2.2. Preoperative preparation: Ensure that the child/young person is fit for surgery. If there is any doubt consult the anaesthetist.

Transcription

1 Clinical guideline for the supportive care and insertion of skin tunnelled catheters (Hickman lines) and totally implantable devices (Portacaths) in children and young people on the CLIC Unit at RCHT. 1. Aim/Purpose of this Guideline 1.1. This guideline aims to give clear information for supportive care for the insertion of skin tunneled catheters (Hickman lines) and totally implantable devices (Portacaths) in children and young on the CLIC Unit at RCHT. 2. The Guidance 2.1. Skin tunnelled catheters (Hickman lines) and fully implantable devices (Portacaths) are routinely used on the CLIC Unit. In the majority of cases the devices are inserted at Bristol Royal Hospital for Children. Occasionally the devices are inserted at Royal Cornwall Hospitals NHS Trust (RCHT) following discussion and under the care of the vascular surgeons Preoperative preparation: Ensure that the child/young person is fit for surgery. If there is any doubt consult the anaesthetist. The anaesthetist will review the child/young person prior to the procedure. Preparation and education should be provided to the child/young adult and family prior to the procedure e.g. Wiggly Colouring Book, BRHC Information pack for parents, Play Specialists. Bloods should be checked prior to the procedure (e.g. FBC, clotting screen, G&S). It is generally accepted that the platelet count should be > /litre prior to the insertion of the catheter other than a PICC, and the INR <1.5. Ensure that surgeon is aware of the results. The procedure is performed in general theatres under a general anaesthetic. Skin cleansing is the most important part of care for prevention of infection before catheter insertion. The number of lumina and diameter of catheters should be kept to a minimum. The surgeon will consent the child/young person for the procedure and discuss the device placement with the child/young adult and family. Page 1 of 12

2 2.3. Antibiotic prophylais: Prophylactic antibiotics should not be routinely used. Antibiotic cover may be appropriate if there is simultaneous removal and insertion of catheters in a proven case of catheter-related sepsis. In this circumstance antibiotics are continued for a minimum of 48 hours post insertion of the new catheter unless microbiologist advises a longer course. The antibiotics may be given via the new catheter in most cases Postoperative: Following insertion of the device the patient should be carefully monitored. This includes postoperative monitoring of temperature, pulse, BP, respiratory rate, oygen saturation as well as observation of central venous catheter (CVC) eit site, skin tunnel, and insertion site. There are a number of potential post-operative complications following insertion of a CVC. Appropriate supportive care must be commenced immediately if any complications are suspected. Pneumothora Cardiac tamponade Arterial puncture Haemorrhage Haemothora Hydrothora Air embolus Brachial pleus injury Thoracic duct injury Occlusion Thrombosis Fracture Infection Misplacement of central venous catheter The child/young person may have an infusion running into the new line on return from theatre. The child/young adult may be fit for discharge later that day Dressings: The dressing is checked for signs of bleeding and should be changed if bleeding has occurred. Otherwise the dressing is changed hours after the catheter insertion and weekly thereafter (sooner if dressing is no longer intact or if moisture has collected underneath). A sterile gauze type dressing may be used if there is bleeding or oozing post insertion of catheter. When gauze dressings are used the eit site and dressing must be assessed and changed daily. Page 2 of 12

