BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Guidelines for Care and Management of Central Venous Catheters IC/246/10. Supersedes: IC/246/07

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1 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Guidelines fr Care and Management f Central Venus Catheters IC/246/10 Supersedes: IC/246/07 Owner Name Sandy Kirk Jb Title IV Nurse Specialist Final apprval Name Infectin Cntrl Cmmittee cmmittee Date f meeting 05/03/2010 Authriser Name Dr Nicki Hutchinsn Jb title Directr f Infectin Preventin and Cntrl Signature Review date Audience Standards Date f authrisatin (maximum 3 years frm date March 2013 f authrisatin) Standards fr Better Health NHSLA Trust staff NHS General public Related plicies Plicy numbers and names IC/194/07 Preventin and Management f sharps and cntaminatin injuries. IC/277/07 Infectin Cntrl Standard Precautins plicy IC/230/09 Hand Hygiene Plicy Equality Impact Date cmpleted by plicy Assessment wner Reviewed in accrdance with The Health and Scial Care Act 2008: Cde f Practice fr health and adult scial care n the preventin and cntrl f infectins and related guidance as published 16 December Executive Summary This plicy is designed as a resurce t direct all staff in the management and care f the varius frms f Central Venus Catheter (CVC) placed in patients within Basingstke and Nrth Hampshire NHS Fundatin Trust. CVC are inserted: T mnitr central venus pressure T administer large amunts f intravenus fluids (e.g. cllids, bld prducts etc.) T administer irritant, vesicant r hyper-smlar drugs / fluids (fr example Nradrenaline/Adrenaline, sdium bicarbnate, Parenteral Nutritin, chemtherapy etc.) T prvide lng term accesses fr frequent r prlnged use (e.g. chemtherapy, antibitics, bld sampling, haemdialysis etc.). The implementatin f this plicy will be mnitred using clinical audit including the Saving Lives Care Bundles / CVC Insertin and Management Frm (Appendix VIII). 1

2 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Summary f changes This plicy cntains guidance fr Central Vascular Access Devices nly. Peripheral Venus Cannula has been remved frm the plicy. The previus plicy has been reviewed and streamlined. Implementatin Plan Actin needed and wner f actin Staff are required t adhere t new Trust Guidelines, in rder t ensure staff cmply: There will be a week lng launch f the plicy, including teaching sessins fr staff Managers and Link Persnnel t disseminate plicy t nn- attenders f teaching sessins Infrmatin regarding the new plicy will be issued in PULSE Psters will be displayed in all clinical areas utlining the basis f Central Vascular Catheter care and assessment tls Implementatin f Central Venus Catheter care plans Regular Audits f Central Venus Catheter care (including dcumentatin) Table f Cntents Page N 1. Scpe 2 2. Definitins 3 3. Clinical Practice 3 4. Purpse 3 5. Respnsibilities 3 6. Training 3 7. Assciated dcumentatin and references (including related plicies and prcedures) 4 8. Cntributrs 4 Appendix I - Central venus catheter insertin prcedure 5 Appendix II Principles f Care 8 Appendix III Overview f Central Venus Catheters 12 Appendix IV Overview and Specific Care fr Different Types f Catheter 14 Appendix V Management f Cmplicatins 27 Appendix VI Using Thrmblytics 32 Appendix VII Glssary f Cmplicatins 35 Appendix VIII VAD Care and Management frm 40 Appendix IX - References Scpe This plicy applies t all health care prfessinals invlved in the management f patients with central venus catheters in-situ. 2

3 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters 2. Definitins Central Venus Catheter (CVC) refers t an intravenus catheter whse internal tip lies in a large central vein. There are varius different types f CVC but cmmn t all is the idea that the tip f the catheter flats freely within the bldstream in a large vein and parallel t the vein wall. Bld flw arund the catheter is maximised, and physical and chemical damage t the internal walls f the vein are minimised. Aseptic Technique Clinical practices used t prtect the patient frm micr-rganisms by preventing cntaminatin f wunds, manipulated devices and ther susceptible sites. Aseptic technique invlves the use f apprpriate hand hygiene, use f sterile equipment, n tuch technique and rbust patient skin / site disinfectin. Health care prfessinal A registered r trained member f staff, including but nt exclusively nurses, dctrs and perating department practitiners. Infectin Entry f a harmful micrbe int the bdy and its multiplicatin in the tissues. Further infrmatin can be fund in the Appendices. 3. Clinical Practice See Appendices: I. Principles f Care (p5) III. Overview and Specific Care fr Different Types f Catheter (p9) IV. Management f Cmplicatins (p24) V. Using Thrmblytics 4. Purpse T infrm best practice frm the existing evidence n the care and management f CVC lines. The implementatin f this plicy will reduce the risks assciated with these devices including thrmbsis, pain, lcal r systemic infectin and ccupatinal sharps injury. 5. Respnsibilities 1. All Managers - T be aware f Trust Plicy and Guidelines and t ensure their Staff cmply with the requirements f these dcuments. 2. Supervisrs f clinical practice will be respnsible fr mnitring cmpliance with the plicies n an nging basis. 3. Individual members f Staff must ensure they fllw this plicy t ensure safe practice. 4. Wards and Clinical Areas will rutinely audit cmpliance against the Care bundle frm fr nging management f CVCs as per Infectin Preventin and Cntrl guidance (Appendix VIII). 5. IV Therapy Nurse Specialist - Quality cntrl audits t ensure cntinued standards and adherence f Plicy during care and management f CVCs will be undertaken cyclically. 6. Training Nursing staff will be taught at n the IV Therapy Study Day. Clinical Educatrs, Practice Develpment Nurses and Clinical Nurse Specialists will supprt learning and the gaining and maintaining f cmpetencies. Additinal training can be ffered by the IV Therapy Nurse Specialist. Medical Staff wh handle and care fr CVCs shuld be cmpetent t d s. This shuld be assessed by their Educatinal Supervisr. Additinal training can be ffered by the IV Therapy Nurse. 3

4 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters 7. Assciated dcumentatin and references (including related plicies and prcedures) This plicy shuld be read in cnjunctin with the fllwing BNHFT plicies: 1. Safe handling and dispsal f sharps Preventin and Management f sharps and cntaminatin injuries 2. Standard Infectin Cntrl Precautins Infectin Cntrl Standard Precautins plicy 3. Aseptic Technique Aseptic Technique Plicy 4. Hand Hygiene Plicy Hand Hygiene Plicy See als Appendix VIII: References (p42) 8. Cntributrs Dr Andrew Wade 4

5 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Appendix 1: Central venus catheter insertin prcedure Healthcare persnnel caring fr a patient with a central venus catheter shuld be trained and assessed as cmpetent in using and cnsistently adhering t the infectin preventin practices described in this guideline. Patients shuld receive clear and cmprehensive infrmatin explaining the risks,benefits and care f the catheter. Signed cnsent shuld be btained prir t catheter insertin (if the patient is able t d s). Chice and site f catheter Nntunnelled catheters are indicated fr shrt-term use when peripheral venus access is impractical. Tunnelled central venus catheters are indicated fr the repeated administratin f chemtherapy, antibitics, parenteral feeding and bld prducts, and fr frequent bld sampling. They are recmmended fr patients in whm lng-term (>30 days) central venus access is anticipated. Fully implanted catheters (prts) are mre suitable fr children and fr less frequent accessing but lng-term use, whereas skin-tunnelled catheters are recmmended fr intensive access. shuld be avided fr inpatient therapy because f limited catheter lngevity and increased incidence f thrmbsis. They are mre suited t ambulatry r utpatient-based therapy. Plyurethane Peripherally inserted central catheters (PICC) allw easier infusin f bld prducts as greater flw rates are achieved because the thinner walls prvide a larger internal diameter f the catheter. The decisin t use plyurethane catheters shuld be balanced against the higher risk f thrmbsis with these catheters cmpared with silicne catheters. The number f lumina and diameter f catheters shuld be kept t the minimum. Insertin It is strngly recmmended that CVCs shuld be inserted in designated clean areas, eg treatment rms, critical care units, perating theatres. Insertin shuld be perfrmed by trained and cmpetent staff regardless f specialty. - this reduces the mechanical and infectin risks assciated with insertin. Ultrasund guided insertin is recmmended fr all rutes f central venus catheterizatin. The use f ultrasund is als recmmended fr the insertin f PICC when the peripheral veins are nt visible r palpable. Hands shuld be decntaminated using alchl hand rub n visibly clean hands (apply 1 sht, cver all surfaces, rub hands tgether until dry). Alternatively, using an antimicrbial liquid sap eg Hibiscrub, Pvidne idine, hands shuld be thrughly washed, using a technique, which aims t cver all surfaces f the hands. Hands shuld be rinsed in running water befre and after applying the cleansing agent and dried well -this reduces the risk f crss infectin frm the peratrs hands during the prcedure. 5

