CENTRAL VENOUS CATHE TER GUIDELINES

Version 4.3 April 2021 - Review April 2022

Author: Emily Parsons, Practice Development nurse for Oncology, Haematology and Stem Cell Transplant/Reviewed BRHC Nurse Practice Group

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SETTING Division of Women’s and Children’s Services / All Paediatric Areas

FOR STAFF All trained staff and nurses

PATIENTS All patients due to have Central Venous Catheters

1.0 Introduction 2 2.0 Insertion of a CVC 3 2.1 Child and family preparation 2.2 Surgical Procedure 3.0 Potential Complications and Care 4 3.1 Immediate Post-Operative Complications and Care 3.2 Ongoing Risks and Complications 4.0 Training 5 4.1 Staff Training and Competence 4.2 Child and Family Education 5.0 Aseptic Technique 6 5.1 Aseptic Non Touch Technique (ANTT) 5.2 Aseptic Non Touch Technique (ANTT) A step by step guide 5.3 Aseptic Non Touch Technique (ANTT) A step by step guide for Anaesthetists 6.0 Sterile Non Touch Techniques 9 6.1 Sterile Non Touch Technique A step by step guide: Bung change 6.2 Sterile Non Touch Technique A step by step guide: TPN setup and connection 7.0 Accessing a Central Venous Catheter 10 7.1 Drug Administration Principles 7.2 Blood Sampling Principles 7.3 Setting Up and Administering Parenteral Nutrition 8.0 Infusion Equipment 11 8.1 MicroCLAVE Bungs: Principles of Use 8.3 Administration Sets and Add On Devices 8.4 Filters 9.0 Dressings 12 10.0 Bathing and Showering 12 10.1 Bathing 10.2 Showering 10.3 Bathing or showering with a Port 11.0 Swimming 13 12.0 CVC Patency 13 12.1 Maintaining catheter patency 12.2 Lock Solutions Guidance 12.3 Recommended frequency of flush and lock procedure 12.4 For Management Of Persistent Withdrawal Occlusion (PWO) Or Blocked CVC 12.5 Use of Urokinase 12.6 Milking technique with 0.9% Sodium Chloride 12.7 Milking technique with Urokinase 12.8 Push lock technique 12.9 3 Way Tape Method 12.10 Volumes of Urokinase or Alteplase 12.11 Alteplase lock guidance 13.0 Use of CVC’s in Radiology 20 14.0 Hickman Catheters including repair of fractured CVC 20 15.0 Totally Implantable Intravenous Devices ‘Ports’ 26 16.0 Haemodialysis and Apheresis Catheters 28 17.0 Peripherally Inserted Central Venous Catheter ‘PICC’ 29 18.0 Care of Short Term Central Venous Catheters on Wards 34 19.0 Intravenous Midline Catheters 37 References 37

Clinical Guideline

CENTRAL VENOUS CATHETER GUIDELINES



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1.0 INTRODUCTION Within the Bristol Royal Hospital for Children a variety of Central Venous Catheters (CVC) are used. These include:

Tunnelled central venous cuffed catheters (e.g. Hickman, Broviac, Cook and Groshong) Totally implantable intravascular devices (Ports) Peripherally inserted central catheters (PICC) lines beyond neonatal period. Short and Long-term Dialysis catheters Short term central venous catheters (required for less than 30 days).

CVC’s may be used to provide access for children and adolescents requiring intensive intravenous therapy, for example:

Chemotherapy administration Stem cell transplantation Parenteral nutrition Frequent blood sampling Blood product administration Drug therapy for specific disorders or conditions Haemodialysis Apheresis

These guidelines are to be used in conjunction with;

UHBW Aseptic Non Touch Technique Policy TPN guidelines link

http://nww.avon.nhs.uk/dms/download.aspx?did=7740




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2.0 INSERTION OF A CVC 2.1 Child and Family Preparation

Preparation and education should be provided to the child and family prior to the insertion of a CVC. Resources such as the play specialists, Chester Chest , Hickman Catheter – Information for Patients, Parents and Carers, PICC line Competency Pack and, Port information booklet may facilitate this.

The CVC placement site should be discussed with the child and family as part of the

consent process. 2.2 Surgical Procedure

Long term CVC are inserted in theatre under general anaesthetic using optimum aseptic procedures (Pratt et.al 2013).

Prior to CVC insertion the skin should be decontaminated with two applications of 2% chlorhexidine gluconate in 70% alcohol solution (Pratt et.al. 2013) using a single use applicator (ChloroPrep®). Allow to dry before second application and before commencing insertion procedure.

Ultrasound guided percutaneous insertion is standard but the surgeon may choose an open insertion particularly if the external jugular vein is accessable (NICE accessed 2017).

Tunnelled CVC are inserted into the internal or external jugular, subclavian or femoral vein

and then advanced until the catheter tip is just within the right atrium. A subcutaneous tunnel is formed and the catheter is pulled through to an exit site created

on the chest wall. If the femoral vein has been used the exit-site will be on the abdomen. The CVC has a Dacron cuff positioned subcutaneously. This stimulates growth of fibrin around it, providing anchorage of the line and a barrier to ascending micro-organisms.

Implantable ports are inserted in the same way as a Tunnelled CVC. However, the distal

end is attached to a stainless steel, titanium or plastic port, which is implanted in a subcutaneous pocket, usually in the chest wall. The port is secured to the chest wall with sutures. A non-coring (Perfusafe 2 needle) port needle should be used to access the port to prevent damage to the port septum. Following the port insertion procedure the port needle should be left in situ until the patient’s treatment plan and discharge is reviewed by the clinical team. The correct size of port needle required for the patient’s port should be documented within the surgical notes.

CVC’s differ in the number of lumens and the diameter of each lumen. When selecting a

catheter, “use a CVC with the minimum number of ports or lumens essential for the management of the patient” (Pratt et.al. 2013). The type, size and lot number of the CVC inserted should be documented in the patient’s notes to help determine catheter volumes as well as facilitating repair if the catheter becomes damaged.

Syringes of 10ml or greater should be used to access a CVC as the high flush pressure generated by syringes smaller than 10ml can rupture the line.

The position of the catheter and tip should be checked by image intensification in theatre,



http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=23218&f=PiccLinesPeripherallyInsertedCentralVenousCatheter-02.pdf





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and the confirmation of this documented in the operation notes, within the patients notes, prior to utilising the catheter (NICE accessed 2017).

The instrument and guide-wire count needs to be checked at the time of insertion and

documented correctly.

PICC and short term CVC lines may be inserted on the ward by a trained practitioner using optimal aseptic technique. The PICC is inserted into a suitable peripheral vein and then advanced to a more central position. This is commonly from the antecubital fossa into the superior vena cava. All lines must be X-rayed following insertion, to check the tip is in the correct position before it can be used.

3.0 POTENTIAL COMPLICATIONS AND CARE 3.1 Immediate Post-Operative Complications And Care Potential Post Operative Complications following the insertion of a CVC are:

• Infection • Thrombosis • Perforation of vessels and myocardium • Pleural collections • Cardiac arrhythmias • Air embolism • Guidewire/catheter embolism • Catheter occlusion • Catheter breakage/leak/extravasation • Bleeding elsewhere • Central venous stenosis • Neurological injury (Association of Anaesthetists of Great Britain and Ireland: 2016)

Therefore, careful assessment of the patient’s condition following a CVC insertion is required.

Before the line is used, check the operation note to confirm both that the CVC tip position has been documented and that the line is ready to use.

Post-operative patient assessment should include; monitoring of temperature, pulse, blood pressure, respiratory rate and oxygen saturations.

Post-operative assessment of the CVC should include; observation and documentation of the line insertion site, skin tunnel and exit site.

The CVC should be accessed and assessed for blood return and that individual lumens flush without resistance.

If there is any difficulty aspirating blood or blood samples are observed to be dilute, there is increased swelling around the line site, significant pain or the patient’s condition deteriorates stop using CVC. Ask for a medical assessment and notify the person who inserted it.

If there is a concern that the line has become misplaced, then imaging should be performed prior to further use or removal of the line.

3.2 Ongoing Risks And Complications The ongoing risks and potential complications associated with the use of CVC’s are:



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Infection; systemic catheter-related infection, exit site infection, tunnel infections or pocket infection.

Occlusion or thrombosis Damage to the CVC such as fracture or embolisation Accidental dislodgement Infiltration or extravasation (Hamilton 2006: Part 2). Syringes of less than 10ml should not be used to access a CVC as the high flush

pressure generated by a syringe smaller than 10ml can rupture the line.

