Central Venous Catheter Care and Management (1)

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Central Venous Catheters: Care and management

Version 3

Name of responsible (ratifying) committee Infection Prevention Management Committee

Date ratified 1st MAC! "#13

Doc$ment Manager (%ob title) Cons$ltant Infection Prevention

Date iss$ed &t' MAC! "#13

evie date 1st MAC! "#1

*lectronic location Clinical Policies

elated Proced$ral Doc$ments

+r$st Policies,

!and !ygiene policy Asepsis policy-tap'ylococc$s a$re$s policy-tandard Preca$tions policy

.ey /ords (to aid it' searc'ing) Asepsis0 CVC0 central lines0 intraveno$s access

Central Veno$s Cat'eters, Care and Management, Version 3 Iss$e Date, &t' MAC! "#13(evie date 1st MAC! "#1 ($nless re$irements c'ange))



CONTENTS

12 Introd$ction"2 P$rpose32 -cope&2 Definitions2 D$ties and responsibilities2 Process

42 +raining re$irements52 eferences and associated doc$mentation (incl$ding related policies and proced$res)62 *$ality Impact -tatement1#2 Monitoring compliance it' proced$ral doc$ments112 Appendices

Appendix I: Principles of Carei2 7eneral Principlesii2 Accessing t'e Cat'eter iii2 8l$s'ing After 9 :eteen ;sesiv2 Care of t'e *<it sitev2 emoval

Appendix II: Overvie of Central Venous Cathetersa) Definition of a Central Veno$s Cat'eter (CVC)b) Indicationsc) Insertion and emovald) C'oice of Cat'eter

Appendix III: Overvie and Specific Care for !ifferent T"pes of Catheteri2 Care of Centrally=Inserted0 Non=+$nnelled CVCsii2 Care of +$nnelled CVCs (!ic>man lines)iii2 Care of PICCsiv2 Care of Implantable Ports (Portacat's)v2 Care of Care of CVCs $sed for :lood Processing (e2g2 !aemodialysis0 Ap'eresis etc)

vi2 Care in NeonatesAppendix IV: #anagement of ComplicationsAppendix V: $sing Throm%ol"ticsAppendix VI: &lossar" of Complications

i2 Pne$mot'ora<ii2 Infectioniii2 +'rombosisiv2 Mec'anical P'lebitis (PICCs)v2 Air *mbolismvi2 Cardiac Arr'yt'miasvii2 Cardiac +amponadeviii2 Patency Impairment

i<2 Incorrect Position<2 *<travasation ?f 8l$ids@Dr$gs D$e +o IncorrectNeedle Position@ Needle Dislodgement (In Implantable Ports)<i2 Cat'eter 8ract$re<ii2 -eparation ?f Port And Cat'eter ( In Implantable Ports)<iii2 -$rgical (s$bc$taneo$s) *mp'ysema

Appendix VII: 'eferencesAppendix VIII: Clinical Audit tools CVC Insertion and Management 8orm (p&#)

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() INT'O!$CTION

+'is policy is designed as a reso$rce to direct all staff in t'e management and care of t'evario$s forms of Central Veno$s Cat'eter (CVC) placed in patients it'in Portsmo$t'!ospitals2CVC are inserted,

•+o monitor central veno$s press$re

•+o administer large amo$nts of intraveno$s fl$ids (e2g2 colloids0 blood prod$cts etc2)•+o administer irritant0 vesicant or 'yper=osmolar dr$gs @ fl$ids (for e<ample

Noradrenaline@Adrenaline0 sodi$m bicarbonate0 Parenteral N$trition0 c'emot'erapy etc2)

•+o provide long term accesses for fre$ent or prolonged $se (e2g2 c'emot'erapy0

antibiotics0 blood sampling0 'aemodialysis etc2)2

+'e implementation of t'is policy ill be monitored $sing clinical a$dit incl$ding t'e -avingBives Care :$ndles @ CVC Insertion and Management 8orm2 (Appendi< VIII)

*) P$'POSE

+o inform best practice from t'e e<isting evidence on t'e care and management of CVC2 +'eimplementation of t'is policy ill red$ce t'e ris>s associated it' t'ese devices incl$dingt'rombosis0 pain0 local or systemic infection and occ$pational s'arps in%$ry

+) SCOPE

+'is policy applies to all 'ealt' care professionals involved in t'e management of patients it'central veno$s cat'eters in=sit$2

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises

that it may not be possible to adhere to all aspects of this document. In such circumstances,staff should take advice from their manager and all possible action must be taken tomaintain ongoing patient and staff safety’

,) !E-INITIONS

Central Venous Catheter (CVC) refers to an intraveno$s cat'eter 'ose internal tip lies in alarge central vein2 +'ere are vario$s different types of CVC b$t common to all is t'e idea t'att'e tip of t'e cat'eter floats freely it'in t'e bloodstream in a large vein and parallel to t'e veinall2 :lood flo aro$nd t'e cat'eter is ma<imised0 and p'ysical and c'emical damage to t'e

internal alls of t'e vein are minimised2Aseptic Techni.ueClinical practices $sed to protect t'e patient from micro=organisms by preventing contaminationof o$nds0 manip$lated devices and ot'er s$sceptible sites2 Aseptic tec'ni$e involves t'e$se of appropriate 'and 'ygiene0 $se of sterile e$ipment0 no to$c' tec'ni$e and rob$stpatient s>in @ site disinfection2/ealth care professional A registered or trained member of staff0 incl$ding b$t not e<cl$sively n$rses0 doctors andoperating department practitioners2Infection*ntry of a 'armf$l microbe into t'e body and its m$ltiplication in t'e tiss$es28$rt'er information can be fo$nd in t'e Appendices2

2

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0) !$TIES AN! 'ESPONSI1I2ITIES

12 All #anagers = +o be aare of +r$st Policy and 7$idelines and to ens$re t'eir -taff complyit' t'e re$irements of t'ese doc$ments2

"2 Supervisors of clinical practice ill be responsible for monitoring compliance it' t'epolicies on an ongoing basis2

32 Individual mem%ers of Staff m$st ens$re t'ey follo t'is policy to ens$re safe practice2&2 3ards and Clinical Areas ill ro$tinely a$dit compliance against t'e Care b$ndle form forongoing management of CVCs as per Infection Prevention and Control g$idance (Appendi<VIII)2

2 Infection Prevention and Control Team = $ality control a$dits to ens$re contin$edstandards and ad'erence of Policy d$ring care and management of CVCs ill be $nderta>encyclically2

4) P'OCESS

-ee Appendices,I2 Principles of Care (p4)2III2 ?vervie and -pecific Care for Different +ypes of Cat'eter (p11)2IV2 Management of Complications (p")2V2 ;sing +'rombolytics (p3")2

5) T'AININ& 'E6$I'E#ENTS

Nursing staff ill be ta$g't at on t'e IV +'erapy -t$dy Day2 Clinical *d$cators0 PracticeDevelopment N$rses and Clinical N$rse -pecialists ill s$pport learning and t'e gaining andmaintaining of competencies, P!+ Care of a Central Veno$s press$re (CVP) BineCompetency0 P!+ Ad$lt IV administration Competency0 P!+ paediatric CVC Competency0P!+ paediatric +IVAD Competency0 P!+ Paediatric IV administration Competency2 Additionaltraining can be offered by t'e Infection Prevention and Control +eam2

#edical Staff 'o 'andle and care for CVCs s'o$ld be competent to do so2 +'is s'o$ld beassessed by t'eir *d$cational -$pervisor2 8E1s ill be trained at ind$ction2 Additional trainingcan be offered by t'e by t'e Infection Prevention and Control +eam22

7) 'E-E'ENCES AN! ASSOCIATE! !OC$#ENTATION

+'is policy s'o$ld be read in con%$nction it' t'e folloing P!+ policies,12 Safe handling and disposal of sharps -afe !andling and Disposal of -'arps Policy"2 Standard Infection Control recautions = Infection Control -tandard Preca$tions Policy32 !septic Techni"ue Aseptic +ec'ni$e Policy&2 #and #ygiene olicy !and !ygiene Policy2 arenteral $utritional Support management in hospitalised adult patients 8 Parenteral

N$tritional -$pport management in 'ospitalised ad$lt patients

-ee also Appendi< VII, eferences (p36)

9) E6$A2IT I#PACT STATE#ENT

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http://www.porthosp.nhs.uk/Clinical-Policies/Safe%20handling%20and%20Disposal%20of%20Sharps.doc

http://www.porthosp.nhs.uk/Infection-Control-Policies/Standard%20Precautions%20Policy.doc


http://www.porthosp.nhs.uk/Infection-Control-Policies/Asepsis%20Policy.doc


http://www.porthosp.nhs.uk/Infection-Control-Policies/Hand%20Hygiene%20Policy.doc

http://www.porthosp.nhs.uk/Clinical-Policies/Parenteral%20Nutritional%20Support%20management%20in%20hospitalised%20adult%20patients.doc



http://www.porthosp.nhs.uk/Clinical-Policies/Safe%20handling%20and%20Disposal%20of%20Sharps.doc



http://www.porthosp.nhs.uk/Infection-Control-Policies/Hand%20Hygiene%20Policy.doc





Portsmo$t' !ospitals N!- +r$st is committed to ens$ring t'at0 as far as is reasonablypracticable0 t'e ay e provide services to t'e p$blic and t'e ay e treat o$r staff reflectst'eir individ$al needs and does not discriminate against individ$als or gro$ps on any gro$nds2

+'is policy 'as been assessed accordingly2

All policies m$st incl$de t'is standard e$ality impact statement2 !oever0 'en sending for

ratification and p$blication0 t'is m$st be accompanied by t'e f$ll e$ality screening assessmenttool2 +'e assessment tool can be fo$nd on t'e +r$st Intranet =F Policies =F PolicyDoc$mentation

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(;)#ONITO'IN& CO#P2IANCE 3IT/ P'OCE!$'A2 !OC$#ENTS

+'is doc$ment ill be monitored to ens$re it is effective and to ass$rance compliance2

+'e effectiveness in practice of all proced$ral doc$ments s'o$ld be ro$tinely monitored (a$dited) to ens$re t'e doc$ment ob%ectives are beingac'ieved2 +'e process for 'o t'e monitoring ill be performed s'o$ld be incl$ded in t'e proced$ral doc$ment0 $sing t'e template above2

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#inimum re.uirement to%e monitored

2ead Tool -re.uenc" of 'eportof Compliance

'eporting arrangements 2ead<s= for acting on'ecommendations

Saving %ives C&C 'ngoingCare Care (undle

Dr CarolineMitc'ell

CVC Insertionand

#anagementtool <seeappendices=

$arterly as part ofongoing device a$dits

Policy a$dit report to,

•

Infection Prevention and ControlManagement Committee

Medical Director

Director of N$rsing

!eads of N$rsing

C-C 7overnance Beads


•


•



+'e details of t'e monitoring to be considered incl$de,

• +'e aspects of t'e proced$ral doc$ment to be monitored, identify standards or >ey performance indicators (.PIs)G

• +'e lead for ens$ring t'e a$dit is $nderta>en

• +'e tool to be $sed for monitoring e2g2 spot c'ec>s0 observation a$dit0 data collectionG

• 8re$ency of t'e monitoring e2g2 $arterly0 ann$allyG

• +'e reporting arrangements i2e2 t'e committee or gro$p 'o ill be responsible for receiving t'e res$lts and ta>ing action as re$ired2 In

most circ$mstances t'is ill be t'e committee 'ic' ratified t'e doc$ment2 +'e template for t'e policy a$dit report can be fo$nd on t'e +r$stIntranet +r$st Intranet =F Policies =F Policy Doc$mentation

• +'e lead(s) for acting on any recommendations necessary

2

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(() APPEN!ICES

Appendix I: Principles of Care<i= &eneral Principles$se an aseptic techni.ue folloing P/T Asepsis Polic" 'enever t'e CVC is

accessed and d$ring proced$res involving e<it sites2 To prevent infection. ! strongcorrelation e)ists bet*een bacteraemia and the presence of a C&C+.

3ear sterile gloves hen carr"ing out dressing changes and hen accessing thecatheter 2-loves should be *orn to prevent descaling of bacteria onto key parts+.

>Scru% the /u%> ? all needle?free access devices <%ungs= should %e cleaned for +;seconds using chlorhexidine *@ in 5;@ IPA <Sanicloth*@C/&= and then alloed to airdr" for +; seconds prior to accessing

#onitor temperature pulse %lood pressure resp rate and O* saturations at least a

minim$m of 1"'o$rly2 To detect infection

/'en caring for s'ared=care Paediatric ?ncology patients please refer to section /esse<Paediatric ?ncology 7$idelines2

B!o not allo air to enter the catheter 2 All syringes and intraveno$s administration setsm$st be caref$lly primed2 To prevent air embolism. The negative pressure *ithin the chestmay suck air into the catheter during inspiration especially if the patient is sitting up+/.

Cap off the catheter ith a needle?free access device (e2g2 safeflo) 'en not in $se(e<cept Neonates)2 +'is ill minimise interr$ptions to t'e closed system2 ;nlessman$fact$rers instr$ctions vary0 t'is s'o$ld be c'anged every 4 days or every "## $ses0'ic'ever is t'e sooner2 In ad$lt inpatients it' long=term vasc$lar access devices t'e b$ngss'o$ld be c'anged on a set day (-$nday) to ens$re contin$ity it'in and beteen $nits20isk of contamination increases *ith every interruption to the closed system"3.

