Description of VADs | Right Decisions

There are several types of VADs. These devices are classified as either a peripheral or central access device. A VAD is chosen dependent on:

Clinical need of the patient.
Type of IV therapy/treatment required.
Anticipated length of therapy.

Peripheral venous cannula (PVC)

A temporary plastic catheter that is inserted into a peripheral vein to allow administration of IV fluids, medication, IV therapies (e.g. dyes and contrast media) and transfusion of blood products. This device is usually a short-term VAD. PVCs may be ported or non-ported. Immediately following insertion, top ports may be considered sterile and used to administer time critical medications (e.g. anaesthetic medications).

The top ports of PVCs should only be utilised in an emergency as it cannot be adequately decontaminated due to the design of the device. The top port should never be used to administer systemic anti-cancer therapies (SACT) due to the risk of exposure for the practitioner.

Care and maintenance points

The continuing need for a PVC should be reviewed and documented daily.

PVC check is done once daily and documented on the PVC bundle.

Flush the VAD a minimum of once per day; before, between and after medicine administration.

NFADs are changed every 7 days and include an integral tubing to minimise mechanical phlebitis.

Blood sampling should ideally only be done on insertion of PVC, and before administration of flush. Established PVCs should not be routinely used for blood sampling regularly. Blood sampling can occur from PVCs however, this should be discussed with senior medical staff and nurse specialists.

The flush should be administered with ease. If there are signs of resistance, infiltration, extravasation or inflammation discontinue flushing process and consider replacing PVC.

Sterile, semi permeable transparent dressings are used and changed if loose or soiled.

Device securing strips are used to minimise movement of the PVC under the dressing.

Record care and maintenance and complete PVC bundle.

Ensure VAD is positioned to ensure skin health is maintained.

PVCs are removed by a suitably competent practitioner.

Midline catheter

A temporary polyurethane catheter 8–20cm in length inserted in a peripheral vein. A midline catheter is a peripheral device, the tip of which sits in a peripheral vein and does not enter a central vein. Some midlines are inserted in the lower arm and some in the upper arm. Care and maintenance varies depending on the device. Users need be aware of which device is inserted and look at the information supplied regarding care and maintenance. Midlines come in variable gauges that can be inserted at ward level at the bedside or under ultrasound guidance. The size of catheter inserted will depend on the intended duration and nature of treatment. This is ideal for patients who have multiple PVC insertions or require extended term IV access. The midline catheter is also useful when further haemodilution of medications is required, but not necessarily via a central venous catheter. Both types of midlines are maintained and cared for as a peripheral venous catheter. Midlines are inserted within NHSA&A by anaesthetics in paediatrics.

Care and maintenance points

The continuing need for a midline catheter should be reviewed and documented daily.

The midline catheter should be assessed for patency (flushed) prior to each medicine administration and at least weekly if the midline is not in constant use.

Below antecubital fossa midlines should not be used for blood sampling.

The flush should be administered with ease. If there are signs of resistance, infiltration, extravasation or inflammation discontinue flushing process and consider replacing midline.

Fixation devices and sterile semi permeable transparent dressings are used and changed every 7 days or when loose or soiled.

Needle free access devices are changed every 7 days.

A PVC bundle should be used to document care and maintenance of the midline.

Ensure to check the midlines position to ensure skin health is maintained.

Midlines should be removed when no longer clinically indicated. Midlines are removed by a suitably competent practitioner

Peripherally inserted central catheter (PICC)

A Peripherally Inserted Central Catheter (PICC) is inserted into a peripheral vein in the upper arm (basilic, cephalic or brachial vein) and is then advanced until the tip is placed in a central vein, normally the lower superior vena cava (SVC) or proximal right atrium. This is a central device that is inserted peripherally and is most commonly used for short - midterm venous access to facilitate administration of extended IV therapy such as cytotoxic chemotherapy, Parenteral Nutrition and IV medication that needs to be administered centrally. PICCs have centimetre markings to allow easy observation of migration of the catheter. PICCs can be single or multi lumen. A PICC can remain in place for the duration of therapy if no complications occur. PICC lines are inserted within NHSGGC and are non-valved. NHSA&A does not insert PICC lines in paediatrics.

