Transcript Slide 1

CVAD Management
Training
Royal Children’s Hospital
Melbourne, Australia
Contents
Introduction
Selecting the right technique
Procedures
• Changing smartsites
• Changing dressings
• Accessing infusaports
Daily line review
Summary
Preventing CVAD infections
• In part one of this package we showed that
CVAD infections can cause expense, harm and
sometimes death
• At RCH we are aiming to reduce our infection
rate to below 1 per 1,000 line days in all areas of
the hospital
• What is the infection rate in your area? Is it
below the target?
CVAD management
Choosing the right
technique
Which technique should I use?
• Low risk procedures
• Non-touch:
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Administering
medicines
Taking bloods
Flushing line
Changing IV bags/
syringes
Priming, connecting/
disconnecting IV lines
to smartsite
• High risk procedures
• Sterile technique:
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Changing caps or
Smartsites
Changing CVAD
dressings
Accessing an
infusaport
Or put another way:
• Non-touch procedures are used when
connecting to a smartsite or changing IV bags or
syringes
• Sterile procedures are used when the patient’s
lumen is open or the site of CVAD entry to the
skin is exposed
• Note: This section demonstrates ‘sterile’
procedures using sterile pack and gloves
Smartsite change
• Smartsites should be changed
every 6 days
• Sterile technique can be performed
by 1 or 2 operators
• 1 operator technique can be
performed if operator is competent
and confident in performing the
procedure on their own
• Wipe trolley/bench thoroughly with alcohol
• With clean hands, gather equipment
• With clean hands, open equipment on trolley
• Perform hand hygiene and put sterile gloves on
• Draw saline with a needle
• Prime the smartsite
• Always discard used equipment away from sterile field
• Clean connection thoroughly, 3cm on both sides of connection
moving away from connection site
• Then around the connection site
• Allow to air dry for 20 seconds
• 2 person procedure: the helper will clamp the catheter
• 1 person procedure: operator to clamp the catheter
• The operator to disconnect old smartsite and discard away
from sterile field
• If any substance visible on exposed lumen, clean using new
gauze
• Connect new smartsite
• Unclamp the catheter:
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2 person procedure: helper to unclamp the catheter
1 person procedure: operator to unclamp the catheter
• Flush and withdraw to check for blood and flush again to clear
the line using a pulsatile action (if disconnecting, use heparin
and clamp with positive pressure)
• Remove syringe and discard
Dressing change
• Dressings should be changed
every 6 days
• Sterile technique can be
performed by 1 or 2 operators
• 1 operator technique can be
performed if operator is competent
and confident in performing the
procedure on their own
• Remove dressing:
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2 people: the helper removes dressing with non sterile gloves
1 person: remove dressing and discard from sterile field. Perform
hand hygiene and don new sterile gloves
• Clean site with 0.5% chlorhexidine and 70% alcohol in a circular
motion, extending out around 5-10 cm diameter three times
• allow to air dry
• Clean down the lines away from the patient
• Allow to air dry
• Apply dressing either flat or as a sandwich
• In some cases eg. allergy, an alternative dressing may be
required, determined on an individual patient basis
Accessing an infusaport
• Ports need to be accessed
using a sterile technique
• Port needles should be
changed every 6 days
• This procedure can be
traumatic and uncomfortable,
so prepare patient carefully
• Apply local anaesthetic
cream prior to procedure
• Wipe trolley/bench thoroughly with alcohol
• With clean hands, gather equipment
• Open equipment on trolley
• Choose needle gauge according to patient size
• Perform hand hygiene and put sterile gloves on
• Draw saline with a needle
• Prime huber needle
• Prepare set up before bringing patient into room as this
decreases stress of patient
• Remove emla or angel cream
• Wash hands or alco-gel and don sterile gloves
• Clean using chlorhex & alcohol, in a circular motion from
centre of port ,extending out 5-10 cm diameter three times
• Allow to air dry
• Find the edges of the port
• Hold edges between thumb and index finger
• Press the needle through the skin using gentle, but steady
pressure until the needle touches the bottom of the port
• Gently flush port and withdraw to check for blood then flush
again to clear line
• Insert folded gauze under needle for support
• Apply Steristrips to secure needle
• Apply transparent dressing
• Anchor line with tape and safety pin to clothing
Daily Line Review
• CVADs often remain in longer
than required for treatment simply
because removal has not been
considered, or are kept ‘just in
case’
• The longer a CVAD remains
insitu, the greater the infection risk
Daily Line Review
• To prevent delays in removing unnecessary lines
• Multidisciplinary team must review line daily
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Questions to ask
• How long has the line been in for?
• Is central access necessary?
• Are there alternative methods for access/treatment
CVADs no longer required for patient care should be
removed immediately
Daily line review
• Each day, the following should be documented
on the CVAD observation chart MR114:
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Number of days the line has been in for
Reason for access
Whether the line is still required
Adverse Events
• Accidental disconnection
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Immediately clamp catheter/line between leak and
patient
Using aseptic technique, clean patient side connection
Withdraw air (if present) and check for blood return
Flush with normal saline
Prime new lines and continue infusion
Notify RMO to assess patient if required prior to
continuing infusion
• Blocked lines
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Refer to Anticoagulation Therapy Guidelines
Adverse Events
• Suspected infection
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Observe every shift for early signs of infection (record
on MR114)
Notify RMO to assess patient if required
Superficial infection
• Swab site and smear glass slide for microscopy
prior to placing swab in charcoal medium
• Send specimens to bacteriology
Systemic infection
• If temperature 38°C, take blood cultures from
peripheral and central lines
• Samples should be taken from all lumens and these
clearly labeled
Documentation
• MR114 (CVAD Observation Chart)
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Insertion
Dressing
Adverse Events / Variances
• MR52 (Medication Chart)
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Heparin locks
Summary
Summary
• CVAD infections can be a source of harm and
sometimes death, but they can be prevented
• Disinfecting hands effectively before all line
interventions will reduce CVAD related sepsis
Summary
• Use sterile technique for high risk procedures
• Review CVAD’s daily, if they are not needed,
remove without delay
• If in doubt – ask a senior member of staff