obtain chest x-ray post insertion Assist with insertion of chest tube Use luer lock connections and secure well Clamp catheter lumen when changing administration set/cap. Provide patient education re: catheter displacement and disconnection. During insertion ensure that blood is aspirated from each lumen and each lumen is flushed with 20ml normal saline. Position patient in Trendelenberg (if patient condition allows) for CVC insertion and supine using Valsalva maneuver for removal. Observe for early signs of pneumothorax Obtain post-insertion chest x-ray confirming tip placement and ruling out pneumothorax Use ultrasound to guide insertion 3. Hemorrhage/ Hematoma Can be caused by accidental arterial puncture during insertion. Bright red return Rapidly expanding hematoma Respiratory distress Hypotension Decreased LOC Apply pressure to site until bleeding stops Apply O2 Start large bore IV Check VS including pulse below the site Prepare for resuscitative measures Inserted to use ultrasound to landmark vein Page 19 of 26

20 4. Arrhythmias: Tip of catheter is placed within the R atrium; leads to cardiac muscle irritability and arrhythmias Irregular pulse Chest Pain Palpitations Obtain x-ray to confirm tip position If in R Atrium contact Physician to pull back Monitor cardiac rhythm Confirm catheter tip placement prior to use 5. Infection: Could be local or systemic Local: Purulent drainage, erythema Swelling Tenderness at site Systemic: Fever/chills Increased WBC Malaise Hypotensive & shock (severe infection) Local: Contact physician. Swab insertion site for C&S prior to starting antibiotics. Systemic: Contact physician Catheter removal maybe necessary if treatment is unsuccessful. Obtain peripheral blood cultures as well as blood cultures from the central line. Send catheter tip for C&S if line is removed. Assess site every shift & PRN. Aseptic technique to be used at all times during care & maintenance. Monitor vital signs and temperature. Monitor lab results. Assess daily clinical need for line removal. Page 20 of 26

21 Complications Signs & Symptoms Management Prevention 6. Partial Occlusion: Able to infuse, but unable to withdraw blood. Contributing Factors: Failure to flush according to catheter flushing procedure, resulting in lumen obstruction. Catheter opening may draw up against vein wall with aspiration. Blood clot, fibrin sheath, or particulate matter obstructing catheter, when blood is being aspirated from the catheter. Sutures may be too tight. Kinked catheter outside or inside the body. Malposition of catheter tip. Sluggish flow of IV fluids. Difficulty flushing. Inability to aspirate blood. Check lumen for any kinks. Have patient cough, take deep breaths, do Valsalva maneuver, turn head to opposite side, raise arms or change position. Change Positive Pressure Cap (PPC) Flush with 10 ml NS solution in a 10 ml syringe using a gentle push-pull technique, if resistance to flush is felt, stop. After flush aspirate again. Smaller syringe (5 ml) exerts less pressure when aspirating only. If unable to aspirate notify Physician. If able to flush and aspirate blood, flush the lumen with 20 ml Normal Saline and continue with therapy. Document the type of occlusion, intervention, patient response, and physician intervention. Routine turbulent flushing with 10 to 20 ml normal saline after intermittent medications, blood product transfusions or following obtaining blood sample. Follow guidelines for routine CVC flushing. Check for lumen patency Q shift. Do not leave partial occlusion unresolved, as it will turn into total occlusion. 7. Total Occlusion: Inability to withdraw blood or infuse. Contributing factors: Blood or drug precipitate completely obstructs the lumen. May be kinked, coiled or damaged. Sutures used during catheter placement may have tightened and restricted flow. Unable to flush or aspirate blood. Do not force flush. Move the patient s arm, shoulder and head to see if a position change affects the ability to infuse. Assess catheter and tubing for kinks in line or tight sutures. Discuss Radiologic studies, e.g. CXR, Venogram Notify Physician. Report and document occlusion, interventions and response. Routine turbulent flushing with 10 to 20 ml normal saline after intermittent medications, blood product transfusions or following obtaining blood sample. Follow guidelines for routine CVC flushing. Check for lumen patency Q shift. Check for sutures that are tight and restricting flow around the catheter and notify the physician. Page 21 of 26

