Central venous access devices

Central venous access devices (CVADs) provide long term venous access enabling multiple infusions of fluids, blood products, medication and parenteral nutrition; and reduce the need for peripheral blood sampling.​ CVADs can be tunnelled or non-tunnelled or in the case of an implanted venous port; placed in a subcutaneous pocket and accessed via a needle. The tip of the CVAD should lie in the lower third of the superior vena cava (SVC) near the junction of the right atrium where the blood flow around the catheter tip is most rapid with the least resistance to flow. CVADs can have single or multiple lumens; multiple lumens allow for independent access to administer incompatible drugs/fluids simultaneously. CVADs may also be valved (closed) or non-valved (open) and power injectable or non-power injectable.

This document provides information on the management of CVADs including peripherally inserted central venous catheter (PICC), implanted venous port (IVP), tunnelled central venous catheter (Hickman^®) and non tunnelled central venous catheter (CVC). Only health care professionals who have attained competency (as per institutional guidelines) in CVAD care should perform any CVAD procedures.

Peripherally inserted central venous catheter (PICC)

A PICC is a 50-60 cm long CVAD made from either silicone or polymer. A PICC can be inserted in the radiology department, operating theatre, patient’s bedside or a unit procedure room; usually under local anaesthesia. Venous access may be obtained via one of the large veins in the antecubital fossa region (e.g. cephalic or brachial) or via the basilic vein in the upper arm using ultrasound guidance.

Non-valved PICC line	PICC line and fixing device	PICC placement

Implanted venous port (IVP)

An IVP is a device used for long-term intermittent central venous access via a port implanted into a subcutaneous pocket. Common sites for IVP placement include the upper arm access via the basilic or brachial vein, and the anterior chest with access via the subclavian or internal jugular veins. Less commonly, IVPS can be implanted in the abdomen. The IVP consists of either a single or double lumen self-sealing reservoir hub attached to a radiopaque silicone rubber or polyurethane catheter. The septum is made of a silastic material and is secured in a metal or a plastic reservoir hub. The septum serves several functions including allowing an access needle to enter, holding the needle in place - thereby stabilising it during infusion therapy, and resealing once the access needle is removed. Most ports are designed for 1000 to 2000 punctures with a non-coring needle. An implanted venous port is inserted by a surgeon or an interventional radiologist under anaesthesia or light sedation.

Implanted venous ports	Non-coring needles	Position of implanted venous port

Tunnelled central venous catheter (Hickman^®)

Tunnelled catheters are intended for patients who may require longer-term central venous access. The most common sites for placement are the subclavian and jugular veins. The catheter is tunnelled subcutaneously and exits at a convenient site (usually on the chest wall) where it is secured. There is a ‘cuff’ within the tunnel to allow for the adherence of fibrous tissue which helps to prevent accidental dislodgement and acts as a mechanical barrier to ascending bacteria. A tunnelled CVAD is inserted by a surgeon or an interventional radiologist under anaesthesia or light sedation.

Tunnelled catheter	Tunnelled catheter	Placement of tunnelled catheter

Non tunnelled central venous catheter (CVC)

Non tunnelled CVCs can be inserted via the subclavian, jugular or femoral veins (avoid using the femoral vein in adults) with the tip positioned in the superior or inferior vena cava. Attachment of the external portion may be via sutures or an external fixing device. Non-tunnelled CVCs are short term catheters and should be removed as soon as they are no longer required.

Non-tunnelled central venous catheters	Placement of non-tunnelled central venous catheter

Valved (closed ended) catheters

These catheters have a valved opening and do not require clamping or locking with heparinised saline. Valved catheters allow the infusion of solutions and aspiration of blood but when not in use, remain in a closed position preventing reflux of blood into the catheter.

Non-valved (open ended) catheters

Non-valved catheters are open ended catheters and require clamping and positive pressure locking. These catheters may require locking with heparinised saline - refer to manufacturer's instructions and institutional guidelines.

