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Policies and Procedures

Central Venous Access Device Management

  • Disclaimer - 23 May 2018 

    This document is provided for general information purposes only and should not be relied on as the sole determinant of action in any clinical circumstances.  It is not a substitute for specific independent medical advice, nor is it a substitute for the exercise of independent professional judgement in any clinical circumstance.  Additional sources of information should be considered, and independent verification of the material is required, before applying any aspect of the information in this document.  The Royal Children's Hospital Melbourne accepts no responsibility for any loss, damage or injury occasioned by any person’s actions or inactions which are in any way associated with the material in this document. The Royal Children's Hospital Melbourne does not endorse nor take any responsibility for any information or services, which may appear on any linked websites.    

    NOTE: Care should be taken when printing any documents from this site. Updates to these documents will take place as necessary. It is therefore advised that regular visits to this site will be needed to access the most current version of these documents.

     


    CENTRAL VENOUS ACCESS DEVICE 

    CVADs are multipurpose venous catheters that terminate at or close to the heart or in one of the great vessels. CVADs vary in lumen size, numbers of lumens, placement and usage.

    CVADs are indicated in patients who require;

    • Administration of large volumes of intravenous fluids (e.g. resuscitation, blood products)
    • Administration of irritant, vesicant or hyper-osmolar drugs / fluids (e.g. Noradrenaline/Adrenaline, NaHCO3, TPN, chemotherapy)
    • Long term access for frequent or prolonged use (e.g. chemotherapy, antibiotics, blood sampling, apheresis, haemodialysis)
    • Monitoring of central venous pressure

    All inpatients with CVADs in situ should be reviewed daily and CVADs that are no longer required removed without delay.

    CONTENTS

    Types of CVAD

    Choosing correct CVAD

    Consent for CVAD

    Insertion of CVAD

    Who may insert CVAD

    How to request CVAD insertion

    Insertion technique

    • Critical aseptic technique and maximal barrier precautions       

    Confirmation of CVAD position- Imaging guidelines

    Documentation

    Complications of CVAD insertion

    Management of CVAD

    Dressings

    • CVAD appropriate dressings
    • Sutureless securement devices
    • Biopatch
    • Dressing change

    Line access

    Blood sampling 

    Medication administration

    Fluid bag & Infusion changes

    Line changes

    Changing Needleless adaptors (Smartsite)

    Accessing an implanted port/needle change

    Locks/ flushes

    • Pulsatile flush
    • Positive pressure flush
    • Flush volumes / frequency

    CVAD Removal

    CVAD Adverse events/Complications

    Appendices

    • Biopatch instructions
    • Statlock instructions
    • GripLok instructions 
    • CVC- Non tunnelled
    • CVC- Tunnelled non cuffed
    • CVC- Tunnelled cuffed
    • PICC with Statlock
    • Midline with GripLok
    • Implanted Port
    • Vascath

    Priming volumes

    • Calculating the priming volume

    Repair of fracture / damaged catheter

    Blocked catheter guidelines including using a thrombolytic

    Types of CVADs

     NON TUNNELLED

    Non tunnelled central venous catheter (CVC). Inserted into the internal jugular, subclavian or femoral vein.  (EXTERNAL JUGULAR- NOT RECOMMENDED IN CHILDREN) Most commonly used in acute and critical care settings. May have single or multiple lumens. Not suitable for long term use. Usual duration up to 2 weeks

    CVAD 1 - Jan 2017

    Percutanously Inserted Central Catheter (PICC). A long fine bore catheter inserted into a peripheral vein (usually the basilic or brachial vein in the mid upper arm), with the internal tip terminating in the lower SVC. May have single or double lumen. Intended for mid- long term use. Usual duration 2 -12 weeks or longer.

    CVAD 2 - Jan 2017

    Umbilical catheter. CVAD inserted into the umbilical vein or artery of newborns. Umbilical vein catheter tips should lie in the inferior vena cava at or just below the level of the diaphragm. Usual duration 1 week.  http://www.rch.org.au/neonatal_rch/intranet_resources/Umbilical_Venous_Catheterisation_of_the_Newborn/

    Vascath. A specialized CVAD with two large bore lumens – one to take blood and the other to return it. Used for plasmapheresis, plasma exchange or dialysis. Usual duration a few days

    Midline catheter. (Note; not a true CVAD as the tip terminates in the upper arm). A shorter catheter inserted into the basilic or brachial vein in the upper arm. Only suitable for drugs for peripheral infusion. Usual duration, up to 30 days. Included here as the risk of complications of infection and thrombus and management as per a CVAD. http://www.rch.org.au/uploadedFiles/Main/Content/anaes/CPG_midline_catheters.pdf

    CVAD 3 - Jan 2017

    TUNNELED

    Surgically implanted, several centimetres of line are tunnelled beneath the skin from the skin entry site to the vein. This reduces the risk of infection and dislodgement of the line.

    Tunnelled non cuffed CVC. An alternative to a PICC line in a patient with small arm veins (usually less than 3 years or 15kg). Usually inserted into the internal jugular vein, but the femoral vein may also be used. Usual duration 2-12 weeks. 

    Tunnelled cuffed CVAD. (include HICKMAN™, BROVIAC™) In addition to being tunnelled there is a small cuff around the line which lies beneath the skin in the tunnelled section of line. Subcutaneous tissue granulates into the cuff. This prevents accidental dislodgement and acts as a mechanical barrier to bacteria. Usually inserted into the internal jugular or subclavian vein but the femoral vein also may be used. May have single or multiple lumens. Long term access.

    CVAD 4 - Jan 2017 

    >

    CVAD 5 - Jan 2017


    Implanted port. (include INFUSAPORT™) The self sealing injection port is surgically placed under the skin of the chest wall. The catheter is tunnelled beneath the skin to the vein entry point, usually the internal jugular vein. The port is accessed through the skin via a Huber non-coring needle. Long Term access.>

    CVAD 6 - Jan 2017

    CVAD 7 - Jan 2017 


    Choosing the Correct CVAD 

    Selection of the appropriate CVAD involves careful consideration of many factors. For this reason all requests for CVAD insertion should be discussed with a Consultant.

    Considerations for the type of CVAD include

    • Therapeutic purpose – does the therapy need central venous infusion
    • Estimated duration of treatment
    • Medical history (including cardiac anomalies, haematological disorders and/or previous history of line complications (such as thrombosis) 
    • Vein status (difficult peripheral IV access should be a flag for early insertion of a CVAD)
    • Patient age, weight and size
    • Line lumens required. Increased number of line lumens are associated with increased rates of infection. Use a CVAD with the minimum number of ports or lumens essential for the management of the patient
    • Line size: using the smallest diameter line required decreases the rate of thrombus formation and permanent vein blockage.

    Measure the vein diameter with an ultrasound

    The vein diameter in mm is equal to the recommended Fr gauge of the catheter.

    For example

    • For a 3mm vein = 3Fr CVAD
    • For a 4mm vein use a  4Fr CVAD

    Catheter selection

    The following links may be helpful (click on each to open)  

    Click on blue text to open:-  Venous access decision path diagram

    Click on blue text to open:- Choosing an appropriate venous access device

    Consent for CVAD

    Consent is required for CVAD insertion. The child / the child's parent/guardian should have explained the benefits and risks associated with CVAD insertion

    The person inserting the line should ideally be the person gaining consent for it, and ensuring the risks have been understood.

    INSERTION OF CVAD

    Who may insert the CVAD?

    Paediatric CVADs, especially in a child under 4yo can be difficult to insert. 

    Predictors of difficultly include: age <2yo, weight <15kg, previous difficult lines, multiple previous lines.   

    Staff must undergo accreditation with the  CVAD Insertion Education Package prior to inserting CVADs.

    It is imperative that the inserting practitioner be aware of all complications and the necessary steps prior to inserting a line

    Every line has subtle differences in insertion technique, and the product information should be read and understood prior to use

    If additional wires are being used, the inserter should be aware of complications specific to these extra wires and their characteristics.

    Knowledge of venous anatomy and competency with the use of ultrasound are prerequisites for most insertions.   

    It is the responsibility of the manager of the inserting practitioner to decide if the inserter has the necessary experience to insert a line.  Most departments will require a trainee to be supervised for several lines prior to attempting solo insertion.   

