Standard Operating Procedure Central Venous ... - NHS Devon

Standard Operating Procedure- Central Venous Catheters V0.7
Standard Operating Procedure
Central Venous Catheters
Purpose of this document:
The purpose of this document is to inform registered healthcare professionals about the
safe and appropriate procedures for the care and management of Central Venous
Catheters (CVCs).
Review Date: May 2012
Version History
Version Date Issued Brief Summary of Change Owner’s Name
V0.1 September Initial draft based on the guidance from acute trusts. Una Foggitt/Soo
draft 2009
Sims/ Jane Watson
V0.2 October Amended following comments from Jane Barr Una Foggitt/Soo
2009
Sims/ Jane Watson
V0.3 November Amended following comments from Gillian Mills, Tom Una Foggitt/Soo
2009 McEwan, Karen Fredricks
Sims/ Jane Watson
V0.4 March 2010 Amended following Adult Professional Council. Una Foggitt/Soo
Sims/Jane Watson
V0.5 April 2010 Amended following comments from Jan de Witt, Penny Una Foggitt/Soo
Criddle and Henry Tobin
Sims/Jane Watson
V0.5a April 2010 Amendments following discussion at Infection Control Una Foggitt/Soo
Committee
Sims/ Jane Watson
V0.6 April 2010 Amendments by Jane Watson and Una Foggitt flowing Una Foggitt/Soo
comments by Jan Dewitt and Penny Criddle
Sims/Jane Watson
V0.7 May 25 th
Agreed at Infection Control Committee Una Foggitt/Soo
2010 Final
Sims/Jane Watson
For more information on the status
of this document, contact:
Una Foggitt
Clinical Lead- Community Nursing (Eastern)
NHS Devon Provider services
Unit 1 Exeter International Office Park
Clyst Honiton
Exeter EX5 2HL
01392 356939 or 07966147698
Date of Issue
Reference Standard Operating Procedure- Central Venous Catheters
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Standard Operating Procedure- Central Venous Catheters V0.7
Contents
1. Background
2. Definition of Central Venous Catheters
3. Types of Central Venous Lines
4. Principles of Central Venous Catheter Site Care
5. Dressing for PICC
6. Tunnelled Catheter Dressing
7. Totally Implanted Venous Access Device Dressing
8. Maintaining Patency and accessing the CVC
9. Frequency of flushing
10. Blood Aspiration
11. Changing Needle-free Connector
12. Trouble shooting
13. Diagnosis of Catheter-Related Infection
14. Clinical Record Keeping
15. Incidents/Adverse Drug Reactions.
16. Useful Contact Numbers
17. References
This Standard Operating Procedure links to:
Devon PCT Consent Policy
Devon PCT Provider Services Medicines Policy and accompanying Standard Operating
Procedures
Devon PCT Incident Policy
Devon PCT Injectable Medicines Policy
Devon PCT Waste Management Policy
Medical Devices Policy
Infection Control
Anaphylaxis Policy
Devon PCT Clinical Record Keeping
Royal Devon and Exeter NHS Foundation Trust – Guidelines for the Management of Central
Venous Catheters (2008)
South Devon Healthcare NHS Foundation Trust Implanted Central Venous Catheter (protect)
Plymouth Hospitals NHS Trust 9 Central Venous Access Device (CVAD) training and
Resource Pack
Right Patient/ Right Blood
Mental Capacity Act
1. Background
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Standard Operating Procedure- Central Venous Catheters V0.7
A Standard Operating Procedure (SOP) has been developed for the care and management of
Central Venous Catheters (CVC). It acknowledges the work undertaken by the Acute Trusts
at Exeter, Plymouth and South Devon.
This SOP is supported by the Injectable Medicines Policy, which outlines the procedure for the
safe administration of medication via the injectable route and this includes medication e.g.
Heparinised saline (Hepsal)/ and normal saline 0.9% via CVC’s.
The SOP will apply to registered staff employed by Devon Provider Services who work within
the community hospital and community setting with adults and children. Staff will have
undertaken specific training to work within this SOP namely: Intravenous administration, CVC
training, Right Patient Right Blood in addition to the mandatory training required by the
employer.
This SOP refers to the care of a CVC after insertion in the acute trust setting and when
the patient is referred back to primary care. It does not cover the removal of CVC in
Primary Care.
