TM

Alberta Health Services-Calgary Area
Professional Practice and Development
Central Venous Catheter

and Midline Catheter
Learning Module
Level One Skills:
General Care and Use
The following Alberta Health Services staff are acknowledged for their
contributions to the development of this learning module:
Cathy Berry Clinical Nurse Educator, Medical Outpatients

Diane Jack Nurse Clinician, AVAS
Jane Prestie Practice Consultant, Professional Practice & Development
Judy Deane Clinical Nurse Educator, Nephrology and Transplant
Karen Barrie Clinical Nurse Educator, Medicine
Marianne Boucher Nursing Consultant, Professional Practice & Development
Anita Mitzner Education Consultant, Professional Practice & Development
Jane Thompson Secretary, Professional Practice & Development
Alberta Health Services, 2009. All rights reserved. This information is to be

used only by Alberta Health Services staff and persons acting on behalf of the
Alberta Health Services for guiding actions and decisions taken on behalf of
the Alberta Health Services. No part of this information may be reproduced,
modified or redistributed for any purposes other than those noted above
without the prior written permission of the Alberta Health Services.
Central Venous Catheter and Midline Catheter Learning Module
Table of Contents
Introduction ...............................................................................................................................1
Section One:
CVC and Midline Catheter Educational Program for Nurses...................3
Section Two:
Vascular Anatomy and Access..................................................................... 11

Types of CVC and Midline Catheters ............................................................14
Section Three: Insertion of CVC and Midline Catheter and Confirmation

of Tip Placement ...........................................................................................25
Section Four: Principles of CVC and Midline Catheter Care..........................................33
Infection Prevention and Control ...................................................................34
Assessment .....................................................................................................37
Injection Cap Replacement ............................................................................39
Dressing Change ............................................................................................41
Access.............................................................................................................45
Flushing and Locking .....................................................................................46
Administration Sets ........................................................................................49
Accessing and Disengaging an Implanted Port ..............................................51
Obtaining Blood Specimens from the CVC ...................................................53
Managing a Hemodialysis Catheter ...............................................................56
Managing an Apheresis Catheter....................................................................58
Section Five:
Potential Complications with CVC and Midline Catheters .....................65
Section Six:
CVC and Midline Catheter Removal .........................................................99
Section Seven: Discharge and Transfer Planning for Patients with CVC
or Midline Catheters ..................................................................................105
Section Eight: CVC and Midline Qualification Exam ..................................................... 115
Appendix A Child Health Qualification Exam
Section Nine: Performance Checklists .............................................................................125
References .............................................................................................................................137
Module Evaluation ...............................................................................................................139
Alberta Health Services, June 2009
Introduction
Introduction
This learning module is intended to provide the nurse with background information necessary to
understand the care of patients with central venous catheters (CVC) and midline catheters in the
Alberta Health Services-Calgary Area. The learning module is intended to complement the policies
and procedures that are found in the Nursing Policy and Procedure Manual (C-7: CENTRAL
VENOUS CATHETER and MIDLINE CATHETER: GENERAL CARE LEVEL ONE SKILLS).
Learning Goals
On completion of the learning module, the learner will be able to:
1. Discuss the standards for care and use of CVC and midline catheters related to all aspects of
level one catheter care including:
Infection prevention and control practices
Assisting with insertion and ensuring confirmation of tip placement
Assessment of the CVC or midline catheter and catheter/skin junction
Injection cap replacement
Dressing of the catheter/skin junction
Administration of medications and solutions
Flushing and locking
Administration set changes
Accessing/disengaging the port of an implanted CVC
Obtaining blood specimens
Catheter specific care considerations
PICC/midline catheter
Direct percutaneous femoral site
Hemodialysis CVC in emergency situations
Apheresis CVC in emergency situations
Use of CVC or midline catheter for diagnostic imaging procedures
Patient and family teaching
Preventing and managing potential CVC and midline catheter complications
Immediate management of CVC and midline catheter occlusion and/or damaged catheter
2. Demonstrate skills related to level one CVC and midline catheter care.
3. Complete the qualification exam.
Introduction
Target Audience
Registered Nurses, Registered Psychiatric Nurses, and Graduate Nurses who are seeking qualification
in the specialized clinical competency of CVC and midline catheter care according to policy C-7.
Licensed Practical Nurses who are seeking qualification in the specialized clinical competency of
CVC and midline catheter care according to policy C-7 and CLPNA competencies V-4 and V-5.
Prerequisites
Registered Nurses, Registered Psychiatric Nurses, Graduate Nurses, and Licensed Practical Nurses
must be competent in peripheral infusion therapy.
Licensed Practical Nurses, as per CLPNA, must be proficient with peripheral intravenous
medication administration.
Work setting must include opportunities to practice general care of CVCs and midline catheters.
Knowledge of infection prevention and control practices with the Alberta Health Services-Calgary
Area.
Learning Resources
To complete this module the learner must review the Nursing Policy C-7: CENTRAL VENOUS
CATHETER and MIDLINE CATHETER: GENERAL CARE LEVEL ONE SKILLS.
For additional references:
Macklin, D. & Chernecky, C. (2004). Real World Nursing Survival Guide: IV Therapy.
St. Louis: Saunders. Chapters 4 and 5 (pp 83-167).
WB 354 .M33 2004
Weinstein, M. (2007). Plumers Principles & Practice of Intravenous Therapy.
8th Edition. Philadelphia: Lippincott. Chapter 14 (pp 277-330).
WB 354 .p57 2007
Section One
Section One
CVC and Midline Catheter
Educational Program for Nurses
Learning Objectives
On completion of this section, the learner will be able to:
1. Describe Specialized Clinical Competencies as defined in the Alberta Health Services-Calgary
Area.
2. Identify components of CVC and midline catheter qualification for nurses in the Alberta Health
Services-Calgary Area.
3. Describe the role of AVAS in the Alberta Health Services-Calgary Area.
Section One
Specialized Clinical Competencies

Care and use of CVC and midline catheters is a Specialized Clinical Competency for nurses in the
Alberta Health Services-Calgary Area.
Specialized Clinical Competencies are those restricted activities (as defined under the Health
Professions Act) that demand preparation beyond entry level practice taught in nursing educational
programs. Competence to perform these activities must be acquired through successful completion
of additional education (generally specific, work-place sponsored learning programs).
Qualification is required to perform Specialized Clinical Competencies. In the Alberta Health
Services-Calgary Area nurses become qualified by completing educational programs (such as this one
for CVC and midline catheters).
Refer to Nursing Policy and Procedure S-3(a) and S-3(b) for more information on Specialized
Clinical Competencies.
Qualification
Qualification in CVC and midline catheter care requires the following:
Thoroughly review the information contained in this module or attend an equivalent education
program and review the related Nursing Policy and Procedure C-7.
Obtain 85% on the qualification examination prior to demonstration of skills in the skills lab/
clinical setting. Exams may be rewritten, following further review. Follow-up is required if
85% is not obtained on the second exam.
Demonstrate competence in applicable Level One CVC skills to a qualified Clinical Nurse
Educator (CNE) or designate in a skills lab or clinical setting (under direct supervision) using
standardized performance skills checklists. If the nurse is not able to demonstrate all the skills
due to the work setting the nurse will be considered certified in Level One CVC and midline
catheter skills with the exception of the skill not demonstrated. If the nurse, in the future,
requires the previously not demonstrated skill, the nurse must review the module and
demonstrate the skill to be qualified.
Review area specific clinical CVC and midline catheter standards. This educational program,
and the related Nursing Policy and Procedures, set the regional standards regarding
CVC and midline catheter care. Some practice areas may have additional practice guidelines
that relate to that particular setting. Please refer to practice guidelines in your area.
Section One
Maintaining Competence
It is the responsibility of the individual nurse to ensure competence with CVC and midline catheter
care. Nurses are encouraged to independently review the CVC and midline catheter learning module
as necessary, or repeat portions of the entire educational program, as negotiated with their Patient Care
Manager/Clinical Nurse Educator.
Transfer of Competence
CVC and midline catheter qualified nurses who transfer within the Alberta Health Services-Calgary
Area from one clinical area to another should review CVC and midline catheter care specific to the
new setting. Discuss this expectation with the Patient Care Managers/Clinical Nurse Educator in your
Section One
area.
Section One
Central Venous Catheter and Midline Catheter Qualification Algorithm
Advanced Venous Access Service (AVAS)

A team of Health Care Professionals with specialized advanced clinical competence to provide safe
and effective service and support for adult patients of the Alberta Health Services-Calgary Area who
require:
Insertion of a PICC or midline catheter
Advanced care with indwelling CVCs and midline catheters, beyond the competence of the
nurse with level one and two CVC and midline catheter skills
Exception: Apheresis and hemodialysis CVCs
Section One
Checkpoint: Section One Questions

1. Qualification for a specialized clinical competency refers to:
a. writing an exam
b. reading the relevant nursing policies and procedures
c. the education programs nurses are required to complete prior to being permitted to perform a
particular competency with the Alberta Health Services-Calgary Area
d. all of the above
2. Steps a nurse must take to obtain CVC and midline catheter qualifications are:
3. Nurses who transfer to another area of practice within the Alberta Health Services-Calgary
Area automatically transfer their CVC and midline catheter qualification with no additional
expectations.
True
False
4. What is the role of AVAS in the Alberta Health Services-Calgary Area?
Section One
Checkpoint: Section One Answers

1. Qualification for a specialized clinical competency refers to:
all of the above
2. Identify the steps a nurse must take to obtain CVC and midline catheter qualification:
Thoroughly review the information contained in this module or attend an equivalent class
and review the related Nursing Policy and Procedure C-7.
Obtain 85% on the qualification exam prior to demonstration of skills in the clinical setting.
Demonstrate competence in applicable Level One CVC and midline catheter skills to a
qualified CNE (Clinical Nurse Educator) or designate in a skills lab or clinical care setting.
(under direct supervision) using standardized performance skills checklists.
Review CVC and midline catheter care guidelines specific to your practice setting.
3. Nurses who transfer to another area of practice within the Alberta Health Services-Calgary
Area automatically transfer their CVC and midline catheter qualification with no additional
expectations.
False the nurse should review CVC and midline catheter care specific to the new setting
4. Describe the role of AVAS in the Alberta Health Services-Calgary Area.
A team of Health Care Professionals with specialized advanced clinical competence to provide
safe and effective service and support for adult patients of the Alberta Health Services-Calgary
Area who require:
Insertion of a PICC of midline catheter
Advanced care with indwelling CVCs and midline catheters, beyond the competence of the
nurse with level one and two CVC and midline catheters skills.
Exception: Apheresis and hemodialysis CVCs
Note: If you were able to answer these checkpoint questions correctly, proceed to the next
section, otherwise, review the material in this section.
Section Two
Section Two
Vascular Anatomy and Access
Learning Objectives
1. Identify veins used for access with CVCs and midline catheters.
2. Distinguish between valved and non-valved catheters.
3. Describe the different types of CVCs and midline catheters by the following criteria:
Name of catheter
Catheter description
Placement in the body
Indication for use
Duration of use
Setting for use (inpatient or community)
11
Section Two
Vascular Anatomy
A central venous catheter is a venous access device whose tip dwells in the lower 1/3 of the superior
vena cava (SVC) or in the inferior vena cava (IVC) at or above the level of the diaphragm.
A midline catheter is a peripheral venous access device (7.5 cm 20 cm [38 inches] in length) whose
tip dwells in the basilic, brachial, or cephalic vein in the upper arm at or below the level of the axilla.
Midline catheters are NOT considered CVCs.
When inserting the CVC, the qualified health professional will access the SVC or IVC indirectly
through another vein. Common access sites include: subclavian, internal jugular (IJ), femoral,
basilic, brachial, and cephalic veins.
Reprinted with permission: Rouge Valley Health System
Vessel
Hand veins
Upper arm cephalic vein
Upper arm basilic vein
Axillary vein
Subclavian vein
Superior vena cava
12
Vessel Diameter and Flow

Diameter of Vessel
~ 2 5 mm
~ 6 mm
~ 10 mm
~ 16 mm
~ 19 mm
~ 20 mm
Flow
~ 10 mL/min
~ 40 mL/min
90 150 mL/min
150 350 mL/min
350 800 mL/min
~ 2000 mL/min
Section Two
CVC and Midline Catheter Construction

CVC and midline catheters may be non-valved or valved. Understanding the type of construction is
crucial to appropriate care and use of the catheter.
Non-valved Catheter
A catheter constructed with an open-ended tip, no valve, and an in-line clamp. Typically a heparin
solution and positive pressure technique are used to maintain catheter patency. When the catheter is
not in use or the injection cap is removed, the catheter must be clamped to decrease risk of bleeding
or air embolism.
Valved Catheter
A catheter constructed with a three-position valve that minimizes the risk of blood reflux into the
lumen of the catheter. The valve may be located at either the distal or proximal end of the catheter.
Typically normal saline and positive pressure technique are used to maintain catheter patency.
When the catheter is not in use or the injection cap is removed, the catheter does not require clamps.
Groshong Valve at Distal Tip of Catheter
13
Section Two
Types of Central Venous Catheters and Midline Catheters

There are various types of CVC and midline catheters including:
1. Direct percutaneous central venous catheters
2. Tunneled central venous catheters
3. Implanted central venous catheters
4. Peripherally inserted central catheters (PICC)
5. Midline catheters
6. Specialized central venous catheters
Hemodialysis central venous catheters
Apheresis central venous catheters
14
Section Two
Direct Percutaneous Central Venous Catheters

Description:
stiff polyurethane or silicone
non-tunneled, non-cuffed
single or multi lumen (staggered openings along the catheter end)
must be sutured to skin at hub to minimize risk of dislodgment
size ranges:
length 12.5 cm to 30.5 cm (512 inches)
diameter 2.0 Fr to 11.5 Fr
volume 0.9 mL to 1.8 mL
non-valved
Placement:
may be inserted in interventional radiology,
the operating room, or at the patients bedside
inserted into a major vein (e.g. internal or external jugular,
subclavian or femoral veins) and advanced into the superior or
inferior vena cava (see illustration)
tip should dwell in the lower one third of the superior vena cava. If the
CVC is inserted via the femoral vein, the optimal tip placement
should be in the inferior vena cava at or above the level of the diaphragm
Indications for use:
short-term therapy or for emergency access
all infusions (including vesicant medications)
blood withdrawal
hemodialysis
apheresis
Taylor, Lillis, & LeMonel 2005
Duration of catheter use:

days to weeks
if required longer than 4 weeks, requires physician review and order
Settings for use:
inpatient
outpatient (community) settings only when enrolled in hemodialysis or apheresis programs or in
Child Health
15
Section Two
Tunneled Central Venous Catheters

Description:
soft silicone or polyurethane with a dacron cuff on
the external surface of the catheter
single or multi lumen
sutures required initially at insertion site for 7 days,
and at catheter/skin junction for 10 to 14 days
size ranges:
length 36 cm to 110 cm (14.544 inches);
may be cut to desired length at time of insertion
diameter 2.0 Fr to 14 Fr
valved or non-valved
Definitions:
insertion site (entrance site) vein access site
catheter/skin junction (exit site) point where the catheter leaves the skin and where site care is
performed
dacron cuff positioned under the skin. Tissue granulation around the cuff stabilizes the catheter
in the subcutaneous tissue and acts as a mechanical barrier to bacterial migration along the
subcutaneous tract
Placement:
inserted in interventional radiology or the operating room
inserted into a major vein (subclavian, internal or external jugular) and then tunneled through the
subcutaneous tissue
tip should dwell in the lower one third of the superior vena cava
long term therapy
blood withdrawal
hemodialysis and/or apheresis
weeks to years
Settings for use:
inpatient
outpatient (community) settings
16
Section Two
Implanted Central Venous Catheters

Description:
soft silicone or polyurethane catheter attached to
stainless steel, titanium or plastic reservoir which is
covered by a self-sealing silicone septum
access requires a non-coring needle
single or dual reservoirs
insertion sutures, if present, are to be removed
14 days post insertion
size ranges:
length 76 cm (30 inches); may be cut to
required length at insertion
diameter measured in millimeters
volume reservoirs range from 0.2 mL to 1.7 mL
17
Section Two
Placement:
inserted in interventional radiology or operating room
reservoir is inserted in a subcutaneous tissue pocket in the chest, arm, or abdomen and the catheter
segment is threaded into a major vein
tip should dwell in lower one third of the superior vena cava
long term therapy
all infusions including vesicant medications
blood withdrawal
weeks to years
Settings for use:
inpatient
18
Section Two
Peripherally Inserted Central Venous Catheter (PICC)

