Overview of how to access/care for Patients with Central Venous Access Devices (CVAD)

 CVC- An indwelling catheter used where the need for Central Venous access is prolonged or essential to administer drugs  A CVC terminates at or close to the heart or in one of the great vessels leading to the heart – SVC/ IVC

 Hickman line  Peripherally inserted central catheter PICC  Midline  Portacath

Practitioners must :  have undertaken training including theory and simulated practice  must have passed a practical assessment  demonstrate knowledge of the trust Blood transfusion policy  Be accountable for their own practice and ensure their practice remains up to date in line with local policy (NMC 2008).  Take part in appropriate learning and practice activities that maintain and develop your competence and performance

 Used frequently in Haematology/Oncology for Drug and fluid administration:  Infusional chemotherapy pumps  Long chemotherapy regimens  Bone Marrow Transplant  Intermediate-long term Intravenous antibiotics  Poor venous access  Breast cancer patients - Axillary node clearance  The patient can remain at home for part/all of their treatment  Nutritional support (TPN) Assessment by (TPN) Nutrition Specialist Team )  Blood samples  Patient choice

Administration of drugs via a CVAD will not take place if:  The Patient refuses treatment  There is any concern over patency i.e the device is not flushing or aspirating as it should be  There is any concern re the position of the device i.e the exit length has moved (picc) or signs of displacement.

Oncology Nurses  Radiographic evidence of catheter position is not documented (Important if administering vesicant drugs)  Length of line inserted (cm) not documented to compare with exit length prior to use.  Suspected line infection or thombosis

 Hickman lines are inserted under radiological guidance in x-ray  Directly into one of the central veins, the superior or inferior vena cava, both of which return blood into the right atrium and have the largest blood flow of any veins in the body  PICC lines are generally inserted by specialist nurses  via the cephalic/median/basilic veins and the tip is in the superior vena cava under ultra sound guidance  X-ray following insertion to confirm correct placement

Ultra Sound Guidance N. P. S. Sandhu, and D. S. Sidhu Br. J. Anaesth. 2004;93: © The Board of Management and Trustees of the British Journal of Anaesthesia 2004

Statlock Kit…! Take Care not to pull picc line out…! Exit Length must be recorded in notes…!

 Inserted into the upper arm via the cephalic/median/basilic veins and advanced until the tip of the catheter is located in the superior vena cava (svc)  Ultrasound guidance insertion recommended  X-ray required to confirm correct position/placement of tip  X ray guided insertion

 Follow HEFT Standard Operating Procedure for flushing of lines – Under Nursing Guidelines  Weekly flushing, dressing (and change of stat locks-PICC)  Push-pause flushing technique  Needleless Access Device – Max Plus  Minimum of 10 ml syringes for all interventions - Pressure level  Use Aseptic Non Touch Technique as per local policies  If red and/or inflamed swab for MC&S  Document in medical notes

 A tunnelled line made of soft silicone  Single, double, triple lumen lines available  Has cuff which is buried under the skin. This cuff acts as a barrier to infection, the line is sutured in place whilst tissue grows/forms around the cuff to secure it, reducing the risk of accidental displacement-(R.O.S exit site = 14 days)  R.O.S at clavicle entry = 7 days  Weekly Bio patch Change or When Soiled – ie Chlorhexidine Impregnated sponge which covers exit site

 Follow the same principles for using a PICC  Education of patients and relatives imperative  Things to report - redness/swelling, pain, (line is longer PICC)  Teaching the patient/relative to flush/dress lines  Advice re showering  Written information to consolidate all verbal information  Documentation of care in medical notes and Nursing Care Plan

Always use an Aseptic Non Touch Technique  Remove first 5mls of blood - important when checking for asperate pre vesicant drugs or pre taking Bloods.  Ensure a Flush after each use is used with 10mls sterile Sodium Chloride 0.9 % (or manufacturer’s recommended flush solution if not compatible)  Needleless Access device – ie max plus connector  Site care - assess daily for signs of infection & record assessment i.e exit length, dressing intact,  Dressing changes- change weekly transparent dressing for visibility opsite 3000,clean exit site with Alcoholic 2% chlorhexidine solution e.g. ChloraPrep Solution 3ml  Discharge plan & Patient Education

 Unable to with draw blood from line  Unable to flush line Consider the following:  Check clamp is off  Check line not kinked  Positional  Clot in line  fibrin sheath  Line is not inside the vein  Never apply force this can rupture/split line or dislodge a clot –Seek advice

 Occlusion  Phlebitis  Infection  Thrombosis  Catheter embolus  Venous damage  Pneumothorax Cardiac arrhythmias  Arterial puncture  Nerve damage (particularly PICC’s)  Cardiac tamponade

 Urokinase is a naturally occurring enzyme that converts plasminogen to plasmin, which is then able to degrade fibrin and cause the lysis of a clot.  Syner-Kinase is used as a catheter “lock”  Must be prescribed following Trust medicines policy  Dissolve Urokinase 25,000 U with 2mls sterile saline  Follow ALGORITHM FOR PARTIAL WITHDRAWAL OCCLUSION FOR A PICC – SOP You may need to refer patient to experienced practitioner.  Install 1ml =12,500 U using a sterile technique lock in line for 1-4 hours-label line DO NOT USE and inform patient that no one can use the line until urokinase is removed Document actions (Refer to SOP)

 Hickman Lines Ideally should be removed by the practitioner who inserted the line but not always practical  X-Ray department (planned procedure)  Haematology Registrars/Consultants (e.g line needs to be removed due to infection) and have had training  PICC- CNS who inserted/Nurse who has been trained

 Document removal in medical notes including length of line removed  Never attempt to push any line back in position seek advice

 Questions???  Contacts: Tanya Szczygielski Faculty Senior Educator ext Bleep: 3335 or Martina keane Clinical Nurse Educator Ext