Policy For The Management Of Central Venous … for the management of... · Web viewPolicy for the Management of Central Venous Catheters (CVC) Introduction A Central Venous Catheter

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Co-ordinator Reviewer: CVC Working Group Approver:

Identifier Review Date: Date

UNCONTROLLED WHEN PRINTED

VERSION 1

Policies and Procedures for the Management of Central Venous Catheters (CVC)

Signature SignatureSignature

Title: Policies and Procedures for the Management of Central Venous Catheters (CVC)

Policy Ref:

Organisation Wide Directorate Clinical Service Sub Department Area

✔

Controlled Document: This document shall not be copied in part or whole without the express permission of the author or the author’s representative.

Review Date: August 2007

Author: CVC Working Group

Policy Application: NHS Grampian

Purpose: To give all staff guidance in the management of Central Venous Catheters

RESPONSIBILITIES FOR IMPLEMENTATION

OrganisationalClinical GroupCorporateDepartmentalArea

Policy Statement: The management of all aspects of Central Venous Catheter care using evidence based practice.

Review: This policy will be reviewed ever 2 years

Approved by: Date:

Signature:

Designation:

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Policy for the Management of Central Venous Catheters (CVC)

Introduction

A Central Venous Catheter (CVC) provides venous access for patients requiring short/long term therapies. To many patients the catheter is an important lifeline, therefore it is imperative that the catheter is handled and maintained correctly. This policy has been developed by a multidisciplinary group to standardise the management of CVC’s and to ensure that staff caring for the patient with central venous catheters have access to guidelines and procedures to prevent complications occurring. The following evidence based procedures are available within this document.

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Supportive information on CVC’s 4 - 12

General Directions 13

Commencing IV Fluids via CVC 15

Disconnecting IV Fluids via CVC 17

Administration of Medicines via CVC

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Changing Closed Luer Lock Device

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Dressing the CVC 23

Adult - Taking Blood from CVC using Vacutainer system

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Paediatric – Taking Blood from CVC

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Removal of CVC 31

References 34

Bibliography 37

Appendix 1Group Members 38

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Venous Access

DefinitionAn intravascular catheter is defined as a ‘tubular’ device, single or multi lumen, designed to be partially or totally inserted or implanted into the cardiovascular system for diagnostic and/or therapeutic purposes’

Central venous accessCentral catheters are used when access is required for Infusion of high volumes of fluid. Hydration or electrolyte maintenance. Repeated administration of drugs such as chemotherapy or antibiotic

therapies. Repeated transfusions of blood or blood products Repeated collection of blood specimens. Intravenous Nutrition. Haemodialysisor When there is poor venous access.

Sites Available For Insertion Subclavian Internal/External Jugular Femoral Cephalic or Basilic

The most frequently used catheters are: Non tunnelled CVC Tunnelled catheters: i.e. Hickman, Broviac Peripheral inserted central catheters (PICC) Sub cutaneous ports

Table 1 lists the type of catheters available with their advantages and disadvantages.

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Table 1 Advantages and Disadvantages of Catheter TypesAdvantages Disadvantages

Midline catheter Suitable for 1 - 12 weeks use

7.5cm-20cm in length Longer than

peripheral cannula, shorter than PICC

Ease of insertion and removal

Avoids frequent changes of cannula

Reduced risk of thrombophlebitis

Access to peripheral veins may be difficult

Occlusion problems of kinking/phlebitis

Cannot use to infuse solutions with high osmolality/low pH

Peripheral Inserted Central Catheter (PICC)

Central venous catheter accessed via a peripheral vein

20-40cm in length Catheter tip

positioned in the Superior Vena Cava (SVC)

Suitable for up to 12 months use

Ease of insertion and removal

Fewer insertion complications

Bedside access Lower the incidence

of related infection/thrombus

Smaller lumen/flow problems

Inflammation at the insertion site

Higher rate of phlebitis than other CVC’s

Problems with kinking

Non Tunnelled CVC

Single or multiple lumens

Used for short term access

Inserted via internal jugular/subclavian

Can be inserted at the bedside

Insertion procedure quicker, suitable for emergency situations

Several lumens, can be used for continuous access and high flow infusions

Highest infection rate

Requires external sutures

Uncomfortable for patients

Difficulty maintaining dressing at catheter exit site

Requires to be changed every 5 to 7 days

Tunnelled CVC Part of the catheter in tunnel within the subcutaneous tissue

Tip of the catheter in the superior vena cava

Cuffed, non-cuffed Single or multi lumen Last up to 3 years

depending on type of catheter

Lower infection rate Ease of dressing

application Patient comfort, no

external sutures Durability Ideal for repetitive use Don’t require skin

puncture for access

Experienced operator required to insert. Inserted in theatre or radiology dept.

Requires surgical removal

External portion of the catheter visible

Subcutaneous Ports

Similar to tunnelled catheters except access via a subcutaneous reservoir

Use for prolonged treatment

Single/double lumen Accessed with a

Huber right angled needle

Patient acceptance, intact body image

No exit site dressing, allow patient to bathe or swim

Require less maintenance – less flushing/no dressing changes

Use of needle to access port

Local skin ulceration

Shorter life span than tunnelled CVC if accessed regularly

Requires operative placement

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Midline catheter

PICC Line

Hickman line

Implanted Port

Triple Lumen

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Single versus multi-lumen catheters

Multi lumen central catheters can be used for a combination of treatments such as chemotherapy, or antibiotic therapy or nutrition. It has previously been suggested that multi lumen catheters increase the risk of catheter-related sepsis (Pemberton et al 1986) (McCarthy et al 1987). This point has now been refuted by many authors who report that there is no statistical difference in catheter-related sepsis between the use of single or triple lumen catheters. (Johnston et al 1990), (Farkas et al 1992) (Ma Ty et al 1998) (Goetx et al 1998). The choice of catheter for long term use is dependent on venous access available, duration of therapy and, most importantly, patient preference. Table 2 lists the factors that should be taken into consideration when determining the most suitable catheter for the patient.As the availability of these intravascular devices increases, so must the health professional's knowledge base improve. It is essential that health care professionals receive regular educational updates and training sessions in order to maintain standards. Table 3 lists the appropriate use of lumens in multi-lumen catheters