Description:
silicone or polyurethane
single, double or triple lumen
stabilized with an external securement device,
skin closure strips, or sutures
size ranges
length 56 cm to 60 cm (22.124 inches)
diameter 2.0 Fr to 6.0 Fr
Placement:
inserted by a nurse qualified in this advanced specialized clinical competence,
physician, or radiologist
may be inserted in AVAS clinic, patents bedside, interventional radiology,
the operating room, or designated clinic
inserted directly into a peripheral vein (basilic, cephalic, or brachial) in the arm
tip should dwell in the lower one third of the superior vena cava
short or long-term therapy
blood withdrawal (from lumens 4 Fr or larger)
hhtp://www.bardaccess.com/nurse-grosh-picc.php

weeks to months
physician review and order required to leave in
situ longer than one year
Setting for use:
inpatient
19
Section Two
Midline Catheters
Midline catheters are NOT central venous catheters and must not be used for infusions requiring
central tip placement.
Description:
silicone or polyurethane
single or dual lumen
stabilized with an external securement device,
adhesive strips or sutures
size ranges:
length 7.5 cm to 20 cm (38 inches)
(amount inserted is dependent on patient
measurement)
diameter 2.0 Fr to 5.0 Fr (13 to 24 gauge)
volume 0.07 mL to 0.15mL
Placement:
inserted by nurse qualified in this advanced specialized clinical competence,
physician, or radiologist
may be inserted in AVAS clinic, patients bedside, interventional radiology,
the operating room, or designated clinic
inserted directly into a peripheral vein (basilic, cephalic, or brachial) in the arm
tip should dwell at or below the level of the axilla
CVC access is not required, not possible, or contraindicated
limited to solutions with a pH of 59 and an osmolarity of less than 600 mOs/L
days to 4 weeks
physician review and order required to leave in situ longer than 4 weeks
Settings for use:
inpatient
20
Section Two
Specialized Catheters
Hemodialysis Central Venous Catheter
Hemodialysis is a specialized treatment for some patients with renal disease. A hemodialysis
machine removes the blood from the patient, cleanses the blood and then returns it to the patient.
CVCs inserted for long-term hemodialysis are NOT regularly to be used by staff outside the
hemodialysis program (SARP) for procedures such as infusing medications or drawing blood unless
it is a last resort. In a situation where no other venous access is possible, an order from a
nephrologist is required to allow access to a hemodialysis CVC.
Description:
a large diameter (0.5 Fr to 14.5 Fr) dual lumen catheter,
which is inserted either by:
direct percutaneous method into the
internal jugular or femoral veins
tunneled into the internal jugular
hemodialysis catheters (direct percutaneous)
length 12.5 cm to 23 cm (59.1 inches)
hemodialysis catheters (tunneled CVC)
length 19 cm to 23 cm (7.59.1 inches) (these CVCs
are not cut at the time of insertion)
clamps or hubs of each lumen are color coded red and blue
Placement:
inserted by the radiologist in interventional radiology or by a physician
tip dwells in the superior or inferior vena cava
hemodialysis therapy
all infusions
blood withdrawal
weeks to years
21
Section Two
Specialized Catheters
Apheresis Central Venous Catheter
Apheresis: The process of withdrawing whole blood through a central venous catheter into a
blood cell separator where it is divided into its components (RBCs, WBCs, platelets, and plasma).
The desired component is removed and/or replaced. For example, apheresis can be used to remove:
pathological antibodies in the body and replace them with normal plasma or albumin; WBCs in acute
leukemia to allow chemotherapy to begin sooner; and stem cells for transplant.
CVCs inserted for apheresis are NOT to be used by staff outside the apheresis program for
procedures such as infusing medications or drawing blood.
Description:
a large diameter (11.5 Fr to 14.5 Fr) dual lumen catheter, which is inserted either by:
direct percutaneous method into the internal jugular or femoral veins
tunneled into the internal jugular.
apheresis catheters (direct percutaneous)
length 9 cm to 24 cm (3.59.5 inches)
diameter 8 Fr to 11.5 Fr
apheresis catheters (tunneled CVC)
length 36 cm to 40 cm (1416 inches) (these CVCs are not cut at the time of insertion)
apheresis catheters (implanted CVC)
length 76 cm (30 inches); may be cut to required length at insertion
diameter measured in millimeters
volume reservoirs range from 0.2 mL1.5 mL
Placement:
inserted by the radiologist in interventional radiology or by a physician
tip dwells in the superior or inferior vena cava
apheresis therapy
all infusions
blood withdrawal
Duration of use:
weeks to years
22
Section Two
Checkpoint : Section Two Questions

1. Name three veins of the upper anatomy associated with central venous access devices.
2. Optimal position for the tip of a central venous catheter is:
3. Direct percutaneous central venous catheters are for short-term, emergency, and inpatient
(adult) use only.
True
False
4. Which CVC requires sutures to secure the catheter to the skin at all times?
5. Name the point where the catheter leaves the skin and site care is performed.
6. Access to an implanted CVC requires a special needle called:
7. Name the solution that is typically used for flushing the following types of CVCs:
Valved:
Non-valved:
8. State 3 reasons for using a central venous catheter:
9. Under what circumstances is a midline catheter the preferred venous access device?
23
Section Two
Checkpoint: Section Two Answers

1. Name three veins of the upper anatomy associated with central venous access devices.
Cephalic
Axillary
Innominate/Brachiocephalic
Brachial
Internal or External Jugular
Superior Vena Cava
Basilic
Sublclavian
2. Optimal position for the tip of a central venous catheter is:
The lower one third of the superior vena cava
Above the level of the diaphragm in the inferior vena cava
3. Direct percutaneous central venous catheters are for short-term, emergency and inpatient
use only.
False Direct Percutaneous CVC may be used for hemodialysis and apheresis in clients
who live in the community. Occasionally outpatient pediatrics.
4. Which CVC requires sutures to secure the catheter to the skin at all times?
Direct Percutaneous
5. Name the point where the catheter leaves the skin and where site care is performed.
Catheter/skin junction (or exit site)
6. Access to an implanted CVC requires a special needle called:
Non-coring needle
7. Name the locking solution that is typically used for flushing the following types of CVCs:
Valved: Normal Saline
Non-valved: Heparin
8. State 3 reasons for using a central venous catheter:
Infusions of solutions with osmolarity of greater than 600 and/or a pH of less than 5 or
greater than 9; irritants, vesicants
Therapy is expected to be long-term
Therapy involves removing, treating, and re-instilling blood (e.g. hemodialysis or apheresis)
9. Under what circumstances is a midline catheter the preferred venous access device:
CVC access is not required, not possible, or contraindicated
Therapy is expected to be days to 4 weeks
Required solutions have a pH of 59 and an osmolarity of less than 600 mOs/L
section; otherwise, review the material in this section.
24
Section Three
Section Three
Insertion of CVC and Midline Catheter
and Confirmation of Tip Placement
Learning Objectives:
1. Describe nursing responsibilities prior to, during, and post CVC and midline catheter insertion.
2. Describe nursing responsibilities related to tip confirmation.
25
Section Three
Insertion of CVC or Midline Catheter: Nursing Responsibilities

Insertion of a CVC or midline catheter is beyond the competence of the Level One qualified nurse.
This section is intended to assist the Level One qualified nurse to care for a patient prior to,
during, and following CVC or midline catheter insertion.
A CVC or midline catheter may be inserted in a variety of clinical areas, including AVAS clinic,
interventional radiology, patients bedside, the operating room or designated clinic. The
responsibilities of the nurse related to catheter placement will vary depending on the type of catheter,
location of insertion, and the health care professional inserting the catheter.
Prior to Catheter Insertion

ensure physician order has been obtained
assess coagulation status (INR, platelet count) and other labs (CBC) as ordered and notify
physician of results as appropriate
educate patient and/or caregiver with respect to the CVC and midline catheter insertion
description of the catheter that will be inserted
purpose of the catheter
benefits of using a catheter
planned duration of therapy/catheter
possible risks of catheter
insertion procedure
ensure the consent has been signed
ensure the patient is informed to remain NPO, if ordered
obtain baseline vital signs
complete the pre-operative documentation
prime IV tubing and have infusion pump ready for use, if necessary
have flushing and/or locking solution available, if necessary
administer pre-medications, as ordered
26
Section Three
During Catheter Insertion

If a catheter is being inserted at the beside, the Level One or Level Two qualified nurse may be
required to assist the inserter.
clean work surfaces and gather all required equipment as per protocol in your practice setting
restrict activity in the room
adherence to aseptic technique should include:
hand hygiene must be performed by all involved in the insertion procedure
maximal barrier precautions which include the use of a sterile gown, sterile gloves, and
large sterile drapes, hair covering, and procedure mask by all those performing the procedure
masks should be worn by all those assisting with the procedure
turn patients head away from insertion site. If patient is coughing, and/or unable to turn head,
the patient must wear a mask
if aseptic technique was not maintained during an emergency catheter insertion, the most
responsible healthcare professional must be notified so that the catheter should be replaced
as soon as possible (within 48 hours).
position the patient as instructed by the qualified inserter:
for insertion of a direct percutaneous CVC, the bed is placed in trendelenburg position,
unless contraindicated
place patient supine on bed with a rolled towel under the designated shoulder or between
the scapulas to facilitate location of the desired vein for catheter insertion
prepare the multi lumen catheter as directed by the qualified inserter using aseptic technique.
This may include:
attaching needless injection caps and ensuring they are secure
flushing lumens indicated with normal saline
educate patient regarding valsalva maneuver, if applicable
monitor the patient for discomfort and signs and symptoms of complications
catheter hub is secured to the skin by the inserter (e.g. direct percutaneous catheter must be
sutured to the skin)
27
Section Three
Post Catheter Insertion

ensure a transparent semi-permeable membrane and/or sterile gauze dressing is applied
obtain radiographic verification of catheter tip location and order for use prior to using a newly
inserted CVC
Exception: In emergency situations, the CVC may be used prior to radiographic verification of
CVC tip location. Verify tip placement as soon as possible for catheter inserted in
emergency circumstances.
review physicians orders for post catheter insertion care
observe patients comfort level and administer analgesia as ordered
monitor catheter/skin junction every 4 hours for the first 24 hours in acute area. Report excessive
bleeding or discharge from site
sandbags may be necessary for additional pressure especially for CVC inserted into the
femoral vein to control bleeding at the site
apply warm compresses to venous pathway of PICC/midline for 20 minutes every 4 hours for
48 hours post insertion
educate patient and/or caregiver with respect to the CVC and midline catheter insertion
complications to report
review safety precautions
hand washing
bathing and showering
activity restriction
importance of carrying clamp and how to apply, if necessary
securement of the catheter
ensure dressing remains dry and intact
documentation in patients health record should include:
date the catheter was inserted
type of device and its manufacturer (important if the catheter needs to be repaired)
device size, length, number of lumens
the location/vein where catheter was inserted
tip location confirmation
external length of the catheter from catheter/skin junction to the beginning of the hub
post CVC or midline insertion orders, if applicable, such as flush/instillation protocol,
suture removal
problems and complications with the insertion, and what actions taken
28
Section Three
Confirmation of Tip Placement

Radiographic verification of catheter tip location and order for use is required prior to using a
newly inserted CVC.
Exception: In emergency situations, the CVC may be used prior to radiographic verification of
CVC tip location. Verify tip placement as soon as possible for catheter inserted in
emergency circumstances.
Midline catheters do not require radiographic confirmation of tip placement prior to use.
If patient is admitted with CVC or midline catheter without insertion record or tip confirmation
documentation, attempt to obtain from facility where catheter was inserted. If unable to obtain, a
radiographic confirmation of CVC tip location and physician order is required prior to use.
If at any time there is reason to doubt tip placement, radiographic verification should be obtained.
29
Section Three
Checkpoint: Section Three Questions

1. What nursing responsibilities should be considered prior to CVC or midline catheter
insertion?
2. What must the nurse review prior to a CVCs initial use? What exception is there to this
requirement?
3. For a patient in acute care, a nurse must assess the catheter/skin junction every
______ hours for the first _______ hours after the CVC or midline catheter has been
inserted.
4. If a patient is admitted with a CVC in situ, what actions must be taken prior to use?
31
Section Three
Checkpoint: Section Three Answers

1. What nursing responsibilities should be considered prior to CVC or midline catheter
insertion?
assess coagulation status (INR, platelet count) and other labs (CBC) as ordered and notify
physician of results as appropriate
educate patient and/or caregiver with respect to the CVC
ensure the consent has been signed
obtain baseline vital signs
complete the pre-operative documentation
prime IV tubing and have pump ready for use at the bedside, if necessary
2. What must the nurse review prior to a CVCs initial use? What exception is there to this
requirement?
radiographic verification of catheter tip location and order for use prior to using a newly
inserted CVC
Exception: In emergency situations, the CVC may be used prior to radiographic verification
of CVC tip location. Verify tip placement by as soon as possible for catheter inserted in
emergency circumstances
3. For a patient in acute care a nurse must assess the catheter/skin junction every
for the first 24 hours after the CVC or midline catheter has been inserted.
hours
4. If a patient is admitted with a CVC in situ, what actions must be taken prior to use?
obtain copy of insertion record and tip confirmation documentation
if unable to obtain above documentation radiographic verification and physician order
required prior to use
Note: If you were able to answer these check point questions correctly, proceed to next section;
otherwise, review the material in this section.
32
Section Four
Section Four
Principles of Central Venous Catheter
and Midline Catheter Care
1. Explain rationale for major principles of care and assessment related to central venous catheters.
2. Demonstrate knowledge and rationale for the following CVC or midline catheter procedures:
infection prevention and control
assessment
injection cap replacement
dressing change
access
flushing and locking
administration sets
accessing and disengaging an implanted port
obtaining blood specimens from the catheter
33
Section Four
Principles of Central Venous Catheter

and Midline Catheter Care
The safe and effective use of CVC and midline catheters will reduce the risk of life threatening
complications that may accompany the use of these catheters. Many procedural variations of CVC
and midline catheter care are equally effective and practical. Regional programs dictate details
of these procedures based on the patient population and individual patient needs. Manufacturers
guidelines should be followed to ensure appropriate use of specific products.
Desired Clinical Goals

1. Completion of therapy
2. Absence of complications
3. Patient satisfaction
Infection Prevention and Control

Definitions
Asepsis
Aseptic Technique
Infection
Maximal Barrier Protection
Nosocomial Infection
Free from infection.

