Curraheen, Co. Cork. Guidelines on the Management and Care of Central Venous Access Devices

Transcription

1 Curraheen, Co. Cork. Guidelines on the Management and Care of Central Venous Access Devices Date re-approved: 27 th Jan Version No: 2 Revision Due: 2018 Index code: CLIN028 Disclaimer: The information contained within this policy is accurate and up-to-date at date of approval. Page 1 of 38

2 TITLE: Policy on the Management and Care of Central Venous Access Devices Reviewed by: Ⅱ Ⅱ 7 th Jan th Jan th Jan Page 2 of 38

3 CONTENTS: PAGE NO. Page 3 of 38

4 1.0 Aim of Guidelines 2.0 Scope of Guidelines 3.0 Definition of Terms Page 4 of 38

5 ⅱ 4.0 Responsibilities 5.0 Procedure Page 5 of 38

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7 ⅱ Page 7 of 38

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13 No Curios green disinfection cap insitu Curios green disinfection cap insitu Page 13 of 38

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16 Figure 1: Procedure for Blood Sampling via CVAD Page 16 of 38

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19 ⅱ Page 19 of 38

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21 Flow Chart 4.0 Algorithm for Persistent Withdrawal Occlusion Page 21 of 38

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26 Flow Chart 2.0 Procedure for Accessing an Implanted Port. Explain and discuss the procedure with the patient, family/carer. Reassure patient at all times. Assess port initially with washed hands and clean gloves before set up. Apply Ametop (local anaesthetic), if required by patient on the skin over the Implanted port site, secure with tegaderm dressing, minutes before the procedure. Using ANTT, assemble and prepare all equipment on a trolley, creating a sterile field with the dressing pack which equipment is opened onto. Perform hand hygiene Open remaining equipment ensuring no contamination of the sterile field. Wash hands thoroughly as per infection control policy. Put on sterile gloves. Place sterile towel from dressing pack as near as possible to the implantable port site. Using the non-dominant hand, anchor the implanted port using the thumb and index finger, identify the position of the implanted port septum via palpation of the chest wall. (see Appendix 1) Ensure patient comfort Disinfect the skin over the port site with alcohol 70% chlorhexidine 2% wipe for 1 minute and allow to air dry for 30 to 60 seconds. Change sterile gloves. Palpate and stabilise the port for central access with the thumb and index finger of the nondominant hand. Remove the needle guard from the Surecan safety ⅱneedle. Prime the Surecan safety ⅱneedle with sodium chloride 0.9% for injection and close clamp. Remove syringe and attach Microclave connector to end of the gripper extension. Hold the gripper needle between the thumb and index finger (like a dart) and insert through the skin at a 90 angle. Push the needle into the port until it hits the bottom of the port chamber. If the gripper needle and extension set are to remain insitu, secure with an occlusive dressing. The procedure for accessing the device is the same as that for accessing other CVAD devices. If required the needle may be left in situ for 7 days. Regular assessment of the site of the port when accessing same is essential. Check for signs of erythema, swelling or discomfort Assess correct position of gripper needle by attaching a prefilled 10mL sodium chloride 0.9% XS posiflush syringe to the Microclave connector and attempt blood return. If blood return achieved, needle is in correct position. Flush line with 10mls sodium chloride 0.9%. Administer IV medication or commence infusion fluids as prescribed Flush line following use as per table 1.0. Place a green Curios disinfection cap on the Microclave If the implantable port is accessed for flushing purposes only, remove the gripper needle as described in flowchart 3.0 Page 26 of 38

27 Flow chart 3.0 Removal of Surecan Safety ⅱNeedle Explain and discuss the procedure with the patient, family/carer Using ANTT, ensure the Surecan safety ⅱhas been flushed with sodium chloride 0.9% and has had 2-3ml of Heparin Sodium 10units/ml inserted. Wash hands as per infection control policy. Assemble and prepare all equipment on a trolley, creating a sterile field with the dressing pack upon which equipment is opened onto. Ensure patient comfort. Remove the dressing that secures the gripper needle. Apply clean gloves. Wash hands again as per infection control policy. Ensure the clamp is closed on the Surecan safety ⅱ Grasp the wings of the gripper needle with the dominant hand, whilst stabilising the port with the other hand. Using a slow and controlled manner, pull the needle away from the patients chest until completely free from the skin. Apply pressure over the site with sterile gauze for 30 seconds if site is bleeding. Dispose of the needle in the appropriate sharps container. Place a sterile dressing over the needle site when bleeding has stopped. Discard equipment appropriately. Document procedure in patients nursing/ medical notes & CVAD monitoring chart. Page 27 of 38

