Central venous catheter (CVC) care for an infant, child, or young person

Overview

The guideline is not intended to replace clinical judgement, rather the intent is to provide a consistent, evidence based approach to insertion, maintenance and removal of CVC, while highlighting the role of ‘care bundles’ in catheter management.

Principles

• The careful preparation of children and their whānau/caregivers using age appropriate therapeutic play techniques and utilising play specialists, is recommended with all CVC management

• Where a child has a CVC in situ, this is to be used for intravenous therapy in preference to inserting a peripheral cannula

• It is the responsibility of all clinical staff caring for a child with a CVC to familiarise themselves with this guideline and other associated documents

• CVC maintenance and removal of PICC and Percutaneous CVCs is undertaken by registered nurses who have been assessed as competent to do so by designated staff members

	The procedures below should only be undertaken by staff members who have received additional training and demonstrated the required skill: • unblocking CVC • repairing CVC
	Outside of PICU, each child must have a CVC Safety Kit containing 1 pack of gauze swabs, replacement dressing and 1-2 clamps, available in close proximity at all times. Ensure this pack is sent home with the child.
	To reduce the risk of a potentially life threatening septic shower, when initially accessing all CVC which do not have a continuous infusion running, aspirate 2-5mL of blood and discard

• It is recognised that the recommended practices within this document may at times differ within specialty areas and under emergency situations

Definitions

CVC Types

Haemodialysis / apheresis catheters

Some children may require a specialised large bore central venous catheter, commonly referred to as a vascath although a variety of brands are used.

• For patients within the paediatric renal service this catheter is only accessed for haemodialysis/apheresis and managed by haemodialysis/blood bank staff members unless agreed to by the on call paediatric nephrologist.
  

• Children who have a short term, uncuffed large bore catheter are not able to be discharged with the catheter in situ but may move around within the hospital. The exception is where the catheter is positioned in a femoral vein as the patient requires bed rest or wheelchair on the ward only.

Prevention of Central Line Associated Bloodstream Infection (CLASBI)

Strict adherence to the components of the CVC maintenance bundle every time the CVC is accessed is vital in reducing CLABSI

• Hand hygiene before preparing medications and accessing CVC

• Use ANTT for all procedures

• Scrub the hub before every access and allow to dry

• Administration sets and needleless connectors are changed every 96 hours, or weekly if the lumen is not in use

• Dry and occlusive transparent, high moisture vapour transmission rate dressing which is changed weekly or if integrity compromised

• Exit site check each shift (hourly for percutaneous and PICC/tunnelled and uncuffed CVC). Document and notify Vascular Access CNS or medical team if any signs of inflammation.

• Daily (or as service agreed for long term lines) review of line necessity. Lines that are no longer necessary should be removed on discussion with medical staff

CVC safety

All inpatients with a CVC in situ require 4 hourly observations or as PEWS score dictates. If the temperature is > 38˚C and/or the patient exhibits clinical signs of sepsis (chills, rigors, hypotension, or tachycardia) blood cultures should be taken off CVC. For patients in paediatric intensive care unit (PICU), additional blood cultures should be obtained from separate sites. Refer to Starship Child Health Blood Culture Guideline

• Do not remove the CVC on the basis of fever alone, clinical judgment and further evaluation of the patient is necessary. Consult with the paediatric infectious disease team as appropriate

• Safety pack should be present at bedside

• Access lines using a syringe with a standard 10mL syringe to avoid undue pressure

• Avoid BP cuffs or tourniquet on arm with PICC in situ

• Minimise the number of times a lumen with intravenous nutrition (IVN) is manipulated. Where possible, use a new dedicated single lumen CVC or dedicate a previously unused lumen on a multi-lumen CVC to IVN

Care bundle documentation

Use the central line insertion and care bundle checklist and continuation checklist (TRIAL-SSH-CR4030 & TRIAL-SSH-CR4032) to record:

• adherence to the CVC care bundle components

• record on-going CVC management, including complications and removal details

• on-going audit and feedback on adherence to infection prevention practices.

Nursing Management

Preoperative nursing management

Ensure:

• The child has fasted as per Starship guideline and goes to the operating room in clean clothes or pyjamas

• That the pre-anaesthesia assessment has been completed by the child's guardian and that the child’s weight and base line recordings have been recorded (CR8815)

• Informed consent (CR 0111) for the procedure has been obtained by medical staff members and is available in the patients notes

• A full blood count has been taken and documented (CR8815), within the last 24 hours where appropriate and a “Group and Hold” is completed in the instance where blood products may be required

Prepare one parent or caregiver to enter the operating room during anaesthetic induction where appropriate.