Table 2 Factors Influencing Choice of CatheterLocation of venous access available

Gauge of catheter and vein diameter. The narrowest catheter in the largest vein will provide better blood flow around catheter and reduce vein damageShort or long term use

Catheter material: i.e. silicone or Polyurethane

Multi or single lumen catheter, Cuffed or uncuffed catheter

Implantable or external device

Method of catheter removal

Ease of sterile dressing applications

Patient preference/ body image,

Patients/carer’s ability to care for central catheter in the home environment

Table 3 Multi-lumen line - Lumen usage Proximal Blood Sampling

MedicationBlood Administration

Medial Total Parenteral Nutrition (TPN)Medication only if TPN not anticipated

Distal CVP monitoringBlood administrationHigh volume or viscous fluidsColloidsMedication

4th Lumen Medication

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Catheter insertion

The central catheter should be inserted using an aseptic technique under the supervision of an experienced clinician. Potential complications associated with the insertion of the catheter include: Pneumothorax Venous air embolism Arterial puncture Catheter misplacement Cardiac Tamponade Cardiac arrhythmia’s (Drewett 2000)A catheter placed in an optimal position will reduce potential complications.

When inserting the catheter the clinician will consider the following points: The catheter tip should lie above the junction of the SVC and right atrium If a cuffed catheter is used, the cuff should be placed in the mid point of the

tunnel away from the exit site It is recommended that a Chest X-Ray should be performed to check the

position of the catheter before use.

Central Venous Catheter Care

Central venous catheter-related infections account for 90% of nosocomial (hospital acquired) bloodstream infections. Despite the profuse availability of evidence, there continues to be a significant diversity in practice of health care professionals (Clemence et al 1995). It has been well documented that experienced staff and educational programs (Parras et al 1994) can have a significant impact on the rate of catheter related problems. For this reason it is essential that all staff that are caring for a patient with a central venous catheter have access to educational material and research based protocols and procedures.

Hand HygieneThe most common cause of the spread of nosocomial infection is via the hands of health care workers because of their inability to effectively decontaminate their hands. (Horton 1995). Therefore, the first crucial step in the reduction of catheter related sepsis is knowledge of the principles of hand hygiene and the effective use of disposable gloves.

Any procedure connected with an intravenous catheter requires the health care worker to wash with an antibacterial handwash. The purpose of a handwash is to remove dirt and to reduce the load of bacteria on the skin of the hands. Washing with soap and water will remove the transient bacterial flora, and washing with an antiseptic will reduce the resident bacteria on hands. It should be noted however, that resident bacteria would not be totally eliminated by handwashing. (Meers et al 1992) The are several types of handwash available for use, each have different properties and advantages. Choosing the appropriate agent will depend on several factors.

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The use of any handwash solution will prove to be ineffective if staff do not employ the correct handwashing technique. Various studies have concluded that health care workers do not wash their hands effectively, leaving many parts of the hands not exposed to soap, water or handwash. In practice the most commonly missed areas are the fingertips, the thumb and the inside of the fingers.

The use of an alcohol hand rub is known to be effective. It is a powerful antiseptic that can be applied quickly to hands that are not soiled. It will rapidly kill transient bacteria and a proportion of the resident bacteria.

The use of glovesIt is important that gloves are used in conjunction with hand hygiene and not as a replacement. Many health care workers believe that gloves protect staff and patients from cross contamination, but in reality this is not the case as hands can become easily contaminated under gloves when they are unwittingly punctured or when they are removed. The lack of evidence regarding the benefits of using sterile gloves has resulted in many teams developing procedures based on using an aseptic non-touch technique (ANTT).

The care of the hub/the use of connection devicesSeveral studies have implicated contamination of the hub as the major source of catheter related sepsis in catheters that remain in situ for more than two weeks. Sitges Serra (1984) was concerned about the hub and recommended that limited manipulations to the catheter should occur, as each junctional break brings additional risk of infection.Strict adherence to policies and effective hand hygiene techniques are essential to minimise any riskThe use of closed luer lock connection devices (needle free) with a membrane allows access to the catheter whilst maintaining a closed system. (Bionector, Interlink, Smartsite).

Bionector

Smartsite

The perceived benefit of this system is:

Reduction in catheter related sepsis (Segura 1996) Reduction in needle stick injuries Reduction in use of sterile equipment / reduce costs

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Reduction in nursing workload

Connection devices are now widely used in clinical practice. Some health professionals are concerned about the potential risk of contamination. Several studies have addressed this issue and conclude that there is no evidence that their use is associated with increased risk of catheter related infection (Seymour et al 2000), (Luebke at al 1998). When using connection devices the greatest risk leading to contamination is an inability to disinfect the device before puncture (Arduino et al 1997). The most effective method of disinfection according to Brown et al (1997) is the use of a combination of chlorhexidine, followed by 70% isopropyl swab.

Anecdotal evidence suggests that using the closed system is much less cumbersome for nursing staff and patients to use and thus compliance with procedures may be better. However, the use of the closed systems does not diminish the need for careful catheter techniques, and the adherence of staff to guidelines and educational programmes remains the most vital aspect in the rate of catheter related sepsis (Ihrig et al 1997).Recommendation – Bionector or Smartsite

Changing connection devicesRoutine connection device changes should occur as per manufacturer’s instructions. It may be necessary to change earlier if device is damaged, faulty, or if blood products or lipid deposits are present after routine flushing of the catheter.

Principles of catheter site care The site forms an artificial break in the skin and with the catheter insitu is a potential source of infection. An aseptic technique is therefore required when cleaning the site and changing the dressing (Elliot 1993). It has been suggested that the use of an aseptic technique by a specially trained person has more effect on reducing the rate of catheter related infection than the type of antiseptic or dressing used. (Nelson 1986)

There are several issues that require to be addressed when developing guidelines for care of the catheter site. Firstly the most appropriate cleansing solution, secondly the most appropriate dressing and thirdly how often the dressing should be changed.

