Download Policy Template V4 - Northern Ireland Cancer Network

Title
Central Venous Access Device Guidelines
(excluding non-tunnelled catheters)
Developed By
Dympna McParlan, Infusional Services Coordinator
Infusional Services Team
Dr G. Benson, Regional Haemophilia Centre
Director
Status
Consultation Period
Final
March 2015: BHSCT draft CVAD Guidelines
reviewed and updated in accordance with
changes in clinical practice and evidence
based practice (incorporating epic3)
April 2015: Amended following consultation
with Dr G. Benson, IPC Team and Cardiology
(BCH)
May 2015: Circulated to Oncologists,
Haematologists and all other interested parties
(BCH)
July 2015: Amended following comments from
Oncologists, Haematologists and all other
interested parties (BCH)
August 2015: Amended following consultation
with Parenteral Nutrition Team (BHSCT)
October 2015: BHSCT Final draft adapted for
NICaN
February 2016: Amended following
consultation with the NICaN SACT Nurses
Group
Endorsed By
Implementation
Contact person
Review Date
Group Responsible for
Review
NICaN Board
Implementation by relevant Trusts
Dympna McParlan, Infusional Services Coordinator
[email protected]
February 2019
NICaN SACT Nurses Group
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
1 INTRODUCTION / PURPOSE OF POLICY
This document has been produced by the Northern Ireland Cancer Network (NICaN).
It is intended for use across each of the cancer units and the cancer centre. It is
based on a document produced by the Infusional Services Team, Belfast City
Hospital.
This policy is intended to safeguard patients and staff, by defining best practice for
all disciplines involved in the care and maintenance of Central Venous Access
Devices (CVADs). It should be read in conjunction with relevant policies and
procedures available in each individual Trust.
CVADs are specially designed catheters used to provide reliable venous access for
patients requiring a wide range of therapies. To ensure correct use of these devices,
it is essential that all practice is standardised. These guidelines have been produced
to ensure that all care pertaining to CVADs is based upon current evidence based
practice (whenever that is possible). The guidelines encompass the care required for
Peripheral Inserted Central Catheters (PICCs), Tunnelled Catheters and Implantable
Ports in order to prevent associated potential complications.
The purpose of this policy is to provide staff with guidance to care and maintain
CVADs in order to prevent associated potential complications. To ensure all staff are
aware of their roles and responsibilities in relation to the management of CVADs and
to standardise the management of CVADs.
2 SCOPE OF THE DOCUMENT
These guidelines apply to all staff who are involved in any aspect of the selection,
insertion or care and maintenance of CVADs. It applies to patients treated within
adult services throughout Cancer Treatment Services and excludes the use of nontunnelled catheters.
3 ROLES/RESPONSIBILITIES
It is the responsibility of all Cancer Treatment Services staff who manage CVADs to
adhere to this policy.
4 KEY POLICY PRINCIPLES
4.1 Introduction
CVADs are specially designed catheters used to provide reliable venous access for
patients requiring a wide range of therapies. To ensure correct use of these devices,
it is essential that all practice is standardised. These guidelines have been produced
to ensure that all care pertaining to CVADs is based upon current evidence based
practice (whenever that is possible). The guidelines encompass the care required for
these devices.
The following guidelines are designed to be used within the context of the policy
documents published by NICaN and the Nursing and Midwifery Council.
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4.2
Indications for Insertion
 Repeated administration of drugs e.g. cytotoxic chemotherapy or antibiotics
 Poor venous access
 Repeated collection of blood specimens
 Blood product administration
 Bone marrow transplant
 Needle phobia
 Parenteral Nutrition
 Hydration therapy
4.3
Persons authorised to access CVADs
A Medical Practitioner provided they have received education and training in
accessing CVADs.
A Registered Nurse provided that they fulfil the following criteria:
 Successfully completed a recognised IV drug administration course
 Undertaken theoretical and practical training and be deemed competent
Patients, relatives, District Nurses and Radiographers who are trained and deemed
competent by nursing/medical staff.
4.4 Description of CVADs
The CVADs most commonly used are:
4.4.1 Peripheral Inserted Central Catheter (PICC)
A PICC is an intravenous device made from silicone or polyurethane. It measures
approximately 55-60cms in length, ranging in diameter from 2-5 French gauge.
PICCs may be single or dual lumen and can be open ended or valved at the
proximal or distal end of the catheter. Open ended PICCs have a clamp system
attached to prevent blood reflux and air embolism. Power PICCs allow the injection
of contrast media. Insertion is via a cannula into either the basilic, cephalic, brachial
or median cubital vein above the antecubital fossa. PICC tip position is confirmed by
3CG technology, fluoroscopy or a chest X-ray. The tip should be dwelling within the
superior vena cava or near its junction with the right atrium (INS, 2011).
Power PICC insitu
Groshong PICC insitu
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4.4.2 Tunnelled Catheter
A tunnelled catheter is a device which is tunnelled under the skin. It is made from
silicone or polyurethane, ranging in diameter from 7-14 French guage. Tunnelled
catheters are available as single, double or triple lumen configurations. They are
open ended and therefore have a clamp system attached to prevent blood reflux and
air embolism. Valved tunnelled catheters are available but are not widely used.