Postoperative nursing management

Ensure:

• The CVC insertion record (TRIAL-SSH-CR4030) or CVC procedural record is completed and added to the patient’s clinical record

• Where a PICC or uncuffed tunnelled CVC has been inserted, ensure catheter length is documented on the insertion form

• Assess and record vital signs on return to the ward as per postoperative recovery guideline and then as the child’s condition dictates

• Observe insertion and exit sites and dressings for bleeding, on return to the ward and at least 4 hourly. Document assessment findings each shift. If excess bleeding at exit site notify Vascular Access CNS or medical team

• Prior to using the CVC, ensure correct placement of CVC has been confirmed by X-ray and documented as such by a medical staff member

• If continuous fluids are not in progress ensure that the CVC has a heparin lock (refer to section on Nursing Managment - CVC heparin lock instillation)

Note that implantable venous access devices remain accessed as required.

Continue maintenance bundle record (TRIAL-SSH-CR4032) for all vascular access devices and transcribe insertion and catheter details.

Use of infusion pumps with a CVC

To minimise the risk of potential complications from CVC therapy within Starship Child Health, all children receiving continuous intravenous fluids via a CVC must have their infusion controlled by an infusion pump. The programmed volume to be infused should be set and is not to exceed 2 hours

CVC exit site dressing

Usually a transparent, high moisture vapour transmission rate dressing is used. These dressings are routinely changed weekly or more frequently if the dressing is compromised or blood is present at exit site.

If there is excessive ooze on the dressing within the first 24 hours of catheter placement contact the Vascular Access CNS or for after hours the appropriate staff as below to assess the dressing and further management:

• For tunnelled cuffed CVCs contact the surgical registrar

• For PICCs and tunnelled uncuffed CVCs contact the anaesthetic registrar

If a tunnelled cuffed catheter has a non-transparent dressing in situ, contact the surgical registrar for guidance about management.

The neck wound site dressing can be removed once site is healed.

If the child is discharged less than 24 hours post insertion with a non-transparent dressing, arrange for the community nursing service to change to a transparent, high moisture vapour transmission rate dressing the following day.

Some PICC and tunnelled uncuffed CVCs may be secured using a Securacath or at times Statlock. Click here for more information on how to apply and remove dressings on catheters with SecurAcath.

Note:

• On exception, with well healed, tunnelled cuffed CVCs it may not be necessary to apply a dressing. This should be decided by the primary team, discussed with Vascular Access CNS and clearly documented on an individual basis

• In exceptional circumstances where the recommended dressing is not used, the frequency of dressing changes are as per manufacturer’s instruction

• To prevent medical adhesive related injuries (MARSI), ensure the cleaning solution is completely dry before applying the dressing.

• To protect skin under dressing, barrier film such as Cavilon™ wipes should be used after cleaning the exit site and before applying the dressing in all compliant patients.
  
  

CVC exit site dressing procedure

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70% (solution, wipe or swab-stick)

• Aseptic field (reusable tray if using wipe/swabstick, dressing pack if using solution)

• Recommended dressing - Tegaderm IV advanced or Polyskin

• Remove wipes - if required

Procedure

• Follow ANTT and hand hygiene moments throughout the procedure

• Remove previous dressing (with remove wipes if required) and discard

• Inspect exit site for signs of infection, then perform hand hygiene again and don non-sterile gloves

• Pick up the distal end of the CVC and clean CVC from the exit site to the CVC hub and allow to dry

• Clean site starting from the exit site extending to the area which should be covered by the dressing and allow to dry

• Apply barrier film, i.e. Cavilon™ wipes and allow to dry

• Apply recommended dressing, ensuring it is sealed around the CVC site. Tunnelled cuffed CVCs i.e. Hickman and Broviac catheters must ALWAYS be looped under the dressing for extra security

• Do not apply gauze around the catheter or exit site as this will inhibit vision of the site and alter the moisture transmission rate of the recommended dressing

• Dispose of all waste as per individual area practices

• Document the date of dressing change, physical condition of the site and any nursing intervention in the clinical record (TRIAL-SSH-CR4030 & TRIAL-SSH-CR4032)

• Report any signs of infection or changes in skin integrity to Vascular Access CNS and member of the primary medical team

See CVAD Assessment and Dressing Management Guide - advice on standard care and management of skin changes

Alcohol impregnated caps

Alcohol impregnated caps (e.g. Dual Caps) should be attached to all regularly accessed needleless connectors on medium or long-term CVCs. They are used in addition to scrubbing the hub, not as a replacement for this. Each alcohol impregnated cap is single use only.

Dual Caps are changed:

• With every access of a needleless connector

• Minimum of every seven days

CVC administration set change

Continuous CVC administration sets are changed:

• On completion of blood product infusion

• Following any form of disconnection from CVC

• Every 24 hours if IVN is in progress

• As indicated for medication infusions

• Every 96 hours in all other instances

Once an administration set has been disconnected from a CVC, it should not be reconnected later. If intermittent medications are being given via a CVC, a new administration set should be used each time.

