[Skip to content]

.

Central venous access devices (long term)

The purpose of this guideline is to provide guidance on the care and use of central venous access devices (short and long term) including advice on dealing with any problems encountered.

A central venous access device (CVAD) is a catheter that is inserted into the central venous system with the internal tip sitting within the superior/inferior vena cava or right atrium (Royal College of Nursing (RCN) 2010; Doughtery and Lister 2008).

Note: While this guideline refers to the 'child' throughout, all activities are applicable to young people.

Vascular access devices are an integral component of care for children at Great Ormond Street Hospital (GOSH) and many different devices are used in a range of situations. 

Devices can be categorised into a range of groups:

 

When following this policy, it must be used in conjunction with other related policies:

 

Table of contents

 

Training and competency assessment

Intravenous therapy is now an integral part of the majority of nurses' professional practice (RCN 2010). Any nurse involved in the administration of intravenous therapies must be competent to undertake the procedure and act in accordance with the Nursing and Midwifery Council (NMC) Code and maintain knowledge and skills (NMC 2008a).

Staff who use CVADs must be trained and undergo competency assessment. This includes completion of the 'Administering medicines intravenously to children at Great Ormond Street Hospital' workbook, a period of supervised practice and a formative assessment. All staff must be registered as competent to administer intravenous medication on the GOSH training and development database. Re-assessment of IV practice should take place yearly from the date of the initial competency.

The common types of long term CVADs used at GOSH include:

  • Skin tunnelled cuffed central venous catheters (CVC) (commonly referred to as Hickman® or Broviac®). These CVCs may have one, two or three separate lumens and a tissue ingrowth cuff.

  • Implanted ports (Port) (commonly referred to as ports, port-a-cath, Bardport®). May have one or two reservoirs implanted subcutaneously.

  • Peripherally inserted central catheter (PICC) (often inaccurately referred to as long-lines, PICC, short-long line, midlines). There are two types of PICCs used which may have one or two separate lumens:

    • open ended ie Cook® PICC with clamps

    • valved ie Groshong® NXT ClearVueTM PICC
  • Non-cuffed tunnelled CVCs.

Historically the brand name of Hickman® has always been used to refer to all different types of skin tunnelled cuffed central venous catheters, while Port/portacath®/Bardport® are used to refer to implanted ports. 

Due to the common usage of these brand/common names by practitioners and families, there is a risk that incorrect information about the device brand may lead to safety issues or a delay in treatment. Therefore it is important that the brand of the catheter is clearly documented.

Catheters for extracorporeal therapies such as haemodialysis, haemofiltration, apheresis and plasma exchange are also used at GOSH. Separate guidelines are available for these CVADs (see central venous access (temporary) for extracorporeal therapies). NB: There are significant differences in the strength of heparin used and the access technique - contact the renal team for further advice and information. A parent information leaflet is available on central venous haemodialysis catheters.

Brand names/trademarks

In order to maintain correct terminology, the commonly referred to brand names of Hickman®/Broviac® will not be used. The abbreviation CVC will be used instead and Port will be used to refer to implanted ports.

The following table lists the brand names of some CVADs (this is not an exhaustive list):

Skin tunnelled cuffed central venous catheters (CVC)

Implanted Ports (PORT)
  • Hickman®
  • Broviac®
  • Leonard®
  • Cook® catheter
  • Vygon Lifecath
  • Vygon Lifecath Expert
  • Vygon Leadercath
  • Vygon Multicath

 
  • Port-a-cath®
  • BardPort®
  • Mediport
  • Cook® port
  • Infus-a-port
  • X-Port
  • Vitalport®
  • P.A.S.Port®

 
This table lists the brand names of some CVADs.

These CVADs are used for long term, intermittent and continuous intravenous access (IV). 

CVADs are recommended when obtaining peripheral venous access is difficult or when certain intravenous therapies are required, for example, chemotherapy, total parenteral nutrition (TPN), weeks of intravenous antibiotics, repeated transfusions of blood or blood products and frequent blood sampling (Dougherty and Lister 2008). 

The number of lumens or ports will be dependent on the intravenous therapy the child will require, such as children requiring long term TPN only will require a single lumen device, children undergoing a bone marrow transplant will require a dual lumen device and some oncology patients may require a triple lumen catheter. It is important that the most appropriate device is placed as multi lumen CVADs may be associated with an increased risk of infection (Pratt et al 2007).

Advantages and disadvantages

All CVADs have their advantages and disadvantages, which may influence the child/parents or clinican's choice of device (if appropriate).

 Type of device
  Advantages  Disadvantages
 General (all CVADs)
  • Reduces the need for peripheral cannulation/venepuncture.
  • Reduces trauma and anxiety to the patient relating to treatment delivery ie less pain and trauma caused by frequent cannulation and drug administration.
  • Provide long-term venous access.
  • Provide a safer route of administration for vesicant therapy than peripheral or midline access as there is a less risk of extravasation with CVADs than peripheral devices (refer to the extravasation CPG).

 
  • Increased risk of infection.
  • They all require routine care and maintenance to facilitate their effectiveness.
  • Placement of CVADs poses a potential risk to the patient for developing bleeding, venous obstruction, cardiac tamponade, emboli, SVC/IVC obstruction and sepsis. 
  • CVADs have an increased risk of developing thrombi and/or fibrin sheaths.
Skin tunnelled central venous catheters (CVC)
  • Does not require a needle to access.
  • Has a lesser risk of extravasation than a Port as catheters are anchored in situ with a dacron cuff.
  • Easy to access.
  • Cosmetically visible causing some patients issues with body image.
  • Higher risk of accidental damage and removal compared to implanted ports.
  • Potentially may have a greater risk of developing a catheter-related infection than PICCs and implanted ports.
  • Extra care is required when bathing.
  • Swimming is not recommended in immunosuppressed children.
PICCs
  • These are commonly inserted in the veins above the antecubital fossa. There are less bacterial colony forming units on the arm than the chest potentially reducing the risk of infection.
  • May be inserted without the use of a general anaesthetic.
  • They can be removed by an experienced nurse/doctor in the ward environment, without the need for an anaesthetic.
  • Not generally used for long term IV therapy (>6 months), but have been used for longer when required.
  • Accidental damage and/or removal, due to their small lumen size, placement and inadequate securing in paediatric patients. If not adequately secured under a dressing there is a risk a hole/split or break may occur, thus requiring repair.
  • Although possible, it is not advisable to insert a 3 French gauge (Fr) PICC if blood sampling is routinely required.
Implanted ports (Ports)
  • Cosmetically less noticeable and may improve body image concerns.
  • Probable lower risk of infection than external catheters (Pratt et al 2007). 
  • Less risk of accidental damage to the device.
  • Require less care and maintenance than external devices (only monthly flushes required). 
  • Children/young people can go swimming when the Port needle is not in situ.
  • Not suitable for a needle phobic child.
  • Ports may not be suitable for the administration of long-term continuous vesicant therapy such as TPN (Rationale 1).
  • Ports are not recommended for use in very overweight or very underweight children (Rationale 2).

 
Table outlining the advantages and disadvantages of different CVADS.

Where it is possible for a patient to have a choice of CVAD, the older child and parents need to be given the information to enable them to choose the device most suited to the child and their lifestyle (Bravery 2008).

Child/young person/family information

Clear information, education and advice must be given so that the family have knowledge of the specific CVADs (Dougherty & Lister 2008). Information leaflets are available here and should also be given, so that families have written information:

 

Other guides are also available: 

 

Contact an appropriate play specialist or nurse to help prepare the child for the procedure. Play preparation can prevent or reduce psychological trauma for the child, family and healthcare professional (McInally 2005).

The information discussed with the child and family should include the following:

  • The reason for the CVAD and the length of time it may be in situ.

  • The type/s of CVAD that may be suitable (Rationale 3).

  • The preparation required and what to expect immediately afterwards.

  • Advantages and disadvantages of the CVAD. 

  • The care and maintenance required for the CVAD.

  • What the insertion of a CVAD entails.

  • Written/signed consent is also required for any surgical procedure.