    Short term and medium term CVADs (CVCs/PICCs/ Midlines / Tunnelled non cuffed lines) are usually inserted in the operating theatre or critical care areas.

    Long term venous CVADs (Tunnelled, Cuffed and Ports) are usually placed by surgeons but may be placed by interventional radiologists and anaesthetists.

    How to request CVAD insertion

    For emergency or urgent CVAD insertion in theatre

    • Order surgical consult in Epic and phone on call surgical registrar 52193
    • Order AVAS in Epic and call the duty anaesthetist on 52000

    AVAS Referral Process   

    For elective surgical CVAD insertion 

    • Referral in EMR specifying the type and timeframe required

    Insertion technique  

    Insertion technique will depend on the patients age/size, type of CVAD, site of insertion and the need for sedation or general anaesthesia.

    Each CVAD has subtle differences in insertion technique, and the product information should be read and understood prior to use.

    Specific line insertion techniques are outside the scope of this document

    Critical aseptic technique and maximal barrier precautions http://www.rch.org.au/policy/policies/Aseptic_Technique/

    Hand Hygiene should be conducted before & after palpating catheter insertion sites

    Use maximal barrier precautions, including a 60 seconds hand scrub with alcohol or disinfectant preparation, the use of a cap, mask, sterile gown, and sterile gloves for the operator and those assisting in the procedure for the insertion of CVADs or guide wire exchange.

    For the patient, applying maximal barrier precautions means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion.

    Where possible staff should be kept to a minimum in the room where the procedure is being undertaken and staff present in the room should wear a hat and mask.

    Skin antisepsis

    • Use chlorhexidine 0.5% in Isopropyl Alcohol 70% solution
    • If patient < 1500g and < 1 week age use chlorhexidine 1% in Aqueous solution
    • Press chlorhexidine soaked gauze against the skin and apply a back-and-forth friction scrub for at least 30seconds, do not wipe or blot
    • Allow antiseptic solution time to air dry completely before puncturing the site 

    NOTE: All alcohol preparations are flammable. It is imperative that the preparation should be allowed to evaporate completely and that care is taken to avoid pooled pockets of chlorhexidine before exposure to ignition sources such as diathermy. In light of this, tunnelled CVADs inserted in theatre with the aid of diathermy may use povidone-iodine solutions as an alternative to chlorhexidine, provided it is documented on the insertion notes. Allow at least 2 minutes for povidone-iodine solution to dry completely.

    Compliance with this technique is audited by the assistant during insertion.


    Confirmation of CVAD Position- Imaging Guidelines

    Tip position:

    Upper venous system:

    • Position at lower SVC / cavo-atrial junction
    • Approximate anatomical landmark: one vertebral body below the carina

    Lower Venous system:

    • CVC/ Vascath: position in the IVC
    • L5 is the anatomical landmark of the lower border of the IVC
    • Catheter should lie above L5 and parallel to the vertebral column
    • Avoid L1 (renal veins)
    • PICC / UVC position at / just above the level of the diaphragm

    The following link may be helpful: CVAD tip position http://www.rch.org.au/uploadedFiles/Main/Content/anaes/CVAD_tip_positioning_and_xraying_CVADS.pdf

    Practitioners ensure that all guide wire(s) used are removed and that number of wires used and discarded is documented.

    X-ray should be performed prior to use. A transducer or blood gas can also be used to assist in the determination of position

    CVCs inserted peri operatively or in an urgent situation may be used prior to imaging provided the majority of the following criteria are met:

    • Uncomplicated insertion with no concerns re line placement
    • Ultrasound was used
    • Transduced pressure wave confirms placement in venous system
    • Free aspiration of blood from all lumens of CVAD
    • No pulsatile blood flow observed

    For PICC/Implanted port, tip position should be determined during insertion with the image intensifier.  

    Umbilical catheters: http://www.rch.org.au/neonatal_rch/intranet_resources/Umbilical_Venous_Catheterisation_of_the_Newborn/

    NOTE:

    1. If there is any doubt about CVAD position, an x-ray should be taken prior to use; an x-ray must be performed as soon as possible post insertion.
    2. If CVAD re-positioning is required the patient will require a second anaesthetic or sedation. It is highly recommended that the x-ray be performed whilst the patient is still anaesthetised.  

    Documentation

    The insertion of all CVADs should be documented including date, time, inserter, assistant, indication for CVAD, brand/ type of catheter, site of insertion, depth of catheter placement and confirmation of catheter site on CXR. 

    Complications of CVAD Insertion

    Complication Risks & Actions
    Bleeding, haematoma at insertion site • Apply pressure to vein insertion site until bleeding stops
    • If bleeding continues or is excessive, notify medical team. Consider investigating coagulopathy
    Difficulty inserting catheter • Use ultrasound to pre-scan predicted difficult patients (age <2yo, <15kg, previous multiple or difficult CVADs – cystic fibrosis, home TPN or oncology patients). 
    • Have a clinician skilled with ultrasound guided venous access be present/ do these predicted difficult lines
    • Ensure a patent vein with diameter > 3x catheter diameter  present
    • Seek assistance if >3 attempts (2 for neonates) or more than 10 minutes attempting to access a vein 
    Malposition • Verify placement using X-ray, transducer waveform and/or blood gas  
    Temporary nerve damage/pain • Using ultrasound guided insertion reduces nerve injury
    Dysrhythmias • May occur if catheter and/or wire enter heart 
    • Withdraw catheter within SVC/IVC and observe
    • Verify position with x-ray/ ultrasound
    Arterial puncture • Verify placement with x-ray, transducer waveform and/or blood gas. 
    • If arterial, remove small bore catheters and apply pressure to insertion site. Large bore catheters may require surgical consult prior to removal 
    Damage to blood vessels, heart or lungs  • Use ultrasound guidance for insertion 
    • If sudden haemodynamic instability or respiratory compromise, request urgent x-ray
    • MET if urgent medical help required
    Air Embolism • Always ensure needle and catheter is flushed, not open to air and is patent. 
    • Patient head down for neck lines
    Reaction to contrast • Contrast can cause reactions and, rarely, anaphylaxis


    MANAGEMENT OF CVAD

    All CVADs are reviewed daily by the multidisciplinary team. Review includes; how long the line has been in for, the necessity for central access, alternative methods of access/treatment. CVAD's no longer needed for patient care are removed without delay. The longer a CVAD remains in-situ the greater the infection risk.   

    CVAD insertion site is assessed every shift for early signs of infection and this is documented. Check insertion sites visually when changing the dressing or by palpation through an intact dressing. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. 

    All staff accessing CVAD's have completed the CVAD Maintenance Education Package.

    Management of CVADs requires an aseptic technique.   
    Key parts (i.e. end of CVAD) and key sites (i.e. insertion site) are identified and protected from contamination. If there is a risk of contamination to key parts or key sites, sterile gloves and an aseptic field is required. An aseptic field is a controlled working space that ensures the integrity of asepsis during a clinical procedure. The complexity of the procedure to be performed will determine the size of the aseptic field. For example; maintaining asepsis for line change with one line may be able to be performed with dressing pack, whereas multiple lines may require sterile drapes in addition to a dressing pack. 

    Procedures where there is high risk to key parts and/or key sites such as; changing caps or needleless adaptors, change of dressing, accessing an implanted device require sterile gloves and an aseptic field. 

    Lower risk procedures where key parts and key sites are able to be protected such as; medication administration, accessing needleless adaptors, flushes, changing IV bags and syringes, priming lines, taking bloods use aseptic non touch technique at a minimum.

    RCH Procedure - Aseptic Technique    

    Dressings 

    All CVADs are dressed with a sterile, transparent semi-permeable membrane (Tegaderm™ or IV-3000™). CVAD dressings are changed at least every 7 days or sooner if the dressing becomes soiled or loosened. Neonatal PICC line dressings are not routinely changed unless compromised. If the patient is diaphoretic or if the site is bleeding/ oozing, a sterile gauze dressing can be used on the site until this is resolved.   