6 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Use ptimum aseptic technique, including a sterile gwn, glves, hat and mask, and a large sterile drape (dedicated CVP insertin packs shuld be used where available) -Evidence has identified that using maximal barrier precautins reduces the risk f subsequent CVC related infectin. Effective skin preparatin will remve bacteria frm bth hair and skin, aviding the need fr shaving, which can result in micrscpic damage and thus micrbial clnisatin. If hair remval is cnsidered necessary, clipping is the preferred ptin using a dispsable clipper head. -Evidence suggests that shaving results in micrscpic damage and thus micrbial clnisatin f the skin. Using Chlrhexidine 2% in 70% alchl (1-2 applicatrs f Chlraprep 3mls) applying gentle frictin, disinfect the skin insertin site fr 30 secnds. Allw the antiseptic t dry befre inserting the catheter. Use an alchlic pvidne-idine slutin fr patients with a histry f chlrhexidine sensitivity. -Skin cleansing/antisepsis f the insertin site is ne f the mst imprtant measures fr preventing catheter related infectin. EPIC (2006) recmmends an alchlic slutin f chlrhexidine glucnate 2% as this cmbines the benefits f rapid actin and excellent residual (nging) activity. Antibitic/antimicrbial impregnated catheters, fr example, chlrhexidine and silver sulfadiazine impregnated catheters shuld be cnsidered fr apprpriate risk grups f patients t minimize infectin risk. Rutine antibitic prphylaxis is nt recmmended. Rutine replacement, fr example, weekly change, f shrt-term catheters as a means t reduce infectin rates is nt recmmended. Guidewire-assisted catheter exchange t replace a malfunctining catheter is acceptable if there is n evidence f infectin. Hwever, if infectin is suspectedthe existing catheter shuld be remved and a new catheter inserted at a different site. This technique is generally impractical fr cuffed tunnelled catheters r prts when it may be technically easier and safer t insert a new catheter int a clean site. It is usually preferable t insert a new catheter int a clean site. The CVC shuld be firmly anchred t prevent mvement using a mn filament suture -CVCs readily becme clnised and carry micr-rganisms frm the skin int the insertin tract. Use a sterile, transparent, semi permeable plyurethane dressing CVC dressing ie IV This allws fr cntinuus inspectin f the site. If ttal parenteral nutritin is being administered use ne central venus catheter r lumen exclusively fr that purpse. The prcedure must be dcumented in the nursing and medical recrds, stating the name f the persn inserting the CVC, the date f insertin, site, catheter size and reasn fr insertin (insert prduct label int patient s ntes) T meet legal and patient care requirements/facilitate audit. Radilgical cnfirmatin f the psitin f the catheter tip must be undertaken T cnfirm precise lcatin f the catheter tip and exclude immediate cmplicatins such as pneumthrax. 6

7 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters References: Guidelines n the insertin and management f central venus access devices in adults L. Bishp, L. Dugherty, A. Bdenham, J. Mansi, P. Crwe, C. Kibbler, M. Shannn, J. Treleaven Int. Jnl. Lab. Hem. 2007, 29, Pratt RJ et al (2007) epic2: Natinal Evidence-Based Guidelines fr Preventing Healthcare- Assciated Infectins in NHS Hspitals in England. Natinal Institute fr Clinical Excellence (September 2002) Guidance n the Use f Ultrasund Lcating Devices fr Placing Central Venus Catheters. NICE Technlgy Appraisal N 49. Lndn: Natinal Institute fr Clinical Excellence. An Interventin t Decrease Catheter-Related Bldstream Infectins in the ICU Peter Prnvst, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenhltz, M.D., David Sinpli, M.P.H., M.B.A., Haita Chu, M.D., Ph.D., Sara Csgrve, M.D., Bryan Sextn, Ph.D., Rbert Hyzy, M.D., Rbert Welsh, M.D., Gary Rth, M.D., Jseph Bander, M.D., Jhn Keprs, M.D., and Christine Geschel, R.N., M.P.A. N Engl J Med 2006;355: East Kent Hspitals NHS Trust vascular access guidelines sectin 7: cvc lines May

8 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION Appendix II: IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Principles f Care (i) General Principles Use an aseptic technique fllwing BNHFT Asepsis Plicy whenever the CVC is accessed and during prcedures invlving exit sites. T prevent infectin. A strng crrelatin exists between bacteraemia and the presence f a CVC22. Wear sterile glves when carrying ut dressing changes and when accessing the catheter. Glves shuld be wrn t prevent descaling f bacteria nt key parts23. Mnitr temperature, pulse, bld pressure, respiratry rate and O 2 saturatins at least a minimum f 12hurly. T detect infectin D nt allw air t enter the catheter. All syringes and intravenus administratin sets must be carefully primed. T prevent air emblism. The negative pressure within the chest may suck air int the catheter during inspiratin especially if the patient is sitting up24. Cap ff the catheter with a needle-free access device) when nt in use (except Nenates). This will minimise interruptins t the clsed system. Unless manufacturer s instructins vary, this shuld be changed every 7 days r every 200 uses, whichever is the sner. In adult inpatients with lng-term vascular access devices the bungs shuld be changed n a set day (Sunday) t ensure cntinuity within and between units. Risk f cntaminatin increases with every interruptin t the clsed system22. Whenever the bung/access device is remved frm the catheter then it must be replaced with a new, needleless access device/bung. T prevent infectin. If the catheter pssesses an integral clamp, keep it clsed whenever the cap is remved and at all ther times except when administering r withdrawing fluids. Clamping shuld always take place at the designated area and never at the thickened area near the hub (except Hickmans). The clamp will prevent air entry and bleeding shuld the luer lck cap becme unattached. Repeated clamping away frm the specially reinfrced area may result in damage t the catheter. Always take signs f systemic r lcal infectin seriusly and refer t a member f the medical staff. "Infectin cntinues t be ne f the mst frequent and mst serius cmplicatins assciated with CVC Catheters"22. The practice f administering prphylactic antibitics at the time f CVC insertin shuld NOT be rutinely fllwed. The Department f Health s Epic2 Guidelines n the preventin f infectin in Central Venus Catheters specifically states that this practice is nt supprted by research and may encurage resistant rganisms11. The practice f administering prphylactic mini-dse Warfarin t patients with CVCs shuld NOT be fllwed. Mini-dse Warfarin has recently been shwn t be ineffective in the preventin f thrmbsis in cancer patients with CVCs25. (NB dse adjusted Warfarin did shw sme efficacy but with an increased risk f serius bleeding). Shuld the catheter fracture r be accidentally cut, clamp it withut delay prximal t the break. Specialist advice shuld be sught immediately t cnsider remval r repair f the catheter. T prevent haemrrhage, air emblism and infectin. Always secure the catheter firmly t the skin away frm the exit site with tape r with a dedicated device such as 'Statlck'. Fr patient's cmfrt, t prevent tensin r accidental disldgement, and t reduce 't and fr' mtin which increases the risk f catheter related 8