This SOP refers to Peripherally Inserted Central Catheter (PICC); Skin tunnelled
catheter (Hickman) and Totally implanted venous access device (TIVAD Portacath) and
does NOT refer to short-term non-tunnelled catheters.
In undertaking any procedure relating to Central Venous Catheters consent must be
obtained in accordance with NHS Devon Provider Services Consent Policy.
2. Definition of a Central Venous Catheter
An intravascular catheter placed, within the superior or inferior vena cava or other large
central vein. Ideal tip placement is the distal innominate vein or proximal superior vena cava
(SVC).
3. Types of Central Venous Lines
3.1. Peripherally Inserted Central Catheter (PICC) - is sited in the Basilic or cephalic veins
or brachial complex vein utilising ultrasound.
3.2 Skin tunnelled long term catheter (Hickman) – lies in a subcutaneous tunnel before
entering a central vein usually the subclavian.
3.3 Totally implanted venous access device (TIVAD Portacath). A tunnelled device under
the skin in the internal jugular or subclavian vein.
4. Principles of Central Venous Catheter Site Care
The main principles listed below apply to all CVCs; specific management issues will be
addressed under each heading.
4.1 A care plan must always be in place when undertaking care of a patient with a CVC.
4.2 Following insertion CVCs must be securely fixed, with sutures or a securing device, to
reduce trauma to the exit site and to prevent movement of the line (exception tunnelled
lines ref section 6), which may allow organisms to migrate into the vein.
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4.3 Adherence to infection control principles is key in reducing risk of CVC related
infection. Before dressing a CVC hands must be cleansed with an alcohol rub, an
apron worn, and an aseptic technique using sterile gloves and a sterile pack.
4.4 If there is haemoserous fluid (usually 24- 48 hours post insertion) sterile gauze
secured with a sterile transparent dressing should be applied, but changed daily.
4.5 Where possible the use of sterile gauze should be avoided as this prevents the site
being observed. If unavoidable this should be changed every 24 hours and when
visibly soiled.
4.6 The site must be disinfected at every dressing change to reduce microbial colonisation.
2% chlorhexidine gluconate in 70% alcohol is the standard cleansing solution.
4.7 A transparent semi-permeable Intravenous (IV) dressing should be applied when area
is dry, and changed every 7 days or more frequently if dressing is no longer intact or if
moisture collects at site.
4.8 Once Hickman line sutures are removed, it is best practice to leave the site uncovered.
4.9 Scissors should not be used near CVCs because of the risk of damage to the catheter.
4.10 Dressing change or observation must be documented including site condition, dressing
used and action taken if complication has arisen.
5. Dressing for PICC
A securing device (e.g. Stat-lock) is used to secure the catheter in place. Following insertion
there is one puncture site. This should be observed daily (through a transparent dressing)
when an inpatient.
5.1 Frequency of dressing change:
Every seven days
When required if dressing is loose or damp
5.2 Equipment for Procedure:
Clean Trolley, Tray and a sterile field
Dressing pack (containing sterile gloves & apron)
2% chlorhexidine gluconate in 70% alcohol (e.g. Chloraprep)
Transparent semi-permeable dressing (e.g. IV 3000)
Securing device e.g.Stat-lock
Skin closures e.g. steristrips
5.3 Procedure:
5.3.1 Explain procedure to patient and obtain consent in accordance with the NHS Devon
Consent Policy.
5.3.2 Cleanse hands.
5.3.3 If visibly soiled, wash and dry hands thoroughly.
5.3.4 If visibly clean, rub alcohol hand gel into all surfaces until completely dry.
5.3.5 Open dressing pack.
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5.3.6 Put on apron.
5.3.7 Cleanse hands.
5.3.8 Remove old transparent dressing in an upwards direction to prevent displacement.
5.3.9 Observe condition of catheter insertion site.
5.3.10 Cleanse hands and prepare equipment
5.3.11 Apply sterile gloves.
5.3.12 Disinfect around line site using 2% chlorhexidine gluconate in 70% alcohol (contact
time 30-60 seconds, allow 30 seconds to air dry) .
5.3.13 Renew skin closures e.g. steristrips.
5.3.14 Replace transparent dressing (e.g..IV 3000).
5.3.15 Change Statlock every 7 days, unless visibly soiled and/or lifting, in which case it
should be changed earlier.