3.3 Documentation using online data base • At the time of insertion patient details and type of central line inserted will be recorded into a

trust electronic database. • At the time of removal the database should be updated to record date of CVC removal and

the clinical indication for doing so. • Complications during ongoing care such as CVC infection, blockage or damage should be

recorded onto the database and outcome of any intervention documentated. 4.0 TRAINING 4.1 Staff Training and Competence

In order to reduce the risks and prevent complications associated with the use of CVC’s, only those trained and assessed as competent should be involved in accessing and caring for these devices (INS, 2016).

The Paediatric Practitioners Vascular Access Management Competency Bookshould be used for training and competency assessment.

Separate training and competency in Haemodialysis and Apheresis CVC access and care Haemodialysis and Apheresis CVC access and careis required due to the risks associated with the anti-coagulant ‘lock’ solution.

4.2 Child And Family Education

The child and family should receive education and training in the risks associated with a CVC and the appropriate monitoring and ongoing care of the device Hickman, Port and PICC patient pack(RCN 2016).

This includes daily inspection of the exit site (DOH 2007), weeklydressing changes and specific training in CVC safety.

A CVC Safety Pack should be provided, with training, so that the carer or child knows what to do in case of an emergency.

If carers or patients are required to undertake additional interventions involving the CVC, such as administering intravenous medication, specific training must be provided and competency assessed and documented in the patients notes (RCN 2016).

5.0 ASEPTIC TECHNIQUE 5.1 Aseptic Non Touch Technique (ANTT)

http://workspaces/sites/teams10/BCHNursing/Working%20Group%20Papers/Clinical%20Competencies/Paediatric%20Practitioner’s%20Vascular%20Access%20Management%20Competency%20Book.pdf


http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=23042&f=HaemodialysisApheresisCentralVenousCatheters-3_0.pdf




http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5820&f=3ResourcesHickmanLineSafetyPackContents-1.pdf



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Effective hand washing practice used alongside Aseptic Non Touch Technique (ANTT) is vital in reducing the risk of infection and should be applied to all aspects of the care and management of CVC (Pratt et.al. 2013, RCN 2016). Key principles of ANTT include:

Effective hand washing before and after patient contact and if hands become contaminated during the procedure (Rowley 2010, DOH 2007).

The use of personal protective equipment including gloves and aprons. Additional equipment such as eye protection may be required in some high risk procedures (Rowley 2010).

Protection of key parts: ‘Those parts, if contaminated by infectious material, increase the risk of infection. In IV therapy, key parts are usually parts of equipment which come into direct contact with the infusate – for instance, needles, syringe tips, IV line connections or central line lumens’ (Rowley 2010).

Prior to accessing the CVC, the bung should be scrubed using a scrubbing action for 15 seconds and then allowed to dry for 30 seconds (Pratt et.al. 2013).

An annual audit of ANTT practice will be carried out in each clinical area.

5.2 Aseptic Non Touch Technique (ANTT) for Intravenous (IV) Practice. A step by step guide



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Remember: Wash all work surfaces on a daily basis Clean all trays after each patient use

1. All watches and rings must be removed and the practitioner must be naked below the elbow.

2. Wash & dry hands thoroughly.

3. Put on a clean, disposable apron.

4. Clean tray inside and out, including the base.

5. Whilst the tray is drying, gather equipment required. Place to the side of the tray.

6. Alcogel or re-wash hands.

7. Put on non-sterile gloves. If contaminated at any time, remove, alcogel hands & put on a new pair of gloves.

8. Peel open syringe and needle packaging, without touching key parts (i.e. tip of syringe + needle hub) & connect together before placing in the tray.

9. Open 0.9% sodium chloride & draw up. Attach label to identify & place syringe in tray.

10. Mix IV medication & draw up as per protocol. Label syringes.

11. Remove gloves and place a new set in the tray ready to use when accessing the patients line.

ONLY HAVE IN YOUR TRAY WHAT YOU NEED TO GO TO YOUR PATIENT. THERE SHOULD BE NO WRAPPERS, EMPTY BOTTLES OR VIALS.

1. Go to the patient & expose IV access. Alcogel or re-wash hands before applying clean gloves.

2. Using a scrubbing action, clean hub of bung with a 2% chlorhexidine gluconate in 70% alcohol wipe for 15 seconds. Allow to dry for 30 seconds.

3. Connect syringe to bung.

4. Clamp off line in between pushes.

5. Administer IV medication as per medicines code and Medusa.

6. Flush with appropriate solution between drugs.

7. Flush and lock off line as per guidelines, using positive pressure to lock off.

8. Clean bung with 2% chlorhexidine gluconate in 70% alcohol wipe at the completion of any access procedure.

9. Dispose of all sharps and used equipment safely.

10. Wash and dry hands.

Use Sterile ANTT procedure for: Set up & connection of TPN, insertion of Port needle, during bung changes, any IV activity for NICU patients, gastrointestinal patients on long term TPN, any intervention with Haemodialysis/Apheresis catheters.

5.3 Aseptic Non Touch Technique (ANTT) A step by step guide: For Anaesthetists Accessing IV Lines



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1. All watches and rings must be removed.

2. Wash and dry hands thoroughly.

3. Acquire a clean tray & the equipment needed for drug administration.

4. Put on non-sterile gloves.

5. Peel open syringes and needle packaging, without touching key areas (i.e. tip of syringe + needle hub) and connect together before placing in the tray.

6. Draw up medications and flush (0.9% sodium chloride or Heparin Sodium 10units/mL)

ONLY HAVE IN YOUR TRAY WHAT YOU NEED TO GO TO YOUR PATIENT. THERE SHOULD BE NO WRAPPERS, EMPTY BOTTLES OR VIALS.

1. Go to the patient & expose and unclamp the line.

2. Using a scrubbing action, clean the bung with 2% chlorhexidine gluconate in 70% alcohol wipe for 15 seconds. Allow bung to dry for 30 seconds.

3. Administer medication, flush and lock off as per manufacturers guidelines and medusa, using positive pressure to lock.

4. Clean bung with 2% chlorhexidine gluconate in 70% alcohol wipe at the completion of any access procedure.

5. Dispose of all sharps and used equipment safely.

6. Wash and dry hands on completion of patient contact.

6.0 SURGICAL NON TOUCH TECHNIQUES Surgical Non Touch Techniques should be used in:

All IV access in gastroenterology patients on long term Parenteral Nutrition (PN), Neonatal



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Intensive Care Unit (NICU) and Haemodialysis patients The setup and connection of Parenteral Nutrition Removal and changing of bungs Accessing a Port-a-Cath with a perfusafe 2needle Repair of CVC Undertaking any prolonged procedure

6.1 Surgical Non Touch Technique example A step-by-step guide: Bung change

1. Arms must be bare below the elbow

2. Wash and ry hands thoroughly.

3. Put on a clean, disposable apron

4. Gather together equipment: sterile gloves,4x alcohol wipes (2% Chlohexidine gluconate in

70% alcohol), Sterile gauze, new microclave bungs.

5. Wash and dry hands as per trust guideline.

6. Open sterile gloves and use inner wrapping as a sterile field.

7. Drop gauze, alcohol wipes and bungs onto sterile field.

8. Go to patient and expose line

9. Ensure all lumens are clamped

10. Wash and dry hands as per trust guideline

11. Put on sterile gloves being careful not to contaminate equipment.

12. Hold lumen with gauze to stabalise.

13. Clean connection area between lumen and bung with alcohol wipe and remove bung.

14. Clean luer lock area at end of lumen with new alcohol wipe for 15 seconds and allow to dry

for 30 seconds.

15. Securely connect new bung

16. Dispose of used equipment safely

17. Wash and dry hands as per trust guideline

18. Document procedure in patients care plan.

7.0 ACCESSING A CENTRAL VENOUS CATHETER 7.1 Drug Administration Principles

Inform patient of procedure. Follow ANTT principles.



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Prepare and check drugs as per prescription, following manufacturers and hospital guidelines.

Draw up appropriate flush and locking off solutions. Access the catheter and assess function, checking for blood return and ease of flushing. Syringes of less than 10ml should not be used to access a CVC as the high flush

pressure generated by a syringes smaller than 10ml can rupture the line. Administer drugs as per manufacturers and UHBW Medicines Code MO9 Flush and lock catheter as per guidelines (see section 12). Document drug administration in drug chart, fluid charts and patients notes as necessary.

7.2 Blood Sampling Principles

Inform patient of procedure. Follow ANTT principles. Draw up appropriate flush and locking off solutions. Turn off any ongoing infusions and clamp all lumens of CVC. Access the catheter and assess function, checking for blood return and ease of flushing. If catheter can be flushed, but it remains difficult to aspirate blood: reposition patient eg

raise arms, rotate head and neck, move from side to side or ask patient to breath deeply and cough (see Occlusion Guide: Section 12.3 if further intervention required).

For blood cultures only: withdraw blood from each lumen prior to flushing and place in blood culture bottles that have been cleaned with 2% chlorhexidine gluconate in 70% alcohol wipe. Take care not to contaminate sample or blood culture bottles. Ensure culture bottles are labelled with which lumen the sample was taken from.

