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Post insertion Care of the Central Venous Access Device

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Health question/s at focus of clinical practice

“What nursing interventions can reduce the risk of device failure (i.e. bacteraemia /bloodstream infection, local infection, blockage, accidental removal or dislodgement, thrombosis, phlebitis), reduce costs, and improve patient satisfaction for patients with a CVAD?”

Target clinicians

This guideline is aimed at clinicians who care for adults across acute care hospitals in NSW. Specifically it refers to nursing staff as this clinical practice falls within their scope of practice. Medical officers were consulted and included during consensus development.

Scope

For the purposes of this document a central venous access device (CVAD) refers to a temporary intravascular catheter for infusing drugs, fluids, nutrition, blood sampling and/or haemodynamic monitoring and renal replacement therapies. It includes central venous catheters (CVC) and peripherally inserted central catheters (PICC). For the purposes of this guideline long term devices (tunnelled and implantable ports) are excluded.

Insertion of a central venous access device (CVAD) is a common hospital procedure and an estimated 15,000 devices are inserted in NSW ICUs every year (53). It is unclear how many CVADs are inserted in patients presenting to acute care facilities. Most commonly CVADs are inserted into the internal jugular, subclavian or femoral vein. A peripherally inserted device may be inserted via the cephalic or basilic vein. The insertion of a CVAD is not risk free for patients. Factors such as inexperienced proceduralists, multiple needle passes, high or low body mass index, previous catheterisations, and severe dehydration or hypovolaemia, uncorrected coagulopathy, and insertion of large bore devices, place the patient at risk for complications. Some of the major risks include infection, malposition, pneumothorax, thrombosis, vascular injury, and air embolus (54).

The most frequent complication of post insertion care is infection. The NSW ICU incidence has been reported at 1.2/1000 patient line days after a large project to standardise aseptic insertion (53). Most infections are attributed to contamination from the insertion site or the catheter hub. Infection risk increases the longer a device is left in situ (55), and is perpetuated by biofilm, therefore many of the suggested management strategies in this document are in place to reduce infective risk. Thrombosis is also a frequent occurrence with minimal clinical symptoms. There are many reasons for thrombosed CVADs, including but not limited to, endothelial injury, turbulence of the venous circulation, the catheter itself, and the composition of the infusions delivered (54). A fibrin sheath usually develops soon after CVAD insertion, which contributes to catheter occlusion and may lead to vessel stenosis. For this reason there are a number of recommendations relating to maintaining lumen patency and while there is increasing interest in restoring patency through infusion of fibrinolytic agents, this guideline includes no specific recommendations related to that practice. Removal of CVADs has been highlighted due to the number of occurrences of air embolus in patients in NSW. This is a severe complication with an associated high morbidity and mortality. Air embolism may also occur with accidental hub disconnection or through a residual catheter track. There are therefore a number of recommendations specific to removal.

The recommendation statements have been divided into the following sections; Assessment; Interventions; Infection prevention; Governance. There are 50 recommendations with varying levels of evidence.


Recommendation 

Grade of Recommendation

Assessment

1.

The nurse must systematically assess the CVAD each shift covering the elements of
i. Dressing
ii. Securement
iii. Integrity of CVAD
iv. Labeling of administration sets and infusion therapies

The findings must be documented in the clinical record. 

   Consensus

Interventions: Securement

2. Appropriate securement techniques include suturing of the CVAD with monofilament non graded nylon or the use of sutureless securement devices (1-3).
B
  3. The CVAD must be secured at the insertion site and also at the anchor point (if present).    Consensus
4.  The securement of the CVAD must be assessed at least once per shift and more frequently if required.    Consensus
5. Sutureless securement devices should be changed when the dressing is changed, or if loose or soiled.    Consensus
6. Peripherally Inserted Central Catheters (PICC) are to be secured by sutureless fixation devices (3). B  
7.  The weight of administration sets must be supported with additional fixation to reduce risk of unplanned dislodgement of the CVAD.    Consensus

