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Applies To: All HSC Hospitals, CRTC, or UNMH<br />
Component(s): UH<br />
Responsible Department: ALL<br />
Title: Venous Access Devices<br />
Procedure<br />
Patient Age Group: ( ) N/A ( ) All Ages ( ) Newborns ( X) Pediatric ( X) Adult<br />
<strong>DESCRIPTION</strong>/<strong>OVERVIEW</strong><br />
<strong>The</strong> <strong>purpose</strong> <strong>of</strong> <strong>this</strong> procedure is to standardize care in the insertion and use <strong>of</strong> venous access<br />
devices by their appearance, assist in the selection <strong>of</strong> catheters based on length <strong>of</strong> therapy, to<br />
outline the care and maintenance <strong>of</strong> venous access devices, and provide strategies for<br />
troubleshooting the venous access device difficulties or complications.<br />
CROSS REFERENCES<br />
• EMLA (Eutectic Mixture <strong>of</strong> Local Anesthetic Cream)<br />
• Intravenous <strong>The</strong>rapy<br />
• Alteplase for Catheter Occlusion<br />
• Patient Education and Documentation<br />
• Medication Administration<br />
• Patient Identification<br />
• Policy: Tissue Plasminogen Activator (tPA) for Catheter Occlusion<br />
AREAS OF RESPONSIBILITY<br />
Patients may have the catheter inserted while in the Emergency Room, in their hospital room,<br />
Operating Room, Interventional Radiology department, Cancer Research Treatment Center,<br />
Pediatric Intensive Care Unit, or in the Pediatric Procedure/Treatment Room. Nurses who are<br />
assigned to work in any <strong>of</strong> these areas must be familiar with <strong>this</strong> procedure.<br />
Interested Registered Nurses will be specifically trained and deemed competent prior to<br />
initiating the insertion <strong>of</strong> a Peripherally Inserted Central Catheter (PICC) on adult patients.<br />
Members <strong>of</strong> the PICC team may be able to place a PICC in a child over 10 years <strong>of</strong> age.<br />
Pediatric Hospitalists and Pediatric Intensivists will be specifically trained and deemed<br />
competent prior to initiating the insertion <strong>of</strong> a PICC on pediatric patients.<br />
PROCEDURE<br />
1. Determining appropriateness <strong>of</strong> Long Arm Catheter therapy:<br />
1.1. See attached competency for insertion procedure.<br />
1.2. Per EMLA policy: EMLA may be placed after obtaining a physician's order<br />
and after ensuring that patient has no lidocaine or EMLA allergies.<br />
1.3. Placement <strong>of</strong> an infusion catheter requires a physician's order. <strong>The</strong> order must<br />
specify the requested tip placement.<br />
1.4. <strong>The</strong> Health Unit Clerk notifies the PICC team member.<br />
1.5. <strong>The</strong> decision on whether and where to place an infusion catheter and the<br />
position <strong>of</strong> its tip must be a collaborative decision. Those involved in the<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 1 <strong>of</strong> <strong>25</strong>
decision are the patient, the patient's family, the physician, and the nurse<br />
assigned to the Vascular Access Resource Team (VART). Appropriateness <strong>of</strong><br />
the candidate, the prescribed therapy, expected outcomes, as well as the<br />
potential benefits and risks will be determined.<br />
1.6. <strong>The</strong> PICC team member evaluates the patient for the placement <strong>of</strong> the PICC at<br />
the bedside.<br />
1.7. If the PICC team member determines that a PICC cannot be placed at the<br />
bedside, a physician’s order is required for placement <strong>of</strong> the PICC in<br />
Interventional Radiology.<br />
1.8. A request is sent to Interventional Radiation (IR) for placement <strong>of</strong> the PICC.<br />
Scheduling proceeds from the IR.<br />
2. Qualifications for selection <strong>of</strong> a VART candidate:<br />
2.1. Selection Criteria:<br />
2.1.1. Registered nurse with current New Mexico licensure<br />
2.1.2. IV module completed.<br />
2.1.3. Recommended by Unit Director.<br />
2.1.4. Successful completion <strong>of</strong> Long Arm Catheter (LAC) training process<br />
as verified by the University Hospital Education Department<br />
2.1.4.1. Completion <strong>of</strong> competency checklist and receipt <strong>of</strong> form by<br />
the Education Department. A certificate <strong>of</strong> completion is<br />
awarded to the individual.<br />
2.1.4.2. Successful placement <strong>of</strong> five long arm catheters in the<br />
presence <strong>of</strong> a preceptor during training.<br />
2.2. Maintaining Qualification:<br />
2.2.1. Successful placement <strong>of</strong> 10 LAC per year.<br />
2.2.2. Participate in annual VART update<br />
2.2.3. Development <strong>of</strong> unit in-services and updates.<br />
2.2.4. Participation in the Performance Improvement Patient Safety<br />
Committee<br />
3. Long Arm Catheter Insertion Procedure- Attachment A<br />
4. Long Arm Catheter Removal Procedure- Attachment B<br />
5. Long Arm Catheter Length Selection Guidelines- Attachment C<br />
6. Care Of Pediatric Central Catheters- Attachment D<br />
7. Venous Access Port Addendum- Attachment E<br />
8. Care Of Adult Central Catheters- Attachment F<br />
9. Quick Reference Guide For Venous Access Devices- Attachment G<br />
10. Care <strong>of</strong> the VAD in the Post Anesthesia Care Unit- Attachment H<br />
11. Evaluation<br />
11.1. After VAD inserted, chest xray required for line placement. This is to be done<br />
wherever the patient had the catheter inserted. Adult midline PICCs do not require an<br />
xray prior to use. If PICC inserted in the IR, it is in the correct position and is okay to<br />
use, no xray is required. A physician’s written order is required for permission to<br />
infuse fluids.<br />
11.2. After xray evaluated by physician or radiologist, a written order is required for<br />
administration <strong>of</strong> fluids into <strong>this</strong> line.<br />
11.3. Ensure the dressing over the catheter is secure.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 2 <strong>of</strong> <strong>25</strong>
12. Patient Education<br />
12.1. Instruct patient/family regarding the procedure.<br />
12.2. Instruct patient/family regarding any local anesthetic/sedation needed to<br />
perform the procedure.<br />
12.3. Instruct patient/family on care <strong>of</strong> the catheter after placement.<br />
13. Discharge Planning<br />
13.1. Discharge planning begins with the plan to place a VAD.<br />
13.2 <strong>The</strong> Discharge Planner Nurse needs to meet with patient/family to order supplies<br />
and equipment for home use<br />
13.3. Provide education to patient/family with return demonstration <strong>of</strong> dressing<br />
change prior to discharge.<br />
13.4. Discharge education to include flushing the catheter with heparin, dressing<br />
changes with end cap changes, and signs and symptoms <strong>of</strong> infection, line occlusion,<br />
and line breakage.<br />
AGE OR DEVELOPMENTAL VARIATIONS<br />
1. Pediatric patients- see Attachment D, Care <strong>of</strong> Pediatric Central Catheters<br />
2. Neonatal patients- see Policy: Venous & Arterial Line Management - SCN<br />
COMPONENT/AREA/UNIT SPECIFICS<br />
1. In units using positive pressure devices, do not clamp VAD prior to disconnect.<br />
2. Behavioral Health<br />
a. Behavioral Health Inpatient Nurses:<br />
i. Maintain PICC lines per UH procedure<br />
ii. May use the PICC line for blood draws per UH procedure<br />
iii. May NOT administer any medications, other than heparin and saline used for line<br />
flushes, through the PICC or other VAD.<br />
KEY DOCUMENTATION<br />
1. With any VAD, document the following:<br />
1.1. Type <strong>of</strong> device and where located<br />
1.2. Insertion site <strong>of</strong> catheter or insertion site <strong>of</strong> needle and the characteristics <strong>of</strong> the skin<br />
(i.e. redness, edema, drainage)<br />
1.3. Number <strong>of</strong> lumens or ports<br />
1.4. Type and rate <strong>of</strong> infusions<br />
1.5. Date <strong>of</strong> dressing change or site care<br />
2. Document complications or problems in the following manner:<br />
2.1. Thrombus or mechanical phlebitis<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 3 <strong>of</strong> <strong>25</strong>
