VALARMATHI KARUNANITHI

CENTRAL VENOUS CARE

PERSONAL PROTECTIVE EQUIPMENT (PPE)

The clinician inserting the CVAD and assistant/supervisor (if they are entering the sterile
field)
must use the following personal protective equipment –
surgical mask, (head and facial hair cover), eye protection, sterile gown and sterile gloves
The following order for donning PPE must be followed:
• routine hand hygiene
• don hat
• don surgical mask and eye protection
 procedural hand hygiene
• don sterile gown
• don gloves

Aseptic technique must include:

• Two minute hand hygiene
• Full sterile gown and sterile gloves, and surgical mask/hat/eye protection
• Meticulous skin preparation with an antiseptic solution, preferably alcoholic chlorhexidine
(unless contraindicated e.g., flammability issues, children under 2 months of age, allergy)
and allowing it to dry before insertion. See Appendix 4 – Antiseptic solutions for a list of
approved solutions
• Sterile drape/s fully covering the patient and their bed (unless this is impractical).
• Hair at the insertion site, which would interfere with the sterile field or adherence of the
dressing, should be removed using clippers. Shaving is not recommended.
• Equipment to be used in placing a CVAD should be opened as close to the time of line
insertion as practical.
MANAGEMENT
Use an aseptic technique whenever the CVC is accessed and during procedures involving exit
sites to prevent infection. A strong correlation exists between bacteraemia and the presence of
a CVC. Wear sterile gloves when carrying out dressing changes and when accessing the
catheter. Gloves should be worn to prevent de-scaling of bacteria onto key parts. Monitor
temperature, pulse, blood pressure, respiratory rate and oxygen saturations at least a
minimum of 12 hourly to detect infection. Do not allow air to enter the catheter. All syringes
and intravenous administration sets must be carefully primed to prevent air embolism. The
negative pressure within the chest may suck air into the catheter during inspiration especially
if the patient is sitting up. Cap off the catheter with a needle-free access device when not in
use (except Neonates). This will minimise interruptions to the closed system. Unless
manufacturer’s instructions vary, this should be changed every 7 days or every 200 uses,
whichever is the sooner. In adult inpatients with long-term vascular access devices the bungs
should be changed on a set day (e.g. Sunday) to ensure continuity within and between units.
The risk of contamination increases with every interruption to the closed system.

FLUSHING TECHNIQUE
The catheter must be flushed to maintain patency. Otherwise, it becomes sluggish, blood
return is impeded, and blood and medication build up on the inside of the catheter, forming
fibrin. Fibrin can act as a barrier inside and around the catheter, leading to occlusion. Also,
pathogens cause development of biofilm, which can lead to catheter malfunction and
infection.
All central catheters should be flushed with normal saline solution before and after
medication administration. Flushing frequency varies with catheter type. Nonvalved catheters
require more frequent flushing, with recommendations varying from every shift to every day.
Follow your facility’s guidelines on flushing frequency. Valved catheters require once-
weekly flushing when not being used to administer fluids or medications. Failure to flush
between medications can cause catheter occlusion from precipitate formation.
Where possible, do not use syringes smaller than 10 ml for infusion into the catheter to
prevent excessive pressure being exerted on the lumen which might cause it to rupture.
Smaller syringes exert greater pressure but please note that syringe size alone is not sufficient
to prevent rupture. When resistance is felt, if more pressure applied to overcome it, catheter
fracture could result regardless of the syringe size. Use a brisk 'push-pause' flushing
technique routinely when flushing the catheter - i.e. flush briskly, pausing briefly after
approximately each ml of fluid. The 'push-pause' technique causes turbulence within the
catheter, which helps to flush away any debris and prevent occlusion of the lumen. If the
catheter possesses a clamp, clamp the line while the final ml of the flush is being injected. If
there is no clamp you can achieve a “positive pressure finish” by removing the syringe from
the needle free bung) while injecting the last ml: but note that to avoid any spray from the
syringe you should hold sterile gauze around the connector while doing this. Maintaining
positive pressure helps prevent blood entering the catheter after flushing, which might lead to
occlusion or thrombus formation. Do not routinely withdraw and discard blood from the
catheter before flushing (except Renal Dialysis Catheters) in an attempt to avoid flushing
bacteria and clots into the patient. There is no evidence that withdrawing prior to flushing
reduces infection or embolism.
When they’re not in regular use, you typically need to flush:

 Ports once every 4 weeks

 Tunneled CVCs and PICC lines once a week

To flush your catheter, you’ll follow a very clean process to inject it with one or both of
these fluids:

 Saline, a specific mix of salt and water

 Heparin , a drug that prevents blood clots from forming and clogging your catheter

DRESSING CHANGES
The dressing at the insertion site helps protect the catheter. Frequency of dressing changes
depends on dressing type and integrity. Change a transparent dressing every 7 days; change a
gauze dressing every 48 hours.
If the dressing is no longer intact, is oozing, or has become bloody or contaminated, change it
as soon as possible. Apply an impermeable cover before the patient takes a shower or bath to
protect it from direct contact with water. Manufacturers make covers specifically for central
catheters to keep dressings dry in the shower. If the dressing gets wet and is no longer intact,
change it to prevent infection.
Chlorhexidine sponges or dressings and silver patches provide continued antisepsis under the
dressing. If your facility’s central catheter infection rate hasn’t decreased despite adherence
to ba-sic prevention measures, use a chlorhexidine-impregnated sponge for temporary short-
term catheters in patients older than 2 months, per CDC recommendations.