For NHS North West CINS Guidelines... · Web view40 40 40 54 Disconnection of Ambulatory Chemotherapy (Infusor/ Infuser) from Central Venous Access Device (DST1) 54 54 Disconnection

Policy Number LCH-140

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.Part A – Information about this Document

Policy NameClinical Guidelines Intravenous Access Care and Maintenance for Adult Patients in hospital and at home

Policy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☒

Action No Change ☐ Minor

Change ☐ MajorChange ☐ New

Policy ☒ No LongerNeeded ☐

Approval

As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:a) complies with the latest statutory / regulatory requirements,b) complies with the latest national guidance,c) has been updated to reflect the requirements of clinicians and officers, andd) has been updated to reflect any local contractual requirements

Signature: Date:Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document New terminology when reading this Document

Part C – Additional Information Added (to be used with ‘Major Changes’ only)Section /

Paragraph NoOutline of the information that has been added to this document – especially where it may

change what staff need to do

Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)Accountable Director

Recommending Committee

Approving Committee

Next Review Date

LCH Policy Alignment Process – Form 1

SUPPORTING STATEMENTS This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESSAll Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of

abuse, or by professional judgement made as a result of information gathered about the child / adult;

knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they

have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your

role); ensuring contemporaneous records are kept at all times and record keeping is in strict

adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTSMersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

Clinical Guidelines

For NHS North West

Intravenous AccessCare and Maintenance for Adult

PatientsIn Hospital and at Home

Developed byCollaborative Intravenous Nursing

Service (CINS)

If you would like further information about using these guidelines, contact Mrs A Young 0151 706 3650

Version 11

Issue date September 2014 Review date due September 2016

the works herein in accordance with the Data Protection Act 1988.Policy review date 01/09/16

1Index Page

Background and Objectives 2

Terms of Reference 3

STC1 Care and Maintenance of a Skin Tunnelled Catheter 4

STC2 Skin Tunnelled Catheters - Saline Flush and Hepsal Lock 6

STC3 Skin Tunnelled Catheters – Blood sampling 9

STC4 Skin Tunnelled Catheters – Administration of antibiotics/infusion/additives 12

CVC1 Care and Maintenance of a non tunnelled Central Venous Catheter 17

CVC2 Central Non-Tunnelled Catheters - Saline Flush and Hepsal Lock 19

CVC3 Central Non-Tunnelled Catheters – Blood Sampling 22

CVC4 Central Venous Non-Tunnelled Catheters – Administration of antibiotics/infusion/ Additives

25

PL1 Care and Maintenance of a Peripheral Inserted Central Catheter (PICC) 30

PL2 Peripherally Inserted Central Catheter – Sodium Chloride Saline Flush 33

PL3 Peripherally Inserted Central Catheter – Blood Sampling 36

PL4 Peripherally Inserted Central Catheter – Administration of antibiotics/infusion/ additives

39

PM1 Care and Maintenance of a Peripheral Midline Catheter 45

PM2 Peripheral Midline - Saline Flush and Hepsal Lock 47

PM3 Peripheral Midline – Administration of antibiotics/infusion/additives 50

DST1 Disconnection of Ambulatory Chemotherapy Infusor from Central Venous Access Device

54

TIVAD1 Care and Management of an Implantable Venous Access Device 57

TIVAD2 Care and Management of an Implantable Venous Access Device 60

TIVAD3 Administration of antibiotics/infusion/additives via implantable port 63

PCN1 Care and Management of Peripheral cannula 66

NFS1 Changing a needle-free system 69

Trouble Shooting Guides 70

Care Plans 74

Appendix/ContributorsThe CINs group hereby assert their moral rights to 94

2

The CINs group hereby assert their moral rights tothe works herein in accordance with the Data Protection Act 1988.

Policy review date 01/09/16

Intravenous Access Care and MaintenanceBackground

“Every effort has been made to present accurate and up to date

information from the best and most reliable sources. However, the results

of caring for individuals depend on a variety of factors not under the

control of the authors of these documents. Therefore, neither the authors

nor any publishers assume responsibility for, nor make any warranty with

respect to the outcomes achieved from the guidance herein”.

The service provision for patients who require intravenous care and management has been

variable with no universally agreed competency based framework. It has been extremely

difficult for district nurses to obtain clarity about which protocol/procedures they should follow.

Several guidelines can be in circulation at any one time from different Trusts. As a result of

these inconsistencies the Collaborative Intravenous Nursing Service (CINS) was formed to

gained consensus for universally agreed guidelines, competencies, care plans and resources

for the Cheshire and Merseyside strategic Health Authority. The CINS group has since

developed into a network of lead nurses, key experts and others with a specific interest in IV

therapy. These leads have contributed to the development of these guidelines and have

consulted locally with key experts.

Key Objectives

To provide universal guidelines for care and maintenance of venous access devices, care plans and troubleshooting guidelines for members of the CINS network.

To provide a competency framework for individuals in caring and maintaining venous access devices

To provide a training programme.

To ensure that those individuals caring for venous access devices have received an annual update.

To develop an expert group that will ensure that the best evidence based practice is available.

3



CINS NetworkVenous Access Clinical GroupTerms of Reference

The purpose of the group is to ensure that all nurses with relevant competencies across Cheshire CINS network utilise universal guidelines, competencies and training.

To act as the primary source of advice on issues relating to the care and maintenance of venous access devices (VADs).

To provide a resource for the implementation, co-ordinated procedures and guidelines across the CINS network

To promote consistent clinical competencies for VADs across the CINS Network.

To collaborate with workforce and education stakeholders to promote consistent clinical competencies and ensure the availability of the VAD training programmes.

To ensure that there is a network of support for nurses involved in IV therapy.

To ensure that in development of CINS resources appropriate consultation across multi-agencies and multi-professional groups is sought.

Membership

All Hospital Trusts, Primary Care organisations and other relevant stakeholders within Cheshire and Merseyside North West Strategic Health Authority were invited to take part in the development of these guidelines.

All healthcare professions with an interest in IV therapy who are members of the CINs network.

Chair/Reporting

The chair will be a member of the group who is dually elected. The group will report to the Directors of Nursing Group within the region and to NHS North West.

Use of the Guidelines

This document contains several guidelines which can be utilised as required.

4



Care and Maintenance of a Skin Tunnelled Catheter (STC1)

EXIT DRESSING CHANGE (Weekly)

A

ction RationaleEquipment r e quired

Dressing Pack containing sterile towel and Gloves Surgical tape2% Chlorhexidine in 70% Isopropyl alcohol impregnated applicator ( SEPP) Chlorhexidine 2% wipe (e.g. sani cloth)Skin fixation device (e.g. Stat lock or grip lock) Semi- Permeable transparent IV dressing Alcohol hand rub or gelPlastic apron

Care of E x it site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose. Explain the procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and dried

thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn.

Maintain aseptic technique at all times.

To prevent/reduce patient anxiety.

To prevent infection.

Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment/trolley to patient.

Maintain safety.

To prevent infection and catheter contamination.

5



Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble- shooting guide.

Exit site dressings are important in preventing trauma and the extrinsic contamination of the site of entry (Jones 2004).

Decontaminate hands Open sterile pack and use a non-touch technique to place inner pack onto clean

working area. Open out sterile pack to create an aseptic field. Open remaining equipment using

a non touch technique, ensuring no contamination of aseptic field.

Loosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressing off, from the skin using an aseptic technique.

To avoid contamination of aseptic field. To allow for an aseptic environment for accessing intravenous catheter,and to reduce incidence of infection. Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001).To prevent accidental removal of the catheter and friction or trauma to skin surface.

Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the catheter. Clean around the catheter and exit site with Chlorhexidine 2% impregnated applicator. The solution should be applied with friction but should not be too vigorous or the

skin's natural defence may be destroyed. Using a Chlorhexidine 2% wipe, carefully clean the catheter from the exit site to

the part of the catheter that will be covered by the sterile dressing. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device (if required) Apply new dressing to exit site without touching the adhesive site. Remove the dressing towel Remove gloves. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley if used during the procedure with multi-surface detergent wipes. Wash hands. Document care on patient’s records.

Alcohol Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001)

Semi-permeable transparent IV dressings are well tolerated by patients (Campbell et al 1999, Treston-Aurand et al 1997, Wille 1993) and are easy to apply and remove (Wille 1997).

6



Skin Tunnelled Catheters – 0.9% Sodium Chloride and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (STC2) for weekly maintenance Flush

Action Rationale

Equipment Required

Dressing Pack containing sterile towel and glovesChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (sani cloth) x 310ml syringe x 2 (1 if using a prefilled saline syringe)10ml 0.9% Sodium Chloride (or 0.9% Sodium Chloride prefilled syringe) 5ml Heparin 10units/ml in 0.9% Sodium ChlorideOne blue needle/filter straw (for glass ampoules). Sharps containerSurgical tape Alcohol hand rub/gel Plastic apron

Needle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline

NB. 5ML HEPARIN SODIUM (10 UNITS/ML)FOR OPEN ENDED CATHETER

10ml syringes should always be used; smaller syringe sizes may damage the catheter (Hadaway 1998).

Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust

policy for the administration of medications. Before the procedure begins make sure that your hands are washed and dried



Reduce anxiety Patient compliance

Maintain asepsis and safety. Reduce risk of infection.To avoid contamination.To ensure that the procedure can be

7



Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all

packaging is intact and in date. Take equipment/trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.

exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble- shooting guide

Open sterile pack and use a non-touch technique to place inner pack onto clean working area.

Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a

non-touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and

place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,

rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe over a period of 30 seconds. Allow to dry.

Attach syringe with 0.9% Sodium Chloride flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter.

Remove the syringe and discard. If open ended skin tunnelled catheter repeat this procedure using syringe containing 5ml Heparin 10units/ml in 0.9% Sodium Chloride.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the

carried out safely.

To maintain a sterile field.

Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001).

There is no requirement to routinely withdraw blood and discard it prior to flushing (except prior to blood sampling although the first sample can be used for

8



catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice.

Wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients’ chest. Ensure that the catheter is secure and comfortable.

Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of sharps and waste as per organisational policy.

Wipe down the trolley (if used) with multi-surface detergent wipes Decontaminate hands Document care in patient’s records.

blood cultures (RCN 2010).

There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2010), therefore for routine flushing of a line withdrawal of blood is not required.

The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998).

Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000)

9



Skin Tunnelled Catheters – Blood Sampling (STC3)

Action RationaleEquipment Required

Dressing Pack containing sterile towel and glovesChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (Sani Cloth) x 310ml syringes x 4 (or appropriate size syringe to collect the blood sample) 10ml 0.9% Sodium Chloride for injection prefilled syringe (or a 10ml ampoule of 0.9% Sodium Chloride)5ml Heparin10units/ml in 0.9% Sodium Chloride One blue needle/filter straw.Sharps container Surgical tape Alcohol hand rub/gel Plastic apronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline

NB 5ML HEPARIN 10 UNITS/ML IN SODIUM CHLORIDE WITH OPEN ENDED CATHETER

10 ml syringes should always be used. Smaller syringe sizes may damage the

catheter (Hadaway 1998)





Reduce anxiety Patient complianceTo ensure that the procedure can be carried out safely.

Reduce risk of infection To avoid contamination

10



Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment /trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.



Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using

a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and

place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,

rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry.

Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml of blood from the catheter. Note if taking blood samples from a parenteral nutrition line or for INR sample at least 10-20mls of blood should be taken and disguarded before taking the sample (check local policy). If unable aspirate blood from the line attach the syringe containing the saline solution to the needle free system gently flush with 1-2mls

To maintain a sterile field.

Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001).

Check catheter patency. Remove any residual solution from catheter.

11



0.9% Sodium Chloride for injection (do not use force) then aspirate blood from catheter. Discard blood aspirated as per policy

Attach an empty syringe and withdraw amount of blood required for analysis. Attach syringe with 0.9% Sodium Chloride for injection flush and inject the flush using

a push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. If open ended skin tunnelled catheter repeat this

procedure using 5ml Heparin 10units/ml in 0.9% Sodium Chloride for injection. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the

catheter. The solution should flow easily. If resistance is felt refer to the trouble shooting guide or contact IV access team.

Wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients’ chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands Document care in patient’s records.


Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

12



Skin Tunnelled Catheters – Administration of IV medications/infusion (STC4)Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter.

A ction RationaleEquipment Required

Dressing pack containing sterile towel and glovesChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe 10ml syringes x 42 x 10ml 0.9% Sodium Chloride for injection prefilled syringes (or 2 x 10mls 0.9% Normal Saline ampoules)5ml Heparin10units/ml in 0.9% Sodium Chloride for injection Two blue needle/ filter straw.Sharps container Surgical tape Alcohol hand rub/gelAntibiotics/Infusion/additives as prescribed Plastic apron

NB 5ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER




policy for the administration of medications. Medication reconstitution should be performed in a clean clinical environment. This

may be performed in an area designated for drug preparation or next to the patient as part of this procedure.

Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn.


Ensures patient compliance and reduce anxiety

Reduce the risk of infection and contamination

Maintain asepsis.

13



Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all

packaging is intact and in date. Take equipment/ trolley to the patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.




a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and

place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Attach syringe with 0.9% sodium chloride for injection, aspirate enough blood to colour 0.9% Sodium Chloride solution then inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard.

If unable to aspirate blood from the line continue to administer prescribed medication

To check catheter patency and to remove residual solution from catheter. The RCN Standards for infusion Therapy state, “the nurse should aspirate the catheter and check for blood return to confirm patency prior to the administration of medications and/or solutions (INS 2000). On no account

14



unless this is a vesicant drug/infusion, in this case refer to algorithm on persistant withdrawal occlusion.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice.

Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If open ended skin tunnelled catheter and this is the final dose of treatment for the day,

repeat this procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency.

Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the

line in sterile gauze (gauze cot). Tape this to the patients’ chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the


should a vesicant drug or vesicant infusion be administered through a vascular access device where difficulty is experienced in withdrawing blood (Masoorli 2003).

Creates turbulence in catheter, preventing clotting in the catheter.

Maintains positive pressure and prevents backflow of blood into the catheter.


15

Algorithm persistent withdrawal occlusion (PWO)i.e. fluids can be infused freely by gravity but blood cannot be withdrawn from the device

Adapted from Standards for Infusion Therapy RCN

(2010)

Blood return is absent

Check equipment,

Position, clamps, kinking. etc

Blood return

obtained - use central venous

catheter as usual

F

lush central venous

catheter with 0.9% Sodium chloride in 10ml syringe using a brisk “push pause” technique. Check for

No

No

Proceed if happy to do

as long as there are no other complications

or pain

Blood return is still absent

Ask patient to cough, deep Breathe, change position, stand up or lie with foot of

the bed tipped up.Ascertain possible cause of

PWO



16SECONDARY CARE

ONLYThe following steps should

initially be done on admission or prior to drug

administration and documented in nursing

care-plan so that all staff are aware that patency has

been verifiedStep 1

Administer a 250ml normal saline “challenge” (unless

serum sodium≤ 120 mmol/l) via an infusion p

ump over 15 minutes to test for patency – the infusion will probably not resolve the lack of blood return (unless the patient has a high sodium or

fluid restricted go to step 2)If there have been no problems, therapy can be administered as normal.

If the patient experiences ANY discomfort or there is any unexplained problems then stop and seek medical advice. It may be necessary to verify tip location by chest X Ray.

ORStep 2 Instill Urokinase 12,500iu in 2 mls and leave for minimum of 2 hours.

After this time withdraw the urokinase and assess the catheter again.Repeat as necessary. If blood return is still absent, it may be

necessary to verify tip location by chest X Ray.The CINs group hereby assert their moral rights to

Yes

Yes



171. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of

central venous catheters, Journal of Hospital Infection, 47 Supplement S47 – S67

2. Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England

3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA

4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of Intravenous Nursing, 16 (2) 92-103

5. Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.

6. INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23 (6S) supplement

7. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing 20(4):201-206.

8. Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113- 121.

9. Pratt RJ et al (2006) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (epic 2). Thames Valley University, London.

10.RCN (2010) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III). In RCN Standards for Infusion (2005)

11.Masoorli S (2003) Extravasation injuries associated with the use of central venous access devices. Journal of vascular access devices. 21-23 Spring

18



Care and Maintenance of a non tunnelled Central Venous Catheter (CVC1) All lumens on a non-tunnelled access device should be flushed using an aseptic technique.


Action RationaleEquipment required

Dressing Pack containing sterile towel and Gloves Surgical tapeChlorhexidine 2% impregnated applicator (SEPP) Chlorhexidine 2% wipe (sani cloth)Semi-Permeable transparent IV dressing Alcohol hand rub or gel

Care of Exit site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose.

Explain the procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and dried



To prevent/reduce patient anxiety.

To prevent infection

Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packing is

intact and in date Take equipment/trolley to patient.


Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please

19



contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide.

Decontaminate hands Open sterile pack and use a non-touch technique to place inner pack onto clean working

area. Open out sterile pack to create an aseptic field. Open remaining equipment using a

non touch technique, ensuring no contamination of aseptic field.

Loosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressing off, from the skin.

To allow for a sterile environment for accessing intravenous catheter,and to reduce incidence of infection.

To prevent accidental removal of the catheter and friction or trauma to skin surface.

Aseptically remove the dressing Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the catheter exit site. Clean around the catheter and exit site Chlorhexidine 2% impregnated applicator

(SEPP). The solution should be applied with friction, but should not be too vigorous or the skin's natural defence may be destroyed.

Using a Chlorhexidine 2% wipe, carefully clean the catheter from the exit site to the part of the catheter that will be covered by the sterile dressing.

Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device (if required) Apply new dressing to exit site without touching the adhesive site. Remove the dressing towel Remove gloves. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands. Document care on patient’s records.

Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001).

Alcohol Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001).


20



Central Non-Tunnelled Catheters - Saline Flush and Hepsal Lock (CVC2)If each lumen of a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flush

Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 1Chlorhexidine 2% impregnated wipes x 310ml 0.9% Sodium Chloride for injection(Saline) prefilled syringes or a 10ml ampoule of 0.9% Normal Saline5ml Heparin 10units/ml in 0.9% Sodium Chloride 1 x blue needle/filter strawSharps container Surgical tape Alcohol hand rub/gel Plastic apronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline

NB 5ML HEPARINISED SALINE 10 UNITS/ML WITH OPEN ENDED CATHETER

10ml syringes should always be used; smaller syringe sizes may damage the catheter (Hadaway 1998).

Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy

for the administration of medications. Before the procedure begins make sure that your hands are washed and dried


Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is

Reduce anxiety Patient complianceTo ensure that the procedure can be carried out safely

Reduce risk of infection. To avoid contamination.

21



intact and in date. Take equipment /trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.

exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide



non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and

place near to but not on the sterile field. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter.

Remove the syringe and discard. Repeat flush now using Heparinised saline if required. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter.

The solution should flow easily. If resistance felt, refer to trouble shooting guide or contact the hospital team who placed the catheter for advice.

Clean the needle free connector again with a sanicloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to patient’s skin.

To maintain an aseptic field

Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001).There is no requirement to routinely withdraw blood and discard it prior to flushing (except prior to blood sampling although the first sample can be used for blood cultures (RCN 2005).There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2005), therefore for routine flushing of a line

22



Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down

the trolley that has been used during the procedure with multi-surface detergent wipes.

Decontaminate hands. Document care in patient’s records.

withdrawal of blood is not required. The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).10ml syringes should always be used; smaller syringe sizes may damage the catheter (Hadaway 1998).

23



Central Non-Tunnelled Catheters – Blood Sampling (CVC3) If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flushFor multi-lumen non-tunnelled catheters ideally one lumen should be used for blood sampling.

Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 32% Chlorhexidine impregnated wipes x 210ml 0.9% Sodium Chloride for injection, prefilled syringe (or 10ml ampoule of 0.9% Normal Saline)5ml Heparin 10units/ml in 0.9% Normal Saline One blue needle/filter straw. Sharps container Surgical tapeAlcohol hand rub/gel ApronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline


10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway 1998)


for the administration of medications. Before the procedure begins make sure that your hands are washed and dried


Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is

intact and in date. Take equipment/ trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.

Reduce anxiety Patient compliance Maintain safety.

Reduce risk of infection. To avoid contamination.

To ensure that the procedure can be carried out safely

24






non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required)

and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle/filter straw to the syringe. Place sterile towel as near as possible to the catheter. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up



Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml of blood from the catheter. If unable to do so attach the syringe containing the saline solution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride (do not use force) then aspirate blood from catheter. Discard blood aspirated as per policy. Note if taking blood samples from a parenteral nutrition line or for INR sample at least10-20mls of blood should be taken and disguarded before taking the sample (check local policy).

Attach an empty 10ml syringe and withdraw amount of blood required for analysis. Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a

To maintain an aseptic field


Check catheter patency. Remove any residual solution from catheter.

The pulsated flush creates turbulence

25



push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. Repeat flush now using Heparinised saline if required. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter.

The solution should flow easily. If resistance felt, refer to trouble shooting guide or contact IV access team.

Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to patients’ skin.




within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998). Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

26



Central Venous Non-Tunnelled Catheters – Administration of antibiotics/additives/infusions (CVC4)

Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter. If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flush

Action RationaleEquipment Required Dressing pack containing sterile towel and gloves 2% Chlorhexidine impregnated wipes x 210ml syringes x 4 (this will vary depending on amount of medication being administered).2 x 10ml 0.9% Sodium Chloride (saline) prefilled syringes (or ampoules) 5ml Heparin 10units/ml in 0.9% Sodium ChlorideTwo needles/ filter straws (this will vary depending on medication being administered).Sharps container Surgical tape Alcohol hand rub/gel Plastic apronAntibiotics/additive/infusion as prescribed





for the administration of medications. Medication reconstitution should be performed in a clean clinical environment. This may

be performed in an area designated for drug preparation or at the patient’s bedside as part of this procedure.

Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic

Reduce the risk of infection and contamination.

Ensures patient compliance and reduce anxiety

27



apron should be worn. Maintain aseptic technique at all times Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment/ trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.



Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non

touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required)

and place near to but not on the sterile field. Remove dust cap from antibiotic vial/vials and place near to but not on sterile the field. Ensure easy access to the needle free system. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Reconstitute antibiotics in accordance with manufacturer’s guidelines (as appropriate)

Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Maintain asepsis.

28



Attach syringe with 0.9% sodium chloride for injection, aspirate enough blood to colour 0.9% Sodium Chloride solution then inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard.

If unable to aspirate blood from the line continue to administer prescribed medication unless this is a vesicant drug/infusion, in this case refer to algorithm on persistant withdrawal occlusion.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice

Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If this is the final dose of treatment for the day, repeat this procedure using 5ml Heparin

10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency.

Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the line

in sterile gauze (gauze cot). Tape this to the patient’s chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the


To check catheter patency and to remove residual solution from catheter.The RCN Standards for infusion Therapy state, “the nurse should aspirate the catheter and check for blood return to confirm patency prior to the administration of medications and/or solutions (INS 2000). On no account should a vesicant drug or vesicant infusion be administered through a vascular access device where difficulty is experienced in withdrawing blood (Masoorli 2003).

Creates turbulence in catheter, preventing clotting in the catheter.



29


Adapted from Standards for Infusion Therapy RCN

(2010)


Check equipment,


Blood return


catheter as usual

F

lush central venous


No

No



or pain


Ask patient to cough, deep breathe, change position, stand up or lie with foot of


PWO



30SECONDARY CARE

ONLYThe following steps should

initially be done on admission or prior to drug

administration and documented in nursing

care-plan so that all staff are aware that patency has

been verifiedStep 1

Administer a 250ml normal saline “challenge” (unless

serum sodium≤ 120 mmol/l) via an infusion p

ump over 15 minutes to test for patency – the infusion will probably not resolve the lack of blood return (unless the patient has a high sodium or

fluid restricted go to step 2)If there have been no problems, therapy can be administered as normal.

If the patient experiences ANY discomfort or there is any unexplained problems then stop and seek medical advice. It may be necessary to verify tip location by chest X Ray.


After this time withdraw the urokinase and assess the catheter again.Repeat as necessary. If blood return is still absent, it may

be necessary to verify tip location by chest X Ray.The CINs group hereby assert their moral rights to

Yes

Yes



3112.Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of

central venous catheters, Journal of Hospital Infection, 47 Supplement S47 – S67

13.Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England

14.Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA

15.Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of Intravenous Nursing, 16 (2) 92-103

16.Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), 40.


18.Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing 20(4):201-206.

19.Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113- 121.

20.Pratt RJ et al (2006) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (epic 2). Thames Valley University, London.

21. INS (2000) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III). In RCN Standards for Infusion (2005)


32



Care and Maintenance of a Peripheral Inserted Central Catheter (PICC). (PL1)


A

ction RationaleEquipment r e quired Dressing Pack containing sterile towel and Gloves Surgical tape

2% Chlorhexidine impregnated applicator (SEPP) Chlorhexidine impregnated wipe (sani cloth) Semi-Permeable transparent IV dressingAlcohol hand rub or gelSkin fixation device (e.g. stat-lock or grip lock) Plastic apron

Care of E x it site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose.



Maintain aseptic technique at all times



Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is

intact and in date. Take equipment/ trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.

exudate from exit site. Check observation and VIAD chart for any indications of infection

To prevent/reduce patient anxiety Maintain safetyTo minimise the risk of infection and catheter contamination.

33



or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide.

Decontaminate hands Open sterile pack and use a non-touch technique to place inner pack onto clean

working area. Open out sterile pack to create an aseptic field. Open remaining equipment using a non

touch technique, ensuring no contamination of aseptic field.

Loosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressing off, from the skin. Dressing should be removed from hand to elbow to prevent accidental catheter removal. Be aware that the fixation device may also come off with the dressing.

To allow for a sterile environment for accessing intravenous device.

Chlorhexidine based solutions are recommended (in alcohol) dependent on the availability and catheter manufacturers. Recommendations (DOH 2001).

To prevent accidental removal of the catheter and friction or trauma to the skin surface

Aseptically remove the dressing. Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the PICC catheter. Clean around the catheter and exit site with Chlorhexidine 2% impregnated applicator

(SEPP). The solution should be applied with friction but should not be too vigorous or the

skin's natural defence may be destroyed. Using a Chlorhexidine 2% wipe (sani cloth), carefully clean the catheter from the exit

site to the part of the catheter that will be covered by the sterile dressing. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device. Apply new dressing to exit site. Remove the dressing towel Remove gloves and wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

Alcoholic Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001)


34



trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands. Document care on patient’s records.

35



Peripherally Inserted Central Catheter – 0.9% Sodium Chloride for injection and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (PL2) for weekly maintenance Flush

Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 1Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe 10ml 0.9% Sodium chloride for injection prefilled syringeOne blue needle/filter straw. Sharps container Surgical tapeAlcohol hand rub Plastic apronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline

NB 5ML HEPARIN 10 UNITS/ML in 0.9% SODIUM CHLORIDE WITH OPEN ENDED CATHETER

10ml syringes should always be used, smaller syringe sizes may damage the catheter (Hadaway 1998)




Maintain aseptic technique at all times. Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment/trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection, e.g.

exudate from exit site. Check observation and VIAD chart for any indications of

Reduce anxiety and improve patient compliance

Maintain asepsis.

Reduce risk of infection. To avoid contamination and to reduce risk of infection

36



infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble- shooting guide



a non touch technique, ensuring no contamination of aseptic field. Ensure easy access to the needle free system. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if

required) and place near to but not on the sterile field. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Place sterile towel as near as possible to the catheter Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,



Remove the syringe and discard. If open ended PICC repeat this procedure using syringe containing 5ml Heparin 10units/ml in 0.9% Sodium Chloride.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact IV access team.

Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patient’s arm.

Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands.


There is no requirement to routinely withdraw blood and discard it prior to flushing (except prior to blood sampling although the first sample can be used for blood cultures (RCN 2005).

There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2005), therefore for routine flushing of

37



Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes

Decontaminate hands Document care in patient’s records.

a line withdrawal of blood is not required.

The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

38



Peripherally Inserted Central Catheter – Blood Sampling (PL3)

A

ction RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 4Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (Sani Cloth) x 210ml 0.9% Sodium Chloride for injection prefilled syringe (or ampoule) One green needle/filter straw. Sharps containerSurgical tape Alcohol hand rubNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 CINs guideline






Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment/ trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.

exudate from exit site. Check observation and VIAD chart for any indications of


Maintain asepsis.

Reduce risk of infection. To avoid contamination and to reduce risk of infection

39



infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble- shooting guide



a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if

required) and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle/filter straw to the syringe. Place sterile towel as near as possible to the catheter. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up



Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml of blood from the catheter. If unable to do so attach the syringe containing the saline solution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride (do not use force) then aspirate blood from catheter. Discard blood aspirated as per policy. Note if taking blood samples from a parenteral nutrition line or for INR sample at least 10-20mls of blood should be taken and disguarded before taking the sample (check local policy).

Attach an empty 10ml syringe and withdraw amount of blood required for analysis. Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using

a push/pause action, clamping as the last ml of solution is instilled into the catheter.

Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001)


Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

40



Remove the syringe and discard. If open ended PICC, repeat this procedure using 5ml Heparinised saline lock.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance felt, refer to trouble shooting guide or contact IV access team.

Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to patients’ skin.




41



Peripherally Inserted Central Catheter – Administration of antibiotics/additives/infusion (PL4)Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter.

Action RationaleEquipment Required Dressing pack containing sterile towel and gloves GlovesChlorhexidine impregnated wipes x 2 (sani cloth)10ml syringes x 3 (may vary depending on amount of medication being administered)2 x 10ml 0.9% Sodium chloride (saline) prefilled syringes (or ampoules)One blue needle/ filter straw (may vary depending on amount of medication being administered)Sharps container Surgical tape Alcohol hand rub Plastic apronAntibiotics/additives/infusion as prescribed

NB 5ML HEPARINISED SALINE 10UNITS/ML FOR OPEN ENDED CATHETER




policy for the administration of medications. Medication reconstitution should be performed in a clean clinical environment. This

may be performed in an area designated for drug preparation or at the patient’s bedside as part of this procedure.


Maintain aseptic technique at all times

Ensures patient compliance and reduces anxiety

To minimise risks of infection and contamination.

Maintain asepsis.

42



Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all

packaging is intact and in date. Take equipment trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.




a non touch technique, ensuring no contamination of aseptic field. Ensure easy access to the needle free system. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if

required) and place near to but not on the sterile field Remove dust cap from antibiotic vial/vials and place near to but not on sterile the field. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Reconstitute antibiotics in accordance with manufacturer’s guidelines (as appropriate) Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Flush catheter with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard.

Chlorhexidine based solutions are recommended (in alcohol) dependent on the availability and catheter manufacturers recommendations (DOH 2001).

To check catheter patency and to remove residual solution from catheter.

The pulsated flush creates turbulence

43



NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact IV access team.

Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If open ended PICC and this is the final dose of treatment for the day, repeat this

procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency.

Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the

line in sterile gauze (gauze cot). Tape this to the patients’ chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the


within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

42



Adapted from Standards for

Infusion

The C


Check equipment,


Blood return


catheter as usual

F

lush central venous


No

No



or pain


Ask patient to cough, deep breathe, change position, stand up or lie with foot of


PWO

43


INs group hereby assert their moral rights to

SECONDARY CARE ONLYThe following steps should initially be done on admission or prior to

drug administration and documented in nursing care-plan so that all staff are aware that patency

has been verifiedStep 1

Administer a 250ml normal saline “challenge” (unless serum sodium

– the infusion will probably not resolve the lack of blood return (unless the patient has a high sodium or fluid restricted go to step 2)

If there have been no problems, therapy can be administered as normal.If the patient experiences ANY discomfort or there is any

unexplained problems then stop and seek medical advice. It may be necessary to verify tip location by chest X Ray.


After this time withdraw the urokinase and assess the catheter again.Repeat as necessary. If blood return is still absent, it may be

necessary to verify tip location by chest X Ray.Therapy RCN (2010) the works herein in accordance with the Data Protection Act 1988.

Yes


Yes



44

References

1. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of central venous catheters, Journal of Hospital Infection, 47 Supplement S47 – S67





6. Infection Control Nurses Association (2001) Guidelines for Preventing Intravascular Catheter-related Infection.


8. Todd J (1998) Peripherally inserted central catheters. Professional Nurse 13(5) 297-302

9. Jones A (2004) Dressings for the Management of Catheter Sites – A review. JAVA, Vol. 9 No 1, 1-8.

10.Campbell H, Carrington M (1999) Peripheral IV cannula dressings: advantages and disadvantages. British Journal of Nursing, 8(21):1420-1422, 1424-1427


12.Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113- 121.

13. INS (2000) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III) In RCN Standards for Infusion (2005).

45




45



Care and Maintenance of a Peripheral Midline Catheter (PM1)


Action RationaleEquipment requiredDressing Pack containing sterile towel and Gloves Surgical tapeChlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated applicator (SEPP)Semi-Permeable transparent IV dressing Alcohol hand rub or gelSkin fixation device (e.g. stat-lock or grip look) Plastic apron.Care of Exit site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose.






Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packing is

intact and in date. Take equipment /trolley to patient.

To prevent/reduce patient anxiety Maintain safety and reassure patient.


Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection

46



or compl

ications. Ensure the intravenous access device has been comfortable and

pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide.

Decontaminate hands

To allow for a sterile environment for accessing intravenous catheter.

To reduce incidence of infection

To prevent accidental removal of the catheter and friction or trauma to skin surface.

Aseptically remove the dressing. Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the midline catheter. Clean around the catheter and exit site with Chlorhexidine 2% impregnated

applicator (SEPP). The solution should be applied with friction but should not be too vigorous or the

skin's natural defence may be destroyed. Using a Chlorhexidine 2% wipe (sani cloth), carefully clean the catheter from the

exit site to the part of the catheter that will be covered by the sterile dressing. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device. Apply new dressing to exit site without touching the adhesive site. Remove the dressing towel Remove gloves and wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down


Decontaminate hands.

Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001)

Alcoholic Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001)


47



Peripheral Midline - 0.9% Sodium Chloride and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (PM2) (At least once daily, more frequently if required) It is not always possible to aspirate blood from a peripheral midline, as the lumen of the catheter maybe too small. If using a 2.5fr device blood withdrawal is not always possible.

