INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure TITLE:

Percutaneous Introducer(Cordis), SLIC, Companion Kit, AVA Catheter, MAC, PICL - Care, Maintenance and Removal of

NUMBER:

CC 80-030

Effective Date:

February 2012

Page

1 of 20

Applies To:

Holders of the Interdisciplinary Clinical Manual

THIS IS A POST ENTRY LEVEL COMPETENCY FOR REGISTERED NURSES THAT REQUIRES ASSESSMENT OF COMPETENCY PRIOR TO PERFORMING TABLE OF CONTENTS Policy………………………………………………………………………………. Definitions…………………………………………………………………………. Guidelines A. General………………………………………………………………… B. Percutaneuous Introducer (CORDIS) Peripheral and Central…… C. SLIC……………………………………………………………………. D. Companion Kits………………………………………………………. E. PICL…………………………………………………………………… F. Advanced Venous Devices (AVA Catheter)………………………. G - MAC References……………………………………………………………….………. Related Documents…………………………………………………….……….. Appendix A ……………………………………………………………………….

2 2 4 4 7 8 9 10 11 11 12

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POLICY 1. The Safer Health Care Central Line Bundle requires that 1.1. the need for central lines be assessed daily and lines be removed as soon as possible 1.2. the insertion site be checked daily 1.3. central lines are inserted using maximum barrier precautions including full drape, gloves, cap, mask and gown. 1.4. hand hygiene be performed prior to insertion 1.5. there be optimal site selection and avoidance of the femoral site. Note: The subclavian is the preferred site with the jugular being the alternate) 1.6. use of Chlorhexidene 2% for skin asepsis 2. Removal of any of these lines {Percutaneous Introducer (Cordis), SLIC, Companion Kit, AVA Catheter, MAC, PICL)} requires a written authorized prescriber’s order. Rtn to ToC

DEFINITIONS Percutaneous Sheath Introducer FIGURE 1 and 2

Large bore IV that may be used to insert a PA catheter, SLIC, or companion kit. Note: Commonly referred to as CORDIS (brand name). Size #8.5 used at Capital Health Each cordis has a side port used for infusion. The cordis can be used alone with the rubber valve capped or with: the PA catheter (Critical Care only), companion kit, (any unit that can accept a percutaneous introducer), or SLIC (Critical Care only)

Single Lumen Infusion Catheter (SLIC)

A catheter designed to fit inside an introducer adding an additional lumen for infusion. This lumen is meant to be a short term solution to the need for another infusion port. If the patient requires continued use of multiple lumens after a 48-72 hr period then a multilumen catheter should be inserted. (Figure 3)

Companion Kits

Double and Triple lumen central lines that are designed to fit and lock inside an introducer .There are 2 types of companion kits: fixed length type (more common) – stocked in the ICU’s (3A and 5.2) and Operating Rooms (Figure 5) adjustable length (stocked only in the OR – rarely used elsewhere) (Figure 4)

Pulmonary Artery (PA) catheter

A multilumen hemodynamic catheter that may be inserted through the percutaneous introducer and used only in critical

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care areas. Note: PA catheters will not be discussed in this policy; refer to Care of the Patient with a Pulmonary Artery Catheter Hemodynamic Monitoring (CC 10-090). AVA Catheter (size #9)

A one piece unit which includes a cordis and a triple lumen catheter. The lumens are labeled proximal 1, proximal 2 and distal. If a PA catheter is inserted into the cordis valve, a specially designed sleeve is required to cover and secure to the PA catheter into the AVA catheter. A special obturator is needed to plug the rubber valve if the cordis port is not used and after the PA catheter is removed. A triple lumen central line is built into the design of this catheter and is treated the same as a regular multilumen. (Figure 8 and Figure 9)

PICL (Critical care only)

Peripherally Inserted Central Line - an antimicrobial and heparin coated catheter. Note - this is not a PICC-peripherally inserted central catheter) (Figure 6 and Figure 7)

Single Lumen Heparin Coated Central Line inserted through a Peripheral Percutaneous Sheath Introducer.