Methods to minimize contamination by micro-organisms including
hand hygiene, sterile gloves, masking and using antiseptic cleansers.
Invasion and multiplication of pathogenic micro-organism into blood
and body tissues.
Equipment and clothing used to avoid exposure to pathogens
including mask, gown, protective eyewear, head covering, sterile
gloves sterile drapes, towel.
An infection originating from the hospital (or caregivers).
Transmission of Micro-organisms
Transmission of micro-organisms may occur by various routes:
Direct contact/direct physical transfer from one surface (e.g. hands and clothing) to the central
venous access system.
Indirect contact with a contaminated item (e.g. catheter hub or contaminated antimicrobial
solution).
Four potential causes of catheter related blood stream infections (CR-BSI) are:
Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization
of the catheter tip.
Contamination of the catheter hub.
Haematogenous seeding from another source of infection.
Infusate contamination.
34
Section Four
Hand Hygiene
Microbes on the hands of healthcare personnel, including antibiotic resistant organisms, contribute
to infections. To help decrease CR-BSI, all staff that handle a CVC or midline catheter, either during
insertion or while maintaining the catheter, must perform hand hygiene. Hand hygiene with an
antiseptic agent is the single most important procedure for preventing nosocomial infection.
Maintaining Aseptic Technique

During all procedures related to CVC and midline catheter care it is essential that aseptic technique
is maintained. There are a variety of methods that can be used to maintain asepsis. One of these
methods involves the use of sterile gloves. Alternatively, non-touch technique, which involves the
use of barriers such as gauze or forceps, may be used. If a sterile item being used to maintain asepsis
(e.g. sterile gloves) becomes contaminated it must be replaced.
Alberta Health Services-Calgary Area Infection Prevention and Control

Guidelines for Central Venous Catheters and Midline Catheters
Procedure
Non-Sterile
Gloves
Sterile
Gloves
Mask
Sterile
Gown
Insertion
Injection Cap
Replacement
Accessing Open
System
Dressing Change
Removal of
old dressing
Removal
PICC or
midline catheter
Hair
Patient to
Covering Wear Mask
(if needed)
X
Note: Strict aseptic technique, including hand hygiene and cleansing of work surface area with
low level disinfectant cloth (e.g. Cavi-wipes) shall be done prior to all procedures associated
with CVC and midline catheters. For further information see the Infection Prevention &
Control Manuals.
35
Antimicrobial Agent
Section Four
Rationale/Information
Preferred Agent
0.5% or 2% Chlorhexidine
with 70% Alcohol Solution
chlorhexidine with alcohol leads to a residual antibacterial

activity that persists for 6 hours post application
single use container preferred
dry time 30 seconds
In Case of Allergy to Chlorhexidine

Iodophor (10% Povidone Iodine)
povidone iodine requires a 2 minute skin contact time

using friction
dry time 2 minutes
70% Alcohol
70% alcohol requires a 1 minute friction application,

no residual antibacterial activity
dry time 30 seconds
Normal Saline
to be used only if patient is allergic to all other

antimicrobial agents or the skin around the insertion site
is not intact
36
Section Four
Assessment
Assess and document the condition of the catheter/skin junction, venous access pathway, catheter,
injection cap, connections, tubing, and other potential catheter related complications once per shift
and as needed, or at each home visit.
Principle
1. Assess the catheter/skin junction and

surrounding area for:
erythema
edema
skin ulceration
pain
drainage
condition of dressing
catheter securement intact
Note: gauze dressings that prevent
visualization of the catheter skin
junction should be palpated through
the intact dressing. In the presence
of tenderness at the site or other signs
and symptoms of infection, dressing
should be removed to inspect the site
directly.
early recognition of local complications

and appropriate corrective action can
prevent more serious or life threatening
complications
if catheter/skin junction infection is
suspected obtain specimen and order for
culture and sensitivity
2. Assess venous access pathway for:

phlebitis
swelling
early detection of phlebitis and appropriate

interventions may prevent the development
of a thrombus and sepsis
3. Assess catheter and injection cap for:

damage
traction
change in external length
change in external length of the catheter

indicates a change in catheter tip location.
If migration is suspected do not infuse into
the CVC until tip placement is verified
4. Assess that inline clamps are present and

functioning.
Assess that a non-toothed, plastic clamp
is available.
Exception: valved catheters
to be used when catheter not in use or

injection cap removed to decrease risk of
bleeding or air embolism
to be used in the event of catheter damage to
prevent bleeding or air embolism
37
Principle
5. Additional catheter specific assessment:
Direct Percutaneous:
observe that sutures are securing catheter
to skin
Note: in child health sutures are not
always used to secure direct
percutaneous CVC.
Tunneled:
observe that sutures are securing catheter
to skin until they are removed at:
catheter skin junction (1014 days)
insertion site (7 days)
Implanted Port:
observe for intact sutures until removed
at:
catheter skin junction (1014 days)
insertion site (1014 days)
Note: some newly implanted ports may
have dissolvable sutures which
may not be visible, others may
have skin closure strips
observe for dislodgement of access needle
PICC and Midline:
observe for intact securement device
(e.g. StatLock), skin closure strips, or
sutures
Note: securement device should be
covered by dressing
the external length of the PICC or
midline catheter from the catheter/skin
junction to the beginning of the hub is
measured and documented once per shift
and as needed at each home visit
6. Assess for other potential complications
associated with CVC and midline catheters
(see Section 5).
38
Section Four
direct percutaneous catheters require the hub

to be sutured to maintain catheter placement
during entire dwell time
sutures remain in situ until granulation of

skin to catheter has occurred. If sutures
remain in place longer they present a
potential source of infection and increased
difficulty to remove
sutures remain in situ until pocket is healed.
If sutures remain in place longer they present
a potential source of infection and increased
difficulty to remove
patient may be experiencing pain during
infusion and swelling at the site
if sutures present consideration should be

given to their removal and replacing with a
securement device
sutures increase the risk of infection
change in external length of the catheter
indicates a change in catheter tip location.
If migration is suspected do not infuse into
the PICC until tip placement is verified
earlier detection of other potential
complications will aid in ensuring patients
safety
Section Four
Injection Cap Replacement

Luer lock injection cap(s) are to be placed on all CVC and midline catheter lumens.
Principle
1. Injection cap change procedure must be

done using aseptic technique.
to prevent the entry of microorganisms into

the vascular system
2. If injection cap changes are done as part of

the dressing change the cap should be
changed prior to the dressing.
during injection cap replacement the

system is open with an increased risk of
contamination from bacteria on the skin.
changing the injection cap first minimizes the
possibility of introducing microorganisms
into the catheter
3. Injection caps must be replaced:

every 7 days and as needed in hospital
every 7 days and as needed in community
when catheter in use
every 30 days and as needed in
community if catheter not in use
injection cap is designed to accommodate a

specified number of punctures
increased risk of contamination from bacteria
with frequent opening of the system
4. Injection cap must be changed if leaking or

broken.
risk of microorganism or air entry into

vascular system or backup of blood into
catheter if injection cap integrity
compromised
5. Injection cap must be changed if residual

blood can not be cleared with adequate
flushing.
residual blood provides a medium for

bacterial growth and may cause occlusion
6. Injection cap must be changed if cap

removed from the catheter for any reason.
risk of contamination of injection cap
7. Injection caps must be applied when a

removable positive pressure device is
present.
Alberta Health Services-Calgary Area does

not supply or utilize these devices although
they may present on a line if a patient is
admitted from another health region
39
Section Four
Principle
8. Clamp the lumen near the catheter/hub

connection before removing the injection cap.
Exception: Valved Catheters
clamps prevent air entry into the venous

system and possible risks resulting from
venous air embolism
clamps may cause valved catheter damage
9. Clean the injection cap catheter connection

extending 1.5 cm (0.6 inch) below cap, prior
to removing the injection cap.
risk of microorganism entry into vascular

system
10. It is not necessary to pre-fill the injection cap

with flush solution prior to application.
the injection cap volume is approximately

0.2 mL therefore does not pose a risk for air
embolism
11. Once injection cap removed from catheter,

cleanse outside threads of catheter hub
ONLY if visibly soiled.
blood provides a medium for bacterial

growth
40
routine cleansing of the threads poses an

increased risk of microorganism entry into
vascular system
Section Four
Dressing Change
The catheter/skin junction for all CVC and midline catheters is to be covered with a sterile transparent
semi-permeable membrane or gauze dressing. When an implanted CVC port is not accessed a
dressing is not necessary.
Types of Dressings
Several dressing materials are considered equally effective if used appropriately. Studies have
indicated a strong association between increased humidity and increased cutaneous colonization of
catheter related infection.
Dressing Type
Gauze
Principle
use gauze dressing if any drainage
at catheter site (e.g. for 24 hours
post-insertion)
if early signs of inflammation are
present
must be changed every 48 hours
and as needed
Transparent
semi-permeable
membrane
dressing
use transparent semi-permeable

membrane dressing if catheter skin
junction site is dry and
non-inflamed
must be changed every 7 days and
as needed
Transparent with
gauze dressing
when used as an initial dressing,

must be changed after 24 hours
then every 48 hours and as needed
the absorptive capacity of gauze
wicks drainage away from
the skin catheter junction and
maintains a drier environment
gauze allows air movement,
facilitates evaporation of moisture
facilitates frequent visual
inspection of the catheter skin
junction site
protects site from external
moisture contamination, while
allowing moisture vapor to escape
from skin
transparent dressing maintains the
integrity of the gauze
gauze will wick moisture away
from skin/catheter junction
41
Section Four
The following guidelines are basic to all CVC dressing change procedures.
Principle
1. Dressing change procedure must be done

using aseptic technique.
to prevent entry of microorganisms into the

vascular system
old dressing should be removed with clean
gloves
sterile gloves or non-touch technique should
be used when removing securement device
and/or sterile wound closure strips
if sterile gloves touch old securement device,
wound closure strips, and/or skin, new sterile
gloves must be applied prior to continuing
with the dressing change procedure
2. If injection cap changes are done as part

of the dressing change the cap should be
changed prior to the dressing.
during injection cap replacement the

system is open with an increased risk of
contamination from bacteria on the skin
changing the injection cap first minimizes the
possibility of introducing micro-organisms
into the catheter
3. When removing the transparent dressing

anchoring the catheter, peel the dressing
toward the catheter/skin junction.
prevents catheter dislodgement
4. If excess hair removal is necessary it should

be performed by clipping with scissors.
shaving is not recommended as it may

increase the potential for micro abrasions
the skin is the patients first line of defense
and if broken creates a vulnerable point for
bacterial migration
42
Principle
Section Four
5. Topical antimicrobial agents used for

cleansing must be applied using friction
and they have different properties that
define their effectiveness.
see page 36
6. The catheter skin junction must be

cleansed beyond the size of the dressing
to be applied.
to minimize the microbes at the catheter skin

junction site
7. Cleanse the length of the catheter with

the antimicrobial agent from catheter skin
junction site outward (see page 36).
microbes on the catheter may transfer onto

the catheter/skin junction and surrounding
skin
maintain asepsis by holding catheter with
sterile gauze or forceps
8. Antimicrobial agents and protective skin

barriers must be allowed to air dry
completely before dressing application.
antimicrobial effectiveness is dependent on

drying
solutions can act as an irritant if trapped
under an occlusive dressing
dry times: see page 36
9. Use of protective skin barrier should be

considered. If using, avoid applying directly
on the catheter skin junction site.
to maintain skin integrity

to promote adhesion of dressing
10. Direct percutaneous CVC must be stabilized

to the skin using sutures at the hub of the
catheter.
PICC and midline catheters must be
stabilized using sutures at the hub of the
catheter, skin closure strips, and/or
securement devices.
Sutures of tunneled and implanted CVC are
removed as ordered.
to prevent accidental dislodgement or

damage, and occlusion
11. Any tape, skin closure strips or securement

device applied under the dressing must be
sterile.
microbes on non sterile items will transfer

onto the catheter/skin junction and
surrounding skin
once tissue granulation has occurred

tunneled and implanted CVC do not require
external stabilization
43
Principle
Section Four
12. Securement device and skin closure strips

should be changed every 7 days and as
needed.
to maintain skin integrity, promote adhesion

of device and prevent infection
13. Caution should be taken if using safety pins

and/or securing catheter to patient clothing.
inadvertent dislodgement may occur with the

removal of the patients gown or clothing
14. Dressing should be centered over the

catheter skin junction and cover any sterile
skin closure strips or securement devices.
using the maximum adhesive surface of

the transparent dressing over the site helps
anchor the dressing and provides maximum
barrier protection to infection. Use more
than one overlapping transparent dressing
if required for adequate coverage
stretching can cause adhesion failure of the
transparent dressing
Do not stretch transparent semi-permeable

membrane dressings during application.
44
Section Four
Access
Principle
1. Access of a CVC and midline catheter

must be done using aseptic technique.
to prevent the entry of micro-organisms into

the vascular system
2. 10 mL syringes or larger are used for

flushing, locking, or withdrawing from a
CVC and midline catheter unless otherwise
noted in specific programs.
infusion pressures should never exceed

2540 pounds per square inch (psi). Pressure
> 40 psi can cause the catheter to rupture
the psi increases when flushing with smaller
syringes
Syringe Size
PSI when filled
1 mL TB syringe
> 300
3 mL
> 40
5 mL
> 40
10 mL
< 40
3. Separate syringes must be used for each

lumen.
prevents cross contamination between

lumens
4. Needleless system must be used to access

the lumen via the injection cap.
there is a risk of perforating the catheter,

embolization of the needle, or needle-stick
injury if accessing the catheter with a needle
5. Lumen(s) or extension tubing must be

clamped prior to accessing the catheter.
Exception: valved catheter
to minimize the risk of air embolism,

hemorrhage, or infection
6. Injection cap must be cleansed with

antiseptic using friction and allowed to dry.
to prevent catheter related blood stream

infection
7. If catheter is locked with any solution other

than normal saline or low dose heparin
withdraw 3 mL and discard the solution prior
to use.
to prevent inadvertent administration of

potentially hazardous dose of a medication
or solution
8. A small amount of blood must be aspirated

prior to use.
confirms catheter placement in a blood vessel
9. If there is any doubt as to location of the

CVC tip, request radiographic confirmation
prior to use.
confirms catheter placement in a blood vessel
45
Section Four
Flushing and Locking

Principle
1. Flushing and locking must be done using

aseptic technique.

the vascular system
2. Lumens are to be flushed with normal saline

as follows:
prior to and immediately following:
infusion of solutions
administration of medications
(including flushing between
medications)
administration of blood/blood
products
immediately following:
collection of blood specimens
to ensure patency, prevent occlusion and to

minimize potential problems associated with
incompatible drugs
an order is required for all flushing and
locking solutions
3. Normal saline 10 mL is the standard flush

volume.
normal saline 20 mL is recommended
following an infusion of lipids, blood/
blood products, or medications known to
crystallize or precipitate.
Exception: Child Health
to ensure patency, prevent occlusion, and to

minimize potential problems associated with
incompatible drugs
4. A manual push/pause flush with a syringe

using normal saline to create turbulence
within the catheter lumen is recommended
when flushing the catheter.
the turbulent method helps to ensure

medication or blood is not adhering to the
catheter
5. Excessive force must not be used during

flushing or locking.
to prevent embolism or damaged catheter
6. Positive pressure technique will be used

when locking CVC and midline catheters.
non-valved catheters clamp the
catheter when injecting the final 0.5 mL
of lock solution
valved catheters maintain pressure on
the syringe plunger when disconnecting
the syringe from the injection cap
to maintain catheter patency by preventing

backflow of blood into catheter
46
Principle
Section Four
7. When NOT IN USE the catheter must be

flushed and locked at established intervals
(see table: Recommended Lock Solution
Volumes and Frequency page 48).
to maintain patency
8. Non-valved CVC and midline catheters

must be clamped when the catheter is not
in use.
to minimize the risk of air embolism,

hemorrhage, or infection
9. A variety of locking solutions may be used

to maintain patency or for treatment of
complications such as catheter related
infection or occlusion.
locking solutions may include solutions

such as normal saline, low dose heparin
solution (10 to 100 u/mL), high dose heparin
(1000 to 10,000 u/mL), sodium citrate,
vancomycin, 70% ethyl alcohol
10. Prior to instilling any lock solutions ensure

that the solution is compatible with the
composition of the catheter.
some catheters will disintegrate in the

presence of certain solutions (e.g. instillation
of 70% alcohol into polyurethane catheter)
11. The lumen must be labeled if it is locked

with any solution other than normal saline
or low dose heparin.
to identify the contents in the lumen

or solution
12. If catheter is locked with any solution other

than normal saline or low dose heparin
withdraw 3 mL and discard the solution prior
to use.

or solution
13. If there is any doubt as to what solution the

catheter has been locked with, withdraw
3 mL and discard the solution prior to use.

or solution
47
Section Four
Recommended Lock Solution Volumes and Frequency

When CVC and Midline Catheters are Not In Use
Non-Valved CVC and Midline Catheters Adults
Device
Frequency
Solution and Strength
Volume
Implanted Ports
Once a month
Heparin 100 units/mL
5 mL
Tunneled
q 7 days
Heparin 10 units/mL
5 mL
Direct Percutaneous
q 12 hours
Heparin 10 units/mL
5 mL
PICC and Midline
q 24 hours
Heparin 10 units/mL
3 mL
Non-Valved CVC and Midline Catheters Children and Infants

Device
Frequency
Volume
Implanted Ports
Once a month
Heparin 100 units/mL
35 mL
Tunneled
q 24 hours
Heparin 10 units/mL
35 mL
Direct Percutaneous
q 12 hours
Heparin 10 units/mL
35 mL
q 12 hours
Heparin
Infant 10 units/mL
Child 100 unit/mL
23 mL
PICC and Midline
Note: for infants continuous intravenous infusion may be utilized to maintain patency
Valved CVC and Midline Catheters Adults
Device
Frequency
Volume
Midline
q 7 days
Normal Saline
10 mL
Tunneled
q 7 days
Normal Saline
10 mL
PICC and Midline
q 7 days
Normal Saline
10 mL
Note: valved CVCs and midlines may require a heparin lock order if patency is difficult to
maintain
48
Section Four
Administration Sets
Principle
1. Administration set changes must be done using

aseptic technique.
to prevent the entry of microorganisms

into the vascular system
2. Newly primed infusion tubing and solution

must be used when a CVC or midline catheter is
inserted.
new tubing/solution prevents

contamination
3. Infusion tubing systems are to be changed every

72 hours.
Exception:
intermittent tubing is changed every 24 hours
propofol tubing is changed every 24 hours
parenteral nutrition/lipid emulsions tubing is
changed every 24 hours
blood administration sets/filters must be
changed after a maximum of two units
of whole blood or red cells, or 4 hours,
which ever comes first. Change set after
completion of infusion of fractionated blood
products (IVIG, clotting factors, albumin)
community setting every 96 hours
prevention of catheter related blood

stream infection
the more frequently the tubing is
disconnected the greater the risk for
tubing contamination
4. If removable extension tubing is attached to

a single lumen PICC or midline at time of
insertion, it is part of the catheter and only
changed if required.
if the original PICC or midline extension
tubing is changed, then the extension tubing
is labeled with the date and changed every
7 days.
attached at time of insertion under

maximal barrier precautions
5. Infusion pumps must be used for ALL CVC

infusions.
Exception: Child Health, direct IV push,
emergency situations
to prevent fluid overload, drug toxicity,

and air embolism
49
Principle
Section Four
6. Luer lock connections are required for all