CVC administration set change

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Sodium chloride 0.9% or pre filled sodium chloride 0.9% syringe

• 10 mL syringes and needles as required

• New administration set/intravenous fluid with Dual Caps applied to needleless connectors as required

Procedure

• Follow hand hygiene moments and ANTT throughout the procedure

• Prime new administration set and clamp set

• Prepare patient by placing supine and ensure clamps on catheter are closed and any infusion in progress is stopped

Where there is a current infusion in progress

• Disconnect the current administration set

• Scrub the hub and allow to dry

• Connect 10 mL syringe containing sodium chloride 0.9% and assess patency of catheter

• Disconnect syringe, scrub the hub and connect primed administration set

Where the catheter has a heparin lock in situ

• Remove Dual Cap from needleless connector

• Scrub the hub and allow to dry

• Connect an empty syringe, remove 2-5 mL of blood from the catheter and discard (removes heparin and reduces risk of ‘septic shower’)

• Scrub the hub before connecting a 10 mL syringe with 0.9% sodium chloride

• Flush CVC using a ‘turbulent flow’ technique

• Remove syringe, scrub the hub before connecting new administration set to CVC

NB If you are unable to remove the heparin lock from the CVC, stop the procedure, and inform Vascular Access CNS or member of the primary medical team that the heparin lock (200 units/2 mL or 5000 unit/5 mL) is unable to be withdrawn.

• Place new administration set in appropriate volumetric pump or syringe driver

• Verify pump setting is correct as per prescription, independently double check with a colleague if required

• Open clamps and commence infusion at prescribed rate

• Ensure that all lines are clearly labelled

• Dispose of all waste as per individual area practices

• Document the date of administration set change in the patient’s clinical record and on the administration set

CVC needleless connector

CVC needleless connectors are changed:

• Every 96 hours when being regularly accessed in hospital

• Weekly if not being regularly accessed. This should coincide with catheter flush, heparin lock instillation and exit site dressing change.

CVC needleless connector change

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Needleless connector(s)

• Sodium chloride 0.9% or pre filled sodium chloride 0.9% syringe

• 10 mL syringes and needles as required

• Alcohol impregnated cap as required

Procedure

• Follow hand hygiene moments and ANTT throughout the procedure

• Prime new administration set if required

• Prime new needleless connector with 0.9% sodium chloride

• Prepare patient by placing supine and ensure clamps on catheter are closed and any infusion in progress is stopped

Where there is an infusion in progress

• Hand hygiene

• Disconnect the current administration set

• Scrub the hub and allow to dry

• Remove the needleless connector, scrub the hub of the CVC and replace with a new primed needleless connector

• Connect 10 mL syringe containing sodium chloride 0.9% and assess patency of catheter by first bleeding and then flushing the line

• Disconnect syringe, scrub the hub before connecting new primed administration set

Where the catheter has a heparin lock in situ

• Remove alcohol-impregnated cap from needleless connector

• Scrub the hub and allow to dry

• Remove the needleless connector, scrub the hub of the CVC then replace with a new primed needleless connector

• Connect an empty syringe, remove 2-5 mL of blood from the catheter and discard (removes heparin and reduces risk of ‘septic shower’)

• Scrub the hub and connect a 10 mL syringe with sodium chloride 0.9%

• Flush CVC using a ‘turbulent flow’ technique

• Remove syringe, scrub the hub and allow to dry

• Attach syringe and instil heparin lock

• Where 200 units/2 mL or 5000 units/5 mL strength of heparin is instilled, clearly label the catheter indicating this

• Apply Dual Cap to end of needleless connector

NB If you are unable to remove the heparin lock from the CVC, stop the procedure, and inform a member of the primary medical team that the heparin lock (200 units/2 mL or 5000 units/5 mL) is unable to be withdrawn.

• Dispose of all waste at point of care

• Document the date of needleless connector change in the patient’s clinical record

CVC heparin lock instillation

When a continuous infusion is not in progress it is necessary to instil a heparin lock to maintain CVC patency. The strength of the heparin will depend on various factors such as, catheter type, the time between heparin instillation, and patient characteristics.

Catheter used within 8 hours (excludes: Haemodialysis/Apheresis Catheters): Use Heparinised Saline 50 units/5 mL

Catheter used after 8 hours (excludes: Haemodialysis/Apheresis Catheters): Use Heparin 200 units / 2 mL.

Contraindications for heparin use - Anaphylaxis to heparin.

