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CLINICAL GUIDELINE TITLE

Central Venous Access – Guideline on insertion

1) SUMMARY This document has been created as guidance for all staff involved in the care of paediatric Central Venous Catheters (CVC). 2) INTRODUCTION This guideline applies to all care environments and to all staff within Imperial College Healthcare NHS Trust who are involved in the insertion, care and on-going maintenance of CVCs in children. This guideline is to ensure consistent and safe minimum standards are met and maintained in the insertion, care and maintenance of CVC. Staff responsibilities for the care of patients with a CVC:

Clinical teams within the organisation who deem that a CVC is the most appropriate form of vascular access for their patients are responsible for organising the insertion.

The on-going care and maintenance of the CVC is the responsibility of registered nurses, however clinical teams have overall responsibility for all invasive devices and as part of their daily assessment of patients should monitor any vascular access device their patients have in situ and document the clinical indication for the device

Regular agency staff that have provided documentation of intravenous competencies which are up to date may access the CVC after being made aware of the guidelines document.

3) DEFINITIONS

A non-tunnelled CVC is a device that enters through the skin directly into a central vein

4) SCOPE This guideline will apply to all healthcare professionals involved in the care of paediatric Central Venous Catheters (CVC) from pre-insertion care through to post insertion care 5) FULL GUIDELINE CENTRAL VENOUS ACCESS 1.0 Central Venous Catheters (CVCs) 1.1 CVC Size Guide and Recommended Insertion Length at Skin

1.1.1 Double, Triple or Quadruple lumen Central Venous Catheters 1.1.2 Central Venous Access for RRT (Double ‘venous’:’arterial’ lumens)

2.0 PRE-PROCEDURE: 2.1 Indications 2.2 Contraindications 2.3 Considerations 2.4 Complications 2.5 Preparation

2.5.1 Anaesthesia and Sedation 2.5.2 Pre-procedure Checks 2.5.3 Equipment Checklist

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3.0 PROCEDURE: 4.0 POST-PROCEDURE:

4.1 Information for Child / Parent / Carer / Guardian

1.0 Central Venous Catheters (CVCs) CVC insertion should be performed by an appropriately trained practitioner. Current NICE guidelines (www.nice.org.uk/guidance/ta49) recommend that 2D ultrasound imaging is used to assist correct placement of CVCs. Ultrasound should be used to aid siting ALL internal jugular and femoral lines. On St Mary’s PICU two ultrasound machines are available; a Sonosite and an Acuson 300 (use VF13-5 probe on latter machine). The CVC should be inserted in a sterile field in the most appropriate location for the patient (bedside, treatment room, interventional radiology or theatre), with standard ICU monitoring1. There are several different approaches to inserting a CVC as detailed in the table below. Approach Possible Sites Lumens Examples of

Types / Brands

CVC2 Femoral vein - right or left

Internal Jugular vein (IJ) - right or left Subclavian vein (ScV) - right or left

1, 2, 3, or 4 Cook Vygon Arrow

CVC for Renal Replacement Therapy

Femoral IJ ScV

2 (‘Venous’ lumen and ‘arterial’ lumen)

Vascath Gamcath

PICC (Peripherally Inserted Central Catheter)

Any sufficiently large peripheral vein Usually Brachio-cephalic vein or long saphenous vein (scalp vein in neonates can be used)

1 or 2

1.1 CVC Size Guide and Recommended Insertion Length at Skin

1.1.1 Double, Triple or Quadruple lumen Central Venous Catheters

0-5Kg 5-15Kg 16-30Kg 31-45Kg

Size of CVC (Fr) 4.0 - 5.0 4.5 – 6.0 5.0 – 6.0 5.0 – 7.0

R Internal Jugular Vein

5cm 6.5/8cm 8/10cm 10/12cm

L Internal Jugular Vein

6.5cm 8/10cm 10/12cm 12/15cm

R Subclavian Vein

6.5cm 8cm 10/12cm 10/12cm

L Subclavian Vein

6.5cm 8/10cm 10/12cm 12/15cm

Femoral Vein

8cm 8cm 10cm 12cm

In young infants (<2 years) it is safer to pass the Seldinger wire through an abbocath rather than the needle supplied with the kit. An abbocath has a smaller bevel needle and is likely to cause less damage if incorrectly placed. A 20G abbocath is suitable for the wire from a 5Fr line and a 22G abbocath is suitable for the wires from the 4Fr and 4.5Fr lines.

