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INTRAVASCULAR DEVICES CARE, USE AND MAINTENANCE OF CENTRAL INTRAVASCULAR DEVICES PROCEDURE

Procedure: Care, Use and Maintenance of Central Intravascular Devices
Intravascular devices deliver fluid, medications, blood products and parenteral nutrition to patients. Appropriate care and maintenance of the device will promote successful outcomes for patients and prevent device-related complications. Aseptic technique and handwashing are essential when caring for central lines.
Considerations:
Central line devices in this procedure include percutaneous, tunneled, accessed subcutaneous implanted ports umbilical lines and Peripherally Inserted Central Catheters (PICC). Site care for arterial lines is similar to venous lines while flushing and sampling procedures are managed at the unit level. Refer to Implanted Ports: Accessing/Discontinuation.
Note: This procedure reflects the expected practice for most LHSC patients, adult and paediatric. Within this procedure any paediatric specific information is shaded. Specific unit protocols / procedures may apply for dialysis and critical care patients. These protocols / procedures are available and maintained in those units. Dialysis catheters and lines are to be accessed, maintained and used by the dialysis and critical care staff only.


H.  BLOOD SAMPLING
Documentation
   *  designate the port used for sampling if using a multi lumen device    *  avoid using the sampling port for other uses to ↓ risk of contamination
Site Selection
  • except as noted below – the preferred site for blood sampling is a peripheral venous stab
  • paediatrics, a capillary sample is also appropriate
  • the preferred option when there is no peripheral vein or arterial line available, is to use one port of multi lumen line that is dedicated to sampling
  • for adults and paediatric patients with chronic illnesses including cancer, the central line may be placed to facilitate sampling as well as therapeutic regimens
  • peripheral stab may be necessary to confirm that PTT has not been prolonged as a result of contamination when heparin has been infusing through the line
  • PICC Lines should only be used as a last resort for sampling
    • Criteria if PICC line to be used
      • Double lumen
      • Validate with person who inserted line to ensure diameter adequate for blood draw

Paediatrics

  • do not sample from PICC lines unless otherwise ordered
  • do not sample from catheters if the PICC is ≥20g
      
  • peripheral venous lines should be avoided for sampling because the device and/or vein will collapse and not be available for IV therapy
  • all nurses who sample from central lines must meet the Competency Expectations (see Competency Expectations for Blood Sampling in Appendix A)
  • the use of central lines for blood sampling puts the patient at ↑ risk for infection because of ↑ hub manipulation and static blood left in ports acting as a medium for bacterial growth
  • single lumen TPN lines should not be used for sampling because of the high risk of microorganism growth with accessing the line
  • the fragility of peripheral veins, toxicity of chemo agents and the frequency of blood sampling necessitate the use of central lines for sampling in these populations
  • frequent sampling with the necessary wastage may compromise the patient
  • do not work well for sampling due to the long length and small lumen size
  • lumen size is too small, sampling will increase the risk of damaging the catheter
Equipment
Adults  
   *  chlorhexidine swab sticks (2%)  
   *  multi sample luer adapter and syringe cannula  
   *  required specimen tubes  
   *  1 – 10 mL syringe with syringe cannula filled with 3 mL of Bacteriostatic Normal Saline for wastage    *  the saline in the syringe may be needed to flush the line prior to removing the wastage
   *  1 – 10 mL syringe with syringe cannula with 10 mL Bacteriostatic Normal Saline  
For capped lines add  
   *  1 – 10 mL syringe with syringe cannula with 5 mL  
   *  1 - 5 mL syringe with Heparin 100 U/mL flush solution  
      

Paediatrics

  • Chlorhexidine swab sticks
  • multi sample luer adapter and syringe cannula
  • vacutainer holder may be used
    - optional – syringe with syringe cannula
  • required specimen tubes
  • 1 – 5 or 10 mL syringe with syringe cannula with 2 – 3 mL
    Non-preserved Sterile Normal Saline for wastage
  • 1 – 5 or 10 mL syringe with syringe cannula filled with Nonperserved Sterile Normal Saline
  • for capped lines add: 1 – 5 or 10 mL syringe with syringe cannula with 3 mL of 100 U/mL Heparin flush solution
  • the use of syringes in some infants, allows for better control of withdrawal pressure in the vein
  • the saline in the syringe may be needed to flush the line prior to removing the wastage
  • the preservative may cause allergic reactions/cardiac arrhythmias in children where the distance to the heart is shorter from the injection site and there is less blood dilution than in an adult
Essential Steps
1   If using a vacutainer, attach multi sample luer adapter to vacutainer holder and syringe cannula to the luer adapter  
2   Ensure all lines and ports are clamped  
3   Prior to accessing the injection site each time throughout this procedure – cleanse with Chlorhexidine and let dry at least one minute
  • if necessary disconnect IV tubing. Interlink injection site stays in place (lock)
  • attach new luer lock cannula to IV tubing
  • the solution must dry to allow for maximum antimicrobial and cumulative affect
  • using a closed system decreases the risk of contamination of the line, the specimen and ↓ risk to patient
4   Insert the partially filled Saline syringe with attached cannula into the injection site and draw back the required amount of wastage
  • if there is difficulty aspirating the wastage, flush with the saline and retry aspirating
  • Adult – if TPN is infusing flush line with 20 mL Saline
  • Paediatrics – if TPN is infusing flush line with 3x the volume in line
 