It is important that:

• The correct anatomical placement of the catheter tip is confirmed and documented in the patient record prior to the first use of the catheter, to make sure the catheter tip is in the correct place.
• Radiological examination is used to confirm absence of any adverse events related to the catheter location e.g. pneumothorax.
• The integrity of the catheter is checked with blood aspiration to ensure the catheter is in the venous system.
• The catheter is not used if occlusion or backtracking is present until patency can be established (e.g. imaging to ascertain patency).
• Optimal hand hygiene and aseptic non-touch technique is used during all CVAD manipulation to reduce the risk of infection.
• Sutures securing a cuffed tunnelled central venous catheter are removed at a specified time if not dissolvable.
• Post insertion care for an IVP is attended to until the incision has healed; e.g. keep area dry and covered until any sutures present are removed/dissolved.
• CVADs are clamped when not in use or as per institutional guidelines.
• The catheter is secured to the patient's skin for stability:
  • a PICC should be secured at all times using a sutureless securement device, and
  • an IVP once accessed requires the needle and intravenous lines to be secured to the patient's skin for stability.

Mechanical phlebitis (sterile phlebitis)

Mechanical or sterile phlebitis is a common problem that develops within about 1 week of insertion of a PICC line, where movement of a foreign body within the vein causes inflammation.

The symptoms include:

• redness
• swelling
• pain
• heat and venous cording.

When symptoms of mechanical phlebitis are present, it is important to observe device closely and rule out other causes such as thrombosis, tip migration or infection.

Treat mechanical phlebitis with the use of intermittent, warm compress to the red tender area of the upper arm and elevate the limb.^r

If the phlebitis does not settle within two days or if the patient develops fever or purulent drainage and/or the site appears worse after two days of treatment, consider infection and refer patient to a medical officer. 

Management of a fractured or damaged PICC^r

Damage to the integrity of lines can be sustained over time or with improper handling. Adherence to correct management techniques can minimise the risk of catheter damage. Tears and splits in the catheter can occur at any point along the length of the line and may present as:

• leakage from the line when flushing
• unexplained fluid or precipitate under the dressing or along the external part of the catheter
• separation of the connector from the catheter.

If the catheter breaks externally:

• immediately clamp the remaining portion of the catheter
• stabilise the catheter to prevent migration into the vein
• repair or remove the catheter.

If the catheter fracture occurs within the vein:

• contact a medical officer
• place the patient in the Trendelenberg position
• manage the presenting symptoms
• urgent x-ray to confirm catheter fragmentation and location
• if the catheter breaks while being removed immediately tourniquet the arm and monitor vital signs and pulses and seek medical attention.

Skin preparation and antiseptics

• Assess patient for a history of allergies to cleaning agents and dressing materials.
• 2% chlorhexidine gluconate v/v 70% isopropyl alcohol is the recommended cleaning solution for catheter care:
  • in patients with sensitivities to 2% chlorhexidine gluconate v/v 70% isopropyl alcohol consider the use of topical povidone iodine (note: povidone iodine has a longer drying time of 2 to 3 minutes).^r
• Clean the insertion site using gentle friction in a back and forth motion for at least 30 seconds:
  • allow to dry naturally for at least 30 seconds; do not rinse off or blot excess solution from the skin
• Do not use solvents such as acetone or ether or apply any antimicrobial ointments or creams at the insertion site or under the dressing.
• Ensure that hair at the insertion site has been clipped (do not use a razor) to improve adherence of the dressing.
• Consider the use of a small ice pack for 10 minutes or application of topical local anaesthetic prior to skin disinfection to reduce pain associated with access of an intravenous port (IVP).

