CMB/OncCNS/CVC guidelines07 1

1.0
Introduction
2.0
Patient information
2.1
Showering
2.2
What
3.0
Flushing
4.0
Dressing
5.0
Non
5.1
Dressing change
5.2
Bung change
5.3
Flushing
6.0
Implantable PORTS
6.1
flushing
6.2
Blood sampling
6.3
De – accessing
3
3
4
4
5
6
8
9
10
CMB/OncCNS/CVC guidelines07 2

1.0
Introduction.
Definition: A Central Venous Catheter (CVC) is a device with the tip placed ideally in the lower third of the superior vena cava (SVC).
There are a variety of Central Venous Catheters in use within BHOC:
These include:
•
Tunnelled Central venous cuffed catheters (e.g. Hickman Groshong and
Apheresis)
•
Non tunnelled central venous catheter (e.g. CVP, Vas Cath)
•
Peripherally inserted central catheters (PICC lines)
•
Totally implantable intravascular devices. (Ports)
Lines can be open or closed ended. The open ended lines are recognisable by the external clamp which will need to be released prior to the line being accessed and then clamped once the line has been flushed. The Groshong®-valved line does not have a clamp but has a three-way valve at the internal tip of the catheter. Please refer to the medical notes for information on the type of device that has been inserted.
Once a Central line is in place, it needs to be looked after carefully, to help prevent complications from occurring. These guidelines are based on the evidence in the epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated
Infections in NHS Hospitals in England.
The line should be dressed cleaned and flushed by a competent member of nursing staff. However if preferred and appropriate, a District Nurse / Practice Nurse / friend or relative may be trained to look after the line in the community. The dressing and flushing of a line would normally be done at the same time.
2.0
Patient Information
2.1
Showering and bathing
Patients should be advised to shower rather than bath. The line will be covered with a semi-waterproof dressing which can remain in place during showering however if the line is submerged in water then the risk of infection is increased.
2.2
What to avoid
Patients should be advised to avoid swimming as this increases the risk of infection.
Patients should also avoid hobbies and sports which involve repetitive arm movements for instance golf, fly-fishing, painting and decorating, bell-ringing, racket sports.
CMB/OncCNS/CVC guidelines07 3

3.0
Flushing
The table below shows the timings and solutions required to flush a CVC.
A 10ml syringe is the minimum syringe size to be used with all Groshong®-valved central venous access devices. (To prevent excess pressure within the lumen). BARD lines cannot be used for administering CT contrast due to pressure.
If a central venous access device has more than one lumen, then each lumen must be treated as a separate line.
See Standard Operating Procedure for Heparin usage in Hickman Apheresis and Vas Cath lines.
Groshong-valved line, no external clamp
(skin tunnelled or PICC)
- 10mls sodium chloride
0.9%
- do not need to remove residual saline before next use.
- weekly flush when not in use
Open-ended line with external clamp
(Standard Hickman,
Broviac, CVP, Cook)
- 10mls sodium chloride 0.9% flush then 5mls heparinised saline 10u/ml to lock into line. (eg hepsal)
- do not need to remove residual hepsal before next use.
- weekly flush when not in use.
Wide-bore open-ended line with external clamp
(Hickman Apheresis,
Vas Cath,)
- 10mls sodium chloride
0.9% flush then lumen volume of heparin
1000u/ml to lock into line.
- remove residual heparin prior to next use
- weekly flush when not in use.
Implantable Port
(Bard PORT)
- 20mls sodium chloride
0.9% flush and 5mls heparin 100u/ml to lock into line (eg hepflush)
- remove 10mls heparin/blood prior to next use
- monthly flush when not in use.
4.0
Dressing:
Assess the exit site in the first 24-48 hours post insertion, for redness movement leaking and bleeding and redress. Thereafter line dressings should be carried out according to table below or sooner if the dressing becomes dislodged or an accumulation of blood, fluid or moisture is observed.
During all dressing changes, assess the external length to determine if migration/withdrawal has occurred (excluding PORT).
Non-tunnelled
(CVP Vas Cath)
- clean with Chlorhexidine
2% solution (Chloroprep)
- IV 3000
- daily if neutropenic / haematology patients or
- every 5 days
- patients should not go home with these lines in situ
Tunnelled
(Hickman, apheresis, groshong)
- clean with
Chlorhexidine 2% solution (Chloroprep)
- IV 3000
- weekly
Dressings can be carried out at home by a trained relative or community staff following guidelines.
Entry sutures can be removed after 5 to 7 days. Exit sutures should be left insitu on
Haematology patients, other patients may have sutures removed after 3 weeks when the cuff has grown in. A Statlock may then be used
PICC
(groshong, Vygon)
- clean with
Chlorhexidine 2% solution (Chloroprep)
-IV 3000
-Steristrips
-Statlock device
- weekly
- dressings can be carried at home by a trained relative or community staff following guidelines.
Implantable Port
(Bard PORT, Port-acath)
- access with gripper needle and extension set
(see guidelines)
-clean with
Chlorhexidine 2% solution (Chloroprep)
- gauze and tape (change everyday) or
- IV 3000 (change every
5 days) patients should not go home with gripper needles in situ
-When not accessed no dressing is required.
CMB/OncCNS/CVC guidelines07 4

