Preparation
- Perform hand hygiene
- Decontaminate and disinfect trolley as per local policy
- Gather equipment
- Prepare flush/lock protecting Key-Parts using non-touch technique and Micro-Critical Aseptic Fields if the TIVAD is being deaccessed, or the /intravenous lines if therapy is being commenced
- Proceed to patient area and perform hand hygiene
- Check patient identification and IV fluids as per local policy
- Explain the procedure, and obtain verbal consent
- Ensure patient is in a comfortable position and TIVAD body is accessible
- Perform hand hygiene
- Palpate the TIVAD body, identifying the septum
- Perform hand hygiene
- Skin antisepsis: if using clean swab sticks*, attend to skin antisepsis at this stage using non-touch technique. Disinfect skin over the TIVAD body and under the required dressing field with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick using gentle friction for at least 30 seconds and allow to fully air dry.
- Set up equipment
- Perform hand hygiene
- Put on PPE including sterile gloves
- Prime non-coring needle
- if TIVAD is to remain accessed, attach needleless connector NC to non-coring needle and prime with sterile sodium chloride 0.9%
- if TIVAD is to be flushed, locked and deaccessed – prime non-coring needle with sterile sodium chloride 0.9%, NC not required
* clean swab sticks - are not placed on the Critical Aseptic Field. Swabs are used with clean hands and non-touch technique for skin antisepsis
Access
- Skin antisepsis: if using sterile swab sticks, attend skin antisepsis at this stage, clean the skin over the TIVAD body and all skin under the dressing with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick using gentle friction for at least 30 seconds and allow to fully air dry
- Place sterile drape from dressing pack near TIVAD body to create clean area and ask patient not to touch
- Locate and stabilise the TIVAD body between the index and middle finger and thumb of non-dominant hand
- Inform patient of needle insertion and ask to breathe in and hold their breath until the needle is inserted (if possible)
- TIVAD access (see diagram below): hold non coring needle in the dominant hand and
- insert at a 90o angle with a firm and decisive action through the skin into TIVAD septum (Key-Site) until needle tip touches the bottom of TIVAD body
- tubing outlet where the fluid exits the non coring needle faces away from where the catheter enters the TIVAD body
- non coring needle sits flush with skin
Diagram of accessing TIVAD
© K Curtis 2021
- Ensure extension tubing and needleless connector remains on sterile drape and Key-Parts are protected
TIVAD patency and flushing:
- Assess patency:
Aspiration - blood return:
- attach empty 10 mL luer lock syringe to NC (Key-Part) on extension tubing of non-coring needle
- unclamp non-coring needle extension tubing and aspirate 5 mL blood and discard return, assess ease of withdrawal. Discard syringe
Injection - flushing:
- attach syringe with sodium chloride 0.9% and inject while assessing ease of flushing - using a pulsatile flush technique and complete with the appropriate clamp disconnection technique for the type of NC
Type of needleless connector |
Completion of flushing technique |
Negative |
clamp PRIOR to finishing flush and disconnecting the syringe |
Positive |
clamp AFTER finishing flush and disconnecting the syringe |
Neutral |
no specific clamping sequence required |
Anti-reflux |
no specific clamping sequence required |
Adults: 20 mL using 2 x 10 mL leur lock syringes or 1 x 20 mL syringe
Paediatrics: as clinically appropriate - at least double the volume of the TIVAD and attachments or as per adults
NOTE: Use a manufactured prefilled syringe with anti-reflux and pressure limiting features, or leave small volume e.g. 0.5 mL in syringe to avoid ‘bottoming out’ the syringe.
Patency assessment requires checking both aspiration and injection ability
- Any alteration to either easy (1) blood return or (2) injection:
- primary strategies: reposition the patient, ask patient to take a deep breath, either hold the breath or cough
- check needle is appropriately inserted – refer to step 21
- secondary strategy: for TIVADs flushed and locked with sodium chloride 0.9% , flush with 10 to 20 mL of sodium chloride 0.9% using pulsatile action
- attempt to aspirate blood again
- if still no blood return, discuss with vascular access expert, nurse practitioner, clinical nurse consultant or medical team, and refer to CNSA CVAD Patency Algorithm
- Proceed to step 25 if TIVAD is being deaccessed or step 26 if TIVAD is being used for prescribed therapy
Locking
- Repeat step 22 c with second 10 mL syringe of sodium chloride 0.9% or locking solution as per local policy. Alternatively use 1 x 20 mL syringe with 20 mL sodium chloride 0.9% for flushing and locking
Apply dressing
- If TIVAD is remaining accessed, apply dressing ensuring needle and first part of non-coring needle extension tubing is covered and closed.
© K Curtis 2021
- Add date and time strip to the side of the dressing
Connecting IV administration lines
- Disinfect NC (Key-Part): using non-touch technique, scrub the NC with large 2% chlorhexidine gluconate and 70% isopropyl alcohol swab for at least 15 seconds (refer to local policy) using vigorous friction and allow to fully air dry
- Using non-touch technique, connect primed IV administration line to the NC (Key-Part) and commence infusion as ordered
- Anchor tubing
Deaccessing TIVAD
- Perform hand hygiene
- Remove dressing using non-touch technique
- Using non dominant hand, stabilise TIVAD body and base of non coring needle between fingers and thumb
- With dominant hand, withdraw needle in firm decisive action and engage the safety mechanism on the non-coring needle. Discard immediately into sharps container
- Place small, sterile dressing e.g. intravenous pressure dot over site for approximately one hour or if CVAD access required – re-access TIVAD as per Step 15 – 27
Procedure completion and documentation
- Discard waste and clean trolley
- Remove PPE and discard
- Perform hand hygiene
- Document the procedure in the medical record.