*Neonatal care: PICCs can be placed in any limb, and sometimes the scalp. Neonatal PICC lines can be inserted in NHSA&A by the neonatal team.

Care and maintenance points

Flush and lock of catheter should be carried out every 7 days when not in use.

Clamps integral to PICC should be repositioned on PICC to prevent damage to the device, to optimise the life of the catheter and minimise risks of blockage.

Observe the external length of the PICC for signs of migration, from the exit site to the start of the hub.

Dressings for PICCs should be a chlorhexidine (CHG) impregnated patch (BioPatch) and sterile semi permeable, transparent dressing. Dressing and patch should be changed every 7 days, or if loose or soiled.

Loosen and carefully remove the old dressing in an upward direction towards the exit site, taking care not to pull or dislodge the catheter.

PICCs are secured using a fixation device in addition to the CHG patch and dressing. These are also changed every 7 days or if loose or soiled. Fixation devices should be positioned to allow visualisation of the exit site.

North West Children’s Cancer Operational Delivery Network (2023 ) state that a continuous saline infusion is only required when a double lumen PICC is in situ. However, recommended practice in neonates and infants within NHSA&A is that a continuous saline infusion of 0.5mls/hr should be used to ensure line patency in all PICC lines.

If no continuous infusion is to be connected, or lumens are not being used, PICC lumen may be flushed with heparin sodium I.V. flush 10u/ml. Seek advice.

Inspection should be documented on the CVAD Bundle.

Ensure to check the PICCs position to ensure skin health is maintained.

PICCs should be removed as soon as no longer clinical indicated. PICCs are removed by suitably competent practitioners at ward level. Although the tip of the PICC is situated in a central vein, the risk of air embolism is small due to the entry point being in a peripheral site. The PICC removal procedure outlines the appropriate process (that is different to a non-tunnelled CVC). A suitable sterile dressing should be applied to the puncture site for 24 hours.

Blood sampling

Peripheral venepuncture is the NHSA&A preferred method of blood sampling.

Fine bore PICCs used in paediatrics and may be used for blood sampling but this should be determined by senior medical staff and nurse specialists. Due to limited vascular access in paediatric patients, some PICCs may be used for multiple purposes.

Very fine bore PICCs are not used for blood sampling.

Non-tunnelled central venous catheter (ntCVC)

A non-tunnelled CVC is inserted directly into a large central vein. Depending on the insertion site, the tip of the device will lie in the superior or inferior vena cava. ntCVCs are inserted to provide treatment in the acutely unwell patient for example, the administration of IV medications that require central access, aggressive fluid resuscitation and central venous pressure/haemodynamic monitoring. ntCVCs must be secured in place with sutures. This is a short-term central VAD and is available as a single or multi-lumen device.

Care and maintenance points

ntCVCs should be flushed with sterile 0.9% sodium chloride as often as necessary to administer medications as prescribed; and at least once every 24 hours if CVC is not used for administration of IV fluids or medicines.

If no infusion to be connected, or lumens not being used, the lumens may be flushed with heparin sodium I.V. flush solution 10u/ml. Seek advice.

ntCVCs should be ideally sutured in place and checked daily. Procedures and events should be recorded in the CVAD Bundle and patient notes.

Ensure the ntCVC is positioned correctly to ensure skin health is maintained.

Dressings should be chlorhexidine (CHG) impregnated. This may be a CHG dressing or a CHG patch and sterile semi permeable, transparent dressing.

Dressing (and/or patch) should be changed every 7 days, or if loose or soiled.

The individual lumens and access ports of a ntCVC should have a NFAD attached to each lumen to reduce the risk of catheter related blood stream infections. These should be changed every 7 days or as manufacturer recommendations.

ntCVC removal should be considered when there is no longer a clinical need for the device, infection is suspected or a more permanent VAD is required.