9 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION sepsis22. IC/246/10 Guidelines fr Care and Management f Central Venus Catheters (ii) Accessing the Catheter Befre it is used fr administering therapeutic drugs r fluids, the patency and crrect functining f the catheter shuld be established26 (except Nenates when this shuld nly be dne immediately fllwing catheter insertin). Signs f catheter cclusin, whether partial r cmplete, shuld be taken seriusly and actin shuld be taken earlier rather than later t restre full patency. Ignring the early signs may lead t the develpment f mre serius prblems which cannt then be easily rectified eg cmplete blckage r thrmbsis27. Nurses using CVCs can be cnfident f access if all three f the fllwing apply The catheter can be flushed with ease. Bld can be withdrawn frm the catheter (nt Nenates). The patient experiences n discmfrt during flushing/infusin and there are n ther cmplicatins If any f these criteria are nt met yu shuld refer t Management f Cmplicatins (page 24). Ways f assessing these three criteria will vary with the setting. Here are sme pints t nte: A prper assessment f the catheter invlves bserving the exit site and the area arund as this may reveal any signs f thrmbsis, leakage, infectin etc. While this is nt necessarily apprpriate every time the catheter is used it shuld be a regular part f yur practice. Assessing CVCs in nenates and in patients requiring bld prcessing (e.g. haemdialysis / apheresis) requires specialist knwledge: refer t Overview and Specific Care fr Different Types f Catheter (starting page 11) fr care f these patients. In adults and children ver 1 year wh are due t receive intravenus fluids, a useful technique is t attach an infusin f 0.9% saline, pen the clamp n the giving set fully and bserve fr free-flw. Yu will sn learn t recgnise what is a nrmal free-flw fr a particular type f CVC (fr example the flw n a Nn-tunnelled CVC will be much faster than yu wuld expect frm a PICC which is a much lnger thinner catheter.) Drpping the bag f fluid briefly belw the patient s heart with any clamps pen will allw yu t check fr flashback f bld withut interrupting the clsed system. As sn as bld is seen in the tubing, the bag can be replaced n the drip stand and prescribed infusin started. (NB this technique fr checking flashback des nt always wrk with valved catheters). Ensure t stp the free flw t ensure n unnecessary blus f fluid. Checking fr flashback f bld des nt necessarily mean yu have t discard bld. Fr example, attach a syringe cntaining 10ml 0.9% sdium chlride t the catheter, flush a cuple f ml int the line and then withdraw. As sn as yu see a trace f bld in the catheter r syringe just flush the rest f the sdium chlride int the line using the push-pause technique as described in (iii) a) belw (page 7). (iii) Flushing After and Between Uses (except Nenates) (a) Flushing Technique: Where pssible, d nt use syringes smaller than 10 ml fr infusin int the catheter16. T prevent excessive pressure being exerted n the lumen which might cause it t rupture. Smaller syringes exert greater pressure. But please nte that syringe size alne is nt sufficient t prevent rupture. When resistance is felt, if mre pressure applied t vercme it, catheter fracture culd result regardless f the syringe size 27. 9

10 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Use a brisk 'push-pause' flushing technique rutinely when flushing the catheter - i.e. flush briskly, pausing briefly after apprximately each ml f fluid. The 'push-pause' technique causes turbulence within the catheter, which helps t flush away any debris and prevent cclusin f the lumen16, 26. If the catheter pssesses a clamp, clamp the line while the final ml f the flush is being injected. If there is n clamp yu can achieve a psitive pressure finish by remving the syringe frm the needle free bung) while injecting the last ml: but nte that t avid any spray frm the syringe yu shuld hld sterile gauze arund the cnnectr while ding this. Maintaining psitive pressure helps prevent bld entering the catheter after flushing, which might lead t cclusin r thrmbus frmatin16. D nt rutinely withdraw and discard bld frm the catheter befre flushing (except Renal Dialysis Catheters) in an attempt t avid flushing bacteria and clts int the patient26. There is n evidence that withdrawing prir t flushing reduces infectin r emblism. But nte that if the catheter is t be used fr administering drugs r fluids, checking fr flashback shuld be a rutine part f catheter assessment: see ii) Accessing the Catheter abve (page 6). (b) Frequency f flushing and flushing slutins: This varies depending n the device. See Overview and Specific Care fr Different Types f CVC (starting page 11). Please nte that Hepsal and Heparinised Saline must be prescribed. (iv) Care f the Exit Site (Except Nenates) a) Dressings Immediately pst insertin: As with any surgical wund, the exit site shuld ideally be left undisturbed fr 1-2 days. Rutine taking dwn f the dressing pst-insertin t inspect the site merely expses the patient t increased risk f infectin. On the ther hand mst exit sites bleed t sme extent fllwing insertin. If this leads t strike-thrugh n a dry dressing, (i.e. exudate/bld/serus fluid bserved n the utside f a dry dressing) it shuld be changed immediately since a wet surface prvides a liquid pathway fr bacteria t travel t the wund. The ideal dressing immediately pst-insertin is a dry dressing cvered and sealed with a transparent dressing (IV 3000). In mst cases this will absrb any zing but nt necessitate changing the dressing. Ideally this dressing shuld be left undisturbed fr at 1-2 days. If there is excessive bleeding and the gauze becmes sggy the dressing shuld be changed. If a dry dressing alne is used pst-insertin, it shuld again ideally be left undisturbed fr 1-2 days but shuld always be changed as sn as any strike-thrugh ccurs using an aseptic technique. If bleeding is excessive the dressing shuld be changed every time strike-thrugh ccurs and replaced with a mre absrbent r thicker dressing. Pressure shuld then be applied t the site and the patient encuraged t lie fairly still until the bleeding settles. It is nt acceptable t add mre dressings n tp f bld-saked dressings which have been in cntact with a mist uter surface, because f the infectin risk. b) On-ging Dressing Regimes after the first 1-2 days: 10

11 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters As a general principle, where a dressing is used it shuld be inspected regularly and renewed immediately shuld it becme siled, wet r detached24. A mist envirnment is ne in which bacteria readily multiply28. If the exit site is reddened, painful, exudating r infected, increase the frequency f dressing change depending n the amunt f exudate. The mst suitable dressing will depend n the setting, the type f CVC and the individual patient s needs. See Overview and Specific Care fr Different Types f CVC (starting page 11) fr recmmendatins. The main ptins fr dressings are: IV-dedicated cclusive transparent dressing, changed every 7 days26 except patients n dialysis and nenates. Sme researchers have fund iv-dedicated transparent dressings t be assciated with a lwer risk f infectin than ther transparent dressings29. Sterile dry dressing taped in situ, changed at least twice a week26. N dressing. This may be suitable fr sme patients with Tunnelled CVCs frm 21 days pst insertin nce the tissues have fibrsed arund the cuff and in the absence f exudate r signs f infectin. "N dressing" perfrmed just as well as 3 types f dressing in ne study cmparing infectin rates 22,30,31 c) Cleaning f Exit Site: At dressing changes, the exit site shuld be cleaned using Chlraprep using a criss crss mtin t avid transferring bacteria t the exit site. Cleaning shuld be carried ut using an aseptic technique. Lse bld, exudate r ther debris which might prvide a fcus r infectin r might impair inspectin f the wund may be gently remved by cleaning in the abve manner with sterile 0.9% sdium chlride prir t cleaning with Chlraprep32. (v) Remval If a shrt-term CVC has nt been used fr >24 hurs cnsideratin shuld be given t its remval. Sme CVCs are simple and relatively safe t remve. With thers, there is high risk f air emblism33 and s remval requires a higher level f training and skill. See Overview and Specific Care fr Different Types f CVC (page 11) fr guidelines n remval. 11

12 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Appendix III: Overview f Central Venus Catheters (i) Definitin f a Central Venus Catheter (CVC) The term Central Venus Catheter (CVC) refers t an intravenus catheter whse internal tip lies in a large central vein. There are varius different types f CVC but cmmn t all is the cncept that the tip f the catheter flats freely within the bldstream in a large vein parallel t the vein wall. Bld flw arund the catheter is maximised, and physical and chemical damage t the internal walls f the vein are minimised. Opinins vary abut the ideal place fr the tip f a CVC 2 but it is generally accepted that fr a catheter t be cnsidered a central catheter the internal tip shuld be in ne f the fllwing psitins. a) Superir vena cava (SVC b) RA / SVC junctin c) Right atrium (RA) d) Inferir vena cava abve the diaphragm (femral catheters) Tip psitins utside these areas are thught t be related t a significantly higher risk f cmplicatins, ntably thrmbsis 3,4,5,6,7. In nenatal care, right atrial placement is cntraindicated because f the risk f cardiac tampnade 8. In PICCs, right atrial placement is cnsidered t be inadvisable because the PICC may mve int the right ventricle when the patient mves his/her arm, leading t an increased risk f arrhythmias 9,10. (ii) Indicatins T mnitr central venus pressure T administer large amunts f intravenus fluids in emergency situatins (e.g. cllids, bld prducts etc.) T administer irritant, vesicant r hyper-smlar drugs / fluids (fr example Nradrenaline/Adrenaline, sdium bicarbnate, Parenteral Nutritin, chemtherapy etc T prvide lng term access fr frequent r prlnged use (e.g. chemtherapy, antibitics, bld sampling, haemdialysis etc.) (iii) Insertin and Remval Insertin f a CVC is an invasive prcedure which must nly be perfrmed by trained, cmpetent persnnel using ptimal aseptic technique, including a sterile gwn, glves, and a large sterile drape 11. The use f ultrasund t achieve venus access is recmmended by NICE guidelines11 but this relies upn the availability f apprpriate equipment and training. Whether the catheter is inserted under general anaesthetic, sedatin r simple lcal anaesthetic will depend upn the situatin, the patient, the type f catheter t be inserted and lcal practice. Guidelines fr the insertin f Central Venus Catheters are nt cvered here. Techniques fr the remval f a CVC vary depending n the type f catheter and this is 12

