Central venous access (temporary) for extracorporeal therapies

The catheter is a dual lumen uncuffed central venous access device that is inserted percutaneously.

It is used for short-term vascular access for extracorporeal therapies such as haemodialysis, haemofiltration, plasma exchange or leucopheresis (stem cell harvesting).

A tunnelled cuffed catheter will be required if access is needed for more than one to two weeks. 
The catheter used currently at Great Ormond Street Hospital (GOSH) is the Gamcath®

  • The Gamcath® catheter is made from polyurethane with a winged device that helps secure the access. The catheter is separate from these wings (Rationale 1).
  • The Gamcath® catheter comes in a variety of lengths and diameters (Rationale 2).

The catheter has two lumens of different lengths and inflow/outflow design. The arterial lumen (red clamp) is shorter than the venous lumen (blue clamp) (Rationale 3).

The priming volumes for the catheter are printed on the line or clamps itself and in the insertion leaflet (Rationale 4).

Sites for catheter insertion (Rationale 5):

  • the femoral vein
  • the internal jugular vein
  • the external jugular vein
  • the subclavian vein

The subclavian veins should not be cannulated if the child has renal involvement as this can jeopardise future vascular access management if the child needs long-term therapy (Rationale 6).

A chest x-ray or other radiographic imaging should be taken if the internal or external jugular vein is cannulated. This is usually done at time of insertion in theatres (Rationale 7).

The catheter is normally sutured in place at the exit site with non-dissolvable suture(s) (Rationale 8).

The catheter primarily used for extracorporeal therapy (Gambro 2010). If no other access is available it may also be used for: 

  • administration of IV fluids and blood products
  • administration of IV medication
  • venous blood sampling

If the catheter has to be used for procedures other than extracorporeal treatments it is best practice to co-ordinate procedures so that the line is minimally accessed (Rationale 9).

Wherever possible it should just be used for the extracorporeal therapy (Royal College of Nursing, (RCN) 2010).

All personnel who handle these catheters should be competent in the techniques involved for their care and management (Rationale 10).

An aseptic non touch technique (ANNT) should always be used when handling the line (Rationale 10, 22)

Temporary central venous access for extracorporeal therapies

Inform the child and family

The child and family should be informed of the reasons a catheter is required, how it is inserted, how long it will be in place for and what potential risks are involved (Rationale 11).

Written information should be provided to reinforce explanations, see the haemodialysis access leaflet (Rationale 12, 13).

Viewing a similar catheter in another child or in an adapted teddy may be useful for some children and the play specialist may need to be involved in this process (Rationale 14).

Any concerns about restrictions to activity should also be covered at this stage, for example bathing or walking.

Postoperative care

The child will require a general anaesthetic for the insertion of the catheter. Normal pre- and post-operative care will be required.

Specific points following insertion of the catheter:

  • The child may experience some soreness following the insertion of the catheter and/or during handling of the catheter. Analgesia should be offered.
  • There will be a clear semi-occlusive dressing covering the exit site of the catheter. This dressing should be removed and changed according to the child’s needs and local policy, see CVAD guideline.
  • Care should be taken when removing this dressing as it may adhere to the suture(s) (Rationale 15).
  • If there is oozing around the exit site following insertion, a pressure dressing may need to be applied. An alginate dressing can be used to stop oozing (Rationale 16).
  • The operative notes should be checked to ascertain if the position of the catheter has been verified in theatre. A chest x-ray should be ordered, if required (Rationale 17).

Maintenance: observations

The child’s temperature should be monitored for evidence of pyrexia. This can be done every four hours or more frequently if there is concern (Rationale 18).

The child should be observed for signs of rigor at any time following manipulation of the catheter (Rationale 19).

Line and blood cultures should be taken if there is any suspicion of infection (Rationale 20).

The child should be observed for signs of the following around the area or in the affected limb where the catheter is sited (Rationale 21):

  • pain
  • swelling
  • coolness and skin mottling

Advice should be sought from an experienced nurse or doctor if there is any concern over the circulation to the affected area.

Maintenance: infection control

The principles of asepsis and the CVL care bundle should be adhered to whenever the catheter is accessed, including (Rationale 22):

Hand washing according to the GOSH clinical guideline ‘Hand Hygiene’.