A 2 part kit designed to be used together .The introducer section(cordis) is a (size# 5) and has a side port which may be used for infusion. This is a peripheral introducer so inotropes pressors are not infused through this lumen. The other part is a stiff wire central line that is inserted through a plastic sleeve and advanced as far as the SVC. This portion may be used for CVP tracing /readings and central line infusions. When the central portion of this 2 piece kit is removed the peripheral introducer is removed also. The obturator designed to fit a central cordis is not meant to be used on the peripheral cordis. The side port to the peripheral introducer(cordis) may be saline locked

MAC:

Multi-lumen Central Venous Access Catheter (Antimicrobial Catheter) (Figure 10)

Rtn to ToC

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GUIDELINES A. GENERAL 1. Always practice the principles of aseptic technique, routine practices and sterile technique. 2. Add positive pressure devices to each lumen of these devices. 3. If a lumen is not in use, flush q 8h with a 10 mL turbulent flush technique (stop /start). 4. For blood sampling, temporarily shut off infusions into the affected port or all ports as deemed necessary. 5. Use a 10 mL syringe or larger for flushing irrigation, declogging, and blood sampling. 6. Whenever possible, treat the removal of an introducer, with a line inserted through the rubber valve as a one step procedure. 6.1If removal is performed as a 2 step procedure, take care to plug the rubber valve until the cordis is removed. 7. If ordered by the physician, send the tip for culture and sensitivity. B. PERCUTANEOUS INTRODUCER (CORDIS) PERIPHERAL AND CENTRAL

GUIDING PRINCIPLES AND VALUES 1. A central percutaneous introducer does not provide an accurate ―central venous pressure” reading since it is not positioned in the superior vena cava. It will provide a trend of patient fluid status. 2. The cordis may be inserted in either the jugular or subclavian vein and on occasion, the femoral or brachial vein (Refer to Policy statement #1.5). Rtn to ToC

PROCEDURE 1. INSERTION and MAINTENANCE 1.1. Always use positive pressure adaptors (CLC 2000’s- NEEDLE FREE SYSTEM adapters) on a cordis side port. 1.2. Connect the side port to an IV system if ordered. If no IV infusing then, saline lock/heparin lock the cordis side port q8hrs as per authorized prescriber’s order. Document on the MAR. Note: An authorized prescriber’s order is not required for saline flushes 1.3. Do not run an IV TKVO unless there is a authorized prescriber’s order. 1.4. As needed, use the cordis side port (central) to infuse any type of intravenous solution or blood product. Note: The cordis of the PICL is peripheral and can only accommodate infusions that can be given peripherally. 1.5. Seal the end of the cordis (rubber valve) with the sterile obturator cap (blue cap) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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unless there is a line into this introducer such as a SLIC, PA Catheter, or Companion Kit. Note: The PICL cordis does not come with an obturator cap and is designed to always have the hard wire inserted through it. 1.6. Use a triple lumen catheter for TPN administration. 1.6.1. If using the side port for TPN administration, designate the line as TPN only. 1.7. Use a stopcock on the cordis side port if lipids are administered. 1.7.1. If the Cordis is not used for lipids infusion, do not add a stopcock. 1.7.2. Ensure that the cordis side port has a CLC 2000 in place. 1.8. When removing the PA catheter companion kit/SLIC, use the the cordis cap to completely occlude the hemostasis valve; lock the cap in place. 1.9. Cover the cordis, cap for introducer (Blue Cap), and side port with an occlusive transparent dressing. Ensure that the dressing also covers the insertion site (Figure 1 ) 1.10. In the event that a cordis site is reused, insert a guide wire through the cordis. Remove the cordis and insert a non-tunnelled central venous catheter using the guide wire to place the line. (Refer Non-tunnelled Central Venous Access Catheter (multilumen) CC 80-015.) 1.10.1. Remove the guide wire and obtain an order to x-ray the line to confirm position. 1.11. If the cordis is used for infusion, inspect for desired flow rate q1h. 1.11.1. Check for security of dressing, correct position (by verifying patency) and secure stopcock connections q shift. 1.11.2. To check position aspirate for blood return q12 hours. After aspirating blood, flush the line with 10 mLs of normal saline. Place a CLC on the side port. 2. DRESSING 2.1. Change the transparent dressing once a week or more frequently if the dressing becomes loosened, damp or soiled. 2.1.1. If a gauze has been placed under the clear dressing due to oozing, change the dressing every shift. 2.2. Record the date on the transparent dressing and/or document the date of change in the kardex (care plan). 3. BLOOD SPECIMENS 3.1. If a blood specimen is required and no other access route is available, withdraw and discard 3 mLs of blood prior to obtaining the specimen. 3.2. If coagulation studies are to be drawn and the line is heparinized (Note: heparin requires an authorized prescriber’s order), withdraw and discard an additional 6 This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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mLs of blood to prevent problems with potential inaccurate results. (American Association of Critical Care Nursing Procedure Manual)

3.3. If drawing blood with a syringe, connect the syringe to a double connector to facilitate needle-free transfer into blood tubes. 4. ORDER TO REMOVE Rtn to ToC

