Repair of Cracked Catheter Adaptor, Limb or ... - BC Renal Agency

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Approved Aug 15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
1


Central Venous Catheter (CVC):

Repair of Cracked Catheter Adaptor,
Limb or Clamp

(
Approved Aug 15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012
)


Vascular Access Guideline



Table of Contents


1.0

Pra
ctice Standard

................................
................................
................................
...........

1

2.0

Equipment

................................
................................
................................
......................

3

3.0

Assessment & Interventions

................................
................................
..........................

3

4.0

Patient Education & Resources

................................
................................
......................

4

5.0

Documentation

................................
................................
................................
..............

5

6.0

References

................................
................................
................................
......................

5

7.0

Developed By

................................
................................
................................
.................

6

8.0

Reviewed By

................................
................................
................................
...................

6


This procedure is posted on the BC Provincial Renal Agency website


Health Professionals
Channel


Vascular Ac
cess


http://www.bcrenalagency.ca/professionals/VascularAccess/ProvGuide.htm


1.0

P
ractice Standard



Skill Level (Nursing): Specialized


Registered Nurses who have c
ompleted the required hemodialysis
(HD)
specialty
education and who provide nursing care in a B
C
In
-
Centre and/or Community Renal
Program
AND have received the appropriate training for repairing cracked catheter
adaptors, limbs or clamps
may
perform this p
rocedure.


Need to Know:


1.

This guideline applies only to
cracks
distal to the
“Y”

limb portion of a tunneled CVC.


2.

If the crack is proximal to the “Y” limb portion, clamp the lumen segment of the catheter
with a flat edged scissor clamp (stainless preferr
ed) as close to the exit site as possible
and notify the nephrologist immediately.
Do not attempt to repair this CVC.


3.

The clamp is always applied proximal to the crack (i.e., between the patient and the
c
rack
)
.

CVC: Repair of Cracked Adaptor, Limb or Clamp



Approved Aug
15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
2


4.

Standard/routine precautions
are
used
to r
epair tunneled catheters
to reduce the
risk of
transmission of
blood
-
borne and other pathogens
.



Wash hands before and after manipulation of the CVC and administration lines.

If
hands visibly soiled, wash with antimicrobial soap; if not, may use either an
antimicrobial soap or alcohol hand sanitizer.



Wear
gloves

(
non
-
sterile

for some parts of procedure and
sterile

for other parts)
,

non
-
sterile
gown and
non
-
sterile

mask/face shield

during
repair
procedure.


5.

M
edical
/clean

aseptic technique is
used
to
repair
tunneled catheters
, with
a
dditional
precautions as follows
:



Use sterile equipment

and
supplies
and a “no touch” technique
when
handling the
catheter

and catheter ports
.



Maintain a
sterile

drape
/gauze

under the catheter ports.



Use
a
sterile

antiseptic sol
ution

(see #
6

for a list of recommended antiseptic
solutions)
and
sterile

gauze to clean catheter hubs (
“hub scrubs
”)
.



Use a
sterile

syringe and
sterile

normal saline to flush the catheter lumens.


6.

Recommended
antiseptic solutions
,

in order of priority:


S
olution

Required Drying Time

Chlorhexidine gluconate 2% with alcohol

30 seconds
(persistent antimicrobial
activity, up to 48 hours)

Chlorhexidine gluconate without alcohol

2 minutes

Sodium hypochlorite 0.11% (ExSept Plus
®
)
or Amuchina 10%

2 minutes

Po
vidone
-
iodine

10% (Betadine)

2 minutes


7.

Air embolus is a potential catastrophic complication of
CVCs

and the relative risk while
accessing a CVC
is high
.


Ways to reduce the
risk
:



Place the patient supine in
as flat a position as the patient can comfort
ably tolerate.



N
ever
leave catheter ports
unattended
and
open to the air;
cl
amp
p
ort
s

when not
being used
.

CVC: Repair of Cracked Adaptor, Limb or Clamp



Approved Aug
15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
3


2.0

E
quipment




Non
-
sterile gown



Non
-
sterile mask/e
ye protection

(2)



Sterile gloves



Sterile dressing tray



Sterile drape

(or sterile 4x4)



4 x 4 ster
ile gauzes (several)



Antiseptic solution, preferably
chlorhexidine gluconate 2% with alcohol



1x 3 mL
sterile
syringe filled with sterile NS



1

x 10 mL
sterile
syringe



Sterile beta
-
cap adapter



Sterile surgical scissors



Sterile replacement clamp



Supplies for

flushing and locking, as
needed.



Garbage receptacle


3.0

Assessment & Interventions


Preparation:

1.

Place the patient supine in
as flat a position as the patient can comfortably tolerate.


2.

Wash
hands

with antimicrobial soap
.


3.

Don
non
-
sterile

gown (staff)
.


4.

Don
non
-
sterile

mask (staff and patient).


5.

Open the tray and add supplies.

Supplies to include

a

10 mL
sterile
syringe filled with
sterile

normal saline.


Access hemodialysis
catheter lumens
:

6.

Don
sterile

gloves.


7.

Using a
sterile

4x4
gauze
soaked in
a
n
a
ntiseptic solution, cleanse
the port,
clamp and
limb
of the “suspected” cracked limb
using friction
scrub
for
3
0 seconds
.
Discard used
gauze.


8.

Place catheter limbs on a
fresh,
dry,
sterile

4x4

drape/
gauze
.
Air
-
dry
(see point
#
6

under
“need to know” for dr
ying time).



9.

Move the clamp of the “suspected” cracked limb as close to the “Y” hub as possible.
Close clamp.


10.

