Policies, Procedures, Guidelines and Protocols Document Details Title

Procedural Guidelines to care for the patient with a Central Vascular Access Device (CVAD)-Central Line or Peripherally Inserted Central Catheters (PICC)

Trust Ref No

1893-23653

Local Ref (optional) Main points the document covers

Guidance for care of patient with Central Line/PICC line in a Community setting.

Who is the document aimed at?

Staff in the Community Teams (Adults and Children) and Community Hospitals, DAART who care for patients with Central Line/PICC line.

Author

Cath Molineux/ Becky Salisbury/ Michelle Athersmith Approval process

Approved by (Committee/Director)

Clinical Policy Group

Approval Date

10/2/14

Initial Equality Impact Screening

NA

Full Equality Impact Assessment Lead Director

Steve Gregory

Category

Clinical

Sub Category Review date

10/2/17 Distribution

Who the policy will be distributed to

All Community Staff- Adults and Children’s Services

Method

Via DATIX and email Document Links

Required by CQC Required by NHSA Other Amendments History No

Date

Amendment

1

March 2014

Version 1

2 3 4 5

Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014

Contents 1 2 3 4 5

Introduction .................................................................................................................. 1 Purpose........................................................................................................................ 1 Definitions .................................................................................................................... 1 Duties ........................................................................................................................... 2 Principles of Care ......................................................................................................... 2 5.1 Prevention of Infection ........................................................................................... 2 5.2 Securement of device and dressings………………………………………………… 3 6 Maintaining a closed intravenous system………………………………………………… 3 7 Maintaining Patency ..................................................................................................... 3 8 Preventing Damage of a VAD and performing a repair………………………………….. 4 9 Consultation ................................................................................................................. 4 10 Dissemination and Implementation ............................................................................... 5 11 Monitoring Compliance ................................................................................................. 5 12 References ................................................................................................................... 5 13 Associated Documents ................................................................................................. 6 14 Appendices ................................................................................................................. 6

Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014

Shropshire Community Health NHS Trust

1. Introduction A Vascular Access Device (VAD) is a device that is inserted into either a vein or an artery via the peripheral or central vessels to provide for diagnostic (blood sampling) and or therapeutic administration of fluids, medications or blood products. There are a wide range of VADs; these guidelines will provide guidance on caring for a patient with a Central Venous Access Device (CVAD) or a Peripherally Inserted Central Catheter (PICC). Regardless of the type of VAD used the principles of care remain the same. More patients are being cared for in the community and community hospitals who are having therapy via a CVAD; the length of their course of treatment will vary from a few weeks to several months. Some may need their line flushing to ensure continued patency and others may need daily/weekly medication. Regardless of the treatment they receive the following principles of care are the same:

1.1    

To prevent infection To maintain a closed intravenous system with few connections to reduce the risk of contamination To maintain a patent device To prevent damage to the device and associated intravenous equipment

2 Purpose The purpose of these guidelines is to provide guidance to all Clinical staff in the Community Teams, Community Hospitals and Diagnostics Assessment and Access to Rehabilitation and Treatment (DAART), who care for a patient with a CVAD or a PICC line. This is to ensure that all care that is given is based on the principles of care outlined in these guidelines. Some patients may have had their CVAD inserted at a different acute trust and may be discharged with that Trust’s procedure and guidance. These guidelines give a sound basis to provide the care for a patient with a Central line/PICC line based on the Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty et al 2008) This can be accessed via the staff zone on the Community Trust’s website and follow the link www.rmmonline.co.uk

3 Definitions VAD

Vascular Access Device

PICC

Peripherally Inserted Central Catheter- a catheter that is inserted via the antecubital fossa veins (usually into the Basilica or Cephalic veins) and advanced into the central vein with the tip in the superior vena cava (SVC), usually the lower third. These are finer and more flexible, which enable peripheral insertion with minimal trauma to the patient. Requires x-ray confirmation before use and can stay in for 3 to 6months. PICC lines must not be confused with a midclavicular catheter (sometimes referred to as a long line) where the tip is located in a central vein leading to the SVC.