Interventions: Antiseptic solution and cleaning of skin and catheter

8. • Single use 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is the preferred antiseptic agent for insertion and dressing of CVADs (4-6).
• If this is not available, chlorhexidine 0.5% in 70% alcohol or iodine in alcohol should be used (7-12).
• Solutions must not be decanted into smaller containers and unused portions must be discarded. Where a patient demonstrates chlorhexidine sensitivity topical povidone iodine 10% in 70% alcohol may be used
   NSW Policy
9. Avoid organic solvents (e.g., acetone, ether, adhesive remover wipes) on the CVC or surrounding skin. (12,13) B
10. Prior to cleaning with chlorhexidine in alcohol, sterile 0.9% saline is to be used to remove dried blood or other fluids from around the catheter and under the securement hub.    Consensus

Interventions: Dressing of CVAD and insertion site

11. A sterile transparent semi permeable dressing or sterile gauze and hypoallergenic tape must be used to cover the CVC insertion site. If allergy is suspected, an alternative dressing must be used (12, 14) (PD2010_036). B
12. Regardless of dressing type used for the CVAD, the dressing should:
a. Be positioned so the catheter insertion site is in the centre of the dressing
b. Cover the catheter from the insertion site and the first securement
c. Create a complete seal from the securement through to the insertion site.
   Consensus
13. Transparent dressings must be changed every 7 days or sooner if (12, 15-18):
a. The dressing is not intact (i.e., there is no longer a seal)
b. There is evidence of inflammation
c. There is excessive accumulation of blood and or moisture under the dressing.
A
14. Sterile gauze and hypoallergenic tape dressing is preferable to a transparent dressing if the patient is diaphoretic, or if the site is bleeding or oozing (12, 19).
• If a patient is oozing post insertion (e.g., thrombocytopenic) use a sterile gauze square on top of the insertion site, covered with semi permeable dressing.
• Consider use of a calcium alginate fibre dressing to achieve haemostasis if oozing is problematic.
   Consensus
15. Sterile gauze and hypoallergenic tape dressing should be changed every 48 hours, and whenever loose, soiled, or moist. B
16. A chlorhexidine impregnated sponge must be placed around the catheter at the insertion site after insertion and replaced at each dressing change (20-25). A

Interventions: Fluid and Drug Administration

17.  Ensure drug compatibility when administering multiple IV medications via the CVAD lumen. Refer to drug resources such as Micromedex or the institutional pharmacist.    Consensus
18. Crystalloid solutions without drug additives (e.g. 0.9% saline) should be changed only with administration set or catheter change and when infusion is complete.    Consensus
19. All blood products should be infused as per the National Blood Authority Australia Patient Blood Management Guidelines.    National                Guidelines
Interventions: Accessing connectors
20. Catheter hubs (including needless injection sites and blood sampling ports) must be vigorously cleaned with alcoholic chlorhexidine swabs before and after use to ensure removal of micro-organisms and particulate matter. The solution must be allowed to dry naturally prior to accessing the device, i.e. scrub the hub. A
21. When an unused lumen is accessed to administer a medication or commence an infusion a small volume of blood should be gently aspirated and discarded and the lumen flushed with 10mL 0.9% saline prior to medication administration or fluid commencement (26).    Consensus

Interventions: Intravenous administration sets


22. Intravenous administration sets attached to a CVAD must be attached to the patient so that no tension is applied to the catheter, to reduce risk of dislodgement.    Consensus
23. Administration sets (burettes, administration sets, multi-flow adapters, caps, connectors, extension devices) attached to antimicrobial or antibiotic-coated multi-lumen CVAD should be changed at 7 days, when clinically indicated (e.g. precipitate, particulate matter, blood in administration set, faulty set), or when the catheter is changed. (27)
This excludes blood products and lipids.
B
24. Administration sets (burettes, infusion sets, multi-flow adapters, caps, connectors, extension devices) attached to standard CVADs should be changed at 96 hours, when clinically indicated (e.g. precipitate, particulate matter, blood in administration set, faulty set), or when the catheter is changed. This excludes blood products and lipids. (12, 28-30) B
25. Administration sets for lipid based emulsions should be changed within 24 hours of starting the infusion or as per manufacturer’s recommendations. A

