Central Venous Access Devices (CVAD) Management (Adult) Resource Package

Transcription

1 Nursing and Midwifery Professional Stream 121/RP Vascular Access Surveillance and Education Central Venous Access Devices (CVAD) Management (Adult) Resource Package Completion of this package, if relevant to the context of practice, attracts sixteen (16) Continuing Professional Development (CPD) hours of learning. CPD hours can contribute to the nurse / midwife CPD requirements as per the Nursing and Midwifery Board of Australia Continuing Professional Development. V01 Effective:06/2017 Review: 06/2020

2 Statement of Copyright THE STATE OF QUEENSLAND (METRO NORTH HOSPITAL AND HEALTH SERVICE) 2017 This work is licensed under a Creative Commons Attribution No Derivatives 3.0 Australia licence. To view a copy of this licence, visit You are free to copy, communicate and adapt the work, as long as you acknowledge the authors and attribute to the State of Queensland (Metro North Hospital and Health Service). For more information, contact: Workforce Development and Education Unit (WDEU), Centre for Clinical Nursing, Royal Brisbane and Women s Hospital (RBWH), Metro North Hospital and Health Service, Herston Qld 4029, CCN-Education@health.qld.gov.au Phone (07) Statement of Indemnity Disclaimer: The State of Queensland (Metro North Hospital and Health Service) does not accept any responsibility for the use of this material outside of the scope for which it has been designed and outlined in this document. The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland (Metro North Hospital and Health Service) makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland (Metro North Hospital and Health Service) disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information. Version Control This is Version (01) of the Central Venous Access Devices Management (Adult) Resource Package and will remain current until 2020 or earlier when modifications required. The current version will be available for access on the Intranet at: Authors Initiated by: Developed by: Barbara Hewer, Clinical Nurse Consultant VASE Barbara Hewer and VASE Team Additional support and editing: Workforce Development and Education Unit, RBWH The authors wish to acknowledge the support, contributions and direction provided by: MNHHS Nurse/Midwifery Educators and Nurse/Midwifery Unit Managers Workforce Development and Education Unit, Centre for Clinical Nursing for education standards MNHHS Nursing and Midwifery Education and Workforce Development Committee: Sub Group Scope of Practice for guidance and direction MNHHS Nursing and Midwifery Education and Workforce Development Committee for endorsement Resource Package Version Control 1.0 Page 2 of 110

3 Table of Contents STATEMENT OF COPYRIGHT... 2 STATEMENT OF INDEMNITY... 2 VERSION CONTROL... 2 AUTHORS... 2 TABLE OF APPENDICES... 6 OVERVIEW OF THE RESOURCE... 7 Participant eligibility criteria:... 7 HOW TO USE THE RESOURCE PACKAGE... 8 REQUIRED RESOURCES TO COMPLETE THE PACKAGE... 8 WORKSHOP AND ASSESSMENT... 8 Ongoing Competence... 8 Recognition of Prior Learning (RPL) & Recognition of Clinical Competency (RCC)... 9 OBJECTIVES... 9 RELATED DOCUMENTS SECTION 1 GENERAL THEORY Clinical Handover Standard Precautions Care and Maintenance Bundle Hand Hygiene Aseptic Non-Touch Technique (ANTT) Site Inspection Catheter Maintenance Documentation SECTION 2 - DEVICE CHARACTERISTICS CVAD Overview Types of CVADs Non-Tunnelled (Percutaneous) Central Venous Catheters (CVC) Haemodialysis/Apheresis Catheters Peripherally Inserted Central Catheter Tunnelled Catheters (Cuffed) Haemodialysis/Apheresis Tunnelled Catheters Totally Implanted Central Venous Access Device Specialty Features Valved Catheters Pressure Injectable CVADs Coated or Impregnated Catheters SECTION 3- THE RIGHT DEVICE FOR THE RIGHT PATIENT Pre Insertion Patient Education Post Insertion Patient Assessment Post Insertion Patient Education SECTION 4 - CATHETER CARE Page 3 of 110 Version Control 1.0 Resource Package

4 4.1 Dressing Gauze Dressing Securement Skin Preparation CVAD Access and Commencement of IV Therapy Accessing a Totally Implanted Central Venous Access Port Infusion Pressures Maintaining Patency Catheter Locks Line Changes Removal Overview PICC Specifics SECTION 5 - COMPLICATIONS Infection Local Infection and Allergy Systemic Infection Infiltration and Extravasation Phlebitis Chemical Phlebitis Mechanical Phlebitis Bacterial Phlebitis Post-infusion Phlebitis Malposition Catheter Tip Migration Occlusion Mechanical Occlusion Pinch-Off Syndrome Non-Thrombotic Occlusions Thrombotic Occlusion Venous Thrombosis Mural Thrombus Superior Vena Cava Syndrome Air Embolism Catheter Damage SECTION 6 PRINCIPLES OF CVAD BLOOD COLLECTION Safe Blood Collection from a CVAD Blood Cultures Restoring Patency SECTION 7: CENTRAL VENOUS ACCESS DEVICES MANAGEMENT THEORY EXAMINATION SECTION 8 CLINICAL PRACTICE GUIDING PRINCIPLES Clinical Principle 1: Accessing and Flushing Clinical Principle 2: Needleless Connector Change Clinical Principle 3: Dressing Change Clinical Principle 4: Collecting Blood from a CVAD Clinical Principle 5: Accessing a Totally Implanted Central Venous Access Port (port) Clinical Principle 6: Instilling Thrombolytic Agent Complete Occlusion Clinical Principle 7: Removal of a CVAD Resource Package Version Control 1.0 Page 4 of 110

5 SECTION 9 - APPENDICES Appendix 1: Initial Assessment and Troubleshooting of CVAD Occlusion Appendix 2: Assessment of Thrombotic Occlusion Appendix 3: External Mechanical Occlusions Appendix 4: Internal Mechanical Occlusions Appendix 5: Treatment of Non-thrombotic Occlusions Appendix 6: Symptoms of Thrombotic Occlusion Appendix 7: Other CVAD-Related Complications CVAD MANAGEMENT PRACTICE AND ASSESSMENTS LOGBOOK Record of Supervised Practice of CVAD Management Procedures Clinical Activity: Supervised Practice of CVAD Procedures Clinical Skills Assessment Tool (CSAT) Needleless Connector Change, Flushing and Locking a Central Venous Access Device Clinical Skills Assessment Tool (CSAT) Dressing Change for a Central Venous Access Device Clinical Skills Assessment Tool (CSAT) Blood Sampling from a Central Venous Access Device Clinical Skills Assessment Tool (CSAT) Removal of a Central Venous Access Device (excludes tunnelled and totally implanted devices) Clinical Skills Assessment Tool (CSAT) Accessing a Totally Implanted Central Venous Access Device (TICVAD) Clinical Skills Assessment Tool (CSAT) De-Accessing a Totally Implanted Central Venous Access Device (TICVAD) Clinical Skills Assessment Tool (CSAT) Central Venous Access Device Occlusion Management with a Thrombolytic Agent CVAD MANAGEMENT- COMPETENCY RECORD REFERENCES Table of Activities Activity 1: Post Insertion of a CVAD Activity 2: Ongoing Management Activity 3: Understanding Phlebitis Activity 4: Identifying Malposition Activity 5: Risk Prevention and Occlusion Management Activity 6: Indication for Blood sampling from a CVAD Activity 7: Safe Collection of Blood Samples Table of Readings Reading 1: Clinical Handover Reading 2: Standard Precautions Reading 3: Hand Hygiene Reading 4: ANTT Reading 5: 05600/Proc: Central Venous Access Devices (CVADs); Management - Adult Page 5 of 110 Version Control 1.0 Resource Package

6 Table of Figures Figure 1: Correct CVAD Placement Figure 2: Non-Tunnelled Percutaneous Central Venous Catheter Figure 3: Non- Tunnelled Haemodialysis Catheter Figure 4: Peripherally Inserted Central Catheter (PICC) Figure 5: Tunnelled Catheter Figure 6: Cuffed Tunnelled Catheters Figure 7: Pressure Injectable PICCs Figure 8: Pressure Injectable Port Figure 9: Example of port access needle Figure 10: Non-Coring (safety) Needle Figure 11: National Safety and Quality Service (NSQHS) Catheter Lock Label Figure 12: Skin Antiseptic Allergy Figure 13: Dressing Allergy Figure 14: CVAD Malposition Table of Tables Table 1: Identification of Port Needle Malposition Table 2: Catheter Malposition Management Table 3: Causes and Symptoms of External Mechanical Occlusion Table 4: Causes and Symptoms of Internal Mechanical Occlusion Table 5: Causes and Treatments for Non-thrombotic Occlusions Table 6: Thrombotic Occlusion: Types and Causative Considerations Table 7: CVAD-Related Complications: Types and Causative Considerations Table of Appendices Appendix 1: Initial Assessment and Troubleshooting of CVAD Occlusion Appendix 2: Assessment of Thrombotic Occlusion Appendix 3: External Mechanical Occlusions Appendix 4: Internal Mechanical Occlusions Appendix 5: Treatment of Non-thrombotic Occlusions Appendix 6: Symptoms of Thrombotic Occlusion Appendix 7: Other CVAD-Related Complications Resource Package Version Control 1.0 Page 6 of 110

7 Overview of the resource This Resource Package aims to assist the development of clinical competence of nominated eligible staff in the Royal Brisbane and Women s Hospital (RBWH) to safely and effectively manage all aspects of Central Venous Access Devices (CVADs) and care of the patient with a CVAD. Completion of the Resource Package is a pre-requisite to registration and attendance at the CVAD Workshop. The participant must have completed all written activities satisfactorily, prior to submitting registration. Non-completion will invalidate workshop registration and attendance at the workshop will not be permitted. Non-RBWH Nurse, Midwife and Undergraduate Student CVAD Interaction RBWH Registered Nurses (RNs) and Midwives with CVAD competency may directly supervise non-rbwh nurses, midwives and undergraduate nursing/midwifery students to undertake CVAD cares and management (refer to Assessment). Undergraduate nursing/midwifery students must have covered the relevant topics within the university curriculum prior to undertaking supervised practice. Due to the complexity and risks associated with blood collection from, and removal of a CVAD, undergraduate nursing/midwifery students may only observe these procedures to support learning in alignment with their clinical placement objectives. N.B. Prior to accessing CVADs as a learning opportunity for undergraduate nursing/midwifery students the supervising RBWH RN/midwife and/or Student Clinical Facilitator should confirm the appropriateness of this learning activity (to be performed under direct supervision) with the work unit Line Manager/Service Line directive. Participant eligibility criteria: This resource is targeted towards: All RNs and midwives wishing to learn or re-skill in all aspects of CVAD care and maintenance RNs/midwives who are required to care for patients with CVADs in their clinical setting Health professionals in departments where CVAD management is a requisite skill Participants are required to complete the entire CVAD Resource Package followed by the eight (8) hour CVAD Workshop and be assessed as competent in CVAD Management by an appropriate Vascular Access Device (VAD) Trainer. The VAD Trainer is an RN/midwife, who has successfully completed all aspects of the CVAD Management program (i.e. Resource Package, Workshop and Clinical Skills Assessments), attended the Preceptor Program, the VAD Train-The-Trainer Workshop, and maintains contemporary competence. Page 7 of 110 Version Control 1.0 Resource Package

8 How to use the resource package Participant assessment will be conducted through review and appraisal of the completed learning activities and clinical skills assessments, as identified throughout the Resource Package. Participants are required to complete the nominated theoretical components, including hyperlinked readings, activities and theoretical exam. All theoretical and practical learning activities must be marked, supervised and assessed by the Service Line Nurse/Midwifery Educator or Vascular Access Device (VAD) Trainer prior to CVAD Management Workshop registration. Vascular Access Surveillance and Education (VASE) are available in an educational and supportive capacity to VAD Trainers, if required. Required Resources to complete the package Access to QHEPS Access to MNHHS / RBWH Policy website Nurse/Midwifery Educators VAD Trainers Workshop and Assessment The CVAD Workshop will provide participants with the opportunity to consolidate learning and apply theory to practice. The workshop will enable participants to become familiar with the different CVAD devices and associated practical skills related to CVAD management. Opportunity will be provided for the participant to gain competency in the workshop for the following: access and commencement of IV therapy flushing and locking CVAD lumen(s) needleless connector change occlusion recognition and classification theory removal theory of a percutaneous CVAD de-access of a TICVAD Under the direct supervision of a VAD Trainer participants are required to undertake the following CVAD activities relevant to their practice setting: dressing change concepts of blood taking (blood withdrawal and sampling) demonstrate monitoring requirements demonstrate appropriate management of an occluded device accessing a totally implanted central venous access port (optional) removal of a percutaneous CVAD (optional) Resource Package Version Control 1.0 Page 8 of 110