CVAD

Central Venous Access Device is where the catheter is threaded into the central vasculature. A central venous catheter will always be in

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the SVC. These can be either single or multiple lumens, the choice of catheter will depend upon the purpose for which it is required and the length of time it is to stay insitu. CVC

Central Venous Catheter is a radio opaque silicone rubber tube, which is tunnelled under the skin of the chest wall to a vein in the neck. From there it is inserted into the SVC- right atrium of the heart. Requires an x-ray prior to use. These are intended for long term, intermittent, continuous or daily access. PICC lines differ from central lines in that they have a two way valve that is pressure sensitive at the internal end of the PICC line. This valve opens outwards to allow fluid to be injected into the catheter and inwards to allow blood to be withdrawn. When the PICC is not in use the valve remains closed, therefore preventing blood from flowing back into the catheter and air entering the circulation

Patency

The inability to infuse through and aspirate blood from a VAD.

PPE

Personal Protective Equipment

4 Duties The Chief Executive has ultimate accountability for the strategic and operational management of the Trust, including ensuring there are safe and effective clinical practices in place to support patients at home or in a community setting. Director of Nursing and Medical Director- have responsibility for ensuring that there is evidence based, quality assured care delivered safely and effectively. Service Managers (Divisional and Clinical Service Managers) - have an operational daily responsibility to ensure that safe, high quality and effective care is delivered to patients at home or in a community setting. All Clinical Staff- involved in the care of the patient with a VAD are expected to have knowledge of this policy and comply with the guidance. They have responsibility to provide safe and effective care for patients at home or in a community setting and that they comply with this policy.

5 Principles of Care These principles are adopted from the Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister 2008). The equipment required to undertake, flushing, administration of medication; withdrawing a blood sample and dressing change are listed in Appendix 1. The procedure for flushing, administration of medication, withdrawing a blood sample and dressing change are detailed in Appendix 2 of these guidelines. 5.1 Prevention of Infection Aseptic technique and compliance with recommendations and dressing changes are essential (Shropshire Community Health Trust- Aseptic Technique Policy). Whenever the insertion site is exposed or the intravenous system is broken, aseptic technique should be practised. Where blood or body fluids may be present, Personal Protective Equipment (PPE) should be worn to comply with safe practice.

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5.2 Cleaning/site inspection Most transient flora can be removed from the skin with soap and water using mechanical friction. To remove resident flora 2% Chlorhexidine gluconate in 70% alcohol has shown to be the most effective agent for skin cleaning around the VAD insertion site and between dressing changes. There have been some incidents where patients have had a sensitivity to Chlorhexidine (Medical Device Alert 2012), prior to use the patient must be asked whether they have had a reaction. Prevail-Fx™ which contains Isopropyl and Povidine Iodine is an alternative. Solutions should be applied with friction using side to side and a back and forth motion for up to 30 seconds and allowed to air dry fully. It is recommended that junctions and connections, injection caps are also cleaned with cleaning agents such as 2%Chlorhexidine gluconate in 70%.alcohol It is recommended that the cleaning of CVC’s and PICC insertion sites should be cleaned weekly at dressing change(unless there is an indication to change the before). The insertion site should be checked regularly for signs of phlebitis, pain or swelling see SCHT - Intravenous Therapy and Cannulation for Adults in the Community Policy and Appendix 3- Trouble Shooting. 5.3 Securement of device and dressings Devices are secured to prevent movement, which reduces the risk of phlebitis, infiltration, infection and migration. An intravenous dressing is applied to minimise the contamination of the insertion site. This dressing should provide a barrier to bacteria, be sterile, waterproof, easy to apply, adheres well. Transparent dressings allow for the inspection of the site, they are waterproof and moisture permeable. The recommended dressing is the IV 3000 (hand) ™, if a patient has a sensitivity to this an alternative dressing will need to be applied, for example Tegaderm™. When the dressing is changed the insertion site should be inspected for inflammation and/or discharge and the condition of the skin noted. The type of CVAD that has been inserted must be recorded with the date and the measurement of the catheter from the entry site at every access or change of dressing; this will indicate migration of the line. See Appendix 3 Troubleshooting for further advice. CVC’s have a Dacron cuff which is under the skin, this helps to keep it in place as the body’s own tissue grows and attaches to it. The cuff is situated between the exit site of the catheter and the neck incision. The cuff takes 3 weeks to knit. There are 2 sutures insitu; one at the insertion site on the neck or just below the clavicle, this suture may be removed after 7 days. The second suture is at the exit site on the chest and should be removed after 21 days when the cuff has firmly knitted. PICC lines are not cuffed and will require fixation with a sutures/dressing/stat-lock. Care needs to be taken with dressing change as the line may become dislodged.

