3.6 Central Venous Catheter Care
Central Venous Catheter Care in the Satellite Context
Variations in practice related to Central Venous Catheter (CVC) Care exist across the five tertiary centres that care for children with cancer in Ontario. Neither a recent literature review by a POGO CVC task force, which included representatives from each of the tertiary and satellite partner sites, nor a Cancer Care Ontario (CCO) review by the CCO “evidence based practice group” plus pediatric representation from SickKids and POGO, produced sufficient evidence to develop recommendations for changes in pediatric CVC practice.
The nurses representing the tertiary and satellite partners in Satellite Guidelines 2006 review group recommend that consistency between CVC care received in the satellite centre and that received in the tertiary centre is important in developing and maintaining the confidence of the patients and families as they move between shared care partners, and is the most important determinant of CVC care in the satellite setting.
Each tertiary hospital that refers patients to a satellite centre is committed to ensuring the initial and ongoing education of the nursing staff caring for their patients. CVC care is a controlled act authorized to Nursing. If this procedure is infrequently practiced, refer to the “Decision Tree’ (http://www.cno.org/globalassets/docs/prac/41071_decisions.pdf ) published by the College of Nurses of Ontario for performance of procedures to help you decide whether or not you should be performing this procedure independently.
Copies of the complete set of guidelines for CVC care for each of the tertiary hospitals which refer patients to a satellite centre should be available in the satellite centre: in the clinic, on the ward and in the emergency department, if appropriate.
Exception
A guideline for Blood Sampling and Flushing (See below) was updated and is included in these guidelines since in the Satellite context children are often cared for in an area where the pediatric population is mixed and the added recommendation for using sterile technique for CVC line manipulation for blood sampling was considered advisable.
- The following are general guidelines for managing CVCs and Port-a-caths in the Satellite context. Contact your patient’s tertiary hospital primary nurse, nurse educator or vascular access resource nurse with questions or concerns.
- For all catheter repairs contact your patient’s tertiary hospital primary nurse, nurse educator.
- Current evidence contradicts using vacutainers or syringes < 10 ml to draw lab work directly from pediatric CVC’s because they can create pressure that can damage CVC’s.
- Coagulation blood work cannot be drawn from a heparinized central venous catheter.
- All CVCs/Port-a-cath should have a needle-less inject cap in place.
- If a CVC/Port-a-cath is not heplocked, it must be infusing on an infusion pump at all times.
- If using a gauze type dressing, palpate the site each 8 hour shift. If patient complains of pain or tenderness, remove the dressing and visually assess the site.
- If a CVC/port-a-cath is not heplocked, it must be infusing on an infusion pump at all times.
- When infusing IV fluids via a port-a-cath, best practice recommendation is that the entry site be viewed hourly, if use of transparent dressing makes this possible.
- Use a transparent dressing over the needle site, especially when administering chemotherapy. Transparent dressing should be changed weekly and PRN.
- If using a gauze type dressing, palpate the site each 8 hour shift. If patient complains of pain or tenderness, remove the dressing and visually assess the site.
- NOTE: Change the Port-a-cath needle weekly and PRN.
External Central Venous Catheter and Port-a-Cath
Blood Sampling and Flushing
Guidelines
This procedure is a controlled act authorized to Nursing. If the procedure is infrequently practiced by you, refer to the CNO “Decision Tree” for performance of procedures to help you decide whether or not you should perform this procedure independently.
Centre for Disease Control states that without a dedicated team, institutions can greatly reduce their rate of catheter-related sepsis by scrutinizing catheter care protocols and more intensively education and training their clinicians. There is evidence to support blood drawing as a clean and also as a sterile procedure. In the community hospitals where there are mixed populations of patients in the same area and nurses have limited experience in accessing lines it is recommended that a sterile procedure be deemed the standard. However, if a needle-less system is used with an injection cap then for any manipulation distal to the injection cap, a clean procedure is adequate.
Equipment
*2 pairs-sterile gloves (to protect self and immunosuppressed child)/or clean gloves.
*2-sterile towel
*1 sterile syringe 10 ml (2 for double lumen) for flush and blood discard.
*1 sterile syringe 10 ml (2 for double lumen) flush post bloodwork.
*1 sterile syringe 10 ml (empty) for drawing blood.
*1 sterile syringe 10 ml (2 for double lumen) if heparinizing catheters post blood draw.
*1 transfer set to insert blood into the blood tubes.
*1-2 10 ml preloaded syringes of normal saline.
*Chlorhexidine swabs
*Sterile 4×4 gauze
*Tapes, gauze to secure connections and prepare “sausage” post procedure.
*Appropriate specimen tubes, syringes and requisitions for bloodwork.
