Title: Greater Manchester and Cheshire Cancer Network Policy for the Care of long term Central Venous Catheters

Title: Greater Manchester and Cheshire Cancer Network Policy for the Care of long term Central Venous Catheters Purpose: For staff to be aware of policies and guidelines for the care of long term Central Venous Catheters Policy application: All staff within the trust and GM&CCN who manage the care of long term central lines Responsibilities for implementation: Procedures Team IV Team Chemotherapy Services Managers Chemotherapy Day Services staff Ward Managers Medical staff Original date of issue: November 2006 Date of revisions: May 2010 Next review date: May 2012 Authors: Lesley Fitzsimmons, The Christie, Procedure Team Lead Katherine Haralambous, The Christie, Lead IV Trainer Steve Hill, The Christie, Procedure Team Manager Oonagh McGugan, The Christie, Lead Nurse Infection Control Reviewed and amended: Sharon Swift (The Christie IV Team) Greater Manchester and Cheshire Cancer Network Steve Hill (The Christie Procedures Team) Katherine Haralambous (The Christie IV Team) Consultation process: The Christie IV Team, Greater Manchester and Cheshire Cancer Network Cross Cutting Group Equality Impact Assessment date: 16/06/2010 References: See section Intranet category for location: policies/clinical practice Key words/phrases: Central Venous Catheters, ANTT, Chlorhexidine. Approved by: Clinical and Research Governance Committee Date: July 2010 Long term Approved LF/KH/SH/OM 2010 Review date: 2012

Contents Page 1. Central Venous Catheters 2 Skin tunnelled central venous catheter 2 Infection 3 Venous thrombosis 4 Maintaining patency 4 Catheter tip migration 4 Patient information 5 Removal of skin tunnelled central venous catheters 5 2. Procedure for blood sampling from a cuffed tunnelled long term central venous catheters 6 3. Procedure for flushing and locking a skin tunnelled central 7 venous catheter 4. Procedure for dressing a Central venous catheter 9 5. Non skin tunnelled Central venous catheter 10 6. Peripherally inserted central venous catheters 10 Indication for patient selection Advantages Disadvantages Post insertion complications Blood sampling from a Groshong catheter (PICC) 7. Procedure for blood sampling from a Groshong catheter (PICC) 12 8. Flushing Groshong catheters 13 9. Dressings 14 10. Procedure for dressing a Groshong catheters (PICC) 14 11. Totally implantable vascular access devices (TIVAD) 15 12. References 16-17 Appendix 1 Algorithm: Unable to aspirate blood from a tunnelled 18 central venous catheter (INPATIENTS) Appendix 2 Advice for district nurses 19-22 Appendix 3 Management of problems related to central venous 23 catheters in the COMMUNITY Appendix 4 Methicillin resistant staphylococcus aureus algorithm 24 1

1. Central Venous Catheters (CVC) Prior to insertion of any central venous access device patients must be swabbed for Methicillin Resistant Staphylococcus Aureus (MRSA) and commence eradication therapy, they are required to continue to use an antibacterial body wash (e.g. HIBISCRUB ) to bath or shower and wash their hair until the line is removed. See MRSA algorithm for guidance on page 23. Many different Central Venous Access Devices (CVADs) are available. The practitioner must be able to identify the line and the specific care required for that device or they must seek advice. They include: Skin tunnelled catheters e.g. Hickman and Broviac Catheters (trade mark of Bard Ltd) Totally Implantable Vascular Access Device (TIVAD) Peripherally Inserted Central Catheters (PICCs) Short term lines (refer to specific short term lines policy) including non tunnelled devices, these may be subclavian, jugular/femoral lines Groshong A Central Venous Catheter (CVC) is defined as having its tip located in the superior vena cava. CVCs are inserted for a variety of reasons including: Access for blood sampling Administration of fluids, drugs, blood and blood products Parenteral nutrition (PN) Safe administration of vesicant drugs Ambulatory chemotherapy Monitoring of central venous pressure Patients with poor peripheral intravenous access or needle phobia CVCs can be single or multiple lumens and the choice of catheter will depend upon the purpose for which it is required and the length of time it is to stay in situ. Skin tunnelled catheters A skin tunnelled CVC is usually inserted via the jugular or subclavian vein and advanced into the superior vena cava so that the tip is lying at the junction of the right atrium. The technique of skin tunnelling reduces the risk of sepsis, as the exit site is distant from the site of insertion. The majority of CVCs inserted for oncology patients are cuffed and made of silicone, which is flexible and non-irritant. These CVCs can remain in situ for an indefinite length of time. 2

Skin tunnelled catheters have a Dracon cuff which engrafts into the tissue in the skin tunnel. Following insertion there is one suture at the insertion site (either jugular or subclavian) and one or two at the exit site. The top sutures should be removed after 7 days and the exit site sutures should remain in situ for at least 21 days or until the skin appears healed. After this time, the granulation tissue will have grown around the Dracon cuff, securing the line in situ. Following removal of the sutures, a dressing is not required providing the exit site remains clean and dry. However, if patients feel more secure with a dressing in place or if they are an inpatient and at increased risk from infection, then a semi-permeable transparent dressing, such as an IV 3000, must be used. Tunnelled lines must remain looped and secure at all times with surgical tape when an IV 3000 is not in place. Most skin-tunnelled CVCs have integral on/off switches or clamps, as they are openended. Some hospitals routinely insert Groshong skin tunnelled CVCs which are cuffed but do not have a clamp or switch. Risks of insertion include: - Pneumothorax - Arterial puncture - Malposition of the catheter tip - Haemathorax - Infection The possible complications of indwelling CVCs are: - Infection (exit site or systemic) Increased risk when multiple lumen CVCs are used, that is why it is very important to treat each lumen separately - Venous thrombosis - Catheter occlusion - Catheter tip migration Infection Infection control and maintenance of line patency are of paramount importance in order to preserve the line for as long as possible. The national standard advised by the Department of Health (DOH) is to use an Aseptic Non Touch Technique (ANTT) for the care of a CVC. Total asepsis is vital during insertion of the CVC and consistent safe standards are equally important for subsequent care and use. Poor catheter care and hygiene can be a factor in catheter related sepsis and patient death, or CVCs being removed prematurely and re-sited. Parenteral Nutrition should be given via a dedicated lumen. Non sterile gloves and an ANTT must always be used when handling CVCs. (However the practitioner needs to assess the risk and if the environment is unsuitable or if the task is complicated and there are multiple key parts exposed then sterile gloves are suitable.) The catheter hub should always be cleaned with 2% Chlorhexidine gluconate and 70% alcohol wipe, (EPIC 2007). Manipulations of the catheter should be kept to a minimum and procedures coordinated to reduce handling e.g. blood sampling, dressing changes or administration set changes. 3