3henever the %ungaccess device is removed from t'e cat'eter t'en it m$st be replacedit'a ne0 needleless access device@b$ng2 To prevent infection.

If the catheter possesses an integral clamp Deep it closed 'enever t'e cap is removedand at all ot'er times e<cept 'en administering or it'draing fl$ids2 Clamping s'o$ld

alays ta>e place at t'e designated area and never at t'e t'ic>ened area near t'e '$b(e<cept !ic>mans)2 The clamp *ill prevent air entry and bleeding should the luer lock capbecome unattached. 0epeated clamping a*ay from the specially reinforced area may resultin damage to the catheter.

Ala"s taDe signs of s"stemic or local infection seriousl" and refer to a member of t'emedical staff . 1Infection continues to be one of the most fre"uent and most seriouscomplicationsassociated *ith C&C Catheters1 "3.

The practice of administering proph"lactic anti%iotics at t'e time of CVC insertion s'o$ldN?+ be ro$tinely folloed2 The 2epartment of #ealth’s 3pic+ -uidelines on the prevention

of infection in Central &enous Catheters specifically states that this practice is not supportedby research and may encourage resistant organisms11.


http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf







The practice of administering proph"lactic mini?dose 3arfarin to patients it' CVCss'o$ld N?+ be folloed2 4ini5dose 6arfarin has recently been sho*n to be ineffective in the prevention of thrombosis in cancer patients *ith C&Cs+7. 8$( dose adjusted 6arfarin didsho* some efficacy but *ith an increased risk of serious bleeding9.

Should the catheter fracture or %e accidentall" cut0 clamp it it'o$t delay pro<imal to t'e

brea>2 -pecialist advice s'o$ld be so$g't immediately to consider removal or repair of t'ecat'eter2 To prevent haemorrhage, air embolism and infection.

Ala"s secure the catheter firml" to the sDin aay from t'e e<it site it' tape or it' adedicated device s$c' as H-tatloc>H2 :or patient;s comfort, to prevent tension or accidental dislodgement, and to reduce ;to and fro; motion *hich increases the risk of catheter related sepsis"3.

<ii= Accessing the Catheter 1efore it is used for administering therapeutic drugs or fluids the patenc" and correctfunctioning of the catheter should %e esta%lished*5 (e<cept Neonates 'en t'is s'o$ld

only be done immediately folloing cat'eter insertion)2 -igns of cat'eter occl$sion0 'et'erpartial or complete0 s'o$ld be ta>en serio$sly and action s'o$ld be ta>en earlier rat'er t'anlater to restore f$ll patency2 Ignoring t'e early signs may lead to t'e development of moreserio$s problems 'ic' cannot t'en be easily rectified eg complete bloc>age ort'rombosis"52

• Nurses using CVCs can %e confident of access if all t'ree of t'e folloing apply

o +'e cat'eter can be flushed ith ease2

o 1lood can %e ithdran from t'e cat'eter (not Neonates)2

o +'e patient e<periences no discomfort d$ring fl$s'ing@inf$sion and t'ere are no ot'er

complications

If an" of these criteria are not met yo$ s'o$ld refer to Management of Complications

•3a"s of assessing these three criteria ill var" ith the setting2 !ere are some points to

note,o A proper assessment of the catheter involves o%serving the exit site and the area

around as t'is may reveal any signs of t'rombosis0 lea>age0 infection etc2 /'ile t'is isnot necessarily appropriate every time t'e cat'eter is $sed it s'o$ld be a reg$lar part ofyo$r practice2

o Assessing CVCs in neonates and in patients re.uiring %lood processing <e)g)

haemodial"sis apheresis= re.uires specialist Dnoledge, refer to Overvie and Specific Care for Different Types of Catheter (starting page 11) for care of t'ese

patients2o In adults and children over ( "ear ho are due to receive intravenous fluids0 a

$sef$l tec'ni$e is to attac' an inf$sion of #26 saline0 open t'e clamp on t'e givingset f$lly and observe for free=flo2 Eo$ ill soon learn to recognise 'at is a normalfree=flo for a partic$lar type of CVC (for e<ample t'e flo on a Non=t$nnelled CVC illbe m$c' faster t'an yo$ o$ld e<pect from a PICC 'ic' is a m$c' longer t'innercat'eter2) Dropping t'e bag of fl$id %riefl" belo t'e patients 'eart it' any clampsopen ill allo yo$ to c'ec> for flas'bac> of blood it'o$t interr$pting t'e closedsystem2 As soon as blood is seen in t'e t$bing0 t'e bag can be replaced on t'e dripstand and prescribed inf$sion started2 (N: t'is tec'ni$e for c'ec>ing flas'bac> doesnot alays or> it' valved cat'eters)2 Ensure to stop the free flo to ensure nounnecessar" %olus of fluid)

o ChecDing for flash%acD of %lood does not necessaril" mean "ou have to discard%lood) 8or e<ample0 attac' a syringe containing 1#ml #26 sodi$m c'loride to t'e




cat'eter0 fl$s' a co$ple of ml into t'e line and t'en it'dra2 As soon as yo$ see a trace of blood in t'e cat'eter or syringe %$st fl$s' t'e rest of t'e sodi$m c'loride into t'eline $sing t'e p$s'=pa$se tec'ni$e as described in (iii) a) belo (page 4)2

<iii= -lushing After and 1eteen $ses <except Neonates=

<a= -lushing Techni.ue:

•3here possi%le do not use s"ringes smaller than (; ml for inf$sion into t'e cat'eter142 To

prevent e)cessive pressure being e)erted on the lumen *hich might cause it to rupture. Smallersyringes e)ert greater pressure. (ut please note that syringe si<e alone is not sufficient to prevent rupture. =6hen resistance is felt, if more pressure applied to overcome it, catheterfracture could result regardless of the syringe si<e>? "5.

•$se a %risD >push?pause> flushing techni.ue ro$tinely 'en fl$s'ing t'e cat'eter = i2e2 fl$s'

bris>ly0 pa$sing briefly after appro<imately eac' ml of fl$id2 The ;push5pause; techni"ue causes turbulence *ithin the catheter, *hich helps to flush a*ay any debris and prevent occlusion of the lumen@A,+A.

• If the catheter possesses a clamp clamp the line hile the final ml of the flush is %eing

inected2 If t'ere is no clamp yo$ can ac'ieve a Jpositive press$re finis'K by removing t'e syringefrom t'e -anloc> (or similar) 'ile in%ecting t'e last ml, b$t note t'at to avoid any spray from t'esyringe yo$ s'o$ld 'old sterile ga$Le aro$nd t'e connector 'ile doing t'is2 4aintaining positive pressure helps prevent blood entering the catheter after flushing, *hich might lead to occlusionor thrombus formation14.

•!o not routinel" ithdra and discard %lood from the catheter %efore flushing <except

'enal !ial"sis Catheters 8 follo 3essex 'enal $nit &uidelines= in an attempt to avoidfl$s'ing bacteria and clots into t'e patient"42 There is no evidence that *ithdra*ing prior toflushing reduces infection or embolism. 1ut note that if the catheter is to %e used for administering drugs or fluids checDing for Fflash%acDG should %e a routine part of catheter assessment, see ii) Accessing the Catheter above (page 4)2

<%= -re.uenc" of flushing and flushing solutions:

•+'is varies depending on t'e device2 -ee Overvie and Specific Care for Different Types of

CVCPlease note t'at !epsal and !eparinised -aline m$st be prescribed2

<iv= Care of the Exit Site <Except Neonates=

a= !ressings Immediatel" post insertion:

• As it' any s$rgical o$nd0 t'e exit site should ideall" %e left undistur%ed for (?* da"s2

o$tine ta>ing don of t'e dressing post=insertion to inspect t'e site merely e<poses t'e patientto increased ris> of infection2 ?n t'e ot'er 'and most e<it sites bleed to some e<tent folloinginsertion2 If t'is leads to Jstri>e=t'ro$g'K on a dry dressing0 (i2e2 e<$date@blood@sero$s fl$idobserved on t'e o$tside of a dry dressing) it s'o$ld be c'anged immediately since a et s$rfaceprovides Ja li$id pat'ay for bacteria to travelK to t'e o$nd2

•The ideal dressing immediatel" post?insertion is a dry dressing covered and sealed it' a

transparent dressing (+egaderm)2 In most cases t'is ill absorb any ooLing b$t not necessitatec'anging t'e dressing2 Ideally t'is dressing s'o$ld be left $ndist$rbed for at 1=" days2 If t'ere ise<cessive bleeding and t'e ga$Le becomes soggy t'e dressing s'o$ld be c'anged2

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• If a dr" dressing alone is used post?insertion0 it s'o$ld again ideally be left $ndist$rbed for 1 =

" days b$t s'o$ld alays be c'anged as soon as any Jstri>e=t'ro$g'K occ$rs $sing an aseptictec'ni$e2

• If %leeding is excessive t'e dressing s'o$ld be c'anged every time stri>e=t'ro$g' occ$rs and

replaced it' a more absorbent or t'ic>er dressing2 Press$re s'o$ld t'en be applied to t'e site

and t'e patient enco$raged to lie fairly still $ntil t'e bleeding settles2 It is not acceptable to addmore dressings on top of blood=soa>ed dressings 'ic' 'ave been in contact it' a moist o$ters$rface0 beca$se of t'e infection ris>2

%= On?going !ressing 'egimes after the first (?* da"s:

• As a general principle0 'ere a dressing is $sed it s'o$ld be inspected regularl" and reneed

immediatel" should it %ecome soiled et or detached") ! moist environment is one in *hich bacteria readily multiply+B.

• If the exit site is reddened painful exudating or infected0 increase t'e fre$ency of dressing

c'ange depending on t'e amo$nt of e<$date2

•The most suita%le dressing ill depend on the setting the t"pe of CVC and t'e individ$al

patients needs2 -ee Overvie and Specific Care for Different Types of CVC (starting page1&) for recommendations2 +'e main options for dressings are,o IV?dedicated occlusive transparent dressing0 c'anged every 4 days"4 e<cept

patients on dialysis and neonates2 Some researchers have found iv5dedicated transparent dressings to be associated *ith a lo*er risk of infection than other transparent dressings.

o Sterile dr" dressing taped in sit$0 c'anged at least tice a ee>"42

o No dressing2 +'is may be s$itable for some patients it' +$nnelled CVCs from "1

days post insertion once t'e tiss$es 'ave fibrosed aro$nd t'e c$ff and in t'e absence

of e<$date or signs of infection2 1$o dressing1 performed just as *ell as types of dressing in one study comparing infection rates"3,@,+ 2

c= Cleaning of Exit Site:

•At dressing changes the exit site should %e cleaned using chlorhexidine *@ in 5;@

Isoprop"l Alcohol <IPA= <Sanicloth*@C/&= $sing an o$tard spiral motion to avoid transferringbacteria to t'e e<it site2 Please note some areas also stocD ;)0@ in 5;@ Isoprop"l Alcohol<IPA= </"drex= for sDin preparation prior to spinal epidural procedures as *@ should notcome onto contact ith meninges %ecause of a perceived increased risD)

•Cleaning should %e carried out using an aseptic techni.ue2

•2oose %lood exudate or other de%ris 'ic' mig't provide a foc$s or infection or mig't impair

inspection of t'e o$nd may be gently removed by cleaning in t'e above manner it' sterile#26 sodi$m c'loride prior to cleaning it' C'lor'e<idine " (-aniclot'")332

d= 'emoval:

If a s'ort=term CVC 'as not been $sed for F"& 'o$rs consideration s'o$ld be given to its removal2-ome CVCs are simple and relatively safe to remove2 /it' ot'ers0 t'ere is 'ig' ris> of airembolism3& and so removal re$ires a 'ig'er level of training and s>ill2 -ee Overvie andSpecific Care for Different Types of CVC (page 1&) for g$idelines on removal2




Appendix II: Overvie of Central VenousCatheters

<i= !efinition of a Central Venous Catheter <CVC=+'e term Central Veno$s Cat'eter (CVC) refers to an intraveno$s cat'eter 'ose internal tiplies in a large central vein2 +'ere are vario$s different types of CVC b$t common to all is t'e

concept t'at t'e tip of t'e cat'eter floats freely it'in t'e bloodstream in a large vein parallelto t'e vein all2 :lood flo aro$nd t'e cat'eter is ma<imised0 and p'ysical and c'emicaldamage to t'e internal alls of t'e vein are minimised2

?pinions vary abo$t t'e ideal place for t'e tip of a CVC" b$t it is generally accepted t'at for acat'eter to be considered a Jcentral cat'eterK t'e internal tip s'o$ld be in one of t'e folloingpositions2

a) -$perior vena cava (-VC)b) A@-VC %$nctionc) ig't atri$m (A)d) Inferior vena cava above t'e diap'ragm (femoral cat'eters)

+ip positions o$tside t'ese areas aret'o$g't to be related to a significantly'ig'er ris> of complications0 notablyt'rombosis2