22 Complications Signs & Symptoms Management Prevention 8. Venous Thrombosis A clot between the catheter and the vein. Contributing factors: Improper flushing of catheter lumen(s) causing fibrin sheath/clot formation in catheter or at tip of catheter in vein. Predisposing patient history related to blood clotting Incorrect tip position (i.e. in Upper SVC or Brachiocephalic, or 9. Superior Vena Cava Syndrome: Occlusion of the SVC by a thrombus. SVC syndrome results in increased venous pressure, which results in central nervous system disturbances. SVC syndrome can lead to cerebral and vocal cord edema and death. 10. Extravasation Soft tissue damage due to leaking of vesicant or irritating drug from a vein into the surrounding tissue. Contributing factors: Catheter dislodgement Catheter broken internally Presence of a fibrin sheath Edema/cyanosis of arm with CVC Line Pain Swelling of neck, face, shoulder, arm or chest. External jugular vein distention Change in ability to infuse or withdraw Progressive edema of upper extremity, neck and face. Dilatation of the superficial veins of the chest, neck, and arms. Collateral veins of chest, neck Peri-orbital edema (swollen eyes) Tachycardia Hypotension Edema Erythema Pain or burning during or after infusion in area of vascular access device Unable to obtain blood return with aspiration Do not remove the CVC Contact Physician. After informing the above clinicians/physician observe the client hourly & PRN Follow up with diagnostic studies (Ultrasound &/or venogram) Anticoagulation therapy as directed by Physician Do not remove the line. Removal is the responsibility of the Physician. (The CVC may be left in place during anticoagulation treatment) Notify physician and Respiratory Therapist STAT. Position patient comfortably. Call a Code if required. Apply O2. Obtain peripheral venous access. Vital signs every 5 minutes and PRN Consider discussing anticoagulation therapy with the physician prior to removing the line. Stop infusion. Notify physician. Warm or cold treatment as per ordered medication protocol. Attempt to aspirate the drug or solution from the catheter. Follow Extravasation Protocol. Document observation, assessment and treatment Assess for signs & symptoms of venous thrombosis every shift and PRN. Check each lumen for patency Q shift. Use turbulent flush (stopstart) technique. Use Positive Pressure Cap Assess Q shift and PRN for signs of increased swelling of face, chest and eyes. Assess for signs & symptoms of venous thrombosis every shift. Check each lumen for patency Q shift. Check site and line patency Q shift & PRN. When administering vesicants check for blood return with aspiration prior to drug administration. Review CXR to confirm correct tip position. Have antidotes available when administering vesicant drugs Page 22 of 26

23 Complications Signs & Symptoms Management Prevention 11. C atheter Dislodgement: Line is partially or totally dislodged. May cause: Hemorrhage or Air Embolus - Air can be drawn up through dislodged, cracked, or disconnected CVC or IV tubing into the patient s vascular system causing and Air Embolus. 12. Catheter damage tear or leak Contributing factors: Contact with a sharp object Rupture from attempt to irrigate an occluded catheter with a syringe smaller than 10 ml Partial Dislodgement: Swelling in the chest wall during infusion. Leaking at catheter site. Pain or discomfort with infusion. External portion of catheter may have increased in length Obvious bleeding from disconnected tubing. Complete Dislodgement: Hemorrhage Hypotension, tachycardia, pallor, altered level of consciousness Catheter has completely dislodged out of the insertion site. IV fluid leaking out of CVC Signs & symptoms of Air Embolism External portion of catheter may have increased in length Partial dislodgement: Stabilize catheter. Stop IV. Position patient supine. Notify Physician. Monitor vital signs. Obtain chest x ray. Completely dislodged: Asymptomatic: Position patient on left side. Apply pressure to insertion site for 5 minutes. Apply occlusive dressing to exit site. Monitor for S&S of air embolism and hemorrhage. Notify physician Symptomatic: Position on left side Initiate resuscitation measures. Call a code Continue to apply pressure until bleeding stops Apply occlusive dressing to exit site. Clamp lumen/catheter close to the insertion site with a nontoothed forceps. Prevent air emboli. If the lumen or catheter is broken obtain an order to remove the CVC Notify Physician. Ensure sutures and/or securement devices are intact. Record catheter length at the beginning of each shift and PRN. Compare measurement to original measurement Secure CVC to skin/ clothing to prevent pulling. Avoid pulling on CVC when transferring/ positioning patient. 10 ml syringe is the smallest size syringe used to flush a CVC. Secure catheter to skin/clothing to prevent pulling Avoid pulling on CVC when transferring/ positioning patient Do not use sharp objects (scissors) near CVC. Compare measurement to original insertion documented measurement. Ensure line is not twisted or kinked before flushing. Page 23 of 26