These catheters are inserted by tunnelling under the patient’s skin on the chest wall
and access the central venous system via the internal jugular or subclavian vein. The
purpose of the tunnel is to remove the entry site into the vein from the exit site on the
skin, so providing a barrier to infection. These catheters have a Dacron Cuff sited
part way along their length. This cuff is in the subcutaneous tunnel and tissue
granulates around it, so reinforcing the barrier to invading organisms and providing
security. The tip of the catheter should lie within the lower third of the superior vena
cava or near its junction with the right atrium (INS, 2011).
Tunnelled Catheter
Tunnelled Catheter in situ
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4.4.3 Implantable Port
An implantable port is a totally implantable intravascular device tunnelled under the
skin to a subcutaneous pocket on the chest wall, on the rib cage or in the upper arm.
This device is a two part system consisting of a subcutaneous injection port with a
self-sealing septum and a venous catheter. These devices are available, assembled
or unassembled, in which case the individual placing the device must securely attach
the catheter to the port, (Gullo, 1993). The device may be open ended or valved and
either single or dual lumen. Implantable ports are accessed by palpating the device
through the patient’s skin using a ‘Huber’ needle to puncture the port’s silastic
membrane. With dual lumen devices, each lumen is attached to a separate injection
port. Power ports allow the administration of contrast media under power injection.
The tip of the catheter should lie within the lower third of the superior vena cava or
near its junction with the right atrium (INS, 2011).
Implantable Port
Power Implantable Port
Implantable Port in situ
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4.5 Selection of Device
The choice of the device should be determined by the clinician responsible for the
patient care in conjunction with and after discussion with the patient.
Factors involved in the decision include;








The clinical need for central venous access
The therapy to be administered
The duration of the therapy
The availability of access site in each patient
Venous anatomy in each patient
Co-existing conditions such as immune compromise or venous thrombosis
Previous relevant surgery and radiotherapy
Patient preference
PICCs are ideally suited for patients in whom peripheral venous access is possible
and the duration of the treatment is relatively short, typically weeks to months, but
they can be used for longer if required.
Tunnelled CVADs may be used for longer periods such as months to years in the
absence of any complications and are therefore better suited for long-term therapy.
Implantable ports are best for cosmesis as there are no lines outside the skin
surface. They can function for several years. They are however, the most invasive in
terms of placement as the port must be placed in a subcutaneous pocket and skin
needling is required to access the system for each use.
Select a single lumen catheter unless multiple ports are essential for the
management of the patient.
4.6 Pre insertion procedures
4.6.1 Introduction
CVADs are clearly indispensable in modern medicine but they do put vulnerable
patients, especially this particular population at increased risk of complications, the
most common of which is infection. The prevention of infection is clearly fundamental
to these guidelines.
4.6.2 Blood Requirements Prior to Insertion of CVADs
PICC:
The risk of complications of bleeding and infection are so low that no abnormality in
platelets or ANC should preclude PICC insertion or removal.
 If the patient is on Warfarin an INR is required. The INR should be ≤ 3. INR can
be checked 72 hours prior to insertion.
Tunnelled Catheter / Implantable Port:
 Full Blood Picture
 Coagulation Screen
 If the patient is on Warfarin an INR is also required.
Pre-procedure agreed blood parameters are:
 Platelets ≥ 30 x 109/1
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




Platelets <30 x 109/1 require a platelet transfusion pre insertion
Prothrombin time 9-11 secs
APTT 23-32secs
INR ≤ 3 within 72 hours of procedure
If coagulation screen abnormality, request mixing studies and discuss with
Haematology Lab Reg or Haematology Cons/Reg on call whether the patient
requires haemostatic cover with FFP. Discuss results with practitioner who is to
perform the catheter insertion.
 ANC ≥ 0.5
4.6.3 Anticoagulation
If the patient is on Warfarin the INR should be ≤ 3 within 72 hours of procedure.
If the patient is on prophylactic LMWH proceed.
If a patient is on therapeutic LWMH it should not be withheld.
The catheter should be inserted 6 hours post LWMH administration.
If the patient is on a newer anticoagulant, such as Apixaban, avoid insertion within
peak anticoagulant effect (which is within 4 hours post infusion). No need to hold or
alter the current drug provided an afternoon insertion is planned.
If the patient is on any dosage of Aspirin/Clopidogrel proceed unless there are any
specific concerns. These should be discussed with the referrer. If there are still
concerns discuss with Haematology Lab Reg. or Haematology Cons/Reg. on call.
Discuss anticoagulation with practitioner who is to perform the catheter insertion.
4.6.4 Insertion
These devices will only be inserted following referral by the Consultant, Registrar or
Staff/Associate Specialist.
Insertion of CVADs must be undertaken by persons deemed competent and having
undergone a recognised training programme.