3 Until wound healing has occurred a sterile dressing change procedure should be used (for the first 28 days after CVC insertion). Then aseptic non touch technique (ANTT) should be followed. The recommended dressing is transparent and semi-occlusive eg Opsite fleigrid, C-view film. This ensures that the device is secure and permits visual inspection of the catheter site. A review has found no consistent benefit for any type of dressing and the choice of dressing may be a matter of preference. Skin-tunnelled dressings may not require a dressing once the wound has healed. However on the CLIC Unit we prefer to use dressings. Nylon fiation sutures may be routinely removed after 4 weeks if: The cuff is securely fied within the skin tunnel The sutures irritate the skin or provide a focus for infection or debris collection The suture is too tight and causing CVC occlusion Steri-strips should be removed after 7-10 days. Routine cleaning of the eit site is not required for established lines. However if the eit site, skin and CVC under the dressing is damp or soiled then the area should be cleaned using non touch technique with a single use 2% chloheidine gluconate in 70% alcohol applicator eg Enturia Chloraprep Check catheter placement: Do not use the new central venous line without ensuring the position of the line has been confirmed. The device position is checked in theatre and recorded in the theatre notes (checked on image intensifier). If it is not clear from the operation note that the device position has been confirmed then tip placement should be checked by X-ray prior to use and the position of the catheter tip should be documented in the patient s notes. The best tip position is the distal vena cava or the upper right atrium Long term catheter care: In order to reduce the risks and prevent complications associated with the use of long term catheters only those trained and assessed as competent should be involved in accessing and caring for these devices. Securing the skin tunnelled CVC is essential to prevent accidental dislodgement or removal especially in the first 4 weeks, until fibrin has collected around the Dacron cuff. The end of the skin tunnelled catheter CVC should be looped and secured to the chest wall under the clear dressing. Fiation tape is used to reduce pull on the CVC and maintain stability eg mepore tape. LOOP IT OR LOSE IT Catheter patency is maintained by flushing with the correct solutions according to the manufacturers recommendations. The flush technique should involve push-pause action to create turbulence within the catheter lumen, removing debris from the internal catheter wall. Page 3 of 12

4 When locking the CVC between uses a positive pressure technique should be used in order to prevent reflu of blood into the catheter. Due to the risk of catheter damage from ecessive pressure syringes smaller than 10ml should not be used. The use of heparin flushes vs. normal saline intermittent flushes remains controversial. A review of the current evidence has concluded that heparin doses of 10 units/ml are no more beneficial than flushing with normal saline alone. Some manufacturers and clinicians recommend heparin flushes when catheters are used infrequently. Eposure to heparin should be minimized. CVCs that are accessed frequently will not need to be locked with heparinised saline after each access At RCHT CLIC Unit the current advice for lock solutions is: Line Solution frequency Skin-tunnelled (Hickman, Cook, Broviac) Ports 5-10mls sodium chloride 0.9% +/- 3-5mls heparinised saline (10 units/ml) 5-10mls sodium chloride 0.9% +/- 4-6mls heparinised saline (100 units/ml) After each access or weekly After each access or monthly 2.9. Swimming Swimming must be avoided with any eternal catheter in order to prevent colonisation by Gram-negative organisms e.g. Pseudomonas spp Bathing and showering The eternal CVC is held in position by tissue growth into the Dacron cuff under the skin. Until this occurs (usually about 4 weeks after insertion) dressings and tapes are important in securing the CVC and should be kept dry. After 4 weeks normal showering or bathing can be resumed. However neither the CVC nor the eit site should be submerged under water for any length of time Bathing The eit site and eternal CVC should be kept out of the water during bathing. If the dressing becomes wet or dislodged during bathing then the eit site should be dried with sterile gauze and a new dressing applied Showering Showering can resume after the eit site has healed (about 4 weeks after insertion of the eternal CVC). The dressing should be removed prior to showering. Do not use soap or shower gel near the eit site. After showering the eit site should be dried with sterile gauze and a new dressing applied. Page 4 of 12

5 2.13. Ports Patients with a Port can swim or shower as long as the port is not accessed with a gripper needle Damage or accidental removal of CVC Patients and carers must be aware of who to contact should a problem arise related to the device (The CLIC Unit ). They should receive education and training in the risks associated with a CVC and the appropriate monitoring and care of the device. A CVC Safety Pack (from CLIC Unit) should be provided, with training, so that the carer or child/young adult knows what to do in an emergency. The CVC Safety Pack consists of: Sterile gauze 2 clamps (gate or peripheral adaptor clamps) Dressings Accidental removal of CVC Apply pressure to the eit site in order to stop bleeding. The patient should be assessed by a doctor. Document the incident in patient s notes Damage to CVC The patient should have a CVC Safety Pack with them at all times. Plastic clamps should be applied proimal to the damaged area of the CVC. If only sterile clamps are available then the CVC must be protected by wrapping sterile gauze around the site to be clamped. Apply a sterile dressing to the damaged area of the CVC for protection prior to assessment for repair Repair of CVCs Long term CVCs that are split, leaking or damaged may be able to be repaired. If possible CVCs should be repaired within 24 hours to reduce the risk of infection. Assessment should be made by a competent member of staff that it is practical for a repair to be done. Only members of staff who are trained and assessed as competent should carry out a CVC repair. Hickman line repair kits are available in the store cupboard on CLIC Unit or General Theatres. Document the repair in the patient s notes. Page 5 of 12