    CVAD appropriate dressings 
    Refer to Appendices for images of recommended dressing for each type of CVAD.  (NOTE: there may be some variation for patients with long term lines (Broviac™) 

    Non tunnelled
    • Simple CVC
    • PICC with Statlock™
    • Midline with GripLok®
    • Vascath

    Tunnelled
    • Tunnelled non cuffed CVC
    • Tunnelled cuffed (Hickman™) with Statlock™
    • Broviac™
    • Implanted port with access needle in-situ

    Sutureless securement device (GripLok® or Statlock™)
    Most CVADs are secured with either sutures or a sutureless securement device such as a GripLok® or Statlock™. Sutureless securement devices reduce risk of catheter dislodgement, infection rate and needle-stick injuries. They are changed when the dressing is changed or at least every 7 days. 

    Chlorhexidine gluconate impregnated dressings (Biopatch ™)
    Biopatch™ is a chlorhexidine gluconate impregnated disc shaped dressing placed at CVAD exit site to reduce local infections, catheter related blood stream infections (CLABSIs) and skin colonization with microorganisms commonly related to CLABSIs. Biopatch™ is replaced when the dressing is changed. 
    Biopatch™ is not be used over infected wounds, directly over burns, on patients with a known sensitivity to Chlorhexidine, or on neonates less than 8 weeks of age or less than 1000g. 
    Routinely used for Oncology patients, cuffed line (Hickman) dressings and with Consultant approval.

    Dressing changes

    CVAD dressing changes expose a key site and require sterile gloves and an aseptic field.

    CVAD dressings are changed at least every 7 days or when assessed to be required (eg. damp loosened or visibly soiled) to minimise the risk of infection.

    Do not use topical antibiotic ointment or creams on insertion sites, unless prescribed.

    Do not submerge the catheter or catheter site in water.  

    Click on underlined text to download a .pdf copy of the guideline:- Dressing Change for Neonatal Peripherally Inserted Central Catheters 

    Preparation

    • Dressing changes can be performed by 1 or 2 personnel. Determine the need for an assistant considering patient age, developmental level and family participation.
    • Prepare the child and family; consider comfort first techniques and analgesia as required.   

    Equipment required

    • Dressing pack
    • Non sterile gloves
    • Sterile gloves
    • Sterile dressing (transparent semi-permeable membrane)
    • Tape/ Sutureless securement device (Statlock™ or GripLok™)
    • Biopatch™ if  required
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution / Chlorhexidine 1% in Aqueous solution

    Technique
    1. Collect required equipment 
    2. Open dressing pack and prepare aseptic field
    3. Perform hand hygiene and don non-sterile gloves
    4. Remove old dressing including Biopatch if insitu and sutureless securement device if under transparent dressing. (See ‘Biopatch™’ and ‘Sutureless securement device’)
    5. Assess insertion site and check CVAD position 
    6. Take precautions to reduce risk of dislodgement
    7. Remove gloves and repeat hand hygiene
    8. Don sterile gloves
    9. Clean skin with Chlorhexidine solution in a circular motion from the centre to the outer area 5-10cm, three times and allow to air dry.  
    If patient < 1500gms and < 1 week age wash skin with Chlorhexidine 1% Aqueous solution.
    Ensure any visible debris or residue is scrubbed away.
    10. Scrub the lines moving away from the patient, allow to air dry
    11. Replace Biopatch™ as required (See ‘Biopatch™ Instructions’ )
    12. If sutureless securement device used this is replaced every 7 days. 
    13. Apply sterile dressing making sure it covers the insertion site and a portion of the line 
    a. include the sutureless securement device for PICCs  and midlines
    b. include the gauze and steri strips for implanted ports
    c. Statlock™ is outside the transparent dressing for Hickmans and Broviacs
    14. Secure lines away from areas of possible contamination, such as the nappy area
    15. Secure lines to reduce pull on catheter
    16. Dispose of equipment/rubbish safely
    17. Perform hand hygiene
    18. Document    

    Line Access

    Line disconnections should be kept to an absolute minimum to reduce the risk of infection. If uncertain, check with member of the senior health care team prior to accessing CVAD lines.

    Administration sets that have been disconnected (either accidentally or planned) are no longer sterile and unless the risk assessed to be greater are discarded and replaced.

    Prior to accessing a CVAD the point of access must be scrubbed vigorously with friction using Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution or equivalent for at least 15 seconds then allowed to air dry completely.

    Patients with a CVAD in-situ (implanted ports are an exception) should have plastic non-traumatic CVAD line clamps (in addition to the integral CVAD clamps) accessible in case of accidental line disconnection or fracture. Refer to Appendices for Management of fractured/damaged line  

    CVAD 8 - Jan 2017


    Blood sampling
    Taking blood samples requires an aseptic non touch technique where there is a needleless adaptor (smartsite™) in-situ. All CVADs can be bled back for blood sampling if required. Steps must be taken to minimise the risk of thrombus formation; ensure lines are flushed well and clear, use extreme caution to sample from CVAD <3Fr. In CVADs with more than one lumen use the largest lumen possible for blood sampling. 

    If blood is unable to be sampled from CVAD refer to Complications of CVAD (LINK)

    Equipment required
    • Clean tray/ Dressing pack
    • Blood tubes (obtain all samples at once to minimize line access)
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution or swabs
    • Syringes (10 ml luerlock)
    • Sterile Normal Saline/ Heparin flush
    • Drawing up needle
    • Non sterile gloves.

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene 
    3. Prepare equipment and work area
    4. Perform hand hygiene and don non- sterile gloves
    5. Scrub access point vigorously with Chlorhexidine soaked gauze or swabs for at least 15 seconds and allow to air dry
    6. Clamp any lumens not being accessed. NOTE: Do NOT clamp lines with vasoactive infusions running.  
    7. Attach 10ml luerlock syringe onto needleless adaptor and aspirate 5mls.
    8. First 5ml of initial fluid drawn up can be used for blood cultures or discarded except for neonates where the blood if  a) syringe is left attached and b) is from non-Heparin locked CVADs may be reinfused at the end of procedure 
    9. Another syringe is used to collect blood for specimens
    10. Draw sterile normal saline up using drawing up needle taking care not to touch key parts
    11. Flush line with 5-10mls sterile normal saline (2mls for neonates) using a pulsatile action. Lock and clamp if disconnecting as per CVAD locks/flushes 
    12. Fill blood tubes to the line. EDTA first, ensure there is no contact with blood tubes.
    13. Dispose of equipment safely 
    14. Perform hand hygiene
    15. Label blood tubes  
    16. Document

    Medication administration

    Medication administration requires an aseptic non touch technique where there is a needleless adaptor (smartsite™) in-situ. 

    Equipment required:
    • Clean tray/ dressing pack
    • Medications as prescribed
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution or swabs
    • Syringes (10 ml luerlock)
    • Drawing up needles
    • Sterile Normal Saline/ Heparin flush
    • Non sterile gloves (if required).

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene
    3. Prepare equipment and work area
    4. Don non sterile gloves if wearing for personal protection
    5. Prepare medications using drawing up needles taking care to protect key parts 
    6. Expose CVAD and needleless adaptor. 
    7. Assess insertion site and check position 
    8. Perform hand hygiene 
    9. Scrub access point vigorously with Chlorhexidine soaked gauze or swabs for at least 15 seconds and allow to air dry
    10. Clamp any lumens not being accessed.  NOTE: Do NOT clamp lines with vasoactive infusions running.
    11. Attach syringe to needleless adaptor, if infusions not running withdraw first until blood flashback to verify patency
    12. Administer medications
    13. Flush line with 5-10mls sterile normal saline using a pulsatile action. Lock and clamp if disconnecting as per CVAD locks/flushes section further down.
    14. Dispose of equipment safely
    15. Perform hand hygiene
    16. Document

    Pump Pressure

    Pressure limit defaults for intravascular infusion pumps are programmed by BioMedical Engineering, based on the manufacturer’s recommendations.

    Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:

    Increased viscosity of the fluid being administered

    High rate of the fluid being administered

    Reduced diameter of the intravascular catheter

    Increased length of the intravascular catheter

    Increased level of patient activity 

       
    Fluid bag / Infusion Changes

    Fluid bags and syringes with nil additives are changed at least every 7 days.   
    Fluid bags and infusions with additives are changed every 24 hours. 
    Fresh blood products and lipid containing solutions; both the bag, syringe, giving set and lines (including needleless adaptor (smartsite™) if contaminated) should be removed or changed at conclusion of infusion or at least every 24 hours. If the needleless adaptor requires changing, a key site is exposed and this procedure requires sterile gloves and an aseptic field. Refer to ‘Changing needless adaptor”

    Equipment required  
    • Clean tray/ dressing pack
    • Fluid bag (s)
    • Syringe (s)
    • Additives (as prescribed)
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution or swabs
    • Syringes
    • Needles
    • Sterile/ Non sterile gloves (as required)

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene
    3. Prepare equipment and work area
    4. Remove bag(s) or syringe(s) from packaging
    5. Check fluids/additives with RN
    6. Perform hand hygiene and don sterile/ non sterile gloves as required
    7. Make up bag or syringe according to prescription and without touching key parts
    8. Scrub access point on IV bag or needleless adaptor/3way tap with Chlorhexidine soaked gauze or swab for at least 15 seconds and allow to air dry.
    9. Without touching key parts remove line from old bag/syringe and attach new bag/syringe
    10. Dispose of equipment safely
    11. Label all fluids/infusions
    12. Dispose of equipment safely
    13. Perform hand hygiene
    14. Document

    Line changes

    CVAD lines are replaced at least every 7 days using an aseptic non touch technique. If needleless adaptor (smartsite™) requires change at the same time this exposes a key site and sterile gloves and an aseptic field is required. Refer to ‘Changing needless adaptor’
    Administration sets that have been disconnected (either accidentally or planned) are no longer sterile and (unless the risk assessed to be greater) are discarded and replaced. 
    If using fresh blood or fresh blood products replace line(s) at the end of the infusion or 24hourly
    If lipid emulsion is being infused change, lipid syringe/bag and line every 24 hours. 

    Equipment required  
    • Clean tray/dressing pack
    • Fluid bag(s)/ Syringe(s)
    • Additives/medications (if prescribed)
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution or swabs
    • Syringes
    • Needles
    • Giving sets 
    • Lines/tubing
    • Burettes (if required)
    • Taps (if required)
    • Non sterile gloves/Sterile gloves 

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene
    3. Prepare equipment and work area
    4. Remove bags or syringes from packaging
    5. Check fluids/additives with RN
    6. Make up bags or syringes according to prescription and without touching key parts
    7. Hand hygiene and don non-sterile/sterile gloves as required
    8. Scrub access point on IV bag or needleless adaptor/3way tap with Chlorhexidine soaked gauze or swab for at least every 15 seconds and allow to air dry.
    9. Without touching key parts, add the required connections and prime the lines and giving sets to remove all air
    10. Scrub access point of CVAD with Chlorhexidine soaked gauze/swab for at least 15 seconds and allow to air dry. 
    11. Disconnect cap from lines/giving set and connect without touching key parts 
    12. Label all fluids/infusions
    13. Dispose of equipment safely
    14. Perform hand hygiene
    15. Document

    Changing needleless adaptors (Smartsites™)

    Unless the risk is greater, needless adaptors (Smartsites™) are changed every 24 hours if running blood products or lipid, if visibly contaminated or at least every 7 days. Ideally needless adaptors are changed in conjunction with line changes. 

    Preparation  
    • Changing a needleless adaptor (smartsite™) exposes a key site and therefore sterile gloves and an aseptic field are required
    • This procedure can be performed by 1 or 2 personnel. Determine the need for an assistant considering patient age, developmental level and family participation. 

    Equipment required:
    • Dressing pack
    • Sterile gloves
    • Syringes- 10ml luerlock
    • Drawing up needle
    • Sterile normal saline
    • Needleless adaptor(s) (Smartsite™)
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene
    3. Prepare equipment and aseptic field
    4. Perform hand hygiene
    5. Don sterile gloves
    6. Draw up sterile saline using drawing up needle without touching key parts
    7. Attach and prime the needleless adaptor(s)
    8. Clean connection point and 3cm each way vigorously with Chlorhexidine soaked gauze for at least 15 seconds and allow to air dry
    9. Clamp catheter in a sterile manner
    10. Using gauze square disconnect old needleless adaptor(s) and discard. Use separate gauze square for each lumen.
    11. Clean any visible debris or residue and scrub end of catheter using Chlorhexidine soaked gauze for at least 15 seconds and allow to air dry
    12. Connect new needleless adaptor
    13. Unclamp catheter (if appropriate) check patency by aspirating for flashback of blood then flush to clear line using pulsatile action
    1. Lock and clamp if disconnecting as per CVAD locks/flushes
    14. Dispose of equipment safely
    15. Perform hand hygiene
    16. Document

    Accessing an implanted port/Needle change 

    Preparation.
    • Implanted ports are accessed using sterile gloves and an aseptic field.
    • Port needles are changed at least every 7 days. 
    • This procedure can be uncomfortable and patients require careful preparation. Consider comfort first techniques, use of topical local anaesthetic cream and analgesia as required.
    • Port access can be performed by 1 or 2 personnel. Determine the need for an assistant considering patient age, developmental level and family participation. 

    Equipment required
    • Dressing pack
    • Sterile gloves
    • Syringes- 10ml luerlock
    • Drawing up needle
    • Sterile normal saline
    • Huber needles
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution
    • Steristrips
    • Sterile dressing (transparent semi-permeable membrane)

    Technique
    1. Collect required equipment 
    2. Perform hand hygiene
    3. Prepare equipment and aseptic field 
    4. Ask patient/assistant to expose port site
    5. Remove local anaesthetic cream and discard
    6. Perform hand hygiene 
    7. Don sterile gloves
    8. Draw saline up using drawing up needle
    9. Prime Huber needle
    10. Clean skin with Chlorhexidine solution in a circular motion from the centre to the outer area 5-10cm, three times and allow to air dry.  
    11. Feel for the edges of the port and hold between thumb and index finger
    12. Press the needle through the skin using gentle but steady pressure until the needle touches the bottom of the port
    13. Gently flush port and aspirate to check for blood flash back then flush to clear line.
    14. Insert folded gauze under needle for support
    15. Apply steristrips over the hub to secure needle
    16. Apply sterile transparent semi-permeable membrane dressing
    17. Secure lines to reduce pull on needle
    18. Dispose of equipment safely
    19. Perform hand hygiene
    20. Document

    Locks/ Flushes

    Heparin or saline locks and/or line flushes promote and maintain CVAD lumen patency.   

    All locks or line flushes must be ordered as a medication. CVAD patency is checked using a 10ml or larger syringe of sterile normal saline. Never use less than 10ml syringe as the amount of pressure can rupture the lumen. If resistance is felt during flushing and force is applied this may result in catheter rupture. (Refer to CVAD adverse events/ complications for blocked catheter).

    NOTE: Patients with haemophilia or other severe bleeding disorders have sterile normal saline flushes/locks only. When haemophilia patients have a CVAD inserted, they will have clotting factor replacement to ensure normal factor levels are maintained during and for approximately three days post insertion.  Long term heparin lock in theatre is appropriate in this setting.
    When de-accessing a newly inserted port, support the port at the time of needle removal to prevent bleeding around the chest wall. 

    NOTE: Ethanol is not compatible with Heparin

    There are two main methods of flushing;

    Pulsatile flush

    This method is used to clear the catheter of blood or drugs that may adhere to the internal surface of the catheter. This technique utilises a rapid stop-start or push-pause method when injecting the flush solution into the catheter. Theoretically, turbulent flow removes any blood attached to the catheter wall and thus reduces the risk of catheter occlusion 

    Positive pressure flushing

    This technique prevents or reduces the risk of blood reflux into the catheter lumen when the pressure is released.
    Positive pressure should be applied and maintained until the needleless adaptor or 3 way tap is turned off or clamped. The technique involves clamping the catheter whilst instilling the last part of the flush, so that 0.5-1ml of solution is left in the syringe immediately after which the pressure is released on the syringe. 

    Flush/Flushing volumes

    Continuous infusion of at least 1ml/hr in neonates and 2ml/hr for infants and older to keep vein open may be considered for small bore lines and essential for all PICC lines < 3Fr.

    The volume of the CVAD should be assessed prior to heparin lock being inserted.

    The following flush and lock volumes are given as a guide. 