PROCEDURE
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Essential Steps |
Key Points |
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1 |
Gather the equipment and wash your hands. |
Wash hands using two-minute aseptic technique. |
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2 |
You may want to set up your sterile field in the treatment room or at the bedside. |
All necessary equipment should be available in the treatment room. |
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3 |
Place sterile towel on table, drop sterile 10 ml syringes onto the sterile field. |
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4 |
Open and place normal saline syringes on the sterile field. If using heparin: swab vial with chlorhexidine and place on side of sterile field; or, if using pre-filled heparin syringes, adjust volume of syringe to the desired amount and then place on the side of the sterile field. |
If chlorhexidine is required, allow chlorhexidine to dry for 1 minute to ensure that its bactericidal properties take effect. |
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5 |
Don sterile/clean gloves. If the CVC/Port-a-cath is to be heparin locked following blood sampling: Attach an appropriate sized needle to a 10ml syringe, draw up appropriate dose of heparin, remove needle. Repeat these steps for a double lumen catheter. |
No heparin is required when an IV infusion is running. Check the expiry date of the heparin (30 days from when opened). Insert hyperlink (here) to CVC Line Flushing Table (PJG) |
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6 |
Prepare your 10 ml 0.9% normal saline syringes. |
If drawing blood from both lumens you will need a total of four 10 ml syringes containing normal saline. PORT-A-CATH ® recommends using a 10 ml or larger syringe, taking care not to apply excessive force to the syringe. |
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7 |
Lay the filled syringes on your sterile towel. Fold up towel and take to child’s bedside. At the bedside explain procedure to child at appropriate developmental age level. |
Use empty 10 ml syringe(s) for the actual blood draw. |
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8 |
Remove the gauze and tape covering the connection (blood drawing site) if applicable Place sterile towel under the CVC line, and remove gloves. |
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9 |
If an IV infusion is in progress, close the clamp on the CVC. Turn off the infusion pump. Open the package from the smart set cap to place on the end of the IV tubing to maintain sterility. |
Ensure that the new smart set cap is not contaminated (leave the end protector in place). |
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10 |
Don sterile/clean gloves. |
If using sterile procedure keep one hand clean and one hand sterile. |
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11 |
With the chlorhexidine swab cleanse the needle less injection cap on the hub of the CVC/Port-a-cath using significant friction. |
Ensure injection cap is not contaminated once cleansed. If you feel that injection cap becomes contaminated at anytime during the procedure, re-swab with chlorhexidine. |
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12 |
Insert the saline filled 10ml syringe to the injection cap. Open the clamp on the CVC/Port-a-cath. Flush line with saline and then withdraw discard amount. Remove syringe and attach empty 10 ml syringe and withdraw the required volume for specific blood sample. Remove syringe and set aside. |
CVC external catheter: withdraw 1.5-2 ml (discard). Port-a-cath: withdraw 3 ml (discard). Lay the line back down on the sterile towel. |
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13 |
Attach 10 ml saline filled syringe and flush the CVC/ Port-a-cath using a pulsating motion. Remove syringe. |
Turbulent flush is accomplished by applying a start/shop, pulsing pressure on the syringe plunger. Turbulent flush better facilitates the clearing of blood or other deposits from within the catheter lumen and improves patency. Please refer to institutional policy re CVC/Port-a-cath maintenance. Ensure all blood is cleared from the injection cap as stagnant blood left in the cap may attract and facilitate the growth of bacteria. Positive pressure clamping is obtained by closing the clamp on the CVC while still applying pressure to the syringe plunger during the last 0.1-0.2 ml of saline. This method of clamping prevents blood from being drawn into the internal tip of the catheter, decreasing the possibility of catheter occlusion. |
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14 |
Proceed to heparin lock the CVC/ Port-a-cath if infusion is to be discontinued. (Flush with 10 ml normal saline and appropriate amount of heparin using turbulent flushing and positive pressure clamping). |
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15 |
To continue the infusion, cleanse injection site with chlorhexidine swab and reconnect IV infusion, start pump. |
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16 |
Transfer the blood in syringes in to appropriate tubes using a transfer set. If a transfer set is not available, use 18 g needle on syringe. Insert needle through diaphragm on top of vacutainer and inject required amounts of blood. Take care to prevent a needle stick injury during this process. Label the blood specimen containers and send to lab. |
If injecting blood specimen into a blood culture bottle, first cleanse top of bottle with chlorhexidine to prevent contamination of blood specimen. |
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17 |
Dispose of sharps and used equipment appropriately. |
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Reference
Infusion Therapy Standards or Practice, INS; 2016 LHSC Nursing Practice Manual Guidelines: Care, Use and Maintenance of Central Intravascular Devices. https://intra.lhsc.on.ca/venous-access-support-team-vast/care-use-and-maintenace-central-intravascular-devices. Infusion Nurses Society Web Page: http://www.ins1.org/i4a/pages/index.cfm?pageid=1
Primary authors Mr. Kaniska Young-Tai, The Hospital for Sick Children, Toronto, Ms. Patti Bambury, Grand River Hospital, Kitchener, Ms. Cristina Peter, Grand River Hospital, Kitchener, Ms. Kirsty Morelli, Scarborough and Rouge Hospital, Scarborough, and Mr. Graham Robinson, Children’s Hospital of Eastern Ontario, Ottawa. Reviewed by POGO Satellite Manual Review Nursing Group, 2016.