Policies & Procedures Title: CENTRAL VENOUS CATHETERS – CARE OF - accessing - dressing changes - tubing and adapter changes - flushing/ locking - blood withdrawal I.D. Number: 1086

Authorization: [x] SHR Nursing Practice Committee

Source: Nursing Cross Index: SHR Nursing Policy and Procedure Manual: CVC-Implanted Ports ID #1032, CVC- Removal of PICCs ID #1003, CVC-Removal of ST lines ID #1058 Date Revised: March 2011 Date Effective: March 1997 Scope: SHR Acute Care

Any PRINTED version of this document is only accurate up to the date of printing 24-Nov-15. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR.

DEFINITIONS This Policy applies to care of Central Venous Catheters(CVC): A venous access device whose tip dwells in the superior or inferior vena cava:  Short Term (Percutaneous) catheter-inserted into the subclavian, jugular or femoral vein used on a temporary basis for patients in acute care only (up to 30 days).  Tunneled (Long Term) tunneled under the skin then inserted into subclavian vein, catheter is used in hospital or home care for long term therapy.  Peripherally Inserted Central Catheter (PICC) inserted into a peripheral vein, used in hospital or home care for long term therapy.  Implanted Ports- access is through a port that is surgically placed in the chest or arm. Note: Accessing Implanted Ports is not an LPN Added skill. LPNs can maintain an Implanted Port once accessed by an RN/GN/RPN. 1. PURPOSE 1.1 To maintain the patency of central venous catheters. 1.2 To minimize the risk of infection, damage, displacement and other complications associated with the care and use of CVCs.

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

2. POLICY Staff who will perform these procedures

Physician Order required Special Considerations

Accessing a CVC

Flushing and locking CVCs (not required for continuous IV infusions) Refer to Adult/Pediatric Standards chart for flushing and locking amounts (Appendix A & B) Changing Tubing and Adapters

These procedures are Special Nursing Procedures requiring certification for RNs/GNs/RPNs and Added Skills requiring certification for LPNs/GPNs as identified by unit Managers of Nursing. (Completion of the IV/Blood Administration Course is a prerequisite for LPNs). Procedures included in this policy: - accessing lumens (accessing Implanted Ports is a separate policy) - dressing changes, - tubing and adapter changes, - flushing, locking - blood withdrawal - Heparin lock for the following CVCs: short term, tunneled and implanted ports - Prior to accessing CVCs for any reason, nurses must perform appropriate Hand Hygiene procedures (Infection Prevention & Control policy 20-20) - To decrease the risk of contamination, accessing CVCs should be kept to a minimum - Assess daily the continued need for a CVC - Flush CVCs using at least a 10ml syringe to avoid excessive pressure,to avoid possible rupture of the catheter or dislodgement of a clot - Notify Physician and consult Medical Imaging immediately if unable to flush - To prevent peripheral PICC or Implanted port occlusion and/or damage, avoid using arm for BP’s or venipuncture - Use direct luer lock connections for continuous infusions - Administer Intermittent medications/fluid through a needleless adapter or tubing port - Clean needleless adapters for 15 seconds using an alcohol swab and friction in a twisting motion prior to accessing - For accessing an Implanted Port see Policy : Central venous CathetersImplanted Ports-accessing and discontinuing access - Flush all CVC lumens: (PICCs, Short term, tunneled and implanted) with 0.9% Sodium Chloride:  after blood withdrawal,  before and after medication administration,  for maintenance of an unused lumen - Flush lumens using stop & start flush technique - See Adult/Pediatric Standards (Appendix A & B) for amounts of flush - Lock with: Heparin flush (100u/ml) : short term, tunneled & implanted See Adult/Ped Standards (Appendix A & B) for amounts of flush - Note: Heparin requires an Independent double check prior to use - PICCs are not locked with Heparin unless ordered by Physician - PICU and NICU follow unit protocols for flushing CVCs - Cap lumens with a sterile needleless adapter at all times when not directly connected to tubing - Change needleless adapters on unused lumens q 7 days (document change on care plan) - Clamp lumens when not in use when manufacturer’s clamp is provided (non-valved CVCs) - Change tubing and extension sets q96hrs except: Lipid emulsions: parenteral nutrition tubing q 24hr ; propofol q 12hr; blood tubing q 8

