Central venous access device

Insertion of a central venous access device (CVAD) is a common hospital procedure with an estimated 15,000 devices inserted in NSW Intensive Care Units every year.

Despite being a common procedure it is not one without significant risks which include risks in the insertion of the devices and those associated with having a CVAD in situ either short or long term. These risks can include infection, malposition, pneumothorax, thrombosis, vascular injury and air embolus.


Read the Central Venous Access Device Post Insertion Management guideline.

In addition to recommendations for clinical practice the full guideline includes a description of all guideline development processes (1).

CVAD Guideline

Resources

Overview

The purpose of this guideline is to provide intensive care clinicians with best practice recommendations so that the evidence-based treatment and care can be delivered and patients can receive the therapy they need.

For the purposes of this document a CVAD refers to a temporary intravascular catheter for infusing drugs, fluids and delivering nutrition. In addition, CVADs are also used for taking blood samples, haemodynamic monitoring and for renal replacement therapies. It includes central venous catheters (CVC) and peripherally inserted central catheters (PICC). For the purposes of this guideline long-term devices (e.g. tunnelled and implantable ports) are excluded.

This guideline has been developed for clinicians practising in NSW Intensive Care Units (ICUs). This review was undertaken by a representative group (Guideline Development Network or GDN) of NSW clinicians with expertise in ICUs and/or CVAD management as part of a joint project between the NSW Intensive Care Coordination and Monitoring Unit (ICCMU) and the Nursing and Midwifery Office (NAMO). The GDN sought to answer the question:

“What nursing interventions can reduce the risk of device failure (i.e. bacteraemia/bloodstream infection, local infection, blockage, accidental removal or dislodgement, thrombosis, phlebitis) and reduce costs while improving satisfaction for patients with a CVAD?”

To answer these questions 45 randomised controlled trials or systematic reviews and 14 guideline documents were reviewed. Additionally, a number of clinicians were surveyed. As a result 50 recommendations for practice were generated and these recommendations have been classified into Assessment; Interventions; Infection prevention and Governance as set out in the Recommendations for Practice table.

Recommendations for Practice

Section Recommendation statement Grading
Assessment
1.

The nurse must systematically assess the CVAD each shift covering the following elements:

  1. dressing
  2. securement
  3. integrity of CVAD
  4. labelling of administration sets and infusion therapies.

The findings must be documented in the clinical record.

Consensus
Interventions: Securement
2. Appropriate securement techniques include suturing of the CVAD with monofilament non-graded nylon or the use of sutureless securement devices (2-4). 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 (4). 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
Interventions: Antiseptic solution and cleaning of skin and catheter
8.
  • Single use 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is the preferred antiseptic agent for insertion and dressing of CVADs (5-7).
  • If this is not available, chlorhexidine 0.5% in 70% alcohol or iodine in alcohol should be used (8-13).
  • Solutions must not be decanted into smaller containers and unused portions must be discarded.
  • Where a patient demonstrates chlorhexidine sensitivity, topical povidone iodine 10% in 70% alcohol may be used.
NSW Policy
9. Avoid organic solvents (e.g. acetone, ether or adhesive remover wipes) on the CVC or surrounding skin (13, 14). Grade B
10. Prior to cleaning with chlorhexidine in alcohol, Sterile 0.9% saline is to be used to remove dried blood and/or other fluids from around the catheter and under the securement hub. Consensus
Interventions: Dressing of CVAD and insertion site
11. A sterile transparent semi-permeable dressing or sterile gauze and hypoallergenic tape must be used to cover the CVC insertion site. An alternative dressing must be used if allergy is suspected (13, 15) (PD2010_036). Grade B
12.

Regardless of the dressing type used for the CVAD , the dressing should:

  1. be positioned so the catheter insertion site is in the centre of the dressing
  2. cover the catheter from the insertion site and the first securement
  3. create a complete seal from the securement through to the insertion site.
Consensus
13.