Insertion procedure should be performed in an appropriate designated area.
Ultrasound guidance should be used to perform the venous access.
Prior to insertion of CVADs a full explanation should be given to the patient and
written consent obtained by a registered Medical Practitioner or a competent PICC
placer who possess the necessary knowledge.
Maximum sterile precautions to be taken on insertion include adherence to strict
hand decontamination, surgical aseptic non touch technique and optimum sterile
barrier precautions i.e. wearing sterile gloves and gown and using full body sterile
drapes.
Cleanse skin with Chlorhexidine Gluconate 2% in 70% alcohol solution (Chloraprep)
prior to CVAD insertion or Povidone Iodine for patients with sensitivity to
Chlorhexidine. Allow antiseptic to dry before insertion of a CVAD (Loveday et al.,
2014).
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If patient is MRSA positive or has a history of MRSA, decolonisation should be
commenced as follows; Nasal Mupirocin ointment TID and Stellisept Antimicrobial
wash daily for 5 days (other decolonisation products maybe advised on an individual
patient basis).
Following mastectomy, radiotherapy, axillary or chest wall surgery, a PICC should
ideally be inserted only on the unaffected side. If a non guided PICC cannot be
inserted on the unaffected side the patient should be referred to the Interventional
Radiologist for insertion of a PICC or failing that, a tunnelled catheter. If treatment is
palliative, prognosis is guarded or if unable to access the unaffected side, then the
responsible Consultant may approve use of the affected side.
When inserting a tunnelled catheter or implantable port it is important to choose the
most appropriate position for the catheter exit site or port. According to Lilienberg et
al (1994) up to 30% of patients expressed concern for cosmetic reasons because of
the position of their tunnelled catheter and over 35% reported discomfort while using
a safety belt due to catheter position. The patient may request a letter regarding
advice about not wearing a seat belt. Please note that this letter will have no legal
standing.
4.6.5 Antibiotic prophylaxis
Systemic antibiotics should not be administered routinely prior to CVAD insertion
unless ANC <1.0.
4.6.6 Parenteral Nutrition
Parenteral Nutrition (PN) should ideally be administered through a single lumen
catheter. If a dual lumen catheter is necessary a port should be dedicated for PN
(Loveday et al., 2014).
4.6.7 Cardiac Pacemaker Implants
If the patient has a pacemaker insitu the request for CVAD placement should be
discussed with the referrer. The device should be placed contralateral to the
pacemaker. The risk of lead dislodgement is minimal, especially if the pacemaker
has been insitu for more than three months, (INS 2011).The placement of tunnelled
devices and implantable ports should take place under fluoroscopic monitoring.
4.6.8 Use of Glyceryl Trinitrate
To deal with difficulties in insertion due to venospasm, Glyceryl Trinitrate Spray 400
micrograms sublingually, may be administered. This is contra-indicated in a small
number of patients who are identified beforehand by the requesting physician.
4.7 Post insertion procedures
4.7.1 Position
All CVADs require a chest X-ray to confirm catheter tip position post insertion except
those placed under fluoroscopy guidance (Dougherty and Lamb, 1999) or Sherlock
3CG Tip Confirmation System.
Documentation of the correct position of the CVAD must be confirmed and written in
the patient’s medical notes prior to initial use. Verbal confirmation is not sufficient.
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If a PICC requires withdrawal post insertion, instructions will be given following tip
confirmation. The required amount should be withdrawn by a competent practitioner.
A chest X-ray will not be required unless the PICC is withdrawn ≥ 5 cms or if there is
another cause for clinical concern e.g. possible malposition.
4.7.2 Dressing and Sutures
Following PICC insertion a securement device e.g. Statlock or Securacath, will be
applied to minimise the risk of catheter migration. A Securacath utilises a small
anchor which is placed under the skin during insertion and remains insitu for the
duration of the catheter dwell time. This device is unsuitable for patients who are
allergic to nickel. A Statlock stabilisation device is replaced during the weekly
dressing change.
Consider the use of a chlorhexidine-impregnated sponge dressing (Biopatch),
(provided there is no known chlorhexidine allergy) encompassing the exit site as a
strategy to reduce catheter related blood stream infections.
A sterile semi permeable transparent dressing (IV 3000) encompasses the above
and should be changed weekly.
The pressure dressing which is applied following insertion of a tunnelled catheter
should be removed after 48 hours. This dressing should be renewed with Biopatch
and a sterile semi permeable transparent dressing (IV 3000). After 21 days a
dressing is no longer required unless the patient is receiving home PN.
Sutures to be removed using an aseptic technique as follows:

PICC
If used, may remain insitu

Tunnelled Catheter
Entry site (neck)
Exit site (chest)

Implantable Port
7 days post insertion (If not sub-cuticular closure)
7 days post insertion
21 days post insertion
4.8 Care and management of CVADs
4.8.1 General Measures
Strict hand hygiene must be adhered to at all times as per Trust Hand Hygiene
Policy.
Always adhere to Standard Aseptic Non Touch Technique (ANTT) as per Trust
ANTT Policy.