6 Maintaining a closed intravenous system If equipment becomes accidentally disconnected, air embolism or profuse blood loss may occur. This poses a greater risk in patients with CVADs than those with peripheral devices (this is because the amount of air that can be introduced via a CVAD and the speed with which it can enter the pulmonary vessels.) Leur-Lok provide a secure connection and all equipment should have these fittings, administration sets, extension sets, injection caps. Needle free systems provide a closed environment, which reduces the risk of air entry. 7 Maintaining Patency Patency should be maintained at all times. Blockage predisposes to device damage and/or infection. Occlusion (clot formation, precipitate formation) of the device can be due Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014 3

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insufficient or incorrect flushing when the device is not in use or inadequate flushing between different medications. There are 2 main types of solutions to maintain patency in VAD’s; Heparin and Sodium Chloride: 

Heparinised saline- Heparin 10international units/ml is the recommended drug and the dose of 30international units/3ml, this must be prescribed and a medication administration authorisation form completed by the prescriber. Heparinised saline is still the accepted solution for maintaining the patency of CVC’s for intermittent or infrequent use. PICC lines do not require heparinisation.  Sodium Chloride 0.9% is used for flushing PICC lines and in-between medications for any CVAD; this avoids side effects of local tissue damage, drug incompatibilities and iatrogenic haemorrhage. Once or twice daily flushing with 2-5ml of Normal saline is acceptable. Using the correct techniques to flush is one of the key issues in maintaining patency; there are 2 stages to flushing: Using a pulsated (push pause) flush to create turbulent flow, this removes debris from the internal catheter wall. Positive pressure technique, this is accomplished by maintaining pressure on the plunger of the syringe while disconnecting the syringe. Most are now needleless injection caps which enable positive pressure. Kinking may also impair patency therefore following a procedure the catheter should be looped and secured. For issues with patency see Appendix 3 Troubleshooting. 8 Preventing Damage of the VAD and emergency management. If damage occurs to peripheral devices they are usually removed and replaced. Most CVC’s are made of silicone which is prone to cracking or splitting. Artery forceps or sharp edged clamps should not be used to clamp the catheter. A smooth clamp should be placed on the reinforced section. Immediate clamping of the catheter proximal to the fracture or split is essential to prevent blood loss or embolism. Syringe size- when accessing a CVAD syringe size of 10ml or above should be used. Smaller syringe sizes increase the internal pressure and can damage the device. Administration sets. Administration sets replacement and changing of IV bags should follow the same aseptic procedure. It is desirable that a closed system of infusion is maintained at all time, with few connections to reduce the risk of contamination. Injection ports on administration sets or injection caps should be cleaned as outline in this guidance. Administration sets should be changed according to use, type of device and type of solution. The set must be labelled with the date and time of change.

