Guidline Of Management Of Porta Cath

1. Key Recommendations Education Patient/ Health Care Professional , All health care professionals involved in caring for a patient with a CVC should be trained, and assessed as competent, in using and consistently adhering to these guidelines. ! Before discharge from hospital, patients and/or their cares should be taught how to safely manage their central venous catheter and be provided with written guidance to support this. Site Care ! Healthcare personnel should ensure that catheter- site care is compatible with the manufacturer’s recommendations (see appendix 4). ! The cleaning solution used should adhere to manufacturer’s recommendations (appendix 4). ! Do not apply organic solvents (acetone or ether) or use topical antibiotic ointment or creams at the catheter insertion site because of the possible incompatibility with catheter tubing and their potential to promote fungal infection and antimicrobial resistance. ! A sterile, transparent, semi permeable polyurethane dressing or all-inclusive sterile gauze dressing should be used to cover the catheter site. ! PICC lines should always have a dressing in situ. Accessing Lines/ Line Maintenance ! The injection port or catheter hub should be cleaned using 70% isopropyl alcohol or alcohol chlorhexidine gluconate. ! When recommended by the manufacturer (appendix 4), implanted ports or open ended catheter lumens should be flushed and locked with heparin sodium flush solutions. ! Sodium chloride O.9% for injection should be used to flush and lock catheter lumens when heparin is not stipulated by the manufacturer. ! Needleless systems are recommended. ! Administration sets must be maintained as a closed system. When used in crystalloid continuous infusions they need not be replaced more frequently than at 72 hour intervals unless they become disconnected, when they must be replaced regardless of time in use, or if a catheter related infection is suspected. Yorkshire Cancer Network Guidance for the Management of Central Venous Catheters – 1. Key Recommendations 2

Unblocking Lines ! The syringe size used for this procedure should be 10ml syringe or larger. ! Any agents used to unblock lines should adhere to the central line manufacturer guidance (RCN 2003) and local protocol. Suspected line infection • A line infection should be considered in cancer patients with a CVC where there is no other obvious source. • Cancer patients with long term lines, with suspected line infection should ideally establish microbiological diagnosis through blood cultures, obtained aseptically

from each lumen and from a peripheral vein. Exit site swabs can be beneficial if there are localized signs of infection i.e. erythema or discharge at the exit site. • Removal of the central should only be done when (i) a definitive microbiological diagnosis has not been achieved and line infection cannot be excluded (ii) there is a tunnel infection or (iii) in cases of infection with particular microorganisms such as Pseudomonas aeruginosa, Bacillus spp., fungi and mycobacteria. Objectives The key objectives of the guidance are: To minimize the infection risk associated with managing central lines To provide uniform guidance across the YCN based on best evidence To provide health care staff with the knowledge to manage CVC’s safely

5.1. Education of Patients, Their Care’s and Other Health Care Personnel To improve patient outcomes in relation to reduction of infection risk, education of those involved in caring for the line is essential. Health care personnel, patients and their carer’s need to be confident and proficient in both infection prevention practices and be aware of the signs and symptoms of infection if they arise (Pratt et al 2001). An awareness of potential line complications and how to seek advice, if suspected, should also be established (see troubleshooting p16). Recommendations: 1. Before discharge from hospital, patients and/or carers should be taught how to safely manage their central venous catheter (CVC) and be provided with written guidance to support this. 2. All health care professionals involved in caring for a patient with a CVC should be trained and assessed as competent, in using and consistently adhering to these guidelines. 3. Ongoing support should be available to patients with CVC’s and their care’s. 4. Each local area should provide information for all patients and/or carers on how to access support both during and outside normal working hours.