CVC tubing/devices.
securing connections with tape is not
recommended
luer lock connections help prevent accidental

disconnection which may result in air
embolism, hemmorhage, or infection
taping connections associated with bacterial
transmission
7. Filters are indicated for specific patient

conditions, medication administration, and
infusions.
filters can help minizmize the infusion of air,

fungi, bacteria and endotoxins
Note: these filters may be contraindicated
for use with some IV medications
50
Section Four
Accessing and Disengaging an Implanted Port

Principle
1. Accessing of an implanted port must be

done using aseptic technique.

the vascular system
2. Implanted ports are only to be accessed using

a non-coring needle (e.g. Gripper or Huber).
to prevent septal damage
http://www.bardaccess.com/infusion-winged.php
3. The non-coring needle must be changed a

minimum of q7 days and as needed.
4. Choose length of needle based on depth of
port implanted.
common needle lengths are: , , 1 and
1 inch
if needle is too short it will not reach the base

of the port
if needle is too long there is the potential for
needle to break or septal damage
5. Promote patient comfort during accessing.
ice and/or topical anesthetic may reduce the

discomfort of the needle puncture
6. Cleanse the insertion site beyond the size

of the dressing to be applied with the
antimicrobial agent.
to minimize the microbes at the injection site
7. Prior to inserting needle consider the location

of the infusion tubing needle is not to be
rotated once inserted. Do not angle or twist
the non-coring needle.
51
Principle
8. Non-coring needle must be inserted at a
90 angle.
Section Four
9. Using a 10 mL syringe filled with normal

saline aspirate a small amount of blood.
Once blood is observed flush with normal
saline using brisk push/pause technique.
Assess for swelling and patient complaints
of pain.
to ensure non-coring needle is located in the

ports reservoir
pain and swelling at site may indicate:
improper placement of non-coring needle
damage to the implanted port
dislodgement of catheter tip
10. If non-coring needle is to remain in situ it

must be secured and covered with a sterile
transparent semi-permeable membrane
dressing.
to prevent infection
to secure non-coring needle
11. Port must be locked when non-coring needle

in situ:
but no infusion
prior to disengaging non-coring needle
every 30 days when not accessed
to maintain the patency of the implanted port
12. The port must be stabilized while

disengaging the non-coring needle.
to prevent septal damage or damage to

insertion pocket
52
Section Four
Obtaining Blood Specimens from the Central Venous Catheter

Principle
1. Aseptic technique must be used when

obtaining blood specimens from a CVC.

the vascular system
2. Limit number of times a day the catheter is

used to obtain blood specimens.
to prevent catheter related blood stream

infections
to prevent blood withdrawal induced anemia
3. If laboratory values for blood withdrawn

from a CVC are significantly altered in a
previously stable patient, the laboratory test
should be repeated before any treatment is
implemented.
potential for blood specimen to be

contaminated by catheter flush solution or
infusate
4. Venipuncture must be used to collect

specimens for coagulation studies, especially
if the results are to be used to titrate
medications or to diagnose coagulopathies.
If venipuncture is not an option, CVC
specimen for coagulation studies must not be
drawn from a lumen:
with an infusion of heparin
distal to an anticoagulant of a multi
lumen catheter
to prevent specimen contamination and

inaccurate laboratory results, which could
lead to inappropriate diagnosis and treatment
5. Discard volume will be dependant on the

specimen required:
Routine blood collection 3 mL
to prevent specimen contamination and

inaccurate laboratory results, which could
lead to inappropriate diagnosis and treatment
Blood collection including coagulation

studies 12 mL (may use a 20 mL syringe)
Blood cultures no aspiration or
discard
53
Principle
Section Four
6. Vacutainer method is the preferred method

for obtaining blood specimens from a CVC.
this method reduces the number of system

punctures and potential blood spillage
Photo used with permission:

Becton Dickinson Medical
Systems
Exception: Use the syringe method:

if the Vacutainer method is unsuccessful
if a small volume specimen is required
if blood cultures are required
7. If syringe method is used, a blood transfer
device must be used when transferring blood
from syringe to blood culture bottles and
Vacutainers.
to promote safety by preventing needle stick

injuries
Photo used with permission:

Tyco Healthcare Group
Canada, Inc.
8. When multi-lumen CVCs are used for blood

withdrawal, the largest available lumen is
preferred.
Blood specimens may be drawn through
any CVC lumen except:
blood specimens for coagulation
studies must NOT be drawn from a
lumen that has an infusion of heparin.
a lumen being used to administer
parenteral nutrition
Exception:
if the lumen dedicated to parenteral
nutrition is suspected of being a source of
infection blood culture specimens may be
drawn from this lumen
in Child Health a lumen used for
parenteral nutrition may be used to draw
blood specimens
54
to prevent hemolysis of sample

to prevent inaccurate laboratory results
parenteral nutrition may enhance bacterial

growth, therefore access of this lumen should
be minimized
Principle
Section Four
9. All lumens should be clamped and all

infusions into the catheter stopped prior to
collecting blood from a CVC.
prevents infusate from entering the lumen

being accessed for blood sampling.
Inaccurate lab values (e.g. potassium and
aminoglycosides) have been reported on
blood specimens obtained from CVCs
10. The order of blood specimens to be drawn

are in accordance with Calgary Lab Services
Standards.
avoid possible test error due to cross

contamination from tube additives such as
clotting activators or anticoagulants
11. Flushing prior to obtaining blood samples is

not required.
Exception: Prior to coagulation studies
catheter is to be flushed with
20 mL normal saline prior to
discard and sample.
Note: If catheter is locked with any solution
other than normal saline or low dose
heparin withdraw 3 mL and discard
the solution prior to flushing.
sample contamination is minimized by

discard collection
more accurate results for coagulation
studies if venipuncture is not an option
12. Catheter lumen is flushed with normal saline,

using brisk push/pause technique after blood
withdrawal.
to prevent catheter lumen occlusion
13. The following measures may be necessary if

difficulty drawing blood:
ask the patient to reposition, take deep
breaths, cough, or raise arms
if still unable to withdraw blood, flush the
catheter with 10 to 20 mL (adult) or
5 to 10 mL (child) normal saline using the
push/pause method and repeat attempt
decrease speed of withdrawal
to withdraw blood from a valved PICC
using the syringe method to open the
valve: begin to withdraw the syringe
plunger, stop, and then proceed to
withdraw slowly
may release catheter from vessel wall or

relieve pinch off syndrome
create turbulence in the catheter,
repositioning catheter in the vessel
prevents catheter collapse
55
Section Four
Managing a Hemodialysis Catheter

In addition to the above principles presented in this section the following principles need to be
adhered to when managing a Hemodialysis Catheter.
Hemodialysis is a specialized treatment for some patients with renal disease where blood is
withdrawn, treated in dialysis machine and re-instilled into the person.
Accessing, flushing and locking of a hemodialysis CVC is an additional skill which some level one
nurses will be qualified in. CVCs inserted for long-term hemodialysis are NOT to be used by staff
outside the hemodialysis program (Southern Alberta Renal Program-SARP) for procedures such as
infusing medications or drawing blood.
Exceptions:
In an emergency situation and no alternative for intravenous access is possible
When no other venous access is possible, an order is required from the nephrologists to access the
hemodialysis catheter.
The following principles are included in this module so that in an emergency situation if a
hemodialysis catheter must be accessed, patient safety will be maintained.
Principle
Accessing
1. Always withdraw and discard 3 mL of
solution to ensure the flush solution is
removed from patient circulation.
locking solutions used with hemodialysis

CVC include high dose heparin (1,000 U/mL
to 10,000 U/mL), sodium citrate, alteplase
(Cathflo) or antibiotics
the patient is at high risk of hemorrhage if
the locking solution is allowed to enter the
vascular system
2. Flush lumen with 10 mL NS prior to

administering medication or intravenous
solution.
to ensure lumen is patent and that no clots

exist
Maintenance Infusion
3. Minimum infusion rate is 20 mL per hour to
maintain lumen patency.
lumen size is larger than standard CVC and

therefore occlusion may occur if rate is less
than 20 mL per hour
56
Principle
Section Four
Locking
4. When locking a hemodialysis catheter a
3 mL syringe is used to instill the ordered
locking solution as per the volume of each
lumen.
The volume of the lumen is marked on
the clamp of hub of the lumen.
Positive pressure technique will be used
when clamping hemodialysis catheters.
Ensure the clamp is locked at all times.
If the specific locking orders for the hemodialysis

catheters are not adhered to:
the catheter could occlude, requiring its
removal and a new catheter inserted for
dialysis treatment
vascular system
5. The hemodialysis catheter must be labeled

indicating locking solution.
Note: Labels can be obtained from SARP
dialysis units.

or solution
Injection Cap Replacement and Dressing

Changes
6. Are completed by staff in the hemodialysis
program (SARP) as part of the patients
hemodialysis treatment.
Where care is required in addition to this
schedule (e.g. to replace a hemodialysis
CVC dressing that is no longer intact)
contact the hemodialysis program to
confirm the care approach.
Diagnostic Imaging (DI) testing
7. CVCs inserted for hemodialysis are NOT to
be attached to power injectors for DI tests.
these catheters are considered life sustaining

and any intervention that carries a risk of
damaging the catheter must be avoided
Repair
8. Repair of a hemodialysis CVC is performed
by those nurses qualified in this procedure
and follows the SARP specific policy and
procedure.
Removal
9. Hemodialysis CVCs may be removed only
when ordered by a nephrologist and must be
removed following the specific policy and
procedure in the hemodialysis program
(SARP).
57
Section Four
Managing an Apheresis Catheter

In addition to the above principles presented in this section the following principles need to be
adhered to when managing a CVC designated for Apheresis use.
Note: Multiple catheters can be used for apheresis including direct percutaneous tunneled and
implanted ports.
Apheresis: The process of withdrawing whole blood through a central venous catheter into a blood
cell separator where it is divided into its components (RBCs, WBCs, platelets and plasma). The
desired component is removed and/or replaced. For example, apheresis can be used to remove:
pathological antibodies in the body and replace them with normal plasma or albumin; WBCs in acute
leukemia to allow chemotherapy to begin sooner; and, stem cells for transplant.
Accessing and locking of an apheresis catheter is an additional skill which some level one nurses
will be qualified in. CVCs designated for apheresis are NOT to be used by staff outside the apheresis
program for procedures such as infusing medications or drawing blood unless by physician order.
Exception:
In an emergency situation and no alternative for intravenous access is possible.
When no other venous access is possible, an order is required from the medical director of
apheresis (weekdays) or nephrologists (evenings, nights, and weekends) to access the apheresis
catheter.
The following principles are included in this module so that in an emergency situation if an apheresis
catheter must be accessed, patient safety will be maintained.
Principle
Accessing
1. Always Withdraw and Discard 3 mL
of solution to ensure the flush solution is
removed from patient circulation.
locking solutions used with apheresis CVC

include high dose heparin (1,000 U/mL to
10,000 U/mL), sodium citrate, alteplase
(Cathflo) or antibiotics
vascular system
2. Flush lumen with 10 mL NS prior to

administering medication or intravenous
solution.
to ensure lumen is patent and that no clots

exist
Maintenance Infusion
3. Minimum infusion rate is 20 mL per hour to
maintain lumen patency.
lumen size is larger than standard CVC and

therefore occlusion may occur if rate is less
than 20 mL per hour
58
Principle
Locking
4. When locking an apheresis catheter a 3 mL
syringe is used to instill the ordered locking
solution as per the volume of each lumen.
The volume of the lumen is marked on
the clamp of the hub of the lumen
Section Four
If the specific locking orders for the apheresis
catheters are not adhered to:
the catheter could occlude, requiring its
removal and a new catheter inserted for
apheresis treatment
vascular system
5. Positive pressure technique will be used when

clamping apheresis catheters.
Ensure the clamp is locked at all times.

6. The lumen must be labeled as an apheresis

catheter.
The label will also indicate the locking
solution instilled into the catheter.
Additional labels can be obtained from
the Apheresis Department.

or solution
Cap Replacement and Dressing Changes

7. Are completed by staff in the Apheresis
program as part of the patients apheresis
treatment.
Where care is required in addition to this
schedule (e.g. to replace a site dressing
that is no longer intact) contact the
apheresis program to confirm the care
approach.
DI testing
8. CVCs inserted for apheresis are NOT to be
attached to power injectors for DI tests.
these catheters are considered life sustaining

and any intervention that carries a risk of
damaging the catheter must be avoided
Repair
9. Repair of an apheresis CVC is performed by
those nurses qualified in this procedure.
Removal
10. Apheresis CVCs may be removed only when
ordered by a Medical Director of Apheresis
(weekdays) or Nephrologists (evenings,
nights and weekends).
59
Section Four
Checkpoint: Section Four Questions

1. What are MAXIMAL barrier precautions and when are they required?
2. What 4 CVC and midline catheter interventions require the use of a mask and sterile gloves,
in addition to hand hygiene?
3. What 5 components of a CVC and midline catheter assessment are required for each shift or
home visit?
4. What action MUST be taken to prevent air entry into the catheter prior to changing the
injection cap?
5. When is an injection cap replaced?
60
Section Four
6. What assessment would indicate the need to change a dressing from transparent to gauze?
7. If both a dressing and injection cap replacement are required at the same time, which should
be performed first, and why?
8. What types of connections are required on all devices attached to a CVC or midline catheter
to prevent accidental disconnection?
9. What action must be done initially when accessing a catheter locked with any solution other
than normal saline or low dose heparin?
10. What is the name of the special needle used to access the port of an implanted CVC?
Why is it necessary to use?
11. What specimen should be collected PRIOR to any flush or discard?
12. What is the single most important action that helps prevent occlusion of a CVC or midline
catheter after blood specimens have been obtained?
13. Outside the hemodialysis or apheresis programs, under what circumstances can a
hemodialysis or apheresis catheter be accessed?
61
Section Four
Checkpoint: Section Four Answers

1. What are MAXIMAL barrier precautions and when are they required?
mask
head covering
sterile gown and
sterile gloves and
sterile drapes over the patient
maximal barrier precautions are required for the INSERTION of a CVC and midline catheter.
2. What 4 CVC and midline catheter interventions require the use of a mask and sterile gloves,
in addition to hand hygiene?
insertion of CVC
dressing change
accessing open system
injection cap change
3. What 5 components of a CVC and midline catheter assessment are required for each shift or
home visit?
condition of the catheter; injection caps, connections, and tubing
measure the external portion of the catheter from catheter/skin junction (exit site) to the
beginning of the hub
dressing
catheter/skin junction (exit site) for any evidence of inflammation, edema, erythema, pain,
vein cording, drainage
sutures and or securement device
non-coring needle (if present in an implanted port)
other potential complications see Section 5 (e.g. Superior Vena Cava Syndrome)
4. What action MUST be taken to prevent air entry into the catheter prior to changing the
injection cap?
clamp the catheter
Exception: Valved catheters
62
Section Four
5. When is an injection cap replaced?

every 7 days and as needed in hospital
every 7 days and as needed in community when catheter in use
every 30 days and as needed in community if catheter not in use
if it is leaking or broken
if blood trapped in injection cap
injection cap has been removed from the catheter for any reason
a removable positive pressure device is present
6. What assessment would indicate the need to change a dressing from transparent to gauze?
presence of drainage, moisture, or erythema under the transparent membrane dressing
7. If both a dressing and injection cap replacement are required at the same time, which
should be performed first, and why?
change the injection cap first to help prevent cross contamination of the cap with skin flora
8. What types of connections are required on all devices attached to a CVC or midline catheter
to prevent accidental disconnection?
luer lock connections
9. What action must be done initially when accessing a catheter locked with any solution
other than normal saline or low dose heparin?
withdraw 3 mL and discard the solution prior to use
10. What is the name of the special needle used to access the port of an implanted CVC?
Why is it necessary to use?
non-coring needle prevents damage to port septum
11. What specimen should be collected PRIOR to any flush or discard?
blood cultures, especially where the CVC is suspected of being a source of the infection
12. What is the single most important action that helps prevent occlusion of a CVC or
midline catheter after blood specimens have been obtained?
flush the catheter with 20 mL normal saline using brisk push-pause technique to create
turbulence in the catheter
Exception: Child Health
63
Section Four
13. Outside the hemodialysis or apheresis programs, under what circumstances can a
hemodialysis or apheresis catheter be accessed?
in an emergency situation and no alternative for intravenous access is possible
when no other venous access is possible, an order is required from the medical director
of apheresis (weekdays) or nephrologists (evenings, nights, and weekends) to access the
hemodialysis catheter
Note: If you were able to answer these check point questions correctly, proceed to next section;
otherwise, review the material in this section.
64
Section Five
Section Five
Potential Complications with
CVC and Midline Catheters
1. Discuss the potential complications that may occur when caring for the patient/client with a
CVC or midline catheter.
2. Identify signs and symptoms which may indicate a complication.
3. Outline actions to be taken to help prevent a complication from occurring.
4. Discuss nursing actions to be taken when a complication occurs.
65
Section Five
Potential Complications with CVC and Midline Catheters