5.3.16 A stockinette e.g. Comfifast may be required.
5.3.17 Dispose of equipment as NHS Devon Policy for Waste Management. Cleanse hands.
5.3.18 Document procedure and condition of site in relevant documentation.
6. Tunnelled Catheter Dressing
Sutures must be removed by a practitioner who is competent in the care of tunnelled
catheters, especially the exit site suture due to the close proximity to the catheter.
6.1 Following insertion there are two puncture sites ‘entry and exit’ with sutures. The entry
suture can be removed 7-10 days post insertion, once suture is removed leave
exposed.
Exit (around the line) site suture can be removed 14 -21 days or left longer if required
to allow fibrosis of tissues around Dacron cuff to occur.
6.2 The tunnelled catheter should be looped once around the exit site under the dressing
when suture in situ, to avoid any trauma at the insertion site.
6.3 Fibrosis will occur to secure the catheter in place, and the exit site suture can be
removed. The area can now be left exposed, with micro-pore or a pouch used to
secure the catheter.
6.4 Frequency of Dressing Change:
- Every seven days
- When required if dressing is loose or damp
6.5 Equipment for Procedure:
- Clean Trolley, tray and a sterile field
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- Dressing pack (containing sterile gloves and apron)
- 2% chlorhexidine gluconate in 70% alcohol (i.e. Chloraprep) plus one
disinfectant wipe (e.g.PDI wipe)
- Transparent semi-permeable dressing (e.g.IV 3000)
6.6 Procedure:
6.6.1 Explain procedure to patient and obtain consent in accordance with the NHS Devon
Consent Policy.
6.6.2 Cleanse hands: if visibly soiled wash, and dry hands thoroughly.
6.6.3 If visibly clean, rub alcohol hand gel into all surfaces until completely dry.
6.6.4 Open dressing pack.
6.6.5 Put on apron.
6.6.6 Cleanse hands.
6.6.7 Carefully remove old dressing and discard.
6.6.8 Observe catheter insertion site for complications.
6.6.9 Cleanse hands and prepare equipment.
6.6.10 Apply sterile gloves.
6.6.11 Using a sterile piece of gauze, hold the line away from the skin, clean the area using
2% chlorhexidine gluconate in 70% alcohol swab stick, ensuring a contact time of 30
60 seconds.
6.6.12 Continuing to hold the line away from the skin use 2% chlorhexidine gluconate in
70% alcohol wipe to thoroughly clean line working from exit site outwards.
6.6.13 Allow area to air dry.
6.6.14 Apply dressing. Once sutures have been removed and the wound is sufficiently
healed it can be left exposed if patient chooses.
6.6.15 Dispose of equipment as per NHS Devon Policy for Waste Management.
6.6.16 Cleanse hands.
6.6.17 Document procedure and condition of site in relevant documentation.
7. Totally Implanted Venous Access Device Dressing
Immediately after insertion sterile gauze will be in place, the site should be inspected and
“port” accessed. A sterile gauze dressing is appropriate for the first 24 hours, once the site is
dry dressed with a sterile transparent semi-permeable dressing. Sutures, if used, can be
removed 7-10 days after insertion; once sutures are removed the area should be left exposed.
7.1 Frequency of dressing change
Apply transparent semi-permeable dressing when the “port” is in use.
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Change:
� Every seven days (to coincide with change of Gripper needle)
� When required if dressing is loose or damp
Follow procedure section 6.
8. Maintaining Patency and Accessing the CVC
General Information
• Adherence to infection control principles is key in reducing risk of CVC related infection.
Prior to any manipulation of the line, hands should be washed or an alcohol rub used.
Attention to an “aseptic non-touch technique” is required during procedures where the
system remains closed. Key parts (end of catheter hub, seal of needlefree connector,
luer of syringe or infusion set) must not be handled.
• An aseptic technique using sterile gloves is required whenever the connector is
removed and the catheter is “open”.
• Always observe the insertion site prior to accessing the devices; if any signs of
infection, thrombosis or misplacement are present do not use. See Section 12 on
complications of CVCs for advice on further management.
• A sterile field should be placed under the line during flushing to provide a sterile fluid
impermeable barrier, which will reduce the risk of micro-organisms being introduced.
• Connections must be disinfected with 2% chlorhexidine gluconate in 70% alcohol
(contact time 30-60 seconds, allow 30 seconds to air dry) before breaking connection,
prior to and after accessing the catheter.
• Except for emergency access haemodialysis CVCs must not be used for any other
purpose.
• Manipulation of the catheter should be kept to a minimum by good co-ordination of drug
regimen, blood taking and line connection changing where possible.
