PATIENT CARE MANUAL PROCEDURE NUMBER IV-30 DATE draft January 12, 2012 PAGE 1 OF 18 APPROVED BY: CATEGORY: Parenteral Nurse Clinicians Fluid / IV / Parenteral Therapy INDEX 1.0 PURPOSE Page 2 2.0 GENERAL INFORMATION Page 2-4 3.0 EQUIPMENT Page 5 4.0 PROCEDURE Pages 5-12 4.1 Assisting with Insertion 4.2 Maintaining the Catheter 4.3 Maintaining the Dressing 4.4 Removal of Catheter 5.0 PATIENT TEACHING Pages 12 6.0 DOCUMENTATION Page 13 7.0 COMPLICATIONS Page 14-16 8.0 REFERENCES Page 17 & 18
PAGE 2 OF 18 1.0 PURPOSE 1.1 To provide central vascular access when a peripheral site cannot be accessed or is contraindicated. 1.2 To provide an access site for the administration of: TPN Central Vein Solutions large volumes of crystalloid or viscous fluids simultaneous infusion of incompatible drugs blood and blood components measure right sided heart filling emergency venous access 1.3 To provide an access site for: central venous pressure (CVP) monitoring pulmonary artery catheter myocardial biopsy venous blood sampling 2.0 GENERAL INFORMATION 2.1 Short term use central venous catheters are inserted by the physician or Nurse Practitioner (NP) at the bedside or in O.R. 2.2 A consent is required prior to insertion of the central venous catheter. 2.3 Single and multiple lumen catheters are available.
PAGE 3 OF 18 2.4 The recommended use of Arrow (brand) multi-lumen catheter ports is shown below (Diagram 1). 2.4.1 Proximal lumen (18 g) (white): general access (i.e. intermittent or continuous infusions of medications or IV solutions) blood sampling (when peripheral venipuncture is not possible) blood administration 2.4.2 Middle lumen (18 g) (blue): TPN saline lock if TPN is anticipated general access if TPN is not anticipated 2.4.3 Distal lumen (16 g) (brown): CVP monitoring blood and blood components general access for high volume or viscous fluids, colloids 2.5 Maximum/full barrier precautions will be used during catheter insertion. 2.6 Strict aseptic technique 1 is required for administration set changes, dressing changes, and intermittent injection cap changes. Hands are to be cleansed with alcohol based hand sanitizer or soap and water prior to saline/heparin locking, handling administration sets, etc. Sterile gloves must be worn for dressing changes. 1 Aseptic technique for CVC dressing changes: use sterile gloves, dressing trays and no touch technique.
PAGE 4 OF 18 2.7 To maintain a closed system attach an injection cap (e.g. split septum) to lumen ends. Attach administration sets to the injection cap. 2.8 The most common insertion site is the subclavian vein. Alternate acceptable site internal jugular. See Diagrams 2 and 3. Catheter tip usually terminates in superior vena cava. 2.9 Femoral sites are occasionally used, but have an increased risk of complications (eg. infection and thrombosis). Do not ambulate patients with femoral catheters due to increased risk of dislodgement and catheter related deep vein thrombosis. 2.10 Remove Femoral catheters as soon as possible or replace with other IV access as appropriate to patient condition. 2.11 All short term CVC s require daily review by admitting physician/ designate/np of line necessity, with prompt removal of unnecessary lines. CVC s placed in emergency situations and/or without full barrier precautions are to be re-sited as soon as the situation becomes stable and within 48 hours.
