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Basic Infection Control and Prevention Plan for Outpatient Oncology Settings guideline coverBasic Infection Control and Prevention Plan for Outpatient Oncology Settings

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VI. Central Venous Catheters

The procedures outlined below pertain to the access and maintenance of long-term central venous catheters (e.g., vascular access devices). These include peripherally inserted central catheters (PICCs), tunneled catheters (e.g., Broviac®, Hickman®, and Groshong® catheters), including tunneled apheresis catheters, and implanted ports. For other types of access devices, such as intraperitoneal ports, refer to guidelines from relevant professional societies (e.g., Oncology Nursing Society).

Several recommendations in this section have been adapted directly from the Oncology Nursing Society Access Devices Guidelines and the Infusion Nursing Society Standards of Practice. There is not a consensus over the use of clean versus sterile gloves when accessing certain vascular access devices, such as implanted ports; where indicated, recommendations by specific professional societies are provided. While the recommendations below apply generally, healthcare personnel are to follow manufacturers’ instructions and labeled use for specific care and maintenance. Only healthcare personnel who have attained and maintained competency should perform these procedures.

A.  General Maintenance and Access Procedures

1.  Accessing Central Venous Catheters

This procedure applies only to PICCs and tunneled catheters, including apheresis catheters. Refer to Part D.1. below for accessing implanted ports. In general, closed catheter access systems should be used preferentially over open systems.

  • Maintain aseptic technique
  • Perform hand hygiene and assemble the necessary equipment
  • Wear clean gloves
  • Scrub the injection cap (e.g., needleless connector) with an appropriate antiseptic (e.g., chlorhexidine, povidone iodine, or 70% alcohol), and allow to dry (if povidone iodine is used, it should dry for at least 2 minutes)
  • Access the injection cap with the syringe or IV tubing (opening the clamp, if necessary)
  • Perform hand hygiene when done

2.  Blood Draws from Central Venous Catheters

  • Access the catheter as outlined above, maintaining aseptic technique
  • Remove the first 3-5 mL of blood and discard
  • Obtain specimen
  • Flush with 10-20 mL of normal saline (clamping the catheter as flushing is completed, if necessary) and promptly dispose of used syringe(s)
  • Perform hand hygiene when done

3.  Flushing technique

Refer to the manufacturer’s instructions of the catheter and the needleless connector for the appropriate technique to use; unless otherwise specified, perform the following:

  • Single-use flushing systems (e.g., single-dose vials, prefilled syringes) should be used
  • Access the catheter as outlined above, maintaining aseptic technique
  • In general, avoid using a syringe less than 3 mL in size to flush, preferably use 10 mL
  • Flush the catheter vigorously using pulsating technique and maintain pressure at the end of the flush to prevent reflux
    • Positive pressure technique (may not apply to neutral-displacement or positive-displacement needleless connectors):
      1. Flush the catheter, continue to hold the plunger of the syringe while closing the clamp on the catheter and then disconnect the syringe
      2. For catheters without a clamp, withdraw the syringe as the last 0.5-1 mL of fluid is flushed
    • Promptly dispose of used syringe(s)
  • Perform hand hygiene when done

4.  Changing Catheter Site Dressing

This procedure applies only to PICCs and tunneled catheters, including apheresis catheters.

  • Supplies for site cleansing and dressing changes should be single-use; refer to manufacturer’s recommendations to ensure compatibility with the catheter material
  • Maintain aseptic technique
  • Perform hand hygiene
  • Wear clean or sterile gloves (additional precaution per Infusion Nursing Society includes use of facemasks and sterile gloves)
  • Remove existing dressing and inspect the site visually
  • Apply antiseptic to the site using >0.5% chlorhexidine preparation with alcohol; if there is contraindication to chlorhexidine, use tincture of iodine, an iodophor, or 70% alcohol as alternative
  • Do not apply topical antibiotic ointment or creams to catheter site
  • Cover with either sterile gauze or sterile, transparent, semipermeable dressing (refer to catheter-specific recommendations for frequency of dressing changes)
  • Perform hand hygiene when done

5.  Changing the Injection Cap (e.g., Needleless Connector)

This procedure applies only to PICCs and tunneled catheters, including apheresis catheters. Refer to manufacturer’s instructions for how frequently to change the injection cap; if information is not available, in general, change every week or when there are signs of blood, precipitate, cracks, leaks, or other defects, or when the septum is no longer intact.

