Collaborative Intravenous Nursing Service (CINS) Guidelines

Intravenous Access Care and Maintenance2Background“Every effort has been made to present accurate and up to dateinformation from the best and most reliable sources. However, the resultsof caring for individuals depends on a variety of factors not under thecontrol of the authors of these documents. Therefore, neither the authorsnor any publishers assume responsibility for, nor make any warranty withrespect to the outcomes achieved from the guidance herein”.The service provision in the community for patients who require intravenous care andmanagement has been largely ad hoc. Training has been offered to district nurses in thepast but was not always linked to an agreed competency-based framework or universallyadopted set of Cancer Network or Strategic Health Authority guidelines. It has beenextremely difficult for district nurses to obtain clarity about which protocol/procedures theyshould follow. Several guidelines can be in circulation at any one time from different Trusts.As a result Primary Care Trusts were attempting to develop their own guidelines furtheradding to potential confusion and lack of consistency. District nurses have different levels ofskills and competency in managing central catheters across the Cancer Network/SHA.One of the major quality of life issues for this group of patients has been the need for them totravel to their local hospital trust for catheter care and/or chemotherapy pump disconnection,whilst they are feeling unwell. The inability to alter clinic sessions/times has resulted in theneed to have the chemotherapy pump disconnected on a Sunday. The weekend periodprovides problems for both community and hospital staff mainly due to a reduced availabilityof staff. In addition to travelling whilst feeling unwell patients have the challenge of findingavailable transport.As a result of these inconsistencies Merseyside and Cheshire Cancer Network has led withthe Royal Liverpool and Broadgreen Hospitals NHS Trust, Clatterbridge Centre for Oncology,Central Liverpool Community IV team and all trusts and PCTs within the North WestMerseyside and Cheshire Strategic Health Authority to gain consensus for universally agreedguidelines, competencies, care plan and resources. Directors of Nursing from all HospitalTrusts and PCTs nominated a representative to lead on these guidelines in their specificarea. These leads have contributed to the development of these guidelines and haveconsulted locally with key experts.Key Objectives• To ensure that universal guidelines for care and maintenance of venous accessdevices, care plans and trouble shooting guidelines are available for organisations touse across Cheshire and Merseyside North West Strategic Health Authority.• To ensure that universal guidelines for care and maintenance of venous accessdevices are utilised.• To ensure that individuals caring and maintaining venous access devices havecompleted a Cheshire and Merseyside North West Strategic Health Authority agreedcompetency framework.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

3• To ensure that individuals caring for venous access devices have completed aCheshire and Merseyside North West Strategic Health Authority agreed trainingprogramme.• To ensure that those individuals caring for venous access devices have received anupdate within the last 6 months.• To develop an expert group that will ensure that the best evidence based practice isavailable.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

4Cheshire and Merseyside NHS North WestVenous Access Clinical GroupTerms of ReferenceThe purpose of the group is to ensure that all nurses with relevant competencies acrossCheshire and Merseyside North West Strategic Health Authority utilise universal guidelines,competencies and training.• To act as the primary source of advice on issues relating to the care andmaintenance of venous access devices (VADs).• To ensure co-ordination and consistency across Cheshire and Merseyside NorthWest Strategic Health Authority for the implementation of policies and guidelines.• To implement consistent clinical competencies for VADs.• To collaborate with workforce and education stakeholders to ensure theavailability of the VAD training programme and facilitate ease of access forclinical staff.• To develop and implement guidelines and policies relating to the trainingprogramme.• To ensure that there is a network of support for nurses across the Cheshire andMerseyside North West Strategic Health Authority.• To ensure appropriate consultation across multi-agencies and multiprofessionalgroups.MembershipAll Hospital Trusts, Primary Care organisations and other relevant stakeholders withinCheshire and Merseyside North West Strategic Health Authority were invited to take part inthe development of these guidelines.Chair/ReportingThe chair will be a Director of Nursing from within Cheshire and Merseyside North WestStrategic Health Authority. The group will report to the Directors of Nursing Group atCheshire and Merseyside North West Strategic Health Authority.Use of the GuidelinesThis document contains several guidelines which can be utilised as required.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Care and Maintenance of a Skin Tunnelled Catheter (STC1)6EXIT DRESSING CHANGE (Weekly)Equipment requiredActionRationaleDressing Pack containing sterile towel and GlovesSurgical tapeChlorhexidine Gluconate 2% in 70% Isopropyl alcohol solution and sterile gauze or2% Chlorhexidine in 70% Isopropyl alcohol impregnated applicatorSemi- Permeable transparent IV dressingAlcohol hand rub or gelPlastic apronCare of Exit siteDressing changes should be performed on a weekly basis or when dressing is dirty orloose. Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.Maintain aseptic technique at all times.Observe exit site for signs of discolouration of skin or signs of infection e.g. exudatefrom exit site. If you suspect infection please contact the hospital team who placed thecatheter for advice. Follow trouble -shooting guide.Explain the procedure to the patient.Ensure that valid consent is gained.Ensure working area is clean.Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.To prevent infection.Exit site dressings are important inpreventing trauma and the extrinsiccontamination of the site of entry (Jones2004).To prevent/reduce patient anxiety.Maintain safety.To prevent infection and cathetercontamination.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Open sterile pack, allowing inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field.Open remaining equipment ensuring no contamination of sterile field.Pour out alcohol Chlorhexidine solution or open Chlorhexidine impregnated applicatordevice.Loosen exit site dressing. To loosen dressing lift lower-end and gently ease thedressing off, from the skin.To allow for a sterile environment foraccessing intravenous catheter,and to reduce incidence of infection.Chlorhexidine-based solutions arerecommended (in alcohol) as per policy(DOH 2001).7Aseptically remove the dressingDecontaminate handsPut on sterile glovesPlace sterile towel as near as possible to the catheter.Clean around the catheter and exit site with gauze soaked in alcohol Chlorhexidinesolution or 2% Chlorhexidine impregnated applicator.The solution should be applied with friction but should not be too vigorous or the skin'snatural defence may be destroyed.Allow to dry.Apply new dressing to exit site.Remove the dressing towelRemove gloves.Clear away equipment. Dispose of waste as per policy.Wash hands.Document care on patient’s records.To prevent accidental removal of thecatheter and friction or trauma to skinsurface.Alcohol Chlorhexidine combines thebenefits of rapid action and excellentresidual activity (DOH 2001)Semi-permeable transparent IVdressings are well tolerated by patients(Campbell et al 1999, Treston-Aurand etal 1997, Wille 1993) and are easy toapply and remove (Wille 1997).The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Skin Tunnelled Catheters – 0.9% Sodium Chloride and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (STC2) forweekly maintenance Flush8ActionRationaleEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 3 and Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol orChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (sani cloth)10ml syringes x 210ml 0.9% Sodium Chloride (Saline)5ml Heparin 10units/ml in 0.9% Sodium ChlorideTwo green needles/filter straws (for glass ampoules).Sharps containerSurgical tapeAlcohol hand rub/gelPlastic apron10ml syringes should always be used;smaller syringe sizes may damage thecatheter (Hadaway 1998).Needle free I/V access connector change as per manufacturer’s guidelines seeNSF1 Cins guideline5ML HEPARIN SODIUM (10 UNITS/ML)FOR OPEN ENDED CATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn. Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudate from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide• Ensure working area is clean.Maintain asepsis and safety.Reduce risk of infection.Reduce anxietyPatient complianceTo avoid contamination.To ensure that the procedure can becarried out safely.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium Chloride (saline) & Heparinised Saline ampoules near to theworking area but not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves.• Connect needle/ filter straw to the syringe.• With a piece of sterile gauze pick up the Sodium Chloride 0.9% (saline) ampoule, drawup 10ml of solution. Repeat for Heparinised Saline. If used, dispose of the needledirectly into sharps container, place the filled syringes on the sterile field.• Place sterile towel as near as possible to the catheter• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with 2% Chlorhexidineimpregnated wipe, rubbing from the top of the needle free connector to the sides. Dothis three times using different parts of the wipe over a period of 30 seconds. Allow todry.• Attach syringe with 0.9% Sodium Chloride flush and inject the flush using apush/pause action, clamping as the last ml of solution is instilled into the catheter.• Remove the syringe and discard. If open ended skin tunnelled catheter repeat thisprocedure using syringe containing Heparin 10units/ml in 0.9% Sodium Chloride.• For Patients’ in the community discharged from Christie Hospital, Attach empty 10mlsyringe into needle free system and aspirate at least 10ml of blood from the catheterand discard. If unable to do so refer to The Christie management of problems relatedto central venous catheters in the community.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage thecatheter.• Ensure that the catheter is secure and comfortable.To maintain a sterile field.Chlorhexidine-based solutions arerecommended (in alcohol) as per policy(DOH 2001).10ml syringes should always be used;smaller syringe sizes may damage thecatheter (Hadaway 1998).There is no requirement to routinelywithdraw blood and discard it prior toflushing (except prior to blood samplingalthough the first sample can be used forblood cultures (RCN 2005).There is an increased risk of infection andocclusion when withdrawing blood via acentral venous catheter (RCN 2005),therefore for routine flushing of a linewithdrawal of blood is not required.The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of thecatheter should be maintained to preventreflux of blood (INS 2000).9The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Remove dressing towel and discard. Remove gloves. Wash hands.• Clear away equipment disposing of waste as per organisational policy.• Decontaminate hands• Document care in patient’s records.10The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Skin Tunnelled Catheters – Blood Sampling (STC3)11Equipment RequiredActionRationaleDressing Pack containing sterile towel and glovesGauze swabs x 3 and Chlorhexidine Gluconate 2% in 70% Isopropyl alcoholOr use Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe(Sani Cloth)10ml syringes x 410ml 0.9% Sodium Chloride for injection5ml Heparin10units/ml in 0.9% Sodium ChlorideTwo green needles/filter straws.Sharps containerSurgical tapeAlcohol hand rub/gelPlastic apronNeedle free I/V access connector change as per manufacturer’s guidelines seeNSF1 Cins guideline5ML HEPARIN 10 UNITS/ML IN SODIUM CHLORIDE WITH OPEN ENDED CATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.Maintain asepsis and safety.Reduce risk of infectionReduce anxietyPatient complianceTo avoid contaminationTo ensure that the procedure can becarried out safely.To maintain a sterile field.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium Chloride for injection and Heparin 10units/ml in sodium chloride forinjection ampoules near to the working area but not on the sterile field. Pour outalcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves.• Connect needle/ filter straw to the syringe.• With a piece of sterile gauze pick up the Sodium Chloride 0.9% (saline) ampoule, drawup 10ml of solution. Repeat for Heparinised Saline. If used, dispose of the needledirectly into sharps container, place the filled syringes on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with 2% Chlorhexidineimpregnated wipe, rubbing from the top of the needle free connector to the sides. Dothis three times using different parts of the wipe, over a period of 30 seconds.• Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml ofblood from the catheter. If unable to do so attach the syringe containing the salinesolution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride forinjection (do not use force) then aspirate blood from catheter. Discard blood aspiratedas per policy. Note if taking blood samples from a parenteral nutrition line or for INRsample at least 10-20mls of blood should be taken and disguarded before taking thesample (check local policy).• Attach an empty 10ml syringe and withdraw amount of blood required for analysis.Attach syringe with 0.9% Sodium Chloride for injection flush and inject the flush using apush/pause action, clamping as the last ml of solution is instilled into the catheter.• Remove the syringe and discard. If open ended skin tunnelled catheter repeat thisprocedure using Heparin 10units/ml in 0.9% Sodium Chloride for injection.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage theChlorhexidine-based solutions arerecommended (in alcohol) as per policy(DOH 2001).Check catheter patency. Remove anyresidual solution from catheterThe pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of thecatheter should be maintained to preventreflux of blood (INS 2000).12The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

catheter.• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves and apron.• Clear away equipment disposing of waste as per organisational policy.• Wash hands• Document care in patient’s records.13The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Skin Tunnelled Catheters – Administration of antibiotics/infusion/additives (STC4)Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use forceto flush the catheter.ActionRationaleEquipment RequiredDressing pack containing sterile towel and glovesGauze swabs x 3,Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate2% in 70% Isopropyl alcohol impregnated wipe10ml syringes x 42 x 10ml 0.9% Sodium Chloride for injection5ml Heparin10units/ml in 0.9% Sodium Chloride for injectionThree green needle/ filter straw.Sharps containerSurgical tapeAlcohol hand rub/gelAntibiotics/Infusion/additives as prescribedPlastic apron145ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudate from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is clean.• Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.Reduce the risk of infection andcontamination.Ensures patient compliance and reduceanxietyThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field. Place 0.9% Sodium Chloride (saline) and Heparinisedsaline ampoules near to the working area but not on the sterile field.• Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Put on sterile gloves. Connect needle or filter straw to the syringe.• Pick up a piece of sterile gauze and with it pick up the 0.9% Sodium Chloride forinjection ampoule, then draw up 10ml of solution, Repeat for second 0.9% SodiumChloride and Heparin 10units/ml in 0.9% Sodium Chloride. Dispose of the needledirectly into the sharps container. Place the filled syringes on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in 2% Chlorhexidine solution, scrub the top thenthe sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with 2% Chlorhexidineimpregnated wipe, rubbing from the top of the needle free connector to the sides. Dothis three times using different parts of the wipe, over a period of 30 seconds. Allow todry.• Attach syringe with 0.9% sodium chloride for injection, aspirate enough blood to colour0.9% Sodium Chloride solution then inject the flush using a push pause actionclamping as the last ml of the solution is instilled into the catheter. Remove the syringeand discard.• If unable to aspirate blood from the line continue to administer prescribed medicationunless this is a vesicant drug/infusion, in this case refer to algorithm onpersistant withdrawal occlusion.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage thecatheter.• Administer IV antibiotics/infusion/additives as prescribed following trust policy.• Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action.• Remove the syringe and discard.• If open ended skin tunnelled catheter and this is the final dose of treatment for the day,repeat this procedure using Heparin 10units/ml in 0.9% sodium chloride clamping asMaintain asepsis.To check catheter patency and toremove residual solution from catheter.The RCN Standards for infusion Therapystate, “the nurse should aspirate thecatheter and check for blood return toconfirm patency prior to theadministration of medications and/orsolutions (INS 2000). On no accountshould a vesicant drug or vesicantinfusion be administered through avascular access device where difficulty isexperienced in withdrawing blood(Masoorli 2003).Creates turbulence in catheter,preventing clotting in the catheter.Maintains positive pressure and preventsbackflow of blood into the catheter.15The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

the last ml of solution is instilled into the catheter to maintain catheter patency.• Remove the syringe and discard• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Clear away equipment used.Dispose of waste as per organisational policy.• Wash hands• Document care in patient’s records.16The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Algorithm persistent withdrawal occlusioni.e. fluids can be infused freely by gravity butblood cannot be withdrawn from17Blood return isabsentCheck equipment,Position, clamps, kinking.etcAsk patient to cough, deepbreathe, change position,stand up or lie with foot ofthe bed tipped up.Ascertain possible cause ofPWOBlood returnobtained - usecentral venouscatheter as usualFlush central venouscatheter with 0.9%Sodium chloride in10ml syringe using abrisk “push pause”technique. Check forflashback of bloodBlood return isstill absentPatient to receive highlyirritant/vesicant drugsor chemotherapyExclusionDormant lineIf unable to aspirate.Do not continue.Refer to Medic closeline and labelNo YesConsiderBlood return is stillabsentNoProceed if happy to doas long as there areno other complicationsor painAdapted from Standards for InfusionTherapy RCN (2005)SECONDARY CARE ONLYThe following steps should initially be done on admission or prior to drugadministration and documented in nursing care-plan so that all staff are awarethat patency has been verifiedStep 1Administer a 250ml normal saline “challenge” (unless serum sodium≤ 120 mmol/l) via an infusion pump over 15 minutes to test for patency –the infusion will probably not resolve the lack of blood return (unless thepatient has a high sodium or fluid restricted go to step 2)If there have been no problems, therapy can be administered as normal.If the patient experiences ANY discomfort or there is anyunexplained problems then stop and seek medical advice.It may be necessary to verify tip location by chest X Ray.ORStep 2 Instill Urokinase 5000iu in 2 mls and leave for 60 minutes. Afterthis time withdraw the urokinase and assess the catheter again.The CINs group hereby Repeat assert necessary. their moral If blood rights return to is still absent, it may bethe works herein in accordance necessary with the to Data verify Protection tip location by Act chest 1988. X Ray.Policy review date 01/10/10