It is important for the nurse to be knowledgeable about possible complications that may occur. It is
estimated that approximately 10% of all patients who have a CVC or midline catheter will experience
a complication secondary to the catheter insertion or its use. For the patient with a CVC or midline
catheter, problems that may develop include (the more common complications are in bold):
Arrhythmia
Arterial puncture
Bleeding
Blood backup in catheter
Damaged catheter
Dislodge catheter
Embolism, air
Embolism, catheter
Extravasation or infiltration
Hemothorax
Horners syndrome
Hydrothorax
Infection
Migration of catheter
Occlusion
Phlebitis
Pneumothorax
Superior vena cava syndrome
Thrombosis
Each of these complications will be described by identifying signs and symptoms and preventative
nursing interventions to minimize complications.
66
Section Five
Arrhythmia
Signs and Symptoms:
irregular pulse
palpitations
hypotension
dizziness
weakness
dyspnea
Possible Cause:
irritation to the myocardium from the catheter in the right atrium
Prevention:
insertion of CVC completed by qualified health professional
radiographic verification of catheter tip location and order for use prior to using a newly
inserted CVC or when there is reason to doubt CVC tip location is in the vena cava
assessment of external catheter length every shift or at each home visit
Actions to Take:
monitor patient
treat signs and symptoms
notify setting appropriate personnel regarding potential need to adjust CVC
anticipate need for repeat x-ray
67
Section Five
Arterial Puncture
Signs and Symptoms:
pulsating blood in CVC or midline catheter
bright red blood return in syringe when confirming catheter placement
hematoma or bleeding at insertion site
hypotension
respiratory distress
mediastinal shift (structures in chest shifted to one side)
tracheal deviation
massive hemorrhage not amenable to pressure
Possible Cause:
cannulation or trauma of an artery during catheter insertion
Prevention:
insertion of catheter completed by qualified health professional
patient in optimal position for CVC or midline catheter insertion
use of visualization technology to aid vein identification and selection, when appropriate
Actions to Take:
Arterial Puncture May Constitute A Medical Emergency activate setting appropriate
emergency response (e.g. code 66; code blue; 911)
any percutaneous catheter suspected of arterial cannulation can be removed without radiological
or vascular surgery consultation
IMMEDIATELY apply manual pressure to the insertion site for at least 5 minutes
elevate head of bed
monitor patient
prepare for interventions to investigate and control bleeding
68
Section Five
Bleeding
Signs and Symptoms:
blood on dressing
Note: some bleeding is to be expected the first 24 hours post-insertion
Possible Causes:
large bore introducer used for catheter insertion
traumatic venipuncture
increased clotting time
decreased platelet count
inadequate anchoring of catheter post insertion
Prevention:
insertion and removal of catheter completed by qualified health professional
use visualization technology to aid in vein identification and selection, when appropriate
patients platelet count and INR known prior to catheter insertion and removal, when appropriate
catheter anchored appropriately after insertion
Actions to Take:
apply pressure dressing to catheter/skin junction on top of transparent dressing
apply rolled gauze along sides of track of tunneled CVC
reassess as appropriate for the setting and amount of bleeding
provide patient with guidelines on when to contact staff
notify setting appropriate personnel if bleeding persists
monitor patient
obtain laboratory test, as ordered (e.g. INR, CBC)
prepare for intervention to control bleeding
monitor dressing post CVC or midline catheter removal
69
Section Five
Blood Backup in Catheter

Signs and Symptoms:
blood visualized in injection cap
difficulty flushing
downstream occlusion alarm
Possible Causes:
pressure in catheter is less than in vein, for example, occurring when:
catheter is open but solution is not infusing
patient changes position creating increase in venous pressure
luer lock connection is loose (resulting in fluid leaking out)
damaged catheter or tubing (resulting in fluid leaking out)
improper locking technique
Prevention:
ensure the catheter is clamped at all times when not in use
Note: valved CVC or midline catheter does not need to be clamped
infusion pumps must be used for all CVC infusions
Exception: Child Health, direct IV push, emergency situations
ensure luer lock connections are secure
ensure the anti-siphon valve is attached to the tubing of ambulatory infusion pumps in community
settings
use push/pause method of flushing
use positive pressure technique when locking catheters:
non-valved catheters clamp the catheter or extension tubing while injecting the last 0.5 mL
of lock solution
valved catheters maintain pressure on syringe plunger when disconnecting the syringe
Actions to Take:
assess the catheter for possible damage
flush the catheter with saline using brisk push/pause method
ensure luer lock connections are secure
restart the infusion or lock the catheter using positive pressure technique
increase the frequency of flushing and/or the KVO rate if the problem persists
notify AVAS or qualified health professional to manage CVC occlusion, if indicated
70
Section Five
Damaged CVC and Midline Catheter

Signs and Symptoms:
dressing or patients clothing are wet
leakage is observed during infusion or flushing of catheter
swelling noted around point of catheter insertion or along venous pathway
pain or burning during infusion
if there is a delay in recognizing or treating symptoms, patient may develop pallor, cyanosis,
shortness of breath, tachycardia
ballooning of catheter
Possible Causes:
sharp objects used on or near catheter (rough clamps, scissors, needles)
damage from clamping
defective catheter
catheter damaged during insertion
catheter not secured or protected adequately
excessive pressure applied to catheter
use of syringe smaller than 10 mL
inappropriate use of power injector
pinch off syndrome (compression of a CVC between the first rib and the clavicle)
separation of catheter from implanted port
damage to implanted port septum due to use of a coring needle
tight sutures around catheter
instillation of solutions incompatible with composition of catheter
Prevention:
insertion and removal of catheter completed by qualified health professional
avoid use of sharp objects near the catheter and during dressing change
use only approved smooth-edged clamps or padded clamps
rotate clamp sites on the catheter or extension tubing
clamp only on reinforced area of tunneled catheters
use needleless cannula when accessing the catheter
Note: if a needle must be used (e.g. during code blue interventions), it should be 25 g to 20 g and
no longer than 2.5 cm (1 inch) length
use 10 mL syringes or larger to flush catheter
never use excessive force when flushing the catheter
use non-coring needle to access implanted CVCs and secure needle to prevent dislodgement or
damage to the reservoir
secure catheter to patient to avoid potential damage (e.g. stretching resulting in breakage or
migration of catheter into the body)
71
Section Five
peripheral IVs are the preferred route for diagnostic imaging procedures
automatic power injectors, used for some diagnostic imaging procedures, may be used on
direct percutaneous CVCs if ordered by the attending physician
automatic power injectors are not to be used on tunneled, implanted, PICC or midline catheters
unless specifically designed for that purpose (e.g. Power PICC)
ensure that instilled solutions are compatible with the composition of the catheter
Actions to Take:
Maintain patients safety by implementing the following:
Direct Percutaneous CVC
clamp (non-toothed) catheter lumen proximal to the site of damage
wrap the damaged area with a sterile occlusive dressing
secure catheter to the skin to minimize the risk of migration
label the lumen Damaged DO NOT USE
notify setting appropriate personnel
damaged direct percutaneous catheters are not repairable therefore are to be removed or replaced
if only one lumen of the catheter is damaged the other lumen (s) may be used until the catheter
is replaced, or removed
Note: A damaged catheter is a risk for infection and air embolism. Catheter should be replaced
or removed as soon as possible to decrease these risks.
PICC or Midline catheter
a catheter is to be folded over on itself proximal to the site of damage
wrap the damaged area with a sterile occlusive dressing
notify AVAS or qualified health professional
if only one lumen of the catheter is damaged the other lumen(s) may be used until the catheter is
replaced, repaired or removed
Note: A damaged catheter is a risk for infection and air embolism. Catheter should be replaced,
repaired or removed as soon as possible to decrease these risks.
Tunneled CVCs
clamp (non-toothed) the catheter lumen proximal to the site of damage
wrap damaged area with a sterile occlusive dressing
notify AVAS or qualified health professional
if only one lumen of the catheter is damaged the other lumen(s) may be used until the catheter is
replaced or removed
Note: A damaged catheter is a risk for infection and air embolism. Catheter should be replaced,
repaired or removed as soon as possible to decrease these risks.
72
Section Five
Implanted Port
implanted ports can only be repaired, replaced or removed in interventional radiology or
in the operating room
73
Section Five
Dislodged CVC and Midline Catheter

Signs and Symptoms:
catheter is partially pulled out, observed by increased external length
cuff on tunneled CVC is visible external to catheter/skin junction
implanted CVC has moved or flipped over, preventing access
difficulty with aspiration or infusion
leaking of solution from catheter/skin junction
swelling along venous pathway
burning sensation or pain on infusion
Possible Causes:
tension on the catheter
catheter not properly secured or sutured
implanted CVC has become free moving or migrated
dacron cuff not secured (by tissue granulation) to surrounding tissue because of altered healing
response in patient
Prevention:
minimize tension at catheter/skin junction by properly securing catheter, extension, and IV tubing
secure the CVC or midline catheter to the patient with sterile securement device (e.g. sutures,
sterile adhesive strips, Statlock, Flexitrak)
loop the catheter to prevent pulling at the catheter/skin junction
further secure PICC, midline and IV tubing on arm with tubular mesh dressing
ensure sutures are in situ on direct percutaneous CVCs at all times
ensure sutures are present at catheter/skin junction of tunneled CVCs for 1014 days post
insertion, as ordered (or longer for patients with impaired healing)
Note: Child Health sutures may not be used, therefore ensure catheter is adequately secured
by other means
ensure dressing is intact
educate the patient on how to minimize the risk of catheter dislodgement
Actions to Take:
discontinue infusion
notify AVAS and or setting appropriate personnel
obtain order for x-ray to verify tip placement
prepare for possible replacement of catheter
74
Section Five
Embolism Air
Definition: The presence of air in the vascular system.
Signs and Symptoms:
sharp chest pain
palpitations
shortness of breath
shoulder or low back pain
anxiety
hypotension
cyanosis
weak, rapid pulse
hypoxia
syncope or loss of consciousness
shock or cardiac arrest
Possible Causes:
bolus of air in syringe, IV tubing
inadequate clamping of catheter during injection cap replacement
inspiration of air (by patient) during insertion or removal of catheter
accidental disconnection of infusion tubing or injection cap from catheter
damaged or severed catheter or extension tubing (see page 71)
a tract left open after catheter removal
use of vial access cannula on injection caps
Note: the exact amount of air necessary to cause death remains unknown and also depends
on the patients clinical status
Note: air embolism occurs more readily in patients who are in an upright position, dehydrated,
or hypovolemic
Prevention:
remove all air when priming IV tubing and extension sets
remove air from syringes used to access catheter
ensure catheter is clamped during injection cap replacement and with tubing changes
ensure all connections are luer lock and secure
take measures to prevent catheter damage (see page 71)
rotate clamp sites or clamp only on designated reinforced site on tunneled catheters
avoid twisting and kinking of CVC
secure tubing to patient
use infusion pumps for all CVC infusions
Exception: Child Health, direct IV push, emergency situations
75
Section Five
keep smooth-edged clamp with patient at all times

