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Alberta Health Services-Calgary AreaProfessional Practice and Development

Central Venous Catheter and Midline Catheter Learning Module

Level One Skills:General Care and Use

The following Alberta Health Services staff are acknowledged for their contributions to the development of this learning module:

Cathy Berry Clinical Nurse Educator, Medical Outpatients

Diane Jack Nurse Clinician, AVAS

Jane Prestie Practice Consultant, Professional Practice & Development

Judy Deane Clinical Nurse Educator, Nephrology and Transplant

Karen Barrie Clinical Nurse Educator, Medicine

Marianne Boucher Nursing Consultant, Professional Practice & Development

Anita Mitzner Education Consultant, Professional Practice & Development

Jane Thompson Secretary, Professional Practice & Development

Alberta Health Services, 2009. All rights reserved. This information is to be used only by Alberta Health Services staff and persons acting on behalf of the Alberta Health Services for guiding actions and decisions taken on behalf of the Alberta Health Services. No part of this information may be reproduced, modifi ed or redistributed for any purposes other than those noted above without the prior written permission of the Alberta Health Services.

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Table of ContentsIntroduction ...............................................................................................................................1

Section One: CVC and Midline Catheter Educational Program for Nurses ...................3

Section Two: Vascular Anatomy and Access .....................................................................11 Types of CVC and Midline Catheters ............................................................14

Section Three: Insertion of CVC and Midline Catheter and Confi rmation of Tip Placement ...........................................................................................25

Section Four: Principles of CVC and Midline Catheter Care ..........................................33 Infection Prevention and Control ...................................................................34 Assessment .....................................................................................................37 Injection Cap Replacement ............................................................................39 Dressing Change ............................................................................................41 Access .............................................................................................................45 Flushing and Locking .....................................................................................46 Administration Sets ........................................................................................49 Accessing and Disengaging an Implanted Port ..............................................51 Obtaining Blood Specimens from the CVC ...................................................53 Managing a Hemodialysis Catheter ...............................................................56 Managing an Apheresis Catheter ....................................................................58

Section Five: Potential Complications with CVC and Midline Catheters .....................65

Section Six: CVC and Midline Catheter Removal .........................................................99

Section Seven: Discharge and Transfer Planning for Patients with CVC or Midline Catheters ..................................................................................105

Section Eight: CVC and Midline Qualifi cation Exam .....................................................115 Appendix A Child Health Qualifi cation Exam

Section Nine: Performance Checklists .............................................................................125

References .............................................................................................................................137

Module Evaluation ...............................................................................................................139

Alberta Health Services, June 2009 1

Central Venous Catheter and Midline Catheter Learning Module Introduction

Introduction

This learning module is intended to provide the nurse with background information necessary to understand the care of patients with central venous catheters (CVC) and midline catheters in the Alberta Health Services-Calgary Area. The learning module is intended to complement the policies and procedures that are found in the Nursing Policy and Procedure Manual (C-7: CENTRAL VENOUS CATHETER and MIDLINE CATHETER: GENERAL CARE LEVEL ONE SKILLS).

Learning Goals

On completion of the learning module, the learner will be able to:

1. Discuss the standards for care and use of CVC and midline catheters related to all aspects of level one catheter care including: Infection prevention and control practices Assisting with insertion and ensuring confi rmation of tip placement Assessment of the CVC or midline catheter and catheter/skin junction Injection cap replacement Dressing of the catheter/skin junction Administration of medications and solutions Flushing and locking Administration set changes Accessing/disengaging the port of an implanted CVC Obtaining blood specimens Catheter specifi c care considerations PICC/midline catheter Direct percutaneous femoral site Hemodialysis CVC in emergency situations Apheresis CVC in emergency situations

Use of CVC or midline catheter for diagnostic imaging procedures Patient and family teaching Preventing and managing potential CVC and midline catheter complications Immediate management of CVC and midline catheter occlusion and/or damaged catheter

2. Demonstrate skills related to level one CVC and midline catheter care.

3. Complete the qualifi cation exam.

2 Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module Introduction

Target Audience

Registered Nurses, Registered Psychiatric Nurses, and Graduate Nurses who are seeking qualifi cation in the specialized clinical competency of CVC and midline catheter care according to policy C-7.

Licensed Practical Nurses who are seeking qualifi cation in the specialized clinical competency of CVC and midline catheter care according to policy C-7 and CLPNA competencies V-4 and V-5.

Prerequisites

Registered Nurses, Registered Psychiatric Nurses, Graduate Nurses, and Licensed Practical Nurses must be competent in peripheral infusion therapy.

Licensed Practical Nurses, as per CLPNA, must be profi cient with peripheral intravenous medication administration.

Work setting must include opportunities to practice general care of CVCs and midline catheters.

Knowledge of infection prevention and control practices with the Alberta Health Services-Calgary Area.

Learning Resources

To complete this module the learner must review the Nursing Policy C-7: CENTRAL VENOUS CATHETER and MIDLINE CATHETER: GENERAL CARE LEVEL ONE SKILLS.

For additional references:Macklin, D. & Chernecky, C. (2004). Real World Nursing Survival Guide: IV Therapy.

St. Louis: Saunders. Chapters 4 and 5 (pp 83-167). WB 354 .M33 2004

Weinstein, M. (2007). Plumers Principles & Practice of Intravenous Therapy. 8th Edition. Philadelphia: Lippincott. Chapter 14 (pp 277-330). WB 354 .p57 2007


Central Venous Catheter and Midline Catheter Learning Module Section One

Section One

CVC and Midline Catheter Educational Program for Nurses

Learning Objectives

On completion of this section, the learner will be able to:

1. Describe Specialized Clinical Competencies as defi ned in the Alberta Health Services-Calgary Area.

2. Identify components of CVC and midline catheter qualifi cation for nurses in the Alberta Health Services-Calgary Area.

3. Describe the role of AVAS in the Alberta Health Services-Calgary Area.



Specialized Clinical Competencies

Care and use of CVC and midline catheters is a Specialized Clinical Competency for nurses in the Alberta Health Services-Calgary Area.

Specialized Clinical Competencies are those restricted activities (as defi ned under the Health Professions Act) that demand preparation beyond entry level practice taught in nursing educational programs. Competence to perform these activities must be acquired through successful completion of additional education (generally specifi c, work-place sponsored learning programs).

Qualifi cation is required to perform Specialized Clinical Competencies. In the Alberta Health Services-Calgary Area nurses become qualifi ed by completing educational programs (such as this one for CVC and midline catheters).

Refer to Nursing Policy and Procedure S-3(a) and S-3(b) for more information on Specialized Clinical Competencies.

Qualifi cation

Qualifi cation in CVC and midline catheter care requires the following:

Thoroughly review the information contained in this module or attend an equivalent education program and review the related Nursing Policy and Procedure C-7.

Obtain 85% on the qualifi cation examination prior to demonstration of skills in the skills lab/clinical setting. Exams may be rewritten, following further review. Follow-up is required if 85% is not obtained on the second exam.

Demonstrate competence in applicable Level One CVC skills to a qualifi ed Clinical Nurse Educator (CNE) or designate in a skills lab or clinical setting (under direct supervision) using standardized performance skills checklists. If the nurse is not able to demonstrate all the skills due to the work setting the nurse will be considered certifi ed in Level One CVC and midline catheter skills with the exception of the skill not demonstrated. If the nurse, in the future, requires the previously not demonstrated skill, the nurse must review the module and demonstrate the skill to be qualifi ed.

Review area specifi c clinical CVC and midline catheter standards. This educational program, and the related Nursing Policy and Procedures, set the regional standards regarding CVC and midline catheter care. Some practice areas may have additional practice guidelines that relate to that particular setting. Please refer to practice guidelines in your area.