References181. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of centralvenous catheters, Journal of Hospital Infection, 47 Supplement S47 – S672. Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of IntravenousNursing, 16 (2) 92-1035. Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.6. INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23 (6S) supplement7. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing20(4):201-206.8. Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113-121.9. Pratt RJ et al (2006) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England(epic 2). Thames Valley University, London.10. INS (2000) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III). In RCN Standards for Infusion (2005)11. Masoorli S (2003) Extravasation injuries associated with the use of central venous access devices. Journal of vascular access devices.21-23 SpringThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1019

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1020

Care and Maintenance of a non tunnelled Central Venous Catheter (CVC1)All lumens on a non-tunnelled access device should be flushed using an aseptic technique.21EXIT DRESSING CHANGE (Weekly)Equipment requiredActionRationaleDressing Pack containing sterile towel and GlovesGauze swabs x 3, Surgical tapeChlorhexidine Gluconate 2% in 70% Isopropyl alcohol solution or Chlorhexidineimpregnated applicatorSemi-Permeable transparent IV dressingAlcohol hand rub or gelNeedle free I/V access connectorCare of Exit siteDressing changes should be performed on a weekly basis or when dressing is dirty or loose.To prevent infection.Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.Maintain aseptic technique at all times.Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.Explain the procedure to the patient.Ensure that valid consent is gained.Ensure working area is as clean as possible.Ensure all equipment is gathered before commencing the procedure and all packing isintact and in date.Exit site dressings are important inpreventing trauma and the extrinsiccontamination of the site of entry(Jones 2004).To prevent/reduce patient anxiety.Maintain safety.To prevent infection and cathetercontamination.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Open sterile pack, allowing inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field.Open remaining equipment ensuring no contamination of sterile field. Place sterile towelas near as possible to the catheter.Pour out alcohol Chlorhexidine solution or open Chlorhexidine impregnated applicatorLoosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressingoff from the skin.To allow for a sterile environment foraccessing intravenous catheter,and to reduce incidence of infection.Chlorhexidine based solutions arerecommended (in alcohol) as perpolicy (DOH 2001).22Aseptically remove the dressingWash hands and put on sterile glovesClean around the catheter and exit site with gauze soaked in alcohol Chlorhexidine orusing 2% Chlorhexidine impregnated applicator. The solution should be applied withfriction, but should not be too vigorous or the skin's natural defence may be destroyed.Allow to dry.Apply new dressing to exit site.Remove the dressing towelRemove gloves.Clear away equipment. Dispose of waste as per policy.Wash hands.Document care in patient’s records.To prevent accidental removal of thecatheter and friction or trauma toskin surface.Alcohol Chlorhexidine combines thebenefits of rapid action and excellentresidual activity (DOH 2001).Semi-permeable transparent IVdressings are well tolerated bypatients (Campbell et al 1999,Treston-Aurand et al 1997, Wille1993) and are easy to apply andremove (Wille 1997).The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Central Non-Tunnelled Catheters - Saline Flush and Hepsal Lock (CVC2)If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flushActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 310ml syringes x 3Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine impregnated wipe10ml 0.9% Sodium Chloride for injection(Saline)5ml Heparin 10units/ml in 0.9% Sodium ChlorideTwo green needles/filter straws. Sharps containerSurgical tapeAlcohol hand rub/gelPlastic apronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cinsguideline Before the procedure begins make sure that your hands are washed and dried thoroughly andthat they continue to be decontaminated during the procedure. A plastic apron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packaging is intactand in date.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudatesfrom exit site. If you suspect infection please contact the hospital team who placed the catheterfor advice. Refer to trouble-shooting guide.• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium Chloride & Heparin 10units/ml in 0.9% Normal Saline ampoules near to theworking area but not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.Put on sterile gloves. Connect needle/ filter straw to the syringe.• With a piece of sterile gauze pick up the 0.9% Sodium Chloride ampoule, draw up 10ml ofsolution. Repeat for Heparinised Saline. If used, dispose of the needle directly into sharpsThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10Rationale10ml syringes should always be used; smallersyringe sizes may damage the catheter(Hadaway 1998).Maintain asepsis and safety.Reduce risk of infection.Reduce anxietyPatient complianceTo avoid contamination.To ensure that the procedure can be carried outsafelyTo maintain a sterile fieldChlorhexidine based solutions are recommended(in alcohol) as per policy (DOH 2001).There is no requirement to routinely withdrawblood and discard it prior to flushing (except prior23

container, place the filled syringes on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the top then thesides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnated wipe,rubbing from the top of the needle free connector to the sides. Do this three times using differentparts of the wipe, over a period of 30 seconds. Allow to dry.• Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a push/pauseaction, clamping as the last ml of solution is instilled into the catheter.• Remove the syringe and discard. Repeat flush now using Heparinised saline.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Wash hands.• Clear away equipment disposing of waste as per organisational policy.• Document care in patient’s records.24to blood sampling although the first sample canbe used for blood cultures (RCN 2005).There is an increased risk of infection andocclusion when withdrawing blood via a centralvenous catheter (RCN 2005), therefore for routineflushing of a line withdrawal of blood is notrequired. The pulsated flush creates turbulencewithin the catheter lumen, removing debris fromthe internal catheter wall (Goodwin & Carlson1993, Todd 1998).Positive pressure within the lumen of the cathetershould be maintained to prevent reflux of blood(INS 2000).10ml syringes should always be used; smallersyringe sizes may damage the catheter(Hadaway 1998).The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Central Non-Tunnelled Catheters – Blood Sampling (CVC3)If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flushFor multi-lumen non-tunnelled catheters ideally one lumen should be used for blood sampling.ActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 310ml syringes x 3Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or 2% Chlorhexidineimpregnated wipe10ml 0.9% Sodium Chloride for injection5ml Heparin 10units/ml in 0.9% Normal SalineTwo green needles/filter straws. Sharps containerSurgical tapeAlcohol hand rub/gelApronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1Cins guideline Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packaging isintact and in date.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.RationaleMaintain asepsis and safety.Reduce risk of infection.Reduce anxietyPatient complianceTo avoid contamination.To ensure that the procedure can becarried out safelyTo maintain a sterile fieldChlorhexidine based solutions are25The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Place 0.9% Sodium Chloride and Heparinised Saline ampoules near to the workingarea but not on the sterile field. Pour out Alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Put on sterile gloves.• Connect needle/filter straw to the syringe.• With a piece of sterile gauze pick up the Sodium Chloride 0.9% ampoule, draw up 10mlof solution. Repeat for Heparinised Saline. If used, dispose of the needle directly intosharps container, place the filled syringes on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this three timesusing different parts of the wipe, over a period of 30 seconds. Allow to dry.• Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml ofblood from the catheter. If unable to do so attach the syringe containing the salinesolution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride (donot use force) then aspirate blood from catheter. Discard blood aspirated as per policy.Note if taking blood samples from a parenteral nutrition line or for INR sample at least10-20mls of blood should be taken and disguarded before taking the sample (check localpolicy).• Attach an empty 10ml syringe and withdraw amount of blood required for analysis.• Attach syringe with 0.9% Sodium Chloride flush and inject the flush using a push/pauseaction, clamping as the last ml of solution is instilled into the catheter.• Remove the syringe and discard. Repeat flush now using Heparinised saline.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Wash hands.• Clear away equipment disposing of waste as per organisational policy.• Document care in patient’s records.recommended (in alcohol) as per policy(DOH 2001).Check catheter patency. Remove anyresidual solution from catheter.The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of thecatheter should be maintained to preventreflux of blood (INS 2000).26The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Central Venous Non-Tunnelled Catheters – Administration of antibiotics/additives/infusions (CVC4)27Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter.If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flushActionEquipment RequiredDressing pack containing sterile towel and glovesGauze swabs x 3,Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or 2% Chlorhexidineimpregnated wipe.10ml syringes x 42 x 10ml 0.9% Sodium Chloride (saline)5ml Heparin 10units/ml in 0.9% Sodium ChlorideThree green needle/ filter straw. Sharps containerSurgical tapeAlcohol hand rub/gelPlastic apronAntibiotics/additive/infusion as prescribed Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packaging isintact and in date.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Open sterile pack allowing inner pack to fall onto clean working area.RationaleReduce the risk of infection andcontamination.Ensures patient compliance and reduceanxietyMaintain asepsis.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% Sodium Chloride (saline) & Heparinised saline ampoules near to the workingarea but not on the sterile field.• Pour out Alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Put on sterile gloves. Connect needle or filter straw to the syringe.• Pick up a piece of sterile gauze and with it pick up the 0.9% Sodium Chloride (saline)ampoule, then draw up 10ml of solution, repeat for second 0.9% Sodium Chloride andHeparinised saline. Dispose of the needle directly into the sharps container. Place thefilled syringes on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this three timesusing different parts of the wipe, over a period of 30 seconds. Allow to dry.• Attach syringe with 0.9% Sodium Chloride (saline), aspirate enough blood to coloursaline solution then inject the flush using a push pause action camping as the last ml ofthe solution is instilled into the catheter. Remove the syringe and discard.• If unable to aspirate blood from the line continue to administer prescribed medicationunless this is a vesicant drug/infusion, in this case refer to RCN algorithm attachedto this guideline.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage thecatheter.• Administer IV antibiotics/additives/infusion as prescribed.• Flush catheter again as above, followed by Heparinised saline (5ml of 10units/ml) lock.• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Wash hands• Clear away equipment used. Dispose of waste as per organisational policy.• Document care in patient’s records.To check catheter patency and to removeresidual solution from catheter.The RCN Standards for infusion Therapystate, “the nurse should aspirate thecatheter and check for blood return toconfirm patency prior to the administrationof medications and/or solutions (INS 2000).On no account should a vesicant drug orvesicant infusion be administered through avascular access device where difficulty isexperienced in withdrawing blood (Masoorli2003).Creates turbulence in catheter, preventingclotting in the catheter.Maintains positive pressure and preventsbackflow of blood into the catheter.28The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Algorithm persistent withdrawal occlusioni.e. fluids can be infused freely by gravity butblood cannot be withdrawn from29Blood return isabsentCheck equipment,Position, clamps, kinking.etcAsk patient to cough, deepbreathe, change position,stand up or lie with foot ofthe bed tipped up.Ascertain possible cause ofPWOBlood returnobtained - usecentral venouscatheter as usualFlush central venouscatheter with 0.9%Sodium chloride in10ml syringe using abrisk “push pause”technique. Check forflashback of bloodBlood return isstill absentPatient to receive highlyirritant/vesicant drugsor chemotherapyExclusionDormant lineIf unable to aspirate.Do not continue.Refer to Medic closeline and labelNo YesConsiderBlood return is stillabsentNoProceed if happy to doas long as there areno other complicationsor painAdapted from Standards for InfusionTherapy RCN (2005)SECONDARY CARE ONLYThe following steps should initially be done on admission or prior to drugadministration and documented in nursing care-plan so that all staff are awarethat patency has been verifiedStep 1Administer a 250ml normal saline “challenge” (unless serum sodium≤ 120 mmol/l) via an infusion pump over 15 minutes to test for patency –the infusion will probably not resolve the lack of blood return (unless thepatient has a high sodium or fluid restricted go to step 2)If there have been no problems, therapy can be administered as normal.If the patient experiences ANY discomfort or there is anyunexplained problems then stop and seek medical advice.It may be necessary to verify tip location by chest X Ray.ORStep 2 Instill Urokinase 5000iu in 2 mls and leave for 60 minutes. Afterthis time withdraw the urokinase and assess the catheter again.The CINs group hereby Repeat assert necessary. their moral If blood rights return to is still absent, it may bethe works herein in accordance necessary with the to Data verify Protection tip location by Act chest 1988. X Ray.Policy review date 01/10/10