Non Touch techniques with sterile gloves should be used in:
The setup and connection of TPN
Dressing change prior to exit site healing
Removal of bungs
Accessing a Port a Cath
Repair of CVC
Undertaking any prolonged procedure
5.1 Non Touch Technique with sterile gloves
A step by step guide : Dressing change
1.
All watches and rings, except wedding ring must be removed.
2.
Explain procedure to patient.
3.
Wash and dry hands thoroughly
4.
Put on clean disposable apron.
5.
Prepare equipment and dressing trolley. a.
Clean Trolley b.
Dressing pack containing swabs c.
Chlorhexidine 2% solution (Chloroprep) d.
Non sterile gloves e.
Sterile gloves f.
IV3000 g.
Tape measure if required h.
Steristrips and statlock if required.
6.
Open sterile dressing pack and other equipment onto clean surface taking care not to contaminate during procedure.
7.
Place yellow waste bag on side of trolley.
8.
Put on non sterile gloves and carefully remove the existing dressing. Avoid tugging or moving the position of the line and avoid the use of scissors or other sharp instruments.
9.
Observe exit site for signs of redness, swelling or oozing. Notify a member of the medical team if such symptoms are apparent and take swab prior to cleaning.
10.
Assess the distance of line from exit point to the distal end of bung. Either through measuring or observation.
11.
Wash hands and put on sterile gloves.
12.
Place sterile paper towel under line (under arm if PICC)
13.
Clean site with Chlorhexidine 2% solution (Chloroprep), starting at the exit site and spiralling outwards using cleaning sponges from dressing pack or gauze and forceps.
14.
Allow cleaning agent to dry.
15.
If Statlock device is insitu ensure it is firmly attached. Change if necessary. NB A statlock device should only remain insitu for a maximum of 3 weeks.
16.
Apply IV3000 dressing. (PICC: Leave bung exposed if line is to be accessed prior to next dressing change)
17.
Dispose of equipment and document
CMB/OncCNS/CVC guidelines07 5

5.2 A step by step guide : Bung change
Non Touch Technique with sterile gloves
The Vygon needlefree bung should be changed every 3 weeks or after 100 uses.
•
Bung change may be done prior or during dressing change.
•
If bung is covered under a dressing then follow guide to dressing change to expose bung.
•
Wearing sterile gloves and maintaining a Non Touch technique hold the end of the line with a square of sterile gauze.
•
Remove old bung
•
Clean hub of catheter with a 2% Clorhexidine/Alcohol swab
•
Allow to air dry
•
Secure new bung to end of line.
CMB/OncCNS/CVC guidelines07 6