In neonatal care0 rig't atrial placement iscontraindicated beca$se of t'e ris> ofcardiac tamponade52 In PICCs0 rig't atrial

placement is considered to be inadvisablebeca$se t'e PICC may move into t'e rig'tventricle 'en t'e patient moves 'is@'erarm0 leading to an increased ris> ofarr'yt'mias

<ii= Indications• +o monitor central venous pressure

• +o administer large amounts of intraveno$s fl$ids in emergency sit$ations (e2g2 colloids0

blood prod$cts etc2)

• +o administer irritant vesicant or h"per?osmolar dr$gs @ fl$ids (for e<ample

Noradrenaline@Adrenaline0 sodi$m bicarbonate0 Parenteral N$trition0 c'emot'erapy etc

• +o provide long term access for fre$ent or prolonged $se (e2g2 c'emot'erapy0 antibiotics0

blood sampling0 'aemodialysis etc2)

<iii= Insertion and 'emovalInsertion of a CVC is an invasive procedure 'ic' m$st only be performed by trained0competent personnel $sing Joptimal aseptic tec'ni$e0 incl$ding a sterile gon0 gloves0 anda large sterile drapeK2 The use of ultrasound to achieve venous access is recommendedby NIC* g$idelines1" b$t t'is relies $pon t'e availability of appropriate e$ipment andtraining2 /'et'er t'e cat'eter is inserted $nder general anaest'etic0 sedation or simple localanaest'etic ill depend $pon t'e sit$ation0 t'e patient0 t'e type of cat'eter to be inserted and

local practice2 7$idelines for t'e insertion of Central Veno$s Cat'eters are not covered 'ere2Techni.ues for the removal of a CVC vary depending on t'e type of cat'eter and t'is is

Central Veno$s Cat'eters, Care and Management, Version 3 Iss$e Date, &t' MAC! "#13(evie date 1st MAC! "#1 ($nless re$irements c'ange)) Page 1" of &



addressed in Appendix III: Overvie and Specific Care for Different Types of Catheter 2




<iv= Choice of Catheter

Various different t"pes of CVCs are availa%le and t'ese are described belo2

+'e c'oice of device ill depend c'iefly on t'e p$rpose for 'ic' it is intended0 t'o$g'patient preference may be a >ey factor it' long=term cat'eters2 As a general principle thelumen diameter and the num%er of lumens should %e Dept to a minimum 0 since largerbore cat'eters and m$ltiple l$mens are associated it' 'ig'er infection and t'rombosisris>s110132 Clearly t'ere are many ot'er factors to be eig'ed against t'ese ris>s e2g2 in 'ig'dependency settings large bore cat'eters and m$ltiple l$mens tend to be $sed as t'ey areessential for management of t'e ac$tely ill patient2 /'ere Parenteral N$trition is to beadministered0 ideally a single=l$men cat'eter s'o$ld be $sed2 If m$ltiple l$mens areessential0 t'en one l$men s'o$ld be dedicated Je<cl$sively for t'at p$rposeK (e<cept inNeonates)21101&2



Appendix III: Overvie and Specific Care for !ifferent T"pes of Catheter

Care of Centrally-Inserted, Non-tunnelled CVCs

'ften called Central %ines D $eck %ines DC& lines.

• Centrally Inserted Non=t$nnelled CVCs are

most commonly fo$nd in acute settings) +'eyare not s$itable for long=term $se beca$se t'eyrarely remain free of infection for longer t'an 4 1# days and also beca$se t'ey are relatively$ncomfortable and $nsig'tly2

• The catheter is usuall" inserted via the

su%clavian ugular or femoral veins it't'e tip positioned in t'e ig't Atri$m0 t'e-$perior or Inferior Vena Cava2 It is attac'ed tot'e patients s>in $sing non=dissol$ble s$t$res2

• Non?tunnelled CVCs ma" have single

or multiple lumens2 *ac' l$men providesindependent access to t'e veno$s circ$lation0 sot'at incompatible dr$gs@fl$ids may beadministered sim$ltaneo$sly2

• Each lumen is e.uipped ith an integral clamp to seal t'e cat'eter and g$ard against

air entry0 'aemorr'age and infection2

-lushing1efore flushingo If t'ere are inf$sional vasoactive dr$gs in t'e l$men0 it'dra prior to fl$s'ing to avoid

bol$s dose2Techni.ue:o :ris> p$s'=pa$se tec'ni$e it' positive press$re finis'

3hat to flush ith:o #26 sodi$m c'loride beteen incompatible dr$gs @ inf$sions and after blood sampling

(if sodi$m c'loride #26 incompatible $se s$itable alternative)2o Boc> it' 1#ml #26 sodi$m c'loride if cat'eter is to be accessed again it'in 1 day2

o Boc> it' ml !epsal 1# ;@ml if cat'eter not to be $sed again it'in 1 day2-re.uenc" of flushing:o 8l$s' unused l$mens at least once a ee> (1#ml #26 sodi$m c'loride t'en loc> it'

ml 'epsal 1# ;@ml)2

Exit site CareSecurement,o Bines are s$t$red in place0 alternatives s$c' as a -tatloc> can be $sed2

Sutures,o Beave in place as long as t'e cat'eter is in sit$2

Cleaning,

o Clean e<it site at dressing c'anges using chlorhexidine *@ in 5;@ IPA<Sanicloth*@C/&= $sing an o$tard spiral motion to avoid transferring bacteria tot'e e<it site2



!ressings,o Post=insertion, ga$Le $nder transparent dressing for 1=3 days2

o After 3 days, +ransparent dressing recommended2 C'ange every 4 days

1athing H shoering +'e e<it site m$st not be alloed to get et2

'emoval3ho can remove Non?tunnelled CVCso Any $alified n$rse 'o 'as been assessed as competent and 'o follos t'ese

g$idelines2Procedure,o ou ill need assistance d$ring t'is proced$re, do not attempt it alone2

o ChecD patientJs coagulation status2 If t'ere is an increased ris> of bleeding disc$ss

it' medical team before proceeding2 If platelets are #0 platelets s'o$ld beadministered immediately prior to t'e proced$re2 If t'e patient is anticoag$lated0 t'iss'o$ld be managed as for s$rgery2

o The risD of air em%olism increases if patient is deh"drated is una%le to lie flat or

has an uncontrolled cough) Assess for t'ese ris>s2 ?nly proceed if satisfied t'at it issafe to do so2

o $se aseptic techni.ue t'ro$g'o$t2

o 2ie the patient flat and tip the head of the %ed donard to red$ce t'e ris> of air

embolism (e<cept femoral cat'eters)2o 'emove the dressing2 If t'ere is any sign of infection0 ta>e a sab of t'e e<it site2

o 'emove an" stitches2

o AsD patient to perform ValsalvaJs manoeuvre (ie ta>e a deep breat'0 'old it0 and

bear don)2 If patient $nable to do t'is0 remove t'e cat'eter d$ring e<piration andN*V* 'en t'e patient is breat'ing in0 as t'is ill increase t'e ris> of air beings$c>ed into t'e veno$s system2

o &entl" and siftl" pull out the catheter and immediately apply press$re to t'e site

$sing sterile ga$Le2 +'e patient t'ey can no breat'e normally and t'e bed can beret$rned to t'e flat position2

o Continue appl"ing pressure to the exit site for three minutes (or longer in cases of

deranged clotting)2o If s"stemic infection is suspected0 $se sterile scissors to c$t off t'e tip of t'e cat'eter

and it'o$t contaminating it drop it into a dry sterile specimen pot2 -end it tomicrobiology for c$lt$re (DCC all tips sent for c$lt$re)2

o Appl" a sterile occlusive dressing to prevent air from entering t'e veno$s system2

o Advise the patient to lie flat for +; minutes2

o !uring this time o%serve patient for signs of 'aematoma (ie0 selling0 pain0 altered

voice0 airay obstr$ction)2

o The ound should %e Dept dr" for 0 to 5 da"s and t'e o$nd monitored $ntil 'ealed2



ii) Care of Tunnelled CVCs often called Hickman lines

• Tunnelled CVCs are intended for longer?term use in patients 'o re$ire m$ltiple

inf$sions of fl$ids0 blood prod$cts0 dr$gs or Parenteral N$trition2 +'ey also provide easyaccess for ro$tine blood sampling2 +'ey are more comfortable and discreet t'an t'e non=t$nnelled CVCs described in a) above0 and can last for m$c' longer2

• +'e +$nnelled CVC is inserted via t'e s$bclavian0 %$g$lar or femoral veins2 The catheter is

tunnelled su%cutaneousl" and exits at a convenient site ($s$ally on t'e c'est all)'ere it is sec$red it' s$t$res2 +'ere is a c$ff it'in t'e t$nnel to allo for t'e ad'erenceof fibro$s tiss$e 'ic' 'elps to prevent accidental dislodgement after t'e removal of t'es$t$res and acts as a mec'anical barrier to ascending bacteria1012

• Single dou%le and triple lumen

catheters are availa%le2 *ac' l$menprovides independent access to t'eveno$s circ$lation0 so t'at incompatibledr$gs@fl$ids may be administeredsim$ltaneo$sly2

• Each lumen of the catheter is

e.uipped either ith an integralclamp or a +?a" valve2 Valvedcat'eters vary in design, t'e valve maybe at t'e internal or external end ofeac' l$men (e2g2 -roshong cat'eters'ave a valve at t'e internal end0 'ereas!S& cat'eters contain a valve at t'ee<ternal end)2 +'e clamp (or valve)

serves to seal t'e cat'eter and g$ardagainst air entry0 'aemorr'age andinfection2

• Patients ith tunnelled CVCs ma" %e discharged home ith the catheter in situ 2 In

t'ese cases patient ed$cation regarding t'e recognition and reporting of complications is ofgreat importance2 /'ere possible0 care in 'ospital s'o$ld be aimed at t'e promotion ofindependence in caring for t'e +$nnelled CVC0 b$t liaison it' t'e primary 'ealt'=care teamremains vita

-lushing• Techni.ue:o :ris> p$s'=pa$se tec'ni$e it' positive press$re finis'

• 3hat to flush ith:

o #26 sodi$m c'loride beteen incompatible dr$gs @ inf$sions and after blood sampling (if

sodi$m c'loride #26 incompatible $se s$itable alternative)2o Boc> it' 1#ml #26 sodi$m c'loride if cat'eter to be $sed again it'in 1 day2

o Boc> it' ml !epsal 1# ;@ml if cat'eter not to be $sed it'in 1 day2

o Paediatrics ml !epsal 1#$@ml fl$s' if not to be $sed it'in 5 'o$rs2

• -re.uenc" of flushing:

o 8l$s' $n$sed l$mens once a ee> it' ml !epsal 1# ;@ml2



Exit Site Care• Securement,

o /'en stitc'es removed no f$rt'er sec$rement re$ired Paediatrics tape lines to

patient2

• Sutures,

o Exit site, remove at "1 days

o Venepuncture site, emove stitc'es @ -teristrips at 4 days ($nless dissolvable)• Cleaning,

o Clean e<it site at dressing c'anges $sing chlorhexidine *@ in 5;@ IPA <Sanicloth

*@C/&= $sing an o$tard spiral motion to avoid transferring bacteria to t'e e<itsite2

!ressings,o Exit site,

Post?insertion, ga$Le $nder transparent dressing for 1= " days2

After (?* da"s c'oose beteen

• +ransparent dressing (c'anged every 4 days)

• ? dry dressing (c'anged at least every 4 days)

After *( da"s, c'oose beteen• transparent dressing (c'ange every 4 days)

• ? dry dressing (c'ange at least tice a ee>)

• ? no dressing2

o Venepuncture Site:

Dry dressing and@or transparent dressing $ntil s$t$res removed @ dissolve1athing shoering H simming

o 1athing, Patient s'o$ld not s$bmerge e<it site in bat'ater2 8or clean ater %$gged

from tap see Jshowering” belo2o Shoering, If transparent dressing is intact patient can s'oer2 If patient 'as dry

dressing or no dressing0 s@'e can s'oer after "1 days as follos,

o emove dry dressing (if any) immediately before or after s'oeringo Dry e<it site after s'oer $sing sterile ga$Le and non=to$c' tec'ni$e2

o Clean e<it site as $s$al 9 apply ne dressing (if any)2

o Simming, not advised Paediatrics liaise it' Clinical N$rse -pecialists2

Patient EducationIf patient is discharged ith catheter in situo Ideally0 teac' patient @ carer to care for t'eir on cat'eter

o efer to Comm$nity N$rsing -taff if necessary

o Provide to ee>s dressing and fl$s'ing s$pplies $nless t'ere are local

arrangements it' Comm$nity teams2 Provide emergency clamp >its for paediatricpatients2

o *ns$re patient is aare of care re$ired

o *ns$re patient is aare of t'e importance of reporting complications and 'as a

contact n$mber for t'is p$rpose

'emoval!o not remove Tunnelled CVCs unless "ou have %een specificall" trained to do so2



