Guideline Detail
Ownership Lorna Johnson
Publication date April 2012
Next Review date April 2015
Status
Guideline for the Insertion, Management, Replacement and Removal of Central Venous Catheters in Adults and Children
1 Background 5
1.1 Key Changes from previous policies 5
1.2 Aim 5
1.3 Objectives 5
1.4 Definitions 6
1.5 Abbreviations used in this document 6
2 Before inserting a catheter 6
2.1 Warnings 6
2.2 Emergencies 7
2.3 Competent personnel 7
2.4 Indications 8
2.5 Choice of catheter 8
2.5.1 Number of lumens 8
2.5.2 Antimicrobial-impregnated catheters 8
2.5.3 Tunnelled/non tunnelled 8
2.5.4 Implantable access devices (Ports) 9
2.5.5 Choice of entry site 9
2.6 Consent 9
3 Insertion 9
3.1 Hand hygiene 9
3.2 Minimum aseptic precautions 9
3.3 Personal protective equipment 9
3.4 Environment 9
3.5 Insertion procedure 10
3.6 Skin decontamination 10
3.7 Insertion problems 10
3.8 If asepsis is breached 10
3.9 Ultrasound 11
3.10 Landmark method 11
3.11 Securing the catheter 11
3.12 Dressing the newly inserted CVC 11
3.13 Needle-free devices 12
3.14 Three-way taps 12
3.15 Extensions 12
3.16 Sharps disposal 12
3.17 Confirmation of placement 12
4 Ongoing care of catheter 13
4.1 Key points 13
4.2 Dressings 13
4.2.1 Impregnated dressings 14
4.3 Accessing the CVC 15
4.3.1 Key points 15
4.3.2 Hand hygiene 15
4.3.3 Personal protective equipment 16
4.3.4 Asepsis 16
4.3.5 Giving sets 16
4.3.6 Flushing 16
4.3.7 Three way taps, extensions and needle-free devices ……………….18
4.3.8 Blood sampling…………………………………………………………..18
4.4 TPN 19
4.5 Medications 19
4.6 Infusions 19
4.7 Line associated infection indications………………………………….20
4.8 Site inspection 20
4.8.1 Visual inspection of CVC entry site. 20
4.9 Removal or replacement of catheter 21
4.9.1 Key points 21
4.9.2 Routine replacement 22
4.9.3 Microbiology 22
4.9.4 Management of damanaged cathethers…………………………….. 22
4.9.5 Guidewire-assisted catheter replacement ………………………...…22
4.10 Catheter related thrombosis……………………………………………24
4.10.1 Symptoms………………………………………………………………..24
4.10.2 Diagnosis………………………………………………………………...24
4.10.3 Management…………………………………………………………….24
4.11 Management of complications…………………………………………24
4.11.1 Infection 25
4.11.2 Occlusion 26
4.11.3 How to use urokinase to unblock occlusions 27
4.11.4 Management of a blocked central venous line 29
4.11.5 Management of persistent withdrawal occulsion in central venous catheters………………………………………………………………...30
4.11.6 Dislodgement……………………………………………………………31
4.11.7 Damaged CVC 31
4.11.8 Breach of asepsis 31
5 Documentation……………………………………………………………….31
5.1 Key points ……………………………………………………………….31
6 Appendix……………………………………………………………………...33
6.1 Procedure for removal of a non-tunnelled CVC 33
6.2 Vascular access device seclection guide……………………………..35
6.3 Different types of venous access devices…………………………….36
6.4 Central Line Entry Site Score (for use in adults)……………………..38
6.5 Catheter selection for oncology patients……………………………...39
6.6 Central venous access catheter selection for chemotherapy patients……………………………………………………………………40
6.7 Manufacturer guidance for central catheters used across the Yorkshire Cancer Network……………………………………………...41
6.8 A Quick reference guide for managing problems with CVAD’s ….. 43
6.9 VYGON vascular access devices flushing guidance………………...46
6.10 Central venous access devices used within oncology………………………………………………..…………….…..47
6.11 Guidelines for the selection of central venous access devices; portacath or hickman line in paediactric and adolescent haematology and oncology……………………………………………………………..48
6.12 Central venous access device insertion and removal…………………………………...……………………………….50
7 Consultation group 51
8 Glossary………………………………………………………………………..53
9 References 55
10 CHECKLIST 56
11 EQUALITY IMPACT 60
1 Background
1.1 Key Changes from previous guidelines
This guideline supersedes the previous policy ‘Prevention of Infection Associated with Central Venous Catheters (CVCs)’, and updates sections from the now expired ‘Insertion of Central Venous Catheters using the Landmark Technique’. These guidelines incorporate the YCN Chemotherapy Nurses Group: Guidance for the Management of Central Venous Access Devices and Yorkshire and Humber Children and Young People’s
Cancer Network Guidance for the Management of Central Venous Access Devices in children and Young People with Cancer.
