paediatric oncology central venous catheter clinical guideline …€¦ · paediatric oncology-...

Paediatric Oncology Central Venous Catheter Clinical Guideline V3.0

December 2018

Paediatric Oncology- Central Venous Catheter Clinical Guideline V3.0

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Contents 1.0 Aim/Purpose of Guideline ……………………………………………………………………………… 4

2.0 The Guidance …………………………………………………………………………………………….. 4

2.1 Insertion of a CVC ……………………………………………………………………………………... 4

2.1.1 Child and family preparation ……………………………………………………………………………… 4

2.1.2 Surgical Procedure…………………………………………………………………………………………. 5

2.2 Potential Complications and Care …………………………………………………………………….. 6

2.2.1 Immediate Post-Operative Complications and Care…………………………………………………… 6

2.2.2 Ongoing Risks and Complications..……………………………………………………………………… 7

2.3 Training ……………………………………………………………………………………………………. 7

2.3.1 Staff Training and Competence…………………………………………………………………………… 7

2.3.2 Child and Family Education ……………………………………………………………………………… 7

2.4 Aseptic Technique……….……………………………………………………………………………… 8

2.4.1 Aseptic Non Touch Technique (ANTT)..………………………………………………………………… 8

2.4.2 Aseptic Non Touch Technique (ANTT) A step by step guide.………………………………………… 9

2.4.3 Aseptic Non Touch Technique (ANTT) A step by step guide for Anaesthetists..…………………… 10

2.5 Sterile Non Touch Techniques…………….…………………………………………………………… 10

2.5.1 Sterile Non Touch Technique A step by step guide: Bung change…………………………………… 10

2.6 Accessing a Central Venous Catheter………………………………………………………………… 11

2.6.1 Drug Administration Principles…………………………………………………………………………… 11

2.6.2 Blood Sampling Principles………………………………………………………………………………… 11

2.6.3 Setting Up and Administering Parenteral Nutrition……………………………………………………… 12

2.7 Infusion Equipment………………………………………………………………………………………. 13

2.7.1 MicroCLAVE Bungs: Principles of Use………………………………………..………………………… 13

2.7.2 Administration Sets and Add On Devices…………………………………..…………………………… 13

2.7.3 Filters………………………………………………………………………………………………………… 13

2.8 Dressings…………………………………………………………………………………………………… 14

2.9 Bathing and Showering………………………………………………………………………………….. 14

2.9.1 General………………………………………………………………………………………………………. 14

2.9.2 Bathing………………………………………………………………………………………………………. 14

2.9.3 Showering…………………………………………………………………………………………………… 14

2.9.4 Bathing or showering with a Port………………………………………….……………………………… 14

2.10 Swimming………………………………………………………………………………………………….. 15

2.11 CVC Patency……………………………………………………………………………………………….. 15

2.11.1 Maintaining catheter patency……………………………………………………………………………… 15

2.11.2 Lock Solutions Guidance………………………………………………………………………………… 15

2.11.3 Recommended frequency of flush and lock procedure………………………………………………… 15

2.11.4 For Management Of Persistent Withdrawal Occlusion (PWO) Or Blocked CVC……………………. 16

2.11.5 Use of Urokinase……………………………………………………………………………………………. 17

2.11.6 Milking technique with 0.9% Sodium Chloride…………………………………………………………… 17

2.11.7 Milking technique with Urokinase…….…………………………………………………………………… 17

2.11.8 Push lock technique………………………………………………………………………………………… 18

2.11.9 3 Way Tap Method……………………………………………………………………………………….. 18

2.11.10 Volumes of Urokinase or Alteplase…….………………………………………………………………… 20

2.11.11 Alteplase lock guidance………………………………………………………………………………….. 20

2.12 Use of CVC’s in Radiology……………………………………………………………………………… 21

2.13 Hickman Catheters……………………………………………………………………………………….. 21

2.13.1 General……………………………………………………………………………………….. 21

2.13.2 Hickman line safety packs…………………………………………………………………………………. 21

2.13.3 Dressing, Cleaning and Securing the CVC……………………………………………………………… 21


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2.13.4 Loop it or Lose it…………………………………………………………………………………………….. 22

2.13.5 Damage,Accidental Removal or Repair..………………………………………………………………… 23

2.14 Totally Implantable Intravenous Devices ‘Ports’…………………………………………………… 24

2.14.1 General …………………………………………………………………………………………………….. 24

2.14.2 How to access…………………………………………………………………………………………….. 25

2.14.3 Trouble shooting…………………………………………………………………………………………….. 26

2.14.4 Documentation………………………………………………………………………………………………. 27

2.15 Haemodialysis and Apheresis Catheters…………………………………………………………… 27

2.16 Peripherally Inserted Central Venous Catheter ‘PICC’ 28

2.16.1 Maintaining patency of PICC ……………………………………………………………………………… 29

2.16.2 Care of a PICC …………………………………………………………………………………………… 29

2.16.3 Dressing a PICC…………………………………………………………………………………………... 30

2.16.4 Removal of a PICC……………………………………………………………………………………….. 30

3 Monitoring compliance and effectiveness 31

4 Equality and Diversity 31

Appendix 1

Governance Information 32

Appendix 2

Initial Equality Impact Assessment Form 36


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1. Aim/Purpose of this Guideline This guideline aims to give clear information for the supportive care of central venous catheters (CVC’s) and for the insertion of skin tunneled catheters (Hickman lines) and totally implantable devices (Portacaths) in children and adolescents on the Paediatric Unit. This guideline excludes Neonates.

2. The Guidance Skin tunneled catheters (Hickman lines) and fully implantable devices (Portacaths) are routinely used on the CLIC unit. In the majority of cases the devices are inserted at the Bristol Royal Hospital for Children (BRHC). Occasionally the devices are inserted at the Royal Cornwall Hospital’s NHS Trust (RCHT) following discussion and under the care of the vascular surgeons. BRHC and RCHT use a variety of CVC’s. These include:

Tunnelled central venous cuffed catheters (e.g. Hickman, Broviac, Cook and Groshong)

Totally implantable intravascular devices (Ports) Peripherally inserted central catheters (PICC) lines beyond neonatal period. Short and Long-term Dialysis catheters

CVC’s may be used to provide access for children and adolescents requiring intensive intravenous therapy, for example:

Chemotherapy administration Post Stem cell transplantation Parenteral nutrition Frequent blood sampling Blood product administration Drug therapy for specific disorders or conditions

These guidelines are to be used in conjunction with;

RCHT Aseptic Non Touch Technique(ANTT) Policy- Documents library or sisters shelf

Clinical guideline for Total Parenteral Nutrition in Paediatric Patients from 4 weeks to 16 years –Documents library or sisters shelf

2.1. INSERTION OF A CVC

2.1.1 Child and Family Preparation

2.1.1.1. Preparation and education should be provided to the child and family prior to the insertion of a CVC. Resources such as the play specialists, Chester Chest , Hickman Catheter – Information for Patients, Parents and Carers, PICC information booklet and, Port information booklet may facilitate this.

http://nww.avon.nhs.uk/dms/download.aspx?did=7740









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2.1.1.2. The CVC placement site should be discussed with the child and family as part of the consent process and on return from theatre side/position documented in clinical notes.

2.1.2 Surgical Procedure

2.1.2.1. Long term CVC are inserted in theatre under general anaesthetic using optimum aseptic procedures (Pratt et.al 2013).

2.1.2.2. Prior to CVC insertion the skin should be decontaminated with two applications of 2% chlorhexidine gluconate in 70% alcohol solution (Pratt et.al. 2013) using a single use applicator (e.g.Chloraprep). Allow to dry for 30 seconds before second application and before commencing insertion procedure.

2.1.2.3. Ultrasound guided percutaneous insertion is standard but the surgeon may choose an open insertion particularly if the external jugular vein is accessible (NICE accessed 2017)

2.1.2.4. Tunnelled CVC are inserted into the internal or external jugular, subclavian or femoral vein and then advanced until the catheter tip is just within the right atrium.

2.1.2.5. A subcutaneous tunnel is formed and the catheter is pulled through to an exit site created on the chest wall and If the femoral vein has been used the exit-site will be on the abdomen side/site/position to be documented in clinical notes. The CVC has a Dacron cuff positioned subcutaneously. This stimulates growth of fibrin around it, providing anchorage of the line and a barrier to ascending micro-organisms.