• Each lumen should be treated as a separate catheter with regard to maintaining
patency and when infusing drugs. If the need arises to infuse two or more drugs via one
lumen refer to Injectable Medicines Policy or contact Lead Pharmacist or acute Trust
Pharmacy for advice on compatibility.
• Syringes smaller than 10ml exert too great a pressure on the central line and should not
be used. (Neonatal and paediatric areas should refer to local guidelines)
• Administer final flush using the push pause method (pushing 1ml at a time). This
causes turbulence within the catheter lumen, removing any debris from the internal
catheter wall. If using an IV connector which does not provide positive pressure, apply
positive pressure by maintaining pressure on the syringe plunger whilst administering
the last 0.5ml and simultaneously clamping the line. If using a positive pressure
connector, administer final flush, remove syringe then clamp the line.
9. Frequency of Flushing
All CVCs.
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• When catheter is in use, it must be flushed before and after blood sampling, drug
administration, or when discontinuing an infusion.
• If blood is noted in the catheter, flushing is required.
• If connector becomes loose, change the connector (see section 11) and then flush.
9.1 Flushing Solution:
• Solution used for the flushing of CVC must be prescribed in accordance with the
Medicines and Injectable Medicines Policy on the Provider Services Prescription and
Medication Administration Record.
• The volume of solution required will vary (e.g. lower volumes will be used in the
neonatal unit). However the volume should be equal to at least twice the volume
capacity of the catheter and add-on devices.
9.2 Frequency of flushing:
For PICC or Tunnelled CVC
Daily access - 0.9% sodium chloride
Weekly access – Heparinised saline (10 units/ml)
Totally implanted venous access device
Daily access - 0.9% sodium chloride (10mls)
Monthly access – Heparinised saline, 5-6ml (100 units/ml)
9.3 Procedure for Access via a Needlefree Connector:
9.3.1 Explain procedure to patient and obtain consent in accordance with the NHS Devon
Consent Policy.
9.3.2 Cleanse hands:
if visibly soiled, wash and dry hands thoroughly;
if visibly clean, rub alcohol hand gel into all surfaces until completely dry.
9.3.3 Open dressing pack.
9.3.4 Put on apron.
9.3.5 Prepare equipment required on a sterile field or clean tray.
9.3.6 Apply clean non-sterile gloves. Draw up required flushing solution/drugs to be
administered, checking against prescription chart. Ensure key parts: tip of
syringe, hub of needle and seal of IV Connector, are not touched during procedure
(“aseptic non touch technique”).
9.3.7 Dispose of non sterile gloves.
9.3.8 Prepare patient and perform necessary checks.
9.3.9 Locate the catheter.
9.3.10 Cleanse hands.
9.3.11 Apply clean non-sterile gloves.
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9.3.12 Position sterile field so that the connector (once disinfected) can rest in the centre.
9.3.13 Disinfect IV connector thoroughly with a 2% chlorhexidine gluconate in 70% alcohol
impregnated swab (contact time 30-60 seconds, allow 30 seconds to air dry).
9.3.14 Remove needle from syringe and discard into sharps bin.
9.3.15 Hold catheter to stabilise.
9.3.16 Firmly push and twist syringe into IV connector, ensure syringe remains securely
attached.
9.3.17 Unclamp line and administer prescribed flush/drug avoiding contact with key parts tip
of syringe, hub of needle, seal of IV Connector
9.3.18 Repeat for each drug/flush administered.
9.3.19 Administer final flush using the push-pause method (pushing 1ml at a time). If using
an IV connector which does not provide positive pressure apply positive pressure
by maintaining pressure on the syringe plunger whilst administering the last 0.5ml and
simultaneously clamping the line. If using a positive pressure connector administer
final flush, remove syringe and then clamp the line.
9.3.20 Check the seal has returned to its normal position (i.e. is not depressed). Disinfect
connector thoroughly.
9.3.21 Dispose of equipment as per NHS Devon Policy for Waste Management.
9.3.22 Cleanse hands
9.3.23 Document procedure and condition of exit site in relevant documentation.
10. Blood Aspiration
10.1 Purpose
To obtain blood samples.
10.2 General Information
The Monovette or vacutainer is the preferred method for blood aspiration.