Cleansing SolutionsIt is generally agreed that disinfection of the insertion site is essential. Various antiseptic solutions are used during insertion and at dressing changes. Povidone iodine 10% Chlorhexidine 0.5% Chlorhexidine 2% (Maki 1991). 0.9% Sodium chloride (Kennlyside 1992)

Chlorhexidine and alcohol based solutions have generally been shown to be more effective. A study by Maki et al (1991) found chlorhexidine to be significantly the most effective when used in the 2% aqueous solution. Mimoz et al (1996) suggest that an alcohol based chlorhexidine solution was more effective than povidone iodine, and Garland et al (1995) concluded that 0.5% chlorhexidine in 70% alcohol was more efficacious than 10% povidone-iodine.

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However Humar et al (2000) found that they was no difference between 0.5% chlorhexidine and 10% povidone-iodine. There has also been interest in the use of antiseptic impregnated catheter. A meta-analysis by Veenstra at al (1999) concluded that central catheters impregnated with chlorhexidine and silver sulfadiazine appear to be effective in reducing catheter- related infection.Recommendation – Chlorhexidine 0.5% in 70%IMS

DressingsThe purpose of a dressing is To prevent trauma to the wound and the cannulated vessel To secure the catheter To prevent extrinsic contaminationThe optimal dressing for the site remains controversial. The type of dressings frequently used includes sterile gauze dressing and transparent occlusive dressing. Several studies have reported an increased rate of infection associated with the use of transparent dressings. This is believed to be due to an increase of moisture at the site (Hoffman et al 1992, Dickerson 1989). However, other studies have found no statistical difference in rates of infection between transparent or gauze dressing. (Madeo at al 1997), (Freiberger et al 1992), (Taylor at al 1996), (Little and Palmer 1998).It has been suggested that transparent occlusive dressings are preferred by the patient (Shivran at al 1991), are cost effective (Brandt et al 1996), and can result in a reduction of nursing time. The need for any type of dressing has also been studied. Lucas and Attard-Montalo (1996) concluded in their study that the frequency of site infection was no greater when there was no dressing applied. They concluded that the use of a dressing has no real benefit in established long-term catheters.

Gauze dressing - Mepore™, Primapore™Limitations associated with the use of this dressing are the inability to visualise the site and the need for frequent manipulation of the dressing if the site needs to be checked. Their inability to provide a bacteria and water barrier allows for the potential contamination from secretions or external moisture.

Transparent/ occlusive dressing – IV 3000™, Tegaderm™The advantage of a transparent dressing is the ability to secure the catheter, to permit continuous inspection of the site, to adhere well to dry skin, and to provide protection against external moisture sources. (Maki 1991).

Recommended dressing properties Transparent – allows continuous visual inspection of the catheter and

catheter site Self-adhesive – ensures greater stability, reducing the risk of trauma,

mechanical phlebitis and external contamination Semi-permeable – protects from bacteria and liquid while allowing the site

to “breathe” Sterile – prevents external contamination of the catheter site

Dressing ChangesThere is no consensus on the issue regarding frequency of dressings but in any protocol this needs to be established and should be weighed against the

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exposure of the site to external micro-organisms. (Young et al 1988). While daily dressings using an antiseptic cleansing solution will significantly reduce skin colonisation (Roberts 1993), it is unclear whether colonisation is related to sepsis and therefore there is a question about the necessity of this. Some authors believe that the dressing is best left undisturbed for as long as possible to reduce the possibility of contamination (Dougerty 1992). Although transparent dressing can remain in-situ for 7 days, it may need changed earlier if there is drainage from the site or the dressing becomes non-occlusive (Brandt et al 1996).

Recommendation - Opsite IV 3000 for subclavian lines or Tegaderm for Jugular lines Changed weekly or sooner if soiled with blood or exudate or if not adhering to the skin.

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General Directions

Pre ProcedureThe following are a set of general instructions to be observed prior to commencing any procedure.

Procedure Rationale

1. Wash and dry hands. 1. To minimise the risk of cross infection.

2. Clean trolley/tray/flat surface as per NHS Grampian Cleaning, Disinfection and Sterilisation Policy.

2. To minimise the risk of infection

3. Prepare and assemble all equipment required for procedure.

3. Procedure can be completed without interruption.

4. Reassure and explain the procedure to the patient/relative in terms that can be understood and gain verbal consent.

4. To have a patient/relative who is knowledgeable of the procedure and a healthcare worker who has been given the authority to proceed.

5. Ensure privacy during the procedure, do not expose the patient unnecessarily and avoid draughts.

5. To avoid unnecessary embarrassment to the patient and minimise airborne contamination.

6. Provide adequate lighting. 6. To enable clear observation.

7. Wear clean disposable white apron.

7. To lessen the possibility of uniform contamination.

Post ProcedureThe following are a set of general instructions to be observed when a procedure has been completed.

Procedure Rationale

1. Wash and dry hands. 1. To minimise the risk of cross infection.

2. Leave the patient comfortable and the area clean and tidy.

2. To ensure patients comfort.

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3. Clean equipment according to NHS Grampian Cleaning, Disinfection and Sterilisation Policy.

3. To minimise the risk of cross infection.

4. Return all opened Sterile Services Department (SSD) items for reprocessing, protecting sharp instruments.

4. For cleaning and reprocessing.

5. Dispose of clinical waste as per NHS Grampian Waste Disposal Policy.

5. To comply with the Environmental Protection Act and Duty Of Care Legislation.

6. Document the procedure in the appropriate records.

6. Accurate records of the patients care journey are available.

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Procedure for Commencing Infusions via a Central Venous Catheter (CVC)

The use of 3 way taps are not recommended on central venous catheters due to the inability to clean effectively and the increased risk of introducing infection from not having a closed system. Closed luer lock systems are recommended e.g. Bionector®, Smartsite® or Interlink®.

Total Parenteral Nutrition (TPN)/ Intravenous Nutrition (IVN) as a highly specialised feed has the ingredients to readily sustain bacterial growth and therefore adherence to strict aseptic technique is paramount.

The administration set for IV fluids should be changed every 24 hours as per NHS Grampian policy unless a local policy has been discussed and agreed with Infection Control. Any local policy should be attached to this document.