Safety aspects

Prior to the child leaving the ward area, CVAD safety issues must be taught to the family and also the child if appropriate. This maintains the safety of a child with a CVAD outside the ward environment and ensures that the family have the information that will help them deal safely with any situation that may arise.

This includes the following information:

  • General advice regarding care of the CVAD.

  • What to do if the PICC/CVC or Port needle is pulled out.

  • What to do if there is a hole/split or break in the PICC, CVC or port needle.

  • What to do if the needleless access device (eg MicroClave®/Bionector®) falls off.

  • What to do if the dressing becomes dirty/wet or is peeling off.

Safety pack contents and information leaflets

A CVAD safety pack and safety information sheet must be given to the family. See following links for appropriate safety sheets. Click on specific CVAD for safety information:

  • CVC (PDF, 28KB)
  • PICC (PDF, 27KB) 
  • Port (PDF, 29KB)

Staff must stress to parents whose child has an indwelling CVC or PICC the importance of having the safety pack with their child at all times. Download a list of equipment required for CVC/PICC safety packs (Word, 21KB).

CVAD insertion

CVADs can be inserted either by surgeons or interventional radiologists. At GOSH, most children will have these CVADs placed under a general anaesthetic. 

PICCs can be placed within interventional radiology using a topical anaesthetic cream if the child is old enough to understand and will keep still or where the child is not clinically fit to undergo anaesthesia.

For children who have had numerous CVADs inserted previously, they are more likely to have the procedure done within interventional radiology (Rationale 5) to enable better visualisation of the structures.

The position of the catheter tip must be determined radiographically and documented in the patient's notes (RCN 2010) before the catheter is used. This is usually performed in theatre/radiology. The operative record should state whether this has occurred in theatre or if a chest X-ray is required on return to the ward (Rationale 5).

Information regarding the CVAD insertion should be documented and filed in the child's notes (Rationale 6). This includes:

  • CVAD manufacturer

  • insertion date

  • site of placement 

  • placer’s details

  • device lot number and product code

The catheter size (possible catheter volume) may be required for:

  • drug administration

  • blood sampling

  • thrombolytic administration

  • catheter repair

  • facilitate audit/research

Post-operative care

PICC site

  • PICCs are usually secured by suturing the catheter to the child's skin in the antecubital region (Rationale 7). There is an increased risk of catheter migration, phlebitis, granuloma and infection if the catheter is not adequately secured.

  • Observe for any oozing from the site; pressure may need to be applied if blood is still oozing post-operatively.

If the CVAD was inserted via a skin tunnel in the chest, specific points to note include:

Neck insertion site

  • Wound closure strips, if used, need to be removed after a week if still in situ.
  • The site should be kept clean and dry during this period; a dressing is not usually required.
  • Observe for any oozing from the site; pressure may need to be applied if blood is still oozing post-operatively.

Chest exit site

  • CVC are secured by suturing the catheter to the child's skin (Rationale 7). There is an increased risk of catheter migration, phlebitis, granuloma and infection if the catheter is not adequately secured.

  • A transparent semi-permeable dressing is usually applied in theatre.

  • Observe for any oozing from the site, pressure may need to be applied if blood is still oozing post-operatively.

If the child bleeds post-operatively:

  • Apply a pressure dressing over the theatre dressing using a pack of sterile gauze and secure firmly with tape, eg Elastoplast®. Care must be taken not to apply too much or too little pressure. The CVAD site must be reviewed frequently to observe for further bleeding and pressure dressings changed at least daily until haemostasis is achieved.
  • Pressure is usually applied over the exit site, but consideration must also be given to the neck site for CVCs and Ports where the bleeding may be originating from, as certain CVADs enters the venous system at that point. Digital pressure may be required at the neck site if a pressure dressing is difficult to apply.
  • The child's current platelets/clotting level may also need to be reviewed and appropriate transfusions may be required.

 

Documentation

All CVAD care should be documented to allow for clear and concise records. Keep clear and accurate records (NMC 2008). Documentation in the relevant nursing notes should reflect routine assessment and describe the condition of the insertion site (RCN 2010). This daily assessment including any care undertaken regarding the CVAD needs to be documented in the CVAD record sheet (PDF, 202KB).

One of the key elements of the Department of Health (DH) Saving lives program (2007) high impact intervention for central venous catheter care is at least daily observation for signs of infection at the catheter site (Pratt et al 2007).

Central venous catheter care bundle

 CVAD maintenance care should adhere to the 'Saving Lives program' High Impact Intervention number 1, central venous catheter care bundle (PDF, 89KB)(DH 2007). This care bundle program aims to reduce catheter related blood stream infections. 

The high impact intervention approach helps trusts achieve this aim by providing a focus on elements of the care process and a method for measuring the implementation of policies and procedures. The risk of infection reduces when all elements within the clinical process are performed every time, these elements of the care process include aspects of insertion and ongoing care actions.

The GOSH transformation project for zero harm supports the high impact intervention and adherence to the care bundles are regularly audited using the central line audit tool (Word, 83KB). 

Maintenance

All personnel who use venous access devices must have knowledge and must be trained and competent in the use and care of these devices. 

"The safe maintenance of a CVAD and relevant care of the insertion site are essential components of a comprehensive strategy for preventing catheter related infections. This includes good practice in caring for the patient’s catheter hub and connection port, the use of an appropriate CVAD site dressing regimen, and using flush solutions to maintain the patency of the CVAD." (Pratt et al 2007)

Aseptic non-touch technique® (ANTT®)

Principles of asepsis must be adhered to whenever the CVAD is accessed. An ANTT® must be used. Refer to the clinical practice guidelines for ANTT for more information and step-by-step guide.

Wipes (for cleaning CVAD hubs and needleless access device)

Decontamination of the hub or needleless access device is necessary prior to accessing the CVAD. Adequate cleaning and evaporation of the alcohol are both necessary steps in this process (RCN 2010; Dougherty 2008). 

Single patient use wipes containing 2% chlorhexidine in 70% isopropyl alcohol (eg Clinell® wipes or other Trust-approved product) are used to clean the hubs of venous access devices and the needleless devices for 30 seconds with friction and allowed to dry prior to use (Pratt et al 2007; RCN 2010).

A study by Kaler & Chinn (2007) showed that prolonged contact with the wipe and the use of friction was effective in disinfecting needleless access devices. 

Maintaining patency

Adequate flushing is important in maintaining catheter function. The following three sections discusses ways of maintaining optimal catheter function. When not in use, CVADs require routine flushes to maintain its patency. Depending on type of CVAD weekly or monthly flushes will be required. Heparinisation of the CVAD may also be needed.

Syringe size

Syringe size has a significant impact on the risk of catheter damage. The basic principle is that smaller syringes generate higher internal pressures, with very little force, than larger syringes when flushing the device (Hadaway 2006, Douglas 2009). 

Smaller syringes can exceed 25 pounds per square inch (psi) which can cause venous damage and catheter rupture. For example, exerting normal pressure on a 10ml syringe produces 11psi, while a 3ml produces 29psi and 1ml produces >100 psi. CVADs can burst above 25-40psi (Bard Access Systems 2008).

The reverse applies when aspirating back on the catheter.

10ml syringes or larger will need to be used when first accessing any CVAD. The back pressure from an occlusion may not be felt when using a small syringe until damage to the catheter has occurred (Conn 1993). Catheter fracture/rupture can be internal or external. A total break can result in the catheter dropping further into the venous system resulting in possible catheter emboli.

Smaller size syringes can be used once catheter patency has first been established using a 10ml syringe (Hadaway 1998).

Flushing problems

When a catheter lumen is totally patent, internal pressure will not increase during flushing (Hadaway 1998). Excessive force must never be used when flushing any device.

Stop flushing CVAD immediately and assess if any of the following occurs (assistance must be sought from a more experienced nurse or doctor if needed):

  • Resistance is felt (never flush against resistance due to the risk of catheter damage).
  • The child/YP reports pain.
  • If unable to inject flush.
  • Swelling is observed along the skin tunnel, around the chest site or in the neck area.
  • Leakage of fluid from the catheter or exit site.

Never force fluid into the catheter.