Maintaining Competence

It is the responsibility of the individual nurse to ensure competence with CVC and midline catheter care. Nurses are encouraged to independently review the CVC and midline catheter learning module as necessary, or repeat portions of the entire educational program, as negotiated with their Patient Care Manager/Clinical Nurse Educator.

Transfer of Competence

CVC and midline catheter qualifi ed nurses who transfer within the Alberta Health Services-Calgary Area from one clinical area to another should review CVC and midline catheter care specifi c to the new setting. Discuss this expectation with the Patient Care Managers/Clinical Nurse Educator in your



area.



Central Venous Catheter and Midline Catheter Qualifi cation Algorithm

Advanced Venous Access Service (AVAS)

A team of Health Care Professionals with specialized advanced clinical competence to provide safe and effective service and support for adult patients of the Alberta Health Services-Calgary Area who require:

Insertion of a PICC or midline catheter

Advanced care with indwelling CVCs and midline catheters, beyond the competence of the nurse with level one and two CVC and midline catheter skillsException: Apheresis and hemodialysis CVCs



Checkpoint: Section One Questions

1. Qualifi cation for a specialized clinical competency refers to:

a. writing an exam b. reading the relevant nursing policies and procedures c. the education programs nurses are required to complete prior to being permitted to perform a particular competency with the Alberta Health Services-Calgary Area d. all of the above

2. Steps a nurse must take to obtain CVC and midline catheter qualifi cations are:

3. Nurses who transfer to another area of practice within the Alberta Health Services-Calgary Area automatically transfer their CVC and midline catheter qualifi cation with no additional expectations.

True False

4. What is the role of AVAS in the Alberta Health Services-Calgary Area?



Checkpoint: Section One Answers

1. Qualifi cation for a specialized clinical competency refers to: all of the above

2. Identify the steps a nurse must take to obtain CVC and midline catheter qualifi cation: Thoroughly review the information contained in this module or attend an equivalent class

and review the related Nursing Policy and Procedure C-7. Obtain 85% on the qualifi cation exam prior to demonstration of skills in the clinical setting. Demonstrate competence in applicable Level One CVC and midline catheter skills to a

qualifi ed CNE (Clinical Nurse Educator) or designate in a skills lab or clinical care setting. (under direct supervision) using standardized performance skills checklists.

Review CVC and midline catheter care guidelines specifi c to your practice setting.

3. Nurses who transfer to another area of practice within the Alberta Health Services-Calgary Area automatically transfer their CVC and midline catheter qualifi cation with no additional expectations.

False the nurse should review CVC and midline catheter care specifi c to the new setting

4. Describe the role of AVAS in the Alberta Health Services-Calgary Area. A team of Health Care Professionals with specialized advanced clinical competence to provide

safe and effective service and support for adult patients of the Alberta Health Services-Calgary Area who require: Insertion of a PICC of midline catheter Advanced care with indwelling CVCs and midline catheters, beyond the competence of the nurse with level one and two CVC and midline catheters skills. Exception: Apheresis and hemodialysis CVCs

Note: If you were able to answer these checkpoint questions correctly, proceed to the next section, otherwise, review the material in this section.


Central Venous Catheter and Midline Catheter Learning Module Section Two

Section Two

Vascular Anatomy and Access

Learning Objectives


1. Identify veins used for access with CVCs and midline catheters.

2. Distinguish between valved and non-valved catheters.

3. Describe the different types of CVCs and midline catheters by the following criteria: Name of catheter Catheter description Placement in the body Indication for use Duration of use Setting for use (inpatient or community)



Vascular Anatomy

A central venous catheter is a venous access device whose tip dwells in the lower 1/3 of the superior vena cava (SVC) or in the inferior vena cava (IVC) at or above the level of the diaphragm.

A midline catheter is a peripheral venous access device (7.5 cm 20 cm [38 inches] in length) whose tip dwells in the basilic, brachial, or cephalic vein in the upper arm at or below the level of the axilla. Midline catheters are NOT considered CVCs.

When inserting the CVC, the qualifi ed health professional will access the SVC or IVC indirectly through another vein. Common access sites include: subclavian, internal jugular (IJ), femoral, basilic, brachial, and cephalic veins.

Reprinted with permission: Rouge Valley Health System

Vessel Diameter and FlowVessel Diameter of Vessel Flow

Hand veins ~ 2 5 mm ~ 10 mL/minUpper arm cephalic vein ~ 6 mm ~ 40 mL/minUpper arm basilic vein ~ 10 mm 90 150 mL/minAxillary vein ~ 16 mm 150 350 mL/minSubclavian vein ~ 19 mm 350 800 mL/minSuperior vena cava ~ 20 mm ~ 2000 mL/min



CVC and Midline Catheter Construction

CVC and midline catheters may be non-valved or valved. Understanding the type of construction is crucial to appropriate care and use of the catheter.

Non-valved Catheter

A catheter constructed with an open-ended tip, no valve, and an in-line clamp. Typically a heparin solution and positive pressure technique are used to maintain catheter patency. When the catheter is not in use or the injection cap is removed, the catheter must be clamped to decrease risk of bleeding or air embolism.


Valved Catheter

A catheter constructed with a three-position valve that minimizes the risk of blood refl ux into the lumen of the catheter. The valve may be located at either the distal or proximal end of the catheter. Typically normal saline and positive pressure technique are used to maintain catheter patency. When the catheter is not in use or the injection cap is removed, the catheter does not require clamps.

Groshong Valve at Distal Tip of Catheter




Types of Central Venous Catheters and Midline Catheters

There are various types of CVC and midline catheters including:

1. Direct percutaneous central venous catheters

2. Tunneled central venous catheters

3. Implanted central venous catheters

4. Peripherally inserted central catheters (PICC)

5. Midline catheters

6. Specialized central venous catheters Hemodialysis central venous catheters Apheresis central venous catheters



Taylor, Lillis, & LeMonel 2005

Direct Percutaneous Central Venous Catheters

Description: stiff polyurethane or silicone non-tunneled, non-cuffed single or multi lumen (staggered openings along the catheter end) must be sutured to skin at hub to minimize risk of dislodgment size ranges:

length 12.5 cm to 30.5 cm (512 inches) diameter 2.0 Fr to 11.5 Fr volume 0.9 mL to 1.8 mL

non-valved

Placement: may be inserted in interventional radiology,

the operating room, or at the patients bedside inserted into a major vein (e.g. internal or external jugular,

subclavian or femoral veins) and advanced into the superior or inferior vena cava (see illustration)

tip should dwell in the lower one third of the superior vena cava. If the CVC is inserted via the femoral vein, the optimal tip placement should be in the inferior vena cava at or above the level of the diaphragm

Indications for use: short-term therapy or for emergency access all infusions (including vesicant medications) blood withdrawal hemodialysis apheresis

Duration of catheter use: days to weeks if required longer than 4 weeks, requires physician review and order

Settings for use: inpatient outpatient (community) settings only when enrolled in hemodialysis or apheresis programs or in

Child Health




Tunneled Central Venous Catheters

Description: soft silicone or polyurethane with a dacron cuff on

the external surface of the catheter single or multi lumen sutures required initially at insertion site for 7 days,

and at catheter/skin junction for 10 to 14 days size ranges:

length 36 cm to 110 cm (14.544 inches); may be cut to desired length at time of insertion diameter 2.0 Fr to 14 Fr volume 0.9 mL to 2.5 mL

valved or non-valved

Defi nitions: insertion site (entrance site) vein access site catheter/skin junction (exit site) point where the catheter leaves the skin and where site care is

performed dacron cuff positioned under the skin. Tissue granulation around the cuff stabilizes the catheter

in the subcutaneous tissue and acts as a mechanical barrier to bacterial migration along the subcutaneous tract

Placement: inserted in interventional radiology or the operating room inserted into a major vein (subclavian, internal or external jugular) and then tunneled through the

subcutaneous tissue tip should dwell in the lower one third of the superior vena cava