5.2. Catheter Management General Asepsis Good standards of hand hygiene and aseptic technique can reduce the risk of infection (Pratt et al 2001). Appropriate aseptic technique does not necessarily require sterile gloves; a new pair of disposable non-sterile gloves can be used in conjunction with non-touch technique. Recommendations: 5. Hands that are visibly soiled or contaminated with dirt or organic material must be washed with soap and water before using an alcohol hand rub 6. Before accessing or dressing a CVC hands must be cleaned either by washing with an anti microbial soap and water, or by using an alcohol (70%) hand rub

7. An aseptic technique must always be used for accessing CVC’s 8. Gloves should always be worn when accessing lines for the prevention of blood borne pathogen exposure (CDC 2002) Catheter Site Care

Dressings The appropriate dressing should be selected for the type of CVC. The type of dressing selected should be based upon minimizing the risk of infection and optimising patient comfort. After CVC placement, the following dressings are recommended: all inclusive sterile gauze dressing or sterile transparent semi permeable polyurethane dressings. For PICC lines the dressing of choice is polyurethane as it secures the line to the skin minimizing movement. Some PICC lines can fracture if movement is not minimized, therefore increasing the risk of mechanical phlebitis, therefore a dress should be used. It should be noted there may be two dressings in place after insertion of a tunnelled line, entry site and exit site. The entry site dressing is generally removed within 48 hours and the suture is left exposed. The exit site generally stays in place until the wound has healed. In general, if blood is oozing from the catheter site a gauze dressing is preferred. Gauze dressings should be changed if they become damp. For long term management of the exit site semi permeable polyurethane dressings are recommended. They are essential for PICC lines. There is currently no evidence that demonstrates one dressing is preferable to another in reducing infection rates (Maki et al 1991, Gillies et al 2003). However polyurethane dressings have the advantage that the line can be seen through the dressing, fully secured and allow the patient to shower or bath without the need to change the dressing. There is concern that the polyurethane dressing leads to increased skin surface humidity thus increased infection risk, however a meta analysis that indicated there was no robust evidence to support this (Gullies et al 2003). Patient/ care preference and clinical judgement should inform selection. Sutures from lines should be removed as per local protocol from cancer centre/unit. On tunneled lines, after the sutures are removed from the exit site, a dressing is no longer required unless it is the patient’s/ care preference. For both adults and children, looping the line and fixing with tape, or incorporating within a dressing, prevents it being accidentally pulled. PICC lines must always have a dressing to reduce the potential risk of shearing/ fracture of the line. A number of manufacturers provide a dressing in the insertion pack for securing the line; this should be used when available. Recommendations: 9. Sterile, transparent, semi permeable polyurethane dressing or an all inclusive gauze dressing should be used to cover the catheter site. 10. Gauze dressings should be changed when they become damp, loosened or soiled. Gauze dressings should be replaced with a transparent dressing as soon as possible if this is acceptable with the patient and their carer. Yorkshire Cancer Network Guidance for the Management of Central Venous Catheters – 5. Guidelines 9

11. Transparent dressings should be changed every 7 days, in line with

manufacturer’s instructions (Appendix 4), or when they are no longer intact, moisture collects under the dressing or no longer required. 12. PICC lines should always have a dressing in situ 13. Dressings can be removed from tunneled lines when the exit sutures have been removed and the site is healed. The line should be looped to prevent pulling in both adults and children.

Cleaning Solutions NICE (2003) site a meta- analysis (Chaiyakunapruk et al 2002) that compared the risk12. PICC lines should always have a dressing in situ 13. Dressings can be removed from tunnelled lines when the exit sutures have been removed and the site is healed. The line should be looped to prevent pulling in both adults and children.

Cleaning Solutions NICE (2003) site a meta- analysis (Chaiyakunapruk et alBased on this study the following recommendation is made: 14. Healthcare personnel should ensure that catheter- site care is compatible with the manufacturer’s recommendations (see appendix 4). 15. Where available aqueous chlorhexidine gluconate solution 2% should be used to clean the catheter site during dressing changes, and allowed to air dry. 16. If aqueous chlorhexidine can not be obtained within the primary or secondary care setting 0.5 –1 % aqueous chlorhexidine gluconate solution should be used. Yorkshire Cancer Network Guidance for the Management of Central Venous Catheters – 5. Guidelines 10

