Central venous access devices (long term)

The purpose of this guideline is to provide guidance on the care and use of long term Central Venous Access Devices (CVAD) including advice on dealing with any problems encountered. For the purpose of this guideline, devices that are required to remain insitu greater than a month will be considered a long term CVAD.

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. These may include:

A 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; Dougherty and Lister 2008).

When following this guideline, it must be used in conjunction with the following policies:

Table of contents

Training and competency assessment 

Brand names/trademarks of different CVADs 

CVAD features (advantages and disadvantages) 

Child/young person/family information

Safety aspects 

Safety pack contents 

Insertion

Post-operative care 

Documentation

Central venous catheter maintenance care bundle

Maintenance

Aseptic non-touch technique® (ANTT®) 

Wipes 

Parafilm

Maintaining patency 

Syringe size

Flushing problems

Turbulent flush

Positive pressure

General principles for all procedures

Dressings

Step-by-step guide to ST-CVC and PICC dressings

Dressing selection

Needleless access devices

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

Accessing CVAD function and patency

Step-by-step guide to flushing CVAD

Blood sampling

Step-by-step guide to blood sampling

Medication administration

Step-by-step guide to bolus administration

Infusion administration

Step-by-step guide using a volumetric pump

Step-by-step guide using a syringe pump

Accessing implanted ports

Step-by-step guide to accessing implanted ports

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

Port maintenance

Infections

Catheter occlusions

Extravasation

CVAD – fracture/damage

CVAD - dislodgement/accidental removal

CVAD removal

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 2015).

Staff who use CVADs must be trained and undergo competency assessment. This may include completion of the GOSH online learning course ‘Intravenous therapy in children & young people’, a period of supervised practice and an assessment. All staff must be registered as competent to administer intravenous medication on the GOSH training database. Re-assessment of IV practice should take place yearly.

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.
  • Subcutaneously implanted/implantable ports (Port) (commonly referred to as ports, port-a-cath, Bardport®). A subcutaneous implanted Port consists of a reservoir/chamber with a self-sealing septum (the portal) which is attached to a catheter. Ports may consist of one or two reservoirs which are implanted subcutaneously in the chest.
  • Peripherally inserted central catheter (PICC) (often inaccurately referred to as long-lines, PIC, short-long line, midlines). There are two common types of PICCs used which may have one or two separate lumens using:
    • Non-valved (open ended) i.e. 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 subcutaneously 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 and size 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 subcutaneously 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)

PICCs
  • 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®
  • Smart Port ®
  • Vortext Port ®
  • Cook® PICC with clamps
  • Groshong® NXT ClearVue™
  • BioFlo PICC
  • Vascu-PICC
  • Xcela® PICC
  • Vaxcel® PICC

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, parenteral nutrition (PN), 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. For example, children requiring long term PN only will require a single lumen, children undergoing a bone marrow transplant will require a dual or triple lumen and oncology patients may require a single/double/triple lumen catheter according to the protocol. It is important that the most appropriate device is placed as multi lumen CVADs may be associated with an increased risk of infection (Loveday et al 2014).

Advantages and disadvantages

All CVADs have their advantages and disadvantages (refer to appendix 1) which may influence the child/parents or clinican's choice of device (if appropriate). The choice of VAD required for the child/young person will depend on the type of therapy required, this will depend on family lifestyle, length of time IV access is required and the type of medication within the treatment regime. Younger patients will have differing considerations to the older age group (Kaye et al 2000).

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 should also be given:

Other guides available includes:

  • Insertion of cuffed tunnelled CVC
  • Insertion of non-cuffed tunnelled CVC
  • Insertion of PICC
  • Insertion of Port
  • Removal of cuffed tunnelled CVC
  • Removal of Port

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).

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, Copanitsanou and Valkeapaa 2013).

  • 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.
  • 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 where 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 SmartSite®/Bionector®MicroClave®) falls off.
  • What to do if the dressing becomes dirty, wet or 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:

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 .

