Securement of CVAD

Section Recommendation statement Grading of recommendations
2. Appropriate securement techniques include suturing of the CVAD with monofilament non-graded nylon or the use of sutureless securement devices (1-3). Grade B
3. The CVAD must be secured at the insertion site and also at the anchor point (if present). Consensus
4. The securement of the CVAD must be assessed at least once per shift and more frequently if required. Consensus
5. Sutureless securement devices should be changed when the dressing is changed or if loose or soiled. Consensus
6. Peripherally Inserted Central Catheters (PICC) are to be secured by sutureless fixation devices (3). Grade B
7. The weight of administration sets must be supported with additional fixation to reduce the risk of unplanned dislodgement of the CVAD. Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Securement of the CVAD is important to safely provide intravenous therapies to patients. Securement prevents migration of the catheter in or out of the entry site, which in turn reduces infective and thrombotic risk, and ensures that therapy is delivered into the venous circulation. It is important that the weight of multiple infusions is supported so that tension is not applied to the catheter and insertion site. In a review of the NSW CVAD ICU data the most common complication associated with CVADs was unplanned removal, which accounted for 23% of incidents.

The GDN found this data surprising and unacceptable. Inadequate fixation by suture or fixation device was often identified as the major contributing factor. Practice is clearly variable among specialties as the issue was not limited to devices inserted in the ICU. Other than fixation concerns, factors influencing unplanned removal included patient transfer or movement, patient confusion or aggression and limited supervision due to staff shortage or multiple patient allocations. The GDN considered sutureless fixation devices preferable in practice due to the invasive nature and added infection risk of sutures, however, current practice and evidence suggests that either sutures or sutureless fixation devices are acceptable.

In a small randomised controlled trial (RCT), sutureless fixation devices were compared to suturing of cuffed tunnelled dialysis catheters with low complication rate of 8.3% versus 13.9% in the control group (2). In another RCT of suturing versus sutureless fixation device there were fewer complications (42 vs. 61) with less  infections and reduced risk to staff from needle stick injury (3) in the intervention group, but this was not statistically significant. Tape alone is insufficient for catheter securement. Graf (1) compared tape and sutures in the paediatric population. The tape intervention group had a significantly higher complication rate (5.8% vs. 32.4%) mostly due to catheter migration, thrombosis and leakage.

Securement techniques vary (see Figure 1) and NSW Health Central Venous Access Device Insertion and Post Insertion Care PD 2011_060 sets out the requirement that:

“The CVAD must be secured at the skin insertion point by catheter clamp or direct suturing and at the anchor point (if present) by suture or sutureless fixation device (to prevent catheter migration).”

Figure 1: Securement of CVADs

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Grading of recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (4)

References

  1. Graf JM, Newman CD, McPherson ML. Sutured securement of peripherally inserted central catheters yields fewer complications in pediatric patients. Jpen: Journal of Parenteral & Enteral Nutrition. 2006;30(6):532-5. PubMed PMID: 17047181.
  2. Teichgraber UK-M, de Bucourt M, Gebauer B, Streitparth F, Hamm B, Enzweiler C. Effectiveness of sutureless percutaneous placement of cuffed tunneled hemodialysis catheters applying StatLock attachment devices. Journal of Vascular Access. 2011;12(1):17-20. PubMed PMID: 21140360.
  3. Yamamoto AJ, Solomon JA, Soulen MC, Tang J, Parkinson K, Lin R, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. Journal of Vascular & Interventional Radiology. 2002;13(1):77-81. PubMed PMID: 11788698.
  4. Hillier S, Grimmer-Somers K, Merlin T, Middleton P, Salisbury J, Tooher R, et al. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology. 2011;11:23. PubMed PMID: 21356039.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.