PAGE 5 OF 18 3.O EQUIPMENT central venous catheter (check with physician/ NP regarding size and type) IV solution as ordered IV administration set injection caps, 1 per lumen 10 ml prefilled saline/ heparinized saline syringes IV pole infusion pump cutdown tray sterile 2% chlorhexidine gluconate with 70% isopropyl alcohol swabsticks suture material (check with physician)/ Statlock securement device lidocaine 1% (check: with or without epinephrine) 2-10 ml syringe with 2 - #18 and 2 - #23 g needles syringes and needles - used for administering local anesthetic transparent dressing 10 cm x 12 cm clippers for removing hair at insertion site Maximum/full Barrier Precautions Equipment sterile full body drape with small opening for site of insertion surgical masks (with shield) for person inserting CVC and assisting individual OR hat/ cap for person inserting and assistant sterile gloves and gowns for person inserting CVC isolation gown for assistant 4.O PROCEDURE 4.1 Assisting with CVC Insertion 4.1.1 Both the person inserting the CVC (inserter) and the person assisting (assistant) clean hands with alcohol based hand sanitizer or soap and water. 4.1.2.Assembles the equipment. 4.1.3 Clip any hair which may be present at and around insertion site. Note:, do not shave as this causes micro-abrasions and is a site of infection. 4.1.4. Place patient in the supine position. Trendelenburg position may be required. For subclavian access, place a rolled up towel between the shoulder blades (no pillow at head). 4.1.5 Open the sterile packages as requested by inserter.
PAGE 6 OF 18 4.1.6 Assistant helps the inserter into sterile gown, withdrawal of local anaesthetic and opening of pre-procedure skin prep as requested by person inserting. The person inserting the CVC will remove manufacturer s injection caps and replace with needleless (interlink) injection caps. Catheter lumens are flushed with preservative-free saline prior to insertion using aseptic technique. The CVC is inserted. 4.1.7 Once access is established and verified by blood return, saline lock the lumen(s). NURSING ALERT: Do NOT infuse medication or TPN into any lumen until catheter placement is confirmed by x-ray. 4.1.8 Apply gauze dressing if bleeding occurs at insertion site. The gauze may be replaced with a transparent dressing (10 cm x 12 cm) when bleeding stops. Change initial dressing 24 hours after insertion. Label dressing with date. 4.1.9 The inserter will either suture or use a stabilizing device to secure the catheter to the skin. Secure the catheter extension to patient s skin with tape / StatLock device to avoid tension on the catheter. 4.1.10 Arrange for a portable chest x-ray (ordered by physician or NP). CVC tip position (superior / inferior vena cava) must be verified by physician/ NP to ensure correct placement prior to infusing medications or TPN. 4.1.11 Observe patient for signs and symptoms of pneumothorax, arterial puncture, and pericardial tamponade (see 7.0 for complications). 4.2 Maintaining the Catheter 4.2.1 Cleanse hands with alcohol based hand sanitizer or soap and water prior to dressing changes, accessing line, accessing caps and stopcocks, tubing changes or manipulations. Use strict aseptic technique. 4.2.2 Infuse all solutions, blood products, and medications via administration sets with luer lock connections. NURSING ALERT: All administration sets, extension tubing, or intermittent injection caps attached to central lines must have leur lock connections.
PAGE 7 OF 18 4.2.3 To attach administration set directly to catheter hub, extension tubing or change injection cap, place the patient supine, clamp the lumen (with slide clamp located on lumen pigtail), cleanse connection with 2% chlorhexidine 70% alcohol swab and ask patient to perform Valsalva Manoeuvre. Make the connection as the patient holds his/her breath or during exhalation. Use Interlink leur adapter to connect tubing set to cap. NURSING ALERT: NEVER use a toothed clamp on the central venous catheter. 4.2.4 It is recommended that an infusion pump is used to infuse medications/iv solutions. 4.2.5 Use Interlink Injection cap. Always cleanse the injection cap with 2% chlorhexidine 70% alcohol and let dry prior to each and every time the injection cap is accessed. Ensure catheter patency by using a syringe to withdraw and observe for blood return, then flushing. The catheter should flush without resistance or leaking from insertion site. Flush with preservative free saline for injection to clear the line. When flushing and/or locking, use Positive Pulsing Pressure by giving short jerky pushes on plunger. 