Planning for discharge

  • Contact local hospitals/community nursing teams
  • Reiterate safety talk

CVAD insertion

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

Policy for intravascular catheter insertion (74.32 KB)and CVAD insertion care bundle must be followed.

The position of the catheter tip must be determined radiographically and documented in the patient's notes (RCN 2010before the catheter is used. This is performed in the IR department/theatre. The operative record should state whether this has been completed (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:

  • medication 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 above the antecubital region or with a securement device e.g. Statlock® (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.
  • Observe carefully for infection & consider covering the site with an occlusive dressing in babies with chunky necks

Chest exit site

  • CVCs 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 Elastoplast®, an alternative tape will need to be used if the child has an allergy to 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 2015). 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

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 (Loveday et al 2014).

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 (DH 2007). This care bundle programme adapted for use at GOSH 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.

Maintenance

Healthcare workers caring for patient with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infections (Loveday et al 2014).

"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." (Loveday et al 2014).

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 & Lamb 2008).

Single patient use wipes containing 2% chlorhexidine in 70% isopropyl alcohol (e.g. Clinell® wipes or other Trust-approved product) are used to clean the hubs of venous access devices and the needleless access devices for 30 seconds with friction and allowed to dry prior to use (Loveday et al 2014, 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.

Parafilm

Parafilm is a water-resistant, mouldable and self-sealing paraffin film. Studies suggest that using a protective barrier around the hub and connections of venous access device (VADs) can be an effective preventative measure against contamination and infection.

Refer to the Infection, prevention and control site on the GOSH Intranet for more information on parafilm.

Application of Parafilm

  • Prepare a 5cm by 5cm (one square) of parafilm, use one square for each required area.
  • Wearing gloves, remove the parafilm from the VAD holding onto the hard plastic coloured hub taking care not pull at the softer section of the catheters as this can cause breaks in the catheter.
  • Ensure all leftover bits of parafilm are removed completely from the VAD.
  • Change gloves.
  • Firmly wipe the needleless access device and hub of the VAD with a 2% chlorohexidine/70% alcohol wipe for 30 seconds, then leave to dry. Visually inspect the needleless access device to confirm the site is dry.
  • Without letting go of the end of the catheter, or contaminating the key part, make a small tear at the top and the bottom of the parafilm and gently stretch apart (you may want to prepare this in advance). Ensure that you do not touch the exposed part of the parafilm. If you have touched any of the key parts you must reclean your needleless access device or use a new piece of parafilm.
  • Wrap the Parafilm over the needleless access device connection & partially up the hub on each side of the catheter (stretching it makes it stick to itself).
  • Using your fingers, twist and mould it around the catheter”.
  • Wrap only around the thicker part of the hard plastic coloured hub. The Parafilm will fit closely around the connector and will stick to itself. Do not wrap around the flexible silicone part of the catheter.
  • There are various ways of applying parafilm, no technique is inaccurate as long as the connections are covered as recommended & the key parts remain uncontaminated. 

Parafilm needs to be replaced 

  • After using the VAD.
  • Every 24hours.
  • If there is moisture underneath the parafilm. 
  • When the parafilm is no longer intact (i.e. visible holes or not sealing the connections).

When not to use Parafilm

  • Do not use as a seal to cover any split or broken central venous access devices.
  • When bathing or showering the patient, the ends of all CVADs must be covered with an additional cover i.e. clingfilm or gloves.

Maintaining patency

Adequate flushing is important in maintaining catheter function. The following three sections discuss 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 link. See CVAD Flushing CPG.

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 2006Douglas 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, 1-2mls flush using 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 whilst using a smooth flush technique, closing the clamp and then immediately after, stop flushing.

For valved PICCs, continue to flush the PICC whilst removing the luer-slip syringe from the needleless access device - do not use a luer-lock syringe. 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.
  • Collect plastic tray. Immediately prior to use, the dry tray should inspected for cleanliness and wiped with a 70% isopropyl alcohol wipe (e.g. 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:

  • Rewash hands or use alcohol hand rub (hand hygiene clinical practice guideline ).
  • Put on well-fitting non-sterile gloves.

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.