Indications for use: long term therapy all infusions (including vesicant medications)

blood withdrawal hemodialysis and/or apheresis

Duration of catheter use: weeks to years

Settings for use: inpatient outpatient (community) settings




Implanted Central Venous Catheters

Description: soft silicone or polyurethane catheter attached to

stainless steel, titanium or plastic reservoir which is covered by a self-sealing silicone septum

access requires a non-coring needle single or dual reservoirs insertion sutures, if present, are to be removed

14 days post insertion size ranges:

length 76 cm (30 inches); may be cut to required length at insertion diameter measured in millimeters volume reservoirs range from 0.2 mL to 1.7 mL






Placement: inserted in interventional radiology or operating room reservoir is inserted in a subcutaneous tissue pocket in the chest, arm, or abdomen and the catheter

segment is threaded into a major vein tip should dwell in lower one third of the superior vena cava

Indications for use: long term therapy all infusions including vesicant medications blood withdrawal






Peripherally Inserted Central Venous Catheter (PICC)

Description: silicone or polyurethane single, double or triple lumen stabilized with an external securement device,

skin closure strips, or sutures size ranges

length 56 cm to 60 cm (22.124 inches) diameter 2.0 Fr to 6.0 Fr volume 0.15 mL to 0.66 mL


Placement: inserted by a nurse qualifi ed in this advanced specialized clinical competence,

physician, or radiologist may be inserted in AVAS clinic, patents bedside, interventional radiology,

the operating room, or designated clinic inserted directly into a peripheral vein (basilic, cephalic, or brachial) in the arm tip should dwell in the lower one third of the superior vena cava

Indications for use: short or long-term therapy all infusions (including vesicant medications) blood withdrawal (from lumens 4 Fr or larger)

Duration of catheter use: weeks to months physician review and order required to leave in

situ longer than one year

Setting for use: inpatient outpatient (community) settings

hhtp://www.bardaccess.com/nurse-grosh-picc.php



Midline Catheters

Midline catheters are NOT central venous catheters and must not be used for infusions requiring central tip placement.

Description: silicone or polyurethane single or dual lumen stabilized with an external securement device,

adhesive strips or sutures size ranges:

length 7.5 cm to 20 cm (38 inches) (amount inserted is dependent on patient measurement) diameter 2.0 Fr to 5.0 Fr (13 to 24 gauge) volume 0.07 mL to 0.15mL


Placement: inserted by nurse qualifi ed in this advanced specialized clinical competence,

physician, or radiologist may be inserted in AVAS clinic, patients bedside, interventional radiology,

the operating room, or designated clinic inserted directly into a peripheral vein (basilic, cephalic, or brachial) in the arm tip should dwell at or below the level of the axilla

Indications for use: CVC access is not required, not possible, or contraindicated limited to solutions with a pH of 59 and an osmolarity of less than 600 mOs/L

Duration of catheter use: days to 4 weeks physician review and order required to leave in situ longer than 4 weeks




Specialized CathetersHemodialysis Central Venous Catheter

Hemodialysis is a specialized treatment for some patients with renal disease. A hemodialysis machine removes the blood from the patient, cleanses the blood and then returns it to the patient. CVCs inserted for long-term hemodialysis are NOT regularly to be used by staff outside the hemodialysis program (SARP) for procedures such as infusing medications or drawing blood unless it is a last resort. In a situation where no other venous access is possible, an order from a nephrologist is required to allow access to a hemodialysis CVC.

Description: a large diameter (0.5 Fr to 14.5 Fr) dual lumen catheter,

which is inserted either by: direct percutaneous method into the internal jugular or femoral veins tunneled into the internal jugular

hemodialysis catheters (direct percutaneous) length 12.5 cm to 23 cm (59.1 inches) volume 1.5 mL to 2.3 mL

hemodialysis catheters (tunneled CVC) length 19 cm to 23 cm (7.59.1 inches) (these CVCs are not cut at the time of insertion)

clamps or hubs of each lumen are color coded red and blue

Placement: inserted by the radiologist in interventional radiology or by a physician tip dwells in the superior or inferior vena cava

Indications for use: hemodialysis therapy all infusions blood withdrawal




Specialized CathetersApheresis Central Venous Catheter

Apheresis: The process of withdrawing whole blood through a central venous catheter into a blood cell separator where it is divided into its components (RBCs, WBCs, platelets, and plasma). The desired component is removed and/or replaced. For example, apheresis can be used to remove: pathological antibodies in the body and replace them with normal plasma or albumin; WBCs in acute leukemia to allow chemotherapy to begin sooner; and stem cells for transplant.

CVCs inserted for apheresis are NOT to be used by staff outside the apheresis program for procedures such as infusing medications or drawing blood.

Description: a large diameter (11.5 Fr to 14.5 Fr) dual lumen catheter, which is inserted either by:

direct percutaneous method into the internal jugular or femoral veins tunneled into the internal jugular.

apheresis catheters (direct percutaneous) length 9 cm to 24 cm (3.59.5 inches) diameter 8 Fr to 11.5 Fr volume 0.8 mL to 1.7 mL

apheresis catheters (tunneled CVC) length 36 cm to 40 cm (1416 inches) (these CVCs are not cut at the time of insertion) volume 1.4 mL to 1.6 mL

apheresis catheters (implanted CVC) length 76 cm (30 inches); may be cut to required length at insertion diameter measured in millimeters volume reservoirs range from 0.2 mL1.5 mL

Placement: inserted by the radiologist in interventional radiology or by a physician tip dwells in the superior or inferior vena cava

Indications for use: apheresis therapy all infusions blood withdrawal

Duration of use: weeks to years



Checkpoint : Section Two Questions

1. Name three veins of the upper anatomy associated with central venous access devices.

2. Optimal position for the tip of a central venous catheter is:

3. Direct percutaneous central venous catheters are for short-term, emergency, and inpatient (adult) use only.

True False

4. Which CVC requires sutures to secure the catheter to the skin at all times?

5. Name the point where the catheter leaves the skin and site care is performed.

6. Access to an implanted CVC requires a special needle called:

7. Name the solution that is typically used for fl ushing the following types of CVCs:

Valved:

Non-valved:

8. State 3 reasons for using a central venous catheter:

9. Under what circumstances is a midline catheter the preferred venous access device?



Checkpoint: Section Two Answers

1. Name three veins of the upper anatomy associated with central venous access devices. Cephalic Brachial Basilic

Axillary Internal or External Jugular Sublclavian

Innominate/Brachiocephalic Superior Vena Cava

2. Optimal position for the tip of a central venous catheter is: The lower one third of the superior vena cava Above the level of the diaphragm in the inferior vena cava

3. Direct percutaneous central venous catheters are for short-term, emergency and inpatient use only.

False Direct Percutaneous CVC may be used for hemodialysis and apheresis in clients who live in the community. Occasionally outpatient pediatrics.

4. Which CVC requires sutures to secure the catheter to the skin at all times? Direct Percutaneous

5. Name the point where the catheter leaves the skin and where site care is performed. Catheter/skin junction (or exit site)

6. Access to an implanted CVC requires a special needle called: Non-coring needle

7. Name the locking solution that is typically used for fl ushing the following types of CVCs: Valved: Normal Saline Non-valved: Heparin

8. State 3 reasons for using a central venous catheter: Infusions of solutions with osmolarity of greater than 600 and/or a pH of less than 5 or

greater than 9; irritants, vesicants Therapy is expected to be long-term Therapy involves removing, treating, and re-instilling blood (e.g. hemodialysis or apheresis)

9. Under what circumstances is a midline catheter the preferred venous access device: CVC access is not required, not possible, or contraindicated Therapy is expected to be days to 4 weeks Required solutions have a pH of 59 and an osmolarity of less than 600 mOs/L

Note: If you were able to answer these checkpoint questions correctly, proceed to the next section; otherwise, review the material in this section.