  • Maintain aseptic technique
  • Perform hand hygiene and assemble the necessary equipment
  • Wear clean gloves
  • Scrub the injection cap and catheter hub with appropriate antiseptic agent; clamp the catheter if necessary as cap is removed
  • Attach new cap to catheter hub using aseptic technique
  • Perform hand hygiene when done

B.  Peripherally Inserted Central Catheters (PICCs)

Refer to steps 1-5 in Section VI.A. above for PICC access and common maintenance procedures. Additional recommendations for routine maintenance and care:

  • Frequency of dressing change:
    • Change 24 hours after insertion
    • Transparent dressing: change every 5-7 days unless soiled or loose
    • Gauze dressing: change every 2 days or as needed if wet, soiled, or nonocclusive
  • Flushing: use of heparin flushes and the recommended concentration and frequency of flushing are determined in accordance with manufacturer’s instructions and per the treating clinician’s orders (in general, for valve catheters or closed tip catheters, flush with normal saline unless otherwise specified)

C.  Tunneled Catheters

Tunneled catheters include Broviac®, Hickman®, and Groshong® catheters, as well as apheresis catheters. Refer to steps 1-5 in Section VI.A. above for catheter access and common maintenance procedures. Additional recommendations for routine maintenance and care:

  • Frequency of dressing change:
    • Change 24 hours after insertion
    • Transparent dressing: change not more than once a week unless soiled or loose
    • Gauze and tape dressing: change every 2 days or as needed if wet, soiled, or nonocclusive
    • Once healed, tunneled catheters may go without a dressing unless the patient is immunocompromised
  • Flushing: use of heparin flushes and the recommended concentration and frequency of flushing are determined in accordance with manufacturer’s instructions and per the treating clinician’s orders (in general, for Groshong® catheters, valve catheters, or closed tip catheters, flush with normal saline unless otherwise specified)

D.  Implanted Ports

1.  Port Access Procedure

  • Perform hand hygiene first; prior to each access, examine the site for complications, including examination of the veins of the chest and neck to look for any swelling, erythema, drainage or leakage, or presence of pain, discomfort, or tenderness
  • Palpate the outline of the portal body
  • Perform hand hygiene again; wear clean or sterile gloves (additional precaution per INS includes use of sterile gloves and facemasks)
  • Cleanse port site with appropriate antiseptic agent
  • Administer topical anesthetic, if ordered
  • Stabilize portal body with one hand, and insert non-coring needle (e.g., Huber needle) with the other hand until portal backing is felt
  • Ensure patency by blood return and dispose of used syringe(s)
  • Stabilize needle/port with tape, securement device, or stabilization device; apply gauze and tape for short-term use (such as for outpatient treatment)
  • Perform hand hygiene when done

2.  Port De-access Procedure

  • Perform hand hygiene; wear clean or sterile gloves
  • Remove dressing and inspect site
  • Remove gloves, perform hand hygiene again, and wear new gloves
  • Flush device with 20 mL normal saline followed by heparin flush, unless otherwise specified by manufacturer and/or treating clinician
  • Stabilize port with one hand, and remove needle with the other hand; maintain positive pressure while deaccessing by flushing the catheter while withdrawing the needle from the septum
  • Promptly dispose of needle and syringe
  • Apply bandage or dressing
  • Perform hand hygiene when done

3.  Maintenance and Care

  • For short-term use in outpatient settings, a light dressing may be used in place of an occlusive dressing during the infusion; ensure the needle is secure in the portal septum as described above
  • Use of heparin flushes and the recommended concentration and frequency of flushing are to be determined in accordance with manufacturer’s instructions and per the treating clinician’s order (in general, when not in use, implanted ports should be accessed and flushed every 4-8 weeks to maintain patency)
  • For blood specimens: discard 5-10 mL of blood, obtain specimen, flush with 10-20 mL of normal saline, and promptly discard used syringe(s)

Adapted with permission from Access Device Guidelines: Recommendations for Nursing Practice and Education (3rd Ed.), by D. Camp-Sorrell (Ed.), 2011, Pittsburgh, PA: Oncology Nursing Society. Copyright 2011 by ONS. 

INS 2011 Infusion Nursing Standards of Practice

CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011

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