(iii) Care of PICCs

• PICCs (Perip'erally Inserted Central Cat'eters)0 li>e +$nnelled CVCs0 are intended for mid

to long?term use <up to 4 months sometimes longer= in patients 'o re$ire m$ltipleinf$sions of fl$ids0 blood prod$cts (not neonates)0 dr$gs or Parenteral N$trition2 +'ey mayalso provide access for ro$tine blood sampling2 PICCs are a common c'oice for central

access in Neonatal care2• A PICC is a fine %ore CVC inserted into

a perip'eral vein $s$ally t'e basilic orcep'alic vein and t'readed $pardstoards t'e 'eart2 +ip position is verified byC'est O=ray folloing insertion ($nless t'etip 'as been screened d$ring insertion$sing 8l$oroscopy)2

• ;nli>e +$nnelled CVCs0 PICCs do not

posses a FcuffG to secure the cat'eter )+'ere is not'ing to >eep t'e PICC in place$nless it is sec$red to t'e s>in of t'epatients arm $sing a dedicated fi<ingdevice2 C'ec>ing t'e e<ternal lengt' of t'ePICC s'o$ld be a ro$tine part of carebefore administering dr$gs or fl$ids toc'ec> t'e line 'as not migrated2

• PICCs can %e single dou%le or triple

lumen2 *ac' l$men provides independentaccess to t'e veno$s circ$lation0 so t'atincompatible dr$gs@fl$ids may be

administered sim$ltaneo$sly

• Each lumen of a PICC is e.uipped either ith an integral clamp or a +?a" valve 2

Valved PICCs vary in design, t'e valve may be at t'e internal tip of eac' l$men (e2g2 t'e-roshong PICC)2 +'e clamp (or valve) serves to seal t'e cat'eter and g$ard against airentry0 'aemorr'age0 bac>trac>ing of blood and infection2

• Patients ma" return home ith a PICC in situ0 and t'erefore patient ed$cation regarding

t'e recognition and reporting of complications is of great importance2 +'e PICC $s$ally e<itsonto t'e patients arm and so it is not alays practical for t'e patient to care for t'e cat'eter'im@'erself2 Biaison it' t'e IV team is vital2

• Placement is contraindicated folloing a<illary node dissection or irradiation0 or in t'e

case of lymp'oedema of t'e arm0 a<illary node disease or s>in infection at t'e insertionsite142

• A PICC should not %e confused ith a Fmidline catheterG 'ic' is $s$ally J"#cm in

lengt'0 it' t'e tip terminating in t'e region of t'e a<illary vein0 and is designed for s'ort=termperip'eral dr$g deliveryK152 A midline cat'eter is not a Central Veno$s Cat'eter2

&eneral points• Assess external length of PICC %efore use, if it 'as increased by more t'an "cm see

Management of Complications2

• TaDe care at all times not to pull PICC out2 emember t'eres not'ing to >eep t'e PICCin apart from t'e dressing and -tatloc>2



• Avoid compression to vein containing the PICC2 Do not $se blood press$re c$ff2 Any

bandage@ t$b$lar dressing m$st be loose2

• $se volumetric pump ith a filtered giving set hen infusing %lood products to avoid

bloc>age2Never use PICC for administering contrast medium unless it is rated for CT usage ast'is ill ca$se t'e PICC to split2

-lushing• Techni.ue:

o :ris> p$s'=pa$se tec'ni$e it' positive press$re finis'

• 3hat to flush ith:

1ard &roshong valvedo #26 sodi$m c'loride beteen incompatible dr$gs @ inf$sions or after blood

sampling (if sodi$m c'loride #26 incompatible $se s$itable alternative)2o Boc> it' 1#ml #26 sodi$m c'loride

CooD Kimal Navil"st open?ended

#26 sodi$m c'loride beteen @ after incompatible dr$gs @ inf$sions or after

blood sampling (if sodi$m c'loride #26 incompatible $se s$itable alternative)2 Boc> it' ml !epsal once a day2

• -re.uenc" of flushing,

1ard &roshong valvedo 8l$s' $n$sed l$mens a ee>ly it' 1#ml #26 sodi$m c'loride

CooD Kimal Navil"st open?ended

8l$s' $n$sed l$mens daily it' ml !epsal 1#;@ml2

Do not disconnect contin$o$s inf$sions to give daily !epsal 1#;@ml2



Exit Site CareSecurement,o Alays fi< cat'eter firmly to patients s>in (dedicated device e2g2 Statlock.)

Cleaning:o Clean e<it site at dressing c'anges it' chlorhexidine *@ in 5;@ IPA <Sanicloth

*@C/&= $sing an o$tard spiral motion to avoid transferring bacteria to t'e e<it site2

!ressings:o Post?insertion, ga$Le $nder transparent dressing for 1= " days2

o After (? * da"s, transparent dressing (c'ange every 4 days incl$ding any dedicated

fi<ing device e2g2 Statlock dressing)1athing shoering H simming,o 1athing H Shoering, Patient s'o$ld not get t'e dressing et as bat'@s'oer ater

can reac' t'e e<it site 'ere t'e PICC protr$des from t'e dressing2 If possible providea aterproof covering for bat'ing and s'oering (e2g2 (athguard or similar )2

o Simming, not advised2

Patient Education•

-or PICCs placed in the inner el%o0 advise patient to >eep $pper arm arm2• If patient is discharged ith catheter in situ

o efer to Comm$nity N$rsing -taff if necessary for ongoing care

o Provide to ee>s dressing and fl$s'ing s$pplies2


o *ns$re patient is aare of t'e importance of reporting complications and 'as a

contact n$mber for t'is p$rposeo If appropriate0 teac' a carer @ member of t'e patients family to care for t'e PICC

'emoval•

3ho can remove PICCso Any $alified n$rse 'o follos t'ese g$idelines2

• Procedure,

o Patient should %e sittingl"ing it' t'e PICC e<it site belo t'e level of t'e 'eart

(t'is ill 'elp prevent air embolism)o 'emove the dressing2 (+a>e sab if signs of infection)

o Pull PICC out slol" and gentl" an inc' or to at a time2 As eac' inc' goes by0

c'ange t'e position of yo$r 'and so t'at yo$r fingers are close to t'e e<it site2 +'isill red$ce t'e li>eli'ood of t'e cat'eter brea>ing2

o If "ou meet resistance STOP2 esistance may be d$e to venospasm2 If t'is

'appens0 apply arm pac>s to t'e patients arm for abo$t min$tes before

res$ming2o Once PICC is out appl" pressure to exit site it' sterile ga$Le for 3 min$tes2

o If s"stemic infection is suspected0 $se sterile scissors to c$t off t'e tip of t'e

cat'eter and it'o$t contaminating it drop it into a dry sterile specimen pot2 -end itto microbiology for c$lt$re2

o Appl" sterile occlusive dressing to prevent air from entering t'e veno$s system2

o Keep exit site ound dr" for ( to * days or $ntil 'ealed2



(iv) Care of Implantable Ports (TIVAD /Portacaths)

• A Totall" Implanta%le Venous Access !evice <TIVA!= is similar to a Tunnelled CVC

b$t instead of protr$ding from t'e patients c'est0 t'e cat'eter terminates in a self=sealingin%ection port 'ic' is implanted $nder t'e s>in2 There are therefore no external parts) +'e

port is accessed t'ro$g' t'e s>in $sing a dedicated non=coring needle

• -ome patients find an Implantable Port more discreet and less intrusive t'an a

+$nnelled CVC162 Ports re.uire less maintenance 'en not in $se t'an ot'er types ofcat'eter2 +'ey may also offer a loer ris> of infection 'en not in $se160"#2

•

Implantable Ports are s$itable for patients 'o re$ire long?term fre.uent andintermittent venous access2 Arg$ably t'ey are less t'an ideal for long=r$nning contin$o$sinf$sions beca$se of t'e ris> of needle dislodgement"12 The patient ma" return home iththe port in situ0 and t'erefore patient ed$cation regarding t'e recognition and reporting ofcomplications is of great importance0 as is liaison it' t'e primary 'ealt'=care team2

• !ual lumen devices are availa%le) +'ese are e$ipped it' to access ports side=by=side

'ic' can be accessed separately $sing to different needles2 *ac' l$men providesindependent access to t'e veno$s circ$lation0 so t'at incompatible dr$gs@fl$ids may beadministered sim$ltaneo$sly2

• Ports may also be $sed as an alternative to su%cutaneous administration of long=term

maintenance t'erapies 'en t'e s$bc$taneo$s ro$te 'as become $nacceptable to t'epatient or $nreliable e2g2 d$e to s$bc$taneo$s nod$le formation2

• Placement is not recommended in obese or cac'e<ic patients0 before or after c'est

irradiation0 or at mastectomy sites162

&eneral Points• Onl" access port using a dedicated non?coring needle it' integral e<tension set it'

clamp @stopcoc>2

• -olloing insertion there ma" %e oedema and tenderness around port2 +'is may

ma>e accessing port painf$l and more diffic$lt t'an $s$al2 Ideally port s'o$ld be accessed'ile patient is in t'eatre if it is to be $sed immediately afterards2 A longer needle may

need to be $sed d$e to selling2• If patient undergoes #'I scan0 inform scanning personnel abo$t t'e port2

• If patient re.uires defi%rillation do not place paddles directly over t'e port2



• Never use port for administering contrast medium as t'is may ca$se t'e cat'eter to

split2

•Sometimes it is not possi%le to %leed %acD ports despite eas" flushing)

Inserting the Non?coring Needle•3hich needle

o St"le, 8or inf$sions0 bol$ses0 blood=ta>ing and fl$s'ing a 6##

non=coring needle it'e<tension set s'o$ld be $sed2

o &auge, A ""=ga$ge needle ill s$ffice for most $ses2 ;se a "#=ga$ge needle for blood

administration and it'draal2o 2ength, /'ere a 6##

needle is $sed0 t'e lengt' ill depend on t'e amo$nt of

s$bc$taneo$s tiss$e beteen t'e s>in s$rface and t'e port2 +'e e<ternal part of t'eneedle s'o$ld not e<ert press$re on t'e s>in b$t e$ally it s'o$ld not stand too pro$d2/int, a 3@& needle is s$itable for most ad$lt patients2 Deeper or more s$perficial portsill re$ire longer or s'orter needles2

• Techni.ue:

o

$se Aseptic Techni.ue2o Num% sDin over the port if re$ired $sing topical anaest'etic before s>in prep (min2 #

min$tes before) or s$bc$taneo$s Bidocaine 1 (after s>in prep)2o Prepare sDin over the port using chlorhexidine *@ in 5;@ IPA <Sanicloth*@C/&=

and allo to dr")o Prime needle andor giving set it' #26 sodi$m c'loride2

o /old port firml" ith thum% and to fingers and stretc' s>in ta$t d$ring insertion of

t'e needle to prevent t'e port sliding o$t of t'e ay of t'e needle0 and to red$ce t'eris> of t'e port becoming dislodged it'in t'e s$bc$taneo$s poc>et2

o Insert needle firml" $ntil it is felt to contact t'e bac> of t'e port2

o Verif" correct position by fl$s'ing it' "# ml #26 sodi$m c'loride and c'ec>ing for

aspiration of blood2o If there is an" local discomfort and or oedema in t'e tiss$es aro$nd or over t'e port

t'is indicates incorrect position of t'e needle2 In t'is case needle s'o$ld be removed(see belo for tec'ni$e) and a fres' attempt made2 (Eo$ can $se t'e same needle for$p to 1 f$rt'er attempt if it 'as not become contaminated or damaged2) +'e s>in illneed re=cleaning after 3 min$tes if not s$ccessf$l2

o If unsuccessful after * attempts please refer to Clinical Nurse Specialists

o If the port flushes easil" ithout an" local discomfortoedema %ut there is no

flash%acD of %lood0 t'is s$ggests t'at needle position is correct b$t t'at t'e cat'eteritself is not f$lly f$nctional2 efer to Management of Complications

-lushing• Non?accessed ports:o -lush at least ever" four to six eeDs it' "#ml #26 sodi$m c'loride and loc> it'

&= ml !eparinised saline 1## ;@ml (not 1#;@ml)

• Accessed ports,

o Techni.ue:

:ris> p$s'=pa$se tec'ni$eo 3hat to flush ith,

;)9@ sodium chloride 0ml %eteen incompati%le drugs @ inf$sions or after bloodsampling (if sodi$m c'loride #26 incompatible $se s$itable alternative)2

If needle to %e removed: loc> it' ml !eparinised saline 1## ;@ml

If needle to remain in situ and port to be $sed it'in 1 day, loc> it' 1#ml

#26-odi$m c'loride and follo it' ml !epsal 1#;@ml2



If needle to remain in situ and port not to be $sed it'in 1 day, loc> it'1#ml #26 -odi$m c'loride and follo it' ml !epsal 1#;@ml2

'emoving the Needle• Techni.ue,

o 2ocD port it' ml 'eparinised saline 1## ;@ml2

o Sta%ilise the port it' one 'and d$ring needle it'draal to avoid tra$ma to tiss$es2+a>e care to avoid a needle=stic> in%$ry2

o Appl" gentle pressure to needle site it' sterile ga$Le $ntil minor bleeding 'as

ceased2 A plaster may be applied if necessary @ desired2

Exit Site Care• Sutures,

o +o side of port, remove at 4=1# days ($nless dissolvable)

o Venep$nct$re site, emove at 4 = 1# days ($nless dissolvable)

• -re.uenc" of needle change:

o If port in constant $se for more t'an a ee>0 c'ange needle ee>ly $sing different

p$nct$re site2o Needles are c'anged every 1& days in paediatric Cystic 8ibrosis patients2

• !ressings

o Non?accessed ports:

No dressing or e<it site care re$ired (e<cept immediately folloing insertion of t'eport 'en o$nd s'o$ld be >ept covered $ntil stitc'es removed2)

o Accessed ports,

Pad needle it' sterile ga$Le if necessary and cover it' transparent iv dedicateddressing2 Needle site s'o$ld be visible for inspection2

+ape t$bing firmly to s>in to prevent p$lling on t'e needle2

Inspect needle entry site at least daily2

Advise patient to report any discomfort or selling at t'e p$nct$re site immediately• 1athing shoering H simming

o Non?accessed ports,

Patient may bat'0 s'oer or sim freely once o$nd 'as 'ealed2o Accessed ports,

1athing, Patient s'o$ld not s$bmerge e<it site in bat'ater

Shoering, Patient may s'oer if needle site is completely covered it' anoccl$sive dressing0 ta>ing care not to dislodge needle confirm it' Clinical N$rse-pecialist2

Simming, not advised 'ile needle is in sit$2

Patient Education• If patient is disc'arged it' port in sit$,

o Ideall" teach patient to care for their on port

o 'efer to Communit" Nursing Staff if necessary2 If comm$nity staff need training in

$se of t'e port0 contact t'e Infection Prevention and Control +eam2o Provide access needles and flushing supplies for t'e first mont'2

o Ensure patient is aare of care re$ired

o Ensure patient is aare of the importance of reporting complications and 'as a

contact n$mber for t'is p$rpose

'emoval

• Do not remove ports $nless yo$ 'ave been specifically trained to do so2



(v) Care of CVCs used for lood Pro!essin" (e"/aemodial"sis Apheresis etc=

'ften called ermacathsD&ascaths.