  • An aseptic non-touch technique.
  • Minimal handling of the catheter.
  • If the catheter becomes infected, it will be removed (Rationale 23). 
  • Decisions regarding catheter removal or antibiotics will be made by the child’s medical team.

Maintenance: exit site care

The exit site of the catheter is covered with a dressing (Rationale 24). This can be:

  • clear occlusive film
  • low adherent dressing

The choice of dressing depends on skin allergies, the site of the exit site, and the condition of the exit site (Loveday et al, 2014). However, the child will usually return from theatres with a clear film dressing which is in the insertion kit.

The exit site should be observed for any of the following (Rationale 25):

  • redness
  • inflammation
  • pus or exudate
  • pain or discomfort

The exit site should also be observed for signs of bleeding. A pressure dressing may need to be applied and the child’s activities restricted to prevent further bleeding (Rationale 26).

Exit site care must be documented using ttbe CVAD Record Chart (see Appendix 1)

The suture(s) should be examined to ensure they are still intact and not too tight (Rationale 27).

The suture(s) should not be removed until the catheter is to be removed, unless deemed necessary by the medical team. If a suture is not to be replaced, the line must be firmly secured with extra strapping.

The exit site should be cleaned and the dressing changed every day or as required using an aseptic non-touch technique and care recorded on the CVAD record sheet (Rationale 28).

The dressing should be changed if:

  • the dressing lifts off
  • the area gets wet or contaminated
  • there is oozing/discharge (Loveday et al, 2014)

The exit site should be cleaned according to local policy with chlorhexidine 2% in 70% isopropyl alcohol (Loveday et al 2014) (Rational 29).

The dressing should be changed if the child has a bath or shower (Rationale 30).

Care should be taken to avoid immersing the caps of the catheter (Rationale 31).

Accessing the catheter: general principles

Inform the child and family (Rationale 32):

  • why the catheter is being accessed
  • what it will entail
  • how long the procedure and/or the treatment will take

An aseptic non-touch technique is used when accessing the catheter (Rationale 33).

  • Following local infection control policy, wash hands and prepare the working surface (Rationale 34).
  • Wear appropriate Personal protective equipment (PPE).
  • Prepare the equipment required (Rationale 35).
  • The child may require play or distraction techniques when the catheter is being accessed (Rationale 36).
  • Adjust the child’s clothing as necessary to allow access to the line, also ensuring protection of their clothing (Rationale 37).
  • Ensure that the child’s privacy and dignity is maintained at all times whilst the catheter is being manipulated (Rationale 38).

Accessing the catheter: preparing for use

The patency and function of the catheter will be assessed prior to every intervention (Rationale 39).

An aseptic non-touch technique is used (Rationale 40).

  • Ensure the catheter clamp is closed (Rationale 41).
  • Clean the lumen/clamp of the catheter for 30 seconds with a 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipes or other Trust-approved product) Allow to dry naturally for 20-30 seconds (Rationale 42).
  • Remove the cap from one lumen and clean the hub again for 30 seconds with another 2% chlorhexidine in 70% isopropyl alcohol (eg Clinell® wipes or other Trust-approved product). Allow to dry naturally for 20-30 seconds (Rationale 43).
  • Attach a 10ml syringe. Open the clamp and withdraw approximately 1-2ml of blood/heparin (Rationale 44).
  • Clamp. Discard this syringe.
  • Attach a syringe of 2-5ml 0.9% sodium chloride (Rationale 45).
  • Unclamp and inject the 0.9% sodium chloride (Rationale 46).

Refer to the troubleshooting section if there are any difficulties accessing the catheter.

Accessing the catheter: heparinisation following use

Heparin is instilled in to the catheter between uses to maintain patency.

Heparin (1000iu/ml) is instilled to the volume of the dead space. The volumes will also be printed on the external clamp of the catheter for easy reference. Refer to the manufacturer's instructions to obtain this priming volume.