13 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters addressed in Appendix III: Overview and Specific Care fr Different Types f Catheter (page11). (iv) Chice f Catheter Varius different types f CVCs are available and these are described belw. The chice f device will depend chiefly n the purpse fr which it is intended, thugh patient preference may be a key factr with lng-term catheters. As a general principle the lumen diameter and the number f lumens shuld be kept t a minimum, since larger bre catheters and multiple lumens are assciated with higher infectin and thrmbsis risks11,13. Clearly there are many ther factrs t be weighed against these risks e.g. in high dependency settings large bre catheters and multiple lumens tend t be used as they are essential fr management f the acutely ill patient. Where Parenteral Nutritin is t be administered, ideally a single-lumen catheter shuld be used. If multiple lumens are essential, then ne lumen shuld be dedicated exclusively fr that purpse (except in Nenates)

14 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Appendix IV: Overview and Specific Care fr Different Types f Catheter Care f Centrally-Inserted, Nn-tunnelled CVCs Often called Central Lines / Neck Lines / CVP lines. Centrally Inserted Nn-tunnelled CVCs are mst cmmnly fund in acute settings. They are nt suitable fr lng-term use because they rarely remain free f infectin fr lnger than 7 10 days, and als because they are relatively uncmfrtable and unsightly. The catheter is usually inserted via the subclavian, jugular r femral veins with the tip psitined in the Right Atrium, the Superir r Inferir Vena Cava. It is attached t the patient s skin using nn-dissluble sutures. Nn-tunnelled CVCs may have single r multiple lumens. Each lumen prvides independent access t the venus circulatin, s that incmpatible drugs/fluids may be administered simultaneusly. Each lumen is equipped with an integral clamp t seal the catheter and guard against air entry, haemrrhage and infectin. Flushing Befre flushing If there are infusinal vasactive drugs in the lumen, withdraw prir t flushing t avid blus dse. Technique: Brisk push-pause technique with psitive pressure finish What t flush with: 0.9% sdium chlride between incmpatible drugs / infusins and after bld sampling (if sdium chlride 0.9% incmpatible use suitable alternative). Lck with 10ml 0.9% sdium chlride if catheter is t be accessed again within 1 day. Lck with 5ml Hepsal 10 U/ml if catheter nt t be used again within 1 day. Frequency f flushing: Flush unused lumens at least nce a week (10ml 0.9% sdium chlride then lck with 5 ml hepsal 10 U/ml). Exit site Care Securement: Lines are sutured in place, alternatives such as a Statlck can be used. Sutures: Leave in place as lng as the catheter is in situ. Cleaning: Clean exit site at dressing changes using Chlraprep using a criss crss methd. Dressings: Pst-insertin: gauze under transparent dressing fr 24 hrs. After 24 hrs: Transparent dressing recmmended. Change every 7 days unless siled r lse in these cases change when required. Bathing & shwering The exit site must nt be allwed t get wet. 14

15 Printed frm the Intranet n 18-Oct-10 CHECK THE INTRANET FOR THE LATEST VERSION IC/246/10 Guidelines fr Care and Management f Central Venus Catheters Remval Wh can remve Nn-tunnelled CVCs? Any qualified nurse wh has been assessed as cmpetent and wh fllws these guidelines. Prcedure: Yu will need assistance during this prcedure: d nt attempt it alne. Check patient s cagulatin status. If there is an increased risk f bleeding discuss with medical team befre prceeding. If platelets are < 50, platelets shuld be administered immediately prir t the prcedure. If the patient is anticagulated, this shuld be managed as fr surgery. The risk f air emblism increases if patient is dehydrated, is unable t lie flat, r has an uncntrlled cugh. Assess fr these risks. Only prceed if satisfied that it is safe t d s. Use aseptic technique thrughut. Lie the patient flat and tip the head f the bed dwnward t reduce the risk f air emblism (except femral catheters). Remve the dressing. If there is any sign f infectin, take a swab f the exit site. Remve any stitches. Ask patient t perfrm Valsalva s maneuvre (ie take a deep breath, hld it, and bear dwn). If patient unable t d this, remve the catheter during expiratin and NEVER when the patient is breathing in, as this will increase the risk f air being sucked int the venus system. Gently and swiftly pull ut the catheter and immediately apply pressure t the site using sterile gauze. The patient can nw breathe nrmally and the bed can be returned t the flat psitin. Cntinue applying pressure t the exit site fr three minutes (r lnger in cases f deranged cltting). If systemic infectin is suspected, use sterile scissrs t cut ff the tip f the catheter and withut cntaminating it drp it int a dry sterile specimen pt. Send it t micrbilgy fr culture (ITU all tips sent fr culture). Apply a sterile cclusive dressing t prevent air frm entering the venus system. Advise the patient t lie flat fr 30 minutes. During this time bserve patient fr signs f haematma (ie, swelling, pain, altered vice, airway bstructin). The wund shuld be kept dry fr 5 t 7 days and the wund mnitred until healed. 15

16 ii) Care f Tunnelled CVCs ften called Hickman lines Tunnelled CVCs are intended fr lnger-term use in patients wh require multiple infusins f fluids, bld prducts, drugs r Parenteral Nutritin. They als prvide easy access fr rutine bld sampling. They are mre cmfrtable and discreet than the nn-tunnelled CVCs described in a) abve, and can last fr much lnger. The Tunnelled CVC is inserted via the subclavian, jugular r femral veins. The catheter is tunnelled subcutaneusly and exits at a cnvenient site (usually n the chest wall) where it is secured with sutures. There is a cuff within the tunnel t allw fr the adherence f fibrus tissue which helps t prevent accidental disldgement after the remval f the sutures and acts as a mechanical barrier t ascending bacteria 14,15 Single, duble and triple lumen catheters are available. Each lumen prvides independent access t the venus circulatin, s that incmpatible drugs/fluids may be administered simultaneusly. Each lumen f the catheter is equipped either with an integral clamp, r a 3-way valve. Valved catheters vary in design: the valve may be at the internal r external end f each lumen (e.g. Grshng catheters have a valve at the internal end, whereas PASV catheters cntain a valve at the external end). The clamp (r valve) serves t seal the catheter and guard against air entry, haemrrhage and infectin. Patients with tunnelled CVCs may be discharged hme with the catheter in situ. In these cases patient educatin regarding the recgnitin and reprting f cmplicatins is f great imprtance. Where pssible, care in hspital shuld be aimed at the prmtin f independence in caring fr the Tunnelled CVC, but liaisn with the primary health-care team remains vita Flushing Technique: Brisk push-pause technique with psitive pressure finish What t flush with: 0.9% sdium chlride between incmpatible drugs / infusins and after bld sampling (if sdium chlride 0.9% incmpatible use suitable alternative). Lck with 10ml 0.9% sdium chlride if catheter t be used again within 1 day. Lck with 5ml Hepsal 10 U/ml if catheter nt t be used within 1 day. Paediatrics 5ml Hepsal 10u/ml flush if nt t be used within 8 hurs. Frequency f flushing: Flush unused lumens nce a week with 5ml Hepsal 10 U/ml. Exit Site Care Securement: When stitches remved n further securement required Paediatrics tape lines t patient. Sutures: Exit site: remve at 21 days Venepuncture site: Remve stitches / Steristrips at 7 days (unless disslvable) Cleaning: Clean exit site at dressing changes using Chlraprep using a criss crss methd Dressings: 16