Turbulent flush

A pulsating, push-pause (turbulent flush) allows turbulent flow to remove any medication or blood residue from the internal lumen of the catheter (Moureau 2000). When first accessing the CVAD, gentle pressure must first be used to assess the patency of the catheter. Then firmly pulsate 1ml at a time into the catheter, so creating turbulent flow within the lumen, thereby decreasing the risk of fibrin and platelets becoming adhered to the internal wall of the CVC and minimising occlusion (Dougherty & Lamb 2008).

Positive pressure

Use of positive pressure when flushing off a CVAD (Goodwin and Carlson 1993; RCN 2010; Dougherty and Lister 2008) also helps to maintain the patency of the catheter. The use of positive pressure helps to prevent a vacuum forming after completion of the flush, preventing blood being sucked (refluxing) back into the catheter. This will help to prevent catheter occlusion.

For CVCs, Ports and open ended PICCs, positive pressure is achieved by closing the clamp whilst flushing in the last ml of heparin.

For valved PICCs, continue to flush the PICC whilst removing the luer-slip syringe from the needleless access device - do not use luer-lock. This technique will ensure that a positive pressure is created when the syringe is removed from the PICC and consequently minimise the risk of blood refluxing into the lumen of the catheter.

General principles for all procedures

Prior to all procedures involving a CVAD, the following step-by-step guide must be carried out:

  • Put on (red) plastic apron.
  • Perform a clinical hand wash using an appropriate hand-washing agent and dry thoroughly (refer to hand hygiene clinical practice guideline).
  • Collect plastic tray. Immediately prior to use, the dry tray should inspected for cleanliness and wiped with a 70% isopropyl alcohol wipe (eg Sani-Cloth 70® Hard Surface wipes). Clean all surfaces of the tray internally and then externally. Once cleaned, allow time to dry.

Once equipment has been collected: 

Re-sheathing of non-blood contaminated needles during medication preparation

Care must be taken with needles which have been used for drawing up purposes to prevent inoculation of syringe contents into the employee with possible deleterious side effects. An approved method can be seen on the GOSH ANTT® which is on each ward (refer to sharps disposal clinical guideline).

End of procedure principles

  • Dispose of all equipment correctly as per Trust Waste Disposal Policy.
  • The plastic tray should be washed with hot water and washing up liquid (neutral detergent). Chlorhexidine-based or other hand wash products are not suitable for this purpose.
  • After washing, the tray should be dried with paper towels and stored in a dry area away from the sink to avoid re-contamination.
  • Infectious patients: prior to an IV tray being taken out of the bedspace/room, it should be cleaned with a decontaminating wipe, eg Tuffie 5. Following that, it should be washed with hot water and neutral detergent, dried and stored as above.
  • Remove gloves and perform a clinical hand wash. 

Dressing

Maintaining the dressing site is important to reduce the risk of infection (Rickard 2003) and to minimise the risk of CVAD dislodgement, fracture or accidental removal.

CVC and PICC dressings need to be changed the day after insertion as any blood left underneath the dressing increases the risk of infection (RCN 2010). After this time, CVAD dressings are changed weekly, unless the exit site has bled, oozed or the dressing is not secure. The dressing should be carefully removed, the site cleaned and a new dressing applied. It is important to ensure the CVAD is not accidentally pulled during dressing changes.

The CVAD exit site should be cleaned with a single patient use application of alcoholic chlorhexidine based cleaning solution, preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol (Rationale 8) (Pratt et al 2007). Alcohol based cleaning solutions have demonstrated good activity against bacteria, viruses and most fungi. Pratt et al (2007) and the RCN (2010) both recommend the use of 2% chlorhexidine in 70% isopropyl alcohol. The recommended product at GOSH is ChloraPrep®. 

2% chlorhexidine gluconate in 70% isopropyl alcohol should not be used on the skin of pre-term infants under 35 weeks gestational age. It can be used with caution in children under two months of age. However, if there is any evidence of skin reaction in this age group, discontinue its use and consult the following for further advice:

  • Tissue viability CNS
  • IV team ICI

Alternative antiseptic solutions:

  • 0.5% chlorhexidine gluconate in 70% denatured ethanol B
  • Povidone-iodine 10%

Step-by-step guide to CVC and PICC dressings

The child may require play and distraction techniques to be utilised whilst changing the dressing on the CVAD.

Assess CVAD site prior to preparing for dressing so that the correct equipment can be prepared and minimise any delays that can distress the child/YP.

As per general principles for all procedures. Collect equipment, this may include the following:

  • new dressing
  • sterile wound closure strips (eg Steri-Strips®) if required
  • ChloraPrep® applicator
  • spare pair of well-fitting gloves
  • receptacle for holding discarded equipment/dressing at bedside 

Procedure

  1. Check the expiry date of the ChloraPrep® applicator (Rationale 9). Peel off paper section and leave sitting in plastic packaging until just before use.
  2. Open the dressing and take out of packaging placing it inside the pre-cleaned plastic tray. Leave protective backing on the dressing.
  3. Open wound closure strips, leave protective backing on and place paper side down into plastic tray.
  4. Prepare child for the dressing change, remove any clothing/net vests etc.
  5. Remove old dressing, being particularly careful around the exit site not to pull CVAD. When the dressing has been removed, change to a new pair of gloves (Rationale 10).
  6. Remove the ChloraPrep® applicator from the packaging.
  7. Pinch the wings to ‘pop’ the enclosed ampoule to release the solution. Hold lollipop side down to allow liquid to drain into the sponge applicator.
  8. Gently press the applicator against the skin and then apply the antiseptic using firm repeated up and down, then back and forth strokes for 30 seconds. Remember to clean the skin around and over where the catheter exits the body.
  9. Discard ChloraPrep® away from clean equipment in tray.
  10. Allow the skin to dry naturally to help prevent dermatitis. Do not dry the skin with sterile gauze (Rationale 12).
  11. Loop or curve the catheter onto the chest/arm and secure with the wound closure strips if required. Ensure they do not cover the exit site (Rationale 13).
  12. Take off protective cover of the dressing and place dressing over the catheter, ensuring it covers the exit site and the reinforced section of the catheter.

Additional skin cleaning may be required if there is blood/ooze present. Any blood/ooze adherent to the skin and catheter must be first removed using sodium chloride 0.9% and sterile gauze before using ChloraPrep®.

Follow end of procedure principles for disposal and decontamination.  

Document dressing change in the care record.

Dressing diagrams to minimise catheter breakage:

  • Place the heaviest part of the catheter completely underneath the dressing eg the bifurcation on multi-lumen CVC and PICCs (download dressing picture guide).
  • For smaller sized CVCs, ie 2.7Fr or 4.2Fr, the dressing needs to cover past the thicker section of the catheter (download dressing picture guide). 
  • For single lumen PICCs, the dressing needs to cover the whole length of the blue catheter past the 2nd wing on the reinforced clear hub section of the catheter (download dressing picture guide).

Dressing selection

The first choice for a CVAD dressing should be a sterile semi-permeable transparent dressing, eg IV3000TM (Pratt et al 2007; RCN 2010). Gauze dressings are not waterproof and require frequent changing in order to inspect the catheter site and are rarely useful in patients with long-term CVADs. 

Sterile transparent, semi-permeable dressings reliably secure the CVAD and Port Needle, permit continuous visual inspection of the catheter site, allow patients to bathe and shower without saturating the dressing, and require less frequent change than that required for standard gauze dressings, thus also saving personal time.

Dressings used at GOSH meet the above criteria and can remain in situ for up to one week. It also provides a sterile barrier yet is permeable to water vapour from the skin in order to reduce the growth of local microflora. Sterile wound closure strips can also be used to provide extra fixation if preferred.

Other dressings

Self-adhesive island non woven dressings, eg Mepore®, need to be used if there is any oozing from the exit site to absorb any exudate. Remanent exudate on the site increases the risk of infection (RCN 2010). The dressing needs to be changed daily if exudate is present and the exit site reviewed. The dressing can be left for 48 hours if there is no ooze. Any dressing change will need to be documented and should include comments on the condition of the exit site. Sterile wound closure strips will need to be used to help prevent dislodgement of the CVAD as these dressings do not allow secure fixation of the device.

