central venous catheters - Wirral University Teaching Hospital NHS ...

CENTRAL VENOUSCATHETERSClinical Education and DevelopmentTeamMay 2010 Review 2012Version 1

Housekeeping• Welcome and registration• Fire safety• Toilets• Facilities• Mobile Phones• Session PlanVersion 1

Why use a central line?• Poor peripheral venous access• Haemodynamic monitoring• Phlebitic drug administration• Haemodialysis/haemofiltration• Temporary cardiac pacing• Emergency access• TPN feedingVersion 1

Dangers of central lines• Infection• Cardiac arrhythmia• Air embolism syndrome• Damage to adjacent vital anatomical structures oninsertionVersion 1

Types of central lines• Single lumen• Multi-lumen• Dialysis line• PICC linesVersion 1

Sites for central lines• Internal jugular• Subclavian• Femoral• Peripheral (PICC)Version 1

Equipment needed• Customised CVC Insertion Pack & Pathway(Located in CEL or ward stock)• Packet of sterile gloves• Central venous catheter• 10ml Lignocaine 1 or 2% (local anaesthetic)• Optional mobile ultrasound (NICE guidelines)• Line flush (saline/hepsal/heparin)Version 1

Customised Insertion PackVersion 1

Key Points of Procedure• Maintain privacy and dignity• Always use an aseptic procedure• Only to be undertaken by a competent person• A competent assistant is required• Check APTT (

Key Points of Procedure• Ensure adequate monitoring ofhaemodynamic status (SaO2, ECG)• Explain procedure and gain consent• POST PROCEDURE CHEST X-RAY• Documentation – CVC Pathway and notingon PCIS (latter enables ‘tracking’)Version 1

PATIENT DETAILSCVC CAREPATHWAYName ……………………………C/S No…………………………..Date of Birth……………………Central Venous Catheter: Comprehensive Care DocumentPlease refer to 2 nd Page for complete user informationDate: ………… Time: ……… Location: ……… Urgency: Planned Urgent Resuscitative INDICATIONS(A) haemodynamic monitoring (C) peripheral access impossible (E) temporary cardiac pacing (B) phlebitic drug administration (D) haemodialysis/filtration (F) other ……………………………...(if applicable)Operator Name: Supervisor Name:(& Grade) ……………………………………………… (& Grade) …………………………………………LINE & SITETechnique: Fresh Puncture Site Guidewire Exchange Line Type: Single Lumen Multi-Lumen (……) Dialysis Gauge (………)Site inserted: Internal Jugular Subclavian Femoral Peripheral ……………………..R L (if device has identification sticker, please place in case sheet) Lot No. …………….………Reason for site: Dialysis ? Coagulopathy Dyspnoea Other …………….………ASEPSISOperator Asepsis: Hand Scrub Sterile Gown Sterile Gloves Patient Asepsis: Chlorhexidine 2% prep (in 70% Alcohol)Betadine prep (in Alcohol)(only if allergic to Chlorhexidine)Sterile Field Drapes Pathway MUST becommenced bythe personinserting the line.DETAILSConsent: Written Verbal Not obtainable Ultrasound: Anatomy check Visualised puncture Visualised wire insertion Not practical Un-available Line Inserted to: (……….) cm Suture: at Hub at Snap-fit Wing Unsutured Line-flush (or lock): 0.9% Saline Hepsal Heparin Other …………………………………..Dressing Applied: IV 3000 Tegaderm IV Variance ……………………………………………DIFFICULTYPatient Cooperation: Cooperative Restless Uncooperative Procedure Difficulty: Uncomplicated Challenging Unsuccessful (please detail)……………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………..OperatorSignature:……………………………………………………………………………………………………………….Check CXR: Not indicated Ordered CXR reviewed LINE POSITIONComment …………………………………………………………………………………………………….PCIS Identifier Signature ……………………………………………………………………….Version 1

Visual Exit Site Score (VES Score):0 1 2 3 4Looks healthyPainless puncture siteSmall Rim Erythema (10mm)plus any of the following:SwellingPainful puncture sitePUS exudateplus any of the following:Erythema (any)SwellingPainful puncture siteRAID Evaluation: [Complete I & D aspects once CVC removed]Required Appropriate Infection DressingDoes the patient still requirethe CVC ?Is the CVC suitable for theclinical indication ?Are any systemic markers ofinfection evident ?Tissue Defectplus any of the following:Erythema PusSwellingPainful puncture siteIs the dressing appropriate, intactand dated ?VES Score& RAIDEvaluationDay1DayDayDayDate …./…../……. 2 Date …./…../……. 3 Date …./…../……. 4 Date …./…../…….E VES Score ……… E VES Score ……… E VES Score ……… E VES Score ………ARLYLATERequiredAppropriateInfectionDressingY N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingY N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingY N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingY N Y N Y N Y N VES Score ……… VES Score ……… VES Score ……… VES Score ………RequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N N VES Score ……… N VES Score ……… N VES Score ……… N VES Score ………IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N Day5DayDayDayDate …./…../……. 6 Date …./…../……. 7 Date …./…../……. 8 Date …./…../…….E VES Score ……… E VES Score ……… E VES Score ……… E VES Score ………ARLYLATERequiredAppropriateInfectionDressingY N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingVersion 1Y N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingY N Y N Y N Y N ARLYRequiredAppropriateInfectionDressingY N Y N Y N Y N VES Score ……… VES Score ……… VES Score ……… VES Score ………RequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N LATERequiredAppropriateInfectionDressingY N Y N Y N Y N N VES Score ……… N VES Score ……… N VES Score ……… N VES Score ………IGHTDay9RequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N IGHTRequiredAppropriateInfectionDressingY N Y N Y N Y N DayDayDayDate …./…../……. 10 Date …./…../……. 11 Date …./…../……. 12 Date …./…../…….E VES Score ……… E VES Score ……… E VES Score ……… E VES Score ………ARRequiredAppropriateY N Y N ARRequiredAppropriateY N Y N ARRequiredAppropriateY N Y N ARRequiredAppropriateY N Y N

