Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 1 of 19
POLICY FOR THE INSERTION AND CARE OF CENTRAL VENOUS
ACCESS DEVICES (CVAD) IN HOSPITAL
Summary
This policy provides an overview of central venous access devices used within the Trust
and includes selection, insertion and removal, training, documentation, care and
management of the device and any resulting complications.
CONTENTS
Page
Definition
1
Types of CVADs
2
Insertion and removal
2
Documentation
5
Care and management
6
Complications
10
Monitoring and Audit
11
References
11
Related policies
12
Central Venous Access Devices
13
Performing procedure
14
Removal Flowchart
15
Protocol for Resolving Patency Problems with Central Venous
Access Devices
16
Algorithm for managing CVAD related thrombosis
19
1. DEFINITION AND TYPES
DEFINITION
A central venous access device is a device that is inserted via a vein where the catheter
tip is located in a central vein, usually the superior vena cava or caval atrial junction. It is
inserted for:
o Short and long term therapy
o Central venous pressure (CVP) readings
o Emergency use, e.g. fluid replacement
o Absence of peripheral veins
o Repeated blood sampling
o Administration of all types of medications
TYPES
Types of CVADs include peripherally inserted central catheters (PICCs), non cuffed central
venous catheters, long term tunnelled (LTS) catheters, skin tunnelled catheters and
implanted ports (see Appendix 1). It is recommended that a single lumen CVAD is inserted
unless indicated otherwise. Antimicrobial impregnated catheter (short term non cuffed)
should be considered if duration of 1 to 3 weeks and if the risk of catheter-related blood
stream infection (CrBSI) is high.
Royal Marsden - CVAD policy: a real world example
This local policy is an example used in the
NICE medical technology guidance adoption support
resource for SecurAcath for securing percutaneous
catheters, and was not produced, commissioned or
sanctioned by NICE.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 2 of 19
Multi-lumen CVADs are available and these can be from dual lumen PICCs and tunnelled
catheters to triple, quad and quin lumen Central venous catheters (CVCs). The advantage
of a multi-lumen catheter is the ability to infuse incompatible mediations and solutions at
the same time. The catheters are designed to ensure that there is no mixing of
medications either within the catheter, OR once they exit from the tip (located in superior
vena cava or right atrium) into the rapid blood flow. When single lumen catheters are in
situ and the patient requires multiple therapies, consideration should be given to either
inserting a peripheral device or an additional CVAD. Guidance as to which medications
can be given concurrently should be sought from pharmacy and the type of medication
prioritised e.g. parenteral nutrition or other medications that must be given centrally.
2. CVADs AND DIAGNOSTIC IMAGING
2.1 All PICCs and ports inserted at The Royal Marsden are suitable for use with a
contrast pump injector.
2.2 Some nuclear medicine tests can be injected via PICCs. Please refer to the Nuclear
Medicine Intranet page (Nuclear Medicine and PET/CT page is under the All
documents feature then select: Departments > General Protocols > General
Protocols \ Use of CVAD for Radiopharmaceuticals administration).
2.3 Short term CVCs inserted in the RM are not pressure pump compatible. If venous
access cannot be obtained via a peripheral cannula then the use of these catheters
should be by hand injection only. The catheter will only be used with a contrast
pump injector if arterial contrast medium is needed. The safe use of the catheter
must be assessed and supervised by the clinician attending with the patient.
2.4 On occasions a patient will have had a port inserted outside of the RM. A thorough
check should be made by the radiographer to ascertain the type of port placed prior
to using it. Pump compatible ports are identified by a patient wrist band, ID card or a
radiopaque marker on the most recent chest X-ray. If these are not available, the
surgical notes should be requested from the organisation who inserted it to confirm
compatibility with a contrast pump injector.
2.5 Pump compatible PICCs are identified by the PICC stating ‘pump injectable’ in the
insertion notes (or on the catheter itself).
3. INSERTION AND REMOVAL (see Appendix 2)
3.1 Consent
All adult patients undergoing the elective placement of a CVAD must be consented prior to
the procedure where it is possible e.g. not always possible in the critical care setting or in
an emergency.
Young people aged 16 years and 17 years (with capacity) can consent for insertion of a
CVAD. People aged 16 or over are assumed to have capacity to consent to their own
treatment, unless there is significant evidence to suggest otherwise, this can only be
overruled in exceptional circumstances.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 3 of 19
For children under 16 years an adult with parental responsibility consents for them.