9 Observations and practical training should be documented in the Practice and Assessment Logbook. Once the participant has acquired the standard of independent practice in the relevant skills they may negotiate clinical skills assessment with a VAD Trainer, utilising the CVAD Clinical Skills Assessment Tools in the Practice and Assessment Logbook at the end of the Resource Package. The Logbook can be used to register an individual s CVAD activity and utilised during the individual s Performance and Development Planning (PDP) review. Ongoing Competence Following initial completion of CVAD training and competency assessment, ongoing competence will be demonstrated by self-assessment and peer review. Recognition of Prior Learning (RPL) & Recognition of Clinical Competency (RCC) Application for RPL and RCC should be progressed through the service line Nurse/Midwifery Educator/s with current training competence for CVAD management in accordance with the MNHHS Recognition of Prior Learning (RPL) and Recognition of Clinical Competency (RCC) Application Guide (2016). The applicant will be required to submit written evidence of validated competency however there may be a need for practice update and assessment, as identified to meet organisational requirements. NB: All RPL and RCC applicants for CVAD management will require a challenge test of supervised practice (by an endorsed VAD Trainer) using the Clinical Skills Assessment Tools in the Practice and Assessment Logbook of this Resource Package. Objectives At the conclusion of the CVAD Management Program (i.e. Resource Package, Workshop and Clinical Skills Assessments) the participant will be able to: recognise the types of CVADs and describe the characteristics that differentiate them discuss and apply the principles of the CVAD Care and Maintenance Bundle perform assessment of all CVADs and demonstrate safe access for use o port access may be non-applicable if there is no clinical exposure to the device perform safe blood sampling, and identify withdrawal issues and management strategies appropriately troubleshoot and manage occlusions identify CVAD insertion and post insertion complications and discuss appropriate prevention and management Page 9 of 110 Version Control 1.0 Resource Package

10 conduct appropriate patient education and patient management pre and post insertion and on patient discharge identify device, and device related complications and manage appropriately. Related Documents 05600/Proc: Central Venous Access Devices (CVADs) Management-Adult /Proc: Peripheral Intravenous Cannulation, Venepuncture and Infusions-Adult and Paediatrics 2 Queensland Health. About Hand Hygiene 3 Centre for Healthcare Related Infection Surveillance and Prevention / Proc: Patient Identification and Procedure Matching /Proc: Standard Precautions /Proc: Documentation in the Patient Record 7 Pathology Queensland Support Home Page /Proc: Hand Hygiene /Proc: Aseptic Non Touch Technique (ANTT) : Venepuncture (Percutaneous Blood Collection) 11 Resource Package Version Control 1.0 Page 10 of 110

11 SECTION 1 General Theory A Central Venous Access Device (CVAD) is an intravenous device (catheter) that resides in the central circulation which enables: the administration of life supporting medications and therapies drawing of blood for clinically necessary laboratory testing 12 advanced procedures such as apheresis and haemodialysis CT investigations if the catheter has pressure injectable features Complications related to CVADs may cause serious morbidity and mortality. When a CVAD is inserted it passes through the skin and enters the blood stream, effectively creating portals of entry for micro-organisms 13. These place the patient at risk for a healthcare-associated blood stream infection 14. Bacteraemia can be fatal but are unquestionably costly for the organisation. CVAD related morbidity can be minimised through implementation of strategies at catheter insertion (e.g. CVAD Insertion Bundle Checklist) and throughout the CVADs use (e.g. Care and Maintenance Bundle) 15. Vessel injury is additionally sustained during insertion because the procedure punctures the vessel wall 16. The catheter additionally takes up volume (or space) in the vessel which slows down blood flow causing venous stasis 13. The combination of sequelae has the potential to contribute to two serious complications, infection and thrombosis (clotting) Clinical Handover Reading 1: Clinical Handover Read the MNHHS-wide Policy Clinical Handover Doc 85/15 POL The Registered Nurse/Midwife must have assessed the CVAD (site and surround) to provide an accurate clinical handover. During clinical handover, the delegator(s) and delegatee(s) must review the CVAD together at the bedside 17. Patients are often familiar with their devices and should be an integral part of care planning and handover 17. Anything that deviates from normal or any variances to routine management should be included in handover. 1.2 Standard Precautions The level of standard precaution protection should be determined by risk assessment, prior to all CVAD procedures. Gown or apron, gloves and protective eye wear must be worn during procedures with potential for blood or body fluid exposure 18. Page 11 of 110 Version Control 1.0 Resource Package

12 Reading 2: Standard Precautions Read the RBWH Standard Precautions procedurehttp://hi.bns.health.qld.gov.au/rbh/policies/ pdf 1.3 Care and Maintenance Bundle All health professionals must apply the CVAD Care and Maintenance Bundle principles when caring for patients with a CVAD. Care bundles have been proven to standardise practice, be cost effective and reduce infection The bundle principles for CVAD are: 1) Hand Hygiene 2) Aseptic Non-Touch Technique 3) Site Inspection 4) Catheter Maintenance 5) Documentation Hand Hygiene Hand hygiene should be undertaken as part of the Hand Hygiene Australia 5 Moments for Hand Hygiene 21. Patients and their carers also may require education about the importance of hand hygiene. Reading 3: Hand Hygiene Read the following RBWH procedure and the 5 Moments for Hand Hygiene RBWH 81004/Proc: Hand Hygiene procedure - Hand Hygiene Australia 5 Moments for Hand Hygiene Aseptic Non-Touch Technique (ANTT) ANTT (also known as Aseptic Technique) is a standardised approach to prevent microbial contamination during the performance of invasive clinical procedures or maintenance of indwelling medical devices through the protection of Key-Parts and Key-Sites 22. According to the ANTT Clinical Guidelines one of the foundation principles (e.g. ANTT Approach) will be determined or changed according to risk assessment, (e.g. depending on the simplicity or complexity of the procedure) 22. Standard ANTT is determined by a small number and size of key parts, small set-up field, short procedure time and low level of technical difficulty Therefore, for the purposes of CVAD interventions Standard ANTT is sufficient to protect Key-Parts and Key-Sites. For the Resource Package Version Control 1.0 Page 12 of 110

13 most part adopting use of micro-critical aseptic fields or a small aseptic field, e.g. dressing pack, will be sufficient to protect key parts 22. In Standard ANTT procedures, Key Parts are managed to promote rather than maintain asepsis. As such, non-sterile gloves are usually worn for Standard ANTT procedures, unless it is assessed necessary to touch a Key-Part/Key-Site or the clinician s experience/competence in the task would indicate that sterile gloves should be worn 23. Reading 4: ANTT Read the RBWH procedure RBWH 81000/Proc: Aseptic Non-Touch Technique (ANTT) Site Inspection The single most effective strategy to prevent site complication is observation or site inspection. Assess the catheter site and surround for complications, including catheter position/external length 24. Visually inspect for signs of: allergic reaction, redness (erythema) 24 oedema, swelling 24 moisture, oozing 24 infection 24 blanching, firmness 24 phlebitis and thrombophlebitis assess for pain or tenderness 24 Site/ catheter monitoring/ assessment must be ongoing and performed at least daily and before and after each occasion of use. This should be increased during intermittent and continuous infusion(s) and during administration of irritant/vesicant medications, as per RBWH procedure 05600/Proc: Central Venous Access Devices (CVAD) - N.B. Assessment of the site and surround must include visual inspection, palpation and patient perspective. Without these three (3) modes of monitoring, there is risk of undetected complications which may lead to a healthcare associated blood stream infection or patient morbidity or mortality. Page 13 of 110 Version Control 1.0 Resource Package

14 1.3.4 Catheter Maintenance To prevent and reduce the risk of device related complications, routine care and maintenance strategies are required (as listed below). Needleless connector(s) require a minimum of weekly change or more frequent if contaminated, visibly soiled or no longer maintaining their integrity. Dressings must be replaced weekly and more often if clinically indicated Use of correct and clinically appropriate skin antiseptic for dressing change. For administration, flushing or assessment of CVAD functionality, use a 10mL syringe or a syringe specifically designed to generate lower injection pressure (e.g. equivalent to a 10mL-diameter syringe barrel) 46. Implement proper flushing technique and correct frequency and sequencing to assist in preventing catheter occlusions Intravenous lines (IV) lines are changed every 72 hours or in accordance with 05450/Proc: Peripheral Intravenous Cannulation, Venepuncture and Infusions - Adult and Paediatrics Documentation Documentation should comply with the medico-legal needs of the patient, the hospital and the health professional performing the clinical skill 29. Observation of the CVAD site should be performed minimally at every access and/or shift change and form part of the clinical handover process. Clinical documentation should provide evidence of : post insertion instructions/recommendations (if applicable) procedure performed (e.g. line change, blood collection, etc.) minimum routine CVAD observations o observations of site or patient reported symptoms (redness, discharge, tenderness or pain, swelling, erythema) o assessment of flashback and quality of flush (i.e. any resistance or occlusion) occlusion management (if applicable) action implementation for variances or untoward clinical outcome(s) name and designation of the clinician who performed CVAD management. Additional information for Totally Implanted Central Venous Access Device (TICVAD) access should include: date and time of needle insertion or removal needle gauge and length number of attempts (maximum of 2 attempts per person) local anaesthetic (if applicable). Resource Package Version Control 1.0 Page 14 of 110

15 SECTION 2 - Device Characteristics 2.1 CVAD Overview Although there are different types of CVADs available, they are all positioned within the central circulation. The optimal catheter tip position recommends placement within the lower third of the superior vena cava (SVC) near the junction of the SVC and the atrium 90 (see image below). Catheters inserted via the femoral vein will have the tip located in the inferior vena cava (IVC) 75. Blood flows rapidly through these central veins enabling adequate haemodilution and safe administration of any type of infusate 32. The high venous flow and the separate pathways of a multiple lumen CVAD, provides the ability to administer incompatible solutions simultaneously 32. Usually CVADs are inserted via the internal jugular, subclavian or femoral veins 33 using a surgical aseptic technique. Femoral veins were once considered less favourable due to proximity of the perineal area. However, investigators have disputed this point, citing that Central Line Associated Bacteraemia (CLAB) at the femoral site is not significantly different than from the head/ neck area (e.g. internal jugular) which can also be contaminated by excessive secretions 34. All CVADs have the risk of blood stream infection (BSI) and therefore should be removed as soon as there is no longer clinical reason for use 35. Figure 1: Correct CVAD Placement Page 15 of 110 Version Control 1.0 Resource Package

16 2.2 Types of CVADs Non-Tunnelled (Percutaneous) Central Venous Catheters (CVC) Haemodialysis/ Apheresis Catheters Peripherally Inserted Central Catheter Cuffed Tunnelled Catheters Haemodialysis/Apheresis Tunnelled Catheter Totally Implanted Central Venous Access Device Non-Tunnelled (Percutaneous) Central Venous Catheters (CVC) A non-tunnelled CVC, often referred to as a central venous line (CVL), is inserted into a large vein via a skin puncture, with direct vein entry and no subcutaneous tunnelling. The preferred site for percutaneous CVC insertion in adults is the subclavian approach, to minimise infection risk 35. Each lumen exits at a different point along the catheter pathway. Each lumen is distinctly labelled to indicate the exit point (see image below). Figure 2: Non-Tunnelled Percutaneous Central Venous Catheter Distal Medial Proximal Photograph VAD/WDEU (2014) simulated These catheters are available in single to multi-lumen, often used in life-threatening situations 36, and for short term use of several days to several weeks where the patient requires delivery of: high volume administration of intravenous fluid for hydration restoration and electrolyte replacement 36 high volume administration of blood products 36 high concentration, volume and frequency of medications 36 Resource Package Version Control 1.0 Page 16 of 110

17 The risk of blood stream infection is greater with non-tunnelled Percutaneous CVC than any other type of central venous access device 37. Factors that may be attributable: short track from skin to vein (percutaneous), therefore direct entry to the blood stream insertion is usually in an area (site) of skin fold enduring warmth and moisture 35 insertion is often in an emergent situation whereby asepsis may be compromised high volume catheter interceptions and manipulations, for administration and blood taking 38 It is recommended that removal or replacement be considered at the earliest possible clinical indication Haemodialysis/Apheresis Catheters Larger catheters are available to provide short (see figure 8) and long term (Haemodialysis/Apheresis Tunnelled Catheters) access for renal and apheresis procedures. Haemodialysis/apheresis catheters are large bore (14-16Fr), dual lumen designed to accommodate high blood outflow and inflow rates The lumens are connected to the haemodialysis filtration system or the apheresis cell separator machine to complete a closed circuit to allow for removal and return of a patient s blood during procedures. Figure 3: Non- Tunnelled Haemodialysis Catheter Image by Clinical Multimedia (2016) Peripherally Inserted Central Catheter Peripherally inserted central catheters (PICCs) are used in the inpatient and ambulatory setting to provide central venous access for at least a week up to an indefinite period 36. A PICC is inserted into the upper arm basilic, brachial or cephalic veins and advanced proximally toward the heart via increasingly larger veins. PICCs are at a relative disadvantage to other CVAD due to: small gauge (3-6 Fr), long length (e.g cm), contributing to greater risk of occlusion peripheral entry/exit site location; upper extremity venous thrombosis (UEVT) is a well-recognised complication Page 17 of 110 Version Control 1.0 Resource Package

18 Figure 4: Peripherally Inserted Central Catheter (PICC) Image by Clinical Multimedia RBWH (2016) Tunnelled Catheters (Cuffed) Tunnelled CVAD catheters are intended to provide long-term central venous access for intermittent or continuous infusion therapy (e.g. anti-neoplastic therapy or parenteral nutrition) 46. Large bore ( 14Fr), cuffed tunnelled catheters with unique tip design, provide long term access for renal and apheresis procedures. (see Haemodialysis/Apheresis Catheter) Tunnelled catheters are typically surgically inserted into an incision in the chest (exit site), tunnelled through the soft tissue beneath the skin to the clavicle/ neck area where entry is made to a larger vessel (entry site), then advanced to the optimal position in the SVC 47. Figure 5: Tunnelled Catheter Entry Site Exit Site Image by Clinical Multimedia RBWH (2015) Resource Package Version Control 1.0 Page 18 of 110