24 Complications Signs & Symptoms Management Prevention 13. Blood noted in catheter Contributing Factors: Placement of the catheter in the right atrium or ventricle. Contractions of the heart muscle can force blood into the catheter Increased pressure in the SVC due to excessive coughing, vomiting. Loosened cap. Tear or hole in the extension tubing. Fractured catheter. 14. Air noted in catheter lumen Contributing Factors: Hole in catheter. CVC/ IV tubing/cap not primed with NS. Loose connections IV tubing or cap. Faulty catheter. Broken catheter or lumen. Blood seen in catheter lumen Signs & symptoms of Air embolism Air seen in catheter lumen Signs & symptoms of Air Embolism External portion of catheter may have increased in length. If catheter is fractured clamp lumen/cvc close to the insertion site with a nontoothed forceps. Attempt to aspirate blood from the catheter, If blood aspirated flush with 20ml NS. If unable to aspirate blood follow total occlusion management protocol (above) Consider CXR to confirm tip placement Ensure Positive Pressure Cap is used and secure. Clamp lumen when not in use. Notify Physician. Treat for Air embolism. Attempt to aspirate air if possible. Check the catheter for leakage by flushing with NS after aspirating. CVC correct tip confirmation prior to use. Ensure PPC, tubing connections are secure. 10 ml syringe is the smallest size syringe used to flush a CVC. Secure catheter to skin/clothing to prevent pulling Avoid pulling on CVC when transferring/ positioning patient. No sharp objects near CVC. Use Positive Pressure Cap. Prime all IV tubing prior to connecting. Check for loose connections-iv tubing or cap and tighten as needed. Clamp lumens when not in use. Ensure PPC, tubing connections are secure. No sharp objects near CVC. Avoid pulling on CVC when transferring/ positioning patient. Page 24 of 26

25 Complications Signs & Symptoms Management Prevention 15. Fluid leakage from CVC insertion site. Caused by: Catheter may have become encapsulated by a fibrin sheath, which prevents infused fluid from entering the venous system. Central vein thrombosis occluding the vein can cause infused fluid to flow back along the outside of the catheter to the skin exit site. Edema. Catheter punctured by sharp object prior to placement Catheter ruptured from attempt to irrigate an occluded catheter with a small syringe Fluid leaking from CVC insertion site External portion of catheter may have increased in length. Infuse 10 ml NS and assess for signs of fluid extravasation/ infiltration under the skin. Notify Physician Venogram may be required CVC will be removed if leak is caused by hole or tear in catheter. If leak is due to seeping edema, fold 2x2 gauze, create pressure point over the insertion site and cover with tegaderm. Change pressure dressing in 24 hours and PRN. No sharp objects near CVC. 10 ml syringe is the smallest size syringe used to flush a CVC. Avoid pulling on CVC when transferring/ positioning patient. Page 25 of 26

26 Appendix B - Flow Rates and Priming Volumes Description Lumens Volume (cc) Priming Volume (cc) Flow Rate Capabilities Gravity standard tubing Normal Saline (Average cc/hr) 7 Fr. x 16 cm (6 ) Dist. (16 Ga.) Med. (18 Ga.) Prox. (18 Ga.) cc 1800 cc 1900 cc 8.5 Fr. x 16 cm (6 ) Dist. (16 Ga.) Med. 1 (14 Ga.) Prox. (16 Ga.) cc 8480 cc 3640 cc Page 26 of 26