NURSING PROCEDURE TITLE: CENTRAL VENOUS CATHETER (CVC) (Short term) A. Assisting with Insertion B. Assessment C. Establishing or Changing Needleless Access Adapter D. Flushing E. Administration of Intravenous (IV) Fluids or Medications F. Dressing Change G. Blood Sampling H. Removal I. Removal of Single Lumen Infusion Catheter (SLIC ) / Multi Lumen Infusion Catheter (MLIC) PURPOSE CATEGORY: General RN, RPN Section A-H Advanced Practice LPN Sections B-G Only SNP RN ICU/CCU/PACU Only (Section I) To provide safe, standardized, evidence based process for CVC care and maintenance. Insertion is the responsibility of a physician. Removal of CVCs is responsibility of a physician or RN/RPN. CVCs are used for patients requiring central venous access on a short term basis (less than 30 days). Ultrasound guidance is used for vein visualization for bedside insertion. Chest x-rays post insertion confirm placement and absence of complications such as pneumothorax. Ensure aseptic technique when performing CVC care, i.e. accessing lumens, opening lumen(s) or exposing insertion site. Ensure needleless access adapter is in place on all lumens including introducer. Use a greater than or equal to 10 ml syringe when flushing. Keep all sharp instruments away from catheter. Allow alcohol to dry before applying needleless adapter to lumen hub. Infusion pump is required for all CVCs unless continuously visualized. For pediatrics, an infusion pump is always required. Approved: June 7, 2017 Page 1 of 21
NURSING ALERT (Continued) If there is accidental breakage or damage to the catheter, pinch catheter closed with fingers between patient and where catheter is damaged/cracked. Fold catheter over on itself and tape in place. Immediately notify Most Responsible Practitioner (MRP). For pediatrics, keep non-traumatic forceps hanging on IV pole of room of patient with CVAD and clamp line if there is accidental breakage. Apply appropriate personal protective equipment (PPE) before direct contact with patient and prior to starting procedure. Utilize 2 client identifiers prior to any catheter care and maintenance as per RQHR policy 0612. Minimize number of times CVC is accessed to prevent complications. A maintenance infusion may need to be initiated. Flush using vigorous push-pause technique creating turbulent flush to maintain patency. IV tubing to be changed as per Appendix B. A. ASSISTING WITH INSERTION EQUIPMENT 1. PPE for assistants clean gloves, protective gown, mask, safety glasses, head covering 2. PPE for physicians sterile gloves, safety glasses, plus PPE items in Central Line Insertion Kit 3. Short term CVC type and size determined by physician 4. Introducer (if requested by physician) 5. Central Line Insertion Kit: (#319123) Head covering Sterile physician s gown Face mask Sterile full body drape (Large #22) Sterile absorbent towel Chlorhexidine 2% with 70% alcohol (ChloraPrep ) (10.5 ml) Sterile bowl with 8 oz sponge Sterile needle holder Sutures 2.0 silk 10 gauze 4x4 s Sterile transparent semi-permeable dressing Pre-filled normal saline (N/S) syringes 10 ml (x3) sterile packaging 6. Needleless access adapters (x4) (#313420) 7. Ultrasound machine 8. Sterile ultrasound transducer cover (Special Order #CV610-637) 9. Local anesthetic 10. Intravenous (IV) solution and primed luer-lock tubing 11. Primed pressure monitoring system (transducer set-up), as required Approved: June 7, 2017 Page 2 of 21
PROCEDURE 1. Explain procedure to patient. 2. Perform hand hygiene. 3. Set up primed IV line and/or pressure monitoring system. 4. Perform hand hygiene. 5. Don PPE as per equipment list NOTE: Every individual in room must wear a mask, safety glasses, gown and head covering. 6. Position patient supine or Trendelenburg as per physician preference. 7. Provide central line insertion kit. NOTE: Physician will open insertion kit and set up sterile field. 8. Assist physician with donning of sterile gown and gloves. 9. Assist physician with draping patient, as necessary ensuring sterility is maintained. NOTE: Inform patient that full body drape will be used to reduce risk for infection. 