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C-31 Clampless Valved Tunneled Central Catheter

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Written: November, 2004 Revised: 03/05; 1/08; 10/10

Nursing Policy: C-31 LSUHSC-Shreveport, LA

CLAMPLESS VALVED TUNNELED CENTRAL CATHETER CARE OF PATIENTS I. PURPOSE: To delineate guidelines for the care of patients who have Clampless Valved Tunneled Central Catheters. II. DEFINITION: A clampless valved tunneled central catheter is placed through one of the large central veins so that the tip lies in the distal third of the superior vena cava above the right atrium. It is tunneled subcutaneously from the desired exit site. The polyester tissue ingrowth cuff, attached to the catheter, is positioned 2-3 centimeters from the skin exit site inside the tunnel. The cuff promotes tissue ingrowth to secure the catheter in place. This catheter is designed for patients who require long-term access to the central venous system for administration of fluids including, but not limited to, hydration fluids, antibiotics, chemotherapy, analgesics, nutritional therapy and blood products. It is also indicated for blood specimen withdrawal. III. POLICY: A. Registered Nurses may perform the following procedures with the tunneled valveless central catheter as defined by the individual unit policy, approved by their director, provided they have documented evidence of the necessary knowledge, skills, and ability to perform such procedures (see Patient Care Services, Policy N38 Competency Assessment for additional information.):

1. Draw blood specimens 2. Flush the tunneled valveless central catheter 3. Administer IV medications via the tunneled valveless central catheter 4. Perform dressing changes on the tunneled valveless central catheter

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C-31 Clampless Valved Tunneled Central Catheter

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B.

Catheter Care and Use 1. The pressure activated safety valve tunneled catheter is designed for use with a "direct-to-hub" connection technique. Apply a sterile end cap to the hub to prevent contamination when not in use. If a needle is used to access the catheter hub do not use a needle longer than 1 ½ inches as this could damage the valve. 2. DO NOT use the catheter for high pressure injections (i.e. diagnostic procedure). 3. Ensure the pressure alarm feature of infusion pumps used with the catheter does not exceed a maximum of 25 pounds per square inch. 4. DO NOT use a small diameter syringe (less than 10 cc) for injection as they can create very high pressures which may result in catheter rupture. 5. Use luer lock adapters to avoid accidental disconnects. 6. DO NOT clean the catheter with acetone or alcohol solutions. 7. When using a multilumen catheter, caution should be exercised when infusing incompatible medications since the distal openings on the catheter are not staggered. 8. Never leave the catheter uncapped. Always apply a sterile end cap when the catheter is not in use. 9. DO NOT use instruments with teeth or sharp edges on the catheter, as catheter damage could occur. 10. Flush the catheter with a minimum of 10cc 0.9% sodium chloride following each use and document each flush.

C. Assessing Catheter Integrity 1. The Registered Nurse shall assess catheter integrity before any injection/infusion by completing the following steps: a. Inquire or observe whether the patient has experienced any symptoms that might warn of catheter fragmentation and/or catheter embolization since the catheter was last accessed; for example, episodes of shortness of breath, chest pain, and/or cardiac arrhythmia.

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C-31 Clampless Valved Tunneled Central Catheter

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b. Examine and palpate the catheter tract and insertion site for erythema, swelling or tenderness, which might indicate infection or catheter leakage. c. Using a 10cc syringe or larger, aspirate for blood return. Difficulty in withdrawing blood may indicate catheter compression, malposition, and/or obstruction. d. Using a second 10cc syringe or larger syringe, flush the catheter with 10ml of 0.9% sodium chloride to clear the catheter, taking care not to apply excessive force to the syringe. During this flush, observe the catheter tract for extravasation or swelling, and question or observe the patient to determine whether burning, pain, or discomfort is experienced. Difficulty in injecting or infusing fluid may indicate catheter compression, malposition, and/or obstruction. Document each flush. e. Notify MD of any problems that occur and document in the medical record. D. Managing obstructions: When this occurs, do not attempt to force fluid through the system. Notify the M.D. immediately. Further flushing could result in catheter rupture with possible embolization. E. Site Care: 1. The external catheter length should be measured and documented with each dressing change. Any change in the effective external length indicates a change in the location of the tip of the catheter. Dressing change procedure shall be performed with sterile technique. The dressing should be removed carefully, stabilizing the external portion of the catheter and peeling the dressing towards the insertion site. If sterile tape or wound closure strips are used to secure the catheter, they should be removed with each dressing change so the skin underneath can be adequately cleaned. 2. Dressings shall be routinely changed at least every 96 hours along with IV administration tubing, needleless device. Dressings shall also be changed any time the dressing has become loosened, wet, or soiled. The injection cap shall be replaced at least every 96 hours and documented. Scissors or other sharp instruments shall not be used when changing the dressing.

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C-31 Clampless Valved Tunneled Central Catheter

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3. The site and a 3 inch diameter around the site shall be cleansed with chlorhexidine and allowed to dry prior to application of the sterile dressing. Reapply sterile tape or wound closure strips to secure the catheter. A sterile transparent dressing shall be applied over the sterile tape/wound closure strips and shall cover the insertion site, the lock mechanism of the catheter, and approximately one inch of the extension tubing. The external portion of the catheter shall not be kinked or occluded. Additional tape may be added to insure an occlusive dressing or and/or to secure external extension tubing to prevent tension. 4. The insertion site shall be assessed for redness, drainage, tenderness, or catheter migration at least every shift with documentation to include the condition of the site, the condition of the catheter and effective external length, any special measures taken and patient education. The tolerance of the patient for the procedure shall also be documented. F. Medication and Fluid Administration: If the catheter is being used intermittently, it shall be flushed at least every 7 days and/or whenever medication is administered via the catheter. 1. Flush the catheter after every use, and or at least weekly, to maintain patency using a 10cc or larger syringe. 2. Flush the catheter with a minimum of 10cc 0.9% sodium chloride, using a "pulse" or "stop/start" technique. 3. Disconnect the syringe and attach a sterile end cap to the catheter hub and tighten securely. 4. When injecting or infusing medications that are incompatible, always flush the catheter with a minimum of 10cc 0.9% sodium chloride before and after the medication. 5. If resistance is met when flushing, no further attempts should be made. Notify the MD immediately and document in the medical record. Further flushing could result in catheter rupture with possible embolization. 6. Evaluate patient for possible "pinch-off" syndrome if resistance or occlusion is intermittent and responds to patient position. 7. If the catheter is not in use, flush every 7 days with a minimum of 10cc 0.9% sodium chloride and cap off. Document each flush.

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C-31 Clampless Valved Tunneled Central Catheter

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G. Drawing blood from a tunneled valved central catheter: 1. Four french and larger single lumen catheters can be used for blood sampling. Use of smaller gauge catheters for blood withdrawal has not been consistently effective. When using multiple lumen catheters, the largest lumen (red) should be used for blood withdrawal and blood infusion. 2. Remove sterile end cap or disconnect infusion. 3. Use a 10cc or larger syringe to aspirate a small amount of blood and fluid (3-5 ml minimum) and discard according to policy. Assure that the catheter is clear of all fluids to ensure a pure specimen. 4. Using a 10 ml or larger syringe, slowly and gently withdraw the sample. A smaller syringe or vacutainer shall not be used since these may cause the catheter to collapse. 5. Flush the catheter using a 10cc syringe with a "stop/start" pulsed technique using a minimum of 20cc 0.9% sodium chloride following withdrawal of a blood sample. Document each flush. 6. Attach a sterile end cap to the catheter hub and tighten securely. Responsible Party A. Site Care MD, RN, RN Applicant Action Rationale

1. Assembles supplies: clean gloves, sterile nonpowdered gloves, sterile transparent dressing, wound closure strips/sterile tape, chlorhexidine.

2. Explains procedure to the patient. 3. Measures external catheter length, noting any catheter migration and notifies M.D. if discrepancy in length. 4. Washes hands, dons clean non-powdered gloves and removes dressing and wound closure strips carefully, stabilizing external catheter and peeling towards insertion site. To avoid accidental removal of the catheter.

