CARING FOR A VENOUS ACCESS CATHETER MIDLINES, PICC S, CUFFED CENTRAL LINES, ARM & CHEST PORTS

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1 1 CARING FOR A VENOUS ACCESS CATHETER MIDLINES, PICC S, CUFFED CENTRAL LINES, ARM & CHEST PORTS This booklet tells you about a special intravenous catheter the doctor has ordered for you or your child. An intravenous catheter can be used to give fluid, medicine or blood. It can also be used to get blood samples. There are several different types of catheters - midlines, PICC s, cuffed (tunneled) central lines, arm or chest ports. Your doctor and nurse will talk to you about which type is best for you or your child. 1. Midline catheter or peripherally inserted central catheter (PICC). The catheter is put in a vein usually on the inside of your child's arm. A midline goes up your child's arm towards the shoulder. A PICC line goes past the shoulder to the large veins near your child's heart. A midline is placed by a specially trained nurse. A PICC is placed by a physician and is longer in length. 2. Cuffed (tunneled) central line. This catheter may be called a Hickman, Broviac, or Cook catheter; they are all the same thing. The central line is put in place in the Operating Room. This catheter is tunneled under the skin away from the vein to an exit site where it comes out from under the skin. The part of the catheter that is tunneled has a small cuff around it to help hold the catheter in place. You may have 1 to 3 small tails (tubes) hanging out from where the catheter was put in.

2 2 3. Implanted Arm or Chest Port An implanted port is made up of two parts: a catheter and a port. A catheter is a small flexible plastic tube. A port is a pocket for fluids that you get through the catheter. It is made of metal or plastic and holds a small amount of liquid. One end of the catheter is connected to the port, and the other end goes through a vein near your heart. The port is placed on your chest near your collarbone, or in your upper arm. Most ports are the size of a quarter. They have plastic or metal on the sides and rubber over the top. The port is placed right under your skin and you can usually feel it through your skin. A special needle goes through your skin and the rubber on top of the port when the port is used. If the port will be used often, there may be a catheter tube (tail) attached to the needle. It will hang down onto your chest. General Care of the Catheter The catheter can stay in the body for a long time, so it is important to care for it properly. A clean technique is used when caring for the catheter. Using a clean technique means cleaning work surfaces before handling the catheter, washing your hands completely for 1 to 2 minutes with antibacterial soap, drying hands on paper towels and not touching supplies unnecessarily or on sterile areas. Never reuse old supplies such as syringes. When the catheter is not being used or cared for, clothing can be worn over the catheter. The catheter will not show under clothing. At first it may be overwhelming to think about caring for this catheter at home, but with practice you will learn to: - flush the catheter - change the catheter cap - change the catheter dressing - recognize and troubleshoot problems It is important to ask questions if anything is not clear when you are learning to do these things. Once you are home, you may call any time for assistance.

3 3 Routine once-a-day flush Flush the catheter once each day through the injection cap to keep blood from clotting in the catheter. Try to do this the same time each day. If your catheter has two or three tails, EACH tail should be flushed. 1. Gather your supplies: heparin flush, 10 ml syringe, alcohol prep pads 2. Wash your hands with antibacterial soap and water. Dry on a clean paper towel. 3. If your syringes are pre-filled, skip to step 5 4. Wipe the top of the heparin flush vial with an alcohol prep pad. Draw up 2ml of heparin flush into a syringe. Cover the end of the syringe, taking care not to touch it. 5. Scrub the top of the injection cap with an alcohol pad. 6. Uncover the syringe with heparin and attach the syringe to the injection cap. 7. Release the clamp on the catheter and push the heparin into the catheter. 8. Remove the syringe 9. Clamp the catheter Changing the Injection Cap Change the injection cap routinely each time the dressing is changed. Each catheter tail cap will need to be changed. Do this at the time you normally flush the catheter. IMPORTANT: Your health care professional may instruct you to change the injection cap at other times such as after blood draws. This is OK. Steps: 1. Gather supplies: injection cap(s), alcohol prep pads, heparin flush(s) 2. Wash hands with antibacterial soap and water. Dry hands on a clean paper towel. 3. Make sure the clamp is closed. 4. Open packages of injection cap(s) and alcohol prep pad(s). 5. Scrub the connection of the catheter to the cap with an alcohol prep pad. Remove the old injection cap by turning it counterclockwise and discard. 6. Remove the new injection cap from its protective cover and attach it to the catheter by turning clockwise. Note: some longer types of injection caps have to be pre-filled with saline to prevent air from entering the system. Your nurse will show you how to change these types of caps.