Central Venous Catheter and Midline Catheter Learning Module Section Three

Section Three

Insertion of CVC and Midline Catheterand Confi rmation of Tip Placement

Learning Objectives:


1. Describe nursing responsibilities prior to, during, and post CVC and midline catheter insertion.

2. Describe nursing responsibilities related to tip confi rmation.



Insertion of CVC or Midline Catheter: Nursing Responsibilities

Insertion of a CVC or midline catheter is beyond the competence of the Level One qualifi ed nurse. This section is intended to assist the Level One qualifi ed nurse to care for a patient prior to, during, and following CVC or midline catheter insertion.

A CVC or midline catheter may be inserted in a variety of clinical areas, including AVAS clinic, interventional radiology, patients bedside, the operating room or designated clinic. The responsibilities of the nurse related to catheter placement will vary depending on the type of catheter, location of insertion, and the health care professional inserting the catheter.

Prior to Catheter Insertion

ensure physician order has been obtained

assess coagulation status (INR, platelet count) and other labs (CBC) as ordered and notify physician of results as appropriate

educate patient and/or caregiver with respect to the CVC and midline catheter insertion description of the catheter that will be inserted purpose of the catheter benefi ts of using a catheter planned duration of therapy/catheter possible risks of catheter insertion procedure

ensure the consent has been signed

ensure the patient is informed to remain NPO, if ordered

obtain baseline vital signs

complete the pre-operative documentation

prime IV tubing and have infusion pump ready for use, if necessary

have fl ushing and/or locking solution available, if necessary administer pre-medications, as ordered



During Catheter Insertion

If a catheter is being inserted at the beside, the Level One or Level Two qualifi ed nurse may be required to assist the inserter.

clean work surfaces and gather all required equipment as per protocol in your practice setting

restrict activity in the room

adherence to aseptic technique should include: hand hygiene must be performed by all involved in the insertion procedure maximal barrier precautions which include the use of a sterile gown, sterile gloves, and large sterile drapes, hair covering, and procedure mask by all those performing the procedure masks should be worn by all those assisting with the procedure turn patients head away from insertion site. If patient is coughing, and/or unable to turn head, the patient must wear a mask if aseptic technique was not maintained during an emergency catheter insertion, the most responsible healthcare professional must be notifi ed so that the catheter should be replaced as soon as possible (within 48 hours).

position the patient as instructed by the qualifi ed inserter: for insertion of a direct percutaneous CVC, the bed is placed in trendelenburg position, unless contraindicated place patient supine on bed with a rolled towel under the designated shoulder or between the scapulas to facilitate location of the desired vein for catheter insertion

prepare the multi lumen catheter as directed by the qualifi ed inserter using aseptic technique. This may include:

attaching needless injection caps and ensuring they are secure fl ushing lumens indicated with normal saline

educate patient regarding valsalva maneuver, if applicable

monitor the patient for discomfort and signs and symptoms of complications catheter hub is secured to the skin by the inserter (e.g. direct percutaneous catheter must be

sutured to the skin)



Post Catheter Insertion

ensure a transparent semi-permeable membrane and/or sterile gauze dressing is applied

obtain radiographic verifi cation of catheter tip location and order for use prior to using a newly inserted CVC

Exception: In emergency situations, the CVC may be used prior to radiographic verifi cation of CVC tip location. Verify tip placement as soon as possible for catheter inserted in emergency circumstances.

review physicians orders for post catheter insertion care

observe patients comfort level and administer analgesia as ordered

monitor catheter/skin junction every 4 hours for the fi rst 24 hours in acute area. Report excessive bleeding or discharge from site

sandbags may be necessary for additional pressure especially for CVC inserted into the femoral vein to control bleeding at the site

apply warm compresses to venous pathway of PICC/midline for 20 minutes every 4 hours for 48 hours post insertion

educate patient and/or caregiver with respect to the CVC and midline catheter insertion complications to report review safety precautions hand washing bathing and showering activity restriction importance of carrying clamp and how to apply, if necessary securement of the catheter ensure dressing remains dry and intact

documentation in patients health record should include: date the catheter was inserted type of device and its manufacturer (important if the catheter needs to be repaired) device size, length, number of lumens the location/vein where catheter was inserted tip location confi rmation external length of the catheter from catheter/skin junction to the beginning of the hub post CVC or midline insertion orders, if applicable, such as fl ush/instillation protocol, suture removal problems and complications with the insertion, and what actions taken



Confi rmation of Tip Placement Radiographic verifi cation of catheter tip location and order for use is required prior to using a

newly inserted CVC. Exception: In emergency situations, the CVC may be used prior to radiographic verifi cation of CVC tip location. Verify tip placement as soon as possible for catheter inserted in emergency circumstances.

Midline catheters do not require radiographic confi rmation of tip placement prior to use.

If patient is admitted with CVC or midline catheter without insertion record or tip confi rmation documentation, attempt to obtain from facility where catheter was inserted. If unable to obtain, a radiographic confi rmation of CVC tip location and physician order is required prior to use.

If at any time there is reason to doubt tip placement, radiographic verifi cation should be obtained.



Checkpoint: Section Three Questions

1. What nursing responsibilities should be considered prior to CVC or midline catheter insertion?

2. What must the nurse review prior to a CVCs initial use? What exception is there to this requirement?

3. For a patient in acute care, a nurse must assess the catheter/skin junction every ______ hours for the fi rst _______ hours after the CVC or midline catheter has been inserted.

4. If a patient is admitted with a CVC in situ, what actions must be taken prior to use?



Checkpoint: Section Three Answers

1. What nursing responsibilities should be considered prior to CVC or midline catheter insertion?

ensure physician order has been obtained assess coagulation status (INR, platelet count) and other labs (CBC) as ordered and notify

physician of results as appropriate educate patient and/or caregiver with respect to the CVC ensure the consent has been signed ensure the patient is informed to remain NPO, if ordered obtain baseline vital signs complete the pre-operative documentation prime IV tubing and have pump ready for use at the bedside, if necessary administer pre-medications, as ordered

2. What must the nurse review prior to a CVCs initial use? What exception is there to this requirement?

radiographic verifi cation of catheter tip location and order for use prior to using a newly inserted CVC

Exception: In emergency situations, the CVC may be used prior to radiographic verifi cation of CVC tip location. Verify tip placement by as soon as possible for catheter inserted in emergency circumstances

3. For a patient in acute care a nurse must assess the catheter/skin junction every 4 hours for the fi rst 24 hours after the CVC or midline catheter has been inserted.

4. If a patient is admitted with a CVC in situ, what actions must be taken prior to use? obtain copy of insertion record and tip confi rmation documentation if unable to obtain above documentation radiographic verifi cation and physician order

required prior to use

Note: If you were able to answer these check point questions correctly, proceed to next section; otherwise, review the material in this section.


Central Venous Catheter and Midline Catheter Learning Module Section Four

Section Four

Principles of Central Venous Catheter and Midline Catheter Care

Learning Objectives:


1. Explain rationale for major principles of care and assessment related to central venous catheters.

2. Demonstrate knowledge and rationale for the following CVC or midline catheter procedures: infection prevention and control assessment injection cap replacement dressing change access fl ushing and locking administration sets accessing and disengaging an implanted port obtaining blood specimens from the catheter



Principles of Central Venous Catheterand Midline Catheter Care

The safe and effective use of CVC and midline catheters will reduce the risk of life threatening complications that may accompany the use of these catheters. Many procedural variations of CVC and midline catheter care are equally effective and practical. Regional programs dictate details of these procedures based on the patient population and individual patient needs. Manufacturers guidelines should be followed to ensure appropriate use of specifi c products.