Following completion of the procedure:

  • Ensure the catheter is clamped (Rationale 47).
  • Clean the connection area for 30 seconds with a 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipe or other Trust-approved product) (Rationale 48). Allow to dry naturally, 20-30 seconds.
  • Disconnect the syringe/extracorporeal circuit/infusion line.
  • Clean the end of the catheter for 30 seconds with another 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipes or other Trust-approved product). Allow to dry naturally, 20-30 seconds (Rationale 49).
  • Attach a syringe filled with 2-5ml of 0.9% sodium chloride. Unclamp and flush the line. Clamp (Rationale 50).
  • Discard the syringe and attach a syringe filled with heparin (1000iu/ml) to the volume of the dead space (Rationale 51).
  • Unclamp, quickly inject the heparin and clamp under positive pressure (Rationale 52).
  • Discard the syringe and attach a new non-injectable cap.
  • Clamps should not be opened once the catheter has been clamped (Rationale 53).

Accessing the catheter: troubleshooting

Assistance should be sought from an experienced nurse or doctor if any of the following occur (Rationale 54):

  • nothing can be withdrawn
  • resistance to saline flush is felt
  • nothing can be flushed in
  • the child experiences pain
  • fluid leaks out around the exit site with infusion

If nothing can be withdrawn but saline can be injected:

  • Ask the child to (Rationale 55):
    • cough or breathe in deeply or raise their arm above head (if in jugular)
    • or change their position

Tissue plasminogen activator (TPA) can be instilled in the lumen of the catheter to clear suspected thrombus if movement doesn’t help (Rationale 56). The amount instilled should be the equivalent of the volume of the dead space. It can be left indwelling for as long as necessary but at least one hour for effect. The contents of the lumen should then be withdrawn and discarded.

The blood flow from the catheter may be insufficient to perform an extracorporeal procedure. The catheter can be rotated – the line is separate from the wing device which helps secure it (Rationale 57). A black dot on the upper surface of the catheter aids orientation of the catheter. This should only be performed following agreement with medical staff or other experienced staff.

The suture may be interfering with manipulation of the catheter:

  • if it is too tight
  • or prevent optimal movement of the catheter

This suture may need to be removed (Rationale 58). This should only be performed following agreement with medical staff or other experienced staff.

Accessing the catheter: haemodialysis/extracorporeal procedures

Commencing the treatment:

  • Ensure the catheter clamps are closed (Rationale 59).
  • Clean the lumen/clamp of the catheter with a two per cent chlorhexidine in alcohol wipe. Allow to dry naturally, 20-30 seconds (Rationale 60).
  • Place a sterile field under the line (Rationale 61).
  • Remove the cap from one lumen and clean the hub with another two per cent chlorhexidine in alcohol wipe. Allow to dry naturally, 20-30 seconds (Rationale 62).
  • Attach a 10ml syringe. Open the clamp and withdraw approximately 1-2ml of blood/heparin. Clamp. Discard this syringe (Rationale 63).
  • Attach a new syringe.
  • Unclamp and draw blood in and out of the syringe a few times (Rationale 64). 
  • Clamp.
  • Repeat this procedure with the second lumen.
  • Any blood samples can be obtained at this point.
  • Attach the clamped arterial and venous lines of the prepared extracorporeal circuit to the appropriate lumens of the catheter (usually red to red and blue to blue) (Rationale 65).
  • Unclamp the clamps on the catheter and extracorporeal circuit and commence treatment (Rationale 66).
  • Rearrange the child’s clothing (Rationale 67).
  • Tidy away used equipment and dispose of in the correct manner (Rationale 68).

Completing the treatment:

  • Ensure the catheter lumens and the extracorporeal circuit lines are clamped (Rationale 69).
  • Clean both lumens of the catheter for 30 seconds with a 2% chlorhexidine in 70% isopropyl alcohol (eg Clinell® wipes or other Trust-approved product). Allow to dry naturally, 20-30 seconds (Rationale 70).
  • Place a sterile field under the lines (Rationale 71).
  • Disconnect one catheter lumen from the circuit (Rationale 72).
  • Clean the hub again for 30 seconds with another 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipes or other Trust-approved product). Allow to dry naturally, 20-30 seconds (Rationale 73).
  • Attach a syringe filled with 2-5ml of 0.9% sodium chloride (Rationale 74). Unclamp and flush the line. Clamp.
  • Discard the syringe and attach a syringe filled with heparin (1000 iu/ml) to the volume of the dead space (Rationale 75).
  • Unclamp, quickly inject the heparin and clamp under positive pressure (Rationale 76).
  • Discard the syringe and attach a non-injectable cap (Rationale 77).
  • Repeat for the second lumen.
  • Tidy away used equipment and dispose of in the correct manner (Rationale 78).