Requirements

1. Fluid (Additive Medicine) Prescription and recording sheet2. Prescribed IV fluid 3. Appropriate IV administration set and infusion device as required4. Alcohol impregnated swab5. Chlorhexidine hand wash solution e.g. Spirigel® with pump dispenser6. Alcohol hand gel e.g. Spirigel® with pump dispenser

Procedure Rationale

1. Follow Pre Procedure General Directions.

1. See Pre Procedure General Directions.

2. Two nurses check infusion fluid and patient identity with prescription chart as per NHS Grampian policy.

2. To ensure correct IV fluids are given to the correct patient at the correct time.

3. Wash hands with Chlorhexidine handwash

3. To minimise the risk of cross infection

4. Open new IV administration set and leave in packet.

4. To minimise contamination.

5. Close clamp on CVC, and on used administration set. Stop infusion device if in use.

5. Prevents air from entering the system.

6. Disconnect from closed luer lock connector.

7. Decontaminate hands with alcohol hand gel.


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8. Prime giving set placing coil of set onto open packet. Use correct procedure for gravity sets and infusion devices as per manufacturer's instruction.

9. Open alcohol impregnated swab and drop swab onto packet of administration set .

10.Decontaminate hands with alcohol hand gel.


11.Holding CVC near the end, wipe around the end of the connector with alcohol impregnated swab allow to dry fully (minimum of 30 seconds).

11. To facilitate optimum disinfection of the connector.

12.Pick up end of administration set and connect firmly and securely to the connector.

13.Ensure CVC is secured safely with the end away from wounds and stoma’s.

15. To minimise the risk of catheter infection.

14.Open clamp on CVC line, set infusion device (volume and rate) and commence or open clamp on gravity set to commence infusion.

15.Follow Post Procedure General Directions.

17. See Post Procedure General Directions.

Note: It is important that users of infusion devices are proficient in their use.

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Procedure for Disconnecting Infusions via a Central Venous Catheter (CVC)

The use of 3 way taps is not recommended on central venous catheters due to the inability to clean effectively and the increased risk of introducing infection from not having a closed system. Closed luer lock systems are recommended e.g. Bionector®, Smartsite® or Interlink®.

Requirements

1. 10 ml syringe(s)2. Green needle(s)/Filter needle3. Alcohol impregnated swab x 2 4. 10mls of Sodium Chloride 0.9% w/v and/or 5mls of Heparinised Saline

(Hepsal)5. Chlorehexidine hand wash solution e.g. Hibiscrub® with pump dispenser6. Alcohol hand gel e.g. Spirigel® with pump dispenser

Procedure Rationale



2. Wash hands with Chlorhexidine handwash.


3. Using a non touch technique draw up Sodium Chloride 0.9% w/v and/or Heparinised Saline.

3. Sodium Chloride 0.9% w/v is adequate to flush the line if it is being used frequently i.e. every day. If not Sodium Chloride 0.9% w/v followed by Heparinised Saline is recommended. (Local policy may apply). For lines designated for TPN administration both should be

used.

4. Close clamp on CVC lumen and administration set. Switch off pump. Disconnect used administration set from closed luer lock connector

5. Decontaminate hands with Alcohol hand gel.


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6. Holding the lumen near the end wipe the end of the closed luer lock with the alcohol impregnated swab allow to dry fully (minimum of 30 seconds).


7. Attach the syringe containing the sodium chloride 0.9%w/v to the connector, open the clamp and using the push, pause technique instil the sodium chloride 0.9%w/v.

7. This causes more turbulence in the lumen and is more effective in flushing the line and maintaining patency.

8. Close clamp when flush is complete, keeping pressure on

the plunger of the syringe, remove syringe and discard.

8. Positive pressure can reduce reflux of the blood into the catheter.

9. Repeat steps 7 & 8 with Heparinised saline if required.

10.Check CVC clamp is closed and clean end of closed luer lock connector with a new alcohol impregnated swab.

11. Ensure line is secure.

12. Follow Post Procedure General Directions


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Procedure for Administration of Medicines via a Central Venous Catheter (CVC)

Administration of medicines via central lines should always be via a closed luer lock connector i.e. Bionector®, Smartsite® or Interlink®. The use of 3 way taps are not recommended on central venous catheters due to the inability to clean effectively and the increased risk of introducing infection from not having a closed system.

Non-sterile gloves should be worn for the protection of the healthcare worker when reconstituting and administering any medicines especially antibiotics.

Requirements

1. Prescription chart, with patients name, unit number, date of birth 2. Prescribed medicine(s)3. Medicine Additive label(s) 4. Ampoule Sodium Chloride 0.9% w/v at least 10mls but will depend on the

number of medications to be given5. Dead ender/IV Plug for the end of each syringe6. Alcohol impregnated swab x 27. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser8. Alcohol hand gel e.g. Spirigel® with pump dispenser9. Non sterile gloves

Procedure Rationale


1. See Pre Procedure general Directions.

2. Wash hands with Chlorhexidine hand wash


3. Reconstitute medicines as per Trust policy and as per manufacturers advice.

3. To ensure safe reconstitution and safe delivery to the patient.

4. Draw up Sodium Chloride 0.9% w/v

5. Attach sterile dead enders and label each syringe as it is prepared.

5. To minimise contamination of the syringe tips and identify medicine in syringe.

6. Explanation and patient identification checks as recommended in NHS Grampian Policy.

6. To ensure the correct medicine is given to the correct patient at the correct time.



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8. Holding CVC near the end wipe around the end of the closed luer lock connector with an alcohol impregnated swab. Allow 30 seconds to dry.


9. Attach syringe containing Sodium Chloride 0.9% w/v to closed luer lock connector, open clamp and flush catheter with 5mls of Sodium Chloride using the “push, pause” technique. (1ml at a time)Volume of flush may need to be reduced in paediatrics.

9. This causes more turbulence in the line and is more effective in flushing the line and maintaining patency.

10.Close clamp keeping pressure on syringe plunger. Remove syringe from closed luer lock connector and re-cover tip of syringe

10. Positive pressure can reduce the reflux of blood into the catheter tip.

11.Attach medicine syringe, open clamp and administer medicine as per Trust Policy and as recommended by manufacturer.

11. Medicines must be administered slowly to prevent speedshock.

12.Close clamp and remove syringe.