Heparin strength:

Exceptions:

• Infants less than 5 kg in PICU (Paediatric Intensive Care Unit) and PCCS (Paediatric Congenital and Cardiac Services) have a continuous low dose heparin infusion administered as prescribed via their CVC until removal of the CVC

• Children under the PCCS require a low rate continuous intravenous infusion via one or both of their CVC lumens, rather than heparin locking, (unless otherwise documented by a medical officer)

• In the Starship Blood & Cancer Centre, lumens which require intermittent medication infusions have a continuous TKVO (to keep vein open) infusion

• The rate of either of these infusions should be agreed upon in line with specialty service and prescribed accordingly

Weekly or monthly, flushing and heparin lock instillation should be timed to coincide with needleless connector change and exit site dressing changes.

Equipment required for CVC heparin lock instillation

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Sodium chloride 0.9%

• 10 mL syringes and needles as required

• Heparin as prescribed

• Needleless connector

• Alcohol impregnated cap as required

Procedure

• Follow hand hygiene moments, ANTT and scrub the hub throughout the procedure

• Prepare equipment, using an independent double check procedure

• Prepare patient by placing supine and ensure clamps on catheter are closed and any infusion in progress is stopped

Where there is a current infusion in progress

• Disconnect the current administration set

• Scrub the hub and allow to dry. If a new needleless connector is required, prime the device and attach to the CVC

• Connect 10 mL syringe containing sodium chloride 0.9% and flush CVC using a turbulent flow technique

• Disconnect sodium chloride syringe, connect and instil heparin solution

• Document heparin lock on Central Line Insertion and Care Bundle

• Place an alcohol impregnated cap on needleless connector

Where the catheter has a heparin lock in situ

• Remove alcohol impregnated cap from needleless connector

• Scrub the hub and allow to dry. If a new needleless connector is required, prime the device and attach to the CVC

• Connect an empty syringe, remove 2–5 mL of blood from the catheter and discard (removes heparin and reduces risk of ‘septic shower’)

• Scrub the hub and allow to dry before connecting a 10 mL syringe with sodium chloride 0.9%.

• Flush CVC using a ‘turbulent flow’ technique

• Instil new heparin lock

• Document heparin lock on Central Line Insertion and Care Bundle

• Place an alcohol impregnated cap on needleless connector

NB If you are unable to remove the heparin lock from the CVC, stop the procedure, and inform Vascular Access CNS or a member of the primary medical team that the heparin lock (200 units/2 mL or 5000 units/5 mL) is unable to be withdrawn.

• Dispose of all waste at point of care

• Document the procedure in the patient’s clinical record (TRIAL-SSH-CR4030 & TRIAL-SSH-CR4032)

• Sign medication administration record for the heparin administered

Blood sampling from a CVC

While blood samples can be obtained from a CVC, it is advisable to assess the appropriateness of sampling from the CVC as per individual area practices. Some tests are not advised to be taken from CVC lines as follows:

• Serum levels should not be obtained from the same lumen as medication administration

• No samples should be routinely taken from renal dialysis catheters by members of the ward nursing staff

• A finger prick should be considered rather than taking blood off a central line when it is not in use. Discuss within specialty.

Equipment

• Gloves

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Sodium chloride 0.9%

• 10 mL syringes and needles as required

• Alcohol impregnated caps as required

Procedure

• Prepare equipment and patient, discontinuing any infusions in progress via all lumens

• Follow hand hygiene moments, ANTT and scrub the hub throughout the procedure

• Where possible, blood sampling should be taken without breaking the line e.g. via a designated needleless connector

• When obtaining a blood culture, use sterile gloves and change the needleless connector immediately prior to aspirating the blood sample. Refer to Starship Child Health Blood Culture Guideline

• Prepare equipment and patient, discontinuing any infusions in progress via all lumens

• Scrub the catheter hub before attaching new needleless connector and with chlorhexidine gluconate 2% /ethanol 70% for 15 seconds and allow to dry

• Scrub new needleless connector with chlorhexidine gluconate 2% /ethanol 70% for 15 seconds and allow to dry. Aspirate initial 2-5 mL and discard (to improve accuracy of results and reduce risk of septic shower). If blood cultures are to be taken and the patient weighs greater than 30kg, the initial blood draw should not be discarded but be included in the blood used to fill the culture bottles

• Obtain blood specimens as requested (blood culture bottles should be filled first)

• Flush CVC with sodium chloride 0.9% using turbulent flow technique prior to either instilling a heparin lock or continuing with infusion

• Ensure no blood remains in the needleless connector

• Fill specimen containers and label containers at the bedside

• Verify patient ID label on specimen container matches the patient ID on the laboratory form and the patient's wristband prior to sending to the laboratory

• Dispose of all waste at point of care

• Document the procedure in the patient’s clinical record (TRIAL-SSH-CR4030 & TRIAL-SSH-CR4032)

Accessing an implanted venous access device

When an implanted port is accessed for treatment, port needles are changed every 7 days. When an implanted port is not being used regularly, it is accessed monthly to flush the catheter and replace the heparin lock.