9 Consultation Becky Salisbury- Children’s Nursing Team- Shropshire Community Health Trust Michelle Athersmith- Community Matron- Shropshire Community Health Trust Narinder Kular- Nurse Consultant for children with complex needs- Shropshire Community Health Trust Andrew Coleman- Deputy Director of Nursing and Quality- Shropshire Community Health Trust. Dr Emily Peer- Associate Medical Director- Shropshire Community Health Trust. Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014 4

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Rachael Allen- Head of Infection Prevention and Control - Shropshire Community Trust. Claire Wheeler- Community Practice teacher- Shropshire Community Health Trust. Georgina English- Clinical Lead for Community Nursing- Shropshire Community Trust. Liz Starkie- Community Matron- Shropshire Community Health Trust. Gilly Scott-Lead Nurse for MIU and Clinical Lead for Community Hospitals- Shropshire Community Health Trust. Rita O’Brien- Chief Pharmacist- Shropshire Community Health Trust. Dr Ganesh- Consultant Paediatrician- Shropshire Community Health Trust.

10 Dissemination and Implementation These guidelines will be disseminated by the following methods:  Managers Informed via DATIX system who then confirm they have disseminated to staff as appropriate  Staff via Team Brief  Published to the staff zone of the trust website

10.1Training- All staff that are caring for patients (adult or child) with a CVAD or PICC line will need to undertake the Community Trusts training- Care of the patient with a PICC line/Central line. 11 Monitoring Compliance These guidelines will be reviewed every 3 years unless there are any changes in practice and or National guidance before that date. All managers and service leads must ensure that all staff are aware of this policy. 11.1Datix-any incident reported via Datix will be investigated as per SCHT procedures 11.2 Staff competencies-post training will be evaluated with a competency based document by assigned mentors.

12 References Royal Marsden Hospital Manual of Clinical Nursing Procedures (7th Edition 2008) L. Dougherty, S Lister. Standards for Medicines Management –Nursing and Midwifery Council 2000 Medical Devices Alert- MHRA- Reference: MDA/2012/075. October 25 2012. All medical devices and medicinal products containing Chlorhexidine. Bradford and Airedale Community Health Services policy on Guidelines for the management of central venous catheters management in adults (September 2012) Nursing and Midwifery Council (2008a) Standards for Medicines Management Nursing and Midwifery Council (2009) Record Keeping- Guidance for Nurses and Midwives epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS- Loveday, H.P., Wilson, J.A., Pratt, R.J., Golsorkhi, M.,Tingle, A., Bak, A., Browne, A., Prieto, J., Wilcox, M. (2014) Hospitals in England. Journal of Hospital Infection 86 (Supplement 1) (2014) S1–S70

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13 Associated Documents Shropshire Community Health Trust- Aseptic Technique Policy Shropshire Community Trust-Administration of Intravenous Therapy and Cannulation in the Community Policy. Shropshire Community Trust- Consent to Examination and Treatment Policy Shropshire Community Trust-Hand Hygiene Policy Shropshire Community Trust-Prevention and Management of Needlestick injuries including inoculation incidents and exposure to blood borne viruses. Shropshire Community Trust-Standard Precautions Policy

14 Appendices Appendix 1- Equipment/information required Appendix 2-Procedural guidance for care of the patient with a CVAD Appendix 3-Troubleshooting- A guide for caring for a patient with a CVAD