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

Dressing Changes

-

Blood Withdrawal

-

I.D.# 1086

hours, after 4 units infused or if more than an hour has elapsed between infusions when tubing is changed, any adapters, stopcocks or other tubing connected to the same lumen must be changed at the same time use new tubing when CVC is inserted Prior to changing needleless adapters or tubing, clean connection for 15 seconds using an alcohol swab and friction in a twisting motion Prime tubing and adapters prior to attaching to CVC Disinfect skin with Chlorhexidine 2% during dressing changes (Note: for infants less than 2 months, or patient sensitive to chlorhexidine, use a povidine-iodine swab or 70% alcohol swab Dressings : Opsite IV 3000 or other semi-permeable transparent dressing – change q 7 days and prn Gauze (or combination of gauze & transparent dressing – change q 24 hrs Assess site at least every 8 hours for any signs of inflammation, infection, bleeding, leakage at insertion site, length of CVC and secure sutures See current lab blood tube chart posted on each unit for correct order of draw and tube choice Withdraw blood from any lumen except one that is dedicated to parenteral nutrition or drugs for which levels must be drawn Use vacutainer or syringe for blood withdrawal A volume of blood must be discarded before drawing blood specimens from a CVC (refer to Standards Appendix A & B) (Exception: pediatric areas may re-infuse discard if ordered) Blood Cultures: use syringe method, no discard required Note: peripheral blood sampling is preferred for blood cultures Before drawing blood from a CVC, turn off IV infusions running in other lumens for 1-2 minutes (unless this would affect the well being of the patient) Use blood transfer device to transfer blood to tubes if syringe method is used to prevent hemolyzation of blood Immediately following blood withdrawal, flush lumen and lock according to Standards (see Appendix A & B)

3. PROCEDURES 3.1 Flushing and Locking 1.3.1 Flushing and locking is performed on Central Venous Catheters that are used intermittently (not connected to a running infusion), following each access. If the CVC is not routinely accessed then these lumens are flushed/locked on a schedule specific to each type of CVC (Adult/Pediatric Standards - Appendix A & B). 1.3.2 Supplies:  10ml syringe prefilled with 0.9% sodium chloride (1 for each lumen to be flushed  Needles (blunt) and syringes to draw up Heparin (if required)  alcohol swabs  CVC Pediatric or Adult Standards chart (Appendix A & B) for amounts of flush and lock solutions to be used 1.3.3 Open catheter clamp (non-valved CVC).

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

1.3.4 Clean needleless adapter and/or tubing for 15 seconds using an alcohol swab and friction in a twisting motion . Allow to dry. 1.3.5 Flush: inject sodium chloride (flush) through the needleless adapter and remove the empty syringe:  after blood withdrawal, before and after medication administration, for maintenance of an unused lumen  Flush with a stop and start motion to create a turbulent flow. NOTE: Turbulence is created to clean fibrin or other materials from the lumen  Do not use force to flush or lock a CVC. 1.3.6 Lock: Inject Heparin flush through the needleless adapter and remove the empty syringe. The MicroClave needleless adapter maintains neutral pressure within the CVC which prevents the back flow of blood into the catheter. 1.3.7 Clamp the catheter after the syringe has been removed if applicable. 1.3.8 Repeat the procedure for other lumens as necessary. Note:

Use a separate flush and lock syringes for each lumen.

1.3.9 Documentation:  Record Heparin administration on appropriate record.  Record fluid volumes as appropriate. (Pediatrics: on Fluid Balance Record) 3.2 Tubing and Adapter Change 3.2.1 Supplies:  alcohol swab  primed needleless adapter  primed tubing  extension set (if needed)  Multiport stopcock (critical care only)  syringe with Heparin if needed - see Standards chart  10ml syringe prefilled with 0.9% Sodium Chloride injection 3.2.2 For tubing change, stop IV infusion. 3.2.3 For clamped CVC, clamp lumen to prevent air embolism or blood loss. 3.2.4 Clean needleless adapter and/or tubing for 15 seconds using an alcohol swab and friction in a twisting motion. Allow to dry. 3.2.5 Loosen connection to facilitate rapid change over. If difficult to loosen, use a tourniquet or glove for improved grip. Note:

Catheter hub may be damaged by using a metal forceps

3.2.6 Disconnect tubing or adapter. 3.2.7 While maintaining aseptic technique to avoid catheter contamination, connect new primed tubing or adapter. 3.2.8 Unclamp catheter and re-establish IV infusion, if applicable. 3.2.9 Flush and lock unused lumens according to Adult or Pediatric Standards Chart (Appendix A & B) 3.2.10 Document date of tubing or adapter change on care plan or other appropriate document. 3.3 Dressing Change

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

3.3.1 Supplies:  dressing tray/set (if needed)  clean gloves  0.9% Sodium Chloride (for skin cleansing if required)  Chlorhexidine 2% - swab or swabstick for skin disinfection  OpSite IV3000 or gauze dressing (if indicated)  tape if needed  sterile cotton tipped applicators (if required) 3.3.2 Use clean gloves to remove dressing. Discard gloves and dressing. Perform Hand Hygiene. Apply clean gloves. 3.3.3 Inspect insertion site for:  signs of infection  secure sutures  catheter slippage/movement  leaking IV fluid  condition of tunneled area 3.3.4 If drainage is present, cleanse skin and catheter with 0.9% Sodium Chloride. 3.3.5 Disinfect skin with 2% Chlorhexidine, using friction. Start at insertion site using a circular motion and move outwards to disinfect an area larger than the size of the dressing. 3.3.6 If there is a contraindication to chlorhexidine, providine-iodine or 70% alcohol can be used as alternatives. Note:

Silicone catheters can be damaged with adhesive removers and acetone.