Desired Clinical Goals1. Completion of therapy2. Absence of complications3. Patient satisfaction

Infection Prevention and Control

Defi nitionsAsepsis Free from infection.Aseptic Technique Methods to minimize contamination by micro-organisms including hand hygiene, sterile gloves, masking and using antiseptic cleansers.Infection Invasion and multiplication of pathogenic micro-organism into blood and body tissues.Maximal Barrier Protection Equipment and clothing used to avoid exposure to pathogens including mask, gown, protective eyewear, head covering, sterile gloves sterile drapes, towel.Nosocomial Infection An infection originating from the hospital (or caregivers).

Transmission of Micro-organismsTransmission of micro-organisms may occur by various routes:

Direct contact/direct physical transfer from one surface (e.g. hands and clothing) to the central venous access system.

Indirect contact with a contaminated item (e.g. catheter hub or contaminated antimicrobial solution).

Four potential causes of catheter related blood stream infections (CR-BSI) are: Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization

of the catheter tip. Contamination of the catheter hub. Haematogenous seeding from another source of infection. Infusate contamination.



Hand Hygiene

Microbes on the hands of healthcare personnel, including antibiotic resistant organisms, contribute to infections. To help decrease CR-BSI, all staff that handle a CVC or midline catheter, either during insertion or while maintaining the catheter, must perform hand hygiene. Hand hygiene with an antiseptic agent is the single most important procedure for preventing nosocomial infection.

Maintaining Aseptic Technique

During all procedures related to CVC and midline catheter care it is essential that aseptic technique is maintained. There are a variety of methods that can be used to maintain asepsis. One of these methods involves the use of sterile gloves. Alternatively, non-touch technique, which involves the use of barriers such as gauze or forceps, may be used. If a sterile item being used to maintain asepsis (e.g. sterile gloves) becomes contaminated it must be replaced.

Alberta Health Services-Calgary Area Infection Prevention and Control Guidelines for Central Venous Catheters and Midline Catheters

Procedure Non-Sterile Gloves

Sterile Gloves

Mask Sterile Gown

Hair Covering

Patient to Wear Mask (if needed)

Insertion X X X X X

Injection Cap Replacement X X X

Accessing Open System X X X

Dressing Change Removal of old dressing X X X

Removal PICC or midline catheter X

Note: Strict aseptic technique, including hand hygiene and cleansing of work surface area with low level disinfectant cloth (e.g. Cavi-wipes) shall be done prior to all procedures associated with CVC and midline catheters. For further information see the Infection Prevention & Control Manuals.



Antimicrobial Agent Rationale/Information

Preferred Agent

0.5% or 2% Chlorhexidine with 70% Alcohol Solution

chlorhexidine with alcohol leads to a residual antibacterial activity that persists for 6 hours post application

single use container preferred dry time 30 seconds

In Case of Allergy to Chlorhexidine

Iodophor (10% Povidone Iodine) povidone iodine requires a 2 minute skin contact time using friction

dry time 2 minutes

70% Alcohol 70% alcohol requires a 1 minute friction application, no residual antibacterial activity

dry time 30 seconds

Normal Saline to be used only if patient is allergic to all other antimicrobial agents or the skin around the insertion site is not intact



Assessment

Assess and document the condition of the catheter/skin junction, venous access pathway, catheter, injection cap, connections, tubing, and other potential catheter related complications once per shift and as needed, or at each home visit.

Principle Rationale/Information

1. Assess the catheter/skin junction andsurrounding area for:

erythema edema skin ulceration pain drainage condition of dressing catheter securement intact

Note: gauze dressings that prevent visualization of the catheter skin junction should be palpated through the intact dressing. In the presence of tenderness at the site or other signs and symptoms of infection, dressing should be removed to inspect the site directly.

early recognition of local complications and appropriate corrective action can prevent more serious or life threatening complications

if catheter/skin junction infection is suspected obtain specimen and order for culture and sensitivity

2. Assess venous access pathway for: phlebitis swelling

early detection of phlebitis and appropriate interventions may prevent the development of a thrombus and sepsis

3. Assess catheter and injection cap for: damage traction change in external length

change in external length of the catheter indicates a change in catheter tip location. If migration is suspected do not infuse into the CVC until tip placement is verifi ed

4. Assess that inline clamps are present and functioning.

Assess that a non-toothed, plastic clamp is available.Exception: valved catheters

to be used when catheter not in use or injection cap removed to decrease risk of bleeding or air embolism

to be used in the event of catheter damage to prevent bleeding or air embolism




5. Additional catheter specifi c assessment:Direct Percutaneous:

observe that sutures are securing catheter to skinNote: in child health sutures are not

always used to secure direct percutaneous CVC.

direct percutaneous catheters require the hub to be sutured to maintain catheter placement during entire dwell time

Tunneled: observe that sutures are securing catheter

to skin until they are removed at: catheter skin junction (1014 days) insertion site (7 days)

sutures remain in situ until granulation of skin to catheter has occurred. If sutures remain in place longer they present a potential source of infection and increased diffi culty to remove

Implanted Port: observe for intact sutures until removed

at: catheter skin junction (1014 days) insertion site (1014 days)Note: some newly implanted ports may

have dissolvable sutures which may not be visible, others may have skin closure strips

observe for dislodgement of access needle

sutures remain in situ until pocket is healed. If sutures remain in place longer they present a potential source of infection and increased diffi culty to remove

patient may be experiencing pain during infusion and swelling at the site

PICC and Midline: observe for intact securement device

(e.g. StatLock), skin closure strips, or suturesNote: securement device should be

covered by dressing the external length of the PICC or

midline catheter from the catheter/skin junction to the beginning of the hub is measured and documented once per shift and as needed at each home visit

if sutures present consideration should be given to their removal and replacing with a securement device

sutures increase the risk of infection

change in external length of the catheter indicates a change in catheter tip location. If migration is suspected do not infuse into the PICC until tip placement is verifi ed

6. Assess for other potential complications associated with CVC and midline catheters (see Section 5).

earlier detection of other potential complications will aid in ensuring patients safety



Injection Cap Replacement

Luer lock injection cap(s) are to be placed on all CVC and midline catheter lumens.


1. Injection cap change procedure must be done using aseptic technique.

to prevent the entry of microorganisms into the vascular system

2. If injection cap changes are done as part of the dressing change the cap should be changed prior to the dressing.

during injection cap replacement the system is open with an increased risk of contamination from bacteria on the skin.

changing the injection cap fi rst minimizes the possibility of introducing microorganisms into the catheter

3. Injection caps must be replaced: every 7 days and as needed in hospital every 7 days and as needed in community

when catheter in use every 30 days and as needed in

community if catheter not in use

injection cap is designed to accommodate a specifi ed number of punctures

increased risk of contamination from bacteria with frequent opening of the system

4. Injection cap must be changed if leaking or broken.

risk of microorganism or air entry into vascular system or backup of blood into catheter if injection cap integrity compromised

5. Injection cap must be changed if residual blood can not be cleared with adequate fl ushing.

residual blood provides a medium for bacterial growth and may cause occlusion

6. Injection cap must be changed if cap removed from the catheter for any reason.

risk of contamination of injection cap

7. Injection caps must be applied when a removable positive pressure device is present.

Alberta Health Services-Calgary Area does not supply or utilize these devices although they may present on a line if a patient is admitted from another health region




8. Clamp the lumen near the catheter/hub connection before removing the injection cap.Exception: Valved Catheters

clamps prevent air entry into the venous system and possible risks resulting from venous air embolism

clamps may cause valved catheter damage

9. Clean the injection cap catheter connection extending 1.5 cm (0.6 inch) below cap, prior to removing the injection cap.

risk of microorganism entry into vascular system

10. It is not necessary to pre-fi ll the injection cap with fl ush solution prior to application.

the injection cap volume is approximately 0.2 mL therefore does not pose a risk for air embolism

11. Once injection cap removed from catheter, cleanse outside threads of catheter hub ONLY if visibly soiled.

blood provides a medium for bacterial growth

routine cleansing of the threads poses an increased risk of microorganism entry into vascular system



Dressing Change

The catheter/skin junction for all CVC and midline catheters is to be covered with a sterile transparent semi-permeable membrane or gauze dressing. When an implanted CVC port is not accessed a dressing is not necessary.

