Title:Policies and Procedures for the Management of Central Venous Catheters (CVC)

Policy Ref:

Organisation Wide / Directorate / Clinical Service / Sub Department Area
✔

Controlled Document:This document shall not be copied in part or whole without the express permission of the author or the author’s representative.

Review Date: August 2007

Author: CVC Working Group

Policy Application: NHS Grampian

Purpose: To give all staff guidance in the management of Central Venous

Catheters

RESPONSIBILITIES FOR IMPLEMENTATION

Organisational

Clinical Group

Corporate

Departmental

Area

Policy Statement: The management of all aspects of Central Venous

Catheter care using evidence based practice.

Review:This policy will be reviewed ever 2 years

Approved by:Date:

Signature:

Designation:

Policy for the Management of Central Venous Catheters (CVC)

Introduction

A Central Venous Catheter (CVC) provides venous access for patients requiring short/long term therapies. To many patients the catheter is an important lifeline, therefore it is imperative that the catheter is handled and maintained correctly.

This policy has been developed by a multidisciplinary group to standardise the management of CVC’s and to ensure that staff caring for the patient with central venous catheters have access to guidelines and procedures to prevent complications occurring.

The following evidence based procedures are available within this document.

Page
Supportive information on CVC’s / 4 - 12
General Directions / 13
Commencing IV Fluids via CVC / 15
Disconnecting IV Fluids via CVC / 17
Administration of Medicines via CVC / 19
Changing Closed Luer Lock Device / 21
Dressing the CVC / 23
Adult - Taking Blood from CVC using Vacutainer system / 25
Paediatric – Taking Blood from CVC / 28
Removal of CVC / 31
References / 34
Bibliography / 37
Appendix 1
Group Members / 38

Venous Access

Definition

An intravascular catheter is defined as a ‘tubular’ device, single or multi lumen, designed to be partially or totally inserted or implanted into the cardiovascular system for diagnostic and/or therapeutic purposes’

Central venous access

Central catheters are used when access is required for

  • Infusion of high volumes of fluid.
  • Hydration or electrolyte maintenance.
  • Repeated administration of drugs such as chemotherapy or antibiotic therapies.
  • Repeated transfusions of blood or blood products
  • Repeated collection of blood specimens.
  • Intravenous Nutrition.
  • Haemodialysis

or

  • When there is poor venous access.

Sites Available For Insertion

  • Subclavian
  • Internal/External Jugular
  • Femoral
  • Cephalic or Basilic

The most frequently used catheters are:

  • Non tunnelled CVC
  • Tunnelled catheters: i.e. Hickman, Broviac
  • Peripheral inserted central catheters (PICC)
  • Sub cutaneous ports

Table 1 lists the type of catheters available with their advantages and disadvantages.

Table 1 Advantages and Disadvantages of Catheter Types

Advantages / Disadvantages
Midline catheter /
  • Suitable for 1 - 12 weeks use
  • 7.5cm-20cm in length
  • Longer than peripheral cannula, shorter than PICC
/
  • Ease of insertion and removal
  • Avoids frequent changes of cannula
  • Reduced risk of thrombophlebitis
/
  • Access to peripheral veins may be difficult
  • Occlusion problems of kinking/phlebitis
  • Cannot use to infuse solutions with high osmolality/low pH

Peripheral Inserted Central Catheter (PICC) /
  • Central venous catheter accessed via a peripheral vein
  • 20-40cm in length
  • Catheter tip positioned in the Superior Vena Cava (SVC)
  • Suitable for up to 12 months use
/
  • Ease of insertion and removal
  • Fewer insertion complications
  • Bedside access
  • Lower the incidence of related infection/thrombus
/
  • Smaller lumen/flow problems
  • Inflammation at the insertion site
  • Higher rate of phlebitis than other CVC’s
  • Problems with kinking

Non Tunnelled CVC /
  • Single or multiple lumens
  • Used for short term access
  • Inserted via internal jugular/subclavian
/
  • Can be inserted at the bedside
  • Insertion procedure quicker, suitable for emergency situations
  • Several lumens, can be used for continuous access and high flow infusions
/
  • Highest infection rate
  • Requires external sutures
  • Uncomfortable for patients
  • Difficulty maintaining dressing at catheter exit site
  • Requires to be changed every 5 to 7 days