If the patient develops pyrexia of unknown origin, catheter sepsis should be suspected. Blood cultures should be taken from each lumen of the catheter and the waste sample should be sent for culture. Samples are also required from a peripheral vein. The catheter will only be removed if infection is recurrent and on the advice of the clinician in charge or microbiologist. If intravenous antibiotics are being administered for suspected or proven catheter related sepsis they must be given via the central line. If a double or multi lumen line is in situ alternate lumens should be used. Always assess the insertion and exit site when tending to the CVC, observing for inflammation, discharge, heat or complaints of discomfort. Venous thrombosis A thrombus can occur anywhere along the pathway of inserted central lines. Symptoms can include swelling of the arm, neck or face. Patients also often complain of pain or discomfort. Diagnosis can be confirmed by ultrasound scan and the patient will require anticoagulant therapy. Maintaining patency The CVC must be kept clear of static blood at all times by using an intravenous infusion or by flushing with saline 0.9% and 10 iu/ml heparin (Heparinised saline) after use, in line with manufacturers guidance and Royal College of Nursing (RCN) Standards for infusion therapy, (2007). Occlusion is usually due to: - An infusion running too slowly - An administration set turned off for too long - Inadequate flushing between compatible medications - Infrequent flushing of the catheter when not in use. In all these instances a clot may form in the catheter. Always check that the occlusion is not caused by kinked or pinched tubing. Catheter tip migration Correct position of the catheter cannot always be assumed as catheter migration can occur. Even if the catheter is in regular intermittent use, confirm the position by obtaining a 10ml flashback of blood using a syringe. If there is no flashback, ask the patient to: - Breathe deeply or cough - Raise their arm on the catheter insertion side - Lie down and/or change position The usual reason for lack of flashback is that the tip of the CVC is lying against the wall of the blood vessel. 4

If the above manoeuvres are not successful, seek advice from an experienced colleague. For Christie staff please see attached INPATIENT algorithm. 0.9% Sodium Chloride injection should be used to flush the CVC before and in between each different drug to prevent precipitation inside the lumen and to preserve the integrity of the vein. The CVC should also be flushed after administration of drugs or blood sampling this should be followed by a flush of 10 iu/ml heparinised saline if a continuous infusion is not in progress. (If it is a Groshong line, 0.9% sodium chloride only is required to flush). A 10ml syringe or larger should be used to flush the line as anything smaller can create too much pressure. A chest x-ray done following insertion, may be re-ordered by medical staff to verify tip location before commencing chemotherapy treatment if a CVC will not bleed but will flush. Refer to the in-patient non withdrawal of blood on CVC algorithm. Royal College of Nursing (RCN) guidance for persistent withdraw occlusion, advises administer a 250ml 0.9% sodium chloride challenge over 15mins to test patency. Any discomfort swelling or unexplained problems stop and seek medical advice. CVCs must be flushed every 7-10 days to maintain patency when not in use. When multiple lumen CVC s are used each lumen must be treated as a separate entity and require separate flushing. The technique of using positive pressure to ensure that the flush is retained inside the CVC is important in order to prevent back flow of blood into the lumen. To avoid accidentally severing of a CVC, scissors and toothed forceps must never be used on or near them. In the event of damage, immediately clamp the catheter, protecting it with gauze, above the split to prevent blood loss or air embolus and cover the damaged end with a 2% chlorhexidine in 70% isopropyl alcohol wipe. Some CVCs can be repaired by experienced staff. Patient information Clear, concise patient information is essential. If the patient has a clear understanding of their CVC and the possible complications, they will be less anxious and are more likely to co-operate with treatment. Back up all verbal information given with written information wherever possible. Referral to district nursing teams is recommended when patients are discharged with a CVC in situ, along with clear instructions about care and flushing of the line. This gives the patient support on discharge from hospital. Removal of skin tunnelled CVCs This aseptic procedure must be carried out by experienced and appropriately trained personnel to minimise pain, trauma, risk of air embolus and infection e.g. The Procedure team at The Christie NHS Foundation Trust. 5