4 4 7. Open the clamp. Flush with heparin. IMPORTANT: NEVER TOUCH THE OPEN END OF THE CATHETER (ALSO CALLED THE HUB) OR THE INSIDE OF THE NEW INJECTION CAP Dressing Change The central line dressing is routinely changed on Monday and Thursday. It is also done at any other time the dressing becomes loose, soiled or wet. A clean technique is used. The steps of the dressing change are listed. Remember: Using a clean technique means cleaning work surfaces before the dressing is changed, washing your hands with antibacterial soap, drying hands on paper towels and not touching supplies unnecessarily. Supplies: Antibacterial soap or alcohol for washing the table Infants over 60 days of age: Chloraprep (2% chlorhexadine gluconate with 70% isopropyl alcohol) Infants under 60 days of age: Alcohol swabsticks (package of 3) Sterile 2x2 gauze pads Tape for securing the dressing Clean gloves IMPORTANT: Your home health agency may use a different antiseptic to clean the exit site. This is OK. Steps: 1. Find a comfortable place where supplies can be close at hand, near a sink and table. Move a trash can nearby. A helper may be needed if your child is an infant or young child. 2. Wash the surface of the table with antibacterial soap or alcohol. Rinse with water if soap is used. Dry the table with a paper towel. 3. Wash your hands using antibacterial soap and dry them with paper towels. 4. Remove the old dressing wearing clean gloves. Throw the gloves and dressing in the trash. 5. Look at the skin area around the catheter. It should be clean and dry. You will need to call the doctor if there is any redness, swelling, or drainage on the skin or if you see any changes in the catheter that was under the dressing. 6. Open the 2x2 s and leave them in the package on the table. 7. Open the chloraprep swab package or the package of alcohol swabsticks. 8. Wash your hands thoroughly. Scrub for 1 minute with antibacterial soap and dry with paper towels. 9. Thoroughly clean the catheter exit site with the swabstick. Start at the center where the catheter is in the skin and use gentle friction. Move the swabstick outward in a clockwise manner. You should make larger and larger circles as you move the swabstick away from the center. Let dry. 10. Fold one 2x2 in half and place under the catheter close to the catheter exit site; then place a full 2x2 over the catheter. 11. Coil excess tubing over the 2x2, then cover all parts completely with tape. 12. Always secure the tail of the catheter. No part of the catheter should ever dangle below the waist.

5 5 Living with a Tunneled Central Line, Port, or PICC line Traveling You can travel if your child has a catheter. You should take supplies you would normally use in the time you are to be away, plus a few extra of everything. Staying with a Baby Sitter If your child has a catheter in place, he or she can certainly be left with a baby sitter. The sitter does not need to learn all aspects of catheter care, but should know to clamp the catheter if a problem occurs such as breakage of the catheter. In addition, the telephone number of your doctor should be given to the baby sitter. You might want to have the baby sitter read the safety parts of this handout [below]. Baths and Showers In general, tub baths and showers should not be taken for at least 2 weeks after surgery to put in the central line. After these first 2 weeks, baths and showers are OK with a few precautions. Before a bath or shower, make sure that the tape of the dressing is on securely. Cover the catheter and dressing with a piece of microfoam tape, or plastic wrap like Saran Wrap and secure it with tape. For a bath, the dressing should not be under the water. Water splashing on the dressing in either the bath or shower is OK. Change the dressing right away after a bath or shower. Activities For the most part, activities and play should not be restricted because of having a catheter in place. An exception, though, is swimming. You should discuss this with your doctor. Safety The central line catheter must be clamped at all times except when it is being flushed, while fluids are running in, or blood is being drawn out. Never use scissors around the catheter since the catheter could be accidentally cut. Never take off the injection cap unless the catheter is clamped first. Discard needles in a special container especially for sharp items. Be sure to ask your home health agency nurse to help get this container if you are using needles with syringes in the home. Be sure to keep these items out of the reach of others in the household. Most hospitals and home health agencies now use syringes that do not require a needle or equipment that is needle-free.