10. Open introducer and/or CVC and add to sterile field. 11. Add needleless access adapters and sterile N/S syringes to sterile field for physician to flush lumens. 12. Provide local anesthetic solution for physician to access. 13. Assist physician with applying sterile ultrasound transducer cover to ultrasound probe. 14. Assist physician as required. NOTE: Physician will insert CVC and assess for adequate blood return. 15. Ensure needleless access adapters are flushed and attached to each lumen. NOTE: For pediatrics, see Appendix A for heparinization. 16. Ensure transparent semi permeable dressing has been applied over insertion site. 17. Request chest x-ray to confirm position of catheter unless femoral insertion site used. 18. Infuse IV solution at prescribed rate, once position is confirmed. Approved: June 7, 2017 Page 3 of 21
CVCs with jugular or subclavian insertion sites must have placement confirmed by chest x-ray prior to use. If patient s condition warrants need for immediate infusion, a physician s order is required. 19. Document insertion site, patient s response, type, size and confirmed position. 20. Monitor insertion site for bleeding. B. ASSESSMENT Proper care and handling of CVC is essential to prevent central line associated blood stream infections (CLA-BSI). Accessing any part of CVC for any reason requires: o Hand hygiene. o Cleansing of connection site vigorously with alcohol swab using a 15 second scrub (let dry). Assess need for existing CVC daily. Notify Most Responsible Practitioner (MRP) if signs of malposition are present: o Inability to withdraw blood. o A gurgling sound heard when flushing CVC (if subclavian or jugular insertion). o Edema in neck or shoulder. o Chest, shoulder or back pain. As much as possible, when administering Parenteral Nutrition (PN), use a dedicated lumen and document specified lumen on patient s plan of care. PROCEDURE 1. Perform hand hygiene prior to touching any component of CVC, administration set, or fluid solutions. 2. Assess site minimum once per shift, with each patient assessment and prior to accessing CVC. 2.1. Palpate area around insertion site (through dressing) 2.2. Assess for tenderness or discomfort 2.3. Assess surrounding areas for redness, warmth, edema and drainage 2.4. Assess chest wall for engorged superficial veins (if subclavian or jugular insertion) 3. Document assessment and any unusual findings. Notify MRP of any unusual findings. Approved: June 7, 2017 Page 4 of 21
C. ESTABLISHING OR CHANGING NEEDLELESS ACCESS ADAPTER NOTE: Change needleless access adapter at least every 7 days or at any sign of adapter damage (i.e. cracking, leaking or contamination) and prior to blood culture collection. NOTE: Ensure alcohol is dry before applying needleless access adapter to catheter lumen hub. EQUIPMENT 1. PPE, including mask 2. Needleless access adapters (#313420) 3. Alcohol swabs 4. 10 ml N/S in a greater than or equal to 10 ml syringe 5. Sterile normal saline if needed 6. 2x2 sterile gauze if needed NOTE: For pediatrics, see Appendix A PROCEDURE 1. Perform hand hygiene. 2. Prepare new sterile needleless access adapter for each lumen: 2.1 Open package. 2.2 Prime adapter with N/S while keeping it inside package. 3. Don PPE. 4. Stop IV infusion, if in place. 5. Disconnect IV tubing from adapter, if infusing. 6. Ensure each lumen is clamped. 7. Cleanse adapter connection site vigorously with alcohol swab using 15 second scrub (let dry). Ensure asepsis is maintained during needleless access adapter change. 8. Remove existing adapter and discard. NOTE: Avoid using forceps on catheter lumen hub. This may damage hub. NOTE: Clean CVC catheter lumen hub threads with alcohol only if visibly soiled; ensure alcohol is dry before attaching adapter. If visible encrustations will not come off with alcohol, soak threads with normal saline soaked gauze prior to cleaning CVC lumen threads with alcohol. Approved: June 7, 2017 Page 5 of 21