For antibiotic levels and clotting samples: flush lumen with a minimum of 5ml 0.9% Sodium Chloride using a pulsating push-pause action then withdraw 5ml of blood for discard. Then withdraw required volume for blood sample

For all other blood samples. Withdraw 3-5ml (depending on size of lumen) of blood and discard syringe. The discard blood should not be replaced back into the patient unless clinically indicated

(i.e. frequent blood sampling or a very small patient) due to the risk of infection or reinfusion of a clot. A clear technique on how to reduce these risks should be demonstrated.

Withdraw required amount of blood for test sample. Flush lumen with 5-10ml of 0.9% Sodium Chloride using a pulsating push-pause action. Lock off with a positive pressure technique. Gently agitate blood syringe to mix sample well. Put blood sample in appropriate blood tube, using a blood transfer transfer device with

vacutainer blood bottles, being careful to provide an adequate volume. Check patient details and label samples at patient’s bedside.

7.3 Set Up and Administering Parenteral Nutrition (PN) Principles

Guidance and competency can be found in Paediatric Parenteral Nutrition Guide; TPN Administration Guideline for 1 or 2 Nurse Setup.

Ensure patient and carers understand the indications and risks of PN. PN of greater than 12.5% glucose concentration must only be administered via a central

venous catheter. Check PN with prescription and patient, ensuring PN is the correct date. If patient has a double lumen CVC there should be one lumen designated for PN (Pratt

et.al. 2013). Set up and administer to patient using a Sterile Non Touch Technique All infusion rates must be checked independently by two nurses.

Hospital patients should have routine monitoring of weight, fluid balance, blood glucose,

electrolytes, liver function, full blood count and coagulation. Document start of PN in fluid prescription chart.








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If the PN administration set is disconnected from the patient’s catheter at any time the PN and giving set should be discarded.

PN infusion should never be restarted once disconnected. 8.0 INFUSION EQUIPMENT 8.1 MicroCLAVE Bungs/Needle Free Devices

MicroCLAVE needle free device is a non-sharps system which enables direct syringe and giving set connection, whilst maintaining a closed system.

Prior to accessing, the hub of the bung must be decontaminated by scrubbing for 15 seconds with a 2% chlorhexidine gluconate in 70% alcohol wipe and then allowed to dry.

On completion of any accessing procedure the hub of the bung should be cleaned with a 2% chlorhexidine gluconate in 70% alcohol wipe. This is to ensure the bung access area is clean and no residual blood or drug particles remain.

MicroCLAVE bungs should be changed weekly or every 600 actuations, whichever come first.

Weekly changes for CVC bungs are routinely carried out on Thursday and documented in the patient’s notes.

MicroCLAVE bungs are not compatible with glass prefilled syringes. If treatment is required using a glass syringe bungs should be removed or an adaptor connection used.

See section 6.1 for Bung Changing Procedure 8.2 Administration Sets And Add On Devices

Intravenous giving sets in continuous use which remain connected to the patient, should be changed every 96 hours (Pratt et.al. 2013, RCN 2016).

Intravenous giving sets used for intermittent drug administration which remain connected to the patient should be changed every 24hours (RCN 2016)

Exceptions to this are blood products (maximum of 12 hours) and Lipid emulsions (24 hours), due to increased infection risk (RCN 2016).

Setup date and time labels must be applied to ensure administration sets are changed at the correct time (RCN 2016).

More frequent changes are necessary if contamination is suspected or the integrity of the infusion system has been compromised (INS 2016).

Intravenous giving sets should be discarded once disconnected from the patient (RCN 2016).

Intravenous giving sets should be changed using ANTT and following manufacturer’s recommendations.

Only recommended giving sets should be used in electronic infusion devices. Changes of any add on devices such as filters and extension sets should coincide with the

changing of the administration set (RCN 2016).

8.3 Filters Specific sized filters may be recommended for administration of certain medications or

blood products.

9.0 DRESSINGTHE CVC

See device specific guidance: Hickman (section 14), Ports (section 15) PICC’s (section 17), Short Term CVC’s (section 18).



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Transparent, semi-permeable, self-adhesive, sterile dressings are recommended to dress the CVC to enable observation of the exit site (Pratt et.al. 2013).

However sterile gauze type dressings may be used if there is bleeding or oozing post insertion or for patients who are allergic to a standard dressing (Pratt et.al. 2013).

When gauze dressings are used the exit site and dressing must then be assessed and changed daily (CDC 2011).

The CVC and dressing should be inspected at least once every shift and the dressing replaced weekly or if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016 & CDC 2011).

10.0 BATHING AND SHOWERING

Tunnelled CVC’s are held in position by tissue growth into a cuff under the skin. This cannot be relied upon for approximately four weeks.

Dressing and securement devices are therefore important in holding the CVC securely in place during this time and should be kept dry.

For the first four weeks, washing is best done sitting in a shallow bath, avoiding splashing by the child or and other children.

After four weeks normal showering or bathing can be resumed, but neither the CVC nor the exit site should be submerged under the water for any length of time.

After showering or bathing ensure that exit site and dressing is clean and dry.

10.1 Bathing

• The exit site and bung area of the CVC should be kept out of the water during bathing. • Do not allow the child to submerge or soak in the bath. • If the dressing becomes wet or loose during bathing the exit site should be dried with sterile

gauze and a new dressing applied.

10.2 Showering

• Showering can resume 4 weeks after insertion of the tunnelled CVC, once the exit site is healed.

• The dressing should be removed prior to showering. • Stand under clean running water from the shower. • It is not recommended to use soap or shower gel directly around the exit site. • After showering, dry the exit site with sterile gauze. • Apply a new dressing

10.3 Bathing or Showering with a Port

Showering is not recommended for ‘Ports’ which have been accessed with a needle. For Ports accessed with a needle it is advisable to wash in a shallow bath taking care not to

wet the Port or dressing. 11.0 SWIMMING

Swimming is not recommended for patients with most CVC's due to the risk of infection unless a specially designed dry suit is used.

Patients with a Port can swim as long as the Port is not accessed. 12.0 CVC PATENCY



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12.1 Maintaining Catheter Patency

Guidelines recommend routine flushing of CVC’s to promote and maintain catheter patency and prevent mixing of incompatible medications and/or solutions (RCN 2016). See chart for recommended frequency and lock solution (section 12.3).

The flush technique should involve pulsated push-pause action to create turbulence within the catheter lumen, removing debris from the internal catheter wall (RCN 2016).

When locking the CVC between uses a positive pressure technique should be used in order to prevent reflux of blood into the catheter (RCN 2016).

Syringes smaller than 10ml should NOT be used due to the risk of catheter damage from excessive pressure (RCN 2016).

12.2 Lock Solutions Guidance

On completion of an infusion, blood sampling or drug administration 0.9% Sodium Chloride should be used to flush the lumen using a pulsated push-pause.

For CVC lumens which are accessed 8 hourly or more 0.9% Sodium Chloride can be used as the lock solution using a positive pressure technique.

For CVC lumens used less frequently than 8 hourly or if there is a concern about maintaining patency a heparin lock solution is recommended to lock the catheter using a positive pressure technique.

The strength of Heparin prescribed is dependent on the type of CVC (see chart below) Be aware of the POTENTIAL ADVERSE EFFECTS ASSOCIATED WITH HEPARIN USE

e.g. bleeding complications, allergic reactions and autoimmune-mediated heparin induced thrombocytopenia (Pratt et. al. 2013)

Heparinised solution must be prescribed and each administration documented in the patients medication chart.

12.3 Recommended frequency of flush and lock procedure



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Line Type of lock Concentration Volume of the lock solution

Minimum Frequency of Flush/Lock

Hickman, Cook & Broviac

Heparin Sodium Flushing Solution

10 units/ml (INSP 2011)

3ml Weekly

Groshong 0.9% Sodium Chloride

- 5-10 ml Weekly

‘Ports’ Heparin Sodium Flushing Solution

100 units/ ml (INSP 2011)

4-6 ml Monthly

Haemodialysis and Apheresis lines

Refer to Guideline Renal & Non-renal patientsRenal and Non-renal patients

Caution: Locking solution must be aspirated prior to accessing line

Refer to volume on device

Minimum Weekly

PICC Size 1Fr 2Fr neonatal

Requires a continuous infusion to maintain patency (1ml/hr) Do not lock - requires constant flow

PICC Size 3Fr or greater

Heparin Sodium Flushing Solution

10 units/ ml 2-3ml Weekly

Short term CVC

0.9% Sodium Chloride

3-10ml 6 hourly

12.4 Management of Persistent withdrawal Occlusion (PWO) or Blocked CVC.

This algorithm is to be used when: There is persistent withdrawal occlusion (PWO), an inability to infuse/flush fluid or

sluggish flow through the catheter.



http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=18571&f=LineLocksAnticoagulantsForMaintainingPatencyOfHaem-2.pdf




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12.5 Use of Urokinase to manage CVC occlusions.