2.1.2.6. Implantable ports are inserted in the same way as a Tunnelled CVC. However, the distal end is attached to a stainless steel, titanium or plastic port, which is implanted in a subcutaneous pocket, usually in the chest wall. The port is secured to the chest wall with sutures. A non-coring (e.g. Gripper type) port needle should be used to access the port to prevent damage to the port septum. Following the port insertion procedure the port needle should be left in situ until the patient’s treatment plan and discharge is reviewed by the clinical team. The correct size of port needle required for the patient’s port should be documented within the surgical notes.

2.1.2.7. CVC’s differ in the number of lumens and the diameter of each lumen. When selecting a catheter, “use a CVC with the minimum number of ports or lumens essential for the management of the patient” (Pratt et.al. 2013). The type, size, position(e.g side, site) and lot number of the CVC inserted should be documented in the patient’s notes to help determine catheter volumes as well as facilitating repair if the catheter becomes damaged.

2.1.2.8. Syringes of 10ml or greater should be used to access a CVC as the high flush pressure generated by syringes smaller than 10ml can rupture the line.


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2.1.2.9. The position of the catheter and tip should be checked by image intensification in theatre, and the confirmation of this documented in the operation notes, within the patients notes, prior to utilising the catheter (NICE accessed 2017).

2.1.2.10. The instrument and guide-wire count needs to be checked at the time of insertion and documented correctly.

2.1.2.11. PICC and short term CVC lines may be inserted on the ward by a trained practitioner using optimal aseptic technique. The PICC is inserted into a suitable peripheral vein and then advanced to a more central position. This is commonly from the antecubital fossa into the superior vena cava. All lines must be X-rayed following insertion, to check the tip is in the correct position before it can be used.

2.2. POTENTIAL COMPLICATIONS AND CARE

2.2.1. Immediate Post-Operative Complications and Care

2.2.1.1. Potential Post-Operative Complications following the insertion of a CVC

are:

Infection

Thrombosis

Perforation of vessels and myocardium

Pleural collections

Cardiac arrhythmias

Air embolism

Guidewire/catheter embolism

Catheter occlusion

Catheter breakage/leak/extravasation

Bleeding elsewhere

Central venous stenosis

Neurological injury (Association of Anaesthetists of Great Britain and Ireland: 2016)

Therefore, careful assessment of the patient’s condition following a CVC insertion is required.

2.2.1.2. Before the line is used, check the operation note to confirm both that the

CVC tip position has been documented and that the line is ready to use. 2.2.1.3. Post-operative patient assessment should include; monitoring of

temperature, pulse, blood pressure, respiratory rate and oxygen saturations.

2.2.1.4. Post-operative assessment of the CVC should include; observation and documentation of the line insertion site, skin tunnel and exit site.

2.2.1.5. The CVC should be accessed and assessed for blood return and that individual lumens flush without resistance.

2.2.1.6. If there is any difficulty aspirating blood or blood samples are observed to be dilute, there is increased swelling around the line site, significant pain


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or the patient’s condition deteriorates stop using CVC. Ask for a medical assessment and notify the person who inserted it.

2.2.1.7. If there is a concern that the line has become misplaced, then imaging should be performed prior to further use or removal of the line.

2.2.2. Ongoing Risks and Complications

The ongoing risks and potential complications associated with the use of CVC’s are: Infection; systemic catheter-related infection, exit site infection, tunnel infections

or pocket infection. Occlusion or thrombosis Damage to the CVC such as fracture or embolization Accidental dislodgement Infiltration or extravasation (Hamilton 2006: Part 2). Syringes of less than 10ml should not be used to access a CVC as the high

flush pressure generated by syringes smaller than 10ml can rupture the line.

2.3. TRAINING

2.3.1. Staff Training and Competence

2.3.1.1. In order to reduce the risks and prevent complications associated with the

use of CVC’s, only those trained and assessed as competent should be involved in accessing and caring for these devices (INS, 2016).

2.3.1.2. The Paediatric Practitioners Vascular Access Management Competency Book should be used for training and competency assessment.

2.3.1.3. Separate training and competency in Haemodialysis and Apheresis CVC access and care is required due to the risks associated with the anti-coagulant ‘lock’ solution.

2.3.2. Child and Family Education

The child and family should receive education and training in the risks

associated with a CVC and the appropriate monitoring and ongoing care of the device Hickman, Port and PICC patient pack from Hospital where CVC inserted (RCN 2016).

This includes daily inspection of the exit site (DOH 2007), routine dressing changes and specific training in CVC safety.

A CVC Safety Pack should be provided, with training, so that the carer or child knows what to do in case of an emergency.

If carers or patients are required to undertake additional interventions involving the CVC, such as administering intravenous medication, specific training must be provided and competency assessed and documented in the patients notes at Hospital where CVC inserted, Principle Treatment centre or shared care centre (RCN 2016).

http://workspaces/sites/Teams/IVAndCentralLineNurseGroupBCH/Working%20Group%20Papers/IV%20Competency%20Book%20August%202016.pdf

http://workspaces/sites/Teams/IVAndCentralLineNurseGroupBCH/Working%20Group%20Papers/IV%20Competency%20Book%20August%202016.pdf






http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5820&f=3ResourcesHickmanLineSafetyPackContents-1.pdf


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2.4. ASEPTIC TECHNIQUE 2.4.1. Aseptic Non Touch Technique (ANTT)

Effective hand washing practice used alongside Aseptic Non Touch Technique (ANTT) is vital in reducing the risk of infection and should be applied to all aspects of the care and management of CVC (Pratt et.al. 2013, RCN 2016).

Key principles of ANTT include:

Effective hand washing before and after patient contact and if hands become contaminated during the procedure (Rowley 2010, DOH 2007)

The use of personal protective equipment including gloves and aprons. Additional equipment such as eye protection may be required in some high risk procedures (Rowley 2010).

Protection of key parts: ‘Those parts, if contaminated by infectious material, increase the risk of infection. In IV therapy, key parts are usually parts of equipment which come into direct contact with the infusate – for instance, needles, syringe tips, IV line connections or central line lumens’ (Rowley 2010).

Prior to accessing the CVC, the bung should be scrubbed using a scrubbing action for 30 seconds and then allowed to dry for 30 seconds (Pratt et.al. 2013)

Image used with written permission from the authors at Bristol Royal Hospital for Children,Bristol (obtained 28/09/2018).


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2.4.2. Aseptic Non Touch Technique (ANTT) for Intravenous (IV) Practice. A step by step guide

Remember:

Wash all work surfaces on a daily basis Clean all trays after each patient use

1. All watches and rings must be removed and the practitioner must be naked below the elbow.

2. Wash & dry hands thoroughly.

3. Put on a clean, disposable apron.

4. Clean tray inside and out, including the base.

5. Whilst the tray is drying, gather equipment required. Place to the side of the tray.

6. Alcogel or re-wash hands.

7. Put on non-sterile gloves. If contaminated at any time, remove, alcogel hands & put on a new pair of gloves.

8. Peel open syringe and needle packaging, without touching key parts (i.e. tip of syringe + needle hub) & connect together before placing in the tray.

9. Open 0.9% sodium chloride and flush & draw up as per guidelines. Attach label to identify & place syringe in tray.

10. Mix IV medication & draw up as per protocol. Label syringes.

ONLY HAVE IN YOUR TRAY WHAT YOU NEED TO GO TO YOUR PATIENT. THERE SHOULD BE NO WRAPPERS, EMPTY BOTTLES OR VIALS.

1. Go to the patient & expose IV access. If you touch patient/linen etc. then remove gloves & alcogel hands before applying clean gloves.

2. Using a scrubbing action, clean bung with a 2% chlorhexidine gluconate in 70% alcohol steret for 30 seconds and allow to dry for 30 seconds.

