SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: TUNNELED CENTRAL VENOUS CATHETER CARE AND MAINTENANCE: HICKMAN, GROSHONG, POWERLINE, POWERHICKMAN DATE: REVIEWED: PAGES: 04/83 2/18 1 of 18 PS1094 ISSUED FOR: Nursing RESPONSIBILITY: RN, LPN II Table of Contents Topic Page Purpose 2 Knowledge Base 2 Patient Education 4 Procedures Post-Operative Care 4 Dressings Changes and Site Care 6 Catheter Exit Site Care 8 Entrance Incision Site Care 9 Catheter Flushes 10 Needleless Connector Change 11 Administration Set Change 12 Catheter Removal 13 Potential Complications 13 Documentation 14-15 References 16 Appendix A Comparing Tunneled Catheters 17 Appendix B Maintenance Summary 17 Appendix C Administration Set Changes 18 Related Procedures Title Management of Vascular Access Complications Summarized Protocol for Management of IV Therapy Parenteral Nutrition Peripheral IV Care and Maintenance Implanted Vascular Access ( Port)+ Care and Maintenance Central Line Catheter Care and Maintenance PICC and Mid Line Care and Maintenance Chemotherapy Extravasation Procedure Number cen05 inv01 inv11 inv02 vad01 cen01 pic00 onc10

PAGE: 2 of 18 PURPOSE: KNOWLEDGE BASE: To provide guidelines for the nursing care of tunneled central venous catheters. For tunneled dialysis catheters, see nursing procedure dhd21, Hemodialysis Temporary Catheter (Insertion, Dressing Change, Removal, Medication and Blood Draws, Discontinuation of Meds and IV Fluids). 1. Tunneled venous catheters are used for long-term access (typically greater than 6 months) to the venous circulation. The catheter is inserted into a central vein with the tip lying above or in the lower third of the superior vena cava at the cavoatrial junction... The catheter is used for total parenteral nutrition (TPN) (including up to 50% final concentration Dextrose solutions), lipids, administering drugs (e.g., chemotherapy), blood products, central venous pressure measurements, and withdrawing blood for lab specimens. 2. Features of tunneled catheters include: a. The catheter has a cuff which is positioned in a tunnel under the skin 2-3 inches from the exit site. and allows fixation of the catheter by becoming enmeshed with subcutaneous tissue several weeks after insertion. This helps prevent dislodgement and also minimizes infection. The catheter is usually well tolerated by patients. b. Single, double and triple lumen catheters are available. Internal diameter of the lumens, priming capacity, and flow rates vary depending on the size of the catheter. c. The catheter is thromboresistant if heparin coated. 3. Features of specific catheters include: a. Hickman catheter: the lumen(s) of the catheter are made of medical grade silicone. b. Groshong catheter: 1) The lumen(s) are made of soft, medical grade, alcohol compatible silicone and have rounded tip(s). 2) The Groshong catheter has a patented 3 position, pressure sensitive valve near the radiopaque tip. The valve opens outward during infusion and inward during blood aspiration. The valve closes automatically when not in use. This eliminates the need for heparinization and also eliminates the need for a clamp. c. Power tunneled catheters PowerLine and PowerHickman: 1) The catheter allows for the injection of contrast media for contrast enhanced computed tomography scans at a maximum of 5 ml/sec and 300 psi pressure limit setting. The power catheter may also be used for central venous pressure monitoring.