4.1. As soon as central venous access is no longer required, obtain an order to remove the cordis and insert a peripheral venous access device. Recommendation of Safer Health Care Central Line Bundle. 5. REMOVAL 5.1. Place the patient in the flat/supine position or slightly Trendelenburg if tolerated(AACN 2010). Note: The VAP bundle does not recommended HOB elevation less than 10 degrees at anytime. 5.2. Remove occlusive dressing. 5.3. If applicable, remove sutures from sheath. 5.4. If the patient is conscious, instruct the patient to perform the Valsalva maneuver. 5.5. Withdraw the cordis. 5.6. Apply pressure for 5-10 minutes or until homeostasis is obtained. 5.6.1. Cover exit site with sterile Vaseline gauze. 5.6.2. Over this apply 2 by 2 gauze; cover with a transparent dressing. The longer the cordis is in place the greater the indentation in the vessel wall. This is an important factor to be aware of and to prevent air entry into the central circulation. It may require up to 24 hours for the vessel to recover its internal normal shape 5.7. Upon removal, inspect the cordis to make sure that the entire length has been withdrawn. The cordis is approximately 10 cm in length and is blunt at the end. {(See Appendix -Figure 1 page 8.(actual size)} 5.8. Document removal procedure.

C. SLIC POLICY Rtn to ToC

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1. Only nurses in ICU, CCU, CVICU, Burn Unit, and PACU are certified to perform the care, maintenance and removal of the SLIC.

GUIDING PRINCIPLES 1. After a PA catheter is removed or the patient has a Cordis in place a SLIC may be inserted through the hemostasis valve to allow for another infusion 2. The SLIC is a two-piece assembly consisting of an infusion catheter and a guide wire. During insertion, with the SLIC guide wire in place, the hemostasis valve is occluded preventing air entry and loss of blood through the valve. The SLIC is locked in place. 3. Upon removal of the guidewire, the SLIC permits access to the central venous circulation through the hemostasis valve. The SLIC is connected via a CLC to an infusing IV line.

PROCEDURE 1. SLIC Insertion (Physician Only) (Assist With) If the PA catheter is removed from the percutaneous introducer or extra access to the central venous system is required a SLIC may be added. The entire length of the SLIC assembly is inserted through the homeostasis valve/sheath assembly and locked in place. The physician: 1.1. Preps the hemostasis valve with Chlorhexidene 2% and allows to dry prior to inserting the SLIC. 1.1.1. The exposed portion of the valve on the top is to be included in the cleaning . 1.2. Inserts the SLIC. 1.3. Orients the slot in the hub with the locking pin on the assembly cap. 1.4. Slides the hub forward over the cap and twists. 1.5. Removes the inner guide-wire (obturator). WARNING: Cover the lumen during any manipulation to minimize the risk of blood loss or the introduction of air into the sheath. 1.6. Adds a CLC-2000 device (to limit central circulation exposure to air). 2. The RN connects an IV infusion to the CLC 2000. 3. SLIC CARE - NURSING RESPONSIBILITIES 3.1. Routinely examine the connection to minimize the risk of disconnection, air embolism, hemorrhage or exsanguination. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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3.2. Begin infusion through CLC 2000 as ordered. Note: An infusion must always be connected to the CLC 2000. 4. SLIC REMOVAL/RECAPPING of CORDIS Note: If an IV infusion is not required the SLIC should be removed. 4.1. Using sterile technique (gloves, mask) unlock slick from locking assembly and remove in one continuous motion. 4.2. Place a gloved finger over the valve opening to prevent air from entering the central circulation. 4.3. Apply an obturator cap. Rtn to ToC

D – COMPANION KITS (Refer to Definitions) PROCEDURE Note – only physicians insert companion double or triple lumen 1. Treat the companion double or triple lumen as for any other non-tunneled multi-lumen catheter. (See CC 80-015 - Non Tunnelled Central Venous Access Catheter – Multilumen.) 2. The cordis remains insitu after removal of Double or Triple Lumen companion kit 3. Removal 3.1. Using sterile technique (gloves, mask) unlock from locking assembly and remove in one continuous motion.(I,e,: double or triple lumen companion or double or triple lumen plus cordis) Or 3.2. After removing companion kit, 3.2.1. place a gloved finger over the valve opening to prevent air from entering the central circulation. 3.2.2. Apply an obturator cap.

E - PICL POLICY Rtn to ToC

1. Only nurses in ICU, Burn Unit, and PACU are certified to perform the care, maintenance and removal of the PICL. 2. PICLS are inserted by physicians - usually in the Operating Room during Neurosurgical or Ear, Nose and Throat surgeries. Burn patients also will often have PICLs inserted.