Types of Dressings

Several dressing materials are considered equally effective if used appropriately. Studies have indicated a strong association between increased humidity and increased cutaneous colonization of catheter related infection.

Dressing Type Principle Rationale/Information

Gauze use gauze dressing if any drainage at catheter site (e.g. for 24 hours post-insertion)

if early signs of infl ammation are present

must be changed every 48 hours and as needed

the absorptive capacity of gauze wicks drainage away from the skin catheter junction and maintains a drier environment

gauze allows air movement, facilitates evaporation of moisture

Transparent semi-permeable membrane dressing

use transparent semi-permeable membrane dressing if catheter skin junction site is dry and non-infl amed

must be changed every 7 days and as needed

facilitates frequent visual inspection of the catheter skin junction site

protects site from external moisture contamination, while allowing moisture vapor to escape from skin

Transparent with gauze dressing

when used as an initial dressing, must be changed after 24 hours then every 48 hours and as needed

transparent dressing maintains the integrity of the gauze

gauze will wick moisture away from skin/catheter junction



The following guidelines are basic to all CVC dressing change procedures.


1. Dressing change procedure must be done using aseptic technique.

to prevent entry of microorganisms into the vascular system

old dressing should be removed with clean gloves

sterile gloves or non-touch technique should be used when removing securement device and/or sterile wound closure strips

if sterile gloves touch old securement device, wound closure strips, and/or skin, new sterile gloves must be applied prior to continuing with the dressing change procedure

2. If injection cap changes are done as part of the dressing change the cap should be changed prior to the dressing.

during injection cap replacement the system is open with an increased risk of contamination from bacteria on the skin

changing the injection cap fi rst minimizes the possibility of introducing micro-organisms into the catheter

3. When removing the transparent dressing anchoring the catheter, peel the dressing toward the catheter/skin junction.

prevents catheter dislodgement

4. If excess hair removal is necessary it should be performed by clipping with scissors.

shaving is not recommended as it may increase the potential for micro abrasions

the skin is the patients fi rst line of defense and if broken creates a vulnerable point for bacterial migration




5. Topical antimicrobial agents used for cleansing must be applied using friction and they have different properties thatdefi ne their effectiveness.

see page 36

6. The catheter skin junction must be cleansed beyond the size of the dressing to be applied.

to minimize the microbes at the catheter skin junction site

7. Cleanse the length of the catheter with the antimicrobial agent from catheter skin junction site outward (see page 36).

microbes on the catheter may transfer onto the catheter/skin junction and surrounding skin

maintain asepsis by holding catheter with sterile gauze or forceps

8. Antimicrobial agents and protective skin barriers must be allowed to air dry completely before dressing application.

antimicrobial effectiveness is dependent on drying

solutions can act as an irritant if trapped under an occlusive dressing

dry times: see page 36

9. Use of protective skin barrier should be considered. If using, avoid applying directly on the catheter skin junction site.

to maintain skin integrity to promote adhesion of dressing

10. Direct percutaneous CVC must be stabilized to the skin using sutures at the hub of the catheter.PICC and midline catheters must be stabilized using sutures at the hub of the catheter, skin closure strips, and/or securement devices.Sutures of tunneled and implanted CVC are removed as ordered.

to prevent accidental dislodgement or damage, and occlusion

once tissue granulation has occurred tunneled and implanted CVC do not require external stabilization

11. Any tape, skin closure strips or securement device applied under the dressing must be sterile.

microbes on non sterile items will transfer onto the catheter/skin junction and surrounding skin




12. Securement device and skin closure strips should be changed every 7 days and as needed.

to maintain skin integrity, promote adhesion of device and prevent infection

13. Caution should be taken if using safety pins and/or securing catheter to patient clothing.

inadvertent dislodgement may occur with the removal of the patients gown or clothing

14. Dressing should be centered over the catheter skin junction and cover any sterile skin closure strips or securement devices.

Do not stretch transparent semi-permeable membrane dressings during application.

using the maximum adhesive surface of the transparent dressing over the site helps anchor the dressing and provides maximum barrier protection to infection. Use more than one overlapping transparent dressing if required for adequate coverage

stretching can cause adhesion failure of the transparent dressing



Access


1. Access of a CVC and midline catheter must be done using aseptic technique.

to prevent the entry of micro-organisms into the vascular system

2. 10 mL syringes or larger are used for fl ushing, locking, or withdrawing from a CVC and midline catheter unless otherwise noted in specifi c programs.

infusion pressures should never exceed 2540 pounds per square inch (psi). Pressure > 40 psi can cause the catheter to rupture

the psi increases when fl ushing with smaller syringesSyringe Size PSI when fi lled1 mL TB syringe > 3003 mL > 405 mL > 4010 mL < 40

3. Separate syringes must be used for each lumen.

prevents cross contamination between lumens

4. Needleless system must be used to access the lumen via the injection cap.

there is a risk of perforating the catheter, embolization of the needle, or needle-stick injury if accessing the catheter with a needle

5. Lumen(s) or extension tubing must be clamped prior to accessing the catheter.Exception: valved catheter

to minimize the risk of air embolism, hemorrhage, or infection

6. Injection cap must be cleansed with antiseptic using friction and allowed to dry.

to prevent catheter related blood stream infection

7. If catheter is locked with any solution other than normal saline or low dose heparin withdraw 3 mL and discard the solution prior to use.

to prevent inadvertent administration of potentially hazardous dose of a medication or solution

8. A small amount of blood must be aspirated prior to use.

confi rms catheter placement in a blood vessel

9. If there is any doubt as to location of the CVC tip, request radiographic confi rmation prior to use.

confi rms catheter placement in a blood vessel



Flushing and Locking


1. Flushing and locking must be done using aseptic technique.


2. Lumens are to be fl ushed with normal saline as follows:

prior to and immediately following: infusion of solutions administration of medications (including fl ushing between medications) administration of blood/blood products

immediately following: collection of blood specimens

to ensure patency, prevent occlusion and to minimize potential problems associated with incompatible drugs

an order is required for all fl ushing and locking solutions

3. Normal saline 10 mL is the standard fl ush volume. normal saline 20 mL is recommended

following an infusion of lipids, blood/blood products, or medications known to crystallize or precipitate.Exception: Child Health

to ensure patency, prevent occlusion, and to minimize potential problems associated with incompatible drugs

4. A manual push/pause fl ush with a syringe using normal saline to create turbulence within the catheter lumen is recommended when fl ushing the catheter.

the turbulent method helps to ensure medication or blood is not adhering to the catheter

5. Excessive force must not be used during fl ushing or locking.

to prevent embolism or damaged catheter

6. Positive pressure technique will be usedwhen locking CVC and midline catheters.

non-valved catheters clamp thecatheter when injecting the fi nal 0.5 mLof lock solution

valved catheters maintain pressure onthe syringe plunger when disconnecting the syringe from the injection cap

to maintain catheter patency by preventing backfl ow of blood into catheter




7. When NOT IN USE the catheter must be fl ushed and locked at established intervals (see table: Recommended Lock Solution Volumes and Frequency page 48).

to maintain patency

8. Non-valved CVC and midline catheters must be clamped when the catheter is not in use.

to minimize the risk of air embolism, hemorrhage, or infection

9. A variety of locking solutions may be used to maintain patency or for treatment of complications such as catheter related infection or occlusion.

locking solutions may include solutions such as normal saline, low dose heparin solution (10 to 100 u/mL), high dose heparin (1000 to 10,000 u/mL), sodium citrate, vancomycin, 70% ethyl alcohol

10. Prior to instilling any lock solutions ensure that the solution is compatible with the composition of the catheter.

some catheters will disintegrate in the presence of certain solutions (e.g. instillation of 70% alcohol into polyurethane catheter)

11. The lumen must be labeled if it is locked with any solution other than normal saline or low dose heparin.

to identify the contents in the lumen to prevent inadvertent administration of

potentially hazardous dose of a medication or solution

12. If catheter is locked with any solution other than normal saline or low dose heparin withdraw 3 mL and discard the solution prior to use.