Accessing the catheter: blood sampling

Wherever possible blood samples should be obtained prior to commencing extracorporeal treatment and will be taken by the nurse performing the treatment (Rationale 79).

An aseptic non-touch technique is used (Rationale 80).

  • Ensure the catheter clamp is closed (Rationale 81).
  • Clean the lumen/clamp of the catheter for 30 seconds with a 2% chlorhexidine in 70% isopropyl alcohol (eg Clinell® wipes or other Trust-approved product) . Allow to dry naturally, 20-30 seconds.
  • Remove the cap from one lumen and clean the hub again for 30 seconds üwith another 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipes or other Trust-approved product). Allow to dry naturally, 20-30 seconds. (Rationale 82).
  • Attach a 10ml syringe. Open the clamp and withdraw 5ml of blood/heparin (Rationale 83). Clamp.
  • Discard the syringe of blood/heparin (Rationale 84).*
  • Attach an empty syringe, unclamp and aspirate the amount of blood required for the blood samples (Rationale 85). Clamp.
  • Attach a 5ml syringe of sodium chloride, unclamp and flush (Rationale 86).
  • Clamp.
  • Discard the syringe and attach a syringe filled with heparin (1000 unit/ml) to the volume of the dead space (Rationale 87).
  • Unclamp, quickly inject the heparin and clamp under positive pressure (Rationale 76).
  • Discard the syringe and attach a non-injectable cap (Rationale 88).
  • Fill the specimen bottles in the correct order (Rationale 89).
  • Label specimens in the correct manner at the bedside (Rationale 90).
  • Tidy away used equipment and dispose of in the correct manner (Rationale 80).

*If repeated blood samples are being withdrawn, or the child is severely anaemic or a neonate, the dead space sample can be replaced (Rationale 91). 

If this is the case:

  • Clean, access the catheter and remove the heparin using an aseptic non-touch technique as previously described in the preparing for use section.
  • Attach a new syringe and withdraw 3-5ml of blood (Rationale 92).
  • Place the syringe carefully on the work surface, key part uppermost (Rationale 93).
  • Attach a new syringe and obtain the blood sample.
  • Attach the dead space syringe and reinfuse the blood.
  • Flush and cap off the catheter as described above.

Refer to the troubleshooting section if there are any difficulties accessing the catheter.

Accessing the catheter: bolus drug administration

  • Clean, access the catheter and remove the heparin using an aseptic non-touch technique as previously described in the preparing for use section.
  • Flush the lumen with 3-5 ml 0.9 % sodium chloride (Rationale 94).
  • Attach the syringe containing the drug and administer drug according to manufacturer's recommendations (Rationale 95).
  • Flush the lumen with 5ml 0.9 % sodium chloride (Rationale 96).
  • Discard the syringe and attach a syringe filled with heparin (1000 unit/ml) to the volume of the dead space (Rationale 87).
  • Unclamp, quickly inject the heparin and clamp under positive pressure (Rationale 76).
  • Discard the syringe and attach a non-injectable cap (Rationale 88).

Refer to the troubleshooting section if there are any difficulties accessing the catheter.

Accessing the catheter: infusion administration

Before starting the procedure prepare the infusion and prime the administration set ensuring key parts are protected (Rationale 97).

  • Ensure the infusion clamps are closed (Rationale 98).
  • Clean, access the catheter and remove the heparin using an aseptic non-touch technique as previously described in the preparing for use section (Rationale 99).
  • Attach the primed administration set to the catheter (Rationale 100).
  • Insert the infusion line into the infusion pump if not already done (Rationale 100).
  • Open the clamps on the catheter and the infusion set (Rationale 100).
  • Commence infusion as prescribed ensuring that the rate, pressure limits and volume to be infused limits are set on the infusion pump (Rationale 101).