When the oozing has resolved, it is recommended that transparent, semi-permeable dressings are used as soon as possible (Pratt et al 2007).

If an allergy to any dressing is suspected a barrier film, such as CavilonTM, may be used to protect the skin prior to a dressings' application for sensitive skin or those with mild reactions (see below for more information).

A soft silicone adherent dressing (eg Mepiform® or Mepilex® BorderLite) can be used as an alternative if the child has a severe allergy to the above dressings (generally used for dermatology patients). The adhesive is silicon based and less likely to cause reactions. These should only be used if clinically indicated, ie allergies/dermatology patients or where other dressings cannot adhere to the skin if it is very dry or peeling. Dermatology or Tissue Viability specialist may need be contacted for advice where appropriate.

Other useful equipment   

Antimicrobial dressings 

Antimicrobial dressings such as BioPatch® can be used for high risk children on an individual case by case basis. Advice can be sought from the Infection Prevention and Control team if required.

Barrier film

CavilonTM No Sting barrier film is an alcohol-free liquid barrier film that dries quickly to form a breathable, transparent coating on the skin. It is designed to protect intact, damaged or 'at-risk' skin from urine, faeces, other body fluids, adhesive trauma and friction and also protects the skin from damage (skin stripping) caused by the removal and re-application of tapes and adhesive dressings. 

CavilonTM stick foam applicator can be used on the skin after the CVAD site has been cleaned and prior to dressing application. Follow the manufacturer's instructions for application and place relevant dressing over the catheter where the CavilonTM has been applied.

NB CavilonTM No Sting barrier film spray must not be used as an alternative in this situation as the barrier film should not be sprayed onto catheters.

Other safety measures

Extra security can also be achieved by:

  • Wearing a vest/armband made out of elastic net retention bandage (eg Surgifix®) or similar product.
  • Cropped vests with elastic edging.
  • Pockets attached with velcro or sewn into place on the inside of vests/T-shirts to tuck the ends of the catheter into.
  • Bags with ties to hold the distal end of the CVC. Often refered to as Hickman®/wriggly bags (child must not sleep with the tape/ribbon around their necks).
  • Ensuring any CVC tubing is tucked away and not allowed to hang down outside clothing.
  • Ensure the above are changed regularly or washed.
  • Do not tuck the catheters into nappies.

Needleless access devices

For CVADs, a needleless access device is preferred as it can reduce the risk of needle stick injury and provide a closed access system (Dougherty 2008).

The needleless access device most commonly used at GOSH is MicroClave® and should be changed as per manufacturers' guidelines (every seven days or after 600 activations whichever is the soonest) and must not be accessed in excess of manufacturers' recommendations (MHRA 2005).  

It must be also changed if blood is retained within the device, if the valve appears to be recessed within the access port (MHRA 2008) or if it becomes damaged. Other types of needleless access devices may used be within the hospital and users must refer to appropriate manufacturers' guidelines for up to date information.

Step-by-step guide to changing the needleless access device

As per general principles for all procedures. Required equipment may include the following:

  • new needleless access device(s)
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes)

Procedure

  1. Open the needleless access device by removing the paper backing but placing the connector into the tray still contained in its plastic wrapping (Rationale 10).
  2. Place 2% chlorhexidine in 70% isopropyl alcohol wipe into plastic tray to one side. Take the plastic tray containing equipment to the patient.
  3. Locate the CVAD and visibly ensure any clamps are closed so minimising the risk of haemorrhage or air embolism.
  4. Remove the used device. Clean the CVAD’s hub with the chlorhexidine wipe for 30 seconds (eg Clinell ® )  using friction and allow to dry naturally. Visibly check the device is dry.
  5. Remove the cover over the needleless access device taking care not to contaminate the key part. Connect the device to the hub of the CVAD.
  6. Follow end of procedure principles for disposal and decontamination.
  7. Document device change in the care record.

Accessing CVAD function and patency

Maintaining the patency of the CVAD is important to ensure continued use as well reducing the risk of infection. Follow the CVAD manufacturers' guidelines for flushing or see guidelines for flushing CVADs below.

Step-by-step guide to flushing CVAD

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringes
  • needles to draw up the required solutions
  • 0.9% sodium chloride for injection
  • ampoule(s) of heparin if required
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ®  wipes or other Trust-approved product)
  • white caps

NB: For multi-lumen CVADs, individual sets of the above equipment will be needed for each lumen to reduce the risk of cross-contamination.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost, ie not in contact with tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Re-sheath all the needles prior to removing from syringes (Rationale 9). 
  5. Cover all exposed syringe tips with white caps taking care not to contaminate keyparts when placing them on and removing prior to use.
  6. Clean the CVADs needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ® ) for 30 seconds using friction and allow to dry naturally. Visibly check the device is dry. 
  7. For Ports, the needle position should be verified by withdrawing 1-2ml of blood first.
  8. Attach the syringe of 0.9% sodium chloride to the needleless access device, open the clamp and gently instil the first part of the flush to ascertain patency (see flush problem section) followed by turbulent flushes as described.
  9. Administer heparin as required. Use positive pressure when flushing off the CVAD.
  10. Once completed, tuck away the child’s CVAD (Rationale 7).
  11. Follow end of procedure principles for disposal and decontamination.
  12. Document procedure in care record. 

Blood sampling (using the S-Monovette® system)

Blood samples can be obtained from CVADs. However, an assessment of the technique and the type of blood sample required must be considered. Obtaining blood samples such as coagulation values and also incorrect order of filling blood bottles (see guideline for Blood tests: requesting, labelling and sampling requirements) can lead to unnecessary repeated blood sampling. 

Needle safety devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel (Pratt et al 2007; NICE 2003). Use of Trust standard equipment is best practice; in GOSH, the current standard is the S-Monovette® System. The aim is to protect staff from exposure to blood-borne pathogens and prevent potential contamination of differing samples.

However, safety demands a heightened awareness of unsafe practices in the workplace, such as the recapping of contaminated needles, unprotected transport of contaminated needles, eg in a kidney bowl, and using sharp disposal boxes above the fill line.

Step-by-step guide to blood sampling

As per general principles for all procedures. Required equipment may include the following: 

  • 10ml syringes
  • needles to draw up the required solutions
  • 0.9% sodium chloride for injection
  • ampoule(s) of heparin if required, refer to flushing CPG 
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ®  wipes or other Trust-approved product)
  • S-Monovette® blood bottle(s)
  • S-Monovette® system adaptors (multi-adapter and membrane adapter)
  • white caps

NB For multi-lumen CVADs, individual sets of the above equipment will be needed for each lumen to reduce the risk of cross-contamination.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost, ie not in contact with tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Carefully peel open the membrane adapter and connect to the hub of an empty syringe. 
  4. Peel back the paper cover on the S-Monovette® multi-adapter and place in tray with the plastic packaging acting as a holder (Rationale 9).
  5. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  6. Resheath all the needles prior to removing from syringes (Rationale 9).
  7. Cover all exposed syringe tips with white caps taking care not to contaminate key parts when placing them on and removing prior to use.
  8. Clean the CVADs needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ® ) for 30 seconds using friction and allow to dry naturally. Visibly check the device is dry. 
  9. Connect the S-Monovette® multi-adapter to the needleless access device on the CVAD.
  10. Attach empty 10ml syringe with membrane adapter to the multi-adapter.
  11. Withdraw the appropriate millilitres of fluid/blood for waste/dead space of CVAD (refer to blood sampling from central venous access devices).
  12. Disconnect syringe and discard. This fluid/blood should not be replaced back into child unless clinically indicated (Rationale 14)(Cosca 1998; Frey 2003; Adlard 2008).
  13. If CVAD blood cultures are required, ensure the waste sample is used for this purpose (this will contain the fluid from within the catheter).
  14. Connect blood sampling bottles one by one.
  15. NB Remember the correct order of draw to prevent sample bottle contamination (refer to clinical practice guideline for blood tests: requesting, labelling and sampling requirements).
  16. Disconnect the multi-adapter from the CVAD.
  17. Attach the syringe of 0.9% sodium chloride to the needleless access device, open the clamp and gently instil the first part of the flush followed by turbulent flushes as described.
  18. Administer heparin as required. Use positive pressure when flushing off the CVAD.
  19. Once completed, tuck away the child’s CVAD (Rationale 7).
  20. Follow end of procedure principles for disposal and decontamination.
  21. Document procedure in care record. 