Within Starship, power ports are inserted. These ports are able to withstand 300 pounds per square inch (psi) and can therefore be used for a power injection of contrast media. For a contrast injection to be administered via the port a POWER LOC needle needs to be inserted. The nurse must also attach the sticker provided in the pack onto the extension set which signifies that contrast can be administered.

At all other times a gripper needle is inserted. Both gripper and power loc needles are non-coring and have an extension set attachment.

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70% wipe

• Aseptic field (cleaned reusable tray)

• Needleless connector(s) and alcohol impregnated caps

• Sodium chloride 0.9% and 10 mL syringes and needles as required or pre filled sodium chloride 0.9% syringe

• Gauze swab (for monthly flush and heparin lock)

• Port needle with luer lock extension (e.g. Gripper needle or POWER LOC needle)

• Recommended dressing

• Heparin as prescribed. See table above

Procedure

• Follow ANTT throughout the procedure

• Draw up sodium chloride 0.9% using a 10 mL syringe, (or prefilled syringe)

• Draw up heparin using an independent double check procedure

• Attach needleless connector to the non-coring needle and extension set; prime with 0.9% sodium chloride

• Prepare patient by removing any clothing that obscures port site and raise the child’s arm above head if necessary or position the child as appropriate

• Remove topical anaesthetic if applicable

• Locate the port, identifying the three palpation points which are arranged in a triangle

• Clean the skin with recommended cleaning solution starting in the centre over the implanted CVC site, using a friction motion, clean in concentric circles, extend out to include the area that will be covered by the dressing

• Using the non-dominant hand, stabilise the port with two or three fingers to stop the port moving under the skin during the procedure

• With the dominant hand, insert the needle at a right angle into the middle of the port. Push the needle slowly but firmly through the child’s skin into the septum of the port

• Connect an empty 10 mL syringe to the luer lock at the end of the port extension tubing

• Draw back 5 mL of blood and discard. If blood is unable to be withdrawn:

  • reposition child

  • reposition needle

• If blood is still unable to be withdrawn, stop the procedure and discuss with Vascular Access CNS or member of the primary medical team regarding need for radiological examination prior to further action

• Once blood is withdrawn, or position is confirmed by radiological examination, or by a member of the primary medical team, remove syringe from extension set and discard. Flush with 10 mL of sodium chloride 0.9% using turbulent flow technique. Lock with heparin as prescribed or commence continuous fluids

• Place a Dual Cap on needleless connector

• Remove wings from gripper needle and discard. (Note: if using a Power port needle, wings are not removable).

• Apply dressing securely and firmly over the port needle, ensuring all edges of dressing are sealed securely to prevent dressing lifting. Younger children may need a securing device (eg. Flexi track) to prevent accidental needle removal

• Record the procedure and confirmation of correct needle placement in the patient's clinical record

De-accessing an implanted venous access device

To safely remove a needle from an implanted port when the needle is being changed or cessation of continuous therapy

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70% wipe

• Aseptic field (cleaned reusable tray)

• Sodium chloride 0.9%

• Heparin as prescribed

• Small adhesive dressing (e.g. band aid)

Procedure

• Follow hand hygiene, ANTT and scrub the hub techniques throughout the procedure

• Draw up sodium chloride 0.9% in a 10 mL syringe, or use prefilled syringe

• Draw up heparin in a 10 mL syringe as prescribed, using an independent double check procedure

• Prepare the patient and remove any clothing that obscures the port site

• Loosen the edges of the dressing, leaving the dressing around the port needle

• Remove any alcohol impregnated caps

• Connect syringe and flush with 10 mL of sodium chloride 0.9% using turbulent flow technique

• Administer heparin as prescribed

• Remove the port needle and remaining dressing vertically with the non-dominant hand stabilising the port. Using gauze swab, apply pressure to exit site

• Report any changes to a member of the primary medical team;

• Consider covering the exit site with a small dressing

• Document procedure in the patient’s clinical record

• Dispose of all waste as per individual area practice

Potential complications

See Intravenous Catheters - Peripheral guideline for phlebitis and infiltration scores

Management of occlusion

Partial or complete occlusion of a CVC is due to kinking, malposition, medication precipitation or lipid occlusion, should be ruled out as a potential cause of occlusion:

• Assess the CVC line and corresponding IV lines for kinks/ medication precipitation or lipid occlusion;

• Assess ability to aspirate/flush line while turning the child’s head to the opposite side, elevate their arm, ask the child to cough or bear down in a valsalva manoeuvre, place the child’s head down;

• Change the port needle if applicable

Occlusion of renal haemodialysis catheters should be managed by the renal haemodialysis team.