Dressings

• An appropriate dressing should be chosen according to the clinical situation; allergies and patient preferences should be considered e.g:
  • transparent semi-permeable polyurethane dressings require changing every 7 days
  • gauze dressings require changing every 48 hours and will require protection from water.
• The initial dressing should be changed at 24 to 48 hours post insertion (or according to institutional guidelines), other dressing changes as above or as required.
• The site should be assessed daily for signs of infection (or as clinically indicated) and if indicated, obtain swabs for MCS +/- blood cultures as per MO's orders.
• Protect the catheter exit site from getting wet when showering or bathing.
• Read more about the clinical procedure - central venous access device - dressing and needleless injection cap change.

Implanted venous port (IVP)

• Post insertion care of an IVP is required until the incision has healed.
• Keep dry and covered until all sutures are removed/dissolved.
• When the IVP is accessed, it must be securely fastened and have a dressing in situ.

Peripherally inserted central catheter (PICC)

• The length of the external portion of a PICC should be measured and documented during all dressing changes or as clinically indicated, to assess for catheter migration.
• The PICC should be secured at all times, either via a dedicated fixing device or steristrips.

Line care and line changes

• A closed system using needleless injection caps should be used, and catheter manipulations kept to a minimum.
• Administration sets should never be disconnected and reconnected at a later time.
• All injection caps should be luer locked and cleaned with 2% chlorhexidine gluconate v/v 70% isopropyl alcohol prior to and after any manipulation:
  • connection caps should be changed weekly or earlier if compromised by presence of blood or lack of integrity
  • failure to cap intravenous tubing and disinfect intravenous ports places patients at risk of infection.^r 
• Chemotherapy administration sets should be discarded upon completion of chemotherapy (and flush) or according to institutional guidelines, in order to maintain a closed system.
• There are a variety of recommendations for timing of line changes for continuous infusions - refer to institutional guidelines.
• For blood products, the administration set should be changed upon completion of the transfusion or every 12 hours if the transfusion is not complete:
  • Any number of red cell units may be transfused during this 12 hour period providing the flow rate remains adequate and the number of units recommended by the administration set manufacturer is not exceeded.
  • Red blood cells should be infused using an infusion pump when administered through a CVAD.^r
• For IVP only use non-coring needles to access the IVP; use the smallest size that can accommodate the prescribed therapy:
  • non-coring access needles should be changed every 7 days.^r
• Correct needle placement should be verified by positive aspiration of blood return prior to administration of fluids or medications:
  • In the absence of blood return, infusion therapy should be withheld until the problem can be identified and corrected.
• Read more about the clinical procedure - central venous access device - accessing.

Flushing and locking

• Flushing with 10 to 30 mL of sodium chloride 0.9% using a 10 mL syringe (minimum size) and the positive pressure technique and pulsatile action should occur:
  • before and after and administration of fluids, medications and blood products
  • before and after routine blood sampling 
  • periodically for device maintenance when not in use.
• Never use excessive force when attempting to flush, unblock or inject into a CVAD:
  • if resistance is met or there is an absence of blood aspirate, the patency of the CVAD must be assessed prior to administration of medications or solutions.
• Standard CVADs should not be used for the administration of power injected contrast (used in radiology and nuclear medicine) as the volume and rate of infusion may split the catheter. Always check the product information of the device in question.
• There is insufficient evidence to inform appropriate flushing solution and frequency; refer to institutional guidelines. ONS^r recommends:
  • heparin should be used when necessary for tunnelled non-valved catheters and IVPs in the lowest concentration (commonly 50 IU heparin in 5 mL sodium chloride 0.9%)
  • routine flushing should occur when the line is not in use - refer to your institutional guidelines.
• Read more about the clinical procedure - central venous access device - de-accessing.