Transparent dressings must be changed every seven days or sooner if (13, 16-19):

  1. the dressing is not intact (i.e. there is no longer a seal)
  2. there is evidence of inflammation
  3. there is excessive accumulation of blood and/or moisture under the dressing.
Grade A
14.

Sterile gauze and hypoallergenic tape dressing is preferable to a transparent dressing if the patient is diaphoretic or if the site is bleeding or oozing (13, 20).

  • If a patient is oozing post insertion (e.g. thrombocytopaenic), use a sterile gauze square on top of the insertion site and cover with semi-permeable dressing.
  • Consider use of a calcium alginate fibre dressing to achieve haemostasis if oozing is problematic.
Consensus
15. Sterile gauze and hypoallergenic tape dressing should be changed every 48 hours and whenever loose, soiled or moist. Grade B
16. A chlorhexidine impregnated sponge must be placed around the catheter at the insertion site after insertion. It should be replaced at each dressing change (21-26). Grade A
Interventions: Fluid and drug administration
17. Ensure drugs are compatible when administering multiple intravenous medications via the CVAD lumen. Refer to drug resources such as Micromedex or the institutional pharmacist. Consensus
18. Crystalloid solutions without drug additives (e.g. 0.9% saline) should only be changed when the administration set is changed, when the catheter is changed and or when the infusion is complete. Consensus
19. All blood products should be infused as per the National Blood Authority Australia Patient Blood Management Guidelines. National Guidelines
Interventions: Accessing connectors
20. Catheter hubs (including needleless injection sites and blood sampling ports) must be vigorously cleaned with antiseptic swabs (containing no less than 0.5% chlorhexidine with alcohol, 70% alcohol, or if allergic 10% povidone-iodine) before and after use to ensure removal of microorganisms and particulate matter. The solution must be allowed to dry naturally prior to accessing the device i.e. scrub the hub (13,51). Grade A
21. When an unused lumen is accessed to administer a medication or commence an infusion, a small volume of blood should be gently aspirated and discarded and the lumen flushed with 10mL 0.9% saline prior to medication administration or fluid commencement (27). Consensus
Interventions: Intravenous administration sets
22.

Intravenous administration sets attached to a CVAD must be attached to the patient so that no tension is applied to the catheter  to reduce risk of dislodgement.