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Appendix 1 Equipment for flushing, changing a dressing for a patient with a CVAD CVAD/PICC Lines-Ensure you know which line you are attending to. Aseptic technique applies to all procedures. Equipment/information required prior to procedure: Type of CVAD inserted, date inserted, length of catheter from entry site (this info is needed on discharge from hospital.) Authorisation sheet required for flushing and/or giving medication.  Prescribed medications and appropriate flush  Sodium chloride 0.9% for injection  Heparin 10international units/ml (use 30 international units/3ml10international units/ml) as prescribed. (Heparinised saline is not required to flush a PICC line, 5-10mls of 0.9% Sodium Chloride)  Drug information sheet.  Intravenous 10ml leur lock syringes or above.  Needles –blue needles for drawing up from glass vials (filter needles not required).  Swabs 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol (IPA) (Chloraprep) to clean the entry/exit site if dressing is being changed.  Sharps bin.  Alcohol hand rub  Non sterile disposable single use gloves if required to draw up medication  Sterile disposable,single use gloves for administration  Single use disposable apron  Sterile bung /bionector.(changed weekly with dressing change)  Appropriate dressing (IV 3000) if to be changed.(recommended weekly or less if dressing becomes dislodged)  Cleansing wipes 2% Chlorhexidine Gluconate in 70% alcohol and 2 %IPA (Clinell) for disinfecting of medical devices  Sterile dressing pack(Dressit) A three stage technique should be used for aseptic non touch technique:  Thorough hand washing  Identification and non-contamination of key parts  Protection of yourself and the patient by wearing gloves and apron

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Appendix 2 Procedure for dressing change/giving medication/flushing/withdrawing of blood from CVAD. All procedures must be in line with the Trust’s Aseptic Technique Policy.

Action 1. Explain to the patient and family what you are doing using appropriate language. If patient is going to assist with the clamping and unclamping of the line ensure they decontaminate their hands. 2. Check type of line, the date it was inserted. Measure the length of line from exit/entry site to end of catheter. Compare this to the length when line was inserted. Check if dressing is due to be changed and/or bung/bionector. 3. Put on apron. 4. Decontaminate hands using liquid soap and water and dry thoroughly with disposable paper towels or use alcohol hand gel. 5. Collect all necessary equipment. Calculate all medication dosages, ensure correct patient, correct drug and correct route. 6. Establish a clean area e.g. dressing pack, surface, and tray. Clean surface with a detergent wipe and allow to dry. 7. Wash hands thoroughly, dry thoroughly and apply a small amount of alcohol based gel and rub in. 8. Put on a pair of non-sterile gloves straight from the box. 9. Open equipment and check expiry dates. 10. Connect all needles to syringes and prepare

Rationale To minimise stress and encourage patient with self-care. To obtain informed consent.

To ensure the line has not migrated. If there is a difference in line length a xray will need to be carried out to ensure it is the correct position. Do not administer and medication/flush.

To protect the member of staff against spillage/splashing. To reduce the risk of infection.

To reduce the risk of error.

To ensure the work surface is thoroughly cleaned prior to use.

To reduce the risk of infection.

To ensure the equipment is in date.

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medication. Keep all key parts free from contamination. 11. Check against the prescription the patients name, address and date of birth with the patient/family/carer. 12. Discard needles directly into the sharps bin. Ensure key parts are free from contamination. 13. Ask patient to get into a comfortable position. Ask patient to expose the line. Check the catheter, clamp and bung for damage or displacement. Check the exit site for pain, redness or swelling. 14. Remove non-sterile gloves; decontaminate hands with alcohol gel and replace with sterile gloves. 15. Clean the needle-free access device/bung attached to the end of the CVAD with 2% Chlorhexidine Gluconate in 70% alcohol impregnated swab (Clinell) for 30 seconds using friction. Allow to air dry, visibly checking that it is dry. 16. Attach a 10ml syringe only (nothing less than 10mls in size due to pressure complications i.e. rupture of line) and withdraw 2-5mls of blood. This blood is discarded. If taking blood for blood tests withdraw amount required. Flush line with 5mls of 0.9% Sodium Chloride. Close the clamp and place on the edge of the sterile field. If there is any resistance or pain close the clamp and seek advice. 17. Using the correct technique to flush the CVAD is key in maintaining patency. Use a

To reduce the risk of infection.

To comply with the NMC (2008) Standards for Medicines Management.

To prevent needle stick injury. Reduce the risk of infection.