3. Connect syringe to bung.

4. It is not necessary to clamp off line in between pushes.

5. Administer IV medication as per medicines code.

6. Flush with appropriate solution between drugs.

7. Flush and lock off line as per guidelines, using positive pressure to lock off.

8. Clean bung with 2% chlorhexidine gluconate in 70% alcohol steret at the completion of any access procedure.

9. Dispose of all sharps and used equipment safely.

10. Wash and dry hands.

Use Sterile ANTT procedure for: Set up & connection of TPN, , insertion of Port needle, during bung changes, any IV activity for NICU patients, gastrointestinal patients on long term TPN, any

intervention with Haemodialysis/Apheresis catheters.


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2.4.3. Aseptic Non Touch Technique (ANTT) A step by step guide: For Anaesthetists Accessing IV Lines

1. All watches and rings must be removed.

2. Wash and dry hands thoroughly.

3. Acquire a clean tray & the equipment needed for drug administration.

4. Put on non-sterile gloves.

5. Peel open syringes and needle packaging, without touching key areas (i.e. tip of syringe + needle hub) and connect together before placing in the tray.

6. Draw up medications and flush as per guidelines.

ONLY HAVE IN YOUR TRAY WHAT YOU NEED TO GO TO YOUR PATIENT. THERE SHOULD BE NO WRAPPERS, EMPTY BOTTLES OR VIALS.

1. Go to the patient & expose and unclamp the line.

2. Using a scrubbing action, clean the bung with 2% chlorhexidine gluconate in 70% alcohol for 30 seconds then allow to dry for 30 seconds.

3. Administer medication, flush and lock off as per manufacturers guidelines, using positive pressure to lock.

4. Clean bung with 2% chlorhexidine gluconate in 70% alcohol swab at the completion of any access procedure for 30 seconds.

5. Dispose of all sharps and used equipment safely.

6. Wash and dry hands on completion of patient contact.

2.5. STERILE NON TOUCH TECHNIQUES

2.5.1. Surgical Non Touch Techniques should be used in:

All IV access in gastroenterology patients on long term Parenteral Nutrition (PN),

Neonatal Intensive Care Unit (NICU) and Haemodialysis patients The setup and connection of Parenteral Nutrition Removal and changing of bungs Accessing a Port-a-Cath with a non-coring needle(e.g Gripper) Repair of CVC Undertaking any prolonged procedure

2.5.2. Sterile Non Touch Technique example

A step-by-step guide: Bung change - See table on next page


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2.6. ACCESSING A CENTRAL VENOUS CATHETER

2.6.1. Drug Administration Principles

2.6.1.1. Inform patient of procedure. 2.6.1.2. Follow ANTT principles. 2.6.1.3. Prepare and check drugs as per prescription, following manufacturers

and hospital guidelines. 2.6.1.4. Draw up appropriate flush and locking off solutions. 2.6.1.5. Access the catheter and assess function, checking for blood return and

ease of flushing. 2.6.1.6. Syringes of less than 10ml should not be used to access a CVC as

the high flush pressure generated by syringes smaller than 10ml can rupture the line.

2.6.1.7. Administer drugs as per manufacturers and RCHT Medicines Policy with additional information available from MEDUSA online database

2.6.1.8. Flush and lock catheter as per guidelines (see section 2.11.3). 2.6.1.9. Document drug administration in drug chart, fluid charts and patients

notes as necessary.

2.6.2. Blood Sampling Principles

2.6.2.1. Inform patient of procedure. 2.6.2.2. Follow ANTT principles.

1. All watches and rings, except a wedding band, must be removed

2. Wash and dry hands thoroughly

3. Put on a clean, disposable apron

4. Gather equipment together: 2 x sterile gloves, sterets (2% chlorhexidine

gluconate in 70% alcohol), sterile gauze, syringe, needle, 0.9% Sodium Chloride,

new MicroCLAVE bungs


6. Open sterile gloves and use inner wrapping as a sterile field

7. Drop gauze, steret, bungs onto sterile field taking care not to contaminate during

procedure

8. Put on sterile gloves without contaminating sterile field, draw up saline and prime

bungs

9. Go to patient and expose line

10. Ensure all lumens are clamped


12. Put on new sterile gloves

13. Hold lumen with gauze to stabilise

14. Clean connection area between lumen and bung with steret

15. Remove old bung using steret or gauze

16. Clean luer lock area at end of lumen with new steret and allow drying

17. Connect new bung securely

18. Dispose of used equipment safely


20. Document procedure in patients notes



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2.6.2.3. Draw up appropriate flush and locking off solutions. 2.6.2.4. Turn off any ongoing infusions and clamp all lumens of CVC. 2.6.2.5. Access the catheter and assess function, checking for blood return and

ease of flushing. 2.6.2.6. If catheter can be flushed, but it remains difficult to aspirate blood:

reposition patient eg raise arms, rotate head and neck, move from side to side or ask patient to breathe deeply and cough (see Occlusion Guide: Section 2.11.4 if further intervention required).

2.6.2.7. For blood cultures only: withdraw blood from each lumen place in blood culture bottles (take care not to contaminate sample or blood culture bottles). Ensure culture bottles are labelled with which lumen the sample was taken from.

2.6.2.8. Change bung(s) prior to flushing. 2.6.2.9. For antibiotic levels and clotting samples: flush lumen with a minimum

of 5ml 0.9% Sodium Chloride using a pulsating push-pause action then withdraw 5ml of blood for discard. Then withdraw required volume for blood sample

2.6.2.10. For all other blood samples. 2.6.2.11. Withdraw 3-5ml (depending on size of lumen) of blood and discard

syringe. 2.6.2.12. The discard blood should not be replaced back into the patient unless

clinically indicated (i.e. frequent blood sampling or a very small patient) due to the risk of infection or reinfusion of a clot. A clear technique on how to reduce these risks should be demonstrated.

2.6.2.13. Withdraw required amount of blood for test sample. 2.6.2.14. Flush lumen with 5-10ml of 0.9% Sodium Chloride using a pulsating

push-pause action. 2.6.2.15. Lock off with a positive pressure technique. 2.6.2.16. Gently agitate blood syringe to mix sample well. 2.6.2.17. Put blood sample in appropriate blood tube being careful to provide an

adequate volume. 2.6.2.18. Check patient details and label samples at patient’s bedside.

2.6.3. Set Up and Administering Parenteral Nutrition (PN) Principles 2.6.3.1. Guidance and competency can be found in Clinical Guideline for Total

Parental Nutrition in Paediatric patients from 4 weeks to 16 years, RCHT –Documents library or sisters shelf

2.6.3.2. Ensure patient and carers understand the indications and risks of PN 2.6.3.3. PN of greater than 12.5% glucose concentration must only be

administered via a central venous catheter 2.6.3.4. Check PN with prescription and patient, ensuring PN is the correct date. 2.6.3.5. If patient has a double lumen CVC there should be one lumen designated

for PN (Pratt et.al. 2013). 2.6.3.6. Set up and administer to patient using a Sterile Non Touch Technique 2.6.3.7. All infusion rates must be checked independently by two nurses. 2.6.3.8. Hospital patients should have routine monitoring of weight, fluid balance,

blood glucose, electrolytes, liver function, full blood count and coagulation.

2.6.3.9. Document start of PN in fluid prescription chart. 2.6.3.10. If the PN administration set is disconnected from the patient’s catheter at

any time the PN and giving set should be discarded. PN infusion should never be restarted once disconnected.

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2.7. INFUSION EQUIPMENT

2.7.1. MicroCLAVE Bungs/Needle Free Devices

2.7.1.1 MicroCLAVE needle free device is a non-sharps system which enables direct syringe and giving set connection, whilst maintaining a closed system.

2.7.1.2 Prior to accessing, the bung must be decontaminated by scrubbing for 30 seconds with a 2% chlorhexidine gluconate in 70% alcohol steret and then allow to dry.

2.7.1.3 On completion of any accessing procedure the bung should be cleaned with a 2% chlorhexidine gluconate in 70% alcohol steret for 30 seconds and then allow to dry. This is to ensure the bung access area is clean and no residual blood or drug particles remain.

2.7.1.4 MicroCLAVE bungs should be changed weekly or every 600 actuations, whichever comes first.

2.7.1.5 Weekly changes for CVC bungs need to be documented in the patient’s notes.

2.7.1.6 MicroCLAVE bungs are not compatible with glass prefilled syringes. If treatment is required using a glass syringe bungs should be removed or an adaptor connection used.

