Vascular Access Device Maintenance Guide PDF

## Section II: Device Maintenance ### A. FLUSHING/LOCKING SOLUTIONS & PROCEDURES - Disinfect the needleless connector, injection port or catheter hub using a friction scrub of 70% isopropyl alcohol, alcohol with chlorhexidine gluconate, or an iodophor prior to each access. - Verify blood return an...

## Section II: Device Maintenance ### A. FLUSHING/LOCKING SOLUTIONS & PROCEDURES - Disinfect the needleless connector, injection port or catheter hub using a friction scrub of 70% isopropyl alcohol, alcohol with chlorhexidine gluconate, or an iodophor prior to each access. - Verify blood return and assess for patency of CVAD, with minimal resistance to flush, prior to infusate delivery. - Flush CVAD at regular intervals with 0.9% preservative free sodium chloride (normal saline), or other recommended sterile flush solution (per institutional policy and as required by the infusate, and manufacturer's instructions for use) to maintain patency of lumens. - Lock catheter with Heparin, or Normal Saline per Licensed Independent Practition (LIP) order, institutional policy, and manufacturer's instructions for use. The use of heparin has not shown superiority over 0.9% sodium chloride (NS) alone to maintain patency. - Assess for allergy or other contraindication to Heparin or other lock/flush solution prior to use. Be aware of risk of HIT from use of Heparin as catheter locking agent. - Volume and frequency are based on the type, design, and size of catheter, add-on devices, manufacturer's instructions for use, and institutional policy. - Consider using larger flushing volumes for catheter clearance after administering viscous infusates, blood components, and parenteral nutrition. - Flush with 0.9% preservative free sodium chloride or compatible sterile flush solution or after instillation of each medication to clear the catheter. - If infusate is not compatible with sodium chloride, flush 5% dextrose in water before and after instillation, follow with 0.9% preservative free sodium chloride to clear the line of all dextrose. - For CVAD patency assessment, use a 10 ml. or larger syringe barrel size to minimize pressure on a catheter while checking for a blood return and initial flush. After patency has been verified, the use of smaller syringes sized for specific meditation delivery is acceptable. Transferring medication to a larger syringe is not recommended. Do not flush against resistance as catheter damage may occur. - If resistance is met, check all aspects of the catheter and IV tubing: hub position, lumen, IV tubing, clamps, stopcocks, and connections for kinks or improper connections. - Utilize mechanical interventions (i.e., position changes, coughing) to alter intrathoracic pressure. Consider dressing change to facilitate closer inspection for kinks or catheter position which may contribute to resistance. - Consider changing the needleless connector. - Consider evaluation of possible non-optimal catheter tip position. - If external resistance is ruled out, consider internal occlusion, and follow institutional policy for catheter clearance or replacement. ### Pediatric Considerations - Smaller size catheters may require more frequent flushing or continuous infusions to maintain patency. - Pediatric lock solutions may include lower strengths of heparinized saline if used per institutional policies and manufacturer instructions for use (1-10 u/mL). - Use only preservative free solutions for flushing all VADs in neonates. - Alternative lock solutions may be used in patients with documented repeated CLABSI (e.g., ethanol). ### B. ASSESSMENT - Frequency of site assessment is determined by institutional policy, catheter type, rate of infusion, and patient condition. - Peripheral IV catheters may require more frequent site assessments as the risk of infiltration and extravasation are higher. - Inspect site by visual inspection and palpation through intact dressing for evidence of complications (e.g., erythema, tenderness, swelling, leaking, or damaged catheter). - Assess for systemic signs of infection (e.g, hypotension, tachycardia, fever, or confusion). - Notify licensed independent practitioner when signs of infection or complication are noted. - Assess VAD necessity daily, consider removal of VADs no longer indicated in the patient's plan of care or dormant for 24 hours. #### Dressing Changes: CVADs/Midlines/PIVs - Transparent semipermeable membrane (TSM) polyurethane dressing is recommended as it allows for direct visualization and for release of moisture produced by skin. - Change TSM dressings at least every 7 days, or more frequently, if indicated, to maintain dressing integrity (e.g. dressing becomes wet, loose, visibly soiled, etc.). - Lifting comers are a non-intact dressing. Replace rather than reinforced. - Consider use of a topical coagulant, tissue adhesive or gauze dressings if bleeding or excessive moisture is present until resolved. - Change gauze dressings at least every 2 days, and when wet, loose, or visibly soiled. - If institutional rates of CLABSI are higher than institutional goals, consider routine use of antimicrobial disc or dressing at site. - Dressing change procedure. - Use of an all-inclusive kit or cart is recommended. - Using clean gloves, remove the existing dressing. ### Avoid using organic solvents with CVAD dressing changes. - Assess site for evidence of complications (i.e., erythema, swelling, leaking, or damaged catheter). - Measure the external length of the catheter. Compare to the external length documented at the time of insertions to assess catheter stability/migration. - Remove engineered stabilization device. - Perform hand hygiene and open all sterile supplies, perform hand hygiene, and don sterile gloves. - Clean the insertion site and surrounding skin area. - Alcoholic chlorhexidine gluconate >0.5% with 70% isopropyl antiseptic is the preferred skin antiseptic for site care. - 1% or 2% tincture of Iodine, iodophors, or 70% alcohol can be used, if patient has a known allergy or sensitivity to chlorhexidine. - Allow skin to dry completely. Failure to allow solution to dry completely may result in a skin reaction. - Application of an engineered securement device, subcutaneous anchoring device, tissue adhesive, or specialty dressing indicated for line securement is recommended to prevent catheter movement, migration, or accidental dislodgement. - If used, apply chlorhexidine-impregnated sponge or dressing following manufacturer's instruction for use. - Apply skin protectant and allow to dry per manufacturer's recommendations to improve dressing adherence and preserve skin integrity. - Apply transparent membrane dressing and label with date, time, and initials. - If replacing peripheral IV's only when clinically indicated, change the TSM dressings and securement device at least every 7 days, and when non-adherent, wet, loose, or visibly soiled. - Needleless connectors should be changed with every dressing change, or with IV tubing if continuously connected, but no more often than every 96 hours. - Change Needleless Connectors prior to drawing blood cultures, if blood is visible in connector after flushing, if the connector is removed for any reason, if connector is contaminated or per manufacturer's instructions for use. ### Documentation of dressing change: - Reason for dressing change. - Assessment of site and surrounding tissue. - Type of antimicrobial skin antisepsis used. - Type of dressing(s). - Type of securement and/or stabilization device. - Assessment of patency/functionality. - Needleless connector change. ### Pediatric Considerations - The use of chlorhexidine as a skin antiseptic should be used with caution in premature infants and children < 2 months of age. ### Non-Acute Care Considerations - Patients and caregivers should be reminded of importance of maintaining dressing integrity. - At every encounter, ensure patient and/or caregiver has the contact information for the facility/personnel responsible for overseeing CVAD care and maintenance (e.g., infusion center, home infusion agency) and reinforce the need to call right away if dressing is wet, loose, or otherwise not intact rather than wait until next scheduled dressing change. ### C. REMOVAL OR REPLACEMENT OF VADS - Replace any device as soon as possible, preferably within 48 hours, if adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency, or in field prior to transport to hospital). - Remove the catheter if there are any signs of phlebitis, infection, or malfunction. - Consider removal of catheter when no longer needed for therapy, and if not in use for 24 hours after consultation with the medical team. - Removal of Non-tunneled CVADs - Removed by qualified clinicians who have demonstrated competency. - Patient should be in flat (supine) or slight Trendelenburg position, unless contraindicated. - If patient is on a ventilator catheter removal should occur at maximum inspiration. - If patient is awake and cooperative, the patient should be instructed to execute Valsalva maneuver or hum during catheter removal. - Use petroleum-based ointment and gauze, and sterile occlusive dressing over the site. - Apply continuous pressure to stop bleeding and prevent air from entering the open tract. - Patient should remain supine for at least 30 minutes after removal. 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