19 Tunnelled catheters have a felt cuff (see figure 6 below) which becomes enmeshed with fibrous tissue to ensure the catheter is anchored securely 46. The cuff may be palpable as a bump on the chest wall approximately 3-5 cm from the exit site. Three weeks must be allowed for the cuff to become ingrown and therefore secure. The cuff may act as a mechanical barrier against invasion of skin tract organisms Once granulation has successfully formed around the cuff, the sutures can be removed from the exit site 12. The entry site sutures may be removed one week post insertion (internal sutures will self-dissolve). Once it has been determined that granulation has occurred it may not be necessary to apply a dressing. Immunocompromised or at-risk patients should have a clinically appropriate dressing insitu at all times. If the cuff is physically visible it has dislodged, therefore a dressing will be required to secure the catheter. The decision for a dressing-free site is based on individual patient assessment, clinical need and patient preference. Suggestions would be: skin surround is ulcerated, reddened, painful susceptibility to adhesive-related skin injury known multiple adhesive allergies, for better patient outcomes patient is not immuno-compromised Figure 6: Cuffed Tunnelled Catheters Felt Cuff Non-designated clamp area Designated clamp area Large bore renal/ apheresis catheter Haemodialysis/Apheresis Tunnelled Catheters Tunnelled haemodialysis catheters provide long-term access until a treatment plan is established (e.g. arterio-venous fistula (AVF) or Tenkhoff catheter insertion) or until dialysis is no longer required (e.g. renal transplant, kidney recovery or conservative care) Page 19 of 110 Version Control 1.0 Resource Package

20 Care Bundle principles for large gauge dialysis/apheresis catheters are exactly the same as for the categories of non-tunnelled/non cuffed and cuffed tunnelled CVADs. All Registered Nurses and Midwives competent in CVADs, (caring for a patient with a renal/apheresis catheter), must perform routine dressing changes when due or if clinically indicated, or may take culture bloods if requested Totally Implanted Central Venous Access Device Totally implanted central venous access device (TICVAD) also known as portacaths/ports, are inserted beneath the skin in a subcutaneous pocket within medical imaging or the operating theatre. A port is a reservoir that is connected to a catheter. Ports are usually inserted in the upper chest wall below the clavicle, although they can also be inserted in the abdomen, arms or legs if there is sufficient subcutaneous tissue. A port can be accessed immediately post insertion. A request can be made to the inserters to leave the port accessed for immediate use, to prevent patient discomfort. Topical anaesthetic may be applied (unless contraindicated), but only once the incision is healed and if clinical need allows time for effect. Standard ANTT is adequate for a port access however sterile gloves are worn to enable touching of the port (Key-Site) after skin preparation. There may be clinical reasons to delay access for a few days post insertion: if the (pocket) incision lies across the access point it may split open extreme tenderness presence of oedema or swelling excessive bleeding/ haematoma The port has a self-sealing gel membrane or septum which is accessed using a specifically designed non-coring safety needle. Ports are long-term devices and if well maintained, can last several years until the septum is damaged or if it exceeds the manufacturer s recommendations for the number of accesses. As the port is implanted and completely protected by skin, it allows the patient the benefit of being able to bathe or swim (when not accessed), whereas other CVAD with external catheter lumens do not have this liberty. 2.3 Specialty Features There are several catheters to choose from and generally the patient's condition and treatment regime will help decide which is the most appropriate for the patient's needs Valved Catheters Valved catheters are designed with valve technology which protects the catheter from blood reflux, therefore intraluminal thrombotic occlusion (clotting) 50. The valve remains closed during non-use therefore negates the need for clamps and enables safe interchange of needleless connectors. When a luer connection is made, the valve will open to enable administration or withdrawal. Resource Package Version Control 1.0 Page 20 of 110

21 2.3.2 Pressure Injectable CVADs Pressure injectable catheters are made of reinforced materials designed to withstand rates of at least 5mL per second power injection at 300 pounds per square inch (psi) of pressure. This allows for pressure injection of contrast media during X-ray and computed tomography (CT) imaging 32. The convenience of this specialty feature negates the need for further cannulations and related complications. Pressure injectable devices are easily recognised by the impression labelling on the lumen hubs (e.g. ml/ sec) (see images below). Figure 7: Pressure Injectable PICCs Image 1 Image 2 Valved, no clamps Image by Clinical Multimedia RBWH (2016) Non-valved, with clamps Pressure injectable TICVADs may be recognised by palpation of different features such as raised nodules or triangular shape. The most reliable confirmation however, is radiological/ image technology whereby the letters 'C and T' (e.g. CT) will be visible on the back of the port. Some patients wear a bracelet and others may have the information card which will state the port type. Pressure injectable ports require a purpose-built access needle in order for them to be used for pressure injection. Figure 8: Pressure Injectable Port Images by VASE, RBWH (2017) Coated or Impregnated Catheters Catheters impregnated or coated with an antiseptic/antimicrobial agent, may be considered to reduce the risk of bacteraemia or as a preventative for patients who have a history of recurrent infection, associated with a CVAD. Due to the potential of antimicrobial-resistant pathogens, the decision to use these catheters should be made in consultation with the organisations service of Infectious Diseases 51. Page 21 of 110 Version Control 1.0 Resource Package

22 SECTION 3- The Right Device for the Right Patient Accurate assessment is required to determine the most appropriate device. The least invasive device that will meet the needs of the patient should be chosen There are many factors that influence the selection of the most appropriate CVAD. These include: patient characteristics and preference history and co-morbidities treatment plan available devices 12 consideration for patient lifestyle and activities of daily living The registered nurse/ midwife with knowledge in CVADs should advocate the right device in partnership with the consumer. Patient education around the different devices should commence as early as possible to enable an informed patient decision. If the organisation has specialty infusion therapy or vascular access team they should be utilised as a resource. Specialty teams have a broad knowledge base, can assess, evaluate and recommend products that benefit the patient 52. The inserters and/or treating medical team should be provide guidance of any pre procedure requirements to the patient, carers and other healthcare professionals. 3.1 Pre Insertion Patient Education Education must commence prior to insertion of a CVAD in order to gain informed written consent and be ongoing as part of patient care. If patient education is not possible due to health status, cognition or circumstances consent may need to be sought from an alternate healthcare decision maker but education should ensue at a later stage. Information provided to the patient and / or alternate healthcare decision maker should include: Type of device and what it looks like (product samples/written information) The risks associated with insertion Potential complications of having and invasive device How CVAD is inserted (device specific) Pre-procedural preparation Bloods tests Fasting time Withholding anticoagulation therapy (if applicable) Expected recovery time Expected transient symptoms related to the insertion (pain, stiffness, anxiety, expected bleeding from insertion site) Insertion site and potential body image issues Resource Package Version Control 1.0 Page 22 of 110

23 Implication on lifestyle and activities of daily living (including ongoing management) Reason for Device Length, frequency and purpose of treatment Estimated dwell time 3.2 Post Insertion Verification of correct catheter tip placement must be documented in the patient healthcare record by the medical officer or interventional radiologist prior to first-time use The documentation should state actual CVAD tip position and not use phrases such as verified OK to use or tip in correct position 53. For example, correct documentation should state CVAD tip in lower third SVC or tip location at the Cavo-atrial junction. Check the external catheter length against insertion documentation to ensure the catheter position remains unchanged. This will be documented in the patients chart by the inserter at time of insertion (e.g. 5cm at skin). N.B: Venous access devices placed in the femoral vein do not require chest X-ray to confirm placement. Refer to medical entry in patient healthcare record to confirm use Patient Assessment Care of the patient after the procedure should include: Monitoring; including the patient s vital signs (including sedation score if sedation used) and assessment of the insertion site and/or suture line(s). Assess for swelling, excess bleeding or ooze and pain. Investigation of patient reported symptoms Verification/scheduling of appropriate post-discharge and follow-up appointment and instructions. N.B. Cuffed tunnelled catheters will have two insertion sites to monitor. See Tunnelled Catheters (Cuffed) for information on exit / entry sites. Large gauge catheters such as tunnelled dialysis catheters may bleed significantly post insertion 54. If bleeding is excessive or uncontrolled, apply firm pressure and implement medical review in line with organisational processes for the deteriorating patient. To manage bleeding ooze that is not excessive consider a calcium alginate product such as Kaltostat around the insertion site, then apply an absorbent adhesive dressing. Try to avoid excessive change of dressing as this can disturb clotting, instead consider reinforcing with secondary absorbent dressings. Page 23 of 110 Version Control 1.0 Resource Package

24 3.1.2 Post Insertion Patient Education The patient must be educated about the need for ongoing care requirements, complication risks and the signs and symptoms that should be observed for, and reported. Early recognition and reporting may prevent more serious consequence. Signs the patient should observe and report Redness, that may track along the vein pathway or spread from the insertion site out, may spread quickly to alert to infection Redness ± blistering, may be a defined pattern (e.g. dressing shape) to alert to allergy Swelling/ inflammation at the insertion site, along the vein pathway Blanching defined as a change in skin colour to white Leakage of blood or fluid Symptoms the patient may experience and should report Pain at the insertion site and/ or along the catheter pathway Unexpected pain in the back, chest, neck, arm or shoulder area Itchiness under the dressing Fever, headache, malaise Restricted arm movement If the patient is to be discharged home with the CVAD insitu then appropriate lifestyle education should be included. Discharge education should include emergency management in the event of line breakage, dislodgment or onset of feeling unwell. Education should be individually based depending on patient willingness, cognitive and physical ability. An emergency management pack may additionally be appropriate. Education should include: Infection prevention principles limitations or changes to lifestyle activity applicable to device type instructions not to immerse lumens (and site) in water limitations to physical activity prevention of pulling or kinking of lines where to attend follow up appointments for ongoing care management who to contact in an emergency or should there be any concerns education should be clear about what is considered non-urgent versus urgent, to enable patient to seek appropriate aid Resource Package Version Control 1.0 Page 24 of 110

25 Activity 1: Post Insertion of a CVAD Describe the nursing assessment and interventions required for a patient immediately following insertion of a CVAD Page 25 of 110 Version Control 1.0 Resource Package

26 SECTION 4 - Catheter Care 4.1 Dressing The recommended dressings are transparent, semi-permeable and self-adhesive polyurethane A transparent dressing allows the Key-Site to be visible to enable monitoring of signs of infection and other potential complications 46. Semi-permeability allows breathability to allow moisture vaporisation. A semi-permeable dressing must be single layer to be effective as moisture vaporising. All polyurethane dressings require routine weekly change. If there is gauze underneath the polyurethane dressing, this then becomes a gauze dressing and is changed accordingly. N.B. Change dressings weekly or when clinically indicated; when loose and lifting, when no longer intact or adherent, if there is evidence of inflammation, allergic reaction or excessive accumulation of blood or fluid 35. If there is clinical indication that a polyurethane dressing is not suited to patient condition then the most appropriate dressing should be used. The choice of dressing should be based on clinical indication, availability, cost and/ or patient preference Gauze Dressing Gauze-type dressings would be indicated if the patient is diaphoretic, allergic to all polyurethane adhesives or site is oozing and/or infected 35. Standards of practice recommend a gauze dressing be changed at least every hrs 46 based on assessment and critical thinking. If daily site monitoring is an organisational requirement then the dressing will be required to be changed every 24hrs 35. Polyurethane dressings enable visual inspection of the site and require less intervention, therefore are a clinically practical option over gauze dressings. A recent Cochrane study showed that dressing-related Bloodstream Infection (BSI) of a polyurethane dressing was 75 per 1000 compared to 48 per 1000 when a gauze dressing was used 55. Whilst the evidence for this comparison was rated as low quality, gauze dressings necessitate more frequent skin cleansing, so is likely feasible. N.B. If changing the dressing on any catheter with a medication lock label applied (e.g. haemodialysis/ apheresis), the label will be removed therefore must be replaced with a new one. Information should be copied from the old label before it is removed from the patient (see 4.7 Catheter Locks for information). 4.2 Securement During maintenance, the patient is monitored for signs and symptoms of complications, therefore the site should not be obscured 46. Tube-type, elasticised, non-elasticised or crepetype bandages, should not be used as they contribute to complications and are not adequate Resource Package Version Control 1.0 Page 26 of 110

27 securement for any type of CVAD 46. Apart from obscuring the site, they can impair circulation and the flow of infusates 46. A reduction in blood flow occurs from simply placing a PICC, while the addition of bandages and tapes can further reduce blood flow 66.Loose tube-type coverings tend to roll up and mimic the tourniquet effect so if required must be used with caution. Likewise, circumferential use of tape has the same effect and is a potential fomite 56. Fomites have a potential to harbour pathogenic micro-organisms 56. Surgical tape, such as Micropore and reusable tourniquets are examples of products that have the potential to act as a significant fomite 56. If a secondary securement or engineered stabilisation device is utilised, this should also be replaced every seven days or if placed under the primary dressing then must coincide with dressing change. The Infusion Nursing Standards of Practice (INS) 2016 recommend the use of an engineered stabilisation device (ESD) to: stabilise and secure prevent dislodgement prevent complications that may contribute to premature catheter removal prevent the need for secondary bandages and tapes that restrict flow 4.3 Skin Preparation The Centre for Disease Control (CDC) recommends a skin antiseptic containing 2% chlorhexidine gluconate (CHG) with 70% isopropyl alcohol (unless contraindicated), as an infective preventative measure 66. Cleansing technique should be thorough and vigorous for 30 seconds, and then allowed to air dry. If CHG is contraindicated, then use of Povidone Iodine is the second line skin preparation and in the event of iodine allergy, 70% isopropyl alcohol is third line. In the rare event that all skin preparations are contraindicated, use sterile 0.9% sodium chloride. As sodium chloride does not provide antimicrobial activity, dressing changes will be required 24hrly. To avoid skin cell injury that may be caused by frequent removal of adhesive polyurethane, a gauze-type dressing is best CVAD Access and Commencement of IV Therapy CVAD must always be accessed with aseptic technique to prevent introduction of pathogens. Catheter patency should be assessed on every CVAD access via visualisation of blood return and an unobstructed flush. If the CVAD has not been used for a period, during their weekly access, a blood discard of three (3) times the fill volume of each lumen (approximately 6mL, maximum 10mL) should be Page 27 of 110 Version Control 1.0 Resource Package