2.7.1.7 See section 2.5.2 bung change procedure.

2.7.2. Administration Sets and Add On Devices

2.7.2.1. Intravenous giving sets in continuous use which remain connected to the patient, should be changed every 96 hours (Pratt et.al. 2013, RCN 2016).

2.7.2.2. Intravenous giving sets used for intermittent drug administration which remain connected to the patient should be changed every 24hours (RCN 2016)

2.7.2.3. Exceptions to this are blood products (maximum of 12 hours) and Lipid emulsions (24 hours), due to increased infection risk (RCN 2016).

2.7.2.4. Setup date and time labels must be applied to ensure administration sets are changed at the correct time (RCN 2016).

2.7.2.5. More frequent changes are necessary if contamination is suspected or the integrity of the infusion system has been compromised (INS 2016).

2.7.2.6. Intravenous giving sets should be discarded once disconnected from the patient (RCN 2016).

2.7.2.7. Intravenous giving sets should be changed using ANTT and following manufacturer’s recommendations.

2.7.2.8. Only recommended giving sets should be used in electronic infusion devices.

2.7.2.9. Changes of any add on devices such as filters and extension sets should coincide with the changing of the administration set (RCN 2016).

2.7.3. Filters

Specific sized filters may be recommended for administration of certain medications or blood products.


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2.8. DRESSINGS

2.8.1. See device specific guidance: Hickman (section 2.13), Ports (section 2.14), Haemodialysis and Apheresis Catheters (section 2.15) and PICC’s (section 2.16).

2.8.2. Transparent, semi-permeable, self-adhesive, sterile dressings are recommended to dress the CVC to enable observation of the exit site (Pratt et.al. 2013).

2.8.3. However sterile gauze type dressings may be used if there is bleeding or oozing post insertion or for patients who are allergic to a standard dressing (Pratt et.al. 2013).

2.8.4. When gauze dressings are used the exit site and dressing must then be assessed and changed daily (CDC 2011).

2.8.5. The CVC and dressing should be inspected at least once every shift and the dressing replaced weekly or if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016 & CDC 2011).

2.9. BATHING AND SHOWERING 2.9.1 General

Tunnelled CVC’s are held in position by tissue growth into a cuff under the skin. This cannot be relied upon for approximately four weeks.

Dressing and securement devices are therefore important in holding the CVC securely in place during this time and should be kept dry.

For the first four weeks, washing is best done sitting in a shallow bath, avoiding splashing by the child or and other children.

After four weeks normal showering or bathing can be resumed, but neither the CVC nor the exit site should be submerged under the water for any length of time.

After showering or bathing ensure that exit site and dressing is clean and dry.

2.9.2 Bathing

2.9.2.1. The exit site and bung area of the CVC should be kept out of the water during bathing.

2.9.2.2. Do not allow the child to submerge or soak in the bath. 2.9.2.3. If the dressing becomes wet or loose during bathing the exit site should be

dried with sterile gauze and a new dressing applied.

2.9.3 Showering 2.9.3.1. Showering can resume 4 weeks after insertion of the tunnelled CVC, once

the exit site is healed. 2.9.3.2. The dressing should be removed prior to showering. 2.9.3.3. Stand under clean running water from the shower. 2.9.3.4. It is not recommended to use soap or shower gel directly around the exit site. 2.9.3.5. After showering, dry the exit site with sterile gauze. 2.9.3.6. Apply a new dressing.

2.9.4 Bathing or Showering with a Port

2.9.4.1. Showering is not recommended for ‘Ports’ which have been accessed with a non coring needle (eg gripper) in situ.

2.9.4.2. For Ports accessed with a needle it is advisable to wash in a shallow bath taking care not to wet the Port or dressing.

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../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/amukusca/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/amukusca/AppData/Local/Microsoft/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/WHOK774Z/current%20work/Study%20day%20April%20KB/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/saegenschnitterw/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/YR94QXVL/15.0%20TOTALLY%20IMPLANTABLE%20INTRAVENOUS%20DEVICES%20(‘PORTS’)

../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/amukusca/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/amukusca/AppData/Local/Microsoft/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/WHOK774Z/current%20work/Study%20day%20April%20KB/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/saegenschnitterw/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/YR94QXVL/18.0%20%20Care%20of%20Short%20Term%20Central%20Venous%20Catheters%20(CVC’s)%20on%20Wards%20within%20Bristol%20Royal%20Hospital%20For%20Children%20(BRHC)

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2.10 SWIMMING 2.10.1. Swimming is not recommended for patients with most CVC’s due to the risk

of infection unless a specially design dry suit is used. 2.10.2. Patients with a Port can swim as long as the Port is not accessed.

2.11 CVC PATENCY

2.11.1 Maintaining Catheter Patency

2.11.1.1. Guidelines recommend routine flushing of CVC’s to promote and maintain catheter patency and prevent mixing of incompatible medications and/or solutions (RCN 2016). See chart for recommended frequency and lock solution (section 2.11.3).

2.11.1.2. The flush technique should involve pulsated push-pause action to create turbulence within the catheter lumen, removing debris from the internal catheter wall (RCN 2016).

2.11.1.3. When locking the CVC between uses a positive pressure technique should be used in order to prevent reflux of blood into the catheter (RCN 2016).

2.11.1.4. Syringes smaller than 10ml should NOT be used due to the risk of catheter damage from excessive pressure (RCN 2016).

2.11.2 Lock Solutions Guidance

2.11.2.1. On completion of an infusion, blood sampling or drug administration 0.9% Sodium Chloride should be used to flush the lumen using a pulsated push-pause.

2.11.2.2. For CVC lumens which are accessed 8 hourly or more 0.9% Sodium Chloride can be used as the lock solution using a positive pressure technique.

2.11.2.3. For CVC lumens used less frequently than 8 hourly or if there is a concern about maintaining patency a heparin lock solution is recommended to lock the catheter using a positive pressure technique.

2.11.2.4. The strength of Heparin prescribed is dependent on the type of CVC (see chart below)

2.11.2.5. Be aware of the POTENTIAL ADVERSE EFFECTS ASSOCIATED WITH HEPARIN USE e.g. bleeding complications, allergic reactions and autoimmune-mediated heparin induced thrombocytopenia (Pratt et. al. 2013)

2.11.2.6. Heparinised solution must be prescribed and each administration documented in the patients medication chart.

2.11.3 Recommended frequency of flush and lock procedure

Line Type of lock Concentration Volume of the lock solution

Minimum Frequency of Flush/Lock

Hickman, Cook & Broviac

Heparin Sodium Flushing Solution

10 units/ml (INSP 2011)

3ml Weekly

Groshong 0.9% Sodium Chloride

- 5-10 ml Weekly

‘Ports’ Heparin Sodium Flushing Solution

100 units/ ml (INSP 2011)

4-6 ml Monthly

Haemodialysis and Apheresis lines

Refer to BRHC Guideline: Renal & Non-renal

Caution: Locking solution must be aspirated prior to

Refer to volume on device

Minimum Weekly



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patients- via sisters shelf Oncology folder, portal link.

accessing line

PICC Size 1Fr 2Fr neonatal

Requires a continuous infusion to maintain patency (1ml/hr) Do not lock – requires constant flow

PICC Size 3Fr or greater

Heparin Sodium Flushing Solution

10 units/ ml 2-3ml Weekly

Short term CVC

0.9% Sodium Chloride

3-10ml 6 hourly

2.11.4 Management of Persistent withdrawal Occlusion (PWO) or Blocked CVC.

This algorithm is to be used when: There is persistent withdrawal occlusion (PWO), an inability to infuse/flush fluid or

sluggish flow through the catheter.

CHECK FOR MECHANICAL OBSTRUCTION Inspect line closely (remove dressing if required). Check for kinks or twists in the line.

Adjust line position if required. Ask patient to change position, breathe deeply, cough then re-assess line.

IF FUNCTION RESTORED EXIT POLICY

Lumen feels stiff

when flushing

Complete

occlusion remains

Ability to flush line but unable to

withdraw fluid/blood.

Instill prescribed Urokinase

5000units/ml via the push lock

technique (section 2.11.8)

Able to flush, withdraw blood,

exit policy

Unable to

withdraw blood

Repeat Urokinase lock via push lock technique

(section 2.11.8).