1 Heart rate, BP on 2 minute repeat, Oxygen saturation percentage, respiratory rate, end tidal carbon dioxide

measurement if intubated. Audio cue should be activated on the monitor. 2 CVC insertion can also be tunnelled under the skin if longer term central venous access is required. This will be done

by either the Interventional Radiologists in the Radiology department under screening or by the General Paediatric surgeons in theatres (again under screening).

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1.1.2 Central Venous Access for RRT (Double ‘venous’:’arterial’ lumens)

<3Kg 3-6Kg 6.1 – 30Kg >30Kg

Size of catheter (Fr)

5Fr 6.5-7Fr 8Fr 10 / 11.5 Fr

Length of Catheter (cm)

5 – 8 8 - 10 10 - 12 12 – 19.5

Site Femoral Vein IJ/SC/Femoral IJ/SC/Femoral IJ/SC/Femoral

2.0 PRE-PROCEDURE: 2.1 Indications

Monitoring Central Venous Pressure (CVP).

Delivery of inotropic therapy.

Rapid colloid/volume replacement.

N.B. Wide bore, short peripheral IV cannulae may be better where possible but Lumen 1 of Cook triple lumen catheter is 18G.

Administration of hypertonic solutions.

For example: potassium, calcium, >10% glucose and parenteral nutrition (PN) (in

exceptional circumstances discuss with a paediatric pharmacist whether PN could be given

peripherally for a short time).

Poor peripheral venous access.

When at least 2 secure and reliable peripheral lines cannot be established. 2.2 Contraindications

Coagulopathy – This is a relative contraindication and the most recent INR, APTT, APTTr, PT, Hb and platelet results should be discussed with the Attending Consultant prior to inserting a CVC.

Be aware though, that abnormal clotting results may have more significance if inserting a Subclavian CVC as it is more anatomically difficult to apply direct venous pressure in the event of bleeding (the Subclavian vein winds around the clavicle posteriorly).

Local areas of loss of skin integrity at site of CVC insertion – discuss with a Consultant prior to CVC insertion.

2.3 Considerations

Placement of CVC in areas of potential loss of sterility eg femoral CVC placement in a child with profuse diarrhoea

Optimal choice of CVC placement where there is abnormal body habitus e.g. fixed flexion deformities of limbs may complicate PICC insertion or limited neck length and movement may impede IJ CVC placement

Safety and suitability of general anaesthesia in the child. If unacceptable risk then consider inserting CVC under deep sedation whilst the patient remains self-ventilating or in some instances with skilled operators a PICC can be placed without sedation (discuss this option with PICU consultant).

2.4 Complications

Thrombosis

CVC related infections (at insertion site, along the subcutaneous path if tunnelled and blood borne)

Puncture of the associated artery (ie Femoral Artery puncture if attempting femoral vein CVC) and accidental dilation of that artery.

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Arrhythmias due to intra-cardiac node stimulation from too deep CVC insertion or CVC guide-wire insertion during the Seldinger technique3.

Loss of guide wire in vessel -This should NEVER happen.

Procedural associated trauma: Bleeding / haematoma/pneumothorax/haemothorax / chylothorax

2.5 Preparation 2.5.1 Anaesthesia and Sedation

Decide on level of sedation required and appropriate anaesthesia

Analgesia plan

Conscious sedation can be employed for direct CVC and PICC insertion but an anaesthetist or similarly experienced practitioner must be available to manage the airway

2.5.2 Pre-procedure Checks

Coagulation

Platelet count

Hb

Patient and family understand clinical need for procedure even if consent not required

Attending Consultant and Nurse in Charge informed

No concurrent procedures happening on PICU if possible and DO NOT START CVC INSERTION PROCEDURE AT THE END OF A SHIFT.

Get all equipment required ready and set up sterile field

Prior to scrubbing up, apply ultrasound probe and ascertain vascular anatomy

Fig 1: Ultrasound image using the Linear Array probe of the right Internal Jugular vein (a) – compressibe - and Carotid artery – non compressible. 2.5.3 Equipment Checklist

Sterile field, surgical scrub, sterile gown, sterile gloves, surgical hat, mask and protective eyewear recommended

Ultrasound machine, ‘Vascular Access’ Linear Array probe

Skin disinfectant (e.g. chlorhexidine 2%) and sterile drape

On sterile field on procedure trolley:

Local anaesthetic (e.g. Lidocaine 1%) optional

3 Whilst, an arrhythmia would indicate that the CVC or CVC guide wire used during the insertion process is in too far it

is also a useful marker that the CVC is following the correct venous path and that the tip just requires some withdrawal.

a

b

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Equipment required Quantity

Central Venous Catheter 1

All c

onta

ined w

ithin

sta

ndard

CV

C in

sertio

n p

ack

Scalpel 1

Sterile one-way connectors 3

Sterile 3-way taps 3

Introducer needle or Abbocath (appropriate size for wire)

