ASSESSMENT AND CARE Monitor for the following and remove catheter if there is: redness, pain, swelling, firm tissue, exudates, bleeding or leakage.

Transcription

1 POLICY An Indwelling subcutaneous catheter may be inserted when an infant requires regular subcutaneous injections (At least one subcutaneous injection per day). SUPPORTIVE DATA In the NICU medications that may be delivered by a subcutaneous catheter include: low molecular weight heparin (enoxiparin), standard heparin, insulin, morphine (palliative care) and erythropoietin. Hematomas have been associated with enoxiparin use. PATIENT CRITERIA Use of an indwelling subcutaneous catheter is dependant on the amount of subcutaneous tissue present in the infant. Generally infant should be > 2 Kg. Sufficient subcutaneous tissue must be present to support the catheter especially when administering enoxiparin as hematomas are a common problem if catheter inadvertently placed in muscle. Therefore infants must be > 5 Kg when using enoxiparin. INSERTION GUIDELINES Preferred insertion site for infants is posterior aspect of upper arm and anterior lateral aspect of upper thigh. The abdomen is not recommended for infants due to lack of subcutaneous tissue and mobility concerns. However if the abdomen is used in outstanding circumstances, the catheter should be inserted horizontally. It is important that a second caregiver or parent provide positional support and comfort during the insertion procedure. Insert catheter deep into subcutaneous tissue. In an infant it is approx. a 20 degree angle. Medications such as insulin can cause local irritation if the catheter is too superficial. Insertion technique is important. Due to fragility of catheter, a new one is used with each insertion attempt. Rotate limbs for catheter insertion to avoid tissue damage and with insulin administration, the formation of lipohypertrophies. In a small infant there may only be enough surface area for 2 sites per limb. Record date inserted on patient care plan to ensure indwelling time does not exceed 7 days. Assess site and document findings each shift. REMOVAL GUIDELINES Insert a new catheter prior to removal of old catheter to ensure rotation of sites. To remove catheter: carefully peel off the foam pad beginning at the catheter end and remove catheter. MEDICATION ADMINISTRATION A silicone membrane covers the membrane hub. To maintain integrity of the membrane only a 27 gauge catheter is inserted through this membrane. When the total volume of the dosage is< 0.07 ml. A small amount (0.01 ml) of compatible solution may be considered to flush the medication to prevent medication loss in catheter dead space. ASSESSMENT AND CARE Monitor for the following and remove catheter if there is: redness, pain, swelling, firm tissue, exudates, bleeding or leakage. Page 1 of 6

2 Redness outside the area covered by the adhesive tape is normally caused by too superficial insertion of catheter. Lipohypertrophy or fat cushion at the catheter tip may occur after several days. Replace catheter if you notice deterioration in Insulin effect. Average dwell time is 3-5days. If there are no signs of irritation or infection, catheter can remain in place for a maximum of 7 days before changing sites. If the foam pad used to secure catheter is loose, placing a new pad could easily kink the catheter preventing flow. The literature suggests using a Tegaderm to provide additional adhesion or inserting a new catheter. Individualize to each infant, considering skin integrity, gestational age and weight of infant. If catheter pulls out from skin, no drug will be administered subcutaneously when injecting. Replace catheter. The infant may be bathed. The foam pad works best if bathing is avoided for 2 hours following insertion. Catheter is made from soft plastic which flexes with the body, even with very quick sudden movements. PROCEDURE Procedure Notes INSERTION OF CATHETER 1. Assemble equipment: Insuflon catheter Dexidin 2 antiseptic solution (2% chlorhexidin gluconate with 4% isopropyl alcohol solution) Plastic medication cup to hold Dexidin 2 solution Q-tips 2X2 gauze 2. Wash hands 3. Have second caregiver or parent provide positional support and comfort infant. 4. Clean skin at site with Dexidin 2 solution using Q-tip. Prepare site according to NICU P&P on skin cleaning protocol: Clean/prepare insertion site with Dexidin 2 solution for 30 seconds. Allow to air dry for 60 seconds. For infants < 1000 grams: Remove residual dexidin solution on skin using sterile normal saline or sterile water after securing the catheter, if feasible. 5. Hold catheter hub and remove protective cap. Place the cap in the rear of the grip. Page 2 of 6

3 Procedure 6. During insertion, hold catheter hub between thumb and index finger. Notes 7. Pinch skin at site of insertion. Insert catheter as far as possible at a degree angle in one smooth quick movement with bevel up. If insertion too slow there is a risk of catheter peeling back from needle. 8. Hold catheter hub while slowly removing the steel needle. Do not withdraw catheter during placement. 9. Secure catheter: apply foam pad, ensuring insertion site covered but visible and hub open to air. MEDICATION ADMINISTRATION 1. Assemble equipment: 27 Gauge ½ inch needle 1 cc syringe Chlorhexidine swabs (2% chlorhexidine gluconate with 70% isopropyl alcohol swabs) 2. Wash hands 3. Clean membrane of catheter with chlorhexidine swabs for 30 seconds and allow to air dry for Page 3 of 6

4 Procedure 60 seconds. 4. Insert 27 gauge needle into silicone membrane covering end of hub, rotating the syringe gently as it is advanced. 5. Insert the ½ inch needle fully into the hub before injecting medication. 6. Instill medication SLOWLY then remove needle. 7. Flush catheter with 0.01 mls of normal saline to clear the dead space if require/ordered. Notes Any needle > 27 gauge may be difficult to inset and damage membrane Do not use excessive force to insert needle. Rotating needle helps it to move away from the inner wall of the hub. A needle inserted beyond catheter hub could damage the Teflon catheter. Dead space volume of catheter is ml Injecting is easier if membrane is angled out a little by pressing down gently where catheter enters skin. Slow injection helps to reduce irritation and pain caused by medication. If giving enoxaparin or standard heparin, apply firm pressure to the insuflon catheter site (where the end of the catheter would be) for 2 - minutes after injecting the drug. This will minimize bleeding and bruising at the site. Do not massage site. DOCUMENTATION On Nurses notes: Hourly shift assessment, insertion, removal. Record the site of administration. On Kardex: Note insertion date to ensure catheter dwell time does not exceed 7 days. On MAR: When medication administered Page 4 of 6

5 SUBCUTANEOUS CATHETER SITES SITE ROTATION DATE SITE INITIALS REFERENCES Insuflon Catheter Company Information Package Page 5 of 6

6 Lamacraft, G., Cooper, M. & Cavalleto, B. (1997). Subcutanious cannulae for morphine boluses in children: Assessment of a technique. Journal of Pain and Symptom Management 13(1) Streif, W., Goebel, G., Chan, A.K.C. & Massicotte, M.P. (2003) Use of low molecular mass heparing (Enoxaparing) in newborn infants: A prospective cohort study of 62 patients. Archives of Disease in Childhood Fetal Neonatal, 88: Telephone Communication: Hemostasis-Thrombosis Nurse Coordinator, Toronto s Sick Children s Toronto s Hospital for Sick Children, Policy and Procedure Manual Page 6 of 6