Consider a Alteplase lock (section

2.11.11)

Attempting milking procedure with 0.9% sodium chloride (section

2.11.6)

Complete

occlusion remains

Instill prescribed Urokinase 5000units/ml via the milking procedure (section 2.11.7) or the 3 way tap method (section 2.11.9), leave in situ

for 1 hour.

Complete occlusion remains

Repeat urokinase, consider alternating

techniques

Complete

occlusion remains

Consider Alteplase lock

(section 2.11.11).

If drug or lipid occlusion suspected

consider Ethenol treatment.

Discuss with Pharmacist

and/or nutrition team for protocol

Unable to

withdraw blood

Unable to withdraw blood

Discuss with medics, consider x-

ray, if new line inform surgeons. Then document

plan and outcome

Complete occlusion remains



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2.11.5 Use of Urokinase to manage CVC occlusions.

2.11.5.1. Urokinase will only work on blood related occlusions. It is of no use if the CVC lumen occlusion is due to drug precipitate.

2.11.5.2. If unable to aspirate and remove Urokinase lock, try to flush the lumen with 0.9% Sodium Chloride and then re-assess patency.

2.11.5.3. Urokinase is eliminated rapidly from the circulation by the liver with a half-life of up to 20 minutes, therefore there is not recognised benefit for locking the lumen with Urokinase for an extended period of time such as 24hours.

2.11.5.4. The push lock technique is recommended whenever practical. If a lock of Urokinase is used reassessment can be done after 20 – 60minutes.

2.11.5.5. Urokinase should be restricted to hospital use only. Adequate diagnostic and monitoring techniques should be available, therefore administration or removal of Urokinase lock solutions should not be carried out in the community (Syner-KINASE® : 2015)

2.11.6 Milking technique with 0.9% Sodium Chloride to manage a CVC occlusion

2.11.6.1. Draw up 3ml 0.9% Sodium chloride into a 10ml Leur Syringe.

2.11.6.2. Using ANTT connect the leur syringe to the occluded CVC lumen

2.11.6.3. Unclamp the lumen

2.11.6.4. Draw back with the syringe to 6 or 7ml on the syringe.This will create a vacuum within the CVC lumen

2.11.6.5. Let go of the syringe plunger

2.11.6.6. Draw back with the syringe to 6 or 7ml on the syringe


2.11.6.8. Repeat this procedure rapidly for a minute.

2.11.6.9. Attempt to flush lumen.

2.11.6.10. If lumen remains occluded, repeat the draw back – let go milking procedure multiple times

2.11.6.11. Re-assess lumen function after 5 minutes of draw back – let go milk procedure.

2.11.6.12. Continue to repeat the above procedure until catheter function returns.

2.11.7 Milking technique with Urokinase to manage a CVC occlusion

2.11.7.1. Draw up 5000units Urokinase in 1ml 0.9% Sodium Chloride into a 10ml Leur Syringe.

2.11.7.2. Using Sterile ANTT remove bung from occluded lumen and connect the leur syringe

2.11.7.3. Unclamp the lumen

2.11.7.4. draw back with the syringe to 6 or 7ml on the syringe. This will create a vacuum within the CVC lumen


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2.11.7.6. Draw back with the syringe to 6 or 7ml on the syringe


2.11.7.8. Repeat this procedure rapidly for a minute.

2.11.7.9. Attempt to inject the Urokinase into the lumen.

2.11.7.10. If lumen remains occluded, repeat the draw back – let go milking procedure multiple times until some of the Urokinase has been instilled in the lumen.

2.11.7.11. Clamp the lumen, remove the syringe and place a cap on the lumen end.

2.11.7.12. Wait for a 1-2 hours and then assess lumen patency

.

2.11.8 Push Lock Technique

The Push Lock Technique

Mix Urokinase (syner-KINASE only) with 0.9% sodium chloride to fill lumen volume (section 2.11.10) add 1.5mls

Time 0 minutes Lock lumen with lumen volume + 0.5mls

Time + 10 minutes Push 0.5mls solution into the lumen

Time + 20 minutes Push 0.5mls solution into the lumen

Time + 30 minutes Aspirate lumen

Syner-Med (2015) Solutions for catheter management .

2.11.9 Procedure to be taken when unblocking a totally occluding catheter using Urokinase and a three way tap

Please note that UROKINASE will only work on blood related occlusions. It is of no use if

the line occlusion is due to drug precipitate.

Equipment Needed: Dressing pack Sterile gloves

3 x 10mL luer lock syringes 3 way tap

3 x Blue needles 0.9% Sodium Chloride for dilution

Urokinase 10,000 units 2% chlorohexidine gluconate in 70% alcohol steret

Bung or Cap


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Procedure 1) Explain the procedure to the patient. 2) Wash hands and prepare equipment. Ensure that a doctor prescribes the Urokinase. 3) Open the dressing pack. Tip needle, syringe, sterets and 3-way tap onto sterile field.

Place vial of Urokinase & 0.9% Sodium Chloride outside the sterile field. 4) Wash hands again, put on sterile gloves and draw up 2mLs of 0.9% Sodium Chloride

into one of the syringes.

5) Reconstitute the 10,000 units of Urokinase with the 2ml 0.9% Sodium Chloride. Draw

up 1mL of the Urokinase solution (5,000 units) into syringe. Prime 3- way tap with Urokinase.

6) Clean bung and lumen junction with a 2% chlorhexidine gluconate in 70% alcohol steret for 30 seconds and then allowed to dry , remove bung and attach primed 3-way tap to blocked lumen (see diagram)

How to instil urokinase into an occluded peripherally inserted central catheter

7) Attach the syringe containing 1ml of the reconstituted Urokinase to one access point of

the 3- way tap and the empty syringe to the other point. 8) Turn the off tap to the Urokinase – filled syringe and gently pull back on the empty

syringe to create a vacuum. Keeping the pull pressure on, turn the off switch to the empty syringe and a small amount of Urokinase will then be drawn into the line. Remove the empty syringe and expire air.

9) Repeat this procedure every 5 minutes or until all the Urokinase is inserted into the

line. This can take up to 20 minutes to complete. Once all the Urokinase is inserted, label the line clearly with date and time of insertion and leave in the line for as long as possible, preferably overnight.

10) When attempting to use the line again, first try to withdraw blood back to check for

accurate positioning of the line and to remove any surplus Urokinase.


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11) Dispose of equipment as per hospital policy, wash hands and document in the patient’s notes.

2.11.10 Volumes Of Urokinase or Alteplase

Recommended lumen volumes for Urokinase and Alteplase locks

Catheter Dilution & amount to push

SINGLE LUMEN HICKMAN 4FR DUAL LUMEN HICKMAN 7.0FR

5,000 units in 1ml 0.9% sodium chloride 1ml into each lumen

DUAL LUMEN HICKMAN 9.0FR OR GREATER

BLUE LUMEN 5,000 units in 1.6ml 0.9% sodium chloride, YELLOW LUMEN 5,000 units in 2.1ml 0.9% sodium chloride to fill

IMPLANTABLE PORTS 5,000 units in 2ml 0.9% sodium chloride push 2ml into Port

Cook PICC 3 or 4Fr 5,000 units in 1ml 0.9% sodium chloride 1ml into each lumen

Short Term CVC 5,000 units in 1ml 0.9% sodium chloride insert 0.3mL into lumen

2.11.11. Alteplase Lock Guidance for CVC’s

2.11.11.1. Ensure Alteplase is prescribed for management of CVC occlusion as 1mg/ml to instill the volume indicated for each lumen plus 10%. Therefore for a lumen volume of 1ml the prescription should be for 1.1ml Alteplase lock of 1mg in each ml.

2.11.11.2. Gently mix 2.2mls of water for injection into a vial of Alteplase 2mg. Each vial contains 2.2mg which will provide a solution of 1mg/1ml.

2.11.11.3. Withdraw the prescribed volume of Alteplase for each lumen.

2.11.11.4. Using ANTT instill Alteplase into each lumen

2.11.11.5. After 30minutes of dwell time, assess the CVC function by attempting to aspirate blood

2.11.11.6. If unable to aspirate blood continue Alteplase lock for a total dwell time of 120minutes.

2.11.11.7. Assess CVC function

2.11.11.8. If unable to aspirate blood instill second dose of Alteplase and reassess following the guidance above.

2.11.11.9. If unable to aspirate blood after 120 minutes dwell time for second dose of Alteplase flush lumen with 0.9%Sodium Chloride and reassess function.

