UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
MEDICAL CENTER

PROCEDURE

PROCEDURE:

 112

EFFECTIVE:

 3/83

REVISION:

8/08

APPROVED:

8/08

 

PROCEDURE FOR THE CARE OF CENTRAL VENOUS CATHETERS (HICKMAN, COOK, GROSHONG, ARROW, TRIFUSION, QUINTON, ETC.)

PURPOSE: To prevent infection, maintain patency, and ensure catheter integrity

SUPPORTIVE DATA:

Central Venous Catheters are made of silastic or polymer materials, and are either stitched or subcutaneously tunneled. Care of both types of catheters is similar. Dressing change standards are the same, but volumes and solutions used for flushing may differ. PICCs and apheresis catheters are addressed in separate procedures as care of the lines and dressing change steps differ.

EQUIPMENT:

Flushing

Heparin flush type as indicated per catheter guidlines

Normal saline for flush as indicated

Appropriate syringe(s)

Alcohol or  2% chlorhexidine prep

Dressing/Cap Changes

Subclavian/TPN dressing kit or gauze/tape

Needleless adaptors

PROCEDURE STEPS:

DRESSING CHANGE/CAP CHANGE:

KEYPOINT: There are three standard dressing options: transparent dressing, gauze, and hypoallergenic dressing. Use a transparent dressing unless the site is bleeding, or ointment/medication is needed. In that case, the gauze option would be preferred. If an allergy is noted, hypoallergenic dressing is a good option. Regardless of the dressing used, it is important that the dressing be occlusive. Change dressings which are soiled or are no longer occlusive. Remove the postoperative dressing on SQ tunneled catheters 24 hours after the catheter is inserted.  Transparent dressing with CHG is to be used within 24 hours after insertion of CVL line or PICC lines.  Assess for drainage from the insertion site. Do not remove steri-strips if present. Redress as appropriate. 

 

  1. Position patient, arranging clothing so that nothing touches site. Wash hands. Put on nonsterile gloves.

  2. Carefully remove old dressing and discard. Stitched catheters can be pulled out accidentally, especially if the stitches are loose. Report the need for new stitches immediately. SQ tunneled catheters may have stitches at the exit site postoperatively.

 

KEYPOINT:  For SQ tunneled catheters, stitches at the exit site are generally removed 5-7 days per physician order.

 

  1. Remove gloves and wash hands again.

  2. Assess the insertion site/exit site and the surrounding area for inflammation and infection. Check integrity of the catheter.

  3. Open the kit, touching only corners of the sterile overwrap.

  4. Put on sterile gloves and open all packages in kit, placing upright in tray.

  5. Examine the insertion area, if dry bloody residue is present, clean with single alcohol swab before using 2% chlorhexidine.

  6. Clean the area with the 2% chlorhexidine applicator by alternating horizontal and vertical strokes.  It is not necessary to clean in a circular motion.  Scrub the area for 30 seconds. Allow to dry completely.

 

KEYPOINT:  Do not use alcohol after chlorhexidine is applied.  Alcohol will remove the chlorhexidine barrier left on the skin. 

  1. Apply dressing using one of the standard options as described on chart (ensuring dressing is occlusive):

KEYPOINT:  Saline flush should always be used between any manipulation (antibiotics/med/blood withdrawal).

TROUBLESHOOTING CATHETERS:

1.      Inability to aspirate blood

  1. Check to make sure catheter is not kinked or twisted.

  2. Change patient position (Raise or lower head, lie on side, have patient perform valsalva, if not contraindicated).

  3. Attempt aspiration with syringe connected directly to the lumen.

  4. Attempt flushing with normal saline, alternating with aspiration.

  5. Inform physician, if still unable to aspirate. Xray/dye study may be indicated to determine placement and/or presence of fibrin sheath. The approved catheter clearing agents (i.e. TPA) may be ordered if catheter is occluded with blood.