PAGE: 3 of 18 2) The catheter has a stabilization device imprinted with either PowerLine or PowerHickman. The word CUFF is imprinted on the lumen tubing above the device. 3) The catheter s tubing is marked in centimeters. 4) The lumen(s) are made of polyurethane. Assess patient for polyurethane allergy before insertion. Avoid using alcohol on the tubing. 5) The lumen used for contrast media injection is purple in color and imprinted with POWER INJECTABLE on the lumen s tubing. An identification tag imprinted with 5 ml/sec MAX is located on the lumen s clamp. 4. It is not necessary to obtain a physician order to use the tunneled catheter when IV therapy or labs are ordered. 5. If a patient arrives with an existing tunneled catheter, validate patency by aspirating blood and assure ease of flushing. Determine that the catheter system has not been compromised. 6. If no blood return is present or if there is difficulty flushing, do not use the device. If blood return or functionality cannot be established, a chest x-ray is indicated per physician order. Do not use the device until consultation with resource personnel has occurred. 7. Management and handling of all intravenous related equipment and catheters will be preceded by hand hygiene and all work surface areas will be cleaned with germicidal surface wipes. 8. The Vascular Access Maintenance Bundle is a group of individual evidence-based interventions that when implemented together result in better outcomes. The bundle includes hand hygiene, daily chlorhexidine (CHG) bathing, a standardized routine maintenance schedule and other interventions. 9. Assessment of the catheter site should be done once a shift and PRN. Assessment of the catheter and site includes, but is not limited to, redness, swelling, induration (.skin appearance), tenderness (pain), chlorhexidine impregnated patch (if there is a dressing), catheter and the infusion tubing. If catheter cuff is visualized outside the skin, call physician. Confirm that the dressing site is labeled with the date of the last dressing change. 10.. Blood return shall be evaluated before infusing any fluid, Lack of blood return should be investigated. Notify the PICC Team or Intervention RN for additional assessment of

device if needed. PAGE: 4 of 18 11. The chlorhexidine impregnated patch absorbs fluid that may be around the insertion site. If the patch size exceeds the size of the printed label, it is considered soaked and should be changed. 12. Informed consent for insertion or removal is to be obtained by the physician. The physician will provide information on the procedure, risks, benefits and alternatives. After informed consent is given, the nurse MUST obtain a signed consent. 13. Any questions or concerns should be directed to the Oncology Unit,Sarasota Memorial Infusion, Intervention Team, NPDSs, or PICC Team for clarification. CAUTION NOTE: Do not subject the tunneled catheter to excessive pressure. It is possible to apply a high pressure with a small syringe that may cause a ballooning or fracture of the catheter. Use only a 10 ml syringe or larger when flushing a tunneled catheter. PATIENT EDUCATION: 1. Nursing personnel will begin patient/support person education as soon as the decision is made to insert the catheter. The bedside nurse and Interventional Radiology will instruct the patient/support person on signs and symptoms of infection, phlebitis, and other complications. Instruction will also include all aspects of care and discharge teaching when appropriate. 2. The patient will be instructed to carry an identification card provided by the insertion procedural area that gives information about the date of insertion, size of the catheter, name of the surgeon/physician, name of the facility where the device was implanted, and the patient s name. This card should be carried by the patient at all times. 3. A home care manual and complete patient instructions should be provided prior to discharge on all patients. Home care instructions should include connector changes, dressing changes, and routine irrigations. PROCEDURE: Equipment: POST-OPERATIVE CARE Insertion is performed in Surgery or Interventional Radiology under a local anesthetic. NOTE: DO NOT USE ACETONE ON THE CATHETER 1. Needleless connector, one per lumen 2. 10 ml syringe of normal saline flush solution for needleless

PAGE: 5 of 18 connector priming, 1 syringe per lumen 3. For all catheters (except Groshong catheters): 10 ml syringe of 5 ml heparin flush solution (10 units/ml), 1 syringe per lumen 4. Alcohol wipes Post-Operative Care Steps: 1. Vital signs will be taken as ordered. 2. Upon return from surgery or radiology, assess the dressings every 15 minutes x 4, then every hour x 4, or as ordered by the physician. It is not unusual to see a small amount of bleeding at the catheter exit site. 3. Before using the catheter, review the patient s chart for documentation of proper catheter placement. Placement may be documented in the Operative Note, Surgery Intraop note, Surgery PACU note, or imaging studies. If documentation of placement of catheter is unavailable, notify the physician and clarify the need for a chest x-ray to confirm proper position of the catheter. 4. If no needleless connector is in place, clamp the catheter (except Groshong) and discard the male Luer lock cap. Scrub the hub of the catheter with an alcohol wipe for 15 seconds. Allow to air dry. Prime the needleless connector with normal saline flush solution and attach to the catheter. Attach a Curos cap if not connected to IV tubing. 5. All catheters, except Groshong, should already have been irrigated with heparin solution. Review the Operative Note, Surgery Intraop note, or Surgery PACU documentation for heparinization of the catheter. If the catheter (except Groshong) has not been irrigated with heparin solution, flush with 5 ml of heparin flush solution (10 units/ml). 6. If the catheter exit incision site becomes infected or if the patient s ANC (absolute neutrophil count) drops below 500, sterile technique and sterile dressings will be utilized, regardless of the number of postoperative days. 7. Postoperatively, it will be sufficient for the physician to enter an order in SCM for tunneled catheter care per protocol unless more specific post-op care is ordered by the physician. 8. Bulky pressure dressings will be applied to the entrance incision and catheter exit sites post insertion. Unless otherwise ordered, dressing changes will be started the first post-operative day, using sterile technique.