9. Attach pre-flushed needleless access adapter with N/S filled syringe in place. 10. Release clamp. 11. Aspirate slowly for blood, only until flashback appears. If unable to aspirate blood try the following techniques in this order: Have patient change position, as appropriate to location of CVC, cough or take deep breath and hold. Instill 1 2 ml of N/S using push-pause technique and attempt to aspirate. May repeat above steps. (For pediatrics may repeat x 2). If still unable to aspirate for blood, label lumen plugged, document and notify physician. Attempt access of another lumen. Use of fibrinolytic agents has not been studied in short term central lines, therefore fibrinolytic use on short term central lines is not recommended at this time. 12. Flush with N/S using vigorous push-pause technique. 13. Remove syringe. 14. Initiate infusion if applicable (refer to Section E) or clamp lumen. NOTE: For pediatrics, refer to Appendix A. Follow steps 12 and 13 with heparin as required. 15. Document. D. FLUSHING Avoid previously accessed multi-use vials and bag spikes when flushing CVC. Flush with 10 ml N/S (5-10 ml for pediatrics) between incompatible solutions and 20 ml (10-20 ml for pediatrics) after administration of blood products, PN or blood sampling. Flushing should be done every 24hrs to each unused lumen including introducer and after each access. Heparinization is not required for adults. (Heparin may be required from pediatrics see Appendix A). EQUIPMENT 1. PPE 2. 10 ml N/S in a greater than or equal to 10 ml syringe (per lumen) 3. Alcohol swabs Approved: June 7, 2017 Page 6 of 21
NOTE: For pediatrics, see Appendix A for flushing and heparinization. PROCEDURE 1. Perform hand hygiene. 2. Don PPE. 3. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry). 4. Access needleless access adapter with N/S filled syringe. 5. Release clamp and aspirate slowly for blood return, only until flashback appears. NOTE: If unable to aspirate blood, see related nursing alert in section C. 6. Flush lumen with N/S using a vigorous push-pause technique. 7. Remove syringe. 8. Clamp lumen. 9. Document. For pediatrics, refer to Appendix A. Follow steps 10-13 below with heparin as required. 10. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry). 11. Access needleless access adapter with heparin filled syringe (for pediatrics). 12. Flush with heparin using vigorous push-pause technique. 13. Remove syringe. 14. Clamp lumen. 15. Document. E. ADMINISTRATION OF IV FLUIDS AND MEDICATIONS When administering PN through multi-lumen catheter, use a dedicated lumen as much as possible for PN. Approved: June 7, 2017 Page 7 of 21
NOTE: Refer to Appendix B for routine IV tubing changes. EQUIPMENT 1. PPE 2. Alcohol swabs 3. Infusion pump 4. Primed IV set with solution(s) as ordered 5. 10 ml N/S in a greater than or equal to 10 ml syringe (per lumen) PROCEDURE 1. Perform hand hygiene. 2. Don PPE. 3. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub (let dry). 4. Access needleless access adapter with N/S filled syringe. 5. Release clamp and aspirate slowly for blood, only until flashback appears. NOTE: If unable to aspirate blood, see related nursing alert in section C. 6. Flush lumen with N/S using vigorous push pause technique. 7. Remove syringe. 8. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry). 9. Connect primed IV tubing to adapter. NOTE: Ensure connection and tubing is secure. 10. Start infusion of IV fluid or medication. 11. Document. NOTE: When infusion is complete, refer to section D. Flushing Approved: June 7, 2017 Page 8 of 21