6 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Compliance with all elements of guideline Audit lead Dr.Katrina MacDonald Paediatric oncology team Audit and annual review Peer review- annually Annually or earlier if required Paediatric oncology team Department audit and guidelines meeting Paediatric oncology team Department audit and guidelines meeting Required actions will be identified and completed in 3-6 months Change in practice and lessons to be shared Required changes to practice will be identified and actioned within3-6 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 6 of 12

7 Appendi 1. Governance Information Document Title Clinical Guideline for supportive care for the insertion of skin tunnelled catheters (Hickman Lines) and totally implantable devices (Portacaths) in children and young people on the CLIC unit at RCHT. Date Issued/Approved: February 2014 Date Valid From: February 2014 Date Valid To: February 2017 etended to August 2017 Directorate / Department responsible (author/owner): Contact details: Brief summary of contents Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Dr. K.Macdonald-Associate specialist Sue Turk- CLIC Sargent outreach nurse Sabrina Teirney- senior paediatric pharmacist Clear guidance for supportive care for the insertion of skin tunnelled catheters (Hickman Lines) and totally implantable devices (Portacaths) in children and young people on the CLIC unit at RCHT. Children Oncology Paedaitrics Portacath Hickman line RCHT PCH CFT KCCG Eecutive Director Date revised: December 2013 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Guideline for supportive care for the insertion of skin tunnelled catheters (Hickman lines) and totally implantable devices (Portacaths) in children and young adults on the CLIC Unit at RCHT Paediatric oncology team Department audit and guidelines meeting Divisional Manager confirming approval processes Sheena Wallace Page 7 of 12

8 Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key eternal standards Not Required {Original Copy Signed} Internet & Intranet Paediatrics none Intranet Only RCHT GEN 57 Central Venous Catheter (CVC) Guidelines (ecluding dialysis catheters) Bristol Royal Hospital for Children Clinical Guideline November Central Venous Catheter Guidelines. BCSH (British Committee for Standards in Haematology) for Guidelines on the insertion and management of central venous access devices (2006) Related Documents: Guidelines on the insertion and management of central venous access devices in adults (International Journal of Laboratory Haematology 2007) Ansell et al 2004, Douketis, Johnson & Turpie 2004 Farkas et al 1992, Dezfulian et al 2003 Knutstad, Hager & Hauser 2003 O Grady et al 2002, Pratt et al 2001 Gillies et al 2003 Morris et al 1995, O Grady et al 2002 Fletcher & Bodenham 2000 Pellowe et al 2004 Training Need Identified? No Page 8 of 12

9 Version Control Table Date Versio n No Summary of Changes Changes Made by (Name and Job Title) Feb 12 V1.0 Initial Issue Feb 2014 V2.0 Review and re format Dr.N.Gilbertson-paediatric consultant Dr.K.Macdonald- Assosciate specialist Sue Turk-CLIC sargent outreach nurse Sabrina Tierney-senior paediatric pharmacist. Dr.K.Macdonald- Assosciate specialist Sue Turk-CLIC sargent outreach nurse Tabitha Fergus-Deputy ward manager format only Sabrina Tierney-senior All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 9 of 12

10 Appendi 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Clinical Guideline for supportive care for the insertion of skin tunnelled catheters (Hickman Lines) and totally implantable devices (Portacaths) in children and young people on the CLIC unit at RCHT. Directorate and service area: child health Is this a new or eisting Policy? eisting Name of individual completing assessment: t.fergus 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Telephone: Clear guidance for supportive care for the insertion of skin tunnelled catheters (Hickman Lines) and totally implantable devices 2. Policy Objectives* Clear guidance for supportive care for the insertion of skin tunnelled catheters (Hickman Lines) and totally implantable devices 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Evidence based and standardised practice. audit Children and families no b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Page 10 of 12

11 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Se (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please eplain why. No areas indicated Signature of policy developer / lead manager / director.t.fergus Date of completion and submission5/2/14 Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD Page 11 of 12

12 A summary of the results will be published on the Trust s web site. Signed T.Fergus Date 5/2/14 Page 12 of 12