17 Exit site: Pst-insertin: gauze under transparent dressing fr 24 hrs After 24 hrs chse between Transparent dressing (changed every 7 days) OR dry dressing (changed at least every 7 days) After 21 days: chse between transparent dressing (change every 7 days) OR dry dressing (change at least twice a week) OR n dressing. Venepuncture Site: Dry dressing and/r transparent dressing until sutures remved / disslve. Bathing, shwering & swimming Bathing: Patient shuld nt submerge exit site in bathwater. Fr clean water jugged frm tap see shwering belw. Shwering: If transparent dressing is intact patient can shwer. If patient has dry dressing r n dressing, s/he can shwer after 21 days as fllws: Remve dry dressing (if any) immediately befre r after shwering Dry exit site after shwer using sterile gauze and nn-tuch technique. Clean exit site as usual & apply new dressing (if any). Swimming: nt advised Paediatrics liaise with Clinical Nurse Specialists. Patient Educatin If patient is discharged with catheter in situ Ideally, teach patient / carer t care fr their wn catheter Refer t Cmmunity Nursing Staff if necessary Prvide tw weeks dressing and flushing supplies unless there are lcal arrangements with Cmmunity teams. Prvide emergency clamp kits fr paediatric patients. Ensure patient is aware f care required Ensure patient is aware f the imprtance f reprting cmplicatins and has a cntact number fr this purpse Remval D nt remve Tunnelled CVCs unless yu have been specifically trained t d s. 17

18 (iii) Care f PICCs PICCs (Peripherally Inserted Central Catheters), like Tunnelled CVCs, are intended fr mid t lng-term use (up t 6 mnths, smetimes lnger) in patients wh require multiple infusins f fluids, bld prducts (nt nenates), drugs r Parenteral Nutritin. They may als prvide access fr rutine bld sampling. PICCs are a cmmn chice fr central access in Nenatal care. A PICC is a fine bre CVC inserted int a peripheral vein usually the basilic r cephalic vein and threaded upwards twards the heart. Tip psitin is verified by Chest X-ray fllwing insertin (unless the tip has been screened during insertin using Flurscpy). Unlike Tunnelled CVCs, PICCs d nt psses a cuff t secure the catheter. There is nthing t keep the PICC in place unless it is secured t the skin f the patient s arm using sutures, Steristrips r a dedicated fixing device. Checking the external length f the PICC shuld be a rutine part f care befre administering drugs r fluids. PICCs can be single r duble lumen. Each lumen prvides independent access t the venus circulatin, s that incmpatible drugs/fluids may be administered simultaneusly Each lumen f a PICC is equipped either with an integral clamp, r a 3-way valve. Valved PICCs vary in design: the valve may be at the internal tip f each lumen (e.g. the Grshng PICC). The clamp (r valve) serves t seal the catheter and guard against air entry, haemrrhage, backtracking f bld and infectin. Patients may return hme with a PICC in situ, and therefre patient educatin regarding the recgnitin and reprting f cmplicatins is f great imprtance. The PICC usually exits nt the patient s arm and s it is nt always practical fr the patient t care fr the catheter him/herself. Liaisn with the IV Nurse Specialist is vital. Placement is cntraindicated fllwing axillary nde dissectin r irradiatin, r in the case f lymphedema f the arm, axillary nde disease r skin infectin at the insertin site17. A PICC shuld nt be cnfused with a midline catheter which is usually 20cm in length, with the tip terminating in the regin f the axillary vein, and is designed fr shrt-term peripheral drug delivery 17. A midline catheter is nt a Central Venus Catheter. General pints Assess external length f PICC befre use: if it has increased by mre than 2cm see Management f Cmplicatins page 24. Take care at all times nt t pull PICC ut. Unless there are sutures remember there s nthing t keep the PICC in apart frm the dressing and Statlck. Avid cmpressin t vein cntaining the PICC. D nt use bld pressure cuff. Any bandage/ tubular dressing must be lse. Use vlumetric pump with a filtered giving set when infusing bld prducts t avid blckage. Never use PICC fr administering cntrast medium as this will cause the PICC t split. 18

19 Flushing Technique: Brisk push-pause technique with psitive pressure finish What t flush with: Bard Grshng valved 0.9% sdium chlride between incmpatible drugs / infusins r after bld sampling (if sdium chlride 0.9% incmpatible use suitable alternative). Lck with 10ml 0.9% sdium chlride Ck / Kimal pen-ended 0.9% sdium chlride between / after incmpatible drugs / infusins r after bld sampling (if sdium chlride 0.9% incmpatible use suitable alternative). Lck with 5ml Hepsal nce a day. Frequency f flushing: Bard Grshng valved Flush unused lumens a weekly with 10ml 0.9% sdium chlride Ck / Kimal pen-ended Flush unused lumens daily with 5ml Hepsal 10U/ml. D nt discnnect cntinuus infusins t give daily Hepsal 10U/ml. Exit Site Care Securement: Always fix catheter firmly t patient s skin (e.g. using Steristrips r dedicated device e.g. Statlck.) Sutures (if any): Leave in situ as lng as the PICC is in situ. Cleaning: Clean exit site at dressing changes with Chlraprep using a criss crss methd. Dressings: Pst-insertin: gauze under transparent dressing fr 24 hrs After 24 hrs : transparent dressing (change every 7 days tgether with Steristrips and any dedicated fixing device (e.g. Statlck dressing) Bathing, shwering & swimming: Bathing & Shwering: Patient shuld nt get the dressing wet as bath/shwer water can reach the exit site where the PICC prtrudes frm the dressing. If pssible prvide a waterprf cvering fr bathing and shwering (e.g. Bathguard r similar). Swimming: nt advised. Patient Educatin Fr PICCs placed in the inner elbw, advise patient t keep upper arm warm. If patient is discharged with catheter in situ Refer t Cmmunity Nursing Staff if necessary fr nging care Prvide tw weeks dressing and flushing supplies. Ensure patient is aware f care required Ensure patient is aware f the imprtance f reprting cmplicatins and has a cntact number fr this purpse If apprpriate, teach a carer / member f the patient s family t care fr the PICC Remval Wh can remve PICCs? Any qualified nurse wh fllws these guidelines. Prcedure: 19

20 Patient shuld be sitting/lying with the PICC exit site belw the level f the heart (this will help prevent air emblism) Remve the dressing & any stitches. (Take swab if signs f infectin) Pull PICC ut slwly and gently an inch r tw at a time. As each inch ges by, change the psitin f yur hand s that yur fingers are clse t the exit site. This will reduce the likelihd f the catheter breaking. If yu meet resistance, STOP. Resistance may be due t venspasm. If this happens, apply warm packs t the patient s arm fr abut 5 minutes befre resuming. Once PICC is ut, apply pressure t exit site with sterile gauze fr 3 minutes. If systemic infectin is suspected, use sterile scissrs t cut ff the tip f the catheter and withut cntaminating it drp it int a dry sterile specimen pt. Send it t micrbilgy fr culture. Apply sterile cclusive dressing t prevent air frm entering the venus system. Keep exit site wund dry fr 1 t 2 days r until healed. 20