F. DRESSING CHANGE NOTE: Assess dressing daily; replace dressing when it becomes damp, loosened or soiled. Transparent semi permeable dressing is recommended for site visualization; change every 7 days and PRN. Sterile gauze dressing changed every 2 days and PRN. NOTE: Gauze underneath a transparent semi permeable dressing is considered a gauze dressing. EQUIPMENT 1. PPE including mask 2. Clean gloves 3. Sterile dressing set 4. Sterile gloves 5. Chlorhexidine 2% with 70% alcohol (3 ml ChloraPrep ) (Clear #310410)(Orange tint available if needed, usually used on insertion #310411) NOTE: Chlorhexidine (ChloraPrep ) use on pediatric patients less than 2 months of age is not recommended. Use 70% alcohol. 6. Alcohol swabs 7. Transparent semi permeable dressing (#319299) 8. Sterile normal saline (as required) 9. 2x2 sterile gauze (as required) NOTE: For patients with sensitivities: First, ensure you are applying dressing correctly (see Appendix C for tips on application of dressing) and also make sure Chlorhexidine (ChloraPrep ) is completely dry before applying dressing. Second, rule out if sensitivity is to chlorhexidine or dressing: o Swab area on inner arm with Chlorhexidine 2% with 70% alcohol. Observe for skin reaction. If patient is sensitive to Chlorhexidine 2%, use 70% alcohol first followed by povidone-iodine as an acceptable alternative. o Place a dressing or small section of dressing on opposite inner arm. Observe for skin reaction. It patient is sensitive to dressing, then an alternative dressing will have to be explored. PROCEDURE 1. Explain procedure to patient. 2. Perform hand hygiene. 3. Don PPE including mask and clean gloves. Approved: June 7, 2017 Page 9 of 21
4. Position patient supine with head turned away from dressing site (as appropriate). 5. Assemble supplies on sterile field. 5.1 Open sterile dressing set. 5.2 Add transparent dressing to sterile field. 5.3 Add ChloraPrep to sterile field. 6. Inspect insertion and suture site for redness, inflammation, tenderness or drainage. 7. Remove existing dressing. 8. Remove gloves. 9. Perform hand hygiene. 10. Don sterile gloves. NOTE: If CVC catheter is encrusted with blood or exudate, apply saline soaked gauze to remove prior to cleaning with chlorhexidine. 11. Cleanse skin at insertion site: 11.1 Cleanse entire area where dressing is placed using ChloraPrep in a crosshatch motion (back and forth) with light friction in two different directions for a total of 30 seconds. 11.2 Cleanse length of exposed catheter with same ChloraPrep swab. Let dry 2-3 minutes. NOTE: Never Fan Dry 12. Apply new dressing. 12.1 Apply transparent semi permeable dressing over dry insertion site. (See Appendix C for tips on dressing application). 12.2 Avoid stretching, smooth from center out to edge and mold around catheter lumens. 12.3 Place one tape from dressing package over CVC lumen leg(s). 12.4 Write date and initials on second tape and position just below first tape. 13. Document. Approved: June 7, 2017 Page 10 of 21
G. BLOOD SAMPLING CVC access should be minimized to conserve blood and decrease manipulation of adapter. Assess patient to determine best method for blood sampling. Venipuncture may be an option. Vacutainer with Luer-Lok access device has rubber sheathed needle in centre (ensure caution is taken to avoid skin puncture). If patient has PN infusing through a lumen, avoid blood draws from this lumen as much as possible. EQUIPMENT 1. PPE 2. Blood specimen tubes and labels (plus discard tube 3-5 ml; 7 ml from introducer) NOTE: Refer to test compendium in laboratory services manual on RQHR Intranet for appropriate blood tubes. http://rhdintranet/lab/public/manuals/laboratory%20services%20manual.htm 3. Vacutainer Luer-Lok access device (#952058) 4. 10 ml N/S in a greater than or equal to 10 ml pre-filled syringe 5. Alcohol swabs 6. Blood transfer device (#952056) (if required to transfer blood from syringe draw to blood sample tubes) 7. Blood collection set with male adapter (Angel Wing ) from lab for blood culture collection 8. Needleless access adapter if blood culture collection required. NOTE: For pediatrics, see Appendix A. PROCEDURE In a multi-lumen catheter use proximal lumen for blood sampling when possible. If continuous infusion in place, stop infusion through all lumens, flush and wait for 1 minute before drawing discard. 1. Explain procedure to patient. 2. Perform hand hygiene. 3. Don PPE. Approved: June 7, 2017 Page 11 of 21