Urokinase will only work on blood related occlusions. It is of no use if the CVC lumen occlusion is due to drug precipitate.



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If unable to aspirate and remove Urokinase lock, try to flush the lumen with 0.9% Sodium Chloride and then re-assess patency.

Urokinase is eliminated rapidly from the circulation by the liver with a half-life of up to 20 minutes, therefore there is not recognised benefit for locking the lumen with Urokinase for an extended period of time such as 24hours.

The push lock technique is recommended when ever practical. If a lock of Urokinase is used reassessment can be done after 20 – 60minutes.

Urokinase should be restricted to hospital use only. Adequate diagnostic and monitoring techniques should be available, therefore administration or removal of Urokinase lock solutions should not be carried out in the community (Syner-KINASE® : 2015)

Current shortage of Urokinase, refer to temporary policy -Interim Central Venous Catheter Occlusion Guidance while Urokinase Supply is Low

12.6 Milking technique with 0.9% Sodium Chloride to manage a CVC occlusion

Draw up 3ml 0.9% Sodium chloride into a 10ml Leur Syringe. Using ANTT connect the leur syringe to the occluded CVC lumen Unclamp the lumen Draw back with the syringe to 6 or 7ml on the syringe.This will create a vacuum within the

CVC lumen Let go of the syringe plunger Draw back with the syringe to 6 or 7ml on the syringe Let go of the syringe plunger Repeat this procedure rapidly for a minute. Atempt to flush lumen. If lumen remains occluded, repeat the draw back - let go milking procedure multiple times Re-assess lumen function after 5 minutes of draw back - let go milk procedure. Continue to repeat the above procedure until catheter function returns.

12.7 Milking technique with Urokinase to manage a CVC occlusion

Draw up 5000units Urokinase in 1ml 0.9% Sodium Chloride into a 10ml Leur Syringe. Using Sterile ANTT remove bung from occluded lumen and connect the leur syringe Unclamp the lumen draw back with the syringe to 6 or 7ml on the syringe.This will create a vacuum within the

CVC lumen Let go of the syringe plunger Draw back with the syringe to 6 or 7ml on the syringe Let go of the syringe plunger Repeat this procedure rapidly for a minute. Atempt to inject the Urokinase into the lumen. If lumen remains occluded, repeat the draw back - let go milking procedure multiple times

until some of the Urokinase has been instilled in the lumen.

http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=22727&f=InterimCentralVenousCatheterOcclusionGuidanceWhile-1_2.pdf

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Clamp the lumen, remove the syringe and place a cap on the lumen end. Wait for a 1-2 hours and then assess lumen patency.

12.8 Push Lock Technique

Syner-Med (2015) Solutions for catheter management. 12.9 Procedure to be taken when unblocking a totally occluding catheter using Urokinase and a three way tap-Alteplase can also be used whilst urokinase is in shortage. Please note that UROKINASE will only work on blood related occlusions. It is of no use if the line occlusion is due to drug precipitate.

Equipment Needed: Dressing pack Sterile gloves

3 x 10mL luer lock syringes



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3 way tap 3 x Blue needles

0.9% Sodium Chloride for dilution

Urokinase 10,000 units

2% chlorohexidine gluconate in

70% alcohol wipes Bung or Cap

Procedure 1) Explain the

procedure to the patient. 2) Wash hands and prepare equipment. Ensure that a doctor prescribes the Urokinase. 3) Open the dressing pack. Tip needle, 2% chlorohexidine gluconate in 70% alcohol wipes, and 3-

way tap onto sterile field. Place vial of Urokinase & 0.9% Sodium Chloride outside the sterile field.

4) Wash hands again, put on sterile gloves and draw up 2mLs of 0.9% Sodium Chloride into one of

the syringes. 5) Reconstitute the 10,000 units of Urokinase with the 2ml 0.9% Sodium Chloride. Draw up 1mL

of the Urokinase solution (5,000 units) into syringe. Prime 3- way tap with Urokinase. 6) Clean bung and lumen junction with 2% chlorohexidine gluconate in 70% alcohol wipe, remove

bung and attach primed 3-way tap to blocked lumen (see diagram) 7) Attach the syringe containing 1ml of the reconstituted Urokinase to one access point of the 3-

way tap and the empty syringe to the other point. 8) Turn the off tap to the Urokinase - filled syringe and gently pull back on the empty syringe to

create a vacuum. Keeping the pull pressure on, turn the 3-way tap OFF to the empty syringe and ON to the urokinase. After a while some of the urokinse will be drawn into the empty syringe, so the empty syringe will now become your urokinase syringe and the other your empty syringe.

9) Repeat this procedure approx every 5 minutes or until all the Urokinase is inserted into the line.

This can take up to 20 minutes to complete. Once all the Urokinase is inserted, label the line clearly with date and time of insertion and leave in the line for as long as possible, preferably overnight.

10) When attempting to use the line again, first try to withdraw blood back to check for accurate

positioning of the line and to remove any surplus Urokinase. 11) Dispose of equipment as per hospital policy, wash hands and document in the patient’s notes.



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12.10 Volumes Of Urokinase or Alteplase Recommended lumen volumes for urokinase and Alteplase locks Cathether Urokinase volume (5000units) Alteplase Volume Single lumen Hickman 4Fr Dual lumen Hickman 7.0Fr

1ml 1.1ml

Dual lumen Hickman 9Fr or greater

1.6ml Blue lumen 2.1ml Yellow lumen

1.76ml Blue lumen 2.31 Yellow lumen

Implantable Ports 2ml 2.2ml Cook PICC 3/4 Fr 1ml 1.1ml Short Term CVC 0.3ml 0.33ml BARD Double lumen 7Fr 0.8ml Red lumen

0.6ml White lumen 0.88ml 0.66ml

BARD Single lumen 4.2Fr 0.3ml 0.33ml BARD Single lumen 6.6Fr 0.7 0.77ml BARD Single lumen 9.6Fr 1.8ml 1.98ml Vygon Double lumen 7Fr 1.1ml Large lumen

0.7ml Small lumen 1.21ml 0.77ml

Vygon Double lumen 9Fr 1.44 Both lumens 1.58ml Vygon Single lumen 5Fr 0.7ml 0.77ml Vygon Single lumen 6.6Fr 1.1ml 1.21ml Vygon Single lumen 9.6Fr 1.65 1.82ml BARD 4 Fr Single lumen PICC

0.67 0.74

BARD 5 Fr Single lumen PICC

0.66 0.73

BARD 5 Fr Double lumen PICC

0.57 (both) 0.63

BARD 6Fr Double lumen PICC

0.62 (both) 0.68

12.11 Alteplase Lock Guidance for CVCs

Ensure Alteplase is prescribed for management of CVC occlusion as 1mg/ml to instill the volume indicated for each lumen plus 10%. Therefore for a lumen volume of 1ml the



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prescription should be for 1.1ml Alteplase lock of 1mg in each ml. Gently mix 2.2mls of water for injection into a vial of Alteplase 2mg. Each vial contains

2.2mg which will provide a solution of 1mg/1ml. Withdraw the prescribed volume of Alteplase for each lumen. Using ANTT instill Alteplase into each lumen After 30minutes of dwell time, assess the CVC function by attempting to aspirate blood If unable to aspirate blood continue Alteplase lock for a total dwell time of 120minutes. Assess CVC function If unable to aspirate blood instill second dose of Alteplase and reassess following the

guidance above. If unable to aspirate blood after 120 minutes dwell time for second dose of Alteplase flush

lumen with 0.9%Sodium Chloride and reassess function. If CVC patency has not been resolved discuss next steps with medical staff.

Boehringer Ingelheim (2016) Actilyse Cathflo 2mg (alteplase) rt-PA for venous catheter occlusion. 13.0 USE OF CVCS IN RADIOLOGY

The standard Ports that are placed are “non-power” Ports and are only rated to a maximum pressure of 30psi. This means that they should not be used for Power injection of contrast.

However, the patient with a Port and Gripper or Perfusafe needle in situ can safely undergo MRI as these devices are rated as MRI Safe. (www.smiths-medical.com), Vygon (2016)

Hickman lines can be used to give intravenous contrast as long as the maximum safe flow-rate is not exceeded.

Generally flow rate should not exceed 2ml/sec and total dose of 2ml/kg. It is critical to check that no clamps are closedbefore starting the injection.

14.0 HICKMAN CATHETERS

Only staff or patients/carers trained and assessed as competent in the use of ‘Hickman Catheters’ should be involved in accessing and caring for these devices.