When ntCVC are removed:

Must be carried out by competent practitioners.
Patient MUST BE in bed lying flat in a head-down-tilt position unless contraindicated – seek advice.
Air embolism is a significant risk if procedure not followed. If suspected, turn patient left side down (Trendelenburg position), administer 100% oxygen via a non-rebreathing mask and call 2222.
Cover the site with a sterile occlusive hydrocolloid dressing, ensuring a good adherence of the dressing to the skin (for 24 hours).

ntCVCs are generally not inserted in paediatrics within NHSA&A.

Cuffed tunnelled central venous catheter (tCVC)

A tCVC is sited with the tip in a large central vein (typically the superior or inferior vena cava) the catheter is tunnelled within subcutaneous tissue to exit the skin surface at a point distant to the entry to the vein. These devices are inserted to provide long term IV therapy, such as chemotherapy and parenteral nutrition. tCVCs are inserted within NHSGGC and have a cuff to prevent migration of the catheter and can act as a mechanical barrier to reduce risk of bloodstream infections, however uncuffed versions of the device may be used in other health boards. A tCVC can be valved or non-valved and single or multi lumen.

Care and maintenance points

After 3 weeks the purse string suture (if used) can be removed as the Dacron cuff will have embedded subcutaneously (check with insertion service as not all will have a purse string suture).

Dressings should be chlorhexidine (CHG) impregnated. This may be a CHG dressing or a CHG patch and sterile semi permeable, transparent dressing.

Dressing (and/or patch) should be changed every 7 days, or if loose or soiled. Place the line in a loop, apply dressing and ensure full adherence to skin.

Record procedure and complete CVAD Bundle.

Ensure tCVC is positioned correctly to ensure skin health is maintained.

Inspect the exit site and surrounding skin regularly for signs of phlebitis or infection.

Removal of cuffed tCVC should be undertaken by specially trained and competent practitioners. tCVCs are not inserted or removed in paediatrics within NHSA&A. This is performed within NHSGGC.

Dialysis CVC (tunnelled and non-tunnelled)

Non-Tunnelled Dialysis Central Venous Catheter (ntDCVC)

A ntDCVC is inserted directly into a large central vein. The tip of these devices will lie in the superior or inferior vena cava. ntDCVCs have an access lumen and a return lumen to facilitate the flow of blood for renal dialysis treatment. ntDCVCs must be secured in place with sutures. This is a short term central VAD, inserted to administer renal dialysis. ntDCVC are inserted within NHSGGC.

Tunnelled Dialysis Central Venous Catheter (tDCVC)

tDCVC is sited with the tip in a large central vein (typically the superior or inferior vena cava) and the catheter is tunnelled within subcutaneous tissue to exit the skin at a point distal to the entry to the vein. tDCVCs have an access lumen and a return lumen to facilitate the flow of blood for renal dialysis treatment. These are long term devices inserted to administer renal dialysis. tDCVC are inserted within NHSGGC.

Care and maintenance points

Dialysis CVCs (tunnelled and non-tunnelled) should have sterile chlorhexidine impregnated semi permeable dressing applied. This may be a CHG dressing or a CHG patch and sterile dressing. Dressing and/or patch should be changed every 7 days, or if loose or soiled.

An immobiliser may be considered (used to fix and secure wings of the CVAD).

Record procedures and complete CVAD Bundle.