4. Disconnect infusion if in place, maintaining asepsis, or unclamp lumen. 5. Cleanse needleless access adapter vigorously with an alcohol swab using 15 second scrub (let dry). 6. Change needleless access adapter (if drawing blood cultures). Refer to Section C. 7. Attach greater than or equal to 10 ml syringe with 10 ml N/S. 8. Aspirate slowly for blood, only until flashback appears. NOTE: If unable to aspirate blood, see related nursing alert in section C. If still unable to aspirate sample, attempt blood sampling from another lumen if possible or notify lab to obtain samples via venipuncture. Notify MRP and document. 9. Flush lumen with attached N/S using vigorous push-pause technique and wait 1 minute. 10. Attach Vacutainer Luer Lok TM access device. 11. Insert blood specimen tube (3-5 ml adult) for discard and remove when filled. NOTE: Discard 7 ml from introducer. NOTE: Blood cultures should be collected via venipuncture unless ruling out CVC as source of infection. Change needleless access adapter prior to blood culture sampling from CVC and use discard as part of first sample. Draw one set from CVC and have lab draw one set via venipuncture. 12. Insert appropriate blood specimen tubes in appropriate order and obtain samples, filling each sample to fill line. NOTE: Order of blood draw should be as below: Blood culture (SPS) aerobic then anaerobic Blue (Citrate) Orange, Red or Yellow (Serum Tube) Green (Heparin) Mauve (EDTA) Grey (Fluoride/Glucose) NOTE: If unable to aspirate blood through vacutainer Luer-Lok access device, remove and aspirate blood using greater than or equal to 10 ml syringe. Obtain discard in separate syringe prior to obtaining blood samples. Transfer blood sample to tubes by attaching blood transfer device to blood filled syringe. Insert blood specimen tubes. DO NOT use a needle to transfer blood. 13. Invert tubes gently 5 times immediately following obtaining each sample. 14. Remove Vacutainer Luer-Lok access device and discard in sharps container. Approved: June 7, 2017 Page 12 of 21
NOTE: Discard blood transfer device and blood discard in sharps container. 15. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry). 16. Attach greater than or equal to 10 ml pre-filled N/S syringe and flush with 20 ml using a vigorous push-pause technique (10 20 ml for Pediatrics). 17. Remove syringe. 18. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry). 19. Reconnect infusion to lumen (if applicable) or clamp lumen. NOTE: For pediatrics, refer to Appendix A. 20. Label specimen tubes in presence of patient at time of collection and send to lab immediately. NOTE: Label according to laboratory services manual on RQHR intranet. http://rhdintranet/lab/public/manuals/laboratory%20services%20manual.htm Cross match samples also require birth date. Requisition should indicate where sample obtained from (i.e. CVC). NOTE: For pediatrics, if coagulation studies drawn, indicate on requisition if CVC was heparinized. 21. Document. H. REMOVAL Removal of short term CVC and/or introducer may be performed by RN or RPNs educated in this skill. Ensure that patient has peripheral IV access prior to line removal, if applicable. An occlusive dressing is required to provide a complete seal to prevent air embolism and infection. Routine tip cultures are not performed unless removal for suspected infection or sepsis, per MRP order. If catheter tip is to be sent for C&S, corresponding blood cultures must be drawn prior to removal (1 set drawn via venipuncture and 1 set drawn from CVC). EQUIPMENT 1. PPE 2. Mask 3. Non-sterile gloves Approved: June 7, 2017 Page 13 of 21