End of procedure principles

  • Dispose of all equipment correctly as per Trust Waste Disposal Policy.
  • After use and prior to leaving the patient’s bed space or room, the tray must be decontaminated with a sanitising wipe (e.g. Clinell® universal wipe).
  • The tray should then be washed with hot water and liquid (dishwashing) detergent in an equipment washing sink. Then dried using paper towels (do not leave tray to drip dry) and stored away from sink area to prevent re-contamination with water splashes. N.B. Hibiscrub® or any other liquid hand soaps are not suitable for washing IV trays.
  •  If an equipment washing sink is not available the tray can be cleaned using a sanitising wipe (e.g. Clinell® universal wipe). The tray should be and allowed to dry naturally (do not use a paper towel to dry the tray)
  • Remove gloves and perform hand hygiene.

Dressing

Maintaining the dressing site is important to reduce the risk of infection (Rickard et al 2002) 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) (Loveday et al 2014). 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-LM

Alternative antiseptic solutions:

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

Step-by-step guide to CVC and PICC dressings

The child/YP may require play and distraction techniques to be utilised (McQueen et al 2012) whilst changing the dressing on the CVAD.

Assess the 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 (e.g. Steri-Strips®) if required
  • ChloraPrep® applicator
  • spare pair of well-fitting gloves
  • receptacle for holding discarded equipment/dressing at bedside
  • pack of sterile gauze and 0.9% sodium chloride if there is ooze/debris

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 on top of the dressing
  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/sponge side down to allow the liquid to drain into the sponge applicator.
  8. Firmly press the applicator against the exit site for 10 seconds and then apply the antiseptic using firm repeated up and down, then back and forth strokes for a further 20-30 seconds. Remember to clean all around the exit site
  9. Discard ChloraPrep® away from clean equipment in the tray.
  10. Allow the skin to dry naturally. This helps prevent dermatitis. Do not dry the skin with sterile gauze (Rationale 12)
    Additional skin cleaning will be required if there is blood/ooze present. Any/all blood/ooze adherent to the skin and catheter must be first removed using sodium chloride 0.9% and sterile gauze before using ChloraPrep®.
  11. Loop or curve/S shape 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. Take care not to stretch or use pressure when applying the dressing
  13. Follow end of procedure principles for disposal and decontamination.
  14. Document dressing change in the CVAD record chart

Dressing application to minimise catheter breakage:

  • Place the heaviest part of the catheter completely underneath the dressing e.g. the bifurcation on multi-lumen CVC and PICCs
  • For smaller sized CVCs, i.e. 2.7Fr, 4.2Fr or 5Fr, the dressing needs to cover past the thicker section of the catheter
  • 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

Dressing selection

The first choice for a CVAD dressing should be a sterile semi-permeable transparent dressing, eg IV3000™ (Loveday et al 2014; 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, require less frequent change than that required for standard gauze dressings, thus also saving time renewing dressings. Sterile wound closure strips can also be used to provide extra fixation if preferred

The first option for CVAD dressings at GOSH is IV3000™. A second alternate sterile semi-permeable transparent dressing that is effective where there is skin irritation is Mepitel® film. 
Dermatology or Tissue Viability specialists can be contacted for advice where appropriate.

Other dressings

Self-adhesive island non-woven dressings, e.g. Mepore®, need to be used if there is any oozing from the exit site to absorb any exudate. Remnant 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 (Loveday et al 2014).

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

Other useful equipment

Antimicrobial dressings

Antimicrobial dressings such as BioPatch® can be used for high risk children to prevent infection by providing extra antimicrobial activity at the catheter exit site (Loveday et al 2014) or Zonis®, a silver alginate antimicrobial dressing to treat infection (Hill et al 2010). Advice can be sought from the Infection Prevention and Control team if required.

Barrier film

Barrier films such as Cavilon™ No Sting barrier film can be used to protect the skin.
Cavilon™ 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. Cavilon™ 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 Cavilon™ has been applied.