The size and the number of lumens of the Hickman Catheter may vary. Please refer to the surgical notes for a record of the specific brand and size of the CVC

Prior to discharge ‘Hickman Catheters’ A guide and competency pack for parents, patients and carers’ should be used to help the family understand about the Hickman Catheter, the daily assessment they should carry out and how to trouble shoot the problems which may happen.

A Safety Pack should be given to the patient/family prior to discharge along with training

and assessment that they understand how to use it if required.

A Safety Pack and a nurse/carer competent with central lines should bewith the patient at all times even when transferring to other departments or leaving the hospital.

14.1 Hickman Safety Pack Contents

2 blue clamps 2 sterile bungs

http://www.smiths-medical.com/



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Sterile gauze A small and large sterile dressing 4 2% chlorohexidine gluconate in 70% alcohol wipes A roll of tape A pair of non sterile gloves 2 Chloraprep® swabs Written information on trouble shooting potential problems.

14.2 DRESSING, CLEANING AND SECURING THE CVC

Short term or Newly inserted long term CVCs (the first month)

Following CVC insertion the original dressing should remain in place for no longer than 48

hours. A surgical dressing change procedure should be used until wound healing has occurred (for

the first 28 days for long term CVC insertion), then an aseptic non touch technique (ANTT) should be followed.

Transparent, semi-permeable, self-adhesive, sterile dressings are recommended to dress the CVC to enable observation of the exit site (Pratt et.al. 2013). However sterile gauze type dressings may be used if there is bleeding or oozing post insertion or for patients who are allergic to a standard dressing (Pratt et.al. 2013).

When gauze dressings are used the exit site and dressing must then be assessed and changed daily (CDC 2011).

The CVC entry and exit site, skin tunnel and dressing should be inspected daily and the dressing replaced weekly or if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016 & CDC 2011).

If the exit site, skin and CVC under the dressing is damp or soiled, the exit site should be cleaned using non touch technique with a single use 2% chlorhexidine gluconate in 70% alcohol applicator e.g. Enturia Chloraprep®.

During dressing change the exit site should be cleaned using sterile non touch technique with a single use 2% chlorhexidine gluconate in 70% alcohol applicator e.g. Enturia Chloraprep® (Pratt et.al 2013).

However routine cleaning of the exit site is not required for established tunnelled lines if they are visually clean.

For Long Term CVC’s the Nylon fixation sutures may be routinely removed after 4 weeks if: The cuff is securely fixed within the skin tunnel If the sutures irritate the skin or provide a focus for infection or debris collection. If the suture is too tight and causing CVC occlusion.

Steri-strips, if used, should be removed after 4-7 days. The condition of the exit site,skin tunnel, and dressing change procedures should be

documented in the patient notes and core care plan (RCN 2016). Securing the Hickman

Securing the CVC is essential to prevent accidental dislodgement or removal of the CVC (If

possible the CVC should be looped and secured to the chest wall with the dressing).

LOOP IT OR LOSE IT



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Fixation devices such as StatLock or tape may reduce twisting & pull on the CVC and

maintain stability. Vests made out of surgifix or vest tops for girls, may also help to secure and protect the line. For long term CVC’s due to skin sensitivity and/or patient preference a dressing is not

necessary once the CVC exit site is completely healed and the cuff incorporated (CDC 2011). However, the line should be well secured and kept clean and dry.

14.3 DAMAGE, ACCIDENTAL REMOVAL OR REPAIR Accidental Removal

Pressure should be applied to the original entry scar and the exit site in order to stop

bleeding. The patient should be assessed by the doctor on call and current treatment reviewed. Documentation should be made within the patient’s notes and a trust Clinical Incident Form

completed. Damage to a CVC

A CVC safety pack should be with the patient at all times. Plastic clamps should be applied proximal to the damaged area of the CVC, if only surgical

clamps are available protect the CVC from damage by wrapping sterile gauze around the CVC prior to clamping.

A sterile dressing should be applied to the area of damage to protect it until the line can be assessed for repair.

Repair of a CVC

Long term CVCs found to be split, leaking or damaged may be able to be repaired. Ideally repair should be done within 24 hours to reduce the risk of infection. Senior medical and nursing staff caring for the patient should be involved in the decision as

to whether a repair is worthwhile. Factors to consider are; Not all repairs work, there is approximately a 50% success rate. Are both lumens working or is one or both blocked? Is the leak, split or damage within 5cm of the exit site or double lumen Y junction? If

so a repair should not be carried out. Does the patient still require a long term CVC for treatment or would temporary

peripheral access be adequate? Can the patient’s treatment be managed with peripheral access for at least 24 hours

while the repair adhesive sets? Is a skilled and competent person available to do the repair? Do we have a repair kit of the correct brand and size?

Only members of staff who are trained and assessed as competent can carry out CVC repair.

Consult with the surgical registrar on call if there is no trained staff from within the clinical specialty.

Hickman Line repair kits are kept in BRHC theatres. Documentation should be made within the patient’s notes, a trust Clinical Incident Form

completed and the Central Line Database updated.



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Guidelines for the repair of Hickman Central Venous Catheters

A minimum of 5cm undamaged catheter external to the skin exit site is essential when repairing the main catheter body segment. A minimum of 2.5cm undamaged catheter below the bifurcation is required to repair a 'leg' of any multi lumen catheter. All repair kits are single use only. EQUIPMENT • Repair kit of appropriate Brand, size and expiry from theatre, make sure glue is with pack

• Dressing trolley

• Antiseptic: 2% chlorohexidine gluconate in 70% alcohol wipes and Chloroprep®

• Blue clamps x2

• Small removable clamps

• Straight blade scalpel

• Dressing pack – an Epidural Pack from theatre is helpful, this includes

• Drapes, gallipots, gauze.

• Sterile gloves x 2

• Blue cannula

• 10ml syringe x1*

• blue needle x1*

• 10ml ampoule 0.9% saline*

• 5ml ampoule Heparin (10iu/ml)*

• Tape

• Tegaderm Advance dressing

• Splint (i.e.5ml syringe plunger)

• MicroCLAVE Bung

PROCEDURE • Questions to ask when CVC fracture is reported;

Are there clamps insitu?



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When was the leak noticed?

Is the lumen filled with blood?

• Ensure conversation with senior staff i.e is repair a good idea; discuss fully risks & benefits with parents/child.

• It is often a good idea to assess the leak yourself, even to flush the line to check how extensive the leak is, where it is and if the lumen is patent

• Prepare child for procedure (this will not work if child is uncooperative. If child is crying increase in chest pressure will reduce chance of repair glue creating an effective seal).

• Clean dressing trolley

• Wash hands

• Put on plastic apron and non- sterile gloves.

• Put equipment onto sterile field.

• Wash hands thoroughly.

• Put on sterile gloves.

• Fill syringe with saline or heparin if using.

• Connect bungs to replacement lumens.

• Prime repair set with saline or heparin and clamp

• Slide plastic sleeve up and down new section of line to ensure it is loose.

• Go to child; make sure they are in a position which is comfortable for you to work.

• Remove child’s clothing to access catheter.

• Remove dressing around leak. You may also need to remove exit site dressing to give enough length to repair

• Ensure blue clamps x2 or replace with smaller slide clamps on Hickman catheter near skin exit site.

• Wash hands and put on sterile gloves

• Remove plunger from syringe barrel, fill with glue, re-insert plunger and attach needle provided (blunt). Push plunger until glue reaches end of needle.

• Clean the external segment of the catheter with 2% Chlorhexidine in 70% Alcohol wipes.

• Rest Hickman catheter on sterile drape.



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• Position catheter on flat surface such as small gally pot.

• Re-check Hickman catheter is clamped

• Using sterile scissors or scalpel cut the catheter cleanly above the damaged portion. *it is often difficult to create a straight cut.

Care; the remaining length of catheter must be sufficient to enable repair and prevent catheter retraction under the skin (min. 5cm). • If you wish to try and flush lumen, use the blue cannula, insert plastic straw without sharp into

the cut lumen and flush with heparin. This may not work. Dry cut end of catheter

• Insert metal inner of replacement catheter into Hickman catheter lumen leaving small gap, approx. 1-2mm.

Care; dual lumen repair catheters have two metal inner stents, one larger than the other, which fit into the two lumens of the original catheter. • Fill space between catheter ends with adhesive, using syringe provided, and push ends

together.

• Slide plastic sleeve over join.

Care; the repair can easily be pulled apart at this stage, ensure join is together. • Inject adhesive carefully under each end of plastic sleeve and roll between fingers to evenly

distribute. Wipe away any excess.

• Secure repair with splint (syringe plunger and mepore tape is ideal)

• Re-dress exit site.and secure CVC securely to patient to ensure that the repair is stable.

• Ideally the repair should be left for 24 hours prior to assessment and use to allow the adhesive time to set.