Children under the age of 16 are presumed to lack capacity, but can consent to their own
treatment if it is thought that they have enough intelligence, competence and
understanding to fully appreciate what is involved in their treatment. Otherwise, someone
with parental responsibility consents for them.
3.2 Training and maintaining competency
3.2.1 Nursing staff
Nursing staff are permitted to insert and remove certain types of central venous access
devices (CVAD) or access an implanted port after completion of a planned programme of
theory and practice (see Royal Marsden Manual (2015) for procedures). Skills and
knowledge must be maintained in accordance with The Code (NMC 2015).
3.2.1.1 Insertion of Peripherally inserted central catheters (PICCs)
On successful completion of the planned programme of theory and practice utilising a
reflective practice workbook entitled ‘Role Development Profile – Midline and PICC
insertion’; staff who have completed the relevant workbook and who have had their
workbook signed by the Nurse Consultant IV Therapy (or relevant designated practitioner),
as well as their manager, are able to practice the relevant procedure. The member of staff
will be permitted to perform PICC insertion in accordance with the procedure set out in The
Royal Marsden Manual of Clinical Nursing Procedures, 9
th
edition, 2015, chapter 14.
3.2.1.2 Insertion of Central venous catheters (CVC), skin tunnelled catheters and
ports
On successful completion of a recognised programme (e.g. CVC insertion training
programme), and achieving the required competencies, the member of staff will work
under supervision of a designated consultant anaesthetist or surgeon until the nurse
deems her/himself competent to practice unsupervised within the Trust.
3.2.1.3 Removal of skin tunnelled catheter (STC)
On successful completion of the planned programme of theory and practice utilising a
reflective practice workbook entitled ‘Role Development Profile – Removal of skin
tunnelled catheter’; Staff who have completed the relevant workbook and who have had
their workbook signed by the Nurse Consultant IV Therapy (or relevant designated
practitioner), as well as their manager, are able to practice the relevant procedure. The
member of staff will be permitted to perform STC removal in accordance with the hospital
procedure (The Royal Marsden Manual of Clinical Nursing Procedures, 9
th
edition, 2015,
chapter 14).
3.2.1.4 Accessing an implanted port
On successful completion of the planned programme of theory and practice utilising a
reflective practice workbook entitled ‘Role Development Profile – Accessing an implanted
port’; staff who have completed the relevant workbook and who have had their workbook
signed by the Nurse Consultant IV Therapy (or relevant designated practitioner), as well as
their manager, are able to practice the relevant procedure. Their names will then be added
to the list of competent practitioners on the intranet.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 4 of 19
The member of staff will be permitted to access implanted ports in accordance with the
hospital procedure (The Royal Marsden Hospital Manual of Clinical Nursing Procedures,
9
th
edition, 2015, chapter 14).
3.2.1.5 Deaccessing an implanted port
Any nurse or radiographer, who has been shown how to deaccess a port and how to
activate the safety mechanism of the port needle by a nurse/radiographer competent in
port accessing, can deaccess a port. The nurse/radiographer can then deaccess a port, in
accordance with the procedure set out in The Royal Marsden Manual of Clinical Nursing
Procedures, 9
th
edition, 2015, chapter 14. They do not have to have undergone the port
accessing training prior to this.
3.2.2 Medical Staff
3.2.2.1 Insertion of short term CVCs
All insertions must take place under the supervision of the Anaesthetic Department unless
the individual concerned has been specifically signed off as competent by a consultant
anaesthetist. Medical staff will be assessed by a consultant anaesthetist as competent to
perform insertion.
Individuals requiring training in the insertion of CVCs will have the opportunity to
participate in a simulation based learning programme. This programme will include the
recognition and management of complications.
3.3 Insertion Site
It is recommended that the subclavian or internal jugular veins are used for short term non
cuffed CVC, and the femoral vein is only used where clinically indicated. Subclavian is
associated with less infection but higher rate of pneumothorax. The jugular has higher rate
of infection and risk of arterial puncture (Parienti et al 2015). For PICC placement the
basilic or brachial vein in the upper arm are most suitable.
3.4 Insertion Procedure (to be performed in line with CVC care bundle)
All patients undergoing CVAD insertion should have had MRSA swabs taken within 4
weeks of the procedure and had Octenisan body wash for 5 days prior to procedure (see
MRSA and MSSA Screening Policy for details).
3.4.1 Location of performing procedure (see Appendix 2)
PICCs can be inserted at bedside or appropriate unit e.g. Medical Day Unit (MDU). Short
term CVC insertions must take place in operating theatres or CCU in Chelsea or in the
minor procedures suite or operating theatres in Sutton. Tunnelled catheters and ports to
be inserted in operating theatres.