13.Reattach syringe containing Sodium Chloride 0.9% w/v to closed luer lock connector, open clamp and instil 5 mls Sodium Chloride 0.9% w/v into the CVC using push pause technique, close clamp keeping pressure on plunger of syringe as before and then remove.Volume of flush may need to be reduced in paediatrics.

13. Sodium Chloride 0.9% w/v is thought to be adequate when the CVC is being used at least on a daily basis (excluding TPN).

14.Repeat steps 11 – 13 as necessary.

15.Check clamp is closed and clean end of closed luer lock connector with a new alcohol impregnated swab.

16.Document administration of medicines in drug recording chart.

17. Follow Post Procedure General Directions.


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Procedure for Changing Closed Luer Lock Device

The use of closed luer lock connection devices (needle free) with a membrane allow access to the catheter whilst maintaining a closed system. Closed luer lock systems are recommended e.g. Bionector®, Smartsite® or Interlink®.

These devices should be changed as per manufacture’s instructions. Usually once a week. It may be necessary to change earlier if device is damaged, faulty or if blood products or lipid deposits are present after routine flushing of the catheter.

Requirements

1. Dressing pack2. New closed luer lock connector3. 10ml syringe4. 5mls of Sodium Chloride 0.9%w/v5. Green needle/Filter needle6. Sterile procedure gloves.7. Alcohol impregnated swab8. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser9. Alcohol hand gel e.g. Spirigel® with pump dispenser

Procedure Rationale





3. Open pack and place other equipment onto sterile field. Place opened ampoule of Sodium Chloride 0.9% w/v on trolley next to sterile sheet.

4. Place sterile drape under existing connector.

5. Decontaminate hands with Alcohol hand gel and put on sterile gloves.


6. Using a non touch technique draw up Sodium Chloride 0.9% w/v.

6. To prevent contamination of gloves.

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7. Attach syringe to new connector and flush with Sodium Chloride 0.9% w/v.

7. To prevent air entering the system.

8. Ensure catheter is clamped. If the catheter has no clamp eg a PICC, kink back a portion of the catheter.

8. To prevent possible entry of air.

9. Unscrew old connector and discard. Clean catheter hub with alcohol impregnated swab allow to dry fully (minimum of 30 seconds).

9. To facilitate optimum disinfection of the catheter hub.

10.Attach new connector securely. (Finger tight only - do not overtighten).

10.Overtighten can cause cracking of the catheter hub.

11.Discard gloves.

12.Follow Post Procedure General Directions.


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Procedure for Central Venous Catheters Dressings (CVC)

The dressing that is in place after insertion should be left but observed closely especially in the first 24 hours. Dressings should be changed if soiled with blood or exudate or if not adhering to the skin. This should be weekly or more often if required. The insertion site should be checked daily for swelling, inflammation, pain or discharge or signs that the line may have moved e.g. pulled.

Requirements

1. Sterile dressing pack2. Sterile procedure gloves3. Non sterile gloves4. Sterile dressing ( e.g. Tegaderm, Opsite 3000)5. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser6. Alcohol hand gel e.g. Spirigel® with pump dispenser7. Chlorhexidine 0.5% in 70 % IMS. (check patient sensitivity)

Procedure Rationale





9. Put on disposable apron.

10. Open sterile dressing pack onto dressing trolley.

11. Open gloves onto sterile field. 6. Pour Chlorhexidine 0.5% in 70% IMS into one of the containers in the tray of the dressing pack.

7. Put on non sterile gloves 10.To protect the healthcare worker from body fluid contamination.

8. Carefully remove old dressing from the catheter site and discard.

8. Some CVC’s are not sutured in place so care must be taken to prevent moving or dislodging the catheter.

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9. Remove and discard non sterile gloves. 10. Decontaminate hands with Alcohol hand gel. Put on sterile gloves.


11.Using strict aseptic technique , clean the area around the catheter with the Chlorhexidine solution 0.5% in 70% IMS. Gently clean the skin using a circular movement from the catheter outwards. Clean an area larger than was covered by the old dressing. Allow the skin to dry.

11. Strict asepsis is required to prevent infection being introduced into a

major blood vessel from cross contamination or by introducing resident skin flora.

12. Remove gloves and discard.

13. Apply the dressing onto the skin, one end first, gently press down ensuring no air bubbles are trapped underneath. Ensure line is secure.



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Adults - Procedure for Taking Blood from Central Venous Catheters (CVC) Using Vacutainer System

Blood samples should not be taken routinely from a CVC except in specialist areas where a local policy applies. If line sepsis is suspected blood cultures will be required to be taken from the CVC.

It is recommended that blood specimens are taken from a CVC with the vacutainer system and that a closed luer lock connector is in situ (e.g. Bionector, Interlink or Smartsite). The use of vacutainer system may not be appropriate in paediatrics.

Requirements

1. Non sterile gloves2. Blood tubes and /or blood culture bottles for required tests (x1 spare 10ml

tube)3. Alcohol impregnated swab4. Syringes x2 (10 ml)5. Vacutainer needle holder6. Blue Vacutainer (with needle and connector end) 7. Interlink bare cannula x 3 (when Interlink product in use)8. 5mls Heparinised Saline9. 10mls of Sodium Chloride 0.9% w/v10.Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser11.Request form with patient details

Procedure Rationale



2. Assemble relevant blood specimen tubes as requested on the request form and all relevant equipment.

3. Wash hands using Chlorhexidine handwash


4. Draw up 10mls of Sodium Chloride 0.9% w/v (attach bare cannula if using Interlink).

5. Draw up 5mls Heparinised Saline into 10ml syringe (attach bare cannula if using Interlink).

5. Larger syringe is recommended by manufacturer. This minimises pressure in the line and blood vessel.

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6. Assemble vacutainer device(attach bare cannula if using Interlink).

6. This device minimises the risk of needlestick injuries.

7. If CVC in use device close clamp on CVC and switch off infusion.

8. Put on non-sterile gloves. 8. To protect the healthcare worker from body fluid contamination.

9. Holding CVC near the end wipe around the end of the closed luer lock connector with alcohol impregnated swab, allow to dry fully (minimum of 30 seconds).