PAGE: 6 of 18 9. Medipore dressings will be used post-operatively and will be changed every other day until sutures are removed. 10. After the sutures are removed, a band-aid will be applied daily after bathing or showering. 11. The stabilization device of the power tunneled catheter should be maintained using a catheter securing dressing if the device is not sutured. 12. Patients discharged are taught clean technique for home care. PROCEDURE: DRESSING CHANGES AND SITE CARE NOTE: No physician order is needed for routine, nonpostoperative management. Tunneled catheter care per protocol is managed by the nurse and includes: 1. Dressing changes 2. Irrigations/flushes 3. Clamping 4. Blood drawing for the lab from catheter only (Unless physician specifies, or patient condition warrants, fingerstick or venipuncture) 5. Procedure for non-functioning catheter 1. Sterile technique will be required for dressing changes performed on hospitalized patients for 10 to 14 days post insertion or until the sutures are removed. 2. If the patient s skin does not tolerate a Medipore dressing, sterile 2 x 2 gauze pads and paper tape may be used. The dressing will be changed every other day or if wet, contaminated, soiled or non-occlusive.. 3. Once the cut-down incision and catheter exit sites are well healed, patients can usually take a tub bath or shower, with physician approval. Little data is available on the risk of infection associated with swimming with an external catheter. If physician permits swimming, it is recommended that exit site and catheter be covered with a water-proof covering. 4. If the patient is severely immunosuppressed (ANC < 500), the catheter exit site dressing observations should be documented daily and the dressing changed every other day until the site is healed, ANC recovers, or incision infection is cleared. 5. When the site is well healed around the catheter and the sutures are removed, a band-aid may be applied and the patient may shower. Instruct the patient to wash the catheter

PAGE: 7 of 18 site first and then the rest of body. Change the band-aid daily until the incision is fully healed. 6. Once the entrance incision site is healed and the sutures have been removed by the physician, no further incision care will be required. 7. Sutures will usually be removed seven to fourteen (7-14) days post insertion. 8. Nursing may need to contact the admitting physician and/or surgeon for removal of sutures. Equipment: Dressing Change Steps: 1. Sterile gloves 2. Clean gloves 3. Masks 4. For patients NOT allergic to chlorhexidine: a. Three (3) chlorhexidine swabsticks (May require additional swabsticks to clean sites with excess drainage.) b. Chlorhexidine impregnated patch: one 1-inch disk 5. For patients with an allergy to chlorhexidine: a. Alcohol swabsticks 1 packet (3 swabs) per incision site b. Betadine swabsticks 1 packet (3 swabs) per incision site c. Alcohol wipes 6. For post-operative dressing or established catheter with drainage Medipore dressing (4 x 4 inches) 7. For established catheter without drainage Tegaderm dressing (4 x 4.75 inches) 8. Sterile 2 x 2 gauze pads (4 packs) 9. Paper tape 10. Sterile field 1. Check for possible allergy to chlorhexidine. 2. Clean work area with germicidal surface wipes. 3. Perform hand hygiene. 4. Apply mask to patient. Instruct all other persons within 3 feet of the patient to don masks. 5. Don mask and clean gloves. 6. Remove old dressing being careful not to pull on catheter. 7. Inspect the insertion and incision sites for signs of infection, bleeding, or skin irritation. 8. Remove gloves. Perform hand hygiene.