Medication administration

Administering medications is one of the most common clinical procedures that nurses will undertake. Changes in legal and professional boundaries within healthcare has led to the role of the nurse broadening to medication management (Dougherty 2008). The NMC standards for medicine management 2008 (PDF, 347KB) sets out standards for practice for administration of medications. Staff must also follow the GOSH medication policy located within the document library on the Trust Intranet (GOSH 2012).

The GOSH Medicines and Pharmacy department intranet has an intravenous drug administration resource available for GOSH staff. Refer to the Pharmacy intranet site within the clinical resources section for these guidelines.

The child may require play and distraction techniques to be utilised whilst accessing the CVAD. Involve parents and play specialists in the process.

Step-by-step guide to bolus medication administration

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringes
  • other sizes of syringes for dose accuracy 
  • needles to draw up the required solutions
  • medication(s) and appropriate diluent to prepare if required
  • 0.9% sodium chloride for injection/5% dextrose or appropriate fluid depending on medication compatibility
  • required amount and strength of heparin 
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ®  wipes or other Trust-approved product 
  • Isopropyl Alcohol 70% swab (eg SteretTM or other Trust-approved product) for cleaning the top/rubber bung of any vial
  • white caps

Work out any medication calculations, collect medication vials or pre-prepared medication syringe from CIVAS/satellite. Write out any medication labels that may be needed and research any relevant information as required.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost ie not in contact with the tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Using the same technique detailed above. Draw up all medication(s), flushes, heparin and diluents required for the procedure.
  5. Cover all exposed syringe tips with white caps taking care not to contaminate key parts when placing them on and removing prior to use.
  6. Label syringes. NPSA Safer use of injectable medicines (2007) recommends the labelling of syringes to help reduce medication errors.
  7. When all medication(s), flushes, etc have been prepared, take tray and necessary prescription charts to the child.
  8. Check the patient’s name band against the details on the prescription chart to correctly identify patient.
  9. Locate the CVAD to be used and if applicable, identify the lumen to be used.
  10. Clean the needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ® ) for 30 seconds using friction and allow to dry naturally. Visibly check the device is dry.
  11. For ports and vesicant medications, 1-2ml of blood return must be established prior to administration (refer to extravasation clinical practice guidelines for more information).
  12. Insert 10ml syringe of 0.9% sodium chloride or compatible diluent into the needleless access device. Open the clamp of the CVAD if present and inject flush into the CVAD to ascertain its patency (see flush problem section).
  13. When the patency of the device has been established, remove the syringe containing the flush and insert the syringe containing the drug. Administer the medication over the required time observing the patient and CVAD at all times.
  14. Following the procedure above, administer all required medications ensuring adequate flushing between each of the medications to prevent mixing of incompatible medications.
  15. Attach the flush syringe to the needleless access device and gently instil the first part of the flush followed by turbulent flushes as described.
  16. Administer heparin as required. Use positive pressure when flushing off the CVAD. 

    16.  Follow end of procedure principles for disposal and decontamination.

    17. Complete administration documentation. 

Medication administration – infusions

There are various types of infusion devices available for use within the hospital. Staff must have knowledge and have had training in the use of these devices prior to use.  

Step-by-step guide to using volumetric pumps

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringe(s)
  • other sizes of syringes for dose accuracy
  • needles to draw up the required solutions
  • medication(s) and appropriate diluent to prepare if required
  • 0.9% sodium chloride for injection/5% dextrose or appropriate fluid depending on medication compatibility 
  • ampoule(s) of heparin if required 
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell ®  wipes or other Trust-approved product)
  • Isopropyl Alcohol 70% swab (eg Steret™ or other Trust-approved product) for cleaning the top/rubber bung of any vial 
  • infusion set (buretted or non-buretted)
  • bag of compatible fluid for medication or hydration fluid required

Also work out any medication calculations and infusion rates, collect medication vials or pre-prepared medication syringes from CIVAS/satellite. Write out any medication labels that may be needed and research any relevant information as required.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost ie not in contact with the tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Prepare all flushes, medications(s), syringes and needles as per the bolus medication administration procedure detailed above.
  5. Open the required infusion administration set and close all roller clamps to the off position.  
  6. Check the medications/fluid bags as per medication policy. Open the required bag of infusion fluid and check the bag to ensure it contains no visible precipitate, leaks or damage to bag. Twist off the  bung at the bottom of the fluid bag to reveal the connection port.
  7. Remove the plastic cover over the spike on the infusion set taking care not to touch the spike.  Holding the bung of the fluid bag in one hand and the bottom of the spike on the infusion set in the other, insert the spike into the connection port on the infusion bag using a twisting motion. It is vital not to contaminate these key parts (do not touch any part of the spike) to prevent introducing infection into the bag of infusion fluid. Ensure the spike is inserted fully into the fluid bag.
  8. Hang the fluid bag which is now connected to the infusion administration set onto a stand. 

If using a non-buretted set:

  • Gently squeeze the drip chamber to allow fluid into it, filling the chamber half way.  
  • Hold the air sensor disc in one hand and with the other, gently open the roller clamp until the fluid begins to move down the infusion set. 
  • As the fluid enters the air sensor disc, gently apply pressure over the disc to expel any air, which may be trapped.  
  • Prime the infusion set until fluid is seen at the end of the line (Rationale 15) and then close the roller clamp off.

If using a buretted set:

  • Open the roller clamp between the fluid bag and the buretted set and fill the burette with the required amount of fluid to prime the line. 
  • Close the roller clamp.
  • Gently squeeze the drip chamber to allow fluid into it, filling the chamber approximately half way.
  • Hold the air sensor disc in one hand and with the other; gently open the roller clamp until the fluid begins to move down the infusion set.
  • When the fluid enters the air sensor disc, gently apply pressure over the disc to expel any trapped air. 
  • Prime the infusion set until fluid is seen at the end of the line (Rationale 15) and then close off the roller clamp.
  • If a medication is to be infused, connect the syringe containing the medication to the needleless connector on the top of the burette (clean device first if it may have been contaminated during handling). Push the medication into the burette until the syringe is empty.
  • Remove syringe from needleless access device and dispose.
  • If the medication requires further dilution, open the roller clamp between the fluid bag and burette to add the required amount of fluid.
  • Gently shake the burette to ensure drug and fluid mix thoroughly. 
  • If large amounts of fluid are contained within the burette, close the white clamp on the top of the burette to prevent fluid leaking out when shaken. Remember to open this clamp once mixing is complete as it acts as an air inlet.
  • Attach a medication-added label to the burette with all appropriate detail.
  • When all medication(s), flushes etc have been prepared. Take tray and necessary prescription charts to patient’s cubicle.
  • Check the patient’s name-band against the details on the prescription to correctly identify patient. 
  • Locate the CVAD to be used and if applicable, identify the lumen to be used.
  • Clean the end of the  needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell®) for 30 seconds using friction and allow to dry naturally, visibly check device is dry.
  • For Ports and vesicant medications, 1-2ml of blood return must be established prior to administration (refer to extravasation and infiltration clinical practice guidelinesfor more information).
  • Insert 10ml syringe of 0.9% sodium chloride or compatible diluent into needleless access device. Open any clamps on the CVAD and inject the flush into the CVAD to ascertain its patency (see flush problem section).
  • Attach infusion line to extension tubing. Open clamp. Commence infusion as prescribed ensuring rates, pressure limits and volumes to be infused limits are set.
  • If infusing a drug, it is essential that when the burette empties it is flushed using a compatible diluent of at least 18ml to ensure all of the drug in the infusion tubing is administered to the patient. The rate of the flush should remain the same as the drug infusion. The ‘flush’ must be labelled on the burette to prevent potential extra unnecessary flushes or lack of.
  • When infusion is completed, disconnect the infusion set from the CVAD. Administer flushes and heparin as per guidelines.