4. Sterile dressing set 5. Sterile gloves (if catheter tip C&S is going to be sent) 6. Sterile towel (if not in dressing set) 7. Chlorhexidine 2% with 70% alcohol (3 ml ChloraPrep ) (Clear #310410) (Orange tint available if needed, usually used on insertion - #310411) 8. Stitch cutter (#310085) 9. 2x2 gauze 10. Sterile Petroleum Jelly (single use packet) (#312115) Occlusive dressing 11. Transparent semi permeable dressing (#319299) 12. C & S swab (if signs of infection present) 13. Sterile specimen container if tip is to be sent for culture PROCEDURE 1. Verify order for CVC and/or introducer removal. 2. Review lab data for platelet count, PT, PTT, INR and notify physician of abnormalities prior to removal. 3. Explain procedure to patient. 4. Perform hand hygiene. 5. Don PPE including mask and non-sterile gloves. 6. Discontinue administration of all infusions. 7. Clamp all lumens. 8. Position patient supine or Trendelenburg unless contraindicated. 9. Set up sterile field adding occlusive dressing, stitch cutter and ChloraPrep applicator. 10. Inspect insertion and suture site for redness, inflammation tenderness or drainage. 11. Have patient turn his/her head away from catheter site (if removing an internal jugular or subclavian catheter). 12. Remove dressing. 13. Remove gloves and perform hand hygiene. 14. Don sterile gloves. Approved: June 7, 2017 Page 14 of 21
15. Cleanse skin at insertion site. 15.1 Cleanse entire area where dressing is placed using ChloraPrep applicator in a crosshatch motion (back and forth) with light friction in two different directions for a total of 30 seconds. 15.2 Cleanse length of exposed catheter with same ChloraPrep swab. Let entire area dry 2-3 minutes. NOTE: Never fan dry. 16. Remove suture(s) using stitch cutter. 17. Place gauze over catheter insertion site with non-dominant hand. 18. Remove catheter as follows: 18.1 Instruct patient to forcefully exhale (perform Valsalva maneuver) as the catheter is withdrawn. If patient is on a ventilator, withdraw catheter during inspiratory phase of respiratory cycle. 18.2 Grasp catheter with dominant hand and withdraw catheter in one continuous motion, parallel to skin. 18.3 Lay catheter on sterile towel (if tip to be sent for C&S). 18.4 Inspect tip of catheter. NOTE: If catheter tip is not intact, call MRP immediately and document. 19. Apply direct pressure over insertion site immediately with gauze. 20. Continue to apply pressure for a minimum of 3-5 minutes or until bleeding stops. NOTE: If coagulation results are abnormal, it may be necessary to apply pressure to site for longer duration. 21. Apply occlusive dressing: 2x2 gauze with sterile petroleum jelly and transparent dressing. 22. Instruct patient to remain in supine position (or low Fowlers if supine is not tolerated) for 30 minutes after removal. NOTE: For removal from femoral site, patient is to lie flat x 2 hrs following. Do not allow hip flexion during this period. Assess dressing for bleeding. Approved: June 7, 2017 Page 15 of 21
23. Document date and time of catheter removal, assessment of site and application of occlusive dressing. 24. Assess site for signs of bleeding or hematoma every 15 min x2, every 30 min x2 and then 1 hour later. 25. Reassess site every 24 hours. 26. Remove initial dressing in 24 hrs. Reapply dressing every 24 hrs until site is healed. I. REMOVAL OF SINGLE LUMEN INFUSION CATHETER (SLIC ) / MULTI LUMEN INFUSION CATHETER (MLIC) Removal of single lumen infusion catheter (SLIC) or multi lumen infusion catheter (MLIC) from introducer is the responsibility of RNs/Physicians within ICU/CCU/PACU only. All SLICs must be removed from introducer prior to transfer out of ICU/CCU. If patient has an MLIC out of ICU/CCU/PACU, both introducer and MLIC must be removed simultaneously refer to Section H. Removal of SLIC/MLIC and Introducer should be performed simultaneously if both devices are to be removed. Refer to Section H of this procedure if removal of both devices is required. EQUIPMENT 1. PPE 2. Mask 3. Non-sterile gloves 4. Sterile gloves 5. Sterile dressing set 6. Chlorhexidine 2% with 70% alcohol (3 ml ChloraPrep )(Clear #310410) (Orange tint available if needed, usually used on insertion - #310411) 7. Moisture proof absorbent pad (blue pad) 8. Obturator cap for hemostasis valve 9. Transparent semi permeable dressing (#319299) PROCEDURE 1. Verify physician s order for SLIC/MLIC removal. 2. Explain procedure to patient. 3. Perform hand hygiene. 4. Don PPE including mask and non-sterile gloves. Approved: June 7, 2017 Page 16 of 21