Reduce catheter manipulations to a minimum.
Exit site should be cleansed with Chloraprep. If known allergy to chlorhexidine use
povidine iodine.
Consider the use of a chlorhexidine-impregnated sponge dressing (Biopatch),
(provided there is no known chlorhexidine allergy) encompassing the exit site as a
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strategy to reduce catheter related blood stream infections.
Central Venous Observation Chart to be completed as per device. (Appendix 1).
4.8.2 Dressing
Standard ANTT is used when redressing CVADs, with the addition of sterile gloves.
Renew once weekly with a sterile semi permeable transparent dressing (IV 3000) or
earlier if it becomes wet, torn, loose or dirty.
The Biopatch should be changed weekly.
A tunnelled catheter does not require a dressing after 21 days unless the patient is
receiving home PN.
An Implantable Port does not require a dressing once the wound overlying the skin
incision has healed.
On accessing an implantable port a gauze dressing should be placed around the
‘Huber’ needle and covered with IV 3000 to secure it. If continuous access is
required this dressing can be left undisturbed for 7 days, unless there is any exudate
present (Dougherty and Lamb, 1999).
4.8.3 Accessing, Infusing and Flushing
Venous return should always be obtained from all CVADs before use.
For home PN patients, checking for venous return via the PN lumen on a regular
basis is not advised as it may increase the infection risk. However a full assessment
of any CVAD is advised if there are any doubts about patency or if malposition is
suspected.
Venous return is not required following disconnection of elastomeric infusor systems;
the device is solely flushed during this procedure.
All fluids to be administered via a CVAD should be prepared using Standard ANTT
as per Trust ANTT Policy.
Maintain a closed system at all times, with the use of clamps and a needleless
connector.
Always use 10ml luer lock syringes or greater. Smaller syringes exert excessive
pressure within the catheter and may rupture the device.
All CVADs are flushed before/between/after drug administration and immediately
following blood sampling.
Always ensure that there is no delay in flushing following completion of IV infusions.
CVADs should be flushed using a pulsatile (push-pause) method, completing
procedure using a positive pressure technique.
If you meet resistance, do not force fluid into the catheter.
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PICCs and tunnelled catheters are flushed once weekly and Implantable Ports once
monthly when not in use.
For home PN, flush PICCs and tunnelled catheters twice weekly when not in use.
CVADs should be flushed with 20mL Sodium Chloride 0.9% for injection following
administration of Parenteral Nutrition and CT contrast.
Drug levels should not be taken from the lumen through which the drug has been
infused.
The needleless connector should be changed once weekly, after 100 connections or
if removed for any reason. Each lumen of a dual/triple catheter should be treated
separately.
Ensure the correct size of ‘Huber’ needle is used when accessing an Implantable
Port.
Please refer to the Trust Intravenous Flushing Lines Policy.
4.8.4 Blood sampling
Always adhere to Standard ANTT as per Trust ANTT Policy.
Vacuumed blood collection systems can be used with CVADs.
If using a syringe and transfer device for blood sampling the CVAD should be
flushed prior to filling blood bottles to prevent catheter occlusion.
Discard first 2mL of blood from a PICC and 5mL from a tunnelled catheter and an
Implantable Port prior to sampling.
When IV fluids are in progress through a second or third lumen, they should be
clamped off or stopped prior to blood sampling. This will prevent contamination by
the IV fluids and distortion of the chemical composition of the blood sample.
Routine blood sampling from a catheter should not be performed on home PN
patients.
4.8.5 Blood Cultures
No blood should be discarded when taking blood cultures via a CVAD.
Blood cultures should be obtained peripherally and from all catheter lumens.
4.8.6 Replacement of IV Administration Sets and Connections
IV administration sets should be changed at 72 hour intervals.
IV blood administration sets should be changed at 12 hour intervals.
PN administration sets should be changed at 24 hour intervals.
IV infusions should only be disconnected or reconnected when absolutely necessary
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e.g. blood cultures. Key parts should be protected as per ANTT.
If PN has to be disconnected it should not be reconnected (liaise with the Nutrition
Support Team if further advice required).
4.9 Management of complications
4.9.1 Infection
These guidelines are recommendations only and catheter related infections may
require discussion with a medical microbiologist.
Exit site infections usually respond to oral antibiotics alone. However, exit site
infections along the external path of the tunnel in tunnelled catheters require
treatment with parenteral antibiotics.
Complicated bacteraemia, where there is a suspicion of metastatic disease such as
endocarditis or osteomyelitis must be discussed with a medical microbiologist or an
infectious diseases physician.
A fever/rigor related in time to access of a central catheter or to dialysis should be
treated as catheter related bacteraemia, unless an alternative source of infection is
obvious clinically.
Treatment of infection requires appropriate cultures, and a decision as to whether
the catheter requires immediate removal or, whether a period of observation with
appropriate treatment is required.
Paired blood cultures i.e. both central and peripheral are important in considering
whether a bacteraemia is catheter related. The source of the blood MUST be clearly
labelled on each blood culture bottle.
