Policy for the Insertion and Management of Central Venous Catheters (CVC s)

Policy for the Insertion and Management of Central Venous Catheters (CVC s) This APD supersedes PAT/T 23 v.2 Name and title of author/reviewer Louise Lowry, IP&CP- Lead for Invasive Devices Date revised September 2009 Approved by (Committee/Group) Date approved 3 September 2009 Date issued March 2010 Next review date August 2012 Target audience: Trust-wide Patient Safety Review Group WARNING: Always ensure that you are using the most up to date approved procedural document. If you are unsure, you can check that it is the most up to date version by looking on the Trust Website: www.dbh.nhs.uk under the headings Freedom of Information Information Classes Policies and Procedures Page 1 of 22

Policy for the Insertion and Management of Central Venous Catheters (CVC s) Amendment Form Version Date Brief Summary of Changes Author Version 3 September 2009 Added Appendix 2 Dressing change guidance for Central Venous Access Devices (CVADs) and Appendix 3 - Total Parenteral Nutrition (TPN) - Best Practice Guidelines Louise Lowry Version 2 August 2008 Title from Guidelines to Policy Section on TPN updated page 10 Section on CVC line removal incorporated page 11 Appendix added pages 15 and 17 References updated Gary Donaghue, Emma Stables and the Invasive Device Group Page 2 of 22

Policy for the Insertion and Management of Central Venous Catheters (CVC's) TABLE OF CONTENTS Page No. Table of contents 3 Aims/Objectives/Introduction 4 Identifying need and type of CVC 4 Catheter Insertion 6 - Ultrasound Guidance 6 - General Preparations 6 Documentation 7 Dressing and CVC site care 7 Line replacement 9 References 10 Definition of terms 11 Appendix 1a - Procedure summary for removal of non-tunnelled 12 Central Venous Catheter Appendix 1b - Procedure summary for removal of Tunnelled 14 Central Venous Catheter Appendix 2 - Dressing change guidance for Central Venous Access 16 Devices (CVADs) Appendix 3 - Total Parenteral Nutrition (TPN) - Best Practice Guidelines 18 for commencing feeds and discontinuation of feeds Page 3 of 22

Policy for the Insertion and Management of Central Venous Catheters (CVC's) AIM To promote the appropriate and, safe use of CVCs throughout the Trust. OBJECTIVES 1. To identify the need for CVC and selection of catheter type. 2. To undertake appropriate preparation prior to and during placement of CVC. 3. To document the procedure. 4. To choose a relevant dressing and renew when appropriate. 5. To safely access line when required. 6. To identify a line replacement strategy when required. This policy should be read in conjunction with the following policies, particularly: Hand Hygiene (PAT/IC 5) Safe use and disposal of sharps (PAT/IC 8) Management of inoculation injuries (PAT/IC 14) Policy for the consent to examination or treatment ( PAT/PA 2) Aseptic Non Touch technique (PAT/T 32) INTRODUCTION Bloodstream infections associated with the insertion and maintenance of CVCs are among the most dangerous complications that can occur, prolonging the period of hospitalisation, increasing the cost of care and worsening the severity of the patient s underlying ill health (Epic 2 2007). Approximately 3 in every 1000 patients in UK hospitals acquire a bloodstream infection. A third of these infections will be related to central venous catheters (EPIC 2 2007). IDENTIFY NEED FOR CVC FIGURE 1 INDICATIONS FOR CVC INSERTION (from Curtis et al 1997) THERAPEUTIC INDICATIONS Administration of Intravenous therapy Performance of Plasmapheresis Performance of Haemodialysis Measurement of CVP DIAGNOSTIC INDICATIONS To establish or confirm a diagnosis and monitor the response to treatment Page 4 of 22