Consensus
23. Administration sets (burettes, administration sets, multi-flow adapters, caps, connectors, extension devices) that are attached to antimicrobial or antibiotic-coated multi-lumen CVAD should be changed either after seven days or when clinically indicated (e.g. precipitate, particulate matter, blood in administration set, faulty set), or when the catheter is changed (28). This excludes blood products and lipids. Grade B
24. Administration sets (burettes, infusion sets, multi-flow adapters, caps, connectors, extension devices) attached to standard CVADs should be changed either after 96 hours, or when clinically indicated (e.g. precipitate, particulate matter or blood in apparent in the administration set or the set is faulty), or when the catheter is changed. This excludes blood products and lipids (13, 29-31). Grade B
25. Administration sets for lipid-based emulsions should be changed within 24 hours of starting the infusion or as recommended by the manufacturer. Grade A
Interventions: Adjuncts to IV administration sets
26. Needleless connectors that can be disinfected or decontaminated are to be placed on each lumen of a CVAD (27, 32-37). Grade A
27. Multi-flow adaptors and three-way taps and connectors are to be changed when the administration set is changed (27). Consensus
28. Clamps should be engaged (when in situ) on the device’s lumen when disconnecting the administration set from the lumen. This is to prevent complications such as air embolus, bleeding or inadvertent drug or fluid bolus administration. Consensus
29. Avoid administration set disconnections. If an administration set is disconnected it must be discarded and a new set used.        Consensus
Interventions: Maintenance of lumen integrity
30. How frequently a CVAD lumen should be flushed to maintain lumen patency remains unclear. It is suggested that a CVAD lumen that is used intermittently should be flushed no more frequently than every eight hours.  Consensus
31. The recommended solution for flushing a CVAD lumen is 0.9% saline (38-42). Grade B
32. To reduce the risk of thrombosis and intraluminal occlusion in large bore catheter lumens (e.g. dialysis catheters), an anticoagulant lock may be used when the lumen is not in use (39, 40, 43). Consensus
33. Unused lumens are to be managed to prevent air emboli and backflow of blood, protein or lipid solutions depending on the connector used. Refer to Table 4. Consensus
34. It is recommended that syringes with a capacity of ≥ 10mL be used to access a CVAD for flushing. Smaller syringes exert higher pressure and may cause possible catheter rupture or dislodged an occlusion if excessive force is used. Consensus
35. When flushing a CVAD lumen use a pulsatile positive pressure flushing technique to create turbulence within the device lumen. Grade B
36. If attempting to flush a CVAD lumen due to a blockage, force should never be used because of the risk of catheter rupture. Consensus
37. Use of a solution other than 0.9% saline to unblock a CVAD lumen has been shown to be effective in restoring lumen patency. Use of agents such as urokinase and alteplase require a medical prescription and must be discussed with the Medical Officer or a Vascular Access specialist/team before use (44, 45). Grade B
Interventions: Removal
38. When removing a CVAD the patient MUST be placed in bed in a supine position (6). Prior to repositioning the patient following removal of a CVAD , ensure the dressing is airtight and occlusive. Consensus
39. Removal of a CVAD should be timed to occur at end inspiration or during expiration for patients who are not on a ventilator. Consensus
40. Following CVAD removal pressure must be applied with sterile gauze until haemostasis is achieved. The insertion site must be sealed immediately using an airtight occlusive dressing. This dressing is to remain intact and insitu for 48 hours to reduce the risk of late air embolism. Consensus
41. Routine collection of the CVAD tip is not required when removing the device. If a catheter-related bloodstream infection is suspected the medical team may request that the tip is sent for microbiological examination and a blood culture collected from a peripheral vein within 4 hours of CVAD removal (46). Consensus
42.

Removal of the CVAD must be documented in the clinical record.
The documentation must include:

  • visual inspection and description of the integrity of the CVAD
  • whether the CVAD tip was collected and sent to pathology
  • the condition of the CVAD insertion site.
NSW Policy
43. Following removal of a CVAD the condition of the site must be monitored at 24 and 48 hours at a minimum. This must be documented in the clinical record. Consensus
Infection prevention
44. Clinicians must adhere to the Five Moments of Hand Hygiene. Hand hygiene policy
45. Clinicians are to evaluate the risk of body fluid exposure and cross contamination risk when caring for a patient with a CVAD . PPE , including goggles/face shield, gloves and gown/apron as per the NSW 2007 Infection prevention and control policy, should be worn accordingly. National Guidelines and NSW Policy
46. Aseptic non-touch technique must be used when attending to CVAD dressings, administration set changes and any intervention that involves accessing the CVAD (13, 47, 48). Grade A
Governance
47. CVAD management is provided by nursing staff that are proficient in this activity and/or by nursing staff under the direct supervision of nursing staff that are proficient as per institutional policy (13, 27, 49). Consensus
48. To prevent errors or breaches of asepsis, administration set and dressing changes should be performed when the clinician is unlikely to be interrupted. Consensus
49. Infusions on each lumen of the CVAD are to be labelled as per the National Standard for User-applied Labelling of Injectable Medicines, Fluids and Lines. National Guidelines and NSW Policy
50.

Evaluation of patient outcomes in relation to device failure include:

  1. surveillance of catheter-related bloodstream infection
  2. unintended removal and other complications as reported in the institutional incident management system
  3. audits of clinical practice.
National Guidelines and NSW Policy

Grades 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 (50)

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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. ICCMU 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.