28 taken and the lumen flushed with 10mL- 20mL of 0.9% sodium chloride prior to connection. If a discard is not taken prior to infusion there is risk of introducing pathogens into the patient s blood stream causing a septic shower 66. For CVADs locked with a solution other than 0.9% sodium chloride, the lock solution must be withdrawn to prevent inadvertent administration. Prior to use, withdraw and discard the lock volume as indicated on the hub of each lumen of haemodialysis/ apheresis catheters or the approximate volume of the lumen. Flush lumens with 10-20mL of 0.9% Sodium Chloride immediately post the removal of the lock solution and prior to connection Accessing a Totally Implanted Central Venous Access Port Skill is required to stabilise the port and insert the needle in the correct access point without causing damage to the reservoir or septum. Only a staff member deemed competent can access a port. Thorough assessment of the port and site surround prior to access, using palpation and visual inspection is essential, to ascertain: Complication-free site Septum is identifiable and facing uppermost (toward the skin) Depth of port (to determine appropriate length of non-coring access needle) Difficulty of access e.g. depth, mobility or tilt tendency Ideal positioning of the patient to enable stability of the septum The patient may also be able to provide a historical account during the assessment. Only non-coring safety needles with a bonded extension (and addition of a needleless connector) should be used to access a port. This will provide a closed system to prevent risk of blood loss and entry of air and pathogens. The closed system also protects the healthcare worker from blood exposure Figure 9: Example of port access needle Smiths Medical- Gripper Plus Photo by Clinical Multimedia RBWH, 2016 Resource Package Version Control 1.0 Page 28 of 110

29 N.B. If accessed using an ordinary needle which has a coring effect, or at an incorrect angle, the membrane will sustain damage and cause loss of substance 57. If this event should occur there is risk of blood and/or fluid leakage into the tissue or vesicant extravasation causing skin and soft tissue injury. Figure 10: Non-Coring (safety) Needle Photos by Clinical Multimedia RBWH, 2016 If the needle is too short the reservoir will not be entered with subsequent inability to aspirate and administer. If the needle is too long, it will protrude and present a risk of being dislodged. In the event of partial dislodgement there is risk of infusing into the surrounding tissue. The non-coring needle must be inserted in the correct position to avoid inadvertent drag and it should not be moved once placed. Ports are associated with the highest risk of extravasation and are often secondary to needle mal-positioning or dislodgment 57. Ensure needle is adequately secured. Do not tilt rock, rotate or pull on needle when the port is accessed. Educate patient to avoid bumping and to take care with sleeping position. In the absence of blood return, infusion therapy should be withheld until the problem can be identified and corrected Radiological contrast media studies should be ordered to identify tip placement and evaluate catheter flow or any other potential structural issues The needle and dressing must be changed at least weekly, or sooner if clinically indicated. When not in use, it is recommended to perform flushing every four (4) weeks 57. Less frequent flushing could be safe and feasible and may be beneficial to patients who cannot readily access healthcare facilities Table 1: Identification of Port Needle Malposition Symptoms Management Withdrawal occlusion. It is essential to assess for blood flashback prior to every Inability to flush. bolus administration or commencing an infusion to Tissue swelling around port. confirm needle placement 62. Assess by withdrawing Page 29 of 110 Version Control 1.0 Resource Package

30 Needle dislodgement from port body. Pain in chest, shoulder or back whilst infusing/ flushing slightly until blood is visualized and placement is confirmed, (it is not necessary to draw blood back into syringe) then administer or flush as applicable. If extravasation occurs, stop infusion immediately. Notify medical team. Do not remove needle (in the event of antidote treatment). Treat as per medical team. Surgical intervention may be required. (Refer to 02954/Proc: Cytotoxic Drug Extravasation Procedure) 4.5 Infusion Pressures Infusion pressures should not exceed 25 pounds per square inch (PSI), for standard catheters, as higher pressures may cause catheter rupture and damage to blood vessels 63. Exception to these infusion pressures are pressure injectable CVADs (refer to Pressure Injectable CVADs) 32. It should be noted, the larger the syringe barrel diameter, the lower the PSI generated during injection administration When aspirating the opposite occurs, a larger syringe-diameter barrel will exert higher withdrawal pressure than a smaller-diameter syringe 64. The PSI generated by a syringe is determined by two variables, the syringe diameter and the amount of force applied to the plunger Maintaining Patency Proper flushing technique and correct frequency and sequencing of flushing are the foremost best preventative measures of catheter occlusion Apply a firm, positive pressure flushing technique using a push-pause/pulsatile technique (i.e. approx. 1mL at a time). The pulsatile motion creates a turbulent circular rotation of the solution within the lumen which helps remove residual blood and medication debris 68. When flushing a non-valved catheter, engage the clamp whilst instilling the last ml of solution. The positive pressure lock prevents back flow of blood into the tip of the catheter and subsequent clot formation 69. A valved catheter does not have clamps however on detachment of the syringe the internal valve closes and performs the positive pressure lock. As a clinical guide, a minimum flushing volume of 10 ml is recommended for CVADs 68. Several factors should be considered when choosing a flush volume: type and size of catheter catheter patency relevant medical history current condition/ diagnosis type of infusion therapy given following blood collection or administration 70. Resource Package Version Control 1.0 Page 30 of 110

31 Products or solutions that leave residual blood cells, fatty deposits or drug deposits may require larger volumes to clear the catheter and prevent build-ups which contribute to occlusion 70. Use two (2) 10mL syringes rather than one (1) 20mL, to optimise turbulence and effective washing of the catheter walls. Even though a partially occluded catheter may still function for infusing, there is risk of fibrin dislodgment, infection 71 and development of complete occlusion 70. Complete occlusion will not only cause delay and omission of treatment but increase the risk of blood stream infection considerably (see 5.5 Occlusion). Always: 1. Visualise blood return and consider the need for a discard 2. Flush with 0.9% sodium chloride prior to, and post each IV medication/fluid administration 3. Flush weekly when not in use 4.7 Catheter Locks CVADs may be locked with 0.9% Sodium Chloride, anticoagulant solutions or antimicrobial solutions. The choice of lock is dependent upon the device, length of dwell and medical decision. Medication-type locks are instilled to prevent/ treat catheter infection or thrombotic occlusion. The principle of a catheter lock is to instil a solution into the lumen after each session, leaving it in place until the next session 72. The locking volume must be sufficient to fill the entire catheter with consideration of any add on volumes 68. All catheter locks must be ordered by a medical officer and the medication may need to be specially supplied by pharmacy. Antimicrobial locks have shown to significantly reduce the risk of infections when used as a preventative measure; however, the effect on catheter materials long term is largely unknown 73. A decision regarding the use of antimicrobial lock solutions should be based on potential adverse events, ease of use, interactions with catheter material or medications, stability of the product and cost as well as the lock dwell time 73. Anticoagulant locks are widely used as an anticoagulant locking solution for haemodialysis/apheresis devices 72. The volume required for locking each individual lumen is imprinted on the hub(s). To optimise patient safety prior to use, all efforts should be made to withdraw the anticoagulant lock (by aspiration) to avoid systemic administration. Catheters with a medication lock insitu should be clearly identified and follow the Labelling Standard as part the National Safety and Quality Service (NSQHS) Standard 4: Medication Safety 74 (see label below). Page 31 of 110 Version Control 1.0 Resource Package

32 Figure 11: National Safety and Quality Service (NSQHS) Catheter Lock Label To perform a catheter lock: Ensure medication is indicated and ordered by a medical officer Prepare medication to the correct volume and dosage for the catheter lumen Slowly instil into catheter and clamp lumen Attach a correctly completed Catheter Lock medication label, This label should be sited on the catheter dressing, away from the insertion site. In this way, the semi permeable dressing remains visible while remaining close enough to alert users to the medication insitu 74. Do not apply the catheter lock label to the lumens as a sticky residue will remain and detract from ANTT. 4.8 Line Changes N.B. Infusions MUST NOT be stopped, disconnected or removed from pumps specifically for the purpose of patient transfer, unless clinically indicated. Clinical decisions to disconnect are to be documented in the patient s healthcare record. Continuous infusions are recommended as repeat, intermittent disconnection presents an increased risk of contamination 12. N.B. Once an IV giving set has been disconnected from the needleless connector this must be discarded and a new IV giving set utilised to re-access. The preparation and connection of new lines and IV infusion requires that standard ANTT be used. Prior to connection of the new line, clean the needleless connector thoroughly and vigorously from the tip and away with a sterile single-use 70% alcohol-impregnated swab, for a count of 5 seconds and allow to air dry. Resource Package Version Control 1.0 Page 32 of 110

33 4.9 Removal Overview Review the need for the invasive device daily with the Medical Officer and remove promptly when clinical need is no longer valid 76. Registered nurses and midwives whom are competent in CVAD removal can remove a: percutaneous CVC PICC non-tunnelled short term catheter e.g. non-cuffed renal catheters (Vascath). N.B. Cuffed tunnelled and totally implanted devices are removed by medical officers or interventional radiologists. The patient s treating team is required to document the request for CVAD removal. Prior to CVAD removal check the patient s coagulation status and if the values are abnormal or there are no results available, discuss with the Medical Officer for further instructions. When removing percutaneous CVC and non-tunnelled/non-cuffed large bore catheters, the patient must be: positioned supine (flat) with the exit site below the heart to reduce risk of air embolism 75 instructed on holding breath/valsalva technique when the catheter is being removed to prevent air embolism 76 The insertion site must be covered and firm pressure applied immediately, to prevent air entry and bleeding. Maintain firm pressure for minimum of 5 minutes or until haemostasis. Large bore (Fr) catheters form a larger hole therefore apply extra padding and firm pressure for longer, to achieve haemostasis 77. An appropriate occlusive dressing must remain in place for at least 72 hours, or until the hole is closed and permanently sealed and no visible ooze. The dressing can be changed as necessary. A large bore catheter (exit site) may take significantly longer to heal and is difficult to place a timeframe. The dwell time may also contribute to delay in closure therefore assess to determine the ongoing need for an occlusive dressing. N.B. An occlusive dressing is one that does not allow air entry. A semi-permeable IV dressing is breathable therefore is not acceptable as an occlusive dressing. It is recommended the patient limits activity for mins after central venous access removal. The patient should be monitored post-removal for any signs of bleeding 76. For complete instructions on CVAD removal see Clinical Principle 7: Removal of a CVAD. Documented confirmation of removal and untoward events (if applicable) is required. Page 33 of 110 Version Control 1.0 Resource Package

34 4.9.1 PICC Specifics Considerable resistance may occur as a result of venous spasm 78. The patient should be encouraged to employ relaxation techniques to prevent venous spasm of the extremity vessel during catheter withdrawal 78. Do not stretch the catheter during removal as breakage can occur Do not apply pressure over the insertion site during catheter removal. If slight resistance is felt, pause to allow the vein to relax before continuing 79. If firm resistance is encountered - STOP. Cover insertion site with temporary sterile dressing. Apply a warm compress to the venous pathway from insertion site up to axilla for minutes During this time talk to the patient and you may want to encourage relaxation techniques. After minutes resume. If the catheter is still stuck - STOP, place a sterile IV dressing over the site. Contact Medical Officer. Radiological investigations ± contrast media studies will be required to rule out other complications. The arm should be rested for 24hrs before resuming any further attempts. If the patient complains of severe pain at any time during catheter withdrawal - STOP. Do not make any further attempts until further complications are excluded. In the event of a venous thrombus, the patient may require commencement of anticoagulation therapy before further attempts at removal however this is a medical decision. There is no evidence to support best practice in regards to anticoagulation and the length of time before removal. N.B. If catheter breakage occurs apply a tourniquet or use both hands to create a constrictive affect around the upper arm circumference to possibly prevent catheter embolus. Implement medical emergency response. Resource Package Version Control 1.0 Page 34 of 110

35 Activity 2: Ongoing Management Describe the ongoing routine nursing management required for a patient with a CVAD. Page 35 of 110 Version Control 1.0 Resource Package