PAGE: 8 of 18 9. Establish a sterile field, opening all sterile materials. 10. Open chlorhexidine swabsticks (or alcohol and betadine swabsticks if chlorhexidine allergy) and alcohol wipe packets. 11. Don sterile gloves. CATHETER EXIT SITE CARE: 1. If the patient has visible drainage around the catheter exit site, clean the area to remove the drainage. Hold the catheter up and off the patient s chest. The hand holding the catheter becomes an unsterile hand. a. For patients not allergic to chlorhexidine, cleanse the skin immediately around the catheter with a sterile chlorhexidine swabstick for approximately 30 (thirty) seconds, or per package instructions, working outward, using sterile gloved hand. Clean at least 2-3 inches around the catheter to remove drainage. Be careful not to touch non-sterile items with the sterile gloved hand. b. For patients allergic to chlorhexidine, cleanse the skin immediately around the catheter with sterile alcohol swabsticks working outward, using sterile gloved hand. Clean at least 2-3 inches around the catheter. Repeat x 2. Be careful not to touch non-sterile items with the sterile gloved hand. Avoid prolonged contact of alcohol with tubing of power catheters. 2. Clean the catheter exit site after drainage is removed. Hold the catheter up and off the patient s chest with the unsterile hand. a. For patients not allergic to chlorhexidine, cleanse an area slightly larger than the size of the dressing with a chlorhexidine swabstick for approximately 30 (thirty) seconds, or per package instructions, starting at catheter exit site and working outward in a back and forth motion. Each swabstick cleans a maximum area of 4 x 4 inches. Allow to dry for 90 seconds. b. For patients allergic to chlorhexidine, cleanse an area slightly larger than the size of the dressing with an alcohol swabstick starting at catheter exit site and working outward in a circular motion. Repeat x 2. Avoid prolonged contact of alcohol with tubing of power catheters. Allow to dry. Then cleanse the area with a betadine swabstick starting at catheter exit site and working outward in a circular motion. Repeat x 2. Allow to dry.

PAGE: 9 of 18 3. Use a chlorhexidine swabstick (or, for non-power catheters, sterile alcohol wipes if patient is allergic to chlorhexidine) to clean the catheter line from the catheter exit site upward to the distal end for approximately 30 (thirty) seconds, or per package instructions. (Repeat x 1 if using alcohol wipes.) For patients with power catheters who are allergic to chlorhexidine, use betadine swabstick to clean the catheter line. NOTE: Do not allow any solution to run down catheter to the exit site. 4. For patients not allergic to chlorhexidine, place the sterile chlorhexidine impregnated patch around the catheter exit site with the printed side facing up and visible. Place the slit slightly off from center so that the catheter does not rest over the slit when the dressing is applied. This will assure easier removal with dressing change. NOTE: Do not place sterile 2 x 2 gauze pad under the catheter if using a Tegaderm dressing. A Tegaderm dressing with gauze is considered a gauze dressing and will need to be changed every other day. 5. Cover the catheter exit site with the dressing, taking care not to cover the entrance incision site. 6. Label dressing with date, time, and initials. 7. Tape the catheter upon the patient s chest to avoid tension at the catheter exit site. ENTRANCE INCISION SITE CARE: 1. If the patient has visible drainage around the entrance incision site, clean the area to remove the drainage. a. For patients not allergic to chlorhexidine, cleanse the skin around the incision with a sterile chlorhexidine swab-stick for approximately 30 (thirty) seconds, or per package instructions, working outward. b. For patients allergic to chlorhexidine, cleanse the skin around the incision with sterile alcohol swab-sticks working outward. Repeat x 2. Allow to dry. 2. Clean the entrance incision site after drainage is removed. a. For patients not allergic to chlorhexidine, cleanse the skin around the incision site with a chlorhexidine swab-stick starting at catheter exit site and working outward in a back and forth motion for approximately 30 (thirty)