Interventions: Adjuncts to IV administration sets

26. Needleless connectors that are able to be disinfected / decontaminated are to be placed on each lumen of a CVAD (26, 31-36). A
27.  Multi-flow adaptors and three way taps and connectors are to be changed when the administration set is changed (26).    Consensus
28. Engage clamps (when in situ) on the device lumen when disconnecting the administration set from the lumen to prevent complications such as air embolus, bleeding, or inadvertent drug or fluid bolus.     Consensus
29. Avoid administration set disconnection. If an administration set is disconnected it must be discarded and a new set used.    Consensus

Interventions: Maintenance of lumen integrity

30. Frequency of flushing the CVAD lumen to maintain patency is unclear. It is suggested that CVAD lumen used intermittently be flushed no more frequently than every 8 hours.    Consensus
31. Recommended solution for flushing a CVAD lumen is 0.9% saline (37-41). B
32. To reduce the risk of thrombosis and intraluminal occlusion in large bore catheter lumens (e.g., dialysis catheter), an anticoagulant lock may be used when the lumen is not in use. (38, 39, 42).    Consensus
33. Unused lumens are to be managed to prevent air emboli and backflow of blood, protein or lipid solutions depending on the connector used. Refer to Table 5.    Consensus
34. It is recommended that syringes with a capacity of ≥ 10mL be used to access a CVAD for flushing. Smaller syringes exert higher pressure and may cause possible catheter rupture or dislodge an occlusion if excessive force is used.    Consensus
35. When flushing a CVAD lumen use a pulsatile positive pressure flushing technique to create turbulence within the lumen of the device. B
36. If attempting to flush a CVAD lumen due to a blockage, force should never be used because of the risk of catheter rupture.    Consensus
37. Use of a solution other than 0.9% saline to attempt to unblock a CVAD lumen has shown to be effective in restoring lumen patency. Use of agents such as urokinase and alteplase requires a medical prescription and must be discussed with the Medical Officer or a Vascular Access specialist/team before use (43, 44) B

Interventions: Removal

38. When removing a CVAD the patient should be placed in bed in a supine position (5). Prior to repositioning patient following removal, ensure the dressing is airtight and occlusive.     Consensus
39. In the non-ventilated patient, removal should occur at end inspiration or during expiration.     Consensus
40. Following CVAD removal, pressure with sterile gauze must be applied until haemostasis is achieved. The insertion site must be immediately sealed with an airtight occlusive dressing. This dressing is to remain intact and insitu for 48 hours to reduce the risk of late air embolism.    Consensus
41. Routine collection of the CVAD tip is not required. If a CRSBI is suspected the medical team may request that the tip is sent for microbiological examination and a blood culture collected from a peripheral vein within 4 hours of CVAD removal (45).    Consensus
42. Removal of the CVAD must be documented in the clinical record.
The documentation must include:
• Visual inspection of the integrity of the CVAD
• If CVAD tip collected and sent to pathology
• Condition of CVAD insertion site.
   NSW Policy
43. Following removal of a CVAD the condition of the site must be monitored at 24 and 48 hours at a minimum. This must be documented in the clinical record.    Consensus

Infection Prevention

44. The 5 moments of hand hygiene must be adhered to.    PD2010_058
45. Clinicians are to evaluate the risk of body fluid exposure and cross contamination risk when caring for a patient with a CVAD. PPE (including goggles/face shield, gloves and gown/apron) as per NSW 2007 Infection prevention and control policy should be worn accordingly.

PD2007_036

Australian Infection Control   Guidelines 

46. Aseptic non touch technique must be used when attending CVAD dressings, administration set changes, and any intervention that involves accessing the CVAD (12, 46, 47). A

Governance

47. CVAD management is provided by nursing staff who are proficient in this activity, or by nursing staff under the direct supervision of nursing staff who are proficient as per institutional policy (12, 26, 48).    Consensus
48. To prevent errors or breaches of asepsis, administration set and dressing changes should be performed when the clinician is unlikely to be interrupted.    Consensus
49. Infusions on each lumen of the CVAD are to be labelled as per theNational Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines

NSW Policy
National Guidelines

50. Evaluation of patient outcomes in relation to device failure include:
i. Surveillance of CRBSI
ii. Unintended removal and other complications as reported in the institutional incident management system.
iii. Audit of clinical practice 
 NSW Policy  

National Guidelines