2.11.11.10. If CVC patency has not been resolved discuss next steps with medical staff.

Boehringer Ingelheim (2016) Actilyse Cathflo 2mg (alteplase) rt-PA for venous catheter occlusion.


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2.12. Use of CVC’s in Radiology

2.12.1. The standard Ports that are placed are “non-power” Ports and are only rated to a maximum pressure of 30psi. This means that they should not be used for Power injection of contrast.

2.12.2. However, the patient with a Port and non –coring needle (e.g. Gripper) in situ can safely undergo MRI as these devices are rated as MRI Safe. (www.smiths-medical.com), Vygon (2016)

2.12.3. Hickman lines can be used to give intravenous contrast as long as the maximum safe flow-rate is not exceeded.

2.12.4. Generally flow rate should not exceed 2ml/sec and total dose of 2ml/kg.

2.12.5. It is critical to check that no clamps are closing the line to be used before starting the injection.

2.13. Hickman Catheters

2.13.1 General 2.13.1.1. Only staff or patients/carers trained and assessed as competent in the

use of ‘Hickman Catheters’ should be involved in accessing and caring for these devices.

2.13.1.2. The size and the number of lumens of the Hickman Catheter may vary. Please refer to the surgical notes for a record of the specific brand and size of the CVC

2.13.1.3. Prior to discharge ‘Hickman Catheters’ A guide and competency pack for parents, patients and carers’ should be used to help the family understand about the Hickman Catheter, the daily assessment they should carry out and how to trouble shoot the problems which may happen.

2.13.1.4. A Safety Pack should be given to the patient/family prior to discharge along with training and assessment that they understand how to use it if required.

2.13.2 Hickman Safety Pack Contents

2 blue clamps

2 sterile bungs

Sterile gauze

A small and large sterile dressing

4 x 2% chlorhexidine gluconate in 70% alcohol sterets

A roll of 1” tape

A pair of non sterile gloves

2 chloraprep swabs

Written information on trouble shooting potential problems.

2.13.3 DRESSING, CLEANING AND SECURING THE CVC

Short term or Newly inserted long term CVC’s (the first month)

2.13.3.1. Following CVC insertion the original dressing should remain in place for no longer than 48 hours.

http://www.smiths-medical.com/


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2.13.3.2. A surgical dressing change procedure should be used until wound healing has occurred (for the first 28 days for long term CVC insertion), then an aseptic non touch technique (ANTT) should be followed.

2.13.3.3. Transparent, semi-permeable, self-adhesive, sterile dressings are recommended to dress the CVC to enable observation of the exit site (Pratt et.al. 2013). However sterile gauze type dressings may be used if there is bleeding or oozing post insertion or for patients who are allergic to a standard dressing (Pratt et.al. 2013).

2.13.3.4. When gauze dressings are used the exit site and dressing must then be assessed and changed daily (CDC 2011).

2.13.3.5. The CVC entry and exit site, skin tunnel and dressing should be inspected daily and the dressing replaced weekly or if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016 & CDC 2011).

2.13.3.6. If the exit site, skin and CVC under the dressing is damp or soiled, the exit site should be cleaned using non touch technique with a single use 2% chlorhexidine gluconate in 70% alcohol applicator e.g.Chloraprep for 30 seconds and then allowed to dry for 30 seconds.

2.13.3.7. During dressing change the exit site should be cleaned using sterile non touch technique with a single use 2% chlorhexidine gluconate in 70% alcohol applicator e.g.Chloraprep (Pratt et.al 2013), for 30 seconds and then allowed to dry for 30 seconds.

2.13.3.8. However routine cleaning of the exit site is not required for established tunnelled lines if they are visually clean.

2.13.3.9. For Long Term CVC’s the Nylon fixation sutures may be routinely removed after 4 weeks if:

The cuff is securely fixed within the skin tunnel

If the sutures irritate the skin or provide a focus for infection or debris collection.

If the suture is too tight and causing CVC occlusion.

2.13.3.10. Steri-strips, if used, should be removed after 4-7 days. 2.13.3.11. The condition of the exit site and skin tunnel and dressing change

procedures should be documented in the patient notes (RCN 2016).

2.13.3.12. Securing the Hickman

Securing the CVC is essential to prevent accidental dislodgement or removal of the CVC (If possible the CVC should be looped and secured to the chest wall with the dressing).

2.13.4 LOOP IT OR LOSE IT

2.13.4.1. Fixation devices such as StatLock or tape may reduce twisting & pull on the CVC and maintain stability.

2.13.4.2. Vests made out of surgifix or vest tops, may also help to secure and protect the line.

2.13.4.3. For long term CVC’s due to skin sensitivity and/or patient preference a dressing is not necessary once the CVC exit site is completely healed


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and the cuff incorporated (CDC 2011). However, the line should be well secured and kept clean and dry.

2.13.5 DAMAGE, ACCIDENTAL REMOVAL OR REPAIR

2.13.5.1. Accidental Removal

Pressure should be applied to the original entry scar and the exit site in order to stop bleeding.

The patient should be assessed by the doctor on call and current treatment reviewed.

Documentation should be made within the patient’s notes and a trust Datix report completed.

2.13.5.2. Damage to a CVC

A CVC safety pack should be with the patient at all times.

Plastic clamps should be applied proximal to the damaged area of the CVC, if only surgical clamps are available protect the CVC from damage by wrapping sterile gauze around the CVC prior to clamping.

A sterile dressing should be applied to the area of damage to protect it until the line can be assessed for repair.

2.13.5.3. Repair of a CVC

Long term CVC’s found to be split, leaking or damaged may be able to be repaired.

Ideally repair should be done within 24 hours to reduce the risk of infection.

Senior medical and nursing staff caring for the patient should be involved in the decision as to whether a repair is worthwhile. Factors to consider are;

Not all repairs work, there is approximately a 50% success rate.

Are both lumens working or is one or both blocked?

Is the leak, split or damage within 5cm of the exit site or double lumen Y junction? If so a repair should not be carried out.

Does the patient still require a long term CVC for treatment or would temporary peripheral access be adequate?

Can the patient’s treatment be managed with peripheral access for at least 24 hours while the repair adhesive sets?

Is a skilled and competent person available to do the repair?

Do we have a repair kit of the correct size?

Only members of staff who are trained and assessed as competent can carry out CVC repair-contact CLIC Unit.

Consult with the Vascular surgical registrar on call if there is no trained staff from within the clinical speciality.

Hickman Line repair kits are kept on the CLIC Unit.

Documentation should be made within the patient’s notes and a trust datix report completed.


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2.14. TOTALLY IMPLANTABLE INTRAVENOUS DEVICES (‘PORTS’)

2.14.1. General 2.14.1.1. Only staff or patients/carers trained and assessed as competent in the

use of ‘Ports’ should be involved in accessing and caring for these devices.

2.14.1.2. ‘Ports’ are produced by a range of manufacturers. The size and

material the ‘Port’ is made from will vary. Please refer to the surgical notes for a record of the specific length and make of the patient’s ‘Port’.

2.14.1.3. Patient with a Port and non –coring needle(e.g Gripper) in situ can safely undergo MRI as these devices are rated as MRI Safe- check with MRI department. (www.smiths-medical.com) (www.vygon.co.uk)

2.14.1.4. Patients/families should be trained in safe care and assessment of the ‘Port’ for a. Cystic Fibrosis patient and b. Oncology patient.

2.14.1.5. A ‘Port’ Kit should be given to the patient/family prior to discharge. This includes all the equipment necessary to access the device in an emergency.

2.14.1.6. ‘Ports’ should be flushed and locked with 4 mL Heparin Sodium (100units per ml) at least monthly as per manufacturer’s instructions (see Section 2.11.3).

2.14.1.7. A non- coring needle(e.g. Gripper) should be used to access the Port. The Port needle is changed weekly if ongoing access is required.