When blood sampling from a CVC, first stop any infusions. If a multi lumen catheter is
in situ try to keep one lumen for sampling and the others for infusions/drug
administration. If this is not possible, flush the catheter before sampling to avoid
contamination – this is particularly important when obtaining a sample for drug levels.
All samples should be labelled as per NHS Devon Right Patient Right Blood
guidelines. You may also refer to your acute hospital specimen labelling policy. All
blood samples must be transported in accordance with the NHS Devon policy for
Waste Management.
Do not take blood from a catheter dedicated for Total Parenteral Nutrition infusion
unless catheter related infection is suspected and blood cultures through the line are
required.
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Order of draw for blood samples:
Blood Cultures (Plain Bottles)
Biochemistry (e.g. Brown)
Coagulation (e.g. Green)
If using Heparinised Bottle this is next (e.g. Orange)
EDTA (e.g. Red)
Fluoride (e.g. Yellow)
10.3 Procedure for Blood Aspiration via a Needlefree Connector
10.3.1 Cleanse hands.
10.3.2 Put on plastic apron.
10.3.3 Prepare equipment on a clean trolley, tray or sterile field.
10.3.4 Draw up saline flush using a non-touch technique to be administered checking against
prescription chart.
10.3.5 Cleanse hands
10.3.6 Put on clean gloves
10.3.7 Disinfect connector using a 2% chlorhexidine gluconate in 70% alcohol impregnated
swab before use (thorough clean and 30 secs allow to dry)
10.3.8 If accessing PICC line (and in some cases a Hickman line) first flush with 1-2 mls of
normal saline checking against prescription chart.
10.3.9 Attach Monovette adaptor and bottle or 10ml syringe to connector for discard sample
(non-touch technique) and discard this immediately.
10.310 Obtain samples using a non-touch technique and remove adaptor.
10.3.11 Attach syringe for flushing using a non-touch technique
10.3.12 Flush using a push-pause method and remove syringe before clamping if using a
positive pressure connector
10.3.13 Disinfect connector using a 2% chlorhexidine gluconate in 70% alcohol impregnated
swab after use (thorough clean and 30 secs allow to dry)
10.3.14 Label samples as per NHS Devon Right Patient Right Blood guidelines. All blood
samples must be transported in accordance with the NHS Devon policy for Waste
Management.
10.3.15 Dispose of equipment as per NHS Devon Policy for Waste Management and remove
Gloves.
10.3.16 Cleanse hands.
10.4 Totally Implanted Venous Access Devices
Accessing Implanted Devices Using a Non-Coring Needle
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Anaesthetic cream may be used over the access site if necessary. The anaesthetic
cream should be prescribed on a Provider services Prescription and Medication
Administration Record or initially staff who have signed the Patient Group Direction for
local anaesthetic cream can operate under that authority to administer
Frequency of needle change (when left in situ):
Weekly (Oncology)
Fortnightly (Respiratory medicine)
The needle should be removed earlier if any signs of inflammation/infection are
observed.
Equipment for procedure
Clean trolley or Tray and a sterile field
Dressing Pack (including sterile gloves & apron)
Non – coring needle with extension set (Gripper)
0.9% Sodium Chloride
5ml heparinised saline (10u/ml)
Blue Needle
10ml Syringe x 2
Transparent semi-permeable dressing (e.g. IV 3000)
Sterile Gauze
2% chlorhexidine gluconate in 70% alcohol wipe (e.g. Chloraprep)
(Needlefree IV connector)
Procedure
10.4.1 Explain procedure to patient and obtain consent in accordance with the NHS Devon
Consent Policy.
Cleanse hands:
• if visibly soiled, wash and dry hands thoroughly.
• if visibly clean, rub alcohol hand gel into all surfaces until completely dry.
10.4.2. Open sterile dressing pack.
10.4.3. Put on apron.
10.4.4. Prepare equipment required.
10.4.5 Once device has been located cleanse hands with alcohol hand rub.
10.4.6. Using 2% chlorhexidine gluconate in 70% alcohol wipe disinfect the area around the
access site for 30-60 seconds and allow to air dry for 30 seconds.
10.4.7. Cleanse hands.
10.4.8. Apply sterile gloves.
10.4.9. Connect the non-coring needle with extension set to a 10ml syringe with 0.9% sodium
chloride.
10.4.10.Prime the line. Leave Sodium Chloride syringe attached.
10.4.11.Immobilise the “port” by placing a finger each side, avoiding the access site.
