PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
TITLE
Clinical Guidelines for insertion and immediate care of a Central Venous
access device (CVAD) (adults )
MANAGER /
COMMITTEE
RESPONSIBLE
Sean Elliott. Anaesthetics Consultant
Barry Buchanan. IV Therapy Lead Nurse
DATE ISSUED
13.01.2009
VERSION
1
REVIEW DATE
January 2010
AUTHOR
Sean Elliott. Anaesthetics Consultant
Barry Buchanan. IV Therapy Lead Nurse
Equality Impact
Assessment has been
completed
Sean Elliott. Anaesthetics Consultant
Barry Buchanan. IV Therapy Lead Nurse
RATIFIED BY
Professional Advisory Committee – 07.01.2009
AMENDMENTS RECORD
DATE
PAGE
COMMENTS
APPROVED BY
CONTENTS:
1
2
3
4
5
6
7
8
9
INTRODUCTION
STATUS
PURPOSE
SCOPE
DEFINITIONS
CLINICAL PRACTICE GUIDELINE
SUPPORTING EVIDENCE
DUTIES AND RESPONSIBILITIES
TRAINING
APPENDICES:
APPENDIX I: AUDIT DOCUMENT 1
APPENDIX II: AUDIT DOCUMENT 2
APPENDIX III: Comment on NICE Technology Appraisal Guidance No. 49 on the use of
Ultrasound Locating Devices for Placing Central Venous Catheters
APPENDIX IV: CVC Insertion and Management Form
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
1. Introduction
Insertion of a CVAD is a procedure which while useful carries some significant risks. This policy includes
guidance from NICE and the CVC care bundle from the Institute for Healthcare Improvement to ensure that
the procedure is done by the right person, in the correct manner, in the right place using the correct
equipment.
Subsequent care of the CVAD is described in another policy by Simon Freathy.
2. Status
Clinical Guidelines for insertion and care of a Central Venous access device (CVAD) (adults)
3. Purpose
CVAD’s are inserted to provide central venous access for either diagnostic or therapeutic purposes.
Indications;
a)
Longer term intravenous fluid or drug therapy (usually for more than 3-4 days).
b)
Monitoring central venous pressure in seriously ill or physiologically unstable patients
c)
Parenteral nutrition and infusion of other substances that need diluting in the central circulation
(chemotherapeutic agents, hyperosmolar solutions, inotropes and vasopressors etc).
d)
Specialised uses e.g. haemodialysis, plasmapheresis
Complications include thrombosis, pain, local or systemic infection, catheter embolism, pneumothorax,
haemorrhage, cardiac tamponade and dysrhythmias.
These clinical guidelines outline how these risks to patients may be reduced.
4. Scope
These guidelines apply to all health care professionals inserting and managing CVAD’s in the Trust.
For Central Venous cannulation in paediatric areas, please refer to “Clinical Guidelines for Central Venous
Cannulation (paediatrics)”
For Peripherally-inserted Central Catheters (PICC lines) please refer to Peripherally-inserted Central
Catheters (ADULT)
This document does not refer to cardiac catheterisation or pacemaker insertion.
5. Definitions
Central venous access device
A vascular access device, the tip of which is placed in one of the great veins, for one of the above
indications.
Health care professional
A registered or trained member of staff, including but not exclusively nurses, doctors and operating
department practitioners.
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
6. Clinical Practice Guideline
Action
Identify patient and discuss with patient the need for a
CVAD, obtaining consent for procedure, establishing
whether patient has any known allergies or
contraindications to CVAD insertion.
The individual inserting the CVAD will have been
appropriately trained in the landmark and/or ultrasound
technique.
Where possible, ultrasound imaging guidance should be
used as the technique of choice for insertion of CVAD’s
into the internal jugular vein in adults.
Except in cases of emergency insertion, and according
to clinical judgement, areas such as treatment rooms or
operating theatres will be used for line insertion.
The Trust CVAD (or CVC) pack will be used for the
insertion of CVADs. In general, a line with the minimal
number of lumens required should be used.
Choose appropriate insertion site, weighing up risks and
benefits. Consider that line infection rates seem to be
lower with subclavian vein placement.
Full barrier asepsis will be used for line placement,
including surgical scrub technique, sterile gown and
gloves. Skin will be prepared with 0.5% chlorhexidine in
70% alcohol unless the patient is allergic to this solution
when iodine may be used.
A Chest X-ray is required for subclavian and internal
jugular lines.