2.14.2. How to Access – see next page

http://www.smiths-medical.com/

http://www.vygon.co.uk/

http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5823&f=6ResourcesHowToLookAfterYourPort-1.pdf



http://nww.avon.nhs.uk/dms/Download.aspx?r=1&did=5824&f=7ResourcesPortKitContents-1.pdf


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Continued on next page

How to access a port-a-cath


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7. Access the port

8. Confirm correct position by assessing function – check for blood return if possible and ease of flushing

9. Secure port with IV3000 dressing

10. Aspirate blood/administer fluids and/or drugs then flush with saline and heparin when not in use

11. To de-access: remove dressing, immobilise port and ‘heparin lock’ with positive pressure. If possible, use two nurses

Key Points: Sterile procedure Heparin 100 unity/ml – 4mls Can be left accessed for up to 7

days Resources on DMS Ports – A guide and

competency pack for patients, parents and carers within Paediatric Oncology

Guidelines for the use of ports – CF team

Central venous catheter guidelines for paediatrics

Record of competencies achieved for accessing and managing patients with ‘ports’

Photographs taken by Amanda Searle, Practice Development Nurse, RCHT

2.14.3 Trouble Shooting

2.14.3.1. Judging port needle length

Ask the family

Review patient’s surgical notes and documentation of previous access

Based on size of child, how much tissue over port area

Remember the needle length required can change over time as the child grows

2.14.3.2. If port does not bleed back:

Not all ports will bleed back, ask the patient/family about the port and what is normal


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If the Port usually bleeds back, consider;

o Flushing the port with a minimum of 10mls 0.9% Sodium Chloride. If the port is able to flush without resistance or visible swelling – re-check for blood return. If still unable to aspirate blood consider Urokinase lock.

2.14.3.3. If the port does not bleed back, you are unable to flush, there is resistance or unresolved and repeated occlusion alarms consider:

You may have selected the wrong needle size, check the patient records for previous needle size selected. Attempt re-accessing with a longer needle.

The port needle is in the wrong position. Attempt to re-access as per 2.14.1 with a new needle.

Ask another trained member of staff to re-access

2.14.3.4. If the needle has been pulled

Reassess needle position visually and by aspiration of blood and flushing

2.14.3.5. If there are occlusion alarms during infusion

Reassess needle position visually, by aspiration and flushing

2.14.4 Documentation

A clear record of port needle access, removal procedure, size of gripper and patency should be recorded in the patients notes.

2.15. HAEMODIALYSIS AND APHERESIS LINES 2.15.1. There are two main types – those for short term use (Acute lines) and those

for long term use (Chronic Lines).

2.15.2. The acute lines are usually placed by percutaneous non-tunneled technique by an anaesthetist under general anaesthesia . The chronic lines are tunneled surgically under general anaesthetic.

2.15.3. A selection of the differing types and sizes of acute and chronic lines are kept on the renal unit (ward 37 BRHC). The hemodialysis nurses choose an appropriate line from a selection of several different sizes and types depending on the needs of the patient, enabling the surgeon to have a choice. These catheters will accompany the patient to theatre.

2.15.4. Patients with Acute Vascaths should not leave the hospital due to the difficulty in securing the Vascath and the risk of bleeding or air embolism if the Vascath became dislodged however in extenuating circumstances Vascaths may need to be managed at RCHT.

2.15.5. All patients (except for ward 37 BRHC) will have Alteplase (tissue-type Plasminogen Activator or TPA) used to lock haemodialysis catheters Refer to BRHC Guideline:

Renal & Non-renal patients- via sisters shelf Oncology folder, portal link.



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2.15.6. For patients on ward 37 Heparin 5000units/ml may be used for children older than two years. Alteplase is used for children below 2 years age All patients (except for ward 37) will have Alteplase (tissue-type Plasminogen Activator or TPA) used to lock haemodialysis catheters Refer to BRHC Guideline:

Renal & Non-renal patients- via sisters shelf Oncology folder, portal link

2.15.7. The supply of heparin 5000units/ml is restricted.

2.15.8. Additional education and training are required prior to competency assessment for the use of a Haemodialysis catheter. Any member of qualified nursing staff who has been assessed as competent in the use of Haemodialysis/Aphereisis lines may access the lines.

2.15.9. Following the insertion in theatre, the line will be locked off with Heparin 10units/ml. However due to their lumen size, there is a risk of blockage therefore to reduce the risk of blockage on return to the ward it is the responsibility of the nursing staff to remove the Heparin 10units/ml from the line and to “lock” the line with the lumen volume of prescribed Alteplase.

2.15.10. All line closures caps/bungs will be replaced with TEGO bungs.

2.15.11. Sterile ANTT should be used for any line access procedure.

2.16. PERIPHERALLLY INSERTED CENTRAL VENOUS CATHETER (PICC)

Definition and insertion

PICC stands for peripherally inserted central venous catheter. It is made from a soft, flexible catheter material consisting of either silicone or polyurethane (Cook, 2004). The catheter has a needleless injection cap attached to the hub end and may include a winged portion for help with attachment to the skin. Most PICC’s have a plastic clamp on the external section of the lumen however some PICC’s have internal values and do not have an external clamp. PICC’s can be inserted in theatre or may be inserted at the patient’s bedside using optimum sterile procedures. PICC lines are inserted into a peripheral vein and then carefully advanced upwards by way of the major veins of the upper arm or leg into the superior vena cava. Following insertion imaging is performed to confirm tip placement. Insertion documentation should include the make and size of catheter, any complications during the insertion procedure, tip location, the length of the PICC inserted, if the PICC has been cut to size and if it is safe to use. In some cases it is not possible to advance the PICC into the required central position. The final tip placement should be documented in the patient’s notes and all care and PICC management undertaken with the understanding that this is not a central line.



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For 1Fr (24G) or 2Fr (28G) PICC’s, prior to placement confirmation, patency should be maintained with a continuous infusion of 0.9% Sodium Chloride at 1mL/hr and the infusion pressure on insertion document as a future reference.

2.16.1 Maintaining Patency of PICC in RCHT Patency is maintained depending on the size of the PICC.

For 1Fr (24G) or 2Fr (28G) a continuous infusion is required to maintain patency. They should never be put on hold as this will lead to blockage. If a 1Fr or 2Fr PICC is used for a bolus medication the infusion should be restarted immediately after the PICC is flushed. The infusion pump pressure is usually high. The infusion pressure recorded on insertion should act as a guide. If the pump alarms with an occlusion pressure the PICC should be flushed. It is normal for the 1Fr or 2Fr PICC’s to be very stiff. If a line cannot be flushed is should be reviewed by a senior nurses or doctor. The CVC occlusion guidelines should be followed with early assessment to ensure the PICC has not become kinked or migrated. The 1Fr and 2Fr catheters have very small lumens and are not suitable for transfusing blood products or for aspiration of blood samples. For babies with 1Fr or 2Fr PICC a splint should be used to reduce the risk of blockage. For PICC lines 3Fr or greater patency guidance is as per other central lines. They may be locked off between access with 10units Heparin Sodium using a positive pressure technique.

2.16.2 Care of a PICC in RCHT

2.16.2.1. Securement of PICC

Post insertion where possible the PICC will be secured with a StatLock PICC securing device and this and the exit site will be covered by a sterile, transparent dressing. If there is no wing attachment on the PICC and a Statlock connot be used then steri-strips should be in place under the dressing to secure a loop above the exit site.

2.16.2.2. Assessment and documentation of PICC care

The CVC exit site and vein track should be inspected at least every shift for signs of infection ( i.e. redness, tracking, pain, discharge).

During intermittent drug administrations or continuous infusions hourly pump pressure levels and VIP scores should be documented on the fluid balance chart and used as part of the assessment for complications such as infection, leakage, infiltration or extravasation. Any concerns should be discussed with senior nurses and allocated medical /nursing paediatric teams, with assessment, care plan and any interventions documented in the patient notes.

2.16.3 Dressing a PICC in RCHT


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2.16.3.1. The dressing and StatLock PICC should be replaced weekly or earlier

if the integrity of the dressing is compromised e.g. if it becomes damp, loose or soiled (RCN 2016, INS 2016). A sterile, transparent dressing should be used to allow viewing of the exit site.