To encourage patient participation. To enable the detection of displaced/damaged catheter. To ensure it is safe to proceed.

To reduce the risk of infection.

To reduce the risk of infection.

To check the line patency and to remove/expel previous heparin.

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pulsated (push, pause) flush to create turbulent flow when administering a solution. 18. The procedure is completed using the positive pressure technique; this is achieved by maintaining pressure on the plunger of the syringe whilst disconnecting the syringe from the injection cap. 19. Administer the drug slowly according to the recommendations. The manufacturers licensed recommendations can be found at www.medicines.org.uk 20. If more than one drug given, each should be clearly labelled and a flush of 5mls 0.9% Sodium Chloride given between each one. 21. Heparin Lock i.e. if device is not being used on a daily basis it will require heparin lock on a weekly basis. If patient is on IV medication then heparin lock at the end of the treatment.DO NOT HEPARIN LOCK A PICC LINES, FLUSH ONLY WITH SODIUM CHLORIDE. 22. Slowly administer heparin as prescribed, do not empty the syringe when there is 1ml left in the syringe continue to administer but at the same time close the clamp- still exerting positive pressure. 23. Clean the CVAD with 2%Chlorhexidine Gluconate in 70% impregnated swabs (Clinell) for 15 seconds with friction and allow to air dry and attaché clean bung to line if required. 24. Check if the dressing is due to be changed. Take care when changing the dressing

To remove debris from the internal catheter wall. Prevents reflux of blood into the tip reducing the risk of occlusion. NB- some manufacturers now have produced needleless injection caps which enables positive pressure displacement flush.

To ensure the correct administration of prescribed drugs. To prevent the mixing of incompatible drugs and formulation/administration of new unprescribed drugs (this results from the administration of one drug followed straight away by another.

To maintain patency of device.

To maintain patency of device.

To reduce the risk of infection.

To reduce the risk of infection and prevent line migration.

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for a PICC line as they do not have a Dacron Cuff to secure into place. Migration of the line may occur if dressing is not changed correctly. 25. Clean around the exit site with 2%Chlorhexidine Gluconate in 70% impregnated swabs e.g. Chloraprep, using the recommended technique. Secure the line with the transparent dressing. Make sure the patient is comfortable and replace their clothing. 26. Dispose of all of the equipment, ensure all needles and syringes go into appropriate sharps box. Remove gloves and apron and dispose of as for Trust Policy. 27. Decontaminate hands by washing them with liquid soap and water or use alcohol hand gel. 28. Ensure all documentation is completed and signed. Ensure the drug administered, flush documented.

To reduce the risk of infection.

To reduce the risk of infection and Needlestick injuries.

To comply with the NMC (2008a) Standards for Medicines Management and NMC (2009) Record keeping for Nurses and Midwives.

Appendix 3 Troubleshooting – A guide for caring for a patient with a Central Line/PICC line.

Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014 11

Presenting symptom/s

Potential problem

Chest pain.

Air embolism or

Dyspnoea.

Atrial fibrillation.

Possible cause

Recommended actions

While using the line or putting Medical emergency seek advice Shropshire Community Health NHS Trust the line in air can enter the and admit to hospital. venous system.

Tachycardia/irregular pulse. Hypotension. Pain on inspiration and expiration, dyspnoea.

Pneumothorax.

This occurs when air gets into the area between the lung and plural lining

Medical emergency seek advice and admit to hospital.

Swelling of neck, chest, arm or leg.

Thrombosis in vein.

A blockage of a vessel can be caused by any damage to the wall of a vein as there will be an emission of thromboplastic substances. This causes platelets to gather at the site of the injury growing into a thrombus and breaking away which can case occlusions.

Medical emergency seek advice and admit to hospital.

Catheter not positioned correctly

Site of catheter is in the wrong place.

Patient will require a chest x-ray to determine position of line.

Nerve injury.

Nerve damage in localised area

Contact the Consultant the patient is under for advice.