4.2.5.1 Frequency of flushing: 20 ml saline flush After blood sampling. Before and after blood component administration 10 ml saline flush When converting from continuous to intermittent therapies Before and after intermittent medication therapy For maintenance of dormant CVC s. 4.2.5.2 Maintain each unused lumen by locking with 5 ml of heparin lock solution (10 units/ml) or, if not available, 3 ml heparin lock solution (100 units/ml) q24h or as ordered. Guidelines for locking: The volume should be at least twice the volume capacity of the catheter lumen plus the priming volume of all addon devices (eg. extension tubing)
PAGE 8 OF 18 4.2.5.3 To maintain the patency of catheters locked between medications follow SASH: o Saline to assess catheter patency o Administration of medication o Saline to flush medication out of catheter o Heparin Lock to maintain patency between medication 4.2.5.4 Clamp before removing blunt cannula from injection cap. Clamp the catheter when not in use with the slide clamp provided. Vary position of slide clamp along lumen to prevent wearing of catheter lumen. 4.2.6 Platelet count monitoring is recommended for post-op patients every 2-3 days from day 4-14, or until therapy with heparin is stopped. NURSING ALERTs: Always use a 10 ml syringe/large barrel syringe for flushing as it has a lower pressure rating. Smaller syringes have greater pressures and may rupture catheter. 4.2.7 Refer to P/P #, Maintenance of I.V./Hypodermoclysis Equipment for change times. 4.2.8 Observe the catheter and insertion site for: swelling redness tenderness drainage dislodgement / malposition or advancement of catheter loose sutures Report any of the above to the physician, NP or designee.
PAGE 9 OF 18 NURSING ALERT: If IV solution does not readily infuse or lumen cannot be locked without meeting resistance, DO NOT apply force in attempt to free catheter of clot that may have formed. Apply a piece of tape to lumen indicating not to use the lumen and record date on tape. Document on chart and kardex. Notify physician and/or NP or designee to consider restoring patency to occluded lumen. 4.3 Maintaining the Dressing 4.3.1 Change the transparent dressing q6 days and prn if it is wet, soiled or no longer occlusive. 4.3.3.Cleanse hands with alcohol based hand sanitizer or soap and water. 4.3.4 Apply protective gloves. Remove dressing by stretching the dressing outward to lift and separate it from the skin. Hold the central catheter hub firmly when removing the dressing from the catheter to prevent dislodging it from the vein. If applicable, remove catheter from catheter securement device (eg. StatLock) and remove catheter securement device with alcohol. Remove protective gloves. 4.3.5 Apply sterile gloves. Cleanse catheter with sterile 2% chlorhexidine 70% alcohol swabstick in a back and forth motion, cleansing the entire area that will be covered by the dressing. Repeat. Using a second swab cleanse the catheter and the catheter hub. If applicable apply skin prep and replace catheter securement device. Allow all solutions to dry thoroughly.
PAGE 10 OF 18 4.3.6 Apply transparent dressing. With ballpoint ink pen indicate date on strip provided with dressing. 4.3.7 Observe insertion site and catheter length every eight hours or prn. 4.4 Removal of Catheter 4.4.1 RN s may not remove a central venous catheter that penetrates a heart valve. 4.4.2 Catheters to be removed by physician / NP or RN staff educated in CVC removal. Each patient care area shall identify how often education shall be repeated / competency in CVC removal validated, dependent on the frequency the skill is performed, and the patient population in the area. In non-critical care area, RN s identified by the Unit Supervisor or Patient Care Manager may be certified to remove non-tunnelled central venous catheters for femoral, subclavian or jugular sites. o Unit Supervisor/Patient Care manager shall keep of list of staff who have been identified to remove CVCs and who have demonstrated competency. The staff member shall be given written documentation that they are allowed to perform this task.