2.2. Device related infection<br />
2.3. Interventions implemented<br />
2.4. Date and time that physician was notified<br />
2.5. Annotate all VART team contacts and consultations in the medical record<br />
2.6. Assist VART team members in Quality Assurance documentation.<br />
3. Document all patient/family teaching, patient/family understanding and discharge<br />
planning in the Multidisciplinary Teaching Form and on nursing flowsheet.<br />
DEFINITIONS<br />
Central Venous Catheter (CVC) This is a catheter that is threaded through the internal jugular,<br />
antecubital, subclavian, or femoral vein usually with the tip resting in the superior vena cava or<br />
the right atrium <strong>of</strong> the heart. It is also used to administer fluids or medications. Blood may be<br />
withdrawn for diagnosis and laboratory analysis.<br />
Long Arm Catheter (LAC) This is a catheter inserted into a peripheral vein <strong>of</strong> the upper arm. It<br />
may be inserted into a central vein. This catheter is inserted by a trained RN, member <strong>of</strong> the<br />
VART team or by a physician. Blood may be drawn from any catheter larger than 3 Fr.<br />
Peripherally Inserted Central Catheter (PICC) Same as LAC.<br />
Vascular Access Resource Team (VART) This is a specially trained team <strong>of</strong> individuals who are<br />
competent with the insertion and removal <strong>of</strong> a PICC line. <strong>The</strong>re is a course designed to train<br />
individuals (nurses and doctors) who wish to do <strong>this</strong> procedure. <strong>The</strong>re is a yearly competency to<br />
check the skill level <strong>of</strong> these individuals.<br />
Venous Access Device (VAD) This is a central line that is placed in a patient under sterile<br />
conditions <strong>of</strong> an operating room or interventional radiology. It can be tunneled through the skin<br />
into the central venous circulation (broviac, groshong, or hohn) or placed in a pocket <strong>of</strong> skin on<br />
the chest (infusaport) or arm (PASport), into the central venous circulation.<br />
SUMMARY OF CHANGES<br />
1. This was changed from a policy to a procedure and placed into the new format.<br />
2. Any wording that included the use <strong>of</strong> betadine as the antiseptic skin cleanser was changed<br />
to the wording <strong>of</strong> chlorhexidine.<br />
3. Policy cross-references were increased to be more inclusion <strong>of</strong> current practices.<br />
4. A statement addressing location <strong>of</strong> patient when the venous access device was inserted<br />
was added.<br />
5. References were updated.<br />
6. Within the Attachment D: Care <strong>of</strong> the Pediatric Central Catheter, changes were made to<br />
catheter access, irrigations, frequency <strong>of</strong> dressing and needle less access cap changes, and<br />
whom to call with a central line break.<br />
7. <strong>The</strong> procedure for accessing an infusaport (portacath) has been added.<br />
8. Information regarding caring for a patient in the Post Anesthesia Care<br />
Unit (PACU) when the vascular access device was placed in the Operating Room was<br />
added.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 4 <strong>of</strong> <strong>25</strong>
KEY WORDS<br />
Broviac Catheter, Central Venous Catheter, Device, Groshong Catheter, Hickman Catheter,<br />
Hohn Catheter, Infusaport, Long Arm Catheter, PasPort, Peripherally Inserted Central Catheter,<br />
PortaCath, Sub-Clavian Catheter, Vascular Access Resource Team, Venous Access Device,<br />
Venous Access Port<br />
PROFESSIONAL REFERENCES<br />
(Indicate if reference is R = Research; NS - National Standard;<br />
or L = Literature)<br />
NS: Center for Disease Control. (2002). Guidelines for the Prevention <strong>of</strong> Intravascular Catheter-<br />
Related Infections. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm<br />
R: Chalyakunapruk, N., Veenstra, D., Lipsky, B., & Saint, S. (2002). Chlorhexidine compared<br />
with Povidone-Iodine solution for vascular catheter-site care; A meta-analysis. Annals <strong>of</strong> Internal<br />
Medicine, 136 (11). Pp792-801.<br />
L. Dougherty, L. (2000). Central venous access devices. Nursing Standard, 14(43), pp. 45-50,<br />
54-55.<br />
L: Perry, A. & Potter, P. (2004). Inserting a peripherally inserted central catheter. In Clincal<br />
Nursing Skills and Techniques, 5 th Ed. pp. 577-582.<br />
L: Taketomo, C., Hodding, J., & Kraus, D. (2003). Lexi-Comp’s Pediatric Dosage Handbook,<br />
10 th Ed., p. 558-561.<br />
RESOURCES/TRAINING<br />
Training programs, classes, HSC <strong>of</strong>fices, other University or HSC documentation, telephone numbers, and other<br />
sources <strong>of</strong> help completing forms or carrying out procedures.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 5 <strong>of</strong> <strong>25</strong>
Resource/Dept<br />
Sheena Ferguson, RN, MSN, CNS,<br />
Clinical Education, Interim Chief<br />
Nursing Officer<br />
Jo Anne Wright, RN, MSN, CNS<br />
Pediatrics<br />
Internet/Link<br />
DOCUMENT APPROVAL & TRACKING<br />
Item Contact Date Approval<br />
Owner<br />
Clinical Education Department<br />
Jo Anne Wright, RN, MSN, CNS, Pediatric Specialty Care Unit<br />
Sherman Henderson, RN, BSN, PICC/Conscious Sedation Team<br />
Rebecca Mc Kernan, RN, MSN, APN, Pediatric ENT<br />
Consultant(s)<br />
Ninon Adams, RN, Pediatric General Surgery<br />
Cathy Chavez, RN, BSN, Pediatric Oncology, Research Nurse<br />
Shirley Mc Graw, RN, BSN, MBA, Unit Director, PACU<br />
Committee(s)<br />
NCOC Policy and Procedure Subcommittee<br />
Nursing Clinical Operations Council<br />
Nursing Officer Sheena Ferguson, Interim Chief Nursing Officer Y<br />
Medical Director/Officer<br />
NA<br />
Human Resources<br />
NA<br />
Finance<br />
NA<br />
Legal<br />
NA<br />
Official Approver Sheena Ferguson, Interim Chief Nursing Officer Y<br />
Official Signature<br />
2 nd Approver (Optional)<br />
Signature<br />
Effective Date 07/27/05<br />
Origination Date 08/2002<br />
Issue Date Clinical Operations Policy Coordinator 07/27/05<br />
Y<br />
ATTACHMENTS<br />
Attachment A: Long Arm Catheter (LAC) Insertion<br />
Attachment B: Removal <strong>of</strong> a Long Arm Catheter (LAC)<br />
Attachment C: Long Arm Catheter Length Selection<br />
Attachment D: Care <strong>of</strong> the Pediatric Central Catheters<br />
Attachment E: Venous Access Port Addendum<br />
Attachment F: Care <strong>of</strong> the Adult Central Catheters<br />
Attachment G: Quick Reference for VADs<br />
Attachment H: Care for the VAD in the Post Anesthesia Care Unit (PACU)<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 6 <strong>of</strong> <strong>25</strong>
ATTACHMENT A:<br />
LONG ARM CATHETER (LAC) INSERTION<br />
1. <strong>The</strong> LAC qualified Registered Nurse collaborates with the physician to identify patients who<br />
may benefit from LAC placement.<br />
2. A physician's order is secured indicating the desired placement <strong>of</strong> the catheter tip.<br />
3. <strong>The</strong> patient and/or family is provided with information as to the indications, risks, benefits,<br />
and care that a LAC placement entails, as well as, the possibility that placement may not be<br />
successful.<br />
4. Assessment <strong>of</strong> the veins is completed with the identification <strong>of</strong> the basilic, median<br />
antecubital, and cephalic veins. <strong>The</strong> brachial artery is also palpated. <strong>The</strong> decision to proceed<br />
is made if the patient is a candidate and if informed written consent is obtained. A consent<br />
form is not required with a midline placement.<br />
5. <strong>The</strong> patient is assessed for medical conditions or medications that may be a contraindication<br />
for LAC placement. Examples: sepsis, A-V fistulas, Coumadin, uncontrolled hypertension.<br />
Any concerns that the RN may have with regard to potential contraindications must be<br />
brought to the attention <strong>of</strong> the physician.<br />
6. Medication allergies must be checked. EMLA may be placed per policy and procedure. If<br />
an allergy to EMLA or Lidocaine exists, consult with the patient's nurse for alternative<br />
medications per physician's orders. 0.9% Sodium Chloride (NaCl) may be used as the<br />
preservative acts as an anesthetic.<br />
