Dialysis central venous catheter (tunnelled (tDCVC) and non-tunnelled (ntDCVC)

tDCVC and ntDCVC dressing change (using a surgical ANTT® approach)

Statement	The non-tunnelled and tunnelled double lumen dialysis CVC insertion sites and patency must be assessed for signs of complications to reduce patient harm. There is a high risk for the introduction of organisms through 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 Mobiliser (used to fix and secure wings of line) if appropriate Sterile swab for culture (only if signs of infection) Clinical waste bag.
Timing	All non-tunnelled and tunnelled dialysis CVC exit sites are redressed every 7 days or as required if 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 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. Apply mobiliser if appropriate. 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.

tDCVC and ntDCVC dressing change, flush and catheter lock (using a standard ANTT® approach)

Statement	To ensure safe care and maintenance of catheter/device and maintain patency of catheter/device when not in continuous use.
Requirements	PPE (minimal consideration of gloves and aprons) Clean tray or trolley Sterile dressing pack Sterile gloves 2 x 20ml luer lock syringe 4 x 10ml luer lock syringes IV 0.9% Sodium Chloride (NaCl) amp(s) (appropriate volume for patient and VAD) Tauralock 500 or Taurolock urokinase - volume as guided by size of catheter (*refer to local SOPs and manufacturer recommendations for exact volume) Curos cap (disinfection cap) (x1 per lumen) Sterile semi permeable chlorhexidine impregnated dressing or sterile chlorhexidine impregnated patch and sterile semi permeable transparent dressing 21g safety hypodermic needle or 18G blunt filter needle 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 swab for culture (only if signs of infection) Clinical waste bag Sharps bin.
Timing	All non-tunnelled and tunnelled dialysis CVC exit sites are redressed every 7 days or as required if dressing is visibly loose or soiled.
Procedure	Explain the process to the child and parent and gain consent. Perform hand hygiene. Clean trolley/tray with disinfectant wipes. Perform hand hygiene. Open sterile dressing pack. Using ANTT, assemble sterile file, open all other equipment onto sterile field. Apply PPE, consider eye protection (visor). Attach syringe(s) to sterile needle draw up 20mls of 0.9% sodium chloride, expel all air, place on sterile field. Attach 10ml sterile syringe(s) to sterile needle draw up an appropriate volume of Tauralock500, expel all air, place in sterile field. Place sterile drape under catheter lumens. 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. Inspect exit site and surrounding skin for signs of phlebitis or infection. Apply mobiliser if appropriate. 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. ‘Scrub the cap’ - each CVAD cap for 30 seconds with 2% chlorhexidine and 70% isopropyl alcohol wipe and allow to dry. A separate wipe should be used for each lumen. Ensure clamps are closed. Remove CVAD catheter cap from red (access) lumen. Attach 10ml luer lock syringe to red lumen, unclamp and remove 5ml of blood-stained fluid. Apply clamp. Repeat previous 2 steps for the blue (return) lumen. Disconnect syringe and immediately attach 20ml syringe filled with 0.9% sodium chloride solution to red lumen, unclamp and flush lumen using a push/pause technique. Keep positive pressure on plunger. Apply clamp. Repeat for blue lumen. A smaller flush may be more appropriate. Seek advice. Disconnect syringe and immediately attach primed 10ml syringe with Taualock500 or taurolock urokinase to red lumen, unclamp and insert appropriate volume of lock into red lumen. Keep positive pressure on plunger. Apply clamp. Repeat for blue lumen. Disconnect syringe and immediately attach sterile CVAD catheter caps to both red and blue lumen. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene.
Aftercare	Record procedure and complete CVAD bundle and dialysis book. Ensure VAD is positioned correctly to ensure skin health is maintained.

ntDCVC removal (using a surgical ANTT® approach)

Statement	ntDCVC 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. This should only be carried out by competent practitioners.
Requirements	PPE (minimal consideration disposable apron and gloves) Clean tray or trolley Dressing pack Stitch cutter 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) Sterile hydrocolloid dressing Clinical waste bag Sharps bin.
Timing	When there is no further clinical need or infection of the device is suspected or proven.
Procedure	Explain the process to the child and parent and gain consent. The explanation should include a description of timed inspiration and breath holding. Patient MUST BE in bed lying flat in a Trendelenburg (head-down-tilt) position unless contraindicated – seek advice. Perform hand hygiene. Clean trolley or tray 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. Discard gloves and apply sterile gloves. Place the sterile drape under the CVAD to create a sterile field. Cleanse 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 the securing sutures. Ask patient to hold their breath and perform a Valsalva Manoeuvre. If Valsalva cannot be performed, the catheter should be removed on expiration. ** Increasing the intra thoracic pressure is different in a spontaneous breathing patient and a patient receiving positive pressure ventilation. (please see specific instructions below). As the ntDCVC is being withdrawn/removed, cover insertion site with a sterile swab from the dressing pack, applying gentle pressure at the insertion site as the catheter is being removed. Apply firm pressure immediately to insertion site until haemostasis is achieved. Cover the site with a hydrocolloid dressing, ensuring a good adherence of the dressing to the skin. After removal the ntDCVC should be inspected for integrity, length and damage. Discard all disposable equipment. Remove PPE and discard as healthcare waste. Perform hand hygiene. Patients may then be returned to a comfortable position.
Aftercare	Minimise activity for at least one hour post removal. Observe the patient’s PEWS/vital signs and 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 ntCVC removal and then dressed as required until site has healed. Record procedure and complete CVAD bundle. For femoral venous catheters: Nurse patient flat for 2 hours when 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. Air embolism is a significant risk if procedure not followed. If suspected, turn patient left side, head down (Trendelenburg position), administer 100% oxygen via non rebreathing mask and call 2222. Spontaneous Breathing/Non-Ventilated Patients/Continuous Positive Airway Pressure (CPAP) only/Pressure Support Ventilation (PSV) or Non-Invasive Ventilation (when Pressure Support (PS) set at zero): In these situations, the removal must be timed with expiration (because the intra thoracic pressure is at its highest). Instruct the patient to hold their breath and where possible perform a Valsalva Manoeuvre. If Valsalva cannot be performed, the catheter should be removed on expiration. Patient receiving Positive Pressure Ventilation (fully ventilated) PSV or NIV (when PS is set higher than zero): In these situations, the removal must be timed with inspiration (because the intra thoracic pressure is at its highest).

tDCVC removal

Removal of tunnelled DCVC 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 renal service. tDCVC’s are not removed within NHSA&A, referrals should be made to NHSGGC for removal.