13. If there is any doubt as to what solution the catheter has been locked with, withdraw 3 mL and discard the solution prior to use.




Recommended Lock Solution Volumes and FrequencyWhen CVC and Midline Catheters are Not In Use

Non-Valved CVC and Midline Catheters Adults

Device Frequency Solution and Strength Volume

Implanted Ports Once a month Heparin 100 units/mL 5 mL

Tunneled q 7 days Heparin 10 units/mL 5 mL

Direct Percutaneous q 12 hours Heparin 10 units/mL 5 mL

PICC and Midline q 24 hours Heparin 10 units/mL 3 mL

Non-Valved CVC and Midline Catheters Children and Infants


Implanted Ports Once a month Heparin 100 units/mL 35 mL

Tunneled q 24 hours Heparin 10 units/mL 35 mL

Direct Percutaneous q 12 hours Heparin 10 units/mL 35 mL

PICC and Midline q 12 hoursHeparinInfant 10 units/mLChild 100 unit/mL

23 mL

Note: for infants continuous intravenous infusion may be utilized to maintain patency

Valved CVC and Midline Catheters Adults


Midline q 7 days Normal Saline 10 mL

Tunneled q 7 days Normal Saline 10 mL

PICC and Midline q 7 days Normal Saline 10 mL

Note: valved CVCs and midlines may require a heparin lock order if patency is diffi cult to maintain



Administration Sets


1. Administration set changes must be done using aseptic technique.

to prevent the entry of microorganisms into the vascular system

2. Newly primed infusion tubing and solution must be used when a CVC or midline catheter is inserted.

new tubing/solution prevents contamination

3. Infusion tubing systems are to be changed every 72 hours.Exception:

intermittent tubing is changed every 24 hours propofol tubing is changed every 24 hours parenteral nutrition/lipid emulsions tubing is

changed every 24 hours blood administration sets/fi lters must be

changed after a maximum of two units of whole blood or red cells, or 4 hours, which ever comes fi rst. Change set after completion of infusion of fractionated blood products (IVIG, clotting factors, albumin)

community setting every 96 hours

prevention of catheter related blood stream infection

the more frequently the tubing is disconnected the greater the risk for tubing contamination

4. If removable extension tubing is attached to a single lumen PICC or midline at time of insertion, it is part of the catheter and only changed if required.

if the original PICC or midline extension tubing is changed, then the extension tubing is labeled with the date and changed every 7 days.

attached at time of insertion under maximal barrier precautions

5. Infusion pumps must be used for ALL CVC infusions.Exception: Child Health, direct IV push,

emergency situations

to prevent fl uid overload, drug toxicity, and air embolism




6. Luer lock connections are required for all CVC tubing/devices.

securing connections with tape is not recommended

luer lock connections help prevent accidental disconnection which may result in air embolism, hemmorhage, or infection

taping connections associated with bacterial transmission

7. Filters are indicated for specifi c patient conditions, medication administration, and infusions.

fi lters can help minizmize the infusion of air, fungi, bacteria and endotoxins Note: these fi lters may be contraindicated

for use with some IV medications



Accessing and Disengaging an Implanted Port


1. Accessing of an implanted port must be done using aseptic technique.


2. Implanted ports are only to be accessed using a non-coring needle (e.g. Gripper or Huber).

http://www.bardaccess.com/infusion-winged.php

to prevent septal damage

3. The non-coring needle must be changed a minimum of q7 days and as needed.

4. Choose length of needle based on depth of port implanted.

common needle lengths are: , , 1 and 1 inch

if needle is too short it will not reach the base of the port

if needle is too long there is the potential for needle to break or septal damage

5. Promote patient comfort during accessing. ice and/or topical anesthetic may reduce the discomfort of the needle puncture

6. Cleanse the insertion site beyond the size of the dressing to be applied with the antimicrobial agent.

to minimize the microbes at the injection site

7. Prior to inserting needle consider the location of the infusion tubing needle is not to be rotated once inserted. Do not angle or twist the non-coring needle.





8. Non-coring needle must be inserted at a 90 angle.



9. Using a 10 mL syringe fi lled with normal saline aspirate a small amount of blood. Once blood is observed fl ush with normal saline using brisk push/pause technique. Assess for swelling and patient complaints of pain.

to ensure non-coring needle is located in the ports reservoir

pain and swelling at site may indicate: improper placement of non-coring needle damage to the implanted port dislodgement of catheter tip

10. If non-coring needle is to remain in situ it must be secured and covered with a sterile transparent semi-permeable membrane dressing.


to prevent infection to secure non-coring needle

11. Port must be locked when non-coring needle in situ:

but no infusion prior to disengaging non-coring needle every 30 days when not accessed

to maintain the patency of the implanted port

12. The port must be stabilized while disengaging the non-coring needle.

to prevent septal damage or damage to insertion pocket



Obtaining Blood Specimens from the Central Venous Catheter


1. Aseptic technique must be used when obtaining blood specimens from a CVC.


2. Limit number of times a day the catheter is used to obtain blood specimens.

to prevent catheter related blood stream infections

to prevent blood withdrawal induced anemia

3. If laboratory values for blood withdrawn from a CVC are signifi cantly altered in a previously stable patient, the laboratory test should be repeated before any treatment is implemented.

potential for blood specimen to be contaminated by catheter fl ush solution or infusate

4. Venipuncture must be used to collect specimens for coagulation studies, especially if the results are to be used to titrate medications or to diagnose coagulopathies. If venipuncture is not an option, CVC specimen for coagulation studies must not be drawn from a lumen:

with an infusion of heparin distal to an anticoagulant of a multi

lumen catheter

to prevent specimen contamination and inaccurate laboratory results, which could lead to inappropriate diagnosis and treatment

5. Discard volume will be dependant on the specimen required: Routine blood collection 3 mL

Blood collection including coagulation studies 12 mL (may use a 20 mL syringe)

Blood cultures no aspiration or discard

to prevent specimen contamination and inaccurate laboratory results, which could lead to inappropriate diagnosis and treatment




6. Vacutainer method is the preferred method for obtaining blood specimens from a CVC.

Photo used with permission: Becton Dickinson Medical Systems

Exception: Use the syringe method: if the Vacutainer method is unsuccessful if a small volume specimen is required if blood cultures are required

this method reduces the number of system punctures and potential blood spillage

7. If syringe method is used, a blood transfer device must be used when transferring blood from syringe to blood culture bottles and Vacutainers.

Photo used with permission: Tyco Healthcare Group Canada, Inc.

to promote safety by preventing needle stick injuries

8. When multi-lumen CVCs are used for blood withdrawal, the largest available lumen is preferred.

Blood specimens may be drawn through any CVC lumen except: blood specimens for coagulation studies must NOT be drawn from a lumen that has an infusion of heparin. a lumen being used to administer parenteral nutrition

Exception: if the lumen dedicated to parenteral

nutrition is suspected of being a source of infection blood culture specimens may be drawn from this lumen

in Child Health a lumen used for parenteral nutrition may be used to draw blood specimens

to prevent hemolysis of sample

to prevent inaccurate laboratory results

parenteral nutrition may enhance bacterial growth, therefore access of this lumen should be minimized




9. All lumens should be clamped and all infusions into the catheter stopped prior to collecting blood from a CVC.

prevents infusate from entering the lumen being accessed for blood sampling. Inaccurate lab values (e.g. potassium and aminoglycosides) have been reported on blood specimens obtained from CVCs

10. The order of blood specimens to be drawn are in accordance with Calgary Lab Services Standards.

avoid possible test error due to cross contamination from tube additives such as clotting activators or anticoagulants

11. Flushing prior to obtaining blood samples is not required. Exception: Prior to coagulation studies

catheter is to be fl ushed with 20 mL normal saline prior to discard and sample.