Refer to the troubleshooting section if there are any difficulties accessing the catheter.

Needleless Connectors

A multi-use needleless connector may be used in place of a non-injectable cap (Loveday et al, 2014) eg Tego ® Connector which is suitable for use with a haemodialysis circuit (Icumedical, 2012).

The device can be left in place for a maximum of seven days before being changed (Icumedical, 2012).

The hub is cleaned with a 2% chlorhexidine in alcohol wipe before directly attaching a syringe.

Parafilm

Parafilm® is a semi-transparent, flexible film that provides a secure moisture resistant seal around IV line  connector hubs.

A paraffin film wrap can be placed around the outside of each lumen following use (Rationale 102) 

Removal of catheter

Reasons for removal:

  • Completion of scheduled treatment.
  • Infection of the catheter/exit site.
  • Replacement by a long-term access.
  • Removal of a catheter will be performed in agreement with the medical staff (Royal College of Nursing 2010).
  • It is possible to replace an infection-free catheter with a new catheter of the same design by rewiring the track (Royal College of Nursing 2010). This will be done in theatres (Rationale 103).

Inform the child and family of the intention to remove the catheter, covering the following (Rationale 104):

  • why it is to be removed
  • what it will entail
  • how long it will take
  • any special considerations

The catheter can be easily removed on the ward once the restraining suture is cut (Rationale 105).

  • Prepare the work surface, assemble the equipment and wash hands (Rationale 106).
  • Equipment required:
    • stitch cutter or scissors
    • gauze swabs
    • tape
    • dressing pack with 0.9% sodium chloride
  • Have the child lying down comfortably.
  • Remove the dressing and clean the area with saline if necessary (Rationale 107).
  • Cut suture and release it from the skin (Rationale 108).
  • Withdraw catheter gently from the vein and press firmly over the exit site with gauze for five minutes or longer, as necessary until the site stops bleeding.
  • Apply a pressure dressing (Rationale 109).
  • The child should remain on bed rest for one to two hours. The site should be observed for bleeding. Bathing should be avoided for some hours (Rationale 110, 111).
  • Document the procedure in the child’s notes (Rationale 112).
  • It is possible that the catheter may accidentally get dislodged and fall out (Rationale 113).
  • If this happens, press on the exit site with gauze for five minutes or until the site stops bleeding, then apply a pressure dressing (Rationale 109).
  • Inform the medical staff immediately.
  • Document the event in the child’s notes (Rationale 112).

Rationale

Rationale 1: This design allows rotation of the catheter to improve blood flows. 
Rationale 2: To allow a suitable size for the child to be selected. 
Rationale 3: Allows blood to be simultaneously pumped in and out of the child and around the extracorporeal circuit. This staggered design reduces the degree of re-circulation of blood flow during the procedure. 
Rationale 4: To ensure correct volumes of heparin are used when locking off the catheter. 
Rationale 5: To ensure correct positioning of catheter and that no damage to surrounding anatomy was sustained during insertion (Gambro 2010; Loveday et al, 2014). 