21 (iv) Care f Implantable Prts (TIVAD / Prtacaths) A Ttally Implantable Venus Access Device (TIVAD) is similar t a Tunnelled CVC but instead f prtruding frm the patient s chest, the catheter terminates in a self-sealing injectin prt which is implanted under the skin. There are therefre n external parts. The prt is accessed thrugh the skin using a dedicated nn-cring needle Sme patients find an Implantable Prt mre discreet and less intrusive than a Tunnelled CVC19. Prts require less maintenance when nt in use than ther types f catheter. They may als ffer a lwer risk f infectin when nt in use 18,19. Implantable Prts are suitable fr patients wh require lng-term frequent and intermittent venus access. Arguably they are less than ideal fr lng-running cntinuus infusins because f the risk f needle disldgement20. The patient may return hme with the prt in situ, and therefre patient educatin regarding the recgnitin and reprting f cmplicatins is f great imprtance, as is liaisn with the primary health-care team. Dual lumen devices are available. These are equipped with tw access prts side-by-side which can be accessed separately using tw different needles. Each lumen prvides independent access t the venus circulatin, s that incmpatible drugs/fluids may be administered simultaneusly. Prts may als be used as an alternative t subcutaneus administratin f lng-term maintenance therapies when the subcutaneus rute has becme unacceptable t the patient r unreliable e.g. due t subcutaneus ndule frmatin. Placement is nt recmmended in bese r cachexic patients, befre r after chest irradiatin, r at mastectmy sites18 General Pints Only access prt using a dedicated nn-cring needle with integral extensin set with clamp /stpcck. Fllwing insertin there may be edema and tenderness arund prt. This may make accessing prt painful and mre difficult than usual. Ideally prt shuld be accessed while patient is in theatre if it is t be used immediately afterwards. A lnger needle may need t be used due t swelling. If patient underges MRI scan, infrm scanning persnnel abut the prt. If patient requires defibrillatin d nt place paddles directly ver the prt. Never use prt fr administering cntrast medium as this may cause the catheter t split. 21

22 Smetimes it is nt pssible t bleed back prts despite easy flushing. Inserting the Nn-cring Needle Which needle? Style: Fr infusins, bluses, bld-taking and flushing a 90 0 nn-cring needle with extensin set shuld be used. Gauge: A 22-gauge needle will suffice fr mst uses. Use a 20-gauge needle fr bld administratin and withdrawal. Length: Where a 90 0 needle is used, the length will depend n the amunt f subcutaneus tissue between the skin surface and the prt. The external part f the needle shuld nt exert pressure n the skin but equally it shuld nt stand t prud. Hint: a 3/4" needle is suitable fr mst adult patients. Deeper r mre superficial prts will require lnger r shrter needles. Technique: Use Aseptic Nn-tuch Technique. Numb skin ver the prt if required using tpical anaesthetic befre skin prep (min. 60 minutes befre) r subcutaneus Lidcaine 1% (after skin prep). Prepare skin ver the prt using Chlraprep using a criss crss methd and allw t dry. Prime needle and/r giving set with 0.9% sdium chlride. Put n sterile glves if yu need t palpate the prt t ensure yu are cnfident f its psitin. Hld prt firmly with thumb and tw fingers and stretch skin taut during insertin f the needle t prevent the prt sliding ut f the way f the needle, and t reduce the risk f the prt becming disldged within the subcutaneus pcket. Insert needle firmly until it is felt t cntact the back f the prt. Verify crrect psitin by flushing with 20 ml 0.9% sdium chlride and checking fr aspiratin f bld. If there is any lcal discmfrt and/ r edema in the tissues arund r ver the prt this indicates incrrect psitin f the needle. In this case needle shuld be remved (see belw fr technique) and a fresh attempt made. (Yu can use the same needle fr up t 1 further attempt if it has nt becme cntaminated r damaged.) The skin will need re-cleaning after 3 minutes if nt successful. If unsuccessful after 2 attempts please refer t IV Therapy Nurse Specialist. If the prt flushes easily withut any lcal discmfrt/edema but there is n flashback f bld, this suggests that needle psitin is crrect but that the catheter itself is nt fully functinal. Refer t Management f Cmplicatins (page 24). Flushing Nn-accessed prts: Flush at least every fur t six weeks with 20ml 0.9% sdium chlride and lck with 4-5 ml Heparinised saline 100 U/ml (nt 10U/ml) Accessed prts: Technique: Brisk push-pause technique What t flush with: 0.9% sdium chlride 5ml between incmpatible drugs / infusins r after bld sampling (if sdium chlride 0.9% incmpatible use suitable alternative). If needle t be remved: lck with 5 ml Heparinised saline 100 U/ml If needle t remain in situ and prt t be used within 1 day: lck with 10ml 0.9% Sdium chlride and fllw with 5ml Hepsal 10U/ml. If needle t remain in situ and prt nt t be used within 1 day: lck with 10ml 0.9% Sdium chlride and fllw with 5ml Hepsal 10U/ml. 22

23 Remving the Needle Technique: Lck prt with 5ml heparinised saline 100 U/ml. Stabilise the prt with ne hand during needle withdrawal t avid trauma t tissues. Take care t avid a needle-stick injury. Apply gentle pressure t needle site with sterile gauze until minr bleeding has ceased. A plaster may be applied if necessary / desired. Exit Site Care Sutures: T side f prt: remve at 7-10 days (unless disslvable) Venepuncture site: Remve at 7-10 days (unless disslvable) Frequency f needle change: If prt in cnstant use fr mre than a week, change needle weekly using different puncture site. Needles are changed every 14 days in paediatric Cystic Fibrsis patients. Dressings Nn-accessed prts: N dressing r exit site care required (except immediately fllwing insertin f the prt when wund shuld be kept cvered until stitches remved.) Accessed prts: Pad needle with sterile gauze if necessary and cver with transparent iv dedicated dressing. Needle site shuld be visible fr inspectin. Tape tubing firmly t skin t prevent pulling n the needle. Inspect needle entry site at least daily. Advise patient t reprt any discmfrt r swelling at the puncture site immediately Bathing, shwering & swimming Nn-accessed prts: Patient may bath, shwer r swim freely nce wund has healed. Accessed prts: Bathing: Patient shuld nt submerge exit site in bathwater Shwering: Patient may shwer if needle site is cmpletely cvered with an cclusive dressing, taking care nt t disldge needle cnfirm with IV Therapy Nurse Specialist. Swimming: nt advised while needle is in situ. Patient Educatin If patient is discharged with prt in situ: Ideally, teach patient t care fr their wn prt Refer t Cmmunity Nursing Staff if necessary. If cmmunity staff need training in use f the prt, cntact CNS fr IV Therapy. Prvide access needles and flushing supplies fr the first mnth. Ensure patient is aware f care required Ensure patient is aware f the imprtance f reprting cmplicatins and has a cntact number fr this purpse Remval D nt remve prts unless yu have been specifically trained t d s. 23

24 (v) Care f CVCs used fr Bld Prcessing (eg Haemdialysis, Apheresis etc) Often called Permacaths/Vascaths. CVCs used fr bld prcessing e.g. Haemdialysis and Apheresis - are very similar t the catheters described in a) and b) abve. They can be nn-tunnelled (e.g. Vascaths) r tunnelled (e.g. Permacaths). Patients needing haemdialysis ften require central venus access repeatedly and fr lng perids f time, and s insertin via the jugular vein is preferred t the subclavian apprach because f the high risk f stensis with a subclavian apprach21. These catheters differ frm ther CVCs in the fllwing respects: Larger lumen size cmpared t ther CVCs. The internal tip f the catheter is designed differently s as t allw bld t be withdrawn freely via ne lumen and returned via the ther lumen dwnstream f the bld being withdrawn (thus aviding recirculatin f the treated bld). Cnfusingly, the lumens are ften clur-cded red and blue and referred t as the arterial and venus lumens. In fact bth lumens lead int a vein and nt an artery. In all settings these catheters are lcked between uses with an exact vlume f slutin, usually Taurlck r rarely cncentrated heparin slutin t minimise the risk f cclusin and line clnisatin. This varies depending n the patient s clinical status and lcal guidelines. If a lck is used a red bung must be used t signify that the lck must be withdrawn frm the catheter befre use therwise the patient will receive an unwanted dse f the lcking slutin r embli f cltted bld. Accessing the Catheter Lcking slutins will vary accrding t lcal guidelines and practices. If Taurlck r a cncentrated slutin f heparin is used t lck the catheter, always remve indwelling slutin by withdrawing and discarding at least the vlume f the lumen befre accessing the catheter. If withdrawal is nt pssible r there are ther patency prblems: See Management f Cmplicatins (page 24). Flushing Technique: Brisk push-pause technique with psitive pressure finish Flushing between incmpatible drugs / infusins: Flush with 0.9% sdium chlride (if sdium chlride 0.9% incmpatible use suitable alternative). Flushing after use: Flush bth lumens with 10ml 0.9% sdium chlride in 10ml syringes using a pushpause technique, then lck accrding t lcal guidelines and practices. Unused lumens: Flush at least weekly: withdraw and discard if necessary (as abve), then flush with 10ml 0.9% sdium chlride and lck accrding t lcal guidelines and practices. 24