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30 Appendix 1 Page 30 of 38

31 IV site appears healthy ONE of the following is evident: Slight pain near IV site OR Slight redness near IV site 0 1 No signs of phlebitis Possibly first signs of phlebitis OBSERVE CANNULA TWO of the following are evident: Pain at IV site Erythema Swelling 2 Early stage of phlebitis RESITE CANNULA (CVAD refer to medical team immediately) ALL of the following signs are evident: Pain along path of cannula Erythema Induration 3 Medium stage of phlebitis RESITE CANNULA (CVAD refer to medical team immediately) CONSIDER TREATMENT ALL of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord 4 Advanced stage of phlebitis or the start of thrombophlebitis RESITE CANNULA CONSIDER TREATMENT (CVAD refer to medical team immediately) ALL of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pyrexia 5 Advanced stage of thrombophlebitis INITIATE TREATMENT RESITE CANNULA (CVAD refer to medical team immediately) Page 31 of 38

32 Appendix 2 Monthly Implanted Port Heparin sodium 10units/ ml Flushing Record When not in use the line should be flushed four weekly with Heparin sodium 10units/ ml (If implanted ports are in use a CVAD monitoring chart should be used to record flushing) Heparin sodium 10units/ ml must be prescribed on the patients drug prescription chart Date Blood Return present Saline Flush Heparin sodium 10units/ ml Date of next flush Flushed By Yes No 10 ml Yes 5 ml Yes Yes No 10 ml Yes 5 ml Yes Yes No 10 ml Yes 5 ml Yes Yes No 10 ml Yes 5 ml Yes Yes No 10 ml Yes 5 ml Yes Comment For Port-a-cath use ONLY Page 32 of 38

33 Appendix 3 Site Cautions Dressing & securing the line Bathing Peripherally Inserted Central Catheter (PICC) 6 weeks- 6 months Essentials of Line Care Peripherally inserted central line which is inserted via the ante-cubital veins in the arm and is advanced into the central veins, with the catheter tip located in the lower third of the superior vena cava. It is always necessary to ascertain proper function of the CVAD prior to use. Always check blood return, patency, patient comfort and the CVAD site before, during and after use. Ensure the Microclave connectors are securely tightened & the clamp is closed when the line is not in use. Infection: Use an aseptic non touch technique for drug preparation & administration. Curios caps provide passive disinfection, if in-situ it is not necessary to disinfect using a clinell wipe. Scrub the hub with a clinell wipe before use if no green cap insitu. Symptoms of infection include fever; chills; tachycardia; fatigue; muscle aches; weakness; decreased blood pressure; redness, swelling or purulent drainage at site; or elevated white blood cell count. Catheter Malposition: can occur during PICC insertion or later due to changes in pressure inside the chest or from catheter migration. Confirmation of proper tip placement is required before using the device as a malpositioned catheter can cause serious complications. Document exterior length of catheter post insertion on the CVAD monitoring chart. Thrombus Formation: Any catheter inserted into the vascular system increases the risk of thrombus formation, either in the vessel or in the catheter. Symptoms include swelling in the arm, distension of the veins of the arm and neck on the side in which the PICC is located. The IV solution may not infuse and the patient may have pain in the neck, scapula, arm or ear. Air Embolism: Air bubbles may enter the blood vessel during insertion of a PICC. Ensure all lines are primed correctly. Symptoms of embolism: decreased blood pressure; lightheadedness; confusion; increased heart rate; anxiety; chest pain; or shortness of breath. The IV 300 dressing is changed weekly. The Statlock securement device & Microclave connectors are also changed weekly. Where patients are confused/ agitated use a tubi grip for extra security. Advise the patient not to pull on the line Bathing: patient should not submerge exit site in bathwater Showering: patient may shower if insertion site is completely covered with an occlusive dressing. Maintaining Patency Bp cuff or tourniquet should never be applied over or above the PICC insertion site but may be placed distal to the catheters location. Occlusion Prevention: Use a syringe of 10ml or greater to flush to avoid excessive pressure & possible rupture of the line Regular flushing of the PICC is required to prevent or delay catheter occlusion related to fibrin formation or drug precipitate. Flush through the Microclave with 10mLs pre filled sodium chloride 0.9% syringes using turbulent flushing technique. Clamp on the last 0.5ml of saline flush to maintain positive pressure. If flushing is difficult, this indicates that the PICC is becoming blocked. If it becomes fully blocked, it may not be usable. Report this difficulty in flushing immediately so it can be declotted to regain full functional use. (see CVAD policy) Heparin Flush: Caution: Identify those at risk of H.I.T. Lock with 2-3ml heparin sodium 10units/ ml post drug administration & saline flush if not in use for 12hours or more. Treat each lumen as a separate line & flush accordingly Flush weekly when not in use with 10ml sodium chloride 0.9% followed by 2-3mls heparin sodium 10units/ml Page 33 of 38 A CVAD Monitoring Chart Must be Commenced