Step-by-step guide to using a syringe pump

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringes
  • luer-lock syringe for syringe pump 
  • other sizes of syringes for dose accuracy
  • needles to draw up the required solutions
  • medication(s) and appropriate diluent to prepare if required
  • 0.9% sodium chloride for injection/5% dextrose or appropriate fluid depending on medication compatibility
  • ampoules of heparin if required
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (Clinell ®  wipes or other Trust-approved product)
  • alcohol wipes for cleaning the top/rubber bung of any vials
  • infusion set-long extension set
  • needleless access device
  • compatible fluid for diluting medication if required

Also work out any medication calculations and infusion rates, collect medication vials or prepared medication syringe from CIVAS/satellite. Write any medication labels required and research any relevant data.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost ie not in contact with the tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Prepare all flushes, medication(s), syringes and needles as per the bolus medication administration procedure detailed above. Use a luer-lock syringe for administering the infusion.
  5. Open the required infusion administration set and connect the needleless access device (Rationale 15). Then connect the luer-lock syringe to the needleless access device.
  6. Prime the infusion set until fluid is seen at the end of the set and then close the roller clamp off.
  7. Attach a medication-added label to the syringe with all required details.
  8. When all medication(s), flushes etc have been prepared. Take tray and necessary prescription charts to patient’s cubicle.
  9. Check the patient’s name-band against the details on the prescription to correctly identify patient.
  10. Locate the CVAD to be used and if applicable, identify the lumen to be used.
  11. Clean the end of the needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell®) for 30 seconds using friction and allow to dry naturally, visibly check device is dry.
  12. For Ports and vesicant medications, 1-2ml of blood return must be established prior to administration (refer to extravasation and infiltration clinical practice guidelinesfor more information).
  13. Insert 10ml syringe of 0.9% sodium chloride or compatible diluent into needleless access device. Open the clamp of the device and inject flush into the CVAD to ascertain its patency (see flush problems section).
  14. Attach infusion set to the CVAD's needleless access device. Open clamp. Commence infusion as prescribed ensuring rates and pressure limits are set.
  15. If infusing a drug, it is essential that when the syringe empties it is flushed using a compatible diluent at the same rate. Use a luer-lock syringe for administering all flushes. The ‘flush’ syringe must be labelled to prevent potential extra unnecessary flushes or lack of.
  16. When the infusion is completed, disconnect the infusion set from the CVAD. Administer flushes and heparin if required as per guidelines.
  17. Follow end of procedure principles for disposal and decontamination.
  18. Complete administration documentation. 

Accessing Implanted Ports

The Port is always accessed using non-coring gripper needles (port needle). If any other types of needles are used, this will result in damage to the septum that will require removal of the device.

Different gauges and lengths of port needle are available. The length of the port needle will depend on the amount of subcutaneous tissue over the port and the depth of the reservoir. 

Most of the younger children at GOSH usually require a 20 gauge, 3/4 inch (20mm) length port needle to access their port, but bigger children/young people may require a one inch port needle or longer.

The needle length required is assessed each time the Port is accessed as children/young people can gain or lose weight.

The gauge of the port needle will determine the flow rate of the infusate and the speed at which blood can be withdrawn. 22 gauge needles are usually not recommended for the administration of blood products or for blood sampling.

A topical local anaesthetic cream is often required prior to port access; the aim is to aid pain control or possibly provide a placebo effect. However some children and parents find that the time it takes for the local anaesthetic cream to work can prolong the trauma for the child.

The child may require play and distraction techniques to be utilised whilst the port is being accessed. Involve play specialists as required.

Step-by-step guide to accessing implanted ports

Apply a local anaesthetic cream if  preferred by the patient. Use according to prescription or patient group direction. Allow the time interval required for the cream to take effect. This may reduce any discomfort caused by the port needle puncturing the skin over the port.

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringes
  • needles to draw up the required solutions
  • 0.9% sodium chloride for injection 
  • ampoule(s) of heparin
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (Clinell ® )
  • dressing (preferably a sterile transparent semi-permeable dressing)
  • sterile wound closure strips eg Steri-Strips®
  • one packet of sterile gauze (5x5cm)
  • ChloraPrep® applicator
  • Port needle (winged infusion set)
  • needleless access device
  • white caps

Two trays may be required if there is a risk of key contamination with all the equipment required.

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost ie not in contact with the tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Cover all exposed syringe tips with white caps taking care not to contaminate key parts when placing them on and removing prior to use.
  5. Connect the needleless access device to the port needle hub. Prime the port needle with 0.9% sodium chloride and close the clamp
  6. Carefully open the packs of sterile gauze without touching and leave gauze on the unlabelled side of the paper. Place into tray with the paper-side down acting as a holder for the sterile gauze.
  7. Open the dressing and take out of packaging placing it inside plastic tray. Leave protective backing on the dressing.
  8. Open the wound closure strips, leave protective backing on and place into plastic tray.
  9. Check the expiry date of the ChloraPrep® applicator (Rationale 9). Peel off paper section and leave sitting in packaging until just before use.
  10. Go to the child and ensure easy access to the port site. Remove any clothing that may contaminate the port site once cleaned.
  11. Remove the dressing if using a local anaesthetic cream; wipe off any excess cream.
  12. Locate port and identify the septum first if port is implanted deep with the subcutaneous tissues. 
  13. Change gloves (Rationale 10).
  14. Remove the ChloraPrep® applicator from the packaging.
  15. Pinch the wings to ‘pop’ the enclosed ampoule to release the solution. Hold lollipop side down to allow liquid to drain into the sponge applicator.
  16. Gently press the applicator against the skin and then apply the antiseptic using firm repeated up and down, then back and forth strokes for 30 seconds over the Port site.
  17. Discard ChloraPrep® away from equipment in tray.
  18. Allow the skin to dry naturally. Do not dry the skin with sterile gauze (Rationale 11).
  19. Bend back the wings of the needle/hold the grip section of the port needle.
  20. Remove the needle guard.
  21. Locate and firmly secure the sides/top and bottom of the port firmly between your finger and thumb taking care not to touch the skin surface over the port (Rationale 16; Rationale 17).
  22. Insert the needle at a 90°/perpendicular angle through the septum until the internal base/backplate of the port is felt.
  23. Port needle can secured to the chest first if required. See below for dressing technique.
  24. Clean the needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell®) for 30 seconds using friction and allow to dry naturally, visibly check device is dry.
  25. Connect an empty syringe to the needleless access device.
  26. Withdraw approximately 1-2ml of fluid/blood from the Port (Rationale 18). If blood sampling if required, refer to appropriate section of step-by-step guide to blood sampling.
  27. Insert the 10ml syringe of 0.9% sodium chloride into the needleless access device. Open the clamp of the port needle and gently instil the first part of the flush into the Port to ascertain its patency, followed by turbulent flushes as described. If the Port patency is in doubt, check needle position (see flush problem section).
  28. Use positive pressure when flushing off the Port as described previously. The port will need to be heparinised according to the guidelines.
  29. Fold and carefully slide a layer of gauze underneath the wings of the port needle to support the wings if needed, taking care not to dislodge the needle from the back of the port. Take care not to pull the needle or obscure the upper half of the Port site (Rationale 19).  Refer to a diagram for securing a Port needle (Word, 910KB) to prevent dislodgement and allow visibility to monitor for infection or extravasation,
  30. Apply wound closure strips vertically down the wings of the port needle.
  31. Put a small coil/S curve in the tubing and apply a transparent semi-permeable dressing over the port needle and tubing without covering the clamp (Rationale 6).
  32. Follow end of procedure principles for disposal and decontamination.
  33. Document procedure in care record. 

De-accessing implanted ports

Step-by-step guide to de-accessing implanted ports          

Two people are usually recommended for de-accessing a port, one to flush the port and the other to secure/stabilise the port (Rationale 20), while the port needle is withdrawn. Where they is only one person available, the Port can be flushed and clamped prior to withdrawing the Port needle.