2.      Inability to infuse

 

  1. Make sure catheter is not clamped.

  2. Attempt to flush the catheter but NEVER FORCE fluid through the line.

  3. Position changes may be beneficial.

  4. Attempt aspiration, and assess for occlusion with blood/precipitate.

3.      Leaking catheter

 

  1.  Assess lumen. If split or holes are found, clamp between patient and the damaged area. Notify physician and determine whether catheter can be repaired.

 

REFERENCES:
1999.  Guidelines from Bard Access Systems: Groshong C. V. Catheter

Camp-Sorrell, D.  (2004). Access Device Guidelines, 2nd Edition. Oncology Nursing Society.  Pittsburgh.  p. 6.

Infusion Nursing Standards of Practice (2000).  Journal of Intravenous Nursing.    23(6S):  pp 53-54.

O’Grady NP, Alexander MBS, Dellinger E, et.al. (2002) Guidelines for the Prevention of Intravascular Catheter-Related Infections (Centers for Disease Control).  American Journal of Infection Control.  30(8): 476-489.

Bard Access Systems, Inc.  www.bardaccess.com/pdfs/ifus/ifu-port-arterial.pdf

RESOURCE PERSON(S):   Heather Alverson, RN, BSN, OCN; Shelly Armstrong RN, BSN, CCRN; Amy Hester, RN, BSN, BC; Cheryl Whittington, RN, BSN, CCRN

