Cuffed tunnelled central venous catheter (tCVC)

tCVC patency assessment and flush (using a standard ANTT® approach)

Statement	The tCVC patency must be assessed for signs of complications and to reduce patient harm. To ensure patients receive prescribed medications, in a safe and timely manner.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley 10ml luer lock syringe (x1 per lumen) IV 0.9% sodium chloride (NaCl) (appropriate volume for patient and VAD) X2 21g safety hypodermic needle or 18G blunt filter needle Catheter lock (if required) 2% chlorhexidine in 70% isopropyl alcohol wipe/wand (0.5% chlorhexidine in 70% isopropyl alcohol is recommended as an alternative for babies less than 3 months old) Curos cap (disinfection cap) (x1 per lumen) Clinical waste bag Sharps bin.
Timing	As often as necessary to administer medications as prescribed; once every 24 hours if tCVC is not being used for administration of IV fluids or medicines. For patients receiving care in the community, the tCVC should be inspected at each visit and flushed at least every 7 days.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean tray or trolley with disinfectant wipes. Perform hand hygiene. Apply PPE. Decontaminate neck of ampoule with 2% chlorhexidine and 70% alcohol wipe and allow to dry. Using ANTT, draw up flush using 10ml syringe and hypodermic needle. Dispose of needle into sharps bin protect tip of syringe by placing onto sterile field or by placing in Micro Critical Field (sterile syringe packet). Ensure tCVC is clamped. ‘Scrub the hub’ threads with the 2% chlorhexidine in 70% isopropyl alcohol wipe for 30 seconds. Allow to dry. If removing lock – using ANTT, attach an empty 10ml syringe, unclamp and gently aspirate 2-5mls of blood from the tCVC. Reapply clamp and discard syringe. Using ANTT, attach 10ml syringe filled with 0.9% NaCl to the NFAD, unclamp lumen/catheter, pull back to ensure flashback is achieved, flush the catheter using a push/pause technique, maintaining positive pressure on the plunger of the syringe. Reapply clamp and detach syringe. Never flush if resistance felt. If lock is being used then administer lock following previous step. Check if lock is required in the child’s care plan. Apply curos caps to lumen after use. Repeat procedure for all lumens. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure and complete CVAD bundle. Ensure VAD is positioned correctly to ensure skin health is maintained.

tCVC exit site suture removal and dressing change (using a surgical ANTT® approach)

Statement	The cuffed tunnelled CVC is dressed with an appropriate dressing, whilst allowing for inspection of the exit site.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley Sterile gloves Sterile dressing pack 2% chlorhexidine in 70% isopropyl alcohol wipe/wand (0.5% chlorhexidine in 70% isopropyl alcohol is recommended as an alternative for babies less than 3 months old) Medical adhesive remover (if required) Sterile chlorhexidine impregnated patch Sterile semi permeable transparent dressing Stitch cutter Sterile swab for culture (only if signs of infection) Clinical waste bag Sharps bin.
Timing	Every 7 days or when dressing is visibly loose or soiled. After 3 weeks the purse string suture can be removed as Dacron cuff will have subcutaneously embedded.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean tray or trolley with disinfectant wipes. Perform hand hygiene. Open dressing pack. Using ANTT, assemble sterile field and open all equipment onto sterile field. Perform hand hygiene. Apply PPE. Loosen and carefully remove the old dressing in an upward direction towards the exit site, taking care not to pull or dislodge the catheter. Medical adhesive remover can be used here to aid in the removal of the dressing. Inspect exit site and surrounding skin for signs of phlebitis or infection. Swab area if required. Discard gloves and apply sterile gloves. Place the sterile drape under the CVAD to create a sterile field. Whilst holding the catheter with a sterile swab from the dressing pack, clean the exit site and surrounding skin with the 2% chlorhexidine in 70% isopropyl alcohol wipe/wand starting at the exit site, in a ‘circular’ pattern for 30 seconds before working outward to the periphery (an area slightly larger than the new dressing). Allow to dry for at least 30 seconds. Remove sutures. Cover exit site with sterile chlorhexidine impregnated patch and apply sterile semi permeable dressing. Or apply sterile chlorhexidine impregnated semi permeable transparent dressing, ensuring good adherence to the skin. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure and complete CVAD bundle. Ensure VAD is positioned correctly to ensure skin health is maintained.