    Check individual CVADs for actual catheter priming volumes. If fluid restricted and for neonates, the minimum volume of flush/lock should be twice the actual catheter priming volume plus volume of add on devices. See Priming Volumes for details 

     CVAD TYPE  Saline flush between medications  Saline flush after blood sampling Short term heparin lock (10iu/ml)   Long term heparin lock (100iu/ml)
    Non tunnelled
    (CVC) 

    2mls  5-10mls 1ml   1ml
    Tunnelled 
    non cuffed
    (Midline)

    2mls   5-10mls  2mls  2mls

    Tunnelled cuffed (Hickman)

    2mls   5-10mls  2mls  2mls
    PICC >3Fr 2mls  5-10mls  1ml  2mls
    Midline 2mls  5-10mls

     6.5Fr 2mls

    13.14Fr 3mls 

     
    Vascath 5mls  5-10mls  2mls  
    Implanted ports 2mls   5-10mls  2mls  2mls



     Flush / Lock Frequency  Solution
    Access <6 hours
    Non tunnelled CVCs should be flushed every 6 hours to prevent occlusion OR continuous infusion running. 
    Sterile normal saline
    Access 6-24 hours 
    All CVADs incl midline that require access in 6-24 hours
    Short term heparin lock (10 iu / ml) 
    Access > 24 hours 
    Tunnelled (non cuffed) and PICC lines flush daily to prevent occlusion   
    Hickman’s / Broviacs flush and relock at least every 7 days
    Implanted ports can be left 4-6 weeks between flushes – flush with 10mL

    Long term heparin lock  (100 iu/ml) 

    Note: Aspirate heparin lock first. 
    Pulsatile flush with 5-10ml Sterile normal saline 
    Heparin lock with volume as above 


    CVAD Removal

    CVADs are removed without delay once the multi-disciplinary team decides they are no longer required for patient care. 

    CVAD removal exposes a key site and requires sterile gloves and an aseptic field.

    PICCs and midlines may be removed either in the hospital or at home by an RCH nurse 

    Vascaths and non tunnelled CVCs and tunnelled non cuffed are removed in a hospital. 

    Non-oncology patients: Tunnelled cuffed CVADs (Hickman™, Broviac™) are usually removed under general anaesthesia in theatre as surgical dissection is required to loosen the cuff.

    Oncology patients: Tunneled cuffed CVADs may be removed by a nurse, in the Children's Cancer Centre, trained and certified competent to remove tunneled cuffed CVADs. Such a nurse may have a maximum of two attempts at removing the CVAD. If the CVAD is unable to be removed successfully, an additional two attempts may be performed by another trained and competent Children's Cancer Centre nurse.

    If the CVAD is still unable to be removed, the treating medical team is required to make a referral to the Paediatric Surgical team for the CVAD to be removed via surgical dissection

    If the cuff is retained and is visible at the CVAD skin exit site following removal of the CVAD, a medical review is necessary for removal.

    If the cuff is otherwise retained under the skin it should be left in situ. If an infection later occurs at this site, urgent surgical review +/- drainage and removal is required.

    Tunnelled cuffed CVADs (Hickman™, Broviac™) are usually removed under general anaesthesia in theatre as surgical dissection is required to loosen the cuff. In certain circumstances they may be removed by experienced nurses in the Children’s Cancer Centre. 

    Implanted port (Infusaport™) are removed under general anaesthesia in theatre as surgical dissection and suturing is required.

    Umbilical Catheters - RCH Neonatal Intranet resources - Umbilical venuous catheterisation of the newborn  

    Preparation 
    • For removal of a CVAD, prepare the child and family; consider comfort first techniques and analgesia as required. Anaesthesia or sedation is rarely needed for tunnelled non cuffed or non-tunnelled CVAD removal. 
    • The removal of a CVAD can be performed by 1 or 2 personnel. Determine the need for an assistant considering patient age, developmental level and family participation. 
    • Ensure all bloods required are taken prior to removal, including coagulation studies if necessary.  
    • Where possible, co-ordinate CVAD removal with other planned procedures requiring anaesthesia or sedation.

    Equipment required
    • Dressing pack
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution
    • Non sterile gloves
    • Sterile gloves
    • Stitch cutter
    • Tape  
    • Sterile transparent semi permeable dressing  (e.g. Tegaderm)

    Technique
    1. Collect required equipment
    2. Perform hand hygiene
    3. Prepare equipment and aseptic field
    4. Expose CVAD site and clamp all lines
    5. Don non sterile gloves
    6. Remove dressing and dispose
    7. Perform hand hygiene
    8. Don sterile gloves
    9. Clean insertion site using Chlorhexidine soaked gauze in a circular motion extending outwards.
    10. Remove any securing sutures or sutureless securement devices (Statlock/ Grip-lock)
    11. Ask patient to take a deep breath, hold it. If patient unable to comply, remove catheter during expiration and never when patient is breathing in, as this may cause air to be sucked into the venous system.
    12. Using gauze, place firm pressure over site(s), gently using steady pressure pull the CVAD out. a) For non-tunnelled CVADs, place firm pressure over insertion site with gauze until bleeding stops. 
    b) For tunnelled non cuffed CVADs, place pressure over vein insertion site – lower neck or groin (which is different to the skin insertion site) until bleeding stops.
    13. As catheter is about to exit, increase pressure. If resistance is high at any point, stop and notify medical staff.
    14. Hold gauze over site until bleeding stops
    15. Cover insertion site with a sterile transparent semi-permeable membrane dressing. For removal of Vascath; use gauze, sterile transparent semi-permeable membrane and then reinforce with pressure dressing. 
    16. Following removal of vascath, patient must rest in bed for 4 hours.
    17. Dispose of equipment safely
    18. Perform hand hygiene
    19. Document  

    CVAD Adverse Events and Complications   
    Event or Complication  
    Accidental disconnection Risk venous air embolism and blood loss
    Treatment  
    • Resuscitate and call a MET if cardio respiratory compromise  
    • Immediately clamp catheter between the leak (or damaged area) and the patient with the integral line clamp, atraumatic green plastic clamp or metal clamp covered in gauze. 
    • Using surgical aseptic technique, scrub patient side of line with Chlorhexidine solution
    • Withdraw air and check for blood return
    • Flush with sterile normal saline and clamp line
    • Using surgical aseptic technique prime new lines and continue infusion
    • Document
    • Notify medical team 
    Accidental removal  • Apply pressure to exit site until bleeding stops 
    • Cover site with bandaid
    • Notify medical team
    • Make arrangements for replacement of line if required 
    Air embolus 
    Can occur due to 
    • an uncapped / unclamped line lumen
    • accidental air injection 
    • vein exit site exposed during removal. 
    Prevention  
    • Do not allow air to enter the catheter. 
    • Ensure all lines are primed before attaching to the patient
    • Follow correct CVAD removal procedure  
    • Ensure clamps are closed on lines 
    Symptoms: patient becomes acutely short of breath and distressed, cyanosis, tachycardia, decreased conscious state. 
    Treatment 
    • Call a MET 
    • Lie patient left side down with a head down position 
    • Check the line for any obvious holes / disconnections 
    • Clamp / cover exposed catheter end as per ‘accidental disconnection’ 
    Arrhythmias or palpitations  • See ‘Malposition/Migration’ 
    Blocked catheter