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1030

31References.1. Department of Health (DOH) (2001) Guidelines for preventing infection associated withthe insertion and maintenance of central venous catheters, Journal of Hospital Infection,47 Supplement S47 – S672. Department of Health (DOH 2003). Winning Ways: Working together to reduce healthcare associated infection in England3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce healthcare associated infection including MRSA.4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3years of insertions, Journal of Intravenous Nursing, 16 (2) 92-1035. Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.6. INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23(6S) supplement.7. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheterinfection rates. Journal of Intravenous Nursing 20(4):201-206.8. Wille JC (1993) A comparison of two transparent film-type dressings in central venoustherapy. Journal of Hospital Infection 23(2):113-121.9. INS (2000) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson(III). In RCN Standards for Infusion (2005).10. Masoorli S (2003) Extravasation injuries associated with the use of central venousaccess devices. Journal of vascular access devices. 21-23 SpringThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Care and Maintenance of a Peripheral Inserted Central Catheter (PICC). (PL1)32EXIT DRESSING CHANGE (Weekly)ActionEquipment requiredDressing Pack containing sterile towel and GlovesGauze swabs x 3, Surgical tapeChlorhexidine Gluconate 2% in 70% Isopropyl alcohol or 2% Chlorhexidineimpregnated applicatorSemi-Permeable transparent IV dressingAlcohol hand rub or gelSkin closure stripsSkin fixation device (e.g. stat-lock)Plastic apronRationaleCare of Exit site Dressing changes should be performed on a weekly basis or when dressing is dirty orloose Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn. Maintain aseptic technique at all times. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packaging isintact and in date.To prevent infectionExit site dressings are important inpreventing trauma and the extrinsiccontamination of the site of entry(Jones 2004).To prevent/reduce patient anxietyMaintain safetyTo minimise the risk of infection andcatheter contamination.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open sterile pack, allowing inner pack to fall onto the clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Pour out Alcohol Chlorhexidine solution or open 2% Chlorhexidine impregnatedapplicator• Loosen exit site dressing. To loosen dressing lift lower end gently ease the dressing off,from the skin• Dressing should be removed from hand to elbow to prevent accidental catheter removal.Be aware that the fixation device may also come off with the dressing. Aseptically remove the dressing. Decontaminate hands Put on sterile gloves• Place sterile towel as near as possible to the PICC catheter.• Clean around the catheter exit site with gauze soaked in Chlorhexidine Gluconate 2% in70% Isopropyl alcohol or 2% Chlorhexidine impregnated applicator The solution should be applied with friction but should not be too vigorous or the skin'snatural defence may be destroyed. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device. Apply new dressing to exit site. Remove the dressing towel Remove gloves. Clear away equipment. Dispose of waste as per organisational policy. Wash Hands Documents care in patient’s records.To allow for a sterile environment foraccessing intravenous device.Chlorhexidine based solutions arerecommended (in alcohol) dependenton the availability and cathetermanufacturers. Recommendations(DOH 2001).To prevent accidental removal of thecatheter and friction or trauma to theskin surfaceAlcoholic Chlorhexidine combines thebenefits of rapid action and excellentresidual activity (DOH 2001)Semi-permeable transparent IVdressings are well tolerated by patients(Campbell et al 1999, Treston-Aurandet al 1997, Wille 1993) and are easy toapply and remove (Wille 1997).33The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Peripherally Inserted Central Catheter – 0.9% Sodium Chloride for injection and Heparin 10 units/ml in 0.9% Sodium Chloride forinjection Lock (PL2) for weekly maintenance Flush34ActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 310ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate2% in 70% Isopropyl alcohol impregnated wipe10ml 0.9% Sodium chloride for injectionOne/two green needle/filter straw. Sharps containerSurgical tapeAlcohol hand rubPlastic apronNeedle free I/V access connector change as per manufacturer’s guidelines seeNSF1 Cins guideline5ML HEPARIN 10 UNITS/ML in 0.9% SODIUM CHLORIDE WITH OPEN ENDEDCATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.• Open sterile pack allowing inner pack to fall onto clean working area.Rationale10ml syringes should always be used,smaller syringe sizes may damage thecatheter (Hadaway 1998)Maintain asepsis.Reduce risk of infection. To avoidcontamination and to reduce risk ofinfectionReduce anxiety and improve patientcomplianceThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium chloride (saline) and if needed Heparinised Saline ampoule(s) nearto the working area but not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves. Connect needle/ filter straw to the syringe.• With a piece of sterile gauze pick up the 0.9% sodium chloride ampoule, draw up 10mlof solution. Repeat this procedure using the Heparin 10units/ml in Sodium Chloride ifrequired. Dispose of the needle directly into sharps container; place the filled syringeon the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this threetimes using different parts of the wipe, over a period of 30 seconds. Allow to dry.• Attach syringe with 0.9% sodium chloride and inject the flush using a push/ pauseaction, clamping as the last ml of solution is instilled into the catheter. If open endedPICC, repeat this procedure using Heparinised saline lock.• For Patients’ in the community discharged from Christie Hospital, Attach empty 10mlsyringe into needle free system and aspirate at least 10ml of blood from the catheterand discard. If unable to do so refer to The Christie management of problems relatedto central venous catheters in the community then attach syringe with 0.9% sodiumchloride and inject the flush using a push/ pause action, clamping as the last ml ofsolution is instilled into the catheter. If open ended PICC, repeat this procedure usingHeparinised saline lock.• Remove the syringe and discard.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage thecatheter• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves.Chlorhexidine based solutions arerecommended (in alcohol) as perpolicy (DOH 2001).There is no requirement to routinelywithdraw blood and discard it prior toflushing (except prior to bloodsampling although the first sample canbe used for blood cultures (RCN2005).There is an increased risk of infectionand occlusion when withdrawing bloodvia a central venous catheter (RCN2005), therefore for routine flushing ofa line withdrawal of blood is notrequired.The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd1998).Positive pressure within the lumen ofthe catheter should be maintained toprevent reflux of blood (INS 2000).35The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Wash hands• Clear away equipment disposing of waste as per organisational policy.• Document care in patient’s records.36The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

37Peripherally Inserted Central Catheter – Blood Sampling (PL3)ActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 310ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate2% in 70% Isopropyl alcohol impregnated wipe10ml 0.9% Sodium Chloride for injectionOne green needle/filter straw. Sharps containerSurgical tapeAlcohol hand rubNeedle free I/V access connector change as per manufacturer’s guidelines seeNSF1 CINs guideline5ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and packaging isintact and in date.• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium chloride (saline) and if needed Heparinised Saline ampoule(s) nearMaintain asepsis.RationaleReduce risk of infection. To avoidcontamination and to reduce risk ofinfectionReduce anxiety and improve patientcomplianceThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

to the working area but not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves. Connect needle/ filter straw to the syringe.• With a piece of sterile gauze pick up the 0.9% Sodium Chloride (saline) ampoule, drawup 10ml of solution. Dispose of the needle directly into sharps container; place thefilled syringe on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this threetimes using different parts of the wipe, over a period of 30 seconds. Allow to dry.• Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml ofblood from the catheter. If unable to do so attach the syringe containing the salinesolution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride(saline) (do not use force) then aspirate blood from catheter. Discard blood aspiratedas per policy. Note if taking blood samples from a parenteral nutrition line or for INRsample at least 10-20mls of blood should be taken and disguarded before taking thesample (check local policy).• Attach an empty 10ml syringe and withdraw amount of blood required for analysis.• Attach syringe with 0.9% sodium chloride and inject the flush using a push/ pauseaction, clamping as the last ml of solution is instilled into the catheter. If open endedPICC, repeat this procedure using Heparinised saline lock.• Remove the syringe and discard.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage thecatheter• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves.• Wash hands• Clear away equipment disposing of waste as per organisational policy.• Document care in patient’s records.Chlorhexidine based solutions arerecommended (in alcohol) as perpolicy (DOH 2001)The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd1998).Positive pressure within the lumen ofthe catheter should be maintained toprevent reflux of blood (INS 2000).38The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1039

Peripherally Inserted Central Catheter – Administration of antibiotics/additives/infusion (PL4)Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion.Always use 10ml syringe, never use force to flush the catheter.ActionEquipment RequiredDressing pack containing sterile towel and glovesGlovesGauze swabs x 3,Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidineimpregnated wipe10ml syringes x 32 x 10ml 0.9% Sodium chloride (saline)One green needle/ filter straw. Sharps containerSurgical tapeAlcohol hand rubPlastic apronAntibiotics/additives/infusion as prescribedRationale405ML HEPARINISED SALINE 10UNITS/ML FOR OPEN ENDED CATHETER Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and packaging isintact and in date.• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.To minimise risks of infection andcontamination.Ensures patient compliance andreduces anxietyMaintain asepsis.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Place 0.9% sodium chloride (saline) and if needed Heparinised saline ampoule (s)near to the working area but not on the sterile field. Pour out alcohol Chlorhexidinesolution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves. Connect needle or filter straw to the syringe.• Pick up a piece of sterile gauze and with it pick up the 0.9% sodium chloride (saline)ampoule, then draw up 10ml of solution, Repeat for second 0.9% sodium chloride(saline) Dispose of the needle directly into the sharps container.• Place the filled syringe on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this threetimes using different parts of the wipe, over a 30 second period. Allow to dry.• Attach syringe with 0.9% Sodium Chloride (saline), aspirate enough blood to coloursaline solution then inject the flush using a push pause action camping as the last ml ofthe solution is instilled into the catheter. Remove the syringe and discard.• If unable to aspirate blood from the line continue to administer prescribed medicationunless this is a vesicant drug/infusion, in this case refer to RCN algorithmattached to this guideline.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage thecatheter.• Administer IV antibiotics/additives/infusion as prescribed.• Flush catheter again with 10ml 0.9% Sodium Chloride using a push/pause action,followed by Heparinised saline (5ml of 10units/ml) lock IF OPEN ENDED CATHETER.Ensure that the catheter is secure and comfortable. Remove dressing towel anddiscard. Remove gloves. Wash hands• Clear away equipment used. Dispose of contaminated waste as per policy.• Document care in patient’s records.Chlorhexidine based solutions arerecommended (in alcohol) dependenton the availability and cathetermanufacturers recommendations(DOH 2001).To check catheter patency and toremove residual solution fromcatheter.The RCN Standards for infusionTherapy state, “the nurse shouldaspirate the catheter and check forblood return to confirm patency prior tothe administration of medicationsand/or solutions (INS 2000). On noaccount should a vesicant drug orvesicant infusion be administeredthrough a vascular access devicewhere difficulty is experienced inwithdrawing blood (Masoorli 2003).The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd1998).Positive pressure within the lumen ofthe catheter should be maintained toprevent reflux of blood (INS 2000).41The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Algorithm persistent withdrawal occlusioni.e. fluids can be infused freely by gravity butblood cannot be withdrawn from42Blood return isabsentCheck equipment,Position, clamps, kinking.etcAsk patient to cough, deepbreathe, change position,stand up or lie with foot ofthe bed tipped up.Ascertain possible cause ofPWOBlood returnobtained - usecentral venouscatheter as usualFlush central venouscatheter with 0.9%Sodium chloride in10ml syringe using abrisk “push pause”technique. Check forflashback of bloodBlood return isstill absentPatient to receive highlyirritant/vesicant drugsor chemotherapyExclusionDormant lineIf unable to aspirate.Do not continue.Refer to Medic closeline and labelNo YesConsiderBlood return is stillabsentNoProceed if happy to doas long as there areno other complicationsor painAdapted from Standards for InfusionTherapy RCN (2005)SECONDARY CARE ONLYThe following steps should initially be done on admission or prior to drugadministration and documented in nursing care-plan so that all staff are awarethat patency has been verifiedStep 1Administer a 250ml normal saline “challenge” (unless serum sodium≤ 120 mmol/l) via an infusion pump over 15 minutes to test for patency –the infusion will probably not resolve the lack of blood return (unless thepatient has a high sodium or fluid restricted go to step 2)If there have been no problems, therapy can be administered as normal.If the patient experiences ANY discomfort or there is anyunexplained problems then stop and seek medical advice.It may be necessary to verify tip location by chest X Ray.ORStep 2 Instill Urokinase 5000iu in 2 mls and leave for 60 minutes. Afterthis time withdraw urokinase and assess the catheter again.The CINs group hereby assert their moral rights toRepeat as necessary. If blood return is still absent, it may bethe works herein in accordance with the Data Protection Act 1988.necessary to verify tip location by chest X Ray.Policy review date 01/10/10

References431. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of centralvenous catheters, Journal of Hospital Infection, 47 Supplement S47 – S672. Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of IntravenousNursing, 16 (2) 92-1035. Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.6. Infection Control Nurses Association (2001) Guidelines for Preventing Intravascular Catheter-related Infection.7. INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23 (6S) supplement8. Todd J (1998) Peripherally inserted central catheters. Professional Nurse 13(5) 297-3029. Jones A (2004) Dressings for the Management of Catheter Sites – A review. JAVA, Vol. 9 No 1, 1-8.10. Campbell H, Carrington M (1999) Peripheral IV cannula dressings: advantages and disadvantages. British Journal of Nursing,8(21):1420-1422, 1424-142711. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing20(4):201-206.12. Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113-121.13. INS (2000) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III) In RCN Standards for Infusion (2005).The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

14. Masoorli S (2003) Extravasation injuries associated with the use of central venous access devices. Journal of vascular access devices.21-23 Spring44The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Care and Maintenance of a Peripheral Midline Catheter (PM1)45EXIT DRESSING CHANGE (Weekly)ActionEquipment requiredDressing Pack containing sterile towel and GlovesGauze swabs x 3, Surgical tapeChlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate2% in 70% Isopropyl alcohol impregnated applicatorSemi-Permeable transparent IV dressingAlcohol hand rub or gelSkin closure stripsSkin fixation device (e.g. stat-lock)Plastic apron.Care of Exit siteDressing changes should be performed on a weekly basis or when dressing is dirty orloose. Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn. Maintain aseptic technique at all times. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Explain the procedure to the patient. Ensure that valid consent is gained.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.RationaleTo prevent infectionExit site dressings are important inpreventing trauma and the extrinsiccontamination of the site of entry(Jones 2004).To prevent/reduce patient anxietyMaintain safety and reassure patient.To prevent infection and cathetercontamination.• Open sterile pack, allowing inner pack to fall onto the clean working area. To allow for a sterile environment forThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field. Pour out alcohol Chlorhexidine solution or openChlorhexidine impregnated applicator.• Loosen exit site dressing. To loosen dressing lift lower end and gently ease the dressingoff from the skin• Dressing should be removed from hand to elbow to prevent accidental catheterremoval. Be aware that fixation device may come off with the dressing.accessing intravenous catheter.To reduce incidence of infectionChlorhexidine based solutions arerecommended (in alcohol) as perpolicy (DOH 2001)46Aseptically remove the dressing.Wash hands and put on sterile glovesPlace sterile towel as near as possible to the catheter.Clean around the catheter and exit site with gauze soaked in 2% Chlorhexidine orChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated applicator.The solution should be applied with friction but should not be too vigorous or the skin'snatural defence may be destroyed.Allow to dry.Apply skin closure strips or skin fixation device, then apply highly permeable dressing toexit site.Remove the dressing towelRemove gloves.Clear away equipment. Dispose of contaminated waste as per policy. Remove apron.Decontaminate hands.Document care in patient’s records.To prevent accidental removal of thecatheter and friction or trauma to skinsurface.Alcoholic Chlorhexidine combines thebenefits of rapid action and excellentresidual activity (DOH 2001)Semi-permeable transparent IVdressings are well tolerated bypatients (Campbell et al 1999,Treston-Aurand et al 1997, Wille1993) and are easy to apply andremove (Wille 1997).The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Peripheral Midline - 0.9% Sodium Chloride and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (PM2) (At leastonce daily, more frequently if required)It is not always possible to aspirate blood from a peripheral midline, as the lumen of the catheter is small47ActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 310ml syringes x 3Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or 2% Chlorhexidineimpregnated wipe.10ml 0.9% Sodium Chloride for injection5mls Heparin 10units/ml in Sodium ChlorideTwo green needles/filter straws. Sharps containerSurgical tapeAlcohol hand rubPlastic apronNeedle free I/V access connector change as per manufacturer’s guidelines seeNSF1 Cins guideline Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of inflammation or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packagingis intact and in date.• Open sterile pack allowing inner pack to fall onto clean working area.Rationale10 ml syringes should always be used.Smaller syringe sizes may damage thecatheter (Hadaway 1998)Maintain asepsis.Reduce risk of infection.Reduce anxiety and improve patientcomplianceChlorhexidine based solutions arerecommended (in alcohol) dependenton the availability and catheterThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9% sodium chloride & Heparinised saline ampoule(s) near to the working areabut not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands.• Put on sterile gloves. Connect needle/filter straw to the syringe.• With a piece of sterile gauze pick up the 0.9% sodium chloride (saline) ampoule, drawup 10ml of solution. Repeat for Heparinised saline if open-ended catheter. If useddispose of the needle directly into sharps container, place the filled syringe(s) on thesterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this threetimes using different parts of the wipe, over a period of 30 seconds.• Allow to dry.• Attach syringe with 0.9% sodium chloride flush and inject the flush using a push/pauseaction, clamping as the last ml of solution is instilled into the catheter.• Remove the syringe and discard. Repeat flush now using Heparinised saline• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage thecatheter.• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves.• Wash hands• Clear away equipment used taking care to dispose of contaminated waste as perpolicy.• Document care in patient’s records.manufacturers recommendations(DOH 2001).The pulsated flush creates turbulencewithin the catheter lumen, removingdebris from the internal catheter wall(Goodwin & Carlson 1993, Todd1998).Positive pressure within the lumen ofthe catheter should be maintained toprevent reflux of blood (INS 2000).48The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