Tunnelled CVC /
  • Part of the catheter in tunnel within the subcutaneous tissue
  • Tip of the catheter in the superior vena cava
  • Cuffed, non-cuffed
  • Single or multi lumen
  • Last up to 3 years depending on type of catheter
/
  • Lower infection rate
  • Ease of dressing application
  • Patient comfort, no external sutures
  • Durability
  • Ideal for repetitive use
  • Don’t require skin puncture for access
/
  • Experienced operator required to insert. Inserted in theatre or radiology dept.
  • Requires surgical removal
  • External portion of the catheter visible

Subcutaneous Ports /
  • Similar to tunnelled catheters except access via a subcutaneous reservoir
  • Use for prolonged treatment
  • Single/double lumen
  • Accessed with a Huber right angled needle
/
  • Patient acceptance, intact body image
  • No exit site dressing, allow patient to bathe or swim
  • Require less maintenance – less flushing/no dressing changes
/
  • Use of needle to access port
  • Local skin ulceration
  • Shorter life span than tunnelled CVC if accessed regularly
  • Requires operative placement


Midline catheter /
PICC Line

Hickman line /
Implanted Port

Triple Lumen

Single versus multi-lumen catheters

Multi lumen central catheters can be used for a combination of treatments such as chemotherapy, or antibiotic therapy or nutrition. It has previously been suggested that multi lumen catheters increase the risk of catheter-related sepsis (Pemberton et al 1986) (McCarthy et al 1987). This point has now been refuted by many authors who report that there is no statistical difference in catheter-related sepsis between the use of single or triple lumen catheters. (Johnston et al 1990), (Farkas et al 1992) (Ma Ty et al 1998) (Goetx et al 1998).

The choice of catheter for long term use is dependent on venous access available, duration of therapy and, most importantly, patient preference. Table 2 lists the factors that should be taken into consideration when determining the most suitable catheter for the patient.

As the availability of these intravascular devices increases, so must the health professional's knowledge base improve. It is essential that health care professionals receive regular educational updates and training sessions in order to maintain standards.

Table 3 lists the appropriate use of lumens in multi-lumen catheters

Table 2 Factors Influencing Choice of Catheter

Location of venous access available
Gauge of catheter and vein diameter. The narrowest catheter in the largest vein will provide better blood flow around catheter and reduce vein damage
Short or long term use
Catheter material: i.e. silicone or Polyurethane
Multi or single lumen catheter, Cuffed or uncuffed catheter
Implantable or external device
Method of catheter removal
Ease of sterile dressing applications
Patient preference/ body image,
Patients/carer’s ability to care for central catheter in the home environment

Table 3 Multi-lumen line - Lumen usage

Proximal / Blood Sampling
Medication
Blood Administration
Medial / Total Parenteral Nutrition (TPN)
Medication only if TPN not anticipated
Distal / CVP monitoring
Blood administration
High volume or viscous fluids
Colloids
Medication
4th Lumen / Medication

Catheter insertion

The central catheter should be inserted using an aseptic technique under the supervision of an experienced clinician. Potential complications associated with the insertion of the catheter include:

  • Pneumothorax
  • Venous air embolism
  • Arterial puncture
  • Catheter misplacement
  • Cardiac Tamponade
  • Cardiac arrhythmia’s (Drewett 2000)

A catheter placed in an optimal position will reduce potential complications.

When inserting the catheter the clinician will consider the following points:

  • The catheter tip should lie above the junction of the SVC and right atrium
  • If a cuffed catheter is used, the cuff should be placed in the mid point of the tunnel away from the exit site
  • It is recommended that a Chest X-Ray should be performed to check the position of the catheter before use.

Central Venous Catheter Care

Central venous catheter-related infections account for 90% of nosocomial (hospital acquired) bloodstream infections. Despite the profuse availability of evidence, there continues to be a significant diversity in practice of health care professionals (Clemence et al 1995). It has been well documented that experienced staff and educational programs (Parras et al 1994) can have a significant impact on the rate of catheter related problems. For this reason it is essential that all staff that are caring for a patient with a central venous catheter have access to educational material and research based protocols and procedures.