• CVCs $sed for blood processing e2g2 !aemodialysis and Ap'eresis = are very similar to

t'e cat'eters described in a) and b) above2 The" can %e non?tunnelled <e)g) Vascaths= or tunnelled <e)g) !ermacaths=)

• Patients needing 'aemodialysis often re$ire central veno$s access repeatedly and for

long periods of time0 and so insertion via the ugular vein is preferred to the su%clavianapproach beca$se of t'e 'ig' ris> of stenosis it' a s$bclavian approac'""2

• These catheters differ from other CVCs in the folloing respects,

o 2arger lumen siLe compared to ot'er CVCs2

o The internal tip of the catheter is designed differentl" so as to allo blood to be

it'dran freely via one l$men and ret$rned via t'e ot'er l$men donstream of t'eblood being it'dran (t'$s avoiding recirc$lation of t'e treated blood)2 Conf$singly0t'e l$mens are often colo$r=coded red and bl$e and referred to as t'e JarterialK andJveno$sK l$mens2 In fact bot' l$mens lead into a vein and not an artery2

o In all settings these catheters are locDed %eteen uses ith an exact

volume of solution usuall" TaurolocD or rarel" concentrated heparin solution tominimise t'e ris> of occl$sion and line colonisation2 +'is varies depending on t'e patientsclinical stat$s and local g$idelines2 If a loc> is $sed a red b$ng m$st be $sed to signify t'att'e loc> m$st be it'dran from t'e cat'eter before $se ot'erise t'e patient ill receivean $nanted dose of t'e loc>ing sol$tion or emboli of clotted blood2

o -urther advice on the care and management of renal lines can %e o%tained from

the 'enal Vascular Access Nurse Specialist on 1leep ;;;+ or 'enal registrar on?call)

Accessing the Catheter 2ocDing solutions ill vary according to local g$idelines and practices (DCC +a$roloc>g$ideline)2

• If TaurolocD or a concentrated solution of heparin is used to locD the catheter

ala"s remove indelling solution by it'draing and discarding at least t'e vol$me oft'e l$men before accessing t'e cat'eter2

• If ithdraal is not possi%le or there are other patenc" pro%lems,

o -ee Management of Complications

-lushing• Techni.ue,

o :ris> p$s'=pa$se tec'ni$e it' positive press$re finis'

• -lushing %eteen incompati%le drugs infusions,

o 8l$s' it' #26 sodi$m c'loride (if sodi$m c'loride #26 incompatible $se

s$itable alternative)2

• -lushing after use:

o -lush %oth lumens ith (;ml ;)9@ sodium chloride in (;ml s"ringes $sing

a p$s'=pa$se tec'ni$e0 t'en loc> according to local g$idelines and practices2

• $nused lumens,



o -lush at least eeDl", it'dra and discard if necessary (as above)0 t'en fl$s'

it' 1#ml #26 sodi$m c'loride and loc> according to local g$idelines andpractices2

Exit Site Care•

Securement,o 8olloing removal of s$t$res for t$nnelled lines no sec$rement device is needed2

• Sutures:

o Tunnelled catheters,

*<it site, remove at "1 days

Venep$nct$re site, emove s$t$res or -teristrips at 4 days ($nless dissolvable)o Non?tunnelled catheters,

Beave in place as long as t'e cat'eter is in sit$

• Cleaning:

o ;se sol$tions as per /esse< enal ;nit g$idelines $sing an o$tard spiral motion to

avoid transferring bacteria to t'e e<it site2

• !ressings:o Dressings as for Non=t$nnelled or +$nnelled CVCs0 'ic'ever applies $sing eit'er

+egaderm C!7 dressing ot a non=occl$sive dressing and a :iopatc' C!7 impregnatedfoam dis> dressing2

• 1athing shoering H simming

o As for Non=t$nnelled or +$nnelled CVCs0 'ic'ever applies2

Patient Education• If patient is discharged ith catheter in situ

o 2iaise ith the 'enal Vascular Access Nurse Specialist on 1leep ;;;+)

o Ideally0 teac' patient to care for t'eir on cat'eter

o efer to Comm$nity N$rsing -taff for ongoing care if necessaryo Provide to ee>s dressing and fl$s'ing s$pplies


o *ns$re patient >nos to report any complications and 'as contact n$mber for t'is

p$rpose2

'emoval• As for tunnelled or Non?tunnelled catheters0 'ic'ever applies2



(vi) Care in Neonates

&eneral Points• There are to main t"pes of CVC $sed in neonatal care,

o PICCs (also >non as long lines9 and

o Tunnelled CVCs (also >non as #ickman lines)2

• !o not use CVCs for blood sampling (e<cept blood c$lt$res), $se perip'eral or arterial

access instead2

• !o not use flash%acD of %lood to assess patency of CVC e<cept immediately folloing

insertion

-lushing• ;)0?(ml ;)9@ ;),0@ sodium chloride beteen incompatible dr$gs @ inf$sions (if sodi$m

c'loride #26 @ #2& incompatible $se s$itable alternative)2

• After %lood sampling fl$s' cat'eter straig't aay it' 1="ml #26 @ #2& sodi$m

c'loride2

Exit Site Care• Sutures (if any),

o Beave in sit$ as long as t'e cat'eter is needed2

• !ressings,

o Beave dressings $ndist$rbed in order to avoid tra$ma to t'e babys s>in2

• Cleaning,

o If any cleaning is deemed necessary0 $se only sterile ga$Le and sterile #26 sodi$m

c'loride $sing gentle o$tard single=sipe motion to avoid transferring bacteria to t'ee<it site2 edress e<it site2

'emoval• 3ho can remove neonatal CVCs

o Tunnelled CVCs <ie /icDman lines=: emoved by Medical -taff2

o PICCs: #ust onl" %e removed %" competent #edical Staff) Proced$re,

ChecD the %a%"Js coagulation status2 If t'ere is an increased ris> of bleedingdisc$ss it' medical team before proceeding2

1e aare t'at t'e ris> of air embolism increases if t'e baby is de'ydrated or 'as aco$g'2

Arrange %a%" so the PICC exit site %elo the level of the heart (t'is ill 'elpprevent air embolism)

'emove the dressing 9 any stitc'es2

Pull PICC out slol" and gently an inc' or to at a time2 As eac' inc' goes byc'ange t'e position of yo$r 'and so t'at yo$r fingers are close to t'e e<it site2 +'isill red$ce t'e li>eli'ood of t'e cat'eter brea>ing2

If "ou meet resistance STOP2 esistance may be d$e to venospasm2 If t'is'appens0 ait min$tes before res$ming2

Once PICC is out apply gentle press$re to e<it site it' sterile ga$Le $ntil bleedingstops2

ChecD the length of the internal portion of t'e cat'eter and compare to t'erecorded lengt'2 If yo$ s$spect t'ere is a portion of t'e cat'eter left in t'e baby0inform senior medical staff immediately2

Send tip of line to #icro%iolog": use sterile scissors to cut off the tip of the

catheter and it'o$t contaminating it drop it into a dry sterile specimen pot2Appl" gauLe dressing2



#anagement of Complications

Page "5 Pyre<ia

Page "5 Inflammation @ tenderness at e<it sitePage "5 No flas'bac> of blood (b$t line fl$s'es ell)Page "6 Cat'eter sl$ggis' @ intermittent free flo of fl$idsPage "6 Cat'eter completely bloc>edPage "6 Pain @ visible selling @ lea>age 'en cat'eter $sedPage 3# Bea>age from e<ternal portion of cat'eter Page 3# C$ff protr$des from e<it site (t$nnelled cat'eters)Page 3# Increase in e<ternal lengt' of a PICCPage 3# -elling of s'o$lder @ nec> @ arm or facePage 31 Pain @ armt' @ 'ardness @ redness along vein pat' (PICCs)Page 31 Cardiop$lmonary symptoms

Page 31 Palpitations @ Abnormal *C7



P"rexia pl$s or min$s, rigor after fl$s'ing0 sore t'roat0 generally feeling $nell0 'ypotension0tac'ycardia0 s'oc>0 e<it site @ t$nnel infection

• Possi%le cause:

o Cat'eter elated :lood -tream Infection

• #anagement:

o 'efer to IV Team medical staff 2 May be treatable it'o$t cat'eter removal

depending on patients clinical stat$s and colonising organism2o TaDe %lood cultures if TempM+7); from each lumen and peripherall"2 8ollo P!+

P'lebotomy Policy 'en ta>ing blood c$lt$res2 (Neonates and Paediatrics, only ta>eperip'eral blood c$lt$res if re$ested by Microbiology@Medical +eam)2

o TP' H 1P) 8re$ency ill depend on patients clinical stat$s2

o If there are signs of exit site infection see belo2

Inflammation and tenderness at t'e e<it site @ s>in t$nnel @ port poc>et pl$s or min$s e<$date

• Possi%le cause:

o Infection

• #anagement:o TaDe a sa%

o 'efer to IV Team medical staff) May resolve it' antibiotics0 especially in t$nnelled

cat'eters and PICCs2 (:$t N: infections involving t'e s>in t$nnel above t'e c$ff or aport poc>et are very diffic$lt to treat Do not access in Paediatrics2)

o In Neonates0 CVC ill probably need to be removed2

o Increase fre.uenc" of dressing change H cleaning depending on amo$nt of

e<$date)o , hourl" TP' H 1P if patient in 'ospital2

No flash%acD of %lood at ever" use b$t cat'eter fl$s'es ell it' no pain2 (Not Neonates)

• Possi%le causes:

o Clotted blood in cat'eter

o 8ibrin s'eat'

o Malpositioned cat'eter

o :$ild $p of lipids (Parenteral N$trition)

o Dr$g Precipitation

• #anagement:

o Tr" asDing patient to taDe deep %reath and try different positions2 -lush %risDl" $sing

"#ml sodi$m c'loride2 In a recently inserted line0 c'ec> t'e position of t'e line on O=ray toens$re t'e end is not against a 'eart valve or 'as not moved2 If position satisfactory0 t'eproblem may be d$e to a very small clot at t'e end of t'e line acting as a ball valve2

o If this fails to restore flash%acD use a throm%ol"tic eg ;ro>inase ### $nits in "ml per

l$men (see "sing Throm#olytics page "6) e<cept Paediatrics Neonates 9 Dialysispatients, follo local g$idelines2

o If "ou have no time to ait for throm%ol"tic to orD yo$ can still $se t'e cat'eter0 b$t

not if yo$ are giving vesicants @ irritant dr$gs2 8irst test t'e cat'eter it' "#ml #26sodi$m c'loride over 1 min$tes (#1##ml in Paediatric patients)2 Arrange t'rombolyticas soon as practicable2

o If throm%ol"tic fails see "sing Throm#olytics (page "6)2

http://www.porthosp.nhs.uk/Clinical-Policies/Phlebotomy%20and%20Venous%20blood%20sampling%20Policy.doc







Catheter is sluggish or t'ere is only intermittent free flo of fl$ids2



o Malpositioned cat'eter


o Dr$g Precipitationo Pinc' off syndome

o N1: In Implanta%le Ports needle may be incorrectly positioned, c'ec> before ta>ing

any ot'er action2

• #anagement:

o Tr" asDing patient to taDe deep %reath and try different positions2 -lush %risDl"