49Peripheral Midline –Administration of antibiotics/infusion/additives (PM3)Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion.ActionEquipment RequiredDressing pack containing sterile towel and glovesGauze swabs x 3,10ml syringes x 4Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate 2%in 70% Isopropyl alcohol impregnated wipe2 x 10ml 0.9% Sodium Chloride for injectionNEVER USE LESS THAN A 10ML SYRINGE5ml Heparin 10units/ml in 0.9%Sodium ChlorideOne green needle/ filter straw. Sharps containerSurgical tapeAlcohol hand rub/ gel,Antibiotics/additives/infusion as prescribedPlastic apron Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn.• Maintain aseptic technique at all times.• Explain the procedure to the patient. Ensure that valid consent is gained.• Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.exudates from exit site. If you suspect infection please contact the hospital team whoplaced the catheter for advice. Refer to trouble-shooting guide.• Ensure working area is as clean as possible.• Ensure all equipment is gathered before commencing the procedure and all packaging isintact and in date.RationaleReduce the risk of infection andcontaminationEnsures patient compliance andreduces anxietyMaintain asepsis.Reduce the risk of infection andcontamination.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

• Open sterile pack allowing inner pack to fall onto clean working area.• Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of sterile field.• Place 0.9%Sodium Chloride and Heparinised saline ampoule(s) near to the workingarea but not on the sterile field. Pour out alcohol Chlorhexidine solution.• Ensure easy access to the needle free system.• Decontaminate hands• Put on sterile gloves. Connect needle or filter straw to the syringe.• Pick up a piece of sterile gauze and with it pick up the 0.9% Sodium Chloride (saline)ampoule, then draw up 10ml of solution, Repeat for second Sodium Chloride andHeparinised saline. Dispose of the needle directly into the sharps container. Place thefilled syringe(s) on the sterile field.• Place sterile towel as near as possible to the catheter.• Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.• Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this three timesusing different parts of the wipe, over a period of 30 seconds. Allow to dry.• Attach syringe containing the 0.9% Sodium Chloride solution to the needle free systemthen Inject the solution using a push/pause action, clamping as the last ml of solution isinstilled into the catheter. Remove the syringe and discard.• NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage thecatheter.• Administer IV antibiotics/infusion/additives as prescribed.• Flush catheter again using second syringe containing sodium chloride 0.9%, followed byHeparinised saline (5ml of 10units/ml) lock.• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Wash hands• Clear away equipment used. Dispose of contaminated waste as per organisationalpolicy.• Document care in patient’s records.To avoid contaminationCreates turbulence in catheter,preventing clotting in the catheter.Maintains positive pressure andprevents backflow of blood into thecatheter.50The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1051

References521. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of centralvenous catheters, Journal of Hospital Infection, 47 Supplement S47 – S672. Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of IntravenousNursing, 16 (2) 92-1035. Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.6. INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23 (6S) supplement7. Todd J (1998) Peripherally inserted central catheters. Professional Nurse 13(5) 297-3028. Jones A (2004) Dressings for the Management of Catheter Sites – A review. JAVA, Vol. 9 No 1, 1-8.9. Campbell H, Carrington M (1999) Peripheral IV cannula dressings: advantages and disadvantages. British Journal of Nursing,8(21):1420-1422, 1424-1427.10. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing20(4):201-206.11. Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113-121The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/1053

Disconnection of Ambulatory Chemotherapy (Infusor/ Infuser) from Central Venous Access Device (DST1)54ActionEquipment RequiredDressing Pack containing sterile towel and glovesGauze swabs x 3, 10ml syringes x 3Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in70% Isopropyl alcohol impregnated wipe10ml 0.9% Sodium Chloride for injection5ml Heparin10units/ml in 0.9% Sodium ChlorideTwo green needles/filter straw. Sharps containerSurgical tape,Alcohol hand rub,Needle-free systemPlastic apronPlastic bag for empty cytotoxic chemotherapy infusorLuer lock stopper for InfusorHEPARINISED SALINE WITH OPEN ENDED CATHETER• Explain procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and dried thoroughlyand that they continue to be decontaminated during the procedure. A plastic apron shouldbe worn. Maintain aseptic technique at all times Ensure that the working area is as clean as possible. Ensure that all equipment is gathered before commencing the procedure and allpackaging is intact and in date. Open sterile pack allowing the inner pack to fall onto the clean working area. Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of the sterile field. Decontaminate handsRationaleEnsures patient compliance andreduces anxietyReduce the risk of infection, toavoid contaminationTo maintain asepsisLuer lock stopper will preventleakage of chemotherapy frominfusor this is now a sealed unitThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Put on sterile glovesPlace sterile towel as near as possible to the catheterClose catheter clamp. Use gauze soaked in chlorhexidine to lift the end of the cathetercarefully and clean, including the pump connection, allow to dry.Hold the catheter with sterile gauze; disconnect Infusor from the access device. Apply leurlock stopper to the end of the Infusor tubing and seal it in a plastic bag clearly labelledcytotoxic waste.Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the top thenthe sides of the needle free system connection and allow to dry.Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this three timesusing different parts of the wipe, over a period of 30 seconds. Allow to dry.• Flush with push pause action, clamping as the last ml of 10ml of Sodium chloride 0.9% isinstilled into the catheter. Repeat this action with 5 mls of 10units per ml Heparinisedsaline (if open ended catheter)• Ensure that the catheter is secure and comfortable.• Remove dressing towel and discard. Remove gloves. Wash hands• Clear away equipment used. Dispose of contaminated waste as per organisational policy.• Document care in patient’s records.55The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

56Care and Management of Totally Implanted Venous Access Device (TIVAD) e.g. Port-a-Cath (TIVAD1)0.9% Sodium Chloride for injection flush and Heparin 100 units/ml in 0.9% Sodium Chloride for injection LockHeparin strengths may vary according to the frequency of the flushes required, refer to local policyActionEquipment RequiredDressing Pack containing sterile towel and gloves x2Gauze swabs x 3, 10ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in70% Isopropyl alcohol impregnated applicator10ml 0.9% Sodium Chloride for injection5ml Heparin 100units/ml in 0.9% Sodium Chloride for injection.Two green needles/filter straw. Sharps containerSurgical tape, Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free systemHighly permeable dressing and securing device if receiving therapy other than forflushingPlastic apronRationaleExplain procedure to the patient. Ensure that valid consent is gained.Assess the need for local anaesthetic cream.Before the procedure begins make sure that your hands are washed and dried thoroughlyand that they continue to be decontaminated during the procedure. A plastic apron shouldbe worn.Maintain aseptic technique at all timesEnsure that the working area is as clean as possible.Ensure that all equipment is gathered before commencing the procedure and allpackaging is intact and in date.Open sterile pack allowing the inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of the sterile field.Place 0.9% Sodium Chloride (saline) and Heparin 100 units/ml in 0.9% Sodium ChlorideEnsures patient compliance andreduces anxietyReduce the risk of infection, toavoid contaminationTo maintain asepsisThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

ampoule(s) near to the working area but not on the sterile field. Pour out chlorhexidinesolution or open Chlorhexidine impregnated applicator.Decontaminate handsPut on sterile gloves connect the needle/filter straw to the syringeWith a piece of sterile gauze pick up the 0.9% Sodium Chloride (saline) ampule, draw up10ml. Repeat for Heparinised saline. If a needle is used dispose directly into the sharpscontainer. Place the filled syringes on the sterile field.Prime the non-coring needle device including its tubing with 0.9% Sodium Chloride andclamp extension tube, remove syringe.Remove anaesthetic cream if used, locate septum of TIVAD by palpation, remove gloves.Decontaminate hands and put on new pair of sterile gloves.Place dressing towel as near as possible to TIVAD siteClean the skin covering the TIVAD with gauze soaked in Chlorhexidine Gluconate 2% in70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in 70% Isopropyl alcoholimpregnated applicator. Allow to dry Remove needle cover from non-coring needle device. Insert the non-coring needle at 90-degree angle through the skin into the septum of the TIVAD until the needle comes intocontact with the metal backing.Needle free device must be cleaned prior to reattaching syringe – thoroughly clean thehub of the needle free system with 2% Chlorhexidine impregnated wipe or sterile gauzesoaked in 2% Chlorhexidine, rubbing the top of the needle free connector to the sides.This should be done 3 times over a period of 30 seconds. Allow to dry. Attach syringe with 0.9% Sodium Chloride, aspirate enough blood to colour the solutionand inject the flush using a push pause action clamping as the last ml of the solution isinstilled into the catheter. Remove the syringe and discard.If there is no flash back of blood or if there is swelling around the TIVAD site assess forcorrect needle placement, remove the needle and re-access.Following successful saline flush, repeat the flushing procedure using the Heparinisedsaline.If TIVAD was accessed for flushing purposes only, remove the needle and apply pressureover puncture site for a few minutes until bleeding stops.If the needle is to remain in situ ensure the needle is secured using steri-strips andappropriate highly permeable dressing.57The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Remove dressing towel and discard. Remove gloves. Wash handsClear away equipment used. Dispose of contaminated waste as per organisational policyDocument care in patient’s records58The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

59Totally Implanted Venous Access Device (TIVAD) e.g. Port-a-Cath Blood sampling (TIVAD2)ActionEquipment RequiredDressing Pack containing sterile towel and gloves x2Gauze swabs x 3, 10ml syringes x 4,Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in70% Isopropyl alcohol impregnated applicator10ml 0.9% Sodium Chloride for injection5ml Heparin 100units/ml in 0.9% Sodium ChlorideTwo green needles/filter straw. Sharps containerSurgical tape, Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free systemPlastic apronSemi-permeable transparent IV dressing and securing device if receiving therapy otherthan for flushingRationaleExplain procedure to the patient. Ensure that valid consent is gained.Assess the need for local anaesthetic cream.Before the procedure begins make sure that your hands are washed and dried thoroughlyand that they continue to be decontaminated during the procedure. A plastic apron shouldbe worn.Maintain aseptic technique at all timesEnsure that the working area is as clean as possible.Ensure that all equipment is gathered before commencing the procedure and allpackaging is intact and in date.Open sterile pack allowing the inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of the sterile field.Place 0.9% sodium chloride (saline) and Heparin 100units/ml in 0.9% Sodium Chlorideampoule(s) near to the working area but not on the sterile field. Pour out chlorhexidinesolution or open chlorhexidine impregnated applicator.Ensures patient compliance andreduces anxietyReduce the risk of infection, toavoid contaminationTo maintain asepsisThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Decontaminate hands. Put on sterile gloves connect the needle / filter straw to the syringe With a piece of sterile gauze pick up the 0.9% sodium chloride ampule, draw up 10ml.Repeat for Heparinised saline. If a needle is used dispose directly into the sharpscontainer. Place the filled syringes on the sterile field. Prime the non-coring needle device including its tubing with saline and clamp extensiontube, remove syringe. Remove local anaesthetic cream if required and locate septum of TIVAD by palpation,remove gloves. Decontaminate hands and put on new sterile gloves. Place dressing towel as near as possible to TIVAD site. Clean the skin covering the TIVAD with gauze soaked in Chlorhexidine Gluconate 2% in70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in 70% Isopropyl alcoholimpregnated applicator Allow to dry Remove needle cover from non-coring needle device. Insert the non-coring needle at 90-degree angle through the skin into the septum of the TIVAD until the needle comes intocontact with the metal backing. Needle free device must be cleaned prior to reattaching syringe – thoroughly clean thehub of the needle free system with 2% Chlorhexidine impregnated wipe or sterile gauzesoaked in 2% Chlorhexidine, rubbing the top of the needle free connector to the sides.This should be done 3 times over a period of 30 seconds. Allow to dry. Attach empty 10ml syringe unclamp and aspirate 3-5ml of blood. Clamp catheter andremove the syringe and discard the sample. If unable to obtain blood flush the catheter asdirected below. Using a second syringe, take amount of blood required for analysis thenflush the port as directed below. Attach syringe with 0.9% Sodium Chloride (saline) and inject the flush using a push pauseaction camping as the last ml of the solution is instilled into the catheter. Remove thesyringe and discard. If there is swelling around the TIVAD site assess for correct needle placement, remove theneedle and re-access Following successful saline flush, repeat the flushing procedure using the Heparinisedsaline.60The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