• Document in patient’s notes, include the barcode from the repair kit.

• Fill in Datix.

• In 24 hours attempt to aspirate and flush repaired Hickman catheter.

• Document outcome in patient notes and Medway Lines Database.

15.0 TOTALLY IMPLANTABLE INTRAVENOUS DEVICES (‘PORTS’)

Only staff or patients/carers trained and assessed as competent in the use of ‘Ports’ should be involved in accessing and caring for these devices.

‘Ports’ are produced by a range of manufacturers. The size and material the ‘Port’ is made

from will vary. Please refer to the surgical notes for a record of the specific length and make of the patient’s ‘Port’.



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Patient with a Port and huber needle in situ can safely undergo MRI as these devices are

rated as MRI Safe. (www.smiths-medical.com) Vygon (UK) Ltd Patients/families should be trained in safe care and assessment of the ‘Port’.

A Safety Pack and a nurse/carer competent with central lines should be with the patient at

all times even when transferring to other departments or leaving the hospital.

A ‘Port’ Kit should be given to the patient/family prior to discharge. This includes all the equipment necessary to access the device in an emergency.

‘Ports’ should be flushed and locked with 4 mL Heparin Sodium (100units per ml) at least

monthly as per manufacturer’s instructions (see Section 12.2).

A non- coring (Perfusafe 2) needle should be used to access the Port. The Port needle is changed weekly if ongoing access is required.

15.1 How to Access Port-a-Caths

15.2 Trouble Shooting

Judging port needle length Ask the family Review patient’s surgical notes and documentation of previous access Based on size of child, how much tissue over port area Remember the needle length required can change over time as the child grows

http://www.smiths-medical.com/

https://vygon.co.uk/

http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5823&f=6ResourcesHowToLookAfterYourPort-1.pdf

http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5824&f=7ResourcesPortKitContents-1.pdf



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If port does not bleed back: Not all ports will bleed back, ask the patient/family about the port and what is normal If the Port usually bleeds back, consider;

Flushing the port with a minimum of 10mls 0.9% Sodium Chloride. If the port is able to flush without resistance or visible swelling – re-check for blood return. If still unable to aspirate blood consider Urokinase lock.

If the port does not bleed back, you are unable to flush, there is resistance or unresolved and repeated occlusion alarms consider:

You have selected the wrong needle size, check the patient records for previous needle size selected. Attempt re-accessing with a longer needle.

The port needle is in the wrong position. Attempt to re-access as per 15.0 with a new needle.

Ask another trained member of staff to re-access If the needle has been pulled

Reassess needle position visually and by aspiration of blood and flushing If there are occlusion alarms during infusion

Reassess needle position visually, by aspiration and flushing

15.3 Documentation A clear record of port needle access and removal procedure should be recorded in the

patients notes. The label below can be ordered from the Trust Print Room The order number is ‘THQ0104-

Port Needle Access Record’.

15.4 Removal of port • 2 nurse technique:

• Remove dressing from around the port

• Attach syringe with 4mls of Heparin 100units/ml to cleaned bung

• Flush port under positive pressure and clamp



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• As the port is being clamped a second nurse should be ready and prepared to remove the port, making sure the ports safety mechanism engages before coming away from the patient.

• 1 nurse technique:

• Same as above but once heparin has been instilled the nurse should immediately remove the port making sure the safety mechanism engages.

16.0 HAEMODIALYSIS AND APHERESIS LINES

There are two main types – those for short term use (Acute lines) and those for long term use (Chronic Lines).

The acute lines are usually placed by percutaneous non-tunnelled technique by an anaesthetist under general anaesthesia. The chronic lines are tunneled surgically under general anaesthetic.

A selection of the differing types and sizes of acute and chronic lines are kept on the renal

unit (Lighthouse). The haemodialysis nurses will choose an appropriate line from a selection of several different sizes and types depending on the needs of the patient, enabling the surgeon to have a choice. These catheters will accompany the patient to theatre.

Patients with Acute Vascaths should not leave the hospital due to the difficulty in securing

the Vascath and the risk of bleeding or air embolism if the Vascath became dislodged.

All patients (except for Lighthouse) will have Alteplase (tissue-type Plasminogen Activator or TPA) used to lock haemodialysis catheters as per BRHC guidelines.

For patients on LighthouseHeparin 5000units/ml may be used for children older than two

years. Alteplase is used for children below 2 years age ( Refer to Line Locks for Maintenance and Patency of Haemodialysis/Apheresis Catheters, and SOP for accessing Haemodialysis lines: Haemodialysis/Apheresis Central Venous Catheters (H/A CVC)

The supply of heparin 5000units/ml is restricted to Lighthouse only.

Additional education and training are required prior to competency assessment for the use of a Haemodialysis catheter. Any member of qualified nursing staff who has been assessed as competent in the use of Haemodialysis/Aphereisis lines may access the lines.

Following the insertion in theatre, the line will be locked off with Heparin 10units/ml.

However due to their lumen size, there is a risk of blockage therefore to reduce the risk of blockage on return to the ward it is the responsibility of the nursing staff to remove the Heparin 10units/ml from the line and to “lock” the line with the lumen volume of prescribed Alteplase.

All line closures caps/bungs will be replaced with TEGO bungs. Sterile ANTT should be used for any line access procedure.







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17.0 PERIPHERALLLY INSERTED CENTRAL VENOUS CATHETER (PICC)

17.1 Bristol Royal Hospital for Children (BRHC) Definition and insertion PICC stands for peripherally inserted central venous catheter. It is made from a soft, flexible catheter material consisting of either silicone or polyurethane (Cook, 2004). The catheter has a needleless injection cap attached to the hub end and may include a winged portion for help with attachment to the skin. Most PICC’s have a plastic clamp on the external section of the lumen however some PICC’s have internal values and do not have an external clamp. PICCs can be inserted in theatre or may be inserted at the patients bedside using optimum sterile procedures. PICC lines are inserted into a peripheral vein and then carefully advanced upwards by way of the major veins of the upper arm or leg into the superior vena cava. Following insertion imaging is performed to confirm tip placement. Insertion documentation should include the make and size of catheter, any complications during the insertion procedure, tip location, the length of the PICC inserted, if the PICC has been cut to size and if it is safe to use. In some cases it is not possible to advance the PICC into the required central position. The final tip placement should be documented in the patients notes and all care and PICC management undertaken with the understanding that this is not a central line. For 1Fr (24G) or 2Fr (28G) PICCs, prior to placement confirmation, patency should be maintained with a continuous infusion of 0.9% Sodium Chloride at 1mL/hr and the infusion pressure on insertion document as a future reference. Maintaining Patency of PICC in BRHC Patency is maintained depending on the size of the PICC. For 1Fr (24G) or 2Fr (28G) a continuous infusion is is required to maintain patency. They should never be put on hold as this will lead to blockage. If a 1Fr or 2Fr PICC is used for a bolus medication the infusion should be restarted immediately after the PICC is flushed. The infusion pump pressure is usually high. The infusion pressure recorded on insertion should act as a guide. If the pump alarms with an occlusion pressure the PICC should be flushed. It is normal for the 1Fr or 2Fr PICC’s to be very stiff. If a line cannot be flushed is should be reviewed by a senior nurses or doctor. The CVC occlusion guidelines should be followed with early assessment to ensure the PICC has not become kinked or migrated. The 1Fr and 2Fr catheters have very small lumens and are not suitable for transfusing blood products or for aspiration of blood samples. For babies with 1Fr or 2Fr PICC a splint should be used to reduce the risk of blockage. For 3Fr or greater For PICC lines 3Fr or greater patency guidance is as per other central lines. They may be locked off between access with 10units Heparin Sodium using a positive pressure technique.



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Care of a PICC in BRHC Securement of PICC Post insertion where possible the PICC will be secured with a StatLock PICC securing device and this and the exit site will be covered by a sterile, transparent dressing. If there is no wing attachment on the PICC and a Statlock cannot be used then steri-strips should be in place under the dressing to secure a loop above the exit site. Assessment and documentation of PICC care The CVC exit site and vein track should be inspected at least every shift for signs of infection ( i.e. redness, tracking, pain, discharge). During intermittent drug administrations or continuous infusions hourly pump pressure levels and PIPA scores should be documented on the fluid balance chart and used as part of the assessment for complications such as infection, leakage, infiltration or extravasation. Any concerns should be discussed with senior nurses and allocated medical staff with assessment, care plan and any interventions documented in the patient notes. Dressing The dressing and StatLock PICC should be replaced weekly or earlier if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016, INS 2016). A sterile, transparent dressing should be used to allow viewing of the exit site. During the dressing change the exit site should be cleaned using a 2% chlorhexidine gluconate in 70% alcohol solution e.g. Chloraprep®. During bathing care must be taken to avoid submerging the arm in water (some children may find it useful to protect the PICC line using a clean plastic bag or waterproof sleeve). ANTT For routine medications UHBristol ANTT procedure should be followed. Surgical asepsis is required for dressing change, bung change, TPN administration and any IV procedures for long term TPN patients under the Gastroenterology Team and patients in NICU. Removal of the PICC line Pre-Procedure

When no longer required the line is removed by trained nursing staff. Ask for advice / assistance from the Outreach Team or medical staff if this is a new procedure.