34 Totally Implantable Central Venous Access Ports (Port a Cath) Essentials of Care Site Long Term Use (up to 5 years) Implantable vascular access ports have become the device of choice for patients who require long-term or even permanent access. The implanted port consists of a portal body, a septum, a reservoir, and a catheter. Ideally, the port should not be accessed for several days post insertion to allow oedema and tenderness to resolve. Cautions It is always necessary to ascertain proper function of the CVAD prior to use. Always check blood return, patency, patient comfort and the CVAD site before, during and after use. Ensure the Microclave connectors are securely tightened & the clamp is closed when the post is accessed & the line is not in use. Surecan safety- Non-coring needles that have inbuilt safety devices are used to prevent rebound needlestick injury when de-accessing a port. The access needle and extension set must be primed with 0.9% normal saline Infection: Use an aseptic non touch technique (ANTT) for all manipulations. Curios caps provide passive disinfection, if in-situ it is not necessary to disinfect using a clinell wipe. Scrub the hub with a clinell wipe before use if no green disinfection cap is in-situ. The insertion site should be examined daily (or at each dressing change if gauze is used) for erythema, drainage, tenderness, pain, redness, swelling, and suture integrity (whilst in situ). The patient should also be examined for fever or other signs of sepsis e.g. tachycardia, tachypnoea, hypotension. Patients should be encouraged (where possible) to report any changes in their catheter site or any new discomfort. Catheter related thrombosis Ideally the tip of the catheter should be either in the lower third of the superior vena cava, the IVC or the right atrium. Catheter tips placed outside these areas are at increased risk of catheter related vein thrombosis. Signs & symptoms: Oedema of face, hands, arms, fingers, shoulders, pain, aching, tenderness at thrombosis sites, numbness, tinglingfingers, hands, arms and thrombosis sites, skin temperature changes thrombosis sites, especially hands and arm, severe pain- at thrombosis sites and/or internal catheter tract, chest. Dressing Following insertion of an implanted port the dressing over port site should be changed after 48 hours. When the wound has healed this site may be left exposed. Non Accessed Port No dressing or exit site care required (except immediately following insertion of the port when wound should be kept covered until stitches removed and wound healed). Accessed Port: Weekly dressing and needle changes using ANTT Bathing Non accessed ports Bathing, showering - Patient may bath & shower freely once wound has healed. Accessed Ports/ lines Bathing, showering : if the site is accessed patient should not submerge needle insertion site in bathwater, patient may shower if needle site is completely covered with an occlusive dressing, take care not to dislodge needle. Maintaining Patency Occlusion Prevention: Use a syringe of 10ml or greater to flush to avoid excessive pressure & possible rupture of the line Regular flushing of the port is required to prevent or delay catheter occlusion related to fibrin formation or drug precipitate. Flush through the Microclave with 10mls pre filled sodium chloride 0.9% syringes using turbulent flushing technique. Clamp on the last 0.5ml of saline flush to maintain positive pressure. If flushing is difficult, this indicates that the port is becoming blocked. If it becomes fully blocked, it may not be usable. Report this difficulty in flushing immediately so it can be declotted to regain full functional use. (see CVAD policy) Heparin Flush: Caution: Identify those at risk of H.I.T. Lock with 2-3ml heparin sodium 10units/ ml post drug administration & saline flush if not in use for 12hours or more. Access & flush monthly when not in use with 10ml sodium chloride 0.9% followed by 5mls heparin sodium 10units/ml Page 34 of 38 Marymount University Hospital and Hospice./Approval A CVAD Monitoring Date: 27 th Jan Chart / Must Code No: be CLIN028 Commenced

35 Appendix 5 Heparin-Induced Thrombocytopenia (HIT) Page 35 of 38

36 Appendix 6 Page 36 of 38

37 Appendix 7 Central Venous Access Device Audit Tool Page 37 of 38

38 Revision No: 2 Date: 27 th Jan 2015 Date: 7 th Jan 2015 Date: 19 th Jan 2015 Date: 27 th Jan 2015 ote this completed attendance sheet is to be filed with Policy Folder) Page 38 of 38