It should be read in conjunction with ‘Guideline for management of infected "temporary" central venous catheters (CVC) and arterial catheters in adults’.
Key changes include
· Guidance on the replacement of CVCs that were placed in sub-optimal conditions (section 2.2).
· A recommendation favouring the use of sutureless catheter securement devices over sutures (section 3.11).
· Guidance on dealing with breaches of asepsis (section 4.11.6).
· Guidance on the use of needle-free devices (section 3.13).
· Guidance on flushing (section 4.3.6).
· The requirement to consider, and document, the need for short term CVCs on a daily basis (section 5).
· Guidance that allows for rational risk assessments when considering whether to attempt to salvage potentially infected catheters (section 4.9.1).
· An assessment tool to allow for quick and quantifiable regular inspection of the CVC entry site (section 4.8).
· YCN Chemotherapy Nurses Group: Guidance for the Management of Central Venous Access Devices and Yorkshire and Humber Children and Young People’s Cancer Network Guidance for the Management of Central Venous Access Devices in children and Young People with Cancer have been incorporated into these guidelines.
1.2 Aim
To minimise the risk of CVC-related complications by ensuring that:
a. Intravenous access is accomplished by using the optimal venous access device for that patient.
b. Insertions are performed with minimal delay using the optimal technique via the safest route.
c. Catheters are managed according to best practice and removed as soon as indicated.
d. Complications are recognised and managed as soon as they arise.
1.3 Objectives
· Reduction in catheter-related bloodstream infections.
· Reduction in numbers of unnecessary CVCs.
· All CVCs inserted and managed according to these guidelines.
· Reduce patient suffering and delays in treatments.
· Provide cost effective, safe, timely intravenous therapy for patients.
1.4 Definitions
Central Venous Catheter / A venous catheter that terminates in the great veins near the heart, with one or more lumens for infusion, blood withdrawal and monitoring functions.Aseptic Non-Touch Technique / A technique for minimising the opportunity for contamination by never touching key parts or key sites and by minimising the time that key parts or sites are exposed.
Midline catheter / A peripherally inserted venous catheter, typically 8-20cm long, inserted near the antecubital fossa and terminating in the peripheral vasculature in the upper arm.
1.5 Abbreviations used in this document
· ANTT - Aseptic Non-Touch Technique
· BSI - Bloodstream Infection
· CHG - Chlorhexidine Gluconate
· CVAD - Central Venous Access Device
· CVC - Central Venous Catheter
· CVP - Central Venous Pressure
· HDU - High Dependency Unit
· ICU - Intensive Care unit
· KVO - Keep Vein Open
· PICC - Peripherally Inserted Central (venous) Catheter
· PPE - Personal Protective Equipment
2 Before inserting a catheter
2.1 Warnings
All routes of access for CVCs are associated with risks to the patient.
Careful selection of an appropriate CVC should be made, taking into consideration the size of the patient, the intended route of insertion and predicted use for the device.
The use of real time ultrasound guidance will reduce the risk of complications associated with needle entry into the vessel. It does not eliminate the risk of early vein perforation by the wire, dilator or catheter nor does it eliminate the risk of delayed complications. Ultrasound should be used whenever accessing the internal jugular, subclavian, axillary or femoral veins unless there are specific reasons why it is impractical (NICE 2002).
In order to minimise complications associated with the use of guide wires and dilators:
· Guidewires should only be inserted as far as the position required for the catheter tip, unless X-ray screening is used.
· The dilator should only be inserted far enough to open the vessel puncture site, and NOT pushed to its full length. It is vital that excessive force is not used.
In the event of cardiovascular collapse in a patient with an in-situ or recently removed CVC the possibilities of venous or arterial perforation and haemorrhage, pericardial tamponade, air embolism, arrhythmia, haemothorax or pneumothorax must always be considered.
Central venous access is not usually an emergency procedure. It can and should be abandoned early if difficulties ensue.
2.2 Emergencies
An emergency is defined as a situation that is immediately life-threatening to the patient. Examples include cardio-respiratory arrest, near-arrest situations and severe trauma. During an emergency, inserting or using a CVC may be an essential aspect of that patient’s immediate treatment, and adhering to all the precautions outlined in this document might result in increased risk to the patient.
It is recognised that it may be rational to deviate from these guidelines in an emergency situation. For example, if the sterile field is compromised during the final stages of catheter insertion during an emergency it may not be in the patient’s best interests to restart the procedure.