use IV tubing with inline air eliminating filter if appropriate
valsalva and correct positioning during insertion and removal unless contraindicated
ensure occlusive dressing intact for 24 hours post CVC and midline catheter removal
Actions to Take:
Air Embolism Is A Medical Emergency activate setting appropriate emergency response
(e.g. code blue, code 66 or 911)
immediately place patient on left side in Trendelenburg position (if possible) or flat in bed
immediately eliminate the source of air intake
if catheter is damaged
clamp CVC as close to catheter/skin junction as possible
for damaged PICC or midline fold the catheter over on itself proximal to the damaged area
cover damaged area with sterile occlusive dressing
notify AVAS or qualified health professional so the catheter can be repaired, removed or
replaced as soon as possible
Note: direct percutaneous CVC cannot be repaired. They must be removed or replaced
as soon as possible
treat signs and symptoms (e.g. administer oxygen)
monitor patient
observe and reassure patient
76
Section Five
Embolism Catheter
Definition: A piece of the catheter detaches and enters the vascular system.
Signs and Symptoms:
shortness of breath
cyanosis
hypotension
tachycardia
anxiety
syncope or loss of consciousness
catheter not visible externally at catheter/skin junction (exit site)
Possible Causes:
damaged catheter (see page 71)
Prevention:
take measures to prevent catheter damage (see page 71)
do not continue to remove catheter if resistance is met
Actions to Take:
Catheter Embolism Is A Medical Emergency activate setting-appropriate emergency response
take measures to minimize migration of catheter fragment:
if possible place tourniquet above catheter/skin junction (exit site) to occlude venous return,
but not arterial blood supply to the arm
limit patients mobility:
for PICC or midline immobilize arm and have patient sit upright
for direct percutaneous, tunneled or implanted CVC have patient remain quietly
resting in bed
treat signs/symptoms
monitor patient
have emergency equipment available
prepare patient for interventions related to catheter retrieval, as ordered
77
Section Five
Extravasation or Infiltration
Definitions:
Extravasation: Inadvertent administration of a vesicant solution or medication into surrounding
tissue.
Vesicant: Intravenous medication that has the potential to cause cellular damage or tissue destruction.
Infiltration: Inadvertent administration of a non-vesicant solution or medication into surrounding
tissue.
Irritant: Agent capable of producing discomfort or pain at the venipuncture site or along the internal
lumen of the vein.
See policy M-6 Antineoplastic Medications-Extravasation for further information.
Signs and Symptoms:
slowing or cessation of flow from intravenous solution
frequent pump occlusion alarms
increased resistance when administering the medication
poor or no blood return
patient/client verbalizes infusion feels different from last time
patient/client reports sensations of pain, stinging, burning along the venous pathway, catheter/skin
junction (exit site) or the insertion site
tissue at catheter/skin junction (exit site) and/or along the venous pathway or track of the catheter,
or surrounding the implanted port is discolored (pale or inflamed) and/or edematous or boggy
on palpitation
the skin over the affected area develops blisters, sloughing of tissue and progresses to tissue
necrosis
if there is significant infiltration, patient/client will experience persistent pain and the area will
remain swollen
Used with permission by Covidien
78
Section Five
Possible Causes:
damaged CVC or midline catheter (see page 71)
dislodgment of the catheter or tip not centrally positioned (see page 74)
separation of catheter from implanted port
thrombosis at the catheter tip with backtracking of solution
Prevention:
Prior to administration of any irritant or medication/solution:
confirm catheter tip placement in vein by aspirating for a small amount of blood
establish patency of catheter lumen by flushing
inquire into any problems with CVC or midline catheter (e.g. blocked lumens, pain or swelling
along site)
obtain radiographic confirmation of catheter tip location prior to using a newly inserted CVC or
when there is reason to doubt CVC tip location is in the vena cava
consider need to investigate and treat withdrawal occlusions
provide patient education regarding need to report any sensation changes such as pain, stinging,
burning along the catheter tract, catheter/skin junction (exit site) or the insertion site
Note: often the first indication of extravasation or infiltration is apparent only to patient with no
observable signs to the clinician)
Actions to Take:
stop infusion of drug/fluid and disconnect immediately
attempt to aspirate residual drug
notify setting appropriate personnel and administer antidote as ordered
Note: consult to qualified staff for management of extravasation and administration of antidote
may be required
measure and mark area and photograph (if possible)
apply ice/cold compresses for 20 minutes, four times daily for three days
Exception: vinca alkaloids (use heat for vinca alkaloids, such as vincristine, vinblastine,
vinorelbine)
rest and elevate the affected extremity for three days
administer analgesics as required
monitor site every 2 hours to 4 hours, for 24 hours and then daily; document status and outline
affected area
discuss need for consultation to plastic surgeon (within 2448 hours)
79
Section Five
Hemothorax
Definition: Blood in pleural cavity
Signs and Symptoms:
sudden onset of chest pain
mild to severe shortness of breath
Note: sudden decrease in respiration rate (e.g. from 30 to 12) with reported relief of dyspnea,
may indicate complete collapse of lung
signs/symptoms of shock
hypotension
hemoptysis
tachycardia
cyanosis
diaphoresis
tracheal deviation
Possible Causes:
bleeding into thoracic cavity related to vessel trauma during CVC insertion or vessel erosion by
CVC
previous CVC increases risk of vessel trauma in subsequent CVC
Prevention:
review coagulation status prior to CVC insertion
ensure radiographic verification of catheter tip location prior to using a newly inserted CVC or
ensure CVC is adequately secured to minimize movement
provide patient/client teaching on importance of securing CVC to prevent movement
Actions to Take:
Hemothorax Is A Medical Emergency activate setting appropriate emergency response
(e.g., code blue, code 66 or 911)
stop infusion
place patient in Fowlers position
monitor patient
review coagulation status
prepare for chest tube insertion and removal of CVC
prepare patient for diagnostics and interventions
80
Section Five
Horners Syndrome
Definition: Interruption, damage, or paralysis of the oculosympathetic nerve pathway
Signs and Symptoms:
excessive constriction of the pupil (miosis)
elevation of the lower eyelid
upper eyelid drooping (ipsilateral ptosis)
sinking in of the eyeball
absence of sweating (anhidrosis)
narrowing of the palpebral (eyelid) fissure
hypotension resulting from autonomic CNS effects
Possible Causes:
trauma to the sympathetic nerve during CVC insertion
Note: this condition may result if the CVC catheter inadvertently ascends into the jugular vein
instead of descending into the brachiocephalic
Prevention:
use of visualization technology to aid in catheter placement, when appropriate
Actions to Take:
notify setting appropriate personnel immediately
monitor patient
observe and reassure the patient
prepare for diagnostics and interventions, as ordered
81
Section Five
Hydrothorax
Definition: Accumulation of fluid in the pleural space.
Signs and Symptoms:
rapidly increasing dyspnea
Note: sudden decrease in respiration rate (e.g. from 3012) with reported relief of dyspnea,
may indicate complete collapse of lung
signs/symptoms of shock
hypotension
cough
tachycardia
cyanosis
diaphoresis
tracheal deviation
Possible Causes:
infusion of fluids directly into the thoracic cavity related to vessel trauma during CVC insertion
or vessel erosion by CVC
previous CVC increases risk of vessel trauma in subsequent CVC
Prevention:
ensure radiographic confirmation of tip placement prior to using a newly inserted CVC or
ensure CVC is adequately secured to minimize movement
provide patient/client teaching on importance of securing CVC to prevent movement
Actions to Take:
Hydrothorax Is A Medical Emergency activate setting-appropriate emergency response
stop infusion
place patient in Fowlers position
monitor patient
review coagulation status
prepare for diagnostics and interventions
82
Section Five
Infection
Signs and Symptoms:
May be nonspecific or absent in older adults, those who are immunocompromised, or infants and
children.
Local Infection
erythema
swelling
tenderness
purulence
induration at skin/catheter junction, along tract
of tunneled catheter, along venous pathway of
PICCs/midlines, or implanted port pocket
pain or tenderness radiating to ipsilateral
shoulder or neck
Systemic Infection
fever
chills
diaphoresis
tachycardia
backache
nausea & vomiting
malaise
headache
hypotension
Possible Causes:
increased susceptibility to infection (i.e. immunocompromised)
break in aseptic technique during catheter insertion, and/or during general care of the catheter
hematogenous seeding (micro-organisms carried from a remote site or from another source of
infection and seeds on the intravascular catheter)
infusion of contaminated solutions or medications
adherence of bacteria to fibrin sheath
Prevention:
use of maximal barrier precautions during insertion of CVC and midline catheters
maintain aseptic technique during catheter insertion, and for all interventions involving the
CVC or midline catheter:
exposure of the catheter/skin junction requires staff to mask and don sterile gloves
the patient must mask if coughing and/or unable to turn head
minimize the number of times the system is accessed
the injection cap is disinfected prior to access
skin antisepsis must be done using the chlorhexidine based products
ensure injection cap, dressing and administration set changes are done as per policy
patient/caregiver education (hygiene, catheter care)
inspect medication and solutions prior to use
early recognition and treatment of other sources of infection
83
Section Five
Actions to Take:
monitor patient
administer medication if ordered (e.g. antipyretic, antibiotics, IV fluids)
encourage oral fluids as appropriate
provide comfort measures
consider alternate source for infection
if gauze dressing in situ remove dressing to visually inspect site
if purulent drainage present at catheter skin junction send swab for C&S
obtain specimens and cultures prior to commencing antibiotic therapy (if ordered)
Note: Consideration should be given to obtaining blood cultures from the catheter or midline
catheter as well as via peripheral venipuncture
prepare for possible catheter removal
if catheter is removed, send catheter tip for C&S
84
Section Five
Migration of Catheter
Signs and Symptoms:
external length of catheter is lengthened or shortened by more than 2 cm (0.8 inch) (measure from
the catheter/skin junction to the beginning of the hub)
dacron cuff is visible on a tunneled CVC
change in functional ability of the catheter
sensation of gurgling sound in ear of cannulated side
arm or shoulder pain
vague back discomfort
edema
chest pain
arrhythmia
Possible Causes:
inadequate securement of catheter
spontaneous migration due to increased intrathoracic pressure from coughing, vomiting,
sneezing, or crying
catheter tip not positioned in the lower third of the superior vena cava
Prevention:
ensure CVC or midline catheter is adequately secured to minimize movement
ensure catheter tip is positioned in the lower one third of the superior vena cava
Actions to Take:
ensure radiographic confirmation of tip placement prior to using the catheter
secure catheter to patients skin to prevent further migration
contact AVAS (PICC or midline catheter) or setting appropriate personnel
consider need to remove or replace catheter
if PICC has migrated outward it may be decided to continue using as midline catheter
spontaneous resolution may occur
85
Section Five
Occlusion
Definition: The inability to infuse or inject fluid into a catheter, the inability to aspirate blood from
a catheter or both.
Signs and Symptoms:
Partial Occlusion
discomfort, pain, edema in the shoulder, neck, arm, or insertion site
difficulty withdrawing blood to confirm placement
difficulty infusing/injecting a solution, medication, or flush
leaking of fluid at the catheter/skin junction
withdrawal occlusion: inability to withdraw blood while still able to instill into the CVC or
midline catheter
frequent infusion pump occlusion alarm
Complete Occlusion
unable to either withdraw or instill into CVC or midline catheter
discomfort, pain, edema in the shoulder, neck, arm, or insertion site
Possible Causes:
thrombotic catheter occlusion:
fibrin within or surrounding the catheter
blood clot
non-thrombotic catheter occlusion:
medication or mineral precipitate
lipid deposit
mechanical obstruction, such as:
catheter malposition
migration
kink or clamping
pinch-off syndrome (CVC is compressed between the clavicle and the first rib)
malfunction of valved (closed-ended) catheter
occlusion or malposition of non-coring needle in implanted CVC
Prevention:
use infusion pumps for all CVC infusions
Exception: Direct IV push, Emergency Situations
use a manual push/pause with a syringe using normal saline to create turbulence within the
catheter lumen. The turbulent method will help to ensure the blood is not adhering the catheter.
clamp the catheter/extension tubing while injecting the final 0.5 mL of flush or lock solution to
maintain positive pressure within the CVC or midline catheter
86
Section Five
manually flush the catheter with 20 mL normal saline following:

administration of medications known to crystallize or precipitate (e.g. calcium, phenytoin,
tazocin, diazepam)
administration of lipids
administration of blood products and components
blood withdrawal
Exception: fluid restricted patients and Child Health
administer locking solutions, as ordered, to prevent fibrin build-up, clots and thrombotic device
occlusions
secure the catheter to prevent kinking
secure non-coring needle when in situ
when NOT IN USE the catheter must be flushed and locked at established intervals to maintain
patency
Action to Take:
assess cause of occlusion as per algorithm
follow algorithm for CVC and Midline Catheter Occlusion Management
if occlusion exists, label the lumen as occluded and consult AVAS or qualified health
professional
Exception:
Direct percutaneous notify setting appropriate personnel
Hemodialysis/apheresis CVC notify hemodialysis/apheresis unit
Pediatrics notify setting appropriate personnel
if attempts at catheter clearance are unsuccessful notify setting appropriate personnel and prepare
for catheter removal/exchange/insertion
Note: The patient is predisposed to infection and the possibility of an embolus if catheters are
allowed to remain occluded with blood.
87
Section Five
Algorithm for CVC and Midline Catheter

Occlusion Management
All catheter and IV

tubing and clamps are
OPEN
Yes
Yes
Catheter & IV tubing

free of kinks/tight
sutures?
No
No
Eliminate tight kinks /

sutures
Attempt to flush
Able to flush?
No
Check for catheter pinch or tip mal

- position by having
patient
:
- take deep breaths
- cough
- change position
- remove constrictive clothing
Yes
Yes
Able to aspirate?
Able to flush?
No
No
Label line occluded

and consult AVAS/
qualified health
professional
No occlusion Use line

as required
88
Section Five
Phlebitis
Definition: Inflammation of a vein.
Signs and Symptoms:
pain
redness
edema
inflammation
warmth
induration
palpable venous cord along vein pathway
Possible Causes:
Mechanical:
trauma associated with insertion
presence of a large diameter catheter in relation to the vessel size, causing a mechanical irritation
of the vessel wall and the aggregation of platelets on the catheter surface
movement of the catheter related to improper securement of the device or frequent flexion of the
arm with the PICC/midline in situ (e.g. wheelchair use, crutch walking)
damage to catheter
blood pressure taken or tourniquet used on the arm with PICC or midline catheter in situ
Chemical: inflammation associated with the response of the vein to chemicals
infusion of medications and solutions with extremes in pH and osmolarity
infusion of hypertonic solutions, chemotherapeutic agents, or vesicants into a CVC whose tip is
not in the vena cava
improperly mixed or diluted medications
particulate matter
damage to catheter
Infectious: an inflammation of the vein associated with an infection
poor hand hygiene
break in aseptic technique
integrity of infusion supplies compromised
damage to catheter
Prevention of Mechanical Phlebitis for PICC/Midline Catheters:
apply warm compresses for 20 minutes every 4 hours for 48 hours and prn
patient education
89
Section Five
Actions to Take:
notify setting-appropriate personnel
apply warm packs continuously to venous pathway
ensure patient keeps the arm with the PICC/midline in situ elevated, rested on pillow, and
continues range of motion activity
administer anti-inflammatory medication, if ordered
document, using Phlebitis Grading Scale (see below)
consult AVAS to assess and advise
if phlebitis shows no sign of resolving within 48 hours to 72 hours, prepare for catheter removal
by level two qualified personnel
if catheter is removed, send tip for C&S
Phlebitis Grading Scale
Grade
Clinical Criteria
No symptoms
Erythema at access site with or without pain
Pain at access site with erythema and/or edema

Streak formation
Palpable venous cord

Streak formation
Palpable venous cord > 1 inch (2.5 cm) in length
Purulent drainage
Journal of Infusion Nursing 2006 Vol 29. No. 1S
90
Section Five
Pneumothorax
Definition: Collection of air in the pleural space between the lung and chest wall, caused by
puncture of the pleural covering of the lung.
Signs and Symptoms:
sudden or increasing dyspnea
coughing
decreased breath sounds
the patient may be asymptomatic
signs and symptoms may occur in the first 24 hours post-CVC insertion
Possible Causes:
pleural puncture during catheter insertion into the subclavian vein, causing a collection of air in
the pleural space
Prevention:
Actions to Take:
Pneumothorax Is A Medical Emergency activate setting-appropriate emergency response
place in Fowlers position
monitor patient
prepare for diagnostics and interventions
91
Section Five
Superior Vena Cava Syndrome

Definition: An obstruction of blood flow through the superior vena cava. Extrinsic compression
of the superior vena cava is possible because it has a thin wall coupled with a low intravascular
pressure. Because the SVC is surrounded by rigid structures, it is relatively easy to compress. The low
intravascular pressure also allows for the possibility of thrombus formation, such as catheter-induced
thrombus. The subsequent obstruction to flow causes an increased venous pressure, which results in
interstitial edema and retrograde collateral flow.
Signs and Symptoms:
progressive shortness of breath
dyspnea
anxiety and fear related to feeling of suffocation
cough
sensation of skin tightness
unilateral edema and cyanosis of face, neck, shoulder, and arms
extensive edema of the upper body without edema of the lower body parts
edema and cyanosis of the mucous membranes of the mouth, pharynx, larynx
engorged and distended jugular, temporal, and arm veins
prominent venous pattern often present over the chest
headache, visual disturbances, altered mental status if condition is untreated
Possible Causes:
extensive vein thrombosis
Prevention:
anticoagulant therapy should be considered, especially for patients requiring CVCs for long term
use and for those who are at high risk of clotting
Actions to Take:
stop infusions through CVC
notify setting appropriate personnel immediately
position patient in Fowlers position
reassure patient
prepare for diagnostics and interventions (e.g. anticoagulant therapy, possible intubation, and
CVC removal as ordered)
monitor patient (e.g. fluid volume status, edema, cardiovascular and neurological status)
92
Section Five
Thrombosis
Definition: The formation or existence of a blood clot within the vascular system, in the vessels used
for central venous catheters.
Signs and Symptoms:
pain in the chest, ear, jaw, shoulder
numbness or tingling of extremities
periorbital edema
edema of the neck, supraclavicular area, or extremities
difficulty instilling or aspirating from catheter
leakage of infusion solution from the catheter/skin junction
prominent venous pattern often present over the chest
external jugular distension
tachycardia
shortness of breath
patients may be asymptomatic
frequent infusion pump occlusion alarm
Possible Causes:
triad of thromboses: stasis, vessel wall injury, and hypercoagulability
underlying pathophysiology (e.g. hypovolemia, venous stasis, hypercoagulable states)
damage to vessel wall may be caused by:
infusion of hypertonic solutions, chemotherapeutic agents, or vesicants into a CVC whose tip
is not in the vena cava
presence of a large diameter catheter in relation to the vessel size, causing a mechanical
irritation of the vessel wall and the aggregation of platelets on the catheter surface
blood pressure taken or tourniquet used on the arm with PICC or midline catheter in situ
Prevention:
anticoagulant therapy should be considered, especially for patients requiring CVCs for long term
use and for those who are at high risk of clotting
obtain radiographic confirmation of catheter tip location prior to using a newly inserted CVC or
confirm catheter tip placement in vein by aspirating for a small amount of blood
blood pressure cuffs or tourniquets should not be used on an extremity where a PICC or midline
catheter has been placed
consider need to investigate and treat withdrawal occlusions
93
Section Five
Actions to Take:
notify setting-appropriate personnel immediately
stop infusions through the CVC
encourage patient to rest in semi-Fowlers position to promote venous blood flow
measure upper arm circumference of PICC or midline (10 cm (4 inches) above antecubital fossa)
and compare with insertion record
monitor patient
prepare patient for diagnostics or interventions (e.g. venogram, anticoagulation, catheter removal)
94
Section Five
Checkpoint: Section Five Questions

1. List 5 preventative measures to take to avoid air embolism:
2. If the CVC tip is inserted into the right atrium, what signs and symptoms may be noticed?
3. What actions should be taken if blood has backed up in the CVC or midline catheter?
4. The measurement of the external portion of the PICC has increased from 4 cm to 10 cm
(1.6 to 4 inches). What action should be taken?
5. What are the signs and symptoms related to a local CVC or midline catheter infection?
Systemic infection?
6. What steps should be taken if occlusion is suspected?
95
Section Five
Checkpoint: Section Five Answers