Hand Hygiene

The most common cause of the spread of nosocomial infection is via the hands of health care workers because of their inability to effectively decontaminate their hands. (Horton 1995). Therefore, the first crucial step in the reduction of catheter related sepsis is knowledge of the principles of hand hygiene and the effective use of disposable gloves.

Any procedure connected with an intravenous catheter requires the health care worker to wash with an antibacterial handwash. The purpose of a handwash is to remove dirt and to reduce the load of bacteria on the skin of the hands. Washing with soap and water will remove the transient bacterial flora, and washing with an antiseptic will reduce the resident bacteria on hands. It should be noted however, that resident bacteria would not be totally eliminated by handwashing. (Meers et al 1992) The are several types of handwash available for use, each have different properties and advantages. Choosing the appropriate agent will depend on several factors.

The use of any handwash solution will prove to be ineffective if staff do not employ the correct handwashing technique. Various studies have concluded that health care workers do not wash their hands effectively, leaving many parts of the hands not exposed to soap, water or handwash. In practice the most commonly missed areas are the fingertips, the thumb and the inside of the fingers.

The use of an alcohol hand rub is known to be effective. It is a powerful antiseptic that can be applied quickly to hands that are not soiled. It will rapidly kill transient bacteria and a proportion of the resident bacteria.

The use of gloves

It is important that gloves are used in conjunction with hand hygiene and not as a replacement. Many health care workers believe that gloves protect staff and patients from cross contamination, but in reality this is not the case as hands can become easily contaminated under gloves when they are unwittingly punctured or when they are removed. The lack of evidence regarding the benefits of using sterile gloves has resulted in many teams developing procedures based on using an aseptic non-touch technique (ANTT).

The care of the hub/the use of connection devices

Several studies have implicated contamination of the hub as the major source of catheter related sepsis in catheters that remain in situ for more than two weeks. Sitges Serra (1984) was concerned about the hub and recommended that limited manipulations to the catheter should occur, as each junctional break brings additional risk of infection.

Strict adherence to policies and effective hand hygiene techniques are essential to minimise any risk

The use of closed luer lock connection devices (needle free) with a membrane allows access to the catheter whilst maintaining a closed system. (Bionector, Interlink, Smartsite).


Bionector /
Smartsite

The perceived benefit of this system is:

  • Reduction in catheter related sepsis (Segura 1996)
  • Reduction in needle stick injuries
  • Reduction in use of sterile equipment / reduce costs
  • Reduction in nursing workload

Connection devices are now widely used in clinical practice. Some health professionals are concerned about the potential risk of contamination. Several studies have addressed this issue and conclude that there is no evidence that their use is associated with increased risk of catheter related infection (Seymour et al 2000), (Luebke at al 1998). When using connection devices the greatest risk leading to contamination is an inability to disinfect the device before puncture (Arduino et al 1997). The most effective method of disinfection according to Brown et al (1997) is the use of a combination of chlorhexidine, followed by 70% isopropyl swab.

Anecdotal evidence suggests that using the closed system is much less cumbersome for nursing staff and patients to use and thus compliance with procedures may be better. However, the use of the closed systems does not diminish the need for careful catheter techniques, and the adherence of staff to guidelines and educational programmes remains the most vital aspect in the rate of catheter related sepsis (Ihrig et al 1997).

Recommendation – Bionector or Smartsite

Changing connection devices

Routine connection device changes should occur as per manufacturer’s instructions. It may be necessary to change earlier if device is damaged, faulty, or if blood products or lipid deposits are present after routine flushing of the catheter.

Principles of catheter site care

The site forms an artificial break in the skin and with the catheter insitu is a potential source of infection. An aseptic technique is therefore required when cleaning the site and changing the dressing (Elliot 1993). It has been suggested that the use of an aseptic technique by a specially trained person has more effect on reducing the rate of catheter related infection than the type of antiseptic or dressing used. (Nelson 1986)

There are several issues that require to be addressed when developing guidelines for care of the catheter site. Firstly the most appropriate cleansing solution, secondly the most appropriate dressing and thirdly how often the dressing should be changed.