3.4.2 Personal protective equipment/maximal barriers
Sterile gown, gloves and large drapes must be used for the insertion of CVADs. Gloves
are single-use items and should be removed and discarded immediately after the care
activity. Eye/face protection is indicated if there is a risk of splashing with blood or body
fluids.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 5 of 19
3.4.3 Hand hygiene
Decontaminate hands before and after each patient contact. Use correct hand hygiene
procedure.
3.4.4 Skin cleansing
Use 2% chlorhexidine gluconate in 70% isopropyl alcohol and allow it to dry. If the patient
has a sensitivity use a single patient use povidone-iodine application.
3.4.5 Use of ultrasound
Ultrasound must be used for assessing veins and performing all insertions via the jugular
vein and is recommended for all PICC insertions.
3.4.6 Monitoring during insertion
Transduction must be used for all catheters during insertion to verify venous and no
arterial placement (excluding PICCs). PICCs should be placed using Sherlock 3CG
tracking system to verify tip location (NICE 2015a).
3.4.7 Equipment
All insertions must utilise the pre-prepared kit which can be located in CCU or in theatres
or in MDU/Minor Procedure Suite (MPS).
3.4.8 Securement following insertion
PICCs will be secured using a SecurAcath
©
or a Statlock dressing.
Non cuffed catheters will be secured with sutures.
Skin tunnelled catheters will be secured with sutures.
LTS catheters are sutured.
3.5 Post insertion
Patients must not be discharged until a post-procedure check chest X-ray (CXR) has been
reviewed by the individual who performed the procedure. The tip of a CVAD should be
verified on chest x-ray prior to use and the exact location of the tip documented in the
medical notes, unless a tip location device e.g. Sherlock 3CG has been used to verify tip
location (when a CXR not required).
4. DOCUMENTATION
4.1 Required information
The following information must be recorded in the patient’s medical notes:
The name and designation of the operator
The type of CVAD, brand name and batch no
A description of the insertion technique
The use of imaging
Confirmation of the position of the catheter tip (NCEPOD 2010)
A care plan (specific to the device inserted) should be initiated.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 6 of 19
4.2 CVAD database
All CVADs inserted within the Trust must be entered into the central database on the
computer using ICIP (Clinical Information System) in order to ensure audit data is
collected.
5. CARE AND MANAGEMENT OF CVAD
Nurses undertaking the care and management of a CVAD must have completed the IV
workbook and undergone supervised practice in the practical aspects of care.
Paediatric nursing staff will need to adhere to the local training requirements alongside
attending the paediatric oncology education and skills 2 day foundations programme
provided at The Royal Marsden to comply with national peer review guidance. This will
include a competency domain in CVAD care.
A film aimed at patients and carers on care of a PICC (flushing and dressing), and
deaccessing a port can be found on The Royal Marsden website and can be used by
nurses as an aide memoir.
Where patients have a variety of intravenous devices in situ it is recommended that each
device is clearly labelled e.g. PICC, cannula. If other routes are used as well e.g. arterial,
PEG then these should be clearly labelled to avoid confusion when administering
medications or feeds.
Hands must be decontaminated before and after each patient contact. Use correct hand
hygiene procedure.
5.1 Catheter site inspection
There should be regular observation of the site for signs of infection or any other
complication, at least daily and documented.
5.2 Catheter access
Use aseptic technique and swab ports or hub with 2% chlorhexidine gluconate in 70%
isopropyl alcohol prior to accessing the CVAD for administering fluids or medications or
withdrawing blood (see Manual chapter 10). Needlefree injection caps must be changed
weekly. Port needles must be changed every 7 days.
5.3 Cleaning site
All catheter insertion sites should be cleaned at least weekly with 2% chlorhexidine in
alcohol. Ports should be cleaned with 2% chlorhexidine in alcohol prior to accessing (DH
2008).
5.4 Securement and dressings
PICCs are secured using a SecurAcath
©
securing device which is attached at
insertion and does not require replacement whilst PICC is in situ. If a Statlock
dressing is used it will need to be changed as required usually weekly.
Non cuffed catheters are secured with sutures which are not removed until the
catheter is removed.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 7 of 19
Skin tunnelled catheters are secured with sutures. The top skin suture will be
removed after 1 week and the exit site sutures will be removed after 3-4 weeks.
Where possible loop the catheter under the dressing to prevent pulling.