If TIVAD was accessed for flushing purposes only remove the needle and apply pressureover puncture site for a few minutes until bleeding stops.If the needle is to remain in situ ensure the needle is secured using steri-strips andappropriate highly permeable dressing.Remove dressing towel and discard. Remove gloves. Wash handsClear away equipment used. Dispose of contaminated waste as per organisational policyDocument care in patient’s records61The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Totally Implanted Venous Access Device (TIVAD) e.g. Port-a-Cath Administration of antibiotics/infusion/additives (TIVAD3)Heparin strengths may vary according to the frequency of the flushes required, refer to local policy62ActionEquipment RequiredDressing Pack containing sterile towel and gloves x2Gauze swabs x 3, 10ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in70% Isopropyl alcohol impregnated applicator10ml 0.9% Sodium Chloride for injection5ml Heparin 100units/ml in 0.9% Sodium Chloride for injection.Two green needles/filter straw. Sharps containerSurgical tape, Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free systemHighly permeable dressing and securing device if receiving therapy other than forflushingPlastic apronAntibiotics/additives/infusion as prescribedRationaleExplain procedure to the patient. Ensure that valid consent is gained.Assess the need for local anaesthetic cream.Before the procedure begins make sure that your hands are washed and dried thoroughlyand that they continue to be decontaminated during the procedure. A plastic apron shouldbe worn.Maintain aseptic technique at all timesEnsure that the working area is as clean as possible.Ensure that all equipment is gathered before commencing the procedure and allpackaging is intact and in date.Open sterile pack allowing the inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of the sterile field.Place 0.9% Sodium Chloride (saline) and Heparin 100 units/ml in 0.9% Sodium Chlorideampoule(s) near to the working area but not on the sterile field. Pour out chlorhexidineEnsures patient compliance andreduces anxietyReduce the risk of infection, toavoid contaminationTo maintain asepsisThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

solution or open Chlorhexidine impregnated applicator.Decontaminate handsPut on sterile gloves connect the needle/filter straw to the syringeWith a piece of sterile gauze pick up the 0.9% Sodium Chloride (saline) ampule, draw up10ml. Repeat for Heparinised saline. If a needle is used dispose directly into the sharpscontainer. Place the filled syringes on the sterile field.Prime the non-coring needle device including its tubing with 0.9% Sodium Chloride andclamp extension tube, remove syringe.Remove anaesthetic cream if used, locate septum of TIVAD by palpation, remove gloves.Decontaminate hands and put on new pair of sterile gloves.Place dressing towel as near as possible to TIVAD siteClean the skin covering the TIVAD with gauze soaked in Chlorhexidine Gluconate 2% in70% Isopropyl alcohol or Chlorhexidine Gluconate 2% in 70% Isopropyl alcoholimpregnated applicator. Allow to dry Remove needle cover from non-coring needle device. Insert the non-coring needle at 90-degree angle through the skin into the septum of the TIVAD until the needle comes intocontact with the metal backing.Needle free device must be cleaned prior to reattaching syringe – thoroughly clean thehub of the needle free system with 2% Chlorhexidine impregnated wipe or sterile gauzesoaked in 2% Chlorhexidine, rubbing the top of the needle free connector to the sides.This should be done 3 times over a period of 30 seconds. Allow to dry. Attach syringe with 0.9% Sodium Chloride, aspirate enough blood to colour the solutionand inject the flush using a push pause action clamping as the last ml of the solution isinstilled into the catheter. Remove the syringe and discard.If there is no flash back of blood or if there is swelling around the TIVAD site assess forcorrect needle placement, remove the needle and re-access.Following successful 0.9% Sodium Chloride for injection flush, administerantibiotics/infusion/additives as prescribed following local Trust PolicyFlush the catheter again with the appropriate volume of 0.9% Sodium Chloride forinjection, using a push/pause action, clamping as the last ml of the solution is instilled intothe catheterRepeat the flushing technique using Heparin 100units/ml in 0.9% Sodium Chloride, usinga push/pause action, clamping as the last ml of the solution is instilled into the catheter.63The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

64If TIVAD was accessed for flushing purposes only, remove the needle and apply pressureover puncture site for a few minutes until bleeding stops.If the needle is to remain in situ ensure the needle is secured using steri-strips andappropriate highly permeable dressing.Remove dressing towel and discard. Remove gloves. Wash handsClear away equipment used. Dispose of contaminated waste as per organisational policyDocument care in patient’s recordsThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

65Care and Management of Peripheral Cannula (PCN1)*All peripheral cannulas should be assessed every 8 hours using a cannula site assessment form as per organisational policy.*They require at least a 5ml flush of 0.9% Sodium Chloride for injection before and after the administration of medications.*Syringes smaller than 5ml should not be used as they can exert excessive force and cause trauma.*It is advisable not to use 3 way taps on peripheral cannulas, if required, extension sets with needle free systems can be used.*Administration sets should be changed every 72 hours with the exception of infusion sets used for blood products, blood andlipid emulsion (TPN), which should be changed up to a maximum of 24 hours. Change giving set immediately upon suspectedcontamination or when the integrity of the product or system has been compromised.*Cannula dressings should be assessed at least every 8 hours and changed if required. A highly permeable dressing should beused at all times to secure the cannula.ActionEquipment RequiredPatients drug prescription and administration recordDressing Pack containing sterile towel and gloves x1Gauze swabs x 1, 10ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol or Chlorhexidine impregnatedwipe10ml 0.9% Sodium Chloride for injectionAntibiotic or treatment to be givenOne green needle/filter straw. Sharps containerAlcohol hand rubSemi-permeable transparent IV dressingPlastic apron Explain procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and driedthoroughly and that they continue to be decontaminated during the procedure. A plasticapron should be worn. Maintain aseptic technique at all times Ensure that the working area is as clean as possible. Ensure that all equipment is gathered before commencing the procedure and allRationaleEnsures patient compliance andreduces anxietyReduce the risk of infection, to avoidcontaminationThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

packaging is intact and in date.Check cannula site for signs of skin discolouration, inflammation or any signs ofinfiltration of fluid in tissues (using a phlebitis score tool). If evident do not use cannula,remove, document and resite cannula.Open sterile pack allowing the inner pack to fall onto the clean working area.Open out sterile pack to create a sterile field. Open remaining equipment ensuring nocontamination of the sterile field. Place sterile towel as near as possible to theperipheral cannula.Place 0.9% Sodium Chloride (saline) near to the working area but not on the sterilefield. Pour out chlorhexidine solution.Decontaminate hands.Put on sterile gloves connect the needle/filter straw to the syringeDraw up 10ml of the 0.9% Sodium Chloride (saline) ampule, using a sterile technique.Draw up antibiotics/therapy using a sterile technique. If a needle is used disposedirectly into the sharps container. Place the filled syringes on the sterile field.Using a piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the topthen the sides of the needle free system connection and allow to dry.Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the needle free connector to the sides. Do this threetimes using different parts of the wipe, over a period of 30 seconds.Allow to dryAdminister 5ml of the 0.9% Sodium Chloride (saline) via the cannula port. If patientcomplains of pain or discomfort stop and reassess. If initial flush was problem free,continue to administer treatment as required followed by the remaining 5ml 0.9%Sodium Chloride (saline). Remove the syringe and discard.Ensure the cannula cap is closedDocument drug administration in in-patients records.Record cannula site assessment as per organisational policy.To maintain asepsisTo prevent needle stick injuryTo prevent contaminationTo ensure catheter patency andprevent complications associatedwith extravasation.66The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

67Changing a Needle-free I/V access Connector (NFS1)This procedure should be carried out in combination with routine line flushing. The frequency of the change of the Needle Freeconnector is determined by the number of uses, with reference to the manufacturer’s guidelines.Equipment RequiredNeedle-free I/V access connector.ActionRationaleIn conjunction with line flushing procedure:Maintain aseptic technique at all timesClamp the catheter. Remove the needle free I/V access connector and discard. Usinga piece of sterile gauze soaked in alcohol Chlorhexidine solution, scrub the top thenthe sides of the catheter hub and allow to dry.Alternatively, scrub the hub of the needle free system with Chlorhexidine impregnatedwipe, rubbing from the top of the catheter hub to the sides. Do this three times usingdifferent parts of the wipe, over a period of 30 seconds. Allow to dry.Connect the new needle-free system to the catheter securely.Reduce the risk of infection, to avoidcontaminationThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

68Trouble Shooting GuideOctober 2009For Cheshire and Merseyside NHS North WestIntravenous Access Care and MaintenanceIn Hospital and at HomeDeveloped byCollaborative Intravenous Nursing Services(CINS)The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

69EXIT SITE INFLAMMATION/PHLEBITISPHLEBITIS: PAINFUL INFLAMMATION ALONG VENOUS PATH IN WHICH VASCULAR ACCESS DEVICE IS PLACEDSigns & Symptoms• Raised temperature• Complaints of pain on flushing orinfusing.• Vein hard on palpation• Swelling at and above exit site• Change in colour or tenderness at siteor along the vein.• Exudate present at IV exit site• Raised WBCAction• Increase volume of diluent in case of chemical phlebitis andadminister at a slower rate, seek advice from pharmacy• Advise patient to apply hot/cold compresses to affected area• Redress and secure device using skin fixation device andappropriate moisture permeable dressing to prevent movementand enable observation in case of mechanical phlebitis• Daily observationResolvedUnresolvedPROCEED WITH CAUTION ASLONG AS THERE ARE NO OTHERCOMPLICATIONS OR PAIN• Monitor for signs of infection and take swab from exit site ifexudate present• Re-site cannula using larger vein above original site, avoidingjoints to avoid further episodes of phlebitis• Seek medical advice or contact clinical nurse specialist• If worsening then possible removal of VAD following discussionwith specialist nurse or doctorThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

70EXTRAVASATION/INFILTRATION AT VASCULAR ACCESS DEVICE SITESigns & Symptoms• Burning sensation or swelling in subcutaneoustissue• Blanching• Burning or discomfort at IV site• Cool skin around IV site• Slow or continuing flow rate even when vein isoccluded• Swelling at and above the IV site• Tight feeling at the IV site• Neck swellingActions• Stop the infusion immediately• Elevate limb to reduce oedema (if peripheral line)• Remove VAD and apply pressure• Re-site VAD above affected site• Seek medical help if evidence of infiltration• Advise patient to seek medical help if they experienceburning, stinging or sensation of sudden heat• Observe site daily• See extravasation policyResolvedUnresolvedCONTINUE TREATMENT USING NEWLY SITED VADMONITORING CONTINUALLY FOR SIGNS OFEXTRAVASATIONIF SYMPTOMS PERSISTS FOLLOWING REMOVAL OFCANNULA, SEEK MEDICAL HELP OR URGENT ADVICEFROM IV NURSE SPEVIALIST.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

SYSTEMIC INFECTION71Signs & Symptoms• Fever and chills without other apparent reason• Malaise• Nausea and vomiting• Low grade pyrexia• Unresponsive to broad spectrum antibiotics• Headache• May be no evidence of sepsis at catheter site• Raised WBC and Raised CRP• May be discharge from exit siteActions• Monitor site dailyContinue to use strict asepsis and always use needlefreesystem• Take cultures from VAD and independent venoussample• Treat with IV antibiotics or combination of oral and IVsas indicated by Medical MicrobiologistResolvedUnresolvedPROCEED WITH CAUTION AS LONG ASTHERE ARE NO OTHERCOMPLICATIONS OR PAIN• Seek advice from IV specialist nurse or referring keyworkerphysician and Medical Microbiology• Assess need for VAD and patient's immune system• Swab catheter site, any wound, sputum and urine• Line lock to salvage line if clinically well. Consult specialist nurse orseek medical help.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

72Care PlansOctober 2009For Cheshire and Merseyside NHS North WestIntravenous Access Care and MaintenanceIn Hospital and at HomeDeveloped byCollaborative Intravenous Nursing Services(CINS)The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

FOR CARE OF PERIPHERAL VENOUS CANNULA.73The care plan is designed to be used in conjunction with CINSGuidelines for vascular devices.Manufacturers’ specific recommendations should be noted andadhered to by individual practitioners.Patient addressograph label / patient nameIdentify site/s by numbering.SITENUMBERDATE TIME COLOUR/GAUGEREASON FORSITINGCONSENTY/NSIGNED REMOVEDDATESIGNEDThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Type of device Risks Actions Variations / Comments SIGNInfection due to loss of Site clean and protected with sterile dressingskin integrityas per CINS guidelines.PERIPHERALVENOUSCANNULAMinimum of daily inspection of site for signs ofinflammation or infection.74Observe patient for signs of line infection(vip score)When VIP score 2 or above remove promptly.Ensure administration lines in place followinglocal policy.Replace any infusates with additives and theiradministration lines at 24hrs if constituted inward environment.Label infusion lines with date for renewal.Air embolusOcclusion of lumen.Use needle free systems instead of 3 waytaps/bungs. Change needle free systems asindicated by manufacturers instructionsRecommend all attachments are needle freedevices and are securely fastened. Thisguideline does not promote the use of 3 waytaps.Ensure air dispelled from medication/flushes/infusates prior to administration.Maintain patency via 0.9% Sodium Chloridefor injection flushes as per CINS guidelines,post drug/infusion administration.Ensure compatibility of drugs/infusates toavoid precipitation.If difficult to flush then remove/re-assess.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Bleeding from site / lineitself.Line displacementLine in situ when nolonger required.Observe for signs of bleeding from site.Upon removal of cannula ensure adequatepressure is applied to site for cessation ofbleeding.If bleeding problematical check clotting times.Check each time line accessed for signs ofdisplacement (extravasation and/orinfiltration). Remove immediately if displaced.Anchor lines to avoid accidental displacementUsing fixation devices as in CINS guidelines.Ensure prompt removal when line no longerrequired.75The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

76PATIENT CARE PLAN FOR CARE OF NON TUNNELLED CENTRAL LINE.This care plan applies to patients with the following central lines:• subclavian• jugular• femoralThe care plan is designed to be used in conjunction with CINS Guidelines for vascular devices.Manufacturers’ specific recommendations should be noted and adhered to by individual practitioners.Patient addressograph label/patient nameReview Dates:DateCommentsREASON FOR INSERTION…DEVICE TYPE…DATE OF INSERTION…Named Nurse or Advisor details….The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

77Type of device Risks Actions Variations / Comments SIGNInfection due to loss ofskin integrity• Site clean and protected with steriledressing as per CINS guidelines.• Minimum of 8 hourly inspection of exit sitefor signs of inflammation or infection. Donot remove dressing unless soiled• Take swab for culture and sensitivity ifindicated• Check weekly or at each visit if incommunity settingVisual Infusion Phlebitis scored(VIP) See chart• Observe patient for signs of line infection(pyrexia/raised WCC)• If clinically unstable and patient has hadrigors, take blood cultures from line andindependent venous sample• Assess medical condition prior to removalof line• Send line tip for culture and sensitivityfollowing removal, in community onlysend if line sepsis suspected• Ensure administration lines in placefollowing local policy.• Replace any infusates with additives andtheir administration lines up to a max of24hrs if constituted in ward environment.• Label infusion lines with date for renewal.• Change add-on devices at same time asadministration sets or as soon as integrityis compromised. Use needle free systemsand avoid 3 way tapsAir embolus • Use Needle-free systems• Ensure air dispelled from medication/flushes/infusates prior to administration.• Assess need for infusion pumpOcclusion of lumen. • Maintain patency via 0.9% SodiumThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Bleeding from site / lineitself.Line migration /displacementLine in situ when nolonger required.Chloride for injection flushes as per CINSguidelines, Pre & post drug / infusionadministration. Use heparinised saline asCINS guidelines if open ended catheter• Ensure compatibility of drugs/infusates toavoid precipitation.• Ensure weekly flushes when not in use.Use needle-free system according toCINS guidelines using positive pressureflush• Ensure regular flushes when lumens notin use.• Observe for signs of bleeding from site.• Apply pressure above dressing• Ensure add on devices/taps securelyfastened.• Ensure clotting studies in acceptablerange prior to removal of line.• Check notes to ensure medical staff havedocumented line is in correct place andsafe to use (for sub-clavian and jugularlines)• Ensure line securely sutured.• Check each shift for signs of linemigration, eg visible lumens outside ofexit point.• Anchor lines to avoid accidentaldisplacement.• If in doubt do not use line and ensurepatient is aware of problems which mayoccur.• Daily review on need for line/ consideration ofchange to more appropriate line for patient.• Daily documentation on need for linedocumented in nursing/medical notes.• Ensure prompt removal when line no longerrequired.78The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