Ensure port clamps are closed. Remove
the
port cap
of
the
“suspected”
cracked
limb
and discard.
Hub
-
scrub
(
i.e.,
clean
se

the
outer
hub of the c
atheter

to remove blood and
CVC: Repair of Cracked Adaptor, Limb or Clamp



Approved Aug
15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
4

contaminants that collect
o
n the hub over time
)
port

with
sterile
4x4 gauze

soaked in an
antiseptic solution
.
Discard 4x4.


Identify location
and repair
crack:

11.

Attach a 10
mL

sterile
syringe
with normal saline
to
the

port of th
e

“suspect
ed

cracked
limb. Push
in
saline against the clamped catheter


saline will leak from the crack.


12.

Using sterile scissors, cut
proximal to the crack. Do
not cut off any more than necessary
of the
catheter
limb.


13.

Discard damaged portion
of the li
mb and
, if broken,

the

clamp
.



14.

If
the
clamp needs
to be replaced,
slide
a new
clamp onto
the
lumen
.


15.

Insert
the
long
-
ringed end of
the
beta
-
cap adapter into the newly cut end of the
catheter.


16.

Push
the
adapter all the way in (up to the hub). Pull on the a
dapter to check it is a snug
fit.


17.

Connect 10 mL syringe and withdraw the air now in the limb of the catheter.
Remove
the 10 mL syringe.


18.

Attach a 3 mL syringe
filled
with normal saline

and
instill the saline into the lumen
.
S
lowly withdraw the saline unt
il b
lood

reaches the tip of a 3 mL syringe. Visualize the 3
mL syringe to see the amount of
normal saline

that has been withdrawn. The amount of
normal
saline is the new volume of the lumen.
Record this volume as per unit policy.


Continue with dialysis:

19.

C
ontinue dialysis or flush and lock the lumen

(refer to policy: Flushing and Locking a
CVC)
.



4.0

P
atient Education & Resources




Do not use sharp objects like scissors or a razor near the catheter tubing.



Notify kidney doctor (nephrologist) or dialysis uni
t for any of the following:



Redness, warmth, or pain along the catheter.



Oozing or drainage from catheter exit site.



Noticeable swelling or itching around catheter or neck.



Feverish and any of the above symptoms.



Part of the catheter that is outside the
skin seems to be getting longer.



Catheter is accidentally pulled and there is bleeding around the exit site.



If the gauze around the ports is damp for an unknown reason.

CVC: Repair of Cracked Adaptor, Limb or Clamp



Approved Aug
15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
5



If the catheter develops a
nother

hole or leak or the cap falls off, make sure that t
he
catheter is clamped off between the problem area/catheter tip and the body (move the
catheter clamp up the catheter towards the body; if no clamp, kink the catheter with
fingers to close the catheter off). Call 911.


Resource: Care of Your Catheter



http://www.bcrenalagency.ca


5.0

Documentation




Document
actions taken
to repair the catheter

and the new volume of the lumen

as per
unit protocol.


6.0

R
eferences


1.

Besarab, A., and Brouwer, D. (2004)
.
Aligning hem
odialysis treatment practices with the
National Kidney Foundation’s K/DOQI vascular access guidelines
.
Dialysis &
Transplantation,

33 (11): 694


702.


2.

BC Provincial Renal Agency Guideline
, Prevention, Treatment, & Monitoring of VA
Related Infection in HD
Patients (March 2008).
http://www.bcrenalagency.ca


3.

BC Provincial Renal Agency Patient Teaching Pamphlet,
Your Catheter (2008).
http://www.bcrenalagency.ca


4.

Canadian So
ciety of Nephrology Guidelines: Vascular access. (2006).
Journal of American
Society of Nephrology
, 17: S18
-

S21
.


5.

O’ Grady et al. (2011).
Guidelines for the prevention of intravascular catheter
-

related
infections
. Centre for Disease Control (US). 51 (R
R
-
10): 1
-
26.


6.

Counts, Caroline
. (Ed)
. (
2008
)
.
Core Curriculum for Nephrology Nursing
.
American
Nephrology Nurses’ Association; Pitman, NJ.


7.

Marschall, Jonas et al. (2008). Strategies to Prevent Central Line
-
Associated Bloodstream
Infections in Acute Care
Hospitals,
Infection Control and Hospital Epidemiology
, 29: supp
1, S22
-
S30.


8.

National Kidney Foundation (2006).
KDOQI Clinical Practice Guidelines and Clinical
Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal
Dialysis Adequacy
and Vascular Access.
Am J Kidney Dis 48:S1
-
S322, 2006 (suppl 1).


CVC: Repair of Cracked Adaptor, Limb or Clamp



Approved Aug
15, 2011/Rev Dec 16, 2011
/Rev Jun 17, 2012

Page
6

9.

O’Grady, Naomi et al. (2002). Prevention Guidelines for Catheter
-
Related Infections,

Clinical Infection Diseases
, 24: 1281
-
307


10.

Registered Nurses Association of Ontario, Care and Maintenance

to Reduce VA
Complications
. (2008).
http://www.rnao.org/Storage/39/3381_Care_and_Maintenance_to_Reduce_Vascular_
Acces
s_Complications._with_2008_Supplement.pdf


11.

Safer Healthcare Now! Campaign
. (
2006
)
. How
-
to
-
Guide: Prevent Central Line
Infections
.
http://www.saferhealthcarenow.ca


7.0

D
eveloped By


1.

BCs Vascular Access Educators Group (VAEG).

2.

Adapted from Fraser Health R
enal Program guidelines/standards.


8.0

R
eviewed By




1.

British Columbia Renal Educators Group (BCREG)

2.

BC Provincial Renal Agency


Medical Advisory Committee (MAC)