1

Seldinger guide-wire 1

Dilator 1

Flange (to attach to CVC hub to provide anchor for suture) if not integral to CVC

1

Disinfectant swab (e.g.chlorhexidine 2%) 2

Syringes (2.5ml) 3

Syringe (10ml) 1

Drawing up needles 2

Suture 2/0 non-absorbable straight needle 1

Sterile sodium chloride 0.9% 20ml

Sterile gauze swabs 6

Sterile ultrasound gel 1

Sterile ultrasound probe sheath 1

Transparent adhesive dressing Biopatch 1

Fig 2: Suggested set up of sterile CVC equipment

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3.0 PROCEDURE:

Ensure all CVC lumens, 3-way taps and one-way bungs are flushed with sodium chloride 0.9%

Clean skin with antiseptic solution and allow to dry

Drape patient with sterile field

Cover ultrasound probe with sterile gel and place in sterile sheath (request your assistant to hold the non-sterile probe by the wire, letting the head of the probe dangle down. The sterile sheath can then be placed over the probe head and unfolded up the length of the wire without touching the actual probe or wire). The sheath covered probe can now be left resting on top of the sterile drape on the patient.

Fig 3: Sterile technique for covering the Linear Array probe head

Identify the point of entry of the Introducer needle on the skin after ultrasound assessment of the vessels

(A) (B) Fig 4: (A) Patient covered in sterile drape, Linear Array probe in sterile sheath and applied to skin over region of the Internal Jugular vein territory. (B) Superficial identification of the right Internal Jugular vein after ultrasound assessment

Use Seldinger Technique for CVC insertion: - Insert the Introducer needle and syringe, or Abbocath, slowly at 45 degrees to the skin

with continual aspiration if using a syringe. Look for aspiration of blood into the syringe or flashback of blood into the Abbocath chamber

- If Internal Jugular Vein: aim for ipsi-lateral nipple

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Fig 5: Anatomical diagram detailing insertion point for right internal jugular vein approach for CVL insertion

- If Subclavian vein: aim for sternal notch Fig 6: Anatomical diagram detailing insertion point for right Subclavian vein approach for CVL insertion

- If Femoral vein: aim for umbilicus

(A) (B) Fig 7: Anatomical diagram detailing insertion point for right femoral vein approach for CVL insertion (A) and the underlying anatomy of the femoral canal (B)

- If using USS then direct the needle as indicated by the screen images

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Fig 8: Inserting the Introducer needle / Abbocath

Once the Introducer needle or Abbocath has found the Target vessel and then allow free aspiration of a few millilitres of blood.

At this point it is important to confirm that the vein has been cannulated and not an artery (in particular for femoral CVC access) – this can be done by checking a blood gas or transducing the cannula.

Remove the syringe from the Introducer needle or the cannulation needle from the Abbocath and insert the guide wire via the needle. Ensure correct (J-shaped) end is inserted first.

There should be no resistance, DO NOT FORCE THE WIRE TO GO IN. Ask assistant to monitor looking for ECG changes (suggestive of intra-cardiac placement of wire). Withdraw until abolished, if this is encountered.

Ultrasound again to confirm wire is in the vein (IJ and FV cannulation)

(A) (B) Fig 9: Threading the guide wire through the Abbocath (or introducer needle) with the wire still in the white holder with pink detachable nib (A) and after the white holder has been removed keeping the wire in situ within the Abbocath or introducer needle (B)

When guide wire is in place, remove the white wire holder and pink nib, then withdraw Abbocath or introducer needle.

Pass dilator over guide wire and dilate passage through skin and subcutaneous tissues. It is not necessary to bury dilator up to the hilt. DO NOT USE FORCE. Instead, slightly twist the dilator as you pass it over the wire and through the skin. Consider using scalpel to make a small incision in the skin at the entry point of wire.

(A) (B) Fig 10: (A) Sliding the dilator over the guide wire and twisting through the skin. (B) Making a nick in the skin with the flat edge of the blade against the guide wire and sliding the scalpel down the wire in one smooth incision

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Remove dilator. Pass CVC over the guide wire. Insert to desired depth, according to size of child.

ENSURE THE END OF THE GUIDE WIRE ALWAYS REMAINS VISIBLE

Fig 11: Inserting the CVC over the guide wire to the predetermined length.

REMOVE GUIDE WIRE

Ensure all lines aspirate blood easily and flush with sodium chloride 0.9% without resistance.