Rationale 6: Subclavian vein placement has a high risk of stenosis or occlusion which may affect the creation of an arterio-venous fistula in the future (British Association of Paediatric Nephrology (BAPN) Haemodialysis Clinical Practice Guidelines for Children and Adolescents, 2008).
Rationale 7: To verify safe placement of the catheter (Royal College of Nursing, 2010). The tip should be just above the right atrium. 
Rationale 8: To ensure the catheter is not accidentally dislodged. 
Rationale 9: Uncuffed central venous catheters are associated with a high risk of infection (Weijmer et al, 2004). 
Rationale 10: To meet local policy and professional standards: GOSH policy, the NMC Code of Conduct, the NMC Scope of Professional Practice
Rationale 11: To obtain informed consent. 
Rationale 12: To aid understanding. 
Rationale 13: To reinforce explanations. 
Rationale 14: To aid understanding. 
Rationale 15: To protect and secure the catheter and exit site. 
Rationale 16: To stop the bleeding. 
Rationale 17: To check the catheter and tip position (Royal College of Nursing, 2010)
Rationale 18: This may indicate bacteraemia associated with the catheter. 
Rationale 19: Microorganisms or toxins in the catheter can enter the general circulation when the catheter is flushed or attached to the extracorporeal circuit, causing a systemic reaction. 
Rationale 20: If the catheter is infected, it will be removed. 
Rationale 21: These may be signs of a thrombus or embolism caused by the catheter. 
Rationale 22: To minimise the risk of infection. 
Rationale 23: To remove the focus of infection. 
Rationale 24: The dressing will protect the exit site from exposure to external contamination. It will help support and secure the catheter. 
Rationale 25: These signs could indicate infection. 
Rationale 26: Movement of the catheter may cause enlargement of the insertion site, allowing blood to leak from the vein. 
Rationale 27: If the sutures have separated from the skin there is a risk of catheter displacement. Over-tight sutures can cause pain and discomfort. 
Rationale 28: To keep the exit site clean at all times. 
Rationale 29: To reduce the risk of catheter related bloodstream infections
Rationale 30: To keep the exit site dry. 
Rationale 31: To prevent the risk of infection. 
Rationale 32: To provide full explanation and to minimise distress. 
Rationale 33: To prevent infection. 
Rationale 34: To ensure the area is clean. 
Rationale 35: To minimise disruption. 
Rationale 36: To minimise distress. 
Rationale 37: To protect their clothing from spillages.
Rationale 38: To maintain the privacy and dignity of the child. 
Rationale 39: To ensure patency. 
Rationale 40: To prevent infection. 
Rationale 41: To avoid air embolism or haemorrhage when cap is removed. 
Rationale 42: To clean the external surfaces.
Rationale 43: To reduce the risk of infection (Loveday et al, 2014). 
Rationale 44: To remove the heparin solution and any clot that may be present. 
Rationale 45: To enable the catheter to be flushed. 
Rationale 46: To check the patency of the catheter.
Rationale 47: To avoid air embolism or haemorrhage when the catheter is disconnected. 
Rationale 48: To clean the external surfaces. 
Rationale 49: To reduce the risk of infection. 
Rationale 50: To flush catheter. 
Rationale 51: To prepare to instil heparin. 
Rationale 52: To ensure the heparin reaches the distal ends of the lumens. If injected slowly it escapes out of the proximal holes, increasing the risk of thrombus formation (Gambro 2010). 
Rationale 53: The catheter volume increases when the clamps are opened, and heparin will be drawn away from the tip of the catheter, risking thrombus formation (Gambro 2010). 
Rationale 54: This may indicate: displacement, kinking, blockage/fibrin sheath, thrombus, extravasation. 
Rationale 55: To change the position of the catheter within the vessel. 
Rationale 56: TPA is an anti-fibrinolytic agent that may help dissolve the clot (Besarab and Pandey, 2011).
Rationale 57: The vessel wall may be occluding the flow design of the catheter. Changing the internal position may improve blood flow.
Rationale 58: The suture is responsible for the security of the catheter - without it the line may be displaced. 
Rationale 59: To avoid air embolism or haemorrhage when cap removed. 
Rationale 60: To clean external surfaces. 
Rationale 61: To create a clean area and to protect the child from spills when commencing therapy. 
Rationale 62: To reduce risk of infection. 
Rationale 63: To remove heparin lock and to avoid re-injection. 
Rationale 64: To establish the patency and flow of the catheter. Extracorporeal procedures require a blood flow of approx 100-300ml/min. 
Rationale 65: To minimise risk of re-circulation. 
Rationale 66: To commence treatment. 
Rationale 67: To maintain dignity. 
Rationale 68: To minimise risk of cross infection and in keeping with the Trust Waste Management Policy
Rationale 69: To ensure safety when the lines are disconnected. 
Rationale 70: To clean external surfaces of catheter.
Rationale 71: To give a clean area to work on and to protect the child from spills. 
Rationale 72: To enable the catheter to be accessed. 
Rationale 73: To ensure effectiveness of the cleaning agent. 
Rationale 74: To ensure the patency of the catheter. 
Rationale 75: To lock of the catheter to maintain patency.
Rationale 76: To ensure heparin reaches the distal ends of the lumens. If injected slowly it escapes out of the proximal holes, increasing the risk of thrombus formation (Gambro 2010). 
Rationale 77: To prevent infection or possible air embolism or haemorrhage. 
Rationale 78: To prevent cross infection and in keeping with Trust Waste Policy. 
Rationale 79: To minimise opening the catheter. 
Rationale 80: To prevent cross infection and in keeping with Trust Policy. 
Rationale 81: To avoid air embolism or haemorrhage when cap removed. 
Rationale 82: To enable the system to be accessed. 
Rationale 83: To remove the heparin plus sufficient blood to ensure a good quality blood sample will be obtained.
Rationale 84: To prevent the risk of infection from reinfusing a bacterially contaminated sample. 
Rationale 85: To obtain the blood samples. 
Rationale 86: To flush the catheter. 
Rationale 87: To maintain patency. 
Rationale 88: To prevent infection or possible air embolism or haemorrhage. 
Rationale 89: To ensure samples are not contaminated. 
Rationale 90: To ensure correct identification of sample.
Rationale 91: To prevent a potential reduction in the child's haemoglobin levels. 
Rationale 92: To remove sufficient blood to ensure a good quality blood sample will be obtained. 
Rationale 93: To avoid contaminating the syringe of blood as this will be returned. 
Rationale 94: To check patency. 
Rationale 95: To meet prescription guidelines.
Rationale 96: To prevent drug interactions and to deliver total dose of drug. 
Rationale 97: To facilitate procedure. 
Rationale 98: To prevent inadvertent fluid administration. 
Rationale 99: To ensure catheter patency and function. 
Rationale 100: To facilitate infusion administration. 
Rationale 101: To meet prescription requirements. 
Rationale 102: This makes a protective barrier to prevent microbial contamination to the outside of the catheter/hub.
Rationale 103: This is useful if the previous catheter is malfunctioning or it has been in situ for the maximum period advisable. 
Rationale 104: To gain informed consent and minimise anxiety. 
Rationale 105: There is no restraining internal cuff. 
Rationale 106: To minimise the risk of cross infection. 
Rationale 107: To help visualise the suture. 
Rationale 108: To enable the catheter to be withdrawn. 
Rationale 109: The exit site can be quite large and it may take some time before adequate clot forms. 
Rationale 110: Activity and/or rises in blood pressure can dislodge the clot and bleeding can restart. 
Rationale 111: Bathing may dissolve the clot and cause bleeding to restart. 
Rationale 112: To ensure accurate records are maintained. 
Rationale 113: This may occur if the sutures have been removed or have parted from the skin. 