25 Exit Site Care Securement: Fllwing remval f sutures fr tunnelled lines n securement device is needed. Sutures: Tunnelled catheters: Exit site: remve at 21 days Venepuncture site: Remve sutures r Steristrips at 7 days (unless disslvable) Nn-tunnelled catheters: Leave in place as lng as the catheter is in situ Cleaning: Clean exit site at dressing changes with Chlraprep using a criss crss methd. Dressings: Dressings as fr Nn-tunnelled r Tunnelled CVCs, whichever applies. Bathing, shwering & swimming As fr Nn-tunnelled r Tunnelled CVCs, whichever applies. Patient Educatin If patient is discharged with catheter in situ Ideally, teach patient t care fr their wn catheter Refer t Cmmunity Nursing Staff fr nging care if necessary Prvide tw weeks dressing and flushing supplies Ensure patient is aware f care required Ensure patient knws t reprt any cmplicatins and has cntact number fr this purpse. Remval As fr tunnelled r Nn-tunnelled catheters, whichever applies. 25

26 (vi) Care in Nenates General Pints There are tw main types f CVC used in nenatal care: PICCs (als knwn as lng lines) and Tunnelled CVCs (als knwn as Hickman lines). D nt use CVCs fr bld sampling (except bld cultures): use peripheral r arterial access instead. D nt use flashback f bld t assess patency f CVC except immediately fllwing insertin Flushing 0.5-1ml 0.9% / 0.45% sdium chlride between incmpatible drugs / infusins (if sdium chlride 0.9% / 0.45% incmpatible use suitable alternative). After bld sampling flush catheter straight away with 1-2ml 0.9% / 0.45% sdium chlride. Exit Site Care Sutures (if any): Leave in situ as lng as the catheter is needed. Dressings: Leave dressings undisturbed in rder t avid trauma t the baby s skin. Cleaning: If any cleaning is deemed necessary, use nly sterile gauze and sterile 0.9% sdium chlride using gentle utward "single-swipe" mtin t avid transferring bacteria t the exit site. Redress exit site. Remval Wh can remve nenatal CVCs? Tunnelled CVCs (ie Hickman lines): Remved by Medical Staff. PICCs: Must nly be remved by cmpetent Medical Staff. Prcedure: Check the baby s cagulatin status. If there is an increased risk f bleeding discuss with medical team befre prceeding. Be aware that the risk f air emblism increases if the baby is dehydrated r has a cugh. Arrange baby s the PICC exit site belw the level f the heart (this will help prevent air emblism) Remve the dressing & any stitches. Pull PICC ut slwly and gently an inch r tw at a time. As each inch ges by change the psitin f yur hand s that yur fingers are clse t the exit site. This will reduce the likelihd f the catheter breaking. If yu meet resistance, STOP. Resistance may be due t venspasm. If this happens, wait 5 minutes befre resuming. Once PICC is ut, apply gentle pressure t exit site with sterile gauze until bleeding stps. Check the length f the internal prtin f the catheter and cmpare t the recrded length. If yu suspect there is a prtin f the catheter left in the baby, infrm senir medical staff immediately. Send tip f line t Micrbilgy: use sterile scissrs t cut ff the tip f the catheter and withut cntaminating it drp it int a dry sterile specimen pt. Apply gauze dressing. 26

27 Appendix V: Management f Cmplicatins Page 25 Page 25 Page 25 Page 26 Page 26 Page 26 Page 27 Page 27 Page 27 Page 27 Page 28 Page 28 Page 28 Pyrexia Inflammatin / tenderness at exit site N flashback f bld (but line flushes well) Catheter sluggish / intermittent free flw f fluids Catheter cmpletely blcked Pain / visible swelling / leakage when catheter used Leakage frm external prtin f catheter Cuff prtrudes frm exit site (tunnelled catheters) Increase in external length f a PICC Swelling f shulder / neck / arm r face Pain / warmth / hardness / redness alng vein path (PICCs) Cardipulmnary symptms Palpitatins / Abnrmal ECG 27

28 Pyrexia plus r minus: rigr after flushing, sre thrat, generally feeling unwell, hyptensin, tachycardia, shck, exit site / tunnel infectin Pssible cause: Catheter Related Bld Stream Infectin Management: Refer t IV Therapy Nurse Specialist / medical staff. May be treatable withut catheter remval depending n patient s clinical status and clnising rganism. Take bld cultures frm each lumen and peripherally. Fllw BNHFT Standards in phlebtmy prcedures when taking bld cultures. (Nenates and Paediatrics: nly take peripheral bld cultures if requested by Micrbilgy/Medical Team). TPR & BP. Frequency will depend n patient s clinical status. If there are signs f exit site infectin see belw. Inflammatin and tenderness at the exit site / skin tunnel / prt pcket plus r minus exudate Pssible cause: Infectin Management: Take a swab Refer t IV Therapy Nurse Specialist / medical staff. May reslve with antibitics, especially in tunnelled catheters and PICCs. (But NB infectins invlving the skin tunnel abve the cuff r a prt pcket are very difficult t treat D nt access in Paediatrics.) In Nenates, CVC will prbably need t be remved. Increase frequency f dressing change & cleaning depending n amunt f exudate. 4 hurly TPR & BP if patient in hspital. N flashback f bld at every use but catheter flushes well withut pain. (Nt Nenates) Pssible causes: Cltted bld in catheter Fibrin sheath Malpsitined catheter Build up f lipids (Parenteral Nutritin) Drug Precipitatin Management: Try asking patient t take deep breath and try different psitins. Flush briskly using 20ml sdium chlride. In a recently inserted line, check the psitin f the line n X-ray t ensure the end is nt against a heart valve r has nt mved. If psitin satisfactry, the prblem may be due t a very small clt at the end f the line acting as a ball valve. If this fails t restre flashback use a thrmblytic eg Urkinase 5000 units in 2ml per lumen (see Using Thrmblytics page 29) except Paediatrics, Nenates & Dialysis patients: fllw lcal guidelines. If yu have n time t wait fr thrmblytic t wrk yu can still use the catheter, but nt if yu are giving vesicants / irritant drugs. First test the catheter with 250ml 0.9% sdium chlride ver 15 minutes (50 100ml in Paediatric patients). Arrange thrmblytic as sn as practicable. If thrmblytic fails, see Using Thrmblytics (page 29). 28

29 Catheter is sluggish r there is nly intermittent free flw f fluids. Pssible causes: Cltted bld in catheter Malpsitined catheter Build up f lipids (Parenteral Nutritin) Drug Precipitatin Pinch ff syndme NB: In Implantable Prts needle may be incrrectly psitined: check befre taking any ther actin. Management: Try asking patient t take deep breath and try different psitins. Flush briskly using 20ml sdium chlride. If this fails t restre functin flashback use a thrmblytic eg Urkinase 5000 units in 2ml per lumen (see Using Thrmblytics page 29) except Paediatrics, Nenates & Dialysis patients: fllw lcal guidelines. If thrmblytic fails, see Using Thrmblytics (page 29). Catheter is cmpletely blcked. Pssible causes: Cltted bld in catheter Build up f lipids (Parenteral Nutritin) Drug Precipitatin NB: In Implantable Prts needle may be incrrectly psitined: check befre taking any ther actin. Cnsider using new needle. Management: Cnsider changing bung/needle-free device Use 3-way tap technique t instil thrmblytic int catheter (see Using Thrmblytics page 29) except Paediatrics, Nenates & Dialysis patients: fllw lcal guidelines. If lipids / drug precipitatin suspected cnsult pharmacy advice fr suitable agent t disslve cclusin. Use 3-way tap technique t instil int catheter (see Using Thrmblytics page 29). Pain r visible swelling when catheter is used r fluid leaks frm exit site when catheter is flushed. Pssible causes: Malpsitin f catheter Internal catheter fracture Fibrin Sheath Management: Separatin f prt and catheter (Implantable prts) NB: In Implantable Prts needle may be incrrectly psitined: check befre taking any ther actin. Refer t IV Therapy Nurse Specialist / medical staff: a malpsitined catheter shuld usually be remved. Internal fracture cannt be repaired. If there is a fibrin sheath severe enugh t cause leakage the catheter will usually be remved. Nenates: refer t Plastic Surgen if extravasatin ccurs. Chemtherapy: fllw Guidelines fr the preventin and management f extravasatin f Cyttxic chemtherapy if extravasatin ccurs. If catheter is fractured r faulty cmplete Adverse Incident Frm and retain the catheter t send t IV Therapy Nurse Specialist fr return t manufacturer. 29