LTS catheter - no top suture, exit sutures to be removed after 4 weeks
Port insertion site has absorbable skin sutures.
PICCs and non cuffed CVCs should be dressed with a sterile, transparent, semi-
permeable dressing to allow observation of insertion site - Opsite IV 3000. This dressing
should also be used when a port has been accessed. In the case of an allergy to Opsite IV
3000, cavilon should be applied or the dressing changed to Tegaderm IV.
The dressing must be intact and not lifting (DH 2008). The dressing must be labelled to
indicate the date it was changed (date labels are available on the side panels of the Opsite
IV 3000 dressing).
5.5 Patency
5.5.1 Indications
a) To maintain patency of an intravenous pathway, without the use of a continuous
infusion, when intermittent administration of medications of therapy is prescribed
or may be required urgently.
b) To maintain patency of an indwelling vascular access device, over a period of
weeks or months for intermittent treatment or supportive therapy.
5.5.2 Procedure
Refer to The Royal Marsden Manual of Clinical Nursing Procedures (2015) 9
th
edition, chapter 14.
a) Flush catheter with Sodium chloride 0.9% (in a 10ml or larger syringe) to confirm
patency.
b) Inject medication/commence infusion as prescribed.
c) Flush with Sodium chloride 0.9%, 5-10mls to ensure patient received all
prescribed medication.
d) Flush catheter (see below for solution and frequency) using the push - pause
method (injecting 1ml at a time to create turbulent flow) with the designated
flushing solution (see below) through the needleless injection cap to fill the
catheter dead space with the correct volume and solution in order to maintain
patency.
e) Finish using the positive pressure technique, that is, maintain pressure on
the syringe plunger whilst disconnecting the syringe from the needleless
injection cap. Do not clamp catheter until after syringe has been disconnected.
f) If any device becomes sluggish or there are problems when using 0.9% sodium
chloride then change to heparinised saline after each use or instil urokinase
overnight (see Manual chapter 14).
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 8 of 19
5.5.3 Flushing solutions and frequency as per CVAD type
a) PICC
Inpatient
Flush with 10ml 0.9% sodium chloride after each use with medications and 20ml 0.9%
sodium chloride after blood sampling. Flush all lumens each time and at least once a week
even if not used.
Outpatient
Flush with 10ml 0.9% sodium chloride once a week using a 10ml syringe. Flush all lumens
even if not used.
b) Skin tunnelled catheters
Inpatient
Flush with 10ml 0.9% sodium chloride after each use unless used less than 3 times a day
– then use 5ml Heparinised saline (50 international units Heparin in 5ml 0.9% sodium
chloride) after each use.
Outpatient
Flush with Heparinised saline (50 international units Heparin in 5ml 0.9% sodium chloride)
once a week using a 10ml syringe.
c) Short term non cuffed CVC
Inpatient
Flush with 10mls 0.9% Sodium Chloride after each use.
d) Implanted ports (always use a 10ml syringe or larger for all administration)
Inpatient
Flush with 10ml 0.9% sodium chloride after each use unless used less than 3 times a day
– then use 5ml Heparinised saline (50 international units Heparin in 5ml 0.9% sodium
chloride) after each use.
Outpatient
Flush with 5ml Heparinised saline (500 international units Heparin in 5ml 0.9% sodium
chloride) once every 8 weeks (draw up total of 6ml as 1ml left in extension set). The
exception to this is for shared care of paediatric patients where it remains monthly in line
with shared care guidelines.
e) Long term silicone (LTS) tunnelled CVC (mainly used in Haematology only)
It must be flushed with 10mls 0.9% sodium chloride followed by an intraluminal dose
(volume of each lumen) of strong heparin solution (1000 international units/ml) in each
lumen. The intraluminal dose can vary dependent on the type of CVC but currently this is
1.3ml per lumen. Intraluminal doses MUST be discarded each time prior to using the
catheter.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 9 of 19
5.6 Blood sampling
5.6.1 Blood sampling from a central venous access device (CVAD) is a procedure that is
frequently performed by nurses. It reduces the number of peripheral venepunctures
that a patient may require.
5.6.2 The procedure has been devised to provide nursing staff with the safest method of
obtaining blood samples from a CVAD. Blood sampling from a CVAD MUST always
be performed using a vacuum adaptor system e.g. Vacutainer. The ONLY
exception is if blood cannot be obtained using the vacuum system - then a syringe
may be used. Where possible, the sampling should be carried out via a needleless
injection cap in order to maintain a closed system and prevent contamination of
practitioner with blood. Refer to The Royal Marsden Manual of Clinical Procedures
(2015), 9
th
Edition, chapter 10).