This can be undertaken on the ward, either at the bedside or in procedure room Consider analgesia prior to removal Gather appropriate equipment e.g. stitch cutters, adhesive remover, gauze, tape, occlusive

dressing, clean gloves. The procedure is done using Aseptic Non Touch Technique If the child has prolonged clotting or is receiving heparin therapy the timing of line removal

must be discussed with medical staff. Heparin may be stopped for a period of time prior to removing the line.

The child needs to have an explanation of what is about to happen given at a level suitable for his or her age. Parental presence may help to lessen the child’s anxiety (INS 2016)

Removal



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• To minimise the risk of air embolus the child should be positioned with the PICC exit site below the level of the heart (Association of Anaesthetists of Great Britain and Ireland 2016

Two nurses may be required to remove the catheter. One to ensure that the area where the catheter is sited is immobilised and one to remove the line.

Remove PICC line by holding the lumen at the exit site and gently pulling the catheter straight out parallel to the vein. Pull out short segments of catheter (3-5cm), pause, and continue in this manner until the PICC is finally removed.

If resistance is met, do not continue; redress the site and alert medical staff. Warm, moist heat may be applied to promote relaxation of venous spasm , and

repositioning the child with the arm perpendicular to the body which minimises bends to the catheter.

Examine catheter length and tip to ascertain that the catheter was removed intact (refer to documented length on insertion).

Catheter tips sent to microbiology for culture are no longer routinely processed. Exceptions to this should be discussed directly with a microbiologist by the requesting doctor.

Post-Procedure Once the catheter is removed, apply pressure at insertion site with gauze for a minimum of

two minutes or until bleeding has stopped (RCN 2016). A sterile occlusive dressing is placed over the insertion site for 72 hours to reduce the risk of

air embolism (RCN 2016). The wound should be assessed for signs of infection or bleeding following the catheter

removal until healing occurs (RCN 2016). 17.2 Neonatal Intensive Care Unit (NICU) PICC use on NICU PICC lines are inserted on the neonatal unit. Common sites are the antecubital fossa or long saphenous vein anterior to the medial malleolus, but scalp veins can also be used. As in paediatric use they are advanced to the superior vena cava but also the inferior vena cava. If the line cannot be advanced that far, but is still able to be used the position is documented. The line is still treated as though it is a central line. The catheters used have very small lumens and are not suitable for transfusing blood products or for aspiration of blood samples. Infants less than 1kg or those with difficult venous access will need a premicath 28G (1Fr). The nutriline twinflo 24G (2Fr) can be used for most other infants. In rare circumstances the Cook Medical Peripherally Inserted Central Venous Catheter set may be used (3Fr), usually to access the femoral vein. The Local Safety Standards for Invasive Procedures (LocSSIP’s) for Insertion of Peripherally Inserted Central Catheter must be followed and documented before, during and after the procedure. Care of a PICC in NICU Post insertion, the PICC will be secured with Steristrips and the insertion site will be covered by a sterile, transparent, breathable dressing. The patency of the catheter must be maintained with a continuous infusion of 0.9% sodium chloride until the position of the catheter has been x-rayed and confirmation that it is suitable for



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use been confirmed by the doctor or Advanced Neonatal Nurse Practitioner (ANNP). The catheter may then be used for fluids and infusions as prescribed. Venous access is difficult in most NICU patients so if a premicath has to be used it is accepted practice for Parenteral Nutrition (PN) to infuse alongside other infusions including analgesia, muscle relaxants and inotropes. The nutriline twinflo has 2 ports so that the inotropes may infuse separately to the PN, analgesia and muscle relaxants. Sterile Aseptic Non Touch Technique must be used for any accessing of the line (as per Matching Michigan protocol). Syringe Size

Manufacturers recommend that 10ml syringes or larger should be used when flushing the catheter to prevent damage to the blood vessel or lumen due to high pressure (RCN 2010).

Smaller syringes are used with caution when administering drugs as the volumes are too small to use a 10ml syringe accurately.

The CVC insertion site and vein track should be:

• Inspected hourly for signs of infection, leakage or extravasation and the PIPA score documented.

• Any concerns should be discussed with allocated medical staff with assessment, care plan and any interventions documented in the patient notes.

• The line pressure should be documented. It is usually high; premicaths may be as high as 500. The infusion pressure on insertion should be used as a guide for anticipated infusion pressures.

• If the line rings off ‘occlude’ it should be flushed. It is normal for it to be very stiff. If the line cannot be flushed it needs to be reviewed by a doctor or ANNP as the catheter may by kinked and the line require re-positioning and redressing.

The dressing

• The dressing should be replaced if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016, INS 2016). This must be done by a doctor or an ANNP.

• If the dressing is changed the insertion site should be cleaned using a 2% chlorhexidine gluconate in 70% alcohol solution e.g. Chloraprep®.

Maintaining Patency

• Patency is maintained depending on the size of the PICC. For any PICC of 1Fr or 2Fr a continuous infusion at a minimum of 1ml/hr through each lumen of the line is required to maintain patency.

• The infusion should not be put on hold. If the PICC is used for bolus medications the infusion should be restarted immediately after the PICC is flushed.

• Blood and blood products must not be transfused through the catheter. • Blood must not be aspirated from the catheter.

Removal of a PICC in NICU The Local Safety Standards for Invasive Procedures (LocSSIP’s) for Removal of Peripherally Inserted Central Catheter must be followed and documented before, during and after the procedure.



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Pre-Procedure When no longer required the line is removed by appropriately trained medical or nursing

staff. This is undertaken at the bedside. Consider oral sucrose prior to the procedure. Gather appropriate equipment e.g.: adhesive remover, gauze, tape, occlusive dressing The procedure is done using Aseptic Non Touch Technique If the child has prolonged clotting or is receiving heparin therapy the timing of line removal

must be discussed with medical staff. Heparin may be stopped for a period of time prior to removing the line.

Removal

• To minimise the risk of air embolus the child should be positioned with the PICC exit site below the level of the heart (Association of Anaesthetists of Great Britain and Ireland 2016


Remove PICC line by holding the lumen at the exit site and gently pulling the catheter straight out parallel to the vein. Pull out short segments of catheter (3-5cm), pause, and continue in this manner until the PICC is finally removed.

If resistance is met, do not continue; redress the site and alert medical staff. Warm, moist heat may be applied to promote relaxation of venous spasm , and repositioning the infant with the limb perpendicular to the body which minimises bends to the catheter.

Examine catheter length and tip to ascertain that the catheter was removed intact (refer to documented length on insertion).


Post-Procedure Once the catheter is removed, apply pressure at insertion site with gauze for a minimum of

two minutes or until bleeding has stopped (RCN 2016). A sterile occlusive dressing is placed over the insertion site for 72 hours to reduce the risk of


removal until healing occurs (RCN 2016). Document removal of PICC in Philips electronic system; LocSSIP, flow sheet and

procedural notes. Related guidelines: Percutaneous Longline Insertion Procedure in NICU 18.0 CARE OF SHORT TERM CENTRAL VENOUS CATHETERS (CVCS) ON WARDS WITHIN BRISTOL ROYAL HOSPITAL FOR CHILDREN (BRHC) Short Term Central Catheters are used on wards within BRHC when children require secure venous access for drug administration or regular blood sampling. Examples could be children who have been discharged from Paediatric Intensive Care Unit (PICU), children who have had a long term central line (Port or Hickman) removed or children where reliable venous access is difficult. Common insertion sites are the internal jugular and femoral vein.




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Short term Central Catheters are not designed for long term use and should be removed as soon as no longer required or an alternative is available. Short term Central Catheters are double or triple lumen, with or without clamps. Specific aspects of care are different from that of long term central venous catheters e.g. Hickman lines. Patients with short term CVCs should not leave the ward without a nurse escort or leave hospital due to the difficulty in securing the short term CVC and the risk of bleeding or air embolism if the CVC became dislodged. The nursing care involves catheter care, infection control, drug administration, blood sampling and catheter removal. Ensure that there is a central line safety pack near to the child in case of line breakage/leak. This guideline could therefore relate to:

Children on IV antibiotics, IV heparin Children requiring daily blood for antibiotic levels or clotting. Children receiving IV therapy which is an irritant to small veins or may cause damage to

tissue if extravasation occurs e.g. Total Parental Nutrition or Vesicant Chemotherapy. Children in whom peripheral access is difficult.