    • Impending
    • partial 
    • complete 
    Types of occlusion – ALL need to be treated 
    1. Impending occlusion; can flush but unable to withdraw blood
    2. Partial  occlusion; sluggish blood return 
    3. Complete occlusion; blocked lumen
    Can occur due to
    • clot or drug precipitation within the CVAD lumen 
    • fibrin sheath enveloping the CVAD – a fibrin tail at the tip of the CVAD can cause withdrawal occlusion 
    • an external / mechanical obstruction: catheter kinked within the body or pinched between internal structures   
    • malposition of the tip of the line : in the high SVC, not freely floating parallel to vein wall, in the neck, across to the other side of the chest 
    Treatment  
    • Check for mechanical problems such as kinked tubing, closed clamp
    • Check insertion site for kinking, malposition or migration
    • Change patient position or ask patient to take deep breaths
    • Try flushing the catheter briskly with 10ml luer lock syringe and sterile normal saline 
    • Notify medical team
    • DO NOT REMOVE CVAD if still required. 
    • Use thrombolytic therapy (tPA)   Blocked catheter guidelines including use of thrombolytic or HCl
    • Consider ultrasound as there may be associated thrombus  
    Cardiac tamponade Cause: may occur within several hours of insertion due to accidental perforation of pericardium by insertion needle or catheter tip. Blood accumulates in the pericardial space around the heart and impairs cardiac function. Can be catastrophic and fatal. Rare, more common in neonates. 
    Symptoms: cardiovascular instability and collapse 
    Treatment: Medical emergency. 
    • Call a MET. 
    • Organize an urgent ECHO 
    Catheter damage or  fracture – internal  CVAD catheter breaks inside the patient and the broken end cannot be retrieved. Medical emergency as haemorrhage can occur the catheter may split and embolism of the internal portion can occur into the heart or lungs
    Treatment: 
    • Call a MET. 
    • Organize urgent emergency theatre 
    • Any damaged line that requires removal should be sent to Biomedical and onto the manufacturer. 
    Catheter damage or  fracture – external  CVAD catheter is damaged or broken outside the patient’s body. Medical emergency as high risk of haemorrhage or venous air embolus
    Treatment: 
    • Immediately clamp catheter between fracture and patient with integral line clamp, non-traumatic green plastic clamp or metal clamp covered in gauze. 
    • Place occlusive dressing over fracture site
    • Notify Medical team 
    • Hickman™ and Broviac™ CVADs can be repaired with the appropriate repair kit by trained staff. Management of fractured line 
    • Most lines will need removal and replacement
    • Any damaged line that requires removal should be sent to Biomedical and onto the manufacturer. 
    Central Line associated bloodstream infection (CLABSI) See ‘Infection: Systemic’ 
    Occlusion See ‘Blocked catheter’  
    Difficult to remove  • Reposition patient and reattempt removal
    • Ensure all sutures removed
    • If CVAD remains difficult to remove, stop
    • Notify AUM
    Extravasation  Accidental administration of drugs into the extra vascular tissue instead of into the vein. Tissue damage and necrosis can be extensive with some drugs (e.g. vesicant chemotherapy) and should be treated as a medical emergency 
    Symptoms: pain, redness, swelling, visible leaking of drug via the skin tunnel
    Treatment:
    • Stop infusion
    • Assess insertion site and document
    • Notify medical team 
    • Document
    • http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Extravasation_Injury_Management/ 
    Infection: Local Symptoms: redness, swelling, discharge, ooze, pain or tenderness at site. Neutropaenic patients may not develop symptoms of redness or discharge. 
    Treatment:
    • May be treated with antibiotics and CVAD may be able to remain insitu 
    • Swab site and smear a glass slide for microscopy prior to placing swab into charcoal medium and transporting to the Bacteriology Laboratory
    Note: Local site infections in an implanted port or above the cuff of tunnelled cuffed CVAD are difficult to treat and line removal is often required. 
    Infection: Luminal infection  Symptoms Pyrexia, shivers, rigors following catheter flush. If untreated this may progress to septicaemia 
    Treatment  as for ‘Infection: Systemic’

    Infection: Systemic Symptoms: Pyrexia, hypotension, tachycardia, shock.
    Treatment:
    • If patient febrile (Temp > 38°C), take blood cultures. Sample from all lumens and clearly label each on the bottles.
           (Note: Do NOT sample from lines with vasoactive infusions running).  
    • Antibiotics should be started immediately. 
    • Do not remove CVADs on the basis of fever alone. Use clinical judgment regarding removal of the CVAD. Consider evidence of infection elsewhere, non-infectious cause of fever, difficult line replacement
    Leaking of fluid out of exit site  • Consider ‘Extravasation’ 
    • Assess and document
    • Notify medical team
    Malposition / Migration –too far in Catheter length outside the body gets shorter, tip discovered in an unacceptable low position on CXR or ECHO. 
    Symptoms: Rarely tachycardia and palpitations due to migration into the right ventricle. 
    Treatment
    • Assess and document
    • Notify medical team 
    • Catheter will need to be pulled back to an acceptable position with a sterile technique, resecured, repeat CXR taken. 
    • Tunnelled cuffed and implanted ports need to be pulled back under a general anaesthetic in the operating theatre. 
    Malposition / Migration- too far out Catheter length outside the body gets longer, cuff protrudes from exit site, tip discovered in an unacceptable high position on CXR. 
    Risk of extravasation and loss of therapeutic drug effect
    Symptoms: Neck pain, rushing sound in ear when flushing,  extravasation
    Treatment
    • Stop infusions and clamp
    • Secure catheter
    • Place firm pressure on any bleeding areas
    • Notify medical team
    • Document 
    Phlebitis Irritation of the intima of the vein ,may occur within 72 hours of insertion  
    Symptoms: pain, erythema, warmth, a venous cord may be palpable 
    Treatment: 
    • Often can be treated with warmth and analgesia 
    • Do not remove CVAD 
    Pneumothorax Presence of air in the pleural space between the lungs and the chest wall. Can occur during CVAD insertion when the needle used to access the vein inadvertently punctures the lung. This risk is reduced by using ultrasound.
    Symptoms: shortness of breath, reduced oxygen saturation, tachycardia, hypotension. It may also be “silent “ - discovered incidentally on a CXR 
    Treatment: 
    • Call a MET if cardio respiratory compromise present. 
    • Urgent chest decompression with a needle or a chest tube may be required. Small pneumothorax may  resolve spontaneously  
    Replacement  Routine replacement of working lines is not recommended.
    Rewiring  There is a high infection risk from rewiring and this technique is not recommended unless replacing in an alternative entry site is very difficult / is associated with risk to patient  
    Thrombosis (DVT)  Thrombosis occurs when a clot develops within the vein around the catheter and extends into central veins. More common if the catheter takes up > 1/3 of the vein diameter, the tip of the catheter is malpositioned high in the SVC or in patients with sepsis or cancer 
    Symptoms: May be asymptomatic or cause swelling, pain, tingling or numbness of arm, neck, face or legs. Surface vein collateral blood vessel formation may occur 
    It usually will not affect the patency of the catheter. 
    Thrombosis can be confirmed by ultrasound.
    Treatment
    • Urgent referral to Haematology
    • DO NOT remove CVAD without consulting haematology – removal if patient is not anticoagulated may cause clot embolism
    • It may be possible/ preferable to treat a thrombosis using anticoagulants without removing the catheter if the CVAD is functional and required. Reinsertion risks thrombus at a second site 


    APPENDICES

    BIOPATCH™ INSTRUCTIONS 

    Application - following skin antisepsis, ensure the skin is completely dry before applying Biopatch™.  Apply Biopatch™ around the catheter with blue side up (white foam side to the patient's skin) & with the radial slit approximated (ensure 360 degree contact with the skin around the catheter).  To ensure easy removal, place the dressing so that the catheter rests on or near the radial slit. Cover with an occlusive transparent dressing. 

    Removal - lift the corner of the transparent film dressing & stretch away from the catheter.  When the radial slit is correctly aligned with the catheter, biopatch™ will remain attached to the transparent film dressing, making removal simultaneous. 

    Change - with routine dressing changes (at least every 7 days or sooner if the dressing becomes soiled or loosened). 

    CVAD 9 - Jan 2017

     STATLOCK™ INSTRUCTIONS   
    In most cases PICCs are secured with a sutureless device, Statlock™ that is underneath the dressing. 

    Application.
    Prepare the skin under the Stalock™ site with the skin protectant prep pad included in the pack. Dry for 10-15 seconds. Apply Statlock™ device so the directional arrows point towards the insertion site. Place one catheter wing hole over the Statlock™ post then slide the device to capture the second hole. Press the clear Statlock™ “doors” closed one at a time.                                                                                                                                                                                                                                                                                                                     
     

    CVAD 10 - Jan 2017Statlock applied so PICC catheter is curved away from the elbow joint

     

    CVAD 11 - Jan 2017

    CVAD 13 - Jan 2017



    Peel the stalock paper backing one piece at a time. Place into the skin on side at a time

    Securement strip can be used to stabilize PICC during dressing change catheter 

    Change.
    A Statlock™ should be changed with routine dressing changes (at least every 7 days or sooner if the dressing becomes soiled or loosened). 
    Note: the length of PICC line from insertion site to hub. This is recorded at the time of insertion.
    Follow CVAD dressing change procedure


    CVAD 13 - Jan 2017

    Sterile adhesive dressing is placed over the PICC exit site and Statlock

     



    Removal.
    Remove the old dressing. One of the securement strips included in the new Statlock™ pack can be used to secure the PICC during Statlock™ change.  
    Peel the old Statlock™ off – the adhesive dissolves with alcohol. 