10.Ensure clamp on CVC lumen is closed. Insert needle-less end of blue vacutainer into the closed luer lock connector. 11. Attach spare blood tube, open clamp on lumen, and withdraw 10mls of blood, close clamp, and discard initial blood sample. *See note in relation to blood cultures

11. To ensure blood specimen is not contaminated.

12.Take the other blood samples closing the clamp between each tube. (start with plain tubes and then additive tubes inverting gently)

12. This ensures that plain tubes are not contaminated by additives from

other tubes.

13.Close CVC clamp and remove vacutainer device/syringe and discard in sharps container.

14. Attach syringe containing Sodium Chloride 0.9% w/v to closed luer lock connector, open CVC clamp, and flush using push pause technique. Close clamp and remove syringe.


15. Attach syringe containing Heparinised Saline, open clamp and flush, close clamp and remove syringe.

15. Prevents line from becoming occluded.

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16. Ensure blood tubes are correctly identified with patient details (addressogram labels are not acceptable). Forward specimens to laboratory with completed request form.

16. Ensure patient safety.



*For blood cultures, it is important that potential infection in the CVC device is not discarded, so therefore point 11. should be ignored and no blood should be discarded.

Trouble shooting

Unable to get blood - If the line is flushing but you are unable to withdraw blood, it may be due to a positional problem.

- Ask the patient to change position e.g. sit forward or back.- Ask the patient to lift their arm up and down- Ask the patient to cough- Ask the patient to breath deeplySometimes the above will be enough to move the line. If none of the above work do not persist, simply flush the line and leave it. Inform medical staff of the inability to obtain blood.

Unable to flush or get blood - Check that where the clamp has been closed the lumen is not indented,

massaging gently to prevent pinching can open the lumen.- You should never feel anything other than slight resistance, if you do the

line requires assessment.

Do not under any circumstances try to force fluid into the line, the extra pressure may be caused by a clot which has formed at the end of the lumen.

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Paediatric - Procedure for Taking Blood from Central Venous Catheters (CVC)

If line sepsis is suspected blood cultures will be required to be taken from the CVC.

The use of vacutainer system may not be appropriate in paediatrics.

Requirements

1. Non sterile gloves2. Blood tubes and /or blood culture bottles for required tests 3. Alcohol impregnated swabs4. Syringes 5. Needles are required if taking blood cultures6. 5mls Heparinised Saline7. 10mls of Sodium Chloride 0.9% w/v8. Chlorhexidine handwash solution e.g. Hibiscrub® with pump dispenser9. Request form with patient details

Procedure Rationale



2. Assemble relevant blood specimen tubes as requested on the request form and all relevant equipment.

3. Wash hands using Chlorhexidine handwash solution.


4. Draw up 10mls of Sodium Chloride 0.9% w/v.

5. Draw up 5mls Heparinised Saline into 10ml syringe

5. Larger syringe is recommended by manufacturer. This minimises pressure in the line and blood vessel.

6. If CVC in use close clamp on CVC and switch off infusion device.

7. Put on non-sterile gloves. 7. To protect the healthcare worker from body fluid contamination

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8. Holding CVC near the end wipe around the end of the closed luer lock connector with alcohol impregnated swab, allow to dry fully (minimum of 30 seconds).


9. Insert syringe into closed luer lock system. Unclamp CVC and gently withdraw 2mls blood. Clamp CVC remove syringe and discard sample.

*See note in relation to blood cultures.

10. Insert new syringe into closed luer lock system, open clamp on CVC and gently remove sufficient blood for samples required. Clamp CVC and remove syringe.

10. To ensure blood specimen is not contaminated.

11. Attach syringe containing Sodium Chloride 0.9% w/v to closed luer lock connector, open CVC clamp, and flush using push pause technique. Close clamp and remove syringe.


12. Attach syringe containing Heparinised Saline, open clamp and flush, close clamp and remove syringe.

12. Prevents line from becoming occluded.

13. Fill blood tubes with appropriate quantity of blood. If taking blood cultures (a) Wipe blood culture bottle top with

alcohol swab and allow to dry(b) attach needle to syringe (c) insert into rubber bung of culture

bottle allow vacuum to draw blood into bottle.

(d) Discard needle and syringe immediately into sharps container.

14. Ensure blood tubes are correctly identified with patient details (addressogram labels are not acceptable). Forward specimens to laboratory with completed request form.

14. Ensure patient safety.

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*For blood cultures, it is important that potential infection in the CVC device is not discarded, so therefore point 9 should be ignored and no blood should be discarded.

Trouble shooting

Unable to get blood - If the line is flushing but you are unable to withdraw blood, it may be due to a positional problem.

- Ask the patient to change position e.g. sit forward or back.- Ask the patient to lift their arm up and down- Ask the patient to cough- Ask the patient to breath deeplySometimes the above will be enough to move the line. If none of the above work do not persist, simply flush the line and leave it. Inform medical staff of inability to obtain blood.

Unable to flush or get blood - Check that where the clamp has been closed the lumen is not indented,

massaging gently to prevent pinching can open the lumen.- You should never feel anything other than slight resistance, if you do the

line requires assessment.

Do not under any circumstances try to force fluid into the line, the extra pressure may be caused by a clot which has formed at the end of the lumen.

29

Procedure for Removal of a Central Venous Catheter (CVC).

This is an aseptic technique performed by a doctor or qualified nurse trained in the procedure.

The valsalva manoeuvre is performed by requesting the patient to take a breath in and attempt to breath out with their mouth and nose closed. Some patients may find it useful to pinch their nose closed whilst performing this manoeuvre. (See note)

Please note; if the CVC has a dacron cuff (e.g. a Hickman type line) it will need to be dissected out in the operating theatre, unless staff have been specifically trained in this procedure.

Requirements

1. Dressing pack2. Sterile scissors (if tip of CVC required for microbiology)3. Universal container (if required for CVC tip)4. Stitch cutter and forceps (if required)5. Non sterile gloves x 1pr6. Sterile procedure gloves x 1pr7. Adhesive airtight dressing8. Chlorhexidine 0.5% in 70% IMS9. Chlorhexidine hand wash solution e.g. Hibiscrub® with pump dispenser10.Alcohol hand gel e.g. Spirigel® with pump dispenser

Procedure Rationale



2. Explain procedure to patient, including the valsalva manoeuvre and gain consent to remove central line.

2. To decrease anxiety and increase compliance to ensure safe removal of the central line and prevent complications.

3. Wash hands with Chlorhexidine hand wash solution.


4. Position patient lying flat in bed with one pillow under shoulders and head.

4. This raises the central venous pressure above atmospheric pressure and may prevent air being aspirated into the venous system.