A

ction RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 12% Chlorhexidine impregnated wipe x 2 (Sani cloth)10ml 0.9% Sodium Chloride for injection prefilled syringes(or ampoules) 5mls Heparin 10units/ml in Sodium ChlorideOne Blue needle/filter straw. Sharps containerSurgical tape Alcohol hand rub Plastic apronNeedle free I/V access connector change as per manufacturer’s guidelines see NSF1 Cins guideline

N B 5 M L H E P A R INISED S A L I N E 10 UN I T S / M L F OR OP EN E ND ED C A TH E T ER





Maintain aseptic technique at all times. Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date.


Maintain asepsis.

Reduce risk of infection.

48



Take equipment/trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection, e.g.




a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if

required) and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Place sterile towel as near as possible to the catheter Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard.

If open ended midline repeat this procedure using syringe containing 5ml Heparin 10units/ml in 0.9% Sodium Chloride.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the device.


The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998).Positive pressure within the lumen of the catheter should be maintained to

49



Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients’ arm.

Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes Decontaminate hands Document care in patient’s records.

prevent reflux of blood (INS 2000).

50



Peripheral Midline – Administration of antibiotics/infusion/additives (PM3) Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion.

A

ction RationaleEquipment Required Dressing pack containing sterile towel and gloves Chlorhexidine impregnated wipes x 210ml syringes x 3 (may vary depending on amount of medication being administered) 2 x 10ml 0.9% Sodium chloride (saline) prefilled syringes (or ampoules)5ml Heparin 10units/ml in 0.9%Sodium ChlorideOne green needle/ filter straw (may vary depending on amount of medication being administered)Sharps container Surgical tape Alcohol hand rub Plastic apronAntibiotics/additives/infusion as prescribed

NB 5ML HEPARINISED SALINE 10UNITS/ML FOR OPEN ENDED CATHETER

10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway

1998)





Maintain aseptic technique at all times Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is

Reduce the risk of infection and contamination


Maintain asepsis.

Reduce the risk of infection and contamination.

51



intact and in date. Take equipment trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g.




non touch technique, ensuring no contamination of aseptic field. Place sterile towel as near as possible to the catheter. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required)

and place near to but not on the sterile field Remove dust cap from antibiotic vial/vials and place near to but not on sterile the field. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up

5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Reconstitute antibiotics in accordance with manufacturer’s guidelines (as appropriate) Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Attach syringe with 0.9% sodium chloride for injection, inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. If using a 2.5 fr midline blood return is not possible. Remove the syringe and discard.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide

To avoid contamination


The pulsated flush creates

52



or contact IV access team. Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If open ended midline and this is the final dose of treatment for the day, repeat this

procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency.

Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the line

in sterile gauze (gauze cot). Tape this to the patients’ chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes. Decontaminate hands. Document care in patient’s records.

turbulence in catheter, preventing clotting in the catheter.


53

References

1. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of central venous catheters, Journal of Hospital Infection, 47 Supplement S47 – S67






7. Todd J (1998) Peripherally inserted central catheters. Professional Nurse 13(5) 297-302

8. Jones A (2004) Dressings for the Management of Catheter Sites – A review. JAVA, Vol. 9 No 1, 1-8.

9. Campbell H, Carrington M (1999) Peripheral IV cannula dressings: advantages and disadvantages. British Journal of Nursing, 8(21):1420-1422, 1424-1427.


11.Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2):113- 121



54Disconnection of A m bulat o r y Chemothe r a p y (In f usor/ Infuser) f rom Central V enous A ccess D e v i c e ( D S T 1)



Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 2 or 20ml syringe x 1Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (Sani Cloth) 20ml 0.9% Sodium Chloride for injection prefilled syringe (or ampoules)5ml Heparin10units/ml in 0.9% Sodium Chloride One blue needle/filter strawSharps container Surgical tape, Alcohol hand rub, Needle-free system Plastic apronPlastic bag for empty cytotoxic chemotherapy infusor Luer lock stopper for Infusor

HEPARINISED SALINE WITH OPEN ENDED CATHETER


Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for

the administration of medications. Before the procedure begins make sure that your hands are washed and dried thoroughly and

that they continue to be decontaminated during the procedure. A plastic apron should be worn.

Maintain aseptic technique at all times Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is

intact and in date. Take equipment trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate


Reduce the risk of infection, to avoid contamination

To maintain asepsis

Luer lock stopper will prevent leakage of chemotherapy from infusor this is now a sealed unit

55



from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide.



touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required) and

place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Place sterile towel as near as possible to the catheter Draw up 20mls Normal Saline into a 20ml syringe and place on sterile field. Draw up 5ml

Heparinised Saline into 10ml syringe (if required) and place on sterile field. Place sterile towel as near as possible to the catheter. Hold the catheter with sterile gauze; disconnect Infusor from the access device. Apply

luer lock stopper to the end of the Infusor tubing and seal it in a plastic bag clearly labelled cytotoxic waste.

Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry.

Attach syringe with 0.9% sodium chloride for injection, and flush the catheter with 20mls of 0.9% Normal saline using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard.

If open ended catheter and this is the final dose of treatment for the day, repeat this procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency.

Remove the syringe and discard

56



NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the device.

Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients’ chest/arm.

Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley

that has been used during the procedure with multi-surface detergent wipes. Decontaminate hands. Document care in patient’s records.

57



58



Care and Management of Totally Implanted Venous Access Device (TIVAD) e.g. Port-a-Cath (TIVAD1) 1.9% Sodium Chloride for injection flush and Heparin 100 iu/ml in 0.9% Sodium Chloride for injection Lock Heparin strengths may vary according to the frequency of the flushes required, refer to local policy

Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves x2 10ml syringe x 1Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated applicator x 2 (Chloraprep)10ml 0.9% Sodium Chloride for injection prefilled syringes (or ampoules) 4ml Heparin 100iu/ml in 0.9% Sodium Chloride for injection.One Blue needle/filter straw Sharps containerSurgical tape Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free systemHighly permeable dressing and securing device if receiving therapy other than for flushingPlastic apron Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for



Maintain aseptic technique at all times. Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging is

intact and in date. Take equipment/trolley to patient. . Inspect the catheter exit site for signs of skin discolouration or signs of infection, e.g. exudate

from exit site. Check observation and VIAD chart for any indications of infection or



To maintain asepsis

59



complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide



touch technique, ensuring no contamination of aseptic field. Ensure easy access to the needle free system. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near

to but not on the sterile field Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 4ml

Heparinised Saline 100iu/ml into 10ml syringe and place on sterile field.

Place sterile towel as near as possible to the catheter insertion site. Prime the non-coring needle device including its tubing with 0.9% Sodium Chloride and

clamp extension tube, remove syringe. Remove anaesthetic cream if used, locate septum of TIVAD by palpation, remove gloves. Decontaminate hands, then apply new pair of gloves Clean the skin covering the TIVAD with Chlorhexidine Gluconate 2% in 70% Isopropyl

alcohol impregnated applicator (Chloraprep). Allow to dry. Remove needle cover from non-coring needle device. Insert the non-coring needle at 90-

degree angle through the skin into the septum of the TIVAD until the needle comes into contact with the metal backing.

Needle free device must be cleaned prior to reattaching syringe thoroughly scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe over a period of 30 seconds. Allow to dry.

60



Attach syringe with 0.9% Sodium Chloride flush and aspirate enough blood to colour the solution, then inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter.

If there is no flash back of blood or if there is swelling around the TIVAD site assess for correct needle placement, remove the needle and re-access.


Following successful saline flush, repeat the flushing procedure using the 4mls of Heparin sodium (100 iu/ml).

If TIVAD was accessed for flushing purposes only, remove the needle and apply pressure over puncture site for a few minutes until bleeding stops.

If the needle is to remain in situ ensure the needle is secured using steri-strips and appropriate semi permeable transparent IV dressing.

Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patient’s arm/chest.

Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley

that has been used during the procedure with multi-surface detergent wipes Decontaminate hands Document care in patient’s records.

60To t al l y Impl a n t ed V e nous A ccess De v i c e ( T I V A D ) e.g. P or t - a - Cath Blood sampling ( TI V A D2)



Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves x2 10ml syringes x 3,Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated applicator x 2 (Chloraprep)Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipes x 2 (Sanicloth) 10ml 0.9% Sodium Chloride for injection prefilled syringes (or ampoules)4ml Heparin 100iu/ml in 0.9% Sodium Chloride One blue needle/filter strawSharps container Surgical tape Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free system Plastic apronSemi-permeable transparent IV dressing and securing device if receiving therapy other than for flushing Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for




intact and in date. Take equipment/trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection, e.g. exudate

from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free.



To maintain asepsis

61



Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide


Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch

technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near

to but not on the sterile field Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 4ml

Heparinised Saline 100iu/ml into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter insertion site. Prime the non-coring needle device including its tubing with 0.9% Sodium Chloride and


alcohol impregnated applicator (Chloraprep). Allow to dry. Repeat with second Chloraprep, allow to dry. Remove needle cover from non-coring needle device. Insert the non-coring needle at 90-

degree angle through the skin into the septum of the TIVAD until the needle comes into contact with the metal backing.

Needle free device must be cleaned prior to reattaching syringe – thoroughly scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe over a period of 30 seconds. Allow to dry.

Attach empty 10ml syringe unclamp and aspirate 3-5ml of blood. If there is no flash back of blood or if there is swelling around the TIVAD site assess for correct needle placement,

62



remove the needle and re-access. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter.

The solution should flow easily. If resistance felt refer to trouble shooting guide or contact IV access team.

Clamp catheter and remove the syringe and discard the sample. If unable to obtain blood flush the catheter as directed below. Using a second syringe, take amount of blood required for analysis then flush the port as directed below.


Following successful saline flush, repeat the flushing procedure using the 4mls of Heparin sodium (100 iu/ml).


If the needle is to remain in situ ensure the needle is secured using steri-strips and appropriate highly permeable dressing.


Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley

that has been used during the procedure with multi-surface detergent wipes Decontaminate hands Document care in patient’s records.

63



Totally Implanted Venous Access Device (TIVAD) e.g. Port-a-Cath Administration of antibiotics/infusion/additives (TIVAD3) Heparin strengths may vary according to the frequency of the flushes required, refer to local policy

Action RationaleEquipment Required Dressing Pack containing sterile towel and gloves x2 10ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated applicator 10ml 0.9% Sodium Chloride for injection prefilled syringe or ampoule5ml Heparin 10units/ml in 0.9% Sodium Chloride for injection. Two green needles/filter straw. Sharps containerSurgical tape, Alcohol hand rubNon coring needle (e.g. Huber or gripper needle) with needle free systemHighly permeable dressing and securing device if receiving therapy other than for flushingPlastic apronAntibiotics/additives/infusion as prescribed






intact and in date.



To maintain asepsis

64



Take equipment/trolley to patient. . Inspect the catheter exit site for signs of skin discolouration or signs of infection, e.g.




non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and

place near to but not on the sterile field Remove dust cap from antibiotic vial/vials and place near to but not on sterile the field. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml

Heparinised Saline into 10ml syringe and place on sterile field. Reconstitute antibiotics in accordance with manufacturer’s guidelines (as appropriate) Place sterile towel as near as possible to the catheter insertion site. Prime the non-coring needle device including its tubing with 0.9% Sodium Chloride and


alcohol impregnated applicator (Chloraprep). Allow to dry. Repeat with second Chloraprep, allow to dry.