Accessing and Maintaining the System General principles It is essential that appropriate cleaning agent is used to clean the access port before accessing the system. Compatibility of the cleaning agent and the access port should be checked prior to use. 17. The injection port or catheter hub should be cleaned, and allowed to air dry, with alcohol or an alcoholic solution of chlorhexidine gluconate that is compatible with the access port before and after it has been used to access the system. Do not allow organic solvent-based solutions to come into contact with the catheter tubing. Needleless Devices Clinical areas should be using or positively moving towards the use of needleless devices for line access. Needleless systems have been widely introduced into clinical practice to reduce the incidence of sharps injuries. The Centre for Disease Control and Prevention (CDC) (2002) found that devices when used according to manufacturer recommendations do not substantially affect the incidence of infection related to central venous catheters. 18. The manufacturer’s recommendations for changing the needleless components should be followed (appendix 4). 19. Health care personnel should ensure that all components of the system are compatible and secured, to minimise the leaks and breaks in the system 20. The risk of contamination should be minimised by decontaminating the

access port with a 70% alcohol or alcoholic chlorhexidine solution and accessing aseptically. Change Intravenous Administration Sets Appropriately It is recommended from three studies reviewed by HIPAC (Healthcare Infection21. Administration sets must be maintained as a closed system. When used for continuous crystalloid infusion they need not be replaced more frequently than at 72 hour intervals unless they become disconnected or if a catheter – related infection is suspected. Yorkshire Cancer Network Guidance for the Management of Central Venous Catheters – 5. Guidelines 11

22. 22. Administration sets for blood and blood components should be changed every 12 hours (Murphy et al (1999) BCSH guidelines) 23. Administration sets used for Total Parenteral Nutrition (TPN) infusions should generally be changed every 24hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than 72 hours (CDC 2002) Maintaining Catheter Patency and Preventing Catheter Thrombosis The patency of the catheter will be checked prior to the administration of medicationsFlushing the Line Manufacturers of opened-ended catheter lumens or implanted ports may recommend heparin flushes. Heparin flushes may be appropriate if a CVC is infrequently accessed 24. Infrequently accessed lines or when recommended by the manufacturer, implanted ports or open ended catheter lumens should be flushed and locked with heparin sodium flush solutions (appendix 4). 25. Sodium chloride 0.9% for injection should be used to flush and lock catheter lumens when lines are frequently accessed (unless contraindicated by the manufacturer). 26. The flush will be done using a pulsated push-pause and positive pressure method (RCN 2003).

Management of Blocked CVC’s Prior to flushing a CVC an assessment of the patient will take place as outlined in flow chart 1. The patient must be fully assessed as outline in flow charts 1 and 2 prior to attempting to unblock a line. The following principles should be adhered to: 27. The patient must always be assessed for any history of pain or swelling prior to flushing the line. 28. The nurse shall understand the predisposing factors for catheter occlusion and preventative strategies (Kryzwda 1999). 29. The cause of the occlusion should be established where possible based upon patient history e.g. is it precipitation or blood clot induced or a combination (INS, 2000). 30. The syringe size used for this procedure should be in accordance with the manufacturer guidelines (appendix 4), as excessive pressure may result in catheter separation and/or rupture resulting in loss of catheter integrity. It is recommended that a 10mls syringe or larger is used.