Blood sampling

• It is not recommended that a size 4 French PICC or smaller is used for blood sampling. Smaller gauge PICC lines may not yield blood return.^r
• When the CVAD is in use, or if taking blood through a multi lumen CVAD, stop all infusions and clamp all lumens prior to obtaining sample(s).
• 6 to 10 mL of blood should be collected and discarded prior to blood collection to ensure that the sample is not diluted. If blood cultures are required, the first 10 mL withdrawn should be cultured as it may contain potential contaminants.                                                                                      
• Caution should be used when taking blood samples such as coagulation studies, electrolytes and drug assays from the same lumen that has been utilised for anticoagulant therapy, lipid based solutions, and medications that require blood level monitoring, as the blood sample may be contaminated. Repeat bloods when grossly abnormal results are received:
  • consider taking bloods peripherally
  • if this is not an option, the infusion should be stopped for at least 1 minute and then flushed with a minimum of 20 mL of sodium chloride 0.9% prior to blood sampling.
• Read more about the clinical procedure - central venous access device - blood sampling.

• The appearance, dressing integrity and length of catheter should be assessed and documented daily.
• The insertion site should be examined daily (or at each dressing change if gauze is used) for:
  • erythema
  • drainage
  • tenderness or pain
  • swelling
  • suture and dressing integrity
  • cuff exposure (Hickman)
  • changes to the length of the catheter (CVC, PICC, Hickman).
• Palpate the exit site on top of the dressing for tenderness.
• Site appearance should not be used as the only indicator of infection as local inflammation may not be immediately visible.
• The patient should also be examined for fever or other signs of sepsis, e.g. tachycardia, tachypnoea and hypotension.

Patient, carer and/or family education should cover:

• CVAD line insertion and complications:
  • Avoid blood pressure monitoring from the arm that has the PICC line in situ.
  • Prevention and management of mechanical phlebitis: patients should be encouraged to place a warm compress on the upper part of their arm for 20 minutes 3 times a day for 4 days after the PICC has been inserted.
  • How the IVP is accessed and any care while accessed.
• Checking the exit site each day, and:
  • reporting any symptoms such as pain, redness, discharge, swelling, burning, stinging, pruritus, presence of a rash or leaking around the catheter exit site
  • palpating the exit site on top of the dressing for any tenderness.
• What to do in the event that the catheter ruptures, fractures or cracks.
• Details of appropriate and readily accessible 24-hour medical and nursing contact to whom patients can direct queries.

Patients should be supplied with any printed information currently available and must be given the opportunity to ask questions. Prior to insertion of a CVAD, a valid consent must be obtained as per institutional guidelines.

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Bibliography

Bishop, L., L. Dougherty, A. Bodenham, et al. 2007. "Guidelines on the insertion and management of central venous access devices in adults." Int.J Lab Haematol. 29(4):261-278.

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Central venous access devices are used in many branched of medicine where venous access is required for either long-term or a short-term care. These guidelines review the types of access devices available and make a number of major recommendations. Their respective advantages and disadvantages in various clinical settings are outlined. Patient care prior to, and immediately following insertion is discussed in the context of possible complications and how these are best avoided. There is a section addressing long-term care of in-dwelling devices. Techniques of insertion and removal are reviewed and management of the problems which are most likely to occur following insertion including infection, misplacement and thrombosis are discussed. Care of patients with coagulopathies is addressed and there is a section addressing catheter-related problems

Dougherty, L., Lister, S. 2015.The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 9th Edition. Wiley-Blackwell.

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Polovich, M et al (eds) 2014. "Chemotherapy and Biotherapy Guidelines and Recommendations for Practice" 4th ed. Oncology Nursing Society. Pittsburgh.

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Schiffer, C. A., P. B. Mangu, J. C. Wade, et al. 2013. "Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline." J Clin Oncol 31(10):1357-1370.

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PURPOSE: To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and management of both catheter-related infection and thrombosis. METHODS: A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant articles published in English. RESULTS: The overall quality of the randomized controlled trial evidence was rated as good. There is consistency among meta-analyses and guidelines compiled by other groups as well. RECOMMENDATIONS: There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recommended before insertion. Data are not sufficient to recommend for or against routine use of antibiotic flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained. Some life-threatening infections require immediate catheter removal, but most can be treated with antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended. Prophylactic use of warfarin or low-molecular weight heparin is not recommended, although a tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters. CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that worsens despite anticoagulation therapy.

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