7. Place the patient in a recumbent position to facilitate venous filling <strong>of</strong> the dependent<br />
extremity. A three-minute scrub from hands to elbow area is done.<br />
8. <strong>The</strong> RN measures the patient for the desired length <strong>of</strong> the catheter using the non-sterile tape<br />
measure with the patient's arm at a ninety-degree angle from the body.<br />
9. <strong>The</strong> RN also measures the upper arm circumference midway between the shoulder and the<br />
elbow.<br />
10. <strong>The</strong> RN dons personal protective equipment to include hat, mask, sterile gloves, and a yellow<br />
gown in setting up the LAC field with the contents <strong>of</strong> the tray and other necessary supplies.<br />
<strong>The</strong> patient should wear a mask, but may be omitted if the patient is unable to tolerate it.<br />
11. <strong>The</strong> skin is prepped using chlorhexidine swabsticks using a scrubbing motion back and forth.<br />
Allow the chlorhexidine to dry.<br />
12. Depending on which kit is utilized; two or three drapes are placed for maximal protection <strong>of</strong><br />
the field and to allow the catheter to uncurl. Take the second tape measure (sterile) from the<br />
tray and position it in such a way that the catheter may be straightened onto it using the<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 7 <strong>of</strong> <strong>25</strong>
forceps for the tip. Your gloved hand may be used to hold the catheter hub while placing it<br />
on one end <strong>of</strong> the tape measure. Do NOT touch the catheter with your gloves as the powder<br />
from the gloves may precipitate a sterile phlebitis.<br />
13. Draw up ten to twenty milliliters <strong>of</strong> 0.9% NaCl. Flush the catheter before adjusting the<br />
guide-wire. Examine the catheter for any perforations other than at the tip. Withdraw the<br />
guide-wire to the length <strong>of</strong> the catheter plus one additional inch or two additional<br />
centimeters. At the same time, pull the wire down at a firm angle against the hub. This will<br />
cause the wire to curl for easier manipulation.<br />
14. <strong>The</strong> catheter insertion technique is per the manufacturer recommendations (see LAC Tray<br />
insert). <strong>The</strong> catheter is trimmed straight across. Do not cut the guide-wire. Under NO<br />
circumstances should a damaged guide-wire be used. If the guide-wire is damaged, discard<br />
the catheter/guide-wire unit.<br />
15. Discard gloves and apply the tourniquet. Don a new pair <strong>of</strong> sterile gloves. Apply the 4X4<br />
gauze over the tourniquet end to allow the nurse to release the tourniquet as needed in a<br />
sterile manner.<br />
16. Perform the veni-puncture with the needle/introducer unit at a shallow angle (approximately<br />
twenty degrees). Note that the tip <strong>of</strong> the needle may be in the vein while the shorter<br />
introducer is not. At <strong>this</strong> point, if the needle is removed or if the cannula is pushed forward,<br />
the cannula will be positioned outside the vein. After obtaining a blood return, lower the<br />
angle <strong>of</strong> the needle/introducer unit making it more parallel to the vein. Advance the unit 1/4<br />
to 1/2 inch into the vein and then advance the introducer while holding the needle in position.<br />
<strong>The</strong> tourniquet may be released at <strong>this</strong> point and the needle safely withdrawn and placed in<br />
the tray. In some patients, it may be necessary to maintain the tourniquet until the catheter<br />
has been advanced several inches.<br />
17. Using the forceps, grasp the catheter approximately one centimeter from the catheter tip.<br />
Advance it in small sections through the introducer. Work quickly to minimize blood loss.<br />
Do not force the catheter if resistance is met as <strong>this</strong> could result in vein or catheter damage.<br />
18. If central placement is desired, have the patient turn his head away from the nurse and tuck<br />
the chin to the chest. This will assist the catheter to move into the proper position.<br />
19. When three inches <strong>of</strong> the catheter remains exposed, withdraw the introducer using the<br />
breakaway technique. Take great care to avoid splitting the introducer while still in the vein.<br />
Advance the catheter to leave one to two centimeters exposed.<br />
20. Withdraw the guide-wire with one hand using a gentle pulling action while stabilizing the<br />
hub with the other hand. Wrapping the guide-wire around a finger will provide steady<br />
tension.<br />
21. Aspirate for a blood return then flush with twenty milliliters <strong>of</strong> 0.9% NaCl. Follow-up with<br />
the 100 units/milliliter Heparin flush.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 8 <strong>of</strong> <strong>25</strong>
22. Clean and apply a dressing to the site allowing the chlorhexidine to dry. Use a single layer <strong>of</strong><br />
a folded 2X2 as a wick. Do NOT cover the insertion site. Prep the skin with the pledgett<br />
provided. Cover with the occlusive dressing. <strong>The</strong> butterfly strips are difficult to remove.<br />
Preferably, use hypafix tape above and below the catheter to insure an occlusive dressing.<br />
Do not allow extension connectors to hang unsecured.<br />
23. Dispose <strong>of</strong> all sharps properly and in accordance with appropriate hospital policy.<br />
24. Assess the patient for untoward reactions or complications. Have the physician order a chest<br />
x-ray for mid-clavicular and central placements. Notify the physician when the x-ray is<br />
completed. <strong>The</strong> catheter can only be used after receiving a written order from the physician<br />
or the PICC team member has received the order from the Radiologist.<br />
<strong>25</strong>. If the PICC is placed in Interventional Radiology, no chest x-ray is needed, as <strong>this</strong> was<br />
placed in the correct position. Doctor order stating, “PICC may be used” must be written.<br />
26. Document the following in the progress notes:<br />
- date and time <strong>of</strong> procedure<br />
- catheter brand and size (also document in patient Kardex)<br />
- lot number<br />
- patient allergies<br />
- skin prep<br />
- local anesthetic if used<br />
- use <strong>of</strong> sterile procedure and inserter cover<br />
- measurement <strong>of</strong> upper arm circumference<br />
- total length <strong>of</strong> catheter after trimming (also document in patient Kardex)<br />
- length <strong>of</strong> catheter exposed (also document in patient Kardex)<br />
- insertion site and vein used<br />
- number <strong>of</strong> insertion attempts<br />
- quality <strong>of</strong> bloodflow and if it is non-pulsatile<br />
- estimated catheter tip location<br />
- procedural complications<br />
- patient response to procedure<br />
- patient/family teaching<br />
- completion <strong>of</strong> patient booklet<br />
- retain LAC tray insert and attach cut catheter for chart<br />
- document disposal <strong>of</strong> all sharps<br />
I.e. 10/31/01 Midline, 4 Fr., 20 cm length, 2 cm exposed<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 9 <strong>of</strong> <strong>25</strong>
ATTACHMENT B: REMOVAL OF A LONG ARM CATHETER (LAC)<br />
1. LAC's are removed by a LAC-qualified Registered Nurse when the patient no longer requires<br />
the catheter, the duration <strong>of</strong> recommended use is met, or a complication occurs. A<br />
physician's order must be obtained to remove a LAC.<br />
2. Explain the procedure to the patient/family.<br />
3. Wash hands and don clean gloves.<br />
4. Soak hypafix tape and dressing edges with alcohol to loosen dressing. Remove the dressing<br />
after it is loosened. Cleanse the site with chlorhexidine swabsticks to remove debris and skin<br />
prep.<br />
5. Remove the catheter with a steady, gentle, hand-over-hand technique. Withdraw catheter<br />
approximately four inches at a time. Avoid rapid, jerky movements as they may cause<br />
venospasm. Note the length at which the catheter is cut. Prepare catheter tip for culture in<br />
the event that a culture is required.<br />
6. If resistance is met, do not tug or pull forcefully. Excessive tension may rupture the catheter.<br />
