Transcript Multidisciplinary Care in Regional Victoria

Management of
Central Venous Access Devices
2. HICKMAN CATHETER
Nurse Education Workforce Strategy – Gippsland Region
Gippsland Oncology Nurses Group (GONG)
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Acknowledgements
This project is an initiative of :
Nurse Education Workforce Strategy –Gippsland
Content supplied by:
Gippsland Oncology Nurses Group (GONG)- an initiative of
Gippsland Region Integrated Cancer Services (GRICS)
Special thanks:
Anny Byrne (Gippsland Regional Integrated Cancer Services)
Anne Maree Day (West Gippsland HealthCare Group)
Dianne Fahy (Nurse Education Workforce Strategy)
Anne Johnson (Latrobe Regional Hospital)
Linda Langskaill (Central Gippsland Health Service)
Melanie Regan (Gippsland Regional Integrated Cancer Services)
See other sources and references at the end of this presentation.
Further reading is encouraged to complement these tutorials.
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Scope of Tutorial
• What is a Hickman Catheter?
• List the advantages and disadvantages
• What care should be provided when changing a
cap/bung?
• What is the strength of heparin lock used for a
Hickman catheter?
• Describe how to flush in a ‘pulsatile’ manner
• What is the minimum size syringe used when accessing
a Hickman Catheter?
• List the essentials for documentation
• What are the main complications with a Hickman
Catheter and how to troubleshoot them?
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Hickman Catheter - Description
•
A Hickman Catheter is a tunnelled
Central Venous Catheter. The tip
of the Hickman Catheter resides in
the Superior Vena Cava. The
remaining lumen is tunnelled
under the skin and exits the chest
or abdominal wall. A cuff
attached to the lumen adheres to
the skin and tissues close to the
exit site, which anchors the
catheter.
•
A Hickman catheter can consist of
single, double or triple lumens.
•
A Hickman catheter is used for
intermediate and long term
therapies usually in the
haematology setting.
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Hickman Catheter
ADVANTAGES
DISADVANTAGES
• Large bore lumens
• High maintenance
• Pain free when accessed
• Altered body image
• Single, double or triple
lumens for multiple
infusions
• Theatre for insertion /
removal
• Increased risk of
infection
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Confirmation of placement
• Every time the Hickman Catheter is accessed,
the nurse is responsible for confirming correct
placement by:
–
–
–
–
Aspiration of blood
Ability to easily infuse solutions
Normal appearance of site and patient’s chest
Written x-ray report confirming correct placement
of Hickman Catheter available in patient record
• If unable to confirm correct placement refer
to the troubleshooting section of the GONG
Cancer Care Guidelines ‘Hickman Catheter
Management’ (see Resources)
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Principles of Care
• Clamps are ESSENTIAL
on Hickman catheters
• Must be left open when
a positive pressure bung
is in use
• Must be closed if a nonpositive pressure bung is
in use
• Must be closed when
the system is opened
i.e. cap/bung removed
Non Positive
Pressure Bung
Positive
Pressure Bung
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Note: Above is a sample of one
type of bung currently available
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Accessing
• A clean technique* is required for accessing a
closed system through a cap/bung
• Aspirate for blood return to check patency
and position
• Flush with 10 ml normal saline in a pulsatile
manner when position confirmed
• Connect to IV line
• * Recommended clean technique: clean gloves and
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
clean with 3 alcohol swabs and allow to air dry before
proceeding to access a closed system
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Syringe Size
• Syringes no smaller than 10 ml to be used
• Smaller syringes increase the pressure in the
catheter wall and increase the risk of rupture
of the catheter
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Catheter Removal
• Only to be performed by a doctor in a hospital
setting
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Flushing
• Flush with Normal Saline 10 ml in a pulsatile
(stop/start) manner: that is, push then pause
the plunger of 10ml syringe continuously in
short bursts until syringe empty
• On accessing the Hickman Catheter to
determine patency
• Before and after drug administration
• After blood sampling
• Weekly, when not in use
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Heparin Lock
• Weak heparin lock (heparinization) 50u/s in
5ml is all that is required
– After each use, and weekly, when a non-positive
pressure bung is in use
* Remember never use a syringe smaller than a 10ml
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Cap / Bung Description
• The positive pressure
bung maintains a positive
pressure in the line to
prevent back flow of blood
into the end of the
catheter.