References

Reference 1: 
Gambro (2010) Short-term vascular access for extracorporeal blood purification with Gamcath catheters - Operator's Manual. UK, Gambro Hospital.

Reference 2: 
Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A. Browne J, Prieto J, Wilcox M (2014) epic 3: National evidence –based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection, 86S1, S1-S70.

Reference 3: 
British Association of Paediatric Nephrology (2008) Haemodialysis clinical practice guidelines for children and adolescents, BAPN. [Online] Available from: http://www.renal.org/bapn/clinical-standards-in-paediatric-nephrology [Accessed 9th April 2015]

Reference 4: 
Royal College of Nursing (RCN) (2010) Standards for infusion therapy. London, RCN 

Reference 5: 
Weijmer MC, Vervloet MG, ter Wee PM (2004) Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of useNephrol Dial Transplant 19 (3): 670-7. 

Reference 6: 
Besarab A, Pandey, R (2011) Catheter management in hemodialysis patients: delivering adequate flow. Clinical Journal of the American Society of Nephrology, 6 (1), 227-234.

Reference 7:
Icumedical (2012) [Online] Available from: http://www.icumed.com/products/specialty/renal-systems/tego-connector.aspx [Accessed 9th April 2015]

Appendices

Document control information

Lead Author(s)

Liz Wright, Clinical Nurse Specialist (CNS), Renal Unit

Document owner(s)

Liz Wright, Clinical Nurse Specialist (CNS), Renal Unit

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
02 December 2004
Date approved: 
27 April 2015
Review schedule: 
Three years
Next review: 
27 April 2018
Document version: 
3.0
Previous version: 
2.1