1. What are 5 preventative measures to take to avoid air embolism?
remove all air when priming IV tubing, extension sets, hemodialysis tubings and syringes
ensure catheter and tubing are clamped during tubing change
ensure all connections are luer locked and secure
monitor catheter for evidence of damage
use infusion pump when administering fluids
use IV administration set with air eliminating filter
avoid damaging catheter
use only approved smooth-edged clamps (keep smooth-edged clamp with patient at all times)
rotate clamp sites, or clamp on designated reinforced site on tunneled CVC
avoid twisting and kinking of CVC to avoid damaging catheter
secure tubing to patients
2. If the CVC tip is inserted into the right atrium, what signs and symptoms may be noticed:
arrhythmia
irregular pulse
palpitations
hypotension
dizziness
weakness
dyspnea
3. What actions should be taken if blood has backed up in the CVC or midline catheter?
assess the CVC for damage clamp catheter
ensure all luer lock connections are secure
flush the CVC with saline for injection, followed by the appropriate locking solution,
as per protocol
clamp the CVC or restart the infusion
increase the frequency of flushing and/or the infusion rate if the problem persists
(discuss change in protocol with setting appropriate personnel)
notify qualified staff to manage CVC occlusion, if indicated
96
Section Five
4. The measurement of the external portion of the PICC has increased from 4 cm to 10 cm
(1.6 to 4 inches). What action should be taken?
do not use the catheter until tip location is confirmed by X-ray (turn off infusion if running)
secure the catheter to patient skin to prevent further migration
contact setting-appropriate personnel
consider need to remove and re-insert catheter
Note: If PICC has migrated outward it may be decided to continue using the catheter as a
midline catheter
5. What are the signs and symptoms related to a local CVC or midline catheter infection?
Systemic infection?
Local Infection
erythema
swelling
tenderness
purulence
induration at skin/catheter junction, along
tract of tunneled catheter, along venous
pathway of PICCs/midlines, or implanted port
pocket
pain or tenderness radiating to ipsilateral
shoulder or neck
Systemic Infection
fever
chills
diaphoresis
tachycardia
backache
nausea & vomiting
malaise
headache
hypotension
6. What steps should be taken if occlusion is suspected?

ensure all clamps are open
ensure catheter and tubing are free of kinks and tight sutures
check for catheter pinch or tip malposition
reassess ability to flush and aspirate
if still unable to flush and aspirate label lumen OCCLUDED and consult AVAS or
qualified health professional
97
Section Six
Section Six
Central Venous Catheter and
Midline Catheter Removal
Learning Objective
1. Relate indications for the removal of a CVC and midline catheter.
2. Identify staff qualified to remove a CVC and midline catheter.
3. Explain risk factors associated with CVC and midline catheter removal.
4. Outline nursing care of the patient prior to, during, and post CVC and midline catheter removal.
99
Section Six
Central Venous Catheter and Midline Catheter Removal

This section is intended to assist the Level One qualified nurse to care for a patient prior to, during,
and following CVC or midline catheter removal. It is important for the nurse to understand the
implications of CVC and midline catheter removal to provide safe patient care.
Indications for CVC and Midline Catheter Removal

Ideally the CVC and midline catheter will be removed when no longer required for administering
treatments, medications, or blood collection. Occasionally, a CVC or midline catheter must be
removed if complications occur, such as:
suspected infection
septicemia
thrombosis
thrombophlebitis
unresolved occlusion
tip malposition
non-repairable damaged catheter
Personnel Qualified to Remove CVC and Midline Catheters

Direct percutaneous CVC, PICC and midline catheters may be removed in patient care area by:
Nurses who are qualified in the specialized clinical competency of Level Two Skills
Removal of CVC and Midline Catheter
Physicians
Tunneled and Implanted CVCs
Removed by physician in interventional radiology or operating room
Hemodialysis and Apheresis Catheters
Removed by healthcare professional qualified in the management of hemodialysis and
apheresis catheters
100
Section Six
Removal of CVC or Midline Catheter: Nursing Responsibilities

The responsibilities of the Level One nurse related to catheter removal will vary depending on who is
removing the catheter and where the catheter is being removed.
Prior to Catheter Removal

assess coagulation status (INR, platelet) and other labs as ordered and notify physician of results
Exception: PICC/midline catheter
educate patient and/or caregiver with respect to the CVC or midline catheter removal
obtain baseline vital signs, if required
complete pre-procedural documentation (consent, preoperative record)
anticipate need for alternative venous access
During Catheter Removal

If a catheter is being removed at the bedside, the level one certified nurse may be required to assist the
qualified remover.
clean work surfaces and gather all required equipment as per protocol in your practice setting
restrict activity in the room
adherence to aseptic technique should include:
hand hygiene must be performed by all involved in the removal procedure
turn patients head away from insertion site
mask and sterile gloves or non-touch technique
Exception: PICC or Midline Catheter do not require mask
position the patient as instructed by the qualified remover
for removal of a direct percutaneous CVC, the patient is placed in Trendelenburg position, unless
contraindicated
patients may require coaching in order to perform a valsalva maneuver or inhale and hold their
breath correctly prior to removal of a direct percutaneous CVC
monitor the patient for discomfort and signs and symptoms of complications including air
embolism, catheter fracture, bleeding
anticipate need for sending tip for C&S if infection is suspected
101
Section Six
Post Catheter Removal

immediately following removal apply pressure for a minimum of 5 minutes or until hemostasis
achieved
Note: Hemodialysis or apheresis catheters require a minimum of 20 minutes of applied pressure
monitor the patient for signs/symptoms of complications (air embolism, bleeding, infection)
ensure occlusive dressing remains dry and intact for 24 hours post removal
provide education to the patient/caregiver
follow any post removal orders including:
analgesia
suture removal
documentation in the patients health record should include:
date and time of catheter removal
condition of catheter upon removal
dressing type
patient education
problems or complications with removal and actions taken
102
Section Six
Checkpoint: Section Six Questions

1. List six indications for removal of a CVC and midline catheter.
2. Four complications associated with CVC and midline catheter removal are:
3. When may a nurse remove a CVC and midline catheter?
103
Section Six
Checkpoint: Section Six Answers

1. List six indications for removal of a CVC and midline catheter.
suspected infection
septicemia
thrombosis
thrombophlebitis
unresolved occlusion
tip malposition
non-repairable damaged catheter
2. Four complications associated with CVC and midline catheter removal are:
embolism air
catheter fracture (embolism catheter)
bleeding
infection
3. When may a nurse remove a CVC and midline catheter?
Only the nurse who is qualified in Level Two CVC and midline catheter removal after receiving
an order.
104
Section Seven
Section Seven
Discharge and Transfer Planning for
Patients with CVC or Midline Catheters
Learning Objectives
1. Discuss discharge and transfer planning for patients with CVC or midline catheters.
2. Describe education necessary for CVC or midline catheter self care.
105
Section Seven
Discharge and Transfer Planning for

Patients with CVC or Midline Catheters
Prior to the patient being discharged or transferred with an indwelling CVC or midline catheter, the
nurse must ensure responsibility of care for the CVC or midline catheter is arranged. The planning
and/or education required is dependant on who is assuming responsibility of catheter care.
Discharge and Transfer Planning

1. Transfer to Another Health Care Facility
ensure the receiving care setting will accept responsibility of the CVC or midline catheter
send the catheter insertion record, including CVC tip verification, to the health care facility
taking responsibility for the CVC
send the catheter identification card with the patient
2. Community Setting (Catheter managed by Home Care or Clinic)
ensure supplies have been arranged for the management of the CVC or midline catheter,
as required
send the catheter insertion record, including CVC tip verification, to the community setting
taking responsibility for the catheter
3. Home with Self Care
as required
send catheter insertion record, including CVC tip verification and catheter identification card
with the patient
complete necessary teaching and demonstration of skills, and allow sufficient practice to ensure
patient/family is competent to care for the CVC or midline catheter in the community setting
106
Section Seven
Patient Education
To maximize the effectiveness of patient education:
complete a thorough assessment of patient and caregiver learning needs
choose strategies appropriate to the individual patient and caregivers
utilize regional patient education material to supplement teaching
Regardless of the setting ensure the following basic CVC or midline catheter education
has been completed.
resource person to contact if required
complications to report
safety precautions
handwashing
bathing and showering
importance of carrying clamp and how to apply, if necessary
securement of the catheter
ensure dressing remains dry and intact
lifestyle and activity restrictions
Discharge Teaching for Self Care of CVC or Midline Catheter

Provide Information
Review with patient/family/caregiver the material in the appropriate patient teaching pamphlets.
Patient Education Pamphlets
Order Number
What is a midline catheter?
605637
Care instructions for your childs tunneled central venous catheter
606051
PICC central venous catheter: Self care instructions
606065
What is a PICC?
605058
Tunneled central venous catheter: Self care instructions
605919
Implanted central venous catheter: Self care instructions
606628
Central venous catheters for hemodialysis
605030
107
Section Seven
Knowledge of the following topics is essential for safe care of the CVC and midline catheter:
principles of asepsis
minimizing risk of infection
self care schedule
review applicable skills related to:
dressing change
accessing the catheter
disposal of biomedical waste and sharps
potential complications and actions to take
when catheter is to be removed and healthcare professional responsible for removal
schedule for follow up with health care provider
ordering and obtaining necessary supplies. There may be cost share arrangement for supplies
depending on the program involved in the patients follow up (e.g. Home Care, HPTP, and
outpatient pharmacy).
Use the patient education checklist in the teaching pamphlet to monitor the topics that have been
discussed with the patient.
Demonstrate Safe Standards of Practice

The nurse must demonstrate the following skills and allow the patient and/or family/caregiver
opportunities to practice the skills under supervision:
hand hygiene
asepsis
clamping the catheter if damaged
If applicable, review:
dressing change
108
Section Seven
Evaluate Learning
Consider using a number of the following techniques to help evaluate the competence (knowledge
and skill) of the patient/family/caregiver:
observe a return demonstration of all applicable skills
present possible scenarios and ask open ended questions that require the patient to demonstrate
understanding of knowledge and applicable skills (e.g. Tell me all the steps you would take if
the injection cap came off your catheter.)
listen to the questions and concerns expressed by the patient/family/caregiver
review areas where knowledge and skill deficits have been identified
Document
Document in the patients health record:
information provided to the patient/family/caregiver
response to the teaching
ability to problem-solve potential problems
contact information provided
competence in skills needed for catheter care
communication with other care providers
follow-up plan of care, including plan for catheter removal
109
Section Seven
Checkpoint: Section Seven Questions

1. What 3 nursing actions would you do when discharging or transferring your patient to:
a. Another health care facility
b. Community setting
c. Home with self care
2. List 4 topics that are essential when teaching the patient or caregiver to manage CVC
or midline catheter.
3. What key teaching information must the nurse document on the patients health record?
111
Section Seven
Checkpoint: Section Seven Answers

1. What 3 nursing actions would you do when discharging or transferring your patient to:
a. Another Health Care Facility
ensure the receiving care setting will accept responsibility of the CVC or midline catheter
send the catheter insertion record, including CVC tip verification, to the health care facility
taking responsibility for the CVC
b. Community Setting (Catheter managed by Home Care or Clinic)
as required
send the catheter insertion record, including CVC tip verification, to the community setting
taking responsibility for the catheter.
c. Home with Self Care
as required
send catheter insertion record, including CVC tip verification and catheter identification
card with the patient
complete necessary teaching and demonstration of skills, and allow sufficient practice to
ensure patient/family is competent to care for the CVC or midline catheter in the
community setting
2. List 4 topics that are essential when teaching the patient or caregiver to manage CVC
or midline catheter.
principles of asepsis
hand hygiene and environmental cleanliness
minimize risk of infection
review (if applicable) skills related to:
dressing change
potential complications and actions to take
resource person to contact if required
lifestyle and activity restrictions
ordering supplies
112
Section Seven
3. What key teaching information must the nurse document on the patients health record?
information provided to the patient/family/caregiver
response to the teaching
ability to problem-solve potential problems
contact information provided
competence in skills needed for CVC care
communication with other care providers
follow-up plan of care, including plan for CVC removal
113
Section Seven
Conclusion
This completes the knowledge requirements for obtaining the specialized clinical competence for
general CVC and midline catheter care level one skills in the Alberta Health Services-Calgary Area.
You may be required to attend a CVC and midline catheter educational program, offered by your area
of practice.
The final written exam for CVC and midline catheter care is found in the next section of the Learning
Module. When you have completed the exam, contact your Clinical Nurse Educator (CNE) or
manager to review the answers. A passing score of 85% is required.
Review area specific clinical CVC and midline catheter standards. Some practice areas may have
additional practice guidelines that relate to that particular setting. Please refer to practice guidelines in
your area.
The skills component of the CVC qualification will be arranged by your CNE or manager. You will
have the opportunity to practice the CVC skills required in your practice setting. The criteria used
to evaluate your performance may be found in the skills check lists in Section 9 of this Learning
Guide. Do not carry out CVC skills independently until you have been advised to do so by your CNE/
manager.
114
Section Eight
Section Eight
Qualification Exam
1. General care of CVC and midline catheter is a specialized clinical competency within the
Alberta Health Services-Calgary Area.
True
False
2. Nurses who transfer to another area of practice within the Alberta Health Services-Calgary Area
automatically transfer their CVC and midline catheter qualification with no additional expectations.
True
False
or
3. The tip of a CVC should dwell in the

.
4. Alberta Health Services-Calgary Area Infection Prevention and Control Standard Practice includes:
a. hand hygiene with an antiseptic agent
b. use of personal protective equipment
c. aseptic technique
d. all of the above
5. During insertion of CVC or midline catheter, who needs to wear a head covering?
a. patient
b. nurse assisting
c. health professional inserting
d. family members
6. PICC or midline catheters may be inserted by a Level One qualified nurse.
True
False
115
Section Eight
7. Direct percutaneous CVCs are limited to inpatient care units except for patients in hemodialysis,
apheresis and Child Health programs.
True
False
8. Midline catheters require radiographic verification of the tip prior to use of the catheter.
True
False
9. During the first 24 hours post CVC or midline catheter insertion, the nurse should monitor the
catheter/skin junction every 4 hours and as needed, reporting adverse signs and symptoms.
True
False
10. If bleeding occurs post PICC or midline catheter insertion a pressure dressing may be applied over
the initial transparent dressing.
True
False
11. All aspects of CVC and midline catheter care are documented in the patients health record.
True
False
12. Blood cultures require a 5 mL waste and discard prior to blood draw.
True
False
13. Coagulation studies should always be drawn last.

True
False
14. Three nursing responsibilities prior to CVC or midline catheter insertion include:
116
Section Eight
15. Four nursing responsibilities immediately after CVC or midline catheter insertion are:
16. The catheter/skin junction and surrounding area should be assessed for:
17. Two risks associated with the replacement of injection caps are:
18. Three possible causes of CVC or midline catheter occlusion are:
19. Three actions to prevent catheter occlusion include:
117
Section Eight
20. Injection caps are replaced:

a. every 7 days or if cap has been removed from CVC or midline catheter
b. cap is leaking or broken
c. blood is trapped in the cap
d. a positive pressure device is present
e. all of the above
21. Transparent semi-permeable membrane dressings are changed
and as needed.
22. Transparent over gauze dressing are changed

23. Gauze dressing are changed
and as needed.
and as needed.
24. When would you use a gauze dressing?
25. CVCs or midline catheters may be valved or non-valved.

True
False
26. A valved catheter must be locked with heparin.

True
False
27. Post PICC or midline catheter insertion phlebitis may be minimized by:
118
Section Eight
28. Match the catheter type to the correct description:

a. direct percutaneous
b. tunneled
c. PICC
d. implanted
e. hemodialysis
dacron cuff position under skin
reservoir in subcutaneous tissue pocket
inserted directly into a peripheral vein in the arm
non-tunneled catheter inserted in subclavian, jugular, or femoral vein
double lumen with red and blue clamps or hubs
29. To access an implanted CVC a
to prevent septum damage.
is to be used
30. Infusion pumps must be used for administration of an infusion through a CVC except for direct
IV administration or emergency situations.
True
False
31. For the adult patient who is not on a fluid restriction, the CVC must be flushed with a
mL normal saline following blood withdrawal.
minimum of
119
Section Eight
32. Match the descriptors with the correct signs/symptoms:

a. infection
b. air embolism
c. catheter occlusion
d. dislodged CVC
e. hydrothorax/pneumothorax
dyspnea, cough, chest discomfort
redness, tenderness, swelling, drainage at site
shortness of breath, chest pain, tachycardia, cyanosis
change in external length of catheter
unable to flush lumen
33. A 5 mL syringe must be used for flushing a CVC or midline catheter.
True
False
34. What 4 immediate nursing interventions would you take if an air embolism is suspected ?
35. Two indications for removal of a CVC or midline catheter are:
36. Four actions to be taken when a CVC or midline catheter is damaged include:
120
Section Eight
Appendix A
Central Venous Catheter Child Health Qualification Exam
The following questions must be completed for staff seeking qualification in CVC and Midline
Catheter care in Child Health.
Review of the following policies before completing the exam:
Child Health Policies and Procedures
C 3.0
CVC Introduction and General Principles
C 3.1
CVC Assisting Physician Insert Direct

Percutaneous Catheter
C 3.2
CVC PICC for Pediatrics: Insertion,

Maintenance, & Removal
C 3.3
CVC Tubing Change
C 3.4
CVC Dressing
C 3.5
CVC Flush
C 3.6
CVC Changing Inject Caps
C 3.7
CVC Removal of Direct Percutaneous

Catheters
C 3.8
CVC Drawing Blood Specimens
C 3.9
CVC Catheter Repair
C 3.10
CVC Access Implanted Port
C 3.11
CVC Management of Occlusion
C 3.12
CVC Physician Management of Occlusion
1. Child Health nurses can insert CVC.