    CVAD 14 - Jan 2017

    Additional securement tape used if desired 



    GRIPLOCK™ INSTRUCTIONS

    Application. 
    Open the top flap and slide the Grip-Lok™ under the catheter hub. Position the catheter hub down into the foam cut-out and press gently to the adhesive.    
      CVAD 15 - Jan 2017 CVAD 16 - Jan 2017 
    Pull and remove one side of the bottom release liner while holding Grip-Lok™  in position. Then pull and remove the other side of the bottom release liner.  
    Pull and remove the inner release liner under the top flap to expose adhesive     
    CVAD 17 - Jan 2017    CVAD 18 - Jan 2017
    Secure the top strap over the catheter hub and press the adhesive in place. The top strap can be peeled back to inspect and adjust the catheter hub.      
    Change
    A Grip Lok™ should be changed with routine dressing changes (at least every 7 days or sooner if the dressing becomes soiled or loosened). 
    Removal        
    Remove the old dressing. Take note of the insertion site and length of catheter. Ensure catheter is secure during dressing and Grip Lok™ 
    Peel the old Grip Lok ™ off – the adhesive dissolves with alcohol.  
       


    CVC NON TUNNELLED DRESSING

    The CVC insertion site is covered with a sterile transparent semi permeable membrane.
    There are multiple techniques to secure CVCs in infants and children – a reflection that no technique is ideal 
    Securing the catheter against the skin provides a flatter less mobile surface to reduce the risk of dislodgement
    Sutures are often used in younger patients to prevent dislodgment. Cyano-acrylate glue (Dermabond ™) can also be used 
    There are no ideal sutureless securement devices for a small patient, but a Statlock™ could be considered 
    Reinforcement tapes are used to prevent traction on the line and accidental dislodgement

    CVAD 19 - Jan 2017


        CVAD 20 - Jan 2017


    CVC – TUNNELLED NON CUFFED DRESSING  

    The vein entry site and the skin insertion site are covered with a sterile, transparent semi-permeable membrane.
    The dressing on the vein entry site can be removed 3 days after insertion. 
    A Biopatch™ may be used in patients at increased risk of infection or oncology patients.
    Sutures are often used to prevent dislodgment but a sutureless securement device (Statlock™) may be also used  and should be located under the sterile occlusive dressing
    Reinforcement tapes are used to prevent traction on the line and accidental dislodgement
    Sutures are often used in younger patients to prevent fall out, 

      CVAD 21 - Jan 2017

    CVAD 22 - Jan 2017    CVAD 23 - Jan 2017


    CVC -TUNNELED CUFFED DRESSING  


     Double lumen Hickmann with Biopatch™ & Statlock™    Single lumen Broviac with Biopatch™ & Statlock™
    CVAD 24 - Jan 2017  CVAD 25 - Jan 2017 
    The skin insertion site and part of the catheter are covered with a sterile, transparent semi-permeable membrane. There is a Biopatch™ at insertion site. There is a gentle curve in the line under the dressing to reduce traction on the line. The Statlock™ is outside the sterile dressing and is used to reduce the risk of dislodgement.   


    PICC  DRESSING  WITH STATLOCK™

    CVAD 26 - Jan 2017 
    The PICC insertion site, section of the line and Statlock™ are covered with a large sterile, transparent semi-permeable membrane.

    There is a gentle curve in the line under the dressing to take traction off the line. 

    The Statlock™ is positioned under the sterile dressing to reduce the risk of line dislodgement 
    For instructions on Statlock changes refer to Statlock Instructions ™ 


    MIDLINE  DRESSING  WITH GRIPLOK

    CVAD 27 - Jan 2017
    The insertion site, portion of the catheter and GripLok™ securement device are covered with a large sterile transparent semi permeable membrane. The GripLok™ prevents traction on the line and reduces the risk of dislodgement. Additional tape can be used to further secure the dressing.


    IMPLANTED PORT DRESSING  

    CVAD 28 - Jan 2017 
    The implanted port is accessed with a Huber needle and the line secured with gauze,  Steristrips™  and a flat transparent dressing. Refer to “Accessing an Implanted port/ needle change”


    VASCATH DRESSING  

    CVAD 29 - Jan 2017 
    Vascaths usually only remains in for a few days. The line is secured with either sutures or Statlock™  sutureless securement device and a sterile occlusive dressing covers the exit site, and part of the catheter.


    PRIMING VOLUMES


    CVAD Fill / priming volume (untrimmed
    Note: PICCs and tunnelled lines are the untrimmed volumes. Most lines are trimmed significantly at the time of insertion  
    Non tunneled standard CVC  
    Arrow 4Fr 2 Lumen CVC 0.25 - 0.3 mL
    Arrow 4Fr 3 Lumen CVC 0.27- 0.32 mL
    Arrow 5Fr 2 Lumen CVC 0.3-  0.32 mL
    Arrow 5.5 Fr 3 Lumen CVC 0.3 - 0.34 mL
    Arrow 7Fr 3L CVC 0.39 - 0.44 mL
    Arrow 16g 16cm 0.4 mL
    Arrow 14g 20cm 0.55 mL

     
    Vygon 2F DL 30cm nutriline 0.2 mL
    Vygon 3Fr DL 10cm Multicath 0.07 (distal) - 0.09 (proximal) mL


    PICCS (untrimmed)  
    Angliodynamics BioFlo PICC 3F untrimmed <0.8mL
    Angliodynamics BioFlo PICC 4F untrimmed <1.1mL
    Angliodynamics BioFlo PICC 5F DL untrimmed <1.0mL
     
    Arrow 3Fr PICC untrimmed 0.3mL
    Arrow 4Fr  PICC untrimmed 0.5mL
    Arrow 5Fr PICC untrimmed DL 55cm untrimmed 0.4mL
       
    Arrow 4Fr PICC DL untrimmed 0.30 (proximal), 0.25 mL (distal)
    Arrow 5Fr PICC DL 13cm untrimmed 0.32 (proximal, 0.30mL (distal)
    Arrow 5Fr PICC DL 55cm untrimmed DL 0.4 mL per lumen


    Vygon Pemicath 28g / 1 Fr 20cm 0.09mL
    Vygon Epicutaneo-cava-catheter 24g / 2Fr 15cm 0.10mL
    Vygon Epicutaneo-cava-catheter 24g/ 2Fr 30cm 0.12mL
    Vygon Nutriline Twinflo 24g/ 2Fr 30cm 0.02mL per lumen
       
    Umbilical Venous Catheters
    Argyle 3.5Fr 25cm 0.15 mL
    Argyle 5Fr 25cm 0.33 mL
    Argyle 3.5Fr DL  25cm 0.21 mL (proximal), 0.16mL (distal)
    Argyle 5Fr DL 25cm 0.32 mL (proximal), 0.22mL (distal)
    Argyle 5Fr TL 25cm 0.32mL (proximal), 0.19 mL (middle and distal)
       
    Tunnelled cuffed lines (untrimmed) 
    Bard Broviac 2.7F SL 0.15 mL
    Bard Broviac  4.2F SL 0.3 mL
    Bard  Broviac  6.6F SL  0.7 mL
    Bard  Broviac  9.6 F SL 1.8 mL
    Bard Hickman’s  DL 7F 0.8 mL white 1 mL red
    Bard Hickman’s  DL 9F 0.7 mL white 1.3 mL red
       
    Ports (plus minimum volume extension)  
    Angiodynamics Vortex Smart Port CT 7.5Fr Most common RCH ports used. Once trimmed and  insitu port plus minimum volume extension =  0.5 – 0.8 mL
    Angiodynamics Vortex VX 5.1Fr Port  
    Cook Vital port 11.5Fr Port  (large port 1.2mL)
    Cook Petite Dual 7.5Fr Port   


    Vascaths
    Gamcath 6.5 Fr DL  0.75mL
    Muhurkar 13.5Fr DL 1.4 – 1.5 mL
    Arrow Haemodialysis 14Fr DL 1.2 – 1.4mL
       


    Calculating the catheter fill / priming volume

    CVAD 30 - Jan 2017
    Flush the line with 5-10ml 0.9% NaCl in a 10ml syringe
      CVAD 31 - Jan 2017 Attach a 2ml Luer lock syringe 
      CVAD 32 - Jan 2017 Aspirate back slowly until blood enters the syringe 
    CVAD 33 - Jan 2017  The volume of saline in the syringe just as blood starts to enter is the catheter fill / priming volume 
    CVAD 34 - Jan 2017
    Flush the line with 5-10ml 0.9% NaCl in a 10ml syringe
    The catheter lock volume should always be twice the actual catheter priming volume to calculate plus add on devices. In the example above, the catheter priming volume is 1.1ml so the lock volume used should be 2.2ml. 