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10.4.12. Push needle into the “port” chamber, confirm placement by withdrawing blood or
flushing with sodium chloride checking that it does not infiltrate the surrounding
tissue.
10.4.13. Attach an IV needlefree connector if device is to be access subsequently.
10.4.14 Secure gripper needle with transparent dressing.
10.4.15 Dispose of equipment as NHS Devon Policy for Waste Management.
10.4.16 Cleanse hands
10.4.17 Document procedure and condition of exit site in relevant documentation.
11. Changing Needle-free Connector
11.1 Purpose
Minimise infection risk from overuse or leakage of IV connector.
11.2 Frequency of change
� Local acute sector guidelines recommend change times being based on
number of activations depending on the brand in use and according to
manufacturer’s instructions. In most situations a weekly change is indicated
(e.g. Bionector, Maxplus, Microclave or BD Q-Syte).
In addition the needle-free connector should be changed:
� When it has been removed for any reason.
� If it appears damaged or contaminated, is leaking, or if blood is seen in catheter
or connector.
To reduce catheter manipulation coordinate this procedure with flushing, blood
sampling or drug administration, and or dressing change.
11.3 Procedure for Change of an IV needlefree connector
11.3.1 Explain procedure to patient and obtain consent in accordance with the NHS Devon
Consent Policy.
Prepare patient and perform necessary checks. Locate catheter.
11.3.2 Cleanse hands:
if visibly soiled, wash and dry hands thoroughly
if visibly clean, rub alcohol hand gel into all surfaces until completely dry.
11.3.3 Open sterile dressing pack onto clean surface.
11.3.4 Put on plastic apron.
11.3.5 Cleanse hands again.
11.3.6 Arrange sterile field so that gauze can be accessed, ensuring sterile items are not
contaminated. Open connector onto sterile field.
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11.3.7 Open 2% chlorhexidine gluconate in 70% alcohol impregnated wipes onto sterile field.
11.3.8 Cleanse hands.
11.3.9 Put on sterile gloves.
11.3.10 Place sterile field under catheter. Check catheter is clamped.
11.3.11 Using gauze to hold the catheter disinfect connector with a 2% chlorhexidine in 70%
alcohol wipe before removing connector. Ensure contact time of at least 30 seconds
and allow drying for 30 seconds. Remove connector.
11.3.12 Use 2 nd wipe to disinfect open hub of CVC and allow to dry.
11.3.13 Attach new connector
11.3.14 Dispose of all used items and gloves as per NHS Devon Policy for Waste
Management.
11.3.15 Cleanse hands.
11.3.16 Dispose of equipment as NHS Devon Policy for Waste Management.
11.3.17 Cleanse hands
11.3.18 Document procedure and condition of exit site in relevant documentation.
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Standard Operating Procedure- Central Venous Catheters V0.7
12. Trouble shooting
Complication Signs and symptoms Management
Catheter dislodgement External portion of catheter is
longer
Sudden lack of blood return
Swelling in the arm, neck or
Broken catheter (risk of
catheter or air embolism)
chest
Leakage from line during use.
Any visible damage.
Do not attempt to push
catheter back into place or
use it.
Seek expert help
Clamp catheter between
patient and damaged area,
cover with sterile gauze.
Minimise patient
movement;
Seek expert advice:
removal or repair (of
tunnelled catheters) should
only be undertaken by
specialist staff.
Infection (local or
systemic)
See section 13 See section 13
Catheter occlusion Inability to flush catheter Check external catheter for
Inability to aspirate/obtain kinks.
blood
Attempt gentle irrigation
with 0.9% sodium chloride
Do not exert excessive
pressure or suction.
Thrombosis
Mechanical phlebitis
(PICCs only)
N.B. sometimes not possible
to aspirate blood from TIVADs
and some PICCs, but they
should always flush freely.
Swelling
Pain, numbness or tingling
Coolness, swelling or venous
engorgement discoloration of
neck, chest or arm
Usually occurs within first 72
hours. Pain, erythema or
swelling around site, without
signs of infection (e.g.
discharge, raised temperature)
If unable to remedy, or
patient has any signs/
symptoms of a thrombosis
– seek expert advice on
unblocking lines.
Seek urgent medical
advice.