5. Discontinue administration of all infusions through SLIC/MLIC. 6. Turn stopcock of CVP monitoring system off to patient (if applicable). Do not disconnect luer lock connecting pressure tubing to hub of introducer. 7. Position patient supine in a slight Trendelenburg position unless contraindicated. 8. Place plastic backed pad under patient s upper torso/neck region. 9. Set up sterile field adding obturator cap, ChloraPrep and transparent semi permeable dressing. 10. Remove dressing if required to gain access to the locking mechanism of introducer. 11. Unlock SLIC/MLIC from introducer, but leave in place. 12. Remove gloves. 13. Perform hand hygiene. 14. Don sterile gloves. 15. Remove catheter as follows: 15.1 Instruct patient to forcefully exhale (perform Valsalva maneuver) as SLIC/MLIC is withdrawn. 15.2 Withdraw SLIC/MLIC with a constant, steady motion while stabilizing introducer. NOTE: Forceps from dressing bundle can be used to maintain sterility of one hand removing SLIC/MLIC NOTE: One finger must remain sterile to cover hemostasis valve once SLIC/MLIC removed. 15.3 Inspect tip of catheter to ensure intact. 16. Cover hemostasis valve temporarily with a sterile-gloved finger. 17. Place obturator cap into hemostasis valve of introducer. 18. Perform site care if dressing was removed to gain access to SLIC/MLIC. (Refer to Section F DRESSING CHANGE). 19. Document. Approved: June 7, 2017 Page 17 of 21
REFERENCES Canadian Vascular Access Association (2013) Vascular Access Journal of the Canadian Vascular Access Association. Volume 7 Supplement 1. www.cvaa.info. Centers for Disease Control, (2011). Guidelines for the prevention of intravascular catheterrelated infections, 2011. Atlanta, GA: CDC. Davis, M.B. (2013). Pediatric Central Venous Catheter Management: A review of Current Practice. JAVA Vol 18 No 2 p. 93-98. Hadaway, L. (2008). Targeting therapy with central venous access devices. Nursing, 38(6), 34-40. Infusion Nurses Society. (2016). Infusion nursing standards of practice. Norwood, MA: Lippincott, Williams & Wilkins. Infusion Nurses Society. (2016). Policies and procedures for infusion nursing. Norwood, MA: Infusion Nurses Society. McGee, W., Headley, J., & Frazier, J. (Eds.). (2010). Quick guide to cardiopulmonary care (2nd ed.). Irvine, CA: Edwards Lifesciences LLC. Regina Qu'Appelle Health Region Laboratory Services. (2016). Lab services manual. Wiegand, D. (2017). AACN Procedure Manual for High Acuity, Progressive, and Critical Care (7 th ed.). St. Louis, MO: Elsevier Saunders. Revised by: Lindsay Dusselier, Teresa Vall Date: June, 2014 Revised by: Tracey Wilson, Lindsay Dusselier, Jana Lowey, Lisa Roland, Kim Hunt Date: May 2017 Approved by: RQHR Procedure Committee Date June 7/17 Keyword(s): CVC, Central Line Regina Qu Appelle Health Region Health Services Nursing Procedure Committee Approved: June 7, 2017 Page 18 of 21
PEDIATRIC AND ADOLESCENT CENTRAL VENOUS ACCESS DEVICE PROTOCOL RN must obtain order stating follow pediatric CVAD protocol Short term Tunnelled Central Venous Intravascular Line (CVL)* Catheter (TIC) < 1 year Pre flush with 0.9% saline < 1 year Agent used to maintain patency Implanted Venous Access Device (IVAD) 5ml 5ml 10ml 5ml 50u/ml heparin *Mix 0.5ml of 100u /ml heparin +0.5 ml N/S 50u/ml heparin *Mix 1ml of 100u/ml heparin + 1ml N/S 50u/ml heparin *Mix 1.5ml of 100u/ml heparin + 1.5 ml N/S APPENDIX A Peripherally Inserted Central Catheter (PICC) 0.9% saline < 1 year Final Volume 1ml 2ml 3ml 5ml < 1 year Flushing frequency of unused lumens EOD EOD Q Monthly EOD (clamped) OR Q 7 days PASV (clamp less) > 1 year 18 years of age > 1 year 18 years of age > 1 year 18 years of age > 1 year 18 years of age Pre flush with 0.9% saline Agent used to maintain patency 5-10ml 5-10ml 10ml 5-10ml 100u/ml heparin 100u/ml heparin 100u/ml heparin Final Volume 1ml 2ml 3ml 5ml Flushing frequency of unused lumens *Includes midlines, cut downs and femoral lines. 