Central Venous Catheeter Management

1. PURPOSE:

 1.1 PICC/CVC is inserted when a peripheral access is difficult to obtain. It is used for IV medications,
  IV nutrition, chemotherapy or fluids infusion for an extended period of time. Or those require frequent blood
  sampling without the need for repeated peripheral stick
 1.2 To provide comprehensive, evidence-based standard and guidelines in the care and management of
  residents with PICC/CVC line to prevent potential development of CRBSI.

2. POLICY:

 2.1 Care of PICC/CVC line should be done by IHHC staff on a strict aseptic technique whenever accessing or
  dressing the device 2.2 Standard practices are to be followed in accordance with the guidelines of CDC
  (Center for Disease Control and Prevention) in prevention of CRBSI

3. DEFINITION:

 3.1 Peripherally Inserted Central Catheter (PICC)- a thin flexible tube that is inserted into a vein. The tip of the
  lumen is positioned in the superior vena cava. The end of the PICC exits the body at or near ;anti-cubital
  fossa
 3.2 Central Venous Catheter (CVC)- catheter is surgically placed through the chest and threaded into one of
  the large veins that lie close to the heart
 3.3 Catheter- Related Bloodstream Infection (CRBSI) - a bloodstream infection attributed to an intravascular
  catheter.

4. PROCEDURE:

 4.1 Assessment and monitoring of the insertion site
  4.1.1 Check for post PICC/CVC placement complications such as bleeding, bruising, inflammation,
  tenderness, discharges noted, or if with fever
  4.1.2 Monitor the catheter sites visually when changing the dressing or by palpation through an intact
  dressing on a regular basis
  4.1.3 If manifestations suggesting local or bloodstream infection, the dressing should be removed to allow
  thorough examination of the site
  4.1.4 To contact IHHC Medical Resident if a complication arises and may indicate management or possible
  removal and replacement of PICC/CVC

 4.2 Care and Maintenance
  4.2.1 Daily Flushing with 0.9% Sodium Chloride (saline)
  4.2.2 Dressing at least once a week or as required
  4.2.3 Do not submerge the catheter or catheter site in water
  4.2.4 Do not use topical antibiotic ointment or creams on insertion sites because of their potential to promote
  fungal infections and antimicrobial resistance