Elevate arm and apply
heat for 20 minutes, up to
6 hourly
Encourage mild range of
movement
Seek vascular access
team advice if does not
improve
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13. Diagnosis of Catheter-Related Infection
13.1 Exit Site Infection and Tunnel Infection
Signs of infection:
• Pain at site
• Inflammation
• Cellulitis/tracking (within 2 cm of exit site = exit site infection; at a distance of >2
cm of exit site and along subcutaneous tract or the catheter = tunnel infection)
• Exudate/pus at site
• Fever
N.B: These signs may be absent in a neutropenic patient.
13.2 Specimen collection
If exit site/tunnel infection is suspected, swab the exit site for Microscopy Culture and
Sensitivity (MC&S). A swab (with charcoal medium) should be used; in the absence of
pus/exudate, pre-moisten swab with sterile saline.
13.3 Systemic Infection
If systemic infection is suspected immediately refer to GP and/or acute trust for
advice and appropriate action.
Signs of infection:
• Fever (usually >38 o C)
• Malaise
• Rigors (particularly on flushing)
• Chills
• Hypotension
The patient may become shocked and close observation is indicated.
13.4 Specimen Collection
Obtain 2 sets of blood cultures: one from a peripheral vein and one from the CVC. For
peripheral cultures ensure that skin preparation is thorough, gently rubbing the site
with 2% chlorhexidine gluconate in 70% alcohol wipe for 30-60 seconds and allow to
dry. Label forms clearly to indicate whether cultures are peripheral or from CVC.
13.5 Reporting and Documentation in case of Infection
Any sign of infection must be documented in nursing notes and reported to medical
staff. Assess whether antibiotic treatment and/or line removal is indicated. Refer to
local guidance in oncology/haematology or to medical staff in other areas.
NB. Topical antiseptics or topical antibiotics are not recommended for CVC site
infection. In addition, topical preparations in a polyethylene
glycol base must not be applied as polyethylene glycol will damage the integrity
of the catheter.
13.6 Catheter Tip Culture
If catheter is removed, the catheter tip should be sent for culture. To prevent
contamination, the tip should be cut using sterile scissors on a sterile field and then
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Standard Operating Procedure- Central Venous Catheters V0.7
placed directly into a sterile universal container. Label the form to indicate the site of
the catheter.
14. Clinical Record Keeping
14.1. Patients with Central Venous Catheters will have a care plan in place for all
interventions.
14.2 Patients who require flushing and blood aspiration will require a Prescription and
Medication Administration Record for the solution administered via the injectable route.
14.3. Documentation relating to care of the CVC will be in accordance with the Provider
Services Clinical Record Keeping Policy.
15. Incidents/Adverse Drug Reactions
15.1. In the event of an adverse drug incident or reaction immediate care will need to be
undertaken to minimise harm to the patient.
15.2 The patients GP or consultant/ specialist team must be informed.
15.3 If the incident is as result of an adverse drug reaction the ‘Yellowcard’ will require
completion and be sent to the Medicines and Healthcare products Regulatory Agency
(MHRA) – details are contained in the British National Formulary (BNF). This can be
undertaken by the unit staff or the patient if this is appropriate.
15.4 Staff have a duty to report any undue incidents while the patient is receiving care of
their central venous catheter. This will follow the NHS Devon Provider Services
Incident Reporting Policy.
15.5 The incident must be recorded in the patient records indicating the actions
taken.
16. Useful Contact Numbers
Vascular access Team Exeter RDE 01392 411611
Vascular Access Team Torbay 01803 654942 # 6314
Vascular Access Team Plymouth 01752 202082
17. References
High Impact Intervention No1 Central venous catheter care bundle (2007) Department of
Health.
Nursing and Midwifery Council; Standards for Medicines Management August 2007 reprinted
August 2008.
Nursing and Midwifery Council: The Code. Standards of Conduct, performance and ethics for
nurses and midwives 2008
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Standard Operating Procedure- Central Venous Catheters V0.7
Royal Devon and Exeter NHS Foundation Trust – Guidelines for the Management of Central
Venous Catheters ( 2008)
South Devon Healthcare NHS Foundation Trust Implanted Central Venous catheter
(portacath) No date
Plymouth Hospitals NHS Trust 9 Central Venous and Access Device (CVAD) training and
Resource pack. No date
Epic2 Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals.- The
Journal of hospital Infection.
Administration Intravenous Therapy to Children in the Community setting. (2003) – Royal
College of Nursing.
NPSA 2008 RRROO2 Risks with Intravenous Heparin Flush Solutions
Standard Operating Procedure – Central Venous Catheters V 0.7 Page 17 of 17