EVALUATION RECORD79DATE EVALUATION SIGN,DESIGNATION& PRINTThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

PATIENT CARE PLAN FOR CARE OF SKIN TUNNELLED CENTRAL CATHETER80The care plan is designed to be used in conjunction with CINS Guidelines for vascular devices.Manufacturers’ specific recommendations should be noted and adhered to by individual practitioners.Patient addressograph label/patient nameReview Dates:DateCommentsREASON FOR INSERTION…DEVICE TYPE…DATE OF INSERTION…Named Nurse or Advisor details….The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Type of device Risks Actions Variations / Comments SIGNInfection due to loss ofskin integrity • Site clean and protected with steriledressing as per CINS guidelines.• Minimum of 8 hourly inspection of exit sitefor signs of inflammation or infection. Donot remove dressing unless soiled.• Take swab for culture and sensitivity ifindicated• Check weekly or at each visit if incommunity settingVisual Infusion Phlebitis scored(VIP) See chart• Observe patient for signs of line infection(pyrexia / raised WCC)• If clinically unstable and patient has hadrigors, take blood cultures from line andindependent venous sample• Assess medical condition prior to removalof line• Send tip for culture and sensitivity• Ensure administration lines in placefollowing local policy.• Replace any infusates with additives andtheir administration lines up to a max of24hrs if constituted in ward environment.• Label infusion lines with date for renewal.• Change add-on devices at same time asadministration sets or as soon as integrityis compromised. Use needle-free systemsand avoid 3 way taps81Air embolus • Use Needle-free systems• Ensure air dispelled from medication/flushes/infusates prior to administration.• Assess need for infusion pumpOcclusion of lumen. • Maintain patency via 0.9% SodiumThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Bleeding from site / lineitself.Line migration /displacementLine in situ when nolonger required.Chloride for injection flushes as per CINSguidelines, Pre & post drug/ infusionadministration. Use heparinised saline asCINS guidelines if open ended catheter• Ensure compatibility of drugs/infusates toavoid precipitation.• Ensure weekly flushes when not in use.Use needle-free system according toCINS guidelines using positive pressureflush• Observe for signs of bleeding from site.• Apply pressure above dressing• Ensure add on devices/taps securelyfastened.• Ensure clotting studies in acceptablerange prior to removal of line.• Check notes to ensure medical staff havedocumented line is in correct place andsafe to use• If line disconnected for any reason thendiscard• Check each time line accessed for signsof line migration• Anchor lines to avoid accidentaldisplacement using fixation devices as inCINS guidelines.• If in doubt do not use line and ensurepatient is aware of problems which mayoccur.Ensure prompt removal when line no longerrequired.82The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

EVALUATION RECORD83DATE EVALUATION SIGN,DESIGNATION& PRINTThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

PATIENT CARE PLAN FOR CARE OF PERIPHERAL MIDLINE84The care plan is designed to be used in conjunction with CINS Guidelines for vascular devices.Manufacturers’ specific recommendations should be noted and adhered to by individual practitioners.Patient addressograph label / patient nameReview Dates:DateCommentsREASON FOR INSERTION…DEVICE TYPE…DATE OF INSERTION…Named Nurse or Advisor details….The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

85Type of device Risks Actions Variations / Comments SIGNInfection due to loss ofskin integrity• Site clean and protected with steriledressing as per CINS guidelines.• Minimum of daily inspection of exit site forsigns of inflammation or infection. Do notremove dressing unless soiled.• Take swab for culture and sensitivity ifindicated• Check weekly or at each visit if incommunity settingVisual Infusion Phlebitis scored(VIP) See chart• Observe patient for signs of line infection(pyrexia/raised WCC)• If clinically unstable and patient has hadrigors, take blood cultures from line andindependent venous sample• Assess medical condition prior to removalof line• Send line tip for culture and sensitivityfollowing removal, in community onlysend if line sepsis suspected• Ensure administration lines in placefollowing local policy..• Replace any infusates with additives andtheir administration lines up to a max of24hrs if constituted in ward environment.• Label infusion lines with date for renewal.• Change add-on devices at same time asadministration sets or as soon as integrityis compromised. Use needle-free systemsand avoid 3 way tapsAir embolus • Use Needle-free systems• Ensure air dispelled from medication/flushes/infusates prior to administration.• Assess need for infusion pumpThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

86Occlusion of lumen. • Maintain patency via 0.9% Sodiumchloride for injection flushes as per CINSguidelines, Pre & post drug/ infusionadministration. Use heparinised saline asCINS guidelines if open ended catheter• Ensure compatibility of drugs/infusates toavoid precipitation.• Ensure weekly flushes when not in use.Use needle-free system according toCINS guidelines using positive pressureflushBleeding from site / lineitself.Line migration /displacement• Observe for signs of bleeding from site.• Apply pressure above dressing• Ensure add on devices/taps securelyfastened.• Ensure clotting studies in acceptablerange prior to removal of line.• Check notes to ensure medical staff havedocumented line is in correct place andsafe to use• If line disconnected for any reason thendiscard• Check each time line accessed for signsof line migration• Anchor lines to avoid accidentaldisplacement using fixation devices as inCINS guidelines.• If in doubt do not use line and ensurepatient is aware of problems which mayoccur.Line in situ when nolonger required.Ensure prompt removal when line no longerrequired.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

87EVALUATION RECORDDATE EVALUATION SIGN,DESIGNATION& PRINTThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

PATIENT CARE PLAN FOR CARE OF PERIPHERALLY INSERTED CENTRAL CATHETER (PICC)88The care plan is designed to be used in conjunction with CINS Guidelines for vascular devices.Manufacturers’ specific recommendations should be noted and adhered to by individual practitioners.Patient addressograph label/patient nameReview Dates:DateCommentsREASON FOR INSERTION…DEVICE TYPE…DATE OF INSERTION…Named Nurse or Advisor details….The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

89Type of device Risks Actions Variations / Comments SIGNInfection due to loss ofskin integrity• Site clean and protected with steriledressing as per CINS guidelines.• Minimum of 8 hourly inspection of exit sitefor signs of inflammation or infection. Donot remove dressing unless soiled• Take swab for culture and sensitivity ifindicated• Check weekly or at each visit if incommunity settingVisual Infusion Phlebitis scored(VIP) See chart• Observe patient for signs of line infection(pyrexia/raised WCC)• If clinically unstable and patient has hadrigors, take blood cultures from line andindependent venous sample• Assess medical condition prior to removalof line• Send line tip for culture and sensitivityfollowing removal, in community onlysend if line sepsis suspected• Ensure administration lines in placefollowing local policy.• Replace any infusates with additives andtheir administration lines up to a max of24hrs if constituted in ward environment.• Label infusion lines with date for renewal.• Change add-on devices at same time asadministration sets or as soon as integrityis compromised. Use needle free systemsand avoid 3 way tapsAir embolus • Use Needle-free systems• Ensure air dispelled from medication/flushes/infusates prior to administration.• Assess need for infusion pumpThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

Occlusion of lumen. • Maintain patency via 0.9% SodiumChloride for injection flushes as per CINSguidelines, Pre & post drug/ infusionadministration. Use heparinised saline asCINS guidelines if open ended catheter• Ensure compatibility of drugs/infusates toavoid precipitation.• Ensure weekly flushes when not in use.Use needle-free system according toCINS guidelines using positive pressureflush90Bleeding from site / lineitself.Line migration /displacementLine in situ when nolonger required.• Observe for signs of bleeding from site.• Apply pressure above dressing• Ensure add-on devices/taps securelyfastened.• Ensure clotting studies in acceptablerange prior to removal of line.• Check notes to ensure medical staff havedocumented line is in correct place andsafe to use• If line disconnected for any reason thendiscard• Check each time line accessed for signsof line migration• Anchor lines to avoid accidentaldisplacement using fixation devices as inCINS guidelines.• If in doubt do not use line and ensurepatient is aware of problems which mayoccur..Ensure prompt removal when line no longerrequired.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

91EVALUATION RECORDDATE EVALUATION SIGN,DESIGNATION& PRINTThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

1Appendix 1Guideline recommendationsTo be reviewed following NICE guidanceThe guidelines within this document should support the intravenous care and management ofadults, for guidance on the care of children please refer to the CINs paediatric guidlelines.For guidance on the care of infants consult with your local paediatric specialists.When using Alcohol Chlorhexidine where available use 2% in 70% Isopropylalcohol. If unavailable recommend the use of 0.5% Chlorhexidine in 70% Isopropylalcohol until such time that it is available. Recommend Chloraprep one step(Chlorhexidine Gluconate 2% in Isopropyl alcohol 70%) for cleaning the skin priorto line insertion.The clinician must ascertain whether the Catheter tip is open or closed. A closeddevice does not require Heparinised saline.Heparinised saline recommended concentration 10units in 1 mlWhen Catheters are not in use they should be flushed with 10ml sodium chloride0.9%. (Heparin 10 units/ml in 0.9% Sodium Chloride as well if the catheter is openended). This should be performed on a weekly or monthly basis following themaintenance guidelines.For needle-free connectors, manufacturers' guidance should be followed re lengthof time to remain in situ. Recommend needle-free systems that are changedminimum of every seven days (e.g. Vygon - Bionector).Alcohol gel should be added to FP10 prescription wherever possibleReminder that hands must be washed and dried thoroughly before putting ondisposable gloves and after removing sterile gloves.If there is a sensitivity to Chlorhexidine solution, Providone Iodine may be used asan alternative.If manufacturers' guides prevent the use of Alcoholic Chlorhexidine on certaintypes of IV access devices then 2% Aqueous Chlorhexidine should be used (seeEPIC guidelines).Ensure all interventions are recorded in the patient’s records as per organisationalpolicyBiopatch antimicrobial dressing with Chlorhexidine Gluconate (Johnson &Johnson) is recommend for use in patients with increased risk of line infection.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

2List of contributors to the Venous Access GuidelinesName Organisation Job Title/RolePaul Mackenzie Merseyside and Cheshire CancerNetworkHealth Inequalities ManagerNetwork Primary Care lead nurseAlison Young Royal Liverpool & Broadgreen Nurse Consultant in NutritionUniversity Hospital TrustElaine Sage Knowsley PCT representing Head of NursingDirectors of NursingAndrew Cooper Birkenhead and Wallasey PCT Nurse ManagerAndrew Langley Leighton Hospital, Crewe Paediatric Ward ManagerAngela Madigan St Helens & Knowsley Teaching Lead Cancer Nurse/ManagerHospitalAnita Corrigan Merseyside & Cheshire Cancer Lead Nurse/Nurse DirectorNetworkAnn Reynolds North Cheshire Hospitals NHS Trust IV Nurse SpecialistAnne Hines Merseyside and Cheshire Cancer Network PharmacistNetworkAnn Baker Wirral PCT Professional Development Nurse(community)Alison Smith Liverpool PCT Lead Nurse IV community teamBarbara Lovelady Chester University Senior Lecturer PractitionerBelinda Hazler Halton & St. Helen’s PCT IV Therapy Nurse PractitionerBeverley Tunstall Knowsley PCT IV Therapy Nurse SpecialistCarol Broderick University Aintree HospitalsClinical Skills Tutor/FacilitatorFoundation TrustCarol Kerr Health Protection Agency Consultant Health ProtectionNurse.Carol Wray NHS supplies and Procurement Supplies ManagerCarol McCormick Clatterbridge Centre for Oncology Clinical Nurse Specialist IV andInterventional proceduresCaroline Boyle Knowsley PCT Community Children’s NurseChristine CainChristine RobertsWirral University Teaching HospitalNHS Foundation TrustSefton PCT / University AintreeHospitals Foundation TrustPaediatric Clinical PracticeDevelopment NurseIV Therapy Lead NurseCoral Hulse Leighton Hospital Trust Nurse Consultant in Intensive careDebbie Doran Liverpool PCT IV Therapy TeamDesmond CollinsEddie LawsonWirral University Teaching HospitalNHS Foundation TrustRoyal Liverpool & BroadgreenUniversity Hospital TrustSpecialist Nurse Paediatric HDU,Paediatric Resusitation NurseMatron HaematologyThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

3Emer Bell Liverpool Womens Hospital Trust Critical Care LeadEmma Carrick Clatterbridge Centre for Oncology Specialist Nurse in IV TherapyGill Core Liverpool Womens Hospital Director of NursingHeather Cooper Leighton HospitalEast Cheshire NHS Trust.Consultant Nurse Critical CareHelen DunningHelen HarkerRoyal Liverpool Children’s HospitalTrustRoyal Liverpool & BroadgreenUniversity Hospitals NHS TrustPaediatric nurseSenior Nurse in IntravascularaccessIleene Macauley Countess of Chester Hospital Trust Team leader IV AccessJane Beckett Warrington PCT IV Lead for Warrington PCTJanet English Southport and Ormskirk Hospital Nurse ConsultantTrustJanet McAlpine Southport and Formby PCT Matron/Clinical DevelopmentFacilitatorJanet Vickers Royal Liverpool Children’s HospitalTrustNurse ConsultantJanine Grundy Warrington PCT Intravenous Therapy Team LeaderJo Marinas Royal Liverpool & Broadgreen Clinical Skills ManagerUniversity Hospitals NHS TrustName Organisation Job Title/RoleKath Birchall AlderHey Hospital LiverpoolKaren Clarke Central Liverpool PCT Nurse Manager Community IVLiverpool PCTKaren Ellis University Aintree HospitalsFoundation TrustClinical Skills / Practice EducationManagerKaren Selwood Alder Hey Children’s NHSFoundation TrustOncology Advanced NursePractitionerLesleyFitzsimmonsThe Christie Hospital Manchester Team Leader, Clinical NurseSpecialist IV and InterventionalproceduresLesley Metcalfe Wirral Hospitals NHS Trust Senior Clinical Risk AdvisorLiz CollinsLorraine SmithWirral University Teaching HospitalNHS Foundation TrustWirral University Teaching HospitalNHS Foundation TrustWard Manager Ward 11Women & Childrens DivisionInfection Control Nurse/InfectionControl Surveillance NurseCoordinatorLucy Wallace Leighton Hospital Paediatric Practice EducatorLynda Taylor Central Cheshire PCT District Nursing lead. LocalityNurse ManagerLynn Heathcote Cheshire East Community Health Community IV Nurse/IVThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