A diagnosis of catheter related bacteraemia is highly probable when culture samples
obtained from the catheter becomes positive at least two hours earlier than those
from peripheral blood cultures. Microbiology will advise.
A laboratory confirmed catheter related bacteraemia is indicated by the identification
of the same organism from blood cultures and line tip culture.
Removal of long-term catheters must be discussed with a senior clinician.
Note: Dosage adjustments will be required for patients with renal impairment.
Please refer to the Trust Guidelines for empirical antibiotic prescribing in hospitalised
adults.
4.9.2 Occlusion
Most common non-infectious complication in CVADs and occurs in up to 36-65%.
Definition & Differential Diagnosis
 Inability to infuse through catheter or to withdraw 2mL of blood despite
standard procedures.
 Intra-luminal clotting (25%)
 Intra-luminal precipitate
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




Pinch off syndrome (1%)
External compression
Catheter malposition or device failure
Venous thrombosis (4%)
Fibrin sleeve (57%)
4.9.3 Prevention and Management
All CVADs are flushed before/between/after drug administration and immediately
following blood sampling.
Always ensure there is no delay in flushing following completion of IV infusions.
CVADs should always be flushed using a pulsatile (push-pause) method completing
procedure using a positive pressure technique.
PICCs and tunnelled catheters are flushed once weekly and Implantable Ports once
monthly when not in use.
PICCs and tunnelled catheters are flushed twice weekly for Home PN patients.
If one lumen of a dual/triple catheter is occluded, interventions to re-establish
patency must be undertaken prior to use.
If occlusion occurs check catheter for extrinsic compression e.g. kinking, clamps,
sutures.
Assess if occlusion is related to postural changes.
Check history of recent infusions and care of catheter.
Assess for signs of arm oedema, redness, pain, and signs of SVC obstruction.
Repeated aspiration by gentle pressure and suction action using 10mL Sodium
Chloride 0.9% for injection may be of benefit.
If occlusion persists and the catheter is to be salvaged, Urokinase administration will
be required.
Please refer to the local Urokinase Protocol.
4.9.4 Fibrin Sheath
Fibrin sheaths develop around the tip of all CVADs regardless of the catheter type,
size or tip position. Fibrin sheath development can occur within 24 hours of
placement.
Fibrin sheaths are associated with catheter dysfunction and can be demonstrated by
a linogram.
Treatment by thrombolytic therapy can be effective and a regimen is listed in 4.9.3
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4.9.5 Interventional Radiology
Interventional radiology may be able to perform catheter salvage in a number of
cases and negate the need for catheter removal and replacement.
4.9.6 Catheter Malposition
If Infusional Services experience difficulties in advancing a catheter into the SVC and
venous access is limited a referral can be made to Interventional Radiography.
Tunnelled catheters may have the catheter tip misplaced in the unlikely event of not
using fluoroscopic guidance. Typically the catheter tip will be malpositioned
contralaterally in the brachiocephalic vein or the azygos vein but other sites are
possible.
Catheters should not be removed but referred immediately to interventional radiology
where the catheter tip can be repositioned correctly, often without the need for
catheter replacement.
Tunnelled Catheter or Implantable Port manipulation should only be attempted by a
Consultant Interventional Radiologist.
4.9.7 Thrombosis
Central venous thromboembolism occurs in 30% of CVADs overall, and in 4-5% of
patients with PICCs.
4.9.8





Risk Factors
Sepsis
Malignancy
Large catheter size
Duration of catheter placement
Composition of infusate
NB Upper extremity DVT is associated with 12% risk of PE.
No comparison of treatment options has been performed. Options include:
 Catheter removal
 Anticoagulation with or without catheter removal
 Thrombolysis with or without catheter removal
Treatment is based on severity.
Commentary
Symptomatic thrombosis is observed in approximately 6% of patients.
Intra-luminal clotting accounts for up to 25% of occlusions and factors include:
 Reflux of blood into the lumen
 Coughing
 Pump malfunction
 Low infusion rates
 Not flushing with positive pressure
Catheter associated vessel thrombosis may present as:
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



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Shoulder/Jaw pain
Oedema
Cyanosis
Superior Vena Cava Obstruction (SVCO)
Catheter Occlusion
Recommended treatment in patients without future access needs is removal. All
patients should be treated with LMWH. A series of Randomised Controlled Trials
(RCTs) have demonstrated that patients with advanced cancer are better treated
with LMWH than Warfarin for both DVT and PE. LMWH is more efficacious and
associated with less major bleeding episodes. The duration of anticoagulation is in
discussion with the patient’s Consultant.
Thrombolysis is reserved for SVCO or catheter salvage as the risk of haemorrhage
is increased but it results in approximately 75% salvage.
4.9.9 Prevention and Management
To minimise the risk of thrombosis formation, the smallest catheter size possible for
the needs of the patient should be inserted (Schelper, 1999) into the largest possible
vein.