$sing "#ml sodi$m c'loride2 If this fails to restore function flash%acD use athrom%ol"tic eg ;ro>inase ### $nits in "ml per l$men (see "sing Throm#olyticspage "6) e<cept Paediatrics0 Neonates 9 Dialysis patients, follo local g$idelines2

o If throm%ol"tic fails see "sing Throm#olytics (page "6)2

Catheter is completel" %locDed2




o Dr$g Precipitation

o N1: In Implanta%le Ports needle may be incorrectly positioned, c'ec> before ta>ing

any ot'er action2 Consider $sing ne needle2

• #anagement:

o Consider c'anging b$ng@needle=free device

o $se +?a" tap techni.ue to instil t'rombolytic into cat'eter (see "sing

Throm#olytics page "6) e<cept Paediatrics0 Neonates 9 Dialysis patients, follo localg$idelines2

o If lipids drug precipitation suspected cons$lt p'armacy advice for s$itable agent

to dissolve occl$sion2 ;se 3=ay tap tec'ni$e to instil into cat'eter (see "singThrom#olytics page "6)2

Pain or visi%le selling 'en cat'eter is $sed or fl$id lea>s from e<it site 'en cat'eter isfl$s'ed2


o Malposition of cat'eter

o Internal cat'eter fract$re

o 8ibrin -'eat'

o -eparation of port and cat'eter (Implantable ports)

o N1: In Implanta%le Ports needle may be incorrectly positioned, c'ec> before ta>ingany ot'er action2

• #anagement:

o 'efer to IV Team medical staff , a malpositioned cat'eter s'o$ld $s$ally be

removed2 Internal fract$re cannot be repaired2 If t'ere is a fibrin s'eat' severe eno$g'to ca$se lea>age t'e cat'eter ill $s$ally be removed2

o Neonates: refer to Plastic -$rgeon if e<travasation occ$rs2

o Chemotherap", follo Cytoto<ic Policy if e<travasation occ$rs2

o If catheter is fractured or fault" complete Adverse Incident -orm and retain t'e

cat'eter to send to IV +eam for ret$rn to man$fact$rer2



2eaDage from external portion of catheter 'en fl$s'ed2

• Possi%le cause:

o *<ternal cat'eter fract$re@ damage to e<ternal sitc' mec'anism2

• #anagement:

o Clamp catheter above lea> to prevent air entry2o Paediatrics follo /esse< Paediatric ?ncology 7$idelines regarding prop'ylactic

antibiotics2o Catheter must %e repaired or removed as soon as possi%le contact the IV

Team medical team2 -ome cat'eters can be repaired if e$ipment 9 e<pertiseavailable2 +'e advisability of repair ill depend on t'e patients clinical stat$s as itcarries a ris> of infection2

o Complete Adverse Incident -orm and retain t'e cat'eter if removed to send to IV

+eam for ret$rn to man$fact$rer2

Cuff protrudes from exit site (t$nnelled cat'eters)

•

Possi%le cause:o +iss$es it'in t$nnel 'ave failed to ad'ere to c$ff 9 cat'eter 'as migrated o$t2

• #anagement:

o Stop any inf$sions

o Tape catheter firmly to s>in at e<it site

o 'efer to medical staff for cat'eter removal2

Increase in external length of a PICC

• Possi%le cause:

o PICC 'as migrated o$t

• #anagement:

o !o NOT push the catheter %acD in

o Neonates: disc$ss action it' medical team2

o Other patients:

If PICC has come out %" less than *cm no action needed2

If PICC has come out %" more than *cm refer to specialist team 'o insertedt'e PICC2 *<amination of t'e post=insertion CO may reveal 'et'er or not t'e tipis li>ely to still be in an acceptable place2 ?t'erise a CO ill need to be carriedo$t to c'ec> tip position2

If PICC has come out %" more than (;cm t'e PICC s'o$ld be sec$red and not$sed and t'e IV Team contacted to replace it over a g$ideire at earliestopport$nity2

Selling of shoulder necD arm or face0 it' or it'o$t pain0 inflammation0 distension of nec>veins@perip'eral vessels

• Possi%le cause:

o +'rombosis2

o -$rgical (s$bc$taneo$s) *mp'ysema2

• #anagement:

o 'efer to IV Team medical staff for investigation of s$spected t'rombosis or s$rgical

emp'ysema2 It may or may not be possible to treat t'rombosis it'o$t cat'eterremoval2

o +'rombosis and infection often occ$r toget'er so %lood cultures ma" %e necessar"

if signs of sepsis present)



Patient ith PICC develops pain armth hardness and redness confined topat' of vein2

• Possi%le cause:

o Mec'anical (or Infective) P'lebitis

o +'rombosis

• #anagement:

o 'efer to IV Team or medical staff for investigation of s$spected

t'rombosis (and@or infection)2 It may be possible to avoid cat'eterremoval2

o In meantime0 it may be ort' trying 'eat pac>s0 gentle arms e<ercises0

N-AIDs (i2e2 ib$profen0 diclofenac) and elevation of t'e arm2 +'esesometimes resolve symptoms it'in "& 'rs2

o 8or a heat pacD $se "#ml bag of #26 sodi$m c'loride t'at 'as beenremoved from o$ter pac>aging and 'eated for s'ort (1 second) b$rsts(# seconds ma<im$m) in a microave $ntil arm b$t not too hot toplace on tender sDin 8 test on on forearm) 7et patient to 'old overaffected area $ntil bag cooled2 epeat +D- $sing a ne $nopened bageac' time to prevent ris> of infection2

Cardiopulmonar" s"mptoms including an" of the folloing: respiratory distress @fail$re apnoea0 red$ced o" sat$ration levels0 tac'ycardia0 bradycardia0 'ypotension0pallor0 cyanosis0 an<iety0 c'est pain0 loss of conscio$sness


o Pne$mot'ora<

o Air or cat'eter embolism

o P$lmonary embolism

o Cardiac tamponade @ pericardial eff$sion

• #anagement:

o Call for medical assistance @ ?$treac' @ res$scitation team

o Administer O*

o #onitor vital signs

Palpitations A%normal EC& immediatel" post line placement


o Cardiac arr'yt'mias related to CVC tip placement

• #anagement:

o Call for urgent medical assessment

o #onitor vital signs

o PICCs: P$lling PICC o$t by "cm may resolve t'e problem immediately2



Appendi# V$ %sin" T&rombolyti!s

/'at is a t'rombolyticQPage 33 /'en s'o$ld yo$ $se a t'rombolyticQPage 33 /'at if t'e t'rombolytic fails to restore f$nctionQPage 33 !o to $se a t'rombolyticPage 3& ;sing a +'rombolytic in a Completely :loc>ed Cat'eter



3hat is a throm%ol"tic

• A t'rombolytic is a dr$g capa%le of %reaDing up a throm%us2

•$roDinase is t'e most common t'rombolytic $sed for $nbloc>ing CVCs in P!+, $se ### $nits

in "ml per l$men2

• A t'rombolytic m$st alays be prescri%ed2

•/eparin and /epsal are NOT throm%ol"tics, t'ey are capable only of in'ibiting t'romb$s

formation2

3hen should "ou use a throm%ol"tic

?$tside of specialist areas or if yo$ 'ave not $sed a t'rombolytic before please contact t'eIV +eam on :leep 1&6&2

;se a t'rombolytic to improve patency in t'e folloing sit$ations,o flas'bac> of blood is absent

o free=flo of fl$ids is sl$ggis' or intermittent

o resistance is felt 'en fl$s'ing

o t'e cat'eter@l$men is completely bloc>ed

3hat if the throm%ol"tic fails to restore function

• If failure to %leed %acD is the ON2 pro%lem t'en yo$ can $se t'e cat'eter b$t a C'est O=ay

s'o$ld be carried o$t as soon as practicable to c'ec> t'e position of t'e line2 !oever0 if yo$ aregiving irritant @ vesicant medication0 yo$ s'o$ld test t'e cat'eter first by inf$sing "#ml#26sodi$m c'loride over 1 min$tes (# 1##ml in Paediatrics) and c'ec> position on C'est<=ray2 If t'e patient e<periences no discomfort d$ring t'is time and t'ere are no ot'ercomplications0 yo$ can proceed2

• If free?flo of fluids is still sluggish or intermittent or if resistance is still felt hen

flushing despite $se of a t'rombolytic a C'est O=ay R@= contrast s'o$ld be carried o$t to c'ec>for malposition or >in>ing of t'e cat'eter2

•2ine ma" need replacing)

/o to use a throm%ol"tic

a) Arrange prescription) (Ca$tion if patients clotting is severely deranged or if 'ig' doses of ananticoag$lant are being given conc$rrently2)

b) !ra up the throm%ol"tic as per manufacturerJs instruction eg for ;ro>inase, reconstit$te"0### $nit vial it' "ml ater for in%ection and dil$te f$rt'er to 1# ml2 ;se "ml (### $nits)per l$men2

c) Instil the throm%ol"tic into the catheter and ait (?* hours2 :$t note t'at if t'e l$men iscompletely bloc>ed do N?+ force t'e t'rombolytic into t'e cat'eter, see "sing aThrom#olytic in a Completely $loc%ed Catheter (page 31)2

d) Assess the catheter again) N: if t'e t'rombolytic cannot be it'dran dont orry, t'esevery small dose can be fl$s'ed into t'e patient it'o$t danger $nless t'e patient 'as severelyderanged clotting or is on 'ig' doses of an anticoag$lant2

e) If full function has not returned instil t'e t'rombolytic again and leave in for longer several'o$rs or overnig't if possible2

f) If the procedure fails to restore function consider 'et'er lipids @ dr$g precipitation co$ldbe ca$sing a bloc>age2 If not0 refer to medical staff, C'est O=ay may reveal malpositioned or

cat'eter2



$sing a Throm%ol"tic in a Completel" 1locDed Catheter )

<a= Attach +?a"?tap H s"ringes !iagram ()see rig't2 (available from DCC@CC;) Three?a" Tap Techni.ue<%= Open clamp (if t'ere is one)2<c= Open stopcocD to t'e emptysyringe and t'e bloc>edcat'eter2<d= Pull %acD on the plunger of the empt" s"ringe to createa vacuum in the catheter)

Eo$ ill need to p$ll $iteforcibly2<e= #aintain suction ith onehand and ith the other hand turn stopcocD so it isclosed to t'e empty syringe andopen to t'e syringe containingt'rombolytic0 'ic' ill bes$c>ed into t'e cat'eter2 Dontorry if it seems t'at very littlet'rombolytic is s$c>ed in, evena tiny vol$me ill reac' severalcm into t'e cat'eter2<f= 2eave for (?* hours) D? N?+CBAMP CA+!*+* as t'is ill prevent t'e t'rombolytic from penetrating into t'e line2<g= After this time attempt ithdraal of %lood) If t'is is not possible0 attempt to fl$s' t'ecat'eter $sing #26 -odi$m c'loride in a 1#ml syringe2 Do not $se e<cessive force2<h= This procedure often needs to %e repeated several times %efore it orDs:sometimes leaving t'e t'rombolytic in overnig't seems to 'elp12 Dont orry abo$toverdosing t'e patient, if t'e cat'eter is bloc>ed t'ey ont act$ally 'ave received any of t'edr$g2<i= If the procedure fails despite repeated attempts cons$lt IV or medical team it' a vieto removing t'e cat'eter2

Appendi# VI$ 'lossary of Compli!ations



<i= Pneumothorax A pne$mot'ora< is t'e presence of air in t'e ple$ral space beteen t'e l$ngs and t'e c'est all2 Itcan occ$r d$ring t'e insertion of a CVC 'en a needle $sed to access t'e s$bclavian or %$g$larveins inadvertently p$nct$res t'e l$ng2 +'e person inserting t'e cat'eter is not alays aare t'att'is 'as 'appened0 so it is essential to screen for pne$mot'ora< by carrying o$t a ro$tine CO fo$r'o$rs after insertion2

A pne$mot'ora< may be clinically silent and only noticed on t'e ro$tine O=ay0 or may leadto a life=t'reatening emergency sit$ation it' respiratory distress0 red$ced o<ygen sat$rationlevels0 tac'ycardia or 'ypotension2 A small pne$mot'ora< may resolve spontaneo$sly2 In severecases a c'est drain may be necessary2

<ii= InfectionInfection is t'e most common complication associated it' central veno$s access3 and one of t'emost serio$s3 it' estimated mortality rates ranging from 1 3342

Contamination can occ$r d$ring insertion of t'e CVC or at a later stage via t'e 'ands of 'ealt'careor>ers0 or transferred from t'e patients s>in or ot'er anatomical sites2 Infection may be relatively

minor or may be life=t'reatening2

:acteria can colonise a CVC eit'er on its e<terior or interior s$rface, i2e2 colonisation is eit'erextral$minal or intral$minal2 Extral$minal infections $s$ally begin at t'e e<it site and may remainconfined to t'at area or may trac> along t'e cat'eter into t'e bloodstream2 Intral$minal infectionsare ca$sed by contamination via t'e '$b of t'e cat'eter 352