Attempt to remedy <strong>this</strong> eventuality by applying warm, moist heat to the upper arm for fifteen<br />
to twenty minutes. In the meantime, secure the catheter with tape in an extended position. If<br />
venospasm is the suspected cause, an extended period <strong>of</strong> warm packs or straightened tape<br />
tension may be required.<br />
7. Apply pressure to the site until bleeding stops. Affix a dressing until signs <strong>of</strong> healing (scab)<br />
occurs.<br />
Document all interventions utilized, the catheter length removed, complications, patient<br />
toleration <strong>of</strong> procedure, and whether or not the tip was sent for culture.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 10 <strong>of</strong> <strong>25</strong>
ATTACHMENT C: LONG ARM CATHETER LENGTH SELECTION<br />
CATHETER TIP<br />
LOCATION<br />
MIDLINE<br />
DEEP BASILIC<br />
MID-<br />
CLAVICULAR<br />
PROXIMAL<br />
AXILLARY OR<br />
DISTAL SUB-CLAVIAN<br />
CENTRAL<br />
SUPERIOR VENA<br />
CAVA<br />
LENGTH 8 INCHES or 20<br />
CENTIMETERS<br />
DURATION<br />
TWO to FOUR<br />
WEEKS<br />
15-19 INCHES or<br />
38-48<br />
CENTIMETERS<br />
TWO to FOUR<br />
MONTHS<br />
24 INCHES or 60<br />
CENTIMETERS<br />
UP TO ONE YEAR<br />
MEDS<br />
MANY<br />
ANTIBIOTICS<br />
ANTIBIOTICS<br />
CHEMO-THERAPY<br />
DEXTROSE < OR = TO 10% PPN TPN<br />
WRITTEN<br />
CONSENT<br />
REQUIRED<br />
NO YES YES<br />
PHYSICIAN'S<br />
YES YES YES<br />
ORDER<br />
REQUIRED<br />
X-RAY REQUIRED NO YES YES<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 11 <strong>of</strong> <strong>25</strong>
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 12 <strong>of</strong> <strong>25</strong>
ATTACHMENT D: CARE OF PEDIATRIC CENTRAL CATHETERS<br />
Type <strong>of</strong> Line CVC Catheter Broviac Catheter Groshong Catheter Venous Access Ports Peripherally Inserted<br />
Central Catheter (PICC)<br />
Appearance <strong>of</strong> Catheter<br />
Double Lumen CVC is<br />
white and has 2 lumens<br />
and 2 ports labeled distal<br />
and proximal on the<br />
catheter.<br />
Site is in the subclavian,<br />
femoral, or jugular vein.<br />
Broviac: Catheters are<br />
white and are either single<br />
or double lumen. <strong>The</strong><br />
double lumen lines have 2<br />
ports: red and white<br />
Exit Site: is usually upper<br />
or mid-chest area.<br />
Toddlers may have exit<br />
site in the back.<br />
A dacron cuff and vita<br />
cuff is on the catheter but<br />
are not visible after<br />
placement. <strong>The</strong> dacron<br />
cuff is on the catheter just<br />
under the skin near the<br />
exit site. Its acts as an<br />
anchor holding the line in<br />
place and as an infection<br />
barrier. <strong>The</strong> vita cuff<br />
(made <strong>of</strong> silver iodide) is<br />
proximal to the dacron<br />
cuff. It dissolves in about<br />
3 weeks, and helps<br />
prevent infection in the<br />
newly placed line.<br />
Groshong: Catheter is<br />
clear with a blue stripe. It<br />
can be either single or<br />
double lumen. Double<br />
lumen lines have 2 ports:<br />
red and blue.<br />
Exit Site: is usually upper<br />
or mid-chest area.<br />
A dacron cuff and vita<br />
cuff is on the catheter but<br />
are not visible after<br />
placement. <strong>The</strong> dacron<br />
cuff is on the catheter just<br />
under the skin near the<br />
exit site. Its acts as an<br />
anchor holding the line in<br />
place and as an infection<br />
barrier. <strong>The</strong> vita cuff<br />
(made <strong>of</strong> silver iodide) is<br />
proximal to the dacron<br />
cuff. It dissolves in about<br />
3 weeks, and helps<br />
prevent infection in the<br />
newly placed line.<br />
Venous access ports are<br />
totally implanted in a<br />
subcutaneous pocket <strong>of</strong><br />
the chest. <strong>The</strong>refore, there<br />
no external line is seen.<br />
<strong>The</strong> port shape may be<br />
square or circular. It has a<br />
titanium base with a<br />
silicone dome for venous<br />
access. <strong>The</strong> dome may be<br />
either raised or flat.<br />
Venous access ports may<br />
be connected to a Broviac<br />
or Groshong catheter.<br />
A PICC line is inserted via<br />
the basilic or cephalic<br />
vein. It is threaded so that<br />
the tip lies in the superior<br />
vena cava (SVC).<br />
<strong>The</strong>re are a variety <strong>of</strong><br />
PICC catheters. Most are<br />
white in appearance, made<br />
<strong>of</strong> s<strong>of</strong>t flexible material<br />
(silicone, polyurethane).<br />
Exit Site: is usually just<br />
above or just below the<br />
antecubital space <strong>of</strong> the<br />
arm.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 13 <strong>of</strong> <strong>25</strong>
CARE OF PEDIATRIC CENTRAL CATHETERS<br />
Type <strong>of</strong> Line CVC Catheter Broviac Catheter Groshong Catheter Venous Access Ports Peripherally Inserted<br />
Central Catheter (PICC)<br />
Purpose<br />
Used for short-term<br />
central line access.<br />
Used for long-term<br />
(months to years) central<br />
line access.<br />
Used for long-term<br />
(months to years) central<br />
line access.<br />
Used for long-term<br />
(months to years) central<br />
line access.<br />
Used for intermediate<br />
length therapy – not to<br />
exceed 120 days.<br />
Lumen/Port Size<br />
Port Utilization<br />
Used for fluid<br />
administration, blood<br />
product administration,<br />
blood drawing, parenteral<br />
nutrition, and CVP<br />
monitoring.<br />
Catheter size varies from<br />
4-7 Fr. And length varies<br />
from 5-30 cm. Check<br />
catheter lumen for dead<br />
space volume.<br />
#1 (distal): blood product<br />
administration, blood<br />
draws, and CVP<br />
monitoring.<br />
#2 (proximal): parenteral<br />
nutrition and maintenance<br />
fluids.<br />
Used for fluid<br />
administration, blood<br />
product administration,<br />
blood drawing, parenteral<br />
nutrition, and long-term<br />
medications such as IV<br />
antibiotic therapy and<br />
chemotherapy.<br />
Broviac Catheter: there are<br />
multiple sizes used – 2.7,<br />
4.2, 6.6 and 9.6 Fr. Sizes.<br />
Double lumen line<br />
Red Port (distal): blood<br />
product administration,<br />
blood draws, and CVP<br />
monitoring.<br />
White Port: parenteral<br />
nutrition and maintenance<br />
fluids.<br />
Used for fluid<br />
administration, blood<br />
product administration,<br />
blood drawing, parenteral<br />
nutrition, and long-term<br />
medications such as IV<br />
antibiotic therapy and<br />
chemotherapy.<br />
<strong>The</strong>re are multiple sizes <strong>of</strong><br />
Groshong catheters used –<br />
3.5, 5.5, 7.0 and 8.0 Fr.<br />
Sizes.<br />
Double lumen line<br />
Red Port (distal): blood<br />
product administration,<br />
blood draws, and CVP<br />
monitoring.<br />
White Port: parenteral<br />
nutrition and maintenance<br />
fluids.<br />
Used for fluid<br />
administration, blood<br />
product administration,<br />
and blood drawing.<br />
Parenteral nutrition may<br />
be administered as well as<br />
long-term medication and<br />
chemotherapy. Pas-ports<br />
are placed in antecubital<br />
and used for CF patients.<br />
<strong>The</strong>y may be double<br />
lumen.<br />
<strong>The</strong> size <strong>of</strong> the port<br />
depends on the size <strong>of</strong> the<br />
catheter placed. Most<br />
ports used for pediatric<br />
patients have a 6.6 French<br />
catheter size<br />
Double lumen ports:<br />
occasionally an older child<br />
will have a double port<br />
placement. May also be a<br />
pass-port<br />
Use the larger port for<br />
blood product<br />
administration and draws.<br />
<strong>The</strong> smaller port can be<br />
used for parenteral<br />
nutrition, medications and<br />
maintenance infusions.<br />
Used for fluid<br />
administration, long-term<br />
antibiotics and blood<br />
product administration.<br />
Blood drawing may be<br />
done if the catheter is<br />
larger than 3.0 Fr. Most<br />
pediatric catheters are less<br />
than 3.0 Fr.<br />
TPN and IL may be<br />
administered as long as<br />
the tip <strong>of</strong> the catheter is in<br />
the SVC.<br />
<strong>The</strong> catheter sizes vary.<br />
<strong>The</strong> Fr. Size ranges from<br />
1.9 to 5.0 (16-22 gauge).<br />
Most pediatric patients<br />
have Fr. Size 1.9 (infants)<br />