2. Procedure for blood sampling from a cuffed tunnelled long term central venous catheter, using ANTT Use luer-lok syringe if available or if the patient is high risk, protecting you from splash back. For management of problems see attached inpatient algorithm Equipment: Multiple lumens treat separately Suitable plastic tray cleaned with 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe (Sani-cloth) Non sterile gloves Plastic apron Blood sampling system (e.g. Vacutainer/Monovette) Appropriate tubes for tests required 10ml syringe x 3 (2 x 2Oml syringes if following PN, for withdraw of blood and administration of saline) Green needle x 2 1x syringe 0.9 % sodium chloride for injection (20mls following PN) Pre filled 0.9% sodium chloride syringes may be used 5mls Heparinised saline (Hepsal 10 iu/ml) Sterile bung Isopropyl alcohol based hand rub 2 x large 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe Procedure and rationale (Always use a Aseptic Non Touch Technique keeping key parts protected) Explain procedure to the patient and check identity by asking the patient to give their name, date of birth and address/hospital number. (Wristband for inpatients) Ensure privacy. To gain patient s consent and maintain dignity. Decontaminate hands as per policy. Put on an apron. To minimise risk of infection. Clean your tray with 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe and assemble equipment keeping key parts protected To ensure procedure goes smoothly. To minimise potential contamination. Decontaminate hands with isopropyl alcohol hand gel, put on non sterile gloves Draw up 10mls 0.9% sodium chloride (or use pre filled 0.9%sodium chloride) and 5mls 10 iu/ml Hepsal in a 10ml syringe. Protect key parts in your clean tray To contain any contamination. Ensure you expose the whole area of the tunnelled CVC not just the hub. Clean hands with isopropyl alcohol hand gel. Put on non sterile gloves. To observe site for infiltration. Sterile gloves can be used if you risk assess they are required. Lift the CVC hub end and remove the bung and place in clinical waste bag (if it is a line with a clamp, ensure that clamp is closed). To prevent entry of air in, or leakage of blood out. 6

Use a new 2% Chlorhexidine gluconate and 70% alcohol wipe to clean the hub of the line for at least 30 seconds using different parts of the wipe allowing to air dry for a minimum of 30 seconds. Removes any debris from the hub. Air drying ensures 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe is effective. Using ANTT, attach empty 10ml syringe, open clamp and withdraw 10mls of blood. To establish patency and position of line, to remove stale Hepsal and potential bacteria. Close clamp and discard blood filled syringe into sharps bin. To keep system closed and avoid blood spillage. Attach luer adapter using ANTT, open clamp and insert blood bottles. Reclamp when all bottles are filled and remove adapter. Take all necessary specimens (preferred to take clotting samples peripherally). Attach 10ml syringe of 0.9% sodium chloride, open clamp and flush slowly using a push pause technique to create turbulence in the line. Close clamp and discard syringe. Close clamp on positive pressure. (If Groshong line, flush removing flush on positive pressure.) Attach a new bung. This ensures effective removal of blood and cleaning of the line. Attach syringe of 5mls of Hepsal. Open clamp and slowly flush. To lock the CVC and prevent it blocking between use. Close clamp on CVC whilst injecting the final 1ml of Hepsal To maintain positive pressure in the line and prevent backflow of blood. Remove syringe and discard. Attach new sterile bung. Dress line site as necessary, always ensuring line is looped and secure. Discard waste as per policy. 3. Procedure for flushing and locking a long term cuffed tunnelled central venous catheter Use luer-lok syringe if available or if the patient is high risk, protecting you from splash back. For management of problems see attached algorithm. Equipment: Multiple lumens treat and flushed separately Suitable plastic tray cleaned with 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe (Sani-cloth) Non Sterile gloves Plastic apron 3 x 10ml syringe (x 2 if using pre filled 0.9% sodium chloride) 2 x Green needle (x 1 if as above) 10mls 0.9% sodium chloride for injection (20mls following PN) 5mls Heparinised saline (Hepsal 10 iu/ml) Sterile bung Isopropyl alcohol based hand rub 2 x large 2% Chlorhexidine wipe in 70% isopropyl alcohol (Sani-cloth) 7

Procedure and rationale (Always use a Aseptic Non Touch Technique keeping key parts protected) Explain procedure to the patient and check identity by asking the patient to give their name, date of birth and hospital number/address. Ensure privacy. To gain patient s consent and maintain dignity. Decontaminate hands, wash and dry hands thoroughly. Then use alcohol hand gel. Put on an apron. To minimise risk of infection. Clean your tray with 2% Chlorhexidine gluconate and 70% alcohol isopropyl wipe and assemble equipment using ANTT keeping key parts protected. To ensure procedure goes smoothly. ANTT is the national standard to minimise potential contamination. If required draw up 10mls 0.9% sodium chloride (or use pre filled 0.9% sodium chloride syringe) and 5mls Hepsal 10 iu/ml in a 10ml syringe. Place in your clean tray protecting key parts. To contain any contamination. Ensure you expose the whole area of the CVC and assess. Decontaminate hands with alcohol hand gel, put on non sterile gloves. Lift the CVC and remove the bung and place in clinical waste bag. (If it is a line with a clamp, ensure that clamp is closed first). To prevent entry of air in, or leakage of blood out. Use a new 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe to clean the hub of the line for at least 30 seconds using different parts of the wipe and allowing to air dry completely. Removes any debris from the hub. Air drying ensures wipe is effective. Rationalise what you are doing; following an infusion there is no requirement to withdraw blood prior to flushing. Using an ANTT, attach empty 10ml syringe, open clamp and withdraw 10mls blood. To establish patency and position of line, to remove stale Hepsal and potential bacteria. Attach 10ml syringe of 0.9% sodium chloride, open clamp and flush slowly using a push pause technique to create turbulence in the line. Ask the patient to report any discomfort. And observe for swelling during administration. Close clamp and discard syringe. To check for problems or infiltration. Attach syringe of Hepsal 10 iu/ml Open clamp and slowly flush. To lock the CVC and prevent it blocking between use. Close clamp on CVC whilst injecting the final 1ml of Hepsal To maintain positive pressure in the line and prevent backflow of blood. 8

Remove syringe and discard. Attach new sterile bung maintaining ANTT. Dress line site if necessary. Discard waste as per hospital policy. 4. Procedure for dressing a Central Venous Catheter The initial dressing needs renewing after 24 hours When exit site sutures are removed, cuffed central lines do not need a dressing but do need looping and securing with tape. Equipment: Dressing pack (containing sterile gloves) Plastic apron 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe (Chloraprep) Semi-permeable transparent dressing (e.g. IV 3000) Alcohol based hand rub Procedure and rationale (Always use a Aseptic Non Touch Technique keeping key parts protected) Explain procedure to patient and ensure privacy. Decontaminate hands as per policy. Wash hands with soap and water and dry. Use alcohol hand gel To minimise risk of infection. Open dressing pack and open required equipment onto sterile field. To minimise potential contamination. Gently loosen old dressing and discard. To prevent tugging on the CVC. Inspect CVC exit site. To observe for signs of infection. Clean hands with alcohol based hand rub and allow to dry. Put on sterile gloves. To minimise risk of infection. Place sterile towel from the dressing pack under catheter. To absorb excess cleaning solution, and provide wider clean field Clean using 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe, (Chloraprep is preferred using a back and forth gentle scrub movement). Discard applicator into clinical waste. Allow to air dry. To prevent infection spreading. (Chloraprep complies with the Department of Health, Saving Lives delivery programme) Loop the catheter tubing around the exit site. Check patient is comfortable with line position. To prevent accidental pulling of line and irritation of exit site. 9

Affix transparent semi-permeable dressings (e.g. IV 3000) until sutures are removed and exit site is healed, clean and dry. Following removal of sutures, line may be secured with tape, avoiding the exit site. The Dacron cuff will keep the line in place after the initial 3-4 weeks. The risk of infection following healing is minimal. 5. Non skin tunnelled Central Venous Catheters Non tunnelled catheters are sometimes inserted. The lifespan of a Non Tunnelled line is much shorter than a tunnelled, Groshong or PICC line. On average it will be used for treatments lasting up to 3 weeks. The line requires removal or replacing every 5 days and is mainly found in acute settings such as ITU or HDU. The device provides reliable access and as it can have up to five lumens is ideal for patients requiring multiple therapies. However, they can often look very frightening to patients and their relatives and can be uncomfortable as they are sutured in place and head movements and the weight of administration sets can cause pulling on the sutures. They can also be difficult to dress due to their position, which may lead to movement of the catheter and subsequent mechanical thrombophlebitis. The risk of infection is also much greater than with other CVADs, which may be related to the difficulty of maintaining an intact dressing, frequent handling and multiple lumens. Manufacturers are now producing catheter materials that are impregnated with antimicrobials and antibacterials (Makki 1997). However, nothing should replace a good aseptic technique in practice during insertion and with management once the catheter is in place. The flushing, dressing and blood sampling procedures are the same as for a skin tunnelled CVC. 6. Peripherally Inserted Central Catheter (PICC) The PICC is an intermediate to long term CVC with an average life span of 3-6 months. They can be used for blood sampling, the infusion of IV fluids, antibiotics and other drugs, chemotherapy, parenteral feeding and transfusion of blood and blood products. PICCs are made of radio opaque silicone material. They are finer than cuffed CVC s and more flexible, which enables them to be peripherally inserted with minimal trauma to the patient. The most common type has a Groshong valve at the tip (Groshong is a registered trademark of Bard Ltd.), although some PICCs can be open ended with clamps and should be treated the same as a tunnelled central line. This valve is a pressure sensitive 2 way valve which opens outward to allow fluid to be injected or infused into the catheter and inward to allow blood to be withdrawn. When not in use, the valve remains closed thus preventing blood from flowing back into the catheter and air from entering the venous circulation. The valve also protects the tip of the catheter from clotting and a weekly flush with saline using a positive pressure technique is sufficient to maintain patency (Egan-Sansivero, 1995). Insertion must be an aseptic procedure performed by suitably trained personnel. Topical local anaesthetic is applied to the cannulation site prior to insertion. It is inserted via the basilic, median cubital or cephalic veins located in the ante cubital fossa or upper arm, with its tip in the superior vena cava. Placement is always verified by x-ray before use. 10

Indications for patient selection for a PICC Patients with problematic IV access Patients with needle phobia Patients who are unable to have subclavian/jugular catheters inserted due to clotting problems, previous surgery or anatomical distortion. Patients with poor lung function increasing the risk of complications due to pneumothorax Advantages of the PICC No insertion risk of pneumothorax or haemothorax which are potential risks with a cuffed tunnelled CVC. Can be inserted in patients where subclavian/jugular cuff tunnelled CVC s are contraindicated. IV nurses with good cannulation skills can quickly learn the insertion technique. Saves multiple peripheral cannulation and venepuncture. Insertion is less traumatic for the patient than insertion of a cuffed tunnelled CVC. Have been shown to reduced rate of catheter sepsis due to reduced number of bacteria present on the arm, (Carlson 1999, 2001). Provides reliable IV access with reduced risk of extravasations and infiltration. Disadvantages of the PICC Require regular maintenance, weekly flushing and dressing with the need for strict asepsis. They are a visual reminder to the patient of their therapy. They have a maximum of two lumens therefore may be unsuitable for patients on simultaneous treatments. Patients need to have good IV access in the ante-cubital fossa. The rate of blood aspiration and infusion fluids is slower due to the small lumen of the PICC. Post insertion complications Bleeding from the insertion site A gauze pressure dressing is applied for the first 24 hours post insertion. If bleeding is still a problem, the site must be inspected and further pressure applied. Bruising at the insertion site This can be common following insertion. Pressure at the insertion site and a cold compress can help to alleviate bruising. Mechanical phlebitis This is caused by the vein trying to reject the PICC and can often be mistaken for infection. The symptoms are swelling, discomfort and inflammation at the insertion site. This commonly occurs within the first 7 days post-insertion and is treated by alternating warm and cold compresses intermittently (e.g.20 minutes at a time, for 48 hours). This dilates the vein and minimises the risk of catheter rejection. If symptoms persist, the patient must be seen by an appropriately skilled member of staff. Infection see page 4 (same as long term catheter) Blood sampling from a Groshong catheter/picc Blood sampling systems can be used, due to the narrow lumen, blood must be withdrawn slowly, as aspirating too quickly can cause the catheter to collapse. Blood will also take longer to obtain from a Groshong catheter as the valve has to be allowed time to open. 11

An inability to obtain blood may be due to: Clot or fibrin occluding the catheter/failure of the Groshong valve/incorrect aspiration technique or line tip on vessel wall. NB blood sampling should not be taken from a dedicated Parenteral Nutrition (PN) line, if unavoidable greater waste is required prior, and the Laboratory need to be informed. 7. Procedure for blood sampling from a Groshong catheter/ PICC Use a luer-lock syringe if available or if the patient is high risk, protecting you from splash back.. For management of problems see attached inpatient algorithm. Equipment:- Suitable plastic tray cleaned with 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe Non Sterile gloves 10ml syringe x 2 (20mls following PN) 10mls Saline 0.9% (or use pre filled 0.9% saline syringe) Blood sampling system (e.g. Vacutainer) Appropriate bottles for blood tests required 2% Chlorhexidine in 70% alcohol isopropyl (Sani-cloth) wipes x 2 Sterile bung or needle-free positive pressure bung Green needle Alcohol hand rub Procedure and rationale (Always use a Aseptic Non Touch Technique keeping key parts protected) Explain procedure to patient and check identity by asking patient s name, date of birth and address/hospital number. To gain patients consent and co-operation. Decontaminate hands. Put on an apron. To minimise risk of infection. Clean your tray with 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe and assemble equipment using ANTT. To ensure procedure goes smoothly. ANTT is the national standard to minimise potential contamination. Draw up 10mls of 0.9% sodium chloride (or use pre filled 0.9% sodium chloride syringe). Place in your clean tray. To contain any contamination. Clean hands with isopropyl alcohol rub, put on non sterile gloves. Ensure you have exposed as much of the arm area as possible not just the hub. To assess and observe any potential problems. Lift the PICC carefully, remove the bung and place the bung into the clinical waste bag. Use a new 2% Chlorhexidine gluconate and 70% isopropyl alcohol wipe to clean the hub of the line for at least 30 seconds using different parts of the wipe allowing to air dry completely before use. 12

Removes any debris from the hub. Air drying ensures 2% Chlorhexidine in 70% alcohol is effective. Using ANTT, attach empty 10ml syringe, open clamp and withdraw 5-10mls blood slowly. To establish patency and position of the line and to remove potential bacteria. Discard waste blood filled syringe into sharps bin. (Unless for blood culture sample). To avoid blood spillage. Attach adapter using ANTT and insert required blood bottles. When all bottles are filled remove adapter put this into sharps bin. Attach 10ml syringe of 0.9% sodium chloride, flush slowly using a push pause technique to create turbulence in the line. Disconnecting the syringe on a positive push, Then discard syringe. Blood will clot very quickly in the lumen and should be flushed immediately. The pulsated technique achieves a more effective flush. Attach a new bung ensuring it fits correctly. BD Luer-Lock caps are the best fit for Groshong PICCs. NB If you have taken blood samples with a syringe. Fill the blood bottles by removing lids. Never inject through the top of the bottle. Forcefully injecting blood through needles/rubber bungs will cause haemolysis of blood cells and inaccurate results. To reduce the risk of needlestick injury. Re-apply dressing if necessary as per policy. Ensure that the dressing is comfortable for the patient. Discard waste as per trust policy. 8. Flushing of Groshong catheters In order to flush whilst maintaining positive pressure within the catheter, a different technique must be employed as the catheter does not have clamps to enable this. Flush briskly with saline 0.9% in a 10ml syringe or larger and during the final 2-3mls of fluid, pull the syringe off the catheter whilst maintaining positive pressure with the remaining saline, some trusts use a needle-free system which flushes under positive pressure for you. - Carry out the procedure weekly or after use with 10mls sodium chloride (20mls if following a PN infusion) using a positive pressure technique. - A 10ml syringe or larger should be used. - Treat each lumen of a Groshong catheter as a separate line. - Procedure for flushing is the same as for following blood sampling described above, 10mls blood is withdrawn using a 10ml syringe and discarded. - If a community nurse is flushing the catheter in the patient s home and cannot withdraw blood they must not flush the line but follow the District Nurse Algorithm. 13

9. Dressings The catheter is not cuffed and will always require fixation with either sutures/steristrips or a statlock. If the PICC is not securely fixed: - The catheter will fall out - Mechanical phlebitis may occur The PICC requires weekly dressing changes or more frequent if the dressing is soiled or loose. Old dressings must be removed with great care as not to dislodge or twist the lumen of the catheter when the bung is removed. Carefully replace steristrips/statlock, if used, with each dressing change, normally weekly. Always ensure the patient is comfortable with the dressing. 10. Procedure for dressing a Groshong PICC A pressure gauze dressing is applied immediately after insertion to minimise bleeding and bruising. This should be removed and the catheter re-dressed after 24 hours. The dressing should be changed weekly unless soiled or loose, using strict Aseptic Non Touch Technique. Equipment:- Sterile dressing pack Sterile gloves Chloraprep or 2% Chlorhexidine in 70% Isopropyl alcohol Large semi-permeable dressing e.g. IV 3000 Isopropyl alcohol based hand rub Steri-strips/statlock (if necessary) Procedure and rationale (Always use a Aseptic Non Touch Technique keeping key parts protected) Explain procedure to patient. Decontaminate hands as per trust policy. To minimise the risk of infection. Open dressing pack onto clean trolley and place required equipment onto sterile field. To minimise potential contamination. Loosen old dressing and remove carefully. Use sterile gauze to secure catheter. To prevent tugging on the catheter and possible dislodgement. Inspect the catheter exit site for redness, swelling and signs of infection. To detect problems early and initiate prompt treatment of any post insertion complications. (If apyrexial, redness and swelling possible mechanical phlebitis) Decontaminate hands with isopropyl alcohol hand rub and put on sterile gloves. To minimise risk of infection. 14

Clean the exit site using Chloraprep, or 2% Chlorhexidine gluconate and 70% alcohol wipe. Allow to air dry. To prevent infection spreading from one area to another. Re-apply steri-strips/statlock if required. Place sterile semi-occlusive dressing IV 3000 directly onto catheter insertion site (do not occlude with gauze) including the external part of the catheter under the dressing if the catheter is not in regular use. A piece of sterile gauze can be placed underneath the hub for patient comfort. A clear, semi-occlusive dressing is more effective in minimising the risk of infection. This provides secure fixation of the catheter and a waterproof barrier for the hub/bung when showering. Ensure the patient finds the dressing comfortable. Dispose of waste as per trust policy The procedure for dressing a centrally inserted Groshong catheter or jugular/femoral catheter is the same for a skin tunnelled CVC. 11. Totally Implantable Vascular Access Device (TIVAD) TIVAD s are suitable for patients requiring long term intermittent venous access. They are most commonly inserted in the chest or in the ante cubital fossa of the arm. The port is placed by making an incision into the patient s skin, creating a subcutaneous pocket. The device is then anchored, with sutures, to the underlying muscle and the catheter tunnelled under the skin until it reaches the desired venous access point. The overlying skin is then surgically closed. Only trained personnel should access the device and a non-coring angled needle used. Local guidelines should be adhered to. The main advantage of the system is that it causes very little disturbance to daily activities and body image is not threatened. Many patients can play sport and swim with an implantable port in situ (Camp-Sorrell, 1992). The TIVAD requires only minimal flushing, usually once a month, and the risk of infection is less compared with other CVADs, (EPIC technical report, 2000). TIVAD s are removed under local or general anaesthetic. 15

12. REFERENCES AND BIBLIOGRAPHY Alderman C (April 1998) Chemotherapy by catheter. Nursing Standard. 12. (28). Aseptic non touch technique ANTT (2007) national standard S.Rowley Besley M (1991) Opsite IV3000 Improving Catheter Site Care. In Maki, D. (Ed) Royal Society of Medicine Services. Camp-Sorrell D (1992) Implantable ports: Everything you always wanted to know. Journal of Intravenous Nursing 15, 5, 262-273. Carlson, K.R (1999) correct utilisation and management of PICCs and midline catheters in the alternate care settings. Carlson K (2001) infection control in; infusion therapy in clinical practice, 2 nd edition pp126-40. Christie Hospital NHS Trust (2006) Principle and Practice Manual Guide to Intravenous Therapy Care of CVC/PICC. Conn C et al (1993) The importance of syringe size when using VADs. Journal of Vascular Access. 3 (1). Cornock M (1996) Making sense of central venous catheters. Nursing Times. 922 (49): 30-31. DH, 2001 Guidelines for the preventing infections associated with the insertion and maintenance of central venous catheters. In Journal of hospital infection, 47 (supplement), S47-S67. (I) Egan-Sansivero G (July 1995) Why pick a P.I.C.C? What you need to know. Nursing 95. Pp35-40. Elliot T et al (1994) Guidelines for good practice in CVC. Journal of Hospital Infection. 163. Gabriel J (1996) P.I.C.Cs: Expanding UK nurses practice. Surgical Nurse 5 (2): 71. Goodwin M, Carlson I (1993) The P.I.C.C: A retrospective look at 3yrs of insertions. Journal of Intravenous Nursing. 16 (2): pp92-103. Gourlay DA (1996). Central venous cannulation. British Journal of Nursing. 5 (1): 8-15. Henderson N (1993) Central Venous Lines. A Guide to Intravenous Therapy. RCN Continuing Education Reader. INS, 2000 infusion nursing standards of practice in journal of intravenous nursing, 23, (6S), supplement (111) 16

REFERENCES AND BIBLIOGRAPHY Makki D G (1993) Complications associated with IV therapy. Paper presented at the 7 th NAVAN conference, Washington. Makki D G et al (1997) Prevention of central venous catheter related blood stream infection by the use of an antiseptic impregnated catheter. Annals if internal medicine. 127. 4. Pp257-266. NICE 2003 RCN (2003/Nov 2005) Standards for infusion therapy Richardson D, Bruso P (1993) Vascular access devices management of common complications. Journal of Intravenous Nursing 16 (1): pp44-49. Scales K (1999) Vascular access in the acute care setting in Dougherty L, Lamb J (Eds) IV therapy in nursing practice. Edinburgh, Churchill Livingstone. The Royal Marsden Hospital (1993) Care of patients with central venous lines. Manual of Standards of Care. 3 rd edition. 69. Todd J (Feb 1998) Peripherally inserted catheters. Professional Nurse. 13 (5). Weinstein TSJ et al (1997) Plumer s principles and practice of intravenous therapy. Sixth edition. Philadelphia PA. JB Lippincott. EPIC2 National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England 2006 final draft page 71. BCSH Guidelines for the Insertion and Management of Central Venous Access Devices (2006 page 8). 17

Algorithm: Unable to aspirate blood from a tunnelled central venous catheter (INPATIENTS) Inform medical team, investigate for possible thrombosis (Doppler U/S) Yes Any signs/symptoms of thrombosis NO Remove dressing and loop in line Open clamp and move its position Roll line between fingers where clamp has been Gently stretch line ensuring secured at exit site Ask patient to take deep breaths and/or cough and/or move arms up and down Document & use CVC If flushing and aspirating document and use CVC, monitor the patient for 2 hours Yes Able to aspirate blood? NO Try flushing the line with 5mls of 0.9% sodium Chloride & aspirating Able to flush but not aspirate blood? Not flushing or aspirating The CVC is blocked refer patient to Procedure team/iv trainers For Flush only Why is the line being accessed? For Chemotherapy Continue with procedure document and use CVC, monitor the patient for 2 hours Discuss with medical team. Request CXR, check catheter tip position Refer to medics who will liaise with Procedure team/radiologists RE: Management NO Is CVC in correct position? YES Instil Urokinase; 5000units in 2mls 0.9% Sodium Chloride and leave for 1 hour, as prescribed Document and use CVC Yes Able to aspirate blood? NO Inform medical team who will Inform medical team who will liaise with Procedure team/radiologists liaise with Procedure team/radiolgists RE: Management RE: Management 18

Advice for District Nurses Information on Central Venous Catheters Your patient had a central venous catheter inserted on... There is a small Dacron cuff on the part of the line which lies under the skin in the skin tunnel, between the clavicle and the exit site where the line comes out. The cuff takes about 3 weeks to knit into the tissues under the skin; it helps to secure the line and also acts as a barrier to help prevent infection. There are 2 sutures in situ: 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 in. DRESSING Formal dressings require a strict aseptic non touch technique (ANTT) and they are required until after the sutures have been removed ( 3 weeks) during this time the exit and insertion sites should be cleaned using a solution of 2% Chlorhexidine Gluconate and 70% isopropyl alcohol e.g. Chloraprep Whilst the sutures are in place, the line must be dressed weekly, more frequently if the dressing becomes loose or soiled, using strict ANTT. The line must remain looped and firmly secured with an opaque, semi permeable dressing e.g. IV3000. Once the sutures have been removed, formal sterile dressings are no longer required but the line must remain looped. Surgical tape is sufficient to support the line. The patient is allowed to shower or bath as usual, however, showers are preferable. If baths are taken, please remind the patient to tape the line up and ensure that neither the hub nor exit site is submerged. PLEASE REMIND PATIENTS TO CONTINUE TO USE AN ANTIBACTERIAL BODY WASH (E.G. HIBISCRUB) TO BATH OR SHOWER AND WASH THEIR HAIR UNTIL THE LINE IS REMOVED When continuous infusion pumps are running the line does not need to be flushed. However, if no therapy is in progress, the line will need to be flushed with normal 0.9% sodium chloride and 5mls of Hepsal 10 units/ml once every week whilst the patient is at home. Please note: All essential equipment will be provided for the first dressing/flushing of the line when patients are discharged from The Christie. We will continue to supply bungs, and if you are having difficulty obtaining IV 3000 dressings we will supply these for the first three weeks. Thereafter, they are no longer required. Page 1 of 2 19

Page 2 of 2 Procedure for flushing and locking a skin tunnelled central venous catheter line in the community Materials required: Clean Field i.e. plastic tray or dressing towel 3 x large sterile wipes of e.g. Sani cloth 3 x 10mls syringe (for each separate lumen) 2 x Green needle 10mls of normal saline 0.9% (for each separate lumen) Sterile bung (one for each lumen) 5mls heparinised sodium chloride10 units per ml e.g. Hepsal (for each separate lumen) Each lumen should be accessed separately, setting up a clean field each time. 1. Wash hands thoroughly. Remove soiled dressing and wash or alcohol gel hands again. Prepare clean field, by cleaning plastic tray with 2% Chlorhexidine in 70% isopropyl wipe and allowing to air dry for at least 30 seconds. Or open dressing towel. 2. Draw up 10mls normal 0.9% sodium chloride and 5mls heparinised saline 10 units per ml. Protect key parts by putting back in to packaging and placing on to the clean field. 3. Open and place all other equipment and place on to clean field protecting all key parts. 4. Alcohol gel hands and put on clean non-sterile gloves. Pick up the CVC ensuring the line is clamped shut. Remove the bung and discard. Clean the hub with 3 different areas of the 2% Chlorhexidine wipe (Sani-cloth) for at least 30 seconds and allow to completely air dry. Hold on to the line at all times. Do not drop. Always protect your key parts. 5. Attach an empty 10mls syringe to end of line, open clamp and withdraw 10mls of blood. Close clamp and disconnect syringe and discard. If you are not able to withdraw blood close the clamp, attach a new bung and refer to the management of problems related to central venous catheters in the community (Appendix 3) 6. To flush the line, attach syringe of normal 0.9% sodium chloride, open clamp and slowly flush in, using push pause technique. Close clamp, disconnect syringe and discard. 7. To lock the line, attach syringe of heparinised saline 10 units per ml, open clamp and flush in slowly. Clamp line whilst administering the final 1ml of Hepsal, to maintain positive pressure and prevent the backflow of blood into the line. 8. Clean again if required and allow to air dry for at least 30 seconds. Attach new bung. Please note: Before chemotherapy is administered via a central line/picc, blood must always be withdrawn to ensure that the tip of the line remains in the vein. Please ring The Chemotherapy Day Services on 0161-446 3713 or The Christie IV team 0161 446 3796 for queries related to chemotherapy. For queries related to the care and management of the central line or if you wish to observe and practice the flushing and dressing procedures at The Christie Hospital please contact the procedure team on 0161 446 3916 or The IV Team on 0161 446 3796. Christie Hospital Patient Information Service CHR/010/18.11.02 20

Advice for District Nurses Information on PICC maintenance procedure for district nurses. had a Peripherally Inserted Central Catheter (PICC) inserted on. The tip of the lumen is positioned in the superior vena cava and requires a strict aseptic (non touch) technique whenever accessing or dressing the device. The end of the PICC line exits the body at the ante cubital fossa or on the upper arm. PICCs differ from skin tunnelled central venous catheter lines in that they have a pressure sensitive valve at the internal end of the PICC which allows fluid to be injected into the catheter and blood to be withdrawn. When not in use the valve remains closed, thus preventing blood from flowing back into the catheter and air entering the venous circulation. Clamps or switches are not required. The PICC will require a weekly flush with 5-10mls of normal 0.9% Sodium Chloride and a dressing change at least weekly or as required. Heparinised saline is not required for flushing this device. The procedure for flushing and dressing the PICC is outlined below. Nursing care following PICC placement PLEASE REMIND PATIENTS TO CONTINUE TO USE AN ANTIBACTERIAL BODY WASH (E.G. HIBISCRUB) TO BATH OR SHOWER AND WASH THEIR HAIR UNTIL THE LINE IS REMOVED The patient should be monitored for the following potential complications: Bleeding from insertion site If this occurs, apply a sterile gauze pressure dressing to the site for 24 hours. Observe the site, and then change to a transparent dressing such as IV 3000 Bruising at insertion site Related to vein trauma at insertion. Monitor for changes. Inflammation, oedema and/or tenderness above site This may be related to trauma and possible chemical or dressing reactions and may involve the ante cubital fossa region of the arm. Change dressing to another occlusive type and monitor. If problems persist, please contact the Chemotherapy Day Services (0161-446 3447) for advice. Mechanical phlebitis This is inflammation of the vein caused by the body s response to the catheter and may involve the inner proximal region of the arm. This may occur more commonly during the first 7 days post insertion, but may be a delayed response. Please contact The Christie hotline 0161 446 3658 or the Procedures Team 0161 446 3916 for advice. This is not an infection process. We advise patients to perform light arm exercises and to apply warm compresses intermittently (for example, 20 minutes at a time for 48 hours) post insertion. This will dilate the vein and encourage blood flow, and may need to be continued until the reaction settles. We also ask patients to monitor their temperature during this period, and to contact The Christie Hotline on 0161-446 3658 if abnormalities are detected. 21

Procedure for flushing and dressing a PICC Page 2 of 2 Dressing Materials required: Clean Field i.e. Plastic tray or dressing towel Chlorhexidine Gluconate 2% and isopropyl alcohol 70%. (Chloraprep is recommended) Steristrips s or STATLOCK if sutures are not in place 2 large IV 3000 dressings (10cm x 14cm) or transparent occlusive dressing Wash and dry hands thoroughly. Prepare clean field i.e. clean plastic tray with 2% chlorhexidine wipe (Sani-cloth) and and allow to air dry for at least 30 seconds or open dressing towel. Place all equipment onto the clean field, ensuring key parts are protected. Loosen and very carefully remove the soiled dressing ensuring the PICC remains secured by steristrips, sutures or STATLOCK. Inspect site for signs of tenderness, inflammation and/or swelling. Wash or alcohol gel hands again and put on non sterile gloves, clean the exit site using Chlorhexidine Gluconate 2% and isopropyl alcohol 70%. Chloraprep is recommended, allow to air dry. Replace the STATLOCK and occlusive dressing. Please remember to use the skin preparation in the Statlock packet to protect the patient s skin, prior to placing the STATLOCK. FLUSHING Clean field i.e. plastic tray or dressing towel 3 x large wipes of Chlorhexidine Gluconate 2% and isopropyl alcohol 70%. 2 x 10mls syringe (for each separate lumen) Green needle 10mls of normal 0.9% sodium chloride (for each separate lumen) Sterile bung (one for each lumen) - Small white bungs only please. 1. Wash or alcohol gel hands and prepare clean field. Cleaning plastic tray with 2% Chlorhexidine wipe, allowing to air dry for at least 30 seconds or open dressing towel. 2. Draw up 10mls normal saline 0.9% and place on to clean field ensuring all key parts are protected by putting syringe back into packaging. 3. Open and place all other equipment onto sterile field. 4. Wash or alcohol gel hands and put on non sterile gloves. Pick up the PICC. Remove the bung and discard. Clean the hub with 3 different areas of the 2% Chlorhexidine wipe (Sani-cloth) for at least 30 seconds and allow to completely air dry. Hold on to the line at all times. Do not drop. Always protect your key parts. 5. Attach an empty 10mls syringe to end of line and withdraw 10mls of blood slowly. Disconnect syringe and discard, as per trust policy. If you are not able to withdraw blood attach a new bung and contact The Christie for advice. Please see attached algorithm (Appendix 3) 6 To flush the line; attach the saline syringe and slowly flush using a push pause technique, to maintain positive pressure and prevent the backflow of blood into the line. 7 Clean again if required and allow to air dry for at least 30 seconds. Attach a new small white sterile bung. Please note: Before chemotherapy is administered via a central line, blood must always be withdrawn to ensure that the tip of the line remains in the vein. For queries related to chemotherapy please ring The Christie Chemotherapy Day Services on 0161-446 3713 or The Christie IV team 0161 446 3796. If you have any queries or concerns about any aspect of care and maintenance of PICCs or if you would like to observe this procedure at the Christie hospital (Monday to Friday from 0900-1600) please contact The Christie Procedure Team on 0161 446 3916. The Christie Patient Information Service May 2006 CHR/PRO/117/23.02. 22