PAGE: 10 of 18 seconds, or per package instructions. Allow to dry for 90 seconds. b. For patients allergic to chlorhexidine, cleanse the skin around the incision site with an alcohol swabstick starting at catheter exit site and working outward in a circular motion. Repeat x 2. Allow to dry. Then cleanse the area with a betadine swab-stick starting at catheter exit site and working outward in a circular motion. Repeat x 2. Allow to dry. 3. Apply a 2 x 2 gauze pad and hold in place with a paper tape. 4. Label dressing with date, time, and initials. NOTE: Patients who are readmitted with tunneled catheters in place longer than 10 days may have been instructed by their physician to omit dressings to the catheter entrance and exit sites and may be wearing a band-aid. These patients may shower as ordered. If infection at the catheter exit site is noted, or the patient is severely immunosuppressed (ANC < 500), a dressing should be applied and catheter care should be performed as noted above. PROCEDURE: Equipment: CATHETER FLUSHES The Nurse IV Flush Orders for normal saline and heparin flush solutions will be entered per nursing protocol. Use only a 10 ml syringe or larger when flushing a tunneled catheter. 1. One (1) 10 ml syringe pre-filled with 10 ml normal saline for flushing: a. Between different IV medications or infusions b. With IV tubings changes c. Every day when the continuous IV infusion rate is 50 ml/hour or less d. Between 24-hour IV drips (e.g., chemotherapy) 2. Two (2) 10 ml syringes pre-filled with 10 ml normal saline for flushing: a. After drawing a blood specimen b. After blood administration 3. Three (3) 10 ml syringes pre-filled with 10 ml normal saline for flushing: a. After 24-hour infusions of TPN b. Between bags of TPN c. Upon discontinuation of TPN 4. If the catheter (except Groshong) will not be immediately used: 10 ml syringe pre-filled with 5 ml heparin flush solution (10 units/ml)

PAGE: 11 of 18 5. Alcohol wipes Flushing Steps: 1. Perform hand hygiene. 2. Vigorously scrub the end of the needleless connector with an alcohol wipe for 15 seconds. Allow to dry thoroughly. 3. Attach the flush syringe onto the connector. 4. Unclamp the catheter. 5. Gently irrigate the catheter using a turbulent (push-pause) flush technique. NEVER USE EXCESSIVE FORCE. 6. Clamp the catheter (except Groshong). 7. Remove syringe and discard in the appropriate container. 8. Repeat steps 2 through 7 for each additional flush syringe. 9. If the needleless connector does not appear clear after flushing with normal saline, flush with an additional 10 ml of normal saline. If the connector is still not clear, change the connector. PROCEDURE: Equipment: Connector Change Steps: NEEDLELESS CONNECTOR CHANGE Needleless connector(s) will be changed every Sunday and Thursday, or daily when TPN is infusing. 1. Clean gloves 2. Sterile alcohol wipes 3. Needleless connector(s) one per lumen 4. For catheter that will be immediately used: 10 ml syringe pre-filled with 10 ml normal saline (one per lumen) 5. For catheter (except Groshong) that will not be immediately used: 10 ml syringe pre-filled with 5 ml heparin flush solution (10 units/ml; one per lumen) 1. Perform hand hygiene and don gloves. 2. Clamp the catheter (except Groshong). 3. Using aseptic technique, open the sterile connector package. 4. Attach the syringe containing the normal saline or heparin flush solution onto the new connector and prime the connector. 5. Vigorously scrub the connection between the hub and the old connector for 15 seconds and allow to air dry. Remove

PAGE: 12 of 18 the old connector from the catheter hub and discard. 6. Vigorously scrub the outside of the catheter hub with a sterile alcohol wipe for 15 seconds. Allow to dry. 7. Twist the new connector clockwise onto the catheter hub. 8. Unclamp the catheter (except Groshong). 9. Flush the catheter with the remaining solution in the syringe using a turbulent (push-pause) flush technique. 10. Clamp the catheter (except Groshong). 11. Remove the syringe from the connector and discard in the appropriate container. 12. Apply Curos cap if not connected to IV tubing PROCEDURE: ADMINISTRATION SET CHANGE Administration sets and attachments will be changed every Thursday and Sunday, with new catheter device placement, and PRN for suspected or actual contamination or damage. NOTE: Individual lumens on a multi-lumen catheter device are not considered new devices. Existing administration sets can be used interchangeably on the multiple lumens. Equipment: Administration Set Change Steps: 1. Administration set 2. Extension tubing 3. Other add on devices as needed consistent with Appendix C 4. IV tubing date label 5. Alcohol wipes 6. Red caps 7. Curos caps 1. Obtain administration set, including extension tubing and add on devices as needed consistent with Attachment A. 2. Apply the appropriate IV tubing date label to tubing below the drip chamber. 3. Attach the solution bag to the tubing and purge air. 4. Stop the electronic regulator and close the clamps on the existing administration set, if relevant. 5. Disconnect tubing. 6. Vigorously scrub the needleless connector for 15 seconds