36 SECTION 5 - Complications Reading 5: 05600/Proc: Central Venous Access Devices (CVADs); Management - Adult Read the following RBWH procedure Infection A vascular access device is the most common predisposing factor for patients to develop a blood stream infection 81. Infections that are acquired in a healthcare facility (nosocomial) or occur because of healthcare interventions (iatrogenic) are deemed healthcare-associated infections 82. The skin harbours approximately 250 species of organisms that are either transient or residential (e.g. live in the hair follicles and deeper layers of the skin). Prior to insertion the skin is prepared with an antiseptic to reduce the number of microorganisms that can be potentially introduced, however the residential microorganisms may not be reached by normal skin preparation 83. Within hours the deeper microorganisms will come back up around the hair follicles and recolonise the top skin layers, hence the need for regular skin antiseptic and dressing change 83. Skin organisms may also be introduced into the hub during manipulation or by migration along the catheter-skin tract into the blood stream This usually occurs around 10 days post insertion as a care-associated infection 84, rather than insertion associated, and may be deemed a healthcare-acquired infection (HAI). Healthcare professionals can help prevent HAI s by complying with legislation and the Care Bundle principles. Adhering to the care bundle requires performing concepts collectively and correctly to be effective. Other strategies which may be employed and should be considered for at-risk patients are: application of an antimicrobial dressing at the catheter exit site (unless contraindicated) use of alcohol impregnated caps which remain insitu whilst catheter is not in use insertion of an antimicrobial coated central venous catheter (Antimicrobial Stewardship approved) instilling of a therapeutic catheter lock Local Infection and Allergy Infection can occur locally at catheter exit site, along the catheter tunnel or in the port pocket. Organisms found on the skin such as Staphylococcus Aureus and Epidermidis, are usually identified as the cause of local infection. A sign of redness (erythema) is a symptom of local cellulitis however may also be indicative of allergy. Allergic reactions are usually localised to the source of the irritant, whereas cellulitis has no specific boundary or shape. Sites of Resource Package Version Control 1.0 Page 36 of 110

37 irritation may become infected if unmonitored and not attended to. Allergy may be also differentiated from infection if the site is blistered or there are areas of excoriated skin (see Figure 12 below). Allergic reaction typically presents as: redness limited to the size and shape of the dressing redness consistent with the area of skin antiseptic application Figure 12: Skin Antiseptic Allergy Antimicrobial disk allergy Skin antiseptic allergy Figure 13: Dressing Allergy Image by Clinical Multimedia RBWH (2015) Image by Clinical Multimedia RBWH (2016) Infection can be differentiated from allergy by assessing for other signs and symptoms and includes palpation in the site assessment. Signs and Symptoms: Pain/tenderness Inflammation Erythema Exudate Heat Phlebitis/ Thrombophlebitis Page 37 of 110 Version Control 1.0 Resource Package

38 5.1.2 Systemic Infection Systemic infection is the most common life threatening complication associated with CVADs and can progress to septicaemia. As there appears to be an association between catheter related infection and catheter related thrombosis it is extremely important that strategies to prevent infection and thrombus formation are implemented as an integral aspect of CVAD care. If the patient develops an unexplained fever and has an indwelling CVAD then investigations for Catheter-Line Associated Bloodstream Infection (CLABSI) should commence 82. There may be local signs which would alert to infection but for the most part organisms are introduced, therefore monitor for possible early warning signs of impending sepsis 82. Signs and Symptoms: Fever Rigors Chills Hypotension Red, indurated area or purulent discharge around catheter site 82 Management: Medical review Tachycardia Tachypnoea Blood Cultures from peripheral vein and from the CVAD Close monitoring of vital signs and fluid balance Appropriate antimicrobial Positive blood culture to confirm infection 82 If catheter lumen microbial contamination is suspected, ethanol lock therapy may be prescribed Removal of device may be necessary if infection does not resolve. N.B. The decision to remove the CVAD is at the discretion of the treating team, usually in consultation with Infectious Diseases. This decision will be based on the patient s ongoing condition, effectiveness of antibiotic therapy and the need for vascular access. 5.2 Infiltration and Extravasation Infiltration and extravasation is the inadvertent administration of a solution or medication outside of the vein wall into the surrounding tissue Extravasation is differentiated by leakage of vesicant medication (with a high or low ph, or high osmolarity) into surrounding tissue causing permanent damage, whereas infiltration is a result of leakage of any other solution which whilst less damaging, can cause severe irritation 85. Vesicant solution or medication may cause the formation of blisters which occurs within hours or days, with subsequent sloughing due to tissue necrosis. Progression of ulceration may Resource Package Version Control 1.0 Page 38 of 110

39 continue for up to two (2) weeks therefore immediate attention and ongoing monitoring are essential. Necrosis can involve underlying connective tissue, muscles, tendons and bone, necessitating surgical intervention 86. Common causes include: puncturing of the distal wall vein during venepuncture puncturing the vein wall by mechanical friction from the catheter dislodgement of the catheter from the intima of the vein dislodgement of the port access needle from the septum poor vein or site selection improper catheter size catheter malposition high delivery rate or pressure of the infusate irritating infusates that inflame the intima of the vein, causing susceptibility to rupture. Signs and Symptoms: pain, burning, stinging at or near the insertion site or anywhere along the length of the catheter blanching or redness taut, rigid skin around insertion site (induration) damp or wet dressing swelling proximal to or distal to the insertion site infusion slows or stops running blister formation Prevention: Avoid the antecubital area for PICC insertions Adequate dilution of medications Slow down IV solutions and/or medications Catheter securement Monitor site routinely Educate patient to report symptoms Proper assessment of the device patency prior to administration of medication Verify correct tip location and external length prior to first time use, then provide ongoing monitoring to note any change to external catheter length. Page 39 of 110 Version Control 1.0 Resource Package

40 Management: If infiltration/extravasation suspected, immediately stop all infusions. Early recognition of infiltration/extravasation is critical to minimise the amount of fluid that escapes into the surrounding tissue and subsequent tissue damage 86. Disconnect the giving set and aspirate the catheter. Estimate the volume of fluid that has infiltrated into the surrounding tissue. Mark the affected area to allow for assessment of change 25 o caution is required due to the coning effect of some extravasants, as marking may disguise extent of underlying damage Notify treating team for review. Notify pharmacy as soon as possible as antidote may be available. Do not apply ice pack without first checking with pharmacy as some medications require heat to reduce potential tissue damage. Complete an incident report. 5.3 Phlebitis Phlebitis is inflammation of the intima of the vein because of irritation to the endothelial cells within the intima The damage to the endothelium creates a rough cell wall where platelets readily adhere and consequently thrombophlebitis can develop which may result in thrombosis or sepsis. Phlebitis is classified according to its causative factors - chemical, mechanical, bacterial and post-infusion 87. When assessing the patient for signs and symptoms it is important to also palpate the vein/catheter pathway, as early signs are not always visible. Thrombophlebitis may also reduce blood flow particularly with a PICC, therefore the neck, chest, arm and hand should be observed for increased swelling. Signs and Symptoms: Pain and discomfort 87 Induration 87 Erythema 87 Purulence 87 Warmth 87 Swelling 87 Tracking and/or cording along vein tract or skin tunnel for tunnelled catheters Chemical Phlebitis Chemical phlebitis is an inflammatory response created by the administration of solutions or medications, or because of certain catheter materials used for access. Infusates with a ph less than five (5) or greater than nine (9) or high osmolality, e.g. greater than 300 mosm/l, predispose the vein intima to irritation. Precipitate formation from improper mixture or dilution of medication can also increase the risk of chemical phlebitis as does an increased dwell time. The central catheter tip resides in the SVC where the blood flow rate is very high so chemical Resource Package Version Control 1.0 Page 40 of 110

41 phlebitis is less common. However, chemical phlebitis may be observed with CVADs if the catheter ruptures or if the catheter malposition s into a vein of lesser flow rate. Prevention: Use of recommended diluents and volume Administration of medication at the recommended rate Flushing catheter post administration to clear medication o Flush rate consistent with medication infusion Insertion of appropriate size (Fr gauge) catheter to ratio of vein diameter Close monitoring of catheter for signs and symptoms of catheter rupture Mechanical Phlebitis Mechanical phlebitis is an inflammatory response associated with the placement of the CVAD. Mechanical phlebitis is most commonly seen with PICCs due to constant movement of the extremity creating a piston movement of the catheter thereby causing irritation to the vein intima. Contributing factors are: poor securement, poor insertion technique, catheter gauge too large for vein and patient condition (e.g. dehydration). Prevention: Good securement to minimise movement: maintain a dry and occlusive dressing Reduce strenuous exercise of extremity Reduce frequent bending of elbow (if PICC inserted distal to elbow) or strenuous movement Insertion of appropriate size (Fr gauge) catheter to ratio of vein diameter (particularly PICC) Gentle, gradual catheter insertion Bacterial Phlebitis Bacterial phlebitis is an inflammation of the vein associated with a microbial infection. Prevention: Effective hand washing is the single most important procedure for preventing nosocomial infection Competently trained inserters utilising an insertion bundle and checklist Maintain asepsis during insertion and maintenance procedures Routine site care such as changing the dressings and needleless connectors at recommended intervals, using appropriate skin disinfectant and applying a sterile dressing Routine site monitoring to notice early signs of infection/inflammation. Management: Routine assessment of CVAD Determine the possible aetiology of phlebitis and implement appropriate intervention Page 41 of 110 Version Control 1.0 Resource Package

42 Assess and document response to intervention If bacterial phlebitis is suspected, arrange a medical review Post-infusion Phlebitis Post-infusion phlebitis is an inflammation of the vein associated with infusion therapy which becomes evident hours after catheter removal. Little evidence is available regarding the incidence of post-infusion phlebitis in CVAD. The literature available relating to post-infusion phlebitis primarily concerns peripheral intravenous catheters 88. It is therefore important that monitoring should continue post-removal. Contributing factors: poor insertion technique, patient condition, poor vein condition, vesicant solutions, ineffective filtration, large-gauge catheter and routine maintenance interventions not performed. Activity 3: Understanding Phlebitis a) Please provide a definition of phlebitis b) Under each subheading explain the type of phlebitis, the factors that may contribute and preventative measures i. Chemical ii. Mechanical iii. Bacterial Resource Package Version Control 1.0 Page 42 of 110

43 5.4 Malposition The healthcare practitioner should always compare external catheter length and measurement at skin (exit site) to insertion and relevant ongoing documentation 25 essential to enable the following management strategies: monitor for deviation from documented measurements 57. This knowledge is know the implication for change (e.g. longer or shorter), and action accordingly can identify other signs and symptoms that may denote malposition, and action accordingly Page 43 of 110 Version Control 1.0 Resource Package

44 Table 2: Catheter Malposition Management External Length Management Increases Perform chest x-ray to determine if the tip remains within the lower third of the SVC near the juncture with the right atrium. If the tip no longer dwells within the SVC then the CVAD must be managed as a peripheral catheter A chest x-ray will be required to ascertain possible tip malposition. If the tip is no longer in the central vein this may not meet clinical requirements. If the patient is receiving ongoing vesicant medication(s) and or hypertonic fluids (i.e. osmolarity > 600 mosm/l) which require administration via a CVAD 89, replacement would be required. Decreases Indicates advancement into the vessel and this poses risk for blood stream infection, possible tip migration, perforation and arrhythmias. Removal should be a priority. N.B. Never advance a partially dislodged catheter, the risk of blood stream infection is significant. Consider the appropriateness for catheter removal, change to oral therapy or cessation of prescribed therapy. PICC malposition is reported to be three times more common than other CVAD. A change in measurement, therefore position, can contribute to Catheter Tip Migration and infection or have implication for partial removal. Figure 14: CVAD Malposition a) Subclavian dwell, on opposite side of insertion arm Resource Package Version Control 1.0 Page 44 of 110

45 b) Brachiocephalic dwell Malposition may cause mechanical problems such as catheter kinking or tip occlusion by abutment to the vessel wall. The patient may complain of pain where the infusate continually strikes against the vessel wall, causing injury. Trauma to the vessel wall can contribute to thrombus formation called a mural thrombus because it is a major vessel. Thrombus formation may cause obstruction of blood flow through the SVC resulting in Superior Cava Syndrome. Pain should always be investigated particularly if it coincides with administration because the infusate can corrode through the vessel wall into neighbouring structures and organs resulting in death Catheter Tip Migration Catheter migration is the movement or displacement of the catheter tip from the documented, satisfactory position to a neighbouring vein or less optimal position 90. If the catheter tip is not advanced to the optimal location, then it can spontaneously migrate to another vessel or the heart chambers 91. The high flow rate within the SVC can easily propel the catheter, while the large vessel diameter allows for movement. The external catheter length (e.g. measurement from the skin exit site to lumen hub) may not necessarily alter with an internal malposition therefore assessment cannot be based on this alone. Catheter migration can also be caused by: forceful flushing of the catheter pressure injection changes in intra-thoracic pressure - by sneezing, coughing, vomiting, heavy lifting vigorous upper extremity movement disease process Page 45 of 110 Version Control 1.0 Resource Package

46 - reduced blood flow and dilated vessels e.g. Congestive Heart Failure 90 - tumour displacement or venous thrombosis 90 consequence of suboptimal care by clinician - accidental dislodgement - advancement of catheter into the body - poor securement. The patient may complain of symptoms which could allude to malposition, other symptoms may be observed by assessment of change or infusions and equipment may be proving troublesome. The following signs and symptoms may allude to catheter malposition. Signs and Symptoms: inability to infuse or aspirate pump may alarm intermittently hearing a swishing or running-stream sound 90 ear gurgling 90 cold feeling in an unusual place e.g. the back or neck pain or discomfort in neck, shoulder, arm or back 90. Activity 4: Identifying Malposition What nursing strategies are used to recognise and prevent accidental dislodgment of a PICC? Resource Package Version Control 1.0 Page 46 of 110