• A positive pressure bung
should be used with a
Hickman Catheter. If a
positive pressure bung is
unavailable then use a
non positive pressure
bung and weak
heparinization is required.
Non Positive
Pressure Bung
Positive
Pressure Bung
Note: Above is a sample of one
type of bung currently available
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Changing a Cap / Bung
• Aseptic technique required using a sterile tray
and sterile gloves
• Positive pressure cap/bung should always be
insitu and must be changed at least every 7
days
• Clamp line before removing cap/bung
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Changing a dressing
• Always use an aseptic technique
• Initial dressing should be changed 24 hours
post insertion
• Dressing should be changed every 7 days or
earlier if necessary
• Dressing usually not required 21 days post
insertion
• Entry site may be left uncovered when healed
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Changing an IV Line
• A clean technique* is required when the system is
closed ie. bung is in place
• Continuous IV infusion line is changed every 72 hours
• For intermittent IV infusion, change line with each
infusion
• Change IV TPN/Lipid line every 24 hours
• Blood product infusion sets changed to an IV infusion
set on completion of the blood product infusion
*Recommended clean technique: clean gloves and
clean with 3 alcohol swabs and allow to air dry before
proceeding to access a closed system
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Taking Blood
• Perform initial flush to determine patency (except for
blood cultures)
• Discard the first 5ml of blood withdrawn before
collecting sample
• When taking blood cultures do not perform initial flush
to determine patency, do not discard a sample. Retain
initial sample for blood culture
• Flush Hickman Catheter, in a pulsatile manner, with
20ml of Normal Saline after blood sampling and
continue with treatment as ordered and / or
heparinization if required
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
Management of Central Venous Access Devices
Documentation
Clear, consistent documentation is essential
after each treatment or shift. This should include:
• Ability to confirm placement
• Medications and flushes administered
• Strength of heparinization (if used)
• Type of bung/cap used
• Dressing change
• Signs and symptoms of infection or thrombosis
• Troubleshooting
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
* Written x-ray report confirming correct placement at
time of insertion should be available in patient
documentation
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Complications
1. Blockage of lumens
2. Infection at insertion site or in catheter
3. Thrombosis
4. Damage to exposed catheter
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
1. Blockage of lumen
Difficulty flushing and/or aspirating blood
• Ensure any clamps are open
• Change position of patient
• Change cap or bung
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
2. Infection
• Redness, discharge, tenderness, heat, patient
feels unwell, pain and swelling at Hickman
Catheter site may be symptoms of infection
• If signs of infection are present do not access
Hickman Catheter and consult physician
• Septic shower may occur immediately after
flushing due to infection in the line. There
may be an absence of obvious infection at
entry site, however the patient will experience
rigors and generally feel unwell. Consult
physician
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
3. Thrombosis
• Do not access Hickman Catheter and consult
physician
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
4. Damage to exposed catheter
Check catheter every time it is accessed for:
– Perishing, splitting, damage and if the cap
is firmly in place
– Refer to physician if integrity is
compromised
– This is more common in children
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
Resources
GONG Cancer Care Guidelines have been
accepted to guide the management of all
patients with a CVAD in Gippsland and are
available at each Gippsland Health Service.
Also available on-line at:
www.gha.net.au/grics
TUTORIAL
HICKMAN CATHETER
This Tutorial
Hickman Description
Advantages /
Disadvantages
Confirm Placement
Principles of Care
> Accessing
> Syringe Size
> Removal
> Flushing
> Heparin Lock
> Cap/ Bung Description
> Changing a Cap / Bung
> Changing a Dressing
> Changing and IV line
> Taking Blood
> Documentation
Complications
> Blockage of lumen
> Infection
> Thrombosis
> Damage
Resources
GONG Products
CVAD TUTORIAL SERIES
1. INTRODUCTION
2. HICKMAN CATHETER
3. PORT
4. PICC
Management of Central Venous Access Devices
GONG Products
www.gha.net.au/grics