Only use single lumen CVADs, unless treatment requires a double lumen device.
Ensure all CVADs are flushed as per hospital guidelines.
Please refer to the Trust Intravenous Flushing Lines Policy.
If patient is symptomatic, a Venogram or Doppler Ultrasound scan should be
performed to confirm thrombosis.
If Venogram/Doppler Ultrasound scan is positive, administer anticoagulant therapy
and remove the catheter after 48 hours if it is non-functioning/not required. If the
catheter is to be salvaged and functioning, continue with treatment for the duration of
the catheter required, provided symptoms settle.
In some instances, the catheter may have to be removed depending on the severity
of the thrombosis.
If thrombosis has occurred and patient is on therapeutic Warfarin and a replacement
catheter is required, only consider use of the affected arm for PICC insertion if
absolutely necessary.
4.9.10 Catheter Migration
Migration can be seen as the lengthening or shortening of the catheter on
measurement.
Catheter migration may be suggested by the following:
 Coughing
 Ear / neck pain on the side of insertion
 Chest, back or shoulder pain
 Palpitations / arrhythmias
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

Inability to aspirate blood (or difficulty in doing so)
Continuous backflow of blood into the catheter
4.9.11 Catheter Position
Catheter tip position and suitability for use should be documented.
The ideal tip position for CVADs is within the superior vena cava or near its junction
with the right atrium (INS, 2011).
A post-insertion chest X-ray and all subsequent check X-rays must be performed
with the patient in the standard position.
4.9.12 Prevention and Management
Following PICC insertion a securement device should be applied to prevent the risk
of catheter migration.
Explain to patient that excessive arm movements may contribute to catheter
migration.
Ensure catheter is dressed in accordance with hospital guidelines.
Measure the external length of a PICC from exit site to end of needleless connector
following each dressing and record in the patient’s diary card.
Exit site (chest) sutures for a tunnelled catheter should not be removed before 21
days post insertion (Royal Marsden, 2000).
If patient is receiving home PN ensure the catheter is anchored to prevent tension.
If catheter migrates internally or externally by more than 2cms, assess the position of
the catheter tip by chest X-ray.
Do not administer any solutions via the catheter until X-ray is reported.
Permanent CVADs such as tunnelled catheters may be repositioned by an
Interventional Radiologist, but there should be discussion with the patient’s
Consultant first (Thalhammer et al., 2002).
If PICC lengthens and X-ray confirms inappropriate tip position, then the catheter
should be replaced. If the PICC has shortened and the X-ray confirms internal
migration or migration into the wrong vessel then discuss repositioning with the PICC
inserter/Interventional Radiologist.
There may be exceptional circumstances depending on patient’s condition,
prognosis and venous access where a migrated PICC may be acceptable to the
treating Consultant but it must be documented in writing.
If the catheter is totally dislodged, apply a pressure dressing to the site and seek
Medical advice. Remember to consider the possibility of air embolism.
4.9.13 Catheter Fracture
Pinholes, leaks and tears can appear in the catheter due to accidental catheter
puncture, excessive syringe pressure or poor catheter care.
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
4.9.14 Prevention and Management
Always ensure CVADs are dressed in accordance with hospital guidelines.
If the device is open ended ensure the clamp is applied over the reinforced section of
the catheter.
Always use 10mL luer lock syringe or greater when flushing (Weinstein and Hagle,
2014).
Never instil fluids into the catheter against resistance.
Never use sharp instruments when working with CVADs.
Prevent pinch off syndrome by ensuring confirmation of position is obtained following
insertion.
No high pressure pumps (e.g. those used for IV contrast in imaging studies) should
be used on CVADs due to high rates of CVAD failure following this (unless a Power
injectable device has been inserted).
4.9.15 Serous Ooze
Serous fluid may leak from the exit site. If this occurs, swab the exit site and redress
catheter with the addition of gauze. Monitor dressing, if same become saturated,
redress. If serous ooze continues consider the possibility of catheter fracture or
thrombosis. Consider replacement of the catheter if no cause identified and ooze
persists for more than 14 days.
4.9.16 Repair of CVADs
If damage occurs in a CVAD, its location will determine the possibility of repair.
Repair kits are available to repair the external portion of single, double and triple
lumen tunnelled central catheters and Groshong PICCs if they become damaged.
This eliminates the need of replacing the entire CVAD, which is otherwise still
functional.
It is not possible to repair a Power PICC and the device should be removed
immediately in the event of catheter fracture.
Only personnel who are experienced in the procedure should carry out a repair.
A PICC should be repaired immediately otherwise the dressing should remain insitu
until appropriate trained staff are available.
If it is suspected that the tip of the PICC has moved during the repair, a chest X-ray
should be performed before use of the device is resumed.
If a fracture occurs in a tunnelled catheter it should be clamped with a vascular
clamp to minimise damage immediately proximal to the fracture and advice sought
from staff trained in this type of repair. These clamps can be obtained from theatres.
If an internal fracture is suspected in any CVAD then a linogram should be
performed to ascertain catheter fracture.