If a long term CVC is partially or completely occluded due to thrombosis or fibrin (other causes have been ruled out as above), patency may be restored with the instillation of a fibrinolytic agent. The fibrinolytic agent must be withdrawn and discarded at the end of the prescribed dwell time.

Note: use of fibrinolytic agent (eg Alteplase) should be considered early prior to complete occlusion and when unable to aspirate blood from catheters.

The primary team may consider radiological investigations such as an x-ray to confirm placement or linogram either prior to fibrinolytic agent instillation or if patency fails to be restored after instillation attempt. Note: If the line is able to be flushed without resistance and the primary team approves, the line can continue to be used even if unable to bleed back following catheter tip confirmation via x-ray.

Caution should be exercised in using a fibrinolytic agent with patients who:

• have any condition for which bleeding constitutes a significant hazard

• have had recent severe bleeding

• have had recent major trauma

• have active ulcerative GI disease

• have had a recent stroke

• are receiving warfarin therapy where INR > 1.3

• have had heparin administered on same day or APTT > 45

• have a platelet count < 80

Caution should be exercised in the presence of known or suspected infection in the catheter.

Unblocking CVCs with fibrinolytic agent should be done during pharmacy opening hours. Obtain a pre-prepared alteplase 1 mg/mL syringe using usual pharmacy process. 3 mL of alteplase 1 mg/mL in 10 mL syringes are aseptically manufactured in advance and are frozen at -20 ᴼC. The cold chain must be maintained during transportation. Syringes are thawed by leaving in room temperature for 10 minutes and must be used straight away and never refrozen

If the CVC blocks ‘after hours’, it may be necessary to attain temporary peripheral venous access to maintain therapy until the following morning. If able to flush instill weak heparin until the following morning.

If unblocking the CVC after hours is deemed critical to maintaining the patient’s therapy, contact the Clinical Nurse Manager (CNM) whom will either contact the on call pharmacist or source from a ward who stocks vials or holds frozen syringes (Adult Dialysis).

Alteplase must only be administered in consultation with the patient’s primary consultant and must be prescribed on the patient’s medication chart

Fibrinolytic agent administration

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Needleless connector(s)

• Dual Cap(s)

• Sodium chloride 0.9%

• 10 mL syringes and needles as required

• Fibrinolytic agent as prescribed (alteplase 1 mg/mL)- sourced as per above
  

Procedure for instillation of Alteplase

• Follow aseptic non touch technique throughout the procedure;

• Draw up sodium chloride 0.9% in a 10 mL syringe or use prefilled sodium chloride 0.9% syringe

• Clamp the CVC lumen and disconnect the IV administration set if required

• Attach the 10 mL syringe containing sodium chloride 0.9% and attempt to gently aspirate blood/fluid from the CVC or to flush CVC; If CVC remains occluded attach the 10 mL syringe containing the fibrinolytic agent;

• Using a gentle alternation of irrigation/aspiration over a few minutes, attempt to instil the fibrinolytic agent. The fibrinolysis agent should be instilled slowly to allow it to cover the walls of the catheter;

• Volume to be instilled is the volume of the lumen . DO NOT FORCE the fibrinolytic agent into the catheter lumen;

• If the fibrinolytic agent is unable to be instilled, stop the procedure, discuss with Vascular Access CNS and advise the primary medical team for further guidance (radiological imaging may be required I.e. x-ray for placement or linogram);

• Once the fibrinolytic agent is instilled, clamp the CVC and leave in situ for a minimum of 2 hours. Note: longer dwell time may be required (maximum 24 hours);

• Place Dual Cap on needleless connector. Ensure the catheter is clearly labelled as having alteplase instilled. In case of emergency, a shorter dwell time may be attempted but a dwell of at least 30 minutes is recommended;

• Using a 10 mL syringe, attempt to aspirate fibrinolytic agent in 3-5 mL of blood. If aspiration is unsuccessful, advise the primary medical team for further guidance (radiological imaging may be required I.e. x-ray for placement or linogram);

• If aspiration is unsuccessful it may be necessary to leave the fibrinolytic for a longer dwell time (up to 24 hours). DO NOT FLUSH the catheter as this will result in the administration of the fibrinolytic medication to the patient. If aspiration of alteplase remains unsuccessful after 24 hours consult primary consultant or Vascular Access CNS;

• If aspiration is successful, withdraw and discard 3-5 mL. Flush CVC with sodium chloride 0.9% using turbulent flow technique and resume infusion or heparin lock CVC using positive pressure technique, as per CVC heparin locking guideline;

• Record procedure in the patient’s clinical record (TRIAL-SSH-CR4030 & TRIAL-SSH-CR4032) and medication chart

Fibrinolytic agent instillation volume

Antibiotic lock administration

An antibiotic lock is the installation of a high concentration of an antibiotic, to which the causative organism is susceptible, into the catheter lumen.