GUIDELINES This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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Note: The PICL is inserted through a plastic sleeve before entering the hemostasis valve and has the potential to migrate. 1. Migration of the inner central line may causes cardiac arrhythmias especially ventricular. If cardiac arrhythmias are noted, notify the physician to pull back the inner central line. 1.1. If problems with arrhythmias continue, consult with the physician and obtain an order to remove the 2 piece PICL. 3. Be aware that falsely elevated levels of sodium and potassium have been reported in blood specimens collected through heparin-coated catheters. 4. Do not tape the plastic sheath (sleeve). 5. Routinely inspect the PICL for desired flow rate, security of dressing, catheter position, and secure Leur –lock connection. As necessary, saline lock the PICL side port. 6. Upon arrival in the ICU obtain an order for an X-ray to verify position of the catheter. 6.1. Ensure that the X-ray is taken with the arm abducted at 90 degrees to the trunk as this allows a more accurate reflection of the catheter tip placement. 6.2. Proper placement results in positioning in the superior vena cava. 6.3. Once proper placement is confirmed, the PICL may be used for CVP monitoring and inotropes/pressor infusions as required 7. Restrict patient arm movement to minimize movement of the catheter tip. PROCEDURE 1. PICL REMOVAL 1.1. If the catheter has migrated, consult with the physician and obtain an order to remove. 1.1.1. Ensure both pieces of the PICL are removed. 1.2. Place the patient in the supine position. 1.3. Remove occlusive dressing. 1.4. If applicable, remove sutures from sheath. Unlock from the locking apparatus. 1.5. Remove catheter and sheath slowly pulling parallel to the skin. If the catheter is withdrawn before the cordis, occluded the hemostasis valve. Note: The peripheral cordis is never left in place. The size 8.5 caps used on a central introducer (cordis) do not fit a peripheral introducer. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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1.6. Apply pressure with a dressing until hemostasis occurs. 1.7. Inspect the catheter and sheath to make sure entire lengths have been withdrawn. 1.8. Document the procedure.

F – Advanced Venous Devices (AVA Catheters) (Size 9 F with 3 lumens, 11 cm. in length.)

POLICY Rtn to ToC

1. AVA catheters are stocked and inserted only in the OR's. 2. The multilumen part of the AVA catheter consists of a 3 lumen section labeled proximal 1, proximal 2 and distal; the lumens are to be treated as per CC 80-015 Non-tunneled Central Venous Access Catheter (multilumen) policy. 3. The IMCU is to carry the special obturator as ward stock; the ICU is to carry the special obturator and the special sleeve. 4. When the PA catheter is removed or if the rubber valve has never been used, the valve is to be sealed with the white obturator.(Figure 8)

G – MAC (Antimicrobial Catheter) POLICY 1. As per the manufacturer recommendation, the MAC is to be maintained in closely monitored environments and not on general nursing units.

GUIDING PRINCIPLES AND VALUES 1. With the MAC, there is a potential for a hypersensitivity reaction due to the antimicrobial coating 2. The catheter uses the same obturator cap as a regular cordis and the same sleeve that would be used with PA catheter insertion into the cordis. 3. There is a special triple lumen companion kit available for insertion into the cordis port.

PROCEDURE 1. Follow Section B {Percutaneous Introducer (Cordis) Peripheral and Central} for care and blood sampling.

REFERENCES Arrow, Percutaneous Sheath Introducer Product (Product Insert) see Arrow website for all This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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products Arrow, Product Insert for SLIC, Antecubital PICL, companion kits Arrow Multi-Lumen Central Venous Catheter Nursing Care Guidelines download from Arrow Canada website August 11, 2011. Edwards Life sciences website downloaded August 11,2011 Darovic, G., (2022) Ask the experts, Critical Care Nurse. 22(1)74-78. AACCN Procedure Manual, 2011,McHale-Wiegand,D.L.Elsevier,6th edition,St. Louis.

RELATED DOCUMENTS Policies CC 80-015 CC 10-090 Monitoring CC 80-021

Non-tunneled Central Venous Access Catheter (multilumen) Care of the Patient with a Pulmonary Artery Catheter - Hemodynamic Central Venous Access Device (CVAD) Umbrella Policy

Appendices Appendix A – Illustrations Rtn to ToC

***

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Appendix A Illustrations Figure 1 Percutaneous Introducer with obturator cap attached

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Figure 2 Percutaneous Introducer with obturator cap---not attached

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Figure 3 SLIC—SLIC lumen with guide wire removed

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Figure 4 Percutaneous Introducer with Variable length companion kit in place

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Figure 5 Percutaneous Introducer with Fixed Length Companion Kit

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Figure 6 PICL showing peripheral percutaneous introducer and central catheter going though plastic sleeve shown in Figure 4

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Figure 7 Plastic Sleeve for PICL Contamination Shield for PICL

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l

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Figure 8 AVA catheter

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Figure 9 Obturator plug

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Figure 10 MAC

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