Cleansing Solutions

It is generally agreed that disinfection of the insertion site is essential. Various antiseptic solutions are used during insertion and at dressing changes.

  • Povidone iodine 10%
  • Chlorhexidine 0.5%
  • Chlorhexidine 2% (Maki 1991).
  • 0.9% Sodium chloride (Kennlyside 1992)

Chlorhexidine and alcohol based solutions have generally been shown to be more effective. A study by Maki et al (1991) found chlorhexidine to be significantly the most effective when used in the 2% aqueous solution. Mimoz et al (1996) suggest that an alcohol based chlorhexidine solution was more effective than povidone iodine, and Garland et al (1995) concluded that 0.5% chlorhexidine in 70% alcohol was more efficacious than 10% povidone-iodine. However Humar et al (2000) found that they was no difference between 0.5% chlorhexidine and 10% povidone-iodine. There has also been interest in the use of antiseptic impregnated catheter. A meta-analysis by Veenstra at al (1999) concluded that central catheters impregnated with chlorhexidine and silver sulfadiazine appear to be effective in reducing catheter- related infection.

Recommendation – Chlorhexidine 0.5% in 70%IMS

Dressings

The purpose of a dressing is

  • To prevent trauma to the wound and the cannulated vessel
  • To secure the catheter
  • To prevent extrinsic contamination

The optimal dressing for the site remains controversial. The type of dressings frequently used includes sterile gauze dressing and transparent occlusive dressing. Several studies have reported an increased rate of infection associated with the use of transparent dressings. This is believed to be due to an increase of moisture at the site (Hoffman et al 1992, Dickerson 1989). However, other studies have found no statistical difference in rates of infection between transparent or gauze dressing. (Madeo at al 1997), (Freiberger et al 1992), (Taylor at al 1996), (Little and Palmer 1998).

It has been suggested that transparent occlusive dressings are preferred by

the patient (Shivran at al 1991), are cost effective (Brandt et al 1996), and can result in a reduction of nursing time. The need for any type of dressing has also been studied. Lucas and Attard-Montalo (1996) concluded in their study that the frequency of site infection was no greater when there was no dressing applied. They concluded that the use of a dressing has no real benefit in established long-term catheters.

  • Gauze dressing - Mepore™, Primapore™

Limitations associated with the use of this dressing are the inability to visualise the site and the need for frequent manipulation of the dressing if the site needs to be checked. Their inability to provide a bacteria and water barrier allows for the potential contamination from secretions or external moisture.

  • Transparent/ occlusive dressing – IV 3000™, Tegaderm™

The advantage of a transparent dressing is the ability to secure the catheter, to permit continuous inspection of the site, to adhere well to dry skin, and to provide protection against external moisture sources. (Maki 1991).

Recommended dressing properties

  • Transparent – allows continuous visual inspection of the catheter and catheter site
  • Self-adhesive – ensures greater stability, reducing the risk of trauma, mechanical phlebitis and external contamination
  • Semi-permeable – protects from bacteria and liquid while allowing the site to “breathe”
  • Sterile – prevents external contamination of the catheter site

Dressing Changes

There is no consensus on the issue regarding frequency of dressings but in any protocol this needs to be established and should be weighed against the exposure of the site to external micro-organisms. (Young et al 1988). While daily dressings using an antiseptic cleansing solution will significantly reduce skin colonisation (Roberts 1993), it is unclear whether colonisation is related to sepsis and therefore there is a question about the necessity of this. Some authors believe that the dressing is best left undisturbed for as long as possible to reduce the possibility of contamination (Dougerty 1992). Although transparent dressing can remain in-situ for 7 days, it may need changed earlier if there is drainage from the site or the dressing becomes non-occlusive (Brandt et al 1996).

Recommendation - Opsite IV 3000 for subclavian lines or

Tegaderm for Jugular lines

Changed weekly or sooner if soiled with blood or

exudate or if not adhering to the skin.

General Directions

Pre Procedure

The following are a set of general instructions to be observed prior to commencing any procedure.