Remove needle cover from non-coring needle device. Insert the non-coring needle at 90- degree angle through the skin into the septum of the TIVAD until the needle comes into contact with the metal backing.

Needle free device must be cleaned prior to reattaching syringe – thoroughly scrub the

65



hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe over a period of 30 seconds. Allow to dry.

Attach syringe with 0.9% Sodium Chloride, aspirate enough blood to colour the solution and inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard.

If there is no flash back of blood or if there is swelling around the TIVAD site assess for correct needle placement, remove the needle and re-access.


Following successful 0.9% Sodium Chloride for injection flush, administer antibiotics/infusion/additives as prescribed following local Trust Policy

Flush the catheter again with the appropriate volume of 0.9% Sodium Chloride for injection, using a push/pause action, clamping as the last ml of the solution is instilled into the catheter

Repeat the flushing technique using 5mls of Heparin 10 units/ml in 0.9% Sodium Chloride, using a push/pause action, clamping as the last ml of the solution is instilled into the catheter


If the needle is to remain in situ ensure the needle is secured using steri-strips and appropriate highly permeable dressing.


Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes Decontaminate hands Document care in patient’s records

66



Flushing and administration of IV medication via Peripheral Cannula (PCN1)

*All peripheral cannulas should be assessed every 8 hours using a cannula site assessment form as per organisational policy.*They require at least a 5ml flush of 0.9% Sodium Chloride for injection before and after the administration of medications.*Syringes smaller than 5ml should be avoided where possible as they can exert excessive force and cause trauma.*Three way taps should not be used on peripheral cannulas, if required, extension sets with needle free systems must be used.

*Administration sets should be changed as per manufacturer’s guidelines . Infusion sets used for blood products, blood and lipid emulsion (TPN), which should be changed up to a maximum of 24 hours. Change giving set immediately upon suspected contamination or when the integrity of the product or system has been compromised.* A semi permeable dressing should be used at all times to secure the cannula.

A

ction RationaleEquipment Required Patients drug prescription and administration record Dressing Pack containing sterile towel and gloves x1 10ml syringes x 2Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol10ml 0.9% Sodium Chloride for injection prefilled syringe (or ampoules) IV medication to be administeredOne blue needle/filter straw. Sharps container Alcohol hand rubSemi-permeable transparent IV dressing Plastic apron



be performed in an area designated for drug preparation or at the patient’s bedside as part



67



of this procedure. Before the procedure begins make sure that your hands are washed and dried thoroughly

and that they continue to be decontaminated during the procedure. A plastic apron should be worn.

Maintain aseptic technique at all times Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging

is intact and in date. Take equipment/ trolley to patient. Inspect the cannula exit site for signs of skin discolouration, inflammation or any signs

of infiltration of fluid in tissues (using a phlebitis score tool). Ensure the intravenous access device has been comfortable and pain free. If complications evident do not use cannula, remove, document and resite cannula.



non touch technique, ensuring no contamination of aseptic field. If a bolus is to be administered then the vial should also be placed next to aseptic field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Snap the top from ampoules of Normal Saline 0.9% and place near to but not on

the sterile field Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 5mls Normal Saline into a 10ml syringe and place on sterile field and repeat. Reconstitute antibiotics in accordance with manufacturer’s guidelines (as appropriate) Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing

To maintain asepsis

To prevent needle stick injury

To prevent contamination

To ensure catheter patency and prevent complications associated with extravasation.

68



from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry.

Attach syringe with 0.9% sodium chloride for injection, inject 5ml flush using a push pause action clamping as the last ml of the solution is instilled into the cannula. Remove the syringe and discard.

NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact IV access team.

Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush cannula again with 5ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. Clean the needle free connector again with a sani cloth and allow to dry. Ensure that the cannula is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the

trolley that has been used during the procedure with multi-surface detergent wipes. Decontaminate hands. Document drug administration in in-patients records. Record cannula site assessment as per organisational policy.

69



Changing a Needle-free Connector (NFS1)

This procedure should be carried out in combination with routine line flushing. The frequency of the change of the Needle Free connector is determined by the number of uses, with reference to the manufacturer’s guidelines.

Action RationaleEquipment Required

Needle-free I/V access connector.

In conjunction with line flushing procedure:

Maintain aseptic technique at all times Clamp the catheter. Remove the needle free connector and discard. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe,


Connect the new needle-free system to the catheter securely.


70



Trouble Shooting Guide

May 2012

For NHS North West

Intravenous Access Care and Maintenance

In Hospital and at Home


Services (CINS)

71



EXIT SITE INFLAMMATION/PHLEBITIS

PHLEBITIS: PAINFUL INFLAMMATION ALONG VENOUS PATH IN WHICH VASCULAR ACCESS DEVICE IS PLACED

Signs & Symptoms

UnresolvedResolved

Action

Raised temperature Complaints of pain on flushing or

infusing. Vein hard on palpation Swelling at and above exit site Change in colour or tenderness at site

or along the vein. Exudate present at IV exit site Raised WBC

PROCEED WITH CAUTION AS

LONG AS THERE ARE NO OTHER

COMPLICATIONS OR PAIN

Monitor for signs of infection and take swab from exit site ifexudate presentRe-site cannula using larger vein above original site, avoiding joints to avoid further episodes of phlebitisSeek medical advice or contact clinical nurse specialistIf worsening then possible removal of VAD following discussion with specialist nurse or doctor

Increase

volume of diluent in case of chemical phlebitis and

administer at a slower rate, seek advice from pharmacy Advise patient to apply hot/cold compresses to affected area Redress and secure device using skin fixation device and

72



INFILTRATION AT VASCULAR ACCESS DEVICE SITE

Signs & Symptoms

Unresolved

Resolved

Actions

Burning sensation or swelling in subcutaneoustissue BlanchingBurning or discomfort at IV site Cool skin around IV siteSlow or continuing flow rate even when vein is occludedSwelling at and above the IV site Tight feeling at the IV siteNeck swelling

S

top the infusion immediately

Elevate limb to reduce oedema (if peripheral line) Remove VAD and apply pressure Re-site VAD above affected site Seek medical help if evidence of infiltration Advise patient to seek medical help if they experience

CONTINUE TREATMENT USING NEWLY SITED VAD

MONITORING CONTINUALLY FOR SIGNS OF

EXTRAVASATION

IF SYMPTOMS PERSISTS FOLLOWING REMOVAL OF

CANNULA, SEEK MEDICAL HELP OR URGENT ADVICE

FROM IV NURSE SPEVIALIST.

73



SYSTEMIC INFECTION Signs & Symptoms

PROCEED WITH CAUTION AS LONG AS

THERE ARE NO OTHER

COMPLICATIONS OR PAIN

Unresolved

Seek advice from IV specialist nurse, physician and Medical Microbiology

Assess need for VAD and patient's immune system Swab catheter site, any wound, sputum and urine Line lock to salvage line if clinically well. Consult specialist nurse or

seek medical help.

M

onitor site daily

Continue to use strict asepsis and always use needle-

Resolved

Actions

Fever and chills without other apparent reasonMalaiseNausea and vomiting Low grade pyrexiaUnresponsive to broad spectrum antibiotics HeadacheMay be no evidence of sepsis at catheter site Raised WBC and Raised CRPMay be discharge from exit site High suspicion of infection

74



Care Plans

September 2014

For NHS North West

Intravenous Access Care and Maintenance

In Hospital and at Home


Services (CINS)

75



FOR CARE OF PERIPHERAL VENOUS CANNULA.

The care plan is designed to be used in conjunction with CINS Guidelines for vascular devices.

Manufacturer’s specific recommendations should be noted and adhered to by individual practitioners.

Patient addressograph label / patient name

numbering.Identify site/s by

SITE NUMBER

DATE TIME COLOUR/GAUGE

REASON FOR SITING

CONSENTY/N

SIGNED REMOVED DATE

SIGNED

Type of device Risks Actions Variations / Comments SIGN

76



PERIPHERAL VENOUS CANNULA

Infection due to loss of skin integrity

Site clean and protected with sterile dressing as per CINS guidelines.

Minimum of 8 hourly inspection of site for signs of inflammation or infection.

Observe patient for signs of line infection (VIP score)

When VIP score 2 or above remove promptly.

Ensure administration lines are changed in line with local policy.

Replace any infusates with additives and their administration lines at 24hrs if constituted in ward environment.

Label infusion lines with date for renewal.

Air embolus Recommend all attachments are needle free devices and are securely fastened. This guideline does not promote the use of 3 way taps.Change needle free systems as indicated by manufacturers instructionsEnsure air dispelled from medication/flushes/ infusates prior to administration.Occlusion of lumen. Maintain patency via 0.9% Sodium Chloride for injection flushes as per CINS guidelines, post drug/infusion administration.

Ensure compatibility of drugs/infusates to avoid precipitation.

If difficult to flush then remove/re-assess.Bleeding from site / line itself.

Observe for signs of bleeding from site.

77



Upon removal of cannula ensure adequate pressure is applied to site for cessation of bleeding.

If bleeding problematical check clotting times.Line displacement Check each time line accessed for signs of

displacement (extravasation and/or infiltration). Remove immediately if displaced.

Anchor lines to avoid accidental displacement Using fixation devices as in

Line in situ when no longer required.

Ensure prompt removal when line no longer required.

78



PATIENT CARE PLAN FOR CARE OF NON TUNNELLED CENTRAL LINE.

This care plan applies to patients with the following central lines:

subclavian jugular femoral



Patient addressograph label/patient name

REASON FOR INSERTION…

DEVICE TYPE…

DATE OF INSERTION…

Named Nurse or Advisor details….

Review Dates:

Date Comments

79



Type of device Risks Actions Variations / Comments SIGNInfection due to loss of skin integrity


Minimum of 8 hourly inspection of exit site for signs of inflammation or infection. Do not remove dressing unless soiled

Take swab for culture and sensitivity if indicated

Check weekly or at each visit if in community setting

Visual Infusion Phlebitis scored (VIAD) See chart

Observe patient for signs of line infection (pyrexia/raised WCC)

If clinically unstable and patient has had rigors, take blood cultures from line and independent venous sample

Assess medical condition prior to removal of line

Send line tip for culture and sensitivity following removal, in community only send if line sepsis suspected

Ensure administration lines in place following local policy.

Replace any infusates with additives and their administration lines up to a max of 24hrs if constituted in ward environment.

Label infusion lines with date for renewal. Change add-on devices at same time as

administration sets or as soon as integrity is compromised. Use needle free systems and avoid 3 way tapsAir embolus Use Needle-free systems

Ensure air dispelled from medication/ flushes/infusates prior to administration.

Assess need for infusion pumpOcclusion of lumen. Maintain patency via 0.9% Sodium Chloride for injection flushes as per CINS

80



guidelines, Pre & post drug / infusion administration. Use heparinised saline as CINS guidelines if open ended catheter


Ensure weekly flushes when not in use. Use needle-free system according to CINS guidelines using positive pressure flush

Ensure regular flushes when lumens not in use.Bleeding from site /

line itself. Observe for signs of bleeding from site. Apply pressure above dressing Ensure add on devices if needed

are securely fastened. Ensure clotting studies in

acceptable range prior to removal of line.Line migration /

displacement Check notes to ensure medical staff

have documented line is in correct place and safe to use.

Ensure line securely sutured. Check each shift for signs of line

migration, e.g. visible lumens outside of exit point.

Anchor lines to avoid accidental displacement.

If in doubt do not use line Ensure patient is aware of any potential

problems which may occur. So they can report them immediately


Daily review on need for line/ consideration of change to more appropriate line for patient.