By employing an appropriate level of monitoring, ensure
that the patients’ condition has not changed during the
CVAD insertion procedure, in particular be vigilant for
signs of pain, abnormal swelling, excessive bleeding,
respiratory distress, cardiac arrhythmias, hypotension,
syncope etc.
On each line insertion, a Trust audit form will be
completed as part of Daily care bundle form. These
forms will form the clinical documentation for line care.
(See attached form).
The insertion procedure should be documented in the
patient’s notes (including the date, time and location,
the insertion site, use of ultrasound, the name and
grade of the operator, details of the skin preparation
and anaesthetic used the type of line and length
inserted the lot number of the CVAD and the results of
the CXR.
Where possible patients with CVADs should be nursed
in higher dependency areas.
Patients with CVADs will be reviewed regularly by the Iv
Therapy Team
Nurses caring for patients with CVADs should be
familiar with the appropriate policy. The “Daily checklist”
for line care will be completed for each patient. Nursing
staff are encouraged to challenge the need for a CVAD
in a patient. The nurse will contact the Iv Therapy
Team.
Control Date: 05/02/16
Rationale
To ensure patient is informed of procedure and that the risk of CVAD
insertion is balanced against the clinical benefit.
The operator will be familiar with the appropriate technique and
potential complications of CVAD insertion.
To be compliant with NICE guidance September 2002.
To perform the procedure safely and in a sterile manner, demands
adequate space, lighting and level of cleanliness.
The pack has been designed to offer best value, ease of use and
optimal sterility for the procedure. Unused lumens are associated with
increased risk of line infection.
Optimum site will vary dependant upon both patient factors and
operator factors.
To reduce risk of infection to patient, and risk of exposure of operator to
blood-borne pathogens.
To ensure correct placement and check for complications such as a
pneumothorax
Complications include thrombosis, pain, local or systemic infection,
catheter embolism, pneumothorax, haemorrhage, cardiac tamponade
and dysrhythmias
Documentation will improve infection control surveillance, act as audit
tool and trigger patient visits by the Iv Therapy Team.
To provide evidence of the intervention for subsequent reference.
The incidence of line sepsis increases as the intensity of nursing care
reduces.
The activity of such teams has been shown to reduce line infection
rates.
The incidence of line sepsis increases with the length of time it is in
place.
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PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
7. Supporting evidence
Centers for disease control and prevention (2002) Guidelines for the prevention of intravascular catheterrelated infections.
Institute for Healthcare Improvement (2007) Central line care bundle (www.ihi.org)
NICE (2002) Guidance on the use of ultrasound locating devices for placing central venous catheters
Portsmouth Hospitals NHS Trust (2006) Advice for Medical Staff on Good Practice in Infection Control
Maki D G et al (1991) Prospective randomised trial of povidone iodine, alcohol and chlorhexidine for
prevention of infection associated with CVC and arterial catheters Lancet 338, 339 - 43
8. Duties and responsibilities
Supervisors of clinical practice will be responsible for monitoring compliance with the guidelines on an
ongoing basis.
The Intravenous therapy Nurses will audit compliance as part of the infection control clinical practice audit
process.
A snapshot audit to monitor clinical practice during CVAD insertion and subsequent care will be undertaken
annually.
9. Training
Prior to undertaking any CVAD insertion procedure, staff must be able to demonstrate clinical competence
and a clear understanding of the underlying principles of practice. This will be achieved by:
Medical staff;
PRHO’s and SHO’s should be trained by recognised Trust trainers on local guidelines and principles of
practice.
Specialist Registrars will be assumed competent unless identified otherwise by their supervisor. If problems
are identified, the staff member will be required to complete a period of supervised clinical practice.
Ultrasound guidance
There are lead clinicians in each clinical area to provide training in the use of this technique. Individuals will
have attended this training and/or attended an external course before using Ultrasound guidance for line
insertion.
Control Date: 05/02/16
Page 4 of 8
PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
APPENDIX I: AUDIT DOCUMENT 1
The aim of this audit document is to establish levels of familiarity with the Portsmouth Hospitals Central
Venous Cannulation policy and to assess compliance with said policy on a “snapshot” basis. The intention is
to perform this audit snapshot annually and to use the results to guide future educational interventions.
The standard that should be achieved is 100% compliance in all clinical areas.
For each observed / performed CVAD insertion;
Location / Ward area ……………………………………………………….……….
Grade of Operator ………………………………………………………………….
Indication for CVAD insertion ………………………………………………………
Type of CVAD .………………………………………………………………………
Explanation of procedure to patient
Yes / No / N/A
Surgical Scrub Yes / No
Skin preparation solution …………………………………………………………..