FIGURE 2 POINTS TO CONSIDER PRIOR TO CVC INSERTION (from Dougherty 2000) 1. Will the CVC be required long or short term? 2. Is the therapy continuous or intermittent? 3. What types of drugs/therapies are being used? (e.g. blood transfusions) 4. How many lumens are required? 5. Has the patient had: - Previous surgery such as mastectomy? - Previous problems with CVC insertion? - Surgery or radiotherapy to chest or neck? - Fractures such as clavicle? 6. Does the patient have a clotting disorder? 7. Does the patient have suitable venous access? 8. What is the patient s cardio- respiratory function and are they able to lie flat? 9. Is the patient at increased risk of infection? (e.g. immunocompromised) 10. Is the patient known to be allergic to: - Local anaesthetic? - Sedation? - Dressing? - Cleaning solution? 11. Is the patient cardiovascularly stable? (e.g. pacemaker cardiac arrhythmias) A single lumen catheter should be used unless multiple ports are essential for the management of the patient. If TPN is being administered, use a single lumen (or a dedicated lumen) exclusively for that purpose. Use a tunnelled catheter or implantable vascular access device for patients in whom long-term vascular access is anticipated (>30 days). It is recommended that silver impregnated catheters are used in adults whose CVC is expected to remain in place for more than 5 days. (EPIC 2 2007). In selecting an appropriate insertion site, assess the risk for infection against the risk of mechanical complications. Latest evidence based practice is to use the subclavian as this is suggested to reduce the risk of infection of site (EPIC 2, 2007). Ultrasound guided placement is preferred but is usually only of benefit with internal jugular CVC's. Subclavian CVC may be preferable for longer- term use (easier to fix in place, more comfortable) and when tunnelled lines are being used but has a higher complication rate. Femoral veins should only be used when other routes are impossible. Consider the use of peripherally inserted catheters (PICC) as an alternative to subclavian or jugular vein catheterisation. Evidence suggests they are associated with a reduction in catheter sepsis, patient discomfort and provide reliable access (Marsden Manual 2008). Page 5 of 22

CATHETER INSERTION Prior to insertion of CVCs, please ensure the appropriate consent is obtained in accordance with trust policy on consent (PAT/PA 2). Ultrasound Guidance Central venous access has traditionally been achieved using the landmark methods. However, failure rates up to 35% for initial CVC insertion have been reported (NICE 2002 p2). Two-dimensional (2-D) imaging ultrasound guidance allows visualisation of the desired vein and surrounding structures before and during insertion and is the method of choice. Audioguided Doppler is not recommended as a method of vein identification. In emergency situations when ultrasound equipment and/or expertise is not immediately available, use anatomical landmark methods. Therefore, it is important that this method is taught alongside the 2-D ultrasound-guided technique (NICE 2002). Operators must be trained to use ultrasound-guided techniques. This involves acquiring the necessary manual skills, together with understanding ultrasound principles and the ability to interpret ultrasound images. Training must be carried out in accordance with the Medical Equipment Training Strategy (i.e. it is recorded on database following completion and return of the appropriate training documentation, to the Medical Equipment Department). 2-D imaging ultrasound guidance is recommended as the preferred method for insertion of CVCs into the internal jugular vein, in adults and children in elective situations. 2-D imaging ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary either electively or in an emergency situation. It is recommended that all those involved in placing CVCs using 2-D imaging ultrasound guidance undertake appropriate training to achieve competence. Audio-guided Doppler is NOT recommended for CVC insertion. General Preparations The hands of staff are the most common vehicle by which micro-organisms are transmitted between patients and are frequently implicated as the route of transmission in outbreaks of infection (Wilson 2006 p157). The clinician/practitioner must be competent (or working under the supervision of a competent person) at CVC insertion. They should adhere to the manufacturers guidelines for the device used. Insertion should take place in a clean environment, which can be easily decontaminated. Page 6 of 22

Use optimum aseptic technique including a sterile gown, gloves and a large sterile drape, for the insertion of CVCs (EPIC 2 2007 pps39). Prior to insertion, hands must be decontaminated in accordance with the Trust s Hand Hygiene Policy (PAT/IC 5) Clean the insertion site with a 2% chlorhexidine gluconate in 70% Isopropyl alcohol solution prior to CVC insertion. Use an alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter (at least 30 seconds).n.b. Aqueous Chlorhexidine Gluconate products and not alcohol or iodine based products to be used on neo-natal patients (Irving 2001). Do not apply organic solvents, e.g. acetone, ether to the skin before catheter insertion. Do not apply antimicrobial ointment to the catheter placement site prior to insertion. Ensure that all sharps are used in accordance to the Trust Policy Safe use and disposal of sharps (PAT/IC 8). Adhere to the Trust policy Management of inoculation injuries (PAT/IC 14) regarding any needlestick injuries. DOCUMENTATION The CVC insertion must be documented in the patients records, including date, time, site and clinician. To enable identification of any defective or contaminated central venous catheter, the batch number of the catheter used must be recorded. (Medicines & Healthcare products Regulatory Agency 2004). Nursing care must also be recorded and evaluated each shift. This must include exit site and condition of dressing. DRESSING AND CVC SITE CARE The aim of an intravenous dressing is to minimise the contamination of the insertion site and provide stability of the device. If a gauze dressing has been applied due to bleeding, it should be replaced by a transparent dressing as soon as possible (NICE 2003 p14). Use a sterile transparent semi-permeable polyurethane dressing to cover the catheter site. Strict hand washing must be observed at all times, i.e. before and after touching line. Replace dressing if it becomes damp, loose or soiled. Page 7 of 22