4PCTcoordinatorMalcolm Smith Mid Cheshire Hospitals Foundation Clinical Skills TutorTrustMargaret Wilkie Bebington and West Wirral PCT Professional Development NurseMichael Varey Clatterbridge Centre for Oncology I/V NurseNHS TrustNeil Malley Halton PCT Community Services ManagerNigel Billington Mid Cheshire Hospitals NHST Hospital at Night LeadNigel Evans Countess of Chester Hospital Trust Critical Care Outreach CoordinatorNorma Holt Royal Liverpool & BroadgreenUniversity Hospital TrustLimb Reconstruction SpecialistNursePauline Brown Royal Liverpool Children’s HospitalTrustLead Nurse IV TherapyPaulineHammondRebeccaMolyneuxClatterbridge Centre for OncologyNHS TrustRoyal Liverpool & BroadgreenUniversity Hospital TrustAssistant Director of NursingNurse Consultant in InfectionControlRuth Glenn Halton & St Helens PCT IV Therapy Nurse PractitionerSandra Roberts Cardio Thoracic Centre NurseSara Melville Alder Hey Children’s NHSFoundation TrustPaediatric IV Nurse SpecialistSarah ClarkeSharon LoweSharon IrvingAlder Hey Children’s NHSFoundation TrustAlder Hey Children’s NHSFoundation TrustInfection Control NurseConsultant/DIPSEPaediatric TPN nurse SpecialistShirley Smith Central Liverpool PCT Community IV Team LiverpoolSiobhan Wade Halton & St Helens PCT IV nurse SpecialistStephen Colfar Liverpool Heart & Chest CentreSue Brown Liverpool Womens Hospital Directorate Manager, Theatres,Critical Care and Clinical SupportServicesSue O’Hanlon Halton & St Helens PCT IV therapy Nurse SpecialistTina Twigg CM&MC Manchester Paediatric IV specialist Nurse,Team LeaderTony Nunn Alder Hey Children’s NHSDirector of PharmacyFoundation TrustTracey Forshaw Knowsley PCT Nurse Consultant, Older PeopleTracy Monaghan University Hospital Aintree Clinical EducatorUsha Downie Countess of Chester, Western IV Nurse specialist, paediatricCheshireViki Carter Countess of Chester, WesternCheshireIV Nurse specialist, paediatricThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

5Appendix 2Merseyside & Cheshire Cancer NetworkMerseyside & Cheshire Cancer NetworkNetwork Guidance for the Prevention and Management of ExtravasationInjuries (Revised Mar 08)STOP! – Have you got the most up to date version of this policy?Always Check www.mccn.nhs.ukbefore reading further.Policy formulated and developed by the following:Clatterbridge Centre for Oncology NHS Foundation TrustCountess of Chester Hospital NHS Foundation TrustNorth Cheshire Hospitals NHS TrustRoyal Liverpool & Broadgreen University Hospitals NHS TrustRoyal Liverpool Childrens Hospital NHS TrustSouthport & Ormskirk Hospitals NHS TrustSt Helens and Knowsley Hospital NHS TrustThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

6University Hospital Aintree NHS Foundation TrustWirral University Teaching Hospitals NHS Foundation TrustThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

7CONTENTSPAGENUMBER1 Introduction 32 Definition 33 Scope 44 Evidence Base 45 Causes 46 Risk Reduction 477.1RecognitionSymptoms458 General Procedure for the Management of Extravasation orsuspected Extravasation59 Further notes on treatments for cytotoxic extravasations 61010.110.21111.111.2Extravasation KitsContentsLocationDocumentation & ReportingLocal ProceduresGreen Card Reporting88888812 References & Suggested Further Reading 9Appendix 1 Classification of Cytotoxic Drugs according to their Potential 10to cause severe necrosis when extravasatedAppendix 2 Specific Antidotes in the management of peripheral11extravasationAppendix 3 Extravasation – Evidence behind recommendations 12The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

81. IntroductionThe purpose of this document is to set out the Guidelines for the management of cytotoxicextravasation incidents within the Merseyside and Cheshire Cancer Network.National and Regional standards that this document adheres to and should be read inconjunction with include:• Manual For Cancer Standards 2004• MCCN Guide to Care and Maintenance of Venous access devices incorporating theCollaborative Intravenous Nursing Service guidelines for venous access devices forCheshire and Merseyside NHS Northwest• Reference guide to Consent and Treatment, DH 2001Additionally, network and local policies that support and comply with this document havebeen developed. These include• Network guidelines for the safe prescribing, handling and administration of cytotoxicdrugs• Network 24 hour telephone advice specification• Local chemotherapy administration policies• Local consent policiesThis policy has been written using the best available current evidence and will be reviewedas other evidence becomes available.2. DefinitionExtravasation is defined as the leakage of a vesicant drug or fluid from a vein into thesurrounding tissue during intravenous administration 1 . A vesicant is defined as a drug orsolution which has the potential to cause blistering, severe tissue damage and even necrosisif extravasated. 2 Vesicants may cause damage to the surrounding tissue nerves, tendons orjoints. This may be accompanied by pain, erythema, inflammation and discomfort, which, ifleft unrecognised or treated inappropriately can lead to necrosis and functional loss of thevein and possibly limb concerned 3 . Infiltration is the inadvertent administration of a nonvesicant solution into surrounding tissues. While this may cause inflammation and discomfort,damage and necrosis rarely occurs. 1For clarity the term extravasation will be used to describe the inadvertent leakage ofany drug or fluid into surrounding tissues.Once an extravasation has occurred, the full extent of the injury may be unclear, and damagemay continue for weeks or months. Any extravasation should be considered a medicalemergency and a prompt, appropriate response is essential. The degree of injury can rangefrom apparently insignificant erythema through to blistering, skin sloughing and severenecrosis, which often require corrective plastic surgery. Accurate documentation of theincident is essential. There is no National Standard of Practice.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

93.0 ScopeThe aim of this document is to provide a framework based on current available evidence forthe appropriate management of cytotoxic-inducedextravasation within the Merseyside and Cheshire cancer network. It includes paediatricpractise.Cytotoxic drugs may be divided in 5 categories based upon their propensity to causeextravasation injury. The drugs included in this policy are listed in appendix 1. However thislist may not be exhaustive and it is the practitioner’s responsibility to recognise the potentialfor injury and appropriate management for any drug which they are administering 2 .4.0 Evidence baseExtravasation is a condition that is often under-diagnosed, under-treated and unreported. Therelevance of many published articles is difficult to assess because they often refer to isolatedincidents that have been treated in an inconsistent way. Treatment recommendations in thispolicy have been made based on the best available evidence or where such evidence islacking, based on a consensus of professional opinion from expert pharmacists, nurses, anddoctors from the Merseyside and Cheshire Cancer Network and other network andprofessional body extravasation documents.For the evidence base for specific recommendations made in this policy see appendix 3.5.0 Causes• Dislodgement of the distal tip of the cannula into the tissues surrounding the vein.• Constriction of the blood flow distal to the cannula tip which increases venouspressure and allows fluid to leak from the hole in the vein made by the cannula.• Inappropriate selection of the position and size of cannula and the length of time whichthe cannula is left in situ.• Practitioner unfamiliarity with the drug and the manufacturer’s recommendations foradministration.6.0 Risk Reduction• Only authorised practitioners who have been trained and are included on a registermay administer chemotherapy• At all times the standards in local and network chemotherapy administration policiesmust be adhered to.• Particular care must be taken with the selection and positioning of the cannula.• Drugs with the highest vesicant potential should be given first.• All practitioners administering cytotoxic drugs must have an understanding of themanagement of extravasation and know the contents and whereabouts of theextravasation kit.• If vesicant drugs are administered by a non ambulatory infusion pump then the pumpmust have appropriate pressure sensors that will give early warning of an occlusion7.0 RecognitionIt is important that extravasation is not misdiagnosed because the treatment itself mayinvolve the administration of drugs which themselves can cause further physical trauma tothe patient, and may also potentiate extravasation. Early recognition is vital. Misdiagnosisoften occurs when the practitioner fails to differentiate discolouration reactions in the vein,The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

venous shock, flare or phlebitis. Some cytotoxic drugs are coloured and if the selected veinlies superficial to the skin, the injection of a red coloured drug may cause local venousdiscolouration. 47.1 SymptomsSigns and symptoms of possible extravasation include:• pain, stinging, burning or any other acute change at the injection site. NB Children whoare frightened of needing a new cannula may deny pain or discomfort.• Induration, erythema, venous discolouration or swelling at the injection site.• No blood return is obtained. If this is found in isolation, other signs should be lookedfor, as this can be misleading and has been implicated in a number of seriousincidences. There are 2 ways in which the return of blood may be misleadingo If there has been an extravasation injury and the cannula has become displaced,the act of trying to draw back blood to test for return may move the cannula backinto the vein. Thus blood is returned and the vein appears patent. However, thereis a hole in the vein wall in the proximity of the cannula tip and when administrationof chemotherapy recommences, a larger and more significant extravasation injurywill occur.o Alternatively, the bevel of the needle can puncture the vein wall duringvenepuncture, allowing the drug to escape into the tissue while the lumen of theneedle may still remain in the blood vessel and allow adequate blood return. 4• there is increased resistance to administration once possible positional changes havebeen discounted• changes in infusion rate – Nb these may not be seen if using an infusion pump soclose observation required.•8.0 General procedure for the management of extravasation or suspectedextravasationIf extravasation is suspected, it is important to act quickly to prevent tissue necrosis. Thepractitioner who is responsible for the administration of the vesicant should recognise that anextravasation has occurred and initiate the procedure.Immediate Management (Central and Peripheral)Never apply pressure initially10Step 1Step 2Step 3Step 4Stop the infusion or injection – Do not remove the venflonSeek assistance if neededDisconnect drip and aspirate as much drug as possible, trying also to drawsome blood back into the cannula.Remove cannula with minimal pressure – if central or mixed chemotherapyadministration inform consultant with a view to immediate plastic surgeonreferral. Extravasations from portacath needle locking points may be treated asperipheral.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

11Step 5Step 6Step 7Step 8Step 9Step 10Mark the affected areaElevate the limb and encourage movementFor Mustine, anthracyclines, other vesicants , vinka alkaloids, and otherdrugs FOLLOW SPECIFIC ANTIDOTE GUIDANCE. (See below for furthernotes)Inform consultantProvide analgesia if requiredMeasure the area of extravasation, document any treatment as per local policyand photograph injury if possibleStep 11 Provide patient information leaflet with documented measurements of injury –The practitioner must be aware of the possibility of delayed injury. Ensure thatthe patient knows to contact chemotherapy unit if symptoms worsen or persist.Advise the patient to elevate the affected limb as often as possible for the next2-3 days. Arrange a follow up appointment if needed.Subsequent StepsStep 12Step 13Step 14Complete Green Card, trust incident form and any other local documentation asrequired. Send copy of green card to trust pharmacist who will send to thenetwork pharmacistConsider referral to physiotherapistRefill extravasation kit – local policy to detail procedure for refill9.0 Further notes on treatments for cytotoxic extravasationsSee appendix 3 for evidence base for specific treatments.Treatment principles• Localise and neutralise uses pulsed cold compression with or without a specifictreatment to stop the further spread of the drug and prevent further injury.• Spread and dilute uses warm compression with or without hyaluronidase to facilitatedispersal of the extravasated drug thus reducing its concentration and potential fortissue damage.As a general rule cold compression is used except in the case of vinca alkaloids where warmcompression is used. The practitioner must check the specific antidote table (appendix 2)before proceeding with any intervention.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

12Hyaluronidase: Dilute 1500 units of hyaluronidase in 2 ml of water forinjection, or 0.9% sodium chloride. Gently massage the area to facilitatedispersal.Sodium Thiosulphate: Infiltrate 1-3 ml of 3% isotonic sodium thiosulphateinto the affected area using multiple ‘pin cushion’ injections. To achieve 3%sodium thiosulphate from the 50% vial in the extravasation kit, dilute 1.2 ml of50% to 20 ml with water for injection.Topical DMSO: apply 50% solution topically every 2 hours toThe extravasation site for 24 hours. Avoid contact with good skin. Do notcover the area. If blistering occurs discontinue use and seek further advice.Surgical excision: Wide excision with use of grafts may be indicated if persistent pain 1-2weeks after injury. Inadequate excision is associated with continuing necrosis at themargins, poor granulation and failure of engraftment.Hypodermoclysis: Administering fluids under the skin.Warm Compression W.C.C. Warm Continuous Compression. Apply firmly but withoutundue pressure a heat source (hot water bottle or small electrically heated blanket) to thearea continuously for 24 hours. The heat source should not be in direct contact with the skinand a piece of dry gauze should be laid in between. This assists the natural dispersal of thedrug.Cold Compression: P.C.C Pulsed Cold Compress. Apply firmly but without pressure a coldsource (crushed ice, flexible cold pack or cold bandage) intermittently (for 30 minutes inevery 2 hours) over the area for the first 24 hours, unless advised otherwise. Place a pieceof dry gauze between the skin and cold source.Acidic Extravasations: If the extravasation has been misdiagnosed or the volumeextravasated wrongly assessed, the treatment could lead to an alkali extravasation. If thissecondary extravasation occurs, it is far more serious and the consequence far moredevastating then those associated with venous extravasation. Caution and expert adviceshould be exercised before proceeding with this specific management.Sodium Bicarbonate: Infiltrate with 1-3 ml of 2.1% sodium bicarbonate. 8.4% sodiumbicarbonate must be diluted as follows. To achieve 2.1% sodium bicarbonate take 5ml of8.4% sodium bicarbonate, add 5ml of water for injection, discard 5ml of this new solution andadd a further 5ml of water for injection. Sodium bicarbonate is not in the extravasation kit. Donot use this antidote unless recommended by an expert. (Plastic surgeon)Adapted from the National Extravasation Information Service 2004SteroidsMany guidelines recommend the use of subcutaneous or intradermal steroids. Howevermany reviews state that inflammation is not prominent in the aetiology of tissue necrosis.There is also evidence that subcutaneous or intradermal steroids may be harmful in highdoses, are ineffective in certain extravasations and may increase the skin toxicity of vincaThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