5.3 A step by step guide : Flusing and blood sampling
Non Touch Technique with sterile gloves
See Standard Operating Procedure for Heparin usage in Adult Hickman
Apheresis and Vas Cath lines.
•
All watches and rings, except wedding ring must be removed.
•
Explain procedure to patient.
•
Wash and dry hands thoroughly
•
Put on clean disposable apron.
•
Prepare equipment and dressing trolley or tray o Sterile field/IV access pack o Sterile paper towel o Sterile gloves o 2% Clorhexidine/Alcohol swab o Luer lock syringes o Flushing solution (See table for flushing lines) o Gauze
•
Flushing may be done during dressing change.
•
If bung is covered under a dressing then follow guide to dressing change to expose bung.
•
Open-ended lines will need the clamp released before the line can be used.
•
Open sterile field/IV access pack and other equipment taking care not to contaminate during procedure
•
Put on sterile gloves
•
Place sterile paper towel under central line (Under arm if PICC)
•
Holding the end of the line with a square of gauze so as to maintain a non touch technique, clean the bung thoroughly with 2% Chlorhexidine/Alcohol swab and allow to air dry.
•
Continuing to maintain a non touch technique, connect the empty 10ml luer lock syringe directly onto the bung. Aspirate blood back from the line to determine accurate position. (See table for flushing lines)
(NB this may not always be possible and it may be necessary to flush the line first with a few mls of
N/Saline. If there are difficulties with aspiration of blood please refer to the local policy for
‘management of a totally occluded central catheter or persistent withdrawal occlusion’).
•
BLOOD SAMPLING . At this point bloods may be taken.
o Continuing to maintain a non touch technique, connect one empty 10ml luer lock syringe onto the bung and attempt to aspirate blood back from the line. Continue to aspirate slowly until
5ml of blood is obtained (Not including any heparin that is removed). Remove syringe and discard. (Large lumen lines will require 10mls of blood to be discarded.) o Once blood has been discarded, clean the end of the bung with a 2% Chlorhexidine/Alcohol swab. Continuing to maintain a non touch technique, connect a 2nd empty 10ml luer lock syringe onto the bung and aspirate the necessary amount of blood for testing o Transfer aspirated blood to vacutainer bottles ( Vacutainer system should be used at all times if possible. If blood is being transferred via a syringe, remove blood bottle lid to allow a needlefree transfer.) o At the end of the procedure, ensure that the bung is cleaned with a 2% Chlorhexidine/Alcohol swab and change gauze if blood stained.
NB. If taking blood for cultures, it is important that 20mls of blood is taken and not wasted but placed directly into the culture bottles.
•
Once blood has been aspirated, clean the end of the bung with a 2% Chlorhexidine/Alcohol swab.
Continuing to maintain a non touch technique, connect the saline filled 10ml luer lock syringe directly onto the bung and flush with short ‘pulsating’ bursts. Maintain positive pressure on the end of the syringe as the flush comes to an end and untwist to remove.
•
Lock line and close clamp if necessary (see flushing table and SOP for Heparin usage)
CMB/OncCNS/CVC guidelines07 7

6.0
Implantable PORTs
The following guidance is for the accessing and flushing of all PORTs
Once accessed the PORT can be used to infuse virtually all I.V solutions. 10mls of saline should be used to flush between different infusates to prevent interactions occurring within the PORT. To prevent clot formation and catheter blockage, the
PORT should be filled with heparin solution after each use. (See table on flushing and dressing lines) The gripper needle should be changed every 7 days or sooner if local inflammation is evident.
6.1 A step by step guide Accessing and flushing implantable PORTS ,Bard Ports
Non Touch Technique with sterile gloves
•
Explain procedure to patient
•
Wash hands thoroughly and put on clean apron
•
Prepare equipment and dressing trolley (or 2 blue trays) o Equipment needed: o Sterile dressing pack/IV access pack o Sterile Latex-free gloves (powder free) o 2% Chlorhexidine/Alcohol swab. o Gripper Needle (20g x 19mm) with integral extension o 10ml luer lock syringe x 1 o 20mls syringe of 0.9% sodium chloride o 5ml syringe of 0.9% sodium chloride (to prime the gripper needle) o 5ml syringe of heparin solution 100 units/ml (hepflush) o Gauze squares tape or IV3000 for dressing o New bung i.e. Bionector – to be changed every 7 days
•
Open sterile dressing pack and other equipment onto clean surface of dressing trolley or into clean blue tray
•
Place yellow clinical waste bag in side of trolley
•
Wash hands and put on sterile latex-free gloves
•
Fit bung to the gripper needle extension set, and prime line with saline
•
Clean the area with Chlorhexidine 2% solution (Chloroprep), in a circular motion from inside out for three minutes. Allow to dry
•
Locate PORT by palpation and secure between thumb and first two fingers of non-dominant hand.
Hold needle firmly in other hand and insert vertically into the PORT until contact is made with the metal base of the port.
•
Connect syringe to extension tube and unclamp tube.
•
Verify correct needle placement by aspiration. Discard at least 8mls of the heparin lock and blood.
•
Once blood has been aspirated, clean the end of the bung with a 2% Chlorhexidine/Alcohol swab.
Maintaining a no touch technique, connect the saline filled 20ml luer lock syringe directly onto the bung and flush with short ‘pulsating’ bursts. Maintain positive pressure on the end of the syringe as the flush comes to an end clamp and untwist to remove. The PORT is now ready to use.
•
If the PORT is not going to be used IMMEDIATELY the heparin lock needs to be instilled. Continuing to maintain a no touch technique, connect the 10ml luer lock syringe containing the ‘5mls of Heparin’ and flush once more with short ‘pulsating’ bursts. Maintain positive pressure on the end of the syringe as the flush comes to an end and clamp and untwist to remove.
•
Dispose of all equipment as per local policy
CMB/OncCNS/CVC guidelines07 8