Skin must be cleaned using 2% Chlorhexidine in 70% Isopropyl alcohol and allowed to dry prior to new dressing being applied. OR other appropriate solution if patient has sensitivity to Chlorhexidine. Do not apply antimicrobial ointment to the CVC insertion site during routine catheter site care. Needle free access devices to be connected to lumens. These must be cleaned with 2% Chlorhexidine in 70% Isopropyl alcohol before and after accessing lines for administering infusions or injections. Replace needle free access devices after 7days. The site and connections should be inspected at least once a shift and whenever there is clinical cause for concern and findings documented (Woodrow 2002). Please see appendix 2 for CVC Line care sheet. To access the central venous device for blood sampling, flushing of line etc. follow procedural guidance in the relevant chapter of Dougherty & Lister (2008) [Marsden Book of Nursing Procedures]. Lumens in continuous or daily use do not usually require flushing to maintain patency, but a Saline-Additive-Saline method should be employed during any administration of an additive. Long-term catheters used for intermittent drug administration (such as Hickman lines) should be locked weekly with heparin, determined by local policy, such as critical care and renal areas. Contact the Trust pharmacist for advice. The use of heparin for locking lines must either be prescribed prior to administration or alternatively may be administered by a healthcare professional named on a Patient Group Direction. Prior to accessing any part of the CVC system, hands must be decontaminated in accordance with the hand hygiene policy (PAT/IC 5). Catheter hubs or needle free device should be decontaminated using 2% Chlorhexidine in 70% Isopropyl Alcohol, unless contraindicated by manufacturer s recommendation (EPIC2, 2007). Replace all tubing when the vascular access device is replaced. Replace intravenous tubing and stopcocks (for non-lipid and non-blood products) no more frequently than at 72 hour intervals, unless clinically indicated. Replace intravenous tubing used to administer lipid emulsions at the end of the infusion or within 24 hours of initiating the infusion. Page 8 of 22

Replace intravenous tubing used to administer blood and blood components after every second unit, after transfusion episode OR at 12 hours, whichever is sooner. (EPIC 2 2007, Marsden Manual 2008). Intravenous tubing used for TPN should be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours. N.B. TPN should not be administered via a peripheral cannula. CENTRAL VENOUS CATHETER REPLACEMENT When and how CVC's are replaced can influence the risk of infection (Epic 2 2007). Routine replacement of CVC's was seen as a method of preventing phlebitis and catheter-related infections (Richet et al 1990 cited by Pearson 1996). However, evidence suggests that routine replacement of CVC's without a clinical need does not reduce the rate of catheter colonisation or the rate of catheter related-bloodstream infection (Pearson 1996). Cook et al (1997) suggested that catheter replacement on an as needed basis was more beneficial in reducing infections. Methods: The CVC should be removed if the patient develops a catheter- associated infection and a new catheter inserted at another site. If infection is suspected, the catheter tip should be cultured (Wilson 2006, EPIC 2007). Guide wire-assisted catheter exchange should not be used ( EPIC 2 2007). Do not routinely replace non-tunnelled CVC's as a method to prevent catheterrelated infection. If catheter related infection is suspected, obtain blood cultures from each lumen of the CVC, together with a peripheral sample. Ensure that the origin of each set of culture samples are clearly marked (e.g. CVC sample distal lumen; peripheral sample etc). A clinical assessment for signs of infection at exit site and continue need of CVC line must be carried out daily and documented. Remove any CVC that is no longer required. N.B. Catheters should be removed according to the procedures found in Appendix 1 Page 9 of 22