Daily documentation on need for line documented in nursing/medical notes.


81



EVALUATION RECORD

DATE EVALUATION SIGN, DESIGNATION

& PRINT

82



PATIENT CARE PLAN FOR CARE OF SKIN TUNNELLED CENTRAL CATHETER





DEVICE TYPE…



Review Dates:

Date Comments

83



Type of device Risks Actions Variations / Comments SIGNInfection due to loss of skin integrity Site clean and protected with

sterile dressing as per CINS guidelines.

Minimum of 8 hourly inspection of exit site for signs of inflammation or infection. Do not remove dressing unless soiled.




Observe patient for signs of line infection (pyrexia / raised WCC)

If clinically unstable and patient has had rigors, take blood cultures from all lumens from the line and independent venous sample. Refer to medical team.

If line is removed, Send tip for culture and sensitivity

Ensure administration sets are changed as per local policy.

If administration sets are disconnected from the access device at any time they should be discarded.



administration sets or as soon as integrity is compromised. Use needle-free systems and avoid 3 way tapsAir embolus Use Needle-free systems

Ensure air dispelled from medication/

84



flushes/infusates prior to administration. Assess need for infusion pump

Occlusion of lumen. Maintain patency via 0.9% Sodium Chloride for injection flushes as per CINS guidelines, Pre & post drug/ infusion administration. Use Heparin Sodium as CINS guidelines if open ended catheter


Ensure weekly flushes when not in use. Use needle-free system according to CINS guidelines using positive pressure flushBleeding from site /

line itself. Observe for signs of bleeding from site. Apply pressure above dressing Ensure add on devices/taps securely

fastened. Ensure clotting studies in

acceptable range prior to removal of line.Line migration /

displacement Check notes to ensure medical staff

have documented line is in correct place and safe to use

Check each time line accessed for signs of line migration

Anchor lines to avoid accidental displacement using fixation devices as in CINS guidelines.

If in doubt do not use line and ensure patient is aware of problems which may occur.



85



EVALUATION RECORD


& PRINT

86



PATIENT CARE PLAN FOR CARE OF PERIPHERAL MIDLINE



Patient addressograph label / patient name


DEVICE TYPE…



Review Dates:

Date Comments

87





Minimum of daily inspection of exit site for signs of inflammation or infection. Do not remove dressing unless soiled.








Ensure administration lines in place following local policy..



administration sets or as soon as integrity is compromised. Use needle-free systems and avoid 3 way tapsAir embolus Use Needle-free systems


88



Assess need for infusion pump

Occlusion of lumen. Maintain patency via 0.9% Sodium chloride for injection flushes as per CINS guidelines, Pre & post drug/ infusion administration. Use heparinised saline as CINS guidelines if open ended catheter


Ensure weekly flushes when not in use. Use needle-free system according to CINS guidelines using positive pressure flushBleeding from site /

line itself. Observe for signs of bleeding from site. Apply pressure above dressing Ensure add on devices/taps securely


acceptable range prior to removal of Line migration / displacement

Check notes to ensure medical staff have documented line is in correct place and safe to use

If line disconnected for any reason then discard






89



EVALUATION RECORD


& PRINT

90



PATIENT CARE PLAN FOR CARE OF PERIPHERALLY INSERTED CENTRAL CATHETER (PICC)





DEVICE TYPE…



Review Dates:

Date Comments

91





Minimum of 8 hourly inspection of exit site for signs of inflammation or infection. Do not remove dressing unless soiled








Ensure administration lines in place following local policy.



administration sets or as soon as integrity is compromised. Use needle free systems and avoid 3 way tapsAir embolus Use Needle-free systems


92



Assess need for infusion pumpOcclusion of lumen. Maintain patency via 0.9% Sodium

Chloride for injection flushes as per CINS guidelines, Pre & post drug/ infusion administration. Use heparinised saline as CINS guidelines if open ended catheter


Ensure weekly flushes when not in use. Use needle-free system according to CINS guidelines using positive pressure flush

Bleeding from site / line itself.

Observe for signs of bleeding from site. Apply pressure above dressing Ensure add-on devices/taps securely


acceptable range prior to removal of line.

Line migration / displacement

Check notes to ensure medical staff have documented line is in correct place and safe to use

If line disconnected for any reason then discard




.





93

EVALUATION RECORD


& PRINT

1



Appendix 1

Guideline recommendationsTo be reviewed following NICE guidance

The guidelines within this document should support the intravenous care and management of adults, for guidance on the care of children please refer to the CINs paediatric guidelines. For guidance on the care of infants consult with your local paediatric specialists.

Recommend using Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol available in applicator and impregnated wipes.

The clinician must ascertain whether the Catheter tip is open or closed. A closed device does not require Heparin sodium.

Heparinised saline recommended concentration 10 units in 1 ml

When Catheters are not in use they should be flushed with 10ml sodium chloride 0.9%. (5mls of Heparin 10 units/ml in 0.9% Sodium Chloride or 4mls of Heparin 100 units/ml in 0.9% Sodium Chloride [depending on type of line] as well if the catheter is open ended). This should be performed on a weekly or monthly basis following the maintenance guidelines.

For needle-free connectors, manufacturer’s guidance should be followed regarding when the device should be changed.

Reminder that hands must be washed and dried thoroughly before putting on disposable gloves and after removing sterile gloves.

If there is sensitivity to Chlorhexidine solution, Providone Iodine may be used as an alternative.

If manufacturer’s guides prevent the use of Alcoholic Chlorhexidine on certain types of IV access devices then 2% Aqueous Chlorhexidine should be used (see EPIC guidelines).

Ensure all interventions are recorded in the patient’s records as per organisational policy and NMC requirements.

Biopatch antimicrobial dressing with Chlorhexidine Gluconate (Johnson & Johnson) is recommend for use in patients with increased risk of line infection.

2



List of contributors to the Venous Access Guidelines

Name Organisation Job Title/RoleAlison Young Royal Liverpool & Broadgreen

University Hospital TrustNurse Consultant in Nutrition

Alison Smith Liverpool Community Health NHS Trust

Lead Nurse IV community team

Carol McCormick Clatterbridge Centre for Oncology Clinical Nurse Specialist IV and Interventional procedures

Christine Cain Wirral University Teaching Hospital NHS Foundation Trust

Paediatric Clinical Practice Development Nurse

Christine Roberts Sefton PCT / University Aintree Hospitals Foundation Trust

IV Therapy Lead Nurse

Coral Hulse Leighton Hospital Trust Nurse Consultant in Intensive careDesmond Collins Wirral University Teaching Hospital

NHS Foundation TrustSpecialist Nurse Paediatric HDU, Paediatric Resusitation Nurse

Helen Harker Royal Liverpool & Broadgreen University Hospitals NHS Trust

Senior Nurse in Intravascular access

Janine Grundy Warrington PCT Intravenous Therapy Team LeaderJo Marinas Royal Liverpool & Broadgreen

University Hospitals NHS TrustClinical Skills Manager

Name Organisation Job Title/RoleKaren Ellis University Aintree Hospitals

Foundation TrustClinical Skills / Practice Education Manager

Karen Selwood Alder Hey Children’s NHS Foundation Trust

Oncology Advanced Nurse Practitioner

Liz Collins Wirral University Teaching Hospital NHS Foundation Trust

Ward Manager Ward 11 Women & Children’s Division

Lorraine Smith Wirral University Teaching Hospital NHS Foundation Trust

Infection Control Nurse/Infection Control Surveillance Nurse Coordinator

Malcolm Smith Mid Cheshire Hospitals Foundation Trust

Clinical Skills Tutor

Rebecca Molyneux

Royal Liverpool & Broadgreen University Hospital Trust

Nurse Consultant in Infection Control

Ruth Glenn Halton & St Helens PCT IV Therapy Nurse PractitionerSara Melville Alder Hey Children’s NHS

Foundation TrustPaediatric IV Nurse Specialist

Shirley Smith Liverpool Community Health NHS Trust

Community IV Team Liverpool

Sue O’Hanlon Halton & St Helens CHS IV therapy Nurse Specialist

3



Appendix 2

Merseyside & Cheshire Cancer Network

Network Guidance for the Prevention and Management of Extravasation Injuries (Revised Mar 08)

STOP! – Have you got the most up to date version of this policy?Always Check w w w . m ccn . nhs . u k before reading further.

Policy formulated and developed by the following:

Clatterbridge Centre for Oncology NHS Foundation Trust Countess of Chester Hospital NHS Foundation Trust North Cheshire Hospitals NHS TrustRoyal Liverpool & Broadgreen University Hospitals NHS Trust Royal Liverpool Childrens Hospital NHS TrustSouthport & Ormskirk Hospitals NHS Trust St Helens and Knowsley Hospital NHS TrustUniversity Hospital Aintree NHS Foundation TrustWirral University Teaching Hospitals NHS Foundation Trust

4



CONTENTS PAGE NUMBER

1 Introduction 3

2 Definition 3

3 Scope 4

4 Evidence Base 4

5 Causes 4

6 Risk Reduction 4

77.1

Recognition Symptoms

45

8 General Procedure for the Management of Extravasation or suspected Extravasation

5

9 Further notes on treatments for cytotoxic extravasations 6

1010.110.2

Extravasation Kits Contents Location

888

1111.111.2

Documentation & Reporting Local ProceduresGreen Card Reporting

888

12 References & Suggested Further Reading 9

Appendix 1 Classification of Cytotoxic Drugs according to their Potential to cause severe necrosis when extravasated

10

Appendix 2 Specific Antidotes in the management of peripheral extravasation

11

Appendix 3 Extravasation – Evidence behind recommendations 12

5



1. Introduction

The purpose of this document is to set out the Guidelines for the management of cytotoxic extravasation incidents within the Merseyside and Cheshire Cancer Network.

National and Regional standards that this document adheres to and should be read in conjunction with include:

Manual For Cancer Standards 2004 MCCN Guide to Care and Maintenance of Venous access devices incorporating the

Collaborative Intravenous Nursing Service guidelines for venous access devices for Cheshire and Merseyside NHS Northwest

Reference guide to Consent and Treatment, DH 2001Additionally, network and local policies that support and comply with this document have been developed. These include

Network guidelines for the safe prescribing, handling and administration of cytotoxic drugs

Network 24 hour telephone advice specification Local chemotherapy administration policies Local consent policies

This policy has been written using the best available current evidence and will be reviewed as other evidence becomes available.

2. DefinitionExtravasation is defined as the leakage of a vesicant drug or fluid from a vein into the surrounding tissue during intravenous administration1. A vesicant is defined as a drug or solution which has the potential to cause blistering, severe tissue damage and even necrosis if extravasated.2 Vesicants may cause damage to the surrounding tissue nerves, tendons or joints. This may be accompanied by pain, erythema, inflammation and discomfort, which, if left unrecognised or treated inappropriately can lead to necrosis and functional loss of the vein and possibly limb concerned3. Infiltration is the inadvertent administration of a non vesicant solution into surrounding tissues. While this may cause inflammation and discomfort, damage and necrosis rarely occurs.1

For clarity the term extravasation will be used to describe the inadvertent leakage of any drug or fluid into surrounding tissues.

Once an extravasation has occurred, the full extent of the injury may be unclear, and damage may continue for weeks or months. Any extravasation should be considered a medical emergency and a prompt, appropriate response is essential. The degree of injury can range from apparently insignificant erythema through to blistering, skin sloughing and severe necrosis, which often require corrective plastic surgery. Accurate documentation of the incident is essential. There is no National Standard of Practice.