*<it site infections can often be treated s$ccessf$lly it' antibiotics0 especially in t$nnelled CVCs'ere t'e vein and t'e e<it site are separated by t'e t$nnel2 In non=t$nnelled centrally insertedCVCs0 'oever0 treatment is less li>ely to be s$ccessf$l0 as t'ere is less distance beteen t'e e<itsite and t'e blood stream112 :y t'e same to>en0 infections in t$nnelled CVCs involving t'e s>int$nnel itself above t'e c$ff are notorio$sly diffic$lt to treat and t'e same applies in implantable

ports 'ere t'ere is infection of t'e port poc>et2

+'e ris> of infection can be red$ced by strict ad'erence to Aseptic +ec'ni$e2 Intraveno$s t$bingand stopcoc>s s'o$ld be c'anged according t'e P!+ Intraveno$s +'erapy 7$idelines2 IfParenteral N$trition is to be given0 one l$men s'o$ld be $sed e<cl$sively for t'is p$rpose (e<ceptNeonates)2

<iii= Throm%osis+'rombosis occ$rs 'en a clot develops it'in t'e vein aro$nd t'e cat'eter2 ;nless t'e clot is att'e internal tip of t'e cat'eter0 it ill not $s$ally affect t'e patency of t'e cat'eter2 +'rombosisformation is a nat$ral response to vasc$lar in%$ry2 Damage to t'e vessel all can occ$r d$ringcat'eter insertion0 or may be d$e to mec'anical or c'emical irritation in an incorrectly placed

cat'eter e2g2 'ere t'e tip of t'e cat'eter is in too small a vein0 or r$bbing against t'e vein allinstead of floating parallel to it"#2

+'e ris> of t'rombosis is increased in patients 'o are pregnant or immobile or 'o 'ave diabetesor cancer2 -$rgery0 c'emot'erapy0 'ormonal agents0 'aemodialysis and CVC=related infection areall t'o$g't to be ris> factors130"50360&#2 It $sed to be t'o$g't t'at minidose /arfarin mig't red$ce t'eris> of t'rombosis in Cancer patients0 b$t t'is 'as recently been disproved"2

Patients 'o develop t'rombosis are at increased ris> of p$lmonary embolism and infection362 A large proportion of patients it' CVCs 'ave t'romboses 'ic' are never detected&10&"2 /'en at'rombosis does become symptomatic0 it ill $s$ally ca$se selling of t'e arm0 nec> and @ or face2+'ere may be associated pain0 tingling or n$mbness0 distended nec> or perip'eral veins &30&&2 +'epresence of a t'rombosis can $s$ally be confirmed by $se of Doppler $ltraso$nd2



;nless t'e cat'eter is incorrectly positioned0 it is often possible to treat a t'rombosis $singanticoag$lants it'o$t removing t'e cat'eter2 +'is is probably t'e best co$rse of action for apatient 'o still re$ires a CVC0 beca$se ta>ing t'e cat'eter o$t ill e<pose 'im@'er to t'e addedris>s of anot'er cat'eter insertion0 incl$ding0 of co$rse0 t'rombosis2

<iv= #echanical Phle%itis <PICCs=In PICC patients so=called Jmec'anical p'lebitisK is a ell=>non complication in t'e first 1# daysfolloing insertion0 partic$larly in PICCs placed in t'e crease of t'e elbo2 *<perience in t'is +r$sts$ggests t'at it seems to be m$c' less li>ely in PICCs placed above t'e elbo2Mec'anical p'lebitis is probably ca$sed by damage to t'e vein d$ring insertion and movement oft'e cat'eter it'in t'e vein&2 +'e patient develops Jpain0 redness0 armt'0 veno$s cord (a 'ard0palpable0 t'rombosed vein)0 ind$ration and sellingK along t'e pat' of t'e vein140 $s$ally it'in 1&days of PICC insertion2 JMec'anical p'lebitisK probably represents t'e first stages of t'rombosisdevelopment b$t it' caref$l management $sing 'eat to dilate t'e vein0 gentle e<ercises andelevation of t'e arm may resolve t'e problem before a t'rombosis occ$rs2 It is possible t'atapplying 'eat to t'e $pper arm and ens$ring ade$ate 'ydration d$ring t'e first 1& days folloingPICC insertion may red$ce t'e ris> of mec'anical p'lebitis&2 +'is does not seem to be necessary

it' PICCs placed above t'e elbo2

<v= Air Em%olism An air embolism is a potentially fatal complication2 It can 'appen at any stage if air is alloed toenter t'e cat'eter eg if a cat'eter is left $nclamped 'en t'e cap is removed b$t is most li>elyto occ$r d$ring t'e insertion or removal of t'e cat'eter2 +'e ris> is increased if t'e patient isde'ydrated0 is $nable to lie flat0 or 'as an $ncontrolled co$g' at t'e time of insertion or removal2 As it' pne$mot'ora<0 air embolism may be clinically silent or may be accompanied by any or allof t'e folloing, an<iety0 cyanosis0 dyspnoea0 tac'ycardia0 'ypotension0 c'est pain0 loss ofconscio$sness and deat'2

<vi= Cardiac Arrh"thmias Atrial or ventric$lar arr'yt'mias can occ$r 'en t'e tip of t'e CVC is placed it'in t'e 'eart60&0&42In practice0 CVC tips correctly placed in t'e rig't atri$m rarely ca$se arr'yt'mias2 PICCs areprobably most li>ely to ca$se problems beca$se t'e PICC can move f$rt'er into t'e 'eart as t'epatient moves 'is @ 'er arm2 Arr'yt'mias ca$sed in t'is ay ill $s$ally resolve 'en t'e cat'eteris p$lled bac> by a fe centimetres2 Any patient e<periencing palpitations or arr'yt'mias s'o$ld beassessed by a medical team as soon as possible2

<vii= Cardiac Tamponade+'is is a rare complication of CVCs0 seen mainly in neonates2 Cardiac tamponade arises 'enfl$id (in t'is case blood) acc$m$lates in t'e pericardial space aro$nd t'e 'eart and impairs cardiacf$nction2 +'is is a catastrop'ic0 often fatal event2 +'e patient is li>ely to e<'ibit a s$dden onset of

severe cardiorespiratory symptoms2 Cardiac tamponade can arise in a patient it' a CVC if t'e'eart is p$nct$red eit'er d$ring insertion or s$bse$ently by a malpositioned cat'eter2

<viii= Patenc" ImpairmentPatency s'o$ld be considered to be impaired in any of t'e folloing sit$ations,+'e cat'eter is completely bloc>ed and cannot be fl$s'ed at all2+'e cat'eter can be fl$s'ed $sing a syringe b$t t'ere is sl$ggis'0 absent or intermittent free=flo'en inf$sion of fl$ids by gravity is attempted2



+'e cat'eter fl$s'es easily b$t aspiration of blood is sl$ggis' or absent2Patency problems s'o$ld be ta>en serio$sly2 Ignoring t'e early signs may lead to t'e developmentof more serio$s problems it' cannot t'en be easily rectified eg complete bloc>age ort'rombosis"52+'e ca$ses of patency problems incl$de

Clotted %lood ithin the catheter , +'is can be avoided by good fl$s'ing tec'ni$es as described

in t'ese g$idelines2 /'en problems do arise0 t'ey can $s$ally be solved relatively easily by $se ofa t'rombolytic s$c' as ;ro>inase, see "sing Throm#olytics (page "6)2

-i%rin Sheath, 8ibrin s'eat's are t'o$g't to occ$r in most CVCs left in place for over 4 days&52 Afibrin s'eat' is a >ind of sleeve made of a fibro$s collagen s$bstance 'ic' can form aro$nd t'ecat'eter it'in t'e blood stream2 It may e<tend to form a >ind of Jsoc>K protr$ding beyond t'e tip oft'e cat'eter0 and if t'is 'appens it may impair t'e patency of t'e cat'eter, most commonly it illprevent blood from being it'dran from t'e cat'eter beca$se t'e fibrin s'eat' is s$c>ed againstt'e tip of t'e cat'eter2 In severe cases a fibrin s'eat' may also lead to bac>trac>ing of inf$sedfl$ids beteen t'e fibrin s'eat' and t'e cat'eter0 ca$sing lea>age of t'ose fl$ids into t'e tiss$es&628ibrin s'eat's are associated it' an increased ris> of infection# as t'ey provide an ideal medi$mfor t'e proliferation of bacteria2

#echanical o%struction, A mec'anical obstr$ction can occ$r internally or e<ternally2 Internalobstr$ction may be d$e t'e cat'eter being incorrectly positioned, e2g2 t'ere is an internal >in> ort'e tip of t'e cat'eter is resting against a vessel all rat'er t'an floating free it'in t'ebloodstream (see Incorrect !osition belo)2 +'is mig't be beca$se of poor insertion tec'ni$e0or it mig't be t'at t'e cat'eter as p$t in correctly b$t 'as s$bse$ently become dislodged2 Asimple C'est O=ay ill often reveal an incorrectly positioned cat'eter2 *<ternal >in>ing of t'ecat'eter can also ca$se patency problems, its ort' c'ec>ing for a bra=strap or an over=tig't stitc'before loo>ing for a more complicated ca$seS

1uild up of lipids from parenteral nutrition or drug precipitation it'in t'e cat'eter ca$sed by

too 'ig' a concentration or incompatibility of dr$gs, If t'is appears to be a li>ely ca$se of occl$sion0cons$lt Medical@P'armacy advice for a s$itable agent to dissolve occl$sion2

<ix= Incorrect Position A CVC s'o$ld be considered to be in an incorrect position 'en any of t'e folloing apply,

+'e tip is not in t'e ig't Atri$m0 t'e -$perior Vena Cava or t'e Inferior Vena Cava2+'e tip of t'e cat'eter is not floating freely parallel to t'e vein all2+'e cat'eter is >in>ed it'in t'e body or pinc'ed beteen internal str$ct$res2

Incorrect position may be t'e res$lt of poor insertion tec'ni$e or may occ$r spontaneo$sly in aprevio$sly ell=positioned cat'eter2 It is not $n>non for a CVC to JmigrateK it'in t'e veno$s

system for no apparent reason2 !adaay reports t'at JC'anges in intrat'oracic press$re0co$g'ing0 sneeLing0 Valsalva manoe$vre s$c' as d$ring 'eavy lifting0 vigoro$s e<tremity $se0forcef$l fl$s'ing0 or congestive 'eart fail$re co$ld lead to migration of t'e tipK"52 In addition t'ecat'eter may become dislodged if it is not correctly sec$red in place0 or is accidentally p$lled2

If a CVC is incorrectly positioned t'ere is a 'ig' ris> of t'rombosis and patency impairment"#012 If itis >in>ed internally t'ere is also t'e ris> t'at t'e cat'eter may split0 leading to e<travasation ofdr$gs @fl$ids and in serio$s cases0 embolisation of t'e cat'eter itself2Eo$ s'o$ld s$spect incorrect position if t'ere are patency problems despite t'e $se of at'rombolytic0 if t'e patient complains of pain on fl$s'ing0 if t'e e<ternal lengt' of t'e cat'eterincreases0 if t'e patient develops a t'rombosis0 or if t'e c$ff of a t$nnelled CVC protr$des from t'ee<it site"2



A malpositioned0 >in>ed or pinc'ed cat'eter s'o$ld be repositioned0 replaced or removed as soonas practicable (e<cept PICCs and in Neonates in certain sit$ations disc$ssed belo)2 Beaving it inplace for any lengt' of time represents a 'ig' ris> of t'rombosis and@or cat'eter fract$re @embolism2

Immediately folloing insertion0 PICCs are sometimes fo$nd on O=ray to 'ave fed $p into t'e

%$g$lar vein0 across into t'e opposite s$bclavian0 or bac> don an arm vein2 In t'ese cases it maybe ort' leaving t'e PICC in overnig't or fl$s'ing bris>ly it' "#ml #26 sodi$m c'loride and t'enrepeating t'e O=ray as t'e PICC ill often move into t'e -$perior Vena Cava30&2 Disc$ss it' t'eperson inserting t'e PICC and patients medical team2

N: In Neonatal care if a PICC 'as become displaced it may sometimes be appropriate to leave t'ecat'eter in sit$ and $se as a perip'eral cat'eter2 Disc$ss it' t'e babys medical team2

<x= Extravasation of -luids !rugs due to Incorrect Needle Position or Needle!islodgement <in Implanta%le Ports=+'e non=coring needle s'o$ld be correctly placed into t'e port (Diagram )2 If t'e needle is not

inserted far eno$g' into t'e port or if t'e needle misses t'e port altoget'er fl$ids@dr$gs may beinf$sed into t'e s$bc$taneo$s tiss$es2

+'e needle may become dislodged if it is inade$ately sec$red it' dressing tape0 if t'ere istension on t'e e<tension t$bing or if t'e needle $sed is of ins$fficient lengt'0 ca$sing t'e patientHsnormal movements to loosen t'e needle2 +'e problem ill $s$ally be noticed 'en t'ere isdiscomfort and@or oedema at t'e entry site combined it' lac> of free=flo of fl$ids2

If e<travasation 'as occ$rred or is s$spected0 t'e needle s'o$ld be removed and a fres' needle$sed to access t'e port correctly2 If vesicant or irritant sol$tions (e2g2 c'emot'erapy) aree<travasated0 see> medical @ p'armacy advice and refer to t'e P!+ Policy Cytoto<ic *<travasation+reatment 2

<xi= Catheter -racture+'is may occ$r externall" or internall" and may res$lt from over=forcef$l fl$s'ing0 tra$ma to t'ecat'eter or incorrect position (e2g2 >in>ing leading to ear=and=tear)2