REFERENCES Curtis, A; Lewis, MD; Timothy, E: (1997) SPECIAL COMMUNICATION QUALITY IMPROVEMENT GUIDELINES FOR CENTRAL VENOUS ACCESS: Society of Cardiovascular and Interventional Radiology: Standards and Practice Committee: May-June 1997 Dougherty, L & Lamb, J (Eds.) (2008):2ND Edition: Vascular access in the Acute Care setting: INTRAVENOUS THERAPY IN NURSING PRACTICE: Blackwell Publishing, Oxford.pp.271-320. Dougherty, L & Lister, S: (Eds.) (2008): 7 th Edition: THE ROYAL MARSDEN HOSPITAL MANUAL OF CLINICAL NURSING PROCEDURES: Blackwell Scientific Publ.: Oxford. EPIC 2: (2007): National Evidence-Based Guidelines for preventing Healthcare-Associated Infections in NHS Hospitals in England: JOURNAL OF HOSPITAL INFECTION: 65S,S1-S64 [on line at: http://www.epic.tvu.ac.uk/pdf%20files/epic2/epic2-final.pdf Irving, V: (2001): Skin problems in the pre-term infant: avoiding ritualistic practice: PROFESSIONAL NURSE: Vol. 17: No.1: p63-663. Medicines & Healthcare products Regulatory Agency [MHRA]: (2004): MEDICAL DEVICE ALERT: MDA/2004/01: January 2004: MHRA: London. NICE [National Institute of Clinical Excellence]: (2002): GUIDANCE ON THE USE OF ULTRASOUND LOCATING DEVICES FOR PLACING CENTRAL VENOUS CATHETERS: September 2002: NICE: London. NICE [National Institute of Clinical Excellence]: (2003): INFECTION CONTROL PREVENTION OF HEALTHCARE-ASSOCIATED INFECTION IN PRIMARY AND COMMUNITY CARE Clinical Guideline 2: June 2003: NICE: London. PAT/IC 5: HAND HYGIENE POLICY & PROCEDURE: Doncaster & Bassetlaw NHSF Trust. PAT/IC 8: POLICY FOR THE SAFE USE AND DISPOSAL OF SHARPS: Doncaster & Bassetlaw NHSF Trust. PAT/IC 14: POLICY FOR THE MANAGEMENT OF INOCULATION INJURIES: Doncaster & Bassetlaw NHSF Trust. PAT/T32: Aseptic Non Touch Technique: Doncaster & Bassetlaw NHSF Trust Richet, B; Nitemberg, G et al: (1990): Prospective multi-centre study of vascular catheter related complications and risk factors for positive central-catheter cultures in intensive care unit patients: JOURNAL OF CLINICAL MICROBIOLOGY: Vol.28: p.2520-2525. Wilson, J: (2006): 3rd Edition: INFECTION CONTROL IN PRACTICE: Bailliere Tindall: London. Woodrow, P: (2002): Central venous catheters and central venous pressure: NURSING STANDARD: Vol.16: No.26: p.45-51. Page 10 of 22

FIGURE 4 DEFINITION OF TERMS Audio-guided Doppler This generates an audible sound from flowing venous blood when placed over the vessel. Bacteraemia Bacteria in the circulating blood. CVC Central Venous Catheter (generic includes all types of central venous catheter devices). Implantable Vascular Access Devices The catheter is totally implanted under the skin and accessed by inserting a needle through the skin into a sub-cutaneous selfsealing port (e.g. Port-a-Cath). Landmark methods This involves passing the needle along the anticipated vein using surface anatomical landmarks and knowledge of the anatomy as a guide. TPN Total parenteral nutrition. Tunnelled Catheter Once inserted into the vein, the catheter is tunnelled under the skin to exit on the chest wall, to minimise migration of ascending microorganisms (e.g. Hickman catheters) Two Dimensional (2-D) imaging ultrasound This provides a real time grey scale image of the anatomy. Page 11 of 22