5. Switch off any IV infusions running through CVC.

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7. Open dressing pack and then open all other requirements onto sterile field. Pour a small amount of Chlorhexidine 0.5 in 70% IMS into one of the containers in the tray of the dressing pack.

7. To maintain asepsis.

8. Open gloves and place onto another clean surface.

8. To minimise contamination of open dressing pack.

9. Put on non-sterile gloves. 9. To protect the healthcare worker from body fluid contamination

10.Remove old dressing carefully from CVC site. 11.Remove non sterile gloves and discard.

12.Decontaminate hands with Alcohol hand gel and apply sterile gloves.


13 Clean exit site with cleansing solution.


14. Remove sutures if present.

15. Ask the patient to perform the valsalva manoeuvre (*or to take a breath and hold it.)

15. This manoeuvre raises intrathoracic pressure and will minimise the risk of air embolism.

16. Hold the CVC near the exit site and while the patient is doing the valsalva manoeuvre (see note) remove CVC. If resistance is felt stop immediately and seek medical advice.

16. Holding the catheter near the exit site ensures stability along the length of the catheter. This reduces the risk of CVC fracture.

17. As the catheter is withdrawn, apply gentle pressure around the exit site using a gauze swab.

17. To prevent haemorrhage and bruising.

18. If the tip of the CVC is required for microbiology, it should be placed into a universal container held by an assistant, who should then cut the catheter with the sterile scissors.

18. CVC tips should only be sent to microbiology if there are clear clinical indications or on medical instruction.

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19. Continue to apply firm pressure until bleeding has stopped.

19. To prevent haemorrhage and bruising.

20. Remove gloves and discard

21. Apply a small airtight dressing to the exit site which should remain in situ for 48 hours.

21. Fibrin tracts can form along the length of the CVC , which can provide a portal for air entry after removal of the CVC. An airtight dressing will help to prevent this and give the tract time to heal.

22. Check the catheter is intact. The tip should be smooth, not ragged.

22. To ensure no catheter fracture. If suspected inform medical staff immediately

23. Reposition the patient for comfort and observe the site closely for 30mins.

23. To observe for signs of re-bleeding and swelling.

24. Follow Post Procedure General Directions


25. Document procedure in nursing notes.

Note“A Valsalva manoeuvre (forced expiration against a closed glottis) in the supine position may be the most effective technique. A practical way of achieving this without protracted explanation is to ask the patient to blow into a 20ml syringe with enough force to push back the plunger. They will not be able to achieve this, but they will perform the valsalva manoeuvre during the attempt. “

Advanced Life Support Course Provider manual 4th Edition (Revised) 2004Resuscitation Council (UK)

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References

1. Arduino MJ Bland LA Danzig LE McAllister SK Aguero SM (1997) Microbiologic evaluation of needleless and needle-access devices American Journal of Infection Control 25 (5) 377-80

2. Brandt B DePalma J Irwin M Shogan J Lucke JF (1996) Comparison of central venous catheter dressings in bone marrow recipients Oncology Nursing Forum 23 (5) 829-36

3. Clemence MA Walker D Farr BM (1995) Central venous catheter practices: results of a survey American Journal of Infection Control 23 (1) 5-12

4. Dickerson N, Horton P, Smith S Rose RC (1989) Clinical significance Central Venous Catheter infections in a community hospital: associated with type of dressing Journal of Infectious Diseases 160 720-721

5. Dougarty L (1992) Intravenous therapy care of IV lines Surgical Nurse 5 (2) 10-13

6. Drewett S (2000) Complications of central venous catheters: nursing care British Journal of Nursing 9 (8) 466-478

7. Elliot TSJ (1993) Line associated bacteremia Communicable Diseases Report 3 91-95

8. Engervald P Ringerz S Hogman E Skogman K Bjorkholm M 1995 Change of central venous catheter dressings twice a week is superior to once a week in patients with haematological malignancies Journal of Hospital Infection 29 (4) 275-286.

9. Farkas JC Liu N, Bleriot JP, Chevret S, Goldstein FW, Carlet J (1992) Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population American Journal of Medicine 93(3)277-82

10. Freiberger D Bryant J Marino B (1992) The effects of different central venous line dressing changes on bacterial growth in a pediatric population Journal of Pediatric Oncology Nursing 9 (1) 3-7

11. Garland JS Buck RK Maloney P Durkin DM Toth-Lloyd S Duffy M Ssocik P McAuliffe TL Goldman D (1995) Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonisation in neonates: a prospective trial Pediatric Infection Diseases Journal 14 (6) 510-6

12. Goetz AM, Wagener MM, Miller JM, Muder RR (1998) Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infection Control Hospital Epidemiology 19(11)842-5

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13. Hoffman KK Weber DJ Samsa GP Rutala W (1992) Transparent polyurethane film as an intravenous catheter dressing. Journal American Medical Association 267 2072-2076

14. Horton R (1995) Handwashing: the fundamental infection control principle British Journal of Nursing (40 16 926-933

15. Humar A Ostromecki A Direnfeld J Marshall JC Lazar N Houston PC Boiteau P Conly JM (2000) Prospective randomised trial of 10% povidone-iodine versus 0,5% tincture of chlorhexidine as cutaneous antiseptics for prevention of central venous catheter infection Clinical Infection Diseases 31 (4) 1001-7

16. Ihrig M Cookson ST Campbell K Hartstein AI Jarvis WR (1997) Evaluation of the acceptability of a needleless vascular access system by nurses American Journal of Infection Control

17. Johnson BH, Rypins EB (1990) Single-lumen vs double-lumen catheters for total parenteral nutrition. A randomized, prospective trial. Archives of Surgery 125(8) 990-2

18. Kennlyside D (1992) Every little detail counts. Infection control in intravenous therapy Professional Nurse 7 (4) 226-232