Ultrasound localisation used
yes / no
Successful insertion of CVAD Yes / No
Number of attempts …………………………………………………………………
Action taken if failed ………………………………………………………………..
Type of fixation ………………………………………………………………………
Appropriate sharps precautions demonstrated Yes / No
Application of dressing Good / Bad
Documentation in notes Yes / No
Comments and agreed action:
Completed by:
Date
Control Date: 05/02/16
Page 5 of 8
PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
APPENDIX II: AUDIT DOCUMENT 2
The aim of this audit document is to establish levels of familiarity with the Portsmouth Hospitals Central
Venous Cannulation policy and to assess compliance with said policy on a “snapshot” basis. The intention is
to perform this audit snapshot annually and to use the results to guide future educational interventions.
The standard that should be achieved is 100% compliance in all clinical areas.
For each “in situ” CVAD in the clinical area;
Location / Ward area ……………………………………………………….……….
Indication for continuing CVAD …....………………………………………………
Type of CVAD ……………………………………………………………………….
State of dressing Good / Bad
Documentation in notes referring to CVAD in last 24hrs Yes / No
Comments and agreed action:
Completed by:
Date
Control Date: 05/02/16
Page 6 of 8
PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
APPENDIX III: Comment on NICE Technology Appraisal Guidance No. 49 on the use of Ultrasound Locating
Devices for Placing Central Venous Catheters
There are a growing number of clinicians who believe that, given appropriate equipment and training, the use
of 2D ultrasound represents a major advance in the safety of central venous cannulation. NICE reviewed the
available literature and produced a guidance document in 2002.
A number of medical bodies responded in the consultation period by raising concerns that a recommendation
to always use 2D ultrasound would produce major problems as follows:
1. Subsequent failure to use 2D ultrasound could have major medico-legal implications.
2. In certain situations such as ITU or theatres, serious delays in instigating monitoring and subsequent
treatment could occur.
3. It is relatively impractical in the emergency situation.
4. It would result in deskilling with regard to use of the landmark technique.
5. There would be a significant financial burden on the Trust, since a large number of machines would be
required (20-30) and training would be necessary for all users.
The NICE guidance acknowledges these concerns as follows;
Two-dimensional (2-D) imaging ultrasound guidance is recommended as the preferred method for insertion of
central venous catheters (CVC’s) into the internal jugular vein (IJV) in adults and children in elective
situations.
The use of two-dimensional (2-D) imaging ultrasound guidance should be considered in most clinical
circumstances where CVC insertion is necessary either electively or in an emergency situation.
4.3.3
4.3.5
4.3.6
7.6
Given the constraints outlined in 4.2.2, the Committee concluded that there was evidence of both the
clinical and cost effectiveness of 2-D imaging ultrasound guidance as an adjunct for placing CVC’s in
the majority of clinical scenarios, but that the degree to which this technology would be most
suitably applied would vary according to the clinical situation and the competence/previous
experience of the operator. In addition, there could be potential benefits for patients arising from
reduced discomfort from the procedure and reduced risk of complications compared with the landmark
method, particularly for IJV insertions.
While accepting that, from a patient’s perspective, 2-D ultrasound imaging guidance in CVC insertion
might be more appropriate and probably superior to the traditionally used landmark method in many
circumstances, the Committee also considered the financial and service implications of purchasing
the required equipment and of training sufficient numbers of competent practitioners.
The Committee also considered that although 2-D ultrasound imaging guidance in CVC placement
may eventually become the routine method for placing CVC’s, the landmark method would remain
important in some circumstances, such as emergency situations, when ultrasound equipment and/or
expertise might not be immediately available. Consequently, the Committee thought it important that
operators maintain their ability to use the landmark method and that the method continues to be
taught alongside the 2-D-ultrasound-guided technique.
Healthcare practitioners should consider the most appropriate method of CVC insertion that is in the
best interest of the patient in his or her specific clinical situation, particularly in terms of minimising the
risk of adverse events such as failed catheter placements or catheter placement complications. Trusts
should recognise that the decision to use 2-D imaging ultrasound guidance or the landmark method
will be informed by:
Control Date: 05/02/16
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PORTSMOUTH HOSPITALS NHS TRUST
Multi-Professional Guidelines
Insertion and care of a Central Venous access device (CVAD) (adults) Issue 1. 13.01.2009
APPENDIX IV: CVC Insertion and Management Form
IV team contacted
(Bleep 1494)
YES / NO
(please delete as appropriate)
Control Date: 05/02/16
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