47 5.5 Occlusion Replacing a dysfunctional CVAD is expensive, invasive and inherent with risk, and may contribute to considerable delay in patient treatment therefore steps to prevent, and resolve occlusions are essential 92. Catheter malfunction, due to occlusion is the most common noninfectious complication associated with CVADs, particularly long term use 93. Between 14-36% of CVADs occlude within the first two years of dwell life 94. Occlusions are classified as either thrombotic or non-thrombotic (e.g. chemical or mechanical). An occlusion can be defined as: total or complete, the inability to infuse fluids and withdraw blood from a CVAD partial or withdrawal occlusion, able to infuse fluids but not aspirate variable, the IV infusion pump may alarm intermittently A partial occlusion left untreated may progress to total occlusion and increase the risk of infection. To determine the type of occlusion, complete a review of usage, infusate history, mode of delivery and other possible causative factors (see Appendix 1: Initial Assessment and Troubleshooting of CVAD Occlusion). The clinician should assess for, and identify different signs and symptoms: including the inability to withdraw blood or sluggish blood return 57 sluggish flow or resistant to flushing inability to flush or infuse eliminate mechanical obstruction that could be internal or external in nature frequent alarms on electronic infusion device (e.g. occlusion or pressure) Mechanical Occlusion Mechanical obstruction of the catheter is usually easily remedied if it is an obvious external cause 94 (see Appendix 3: External Mechanical Occlusions Table). However internal mechanical occlusions can be misinterpreted as another cause and not treated correctly 94 (see Appendix 4: Internal Mechanical Occlusions). Unidentifiable cause may require radiological investigations ± contrast media studies Pinch-Off Syndrome Pinch off syndrome (POS) is a significant complication associated with risk that can result in catheter tearing, transection and catheter emboli 94. It occurs when a catheter is compressed by the clavicle and first rib 94 when a catheter is inserted or passes through this routeerror! Bookmark not defined.. Signs and symptoms of pinch-off can mimic partial withdrawal occlusion therefore a chest x- ray may be ordered to provide a definitive answer. Page 47 of 110 Version Control 1.0 Resource Package

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49 The patient may present with: Chest pain, dyspnoea, palpitationserror! Bookmark not defined. Shoulder pain 90 Pain with flushing 90 The healthcare worker may note 90 Intermittent and positional occlusion Difficulty infusing or flushing Complete withdrawal occlusion Swelling in the area that may or may not extend to the arm. A simple test of postural change may differentiate between POS and withdrawal occlusion. Rolling back of the shoulders or raising the arms above the head will open the costoclavicular space and return catheter function. A chest x-ray will confirm or rule out POS. On confirmation, the catheter must be removed and any embolised catheter fragments will need to be retrieved Non-Thrombotic Occlusions Non-thrombotic occlusions are caused by: precipitation of medications with high or low ph 107 calcium phosphate crystals that become insoluble in basic solution 107 lipid emulsions and proteins 94. Before administering any medication, it is important to know the medication and compatibility with other concurrent infusions. Flush the catheter lumen between each medication to clear debris that may contribute to non-thrombotic occlusionerror! Bookmark not defined.. Gravity flushing will not adequately clear debris that may be adhered to the catheter wall therefore turbulent flushing is recommendederror! Bookmark not defined.. Non-thrombotic occlusions will not be resolved with a thrombolytic agent and accurate identification of the cause is required for successful treatment. There are recognised treatments for non-thrombotic occlusions (see Appendix 5: Treatment of Non-thrombotic Occlusions) Thrombotic Occlusion All CVADs are associated with an increased risk of thrombotic occlusion, although PICCs is the most prevalent, as previously discussed. Thrombotic occlusion occurs when blood components accumulate within, surrounding or at the tip of the catheter 95. Certain conditions may predispose to catheter occlusion because of hypercoagulability, such as oncological disease 95. Vessel wall injury and venous stasis may also increase risk 95 (see Appendix 2: Assessment of Thrombotic Occlusion and Appendix 6: Symptoms of Thrombotic Occlusion). Page 49 of 110 Version Control 1.0 Resource Package

50 Activity 5: Risk Prevention and Occlusion Management a) What checks should be performed to determine the type of occlusion? b) Explain the best management for prevention of thrombotic catheter occlusion. Resource Package Version Control 1.0 Page 50 of 110

51 5.6 Venous Thrombosis Thrombosis is simply the formation of a blood clot in a vein 90. Presence of a CVAD increases the risk of venous thrombosis occurrence in the upper extremities or chest Clot formation is a media for biofilm and the patient will be at increased risk for a bacteraemia 13. Trauma to the vessel wall associated with CVAD insertion can interfere with the blood flow rate. There are many risk factors during a CVAD insertion procedure which can contribute to vessel wall injury. These include: the initial cannulation with needle advancement of the guide wire introduction of the introducer sheath difficult advancement of the catheter. Risk factors for catheter-associated thrombus include: tip location 96 insertion site 96 number of venous punctures 96 catheter dwell time 96 characteristics of the infusate(s) traumatic insertion aberrant vasculature poor blood flow interruption of laminar flow high catheter-to-vein ratio 97 Awareness of tip location is important because tip malposition can often contribute to thrombosis 90. Optimal tip placement at insertion is equally significant because when the tip is in the upper superior vena cava (SVC) or a more peripheral location the risk of thrombus is much greater than when it is just above the right atrium Mural Thrombus If the tip is abutted to the vessel wall it can rub and cause injury resulting in formation of a mural thrombus 97. Tip locations in the subclavian vein or at the brachio-cephalic junction are risk areas because of the propensity to catheter contact with the endotheliumerror! Bookmark not defined.. A mural thrombus is caused by the catheter rubbing, and irritating the vessel intima, and potentially leading to an accumulation of fibrin. The fibrin from the vessel wall injury binds to fibrin covering the catheter surfaceerror! Bookmark not defined. 97. The catheter can adhere to the vessel wall, which may lead to a deep vein thrombosiserror! Bookmark not defined.. Page 51 of 110 Version Control 1.0 Resource Package

52 5.6.2 Superior Vena Cava Syndrome Superior vena cava syndrome (SVCS) is the obstruction of blood flow through the SVC 98. It is mostly commonly due to malignancy or thrombus formation associated with an indwelling CVAD 98. The SVC is a large vessel with high flow rate and if occluded prevents blood flow to the heart 98. The SVC drains blood from the head, neck, arms and thorax (to the heart), and if occluded the vein to these areas will become engorged and distended 98. The onset of symptoms is usually insidious particularly if the initial thrombus formation is only partial occlusion. SVCS is recognised as potentially life-threatening 99 and a serious complication of an indwelling CVAD The patient may experience the following symptoms: shortness of breath on lying down facial swelling and puffy eyelids sensation of fullness in the head unrelenting cough and hoarseness hearing loss 99 swelling of arms, chest and upper back SVCS usually presents with typical signs and symptoms and once recognised, requires prompt attention. An X-ray and CT of the chest are the usual imaging studies to confirm thrombosis and SVCS Air Embolism Air embolism is a rare yet potentially lethal complication of a CVAD. The vascular pathway is susceptible to changes in atmospheric pressure. If a catheter is open to room air any changes in intrathoracic pressure (e.g. breathing inwards) cause air to be drawn into the venous system by negative pressure. When this occurs, air will travel to the right ventricle and enter the pulmonary circulation 109. It can occur at various time points: during insertion or removal of CVADs as a result of external damage to the catheter from a faulty catheter accidental removal of CVAD catheter open to air e.g. needleless connector removal may occur post removal if healing is delayed Signs and Symptoms: Tachycardia/ arrhythmia Chest, shoulder or low back pain Hypotension Dyspnoea Cyanosis Tachypnoea Decreased level of consciousness Cardiac arrest Elevated central venous pressure Feeling of impending doom Resource Package Version Control 1.0 Page 52 of 110

53 Management: This is a medical emergency. Call 333. Initiate medical emergency response and/or basic life support, as required Place patient in the left Trendelenburg position (moves air embolus away from pulmonary valve) 100 Deliver high flow oxygen via non-rebreather mask or ambu bag 100 Monitor and document vital signs Complete a patient incident report Prevention: Correct positioning of patient during insertion and removal of CVAD (Supine or Trendelenburg position) Using only luer-lock giving sets and syringes Clamping catheter lumen when changing giving sets or needleless connectors Immediately clamping catheter proximal to any external damage Adherence to air embolism preventative measures on removal of CVAD such as Trendelenburg position and Valsalva Manoeuvre. Refer to 05600/Proc: Central Venous Access Devices (CVADs); Management Adult for specific information Avoid using any sharp objects near the catheter 5.8 Catheter Damage Catheter rupture is when there is an incomplete break in the wall of the catheter and can occur at any place along the CVAD. External catheter ruptures are detected by fluid leakage from the external wall of the catheter on flushing or infusing solution into a lumen. A ballooning in the external wall of the catheter may also be seen on flushing and is a precursor to full catheter wall rupture. Internal ruptures may be detected by leakage from the insertion site causing the dressing to become wet or patient reported symptoms such as pain, burning or stinging on infusion. Management For an external rupture: clamp the portion of the catheter between the site of damage and chest wall or peripheral arm. Notify treating team/after-hours medical officer for management. Depending on the location of the rupture, external ruptures of cuffed tunnelled catheters and PICCs can be repaired by trained personnel. If irreparable, the device will need to be removed. For a suspected internal rupture: Stop the infusion, contact treating team for management such as contrast medium studies to diagnose the rupture and removal of the device. N.B. For other CVAD Complications see Appendix 7: Other CVAD-Related Complications Page 53 of 110 Version Control 1.0 Resource Package

54 SECTION 6 Principles of CVAD Blood Collection Reading 6: QLD Pathology Order of Draw Read the following Safe Blood Collection from a CVAD All CVADs have the capacity to be used for blood sampling however the greater the manipulations of the lumens/hubs the greater the potential of: intraluminal contamination 67 Error! Bookmark not defined. alteration to CVAD patency inaccurate laboratory results iatrogenic anaemia 102. CVAD blood collection should be preserved for the acutely unwell patient, when peripheral access is completely exhausted and/ or, if catheter specimen is indicated for culture and sensitivity PICCs have narrow lumens and long catheter length so predispose to occlusion more than any other CVAD 101. N.B. Only devices with the tip centrally placed (e.g. SVC) can be used for blood collection. The method of blood sampling from a CVAD is the Discard Method 102. This is achieved by attaching an empty syringe and withdrawing three (3) times the catheter fill volume and discarding, prior to collecting the target sample for analysis 102. This is to prevent sampling medicated blood or infusion fluid which could falsify laboratory results 103. This method has a low percentage of error compared with other methods 102. A major concern with the Discard Method is that long term patients who require frequent blood sampling may result in an iatrogenic anaemia, due to the frequent discards 102. By bundling tests together, there are less frequent discards of blood and a decreased risk of infection to the patient 110. Prior to sampling it is necessary to stop all infusions and clamp all other non-sampling lumens to minimise contamination and erroneous pathology results. There is no requirement to wait for any period of time after stopping all infusions before collecting blood from a CVAD. The Discard Method and high flow rate of the SVC is sufficient to clear all infusates. Blood sampling should occur from a dedicated lumen (if clinically appropriate), to minimise potential multi-lumen complications (e.g. occlusion and colonisation). Dedicating one lumen to blood sampling also optimises laboratory results, particularly for therapeutic drug monitoring 25 If a dedicated lumen cannot be used test results may be falsely elevated so careful consideration is required in drug dosage adjustment 25. Retesting via direct venepuncture may be necessary 25. Resource Package Version Control 1.0 Page 54 of 110

55 N.B. Disconnection of infusion lines is discouraged at any time. A disconnected infusion line must be discarded. A dose dependent infusion must not be disconnected as this will result in medication error and may have consequential outcomes for the patient. Direct venepuncture should be considered first. Addition of a 3-way tap/tails at initial setup will minimise the requirement for line disconnection however additional access ports/ mechanical parts may increase the risk of infection 25. If the device is single lumen then the benefits of a 3-way tap/ tail may be negated due to risk of device failure or erroneous samples. N.B. If parenteral nutrition is infusing, the lumen must not be used for blood sampling due to significant risk factor for catheter-related blood stream infection Activity 6: Indication for Blood sampling from a CVAD There must be clinical indication for performing blood sampling from a CVAD. a) Explain the risks associated with blood sampling from a CVAD. b) Describe the reasons when it would be appropriate to take blood from a CVAD Page 55 of 110 Version Control 1.0 Resource Package

56 6.1.1 Blood Cultures Collection of blood cultures through CVADs has a low positive predictive value and specificity for confirming bacteraemia. A set is defined as one (1) x aerobic and one (1) x anaerobic bottle (Queensland pathology reference). The correct volume of blood is the single most important factor in optimising the true pathogen yield 102. The aerobic bottle should be filled first to avoid air contamination of the anaerobic bottle. The Queensland Pathology Test List website for Blood Culture (blood) [adult and paediatric] (BacTAlert system) culture for bacteria, fungi, Mycobacteria states; IV Device Infection: Collection of 2 blood culture sets simultaneously (i.e. within 15 minutes of each other) is recommended. Collect the first set through the catheter and the second set from a peripheral vein 106. The initial catheter blood draw is the target sample for analysis If peripheral access is viable, two sets of culture bloods should be drawn to give greatest sensitivity (90%) and predictive value, prior to the commencement of antibiotics 107. If peripheral and central bloods culture the same pathogen then a Catheter-Line Associated Bloodstream Infection (CLABSI) is suspected. The recommended method of absolute confirmation of a Catheter-Related Bloodstream Infection (CR-BSI) is to culture the CVAD tip. Reading 7: Blood Cultures Read Section 4 of the procedure 05450/Proc: Blood Cultures for correct process of collection Resource Package Version Control 1.0 Page 56 of 110