with an alcohol wipe and allow to air dry. 7. Attach the new tubing. PAGE: 13 of 18 8. Open clamps and resume IV infusion at the ordered rate. 9. Check to see that all of the connections are secure. 10. When disconnecting tubing from the needleless connector, protect the IV tubing ends by applying a red cap. 11. Apply Curos caps to all needless connectors PROCEDURE: CATHETER REMOVAL NOTE: Some patients may require anti-anxiety medications prior to removal. 1. Removal is done by the surgeon or interventional radiologist except on patient expiration. 2. On patient expiration, the catheter may be removed by the Registered Nurse (RN). a. The catheter will be left in place if an autopsy is to be performed. b. Clarify with the physician the need to culture the catheter tip upon removal and obtain order as needed. POTENTIAL COMPLICATIONS 1. Infection, clotting, rupture, and severing are the most common problems. 2. The catheter may be nonfunctioning because it has migrated, has been obstructed by a clot and/or fluid which will not flow in, or return, or has been severed, ruptured, or punctured. 3. Signs and symptoms of catheter migration or dislodgment include the following: a. Patient complains of neck pain or vague back discomfort. b. Patient reports sensation of gurgling in neck, arm/shoulder pain, chest pain, arrhythmias. c. Swelling occurs at the exit site or neck. d. Fluid leaks from the catheter site. e. Catheter appears longer. f. Cuff is visible. g. Inability to infuse fluids or withdraw blood. NOTE: If any of the above signs and symptoms are noted, discontinue use of the catheter and notify the

PAGE: 14 of 18 physician of the possibility that the catheter has become dislodged or migrated. 4. After assessing the patient and the catheter, evaluate the data and determine the possible reason for malfunction. 5. Clotting usually results from improper or inadequate flushing. If the catheter has become clotted, see nursing procedure cen05, Management of Vascular Access Complications for the de-clotting procedure. 6. If the catheter should be accidentally severed, ruptured or punctured, immediately clamp the catheter between the catheter exit site and the damaged area using atraumatic beta clamps close to the exit site. Secure the catheter to the patient s chest wall with a dressing and tape to prevent tension on the catheter and further damage. Notify the physician of catheter damage. 7. For Hickman catheter repair, there must be at least 5 cm of undamaged catheter remaining beyond the skin exit site. For catheter repair of one of the lumens of a multi-lumen catheter, there must be at least 2.5 cm of undamaged catheter remaining beyond the bifurcation or trifurcation. 8. If external repair is needed, notify the physician that repair kits are not stocked at SMHCS and that the repair kit will be ordered for overnight delivery. 9. External repair of the Hickman catheter will be done in interventional radiology. 10. External repair of the Groshong catheter will be done in Interventional radiology or Surgery. Repair cannot be performed at the bedside by a registered nurse. 11. The PowerLine and PowerHickman catheters cannot be repaired. DOCUMENTATION: 1. IV/Lines flowsheet Central line (added parameter): site location, type, insertion date, discontinuation date, site appearance, blood return, interventions, date of dressing,

PAGE: 15 of 18 connector and tubing changes. a. Site assessment shall be documented at least once per shift. b. Document as needed if the site requires more frequent assessment. c. All discontinued sites will be documented. d. If the site infiltrates, extravasates or develops other complications, review nursing procedure cen05, Management of Vascular Access Complications, and document in the Central Line Complication section once per shift until resolved or until the patient is discharged. Complete an incident report. 2. Electronic Medication Administration Record (EMAR): irrigation and/or flushes. 3. Education Record: patient/support person education including content, patient participation and response, education materials utilized and/or given to patient/support person. 4. Nursing Assessment/Reassessment flowsheet: any other pertinent information or physician communication relevant to the care of the patient s tunneled catheter. REFERENCE: 1. Bard Access Systems. (2015). Groshong C.V. catheters nursing procedure manual. Salt Lake City, UT: Author. Retrieved January 12, 2017 from http://www.bardpv.com/wpcontent/uploads/2016/02/s120765r0_groshong_nursin g-manual. 2. Bard Access Systems. (2007). Hickman, Leonard, and Broviac Catheters: Nursing Procedure Manual. Salt Lake City, UT: Author. Retrieved from http://www.bardpv.com/wpcontent/uploads/2013/10/hickmancvcifu.pdf 3. Bard Access Systems. (2006). PowerHickman* Central Venous Catheter. Polyurethene Catheter Instructions For Use. Salt Lake City, UT: Author. Retrieved from http://www.bardpv.com/wpcontent/uploads/2013/02/0712870_powerhickman_ifu.pd f 4. Bard Access Systems. (2009). PowerLine* Central Venous Catheter. Polyurethene Catheter Instructions For Use. Salt Lake City, UT: Author. Retrieved from http://www.bardpv.com/wpcontent/uploads/2013/07/0717666_powerline_ifu_web.pdf