to 2.8. <strong>The</strong> internal<br />
volume ranges from 0.04<br />
ml to 0.34 ml.<br />
PICC’s are single lumen<br />
ports only.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 14 <strong>of</strong> <strong>25</strong>
CARE OF PEDIATRIC CENTRAL CATHETERS<br />
Type <strong>of</strong> Line CVC Catheter Broviac Catheter Groshong Catheter Venous Access Ports Peripherally Inserted<br />
Central Catheter (PICC)<br />
Catheter Access<br />
Irrigation<br />
Irrigate each port with<br />
Heparin flush<br />
concentration between 10-<br />
100 units/cc.<br />
Determinations based on<br />
patient’s weight and<br />
diagnosis.<br />
All central lines should have a needle-less access cap on each access port. Only<br />
access lines through the needle-less access cap. <strong>The</strong> needle-less access cap should be<br />
cleansed with three alcohol swabs for 60 seconds prior to access.<br />
Maintenance Flushing:<br />
CVC: Heparin flush<br />
1 cc/port every 24 hours.<br />
Medications: 1-3 cc flush<br />
with NaCl before and after<br />
medication. Follow with<br />
Heparin flush (CVC 1 cc).<br />
Maintenance Flushing:<br />
Heparin flush<br />
1-3 cc/port every 12<br />
hours.<br />
Medications: 5 cc flush<br />
with NaCl before and after<br />
medication. Follow with<br />
1-3 cc Heparin flush.<br />
Maintenance Flushing:<br />
NaCl 10 cc flush every 7<br />
days when not in use.<br />
Medications: NaCl 10 cc<br />
flush before and after<br />
medications.<br />
Only use a non-coring<br />
(Huber) needle for access.<br />
Maintenance Flushing:<br />
Heparin flush 5 cc every 4<br />
weeks when not in use.<br />
Medications: 10-20 cc<br />
flush with NaCl before<br />
and after medication.<br />
Follow with 5 cc Heparin<br />
flush.<br />
See access for CVC,<br />
Broviac, and Groshong<br />
catheters.<br />
Maintenance Flushing:<br />
Heparin flush 1 cc q 12<br />
hours.<br />
Medications: 5 cc flush<br />
with NaCl before and after<br />
medication. Follow with<br />
1 cc Heparin flush.<br />
Utilize pulsatile flushing<br />
to prevent clot and fibrin<br />
formation.<br />
TPN: (discontinuing)<br />
Flush with 5-10 cc <strong>of</strong><br />
NaCl followed by Heparin<br />
flush (1 cc).<br />
TPN: (discontinuing)<br />
Flush with 5-10 cc <strong>of</strong><br />
NaCl followed by 1-3 cc<br />
Heparin flush.<br />
TPN: (discontinuing)<br />
Flush with 20 cc <strong>of</strong> NaCl<br />
before and after<br />
medications.<br />
TPN: (discontinuing)<br />
Flush with 10-20 cc <strong>of</strong><br />
NaCl followed by 3-5 cc<br />
Heparin flush.<br />
TPN: (discontinuing)<br />
Flush with 5-10 cc <strong>of</strong><br />
NaCl followed by 1 cc<br />
Heparin flush.<br />
Blood (draw or<br />
administration): flush with<br />
3-5 cc NaCl followed by<br />
Heparin flush ( 2 cc).<br />
Blood (draw or<br />
administration): flush with<br />
5-10 cc NaCl followed by<br />
1-3 cc Heparin flush.<br />
Blood (draw or<br />
administration): flush with<br />
10 cc NaCl before and<br />
after blood draw or<br />
administration.<br />
Blood (draw or<br />
administration): flush with<br />
20 cc NaCl followed by 5<br />
cc Heparin flush.<br />
Blood (draw or<br />
administration): flush with<br />
5-10 cc NaCl followed by<br />
1 cc Heparin flush.<br />
PSCU, PEDS, PICU<br />
PICC lines will have a<br />
continuous heparin<br />
infusion (1 unit/cc) at<br />
2cc=2 units/hr. if no other<br />
fluid is infusing.<br />
From Lexi-Comp’s Pediatric Dosage Handbook, p. 559, “Line flushing: When using daily flushes <strong>of</strong> heparin to maintain patency <strong>of</strong> single lumen or double lumen central<br />
catheters, 10 units/ml is commonly used for younger infants,(i.e.
CARE OF PEDIATRIC CENTRAL CATHETERS<br />
Type <strong>of</strong> Line CVC Catheter Broviac Catheter Groshong Catheter Venous Access Ports Peripherally Inserted<br />
Central Catheter (PICC)<br />
Dressing: Use central line<br />
dressing kit.<br />
Type <strong>of</strong> Dressing: use a<br />
bio-occlusive (Op-site,<br />
Tegaderm, etc.) type <strong>of</strong><br />
dressing. Place a BioPatch<br />
over the insertion site.<br />
Frequency <strong>of</strong> Dressing<br />
Change: change every 7<br />
days or PRN loss <strong>of</strong><br />
occlusiveness. Change<br />
BioPatch every 7 days.<br />
Change non-occlusive<br />
gauze dressings every 72<br />
hours and PRN if dressing<br />
is soiled or wet.<br />
Type <strong>of</strong> Dressing: use a<br />
bio-occlusive (Op-site,<br />
Tegaderm, etc.) type <strong>of</strong><br />
dressing unless otherwise<br />
ordered. Place a BioPatch<br />
around the catheter at<br />
insertion site.<br />
Frequency <strong>of</strong> Dressing<br />
Change: change every 7<br />
days or PRN loss <strong>of</strong><br />
occlusiveness. Change Bio<br />
Patch every 7 days.<br />
Change non-occlusive<br />
gauze dressings every 72<br />
hours and PRN if dressing<br />
is soiled or wet.<br />
Type <strong>of</strong> Dressing: use a<br />
bio-occlusive (Op-site,<br />
Tegaderm, etc.) type <strong>of</strong><br />
dressing<br />
Frequency <strong>of</strong> Dressing<br />
Change: change every 7<br />
days or PRN loss <strong>of</strong><br />
occlusiveness.<br />
Change non-occlusive<br />
gauze dressings every 24<br />
hours and PRN if dressing<br />
is soiled or wet.<br />
Type <strong>of</strong> Dressing:<br />
New Port Placement:<br />
when the port is new,<br />
steri-strips should be<br />
applied to the incision and<br />
the site should be left open<br />
to air. After the site heals,<br />
no dressing is necessary<br />
unless port is in use.<br />
Port in Use: when the<br />
port is in use, the noncoring<br />
(Huber) needle<br />
must be secured and a bioocclusive<br />
dressing should<br />
be applied and left in<br />
place until the needle is<br />
changed. <strong>The</strong> needle is<br />
left in place for up to 7<br />
days.<br />
Type <strong>of</strong> Dressing: use a<br />
bio-occlusive (Op-site,<br />
tegaderm, etc.) type <strong>of</strong><br />
dressing. Place a BioPatch<br />
around catheter at<br />
insertion site.<br />
Frequency <strong>of</strong> Dressing<br />
Change: the initial<br />
dressing should be<br />
changed within 24 hours.<br />
After the initial dressing<br />
change, the dressing<br />
should be changed every 7<br />
days or PRN. Change<br />
BioPatch every 7 days.<br />
Remove the dressing from<br />
distal to proximal to avoid<br />
pulling out the catheter.<br />
For all catheter sites, clean the site with chlorhexidine prepstick in a scrubbing motion, working from side to side for 30 seconds. Also, clean the catheter with chlorhexidine.<br />
Apply the dressing – be sure to coil the line before placing the tegaderm– up to – but not including the access ports. Observe the site for signs and symptoms <strong>of</strong> infection. Be<br />
sure to date, time, and initial the dressing. Do not use BioPatch on Pediatric Oncology patients at <strong>this</strong> time.<br />
Patients on the Pediatric Hematology/Oncology Service with broviac central line catheters will have the dressing changed every seven days, with the line coiled on top <strong>of</strong> a<br />
sterile 2x2 gauze covered with a bio-occlusive dressing as per procedure listed within <strong>this</strong> document. If catheter is covered by a 2x2 gauze, the dressing will be changed every<br />
72 hours.<br />
Cap and Cap Changes<br />
Frequency <strong>of</strong> Cap Changes: for all types <strong>of</strong> lines, needle-less access caps should be on all ports. Needle-less access caps should be changed<br />
every 72 hours (3 days). If a hub-to-hub access is done for a blood draw or CVP reading, a new injection cap should be placed on the line when<br />
finished.<br />
Changing the Cap: Clamp all lines (except Groshong). Prep the cap/catheter hub for sixty seconds with an alcohol or chlorhexidine. Remove the<br />
old cap and apply the new cap using sterile technique. Unclamp the line (if in use) and place a courtesy tab on the cap/hub. Be sure to date,<br />
time, and initial the cap change on the courtesy tab.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 16 <strong>of</strong> <strong>25</strong>
CARE OF PEDIATRIC CENTRAL CATHETERS<br />
Type <strong>of</strong> Line CVC Catheter Broviac Catheter Groshong Catheter Venous Access Ports Peripherally Inserted<br />
Central Catheter (PICC)<br />