An antibiotic lock is used to treat central line associated blood stream infections in long term CVC with no signs of exit site or tunnel infection for which catheter salvage rather than catheter removal is the goal.

The decision to initiate antibiotic lock therapy is a collaborative decision by the primary medical team, the paediatric infectious diseases service and the paediatric pharmacist. The paediatric infectious diseases team in collaboration with the paediatric pharmacist will determine the appropriate solution, dwell time and duration of therapy. The antibiotic lock should be used in conjunction with systemic antimicrobial therapy.

An antibiotic lock may be considered for

• Recurrent infections

• Multiple previous lines with limited vascular access

• Polymicrobial infections

• Unable to change catheter (e.g. patient with haemophilia)

Contraindications for antibiotic locks

• Infants less than 6 months, including neonates

• Non-patent lumens

• Pocket, tunnel or exit site infection

• Anaphylaxis to antibiotic

• Abnormal renal function test for aminoglycoside locks

Dwell time and duration of antibiotic locks

• ADHB, antibiotic locks can be dwelled for 1 hour every other day or left in the line between use for up to 24 hours

• Dwell times should not exceed 48 hours between installations of lock solution because antibiotic concentration may reduce rapidly over time

• Children undergoing haemodialysis, the lock solution with the addition of heparin can be renewed after every dialysis session (refer to associated ADHB documents section)

• For multi-lumen catheters, ideally all lumens should be locked at the same time

• If this is not possible the antibiotic lock should be instilled into alternating lumens every 24 hours

• Antibiotic locks must be prescribed on the medication chart as gentamicin 5 mg/mL line lock or vancomycin 5 mg/mL line lock, which lumens to instil antibiotic into, volume of lumen, and dwell time

Collect and prepare equipment for antibiotic lock

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Needleless connector(s)

• Sodium chloride 0.9%

• 10 mL syringes and needles as required

• Gentamicin 80 mg/2 mL ampoule (as required)

• Vancomycin lock (as required)

Procedure for instillation of antibiotic locks

• Follow aseptic non touch technique throughout

• Ensure the CVC is clamped

• Attach a sodium chloride 0.9% prefilled syringe to the needleless connector

• Unclamp the CVC and gently flush with sodium chloride 0.9% to ensure catheter patency

• Change syringes and instil volume of antibiotic lock equivalent to the intraluminal volume of the catheter (see table below). The required volume is inserted into one or two lumens as prescribed

• Clamp the CVC and leave solution within the lumen for the prescribed dwell time. Clearly label the lumen with medication instilled and time of instillation. Do not use lumen during the dwell time period;

• After prescribed dwell time has elapsed the lock solution must be withdrawn. Remove and scrub the hub. Attach clean syringe and withdraw 3-5 mL and discard;

• Flush with sodium chloride 0.9% using a turbulent flow technique. Instil heparin lock and place alcohol impregnated cap on needleless connector or connect IV administration set as required

	Type of line	Volume
	SVAD	2 mL
	Tunnelled	> 1 year = 1mL and < 1 year = 0.5 mL (each lumen if prescribed)
	PICC	>1 year = 1 mL and < 1 year = 0.5 mL (each lumen if prescribed)
	Haemodialysis/Apheresis Catheters	Use intraluminal volumes specified on the catheters

Ethanol lock administration

An ethanol lock is used to prevent central line associated blood stream infections in children with recurrent infections with limited vascular access that require long term CVC use and have no evidence of active infection. However, it may have a negative impact on line integrity. Only silicone tunnelled central venous catheters (e.g. hickman, broviac) or silicone Peripherally Inserted Central Catheters (PICC) are compatible with ethanol.

The decision to initiate ethanol lock therapy is a collaborative decision by the primary team, the paediatric infectious diseases service and the paediatric pharmacist. The paediatric infectious diseases team in collaboration with the paediatric pharmacist will determine the appropriate solution, dwell time and duration of therapy.

Children on long term IVN may have 70% ethanol locks prescribed by the paediatric gastroenterology service as per the Starship Intravenous Nutrition Clinical Guidelines (see associated ADHB documents section).

An ethanol lock may be considered for

• Recurrent infections

• Multiple previous lines with limited vascular access

• Polymicrobial infections

• Unable to change catheter (e.g. patient with haemophilia)

Contraindications for ethanol lock

• Anaphylaxis to ethanol solution

• Non silicone catheters e.g. short term percutaneous CVC

• Subcutaneous vascular connector (port)

• Abnormal liver function test

• Heparin administration

Dwell time and duration of ethanol locks

Within ADHB, dwell times of a minimum of 2 and maximum of 6 hours are used. Ethanol is used weekly with a review at 3 months.