Such deviations from guidelines, and their rationale, must be clearly documented retrospectively in the patient’s medical notes. If the patient is then transferred to another area, these deviations must be communicated to the receiving staff.
Central venous access devices that have been placed in sub-optimal conditions should be removed, and replaced if needed, as soon as possible. Usually this will mean following admission to ICU/HDU and a period of stabilisation and the presence of a competent operator with the time and expertise to replace the catheter in optimal circumstances.
2.3 Competent personnel
Operators should only undertake CVC insertion using a technique or route in which they are recognised to be competent, and that is suitable for the type of catheter being used. Operators who are not competent in the employed technique may insert CVCs but this must be under the direct supervision and control of a competent individual. The responsibility for insertion and troubleshooting of the CVC will remain with the competent individual at all times.
2.4 Indications
Indications for placing a CVC include
· The need for IV access lasting longer than a week where a midline catheter is considered inappropriate.
· Repeated collection of blood specimens in the absence of good peripheral veins.
· Intravenous nutrition.
· Haemodialysis.
· The need for IV access when peripheral venous access is poor.
· Administration of vesicants
· Administration of preparations with extremes of pH or high osmolarity.
· Administration of vasoactive drugs.
· Monitoring of central venous pressure.
· Certain cardiac procedures.
2.5 Choice of catheter
2.5.1 Number of lumens
Each extra lumen may increase the opportunity for microbial contamination of the system so the number of lumens should be kept to a minimum, ensuring that the device has sufficient access ports to achieve therapeutic goals, and avoids the mixing of non compatible fluids and medications.
Use a single lumen CVC unless multiple lumens are essential for the management of the patient (CVAD 7 epic2 Class A).
If it is known that TPN will be given to the patient then a dedicated lumen should be allocated and not used for any other purpose (CVAD 8 epic2 Class D/GPP).
A multiple lumen CVC will be necessary for the management of most patients undergoing major surgery or who are critically ill.
2.5.2 Antimicrobial-impregnated catheters
Catheters impregnated with antimicrobials are not currently recommended for routine use in this Trust.
2.5.3 Tunnelled/non tunnelled
If the need for central venous access is expected to last for less than 3-4 weeks then a non-tunnelled catheter should be used. Tunnelled catheters should be considered if access is needed for longer than 3-4 weeks, particularly for continuous access or long infusions (CVAD 9 epic2 Class A).
2.5.4 Implantable access devices (Ports)
An implantable access device should be considered if IV therapy will be long term, particularly if the patient has difficulty in accepting or safely managing the external portion of an IV device. An implantable device is suitable for intermittent access, but less suitable than a tunnelled device for continuous access or access for long infusions (epic2 CVAD 13 Class C).
2.5.5 Choice of entry site
Because of the risk of contamination and subsequent bacteraemia the femoral site should be avoided if possible (epic2 CVAD 12 Class C). It is also thought to have higher risks of thrombosis.
The risk of infection is lower from a non-tunnelled subclavian catheter when compared with a non-tunnelled jugular catheter (epic2 CVAD 12 Class C).
Patients tend to report finding PICCs and subclavian catheters more tolerable than jugular catheters.
2.6 Consent
Informed consent must be obtained from the patient in accordance with LTHT (DOH) Policy for Consent to Examination or Treatment.
3 Insertion
3.1 Hand hygiene
Hands must be decontaminated immediately prior to the procedure in accordance with LTHT hand hygiene policy.
3.2 Minimum aseptic precautions
The patient should be covered with a body-length sterile drape, fenestrated to allow access to the entry site (epic2 CVAD 14). The operator should wear a sterile gown, sterile gloves, head cap and facemask for every CVC insertion (Hu 2004).
3.3 Personal protective equipment
Eye protection should be available for the operator. It is advisable to use eye protection for inserting a CVC and the operator is under no obligation to continue with insertion if eye protection is not available.
3.4 Environment
The environment must be clean, free from extraneous items and be easy to clean in the event of a spillage. There should be sufficient space for the operator and operator’s assistant when considering the most appropriate clinical area for insertion.
3.5 Insertion procedure
CVCs must be inserted by experienced clinicians with accepted expertise in this area. Clinicians who are not competent may insert CVCs but this must be under the direct supervision and control of a competent individual.
3.6 Skin decontamination
In patients without an allergy to any of the contents, skin should be decontaminated using a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol with tint. It should be applied over the proposed entry site using repeated strokes in a cross-hatching pattern for thirty seconds before moving outwards until an area significantly wider than that which will be visible through the fenestration of the drape has been covered.
If an allergy to chlorhexidine is known or suspected then Povidone iodine 10% is the second line cleaning agent. Povidone iodine is available in alcohol or water-based solutions. The water-based formulation should only be used if the patient is sensitive to alcohol.