Blood Drawing<br />
Blood Administration<br />
Complications:<br />
1. Possible blood clot<br />
occlusion<br />
Use the distal port.<br />
Stop all infusions. Using<br />
the needle-less system,<br />
aspirate 3-5 cc <strong>of</strong> blood<br />
and discard. (For blood<br />
cultures, do not discard)<br />
In second syringe, aspirate<br />
the amount needed for<br />
specimen and place in<br />
blood tube. Immediately<br />
flush line with 3-5 cc<br />
NaCl and 1 cc Heparin, if<br />
not being used with an<br />
intravenous infusion.<br />
Use the distal port.<br />
Flush with 3-5 cc NaCl<br />
and 1 cc Heparin after<br />
infusion <strong>of</strong> blood is<br />
complete, if not being<br />
used with intravenous<br />
infusion.<br />
Broviac: Use red port if<br />
double lumen.<br />
Stop all infusions. Using<br />
the needle-less system,<br />
aspirate 3-5 cc <strong>of</strong> blood<br />
and discard. (For blood<br />
cultures, do not discard) In<br />
second syringe, aspirate<br />
the amount needed for<br />
specimen and place in<br />
blood tube. Immediately<br />
flush line with 5-10 cc<br />
NaCl and 3 cc Heparin, if<br />
not being used with an<br />
intravenous infusion.<br />
Use the red port if double<br />
lumen.<br />
Flush with 10 cc NaCl and<br />
3 cc Heparin after infusion<br />
<strong>of</strong> blood is complete, if<br />
not being used with<br />
intravenous infusion.<br />
Use red port if double<br />
lumen.<br />
Stop all infusions. Access<br />
the line hub-to-hub. Flush<br />
first with 10 cc NaCl, then<br />
aspirate 6 cc <strong>of</strong> blood and<br />
discard. (For blood<br />
culture, do not discard)<br />
Attach second syringe<br />
directly to the hub;<br />
aspirate the amount<br />
needed and place in blood<br />
tube.<br />
Immediately irrigate the<br />
lines with 10 cc NaCl.<br />
Apply a new injection cap<br />
to the hub.<br />
Use the red port if double<br />
lumen<br />
Flush with 10 cc NaCl<br />
following administration<br />
<strong>of</strong> blood, if not being used<br />
with intravenous infusion.<br />
Stop all infusions. If<br />
accessing the line for<br />
blood draw, use a noncoring<br />
needle. (For blood<br />
cultures, do not discard)<br />
Aspirate the first 5-10 cc<br />
<strong>of</strong> blood and discard. In<br />
second syringe, aspirate<br />
the amount needed for<br />
specimen and place in<br />
blood tube.<br />
Immediately irrigate the<br />
line with 20 cc NaCl and 5<br />
cc Heparin, if not being<br />
used with an intravenous<br />
infusion.<br />
Access the port with an<br />
appropriate sized noncoring<br />
needle.<br />
Flush line with 20 cc NaCl<br />
and 5 cc Heparin<br />
following blood<br />
administration, if not<br />
being used with<br />
Must have at least a 3.8 Fr<br />
PICC. A 5 cc NaCl flush<br />
prior to blood draw may<br />
be <strong>of</strong> help. Never use a<br />
vacutainer as excessive<br />
pressure from the draw<br />
can cause the catheter wall<br />
to collapse.<br />
Aspirate 2 cc <strong>of</strong> blood and<br />
discard and then obtain<br />
sample.<br />
Vigorously flush with 5-<br />
10 cc NaCl followed by 1<br />
cc Heparin flush.<br />
Flush with 5-10 cc NaCl<br />
and 1 cc Heparin flush<br />
following blood<br />
administration, if not<br />
being used with<br />
intravenous infusion.<br />
intravenous infusion.<br />
1. Change the position <strong>of</strong> the patient. This may change the position <strong>of</strong> the central line. Ask the patient to change from sitting to lying/lying to<br />
sitting position; put hands over their heads; do valsalva maneuver or to cough.<br />
2. Aspiration. Attempt to aspirate the line, but do not irrigate. If able to aspirate blood, then irrigate with NaCl. If unable to aspirate, identify<br />
the port occluded and notify physician.<br />
3. Contact physician for tPA order. Typical dose should be 1 unit/ml <strong>of</strong> line dead space volume. Use ½ cc more than the catheter filling<br />
volume. After administration <strong>of</strong> tPA, leave in catheter for 1 hour. After 1 hour, aspirate for blood. This may be repeated.<br />
2. Fibrin Sheath A fibrin sheath is a mucous-like plug which building up around the tip <strong>of</strong> the catheter. It is manifested by easy infusion <strong>of</strong> fluids, but the inability<br />
to aspirate blood. In the case <strong>of</strong> a fibrin sheath, tPA (see above) may be beneficial.<br />
3. Broken Line If the central line breaks or is damaged, immediately clamp the line (except Groshong) proximal to the line break.<br />
Contact the Surgeon , Pediatric Surgery Nurse or the Pediatric Clinical Nurse Specialist for repair <strong>of</strong> <strong>this</strong> line.<br />
If a PICC line breaks, it<br />
must be removed.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 17 <strong>of</strong> <strong>25</strong>
ATTACHMENT E: VENOUS ACCESS PORT ADDENDUM<br />
1. Identify the correct patient. Confirm gauge and needle length <strong>of</strong> non-coring (Huber) needle.<br />
2. Explain the procedure to the patient/parent using age appropriate language.<br />
3. Approximately 45-60 minutes prior to accessing the infusaport/PASport apply a layer <strong>of</strong> EMLA cream over the site. Cover with bio-occlusive dressing.<br />
4. After the allotted time, prepare to access the infusaport/PASport using the appropriate size non-coring (Huber) needle.<br />
5. Remove the bio-occlusive dressing from the patient. Remove all remaining EMLA from the site with a dry 4 x 4 gauze.<br />
6. Allow the patient to assume comfortable position. Child may sit on parent’s lap. Supine position is preferable.<br />
7. Wash hands. Open the prepackaged Skin Prep tray with Chloraprep. Use <strong>this</strong> as your sterile field. Place the sterile non-coring (Huber) needle, a sterile needle-less access cap<br />
(Clave), and 10cc syringe on the field. Put on the mask. Use alcohol pad to cleanse the top <strong>of</strong> the NaCl vial.<br />
If accessing the port for lab draws only, you do not need to use the Skin Prep tray. You will need a sterile field, non-coring (Huber) needle, and a chloraprep sponge, and a<br />
mask. Proceed as listed below.<br />
8. Don sterile gloves. (You can do <strong>this</strong> with one sterile glove on the dominant hand, and the other hand is used for non sterile procedures)<br />
9. As you maintain sterility, have a second person assist with drawing up 10 cc NS from vial.<br />
10. Maintaining sterility, place the needless access cap (clave) onto the non-coring (Huber) needle, prime with the NS. You may use the prepackaged NS syringe, but realize the<br />
outer part <strong>of</strong> the syringe is not sterile, just the fluid inside. Set aside on the sterile field.<br />
11. Prep the skin over the infusaport/PASport using the chloraprep (3 ml). Using a scrubing motion, starting at the port site and working outward to a 4 to 5 inch diameter for 30<br />
seconds. Do not retrace steps. Allow to dry.<br />
12. Locate the port septum by palpation. Triangulate the port between the thumb and first fingers <strong>of</strong> the non-dominant hand. Aim for the central point <strong>of</strong> these fingers.<br />
13. Insert the non-coring (Huber) needle perpendicular to the port septum, and advance the needle through the skin and the septum until reaching the back <strong>of</strong> the port.<br />
14. Verify correct placement by aspiration <strong>of</strong> blood. If blood cannot be aspirated, use NS and pull/push technique to attempt to initiate blood flow. If blood return still cannot be<br />
obtained, pull back and attempt to reposition the needle. If needle is withdrawn from the skin, a new prep and new non-coring needle must be used.<br />
15. Proceed with desired procedure. If the needle is left in place, apply a bio-occlusive dressing securing the needle and tubing coil. (May place folded 2x2 gauze or Biopatch,<br />
under wings <strong>of</strong> needle if needed, for support <strong>of</strong> wings). Coil excess tubing under bio-occlusive dressing. Connect to ordered IV fluids. To heplock, instill 10U/ml in young infants<br />
ATTACHMENT F: CARE OF ADULT CENTRAL CATHETERS<br />
Type <strong>of</strong> Lines<br />
Appearance <strong>of</strong> Catheter<br />
Subclavian Catheters:<br />
• CVC Catheter<br />
• Hohn Catheter<br />
Triple Lumen CVC: white<br />