Pain redness along the vein, tracking and swelling. For PICC lines – if post 10days insertion consider whether chemical phlebitis or infection. Mechanical phlebitis less likely after 10 days insertion.

Mechanical

Irritation of the vein due to movement of the catheter in the vein (not associated with tunnelled CVCs but can occur with PICC’s).

Ensure the line is appropriately secured. If less than 10 days ensure the patient is applying heat packs as advised.

Catheter.

Blood present in the lumen of the catheter.

Fault in catheter, or line flushed incorrectly.

Flush the line using correct technique. If back flow continues seek advice from where the patient has line inserted.

Inability to flush the line.

Catheter occlusion

Line adhered together near clamp.

Refer to Consultant the patient is under for advice.

Skin discoloration. Skin temperature changes. Infusion difficulties. Inability to aspirate blood. Coughing. Ear/neck pain on the side of insertion/palpitations or arrhythmia’s Inability or difficulty aspirating blood Swelling of neck, chest arm or leg. Shoulder tip pain. Tingling. Loss of movement down part or all of the affected limb. Shooting pain.

Phlebitis/ infection.

Pinch off Syndrome

Refer unit for advice, may require anti-inflammatory or antibiotic medication

Line kinked or twisted Clot or fibrin sheath in catheter. Infusion stopped. Drug precipitate blocking catheter. Lipids from TPN feed blocking catheter. When the catheter is compressed between the clavicle and the first rib

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Presenting symptom/s

Potential problem

Difficulty in aspirating blood.

Catheter occlusion Pinch off syndrome. Fibrin sheath formation.

Possible cause

Recommended actions

Line adhered together near clamp Clot or fibrin sheath in catheter

Ask patient to cough, deep breathe, change position, stand up or lie down.

Line kinked or twisted

Flush with 0.9% Sodium Chloride in 10ml syringe using brisk ‘push pause’ technique. If no other complications proceed.

Drug precipitate blocking catheter. Lipids from TPN feed blocking catheter When the catheter is compressed between the clavicle and the first rib Sheath has formed around the catheter tip

Secondary care provider to consider venogram to confirm patency dependant on the chemotherapy regimen. Medical consultation required.

Redness and tracking at site. Purulent discharge at site

Infection at insertion site

Insertion site infection.

Check patient’s temperature,blood pressure and pulse, take swab from site and send to Microbiology, if patient pyrexial and unwell -Refer to the Secondary care

Pyrexia of unknown origin, rigors. These may occur up to one hour after line has been flushed and should be investigated

Infection associated with the catheter

Infection

Refer to the Secondary care

Leakage from the catheter when used. Damage visible

Damage to catheter

Use of a sharp object near the catheter or movement twisting of the catheter (PICC’s are vulnerable to fracture).

Refer to the Secondary care (NB Many CVCs can be repaired by unit)

High pressure on the syringe as injecting into the catheter. Line appears longer at the exit site or the cuff is visible.

Line migration (Common problem

On measurement the length is on longer than upon insertion.

Can occur with general activity, caution should be taken when removing dressings specifically

for PICC’s)

PICC’s not to pull the line.

Skin changes at insertion site

Skin over granulation

- thickening of skin at point of insertion. - pink/red in colour.

Unknown - possibly due to inflammatory response of injured tissue, as prolonged and excessive inflammation can lead to over granulation.

Refer to the secondary care provider for advice. X-ray to confirm the catheter tip may be required Discuss with secondary care A change of dressing may be indicated. Polyurethane foam dressings e.g. Lyofoam are suggested for over granulation

The presence of a foreign body interfering with healing may also contribute

Trouble Shooting - A guide for the management of central venous catheters. Adapted from Bradford and Airdale Community Health services policy on Guidelines for the management of central venous catheters management in adults. (September 2010) Procedural Guidelines for the Care of the patient with a Central Line or PICC line. Final March 2014 13