 See Chart Below

UAMS Medical Center
 Standards for Vascular Access Devices

PRINTER FRIENDLY VERSION - Standards for Vascular Access Devices Chart 

Standards for vascular access devices
Access devices Flushing requirements when in use ALWAYS USE 5 ML SYRINGE OR GREATER Flushing requirements when not in use ALWAYS USE 5 ML SYRINGE OR GREATER Dressing Change /Caps Change  Blood Draw    ALWAYS USE 5 ML SYRINGE OR GREATER
Groshong Flush with 5-10 ml of Normal Saline (NS) Administer meds/fuids. Flush with 10-20 ml NS after intermittent use 5 ml Normal saline Flush once every day Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          Before blood draws, flush with 10 ml NS and *wait 2 minutes. Aspirate 3-5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush with 10-20 ml NS or attach IV tubing
Hickman Flush with 5-10 ml of Normal Saline (NS) Administer meds/fuids. Flush with 5-10 ml NS after intermittent use 2 ml 100 units/ml Heparin flush solution per lumen every 24 hours Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          Before blood draws, flush with 10 ml NS and *wait 2 minutes. Aspirate 3-5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush with 5-10 ml NS followed by  2 ml Heparin flush solution (100 units/ml) or attach IV tubing
Implanted Venous Ports Flush with 5-10 ml of Normal Saline (NS) Administer meds/ fluids, Flush with 5-10 ml NS followed by 5 ml Heparin flush solution (100 units/ml) after intermittent use.  5 ml Heparin flush solution (100 units/ml) every 30 days Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          Before blood draws, flush with 10 ml NS and *wait 2 minutes.  Aspirate 3-5 ml blood and discard.  Aspirate appropriate amount of blood for tests.  Flush with 10 ml NS, using the “start/stop” method to create turbulence in the port reservoir, followed by 5ml heparin flush solution (100 units/ml) or attach IV tubing.
Implanted Arterial Ports Catheter: Flush with 5-10 ml of Normal Saline (NS) Administer meds/fluids, Flush with 5-10 ml NS followed by 3-5 ml Heparin flush (100units/ml solution or per MD order). Catheter: aspirate 5ml of heparin flush, discard. Heparin flush solution (100 units/ml) every 24 hours or per MD order. Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          Before blood draws, flush with 10 ml NS and *wait 2 minutes. Aspirate 5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush each site (catheter vs. port) as described in flushing requirements.
Port: Flush with 20 ml NS, administer meds/fluids, flush with 20 ml NS followed by 5 ml heparin flush (100 units/ml solution or per MD order). Port: aspirate 5ml of haparin flush, discard 5ml heparin flush solution (100 units/ml) every week or per MD order.
PICC Flush with 5-10 ml of Normal Saline (NS) administer meds/ fluids and then flush with 5-10 ml NS followed by 1ml Heparin flush solution (100 units/ml) per lumen after intermittent use. 1 ml Heparin flush solution (100 units/ml) per lumen every 24 hours Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          Before blood draws, flush with 10 ml NS and *wait 2 minutes.  Aspirate 3-5 ml blood and discard.  Aspirate appropriate amount of blood for tests.  Flush with 5-10 ml NS followed by 1 ml Heparin flush solution (100 units/ml) or attach IV tubing.
Trifusion Tunneled Catheter  Flush with 5-10 ml of Normal Saline (NS), administer meds/fluids and then flush with 10 ml NS followed by 1 ml Heparin flush solution (1000 units/ml) after intermittent use.    Aspirate 2 ml of fluid out of the lumen and discard, flush with 10 ml NS and then 1 ml Heparin flush solution (1000 units/ml) per lumen every 24 hours. Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          ***Before blood draws, aspirate 2 ml heparin solution from lumen and discard. Flush with 10 ml NS and *wait 2 minutes. Aspirate 3-5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush with 10 ml NS followed by 1 ml Heparin flush solution (1000 units/ml) or attach IV tubing.
Quinton/Arrow  (Single or Double Lumen) Flush with 5-10 ml of Normal Saline (NS), administer meds/fluids and then flush with 10 ml NS followed by 2 ml Heparin flush solution (1000 units/ml) after intermittent use.       Aspirate 3 ml of fluid out of the lumen and discard, flush with 10 ml NS and then 2 ml Heparin flush solution (1000 units/ml) per lumen every 24 hours. Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          ***Before blood draws, aspirate 3 ml heparin solution from lumen and discard. Flush with 10 ml NS and *wait 2 minutes. Aspirate 3-5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush with 10 ml NS followed by 2 ml Heparin flush solution (1000 units/ml) or attach IV tubing.
Quinton Mahurkar Acute Triple Lumen Catheter (2 large pheresis lumens and 1 smaller infusion lumen) **Large Lumens: Flush with 5-10 ml of Normal Saline (NS), administer meds/fluids and then flush with 10 ml NS followed by 2 ml Heparin flush solution (1000 units/ml) after intermittent use. **Large Lumens: Aspirate 3 ml of fluid out of the lumen and discard, flush with 10 ml NS and then 2 ml Heparin flush solution (1000 units/ml) per lumen every 24 hours. Transparent Dressing:  Every seven days or PRN Gauze Dressing: daily or PRN CAPS: every 7 days or PRN          **Large Lumens: ***Before blood draws, aspirate 3 ml heparin solution from lumen and discard. Flush with 10 ml NS and *wait 2 minutes. Aspirate 3-5 ml blood and discard. Aspirate appropriate amount of blood for tests. Flush with 10 ml NS followed by 2 ml Heparin flush solution (1000 units/ml) or attach IV tubing.
Small Lumen: Flush with 5-10 ml of Normal Saline (NS) Administer meds/ fluids, Flush with 5-10 ml NS followed by 1ml Heparin flush solution (100 units/ml) per lumen after intermittent use.      Small Lumen: 1 ml Heparin flush solution (100 units/ml) per lumen every 24 hours Small Lumen: Before blood draws, flush with 10 ml NS and *wait 2 minutes.  Aspirate 3-5 ml blood and discard.  Aspirate appropriate amount of blood for tests.  Flush with 5-10 ml NS followed by 1 ml Heparin flush solution (100 units/ml) or attach IV tubing.
*KEYPOINT: If patient is on vasoactive drips, drips do not have to be placed on hold for 2 minutes prior to drawing blood.
  **KEYPOINT:  Doctor's order must be obtained to access dialysis specific Quinton Catheters for purposes other then Hemodialysis.
***KEYPOINT:  Highflow catheters require increased concentration of heparin flush (1000U/ml).  Flushing the catheter without first aspirating the heparin flush out of the lumen may dose the patient with a therapeutic amount of heparin and cause increased risk of bleeding.

 

Nursing Manual Home Page