alkaloids. For this reason, this policy does not recommend the routine use of subcutaneoussteroids and injectable steroids are not included in the extravasation kit. Topicalhydrocortisone 1% cream is unlikely to do harm and may reduce non-specific inflammation,except in vinca-alkaloid injuries 510.0 Extravasation KitsBoth the emergency policy and the extravasation kit should be simple and easy to follow toreduce the risk of inflicting further damage. It is necessary to hold a complete set of antidotesand hot and cold facilities in all areas where the administration of chemotherapy takes place.1310.1 Contents• Topical DMSO (dimethylsulfoxide solution 50%)• Hyaluronidase 1500 units injection• Hydrocortisone 1% cream• Sodium thiosulphate 50% solution (DO NOT USE UNDILUTED – use as 3% solution),only for units using mustine• Sodium chloride 0.9% injection• Water for injection• Selection of needles, syringes, alcohol wipes, sterile gauze• Directions to the nearest hot/cold pack• Guide to immediate management including use of specific antidotesIt is the responsibility of the practitioner to ensure that they are familiar with the general policyand the extravasation kit.10.2 Location(insert location of all extravasation kits)Kits must be available in any area where intravenous chemotherapy is given.A laminated copy of the immediate management of extravasation should be available in allclinical areas and with the extravasation kit.Practitioners should liase with pharmacy to ensure timely refill of the kit after use.For CCO outreach clinics, CCO will be responsible for supplying the extravasation kits foruse in the clinic. Local arrangements must be in place if CCO cannot provide any part of thekit e.g. warm/cold packs.11.0 Documentation and reporting11.1 Local proceduresFollow local procedures for documentation and clinical incident reporting. If possiblephotograph the injury. Documentation should include the drugs involved, size and location ofcannula, procedure followed and any specific antidotes used, and outcomes.11.2 Green Card ReportingMost information about the treatment of extravasation is anecdotal. The “Green Card”scheme should be used for reporting extravasation incidences, treatments and outcome. ThisThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

scheme is co-ordinated through the St.Chad’s Unit, City Hospital, Birmingham. Green cardscan be filled in online14The aims of the Green Card are:• to obtain accurate statistical information on the number of incidents categorised byextravasating drug and type of treatment• to collect data on treatment methods and antidotes being used for extravasationincidents• to obtain accurate information on the outcome of incidents• to feedback information on the treatment and its effectivenessGreen Cards ask for the following information:• the drug or drugs involved• how was it detected• the extent of the problem• drugs used in the treatment of the extravasation• the procedure for treatment• type of cannula used for the administration of the chemotherapy• location and extent of the extravasation• outcomeThese reporting cards are user friendly. The information given can remain anonymous for thereporter, the patient and the Centre involved.Reporting can be done online athttp://www.extravasation.org.uk/Greenmenu.htmGreen cards should be available alongside the extravasation kit and can be obtained fromhttp://www.extravasation.org.uk/Greenmenu.htm or by post from Extravasation Co-ordinator,c/o St Chad’s Unit, City Hospital, Dudley Road, Birmingham B1 8 7QHIf reporting online please print a copy of the form before submitting and send to the networkpharmacist. If using a green card please make a copy and send to your trust pharmacist whowill send it to the network pharmacist.12 References and suggested further reading1 Mallet and Dougherty (2004) The Royal Marsden Manual Handbook2 How, C and Brown J. (1998) Extravasation of cytotoxic chemotherapy from peripheral veinsEuropean Journal of Oncology Nursing 2 (1) 51-583Hadaway L.C. (2001) Vesicant Extravasation. Nursing 31(8) 884National Extravasation Information Service (2004)www.extravasation.org.uk accessed 19/04/20065UKCCSG extravasation policy (2005)The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

15Appendix 1CLASSIFICATION OF CYTOTOXIC DRUGS ACCORDING TO THEIR POTENTIAL TO CAUSE SEVERENECROSIS WHEN EXTRAVASATEDVesicants:Group 1Exfoliants:Group 2Irritants:Group 3Inflammitants:Group 4Amsacrine Aclarubicin Carboplatin EtoposideCarmustine Cisplatin (concDacarbazine>0.5mg/ml)DaunorubicinLiposomalPhosphateNeutrals:Group 5(unlikely tocause problemsif extravasated)AsparaginaseEtoposide Fluorouracil BleomycinIrinotecan Methotrexate CladribineDactinomycin Docetaxel Teniposide Raltitrexed CyclophosphamiDaunorubicinDoxorubicinLiposomaldeCytarabineDoxorubicin Floxuridine bortezomibEpirubicin Oxaliplatin FludarabineIdarubicin Topotecan GemcitabineMitomycinMitoxantroneMustinePaclitaxelPlicamycinIfosfamideMelphalanPentostatinRituximabThiotepaBeta-InterferonsStreptozocin Aldesleukin (IL-TreosulfanVinblastineVincristineVindesineVinorelbine2)TrastuzumabcisplatinalemtuzumabNb this list may not be exhaustive. It is the practitioners responsibility to know the vesicant potential of any drugnot on this list Appendix 2The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

16Appendix 2Specific antidotes in the management of peripheral extravasationDrug/class ofdrugVinca AlkaloidsVincristineVindesineVinblastineVinorelbineMustineAnthracyclinesDaunorubicnDoxorubicinEpirubicinIdarubicnMitoxantroneMitomycin CAny othercytotoxic drug(See appendix 1for list.)Warm/ColdcompressionWarm compressionapplyfor 24 hoursApply cold packintermittently for30minutes in every 2hours for 24 hours.Place a piece of drygauze between skinand cold packApply cold packintermittently for30minutes in every 2hours for 24 hours.Place a piece of drygauze between skinand cold packAutomatic cold orwarm compression isnot required.However if symptomswarrant then useintermittent coldcompression exceptin the case ofoxaliplatin, cisplatin,or carboplatin whenwarm compressionmay be used.Specific antidoteHyaluronidase 1500 IUDraw up 1500IU hyaluronidase in 1 to2ml water for injection or 0.9% sodiumchloride. Inject 0.1 to 0.2mlsubcutaneously at points of the compassaround the circumference of the area ofextravasation. Gently massage area tofacilitate dispersal.3% Sodium Thiosulphate – Dilute thesolution provided before use – dilute1.2ml of 50% sodium thiosulphate to20ml with water for injections.Infiltrate the site with 1 to 3ml of dilutedsolution using multiple “pin cushion”injections around the circumference ofthe area.Apply topical hydrocortisone 1% creamfour times a day for the next 7 days orfor as long as erythema persistsTopical DMSO 50%Apply Topical DMSO 50% using acotton bud every 2 hours at theextravasation site for 24 hours. Avoidcontact with good skin. For the next 7days apply DMSO50% every 6 hoursalternating with topical hydrocortisone1% cream every 3 hours. Do not use anocclusive cover. If blistering occurs, stopDMSO and seek further advice.No specific antidote neededIf signs of erythema persist then topical1% hydrocortisone cream may beused. Apply sparingly to the affectedarea 4 times a day while symptomspersist.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

17Appendix 3EXTRAVASATION – EVIDENCE BEHIND RECOMMENDATIONSControversy continues about appropriate antidote therapy and the situation is complicated bythe inability to conduct controlled studies on human subjects. Ethical constraints anddifferences in tissue structure between human and animal skin are two of the biggestobstacles of antidote research. In this section the evidence behind the recommendationsmade in the monographs will be graded according to the definitions derived from US Agencyfor Health Care Policy and Research below.Type and level of evidenceLevelType of evidenceIaIbIIaEvidence obtained from meta-analysis of randomised controlledtrials.Evidence obtained from at least one randomised controlledtrial.Evidence obtained from at least one well-designed controlledstudy without randomisation.IIbEvidence obtained from at least one other type of welldesignedquasi-experimental study.III Evidence obtained from well-designed non-experimentaldescriptive studies, such as comparative studies, correlationstudies and case control studies.IVEvidence from expert committee reports or opinions and/orclinical experiences of respected authorities.A) Grade of RecommendationGrade Evidence RecommendationLevelA Ia, Ib Required – at least one randomised controlledtrial as part of the body of literature of overallgood quality and consistency addressing specificrecommendation.B IIa, IIb, III Required – availability of well conducted clinicalstudies but no randomised clinical trials on thetopic of recommendation.C IV Required – evidence obtained from expertcommittee reports or opinions and/or clinicalexperiences of respected authorities.Indicates absence of directly applicable clinicalstudies of good quality.Unfortunately, no antidote has so far received a clear validation in controlled clinical trials.Therefore, case reports and uncontrolled studies are still the only evidence for the role ofantidotes in the clinical setting and, in some cases they do provide relevant cumulativeThe CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

experience. Due to the volume of the above studies the authors of this policy decided to useonly reviews as evidence. The authors also reviewed other policies from the UK andcontacted the manufacturer of each drug asking for their recommendations for the treatmentof an extravasation with that particular drug.As a result most of the recommendations contained in this policy will be Grade B or C andwill be a result of evidence obtained from reviews, other UK extravasation policies, andmanufacturers.18Treatment RecommendationsEvidenceA. Apply cold pack, firmly but withoutpressure, intermittently for 30 minutesin very 2 hours over the area for thefirst 24 hours, unless advisedotherwise. The cold pack should not beplaced directly on the skin. Place apiece of dry gauze between the skinand the cold pack.Application of cold to the site is thought todecrease toxicity of the agent to the area. It isbelieved this causes vasoconstriction, localisingthe extravasation and perhaps allowing time forlocal vascular and lymphatic systems todisperse the agent as well as shunting bloodaway from the area and reducing cellularmetabolism i,ii,iii,iv . The application of cold tovinca-alkaloid induced injuries has been shownto increase ulcer formation in animal studiesand therefore the use of cold should bereserved only for the treatment of non vincaalkaloidvesicant injuries i,ii,iii,ivIntermittent local cooling for up to 24 hoursappears to be the recommended schedule ii .The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.B. Apply topical hydrocortisone 1% creamevery six hours for the next 7 days orfor as long as erythema continues.Many guidelines recommend the use ofsubcutaneous or intradermal steroids. Howevermany of the reviews found argued thatinflammation is not prominent in the aetiologyof tissue necrosis i,ii,iii,iv,v . There is also evidencethat subcutaneous or intradermal steroids maybe harmful in high doses i,ii , are ineffective incertain extravasations ii and may increase theskin toxicity of vinca alkaloids i,ii . Therefore thisguideline recommends that topicalhydrocortisone 1% is used, which can do littleharm and may bring down non-specificinflammation, except in vinca-alkaloid injuries.The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

19C. Infiltrate the site with 1500 units ofhyaluronidase in 1ml Water forInjection. Inject subcutaneously atseveral areas around thecircumference of the extravasatedarea. Gently massage the area tofacilitate dispersion.Hyaluronidase has been reported to be aneffective antidote for vinca alkaloids andetoposide i.ii,iii,iv . Animal studies have also shownhyalouronidase to be of potential benefit inpaclitaxel extravasations. It is believed injectionof hyalouronidase promotes the permeability oftissue, improving the absorption of infiltratedcytotoxic. Tissue injury is decreased secondaryto the dilution of the cytotoxic across a largertissue area. The guideline thereforerecommends that the use of hyalouronidase isunlikely to cause harm and recommends its usewhere a policy of “spread and dilute” isindicated.The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.D. Apply heat pack, firmly but withoutpressure, continuously for 24 hours.The heat pack should not be placeddirectly on the skin. Place a piece ofdry gauze between the skin and theheat pack.Application of heat is thought to inducevasodilation, which facilitates increasedsystemic absorption and distribution of thecytotoxic. It is thought to aid the dispersal of thevinca-alkaloids. The application of heat toanthracycline induced injuries increases tissuedamage and therefore the use of heat shouldbe reserved only for the treatment of vincaalkaloid and non-vesicant induced injurieswhere a policy of “spread and dilute” isindicated i,ii,iii,iv .The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.E. Apply topical Dimethyl Sulfoxide(DMSO) 50%(v/v), by painting on witha ‘cotton bud’, every 2 hours at theextravasation site for 24 hours. Avoidcontact with good skin. If blister formsstop DMSO and seek further advice.F. For the next 7 days apply DMSO every6 hours, alternating with topicalhydrocortisone 1% cream every 6hours (a preparation applied every 3hours on an alternate basis). Do notuse an occlusive cover. If requiredcover once the area is dry. If blisterforms stop DMSO and seek furtheradvice.This is recommended for the anthracyclinesand mitomycin i,ii,iii,vi,vii . The use seems wellsupported, and seems unlikely to cause anyharm. The optimal schedule and duration ofDMSO applications is unclear but shouldprobably be at least every 6 hours for aminimum of 3 days ii . It should be noted thatDMSO is not licensed for this use.The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10

20G. Infiltrate the site with 1-3ml of 3%isotonic sodium thiosulphate into theaffected area using multiple ‘pincushion’ injections at several areasaround the circumference ofextravasated area. Beforeadministering Sodium Thiosulphatethe solution provided in the packMUST BE DILUTED FIRST. Dilute1.2ml 50% sodium thiosulphate to 20mlwith water for injectionThis is recommended for mustine i,ii,iii . The useseems well supported, and seems unlikely tocause any harm. It should be noted that sodiumthiosulphate is not licensed for this use.The evidence supporting this treatmentconsists entirely of III or IV reports but issufficiently extensive that this can berecommended at Grade B.H. Monitor patient closely for “recallreactions”.Anthracyclines administered after radiotherapyhave been shown in a reactivation of skintoxicity known as a “recall reaction”. A similarreaction may be seen in patients who have hadprevious extravasations. This reaction has alsobeen shown with paclitaxel ii .The evidence for this approach in patients onanthracyclines and Paclitaxel is very limited(level IV) and the confidence with which it canbe recommended is Grade C.Reproduced with thanks from the UKCCSG paediatric extravasation policyi Pharmacologic Management of Vesicant Chemotherapy Extravasations. CancerChemotherapy Handbook. 2 nd Edition. Chapter 6. Ed. Dorr R.T., Von Hoff D. Appleton &Lange, Norwalk, Conneticut.iiBertelli, G. Prevention and Management of Extravasation of Cytotoxic Drugs. Drug Safety12(4): 245-255. 1995.iiiDorr R.T. Antidotes to Vesicant Chemotherapy Extravasations. Blood Reviews 4: 41-60.1990.iv Kassner E. Evaluation and Treatment of Chemotherapy Extravasation Injuries. Journal ofPaediatric Oncology Nursing 17(3): 135-148. 2000.v Extravasation of drugs. Anaesthesia Review. Chapter 13. Ed. Kaufman L., Ginsbury R.Churchill Livingstone. 1997. London.viRospond R.M. Utilization of dimethyl sulfoxide for treating anthracycline extravasation. JOncol Pharm Practice 1(4): 33-39. 1995.viiLawrence H.J., et al. Topical dimethylsulfoxide may prevent tissue damage fromanthracycline extravasation. Cancer Chemotherapy and Pharmacology 23: 316-318. 1989.The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.Policy review date 01/10/10