PAGE 11 OF 18 4.4.3 An order is required to remove a short term CVC. Check platelet count. Check PT/INR if on anticoagulants. Platelet count less than 50 and prolonged clotting time increase the risk of bleeding. In these cases, consult the physician/np before removal of CVC. Ensure all IV medications/ solutions are discontinued by the prescriber, or that alternate IV access has been established. 4.4.4. Explain procedure to patient. Remove the sutures. Cleanse site with 2% chlorhexidine 70% alcohol swab and allow to dry thoroughly. 4.4.5 Position the patient Trendelenburg if respiratory status allows, if not use the supine position. Ask the patient to perform the Valsalva manoeuvre if able to co-operate and slowly with draw the CVC. If unable to perform Valsalva, withdraw catheter as the patient holds his/her breath or on exhalation. Stop if resistance is encountered, and advise prescriber. 4.4.6 Using a sterile gauze, apply manual pressure to the catheter site for a minimum of five minutes or until haemostasis is achieved. Have patient perform valsalva manoeuvre, hold breath, or exhale when gauze removed to assess site for bleeding. 4.4.7 Apply airtight/occlusive dressing. The dressing should remain in place for 72 hours Examples of occlusive dressings are: petroleum impregnated gauze and transparent dressing. Gauze and DuoDERM Extra thin Restore Plus Hydrocolloid Dressing Antibacterial ointment, gauze and transparent dressing. Note: Gauze and transparent dressing alone is not airtight. Gauze and Microfoam Surgical Tape. 4.4.8 Bed rest should be maintained for 30-60 minutes. 4.4.9 If catheter related blood stream infection is suspected, using aseptic technique cut the catheter tip and place in a sterile specimen container. Label with patient name and send to the lab for culture and sensitivity.
PAGE 12 OF 18 4.4.10 Observe the patient for signs and symptoms of air embolism (sudden onset of chest pain, dyspnea, unequal breath sounds, decreased O 2 saturations, cyanosis, hypotension, weak pulse, decreased LOC, churning murmur over precordium). 5.0 PATIENT TEACHING 5.1 Insertion of Catheter 5.1.1 Sterile drapes will cover the entire body and face during catheter insertion. 5.1.2 A burning sensation will be felt as local anaesthetic infiltrates tissue. (Patient discomfort can be minimized with the use of buffered lidocaine.) 5.1.3 A pressure sensation will accompany catheter insertion. 5.2 To prevent air embolism, perform the Valsalva Manoeuvre for: catheter insertion administration set change / positive pressure valve change catheter removal 5.3 Report any of the following symptoms: pain/tenderness or swelling at site, neck or shoulder unexplained shortness of breath, coughing chest pain, palpitations fever tingling finger or shooting pain down arm ear pain or gurgling in ear
PAGE 13 OF 18 Central Venous Catheter - Non-tunneled 6.0 DOCUMENTATION 6.1 Patient Care Record insertion - time, site, by whom, any complications integrity of site complications of indwelling catheter status of infusion injection cap and dressing changes, observation of insertion site, sutures / catheter securement device CVC removal, catheter status (is it intact), bleeding from site, dressing applied and procedure tolerance. 6.2 Fluid Therapy Record nature of infusion - volume and type of solution initiation and discontinuation of therapy 6.3 Medication Administration Record (MAR) record locking solutions 6.4 Kardex dates of planned equipment changes;
NUMBER IV-30 PAGE 14 OF 18 7.0 COMPLICATIONS COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION AIR EMBOLISM coughing, chest pain, respiratory distress, sob cyanosis altered level of consciousness ARTERIAL PUNCTURE BRACHIAL PLEXUS INJURY CATHETER OCCLUSION DAMAGED CATHETER pulsating blood return respiratory distress massive hematoma with tracheal compression blood backing up into tubing during infusion tingling of fingers, pain shooting down arm and/or paralysis unable to inject or infuse solution leaking of fluid or blood from insertion site leaking of fluid or blood at damaged area swelling of chest area stop infusion(s) clamp or pinch catheter (above damaged area) patient to lie on left site in Trendelenberg position begin resuscitation procedure if required. Notify physician/np administer O 2 monitor V/S apply pressure over puncture site begin resuscitation procedures if required notify physician/np immediately portable CXR (ordered) Always clamp catheter before opening. Have patient perform Valsalva Manoeuvre. Remove all air from tubing and syringes. Use leur lock connections - ensure they are tight. Have non-toothed clamp available. Occurs inadvertently during insertion. notify physician/np Occurs inadvertently during insertion. attempt to aspirate then attempt to flush the catheter (do not apply force when flushing) apply label to lumen stating Do NOT Use - Occluded and date notify physician/np stop infusion do not use catheter clamp catheter with a non-serrated clamp proximal to the damaged area notify physician/np Use positive pulsing pressure when flushing/locking Flush/lock lumens at recommended intervals. Clamp catheter when not in use. Never use scissors or sharp objects around catheter. Use 10 cc syringes when flushing to prevent catheter rupture. Never use force when flushing. Unclamp before flushing. Keep catheter securely taped. Vary position of clamps along lumen.
COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION INFECTION redness, pain, warmth, swelling around exit site, drainage (purulent, discoloured) fever and chills generalized malaise elevated WBC MALPOSITION difficulty with aspiration or infusion discomfort in sound, neck or arm edema of neck or shoulder ear gurgling sound described during infusion arrhythmias (if in right atrium) HEMOTHORAX PNEUMOTHORAX PERICARDIAL TAMPONADE mild to severe dyspnea and/or chest pain delayed symptoms include tachy cardia, hypotension, cyanosis, diaphoresis and hemoptysis tracheal deviation hypotension neck vein distention THROMBOSIS upper chest pain, jaw pain, ear ache swelling of arm, neck and shoulder on same side a catheter sluggish flow of IV solution SUPERIOR VENA CAVA SYNDROME progressive shortness of breath, dyspnea, cough, chest skin tightness; unilateral edema, cyanosis of face, neck, shoulders and arms; jugular, temporal and arm vein distention do not use catheter notify physician/np immediately Obtain blood cultures from a peripheral site and the CVC. do not use catheter inform physician/np CXR Wash hands well with antimicrobial soap before handling catheter or equipment. Strict aseptic technique. Change dressings and equipment according to procedure and prn; i.e. soiled, loose, contaminated. Minimize accessing catheter. Remove catheter when therapy complete Ensure catheter and tubing taped securely. Ensure sutures remain secure. Monitor catheter insertion length each shift and prn. notify physician/np immediately Occurs inadvertently during insertion. notify physician/np immediately begin resuscitation if required do not use catheter notify physician/np notify physician/np immediately at first signs and symptoms place in semi-fowlers position and start oxygen at 2 L/min. provide emotional support monitor cardiovascular and neurologic status Occurs inadvertently during insertion. Monitor for signs and symptoms and report. Avoid trauma or movement of catheter. Monitor for signs and symptoms.
COMPLICATION SIGNS & SYMPTOMS ACTION PREVENTION CATHETER PINCH- OFF SYNDROME (when catheter is inserted via the percutaneous subclavian site and is compressed by the clavicle and first rib) intermittent catheter occlusion that is relieved by postural change weak point on the catheter balloon out difficult to aspirate blood resistance to flushing or infusion with catheter fracture - intraclavicular pain - palpitation, chest pain notify physician/np do not use catheter x-ray confirmation contrast dye study via catheter to rule out partial transection of catheter can result in complete or partial catheter transection and catheter embolization Can not be prevented.
