What is the proper technique for cleaning catheter insertion site when performing a CVC dressing change?

Note: This guideline is currently under review. 

Introduction

Aim

Definition of terms

Assessment

Management

Companion Documents

References

Evidence Table 

Introduction

Peripheral intravenous catheters (PIVC) are the most commonly used intravenous device in hospitalised patients. They are primarily used for therapeutic purposes such as administration of medications, fluids and/or blood products as well as blood sampling. 

Aim

The aim of this guideline is to provide an outline of the ongoing maintenance and management of the PIVC for patients in hospital, outpatient, and home healthcare settings. For information related to insertion of PIVC, please refer to intravenous access guideline . Nurses who are deemed competent in IV insertion could continue to insert PIVC in consultation with NUM/CSN’s. 

Definition of terms

• Peripheral IV devices: are cannula/catheter inserted into a small peripheral vein for therapeutic purposes such as administration of medications, fluids and/or blood products.
  
• Aseptic technique: is a part of all procedures which aims to prevent pathogenic microorganisms, in sufficient quantity to cause infection, from being introduced to susceptible key sites by key parts, hands, surfaces and equipment. Therefore, unlike sterile techniques, standard and surgical aseptic techniques are possible and can be achieved in typical hospital and community settings.
  
• Decontaminate hands: Perform hand hygiene in order to protect the patient from organisms which may enter their key sites or devices during a procedure.
• Key Parts: part of the device/s that must remain aseptic throughout the clinical procedures. Examples of Key parts include, catheter hub, needleless connector, syringe hub, needle etc.
  
• Key Sites: the area on the patient such as IV insertion site that must be protected from microorganisms. 
  
• Extravasation: An extravasation occurs when there is accidental infiltration of a vesicant drug or fluid into the tissue surrounding the venipuncture site.
  
• Infiltration: occurs when drugs or fluid infiltrates into the tissue surrounding the venipuncture site. This happens when the tip of catheter slips out of the vein, catheter passes through the wall of the vein, or as blood vessel wall stretches which allows fluid to infuse into the surrounding tissue. 
  
• Phlebitis: a sign of vessel damage. The cause can be chemical (due to the osmolarity of the solution), mechanical (from trauma at insertion or movement) or infective (microorganisms contaminating the device). Signs include swelling, redness, heat, induration, purulence, a palpable venous cord (hard vein) and pain related to local inflammation of the vein at or near the insertion site.
  
• Infusion Pump: refers to infusions pumps like large volume pumps (LVPs)/volumetric pumps e.g. Alaris Signature Edition (SE), Syringe drivers (e.g. Alaris GH+), Patient Controlled Analgesia/PCA pumps (Alaris PCAM) etc.
  
• Double checking: refers to the practice of two clinicians (appropriately endorsed Enrolled nurses (EN), Registered Nurses (RN), Doctors or Pharmacists) independently checking the medications. 
  

Assessment

Patient and IV site assessments should be done on a regular basis. 

PIVC assessment includes: 

• Assessment of PIVC insertion site - Catheter position, patency/occlusion, limb symmetry, any signs of phlebitis (erythema, tenderness, swelling, pain etc.), infiltration/extravasation. PIVC are considered as high risk for pressure injury. PIVC sites should be checked hourly for pressure sore and any signs of infection unless documented otherwise. http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/.
  
• Assessment of PIVC dressing and splints: check securement of dressing- if it’s intact, clean and dry or if it’s loose or if visible ooze was present underneath the dressing. Check splint tapes are not too tight or restrictive.
  
• Assessment of IV lines, equipment and IV fluid infusions:
  
  • If the patient is receiving continuous IV fluid infusion- observations of the IV site, type of fluid and volume infused, accurate rate of infusion for patient and pressure alarms of infusion pumps are observed hourly and documented in the fluid balance flowsheet. 
    
  • If the patient (inpatient setting) is having intermittent infusion, eight hourly assessments are a minimum. Unstable patients who have signs and symptoms of complications are to be assessed more frequently.
    
  • If the patient no longer requires IV access for infusions, remove the cannula at the earliest to avoid complications.
    
• For Hospital in the Home (HITH) patients, the nurse will assess the PIVC with each visit. 
  
• Caregiver and patient education will be provided on the signs of injuries and the process of contacting the nurse.
  

Management

Administration of intravenous fluid, drug infusions or blood products 

a) Continuous infusion of IV fluids
Assessment and documentation of findings are to be completed hourly to determine effective delivery of prescribed medications and fluid.  

• Each bag of fluid is independently double checked and a signed patient label is put on the bag. 
  
• Check the solution is the prescribed one, the rate of infusion, and the amount infused is noted.  
  
• Document the infused volume: Hourly on fluid balance flowsheet (it is advised to clear the infusion pump hourly)
  
• Check the infusion site for any signs of complications and document the assessment findings hourly in fluid balance flowsheet
  
• Review the cumulative volume infused and fluid output as required based on patient’s clinical condition.
  
• Pump pressures for each IV line should be documented hourly or when adjusted on the flow sheet
  

Infusion Pump Pressure
Pressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer’s recommendations. 
Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:

• Increased viscosity of the fluid being administered 
  
• High rate of the fluid being administered 
  
• Reduced diameter of the intravascular catheter
  
• Increased length of the intravascular catheter 
  
• Increased level of patient activity 

If pump pressure exceeds the recommended limits, check the patency of the PIVC.

b) Administration of bolus/loading doses: 

Administering drugs: 

Drugs administered via PIVC may be 

• diluted into a bag of IV fluids 
  
• added to the burette of an infusion set 
  
• prepared for administration via a volumetric infusion pump 
  
• in a syringe for use in a syringe driver 
  
• administered directly as a bolus or push

The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery.

Drugs administered via:

• Burette of an infusion set: to dilute the drug in a smaller volume via burette giving system, hang the bag of infusion fluid and gradually open the roller camp to allow appropriate amount of diluent into the burette. Inject the prescribed drug into the burette via the additive port.
  
• Syringe driver:  is recommended for children weighing less than 10 kg. Draw up required volume of diluent in appropriate size syringe and then pull back the syringe plunger to enable you to inject the drug into the syringe using aseptic technique.
  
• Infusion bag: Clean the access port with disinfectant swab before injecting prepared drug into infusion fluid bag via the additive port. Without contaminating the key part (spike) insert the spike on the administration set into the septum of the infusion bag.
  

Attach a completed drug label detailing the drug, dose, diluent, volume of diluent, date, time and signature of the nurse and the staff who double checked.

Access PIVC only after cleaning the access port and scrub the hub.

For intermittent infusions, IV lines which are disconnected are to be discarded between infusions.  Ensure the cannula is flushed with normal saline once the giving set is disconnected from the cannula. For Opioid infusion bolus refer to the specific guidelines: Children’s Pain Management Service (CPMS)(opioid infusion guideline)

Administering blood products:

• Check patient and blood product identification as per the Blood Product Transfusion Procedure.
  
• Administer blood product transfusions via a volumetric infusion pump or syringe driver to ensure accurate delivery. Use gravity sets only when rapid administration is required with diligent monitoring of volume.
  
• Use a Neonatal transfusion set (includes a 170 to 200 micron filter required for blood products) and syringe driver for delivering small volumes of blood products.
  
• Using aseptic non touch technique, spike the blood product septum with the Neonatal transfusion set and attach an appropriate sized syringe for the transfusion to the 3 way tap.
  
• Draw the required volume into the syringe and prime the rest of the neonatal transfusion set. Label the syringe with both patient and blood product identification details including expiry date and time of blood product.
  
• If rapid transfusion of small volumes is required, draw the required volume into a syringe through a 170 to 200 micron filter. 
  
• Burettes should not be used for transfusion of blood products.

Flushing of PIVC’s

• If the cannula is accessed intermittently for the administration of medications or fluids, the cannula should be flushed prior to infusion or at least once a shift.
  
• Sterile 0.9% sodium chloride for injection should be used to flush a catheter. This must be prescribed as a medication.
  
• The optimal volume used for intermittent injections or infusions is unclear. The literature suggests the volume of flush should equal at least twice the volume of the catheter and add on devices and a minimum of 2mL normal saline flush is recommended.
  
• Use 10ml syringe for flushing to avoid excessive pressure and catheter rupture. Syringes with an internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and rupture the catheter. If resistance is felt during flushing and force is applied this may result in extravasation
• Use aseptic non touch techniques including cleaning the access port (scrub the hub) with a dual disinfectant agent (e.g. chlorhexidine and alcohol) vigorously for at least 15 seconds and allowing to dry prior to accessing the system.
  
• Flush in a pulsatile (push-pause) motion.
  Flush catheters:
  
  • Immediately after placement
    
  • Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection.
    
  • Prior to and after blood drawing.

Change of PIVC dressing and securement of cannula: 

• Dressings to PIVC sites are the first line of defence against infection and dislodgements. The dressing must be kept secure, clean dry and intact. 
  
• Indications for dressing change: when it becomes insecure or if there is blood or fluid leakage under the dressing. 
  
• Determine the need for an assistant considering patient age, developmental level and family participation prior to the procedure.  
  
• If patient is allergic to transparent film dressings, use sterile film dressing to be used and changed daily. 
  
• Carefully remove the old dressing, holding the cannula in place at all times 
  
• Take the opportunity to thoroughly inspect the site of entry of the cannula for any sign of infection.
  
• Skin preparation using alcohol in 2% chlorhexidine is the preferred solution for dressings.
  
• Cleanse the area around the catheter insertion site including under the hub using a pattern which will ensure entire area is covered.
  
• Allow skin preparation to air dry prior to applying any dressing, this allows the disinfectant to work. 
  
• Consider placing a small piece of sterile cotton wool ball or gauze underneath the hub of the cannula to reduce pressure.
  
• If desired, place sterile tape over the hub of the device before placing the transparent dressing.
  
• Cover the cannula insertion site with sterile transparent semipermeable, occlusive dressing (e.g. Tegadermtm, IV 3000tm) placed using an aseptic non touch technique over the catheter. This will allow continuous observation of the site and to help stabilise and secure the catheter.
  
• IV board / splints are recommended to secure PIVC placed in or adjacent to areas of flexion. This will adequately immobilize the joint and minimise the risk of venous damage resulting from flexion.
  
  • When using Splints, ensure these are positioned and strapped with the limb and digits in a neutral position to prevent injury from restricting blood or nerve supply and to prevent pressure sores
  • Inspect the splint at least daily and change if soiled by blood or fluid leakage.
    
• Cover with non-compression tubular bandage. Ensure there is a clear window where the cannula enters the skin- insertion site, so the site can be regularly viewed.
  
• In Summary, when dressing a peripheral IV cannula ensure: 
  
  • it is secure
    
  • the site is visible
    
  • the child can't injure themselves, or be injured by the connections
    
  • the child can't remove or dislodge the cannula
    
  • tapes are not too tight or restrictive.
    
• Refer to  Intravenous access–Peripheral guideline for steps involved in accessing and securing the cannula http://www.rch.org.au/clinicalguide/guidelineindex/Intravenous_access_Peripheral/
  
• Documentation shall contain information on the insertion site, gauge of the needle and date and time of insertion has been documented in the EMR- LDA properties.

Change of Extension sets

• Extension sets are to be changed when the access device is changed or immediately upon suspected contamination or when any break in integrity.
  
• Extension sets are to be primed and attached to the cannula at the time of IV insertion using an aseptic non touch technique 
  
• When exiting the flushing of extension set you must use a positive pressure clamping technique. 
  
• When not in use, extension sets must be clamped 

IV Fluid Considerations via Peripheral IV line

Which Fluids and how much fluids to use
Refer to the Intravenous Fluids Clinical Practice Guideline: Intravenous Fluids

• Administering fluids containing glucose concentration greater than 12.5% will require central venous line access.

Labeling infusions:

• Label the fluid bag/syringe with date, time, patient name and signature of two checking staff. The label must be placed on the front of the fluid bag ensuring the fluid name, batch number, expiry date and graduations remain visible (link to national standard). Labels on syringes should be placed parallel to the long axis of the syringe barrel with the top edge of the label flush with (but not covering) the graduations ( link to national standard).
  
• Label IV line if multiple lines are running: label close to the fluid bag or syringe or below the drip chamber.
  
• If additives are added to infusion, please label the bag or syringe driver with additives added.
  
• Approved label can be generated by the EMR.

Fluid bag and infusion changes: 

• Fluid bags and syringes with nil additives are changed at least every 7 days.    
  
• Fluid bags and infusions with additives are changed every 24 hours. 
  
• Fresh blood products and lipid containing solutions; both the bag, syringe, giving set and lines should be removed or changed at conclusion of infusion or at least every 24 hours. 
  

Line changes 

• Infusion lines are replaced at least every 7 days using standard aseptic technique. 
  
• Administration sets that have been disconnected (either accidentally or planned) are no longer sterile and to be discarded and replaced.  
  
• If using fresh blood or fresh blood products replace line(s) at the end of the infusion. 
  
• If lipid emulsion is being infused change the lipid syringe/bag and line every 24 hours.  

Table 1.Changing IV bags and lines  

Removal of PIVCs: 

There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC’s should be maintained with regular assessment and documentation of complications.
The possible reasons for removal of PIVC’s include a number of complications which range from infiltration, extravasation, phlebitis, occlusion, dislodgement and migration. Once the child’s treatment is over, the PIVC should be removed to avoid any additional complications. 

• Perform hand hygiene
  
• Prepare patient and caregiver
  
• Perform hand hygiene and apply non-sterile gloves, carefully remove the adhesive dressing, holding the cannula in place at all times
  
• Hold a piece of sterile gauze or cotton wool over the exit site but do not apply pressure
  
• Slowly withdraw the cannula, maintaining a neutral angle with the child’s skin
  
• Cover site with dressing e.g. pressure dot, cotton wool and tape or Band-Aidtm
  
• Advise the child and family that the cotton wool and tape or Band-Aid should remain in situ for up to 24 hours
  
• Remove gloves, perform hand hygiene 
  
• Dispose of waste according to clinical practice, perform hand hygiene 
  
• Document date and reason for removal. Ensure the device is also removed from the LDA in EMR.
  

Management of complications

There are a range of complications that could occur with the presence of a PIVC in insitu. Some of these complications can be prevented by the correct use of aseptic technique for insertion and maintenance as well as assessing the device as indicated. 
Common complications are:

• Infection:
  
  • Skin-based bacteria may enter through insertion site
  • Local cellulitis or systemic bacteraemia are possible.
    
• Phlebitis: Vein irritation
  
  • Due to the presence of the catheter/fluids or medication
  • Chronically ill patients requiring multiple and recurrent IV access.
    
• Infiltration/Extravasation: delivery of fluids or medications into surrounding tissue
  If Infiltration/extravasation occurs... (Link to neonatal extravasation guideline). 
  
  • Immediately stop the infusion and disconnect the tubing as close to the catheter hub as possible. 
    
  • Remove the catheter without placing pressure on the site. 
    
  • Elevate the affected limb.
    
  • Apply either ice packs or warm compresses to the affected area, depending on the drug that extravasated.
    
  • Continue to assess and document the appearance of the site and associated signs and symptoms. Some signs, such as erythema and ulceration, may be delayed for 48 hours or more after the extravasation.
    
  • For neonatal extravasation refer to RCH guideline Neonatal Extravasation
    
  • Plastics team to review the patient
    
  • Document the date and time of the infusion when extravasation was noted, the type and size of catheter, the drug administered, the estimated amount of extravasated solution, and the administration technique used.
    
  • Document the patient's signs and symptoms, treatment, and response to treatment. Include the time you notified the patient's primary care provider and the primary care provider's name. 
    

Companion Documents

1. http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/
   
2. http://www.rch.org.au/policy/policies/Central_Venous_Access_Device_Management/
   
3. http://www.rch.org.au/policy/policies/Medication_Management/
   
4. http://www.rch.org.au/policy/policies/Procedural_Pain_Management/
   
5. http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal_Extravasation/
   
6. http://www.rch.org.au/policy/policies/Blood_Product_Transfusion/
   
7. http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/
   
8. http://www.rch.org.au/policy/policies/Aseptic_Technique/

References

• Abolfotouh, M. A., Salam, M., Bani-Mustafa, A., White, D., & Balkhy, H. H. (2014). Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications. Therapeutics and clinical risk management, (10) 993-1001.
• Ben Abdelaziz, R., Hafsi, H., Hajji, H., Boudabous, H., Ben Chehida, A., Mrabet, A., . . . Tebib, N. (2017). Full title: peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study. BMC Pediatrics, 17(1), 208-208. doi: 10.1186/s12887-017-0965-y
  
• Callaghan, S., Copnell, B., & Johnston, L. (2002). Comparison of two methods of peripheral intravenous cannula securement in the pediatric setting. Journal Of Infusion Nursing, 25(4), 256-264.
  
• Fidler, H. (2010). To splint or not to splint: securing the peripheral intravenous cannula. Advances In Neonatal Care (Elsevier Science), 10(4), 204-205
  
• Gabriel, J. (2010). Vascular access devices: securement and dressings. Nursing Standard (Royal College Of Nursing (Great Britain): 1987), 24(52), 41-46. 
  
• Gunes, Aynur and Bramhagen, Ann-Cathrine (2018). Heparin or Sodium Chloride for Prolonging Peripheral Intravenous Catheter Use in Children - A Systematic Review. Journal of pediatric nursing
  
• Hadaway, L. C. (2009). I.V. rounds. Preventing and managing peripheral extravasation. Nursing, 39(10), 26-27
  
• Hugill, K. (2016). Is there an optimal way of securing peripheral IV catheters in children? British Journal of Nursing, 25(19), S20-S21. doi: 10.12968/bjon.2016.25.19.S20
  
• Inge J. J, A., Johanna A, H., Henriette T. M, W., Gert-Jan, v. d. W., Johannes M. M, G., & Kian D, L. (2011). Effectiveness of heparin solution versus normal saline in maintaining patency of intravenous locks in neonates: a double blind randomized controlled study. Journal of Advanced Nursing(12), 2677. doi: 10.1111/j.1365-2648.2011.05718.x
  
• Keogh, S., Flynn, J., Marsh, N., Mihala, G., Davies, K., & Rickard, C. (2016). Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients (Vol. 17).
  
• Laudenbach, N., Carie A, B., Klaverkamp, L., & Hedman-Dennis, S. (2014). Peripheral IV Stabilization and the Rate of Complications in Children: An Exploratory Study. Journal of Pediatric Nursing, 29, 348-353. doi: 10.1016/j.pedn.2014.02.002
  
• Lim, E. Y. P., Wong, C. Y. W., Kek, L. K., Suhairi, S. S. B. M., & Yip, W. K. (2018). Improving the Visibility of Intravenous (IV) Site in Pediatric Patients to Reduce IV Site Related Complications - An Evidence-based Utilization Project (Vol. 41, pp. E39-E45).
  
• Lucchini, A., Angelini, S., Losurdo, L., Giuffrida, A., Vanini, S., Elli, S., . . . Fumagalli, R. (2015). [The impact of closed system and 7 days intravascular administration set replacement on catheter related infections in a general intensive care unit: a before-after study]. Assistenza Infermieristica E Ricerca: AIR, 34(3), 125-133. doi: 10.1702/2038.22138
  
• Malyon, Lorelle & Ullman, et al. (2014). Peripheral intravenous catheter duration and failure in paediatric acute care: A prospective cohort study. Emergency Medicine Australasia. 26. 10.1111/1742-6723.12305.Marsh, N., Webster, J., Mihala, G., & Rickard, C.
• M. (2015). Devices and dressings to secure peripheral venous catheters to prevent complications.
  
• Marsh, N., Webster, J., Mihala, G., & Rickard, C. M. (2015). Devices and dressings to secure peripheral venous catheters to prevent complications.
  
• Morris, W., & Tay, M. (2008). Strategies for preventing peripheral intravenous cannula infection. British Journal Of Nursing, 17(19), S14-21.
  
• O’Grady N, Alexander M, Burns L, Dellinger E, Garland J, et al. (2011) The Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clinical Journal of Infectious Diseases 2011 May;52(9): 1087–99.
  
• Phulara, U. (2018). Effectiveness of Normal Saline Flush versus Heparin Saline Flush in Maintaining the Patency of Peripheral Intravenous Cannula and on Occurrence of Intravenous Local Vascular Complications in Patients Receiving Intermittent Intravenous Medications, 51.
  
• Rickard, C. M., Marsh, N., Webster, J., Runnegar, N., Larsen, E., McGrail, M. R., . . . Playford, E. G. (2018). Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial (Vol. 392, pp. 419-430).
  
• Rickard, C. M., Webster, J., Wallis, M. C., Marsh, N., McGrail, M. R., French, V., . . . Whitby, M. (2012). Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet, 380(9847), 1066-1074.
  
• Rickard, C. M., McCann, D., Munnings, J., & McGrail, M. R. (2010). Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Medicine. 
  
• Rickard, C. (2004). Prolonged use of intravenous administration sets: a randomised controlled trial.
  
• Rita, A., Hindra Irawan, S., & Pustika, A. (2013). Duration of peripheral intravenous catheter use and development of phlebitis. Paediatrica Indonesiana, Vol 53, Iss 2, Pp 117-20 (2013)(2), 117. doi: 10.14238/pi53.2.2013.117-20
  
• Smith, B., & Royer, T. I. (2007). New standards for improving peripheral i.v. catheter securement. Nursing, 37(3), 72-74. 
  
• Tripathi, S., Kaushik, V., & Singh, V. (2008). Peripheral IVs: Factors Affecting Complications and Patency-A Randomized Controlled Trial, 182.
  
• Ullman, A., Marsh, N., & Rickard, C. (2017). Securement for vascular access devices: looking to the future. British Journal of Nursing, 26(8), S24-S26. doi: 10.12968/bjon.2017.26.8.S24
  
• Ullman  AJ, Cooke  ML, Gillies  D, Marsh  NM, Daud  A, McGrail  MR, O'Riordan  E, Rickard  CM. Optimal timing for intravascular administration set replacement. Cochrane Database of Systematic Reviews 2013, Issue 9.
  
• Webster, J. (2015). Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews(8). 

Evidence Table

The evidence table can be found here. 

The development of this nursing guideline was coordinated by Mercy Thomas, Nursing Educator, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018.  

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