All catheters should be secured with black silk (3/0) sutures two on the winged hub and one on the hub but not on the soft catheter itself. This suture should be distal to the wing but proximal to the origin of the catheter.

Trust policy is now to place a BiopatchTM over the insertion site to prevent infection.

Then apply a transparent and occlusive dressing e.g. Tegaderm®.

(A) (B) Fig 12: CVC in situ: Right Internal Jugular vein (A) and right Subclavian vein (B). Sutured in place with a transparent adhesive dressing. All lumen have been aspirated to ensure patency with good flow of blood and then flushed with sodium chloride 0.9% and then clamped. One way bungs and three-way taps have been attached to the ends of the lumens. 4.0 POST-PROCEDURE:

Fully document procedure in the medical notes – as a procedure note on ICIP

Chest radiograph for all attempted neck/subclavian lines even if unsuccessful o To exclude pneumothorax o Identify tip position – should be in SVC above right atrium which approximates to within

top 1/3 of sternum. If in too far, then withdraw under sterile conditions.

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Fig 13: Screen shot of correct documentation for CVC line insertion on ICIP 4.1 Information for Child / Parent / Carer / Guardian

Whilst insertion of a CVC on PICU does not require parental consent it is best practice to keep the responsible adult informed and up to date with events.

Salient information to be shared would include indication for the CVC, potential benefits, potential complications, duration the CVC is expected to be in situ and after-care of the CVC.

Lumen utilization Lumen 1 Keep one way for CVP monitoring and use the second for high flow rate infusions or rapid boluses of colloid and blood products. Avoid using this lumen for inotrope, calcium, potassium or bicarbonate infusions. Lumen 2 For inotrope, calcium, potassium and bicarbonate infusions, acute hyperalimentation or maintenance infusion of >10% glucose. Lumen 3 For calcium, potassium and bicarbonate infusions or boluses. Also used for sedation, paralysis and standard maintenance fluid infusions. References Bishop L et al. 2007. Guidelines on the insertion and management of central venous access devices in adults. Int. Jnl. Lab. Hem. 29, 261–278. David C. McGee, M.D and Michael K. Gould, M.D. 2003. Preventing Complications of Central Venous Catheterization. N Engl J Med. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. 2012. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane database review, 14;3:CD004084. Jeffries HE, Mason W, Brewer M, et al. 2009. Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: A performance improvement collaborative. Infection Control and Hospital Epidemiology, 30(7):645-65 NICE technology appraisal guidance [TA49]. Guidance on the use of ultrasound locating devices for placing central venous catheters. October 2002. www.nice.org.uk/guidance/ta49 Smith RN. 2013. Central venous catheters. BMJ. 347:f6570

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5) IMPLEMENTATION

Training required for staff Yes

If yes, who will provide training: PICU consultant staff and senior PICU trainees

When will training be provided? Trainees will be supervised during their posts on PICU

Date for implementation of guideline: Immediate

6) MONITORING / AUDIT

When will this guideline be audited? September 2018

Who will be responsible for auditing this guideline? David Inwald

Are there any other specific recommendations for audit? None

7) REVIEW

Frequency of review

Please indicate frequency of review: 3 years Person and post responsible for the review: Dr David Inwald & Dr Mehrengise Cooper Consultant Paediatric Intensivists

8) GUIDELINE DETAIL

Start Date: Immediate

Approval Dates Name of Divisional group: Children’s Q&S Committee Date of ratification: 25th April 2018

Name of Directorate group: Paediatric Guidelines Group Date of ratification: 11th April 2018

Has all relevant legislation, national guidance, recommendations, alerts and Trust action plans been considered, and included as appropriate in the development of this guideline?

Please list ALL guidance considered:

Have all relevant stakeholders been included in the development of this guideline?

Please list all (name and role): PICU consultants

Who will you be notifying of the existence of this guidance?

Please give names/depts: All doctors & PICU nurses

Related documents

Author/further information

Name: Dr David Inwald / Dr Mehrengise Cooper Title: Consultant Paediatric Intensivists Division: WCCS Site: SMH Telephone/Bleep: 020 3312 7683 Email: david.inwald@nhs.net/mehrengise.cooper@nhs.net

Document review history Next review due: April 2021

THIS GUIDELINE REPLACES: sid_101054

9) INTRANET HOUSEKEEPING

Key words Central venous line, central venous catheter

Which Division/Directorate category does this belong to?

WCCS / Children’s Services

Which specialty should this belong to when appearing on the Source?

Intensive care PICU

10) EQUALITY IMPACT OF GUIDELINE Is this guideline anticipated to have any significant equality-related impact on patients, carers or staff? No