 4.3 Flushing and Dressing
    4.3.1 Preparation:
    4.3.1.1 Always check for patient’s sensitivity to Chlorhexidine
    4.3.1.2 Work area surface should be thoroughly cleaned
    4.3.1.3 Check expiry dates of prefilled syringes (Saline/Heparin)
    4.3.1.4 Hand hygiene - Wash hands with conventional soap and water or with alcohol-based hand rubs.
    It shoud be performed:
    4.3.1.4.1 Before and after palpating catheter insertion sites
    4.3.1.4.2 Before and after accessing for flushing or dressing an intravascular catheter.
    4.3.1.5 Aseptic Technique
    4.3.1.5.1 Palpation of the insertion site should not be performed after the application of
    antiseptic, unless aseptic technique is maintained
    4.3.1.5.2 Wear sterile gloves in flushing procedure or when changing dressing
    4.3.2 Flushing- Prevent Occlusion
    4.3.2.1 Disinfect pre and post flushing using juicing technique (10-15 seconds) the end of the PICC with
    chlorhexidine swab and allow to air dry. This is the most effective way of reducing colonization
    4.3.2.1.1 Equipment
     4.3.2.1.1.1 Dressing pack with gloves and paper towel
     4.3.2.1.1.2 Chloraprep
     4.3.2.1.1.3 (2) pair of gloves
     4.3.2.1.1.4 Transparent occlusive dressing/ transparent film (Tegaderm)
     4.3.2.1.1.5 (10ml) posiflush syringe (1 syringe for each lumen/if with heparin 2 syringes for each
          lumen)
     4.3.2.1.1.6 Needle free connector valve
     4.3.2.1.1.7 (2) alcowipes/chlorhexidine in alcohol swab
     4.3.2.1.2 Procedure
     4.3.2.1.2.1 Wash hands prior to opening of the dressing pack.
     4.3.2.1.2.2 Open and place all items in the dressing pack
     4.3.2.1.2.3 Do hand hygiene once again and put on the gloves.
     4.3.2.1.2.4 Wrap patient’s arm with the towel
     4.3.2.1.2.5 Pick up and clean the the free valve with an alcowipe/chlorhexidine swab.
     4.3.2.1.2.6 Open the clamp, flush the solution then close the clamp whilst injecting the final 1 ml of
          the saline.
    4.3.2.1.2.7 Clean again the valve connector with an alcohol swab with 2% chlorhexidine
    4.3.2.1.3 If the PICC being used has a clamp, ensure it is shut/closed
    4.3.2.1.4 The flushing technique should be a start/stop method, otherwise known as “turbulent flush”.
    This type of flushing technique helps clear the walls of the PICC line more efficiently then a straight
    flush. If blood is noted in the catheter or at the hub, flush the PICC with 20mLs normal saline.
    4.3.2.2 Flush with Heparin, as ordered by Medical Practitioner
    4.3.3 Dressing – it serves to secure and held PICC/CVC line in place - Infection prevention
    4.3.3.1 Always clean the insertion site, on the patients arm or chest, with chloraprep swab
     4.3.3.1.1 Procedure:
     4.3.3.1.1.1 Do hand hygiene, let it dry and put on the gloves
     4.3.3.1.1.2 Remove dressing
     4.3.3.1.1.3 Again, wash hands, dry and put on a new pair of gloves
     4.3.3.1.1.4 Gently loosen and remove the dressing, while ensuring the PICC is secured
     4.3.3.1.1.5 Clean the insertion site on the patient’s arm with chloraprep swab using “juicing technique”
     4.3.3.1.1.6 Place a catheter stabilization if necessary
     4.3.3.1.1.7 Cover with transparent dressing, ensure PICC site is well covered.
    4.3.3.2 Place a sterile gauze swab between the bung and the patient’s skin to prevent discomfort
    if necessary
    4.3.3.3 Use either sterile gauze or sterile, transparent, semi-permeable dressing to cover the catheter
    site
    4.3.3.4 If gauze dressing is used, change every 2 days
    4.3.3.5 Replace transparent dressings at least every 7 days, except in those pediatric patients in which
    the risk for dislodging the catheter may outweigh the benefit of changing the dressing.

 4.4 Complications
  4.4.1 Thrombosis/Blood Clot formation- Heparin to dissolve clots
  4.4.2 Venous air- line must not be left unclamped when not in use.
  4.4.3 Dislodgement- should be secured with tape or covered with dressing.
  4.4.4 Break or cut- avoid use of instruments which may puncture catheter.
  4.4.5 CRBSI/Infection– conformity to aseptic technique when procedure is being performed, utilization of
  CRBSI bundle.

 4.5 Documentation
  4.5.1 Document all assessment, interventions and evaluation that occur while caring for patients with
  PICC/CVC
  4.5.2 Utilization of the standardized checklist in CRBSI prevention (CRBSI Bundle)
  4.5.3 To communicate with the IHHC resident physician any significant finding that is essential in decision to
  maintain, replace or need for prompt removal of the device

5. RESPONSIBILITIES:

 5.1 IHHC Staff
  5.1.1 Strict adherence to the policy
 5.2 IHHC Management
  5.2.1 Designate only trained staffs who demonstrates competence on care and maintenance of PICC/CVC
  5.2.2 Provide continuing education on PICC/CVC line, proper procedure on care and maintenance, and
  appropriate infection control measures to prevent CRBSI
  5.2.3 To periodically assess IHHC staff knowledge of and adherence to guidelines and protocols

6. APPENDICES

 6.1 CRBSI Bundle (IHHC/PCI/F-0009-16)

7. REFERENCES:

 7.1 Pan Birmingham Cancer Network Guide for Nurses in PICC Flushing and Dressing 2010, Accessed March
  2013. Available at http://www.birminghamcancer.nhs.uk
 7.2 http://www.birminghamcancer.nhs.uk/uploads/document_file/document/
  4cc5b6c8358e987568000151/flushing_dressing_picc_nurses.pdf
 7.3 American Cancer Society. Last revised February 11, 2016
   https://www.cancer.org/treatment/treatments-and-side-effects/central-venous-catheters.html
 7.4 Ceneter for Disease and Control Prevention. Last updated February 8, 2011
   https://www.cdc.gov/hicpac/BSI/12-appendix-C-BSI-guidelines-2011.html