31. Any agents used to unblock lines should adhere to the central line manufacturer guidance (RCN 2003). 32. Medical staff should be informed if catheter patency is not restored using thrombolytic or precipitate clearance agents (RCN 2003). 33. The procedure should be documented in the patient’s records (NMC 2002). Recognition of line-associated infection Although signs of inflammation at the exit site or over the tunnel or phlebitis may indicate infection, these are often not present. Accordingly, a high index of suspicion of line-associated infection should be maintained in cancer patients with a line and a fever but without an obvious source, especially if the patient does not respond to apparently appropriate antimicrobial therapy. Fever with or without rigors or hypotension following use or flushing of the line may also suggest line-related infection. Blood cultures which grow bacteria frequently associated with line infection, such as coagulase-negative staphylococci and diphtheroids, may indicate infection of a line as may cultures positive for other types of bacteria or yeasts where there is no immediately recognisable focus of infection. Resolution of signs or symptoms of infection following line removal provides circumstantial evidence of a line-related infection; however culture of the tip following removal of the device may give a definitive answer (see below). Investigation of suspected line-related infection. Removal of the device and culture of the tip is usually regarded as the gold standard for diagnosis. Taking out the line for diagnostic purposes may also have benefits in terms of patient management, as infections associated with some pathogens e.g. Candida species and Pseudomonas aeruginosa, require removal of the infected device to achieve a successful outcome. However for many patients – especially those with long term lines – methods to establish microbiological diagnosis through other means will be desirable. Exit site swabs are often obtained in cancer patients with undiagnosed fever or in suspected cases of line-associated infection. In general, these swabs are only useful when there are signs of localised infection, such as erythema along the tunnel or discharge at the exit site. Blood cultures should be taken from each lumen of the line as well contemporaneous cultures from a peripheral vein. Cultures must be obtained contemporaneously as the “differential time to positivity” of blood cultures is used to calculate the likelihood of a line-related infection. Aseptic technique should be maintained as common blood culture contaminants are also frequent causes of line-associated infection. Whenever possible cultures should be obtained before antimicrobial therapy is started. Other methods of diagnosis, such as endoluminal brushing, are expensive and are not yet available at the majority of centres. Local protocols should be agreed for management of line infections. Key recommendations: 36. A line infection should be considered in cancer patients with a CVC where there is no other obvious source. 37. Cancer patients with long term lines, with suspected line infection should ideally establish microbiological diagnosis through blood cultures, obtained

aseptically from each lumen and from a peripheral vein. Exit site swabs can be beneficial if there are localised signs of infection i.e. erythema or discharge at the exit site. YorkshireManagement of Damaged Catheters When the external portion of a CVC is damaged, the device shall be repaired according to the manufacturer’s guidelines, within the cancer centre or unit using aseptic technique and observing universal precautions (ReedEntry site – site of insertion of the central line Exit site – site where the central line exits the body (e.g. chest wall) External device e.g. Hickman, Groschong – single, double or triple lumen lines, usually inserted into the subclavian vein or the internal jugular vein. Fibrin sheath –Fibrin grows along the catheter’s length and extends past the catheter’s tip. Withdrawal occlusion or extravasation of IV fluids may occur causing serious and sometimes life threatening complications. Bacteria embedded in the fibrin increase the risk of persistent catheter related sepsis. Implanted devices e.g. Porta cath – A catheter surgically placed into a vessel or cavity and attached to a reservoir located under the skin that contains a pumping mechanism for continuous medication administration. Line migration – movement of the line from its original position, common in PICC lines. Lumen – Interior space of a tubular structure, such as blood vessel or catheter. No touch technique – A method used to avoid touching the catheter directly with hands. Yorkshire Cancer Network Guidance for the Management of Central Venous Catheters – 8. Glossary 23

Phlebitis –Inflammation of the vein; may be accompanied by pain, erythema, oedema, a streak formation and/or palpable cord; rated by a standard scale can be caused by movement of the catheter. Chemical Phlebitis – Phlebitis caused by chemical solutions such as chemotherapyGlossary 23

Phlebitis –Inflammation of the vein; may be accompanied by pain, erythema, oedema, a streak formation and/or palpable cord; rated by a standard scale can be caused by movement of the catheter. Chemical Phlebitis – Phlebitis caused by chemical solutions such as chemotherapy drug. Mechanical phlebitis – Phlebitis caused by movement of the catheter on the vessel wall. Peripherally inserted central catheter (PICC line) – Soft, flexible central venous catheter inserted into an extremity and advanced until the tip is positioned in the lower third of the superior vena cava. Pinch off syndrome – When catheter is compressed between clavicle and first rib. Positive pressure - Constant, even force within a catheter lumen that prevents reflux of blood; achieved by clamping while injecting or by withdrawing from the catheter while injecting. Push pause/ Pulsated flush – a flush using a push pause technique, creating turbulence within the lumen thus preventing adherence of debris to the vessel wall, aiming to reduce the incidence of line blockage.

Tunnelled line – applies to external devices. The catheter is tunnelleof the shoulder area for extra security.