5.6.3 Flush with at least 20ml 0.9% sodium chloride after blood sampling.
5.7 Administration set replacement
Administration sets should be labelled with a change date and changed immediately
following administration of blood, blood products, after 24 hours following parenteral
nutrition and every 96 hours if continuous fluids (see Infusion Administration Sets policy).
5.8 Restriction on use
No CVAD should be used for the injection of CT contrast by pump unless it has been
confirmed that the patient has a CT compatible device in situ. All implanted ports inserted
after 1
st
October 2011 in the Royal Marsden are CT compatible and these ports can be
identified by 3 palpation points on the septum and on CXR the letters CT are visible on the
port. Patients will receive written information highlighting the type of port they have in situ.
CT compatible PICCs are purple.
5.9 Removal
CVADs should be removed as soon as they are no longer required and the necessity
should be reviewed on a regular basis. Routine catheter replacement is not recommended
and the catheter should only be changed when clinically indicated (or within manufacturers
guidelines) (DH 2008).
Nurses can remove PICCs and non cuffed CVC (see the Royal Marsden Manual of
Clinical Nursing Procedures chapter 14, pages 902-903, 909-910). Nurses and doctors
may remove skin tunnelled catheters and LTS catheters using surgical technique (see the
Royal Marsden Manual of Clinical Nursing Procedures chapter 14, pages 912-914), if they
have received appropriate training. Implanted ports will be removed by surgeons,
anaesthetists or trained nurses. FBC and Coagulation screens are required to be taken
and checked prior to removal of non cuffed, cuffed CVCs and ports. Anticoagulants should
be reviewed in case they need to be stopped or reduced prior to removal.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 10 of 19
If the patient has a SecurAcath
©
, assess ease of removal using table in Appendix 3. If a
simple removal then remove as per instructions. If a difficult removal contact IV
Team/MDU for advice or follow the guidance in the table.
5.10 Discharge Planning
If the care of the CVAD is to be provided by community staff, the relevant documentation
must be completed and sent to the nurse prior to discharge. A checklist of all the
equipment sent home with the patient should also be completed, along with contact details
of who the community nurse should contact with any queries. Relevant equipment e.g.
dressings and flushing kit must be sent home with patient or CVAD safety pack for parents
and children. A discharge summary must be done and emailed or faxed to GP for all day
case PICC insertions (see Intravenous Therapy at Home Policy)
6. DETECTION AND MANAGEMENT OF COMPLICATIONS
6.1 Occlusion
Prevention of occlusion can be achieved by correct use of flushing solutions, frequency
and method and not allowing infusions to ‘run dry’. A PWO (persistent withdrawal
occlusion – when can inject in but cannot get blood return) may be resolved using push
lock protocol by bolus or infusion (see Appendix 4). Only 10ml syringes or larger should be
used.
If a total occlusion does occur - do not use heparin as this will not unblock an occluded
catheter. Urokinase (Syner KINASE) can be instilled to unblock the device using the 3 way
tap method (see Manual chapter 14 pages 872-874 for procedure). Never use small
syringes (under 10ml) as this causes damage to the catheter e.g. splitting.
6.2 Infection
If a patient develops a local site infection then a swab should be taken and the patients
commenced on antibiotics. If the patient has signs and symptoms of a systemic infection
and/or the patient has a rigor when flushing the CVAD then blood cultures should be taken
from both the CVAD (all lumens) and a peripheral sample. The patient can then be
commenced on antibiotics. The CVAD may need to be removed and the tip should be sent
to microbiology.
See section entitled Management of Vascular-Access Device (VAD) Infection in DTC
Antimicrobial Guidelines for details of antibiotics.
6.3 Thrombosis
If thrombosis occurs, it is recommended that the patient has an ultrasound to ascertain the
size and location of the thrombosis and then is commenced on anticoagulant therapy as
per DTC guidelines (see Appendix 5). If patients have any haematological conditions that
may have resulted in the thrombosis then refer to haematologist for guidance.