2.16.3.2. During the dressing change the exit site should be cleaned using a 2% chlorhexidine gluconate in 70% alcohol solution e.g. Chloraprep for 30 seconds and then allowed to dry for 30 seconds

2.16.3.3. During bathing care must be taken to avoid submerging the arm in water (some children may find it useful to protect the PICC line using a clean plastic bag or waterproof sleeve).

2.16.3.4. ANTT

For routine medications UHBristol ANTT procedure should be followed. Surgical asepsis is required for dressing change, bung change, TPN administration and any IV procedures for long term TPN patients e.g under the Gastroenterology Team.

2.16.4 Removal of the PICC line

2.16.5.1. Pre-Procedure

When no longer required the line is removed by trained nursing staff. Ask for advice / assistance from the Outreach Team or medical staff if this is a new procedure.

This can be undertaken on the ward, either at the bedside or in procedure room

Consider analgesia prior to removal

Gather appropriate equipment e.g. stitch cutters, adhesive remover, gauze, tape, occlusive dressing, clean gloves.

The procedure is done using Aseptic Non Touch Technique

If the child has prolonged clotting or is receiving heparin therapy the timing of line removal must be discussed with medical staff. Heparin may be stopped for a period of time prior to removing the line.

The child needs to have an explanation of what is about to happen given at a level suitable for his or her age. Parental presence may help to lessen the child’s anxiety (INS 2016)

2.16.5.2. Removal

Two nurses may be required to remove the catheter. One to ensure that the area where the catheter is sited is immobilised and one to remove the line.

Remove PICC line by holding the lumen at the exit site and gently pulling the catheter straight out parallel to the vein. Pull out short segments of catheter (3-5cm), pause, and continue in this manner until the PICC is finally removed.

If resistance is met, do not continue; redress the site and alert medical staff.

Warm, moist heat may be applied to promote relaxation of venous spasm , and repositioning the child with the arm perpendicular to the body which minimises bends to the catheter.

Examine catheter length and tip to ascertain that the catheter was removed intact (refer to documented length on insertion).


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Catheter tips sent to microbiology for culture are no longer routinely processed. Exceptions to this should be discussed directly with a microbiologist by the requesting doctor.

2.16.5.3. Post-Procedure

Once the catheter is removed, apply pressure at insertion site with gauze for a minimum of two minutes or until bleeding has stopped (RCN 2016).

A sterile occlusive dressing is placed over the insertion site for 72 hours to reduce the risk of air embolism (RCN 2016).

The wound should be assessed for signs of infection or bleeding following the catheter removal until healing occurs (RCN 2016).

3. Monitoring compliance and effectiveness

Element to be monitored

All elements of procedure.

Lead Oncology multi-disciplinary team.

Tool Audit and peer review process.

Frequency Annually

Reporting arrangements

Oncology multi-disciplinary team. Directorate audit and guidelines

Acting on recommendations and Lead(s)

Oncology multi-disciplinary team. Directorate audit and guidelines

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 6-12 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared

with all the relevant stakeholders

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2 Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/RoyalCornwallHospitalsTrust/OurOrganisation/EqualityAndDiversity/HumanRightsEqualityAndInclusion.aspx


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Appendix 1. Governance Information

Document Title Paediatric Oncology- Central Venous Catheter Clinical Guideline V3.0

Date Issued/Approved: March 2018

Date Valid From: December 2018

Date Valid To: December 2021

Directorate / Department responsible (author/owner):

Karen Berriman and Pip Bird Paediatric Oncology Team

Contact details: 01872 252891

Brief summary of contents

Clinical guideline for the supportive care and insertion of skin tunnelled catheters(Hickman lines) and totally implantable devices(Portacaths) in children and young people on the CLIC Unit at RCHT

Suggested Keywords:

Oncology Paediatric Child Blood count Home blood test

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: February 2018

This document replaces (exact title of previous version):

Clinical guideline for the supportive care and insertion of skin tunnelled catheters(Hickman lines) and totally implantable devices(Portacaths) in children and young people on the CLIC Unit at RCHT V2.0

Approval route (names of committees)/consultation:

Paediatric oncology MDT Directorate business and guidelines meeting

Divisional Manager confirming approval processes

Tunde Adewopo

Name and Post Title of additional signatories

Not Required


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Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name: Caroline Amukusana

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Paediatrics

Links to key external standards none

Related Documents:

Association of Anaesthetist of Great Britain and Ireland. Safe vascular access 2016. Anaesthesia 2016; 71: 573-585

Centre for Disease Control and Prevention (CDC) (2011) Guidelines for the Prevention of Intravascular Catheter-Related Infections.

Cook Medical Incorporated (2004): “Caring for Your PICC catheter; A patient guide”, Cook Incorporated, USA

Department of Health (2007), Saving Lives: High Impact Intervention No 1. Central venous catheter care bundle.

Hamilton, H. (2006) Complications associated with venous access devices: part two. Nursing Standard. Vol.20, no. 27, 59-65.

Infusion Nurses Society (INS) (2016) Policies and Procedures for Infusion Therapy: Neonate to Adolescent. Tizrapublisher

NICE (2014) Infection prevention and control. Quality Statement 5: Vascular Access Devices.

NICE. Healthcare associated infections: Prevention and control in primary and community care - Vascular Access Devices 1.4 https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices (accessed 14th March 2017)

Pratt, R., Wilson, J., Loveday, H.,Golsorkhi, M. Tingle, A. Bak, A. Browne, J. Prieto, J. and Wilcox, M.

https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#vascular-access-devices




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(2013) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospital in England. Journal of Hospital Infection

RCN. (2016) Standards for infusion therapy. RCN. London.

Rowley, S., Clare, S., Macqueen, S. & Molyneux, R. (2010) ANTT v2: An updated practice framework for aseptic technique. British Journal of Nursing. (IV Supp). Vol 19, no. 5.

https://www.smiths-medical.com/products/vascular-access/implantable-ports/portacath-portacathii-and-pas-port-power-pac-implantable-access-systems Accessed 26/1/18

Syner-Med (2015) Solutions for catheter management: Haematology-Oncology. Surrey.

Vygon (2016) Perfusafe 2 product information

Training Need Identified? As per oncology update study day.

https://www.smiths-medical.com/products/vascular-access/implantable-ports/portacath-portacathii-and-pas-port-power-pac-implantable-access-systems






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Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

Feb 12 V1.0 Initial Issue

Dr.N.Gilbertson-paediatric consultant Dr.K.Macdonald-Assosciate specialist Sue Turk-CLIC sargent outreach nurse

Sabrina Tierney-senior paediatric pharmacist.

Feb 2014 V2.0 Review and re format

Dr.K.Macdonald-Assosciate specialist Sue Turk-CLIC sargent outreach nurse Tabitha Fergus-Deputy ward manager format only

Sabrina Tierney-senior paediatric pharmacist

Feb 2018 V3.0 Re written as per standardised Bristol Children’s Hospital Guideline.

Karen Berriman CLIC sargent outreach nurse. Pip Bird Deputy ward manager.

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.


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Appendix 2. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Name of the strategy / policy /proposal / service function to be assessed Paediatric Oncology- Central Venous Catheter Clinical Guideline V3.0

Directorate and service area: child health

Is this a new or existing Policy?existing

Name of individual completing assessment: K.Berriman

Telephone: 01872252069

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

Set guidance for staff caring for children and young people with a central venous catheter.

2. Policy Objectives*

Set guidance for staff caring for children and young people with a central venous catheter.

3. Policy – intended Outcomes*

Standardised practice

4. *How will you measure the

outcome?

Audit and review.

5. Who is intended to benefit from the

policy?

Children and families

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups Oncology MDT Paediatric business meeting. Practice development.

What was the outcome of the consultation?

Guideline agreed.


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Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X No areas indicated.

Sex (male,

female, trans-gender / gender reassignment)

X No areas indicated.

Race / Ethnic communities /groups

X Any written information should be provided in a suitable format for the individual.

.

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

X Any written information should be provided in a suitable format for the individual.

Religion / other beliefs


Marriage and Civil partnership


Pregnancy and maternity


Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

x

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated.

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


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Signature of policy developer / lead manager / director K.Berriman

Date of completion and submission February 2018

Names and signatures of members carrying out the Screening Assessment

1. K.Berriman

2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site. Signed: Chris Warren Date: February 2018