3.3.7 Allow skin to dry completely. 3.3.8 Apply dressing to cover both the insertion site and suture site. Lay Opsite IV 3000 in place and mold it over the catheter with fingertips. 3.3.9 If using plain gauze, secure with a full border of tape. 3.3.10 Secure tubing to the skin with tape to prevent traction on the dressing or insertion site if needed. 3.3.11 Document dressing change and condition of insertion site on appropriate record. 3.4 Blood Withdrawal 3.4.1 Supplies:  Current blood tube chart  vacutainer luer – lok access device (if using vacutainer method)  vacutainer blood transfer device (if using syringe method)  blood sample tubes (including discard tube)  blood cultures: culture vials if needed  clean gloves  alcohol swabs  bleach swabs  cotton tipped applicators (if required)  plastic bags  requisitions and labels  refer to Standards chart (Appendix A & B) for flushing/locking supplies 3.4.2 Glove. 3.4.3 Turn off IV infusions to all lumens (unless this would affect the well being of the patient).

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

3.4.4 Clean needleless adapter and/or tubing for 15 seconds using an alcohol swab and friction in a twisting motion. Allow to dry. 3.4.5 Withdraw blood for discard using discard tube or syringe. See Adult/Pediatric Standards chart for amount of discard required for each CVC type (Appendix A & B).  Exceptions: - blood cultures do not require a discard - withdrawn blood may be reinfused (ifordered) in Pediatric areas - PICU and NICU as per unit policies. Note:

If unable to withdraw blood using vacutainer method: - reposition patient by raising shoulder or asking to cough - reposition blood tube and needle - try a new blood tube - flush with 10 ml 0.9% Sodium Chloride and reattempt vacutainer method - change to syringe method

3.4.6 Withdraw total blood sample as required attaching tubes in quick succession. See current lab-blood tube chart on your unit for recommended order of withdrawal and tube choice for each test. Note: If using syringe method, do not actively inject blood into the blood tube. Use the vacutainer blood transfer device to connect the syringe to tube. Allow the vacuum to draw blood from the syringe, to avoid damaging specimen. 3.4.7 Resume IV infusions if applicable. 3.4.8 Immediately flush all lines with 0.9% Sodium Chloride, using a stop and start motion to create a turbulent flow to clean internal lumen 3.4.9 Lock Short term, Tunnelled and Implanted Ports with Heparin flush via the needleless adapter and remove the empty syringe. Clamp the catheter after the syringe has been removed. 3.4.10 Clean tops of specimen tubes with bleach swab. Label tubes and place in plastic bag for transportation to lab with appropriate requisition. 3.4.11 Documentation:  Indicate CVC as source of specimen on blood requisition.  Record Heparin administration on appropriate record.  Record fluid volumes as appropriate (pediatrics) on Fluid Balance Record. 4. REFERENCES Bernier, P et al (2009) Getting Started kit: Prevent Central line Infections, How to Guide. Institute for Healthcare Improvement-Safer Healthcare Now! Campaign Hughes,J. (2002) Guidelines for the Prevention of Intravascular Catheter-Related infections. National Center for Infectious Diseases. Recommendations and Reports 51(RR10);1-26 Marschall, J et all, (2008) Strategies to Prevent Central Line – Associated Bloodstream infections in Acute Care Hospitals. S22 Infection Control and Hospital Epidemiology, October 2008, Vol. 29, Supplement 1 O’Grady,N et al. (2011) Guidelines for the Prevention of Intravascular Catheter-Related infections. National Center for Infectious Diseases. Atlanta, Georgia. http://cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

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Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

APPENDIX A

CENTRAL VENOUS CATHETERS - Adult Standards March 2011 Prior to accessing CVC for any reason perform Hand Hygiene for at least 15 seconds with alcohol-based hand rub or antiseptic soap and water. PICC Clampless, valved e.g. Power PICC Solo, Xcela

PICC With clamps, nonvalved e.g. Cook

Short Term Percutaneous -jugular, subclavian or femoral

Tunneled Long term e.g. Hickman

Accessing

Flush Volume (0.9% sodium chloride) Heparin Lock (100u/ml) Heparin Lock Syringe Size Dressing changes