Ethanol locks must be prescribed on the medication chart as ethanol 70% line lock, which lumens to instil ethanol lock, volume of lumen, and dwell time.

	Type of line	Volume
	Tunnelled	> 1 year = 1mL and < 1 year = 0.5 mL (each lumen)
	PICC	>1 year = 1mL   and < 1 year = 0.5 mL (each lumen)

Percutaneous (non-tunnelled) CVC removal

Removal of a percutaneous (non-tunnelled) CVC should be undertaken by staff who are knowledgeable and skilled in this procedure.

All cuffed and surgically placed CVCs e.g. Hickman lines, Portacaths, must be removed in the operating room.

There is risk of air embolism during removal of internal jugular/subclavian non-tunnelled, non-cuffed CVC and large bore catheters.   In addition, some children are at increased risk of air embolism during catheter removal. Children with increased work of breathing (due to higher negative intrathoracic pressure than normal). Children with minimal subcutaneous tissue Children who have had catheters in situ for a longer period of time (associated with development of a well-formed tract in the tissues)

Ensure the below procedure is followed when removing these catheters:

Collect and prepare equipment

• Gloves (non-sterile)

• Chlorhexidine gluconate 2% in ethanol 70%

• Aseptic field (cleaned reusable tray)

• Recommended occlusive dressing

• Stitch cutter

• Paper tape measure (as required to measure PICC)

• Check removal is not contraindicated due to patient’s coagulation status

Trendelenberg

Low semi-Fowler

Breathing

If the child can cooperate, they should be instructed to breathe in, hold their breath and bear down (perform a Valsalva), and then the catheter should be removed. If they are not able to perform this manoeuvre reliably then the CVC should be removed during exhalation.

Procedure

Follow aseptic non touch technique throughout the procedure. Ensure an airtight occlusive dressing is ready to be applied before commencing removal of the CVC.

1. Clamp CVC and discontinue any infusion if in progress.

2. Remove CVC site dressing and discard.

3. Clean exit site with recommended cleaning solution and allow to dry.

4. Remove any sutures that are present, (cut away from the patients skin).

5. Remove CVC briskly from the vein in a smooth consistent motion (NOT slowly or tentatively).

6. Apply the dressing to the exit site as the CVC is removed, aiming for immediate occlusion of exit site.

7. Pressure should be maintained on this dressing for 5 minutes to reduce the risk of air embolus and ensure haemostasis. (Do not remove the dressing to check if the blood has stopped as this increases the risk of air embolus).

8. Assess the patient regularly post CVC removal, ensuring the dressing is assessed to ensure it remains occlusive. If the dressing appears blood soaked consider changing the dressing, and/or a medical review dependent on the patient's current coagulation status.

Peripherally Inserted Central Catheter (PICC) and Tunnelled Uncuffed CVC removal

The nurse should:

• Perform hand hygiene and don non-sterile gloves

• Remove dressing and securement device

• Clean the site thoroughly with chlorhexidine gluconate 2% /ethanol 70% and allow to dry prior to removal of catheter

• Apply simple traction to withdraw the catheter

• Cover the site with gauze and maintain pressure until haemostasis is achieved

• Apply transparent dressing and assess site every 24 hours until the site is epithelialized

• On removal the nurse should visually check the integrity of the line to ensure that the tip is present, the complete line has been removed and no breakage has occurred

• The removed line should be measured and its length documented and checked against the length documented on insertion

• PICC and tunnelled uncuffed CVC may be secured using a Securacath device. These devices should only be removed by designated staff trained in their removal. For more information about removing these lines, view SecurAcath removal instructions.

Discharge of a child with an intermediate or long term CVC in situ

Ensure the careful preparation of family/whānau/caregivers and children where the child is being discharged with an intermediate or long term CVC in situ, as per discharge checklist and parent teaching information. Provide a CVC Safety Pack prior to discharge to whānau/caregivers.

If child is being sent home on IV therapy which the parents are to administer please ensure the following documents are completed:

• Discharge summary to document the type of line, care, maintenance plan and plan for removal required.

• CR8877: Home IV Therapy Agreement and Training Record

• DD2909 Home IV therapy assessment

Associated clinical forms

• TRIAL-SSH-CR4030: Central Line Associated Bacteraemia (CLAB) Insertion Bundle Checklist

• TRIAL-SSH-CR4032: Central Line Associated Bacteraemia (CLAB) Maintenance Bundle Checklist Continuation Sheet