True
False
2. To secure a Child Health tunneled catheter (Broviac), steri-strips are applied prior to the dressing.
True
False
121
Section Eight
3. If the Child Health CVC or midline catheter does not have a clamp, an extension set with clamp
is required at the terminal end of an IV set-up.
True
False
4. Pre/Post IV medication administration of normal saline flush volume is:

a. Infant
mL
b. Child
mL
5. Post blood and blood product administration of normal saline flush volume is:
a. Infant
mL
b. Child
mL
6. Heparin lock volume is:

a. Direct or tunneled catheter:
Infant
mL with Heparin
U/mL
Child
mL with Heparin
U/mL
b. Implanted port:
Infant and Child ________mL with Heparin
U/mL
c. PICC non-valved (open ended):

Infant
mL with Heparin
U/mL
Child
mL with Heparin
U/mL
7. In Child Health, blood specimens may be drawn from lumens used to administer Parenteral
Nutrition.
True
122
False
Section Eight
8. The usual volume of discard prior to CVC blood collection except for blood culture for Child
Health is:
a. 3 mL
b. directed volume, 2 X catheter volume
c. 710 mL
d. 15 mL
9. In Child Health, following blood specimen collection the catheter is flushed with what solution?
. The amount of solution is
The solution should be administered using a
mL.
mL syringe.
10. Coagulation studies can be drawn from a CVC in Child Health.

True
False
11. The amount of blood required for a blood culture is:

a. Neonates 3 months
mL
b. Pediatrics 14 years
mL
c. 1518 years
mL
12. A physician must remove all central lines in Child Health.

True
False
123
Section Nine
Section Nine
Performance Checklists
Dressing Change
Flushing and Locking
1. If infusion in progress
2. If normal saline or low dose heparin solution in situ
3. If locking solution other than normal saline or low dose heparin in situ
Administration Set/Extension Set Change

Accessing an Implanted Port
Disengaging an Implanted Port
Obtaining Blood Specimens from the CVC
Vacutainer Method for Blood Withdrawal
Syringe Method for Blood Withdrawal
125
Section Nine

Performance Checklist
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Explain the procedure.

Clean the work surface with an appropriate disinfectant. Allow to dry.
Mask and perform hand hygiene.
Ask the patient to turn their head away from the catheter or apply mask.
Prepare supplies on sterile field.
Ensure catheter lumen(s) are clamped, if applicable.
Perform hand hygiene and apply sterile gloves.
Pick up catheter using sterile gauze.
Vigorously clean the injection cap/catheter connection extending 1.5 cm (0.6 inch)
below the injection cap using antiseptic agent. Allow to dry.
Remove injection cap from catheter lumen using sterile gauze.
Clean outside threads of catheter port ONLY if visibly soiled.
Apply new sterile injection cap to lumen.
Flush and lock lumen following injection cap change.
Document in the patient health record.
Date:
126
Completed
Signature of Trainer:
Section Nine

Dressing Change
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Completed

Clean the work surface with a appropriate disinfectant. Allow to dry.
Ask the patient to turn their head away from the catheter or apply mask.
Apply non-sterile gloves.
Remove old dressing.
If doing cap change, follow Injection Cap Replacement procedure now.
If necessary, remove skin closure strips and/or securement device.
If non-touch technique not maintained, apply new sterile gloves.
Clean the catheter/skin junction with antiseptic beyond the size of the dressing
to be applied. Repeat. Allow to dry.
Cleanse the length of the catheter with antiseptic. Allow to dry.
If necessary, apply protective skin barrier, sterile securement device, and/or skin
closure strips.
Apply sterile dressing(s), ensure adequate coverage of catheter/skin junction
and securement device.
Secure the catheter to prevent traction.
Label dressing with date and initials.
Document in the patients health record.
Date:
127
Section Nine

Flushing and Locking:
If infusion in progress
Name:
Unit/Dept:
Criteria
Completed
1.
2.
3.
4.

Perform hand hygiene.
Draw up solutions as required, in 10 mL syringes. Each solution should be
drawn up in a separate syringe with a separate cannula.
5. Label contents of syringes as they are prepared.
6. Stop infusion, clamp and disconnect IV tubing maintaining asepsis by
attaching a new threaded lock cannula to the end of tubing.
7. Cleanse injection cap vigorously with antiseptic. Allow to dry.
8. Attach normal saline filled syringe, unclamp catheter if applicable.
9. Flush with normal saline using brisk push/pause technique.
10. Instill locking solution as ordered.
Valved catheter maintain pressure on the syringe plunger when disconnecting
the syringe from the injection cap.
Non-valved catheter clamp the catheter/extension tubing while injecting the
final 0.5 mL to create positive pressure within the CVC or midline catheter.
11. Document in the patients health record.
Date:
128
Section Nine

If normal saline or low dose heparin solution in situ
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Completed

Label contents of syringes as they are prepared.
Cleanse injection cap vigorously with antiseptic. Allow to dry.
Attach normal saline filled syringe, unclamp catheter if applicable.
Aspirate a small amount of blood to confirm tip location.
Flush with normal saline using brisk push/pause technique.
Instill locking solution as ordered.
the syringe from the injection cap.
Non-valved catheter clamp the catheter/extension tubing while injecting
the final 0.5 mL to create positive pressure within the CVC or midline catheter.
Date:
129
Section Nine

If locking solution other than normal saline
or low dose heparin in situ
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Label contents of syringes as they are prepared.
Attach empty 10 mL syringe, unclamp catheter if applicable, and
withdraw 3 mL and discard
Attach a new normal saline filled syringe, unclamp catheter if applicable.
Instill locking solution as ordered.
the syringe from the injection cap
Non-valved catheter clamp the catheter/extension tubing while injecting the
final 0.5 mL to create positive pressure within the CVC or midline catheter.
Date:
130
Completed
Section Nine

Administration Set/Extension Set Change
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Completed

Attach threaded lock cannula to administration tubing.
Spike new solution bag and prime IV tubing maintaining the sterility of the
threaded cannula by leaving the protective covering (cap) in place.
Disconnect existing IV tubing by removing threaded lock cannula from
existing injection cap.
Cleanse injection cap vigorously using antiseptic agent. Allow to dry.
Connect new IV tubing by securing the threaded lock cannula onto injection cap.
Restart infusion pump.
Label tubing with date and time.
Date:
131
Section Nine

Accessing Implanted Port
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
132
Completed

Remove restrictive clothing as necessary and position patient supine.
Ask patient to turn their head away from port site or apply mask.
Cleanse the port site with an antiseptic agent beyond the size of the dressing
to be applied. Allow to dry. Repeat.
Attach injection cap to the extension tubing of the non-coring needle.
Prime the extension tubing and non-coring needle with normal saline.
Close clamp of extension tubing and set on sterile field.
Using non-dominant hand, locate and stabilize port by palpation.
Using dominant hand, grasp the finger grip of the non-coring needle and advance
the non-coring needle at a 90 degree angle, through the skin and septum of the
implanted port until the needle tip touches the bottom of the reservoir.
Note: Do not tilt, rock or rotate the non-coring needle as this may damage
the septum and cause it to leak.
If locking solution other than normal saline or low dose heparin in situ:
Attach empty 10 mL syringe, unclamp catheter if applicable, and
withdraw 3 mL and discard.
Attach a new normal saline filled syringe, unclamp catheter.
If normal saline or low dose heparin solution in situ:
Attach normal saline filled syringe, unclamp catheter.
Aspirate a small amount of blood.

Accessing Implanted Port (continued)
Section Nine
Criteria
Completed
15. Flush with normal saline using brisk push/pause technique.

Clamp the extension tubing.
16. If no infusion is being connected:
Attach lock solution filled syringe.
Unclamp extension tubing.
Instill lock solution, using positive pressure technique.
If applicable, repeat procedure for each lumen.
17. If access is not needed, stabilize port and remove non-coring needle.
18. If non-coring needle remaining in situ, apply protective skin barrier,
avoiding insertion site. Apply sterile closure strips as necessary.
Apply dressing over the non-coring needle, extension tubing and port site.
Label dressing with date and initials.
19. If infusion required, attach intravenous tubing using threaded lock cannula
and start prescribed infusion.
20. Secure intravenous tubing to patients skin to prevent traction.
Date:
133
Section Nine

Disengaging Implanted Port
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Remove restrictive clothing as necessary.
Prepare supplies.
Stop infusion, if applicable, clamp extension tubing and disconnect administration set.
Cleanse injection cap with antiseptic agent.
Attach 10 mL syringe of normal saline, unclamp extension tubing and
aspirate a small amount of blood.
Clamp the extension tubing.
Attach syringe with lock solution.
Unclamp extension tubing.
Instill lock solution, using positive pressure technique.
If applicable, repeat procedure for each lumen.
Apply non-sterile gloves.
Remove dressing and sterile skin closure strips.
Stabilize port and remove non-coring needle. May use safety removal device
if available.
Document in patients health record.
Date:
134
Completed
Section Nine

Obtaining Blood Specimens from the CVC:
Vacutainer Method for Blood Withdrawal
Name:
Unit/Dept:
Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Completed

Clean the work surface with a disinfectant. Allow to dry.
Draw up flushing and locking solutions as required, in 10 mL syringes.
Confirm patient identity by comparing arm band to specimen requisitions.
Confirm the order of blood specimens to be drawn.
Stop all infusions and clamp CVC lumens, for appropriate amount of time.
Disconnect tubing from lumen to be used for blood withdrawal and attach
new threaded Lock cannula to tubing, to maintain sterility.
Apply non sterile gloves.
Connect blood collection needle and blunt cannula to Vacutainer holder.
Insert blunt cannula into the CVC injection cap. Unclamp CVC lumen.
Withdraw appropriate volume for discard via Vacutainer tube(s).
Draw blood work samples in correct order.
Clamp CVC lumen and withdraw blunt cannula from injection cap.
Flush lumen with 20 mL normal saline using a brisk push-pause technique.
Exception: Child Health verify amount
Label all blood tubes with patient identification and place in biohazard bag,
along with corresponding requisitions prior to leaving the patient.
Date:
135
Section Nine
Obtaining Blood Specimens from the CVC:

Syringe Method for Blood Withdrawal
Name:
Unit/Dept:
Criteria
Completed
1.
2.
3.
4.

Clean the work surface with a disinfectant. Allow to dry.
drawn up in a separate syringe with a separate cannula. Label contents of
syringe as it is prepared.
5. Confirm patient identity by comparing arm band to specimen requisitions.
6. Confirm the order of blood specimens to be drawn.
7. Stop all infusions and clamp CVC lumens for 1 minute prior to drawing blood
or 35 minutes if parenteral nutrition is infusing, if required.
8. Disconnect tubing from lumen to be used for blood withdrawal and attach
new threaded Lock cannula to tubing, to maintain sterility.
9. Apply non sterile gloves.
10. Connect blunt cannula to empty syringes.
11. Cleanse the injection cap vigorously with antiseptic. Allow to dry.
12. Insert blunt cannula into CVC injection cap. Unclamp CVC lumen.
13. Withdraw appropriate volume for discard.
Exception: No discard required if drawing blood cultures.
14. Attach next syringe, if necessary to draw remainder of blood samples.
15. Remove blunt cannula from syringe and attach blood transfer device.
16. Fill blood tubes in correct order.
17. Flush lumen with 20 mL normal saline using a brisk push-pause technique.
Exception: Child Health verify amount
18. Ensure all samples are labeled and placed in biohazard bag, along with
corresponding requisitions prior to leaving the patient.
Date:
136
References
References
Arkin, C. F., Adcock, D. M., Ernst, D. J., Marlar, R. A., Parish, G. T., Szamosi, D. I., et al. (2003).
Collection, transport, and processing of blood specimens for testing plasma-based coagulation
assays. Clinical and Laboratory Standards Institute, 23(35), 1-17.
Bard Access Systems (2008). Retrieved from www.bardaccess.com
Calgary Health Region (2008). Blood collection tubes/order of draw from
http://www.calgarylabservices.com/HealthcareProfessionals/SpecimenCollection/
BloodCollectionGuidelines/
Calgary Health Region (2008). Acute Care Infection Prevention and Control Manual from
http://iweb.calgaryhealthregion.ca/ipc/manuals.htm
Centers for Disease Control and Prevention (2002). Guidelines for the prevention of intravascular
catheter-related infections. Morbidity and Mortality Weekly Report, 51 (RR-10), 1-34.
Chaiyakunapruk, N., Veenstra, D., Lipsky, B., & Saint, S. (2002). Chlorhexidine compared with
povidone iodine solution for vascular catheter-site care: A meta-analysis. Annals of Internal
Medicine, 136(11), 792-801.
Clinical and Laboratory Standards Institute (2007). Procedures for the collection of Diagnostic Blood
Specimen by Venipunctuce; Approved Standard 6th Edition, 27(26), 1-41.
College and Association of Registered Nurses of Alberta (2003). CARNA Supervision of care provided
by nursing students and undergraduate nursing employees. (Draft) Edmonton, AB: Author
Covidien (2008). Retrieved from www.covidien.com
INS (2006). Infusion nurses society: Infusion nursing standards of practice. Journal of Infusion
Nursing, 29(1S), S12-S78.
LeBlanc, A., & Cobbett, S. (2000). Traditional practice versus evidence-based practice for IV skin
preparation. The Canadian Journal of Infection Control, X, 9-14.
Oncology Nursing Society (2004). Access Device Guidelines 2nd Edition. Recommendation for
Nursing Practice and Education. Oncology Nursing Society. Pittsburg.
Registered Nurses Association of Ontario (2004). Best Practice Guideline. Assessment and Device
Selection for Vascular Access. Toronto, Canada: Registered Nurses Association of Ontario.
Registered Nurses Association of Ontario (2005). Best Practice Guideline. Care and Maintenance
to Reduce Vascular Access Complications. Toronto, Canada: Registered Nurses Association of
Ontario.
137
References
Rouge Valley Health System (2007). Central Venous Access Devices: Self Learning Packages for
Nurses.
Safer Health Care Now (2006). Prevent Central Line Infections: How to Guide. Institute for
Healthcare Improvement.
Taylor, C., Lillis, C., LeMone, P. (Eds.) (2005). Fundamentals of Nursing: The Art and Science of
Nursing Care. 5th Edition, Philadelphia: Lippincott Williams & Wilkins (http://1ww.com); pp
1462-1463.
Weinstein, S. (2007). Plumers Principles & Practice of Intravenous Therapy. 8th Edition, Lippincott,
Williams & Wilkins. Philadelphia, PA.
138
Module Evaluation
Module Evaluation
Please photocopy, complete, and return this section to your Clinical leader (e.g. Clinical Nurse
Educator, Patient Care Manager), who will submit it to Professional Practice & Development
Yes
No
1. The module was easy to read and comprehend.

2. The checkpoints were clear and aided my learning of the material.
3. The amount of detail was appropriate.
4. The qualification exam was appropriate.
5. The contents of this module will help you to care for patients with
a midline or central venous catheter.
Comments:
Signature:
(optional)
Date:
Site:
139

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Alberta Health Services-Calgary Area

Professional Practice and Development

Central Venous Catheter

Cathy Berry Clinical Nurse Educator, Medical Outpatients

Alberta Health Services, 2009. All rights reserved. This information is to be

Central Venous Catheter and Midline Catheter Learning Module

CVC and Midline Catheter Educational Program for Nurses...................3

Vascular Anatomy and Access..................................................................... 11

Section Three: Insertion of CVC and Midline Catheter and Confirmation

Potential Complications with CVC and Midline Catheters .....................65

CVC and Midline Catheter Removal .........................................................99

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Specialized Clinical Competencies

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Central Venous Catheter and Midline Catheter Qualification Algorithm

Advanced Venous Access Service (AVAS)

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Checkpoint: Section One Questions

4. What is the role of AVAS in the Alberta Health Services-Calgary Area?

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Checkpoint: Section One Answers

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Reprinted with permission: Rouge Valley Health System

Vessel Diameter and Flow

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

CVC and Midline Catheter Construction

Reprinted with permission: Rouge Valley Health System

Reprinted with permission: Rouge Valley Health System

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Types of Central Venous Catheters and Midline Catheters

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Direct Percutaneous Central Venous Catheters

Taylor, Lillis, & LeMonel 2005

Duration of catheter use:

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Tunneled Central Venous Catheters

Alberta Health Services, June 2009

Central Venous Catheter and Midline Catheter Learning Module

Implanted Central Venous Catheters

Reprinted with permission: Rouge Valley Health System

Taylor, Lillis, & LeMonel 2005

Alberta Health Services, June 2009