Alternatives such as LBF® or Sorbaderm® can be used instead
NB 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

Often extra securement to maintain CVAD safety is required for active children/YP. Extra security can also be achieved by:

  • Wearing a vest/armband made out of elastic net retention bandage (e.g. Surgifix®) or similar product.
  • Bags with ties to hold the distal end of the CVC. Often referred to as Hickman®/wriggly bags (children/YP must not sleep with the tape/ribbon around their necks).
  • Securement devices such as Statlocks® or Griploks
  • 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.
  • 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 ends 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 and Lister 2008).

The needleless access device should be changed as per manufacturers' guidelines and must not be accessed in excess of manufacturers' recommendations (Medicines and Healthcare Products Regulatory Agency (MHRA) 2005). Currently GOSH uses MicroClave® needleless access device. 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 within the hospital and users must refer to appropriate manufacturers' guidelines for up to date information.

Needleless access devices contain a minimal dead space, so priming of the device is generally not required.

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 firmly with the chlorhexidine wipe for 30 seconds 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 CVAD record chart or CareVue.

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 (e.g. 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 11).
  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. Clean the CVADs needleless access device with the 2% chlorhexidine in 70% isopropyl alcohol wipe (e.g. 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 (Blood tests: requesting, labelling and sampling requirements guideline) 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 (Loveday et al 2014; National Institute for Clinical Excellence (NICE) 2012). 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, e.g. in a paper tray, 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, i.e. 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 et al 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 CVAD record chart.

Medication administration

Administering medications is one of the most common clinical procedures that nurses will undertake. Changes in legal and professional boundaries within healthcare have led to the role of the nurse broadening to medication management (Dougherty & Lamb 2008)The NMC standards for medicine management (2010) set out the standards of practice for the administration of medications. Staff must also follow the GOSH Medicines Administration Policy (2014) located within the document library on the Trust Intranet.

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 wipes (eg Clinell ® wipes or other Trust-approved product
  • 2% chlorhexidine in 70% isopropyl alcohol wipes 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. National Patient Safety Agency (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 / EP tablet to the child.
  8. Check the patient’s name band against the details on the EP device/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.
  17. Follow end of procedure principles for disposal and decontamination.
  18. 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 wipes (eg Clinell® wipes or other Trust-approved product)
  • 2% chlorhexidine in 70% isopropyl alcohol wipe (eg Clinell® wipes 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 the roller clamp 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; slowly 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). 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). 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 (e.g. 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 guidelines for 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 23ml 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.
  • Follow end of procedure principles for disposal and decontamination.
  • Complete administration documentation.

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 (eg 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 i.e. 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 & 16). 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 / EP tablet 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 (e.g. 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 guidelines for 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 needles that are not designed for implanted Ports are used, then this will result in damage to the septum and require removal of the Port itself.

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 by the person accessing the Port 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 (eg 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 12).
  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 (Rationale 17) 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 18).
  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 19). 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 20). Refer to diagram below for securing a Port needle 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 7).
  32. Follow end of procedure principles for disposal and decontamination.
  33. Document procedure in CVAD record chart/CareVue

Accessing implanted ports

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 21). while the port needle is withdrawn. Where there 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 (e.g. 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 (e.g. 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 21).
  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 22).
  12. Use a small plaster to cover needle site if required.
  13. Follow end of procedure principles for disposal and decontamination.
  14. Document procedure on CVAD record chart 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, depending on clinical advice, 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 23). 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 24).

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.
  • Clinical Site Practitioners for the rest the hospital only if your own unit has no-one trained.
  • Intravenous Therapy Team for the ICI-LM.

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 25).

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.

At GOSH, non-cuffed PICCs 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 entry/exit site using packs of sterile gauze and secure firmly with tape, e.g. 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 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

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Document control information

Lead Author(s)

Anne Ho, Specialist Nurse - Intravenous Therapy Team, Infection, Cancer and Immunity

Additional Author(s)

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

Document owner(s)

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

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
21 February 2009
Date approved: 
01 June 2015
Review schedule: 
Three years
Next review: 
01 June 2018
Document version: 
2.0
Previous version: 
1.0