tCVC entry site dressing change (using a surgical ANTT® approach)

Statement	A tCVC entry site is covered with an appropriate dressing, whilst allowing for inspection of the entry point.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley Sterile gloves Sterile dressing pack 2% chlorhexidine in 70% isopropyl alcohol wipe/wand (0.5% chlorhexidine in 70% isopropyl alcohol is recommended as an alternative for babies less than 3 months old) Medical adhesive remover (if required) Sterile chlorhexidine impregnated semi permeable transparent dressing Sterile swab for culture (only if signs of infection) Clinical waste bag.
Timing	After 7 days or when dressing is visibly loose or soiled.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean tray or trolley with disinfectant wipes. Perform hand hygiene. Open dressing pack. Using ANTT, assemble sterile field and open all equipment onto sterile field. Perform hand hygiene. Apply PPE. Loosen and carefully remove the old dressing and steri-strips. Medical adhesive remover can be used here to aid in the removal of the dressing. Inspect entry site and surrounding skin for signs of phlebitis or infection. Swab area if required. Discard gloves and apply sterile gloves. Place the sterile drape under the CVAD to create a sterile field. Cleanse the area around the entry site with the 2% chlorhexidine in 70% isopropyl alcohol wipe/wand starting at the entry site, in a ‘circular’ pattern for 30 seconds before working outward to the periphery (an area slightly larger than the new dressing). Allow to dry for at least 30 seconds. Apply sterile chlorhexidine impregnated semi permeable transparent dressing, ensuring good adherence to the skin. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure in patient notes. Monitor for signs of infection, bleeding and bruising.

tCVC exit site dressing change (using a surgical ANTT® approach)

Statement	The tCVC is covered with an appropriate dressing, whilst allowing for inspection of the exit site.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley Sterile gloves Sterile dressing pack 2% chlorhexidine in 70% isopropyl alcohol wipe/wand (0.5% chlorhexidine in 70% isopropyl alcohol is recommended as an alternative for babies less than 3 months old) Medical adhesive remover (if required) Sterile chlorhexidine impregnated semi permeable transparent dressing or sterile semi permeable transparent dressing and sterile chlorhexidine impregnated patch Sterile swab for culture (only if sings of infection) Clinical waste bag.
Timing	Every 7 days or when the dressing is visibly loose or soiled.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean tray or trolley with disinfectant wipes. Perform hand hygiene. Open dressing pack. Using ANTT, assemble sterile field and open all equipment onto sterile field. Perform hand hygiene. Apply PPE. Loosen and carefully remove the old dressing in an upward direction towards the exit site, taking care not to pull or dislodge the catheter. Medical adhesive remover can be used here to aid in the removal of the dressing. Inspect exit site and surrounding skin for signs of phlebitis or infection. Swab if required. Discard gloves and apply sterile gloves. Place the sterile drape under the CVAD to create a sterile field. Whilst holding the catheter with a sterile swab from the dressing pack, clean the exit site and surrounding skin with the 2% chlorhexidine in 70% isopropyl alcohol wipe/wand starting at the exit site, in a ‘circular’ pattern for 30 seconds before working outward to the periphery (an area slightly larger than the new dressing). Allow to dry for at least 30 seconds. Cover exit site with sterile chlorhexidine impregnated patch and apply sterile semi permeable dressing. Or apply sterile chlorhexidine impregnated semi permeable transparent dressing, ensuring good adherence to the skin. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure and complete CVAD bundle. Ensure VAD is positioned correctly to ensure skin health is maintained.

tCVC dressing change, flush, needle free access device change and catheter lock (using a surgical ANTT® approach)