Catheter Related Blood StreamInfection(CR-BSI)• VES score is 2 or more• Pyrexia of unknown origin• Raised WCC & CRP• CVC inserted over 5 days ago• Take blood cultures from central line andperipheral• Senior experienced professional to decide onoptimum management for each caseVersion 1

Accessing the line…• Decontaminate hands as per Trust policy• ALWAYS USE ANTT® OR ASEPTIC TECHNIQUE• Always use a 10ml syringe• Disinfect hub/needle free system with 2%chlorhexidine/70% alcohol wipe & allow to dry• Flush line with 0.9% saline if required• Repeat disinfection, apply new luer-lock• Ensure that no lumen is left open to atmosphereVersion 1

Blood collection from lines..• Access as previous slide• For PICC lines - flush with 10mls saline priorto removing 10mls ‘dead space’ then collectblood• For other lines remove 10mls ‘dead space’then collect blood but if fluids are beinginfused 20mls ‘dead space’ should beremovedVersion 1

Dressings• ALWAYS USE ASEPTIC TECHNIQUE• Smith & Nephew IV 3000 ,Tegaderm IV or C-View• Change 24hrs after insertion and then if site is satisfactoryand dressing remains intact change every 7 days• Only change if dressing becomes non-adherent, moisturecollects beneath it, or site appears infected• In extreme circumstances of sweating/oozing, gauzedressings may be applied and secured with adhesive tape.These dressings must be changed every 24 hours or soonerif heavily soiled• Ensure dressings are labelled appropriately with date & timeVersion 1

IV Needle-free Devices andAdministration Sets• IV needle-free devices must be decontaminated with 2%chlorhexidine/ 70% alcohol wipe• Replace IV needle-free devices after one week or accordingto manufacturer instructions• Replace non-blood administration sets every 72 hrs• Replace blood administration sets every 12hrs or uponcompletion• Administration sets used for TPN should be replaced every24hrs• Ensure administration sets are date & time labelled• Replace all sets following disconnection from catheter hubVersion 1

Wirral University Teaching HospitalNHS Foundation TrustQuick Guide to Central VenousCatheter Insertion & Ongoing CareCentral venous catheters should always be inserted usingcustomised insertion pack.Enter insertion details onto PCIS via master guide andcommence CVC Comprehensive Care Document (CarePathway).Never access or manipulate line without disinfectinghubs/ports and needle-free devices with 2%chlorhexidine/70% alcohol.Time and date label on dressing. Always use aseptictechnique to change dressing.Record exit site observations on VESS chart and useRAID to evaluate if line still required.Audit daily and record High Impact Intervention onelectronic system.Line removal decision must be made by senior doctor.Exit site MUST be monitored and dressed as per CVCguideline instructions until exit site is fully healed.Version 1

Removal of central line• Review on daily basis• Removal decision must be made by senior, experiencedprofessional• Send line ‘tip’ for microbial culture (only if CR-BSI issuspected)• Correct positioning of patient & application of pressure for5 minutes post removal• Document removal details on Care Pathway• PCIS central line noting – remove via Master Guide• Dressing to be applied & exit site monitored until fullyhealed (document on care pathway)Version 1

How to access PCIS Removal• Select patient• Select Master Guide• Select ‘Central Line Removal’ or• Delete entry – flagged as ‘removed inerror’• Follow on screen instructions….Version 1

QUESTIONS?ANY ADVICE - CONTACT CRITICAL CARE OUTREACH TEAM EXT8196/ BLEEP 7044For Renal patients – John Casey & Moira SavageFor Haematology patients – Amanda Goodier & Maria ChapmanFor Nutrition/Surgical PICCs – Angela Kenyon/Amy CorissFor other PICCs – Donna Taylor CCU, Rebecca Holland Ward 34,Rebecca Close & Jennifer Rigby Ward 30, Sarah Bellis & Carol Wood X-Ray.Version 1

REFERENCES• Epic 2: National Guidelines for Preventing HAI’s in NHSHospitals in England. Pratt RJ et al (2007) Jnl Hosp Infection65:s1-s64• Saving Lives: Reducing infection, delivering clean and safecare: High Impact Intervention No1; DoH (2007)• ANTT: Aseptic Non-Touch Technique. Hart. S (2007) Usingaseptic technique to reduce risk of infection. Nurs.Stndrd. 21,47, p43-48Version 1