    REPAIR OF DAMAGED/ FRACTURED LINE   

    External fractures of or damage to CVADs (Hickman™ and Broviac™) lines can be repaired using designated catheter repair kits. Only staff who are trained and competent in fracture repair should perform catheter repair.

    Repair of a CVAD line requires that there is at least 5cm of undamaged catheter remaining between the damaged area and the insertion site. Repair of an arm of a multi-lumen requires at least 2.5cm of undamaged catheter remaining between the damaged area and the junction of the lumens.  

    The catheter should be clamped immediately between fracture and patient with integral line clamp, with non-traumatic green plastic clamp or metal clamp covered in gauze and must remain clamped for the duration of repair. 

    Equipment
    • Dressing pack
    • Sterile drapes
    • Chlorhexidine 0.5% in Isopropyl Alcohol 70% solution
    • Catheter repair kit
    • Scalpel
    • Sterile gloves
    • Syringes
    • Drawing up needle
    • Sterile normal saline

    Technique
    1. Collect required equipment
    2. Prepare equipment and aseptic field
    3. Perform hand hygiene and don sterile gloves
    4. Clean the fractured segment with chlorhexadine solution and place on sterile drape.
    5. Remove plunger from syringe and insert medical adhesive into the syringe barrel. Replace plunger and attach blunt needle
    6. Clean catheter attached to patient vigorously with Chlorhexidine soaked gauze for at least 15 seconds and allow to air dry
    7. Cut the patient side of the catheter immediately adjacent to damaged area at 90 degrees (Ensure remaining length of catheter does not slide under the skin)
    8. Insert the stent attached to the replacement catheter segment into existing catheter lumen until the end of the replacement catheter tubing is 3mm from the cut end of patient catheter.
    9. Dry the space between catheter ends.
    10. Fill the 3mm space with adhesive and push the catheter ends together. Ensure adhesive does not come into contact with patient skin
    11. Apply adhesive around the spliced joint to cover around 2.5cm
    12. Slide the splice sleeve down and centre it over the joint
    13. Inject adhesive underneath each end of the splice sleeve
    14. Roll the splice sleeve between fingers to distribute adhesive and extrude excess.
    15. Wipe away excess adhesive
    16. Fasten splint to repaired section of catheter with tape. The repair will not achieve full mechanical strength for 48 hours but may be used if necessary in 4 hours,
    17. Attach syringe of normal saline, unclamp and aspirate air from repaired section. GENTLY fill the catheter with lock and reclamp. 

    BLOCKED CATHETER GUIDELINES INCLUDING USING A THROMBOLYITIC or  HCl

    3 types of occlusion – all need to be treated as they are all signs of potential complete occlusion 

    1. Complete occlusion : Blocked lumen 
    2. Partial  occlusion:  Sluggish blood return 
    3. Withdrawal occlusion:  an inability to withdraw blood, but fluids can be administered  

    Causes 

    • Clot or drug precipitation within the CVAD lumen 
    • Fibrin sheath enveloping the CVAD – a fibrin tail at the tip of the CVAD can cause withdrawal occlusion 
    • An external / mechanical obstruction: catheter kinked within the body or pinched between internal structures   
    • Malposition of the tip of the line : in the high SVC, not freely floating parallel to vein wall, in the neck, across to the other side of the chest 
    • Large vessel thrombosis associated with the catheter

    Initial instructions for blocked catheters 

    • Treat all the above as they are signs of impending complete occlusion  
    • Check for mechanical problems such as kinked tubing, closed clamp
    • Check insertion site for kinking, malposition or migration
    • Change patient position or ask patient to take deep breaths
    • Try to flush the catheter briskly with 10ml luer lock syringe and 0.9% saline 
    • Notify medical team
    • Obtain CXR to confirm line placement and absence of kinking.
    • Catheter completely blocked: Do not remove CVAD if still required. Line replacement may be difficult and unnecessary. Use thrombolytic therapy (tPA)  
    • Consider appropriate imaging as there may be associated thrombus 

    USING A THROMBOLYTIC (tPA) IN A BLOCKED CATHETER      

    A thrombolytic is a drug capable of breaking up a thrombus. At RCH tPA is used. Use caution if a patients clotting is severely deranged 

    Follow initial instructions for blocked catheter (see above) 

    Using tPA 

    • Use tPA solutions prepared by pharmacy.  If unable to obtain blood return, repeat once in 24 hours. Suggested volumes below but take into account line volume may be much less in small lines. Always use a 10ml leurlock syringe regardless of the volume.

    CVC / PICC / tunnelled line  Infusaport
    • <10kg: 0.5mg tPA in 2ml 
    • >10kg: 2.0mg tPA in 2ml

    • < 10kg: 0.5mg tPA in 3ml 
    • >10kg: 2.0mg tPA in 3ml


    • Instill thrombolytic into the catheter and wait 2 hours (or preferably longer)
    • If the lumen is completely blocked do not force the thrombolytic into the catheter – see using  a 3-way tap technique to instil thrombolytic into a completely blocked catheter
    • After at least 2 hours flush the catheter with 0.9% saline prior to drawing back. Drawing back first risks creating a further blockage in the line before you have cleared it 
    • Note: there is no need to worry you are flushing the thrombolytic into the patient: small doses can be flushed into the patient without danger unless the patient has exceptionally deranged clotting 
    • If full function has not returned repeat once within 24 hours, leave it in the catheter for longer – preferably several hours or overnight. The tPA continues working in the catheter (even though in the bloodstream it has a short half life)
    • This process is very different from giving full dose systemic thrombolysis which should only be done in consultation with haematology department.

    3-WAY TAP TECHNIQUE TO INSTILL THROMBOLYTIC INTO A COMPLETELY BLOCKED CATHETER 
    Attach 3-way-tap & luer lock syringes (see right). 
    Always use a 3-way tap without an extension set. 
    Open clamp (if there is one). Open stopcock to the empty syringe and the blocked catheter
    Pull back on the plunger of the empty syringe to create a vacuum in the catheter.  You will need to pull quite forcibly. Maintain suction with one hand and with the other hand turn stopcock so it is closed to the empty syringe and open to the syringe containing thrombolytic, which will be sucked into the catheter. 
    Don’t worry if it seems that very little thrombolytic is sucked in: even a tiny volume will reach several cm into the catheter

    CVAD 35 - Jan 2017


     
    Leave for several hours or overnight.

    DO NOT CLAMP CATHETER as this will prevent the thrombolytic from penetrating into the line. 
    After this time, assess the catheter by attempting to flush it catheter using 0.9% saline* in a 10ml syringe. Do not use excessive force. (It is best NOT to try aspirating before flushing at this stage as you may block the catheter again). 
    If the catheter is still completely blocked, repeat the procedure: sometimes you will need to do it several times before it works. Sometimes leaving the thrombolytic in overnight seems to help 
    Don’t worry about overdosing the patient: if the catheter is blocked none of the drug will actually have been flushed into the blood stream 

    Once the catheter can be flushed, and only then, check for flashback. If flashback is absent, administer thrombolytic as described above. If the procedure fails despite a repeated attempt consult the medical team with a view to removing the catheter.

    CHEMICAL RELATED BLOCKAGE      

    • Signs: Infusion running through line suddenly occludes.
    • Flush with 0.9% NaCL
    • Consider using HCl 0.1M 1.5mL per lumen and 3-way tap technique – refer to senior medical staff for instructions.