Appendix 1a Procedure summary for removal of non-tunnelled central venous catheter: (based on Department of Critical Care Procedure and Dougherty & Lister (2008). 1. Explain the procedure to the patient. 2. Place patient in a supine position (to potentially prevent embolism). 3. Cleanse hands with alcohol rub. 4. Prepare sterile field and open supplies. 5. Using clean gloves remove old dressing and dispose in biohazard container. 6. Cleanse hands with alcohol rub 7. Discontinue and disconnect infusions 8. Inspect the area for signs of infection. If indicated swab insertion site for culture. Wash hands and put on sterile gloves. 9. Prep the catheter site with Chlorhexidine. Commence cleansing at the catheter Insertion site, moving outward, in a circular motion. Allow solution to dry. 10. Clip and remove the sutures, holding the catheter (to make sure it is completely free). 11. Instruct patient on Valsalva maneuver. N.B. Valsalva maneuver, forcible exhalation effort against a closed glottis; the resultant increase in intrathroacic pressure interferes with venous return to the heart (Taylor 1988). 12. Place sterile gauze dressing over the insertion site 13. Employing the Valsalva maneuver, using gentle traction, withdraw the catheter. If Any resistance is encountered do not force the catheter and seek senior advice. 14. Apply pressure to gauze over site, using free hand. 15. Avoid any contamination of the catheter tip during removal, if culture is to be obtained. 16. f the catheter tip is to be cultured: Have a colleague assist by cutting off 1 to 2 inches of the catheter at tip into a sterile container, using a pair of sterile scissors NOT the ones used to cut sutures. N.B. Routine line removals do not require the line tip to be sent for culture. Only send tip of line if line related sepsis is suspected. 17. As soon as the catheter is free, apply firm steady pressure to the exit site and place patient in a 45 degree sitting position. 18. Hold pressure for a minimum of 5 minutes. 19. When bleeding stops, dress the site with a sterile transparent bio-occlusive dressing (Tegaderm etc) 20. Inspect the catheter to make sure the tip was removed intact. If not inform senior staff. 21. If the site bleeds, maintain pressure for a further 15 minutes. 22. If bleeding is still present after 15 minutes of undisturbed pressure, contact senior staff. Page 12 of 22

Ongoing care/observation: 1. Instruct patient to: a. Avoid lifting, stooping, squatting, or any strenuous activity for 24-72 hours b. Avoid getting dressing wet or soiled c. Leave dressing in place for 24 hours 2. Signs and symptoms to report: a. Bleeding. b. Shortness of breath. c. Fever. d. Swelling of the site, (face, neck, arm or groin depending on site of catheter). e. Drainage from the site. Page 13 of 22

Appendix 1b Procedure summary for removal of tunnelled central venous catheter: (based on Dougherty & Lister 2008) N.B. The clinician/practitioner must be competent (or working under the supervision of a competent person) in removal of tunnelled catheters. 1 Check patient s FBC and clotting profile for that day. 2 Discuss procedure with patient (explaining each step as you go). 3 Screen bed area and remove clothing down to the waist. 4 Ask patient to lie as flat as possible with their arms by their sides. 5 Identify the position of the cuff in the patient by palpation. N.B. If cuff can not be easily felt, measure 22cm up from bifurcation at the end of the catheter then palpate again. If it still cannot be felt, seek assistance from a more experienced colleague. 6 Open outer bag (of minor operation pack). Put on plastic apron. Wash hands thoroughly and dry on sterile towel (provided in the pack). 7 Accept and put on sterile gloves from assistant and assemble all necessary equipment. 8 Clean the area directly over the cuff with swabs soaked in chlorhexidine in 70% alcohol. Use a circular motion, working out from the centre directly over cuff and allow to dry. 9 Position 2 sterile towels one horizontally across the waist, the other longitudinally down the side of the patient (between yourself and the patient). 10 Inform patient when you are about to administer the local anaesthetic and with a 25G needle inject 1ml of local intradermally *directly over cuff causing a raised bleb). 11 Administer a further 1 2 ml of local subcutaneously (around the cuff site area). 12 Attach a 21G needle and inject approx 4 ml of local using 2 deeper injections (one either side of the cuff area). 13 When the local anaesthetic has taken effect, make an incision over the cuff site. This should be longitudinal and about 2cm in length ensuring it has incised both the epidermis and dermis. 14 Using small artery forceps, commence blunt dissection of tissue from around and under the cuff, placing your finger into the site, at intervals, until the cuff feels mobile. 15 Clamp a pair of artery forceps onto the cuff and lift it up and out of the incision. 16 Once the catheter is clearly visible, maintaining your grip on the cuff with the forceps, cut through the full thickness with the blade. Then pull the portion of the catheter distal to the cuff, out through the exit site. 17 Still maintaining your grip on the cuff, gently dissect away fibrous tissue from around the cuff and the first 5cm of the catheter, immediately above the catheter. 18 Once the cuff is free (still maintaining your grip on the cuff) gently and carefully peel away the thin straw-coloured tissue from the catheter with the blade, ensuring the blade is pulled away from the catheter. 19 As the last strands of fibre are separated the catheter should feel freer and the white material of the catheter should become visible. Page 14 of 22

20 While holding a low-lint swab to the incision site, gently pull out the catheter and apply pressure. 21 Close the incision with three sutures. Commence the first suture in the middle of the incision and insert the remaining sutures evenly on either side. 22 If there continues to be any bleeding, steri-strips can be applied across the incision over the sutures. 23 Apply a small pressure dressing and advise the patient that there may be some oozing. Renew dry dressing daily observing the site until the sutures are removed (normally after 7 days). 24 Ask the patient to rest on the bed for 30 60 minutes following removal (longer may be required if the patient is prone to bleeding). 25 Document procedure in the patient s notes. Page 15 of 22

Appendix 2 PAT/T 23 v.3 Dressing change guidance for Central Venous Access Devices (CVADs) Equipment: Dressing trolley Sterile dressing pack Sterile dressing Non sterile gloves Apron 2% Chlorhexidine in 70% Isopropyl Alcohol (PDI wipe) Anchor device Remember: Always use Aseptic Non-Touch technique (ANTT) IV transparent dressings should be used and changed every 7 days If Central Venous Access Device (CVAD) site is oozing, a gauze dressing can be used BUT must be change daily or earlier if become loose, damp or soiled Dressing should be changed IMMEDIATELY if it becomes LOOSE, DAMP OR SOILED. Dressing is not required on a tunnelled line once sutures have been removed and site is healed Procedure; Explain and discuss procedure with patient Wash hands with soap and water and dry Clean trolley with 2% Chlorhexidine in 70% Isopropyl Alcohol (PDI) wipes and don apron Gather equipment and place on bottom shelf when trolley is dry, check equipment is intact and not past expiry date Take trolley to treatment room or patient s bedside, with minimal disturbance screens Inspect catheter for signs of infection, dislodgement or damage, discuss with medical team immediately if concerned. If catheter site is free from any of the above then loosen old dressing and clean hands with alcohol gel Open sterile dressing pack and slide contents onto top of trolley Open the sterile field using only the corners of the paper Open other equipment and decant onto sterile field Clean hands with alcohol gel, allow to dry and then place hand in disposable bag and arrange contents on trolley, then invert bag and stick to trolley below shelf level, side closest to patient to reduce risk of contamination of sterile field Don non- sterile gloves and remove old dressing, dispose of dressing into bag and remove gloves Clean hands with alcohol gel and don sterile gloves If Central Venous Access Device (CVAD) site is inflamed or discharging, obtain a swab for culture and sensitivity, send to microbiology Clean site using 2% chlorhexidine in 70% Isopropyl (PDI wipe), cleaning from entry site outwards, allow to dry 30 seconds Apply sterile dressing Dispose of equipment, wash hand with soap and water. Document procedure in patients notes. Page 16 of 22

Signs of infection Hyperthermia > 38 C OR Hypothermia <36 C Chills with Rigors Tachycardia >90min -1 Tachypnoea > 20min -1 WBC > 12.0 OR WBC <4.0 Inflammation, pain, swelling or heat around CVAD site Raised CRP What should you do? Discuss with medical team as soon as possible Obtain blood cultures from Central venous access device and a peripheral sample, if line infection is suspected If CVAD is removed due to suspected cause of infection, send tip to microbiology for culture and sensitivity References: Dougherty & Lamb 2008, Royal Masden Hospital Manual of Clinical Nursing Procedure 2008. BCSH Guidelines on the Insertion and Management of Central Venous Access Devices 2006. North Trent Cancer Network 2008. Wilson Infection Control In Clinical Practice 2006. National Collaborating centre for Acute Care 2006. Written by Louise Lowry, IP&CP Lead for Invasive Devices, 2009. Page 17 of 22

Appendix 3 PAT/T 23 v.3 Total Parenteral Nutrition (TPN) - Best Practice Guidelines Parenteral Nutrition is the delivery of essential nutrients in a solution infused directly into a vein. This can be either by central venous access (preferred method) or peripherally. Peripherally inserted central catheter (PICC) should be considered for short term treatments. TPN should be reviewed at regular intervals to reassess the indications, route, risks, benefits and goals of nutrition support. No additions are to be made to a TPN bag at ward or dept level. Equipment: Dressing trolley Drip stand Sterile dressing pack Non sterile gloves Sterile gloves Apron 2% Chlorhexidine in 70% Isopropyl Alcohol (PDI wipe) Prescription chart and solution IV administration Pump and Infusion giving set (Baxter or Alaris) Sharps bin 10mls IV N/Saline ampoule Alcohol gel Needle free device for IV administration Remember: Always use Aseptic Non Touch Technique (ANTT) Dedicated lumen for TPN Inspect catheter site daily for signs of inflammation and infection. Record in Patients notes and discuss with medical staff if signs of infection or inflammation present. No blood to be taken from TPN lumen No other fluids or medication to be administered via TPN lumen IV giving set to be changed every 24 hours IV giving set should be labelled with date and time of use If dressing loose, damp or soiled change immediately Change needle free access device every 7 days OR 100 uses. If needle free access device is showing signs of wear or damage change immediately. Record weight and fluid balance daily until stable, then twice weekly. Contact dietician and Pharmacist for advice if needed Daily U&E and twice weekly Calcium, Magnesium and phosphate blood tests. Procedure: 1. Explain and discuss procedure with patient 2. Check details of TPN bag as per Trust policy and expiry date 3. Wash hands with soap and water and dry. 4. Clean dressing trolley with 2% Chlorhexidine in 70% Isopropyl Alcohol (PDI wipe) and allow to dry Rationale: To prepare the patient and obtain consent To confirm correct prescribed TPN bag is used To remove dust from trolley. Page 18 of 22

5. Gather equipment and place on bottom shelf, checking expiry dates and product is intact 6. Stop current infusion and clamp central line 7. Hang bag on drip stand 8. Don apron and clean hands with alcohol gel 9. Disconnect giving set leaving needle free device on line if not due change. 10. Open sterile dressing pack and slide contents onto trolley 11. Clean hands with alcohol gel 12. Open sterile field using corners of the paper only 13. Open other equipment and decant onto sterile field 14. Snap top of 0.9% Sodium Chloride ampoule and place at side of sterile field, ensuring it does not touch field 15. Remove tab from TPN bag 16. Clean hands with alcohol gel and don sterile gloves 17. Connect syringe to ampoule 18. Ensure roller clamp on giving set is in the closed position. 19. Connect giving set to TPN bag, by inserting spike of giving set into port of TPN bag. 20 Once giving set is connected to TPN bag, purge line, ensuring dominant hand remains sterile 21. Observe for air bubbles, decant fluid into gallipot to remove air bubbles if necessary 22. Take 10 ml syringe in dominant hand and holding ampoule in non dominant hand draw up 10mls of IV 0.9% Sodium Chloride 23. Remove gloves and place in to bag 24. Clean hands with Alcohol gel and pick up sterile 25. towel at corners and place under the CVC line 25. Clean needle free device with 2% Chlorhexidine (PDI wipe) for 30sec and allow drying for 30 secs. 26. Clean hands with alcohol gel and don new pair of sterile gloves 27. Attach syringe with 0.9% sodium chloride to needle free device by pushing tip of syringe into device and twist to secure 28. Unclamp central line and flush with 10mls of 0.9% sodium chloride and re clamp line 29. Pick up giving set and attach to needle free device 30. Place giving set into Baxter or Alaris pump and unclamp line 31. Set pump at prescribed rate and start infusion 32. Remove sterile towel, dispose all waste and sharps according to hospital policy 33. Wash hands with soap and water and dry. 34. Document episode in patients notes To reduce risk of cross infection To reduce risk of contamination To reduce risk of contamination of sterile equipment Reduce risk of contamination To keep dominant hand sterile, so reducing risk of contamination Preserve asepsis To reduce risk of air embolus Reduce risk of contamination Reduce risk of contamination by microorganisms To maintain patency of line Maintain good records of patients treatment Page 19 of 22