and has 3 ports: brown, white,<br />
and blue<br />
Hohn Catheter: white and<br />
may be either single or double<br />
lumen. Double lumen lines<br />
have 2 port: red and white<br />
Long-Term External<br />
Catheter:<br />
• Hickman & Broviac<br />
• Groshong Catheter<br />
Hickman & Broviac: <strong>The</strong>se<br />
lines are white and may be<br />
either single or double lumen.<br />
<strong>The</strong> double lumen lines have<br />
two ports: red & white.<br />
Hickman differs from Broviac<br />
only in lumen size; Hickman<br />
is larger than Broviac.<br />
Groshong: is clear with a blue<br />
stripe: it may be either single<br />
or double lumen. Double<br />
lumen lines have 2 ports: red<br />
& white.<br />
Venous Access Ports:<br />
• Port-A-Cath<br />
• PAS port<br />
Port-A-Cath: This is tottaly<br />
implanted in a subcutaneous<br />
pocket <strong>of</strong> the chest.<br />
PAS port: This is totally<br />
implanted in a subcutaneous<br />
pocket either in the medial<br />
aspect <strong>of</strong> the upper arm or just<br />
above the antecubital space.<br />
<strong>The</strong> port may be square or<br />
circular with a metal base and<br />
silicone dome for venous<br />
access.<br />
Long Arm Catheters or<br />
PICC<br />
LAC Catheter: is white and<br />
may be either single or double<br />
lumen. <strong>The</strong> catheter is made<br />
<strong>of</strong> a silicone material. It is<br />
inserted through the basilic or<br />
cephalic vein and is threaded<br />
so that the tip lies in the<br />
axillary subclavian or superior<br />
vena cava.<br />
Exit site: is usually in the<br />
upper chest or in the neck.<br />
Purpose CVC: used for short-term (7-<br />
10 days) central line access.<br />
Hohn: used for intermediate<br />
length (up to 12 weeks)<br />
central line access.<br />
Exit site: is usually upper or<br />
mid-chest area.<br />
Used for long-term (months to<br />
years) central line access.<br />
Exit site: no exit site. Catheter<br />
is totally implanted and not<br />
seen<br />
Both used for long-term<br />
(months to years) central line<br />
access.<br />
Exit site: is just above or just<br />
below the antecubital space <strong>of</strong><br />
the arm.<br />
Used for intermediate length<br />
(months) venous access.<br />
See Long Arm Catheter<br />
Length Selection Guide.<br />
Used for the administration <strong>of</strong>:<br />
IV fluids, IV medications,<br />
parenteral nutrition, and blood<br />
products. Also can be used<br />
for blood drawing, and CVP<br />
monitoring.<br />
Used for the administration <strong>of</strong>:<br />
IV fluids, short and long term<br />
IV medications, parenteral<br />
nutrition and blood products.<br />
Can be used for blood<br />
drawing.<br />
Used for the administration <strong>of</strong><br />
IV fluids, short and long term<br />
IV medications, parenteral<br />
nutrition and blood products.<br />
Can also be used for blood<br />
drawing.<br />
*Long term infusions <strong>of</strong><br />
vesicant chemotherapy agents<br />
should not be given through<br />
ports.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 19 <strong>of</strong> <strong>25</strong>
Type <strong>of</strong> Lines<br />
Lumen or Port Size<br />
Subclavian catheters:<br />
• CVC Catheter<br />
• Hohn Catheter<br />
CVC Catheter:<br />
White port: 18G, dead space<br />
vol. 0.3cc<br />
Blue port: 18G, dead space<br />
vol. 0.36cc<br />
Brown port: 16G, dead space<br />
vol. 0.48cc<br />
Hohn Catheter:<br />
Red port: 16G (7Fr)<br />
White port: 18G (5Fr)<br />
CARE OF ADULT CENTRAL CATHETERS<br />
Long-Term External<br />
Catheter:<br />
• Hickman & Broviac<br />
• Groshong Catheter<br />
Hickman Catheter:<br />
Single lumen: 16G<br />
Double lumen: both at least<br />
16G, but the red port is<br />
slightly larger.<br />
Broviac Catheter:<br />
Single lumen: 18G<br />
Double lumen: both at least<br />
18G, but the red port is<br />
slightly larger.<br />
Venous Access Ports:<br />
• Port-A-Cath<br />
• PAS port<br />
Port-A-Cath: most are<br />
attached to at least a 26G<br />
catheter. Fill volume for both<br />
prot and catheter is 0.80cc<br />
PAS port: most are attached<br />
to at least an 18G catheter.<br />
Fill volume for both port and<br />
catheter is 0.73cc<br />
Long Arm Catheters or<br />
PICC<br />
May be either single or double<br />
lumen. Catheter sizes vary.<br />
Most range between 19 to 20G<br />
(3.0 to 5.0 Fr). <strong>The</strong> internal<br />
fill volume ranges from 0.04<br />
to 0.34 cc.<br />
Port Use<br />
CVC:<br />
White port: (proximal) use for<br />
maintenance solutions & IV<br />
meds.<br />
Blue port: (medial) use for<br />
nutrition.<br />
Brown port: (distal) use for<br />
blood draws or administration<br />
Groshong Catheter:<br />
Single lumen: 16G<br />
Double lumen: both at least<br />
16G, but the red port is<br />
slightly larger.<br />
Double lumen lines:<br />
White port: (proximal) use for<br />
nutrition, IV medications and<br />
maintenance fluids.<br />
Red port: (distal) use for blood<br />
draws or administration<br />
Double lumen ports:<br />
Some patients will have a<br />
double port placement. Use<br />
the larger port for blood<br />
administration and draws, the<br />
smaller port can be used for<br />
maintenance infusions, IV<br />
meds and nutrition.<br />
Double lumen lines:<br />
White port: (proximal) use for<br />
nutrition, IV medications, and<br />
maintenance fluids.<br />
Red port: (distal) use for blood<br />
draws or administration.<br />
Hohn Catheter:<br />
White port: (proximal) use for<br />
nutrition, IV medications,<br />
maintenance fluids<br />
Red port: (distal) use for blood<br />
draws or administration.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 20 <strong>of</strong> <strong>25</strong>
Type <strong>of</strong> Lines<br />
Irrigation: use Heparin flush<br />
concentration <strong>of</strong> 100U/cc.<br />
Patients receiving excessive<br />
flushes, Heparin 10U/cc may<br />
be used<br />
To avoid reflux, maintain<br />
positive pressure in line<br />
Clamp line as irrigation is<br />
completed.<br />
To avoid catheter rupture, do<br />
not exceed pressure <strong>of</strong> 30 PSI.<br />
Use a 10 cc syringe to irrigate.<br />
Subclavian Catheters:<br />
• CVC Catheter<br />
• Hohn Catheter<br />
Maintenance Flush:<br />
CVC: Heparin flush 1cc/port<br />
q24 hours.<br />
Hohn: Heparing flush<br />
2cc/port q24 hours<br />
Medications: 10cc flush with<br />
NS before and after<br />
medication. Follow with<br />
Heparin flush (CVC 1cc/Hohn<br />
2cc).<br />
TPN: 20cc flush with NS<br />
followed by Heparin flush<br />
(CVC 1cc/Hohn 2cc)<br />
Blood in Tubing: with any<br />
blood draw or administration,<br />
flush with 20cc NS followed<br />
by Heparin flush (CVC<br />
1cc/Hohn 2cc).<br />
CARE OF ADULT CENTRAL CATHETERS<br />
Long-Term External<br />
Catheter:<br />
• Hickman & Broviac<br />
• Groshong Catheter<br />
Maintenance Flush:<br />
Hickman/Broviac: Heparin<br />
flush 3cc q24 hours.<br />
Groshong: vigorously flush<br />
10cc NS q7 days when not in<br />
use.<br />
Medications:<br />
Hickman/Broviac: 10cc flush<br />
with NS before and after<br />
medis followed by 3cc<br />
Heparin flush.<br />
Groshong: vigorously flush<br />
with 10cc NS before and after<br />
medications.<br />
TPN:<br />
Hickman/Broviac: flush with<br />
20cc <strong>of</strong> NS followed by 3cc<br />
Heparin flush.<br />
Groshong: vigorously flush<br />
with 20cc NS before and after<br />
TPN.<br />
Blood in Tubing:<br />
Hickman/Broviac: flush with<br />
20cc <strong>of</strong> NS followed by 3cc<br />
Heparin flush.<br />
Groshong: vigorously flush<br />
with 20cc NS before and after<br />
Venous Access Ports:<br />
• Port-A-Cath<br />
• PAS port<br />
Maintenance Flush:<br />
Heparin flush 500U/5cc NS<br />
q4 weeks when not in use.<br />
Medications: 10cc NS flush<br />
before and after medications<br />
followed by a 5cc Heparin<br />
flush. (Home infusion may<br />
use 5cc NS flush the Heparin)<br />
TPN: Flush with 20cc NS<br />
followed by 5cc Heparin<br />
flush.<br />
Blood in Tubing: with any<br />
blood draw or administration,<br />
flush with 20cc NS followed<br />
by 5cc Heparin flush.<br />
Long Arm Catheters or<br />
PICC<br />
Maintenance Flush:<br />
If Bard PICC: Heparin flush<br />
2cc q8-12 hours.<br />
If Boston Scientific PICC:<br />