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
If an internal fracture is confirmed then the CVAD will need to be removed.
If any complications have occurred as a result of the fracture, these should be
treated accordingly.
4.10 Removal of CVADs
All CVADs should be removed as soon as their use is no longer clinically indicated.
Removal of a CVAD (whilst still required for treatment) is a medical decision that is
based on the patient’s condition or clinical findings.
4.10.1 Peripheral Inserted Central Catheter
These are easily removed at the bedside by personnel who are competent in this
procedure. No routine blood tests need be performed.
Remove outer dressing (and Statlock if present).
Clean the area with Chloraprep (if known allergy to chlorhexidine use povidine
iodine) and apply a gentle firm traction to the catheter (not the hub), pulling the
catheter out slowly, parallel to the vein (hand over hand technique) until the catheter
is removed.
Inspect the catheter to ensure that total removal has occurred.
If a Securacath device is insitu, detach cover from anchor base and remove catheter.
Once complete, cut anchor base completely in half along the groove. Stabilise the
tissue, stretch the skin and remove each half of the anchor base with a deliberate
tug.
A small sterile dressing should be applied over exit site.
If catheter is removed due to suspected infection, tip must be sent for bacteriological
analysis and results followed up.
PICC removal normally proceeds uneventfully. Research has reported rates of 7% to
12% of PICC removals being difficult (Marx, 1995). If tethering of the catheter does
occur, this can usually be resolved by the application of a heat pack to the arm,
followed by gentle traction. Only very rarely should it be necessary to dissect the
PICC free under local anaesthetic.
4.10.2 Tunnelled Catheter and Implantable Port
Prior to removal the following bloods should be checked:
 FBP
 Coagulation screen
 INR only if patient is on Warfarin
 Pre-procedure agreed parameters are:
 ANC ≥0.5 x 109/l
 Platelets ≥30 x 109/l
 Prothrombin time 9-11 secs
 APTT 23-32 secs
 INR ≤ 3
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Removal of these devices should only be performed by staff that has had adequate
supervised experience. This may be the vascular surgeon or interventional
radiologist who performed the insertion, a trained Oncologist/Haematologist or a
Nurse trained in the removal of tunnelled catheters. This should only be performed
during office hours (preferably in the morning) with good light, appropriate
instruments and adequate backup. If the procedure is not running smoothly, then
advice should be sought early.
If catheter is removed due to suspected infection, tip must be sent for bacteriological
analysis and results followed up. Following removal, a pressure bandage should be
applied to the exit site and an airtight dressing should remain insitu for 24 hours.
Patient should rest for 30 minutes post procedure.
If present, excision sutures should be removed after 7 days.
NB: Removal of all CVADs must be documented in patient’s medical notes following
procedure.
4.10.3 Pneumothorax / Haemothorax
Pneumothorax/haemothorax occurs if air/blood enters the space between the pleural
lining and the lung. Richardson and Bruso (1993) reported that it was a complication
in 5% of all patients who have their CVAD placed directly into the subclavian vein. It
can be observed at the time of insertion or in the period immediately following
removal.
4.10.4 Prevention and Management
Pneumothorax is associated with subclavian access more frequently than jugular
access. The use of ultrasound guidance for vascular access significantly reduces the
risk of procedural pneumothorax and the risk of inadvertent arterial puncture for all
venous access routes.
Observe for signs of pneumothorax/haemothorax for 24 hours post insertion and
following removal.
All CVADs require a chest X-ray to be performed post insertion if not placed under
fluoroscopy guidance or Sherlock 3CG technology (Dougherty and Lamb, 1999).
Chest X-ray should be reviewed by a Radiologist to exclude pneumothorax or
haemothorax post placement of tunnelled catheter/Implantable port.
Documentation of correct position should be confirmed prior to initial use.
If pneumothorax or haemothorax develops, treat as a medical emergency.
Call for assistance and monitor vital signs.
Monitor respiratory rate and administer oxygen as prescribed.
Have chest drain apparatus available and trained staff alerted in case a chest drain
must be inserted.
Assist with comfortable positioning (Patient should sit upright unless air embolism is
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
suspected).
4.10.5 Suspected Air Embolism
Air embolism is a very rare but potentially preventable complication of catheter
placement and removal. It occurs as a result of air entering the venous circulation
and travelling to the pulmonary vein. It can be life threatening or fatal.
4.10.6 Prevention and Management
Maintain a closed system at all times with the correct use of clamps and a
needleless connector.
Always use luer lock syringes.
Ensure all connections are secure.
On removal of tunnelled catheters the patient should be in the supine position, and
ensure they exhale with the mouth closed as the catheter is coming out.
Always apply pressure to exit site on removal of catheter and a pressure dressing
should remain in place for 24 hours post removal.
If patient develops an air embolism, clamp or pinch catheter proximal to the air entry
point.
Turn patient onto their left side and position with the head lower than the body
(Trendelenberg position).
Administer oxygen as prescribed.
Call for medical assistance or crash team.