6 6 Definitions Catheter Clamp Clean technique Dressing Entrance Site Exit Site a soft tube which goes into a vein and allows fluid to run in and out. plastic piece on lumen that snaps shut and serves as a safety device when fluid is not infusing. refers to an approach that contributes to infection prevention any time the IV must be handled for care such as dressing changes, injection cap changes or flushing the line. It includes cleaning work surfaces, washing your hands with antibacterial soap, drying hands on paper towels and not touching supplies unnecessarily. the gauze and tape which cover the exit site of the catheter and keep the area around the catheter clean. the area where the tunneled central line or portacath catheter is placed into the vein the area where the catheter comes out from the skin Heparin Hub Injection cap Intravenous (IV) therapy Lumen a medicine which stops clotting of blood in the catheter a plastic adapter, located on the catheter. The injection cap is screwed onto the hub of the catheter. prevents blood from exiting the catheter. It also allows the introduction of medicines into the catheter. the administration of medicine through the veins. the central channel inside a catheter. Occluded Catheter Saline Saline flush Vein the catheter lumen is blocked. a salt solution sterile saline is infused to clear the catheter after routine medicine delivery. a vessel which carries blood back to the heart. **Illustrations from Micromedex Healthcare Series and from Cook Incorporated, Caring for Your PICC Catheter 1995**

7 7 Troubleshooting possible problems with the Catheter You should not expect to have problems with your catheter. The following information may help you recognize a problem should it happen. Once you become aware of any of these problems, call your nurse or doctor. PROBLEM SIGNAL OR SYMPTOM ACTION Clogged catheter Catheter breaks or is accidentally cut Air in the catheter The catheter accidentally becomes both unclamped and uncapped at the same time. Blood backing out of catheter The catheter accidentally becomes both unclamped and uncapped at the same time. Infection of catheter or the catheter site or vein (phlebitis) Catheter is accidentally pulled out Tunneled central line cuff is visible If resistance is met infusing drugs into the catheter, stop the infusion immediately and reclamp the catheter. Never try to force the infusion. This may cause the catheter to burst. You notice the catheter is damaged or blood is leaking from the catheter. Your child begins experiencing shortness of breath, coughing or chest pain. You notice blood inside the injection cap or blood is dripping from the catheter hub. Your child develops a fever. You notice any redness, swelling, drainage, tenderness/pain, rash or other changes at the insertion or exit site(s) when you change the dressing You notice the catheter is not in the skin, bleeding from the exit site, pain You notice the cuff during a dressing change. This may occur when a catheter has a blood clot inside or at its tip, preventing fluid from passing. Your doctor may order a drug to dissolve the clot or remove the catheter. Call the nurse or doctor. Clamp the catheter between the leak and where the catheter enters the skin. Cover the catheter with a sterile 2x2 gauze. Call your nurse or doctor. Clamp the catheter right away. Have your child lie on his left side with head down and feet propped up. Keep him in this position for about 5 minutes, or longer if he has any trouble breathing or chest pain on sitting up. Clamp the catheter right away. Scrub the end of the catheter with an alcohol pad; put on a new injection cap; flush with heparin Finish the dressing change. Quickly place a sterile 2x2 over the catheter site. Apply firm pressure for 5 minutes. Tape another 2x2 to cover the site. Finish the dressing change. Do not flush the catheter until you have spoken to your doctor by the Rector and Visitors of the University of Virginia PEME49803a.doc 7/28/03