PAGE 17 OF 18 8.0 REFERENCES Arrow International, Guidelines for the Use of the Arrow-Howes, Multilumen Catheter Terry, J., Baronowski, L., Lonsway, R.A., Hedrick, C. (2001) Intravenous Therapy, Clinical Principles and Practice; Intravenous Nurses Society. Second Edition Weinstein, S.M. (7 th Edition, 2001) Plumer s Principles and Practice of Intravenous Therapy Preventing Infections Associated with Indwelling Intravascular Access Devices, Health Canada, Health Protection Branch, 1998 Pearson, L. (1995) Guideline for Prevention of Intravascular - Device - Related Infections. Infection Control and Hospital Epidemiology Maki, D.G., Ringer, M., Alvarado, C.J. Prospective randomized trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Journal of Hospital Infection. 1982, 3:55-63. Lancet 338; August 10, 1991, p. 339-43. Journal of Infusion Nursing. Infusion nursing standards of practice, revised (2006) Lippincott Williams & Wilkins. Norwood, MA. Camp-Sorrell. D. Access device guidelines. Recommendations for nursing practice and education, 2 nd edition (2004) Oncology Nursing Society Care and Maintenance of Devices, 2005, Nursing Best Practice Guidelines, Shaping the future of Nursing, Registered Nurses Association of Ontario Intravascular Device Infections, 2005, Association for Professionals in Infection Control and Epidemiology, Inc Principles of Flushing Vascular Access Devices, BD, 2006 Institute of Healthcare Improvement, Preventing Catheter Related Bloodstream Infections, 2005 Ingram, p> et al The safe removal of central venous catheters. Nursing Standards, August 16. Vol. 20. No 4009. 2006 Hadaway L. Heparin locking for central venous catheters. Journal of Association for Vascular Access. 2006; 11 (4): 224-231
PAGE 18 OF 18 Hadaway L. Misuses of prefilled flush syringes. Infection Control Resources. 2008;4(4):2-4 Casey AL, Elliot TS. Infection risks associated with needleless intravenous access devices. Nurs Stand. Nov 21 2007; 22(11):38-44. Field K, McFarlene C, Cheng A,et al. Incidence of catheter related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol. 2007;28(5):610-613 Maragakis L. Bradley K, Song X, et al. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol. 2006;27(12):67-70. Muslimani A, Ricaurte B, Daw H. Immune heparin-induced thrombocytopenia resulting from preceding exposure to heparin catheter flushes. American Journal of Hematology. Dec 18, 2006 epub 2006 Smythe M, Koerber J, Mattson J. The incidence of recognized heparin-induced thrombocytopenia Twenty-nine years later. Journal of Vascualr Surgery. 2003;38(6); 1644-1649. Alexander, M., Corrigan, A., Gorski, L., Hankins, J., Perucca, R. Infusion Nurses Society: Infusion Nursing: An evidence-based Approach. 3 rd Edition. 2010 Centres for Disease Control and Prevention. (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Self-published. Infectious Diseases Society of America. (April 1, 2011) Guidelines for the Prevention of intravascular catheter-related infections. Oxford University Press. CID 2011:52 (1 May). Alexander, M. (Jan/Feb 2011) Infusion nursing standards of practice. Journal of Infusion Nursing, supplement, Vol. 34, #1S, S110. Infusion Nurses Society. Policies and procedures for infusion nursing. 4 th edition. 2011 The Canadian Patient Safety Institute. Getting started kit; prevent central line infections. Central line associated blood stream infections. Safer healthcare now! Campaign. February 2009,. The Society for Healthcare Epidemiology of Amerca. (October 2008) Strategies to prevent central line-associated bloodstream infections in acute care hospitals. The University of Chicago Press.
OPTIONAL RESOURCE: Skills Checklist for Clinical Educator Use Removal of Short Term Non-Tunnelled Central Venous Catheter Criteria Checklist Critical Elements Met Not Met 1. Determines appropriateness of proceeding with line removal based on assessment of: Patient Care order on chart Need for alternate IV access Anticoagulation status/platelet level (PT INR/PTT ) Determines whether tip should be sent for culture 2.Explains procedure to patient and verifies understanding and cooperation as appropriate. Washes hands. Wears protective gloves. 3 Positions patients to expose insertion site and reduce risk of air embolus. Removes old dressings without dislodging catheter. 4. Cleans insertion/suture site with 2%chlorhexidine/70% alcohol swab stick using dressing tray. 5. Removes sutures. 6. Withdraws catheter while: Applying pressure over insertion site with sterile gauze Instruct patient to exhale while withdrawing catheter, perform Valsalva or hold his/her breath. Assesses catheter for breakage. 7. Covers site with sterile occlusive dressing. Applies appropriate dressing and maintains pressure over site. 8. Verifies hemostasis. 9. Documents in patient care record. Passed Needs to Repeat Name: Signature: Validated by: Unit Date: Line Location: