CVAD INSERTION COMPETENCY TRAINING

1. CVAD INSERTION COMPETENCYTRAINING Royal Children’s Hospital Melbourne, Australia 2009

2. INTRODUCTION DEFINITIONS CVAD INDICATION PREPARATION HAND HYGIENE BARRIER PRECAUTIONS CHLORHEXIDINE DRESSINGS IMAGING DOCUMENTATION DAILY REVIEW OF LINE NECESSITY CONTENTS

3. INTRODUCTION • Central Venous Access Devices are essential for the care of many sick children. • Careful consideration of the type of catheter required and the manner in which it is inserted is essential to reduce the risk of infection and thrombosis, and to increase line longevity.

4. DEFINITIONS • Peripheral IV Devices:cannulae inserted into small peripheral veins. • Midline Catheters:long catheters inserted into peripheral veins with the catheter tip residing at or below the level of the axilla. • Central Venous Access Devices (CVAD):catheters whose tip terminates in a central vessel.

5. CENTRAL VENOUS ACCESS DEVICES • Central Venous Catheters (CVC) • inserted into the subclavian vein, internal jugular vein, external jugular vein or femoral vein • ‘tunneled’ CVC HICKMAN, BROVIAC, permacaths, infusaports • ‘non-tunnelled’ CVC central lines, vascaths • Percutaneously Inserted Central Catheters (PICC) • inserted into the basilic vein, brachial vein, cephalic vein or long saphenous vein (may be tunneled) • Umbilical Catheters (UVC/UAC): • inserted via umbilical vein & arteries of newborn infants

6. CVAD INDICATION • Considerations for type of CVAD include: • therapeutic purpose (including the need for total parenteral nutrition (TPN) or chemotherapy) • estimated length of treatment (note: any patient requiring more than seven days of intravenous therapy should be assessed for insertion of a central venous access device) • medical history (including any cardiac anomalies or haematological disorders) and previous history of line complications (such as thrombosis) • vein status (difficult peripheral IV access should be a flag for early insertion of a central venous access device if the expected duration of IV therapy exceeds seven days)

7. CVAD INDICATION CNTD

8. PREPARATION (sedation/ assistant) • Sedation/ Analgesia • appropriate sedation and analgesia is essential. • Assistance • all central venous access device insertions should be assisted by a member of staff who has been credentialed in CVAD Insertion or Management.

9. HAND HYGIENE • Hand Hygiene should be conducted • before & after palpating catheter insertion sites • before & after inserting, replacing, accessing, repairing or dressing the device/ line

10. HAND HYGIENE

11. BARRIER PRECAUTIONS • For the operator placing the central line and for those assisting the procedure, barrier precautions means wearing a cap, mask, sterile gown & gloves. • For the patient applying barrier precautions means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion (cover 80-100% of patient). • The procedure trolley should also be thoroughly cleaned with Alcohol 70% and fully covered with sterile drapes.

12. BARRIER PRECAUTIONS Reproduced with thanks from Cincinnati Children’s Hospital

13. CHLORHEXIDINE • CHLORHEXIDINE: • Chlorhexidine 0.5% in Alcohol 70% • patient < 1500g & < 1 week old •  Chlorhexidine 2% in Aqueous Solution Swab • TECHNIQUE FOR CHLORHEXIDINE APPLICATION: • press chlorhexidine soaked gauze against the skin & apply a back-and-forth friction scrub for at least 30sec (do not wipe or blot); discard gauze from sterile site • allow antiseptic solution time to dry completely before puncturing the site (~ 2mins)

14. CHLORHEXIDINE Reproduced with thanks from Cincinnati Children’s Hospital

15. NOTE: All alcohol preparations are flammable. It is imperative that the preparation should be allowed to evaporate completely and that care is taken to avoid pooled pockets of chlorhexidine before exposure to ignition sources such as diathermy. In light of this, tunnelled central venous catheters (hickmans, broviac, permacaths etc) inserted in theatre with the aid of diathermy may use povidone-iodine solutions as an alternative to chlorhexidine, provided it is documented on the insertion notes.

16. DRESSINGS • Non-tunnelled CVAD: Tegaderm ®

17. IMAGING – TIP LOCATION • UPPER VENOUS SYSTEM • Position: lower SVC • Approximate Anatomical Landmark: • tip position one vertebral body below carina

18. IMAGING – LOWER SVC • LANDMARKS • T1 Vertebrae • joined by first rib • Upper SVC • right tracheo-bronchial angle • Lower SVC (approximate) • right superior cardiac shadow meeting mediastinal edge • T6 thoracic vertebrae • Approximate Tip Position • one vertebral body’s distance below carina

19. Further Advice • Tip Too High: positioning the tip too high risks it flicking out of the SVC & upwards with patient arm movement • Position CVAD parallel to SVC wall: tips abutting the wall can cause erosion, perforation & predispose to thrombosis • Imaging: during continual x-ray screening the CVAD tip will move with the heart beat in the atrium & become still when withdrawn into the SVC

20. IMAGING – TIP LOCATION • LOWER VENOUS SYSTEM • PICC/ UVC • Position: at/ just below diaphragm • CVC/ Vascaths • Position: lower IVC • Anatomical Landmarks: • avoid L1 (renal veins) • above L5 (lower border IVC) • NB: line parallel to vertebral column above L5

21. IMAGING – TIP CONFIRMATION CVAD inserted in PICU/ NNU • x-ray should be performed prior to use PICC inserted in theatre • tip position should be determined during insertion with the image intensifier; acceptable positioning should be confirmed before the patient is woken or leaves the operating theatre

22. IMAGING – TIP CONFIRMATION CVCs inserted peri-operatively CVCs inserted for intra-operative use may be used prior to imaging provided the majority of the following criteria are met • uncomplicated insertion with no concerns re line position • ultrasound used for insertion of IJV lines • transduced pressure wave confirms placement in SVC • ventricular ectopic beats on ECG with wire placement • free aspiration of blood from all three lumens

23. IMAGING – TIP CONFIRMATION CVCs inserted peri-operatively NOTE: if there is any doubt that the CVC is in a central vein an x-ray should be taken prior to use NOTE: an x-ray must be performed at the end of the case; this can be done in theatre, recovery or PICU/ NNU NOTE: if re-positioning the CVAD will require a second anaesthetic or sedation it is highly recommended that the x-ray be performed whilst the patient is still anaesthetised

24. DOCUMENTATION • CVAD insertion must be documented in the patient’s notes including: • date/ time/ indication for CVAD/ brand/ type of catheter/ site of insertion/ depth of catheter placement/ number of attempts/ confirmation of catheter site on CXR

25. DAILY REVIEW OF LINE NECESSITY • Daily Review: should include how long the line has been in-situ/ necessity for central access/ alternative methods of access and treatment. • NOTE: CVADs that are no longer needed for patient care should be removed without delay.

26. CVAD TYPES • CONTENT • INFUSAPORTS • HICKMANS/ BROVIAC • VASCATHS • CVC • PICC • UMIBILICAL CATHETERS

27. INFUSAPORTS • INDICATION • > 14days continuous infusate • SITES • enter venous system at internal jugular vein/ external jugular vein • SIZE/ GAUGE

28. INFUSAPORTS • NUMBER OF LUMENS • Single: standard • Double: clinical indication • VOLUME INFUSABLE • N/A • TIP LOCATION • lower SVC • DURATION • indefinite

29. HICKMANS/ BROVIAC • INDICATION • > 14days continuous infusate • SITES • internal jugular vein/ external jugular vein • femoral vein • trans-hepatic

30. HICKMANS/ BROVIAC

31. HICKMANS/ BROVIAC • NUMBER OF LUMENS • Single: standard • Double/ Triple: clinical indication • VOLUME INFUSABLE • N/A • TIP LOCATION • Internal Jugular Vein/ External Jugular Vein: lower SVC • Femoral Vein: lower IVC • DURATION • indefinite

32. VASCATHS • INDICATION • Dialysis • Haemofiltration • Plasmafiltration • SITES • Femoral: standard • Internal Jugular Vein: requires consultant approval • Subclavian Vein: requires consultant approval • NUMBER OF LUMENS • two

33. VASCATHS • SIZE/ GAUGE • VOLUME INFUSABLE

34. VASCATHS • TIP LOCATION • Internal Jugular Vein/ Subclavian Vein: lower SVC • Femoral: common iliac vein or IVC • DURATION • as long as required for temporary extracorporeal therapy

35. CVC • INDICATION • Up to 14 days of continuous IV access • SITES • Internal Jugular Vein • Subclavian Vein • Femoral Vein • SIZE/ GAUGE

36. CVC • NUMBER OF LUMENS • Double: standard • Triple: cardiac surgery/ intensive care patients • VOLUME INFUSABLE • N/A • TIP LOCATION • Internal Jugular Vein or Subclavian Vein: lower SVC • Femoral Vein: lower IVC • DURATION • CVCs should not be inserted with the intention of more than fourteen days of intravenous therapy

37. PICC • INDICATION • > 7 days continuous infusate • poor venous access/ difficult IV insertion • SITES • mid arm with ultrasound guidance is the preferred site for anaesthetic placed PICCS to decrease complication rates and increase patient comfort

38. PICC

39. PICC • SIZE GAUGE

40. PICC • NUMBER OF LUMENS • Single Lumen: standard • VOLUME INFUSABLE • Premicath: < 6ml/hr • 3 Fr: 90ml/hr • 4Fr: 850ml/hr • 5Fr: 1750ml/hr • TIP LOCATION • Upper Limb Insertion: lower SVC • Lower Limb Insertion: IVC (at or just below level of diaphragm) • DURATION • theoretically: up to one year • in practice: often removed earlier secondary to complications

41. UMBILICAL LINES • INDICATION • UAC • blood sampling • continuous arterial blood pressure monitoring • UVC • central venous access • central venous monitoring • SIZE/ GAUGE • UAC • < 1200g 3.5Fr • > 1200g 5Fr • UVC • < 3500g 5Fr • > 3500g 8Fr

42. UMBILICAL LINES • NUMBER OF LUMENS • UVC • One Lumen: standard • Two Lumens: < 1000g/ extremely sick • VOLUME INFUSABLE • N/A

43. UMBILICAL CATHETERS • TIP LOCATION • UAC • High (T6-T9)/ (shoulder  umbilicus + 2cm/) • Low (L3-L5)/ (2/3 distance umbilicus to mid-clavicle) • UVC • IVC at or just below level of diaphragm • NOT portal circulation • NOTE: tip should not be in RA • DURATION • UAC/ UVC should not remain in-situ for more than 5-7 days