Note: If catheter is locked with any solution other than normal saline or low dose heparin withdraw 3 mL and discard the solution prior to fl ushing.

sample contamination is minimized by discard collection

more accurate results for coagulation studies if venipuncture is not an option

12. Catheter lumen is fl ushed with normal saline, using brisk push/pause technique after blood withdrawal.

to prevent catheter lumen occlusion

13. The following measures may be necessary if diffi culty drawing blood:

ask the patient to reposition, take deep breaths, cough, or raise arms

if still unable to withdraw blood, fl ush the catheter with 10 to 20 mL (adult) or 5 to 10 mL (child) normal saline using the push/pause method and repeat attempt

decrease speed of withdrawal to withdraw blood from a valved PICC

using the syringe method to open the valve: begin to withdraw the syringe plunger, stop, and then proceed to withdraw slowly

may release catheter from vessel wall or relieve pinch off syndrome

create turbulence in the catheter, repositioning catheter in the vessel

prevents catheter collapse



Managing a Hemodialysis Catheter

In addition to the above principles presented in this section the following principles need to be adhered to when managing a Hemodialysis Catheter.

Hemodialysis is a specialized treatment for some patients with renal disease where blood is withdrawn, treated in dialysis machine and re-instilled into the person.

Accessing, fl ushing and locking of a hemodialysis CVC is an additional skill which some level one nurses will be qualifi ed in. CVCs inserted for long-term hemodialysis are NOT to be used by staff outside the hemodialysis program (Southern Alberta Renal Program-SARP) for procedures such as infusing medications or drawing blood.

Exceptions: In an emergency situation and no alternative for intravenous access is possible When no other venous access is possible, an order is required from the nephrologists to access the

hemodialysis catheter.

The following principles are included in this module so that in an emergency situation if a hemodialysis catheter must be accessed, patient safety will be maintained.


Accessing1. Always withdraw and discard 3 mL of

solution to ensure the fl ush solution is removed from patient circulation.

locking solutions used with hemodialysis CVC include high dose heparin (1,000 U/mL to 10,000 U/mL), sodium citrate, alteplase (Cathfl o) or antibiotics

the patient is at high risk of hemorrhage if the locking solution is allowed to enter the vascular system

2. Flush lumen with 10 mL NS prior to administering medication or intravenous solution.

to ensure lumen is patent and that no clots exist

Maintenance Infusion3. Minimum infusion rate is 20 mL per hour to

maintain lumen patency.

lumen size is larger than standard CVC and therefore occlusion may occur if rate is less than 20 mL per hour




Locking4. When locking a hemodialysis catheter a

3 mL syringe is used to instill the ordered locking solution as per the volume of each lumen.

The volume of the lumen is marked on the clamp of hub of the lumen.

Positive pressure technique will be used when clamping hemodialysis catheters.

Ensure the clamp is locked at all times.

If the specifi c locking orders for the hemodialysiscatheters are not adhered to:

the catheter could occlude, requiring its removal and a new catheter inserted for dialysis treatment



5. The hemodialysis catheter must be labeled indicating locking solution.Note: Labels can be obtained from SARP

dialysis units.



Injection Cap Replacement and Dressing Changes6. Are completed by staff in the hemodialysis

program (SARP) as part of the patients hemodialysis treatment.

Where care is required in addition to this schedule (e.g. to replace a hemodialysis CVC dressing that is no longer intact) contact the hemodialysis program to confi rm the care approach.

Diagnostic Imaging (DI) testing7. CVCs inserted for hemodialysis are NOT to

be attached to power injectors for DI tests.

these catheters are considered life sustaining and any intervention that carries a risk of damaging the catheter must be avoided

Repair8. Repair of a hemodialysis CVC is performed

by those nurses qualifi ed in this procedure and follows the SARP specifi c policy and procedure.

Removal9. Hemodialysis CVCs may be removed only

when ordered by a nephrologist and must be removed following the specifi c policy and procedure in the hemodialysis program (SARP).



Managing an Apheresis Catheter

In addition to the above principles presented in this section the following principles need to be adhered to when managing a CVC designated for Apheresis use.

Note: Multiple catheters can be used for apheresis including direct percutaneous tunneled and implanted ports.

Apheresis: The process of withdrawing whole blood through a central venous catheter into a blood cell separator where it is divided into its components (RBCs, WBCs, platelets and plasma). The desired component is removed and/or replaced. For example, apheresis can be used to remove: pathological antibodies in the body and replace them with normal plasma or albumin; WBCs in acute leukemia to allow chemotherapy to begin sooner; and, stem cells for transplant.

Accessing and locking of an apheresis catheter is an additional skill which some level one nurses will be qualifi ed in. CVCs designated for apheresis are NOT to be used by staff outside the apheresis program for procedures such as infusing medications or drawing blood unless by physician order.

Exception: In an emergency situation and no alternative for intravenous access is possible. When no other venous access is possible, an order is required from the medical director of

apheresis (weekdays) or nephrologists (evenings, nights, and weekends) to access the apheresis catheter.

The following principles are included in this module so that in an emergency situation if an apheresis catheter must be accessed, patient safety will be maintained.


Accessing1. Always Withdraw and Discard 3 mL

of solution to ensure the fl ush solution is removed from patient circulation.

locking solutions used with apheresis CVC include high dose heparin (1,000 U/mL to 10,000 U/mL), sodium citrate, alteplase (Cathfl o) or antibiotics


2. Flush lumen with 10 mL NS prior to administering medication or intravenous solution.

to ensure lumen is patent and that no clots exist

Maintenance Infusion3. Minimum infusion rate is 20 mL per hour to

maintain lumen patency.

lumen size is larger than standard CVC and therefore occlusion may occur if rate is less than 20 mL per hour




Locking4. When locking an apheresis catheter a 3 mL

syringe is used to instill the ordered locking solution as per the volume of each lumen.

The volume of the lumen is marked on the clamp of the hub of the lumen

If the specifi c locking orders for the apheresis catheters are not adhered to:

the catheter could occlude, requiring its removal and a new catheter inserted for apheresis treatment


5. Positive pressure technique will be used when clamping apheresis catheters.

Ensure the clamp is locked at all times.


6. The lumen must be labeled as an apheresis catheter.

The label will also indicate the locking solution instilled into the catheter.

Additional labels can be obtained from the Apheresis Department.



Cap Replacement and Dressing Changes7. Are completed by staff in the Apheresis

program as part of the patients apheresis treatment.

Where care is required in addition to this schedule (e.g. to replace a site dressing that is no longer intact) contact the apheresis program to confi rm the care approach.

DI testing8. CVCs inserted for apheresis are NOT to be

attached to power injectors for DI tests.

these catheters are considered life sustaining and any intervention that carries a risk of damaging the catheter must be avoided

Repair9. Repair of an apheresis CVC is performed by

those nurses qualifi ed in this procedure.

Removal10. Apheresis CVCs may be removed only when

ordered by a Medical Director of Apheresis (weekdays) or Nephrologists (evenings, nights and weekends).



Checkpoint: Section Four Questions

1. What are MAXIMAL barrier precautions and when are they required?

2. What 4 CVC and midline catheter interventions require the use of a mask and sterile gloves, in addition to hand hygiene?

3. What 5 components of a CVC and midline catheter assessme

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Documents

alberta health services

midline catheter care

hemodialysis catheter

apheresis catheter

midline catheters

insertion of cvc

principles of cvc

types of cvc