Statement	The individual lumens and access ports of a CVAD should have a needle free access device attached to reduce the risk of catheter related blood stream infections.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley Sterile gloves Sterile dressing pack 2% chlorhexidine in 70% isopropyl alcohol wipe/wand (0.5% chlorhexidine in 70% isopropyl alcohol is recommended as an alternative for babies less than 3 months old) Medical adhesive remover (if required) NFAD (x1 per lumen) 10ml luer lock syringe (x1 per lumen) IV 0.9% sodium chloride (NaCl) (appropriate volume for patient and VAD) X2 21g safety hypodermic needle or 18G blunt filter needle Sterile chlorhexidine impregnated semi permeable transparent dressing or sterile semi permeable transparent dressing and sterile chlorhexidine impregnated patch Catheter lock (if required) Curos cap (disinfection cap) (x1 per lumen) Sterile swab for culture (only if signs of infection) Clinical waste bag Sharps bin.
Timing	Every 7 days or when the dressing is visibly loose or soiled.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean tray or trolley with disinfectant wipes. Perform hand hygiene. Decontaminate neck of ampoule with 2% chlorhexidine and 70% alcohol wipe and allow to dry. Using ANTT, draw up flush using 10ml syringe and hypodermic needle. Dispose of needle into sharps bin protect tip of syringe by placing onto sterile field or by placing in Micro Critical Field (sterile syringe packet) and place to the side. Open dressing pack. Using ANTT, assemble sterile field and open all equipment onto sterile field. Perform hand hygiene. Apply PPE. Loosen and carefully remove the old dressing in an upward direction towards the exit site, taking care not to pull or dislodge the catheter. Medical adhesive remover can be used here to aid in the removal of the dressing. Inspect exit site and surrounding skin for signs of phlebitis or infection. Swab area if required. Discard gloves and apply sterile gloves. Place the sterile drape under the CVAD to create a sterile field. Whilst holding the catheter with a sterile swab from the dressing pack, clean the exit site and surrounding skin with the 2% chlorhexidine in 70% isopropyl alcohol wipe/wand starting at the exit site, in a ‘circular’ pattern for 30 seconds before working outward to the periphery (an area slightly larger than the new dressing). Allow to dry for at least 30 seconds. Cover exit site with sterile chlorhexidine impregnated patch and apply sterile semi permeable dressing. Or apply sterile chlorhexidine impregnated semi permeable transparent dressing, ensuring good adherence to the skin. Remove needle free access device and discard. ‘Scrub the hub’ threads with the 2% chlorhexidine in 70% isopropyl alcohol wipe for 30 seconds. Allow to dry. Apply primed needle free access device. If removing lock – using ANTT, attach an empty 10ml syringe, unclamp and gently aspirate 2-5mls of blood from the tCVC. Reapply clamp and discard syringe. Using ANTT, attach 10ml syringe filled with 0.9% NaCl to the NFAD, unclamp lumen/catheter, pull back to ensure flashback is achieved, flush the catheter using a push/pause technique, maintaining positive pressure on the plunger of the syringe. Reapply clamp and detach syringe. Never flush if resistance felt. If lock is being used then administer lock following previous step. Check if lock is required in child’s care plan. Apply curos caps to lumen after use. Repeat procedure for all lumens. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure and complete CVAD bundle. Ensure VAD is positioned correctly to ensure skin health is maintained.

tCVC removal

Removal of cuffed tunnelled CVC should be undertaken by specially trained and competent practitioners. This would normally be undertaken in the area that was responsible for the insertion e.g. Vascular Access Service, theatre, interventional radiology services or haematology clinical nurse specialists. tCVC’s are not removed within NHSA&A, referrals should be made to NHSGGC for removal.

tCVC and ntCVC line fracture (using a standard ANTT® approach)

Statement	All VADs should be inspected for damage on removal. Any device that is removed and found to be fractured or incomplete, must be reported to the patient’s medical team for review and advice immediately.
Requirements	Blue plastic clamps (these should always be at the patient's bedside) Sterile occlusive dressing.
Procedure	If line is fractured, there will be signs of fluid or blood leaking from the line. Immediately after, apply blue plastic clamps around 1 inch above the fractured part of the line and 1 inch below. By applying the clamps around 1 inch above the fracture line, this then allows for movement up the line if the line fractures where the clamp is applied. *DO NOT APPLY CLAMP DIRECTLY AT THE EXIT SITE* - as this means if the line fractures further it will be unrepairable and risk of more significant bleeding. This should prevent an air embolism from occurring. Cover line with an occlusive dressing to secure the line in place.
Aftercare	Referrals for immediate transfer to NHSGGC by medical professionals should be made as fractured lines cannot be repaired in NHSA&A and are a medical emergency. Monitor patient and CVAD closely. All medical staff should be immediately updated if there is a change in condition of the CVAD or patient.