57 Activity 7: Safe Collection of Blood Samples You are required to collect blood samples from a double lumen CVAD for full blood count (FBC), electrolytes (chem 20) and coagulation profile. The patient has a continuous potassium infusion through the white lumen and the red lumen is not in use. Describe the best collection process to prevent: a) contaminated or inaccurate samples b) errors after the samples are collected. Page 57 of 110 Version Control 1.0 Resource Package

58 6.2 Restoring Patency The best treatment is prevention; however, a partially or completely occluded catheter must never be left untreated 92. If one lumen is occluded, the others will be susceptible and eventually will be affected. A full assessment is required to determine cause and treatment. If a thrombotic occlusion is deemed the cause, then a thrombolytic agent may be prescribed and administered. See Section 8 Clinical Practice Guiding Principles for Clinical Principle 3 - Instilling Thrombolytic Agent. Restoring function to a catheter is much easier to achieve when the thrombolytic agent is able to be directly instilled by positive pressure (e.g. able to flush). If the catheter is completely occluded, then a negative pressure technique will need to be undertaken to safely instil the medication (to avoid line rupture). Figure 9: Unblocking a CVAD: Complete Occlusion Setup for 3-way tap negative pressure configuration Needleless connector removed Thrombolytic agent (10mL syringe) Empty (sterile) luer lockable syringe (5mL) Drawing by Clinical Multimedia, RBWH 2016 Resource Package Version Control 1.0 Page 58 of 110

59 SECTION 7: Central Venous Access Devices Management Theory Examination Name: Work Unit: Complete theory examination and submit to VAD Trainer for marking. All health professionals are required to achieve 100% pass grade prior to commencing clinical component. Please tick the most correct response 1) The best preventative measures of partial and complete catheter thrombotic occlusion are a) Proper flushing technique, correct frequency and sequencing b) Avoid routine blood sampling c) Leave clamps open d) Flush the catheter every 4 hours e) a & b 1 Mark 2) After central line insertion what checks must be done prior to first time use, and allow for ongoing monitoring of malposition? a) Check insertion documentation for measurement at skin and overall catheter length and check against the actual device b) Documentation by a radiologist or medical officer verifies actual tip location to confirm use as a central device c) Documentation by a radiologist or medical officer has confirmed the catheter is safe to commence use d) Assess the patient and note any bruising or swelling which may indicate an increased frequency of monitoring e) All the above 3) What is the best practice for preventing catheter occlusion and maintaining patency? a) Forceful flush with 10mL syringe to clear the catheter b) Always use 20mL solution to clear catheter c) Push-pause/ pulsatile technique to create turbulence d) Clamping the lumen whilst instilling the last 0.5mL to prevent reflux e) c & d 1 Mark 4) When a patient has a PICC placed the external measurement (cm) will be documented by the inserter in the patient s clinical record. What is the significance if this measurement should change? a) Indication of catheter rupture internally and a fragment embolised resulting in shorter catheter b) May indicate catheter advancement posing risk for bacteraemia c) Indication for change of management and review of usage d) May indicate catheter migration therefore posing a risk it is no longer a central device e) b, c & d 1 Mark Page 59 of 110 Version Control 1.0 Resource Package

60 5) Prior to use, when should a blood discard be taken from the CVAD? a) When the CVAD has not been in use for one week or longer b) Prior to a routine weekly flush if the CVAD has not been in use c) Every time the CVAD is accessed for use d) Every time a needleless connector is changed e) a & b 6) For a diaphoretic patient, what clinically, would be the most appropriate IV dressing? a) Gauze type dressing, changed daily b) No dressing at all c) Semi-permeable as it is breathable d) Polyurethane transparent to enable observation of the site e) Transparent dressing with extra tape around edges for securement 1 Mark 1 Mark 7) When removing a large bore (14fr) percutaneous catheter what precautions should be taken? a) Check coagulation levels b) Position patient supine with the exit site below the heart to reduce the risk of air embolism c) Instruct patient on Valsalva manœuvre d) Apply firm pressure for minimum 5 minutes e) All the above 1 Mark 8) Extravasation and infiltration are the leakage of infusion fluid/medication into the surrounding tissue. Both are potentially serious complications. What differentiates extravasation from infiltration? a) Causes severe damage of underlying structures b) Causes damage but readily heals c) Damage is only caused by irritating medications d) More likely to develop tissue necrosis requiring surgical intervention(s) e) a & d 1 Mark 9) Changing a needleless connector on a CVAD requires standard ANTT and can be performed wearing non-sterile gloves. Why are sterile gloves not indicated? a) Key-parts will not be touched b) Possible blood contamination renders sterile gloves unnecessary c) It is not a sterile procedure d) A simple procedure whereby a non-touch technique can easily be maintained e) a and d 1 Mark Resource Package Version Control 1.0 Page 60 of 110

61 10) Care Bundles are a group of principles performed collectively for insertion and management of vascular access devices. Why are Care Bundles effective? a) Practice is standardised b) The risk of complication is reduced c) It is proven to be cost saving d) Individualised to the organisations needs e) All of the above 11) What main function, does the cuff on a tunnelled catheter, perform? a) Prevents intraluminal infection b) Maintains securement within the subcutaneous tissue c) Provides a land mark for where the catheter is inserted d) Prevents bacteraemia e) Allows the patient to go swimming 1 Mark 1 Mark 12) What is the single most effective intervention to reduce the risk of healthcare- associated blood stream infection? a) Cleansing inactive Key-Parts b) Use of Care Bundles c) Performing Hand Hygiene d) Patient education e) CVAD Competency 13) Why is the correct tip position in a CVAD important? a) Safe administration of medications b) Decrease the risk of venous thrombus c) Prevent migration into other less optimal vessels d) Decrease the risk of catheter occlusion e) All of the above 1 Mark 1 Mark 14) Prior to administration via a port, the safest and most reliable confirmation of correct needle placement is? a) It is not necessary to check placement if smooth entry was made b) It flushes well with no resistance and no obvious swelling c) The ability to aspirate and visualise blood, using a 10mL syringe d) The back of the portal reservoir should be felt when touched by the non-coring needle e) Absence of pain when the infusion is commenced 1 Mark Page 61 of 110 Version Control 1.0 Resource Package

62 15) What factors may contribute to risk of a thrombotic occlusion? a) Frequent blood withdrawals and blood product administration b) Insufficient flow through lumen & hypercoagulability c) Long catheter dwell time d) Incorrect flushing technique and inappropriate flushing volume e) All of the above 1 Mark 16) When blood sampling from a CVAD no larger than a 10mL syringe should be used. What is the reason for this? a) A large syringe does not create enough pressure to get a good draw. b) A large syringe creates greater withdrawal pressure and may collapse the catheter c) Reduce risk of over blood sampling d) Reduce risk of iatrogenic anaemia e) Increases the risk of catheter occlusion 1 Mark 17) If a catheter has been confirmed by x-ray as having pinch-off syndrome it should be removed due to risk of catheter embolisation and also mural thrombus formation. What is a mural thrombus? a) A vessel occlusive thrombus b) Small thrombus that does not cause any symptoms therefore usually undetected c) Thrombus caused by catheter rubbing against the vessel wall d) Thrombus that may embolise very easily e) Only occurs in small vessels due to blood flow rate 1 Mark 18) You are caring for a patient with a tunnelled cuffed catheter which was inserted 3 days ago. The patient inadvertently catches the end and pulls it out. The site has some blood ooze and the patient suddenly becomes dyspnoeic, cyanosed and complains of sudden onset shoulder pain. What is the likely cause? a) Hypovolaemia due to blood loss b) Severe hypotension c) Air embolism d) Septic shower e) Shock, due to severe patient anxiety 1 Mark Resource Package Version Control 1.0 Page 62 of 110

63 19) What are the risks for catheter-associated thrombus a) Tip location b) Catheter dwell time c) Catheter-to-vein ratio d) Trauma to the vessel wall e) All the above 1 Mark 20) PICCs are at risk of malposition because they are inserted into a moving limb. The higher the tip is placed in the superior vena cava the higher the risk for malposition. If the tip malposition is into the jugular vein what symptoms may the patient experience whilst intravenous treatment is administered a) hearing a swishing or running-stream sound b) cold feeling in the back c) pain or discomfort in neck, shoulder, arm or back d) neck swelling e) sudden onset headache when infusing 1 Mark Comments: Mark:./20 Participant signature: Assessor Name: Assessor Signature: Position: Date: Date: Complete theory examination and submit to VAD Trainer for marking. All health professionals are required to achieve 100% pass grade prior to attending the workshop and commencing clinical component. Page 63 of 110 Version Control 1.0 Resource Package

64 SECTION 8 Clinical Practice Guiding Principles Clinical Principle 1: Accessing and Flushing Equipment green tray/ trolley (general aseptic set-up field) 70% isopropyl alcohol wipe 10 ml luer lock syringe(s), ml sodium chloride 0.9 % ampoule(s), 1-3 Blunt drawing up needles, 1-3 Additional if accessing for use: PPE - non sterile gloves, apron and protective eyewear (if taking blood discard) IV line(s) and intravenous medications or fluids (as required) Procedure 1. Explain the procedure to the patient and obtain verbal consent. 2. Perform hand hygiene 3. Position patient in a comfortable position. 4. Perform hand hygiene. 5. Assess the insertion site for any complications such as signs of redness, discharge, swelling and/or tenderness. If the insertion site shows any signs of an infection, take a swab for Microscopy, Culture and Sensitivity [MC&S]) and refer to medical officer for review. Perform dressing change 6. Perform hand hygiene. 7. Cleanse aseptic field (tray/ trolley). 8. Perform hand hygiene. 9. Set-up equipment (open packets ensuring Key-Parts remain protected). 10. Perform hand hygiene. 11. Draw up flushing solutions. 12. Perform hand hygiene and don PPE (if applicable). Using a non-touch, twist-turning action, clean the needleless connector thoroughly and vigorously for a minimum of 5 seconds with a 70% isopropyl alcohol wipe and allow to air dry. 13. If not taking a discard (as in step 13), attach syringe with drawn up volume of sodium chloride 0.9%. Draw back plunger to simply visualise blood, then flush. Use pulsatile (push-pause) technique Clamp the lumen while flushing the last ml Resource Package Version Control 1.0 Page 64 of 110

65 14. If the CVAD has not been used for a week, attach an empty 10mL syringe and aspirate 6-10mL and discard (PPE should be worn when handling blood). If a catheter lock label is attached to the dressing then this indicates a need to aspirate the medication within the catheter. Withdraw and discard the volume indicated on the sticker. 15. Connect primed IV line(s) to needleless connector(s) (if applicable), anchor tubing as required, unclamp, and commence infusion. 16. Discard waste as per procedure. 17. Remove PPE. 18. Perform hand hygiene. 19. Document in the patients clinical record and record any complications. Page 65 of 110 Version Control 1.0 Resource Package

66 Clinical Principle 2: Needleless Connector Change Equipment green tray/ trolley (general aseptic set-up field) packet sterile gauze sterile needleless connector 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol SoluPrep Wipe PPE- non-sterile gloves/ plastic apron 10 ml luer lock syringe(s) 10 ml sodium chloride 0.9 % ampoule(s) Blunt drawing up needle Procedure 1. Explain the procedure to the patient and obtain verbal consent. 2. Perform hand hygiene 3. Position patient in a comfortable position. 4. Perform hand hygiene. 5. Cleanse aseptic field (tray/ trolley). 6. Perform hand hygiene. 7. Set-up equipment (open packets ensuring Key-Parts remain protected). 8. Draw up flushing solutions and prime new connector. 9. Perform hand hygiene and don PPE (if applicable). 10. Hold catheter lumen in non-dominant hand. 11. Check that clamp is closed. Closed ended or Valved-catheters will not have clamps. 12. Pick up gauze and use to wrap around connector to remove, and then discard both. 13. Place the CHG w/ 70% isopropyl alcohol wipe over the open end of the lumen to completely encase. Cleanse down and away from tip taking care not to introduce contaminants into the open catheter. Utilise a twist-turning action for a minimum of 5 seconds to ensure a thorough and vigorous cleanse and allow to air dry. 14. Attach the new connector. 15. Discard waste as per procedure. 16. Perform hand hygiene. 17. Document in the patients clinical record and record any complications. Resource Package Version Control 1.0 Page 66 of 110

67 Clinical Principle 3: Dressing Change Equipment trolley (general aseptic set-up field) sterile basic dressing pack 2 x 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol Solu-IV Swabstick (1x for site, 1x for top of line, 1x for bottom of line) Sterile gloves Statlock (PICC dressing only) Sterile transparent IV polyurethane dressing (unless contraindicated), ± an antimicrobial impregnated dressing PPE apron and non-sterile gloves Procedure 1. Explain the procedure to the patient and obtain verbal consent. 2. Check allergy to dressing(s), chlorhexidine and other skin preparation(s) 3. Perform hand hygiene 4. Position patient in a comfortable position and easy access to catheter site. 5. Confirm the external catheter length of the PICC and compare against documented length at time of insertion. a. If it is a different length then notify the medical officer as tip placement will need to be verified 6. Perform hand hygiene. 7. Cleanse aseptic field (trolley). 8. Perform hand hygiene. 9. Set-up equipment open dressing pack semi-open swab sticks packaging (to maintain integrity of micro-critical aseptic field) and place beside or underneath the dressing pack open all other equipment on to aseptic field protecting all Key-Parts by non- touch. 10. Perform hand hygiene and don PPE. 11. Remove old dressing ± Statlock ± Biopatch taking care not to dislodge catheter; discard. 12. Perform hand hygiene. 13. Don sterile gloves. 14. Pick up gauze and hold catheter with non-dominant hand. Page 67 of 110 Version Control 1.0 Resource Package