An external fract$re ill res$lt in lea>age of blood or fl$ids from t'e cat'eter2 -ometimes t'ere isan obvio$s fract$re2 +'e line m$st be clamped or folded over on itself immediately to prevent airembolism2 -ometimes t'e cat'eter can be repaired or replaced over a g$ideire b$t t'eadvisability of t'is ill depend on t'e patients clinical stat$s2 In addition0 $nless t'e correcte$ipment and e<pertise are available for a repair to be carried o$t0 t'e cat'eter s'o$ld beremoved immediately0 as t'ere is a 'ig' ris> of infection and air embolism2

Internal fract$re ill $s$ally res$lt in patency impairment and @ or pain0 redness and selling 'ent'e cat'eter is fl$s'ed2 +'ere is a ris> t'at t'e cat'eter itself ill embolise2 If t'is occ$rs t'ere maybe no symptoms at all or t'ere may be signs of p$lmonary embolism2 ie ac$te onset of any or all oft'e folloing = an<iety0 pallor0 cyanosis0 s'ortness of breat'0 rapid ea> p$lse0 'ypotension0 c'estpain0 loss of conscio$sness2

<xii= Separation of port and catheter <in Implanta%le Ports=+'is is rare b$t s'o$ld alays be considered 'en problems arise it' patency of t'e port ort'ere is *<travasation it' associated discomfort and oedema despite proper position of needle2 As it' cat'eter fract$re (see (<i) above) t'ere is a ris> t'at t'e cat'eter may embolise2 -$rgicalremoval or repair of t'e port and cat'eter is essential if separation is confirmed2

<xiii= Surgical <Su%cutaneous= Emph"sema



If air enters t'e tiss$es of t'e body0 partic$larly in t'e loose cell$lar tiss$e immediately $nder t'es>in0 its presence is detected by a crac>ling sensation as t'e s>in s$rface is palpated2 +'e area ofs$rgical emp'ysema may spread it' alarming rapidity beneat' t'e s>in over t'e c'est0 e<tendingell $p into t'e nec> and don onto t'e abdominal all2

-$rgical emp'ysema $s$ally occ$rs after an invasive proced$re and is a rare b$t distressingcomplication of CVC placement2



Appendi# VII$ eferen!es

1 Mayo DT J !dministering ErokinaseF Clearing the 6ay K N$rsing65 December

" Vesely0 +2 JCentral &enous Catheter Tip ositionF ! Continuing Controversy K To$rnal of Vasc$lar and Interventional adiology0 Vol$me 1&() May "##30 pp "4=3&

3 acadio0 TM0 Doellman DA0 To'nson ND0 :ean TA0 Tacobs :2 Jediatric eripherally Inserted Central CathetersF Complication 0ates 0elated To Catheter Tip %ocation2K Pediatrics2 1#4("),*"50"##1 8eb

& P$el V et al 16632 JSuperior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted portsK2 Cancer2 4"(4),""&5="0 1663 ?ct 1

*astridge :T and Befor0 A+2 JComplications of ind*elling venous access devices in cancer patientsK2 To$rnal of Clinical ?ncology2 13(1),"33=50 166 Tan2

-c'$ster M0 et al2 JThe carina as a landmark in central venous catheter placement K2 :ritis'To$rnal of Anaest'esia "###G 5, 16"&

4 8letc'er -0 :oden'am A2 JSafe placement of central venous cathetersF *here should the tip ofthe catheter lieQK :ritis' To$rnal of Anaest'esia "###G 5, 155612

5 Department of !ealt' =0evie* of :our $eonatal 2eaths due to Cardiac Tamponade associated*ith the resence of a Central &enous CatheterF 0ecommendations and 2epartment of #ealth0esponse.? T$ne "##12

6 :ivins M! and Calla'an MT Josition52ependent &entricular Tachycardia 0elated To !eripherally Inserted Central Catheter K Mayo Clinic Proceedings0 4 (&), &1&=0 "### Apr

1# NAVAN (National Association of Vasc$lar Access Netor>s) JTip %ocation 'f eripherally Inserted Central CathetersK To$rnal of Vasc$lar Access Devices0 -$mmer 1665

11 Pratt T et al ("##4) Jepic", National *vidence=:ased 7$idelines for Preventing !ealt'care= Associated Infections in N!- !ospitals in *nglandK2 Uonline Available fromhttpFDD***.epic.tvu.ac.ukD2:G+:ilesDepic+Depic+5final.pdf

1" National Instit$te for Clinical *<cellence (-eptember "##") J-uidance on the Ese of Eltrasound %ocating 2evices for lacing Central &enous Catheters.K NIC* +ec'nology Appraisal No &62Bondon, National Instit$te for Clinical *<cellence2 Available from 2nice2org2$>

13 7rove0 Tay and Pevec0 /illiam C J&enous Thrombosis 0elated to eripherally InsertedCentral CathetersK To$rnal of Vasc$lar and Interventional adiology Vol$me 11(4) T$ly@A$g$st"### pp 534=5&#

1& Portsmo$t' !ospitals N!- +r$st, arenteral $utritional Support management in hospitalised

adult patients

1 /ic>'am et al %ong5term C&Cs 5 Issues for Care -eminars in ?ncology N$rsing Vol 5 No "May 166" pp 133=1&4

1 /ilson T A reventing Infection 2uring I& Therapy Professional N$rse Marc' 166& pp 335=36"

14 +odd T eripherally inserted central catheters Professional N$rse Vol 13 No 8eb 1665 pp"64=3#"

15 +odd0 T Jeripherally Inserted Central Catheters and their Ese in I& Therapy K:ritis' To$rnal of N$rsing Vol 5 No 3 1666 pp 1&#=&5

16

Camp=-orrell D Implantable orts 5 3verything you !l*ays 6anted to Hno* To$rnal ofIntraveno$s N$rsing Vol 1 No -ep@?ct 166" pp "" = "4"





"# .rLyda0 * et al JCatheter InfectionsF 2iagnosis, 3tiology, Treatment, and reventionKN$trition in Clinical Practice Vol 1& No & A$g$st 1666 pp145 = 6#

"1 -c'$lmeister B $eedle 2islodgement from Implanted &enous !ccess 2evices Inpatient and 'utpatient 3)periences To$rnal of Intraveno$s N$rsing Vol 1" No " Marc'@April 1656 pp 6#=6""" National .idney 8o$ndation JHidney 2isease 'utcomes Juality Initiative -uidelines + K2 "##1National .idney 8o$ndation

"3 !aller B and $s' . C&C infectionF a revie* To$rnal of Clinical N$rsing Vol 1 166" pp 1=

"& oley0 - J !septic $on Touch Techni"ue 8!$TT9? N$rsing +imes 8eb 1t' Vol 64 No 4 "##1,Infection Control -$pplement V1=V111

" Cornoc> M 4aking Sense of C&Cs N$rsing +imes Vol 6" No &6 Dec &t' 166 pp 3#=31

" Eo$ng0 A J6!0 5 ! multicentre prospective randomised controlled trial 80CT9 of thrombosis prophyla)is *ith *arfarin in cancer patients *ith central venous catheters 8C&Cs)K "## A-C? Ann$al Meeting

"4 CN IV +'erapy 8or$m JStandards for Infusion Therapy K oyal College of N$rsing ?ctober "##

"5 !adaay B J4ajor Thrombotic and $onthrombotic ComplicationsF %oss of atency K To$rnal of Intraveno$s N$rsing Vol "1 No - -eptember@?ctober 1665

"6 7abriel T Care and management of peripherally inserted central catheters :ritis' To$rnal of N$rsing Vol No 1# 166 pp 6&=66

3# Ma>i D 7 et al rospective 0andomised Trial of ovidone Iodine0 Alco'ol and C'lor'e<idine forPrevention of infection Associated it' Central Veno$s and Arterial Cat'etersK Bancet 353 1661pp336=3&3

31 .rLyda0 * Jredisposing :actors, revention and 4anagement of Central &enous Catheter 'cclusionsK To$rnal of Intraveno$s N$rsing Vol "" No - November@December 1666 pp -11

-14

3" ?lson0 . et al J3valuation of a $o5dressing Intervention for Tunneled Central &enous Catheter3)it SitesK To$rnal ?f Inf$sion N$rsing Vol$me "4(1) Tan$ary@8ebr$ary "##& pp 34=&&

33 ?liver B 6ound Cleansing N$rsing -tandard Vol 11 No "# 8eb t' 1664 pp &4=1

3& Dreett0 - JCentral venous catheter removalF rocedures and rationaleK :ritis' To$rnal of N$rsing2 Bondon, Dec 50 "###=Tan 1#0 "##12Vol260 Iss2 ""G pg2 "3#&

3 .rLyda0 *liLabet' A JCentral &enous Catheter InfectionsF Clinical !spects of 4icrobial 3tiology and athogenesisK2 To$rnal of Inf$sion N$rsing Vol$me "(1) Tan$ary@8ebr$ary "##" pp "6=3

3 ?nc$0 - and -a>arya0 -2 JCentral venous catheter5related infectionsF an overvie* *ith special emphasis on diagnosis, prevention and management?. Internet To$rnal of Anest'esiology0 "##30vol240 no2 1 2

34 Citton= et al2 J'ld and ne* tools in the diagnosis of central venous catheter5relatedbloodstream infectionsF Is there a role for brushingK? To$rnal of Vasc$lar Access "##& Vol$me Iss$e 1 Pg 1#=1"

35 !all0 . and 8arr0 :2 J2iagnosis and 4anagement of %ong5term Central &enous CatheterInfectionsK2 T Vasc Interv adiol "##&G 1,3"433&

36 Marinella0 Mar> A et al =Spectrum of upper5e)tremity deep venous thrombosis in a community teaching hospital? !eart and B$ng, +'e To$rnal of Ac$te and Critical Care Vol$me "6(")

Marc'@April "### pp 113=114

&# Bee0 Agnes E and Bevine0 Mar> N2 J4anagement of &enous Thromboembolism in Cancer atientsK Vol 1&0 no 30 (Marc' "###)



&1 :alestreri=B et al JCentral venous catheter5related thrombosis in clinically asymptomaticoncologic patientsF ! phlebographic study 2K *$ropean To$rnal of adiology W*;=T=ADI?BX01660 Vol@Iss@Pg2 "#@" (1#5=111)2

&" Allen0 Ant'ony / et al2 J&enous Thrombosis !ssociated *ith the lacement of eripherally Inserted Central Catheters? 2 To$rnal of Vasc$lar and Interventional adiology Vol$me 11(1#)

November@December "### pp 13#6=131&&3 Tacobs P et al JChest ain !s The resenting Symptom In Catheter5!ssociated Thrombosis 'f The Superior &ena5CavaK - Afr Medical To$rnal 55(1#) 1665 pp 1"5&=

&& .ayley0 T Skin5Tunnelled Cuffed Catheters Comm$nity N$rse T$ne 1664 pp "1=""

& MaLLola T0 -c'ott=:aer D0 Addy B2 JClinical :actors !ssociated 6ith The 2evelopment 'f hlebitis !fter Insertion 'f ! eripherally Inserted Central Catheter K2 To$rnal of Intraveno$sN$rsing 1666 Mar=Apr,""("),#

& +eic'grYber0 ;. et al JCentral &enous !ccess CathetersF 0adiological 4anagement of ComplicationsK Cardiovasc$lar and Interventional adiology ("##3) ",3"1=333

&5 7abriel T :ibrin sheaths in vascular access devices N$rsing +imes Vol 63 No 1# Marc' 1664

&6 Mayo DT and Pearson DC JC'emot'erapy *<travasation, A Conse$ence of 8ibrin -'eat'8ormation Aro$nd Veno$s Access DevicesK ?ncology N$rse 8or$m Vol$me "" No & May 1660 4=5#

# Me'all0 T0 -altLman DA0 Tac>son T and -mit' -D J:ibrin Sheath 3nhances Central &enousCatheter InfectionK Critical Care Medicine Vol$me 3# (&) April "##"0 6#5=61"

1 Ait>in D and Minton TP +'e HPinc'=off -ignGH A /arning of Impending Problems it'Permanent-$bclavian Cat'eters American To$rnal of -$rgery Vol 1&5 Nov 165& pp 33=3

" Tones 7 JA Practical 7$ide to *val$ation and +reatment of Infections in Patients it' CentralVeno$s Cat'etersK To$rnal of Intraveno$s N$rsing Vol"1 No - -eptember@?ctober 1665 pp -13& - 1&"

3 :an>s N Jositive 'utcome after %ooped eripherally Inserted Central Catheter 4alpositionKTo$rnal of Intraveno$s N$rsing Vol "" No 1 Tan$ary@8ebr$ary 1666 pp 1& = 15

& astogi - et al JSpontaneous Correction 'f The 4alpositioned ercutaneous Central &enous%ine In InfantsK Pediatric adiology2 "5(6), 6&=0 1665 -ep

Portsmo$t' !ospitals N!- +r$st, Cytoto<ic *<travasation +reatment Policy

Moore C et al $ursing Care and 4anagement of &enous !ccess orts ?ncology N$rsing

8or$m Vol 13 No 3 May@T$ne 165 pp 3=36



Appendix VIII 8 Clinical audit tools) CVC Insertion and #anagement -orm

Central Venous Catheter Care and Management (1)

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