It does not relate to:

Children requiring INR levels using the co-aguchek Children with Vascaths in situ for haemodialysis or plasma exchange. Children with long term CVCs e.g. Hickman Catheters, Port-a-caths or Peripherally Inserted

Central Catheters (PICC)

Catheter Care Safety Check – During initial handover from PICU / theatre staff;

Prior to discharge from PICU / theatre – All lumens should be inspected to ensure that the appropriate MicroCLAVE needleless bung is present

Due to the increased risk of infection all line extensions should be kept to a minimum. The catheter insertion site should be visible through a transparent, semi-permeable, self-

adhesive, and sterile dressing e.g. Tegaderm (Pratte et.al 2014). Documentation should include the date of the catheter insertion, date of dressing change,

date of bung change and date and time of last flush. All the above will be checked by the ward staff nurse in the presence of the PICU or theatre

nurse.

Safety Check – each shift by ward staff The nurse is responsible for assessing the catheter as part of each shift safety checks.

These include: o Observing and documenting the condition of the catheter insertion site, o Maintain catheter patency o Ensuring that clamps are only across lumens which are no longer usable. o Check all bungs are clean and secure o Check extension devices are clean and secure, if not required these should be

removed o If required, ensuring that the line and connections are protected from accidental

opening by the child. “Hiding” the line inside clothing such as a babygro or making a “gauze pocket” should ensure this

o Ensure that there is a central line safety pack near to the child in case of line breakage/leak



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Dressing the Catheter

A transparent, semi-permeable, self-adhesive and sterile dressing is recommended to cover the CVC insertion site (Pratt et.al. 2013).

The dressing should be changed every 7 days, or sooner if the integrity is compromised i.e. if moisture has collected under the dressing or it is loose or soiled (Pratt et.al. 2014).

Aseptic Non Touch Technique should be used to clean the skin around the insertion site with 2% Chlorhexidine Gluconate in 70% alcohol (chloraprep®) (Pratt et.al. 2013).

Once the skin is dry the new sterile dressing should be applied to secure the catheter.

Maintaining Patency All lumens without a continuous infusion running should be flushed with 0.9% Sodium

Chloride 6 hourly as per prescription chart. To avoid blood flashing back into the lumen and blocking it the company recommend that

when flushing a lumen “positive pressure” is applied at the end of the flush. This can be achieved by continuing to flush whilst disengaging the syringe from the Microclave bung.

If a lumen of the catheter becomes blocked ask medical staff or the Outreach Team to review immediately. (See section 12.4 Management of Persistent withdrawal Occlusion). If the lumen remains blocked, a red non-injectable bung is placed on the affected lumen to signify “do not use” with a sticker denoting why the lumen is unusable.

Unusable lumens should always be clamped off (if a clamp is present).

Syringe Size Manufacturers recommend that 10ml syringes or larger should be used when accessing the

catheter to prevent damage to the blood vessel or lumen due to high pressure (RCN 2010). However when administering drug volumes of less than 1ml smaller syringes may be used

with caution.

Responsibility Once the child has been transferred to the ward from PICU or Theatres and the handover

completed it is the responsibility of the child’s medical team to give instructions regarding the ongoing care of the central line and the date of line removal.

Drug Administration Safety Checks

The nurse is responsible for checking the drug prescription and all drugs being administered to the child (e.g. infusions) as part of the shift safety checks. This includes concentration, rate, and expiry time.

All drugs should be administered in accordance with local guidelines, Medusa and UH Bristol policies.

Infection Control

When administering drugs via the central line, ANTT should be utilised throughout the procedure.

Air Embolus The risk of complications caused by air embolus is greater when central venous access is

used; therefore extra vigilance is needed to ensure that no air is allowed to enter the line when administering drugs/fluids.

Blood Sampling

Blood samples may be taken from a lumen of a central venous line and this process will be



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the responsibility of appropriately trained staff on the Ward. The procedure is similar to that of sampling from an arterial line or a long-term central venous catheter (see section 7.2).

Line Removal Pre-Procedure

When no longer required the line is removed by trained nursing staff. Ask for advice / assistance from the Outreach Team or PICU staff if this is a new procedure.

The procedure is done using Aseptic Non Touch Technique and may require a stitch cutter to remove anchor stitches.

If the child has prolonged clotting or is receiving heparin therapy the timing of line removal must be discussed with medical staff. Heparin may be stopped for a period of time prior to removing the line.

The child needs to have an explanation of what is about to happen given at a level suitable for his or her age. Parental presence will help to lessen the child’s anxiety.

Removal

To minimise the risk of air embolus the child should be positioned with the CVC exit site below the level of the heart (Association of Anaesthetists of Great Britain and Ireland 2016).



Post-Procedure Once the catheter is removed, pressure is applied to the site for a minimum of two minutes

or until bleeding has stopped (RCN 2016). A sterile occlusive dressing is placed over the insertion site for 72 hours to reduce the risk of


removal until healing occurs (RCN 2016). 19.0 INTRAVENOUS MIDLINE CATHETERS Midlines should not be treated as a central line unless the tip of the catheter has been confirmed to be centrally located. Please refer to the Intravenous Midline Catheter Guideline. The Intra-venous (IV) Midline catheter can be used for non-vesicant intravenous drugs, fluids, blood products and sometimes blood sampling only at the medical team’s request. They can only be used for drugs with a pH between 5-9. Please refer to individual drug information leaflet/Medusa for each IV drug.

REFERENCES

• Association of Anaesthetist of Great Britain and Ireland. Safe vascular

access 2016. Anaesthesia 2016; 71: 573-585 • Center for Disease Control and Prevention (CDC) (2017) Guidelines

for the Prevention of Intravascular Catheter-Related Infections.




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• Cook Medical Incorporated (2004): “Caring for Your PICC catheter; A patient guide”, Cook Incorporated, USA

• Department of Health (2010), Saving Lives: High Impact Intervention No 1. Central venous catheter care bundle.

• Hamilton, H. (2006) Complications associated with venous access devices: part two. Nursing Standard. Vol.20, no. 27, 59-65.

• Infusion Nurses Society (INS) (2016) Policies and Procedures for Infusion Therapy: Neonate to Adolescent. Tizrapublisher

• NICE (2014) Infection prevention and control. Quality Statement 5: Vascular Access Devices.

• NICE. Healthcare associated infections: Prevention and control in primary and community care - Vascular Access Devices 1.4 https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices (accessed 14th March 2017)

• Pratt, R., Wilson, J., Loveday, H.,Golsorkhi, M. Tingle, A. Bak, A. Browne, J. Prieto, J. and Wilcox, M. (2013) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection

• RCN. (2016) Standards for infusion therapy. RCN. London. • Rowley, S., Clare, S., Macqueen, S. & Molyneux, R. (2010) ANTT v2:

An updated practice framework for aseptic technique. British Journal of Nursing. (IV Supp). Vol 19, no. 5.

• https://www.smiths-medical.com/products/vascular-access/implantable-ports/portacath-portacathii-and-pas-port-power-pac-implantable-access-systems Accessed 29/3/17

• Syner-Med (2015) Solutions for catheter management: Haematology-Oncology. Surrey.

• Vygon (2016) Perfusafe 2 product information • BARD Central Venous Catheters Priming Volumes (2015):

https://www.bd.com/en-us/offerings/capabilities/vascular-access/vascular-iv-catheters/central-iv-catheters/hickman-broviac-leonard-central-venous-catheters [Accessed 12/04/2021]

• BARD Power PICC catheter Brochure: https://www.bd.com/en-us/offerings/capabilities/vascular-access/vascular-iv-catheters/nursing-piccs/powerpicc-catheter-nursing [Accessed: 12/04/2021]

• Vygon Lifecath Brochure (2015): https://www.vygon.com/catalog/lifecath_1700_00219127 [Accessed: 12/04/2021]

RELATED DOCUMENTS AND PAGES

None

AUTHORISING BODY

Paediatric Oncology, Haematology and Bone Marrow Transplant Quality Assurance Forum (Quaf)

SAFETY No additional safety concens

QUERIES REGARDING THIS DOCUMENT

Emily Parsons, Practice Development nurse for oncology, Haematology and Stem Cell Transplant Phone: 0117 342 8920 or Bleep 3961

https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices

https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices

https://www.smiths-medical.com/products/vascular-access/implantable-ports/portacath-portacathii-and-pas-port-power-pac-implantable-access-systems



https://www.bd.com/en-us/offerings/capabilities/vascular-access/vascular-iv-catheters/central-iv-catheters/hickman-broviac-leonard-central-venous-catheters



https://www.bd.com/en-us/offerings/capabilities/vascular-access/vascular-iv-catheters/nursing-piccs/powerpicc-catheter-nursing



https://www.vygon.com/catalog/lifecath_1700_00219127



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