If the catheter is to be removed it should be 72 hours after commencing anticoagulants
(Pittaruti 2015). If a patient has a thrombosis but the catheter lumen is still patent then it
can be used for IV therapy. The exception to this would be if the thrombosis is occluding
the tip of the catheter.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 11 of 19
6.4 Others
6.4.1 Damage
If a skin tunnelled catheter becomes damaged then depending on where the damage
occurs it may be repaired e.g. catheters. Repairs can be carried out by those trained in
how to repair by Nurse Consultant IV Therapy (done on individual basis as required) –
contact Nurse Consultant IV Therapy or Minor Procedure Suite. Out of hours repair kits for
the current tunnelled catheters used by the Trust can be obtained in Bud Flanagan East or
Minor Procedure Suite. These contain instructions for use if repair required as an
emergency. PICCs must be replaced where appropriate over a guidewire.
6.4.2 Infiltration/Extravasation – see ‘Extravasation and Infiltration, Policy for the
Management of’.
7. MONITORING AND AUDIT
Audits of the following will be carried out:
CVAD complications
Synbiotix/Saving Lives High Impact Intervention care bundles
Adherence to policy (NCEPOD) (through annual IV audit)
Central venous catheter insertion and care are audited throughout the Trust using the DH
Saving Lives High Impact Interventions. Clinical areas inserting or accessing CVADs are
required to complete a minimum number of observations per month on the Trust’s
Synbiotix System which holds a central dashboard for clinical and quality indicators. This
system can be accessed directly from The Royal Marsden intranet main page, Trust
compliance information may be accessed without a password. For training and information
please contact the Infection Prevention and Control Team.
8. REFERENCES
Department of Health (2008) Clean Safe Care: Saving Lives
NCEPOD (2010) A mixed bag
Dougherty L & Gull, K (2015) Vascular Access Devices in The Royal Marsden Hospital
Manual of Clinical Nursing Procedures, 9
th
edition, Wiley Blackwell
Hughes, M (2014) reducing PICC migration and improving patient outcomes, BJN 23 (2)
S12-S18
NICE (2015a) NICE medical technology adoption support for the Sherlock 3CG Tip
Confirmation System for placement of peripherally inserted central catheters NICE,
London 25 March 2015.
NICE (2015b) The 3M Tegaderm CHG IV securement dressing for central venous and
arterial catheter insertion sites, NICE, London 22 July 2015. nice.org.uk/guidance/mtg25
NMC (2015) The Code, NMC London
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 12 of 19
Parienti, JJ et al (2015) Intravascular complications of central venous catheterisation by
insertion site, NEJM, 24
th
September
http://www.nejm.org/doi/full/10.1056/NEJMoa1500964
Pittiruti, M (2015) What the world needs now is an insertion bundle to prevent catheter
related thrombosis, presentation at Association of Vascular Access conference Dallas,
USA September 26 - 29
9. RELATED POLICIES
Non Royal Marsden Patients who require Care of a Vascular Access Device or
Administration of Medication
Extravasation and Infiltration, Policy for the Management of
Infusion Administration Sets
Intravenous Therapy at Home Policy
MRSA and MSSA Screening Policy
Parenteral Nutrition - Policy and Guidelines for Administration
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 13 of 19
Appendix 1
Central Venous access devices
Type of device
Material
Features
Common
insertion site
(veins)
Recommended
indwelling life and
common uses
Long term
silicone (LTS)
skin tunnelled
catheter
Polyurethane
Dual lumen
These are placed if
the patient is
undergoing
autologous transplant
and has unsuitable
veins for stem cell
harvest. The LTS is a
long-term catheter
which is cuffed and
can be used for
apheresis/dialysis and
transplantation
Peripherally
inserted central
catheters
Polyurethane
Silicone
Dual lumen
Single lumen
Valved
Antecubital
fossa
Basilic
Cephalic
Brachial
Used primarily for
patients requiring
several weeks or
months of intravenous
access
Short-term
percutaneous
central venous
catheters (non-
cuffed)
Polyurethane
Silicone
Heparin,
antibiotic and
antiseptic
coatings,
multiple lumen
(Up to 5 lumens)
Jugular
Subclavian
Femoral
Intended for days to
weeks of intravenous
access
Skin-tunnelled
catheters
Polyurethane
Silicone
Multiple lumen
(1-3 lumens)
Jugular
Axillary
Subclavian
Femoral
Indefinite. Used for
long-term intermittent,
continuous or daily
intravenous access.