19. Little K, Palmer D (1998) Central line exit sites: which dressing? Nursing Standard 12 (48) 42-44

20. Lucas H, Attard -Montalto S (1996) The effectiveness of dressings in reducing exit site infection following central venous catheterization Paediatric Nursing 8 (6) 21-3

21. Luebke MA Arduino MJ Duda DL Dudar TE McAllister SK Bland LA Wesley JR (1998) American Journal of Infection Control 26 (4) 437-41

22. Ma TY, Yoshinaka R, Banaag A, Johnson B, Davis S, Berman SM (1998) Total parenteral nutrition via multilumen catheters does not increase the risk of catheter-related sepsis: a randomized, prospective study. Clinical Infection Diseases ;27(3) 500-3

23. Madeo M, Martin C, Nobbs A (1997) A randomized study comparing IV 3000 (transparent polyurethane dressing) to a dry gauze dressing for peripheral intravenous catheter sites. Journal of Intravenous Nursing 20(5)253-6

24. Maki D.G, Ringer M, Alvarado CJ (1991) Prospective randomised trial of providone-iodine, alcohol and chlorhexidine for prevention of infection associated with central venous and arterial catheters The lancet 338 339-342

25. McCarthy MC, Shives JK, Robison RJ, Broadie TA (1987) Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. Journal of Parenteral Enteral Nutrition 11(3) 259-62

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26. Meers P Jacobsen W McPherson M (1992) Hospital Infection Control for Nurses Chapman and Hall

27. Mimoz O Pieroni L Lawrence C Edouard A Costa Y Samii K Brun-Buisson C (1996) Prospective randomised trial of two antiseptic solutions for the prevention of arterial central venous catheter colonisation and infection in intensive care unit patient Critical Care Medicine 24 (11) 1818-23

28. Nelson DB., Kien CL, Mohr B, Frank S, Davis SD. (1986) Dressing changes by specialised personnel reduce the infection rates in patients receiving central venous parenteral nutrition Journal of Parenteral and Enteral Nutrition 10 (2) 220-2

29. Parras F, Ena J, Bouza E, Guerrero MC, Moreno S, Galvez T, Cercenado E (1994) Impact of an educational program for the prevention of colonization of intravascular catheters. Infection Control Hospital Epidemiology 15(4 Pt 1) 239-42

30. Pemberton LB Ross V Cuddy P Kremer H Fessler T McGurk E (1986) No difference between standard and antiseptic central venous catheters. A prospective randomised trial Archives of Surgery 131 (9) 986-9

31. Roberts PH (1993) Simply a case of good practice Professional Nurse 8 (12) 775-779

32. Segura M, Alvarez-Lerma F, Tellado JM, Jimenez-Ferreres J, Oms L, Rello J, Baro T, Sanchez R, Morera A, Mariscal D, Marrugat J, Sitges-Serra A (1996) A clinical trail of the prevention of catheter related sepsis using a new hub model Annals of Surgery 223 (4) 363-9

33. Seymour VM Dhallu TS Moss HA Tebbs SE Elliot TS (2000) A prospective clinical study to investigate the microbial contamination of a needleless connector Journal of Hospital Infection 45 (2) 165-8

34. Shivnan JC McGuire D Freedman S Sharkazy E Bosserman G Larson e grouleff P (1991) A comparison of transparent adherent and dry sterile gauze dressing for long term central catheters in patients undergoing bone marrow transplant Oncology Nursing Forum 18 1349-1356

35. Sitges Serra A, Linares J, Garau J (1984) Catheter Sepsis :The clue is the hub Surgery 97 (3) 355-7

36. Sitges-Serra A, Pi-Serra T, Garces JM, Segura M (1995) Pathogenesis and prevention of catheter related septicaemia American Journal of Infection Control 23 (5) 310-16

37. Taylor D Myers ST Monarch K (1996) Use of occlusive dressings on central venous catheter sites in hospitalised children Journal of Pediatric Nursing 11 (3) 169-74

38. Veenstra DL Saint S Saha S Lumley T Sullivan SD (1999) Efficacy of antiseptic-impregnated central venous catheters in preventing catheter related bloodstream infections: a meta analysis Journal American Medical Association 281 (3) 261-7

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39. Young GP, Alexeyeff M, Russel DM Thomas RJ (1988) Catheter sepsis during parenteral nutrition: the safety of long term OpSite dressings Journal of Parenteral and Enteral Nutrition 12 365-370

Bibliography

1. APIC Guideline for handwashing and hand antiseptics in health care settings (1995) American Journal of Infection Control 23 (4) 251-69

2. Guideline for prevention of intravascular device-related infections An overview. The hospital Infection Control Practices Advisory Committee Pearson ML American Journal of Infection control 1996 24 (4) 262-93

3. Resuscitation Council UK Advanced Life Support Provider Manual 4th Edition (Revised) Jan 2004 102

4. Nice Institute for Clinical Excellence - Technology Appraisal Guidance – No 49. Sept 2002 Guidance on the use of ultrasound locating devices for placing central venous catheters

5. Infection Control Nurses Association Guidelines for preventing intravascular catheter-related infection June 2001

6. Royal College of Nursing Standards for infusion therapy October 2003

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Appendix 1

Group Members

Dorothy Barber Nutrition Nurse SpecialistJustine Collie ANCHOR Development NurseVanessa Dunbar S/N TheatresLynne Flett S/N Ward 32Claire Fraser S/N Ward 35 HDUMary Glasgow Practice Educator GI & VascularMelaine Hendry S/N Neonatal Unit AMHSue Danby (nee Miles) Sister Ward 4 RACHAnne Smith Senior Nurse Infection Control

Acknowledgements To

Helen Corrigan Sister Infection UnitClaire Jamieson Practice EducatorTanya Learmonth Lead Nurse Chemotherapy TeamElaine Nicol Practice Educator RenalHelen Ogg Practice Educator General SurgeryLinda Still Sister Ward 35 HDUThe nurses from the Scottish Managed Clinical Network for Home Parenteral Nutrition

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Documents

Policy For The Management Of Central Venous … for the management of... · Web viewPolicy for the Management of Central Venous Catheters (CVC) Introduction A Central Venous Catheter