The child may require play and distraction techniques to be utilised whilst de-accessing the port, involve play specialists as required.

As per general principles for all procedures. Required equipment may include the following:

  • 10ml syringes
  • needles to draw up the required solutions
  • 0.9% sodium chloride for injection
  • required amount and strength of heparin
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (Clinell ® )
  • small plaster if required
  • white caps

Procedure

  1. Open equipment by carefully peeling back packaging.
  2. Place syringes into the pre-prepared tray ensuring key parts are uppermost ie not in contact with the tray. If at any time there is a suspicion that a piece of equipment may have become contaminated, dispose of it immediately and use a new piece.
  3. Connect the needles to the syringes as required. Draw up the 0.9% sodium chloride and heparin as required. Ensure all key parts remain uncontaminated.
  4. Cover all exposed syringe tips with white caps taking care not to contaminate key parts when placing them on and removing prior to use.
  5. Clean the needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell®) for 30 seconds using friction and allow to dry naturally, visibly check device is dry.
  6. Connect an empty syringe to the needleless access device.
  7. Open the clamp.
  8. Withdraw 1-2ml of fluid/blood from the Port.
  9. Insert 10ml syringe of 0.9% sodium chloride into the needleless device. Open the clamp of the port needle and flush the Port to ascertain its patency. If the port patency is in doubt, do not force fluid and seek advice (see flush problem section).
  10. Carefully peel dressing from the skin. Locate and firmly secure the sides/top and bottom of the Port firmly between your finger and thumb (Rationale 20).
  11. Attach the syringe of heparin syringe. Inject the heparin and maintain positive pressure by asking a second person to firmly secure/hold down the port, whilst withdrawing the port needle (Rationale 21).
  12. Use a small plaster to cover needle site if required.
  13. Follow end of procedure principles for disposal and decontamination.
  14. Document procedure in care record. 

Port maintenance                       

It is recommended that the port needle and dressing is changed every seven days (Dougherty 2006).

CVAD infections

Infection is the most common complication with CVADs and can manifest itself in several different sites. The sites of infection associated with CVADs include:

  • exit site infection
  • tunnel infection
  • internal lumen infection
  • port pocket infection

Exit site

The exit site must be monitored daily for any signs of infection or dislodgement. These include:

  • redness
  • swelling
  • pus
  • pain or discomfort
  • bleeding
  • phlebitis can be seen with PICCs
  • increased length of catheter
  • visible cuff 

Skin tunnel

Skin tunnelled CVADs can develop an infection within the skin tunnel. The tunnel should be monitored for any of the following signs.

  • inflammation
  • red tracking following the path of the catheter
  • pain or discomfort
  • high temperature
  • pus from exit site

Tunnel infections generally tend to occur within 72 hours of CVAD insertion.

Port pocket infections

  • swelling
  • redness
  • pain or discomfort
  • high temperature  
  • pus around port chamber underneath the skin

When a port pocket infection is suspected and the port is not already accessed. The child/YP should receive 24-48 hours of peripheral IV antibiotics first, as there is a risk of introducing pus/infection from the port pocket into the blood stream if the port is accessed. After 48 hours, the port must then be accessed and the antibiotics continued via the port.

If the port is already accessed, administer antibiotics directly via the port.

Treatment

If an infection is suspected, swabs of all oozing wound sites need to be taken and blood cultures drawn from all lumens of the CVAD. Other potential sources of infection should also be followed up as the CVAD is not the only possible source, although the most obvious. The clinical condition of the child must be monitored for any signs of a catheter related blood stream infection as CVAD infections are serious and potentially life threatening.

Suspected internal catheter related infections are likely to be treated using intravenous broad-spectrum antibiotics until culture and sensitivity results are available. Exit site infections in a well child may possibly be treated oral antibiotics unless neutropenic, refer to local supportive care guidelines where appropriate.

If the CVAD is a multi lumen/ported device, alternate lumens must be used for antibiotic administration, even if only one lumen shows positive cultures. This ensures that each lumen is treated for possible cross contamination.

If the child/YP’s clinical condition deteriorates or they become clinically unstable, the CVAD may have to be removed. If the infection requires the removal of the device, it is essential that adequate time be left between removal and re-insertion. Best practice suggests that peripheral blood cultures should be taken prior to a new line being inserted in patients who have had the CVAD removed due to infection.

Antibiotic locks therapy

Antibiotic locks may in certain situations be appropriate for recurrent CVAD infections (Bagnall-Reeb 2004). The use of this therapy should be discussed with the microbiology department prior to commencement.

A 'line lock' guideline for antibiotic locks is available for internal GOSH staff in the antibiotic policy within the medicines and pharmacy section of the hospital's intranet.

CVAD occlusions

Thrombotic occlusions resulting in loss of CVAD patency can result in delayed treatment, child/YP and family distress and can increase the risk of infection (Hartkopf Smith 2008).

CVAD occlusions can result from a number of reasons. These include:

  • catheter tip malposition
  • intraluminal clot
  • intraluminal drug precipitate
  • fibrin sheath/tail
  • catheter kink
  • “pinch-off”
  • catheter related thrombosis
  • suture constriction
  • catheter rupture
  • port needle dislodgement/malposition
  • fibrin in port reservoir

The above can result in either withdrawal or total occlusion of the CVAD. Thrombolytics are used to restore catheter function.

A thrombolytic (alteplase) guideline for withdrawal and total occlusions of CVADs is available for internal GOSH staff in the medicines and pharmacy section of the hospital's intranet.

CVAD – extravasation

Refer to extravasation clinical practice guidelines. 

CVAD fracture/damage

All CVADs can split, develop holes or fracture, both internally and externally. Internal damage will require complete CVAD removal. With external damage to the port needle, the needle will just need to be removed and the Port re-accessed with a new port needle.

CVCs and PICCs can usually be repaired without the child requiring surgery for a new device providing there is at least two inches of undamaged catheter between the break/hole/split and the exit site.

If the CVC or PICC is damaged, immediately ensure that the device is clamped with two atraumatic clamps, above the damaged section of the catheter (between the break/hole/split and the exit site) (Rationale 22). A layer of gauze is usually placed between the clamp and the catheter as plastic or metal clamps can potentially lead to further catheter damage. An occlusive dressing is then placed over the hole/split/break (Rationale 23).

Within GOSH, contact the relevant person below who will facilitate the repair of the device:

  • Check first for staff within your own unit who have been trained.
  • Intravenous Therapy Team for the ICI Unit.
  • Clinical Site Practitioners for the rest the hospital only if your own unit has no-one trained.

Obtain the relevant equipment needed to repair the device. All wards with children who have a CVC or PICC should have the appropriate repair kits within their own department/unit (Rationale 24).

CVADs – dislodgement/accidental removal

In order to minimise the risk of dislodgement/removal. The CVAD needs to be checked at least daily, ensuring the dressing is secure and there is a loop/curve firmly secured underneath the dressing.

Accidental catheter removal

If the catheter is completely pulled out. Digital pressure needs to be applied immediately to the site where the catheter enters the vein for about five minutes until haemostasis has been achieved.

With PICCs this will be at the antecubital region, unless they are non cuffed tunnelled CVCs. For tunnelled CVCs placed at GOSH, this will usually be in the neck region. A small scar site used to insert the CVC is usually visible which shows where pressure needs to be applied.

Removal of CVADs

CVADs such as CVCs and Ports must be removed in theatre/interventional radiology and should not be removed in the ward environment except under very extreme circumstances.

At GOSH, PICC and non cuffed tunnelled CVCs removals can be performed on the ward; an anaesthetic or sedation is rarely needed. The removal of a CVAD should only be performed by an appropriately educated and trained health care practitioner (RCN 2010) within the hospital environment. The PICC removal may also be co-ordinated with other planned procedures requiring anaesthetic or sedation.

Pre-op care

  1. Prepare child and family for the removal of the CVAD. Involve play specialist if required.
  2. Ensure relevant blood samples are taken and results are available prior to theatre.
  3. Ensure the child is prepared adequately prior to theatre, eg nil by mouth, name band in situ, consent gained for procedure and patient assessed fit for theatre.