May be appropriate for
short-term use if
reliable access
needed
Implanted ports
Catheter
Single or Dual
ports
Jugular
Indefinite. Used for
long-term
Silicone
CT compatible
Subclavian
Femoral
Intermittent,
continuous or daily
intravenous access
Port
Titanium
Plastic
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 14 of 19
Appendix 2
Performing procedure
Device
By whom
Where
Investigation
requirements prior
to elective
insertion and
removal
(* these may depend
on the diagnosis or
clinical condition of the
patient)
Contact for
booking
PICCs
Insertion:
Specifically
trained nurses
Anaesthetists
Removal:
Nurses
Bedside
MDU
MPS
Interventional
radiology
Recent Full Blood
Count (FBC)
MDU (both sites)
Minor procedure
suite
Non cuffed
Central venous
catheter
Insertion:
Specifically
trained nurses
Anaesthetists
Removal:
Nurses
Theatres
CCU
MPS
Interventional
radiology
FBC, coagulation
Long term
silicone (LTS)
skin tunnelled
Insertion:
Anaesthetists
Removal:
Anaesthetists
Theatres
FBC, coagulation*
Theatres
Skin tunnelled
catheters
Insertion:
Anaesthetists
Removal:
Specifically
trained nurses
Theatres
Interventional
radiology
FBC coagulation*
Ultrasound if had
previous CVADs
Theatres
Implanted ports
Insertion:
Specifically
trained nurses
Anaesthetists
Surgeons
Removal:
Specifically
trained nurses
Anaesthetists
Surgeons
Theatres
FBC coagulation*
ECG*
CVAD clinic,
or via individuals
such as
specifically trained
nurses
Anaesthetists or
Surgeons
Vascaths
Anaesthetists
CCU
Theatres
FBC coagulation*
Theatres
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 15 of 19
Appendix 3
Removal Flowchart
Adapted from Hughes (2014)
Follow the instructions for the routine removal of the PICC
with SecurAcath (www.interradmedical.com/removal) until the
PICC has been removed and the lower part of the SecurAcath
is the only item left in situ.
Assess the amount of pain at the exit site by moving the
lower portion of the device slightly:
Is there acute pain?
YES
NO
YES
Remove the SecurAcath by:
a) pinching the 2 sides of the
device together until they meet
and pulling with a swift pluck
OR
b) Cutting the device in half with
sterile scissors and removing
each nitinol anchor separately
with a swift pluck
Observe the skin close to
the SecurAcath pins. Is
the skin overlapping the
pins
Administer a small amount of
the lidocaine 1% around the
exit site with a small 25g
needle. Can be prescribed or
administered under PGD.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 16 of 19
Appendix 4
RM Protocol for Resolving Patency Problems with Central Venous Access Devices
Patency problems are common in CVADs and include:
Poor or no blood return
Sluggish flow
Complete occlusion
Possible causes:
Clotted blood in the catheter (most likely cause)
Fibrin sheath
Malpositioned catheter
Drug precipitation
Build-up of lipids (parenteral nutrition)
Prevention:
a) Flush catheter using the push - pause method (injecting 1ml at a time to create
turbulent flow) with the designated flushing solution through the needleless injection cap
to fill the catheter dead space with the correct volume and solution in order to maintain
patency.
b) Finish using the positive pressure technique, that is, maintain pressure on the syringe
plunger whilst disconnecting the syringe from the needleless injection cap. Do not clamp
catheter until after syringe has been disconnected.
Initial Management:
Poor or no blood return
Ask the patient to take deep breaths and try different positions. Flush briskly using 10mls
0.9% sodium chloride. If this fails consider use of a thrombolytic (see below)
If lipids/drug precipitation suspected consult pharmacy advice for suitable agent to dissolve
occlusion
Catheter flow is sluggish
Ask the patient to take deep breaths and try different positions. Flush briskly with 10mls
0.9% sodium chloride. If this fails consider use of a thrombolytic (see below)
If lipids/drug precipitation suspected consult pharmacy advice for suitable agent to dissolve
occlusion
Catheter is completed occluded
Use a 3-way tap technique to instil thrombolytic into catheter (see below).
What is a thrombolytic?
A thrombolytic is a drug capable of breaking up a thrombus. Syner KINASE reconstituted in 0.9%
sodium chloride is the thrombolytic used for unblocking CVADs. Heparin and Heparinised saline
are NOT thrombolytics. Syner KINASE has a half-life of 20 minutes.
DO NOT EXCEED 25000 international units per lumen.
What if the thrombolytic fails to restore function?
If a thrombolytic fails to restore function, contact the IV Team / MDU, Matron Day Services or
Nurse Consultant IV Therapy.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 17 of 19
A chest x-ray may need to be carried out to check the tip position of the CVAD. If a chest x-ray
shows that the catheter is correctly placed, it may be worth considering fluoroscopy which may
reveal a fibrin sheath.