Signs of infection Hyperthermia > 38 -C OR Hypothermia <36 -C Chills with Rigors Tachycardia >90min -1 Tachypnoea > 20min -1 WBC > 12.0 OR WBC <4.0 Inflammation, pain, swelling or heat around the Central venous access device( CVAD) Raised CRP What should you do? Discuss with medical team as soon as possible Obtain blood cultures from CVAD and a peripheral sample, if line infection is suspected If CVAD is removed due to suspected cause of infection, send tip to microbiology for culture and sensitivity References: Dougherty & Lamb 2008, Royal Masden Hospital Manual of Clinical Nursing Procedure 2008. BCSH Guidelines on the Insertion and Management of Central Venous Access Devices 2006. North Trent Cancer Network 2008. Wilson Infection Control In Clinical Practice 2006. National Collaborating centre for Acute Care 2006. Written by Louise Lowry, IP&CP Lead for Invasive Devices, 2009. Page 20 of 22

The discontinuation of Total Parenteral Nutrition-Best Practice Guidelines The stopping of TPN feeding should be a gradual process. This will allow the gut to adapt to receiving oral food again. Equipment: Dressing trolley Sterile dressing pack Plastic Apron 2% Chlorhexidine in 70% Isopropyl Alcohol Alcohol hand gel 2 pairs sterile gloves 1 10ml syringes 10mls IV 0.9% Sodium Chloride, single use ampoule Remember: Always use Aseptic Non Touch Technique (ANTT) If TPN is to be recommenced follow Total Parenteral Nutrition-Best Practice Guidelines Do not leave Central Vascular Access Device (CVAD) in just in case Procedure: 1. Explain procedure to patient 2. Wash hands with soap and water and dry. 3. Clean trolley with 2% chlorhexidine in 70% Isopropyl Alcohol and allow to dry 4. Gather equipment and place on bottom shelf of trolley 5. Switch off infusion pump and clamp CVC 6. Don apron and clean hands with alcohol gel 7. Open sterile dressing pack and slide contents onto trolley 8. clean hands with alcohol gel 9. Open sterile field using corners of the paper only 10. Open other equipment and decant onto sterile field 11. Snap top of 0.9% Sodium Chloride ampoule and place at side of sterile field, ensuring it does not touch field 12. Clean hands with alcohol gel 13. Disconnect giving set, leaving the needle free device insitu, providing it is not due a change. Rationale: To prepare the patient and obtain consent To clean trolley Reduce risk of contamination Reduce risk of contamination Reduce risk of contamination of sterile towel Reduce risk of contamination Page 21 of 22

14. Clean hands with Alcohol gel and pick up sterile towel at corners and place under the CVC line 15. Clean hands with alcohol gel and don pair of sterile gloves 16. Pick up syringe and attach to vial, using dominant hand and draw up 10mls of the 0.9% Sodium Chloride solution. Discard the ampolue into sharps bin. Place the syringe back onto sterile field 17. Remove sterile gloves and dispose of in waste bag 18. Clean hands with Alcohol gel and don new pair of sterile gloves 19. Clean needle free device with 2% Chlorhexidine in 70% Isopropyl Alcohol wipe (PDI), and allow to dry 20. Attach syringe with 0.9% Sodium Chloride solution to needle free device and unclamp and flush CVC line 21. Clean needle free device with 2% Chlorhexidine in 70% Isopropyl Alcohol wipe (PDI) following access 22. Remove sterile dressing towel from beneath CVC line, remove gloves and discard all waste into waste bag and any sharps into sharps bin. 23. Wash hands with soap and water and dry. 24. Document episode in patients notes Reduce risk of contamination To reduce the risk of contamination, by keeping dominant hand as sterile hand Maintain good records of patient s treatment Signs of infection Hyperthermia > 38 -C OR Hypothermia <36 -C Chills with Rigors Tachycardia >90min -1 Tachypnoea > 20min -1 WBC > 12.0 OR WBC <4.0 Inflammation, pain, swelling or heat around Vascular Access Device (CVAD) site Raised CRP What should you do? Discuss with medical team as soon as possible Obtain blood cultures from CVAD and a peripheral sample, if line infection is suspected If CVAD is removed due to suspected cause of infection, send tip to microbiology for culture and sensitivity References: Dougherty & Lamb 2008, Royal Masden Hospital Manual of Clinical Nursing Procedure 2008. BCSH Guidelines on the Insertion and Management of Central Venous Access Devices 2006. North Trent Cancer Network 2008. Wilson Infection Control I Clinical Practice 2006. National Collaborating centre for Acute Care 2006. Written by Louise Lowry, IP&CP Lead for Invasive Devices, 2009. Page 22 of 22