30 Leakage frm external prtin f catheter when flushed. Pssible cause: External catheter fracture/ damage t external switch mechanism. Management: Clamp catheter abve leak t prevent air entry. Paediatrics fllw Lcal Guidelines regarding prphylactic antibitics. Catheter must be repaired r remved as sn as pssible, cntact the IV Therapy Nurse Specialist / medical team. Sme catheters can be repaired if equipment & expertise available. The advisability f repair will depend n the patient s clinical status as it carries a risk f infectin. Cmplete Adverse Incident Frm and retain the catheter if remved t send t IV Therapy Nurse Specialist fr return t manufacturer. Cuff prtrudes frm exit site (tunnelled catheters) Pssible cause: Tissues within tunnel have failed t adhere t cuff & catheter has migrated ut. Management: Stp any infusins Tape catheter firmly t skin at exit site Refer t medical staff fr catheter remval. Increase in external length f a PICC Pssible cause: PICC has migrated ut Management: D NOT push the catheter back in Nenates: discuss actin with medical team. Other patients: If PICC has cme ut by less than 2cm, n actin needed. If PICC has cme ut by mre than 2cm, refer t specialist team wh inserted the PICC. Examinatin f the pst-insertin CXR may reveal whether r nt the tip is likely t still be in an acceptable place. Otherwise a CXR will need t be carried ut t check tip psitin. If PICC has cme ut by mre than 10cm the PICC shuld be secured and nt used and the IV Therapy Nurse Specialist cntacted t replace it ver a guidewire at earliest pprtunity. Swelling f shulder, neck, arm r face, with r withut pain, inflammatin, distensin f neck veins/peripheral vessels Pssible cause: Thrmbsis. Surgical (subcutaneus) Emphysema. Management: Refer t IV Therapy Nurse Specialist / medical staff fr investigatin f suspected thrmbsis r surgical emphysema. It may r may nt be pssible t treat thrmbsis withut catheter remval. Thrmbsis and infectin ften ccur tgether s bld cultures may be necessary. 30

31 Patient with PICC develps pain, warmth, hardness and redness cnfined t path f vein. Pssible cause: Mechanical (r Infective) Phlebitis Thrmbsis Management: Refer t IV Therapy Nurse Specialist r medical staff fr investigatin f suspected thrmbsis (and/r infectin). It may be pssible t avid catheter remval. In meantime, it may be wrth trying heat packs, gentle arms exercises, NSAIDs (i.e. ibuprfen, diclfenac) and elevatin f the arm. These smetimes reslve symptms within 24 hrs. Fr a heat pack use 250ml bag f 0.9% sdium chlride that has been remved frm uter packaging and heated fr shrt (15 secnd) bursts (60 secnds maximum) in a micrwave until warm but nt t ht t place n tender skin test n wn frearm. Get patient t hld ver affected area until bag cled. Repeat TDS using a new unpened bag each time t prevent risk f infectin. Cardipulmnary symptms including any f the fllwing: respiratry distress / failure apnea, reduced 2 saturatin levels, tachycardia, bradycardia, hyptensin, pallr, cyansis, anxiety, chest pain, lss f cnsciusness Pssible causes: Pneumthrax Air r catheter emblism Pulmnary emblism Cardiac tampnade / pericardial effusin Management: Call fr medical assistance / Outreach / resuscitatin team Administer O2 Mnitr vital signs Palpitatins / Abnrmal ECG immediately pst line placement Pssible causes: Cardiac arrhythmias related t CVC tip placement Management: Call fr urgent medical assessment Mnitr vital signs PICCs: Pulling PICC ut by 2cm may reslve the prblem immediately. 31

32 Appendix VI: Using Thrmblytics Page 30 Page 30 Page 30 Page 30 Page 31 What is a thrmblytic? When shuld yu use a thrmblytic? What if the thrmblytic fails t restre functin? Hw t use a thrmblytic Using a Thrmblytic in a Cmpletely Blcked Catheter 32

33 What is a thrmblytic? A thrmblytic is a drug capable f breaking up a thrmbus. Urkinase is the mst cmmn thrmblytic used fr unblcking CVCs is: 5000iu in 2ml per lumen. A thrmblytic must always be prescribed. Heparin and Hepsal are NOT thrmblytics: they are capable nly f inhibiting thrmbus frmatin. When shuld yu use a thrmblytic? Outside f specialist areas r if yu have nt used a thrmblytic befre please cntact the IV Therapy Nurse Specialist Bleep 2370 Use a thrmblytic t imprve patency in the fllwing situatins: flashback f bld is absent free-flw f fluids is sluggish r intermittent resistance is felt when flushing the catheter/lumen is cmpletely blcked What if the thrmblytic fails t restre functin? If failure t bleed back is the ONLY prblem then yu can use the catheter but a Chest X- Ray shuld be carried ut as sn as practicable t check the psitin f the line. Hwever, if yu are giving irritant / vesicant medicatin, yu shuld test the catheter first by infusing 250ml 0.9%sdium chlride ver 15 minutes (50 100ml in Paediatrics) and check psitin n Chest x-ray. If the patient experiences n discmfrt during this time and there are n ther cmplicatins, yu can prceed. If free-flw f fluids is still sluggish r intermittent r if resistance is still felt when flushing despite use f a thrmblytic a Chest X-Ray +/- cntrast shuld be carried ut t check fr malpsitin r kinking f the catheter. Line may need replacing. Hw t use a thrmblytic a) Arrange prescriptin. (Cautin if patient s cltting is severely deranged r if high dses f an anticagulant are being given cncurrently.) b) Draw up the thrmblytic as per manufacturer s instructin eg fr Urkinase: recnstitute 25,000 unit vial with 2ml water fr injectin and dilute further t 10 ml. Use 2ml (5000 units) per lumen. c) Instil the thrmblytic int the catheter and wait 1-2 hurs. But nte that if the lumen is cmpletely blcked d NOT frce the thrmblytic int the catheter: see Using a Thrmblytic in a Cmpletely Blcked Catheter (page 31). d) Assess the catheter again. NB if the thrmblytic cannt be withdrawn dn t wrry: this very small dse can be flushed int the patient withut danger unless the patient has severely deranged cltting r is n high dses f an anticagulant. e) If full functin has nt returned instil the thrmblytic again and leave in fr lnger several hurs r vernight if pssible. f) If the prcedure fails t restre functin cnsider whether lipids / drug precipitatin culd be causing a blckage. If nt, refer t medical staff: Chest X-Ray may reveal malpsitined r catheter. 33

34 Using a Thrmblytic in a Cmpletely Blcked Catheter. (a) Attach 3-way-tap & syringes Diagram 1. see right. (available frm ITU) Three-way Tap Technique (b) Open clamp (if there is ne). (c) Open stpcck t the empty syringe and the blcked catheter. (d) Pull back n the plunger f the empty syringe t create a vacuum in the catheter. Yu will need t pull quite frcibly. (e) Maintain suctin with ne hand and with the ther hand turn stpcck s it is clsed t the empty syringe and pen t the syringe cntaining thrmblytic, which will be sucked int the catheter. Dn t wrry if it seems that very little thrmblytic is sucked in: even a tiny vlume will reach several cm int the catheter. (f) Leave fr 1-2 hurs. DO NOT CLAMP CATHETER as this will prevent the thrmblytic frm penetrating int the line. (g) After this time, attempt withdrawal f bld. If this is nt pssible, attempt t flush the catheter using 0.9% Sdium chlride in a 10ml syringe. D nt use excessive frce. (h) This prcedure ften needs t be repeated several times befre it wrks: smetimes leaving the thrmblytic in vernight seems t help1. Dn t wrry abut verdsing the patient: if the catheter is blcked they wn t actually have received any f the drug. (i) If the prcedure fails despite repeated attempts cnsult IV Therapy Nurse Specialist r medical team with a view t remving the catheter. 34