How to use a thrombolytic for Persistent Withdrawal Occlusion (PWO)
Push Lock Protocol
Bolus for PWO:-
Priming volumes:
PICC = 0.5ml
Skin tunnelled Catheter = 1ml
Port = 3ml
1. Reconstitute
Reconstitute Syner KINASE 10 000 units with the priming volume of the CVAD plus an
additional 1.5ml of 0.9% NaCl.
2. 1
st
Lock
Inject the priming volume + 0.5ml into the CVAD.
‘Lock’ the solution into the CVAD and leave the syringe attached to the lumen.
Wait 10 minutes
3. 2
nd
Lock
Inject another 0.5mls of solution and lock again
Wait 10 minutes
4. 3
rd
Lock
Inject another 0.5mls of solution and lock again
Wait 10 minutes
5. Aspirate
Aspirate CVAD lumen and flush with 0.9% sodium chloride to establish flow. If it cannot be
aspirated it is safe to flush into patient.
If unblocking a dual lumen catheter then inject 10 000 international units down each lumen.
For a total occlusion:-
Instil using the above protocol via a 3 way tap. See page 872-874 in the Royal Marsden Manual
(2015) for procedure.
If unsuccessful:
If unsuccessful using 10 000 international units for either PWO or total occlusion then consider
escalating dose and repeat the Syner KINASE push protocol using 25 000 international units. This
will need to be prescribed and not administered under a PGD.
If not required the same day then don’t aspirate and leave Syner KINASE in for several hours or
overnight if possible. Then if still unsuccessful then move to infusion or for ‘repeat offenders’ where
patients have a PWO that requires regular Syner KINASE administration to obtain blood samples
and/or verification of a functioning CVAD, where a prophylactic infusion of 25 000 international
units would resolve this problem.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 18 of 19
Syner KINASE Infusion Protocol
Syner KINASE infusion is contraindicated in patients with:
Active GI bleeding or a bleed in the last month
Haemorrhagic stroke or any other cerebrovascular accident in the last month
Major surgery or trauma in the last two weeks
Coagulation defects
Known Urokinase allergy
Hypertension
Syner KINASE infusion should be used with caution in patients receiving antiangiogenic
medication e.g. Bevacizumab.
Procedure:
Take a blood sample from the patient and check FBC to ensure platelets are >100 and Clotting
Screen to ensure that clotting parameters are within the therapeutic range. Take baseline
observations (Pulse and Blood pressure).
The infusion will need to be prescribed and not administered under a PGD.
Reconstitute Syner KINASE 25 000 international units (in 2ml of 0.9% sodium chloride) and add to
50ml bag of 0.9% Sodium chloride. Connect an administration set to the affected lumen of the
catheter and set it to infusion over 100 minutes. This is only required to be administered via one
lumen.
Check the patients pulse and blood pressure every 20 minutes during infusion. Check for any signs
of bleeding from the catheter exit site. If bleeding is present, stop the infusion and discuss with
senior medical staff.
On completion of the infusion, attempt to aspirate from the CVAD. If a PWO is still an issue then
discuss with Nurse Consultant IV Therapy.
If the CVAD is totally occluded then use 3-way tap protocol. If remains totally occluded then
the CVAD will need to be removed and replaced.
Central Venous Access Devices (CVAD) - Policy for
Insertion and Care in Hospital
Royal Marsden NHS Foundation Trust Policy (1748 )
Authoring Department:
Nursing
Version Number:
9
Author Title:
Nurse Consultant, Intravenous Therapy
Published Date:
15/12/2016 14:14:57
Ratified By:
VAD Committee; CGPC
Review Date:
15/12/2017 14:14:57
Uncontrolled if printed
Page 19 of 19
Appendix 5
Algorithm for managing CVAD related thrombosis
[End of Document - Do Not Delete]
Catheter-related
thrombosis
diagnosed by
ultrasound and/or
clinical condition
CVAD not
needed
High risk of
embolisation
Heparin or
LMWH for 3-5
days then
remove CVAD
Heparin or LMWH for
6 weeks to 6 months
Remove
CVAD
Adults: Heparin or LMWH for 6
weeks to 6 months
Low risk of
embolisation
CVAD
needed
Is thrombosis
life or limb
threatening?
LMWH at
therapeutic
dose while
CVAD in
situ
LMWH at
prophylactic dose for
3-6 months after
CVAD removal
YES
Remove
CVAD
NO
Leave CVAD
in situ
Paediatrics: Heparin or LMWH for
3-6 months