Adult Wastage  
   *  central - 8 mL of blood  
   *  arterial -3 - 5 mL of blood  
      

Paediatrics Wastage

  • central – 0.5 - 1 mL of blood (based on twice the length of the line)
  • arterial – 0.5 - 1 mL of blood
 
5   Remove the syringe and cannula from the injection site. Set aside for discard.
Alternately
- the wastage can be drawn using a vacutainer and empty blood tube
      
  • wasted blood is never to be returned to the patient due to clotting and contamination risks
  • discard in bioharzard container
6   After cleansing the injection site, insert the syringe cannula attached to the vacutainer holder into this same injection site and attach blood tubes as your would for a phlebotomy  
7   Withdraw the vacutainer holder and attachments when you have the required samples  
      

Paediatrics

  • may use a syringe cannula and syringe inserted into the Interlink injection site. Once blood is drawn, place cannula into the multi sample Luer adapter and attach appropriate sample tubes

 

 
8   Insert the Normal Saline filled syringe with attached cannula into the injection site and flush using a Push/Stop motion
If line to be locked see section Flushing to maintain patency
   *  essential step to clear blood, which is a rich medium for microorganisms, from ports/stopcocks
9   If a continuous infusion, reconnect the IV line and re-establish IV flow ensuring all clamps are open  

I.  REMOVAL OF CENTRAL INTRAVASCULAR DEVICES
What  
   *  Tunneled devices including Hickman, Perma-Caths and implanted ports must be removed by a physician.  
   *  Central venous access devices, including PICCS, subclavian, femoral and internal/external jugular lines, and venous umbilical lines, may be removed by any RN who has met the competency expectations for these skills  
Standard Equipment
   *  non sterile gloves  
   *  sterile gloves  
   *  dressing tray  
   *  sterile scissors  
   *  chlorhexidine swab stick (2%)  
   *  occlusive dressing  
   *  sterile gauze  
   *  tape  
Optional Equipment  
   *  dressing tray  
   *  sterile scissors  
Essential Steps
1   When indicated review coagulation status (ie. lab work, medications) and ensure results are within normal limits prior to line removal
2   Ensure that all lines are clamped/locked.    *  to prevent air embolism during removal of the central line
3   Position patient appropriately for line being removed
  • femoral lines – supine with head on pillow

  • other lines – supine to semi fowlers to facilitate line removal and patient comfort
    Note - if concerned about patient’s ability to perform Valsalva Manoeuvre or to cooperate with removal, position supine



  • patients with respiratory or cardiac disease or chest/abdominal surgery may not tolerate supine position

  • be ready to lie patient supine should a vasovagal response occur with line removal
4   Wearing non sterile gloves, remove the dressing according to manufacturers directions without dislodging the device.    *  use a lateral pull on the dressing to minimize trauma to the skin and pain for the patient
5   Assess the site for drainage, inflammation, swelling – See section for culture procedure  
6   Apply sterile gloves  
7   With the swab stick, cleanse the insertion site and surrounding skin using a top to bottom motion. Turn the swab stick over and cleanse the area again using an side to side motion. Let the area dry for at least 1 minute.    *  contamination of the open site with skin bacteria is a risk of removing the device
8   Remove any sutures with sterile scissors    *  do not cut line while removing the suture
9   Adults/Older Children
Have patient perform Valsalva Manoeuvre while removing lines situated above the diaphragm, including PICCS
   *  prevents air embolism by raising intra thoracic and venous pressure
      
Infants/Young Children
Remove the line while they are crying or holding their breath
   *  prevents air embolism by raising intra thoracic and venous pressure
10   Holding the gauze in one hand, begin to apply pressure over the site, and use the other hand to steadily withdraw the catheter. Place the removed line on a sterile drape or in the tray.    *  to prevent contamination if line is to be cultured
11   If resistance is noted, stop, reassess, reposition if affected limb, and seek assistance if required.  
       Note - With some PICCS, resistance may be related to venospasm. Replace the dressing, tape the catheter, apply continuous heat to the venous pathway from insertion site to the axilla x 10 minutes, then reattempt removal.If resistance continues, stop, secure line and call the physician.    *  Continuous heat promotes vasodilatation which will make removal easier
12   Exert direct pressure on the site with the gauze until bleeding is stopped. For central lines this will mean at least 5 minutes and continue until the bleeding stops. If bleeding persists, call for assistance from the patient’s bedside while maintaining pressure.
Do not leave the patient.
   *  pressure on the neck when removing jugular lines may produce a vagal response – if so, minimize the pressure, lower the head of the bed and seek assistance if required
13   Once haemostasis is achieved, leave the gauze in place and apply a Tegaderm dressing over the site.    *  do not use elastoplast dressings as adequate visualization of the site is impaired and prompt intervention will be delayed if bleeding does occur
       Alternately, a simple gauze dressing with the tape covering the gauze and all sides may be used. Remove dressing after 24 hours.    *  the site will not be healed for at least 24 hours so should be treated as an open conduit for infection
     *  gauze secured with tape to all sides or an occlusive transparent dressing will protect the site
14   Post femoral venous line removal, the patient should rest in bed for 30 minutes before returning to regular activity  
15   Remind the patient to call if any pain, bleeding or drainage occurs at the site.  
16   Inspect the line for abnormalities and infection. Discard in biohazardous waste if not being sent for culture.  
      

Paediatrics

Check length of PICC line with length recorded upon insertion
 
17   Document removal and any concerns on the appropriate record.