Needleless Adapter Change (Use needleless adapter on all unused and intermittent use CVC lumens) Blood Sampling Discard Volume Use discard tube or 10 ml syringe

Flush after each access or once a week if unused

N/A N/A

chest or arm e.g. Port-a-Cath, P.A.S. port

Syringe or IV tubing via needleless adapter

Safe Step Huber Safety Needle Set* primed with 0.9% Sodium Chloride

Flush with 10mls 0.9% Sodium Chloride

Gently aspirate to visualize blood return then flush with 0.9% Sodium Chloride

Check Placement

Frequency of Flushing and Locking (Flushing and Locking not required for continuous IV infusion)

Implanted Port

Flush after each access or Q 24 h if unused

Flush & lock after each access or Q 24 h if unused

Flush & lock after each access or Once a week if unused

Flush & lock after each access or Once a month if unused

10mls before & after medication administration. 20mls after blood administration or withdrawal N/A 1.5ml 3ml N/A 3ml 12ml Opsite IV 3000 q 7 days and PRN when dressing soiled, wet or non-occlusive Opsite IV3000 with Gauze or Gauze (Primapore) alone q24h Clean skin with saline prn, then for skin antisepsis use Chlorhexidine 2% swabstick.

20ml 5ml 12ml

Once a week

Once a week

Once a week

Once a week

Once a week if port accessed

1 tube or 5 ml

1 tube or 5 ml

1 tube or 5 ml

2 tubes or 7 ml

2 tubes or 7 ml

* Stock # in SPD: Safe Step Huber Safety Needle Set 1/2” 22G #200940, 3/4” 22G #200941, 1” 22G #200942, 1-1/2” 200982

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March 2011

Policy & Procedure: Central Venous Catheters – Care of (accessing, dressing changes, tubing and adapter changes, flushing/locking, blood withdrawal)

I.D.# 1086

APPENDIX B

CENTRAL VENOUS CATHETERS - Pediatric Standards Prior to accessing CVC for any reason perform Hand Hygiene for at least 15 seconds with alcohol-based hand rub or antiseptic soap and water.

PICC

Accessing

Clamps, clampless, valved, nonvalved, e.g. Cook, Power PICC, Solo, Xcela

Heparin Lock (100 units/ml)  5 times or less in 24 hours IF MORE THAN 10 KGS 

6 times or more in 24 hours

OR  LESS THAN 10 KGS Heparin Lock Syringe Size

Long term, e.g. Hickman

Flush with 5 -10mls 0.9% Sodium Chloride Flush after each access or q 24h if unused

Flush & lock after each access or q 24h if unused

Flush & lock after each access or q 24h if unused

According to weight: less than 10 kg: 5 mls more than 10 kg: 10 mils Before and after medication administration, blood administration or withdrawal N/A **unless physician 1.5ml 1.5ml specific orders written** 0. 2ml heparin (100 units/ml) 0. 2ml heparin (100 units/ml) added to added to 1.8 mls 0.9% sodium chloride 1.8 mls 0.9% sodium chloride N/A

Dressing Changes

Needleless Adapter Change Use needleless adapter on all unused/intermittent use CVC lumens) Blood Sampling Discard Volume Use discard tube /10ml syringe

Tunneled

Syringe or IV tubing via needleless adapter

Check Placement Frequency of Flushing/ Locking Flushing/ Locking not required for continuous IV infusion Flush Volume (0.9% sodium chloride)

Short Term

Percutaneous - jugular, subclavian or femoral

3ml    

10ml

Implanted Port

Chest or arm, e.g. Port-a-Cath, P.A.S. port Safe Step Huber Safety Needle Set* primed with 0.9% Sodium Chloride Gently aspirate to visualize blood return then flush with 0.9% Sodium Chloride Flush & lock after each access or Once a month if unused 10 - 20ml

2.5ml 0. 2ml heparin (100 units/ml) added to 1.8 mls 0.9% sodium chloride 10ml

Opsite IV3000 with Gauze or Gauze (Primapore) alone q24h Opsite IV 3000 q 7 days and PRN when dressing soiled, wet or non-occlusive Sterile gloves Clean skin with saline prn, then for skin antisepsis use the following according to age: Less than 2 months: povidine/iodine 2 months and older: 2% Chlorhexidine swabstick.

Once a week

Once a week

Once a week

Once a week if port accessed

3 mls

3 mls

3 mls

3 mls

* Stock # in SPD: Safe Step Huber Safety Needle Set 1/2” 22G #200940, 3/4” 22G #200941, 1” 22G #200942, 1-1/2” 200982

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June 2011