Ensure the CVAD is positioned correctly to ensure skin health is maintained.

dCVC removal should be considered when there is no longer a clinical need for the device or infection is suspected. Non tunnelled Dialysis CVC are removed by suitably competent practitioners:

Patient MUST BE in bed lying flat in a (Trendelenburg) head-down-tilt position unless contraindicated – seek advice.
Ask patient to hold their breath and perform a Valsalva Manoeuvre. If Valsalva cannot be performed, the catheter should be removed on expiration.
Air embolism is a significant risk if procedure not followed. If suspected, turn patient left lateral trendelenburg position, administer 100% oxygen and call 2222.
Cover the site with a sterile occlusive hydrocolloid dressing, ensuring a good adherence of the dressing to the skin (for 24hours)

Minimise activity for at least one hour post removal. Observe insertion site for signs of leakage, haemorrhage, or haematoma. Assess the site for bleeding every 5 minutes for 30 minutes, then every 30 minutes. Observe limb closest to insertion site for signs of swelling and or pain. Dressing must remain in situ for a minimum of 24 hours following CVC removal and then dressed as required until site has healed.

For femoral venous catheters:

Nurse patient flat for 2 hours where possible.
Apply pressure for at least 15 minutes.
Ensure complete cessation of bleeding ensured prior to applying dressing.
Do not allow hip flexion during this period.

tDCVCs are removed by specially trained and competent practitioners. This would normally be undertaken in the area that was responsible for the insertion (NHSGGC). Appropriate referrals should be made.

Implanted ports

An implanted port is a central venous access device, often referred to as a Port-a-Cath®. These are useful for long term vascular access. They are designed to permit repeated access to the venous system for the parenteral delivery of medications, fluids and nutritional solutions. A port consists of a portal chamber (reservoir), which can be made of special plastic, stainless steel or titanium. It has a silicone septum (injection area) and is attached to a catheter which is tunnelled under the skin and advanced until the tip of the catheter lies in the central venous system, normally the lower superior vena cava or proximal right atrium). This device is available as a single chamber or double chamber system. The port is always accessed through the septum of the port into the port reservoir using a deflected tip (Huber/ GRIPPER®) needle to prevent coring of the silicone septum and subsequent leakage.

Care and maintenance points

See NHSA&A documents for flush and locking of Implanted Ports.

A minimum volume of flush is at least twice the volume of the catheter. The volume of the flush solution can vary depending on the patient age, make of device, catheter size and nature and type of infusion/medication.

A specialist non-coring needle (Huber/ GRIPPER®) must be used. The size of the non-coring needle required should be clearly documented. The non-coring needle should be inserted and removed at 90° to the skin.

Newly implanted ports should not have local anaesthetic creams applied to the site, until fully healed.

Huber/GRIPPER® needles may be left in situ for 7 days to prevent discomfort accessing the port.

Sterile semi permeable transparent dressing would secure the non-coring needle in place.

The implanted port requires to be flushed before, after and in between medicine administration, or IV Fluids, after collecting blood samples and monthly when the port is not in use.

The implanted port should be inspected for signs of infection or phlebitis each time it is accessed or at least once daily – minimum whilst an inpatient.

Record procedures and complete CVAD Bundle.

Prior to accessing the implanted port, topical anaesthetic may be applied over the site, covered with an adhesive semi-permeable dressing. Leave for recommended duration for maximum anaesthetic effect. Ensure that the topical anaesthetic has been removed immediately prior to preparing the site for access.

Stretching the skin or asking the patient to change position or lie flat can assist the user/nurse to identify the nodules of the device.

The tissue surrounding the implanted port should be monitored throughout the procedure for:

Redness
Swelling
Discomfort surrounding the port.

It is inadvisable to use the port if these signs are noted – inform medical staff and document whilst monitoring vital signs.

Long term implanted port related complications: These include extravasation, catheter blockage due to thrombosis, local and systemic infection associated with the insertion and maintenance of the CVAD and breakdown of skin integrity over the portal.

Seek medical/nurse specialist advice if: a patient has pyrexia or complaints of any symptoms such as pain, swelling or discolouration of the skin, a doctor or person who has expertise in implanted port complications (e.g. specialist nurses) should be informed immediately so that the problem can be investigated.

Removal of implanted ports should be undertaken by specially trained and competent practitioners. This would normally be undertaken in the area that was responsible for the insertion (NHSGGC). Appropriate referrals should be made.