6



3.0 ScopeThe aim of this document is to provide a framework based on current available evidence for the appropriate management of cytotoxic-inducedextravasation within the Merseyside and Cheshire cancer network. It includes paediatric practise.

Cytotoxic drugs may be divided in 5 categories based upon their propensity to cause extravasation injury. The drugs included in this policy are listed in appendix 1. However this list may not be exhaustive and it is the practitioner’s responsibility to recognise the potential for injury and appropriate management for any drug which they are administering2.

4.0 Evidence baseExtravasation is a condition that is often under-diagnosed, under-treated and unreported. The relevance of many published articles is difficult to assess because they often refer to isolated incidents that have been treated in an inconsistent way. Treatment recommendations in this policy have been made based on the best available evidence or where such evidence is lacking, based on a consensus of professional opinion from expert pharmacists, nurses, and doctors from the Merseyside and Cheshire Cancer Network and other network and professional body extravasation documents.For the evidence base for specific recommendations made in this policy see appendix 3.

5.1 Causes Dislodgement of the distal tip of the cannula into the tissues surrounding the vein. Constriction of the blood flow distal to the cannula tip which increases venous

pressure and allows fluid to leak from the hole in the vein made by the cannula. Inappropriate selection of the position and size of cannula and the length of time which

the cannula is left in situ. Practitioner unfamiliarity with the drug and the manufacturer’s recommendations for

administration.

6.1 Risk Reduction Only authorised practitioners who have been trained and are included on a register

may administer chemotherapy At all times the standards in local and network chemotherapy administration

policies must be adhered to. Particular care must be taken with the selection and positioning of the cannula. Drugs with the highest vesicant potential should be given first. All practitioners administering cytotoxic drugs must have an understanding of

the management of extravasation and know the contents and whereabouts of the extravasation kit.

If vesicant drugs are administered by a non ambulatory infusion pump then the pump must have appropriate pressure sensors that will give early warning of an occlusion

7.1 RecognitionIt is important that extravasation is not misdiagnosed because the treatment itself may involve the administration of drugs which themselves can cause further physical trauma to the patient, and may also potentiate extravasation. Early recognition is vital. Misdiagnosis often occurs when the practitioner fails to differentiate discolouration reactions in the vein,

7



venous shock, flare or phlebitis. Some cytotoxic drugs are coloured and if the selected vein lies superficial to the skin, the injection of a red coloured drug may cause local venous discolouration. 4

7.2 SymptomsSigns and symptoms of possible extravasation include:

pain, stinging, burning or any other acute change at the injection site. NB Children who are frightened of needing a new cannula may deny pain or discomfort.

Induration, erythema, venous discolouration or swelling at the injection site. No blood return is obtained. If this is found in isolation, other signs should be looked

for, as this can be misleading and has been implicated in a number of serious incidences. There are 2 ways in which the return of blood may be misleadingo If there has been an extravasation injury and the cannula has become displaced,

the act of trying to draw back blood to test for return may move the cannula back into the vein. Thus blood is returned and the vein appears patent. However, there is a hole in the vein wall in the proximity of the cannula tip and when administration of chemotherapy recommences, a larger and more significant extravasation injury will occur.

o Alternatively, the bevel of the needle can puncture the vein wall during venepuncture, allowing the drug to escape into the tissue while the lumen of the needle may still remain in the blood vessel and allow adequate blood return.4

there is increased resistance to administration once possible positional changes have been discounted

changes in infusion rate – Nb these may not be seen if using an infusion pump so close observation required.

8.0 General procedure for the management of extravasation or suspected extravasation

If extravasation is suspected, it is important to act quickly to prevent tissue necrosis. The practitioner who is responsible for the administration of the vesicant should recognise that an extravasation has occurred and initiate the procedure.

Immediate Management (Central and Peripheral)

Never apply pressure initially

Step 1 Stop the infusion or injection – Do not remove the venflon

Step 2 Seek assistance if needed

Step 3 Disconnect drip and aspirate as much drug as possible, trying also to draw some blood back into the cannula.

Step 4 Remove cannula with minimal pressure – if central or mixed chemotherapy administration inform consultant with a view to immediate plastic surgeon referral. Extravasations from portacath needle locking points may be treated as peripheral.

8



Step 5 Mark the affected area

Step 6 Elevate the limb and encourage movement

Step 7 For Mustine , anthracyclines, other vesicants , vinka alkaloids, and other drugs FOLLOW SPECIFIC ANTIDOTE GUIDANCE. (See below for further notes)

Step 8 Inform consultant

Step 9 Provide analgesia if required

Step 10 Measure the area of extravasation, document any treatment as per local policy and photograph injury if possible

Step 11 Provide patient information leaflet with documented measurements of injury – The practitioner must be aware of the possibility of delayed injury. Ensure that the patient knows to contact chemotherapy unit if symptoms worsen or persist. Advise the patient to elevate the affected limb as often as possible for the next 2-3 days. Arrange a follow up appointment if needed.

Subsequent Steps

Step 12 Complete Green Card, trust incident form and any other local documentation as required. Send copy of green card to trust pharmacist who will send to the network pharmacist

Step 13 Consider referral to physiotherapist

Step 14 Refill extravasation kit – local policy to detail procedure for refill

9.1 Further notes on treatments for cytotoxic

extravasations See appendix 3 for evidence base for specific

treatments. Treatment principles

Localise and neutralise uses pulsed cold compression with or without a specific treatment to stop the further spread of the drug and prevent further injury.

Spread and dilute uses warm compression with or without hyaluronidase to facilitate dispersal of the extravasated drug thus reducing its concentration and potential for tissue damage.

As a general rule cold compression is used except in the case of vinca alkaloids where warm compression is used. The practitioner must check the specific antidote table (appendix 2) before proceeding with any intervention.

9



Hyaluronidase: Dilute 1500 units of hyaluronidase in 2 ml of water for injection, or 0.9% sodium chloride. Gently massage the area to facilitate dispersal.

Sodium Thiosulphate: Infiltrate 1-3 ml of 3% isotonic sodium thiosulphate into the affected area using multiple ‘pin cushion’ injections. To achieve 3% sodium thiosulphate from the 50% vial in the extravasation kit, dilute 1.2 ml of 50% to 20 ml with water for injection.

Topical DMSO: apply 50% solution topically every 2 hours toThe extravasation site for 24 hours. Avoid contact with good skin. Do not cover the area. If blistering occurs discontinue use and seek further advice.

Surgical excision: Wide excision with use of grafts may be indicated if persistent pain 1-2 weeks after injury. Inadequate excision is associated with continuing necrosis at the margins, poor granulation and failure of engraftment.

Hypodermoclysis: Administering fluids under the skin.

Warm Compression W.C.C. Warm Continuous Compression. Apply firmly but without undue pressure a heat source (hot water bottle or small electrically heated blanket) to the area continuously for 24 hours. The heat source should not be in direct contact with the skin and a piece of dry gauze should be laid in between. This assists the natural dispersal of the drug.

Cold Compression: P.C.C Pulsed Cold Compress. Apply firmly but without pressure a cold source (crushed ice, flexible cold pack or cold bandage) intermittently (for 30 minutes in every 2 hours) over the area for the first 24 hours, unless advised otherwise. Place a piece of dry gauze between the skin and cold source.

Acidic Extravasations: If the extravasation has been misdiagnosed or the volume extravasated wrongly assessed, the treatment could lead to an alkali extravasation. If this secondary extravasation occurs, it is far more serious and the consequence far more devastating then those associated with venous extravasation. Caution and expert advice should be exercised before proceeding with this specific management.

Sodium Bicarbonate: Infiltrate with 1-3 ml of 2.1% sodium bicarbonate. 8.4% sodium bicarbonate must be diluted as follows. To achieve 2.1% sodium bicarbonate take 5ml of 8.4% sodium bicarbonate, add 5ml of water for injection, discard 5ml of this new solution and add a further 5ml of water for injection. Sodium bicarbonate is not in the extravasation kit. Do not use this antidote unless recommended by an expert. (Plastic surgeon)

Adapted from the National Extravasation Information Service 2004

SteroidsMany guidelines recommend the use of subcutaneous or intradermal steroids. However many reviews state that inflammation is not prominent in the aetiology of tissue necrosis. There is also evidence that subcutaneous or intradermal steroids may be harmful in high doses, are ineffective in certain extravasations and may increase the skin toxicity of vinca

10



alkaloids. For this reason, this policy does not recommend the routine use of subcutaneous steroids and injectable steroids are not included in the extravasation kit. Topical hydrocortisone 1% cream is unlikely to do harm and may reduce non-specific inflammation, except in vinca-alkaloid injuries 5

10.1 Extravasation Kits

Both the emergency policy and the extravasation kit should be simple and easy to follow to reduce the risk of inflicting further damage. It is necessary to hold a complete set of antidotes and hot and cold facilities in all areas where the administration of chemotherapy takes place.

10.2 Contents

Topical DMSO (dimethylsulfoxide solution 50%) Hyaluronidase 1500 units injection Hydrocortisone 1% cream Sodium thiosulphate 50% solution (DO NOT USE UNDILUTED – use as 3% solution),

only for units using mustine Sodium chloride 0.9% injection Water for injection Selection of needles, syringes, alcohol wipes, sterile gauze Directions to the nearest hot/cold pack Guide to immediate management including use of specific antidotes

It is the responsibility of the practitioner to ensure that they are familiar with the general policy and the extravasation kit.

10.3 Location(insert location of all extravasation kits)

Kits must be available in any area where intravenous chemotherapy is given.A laminated copy of the immediate management of extravasation should be available in all clinical areas and with the extravasation kit.Practitioners should liase with pharmacy to ensure timely refill of the kit after use.For CCO outreach clinics, CCO will be responsible for supplying the extravasation kits for use in the clinic. Local arrangements must be in place if CCO cannot provide any part of the kit e.g. warm/cold packs.

11.1 Documentation and reporting

11.2 Local proceduresFollow local procedures for documentation and clinical incident reporting. If possible photograph the injury. Documentation should include the drugs involved, size and location of cannula, procedure followed and any specific antidotes used, and outcomes.

11.3 Green Card ReportingMost information about the treatment of extravasation is anecdotal. The “Green Card” scheme should be used for reporting extravasation incidences, treatments and outcome. This

11



scheme is co-ordinated through the St.Chad’s Unit, City Hospital, Birmingham. Green cards can be filled in online

The aims of the Green Card are: to obtain accurate statistical information on the number of incidents categorised by

extravasating drug and type of treatment to collect data on treatment methods and antidotes being used for extravasation

incidents to obtain accurate information on the outcome of incidents to feedback information on the treatment and its

effectiveness Green Cards ask for the following information:

the drug or drugs involved how was it detected the extent of the problem drugs used in the treatment of the extravasation the procedure for treatment type of cannula used for the administration of the chemotherapy location and extent of the extravasation outcome

These reporting cards are user friendly. The information given can remain anonymous for the reporter, the patient and the Centre involved.

Reporting can be done online at http://www.extravasation.org.uk/Greenmenu.htm

Green cards should be available alongside the extravasation kit and can be obtained from http://www.extravasation.org.uk/Greenmenu.htm or by post from Extravasation Co-ordinator, c/o St Chad’s Unit, City Hospital, Dudley Road, Birmingham B1 8 7QH

If reporting online please print a copy of the form before submitting and send to the network pharmacist. If using a green card please make a copy and send to your trust pharmacist who will send it to the network pharmacist.