0.9% saline EOD EOD Q Monthly EOD (clamped) OR Q 7 days PASV (clamp less) NB for all CVAD limit heparinization to no more than 3 times/24 hours If greater than 3 times/24hr required: For single lumen run IV fluid continuously in between meds For dual lumen divide fluid amount between lumens and run continuously Explore with attending physician changing the strength of heparin solution. For example 50u/ml versus 100u/ml. Physicians order required. Attending physicians may override this protocol if they feel the amount of heparin will not jeopardize the child s coagulation status. Physicians order required. CVAD s inserted for purpose of hemodialysis are used exclusively for that purpose, therefore without the express written consent of the nephrologist those lines may not be used. Hemodialysis lines generally contain a much stronger heparin concentration. Heparin in the CVAD used for hemodialysis should be withdrawn and discarded, not flushed through catheter and into patients cardiovascular system. Code: C.2 Author: Pediatrics Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012 Page 19 of 21
APPENDIX B IV Tubing Changes IV Bag change Tubing Change Time Plain IV solution (no additives) this includes pressure tubing Every 96 hours Every 96 hours IV solution with Every 96 hours Every 96 hours additives: manufacturer or pharmacy mixed IV solution with Every 24 hours Every 96 hours additives: nurse mixed IV solution with Every 24 hours Every 24 hours Lipids Propofol Every 12 hours Every 12 hours Blood products Per orders Every 4 units or 24 hrs, whichever occurs first. Intermittent medications Every 24 hours Code: C.2 Author: Pediatrics Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012 Page 20 of 21
APPENDIX C Tegaderm Application Hints 1. Select a dressing size that will adequately cover the catheter and insertion site or wound. Ensure at least a one inch margin of dressing adheres to healthy, dry skin. 2. Prepare the catheter insertion site. 3. To ensure good adhesion, clip excess hair where the dressing will be placed. Do not shave the skin because of the potential for microabrasions. 4. Make sure skin is free of soaps, detergents, and lotions. Allow all preps and protectants to dry thoroughly before applying the dressing. Wet preps and soap residues can cause irritation if trapped under the dressing. Additionally, adhesive products do not adhere well to wet or oily surfaces. 5. Do not stretch the Tegaderm dressing during application. Applying an adhesive product with tension can produce mechanical trauma to the skin. Stretching can also cause adhesion failure. 6. The adhesive of Tegaderm dressing is pressure-sensitive. To ensure best adhesion, always apply firm pressure to the dressing from the center out to the edges. 7. To tailor a dressing for a special application, use sterile scissors to cut the dressing into desired shapes or sizes before removing the printed liner. For best results and ease of application, cut the pieces so that a portion of the frame remains on at least two sides. 8. For subclavian and jugular sites, apply the dressing with the patient s head turned away and neck extended as expected in normal movement. This helps prevent contamination of the site from respiratory secretions and stress on the dressing when the patient moves. Removal Hints Support the skin when removing Tegaderm dressing. For removal from I.V. sites, also stabilize the catheter to prevent dislodgment. Use one of the following removal techniques based on your patient s skin condition and your own personal preference: Gently grasp one edge and slowly peel the dressing from the skin in the direction of hair growth. Try to peel the dressing back over itself, rather than pulling it up from the skin. or Grasp one edge of the dressing and gently pull it straight out to stretch and release adhesion. or Apply an adhesive remover suitable for use on skin to the adhesive edge while gently peeling from the skin. *To aid in lifting a dressing edge, secure a piece of surgical tape to one corner and rub firmly. Use the tape as a tab to help you slowly peel back the dressing. Code: C.2 Author: Pediatrics Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012 Page 21 of 21