PAGE: 16 of 18 5. Centers for Disease Control and Prevention. (2011). Guidelines for the Prevention of Intravascular Catheter Related Bloodstream Infections. Final Issue Review. 6. Infusion Nurses Society. (2016). Infusion Nursing Standards of Practice. Cambridge, MA: Author. 7. Infusion Nurses Society. (2010). Infusion Nursing: An Evidenced-based Approach (3 rd ed.) Alexander, M., Corrigan, A., Gorski, L., Hankins, J., & Perucca R. (Eds.). St. Louis, MO: Author. 8. Johnson & Johnson Ethicon, Inc. (20013). BioPatch Instructions for Use Sheet. http://hostedvl106.quosavl.com/cgiisapi/server.dll?8000?ifus?rkumar12@its.jnj.com?geto nedocpurefulltxt?gstej5h1ghqk97n9o8hvstd8ds?3 9. Oncology Nursing Society. (2017). Access device Standards of Practice for Oncology Nursing. Pittsburgh, PA: Author. REVIEWING AUTHOR (S): Barbara Poropat, BSN, RN, OCN, NPD, Oncology Deena Damsky Dell MSN, CNS, RN-BC, AOCN Rachael Pierce BSN,RN,OCN, Clinical Coordinator SMI APPROVAL: Clinical Practice Council 2/1/18 Appendix A Comparing Tunneled Catheters Groshong Hickman PowerLine PowerHickman Heparin Flush No Yes Yes Yes CT Contrast No No Yes Yes

PAGE: 17 of 18 CVP Monitoring No No Yes Yes Important Note Do not use heparin Clamp only on protective clamping sleeve Power Injectable imprinted on lumen Power Injectable imprinted on lumen Allergy --- ---- Polyurethane Polyurethane Caution Avoid acetone on catheter tubing Avoid acetone on catheter tubing Repair Interventional Radiologist/surgery Interventional Radiologist Identification No clamps White with clamps Avoid acetone and prolonged exposure to alcohol on catheter tubing No Purple, PowerLine imprinted on stabilizing device Avoid acetone and prolonged exposure to alcohol on catheter tubing No Purple, PowerHickman imprinted on stabilizing device Clamps No Yes Yes Yes Appendix B Maintenance Summary Removal Physician/Interventional Radiologist Syringe 10 ml or larger Sutures Be sure plan is made for removal Post-op care: BioPatch at insertion site Sterile dressing change day one, then every other day if gauze dressing used Sterile dressing change every 7 days if Tegaderm dressing used 2 to 3 weeks with epithelialization of the cuff: no dressing needed, or use band aid Appendix C Administration Set Changes (INS 2011 Guidelines pg. 84; CDC 2011 Guidelines pg. 19). Administration Set Device Infusion Status Frequency of Administration Set & Needleless Connector Change

PAGE: 18 of 18 Primary & Secondary Sets Continuous & Intermittent Every Sunday and Thursday, with new catheter placement, and PRN Add on devices including Diala-flow, filters and all other add on devices Continuous or Intermittent With each device change or administration set change Type of Infusate Administration Set Frequency of Administration Set & Needleless Connector Change Blood & Blood Components Intermittent At the end of 4 hours (unless indicated otherwise) Parenteral Nutrition with or Continuous or Intermittent Every 24 hours without Intravenous Fat Emulsion Propofol Continuous Every 12 hours Vasoactive drugs Continuous Every 96 hours Ativan Continuous Every 96 hours