68 15. Clean the insertion site with 2% chlorhexidine gluconate (CHG) w/ 70% isopropyl alcohol Solu-IV Swabstick in concentric circles (outward) from exit site to just beyond dressing size, for 30 seconds; allow to air dry. 16. With the remaining swab stick(s) clean the external length of the catheter from the exit site towards the needleless connector (top and bottom). 17. Apply the antimicrobial impregnated disk dressing (if applicable), as per manufacturer s recommendations. 18. Apply the sterile IV dressing as per manufacturers recommendations if the patient is allergic to one brand then try another if the patient is allergic to all polyurethane dressings or is diaphoretic then apply a gauze dressing. Change daily to enable site monitoring. 19. Apply Statlock if applicable If the external catheter length of the PICC is short the Statlock will need to be placed first as it will be under the dressing. If the external catheter length allows position the Statlock outside dressing 20. Check the external length of the PICC again. If it is a different length than prior to the dressing then notify the medical officer as tip placement will need to be verified. 21. Discard waste as per procedure. 22. Remove PPE 23. Perform hand hygiene. 24. Document in the patients clinical record and record any complications. Resource Package Version Control 1.0 Page 68 of 110

69 Clinical Principle 4: Collecting Blood from a CVAD Equipment green tray/ trolley (general aseptic set-up field) PPE - plastic apron, non-sterile gloves and goggles 70% isopropyl alcohol wipe or 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol SoluPrep Wipe blood tubes, as per Pathology QLD Test List sterile 10 ml sodium chloride 0.9 % vials blunt drawing up needles 10 ml luer lock syringes The following as required vacutainer Luer-Lok holder catheter lock solution (indicated for renal catheters) Procedure 1. Explain the procedure to the patient and obtain verbal consent. 2. Position patient in a comfortable position. 3. Perform 3 patient identifier checks, against the patient ID bracelet, the request form and ask patient to state name, DOB and address/or UR number. 4. If an anticoagulant or catheter lock solution is to be instilled, perform medication check with another health professional and prepare lock correctly. Renal/apheresis-type catheters have the lock volume imprinted on each catheter lumen. 5. Perform hand hygiene. 6. Cleanse aseptic field (tray/trolley). 7. Perform hand hygiene. 8. Set-up equipment (ensuring Key-Parts remain protected). 9. Perform hand hygiene. 10. Draw up flushing solutions. 11. Perform hand hygiene and don PPE. 12. Using a non-touch, twist-turning action, clean the needleless connector thoroughly and vigorously for a minimum of 5 seconds with a 70% isopropyl alcohol wipe and allow to air dry. 13. Attach either the vacutainer (recommended) or syringe to the appropriate lumen(s) a. For blood culture collects it is recommended to remove the needleless connector(s) and aspirate directly from the catheter lumen to prevent contamination of the sample. Page 69 of 110 Version Control 1.0 Resource Package

70 i. Cleanse the end of the catheter lumen by placing a 2% CHG w 70% isopropyl alcohol wipe over the open end ii. Cleanse rotationally down and away from the open end taking care not to introduce contaminants or CHG into the catheter. 14. Draw the first volume blood (e.g. 5-10mL), and discard a. If collecting bloods for culture there is no discard, the first draw is the target sample b. Collect the remaining volume of blood pending the specimens required c. If using a vacutainer, collect specimens in the correct order of draw (see QLD Pathology Order of Draw) 15. Flush with the recommended volume (10 20 ml) of sodium chloride 0.9% using correct flushing technique to maintain patency. 16. As appropriate (Renal/ Apheresis Catheter): Lock each lumen with correct volume (imprinted on catheter hub) of prescribed medication lock. 17. Transfer blood from syringe(s) to specimen tube(s) post flushing and locking. 18. Label specimen tubes at the patient bedside. a. The collector must date, time and sign all specimen tubes and the request form 19. Discard waste as per procedure. 20. Remove PPE. 21. Perform hand hygiene. 22. Document in the patients clinical record and record any complications. Resource Package Version Control 1.0 Page 70 of 110

71 Clinical Principle 5: Accessing a Totally Implanted Central Venous Access Port (port) Equipment Dressing pack Skin Prep single use- 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol (e.g. 3M SoluPrep Swabstick ) If CHG is contraindicated, use single-use Povidone Iodine 10 ml leur lock syringes (as required) Sterile 10 ml sodium chloride 0.9 % vials Blunt drawing up needles Needleless connector PPE- plastic apron, sterile gloves and protective eyewear Port access needle (appropriate size after patient assessment) IV dressing Topical anaesthetic if indicated (30-60 mins for effect) Procedure 1. Explain the procedure to the patient and obtain verbal consent. 2. Perform procedure/ patient matching. 3. Check allergy status 4. Position patient in a comfortable position. 5. Perform hand hygiene 6. Don plastic apron. 7. Remove excess topical anaesthetic (if applicable) with gauze and cleanse with soap and water. 8. Assess port site and surround. Determine appropriate length and gauge port access needle. 9. If there are signs of broken down skin or infection, do not access. Contact medical officer. 10. Perform hand hygiene. 11. Open dressing pack, this is the aseptic set-field. 12. Open 10 ml sodium chloride 0.9 % vial(s) and place under aseptic field. 13. Open skin prep packet, do not remove stick from micro critical aseptic field (MCAF). Place under aseptic field. 14. Open all other equipment and tip directly on to aseptic field. 15. Perform hand hygiene and don PPE. 16. Attach drawing up needle to syringe Page 71 of 110 Version Control 1.0 Resource Package

72 17. Draw up flushing/ priming solution (sodium chloride 0.9 %). Use aseptic field to hold unsterile saline vial(s) to avoid contaminating sterile gloves. 18. Attach a priming syringe to needleless connector. 19. Attach needleless connector to port access needle and prime extension. 20. Remove priming syringe and attach an empty syringe and place on aseptic field 21. Remove swab stick, only touching inside of micro critical aseptic field (MCAF) to avoid contaminating sterile gloves. 22. Perform skin prep. Cleanse the area by swabbing in concentric circles (thoroughly and vigorously) in an outward direction for 30 secs and allow to air dry. Advise patient of possible tingling sensation whilst CHG is drying. 23. With non-dominant hand support the port reservoir by holding between thumb and index finger. 24. Use a smooth, firm technique. Insert needle through septum at 90º to ensure reservoir entry 25. Withdraw 10mL discard blood. This confirms correct placement and withdraws potentially contaminated blood (to prevent BSI). If further screening bloods are required aspirate at this stage. Change syringes as needed. Alternatively: discard blood is not required if performing a routine weekly needle changeover. To confirm needle placement simply draw back until blood is visualised in the extension. Then continue as per next step. 26. Flush with 10-20mL of sodium chloride 0.9 % using turbulent flow technique and clamp under positive pressure. 27. Apply the IV dressing, and date. 28. Discard waste. 29. Remove PPE. 30. Perform hand hygiene. 31. Document in the patients clinical record and record any complications. Resource Package Version Control 1.0 Page 72 of 110

73 Clinical Principle 6: Instilling Thrombolytic Agent Complete Occlusion Equipment Thrombolytic agent (prescribed) and prepared as per administration guidelines 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol wipe (3M SoluPrep wipe ) Sterile vial 10 ml sodium chloride 0.9 % Sterile vial 10 ml injectable water Packet Gauze 3-way tap (no extension) 10 ml syringe 3 or 5 ml syringe PPE- plastic apron, non-sterile gloves Medication label Procedure 1. Confirm valid medication order and SAS Category A form (which includes patient informed consent), is completed by the medical team. 2. Provide any further information to the patient. Advise the patient they cannot leave the ward during dwell time of the medication and 30 minutes after completion (this may take up to several hours) 3. Perform procedure/ patient matching. 4. Position patient in a comfortable position. 5. Perform hand hygiene. 6. Using ANTT, open all packets and prepare equipment and thrombolytic agent. 7. Reconstitute medication as per medication safety sheet and procedure guidelines. 8. Further dilute with sodium chloride to the volume of the catheter plus any add-ons. All removable add-ons should be detached. Check total length of catheter, as some catheters may be trimmed on insertion. 9. Attach medication label(s) to syringe(s) to identify the thrombolytic agent. 10. Perform hand hygiene and don PPE. 11. Pick up gauze. Grip connector with gauze (to prevent cross contamination to gloves), remove and discard. All add-on attachments must be removed. 12. Using the 2% CHG w 70% isopropyl alcohol wipe place over catheter end and cleanse using vigorous, twist-turn technique for 5 seconds, allow to air dry. Wet CHG may inadvertently be introduced into the catheter lumen. 13. Attach the 3-way tap, directly to catheter lumen. Page 73 of 110 Version Control 1.0 Resource Package

74 14. Attach the 10 ml syringe (with thrombolytic agent) to 3-way tap end (should be in line to catheter). It is not necessary to prime the 3-way tap. 15. Attach empty 3 or 5 ml syringe to side port of 3-way tap. It is now ready 16. Turn tap so open is to empty syringe. Pull back syringe plunger and hold firmly. This creates negative pressure in the catheter. 17. Turn tap so open is now to medication syringe. The negative pressure will draw a tiny volume of medication into catheter. It may take multiple manipulations to commence thrombolysis The medication will not advance any further than the clot 18. Repeat step 17 until all the medication is fully instilled 108. A fully occluded catheter can take several hours to resolve. Occlusions should be managed as soon as possible and when clinically appropriate. - It is recommended to commence the procedure early enough that treatment does not occur overnight. 19. After several manipulations blood staining may be noted. This is reassuring that the correct treatment is being employed. As blood staining increases it may be possible to instil the remainder of the thrombolytic agent by positive pressure flush. Ensure the agent reaches the end of the catheter. 20. Check for free-flowing aspirate. When the clot is fully dissolved aspirate the total volume of the thrombolytic agent instilled. 21. Using ANTT, remove the 3-way tap with gauze, discard. Cleanse as per step 12, attach a new needleless connector and flush the lumen well with 20mL 0.9% sodium chloride. N.B. If it is a partial or withdrawal occlusion then the thrombolytic agent can easily be instilled by direct administration. Do not remove the needleless connector however the priming volume should be included in the reconstitution total. Treating early will prevent a full occlusion and long delay to treatment. If treatment of the withdrawal occlusion is unsuccessful the thrombolytic agent may have to be flushed into the patient. Check with the medical team that this is OK before proceeding. Under these circumstances the patient must not leave the ward for 30 minutes. Resource Package Version Control 1.0 Page 74 of 110

75 Clinical Principle 7: Removal of a CVAD Equipment Sterile Gauze Occlusive dressing PPE - apron and non-sterile/sterile gloves (as per risk assessment) Add-on equipment if removing securement sutures or sending tip for culture Dressing pack Skin Prep single use- 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol (e.g. 3M SoluPrep Swabstick ) Sterile scissors (to cut tip) Suture cutter Sterile specimen jar (for tip culture) Procedure 1. Explain the procedure to the patient and provide instructions for breath holding or Valsalva manoeuver 2. Obtain verbal consent 3. Place the patient in supine position (ensuring insertion site is below the heart) 4. If removing a PICC abduct the arm to 45-90, keep arm below heart 5. Perform hand hygiene 6. Using ANTT, open all packets and prepare equipment 7. Perform hand hygiene, don gloves 8. Remove old IV dressing, and any other stabilisation device, discard 9. Undertake cleansing of the site (as per risk assessment and clinical indication) Removing a CVAD with suture securement, or sending tip 10. Using ANTT cleanse insertion site with 2% chlorhexidine gluconate (CHG) w 70% isopropyl alcohol (unless contraindicated), allow to air dry 11. Remove sutures (if applicable), discard suture cutter in sharps container. Proceed as for all CVAD removal. 12. If sending tip for culture ensure the catheter tip does not touch any environmental surround on removal. Place on general aseptic field until clinically appropriate to cut tip Pick up the catheter below the tip to maintain non-touch technique. Using sterile scissors cut the tip directly into the sterile specimen jar. Seal and label. All CVAD removal 13. Instruct patient to take breath and hold, or perform Valsalva (if able), remove CVAD 14. Cover the insertion site immediately with sterile gauze and apply firm digital pressure for a minimum of 5 minutes or until haemostasis is achieved. Page 75 of 110 Version Control 1.0 Resource Package

76 15. Following haemostasis, immediately cover the site with an occlusive dressing 16. Following removal provide instruction to the patient To limit activity for minutes To apply firm hand pressure and call for help, should bleeding occur 17. Discard waste. 18. Remove PPE. 19. Perform hand hygiene. 20. Document in the patients clinical record and record any complications. Removing a PICC 21. Use a hand over hand technique to remove incrementally (to prevent venous spasm). 22. If there is resistance felt e.g. stuck PICC, then stop. Provide some relaxation techniques to the patient, attempt to remove again If unsuccessful, redress with a temporary IV dressing, apply heat pack for 20 minutes, attempt to remove again If unsuccessful, contact the treating team, (further investigations will be required) If painful whilst attempting to remove, stop, do not try again, contact the treating team (further investigations will be required before any further attempts are made) Resource Package Version Control 1.0 Page 76 of 110

77 Section 9 - Appendices Appendix 1: Initial Assessment and Troubleshooting of CVAD Occlusion Illustrated by RBWH Clinical Multimedia, 2017 Page 77 of 110 Version Control 1.0 Resource Package

78 Appendix 2: Assessment of Thrombotic Occlusion Illustrated by RBWH Clinical Multimedia, 2017 Resource Package Version Control 1.0 Page 78 of 110