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5.0
EVIDENCE BASE / REFERENCES
References:
1. Dougherty, L., and Lamb, J. (1999) Intravenous Therapy in Nursing
Practice. Churchill Livingstone, Edinburgh.
2. Gullo, S.M. (1993) Implanted ports: Technologic advances and nursing
care issues. Nursing Clinics of North America 28 (4): 850-871.
3. Infusion Nursing Society (INS) (2011) infusion Nursing Standards of
Practice 34 (number 1S).
4. Lilienberg, A., Bengtsson, M., and Starkhammar, H. (1994) Implantable
devices for venous access: nurses and patients evaluation of three port
systems. Journal of Advanced Nursing 19, 21-28.
5. Loveday, H.P et al (2014) Epic3: National evidence-Based Guidelines for
Preventing Health care Associated Infections in NHS Hospitals In England.
Journal of Hospital Infection 86: S1.
6. Marx, M. (1995) The management of the difficult peripherally inserted
central venous catheter line removal. Journal of Intravenous Nursing 18:
(5) Sept/Oct.
7. Schelper, R., (1999) Endothelium and Venous Access Educational
session. In: A New Dawn of Opportunity National Association of Vascular
Access Networks (NAVAN) 13th Annual Conference, September 16-76,
Navan Publication, Draper, USA.
8. The Royal Marsden Manual of Clinical Nursing Procedures (2015)
Available online: www.royalmarsdenmanual.com
9. Thalhammer, A., Jacobi, V., Balzer, J., and Vogl, T.J. (2002) Repositioning
of Malpositioned or Flipped Central Venous Catheters. European
Radiology 12: 698-700.
10. Weinstein, S.M. and Hagle, M.E.(2014) Plumers Principles and Practice
of
Intravenous Therapy. 9th edition. London: Lippincott Williams and
Wilkins.
Bibliograpghy:
1. Boraks, P., Seale, J., Price, J., et al. (1998) Prevention of central venous
catheter associated thrombosis using minidose Warfarin in patients with
haematological malignancies. British Journal Haematology 101: 483-486.
2. Chemaly, R.J., Barbara de Parres, J., Rehm, S.J., Adal, K.A., Lisgaris,
M.V., Katz-Scott, D.S., Curtas, S., Gordon, S.M., Steiger, E., Olin, J., and
Longworth, D.L. (2002) Venous Thrombosis Associated with Peripherally
Inserted Central Catheters: A Retrospective Analysis of the Cleveland
Clinic Experience. Clinical Infectious Diseases 34: 1179-1183.
3. Heaton, D.C., Han, D.Y., and Inder, A. (2002) Minidose (1mg) warfarin as
prophylaxis for central vein catheter thrombosis. Internal Medicine Journal
32: 84-88.
4. Hinke, L.C., Zandt-Stastny, M.D., Goodman, L.R., Quebbeman, E.J., and
Kyzywda, E.A. (1990) Pinch-off syndrome: a complication of implantable
subclavian venous access devices. Radiology 177: 353-356.
5. Krzywda, E.A. (1999) Predisposing Factors, Prevention and Management
of Central Venous Catheter Occlusions. Journal of Intravenous Nursing
22: (6S) S11-S17.
6. Nursing Midwifery Council (2015) The Code. Professional standards of
practice and behaviour for nurses and midwives, London, NMC.
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
7. Royal College of Nursing (2010) Standards for infusion therapy, London,
RCN.
8. Loveday, H.P et al (2014) epic 3: National Evidence-Based Guidelines for
Preventing Healthcare-Associated Infections in NHS hospitals in England.
Journal of Hospital Infection :86 supplement 1.
9. Walshe, L.J., Malak, S.F., Eagan, J., and Sepkowitz, K.A. (2002)
Complication Rates among Cancer Patients with Peripherally Inserted
Central Catheters. Journal of Clinical Oncology 20 (15) 3276-3281.
6.0
APPENDICES / ATTACHMENTS
Appendix 1 - Central Venous Observation Chart
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Appendix 1
Name:
Hospital Number:
Date of Birth:
(Addressograph label)
Central Venous Access Device Observation Chart
Record observation of the Central Venous Access Device every 4 hours. Document any
variance using the letter code, report to medical staff as necessary and record action taken.
Catheter Type
PICC
Tunnelled
Implantable Port
Non Tunnelled
Femoral
Dialysis
Other (specify)
Date of Insertion
Complication
Bleeding
Dressing
Inflammation
Serous Ooze
Skin integrity
Sutures
Swelling
Other (specify)
Code
A
B
C
D
E
F
G
H
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action
______________________________________________________________________________________________________
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action
______________________________________________________________________________________________________
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NICaN - Central Venous Access Device Guidelines V1.1 February 16
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action _____________________________________________________________________________________________________
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action
_____________________________________________________________________________________________________
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action
_____________________________________________________________________________________________________
Date:
Time:
Observation
satisfactory
Variance
Signature
Comments/action
_____________________________________________________________________________________________________
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NICaN - Central Venous Access Device Guidelines V1.1 February 16