A step by step guide Blood sampling implantable PORTS ,Bard Ports
Non Touch Technique with sterile gloves
•
Explain procedure to patient
•
Wash hands thoroughly and put on clean apron
•
Prepare equipment and dressing trolley (or 2 blue trays) o Equipment needed: o Sterile dressing Pack/IV access pack o Sterile latex-free gloves (powder free) o 10ml luer lock syringe x 2 o 20mls 0.9% sodium chloride o Heparin lock 5ml of heparin solution 100 units/ml (Hepflush) in a 10ml luer lock syringe o 2% Chlorhexidine/Alcohol swab. o Blood specimen tubes (‘vacutainers’) o (NB A Vacutainer system can be used instead of needles and syringes)
•
Open sterile dressing pack and other equipment onto clean surface of dressing trolley or into clean blue tray.
•
Place yellow clinical waste bag on side of trolley
•
Draw up 20mls 0.9% sodium chloride in 10ml luer lock syringes (x 2) with green needle
•
Remove needles from syringes
•
Draw up 5mls of heparin solution 100 units/ml into a 10ml luer lock syringe with a green needle
•
Remove needle from syringe
•
Wash hands and put on sterile latex-free gloves
•
Place sterile paper towel under the extension set
•
Holding the end of the line with a square of gauze so as to maintain a no touch technique, clean the bung thoroughly with a 2% Chlorhexidine/Alcohol swab and allow to air dry.
•
Continuing to maintain a no touch technique, connect one empty 10ml luer lock syringe onto the bung, open the external line clamp and attempt to aspirate blood back from the PORT. Continue to aspirate slowly until 10mls (or 8mls of heparin lock and blood) of blood is obtained. Remove syringe and discard. o NB. This may not always be possible and it may be necessary to flush the line first with a few mls of N/Saline. If there are difficulties with aspiration of blood please refer to the local policy for ‘management of a totally occluded central catheter or persistent withdrawal occlusion’. o NB.If taking blood for cultures, it is important that blood is not wasted but placed directly into the culture bottles (This includes the initial heparin-contaminated blood aspirated)
•
Once blood has been discarded, clean the end of the bung with a 2% Chlorhexidine/Alcohol swab.
Continuing to maintain a no touch technique, connect the 2nd empty 10ml luer lock syringe onto the bung and aspirate the necessary amount of blood for testing.
•
Transfer aspirated blood to vacutainer bottles. ( Vacutainer system should be used at all times if possible. If blood is being transferred via a syringe, remove blood bottle lid to allow a needle-free transfer.)
•
At the end of the procedure, ensure that the bung is cleaned with a 2% Chlorhexidine/Alcohol swab and change gauze if blood stained
•
Continuing to maintain a non touch technique, FLUSH appropriately. (See flushing guidelines)
•
Dispose of all equipment as per local policy.
CMB/OncCNS/CVC guidelines07 9

6.3 A step by step guide: De-accessing implantable PORTS ,Bard Ports
Non Touch Technique with sterile gloves
The PORT should always be flushed and heparin locked before removal of the gripper needle. See flushing
•
Explain procedure to patient
•
Wash hands thoroughly and put on clean apron
•
Prepare equipment and dressing trolley (or 2 blue trays) o Equipment needed: o Sterile dressing Pack/IV access pack o Sterile latex-free gloves (powder free) o Gauze dressing
•
Open sterile dressing pack and other equipment onto clean surface of dressing trolley or into clean blue tray.
•
Place yellow clinical waste bag on side of trolley
•
Carefully remove the existing dressing from bottom up and discard. Avoid tugging or moving the position of the PORT and avoid the use of scissors / or other sharp instruments .
•
Locate PORT by palpation and secure between thumb and first two fingers of non-dominant hand. Hold needle firmly in other hand and withdraw needle slowly in a vertical direction
•
Apply gauze dressing
•
Dispose of all equipment as per local policy.
CMB/OncCNS/CVC guidelines07 10

These guidelines are to be used in conjunction with
•
UBHT Central line policy
•
Aseptic technique and Aseptic Non Touch Technique (ANTT) in clinical areas. (DMS)
•
Standard Operating Procedure for Heparin usage in Hickman Apheresis and
Vas Cath lines. (DMS)
•
Standard Operating Procedure’s for Central Venous Catheter’s (DMS)
Reference
Pratt, R.J. Pellowe, C.M. Wilson, J.A. Loveday, H.P. et. al. (2007) epic2: National
Evidence-Based Guidelines for Preventing Healthcare –Associated Infections in NHS
Hospitals in England. The Journal of Hospital Infection. Vol. 65S, S1 – S64.
CMB/OncCNS/CVC guidelines07 11