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C-31 Clampless Valved Tunneled Central Catheter

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MD, RN, RN Applicant

5. Removes gloves and washes hands using antimicrobial soap and water or alcohol gel. 6. Dons sterile non-powdered gloves and cleanses insertion site, including a 3 inch diameter around the site, with chlorhexidine and allows to dry. 7. Applies wound closure strips. 8. Applies sterile transparent dressing over wound closure strips, covering the catheter lock mechanism and one inch of extension tubing. 9. Applies additional tape as needed. To prevent tension and help secure the external catheter. To secure the catheter.

10. Removes gloves and washes hands. 11. Assesses insertion site at least every shift for signs and symptoms of infection and any catheter migration, documenting findings in the medical record, notifying M.D. of untoward findings. 12. Performs site care and changes dressing, IV tubing and needless device at least every 96 hours. Changes injection cap every seven days. 13. Documents external catheter length, site condition, dressing change and special measures taken in the Nurse's Record. B. Medication and Fluid Administration (Intermittent) MD, RN, RN Applicant 1. Washes hands with antimicrobial soap and water or uses alcohol hand gel sanitizer. Dons clean gloves and cleanses injection cap with alcohol.

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C-31 Clampless Valved Tunneled Central Catheter

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MD, RN, RN Applicant

2. Flushes the catheter after every use and at least every 7 days (uses a 10cc or larger syringe with a minimum of 10cc 0.9% sodium chloride using a "pulse" or "stop/start" technique). Document each flush. 3. Disconnects the syringe, attaches a sterile end cap to the catheter hub and tightens securely. 4. For incompatible medications, always flushes with a minimum of 10cc 0.9% sodium chloride before and after the medication using a 10cc or larger syringe. 5. Removes gloves and washes hands. 6. Documents in medical record and records flushes in the Medication Administration Record.

To maintain patency of the line.

C. Drawing Blood MD, RN, RN Applicant 1. Assemble supplies: alcohol preps, 10cc or larger syringes X 3, 20-25cc sterile 0.9% sodium chloride, Clean gloves 2. Washes hands with antimicrobial soap and water or alcohol gel. Dons gloves and cleanses injection cap with alcohol/removes end cap/disconnects infusion. 3. Aspirates a small amount of blood and fluid (3-5 ml minimum) using a 10cc syringe and discards according to policy. 4. Uses a 10cc or larger syringe to slowly and gently withdraw the sample. A smaller syringe or vacutainer shall not be used since these may cause the catheter to collapse.

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C-31 Clampless Valved Tunneled Central Catheter

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MD, RN, RN Applicant

5. Flush the catheter using a 10cc syringe with a "stop/start" pulsed technique using a minimum of 20cc 0.9% sodium chloride following withdrawal of a blood sample. Document each flush. 6. Attach a sterile end cap to the catheter and tighten securely.

References: 6/2003. Clampless Valved Catheter TM Tunneled Silicone Central Venous Catheter with Pressure Activated Safety Valve TM (PASV) Instructions for Use. Boston Scientific, Natick, MA USA, pages 3-15. 1999. Catheter Innovations Inc., Boston Scientific, Pressure Activated Safety Valve Instructions for Use Clampless Valved Catheter Tunneled, Salt Lake City, Utah, www.pasv.com, pages 1-18. May 2010. Nursing Policy Central Venous Catheters. C-30. LSUHSC-S, pages 1-10. June 2010. LSUHSC Patient Care Services Policy, Peripherally Inserted Central Catheters (PICC) Care of Patients, P-36, pages 1-6.

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C-31 Clampless Valved Tunneled Central Catheter

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Jamie Jett, MBA, RN Administrative Nursing Director Psychiatry, Coordinated Care and Professional Practice

________________________________________ Signature

_______________________ Date

Jean DiGrazia, MBA, RN Acting Assistant Administrator and CNO Patient Care Services

_________________________________________ Signature

_______________________ Date

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