20cc NS flush q12 hours.<br />
Medications: If Bard PICC:<br />
20cc flush with NS before and<br />
after medications followed by<br />
a 2cc Heparin flush.<br />
If Boston Scientific PICC:<br />
flush with 20cc NS.<br />
TPN: If Bard PICC: flush<br />
with 20cc NS followed by 2cc<br />
Heparin flush.<br />
If Boston Scientific PICC:<br />
flush with 20cc NS.<br />
Blood in Tubing: If Bard<br />
PICC: with any blood draw or<br />
administration, flush with<br />
20cc NS followed by 2cc<br />
Heparin flush.<br />
If Boston Scientific PICC:<br />
flush with 20cc NS.<br />
LACs become clotted very<br />
quickly if not flushed within<br />
5 minutes <strong>of</strong> completion <strong>of</strong><br />
IVPB.<br />
Important to use 10cc or<br />
larger syringe when flushing<br />
or withdrawing blood.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 21 <strong>of</strong> <strong>25</strong>
Type <strong>of</strong> Lines<br />
Blood Drawing<br />
Subclavian Catheters:<br />
• CVC Catheter<br />
• Hohn Catheter<br />
CVC: Use brown port<br />
Hohn: Use red port<br />
CARE OF ADULT CENTRAL LINE CATHETERS<br />
Long-Term External<br />
Catheter:<br />
• Hickman/Broviac<br />
• Groshong Catheter<br />
Hickman/Broviac: use red<br />
port (if double lumen)<br />
Groshong: use red port if<br />
double lumen; may access the<br />
line hub-to-hub as opposed<br />
Venous Access Ports:<br />
• Port-A-Cath<br />
• PAS port<br />
Use a 19 or 20 G non-coring<br />
(Huber) needle for port access<br />
Long Arm Catheters or<br />
PICC<br />
LAC or PICC should be at a<br />
3.0 Fr or larger.<br />
A 10cc NS flush prior to<br />
blood draw would be helpful<br />
through interlink.<br />
Stop all infusions. Using a needleless system, aspirate 6cc <strong>of</strong> blood (2cc for LAC and midlines) in syringe and discard. In second syringe, aspirate the amount<br />
needed for the specimen and place in a blood tube. Vigorously flush line immediately with 20cc NS and appropriate amount <strong>of</strong> Heparin (if indicated) as directed<br />
under irrigation section.<br />
Blood Administration<br />
CVC: use the brown port<br />
Hohn: use red port<br />
Hickman/Broviac: use red<br />
port (if double lumen)<br />
Use a 19 or 20 G non-coring<br />
(Huber) needle for port access.<br />
LAC or PICC: Use at least a<br />
3.0 Fr or larger. <strong>The</strong>se are not<br />
optimal gauge given long<br />
lengths.<br />
Administer blood through the needleless injection cap with a needless syringe cannula. After transfusion, vigorously flush catheter with 20cc NS and appropriate<br />
amount <strong>of</strong> Heparin (if indicated) as directed in the irrigation section.<br />
Catheter Access<br />
All central lines should have a needleless cap on each access port. Only access<br />
the lines through the injection cap, with a few exceptions. <strong>The</strong> injection cap<br />
should be cleaned with alcohol for 60 seconds prior to access. Use only a<br />
needleless syringe cannula to access the injection.<br />
Cap Changes<br />
For venous access ports, use only a non-coring (Huber) needle. See venous<br />
access attachment.<br />
Frequency <strong>of</strong> cap changes: for all types <strong>of</strong> lines, needleless injection caps should<br />
be used on all ports. Caps should be changed every 72 hours (3 days) or PRN.<br />
If a hub-to-hub access is done for a blood draw or CVP reading, a new injection<br />
cap should be placed on the line when finished. In the home setting, cap changes<br />
should occur once a week.<br />
Changing the cap: clamp all lines (except Groshong). Prep the cap/catheter hub<br />
with a 60 second chloraprep scrub. Remove the old cap and apply new cap using<br />
sterile technique. Unclamp the line (if in use) and place a courtesy tab on the<br />
cap/hub. Be sure to date, time and initial the cap changed on the courtesy tab.<br />
Clave Adapter special note: Clamp venous access device before final syringe <strong>of</strong><br />
flushing solution used. Betadine should never be used to cleanse the Clave<br />
Adapter. Cleanse it with alcohol or chloraprep, only.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 22 <strong>of</strong> <strong>25</strong>
ATTACHMENT G: QUICK REFERENCE FOR VADs<br />
VADS FLUSHING DRESSING CHANGE CAP CHANGE REPAIR KIT<br />
Hickman/Broviac<br />
3 cc Heparin flush (10 u/cc) q Every seven days or as needed. Every 2 weeks or after 50 Yes<br />
24 hr or after each use<br />
sticks whichever comes first.<br />
Groshong<br />
5 cc NaCl q 7 days or after Every seven days or as needed. Every 2 weeks or after 50 Yes<br />
each use.<br />
sticks whichever comes first.<br />
Hohn<br />
3 cc Heparin flush (10 u/cc) q<br />
12 hour or after each use.<br />
Once daily for life <strong>of</strong> catheter<br />
(these stitches do not come<br />
Every 2 weeks or after 50<br />
sticks whichever comes first.<br />
No<br />
PICC<br />
Port-A-Cath<br />
P.A.S. Port<br />
If Bard PICC: 2 cc heparin<br />
flush (100 u/cc) q 12 hour or<br />
after each use (if a Groshong<br />
PICC line use 20 cc <strong>of</strong> NaCl<br />
after each use or q 7 days).<br />
If Boston Scientific PICC:<br />
20cc NaCl flush<br />
5 cc Heparin flush (100 u/cc) q<br />
4 weeks or after each use. If<br />
Groshong port-a-cath, flush<br />
with 20 cc NaCl q 4 weeks or<br />
after each use.<br />
Flush with Heparinized saline<br />
10 u/cc (5cc) after each use<br />
when Heparin locked; when<br />
not in routine use flush with<br />
heparinized saline 100 u/cc (5<br />
cc) q 4 weeks<br />
out).<br />
Transparent dressing change<br />
24-hour post insertion by a<br />
PICC team member, then q 7<br />
days. If gauze dressing is used<br />
then q 48 hours (stitches do not<br />
come out if sutured). Any RN<br />
may change the PICC dressing<br />
after the initial dressing<br />
change at 24hrs.<br />
No dressing needed after site<br />
heals.<br />
If Heparin locked change q 48<br />
hours for gauze dressing and<br />
every seven days for occlusive<br />
dressing.<br />
No dressing needed after site<br />
heals.<br />
If Heparin locked change q 48<br />
hours for gauze dressing and<br />
every seven days for occlusive<br />
dressing (non-coring needle is<br />
changed q 5 days).<br />
Every 7 days<br />
Every 5 days if Heparin<br />
locked.<br />
Every 5 days if Heparin<br />
locked.<br />
No<br />
No<br />
No<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 23 <strong>of</strong> <strong>25</strong>
ATTACHMENT H: CARE OF THE VASCULAR ACCESS DEVICE IN THE<br />
POST ANESTHESIA CARE UNIT (PACU)<br />
All Central Venous Catheters placed in the OR by the Anesthesia staff or the surgeon will<br />
have a stat chest x-ray done in the PACU to confirm placement without complication. Chest x-<br />
ray for central venous catheter placement will be added to the anesthesia standing orders for<br />
PACU.<br />
PACU personnel will not use the line until verifying that an x-ray for placement without<br />
complication has been confirmed. DO NOT stop the infusion, but slow the infusion to a To<br />
Keep Open (TKO) rate until confirmation has been completed. Anesthesia staff will review x-<br />
ray for placement <strong>of</strong> the central venous catheter and inform the PACU nurse so the intravenous<br />
(IV) rate can be adjusted. Anesthesia staff will document on the PACU Physician Order Sheet,<br />
“Confirmation <strong>of</strong> catheter placement without complication, after review <strong>of</strong> x-ray”.<br />
Anesthesia may occasionally request that PACU continue to use the central line at current<br />
infusion rates, because no other IV access is available on <strong>this</strong> patient. PACU will document <strong>this</strong><br />
order on the anesthesia order form and in the nurses notes. <strong>The</strong> above protocol will be followed.<br />
All changes to the IV rates and confirmation <strong>of</strong> central line placement will be documented in<br />
the PACU nurse notes.<br />
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> 24 <strong>of</strong> <strong>25</strong>
_________________________________________________________________________________________________________________<br />
Title: Venous Access Device<br />
Owner: Clinical Education Department<br />
Effective Date: 07/27/05<br />
<strong>Page</strong> <strong>25</strong> <strong>of</strong> <strong>25</strong>