Post-op care

  1. Observe for bleeding from all wound sites and follow any post-op instructions documented. Pressure dressings may need to be applied if there is any bleeding post-operation.
  2. Apply a pressure dressing over the site using packs of sterile gauze and secure firmly with  tape, eg Elastoplast®. Care must be taken not to apply too much or too little pressure. The CVAD site must be reviewed frequently to observe for further bleeding and pressure dressings changed until haemostasis is achieved.
  3. Pressure is usually applied over the exit site, but consideration must also be given to the neck site for CVCs and Ports where the bleeding may be originating from, as certain CVADs enter the venous system at that point. Digital pressure may be required at the neck site if a pressure dressing is difficult to apply.
  4. The child's current platelets/clotting level may also need to be reviewed and appropriate transfusions may be required.
  5. Keep all wound dressings clean and dry. They should remain in situ for five to seven days post removal of CVAD.
  6. Monitor wound sites for any signs of infection and treat accordingly.

Rationale

Rationale 1: Risk of port needle dislodgement increasing the risk of extravasation.
Rationale 2: A large amount of subcutaneous tissue over the port can impede locating and accessing the port successfully and a lack of sufficient subcutaneous tissue over the port can lead to port erosion through the skin.
Rationale 3: In many situations the child/family can be given the information to decide which CVAD may be better for themselves in terms of lifestyle.
Rationale 4: Possible previous vascular scarring.
Rationale 5: To verify catheter tip placement and retain as a record of placement.
Rationale 6: To maintain accurate records.
Rationale 7: To minimise the risk of accidental dislodgement.
Rationale 8: Aim of reducing catheter related bloodstream infections.
Rationale 9: To ensure "no breaks" in technique once a procedure has been started and to reduce the risk of contaminating equipment.
Rationale 10: To minimise the risk of contaminating key parts.
Rationale 11: To prevent contamination.
Rationale 12: Allowing any cleaning solution to dry is vital in order for disinfection to be completed.
Rationale 13: To maintain visibility.
Rationale 14: Risk of infection/reinfusing clots.
Rationale 15: Reduce risk of air embolism.
Rationale 16: To maintain a sealed intravenous system.
Rationale 17: To stabilise the Port and prevent movement with port needle insertion.
Rationale 18: To prevent contaminating the skin over the Port prior to port needle access.
Rationale 19: To check for correct needle position and patency.
Rationale 20: To allow observation of the Port site for any signs of infection/swelling etc.
Rationale 21: To support the Port during port needle removal and prevent possible trauma.
Rationale 22: To prevent backflow of blood into catheter.
Rationale 23: To prevent blood loss or air embolism.
Rationale 24: To reduce the risk of infection.
Rationale 25: To maintain patient safety. 

References

Reference 1:
Adlard K (2008) Examining the push-pull method of blood sampling from central venous access devices. J Pediatr Oncol Nurs 25 (4): 200-7.

Reference 2:

Bagnall-Reeb H (2004) Evidence for the use of the antibiotic lock technique. J Infus Nurs 27 (2): 118-22.

Reference 3:

Bard Access Systems (2008) Frequently Asked Questions Regarding Bard* Catheters & Ports. Viewed on: 01/12/08

Reference 4:

Barnacle A, Arthurs OJ, Roebuck D, Hiorns MP (2008) Malfunctioning central venous catheters in children: a diagnostic approach. Pediatr Radiol 38 (4): 363-78, quiz 486-7.

Reference 5:

Berrington A, Gould FK (2001) Use of antibiotic locks to treat colonized central venous catheters. J Antimicrob Chemother 48 (5): 597-603.

Reference 6:

Bravery K (2008) Paediatric intravenous therapy in practice Dougherty L and Lamb J In: Intravenous therapy in nursing practice. Oxford, Blackwell Publishing

Reference 7:

Bravery K, Hannan J (1997) The use of long-term central venous access devices in children. Paediatr Nurs 9 (10): 29-35; quiz 36-7.

Reference 8:
Conn C (1993) The importance of syringe size when using an implanted vascular access device. Journal of Vascular Access Networks 3: 11-18.

Reference 9:

Cosca PA, Smith S, Chatfield S, Meleason A, Muir CA, Nerantzis S, Petrofsky M, Williams S (1998) Reinfusion of discard blood from venous access devices. Oncol Nurs Forum 25 (6): 1073-6.

Reference 10:
Department of Health (2007) Saving Lives delivery program: High impact interventions. Viewed on: 19/11/2008

Reference 11:

Dougherty L (2006) Central Venous Access Devices: Care and Management. Oxford, Blackwell Publishing

Reference 12:

Dougherty L (2000) Central venous access devices. Nurs Stand 14 (43): 45-50; quiz 53-4.

Reference 13:

Dougherty L and Lamb J (2008) Intravenous Therapy in Nursing Practice: Second edition. Oxford, Blackwell Publishing

Reference 14:

Dougherty L and Lister S (Editors) (2008) he Royal Marsden Manual of Clinical Nursing Procedures (7th edition). Chichester, Wiley-Blackwell

Reference 15:

Dougherty, L & Lister, S (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford, Wiley-Blackwell

Reference 16:
Douglas, L et al (2009) Central venous access devices: review of practice Paediatric nursing Vol 21 no 5 p19-22

Reference 17:

Frey AM (2003) Drawing blood samples from vascular access devices: evidence-based practice. J Infus Nurs 26 (5): 285-93.

Reference 18:

Goodwin ML, Carlson I (1993) The peripherally inserted central catheter: a retrospective look at three years of insertions. J Intraven Nurs 16 (2): 92-103.

Reference 19:

Hadaway L (2006) Technology of flushing vascular access devices. J Infus Nurs 29 (3): 129-45.

Reference 20:

Hadaway L (1998) Catheter connection. Journal of Vascular Access Devices 3(3): 129-45.

Reference 21:

Hartkopt Smith L (2008) Alteplase for the Management of Occluded Central Venous Access Devices: Safety considerations. Clinical Journal of Oncology Nursing 12(1): 155-7.

Reference 22:

Kaler W and Chinn R (2007) Successful disinfection of needleless access port: A matter of time and friction. The Journal of the Association for Vascular Access Devices 12(3): 140-2.

Reference 23:

McInally W (2005) Whose line is it anyway? Management of central venous catheters in children. Paediatr Nurs 17 (5): 14-8.

Reference 24:

Moureau N (2000) Training for Turbulence. Journal of Vascular Access Devices 5(4): 2.

Reference 25:

National Institute for Clinical Excellance (2003) Prevention of Healthcare Associated Infection in Primary and Community care. Viewed on: 23/12/2008

Reference 26:

Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C, Wilcox MH (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65 Suppl 1: S1-64.

Reference 27:

Rickard CM, Wallis SC, Courtney M, Lipman J, Daley PJ (2002) Intravascular administration sets are accurate and in appropriate condition after 7 days of continuous use: an in vitro study. J Adv Nurs 37 (4): 330-7.

Reference 28:

Robboins J, Cromwell P and Korones DN (1993) Swimming and C.V.C. related infections in the child with cancer. Journal of Pediatric Oncology Nursing 16: 51-6.

Reference 29:

Royal College of Nursing (2010) Standards for Infusion Therapy. Viewed on: 18/06/2010

Reference 30:

Scales K (2008) Intravenous therapy: a guide to good practice. Br J Nurs 17 (19): S4-S12.

Reference 31:

Great Ormond Street Hospital (2009) Administration of medicines policy. London, GOSH

Document control information

 

Lead author(s) 
Anne Ho, Specialist Nurse - Intravenous Therapy Team, Infection, Cancer and Immunity

Additional authors 
Karen Bravery, Advanced Nurse Practitioner, Infection, Cancer and Immunity

Document owner
Anne Ho, Specialist nurse - Intravenous Therapy Team, Infection, Cancer and Immunity

Approved by
Clinical Practice Committee

First introduced: 21 February 2009 
Date approved: 10 January 2013 
Review schedule: Two years 
Next review: 10 January 2015 
Document version: 1.0 
Replaces version: N/A 

Useful links