12 References and suggested further reading

1 Mallet and Dougherty (2004) The Royal Marsden Manual Handbook2 How, C and Brown J. (1998) Extravasation of cytotoxic chemotherapy from peripheral veins European Journal of Oncology Nursing 2 (1) 51-58

3 Hadaway L.C. (2001) Vesicant Extravasation. Nursing 31(8) 88

4 National Extravasation Information Service (2004) www.extravasation.org.uk accessed 19/04/2006

5 UKCCSG extravasation policy (2005)

12



Appendix 1

CLASSIFICATION OF CYTOTOXIC DRUGS ACCORDING TO THEIR POTENTIAL TO CAUSE SEVERE NECROSIS WHEN EXTRAVASATED

Vesicants: Group 1

Exfoliants: Group 2

Irritants: Group 3

Inflammitants: Group 4

Neutrals: Group 5 (unlikely

tocause problems if extravasated)Amsacrine Aclarubicin Carboplatin Etoposide

Phosphate

Asparaginase

Carmustine Cisplatin (conc

>0.5mg/ml)

Etoposide Fluorouracil Bleomycin

Dacarbazine Daunorubicin

Liposomal

Irinotecan Methotrexate Cladribine

Dactinomycin Docetaxel Teniposide Raltitrexed Cyclophosphami

de

Daunorubicin Doxorubicin

Liposomal

Cytarabine

Doxorubicin Floxuridine bortezomib

Epirubicin Oxaliplatin Fludarabine

Idarubicin Topotecan Gemcitabine

Mitomycin Ifosfamide

Mitoxantrone Melphalan

Mustine Pentostatin

Rituximab

Paclitaxel Thiotepa

Plicamycin Beta-Interferons

Streptozocin Aldesleukin (IL-

2)

Treosulfan Trastuzumab

Vinblastine cisplatin

Vincristine alemtuzumab

Vindesine

Vinorelbine

Nb this list may not be exhaustive. It is the practitioners responsibility to know the vesicant potential of any drug not on this list Appendix 2

13

Appendix 2



Specific antidotes in the management of peripheral extravasation

Drug/class of drug

Warm/Cold compression

Specific antidote

Vinca Alkaloids Vincristine Vindesine Vinblastine Vinorelbine

Warm compression- apply for 24 hours

Hyaluronidase 1500 IUDraw up 1500IU hyaluronidase in 1 to

2ml water for injection or 0.9% sodium chloride. Inject 0.1 to 0.2ml subcutaneously at points of the compass around the circumference of the area of extravasation. Gently massage area to facilitate dispersal.

Mustine Apply cold pack intermittently for 30minutes in every 2 hours for 24 hours. Place a piece of dry gauze between skin and cold pack

3% Sodium Thiosulphate – Dilute the solution provided before use – dilute 1.2ml of 50% sodium thiosulphate to 20ml with water for injections.Infiltrate the site with 1 to 3ml of diluted solution using multiple “pin cushion” injections around the circumference of the area.Apply topical hydrocortisone 1% cream four times a day for the next 7 days or for as long as erythema persists

Anthracyclines Daunorubicn Doxorubicin Epirubicin Idarubicn

Mitoxantrone Mitomycin C

Apply cold pack intermittently for 30minutes in every 2 hours for 24 hours. Place a piece of dry gauze between skin and cold pack

Topical DMSO 50%Apply Topical DMSO 50% using a cotton bud every 2 hours at the extravasation site for 24 hours. Avoid contact with good skin. For the next 7 days apply DMSO50% every 6 hours alternating with topical hydrocortisone 1% cream every 3 hours. Do not use an occlusive cover. If blistering occurs, stop DMSO and seek further advice.

Any other cytotoxic drug (See appendix 1 for list.)

Automatic cold or warm compression is not required.However if symptoms warrant then use intermittent cold compression except in the case of oxaliplatin, cisplatin, or carboplatin when warm compression may be used.

No specific antidote neededIf signs of erythema persist then topical 1% hydrocortisone cream may be used. Apply sparingly to the affected area 4 times a day while symptoms persist.

14

Appendix 3



EXTRAVASATION – EVIDENCE BEHIND RECOMMENDATIONS

Controversy continues about appropriate antidote therapy and the situation is complicated by the inability to conduct controlled studies on human subjects. Ethical constraints and differences in tissue structure between human and animal skin are two of the biggest obstacles of antidote research. In this section the evidence behind the recommendations made in the monographs will be graded according to the definitions derived from US Agency for Health Care Policy and Research below.

Type and level of evidence Level Type of evidence

Ia Evidence obtained from meta-analysis of randomised controlledtrials.

Ib Evidence obtained from at least one randomised controlledtrial.

IIa Evidence obtained from at least one well-designed controlled

study without randomisation.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.

III Evidence obtained from well-designed non-experimentaldescriptive studies, such as comparative studies, correlation studies and case control studies.

IV Evidence from expert committee reports or opinions and/or clinical experiences of respected authorities.

A) Grade of Recommendation

Unfortunately, no antidote has so far received a clear validation in controlled clinical trials. Therefore, case reports and uncontrolled studies are still the only evidence for the role of antidotes in the clinical setting and, in some cases they do provide relevant cumulative

Gr a de Evidence Level

Recommendation

A Ia, Ib Required – at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing specific

B IIa, IIb, III Required – availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.

C IV Required – evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.Indicates absence of directly applicable clinical

st u dies o f g o o d q ual i t y .

15



experience. Due to the volume of the above studies the authors of this policy decided to use only reviews as evidence. The authors also reviewed other policies from the UK and contacted the manufacturer of each drug asking for their recommendations for the treatment of an extravasation with that particular drug.As a result most of the recommendations contained in this policy will be Grade B or C and will be a result of evidence obtained from reviews, other UK extravasation policies, and manufacturers.

Treatment RecommendationsEvidence

A. Apply cold pack, firmly but without pressure, intermittently for 30 minutes in very 2 hours over the area for the first 24 hours, unless advised otherwise. The cold pack should not be placed directly on the skin. Place a piece of dry gauze between the skin and the cold pack.

Application of cold to the site is thought to decrease toxicity of the agent to the area. It is believed this causes vasoconstriction, localising the extravasation and perhaps allowing time for local vascular and lymphatic systems to disperse the agent as well as shunting bloodaway from the area and reducing cellular metabolismi,ii,iii,iv. The application of cold to vinca-alkaloid induced injuries has been shownto increase ulcer formation in animal studies and therefore the use of cold should be reserved only for the treatment of non vinca- alkaloid vesicant injuriesi,ii,iii,iv

Intermittent local cooling for up to 24 hours appears to be the recommended scheduleii.The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

B. Apply topical hydrocortisone 1% cream every six hours for the next 7 days or for as long as erythema continues.

Many guidelines recommend the use of subcutaneous or intradermal steroids. However many of the reviews found argued that inflammation is not prominent in the aetiologyof tissue necrosisi,ii,iii,iv,v. There is also evidence that subcutaneous or intradermal steroids may be harmful in high dosesi,ii, are ineffective incertain extravasationsii and may increase the skin toxicity of vinca alkaloidsi,ii. Therefore thisguideline recommends that topical hydrocortisone 1% is used, which can do little harm and may bring down non-specific inflammation, except in vinca-alkaloid injuries. The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

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C. Infiltrate the site with 1500 units of hyaluronidase in 1ml Water for Injection. Inject subcutaneously at several areas around the circumference of the extravasated area. Gently massage the area to facilitate dispersion.

Hyaluronidase has been reported to be an effective antidote for vinca alkaloids andetoposidei.ii,iii,iv. Animal studies have also shownhyalouronidase to be of potential benefit in paclitaxel extravasations. It is believed injection of hyalouronidase promotes the permeability of tissue, improving the absorption of infiltrated cytotoxic. Tissue injury is decreased secondary to the dilution of the cytotoxic across a larger tissue area. The guideline therefore recommends that the use of hyalouronidase is unlikely to cause harm and recommends its use where a policy of “spread and dilute” is indicated.The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

D. Apply heat pack, firmly but without pressure, continuously for 24 hours. The heat pack should not be placed directly on the skin. Place a piece of dry gauze between the skin and the heat pack.

Application of heat is thought to induce vasodilation, which facilitates increased systemic absorption and distribution of the cytotoxic. It is thought to aid the dispersal of the vinca-alkaloids. The application of heat to anthracycline induced injuries increases tissue damage and therefore the use of heat should be reserved only for the treatment of vinca alkaloid and non-vesicant induced injurieswhere a policy of “spread and dilute” is indicatedi,ii,iii,iv.The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

E. Apply topical Dimethyl Sulfoxide (DMSO) 50%(v/v), by painting on with a ‘cotton bud’, every 2 hours at the extravasation site for 24 hours. Avoid contact with good skin. If blister forms stop DMSO and seek further advice.

This is recommended for the anthracyclines and mitomycini,ii,iii,vi,vii. The use seems well supported, and seems unlikely to cause any harm. The optimal schedule and duration ofDMSO applications is unclear but should probably be at least every 6 hours for a minimum of 3 daysii. It should be noted that DMSO is not licensed for this use.The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

F. For the next 7 days apply DMSO every6 hours, alternating with topical hydrocortisone 1% cream every 6 hours (a preparation applied every 3 hours on an alternate basis). Do not use an occlusive cover. If required cover once the area is dry. If blister forms stop DMSO and seek further advice.

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10.0 Infiltrate the site with 1-3ml of 3% isotonic sodium thiosulphate into the affected area using multiple ‘pin cushion’ injections at several areas around the circumference of extravasated area. Before administering Sodium Thiosulphate the solution provided in the pack MUST BE DILUTED FIRST. Dilute 1.2ml 50% sodium thiosulphate to 20ml with water for injection

This is recommended for mustinei,ii,iii. The use seems well supported, and seems unlikely to cause any harm. It should be noted that sodium thiosulphate is not licensed for this use.The evidence supporting this treatment consists entirely of III or IV reports but is sufficiently extensive that this can be recommended at Grade B.

G. Monitor patient closely for “recall reactions”.

Anthracyclines administered after radiotherapy have been shown in a reactivation of skin toxicity known as a “recall reaction”. A similar reaction may be seen in patients who have had previous extravasations. This reaction has alsobeen shown with paclitaxelii.The evidence for this approach in patients on anthracyclines and Paclitaxel is very limited (level IV) and the confidence with which it can be recommended is Grade C.

Reproduced with thanks from the UKCCSG paediatric extravasation policy

iPharmacologic Management of Vesicant Chemotherapy Extravasations. Cancer Chemotherapy Handbook. 2nd Edition. Chapter 6. Ed. Dorr R.T., Von Hoff D. Appleton & Lange, Norwalk, Conneticut.

ii Bertelli, G. Prevention and Management of Extravasation of Cytotoxic Drugs. Drug Safety 12(4): 245-255. 1995.

iii Dorr R.T. Antidotes to Vesicant Chemotherapy Extravasations. Blood Reviews 4: 41-60. 1990.

iv Kassner E. Evaluation and Treatment of Chemotherapy Extravasation Injuries. Journal of Paediatric Oncology Nursing 17(3): 135-148. 2000.

v Extravasation of drugs. Anaesthesia Review. Chapter 13. Ed. Kaufman L., Ginsbury R. Churchill Livingstone. 1997. London.

vi Rospond R.M. Utilization of dimethyl sulfoxide for treating anthracycline extravasation. J Oncol Pharm Practice 1(4): 33-39. 1995.

vii Lawrence H.J., et al. Topical dimethylsulfoxide may prevent tissue damage from anthracycline extravasation. Cancer Chemotherapy and Pharmacology 23: 316-318. 1989.

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