ICID > Clinical Management > Haematology > Groshong Catheters - Care and Management  
 

Groshong Catheters - Care and Management 

1. Indications top

2. Clinical Management

3. Patient Information

4. Audit

5. Evidence Base

1. Indications

1.1 Background

A Skin Tunnelled Central Venous Catheter (STCVC) is a long-term vascular access device typically made from silicone, that can be used for most vascular access indications. The tip is usually placed in the superior vena cava, which is accessed via the internal or external jugular, or the right subclavian vein. The central portion of the catheter lies in a subcutaneous tunnel across the chest. The access ports, which allow fluids to be infused and blood samples to be taken, and the rest of the catheter, exits from the anterior chest via a small puncture wound. Occasionally STCVCs are placed in the inferior vena cava, the catheter usually entering the venous system through the femoral vein in the groin.

Diagram showing groshong line entry and position

The first STCVC, the Broviac, was used for the administration of parenteral nutrition in 1973. Robert Hickman further developed this catheter in 1979 for use in the bone marrow transplantation setting, allowing it to be used for taking blood samples and giving multiple infusions. [1] STCVCs are often given the name "Hickman™ ", as a generic term even though it is a trademark, in much the same way as vacuum cleaners are referred to as "Hoovers ", and ballpoint pens are called "Biros".[2]

The majority of STCVCs, have some sort of clamping mechanism like a traditional CVC (central venous catheter) to prevent unintentional flow of fluid in or out of the catheter. Groshong™ lines were introduced in 1984;[3] by comparison they have no clamp, but have a slit valve instead. Fluid will only pass through the catheter valve when pressure is applied to open the valve. When the catheter is not in use the Groshong™ valve is closed preventing the flow of blood into the catheter. Any blood remaining in the catheter can clot and occlude the lumen. 

    
Further developments of STCVCs have included the Port-a-Cath™  which has a subcutaneous implantable port (replacing the external access hubs) attached to the STCVC, and catheters suitable for dialysis and apheresis procedures.

All staff involved in the care of patients with these catheters should be aware of the basics of Groshong™ catheter care. Apart from the care of the wound, the catheter itself only adds a little to the overall amount of care any patient requires.

In caring for a patient with a Groshong™ catheter, there are many parallels with caring for a traditional CVC. Nurses already familiar with CVCs should need little assistance in adapting skills and knowledge to become competent in the management of a Groshong™ catheter.

All staff intending to perform any aspects of Groshong™ catheter management should first have a basic understanding of central venous catheter care. A period of preceptorship, with subsequent assessment, may be appropriate for some staff who are not experienced in the management of traditional CVCs

To reduce the considerable risk of infection Groshong™ catheters need to be inserted in a clean environment, using an optimum aseptic technique, such as theatre. [4] In Salisbury District Hospital they are usually inserted in room 7 in the Department of Clinical Radiology. Patients are given local anaesthetic and sedation. As for any minor surgery, post insertion, the patient will require recovery from the sedation and observation for any complications.

The procedure is usually done as a day case, the patient attending x-ray, early morning, and recovering on a ward appropriate to the overall care of the patient; Haematology and Oncology patients will normally recovered on The Pembroke Suite (Haematology and Oncology day unit) or Day surgery. The most serious potential risks associated central line insertions of this type are haemorrhage and pneumothorax. If the patient experiences any breathlessness, chest pain or palpitations then a chest x-ray should be performed before the catheter is used, to ensure that no pneumothorax has developed.

If the subclavian approach is used for line insertion there is a greater risk of a pneumothorax, consequently a check x-ray should be performed post insertion to rule out any pneumothorax. In Salisbury the preferred approach is via an ultrasound-guided jugular venous puncture, which carries a very low risk of a pneumothorax as a complication, consequently no post insertion x-ray is normally required

1.2 Aim/purpose

These guidelines for STCVCs are intended for staff caring for patients with Groshong™ catheters. They aim to provide staff with the skills and knowledge to enable them to safely use and care for the catheter.

Four aspects of STCVC care are described: care of a patient having a line inserted; cleaning and dressing the wounds; accessing and flushing the line; and finally unblocking the line. Furthermore they are also intended to be used to assist patients develop the necessary skills and knowledge to enable them to care for their catheters whilst at home.

Care of other STCVCs such as Hickman™, and Apheresis STCVCs is very similar to Groshongs. The majority of care of these lines can be guided by using these guidelines, though the manufacturers recommend the use of heparin solutions for the final flushing of Hickman catheters please see the guidelines which accompany these devices for further details. The Port-a-Cath™ is accessed using a special needle and consequently warrants it's own set of guidelines.

In line with NMC (Nursing Midwifery and Council) guidelines, [13] there must be a current and appropriate plan of care for patients with a Groshong™ catheter. The plan must incorporate ongoing evaluation, reassessment of care and evidence that relevant interventions and observations have been communicated to appropriate members of the multidisciplinary team.

Within this Trust the majority of patients with Groshong™ catheters are likely to be those with a malignancy receiving intravenous (IV) cytotoxic chemotherapy. Other common uses include long term administration of TPN (Total Parenteral Nutrition) and Intravenous Antibiotics. Groshong™ catheters are suitable for all intravenous therapy; particularly those patients who require intermittent or intravenous therapy over a period of greater than a month or continuous IV therapy and are likely to require repeated venepuncture.

The BCSH (British Committee for Standards in Haematology) guideline for central venous catheters 7offers four indications for catheter placement:

  1. When venous access is poor.

  2. Prolonged IV therapy (intravenous chemotherapy or TPN)

  3. When IV therapy involves venous sclerosants.

  4. When ambulatory chemotherapy is to be given as an outpatient.

The manufacturer of Groshong™ catheters states that the line is suitable for blood sampling and all intravenous therapies [5] including:

  • Administration of all blood products and simple hydration

  • Administration of TPN and other hyperosmolar solutions

  • Parenteral antibiotic therapy and continuous drug infusions

  • Administration of vesicant chemotherapy

1.3 Exceptions/ contraindications

It is therefore recommended that these guidelines be adhered to at all times. The Bard promotional and product literature for the Groshong™ catheter together with the available recent research has been used to produce these guidelines.

Although there are many similarities between traditional CVCs and STCVCs, staff caring for a patient with a traditional CVC should refer to the guidelines for care of CVCs. STCVCs other than Groshong™ catheters are, however, unlikely to require care that is substantially different from a Groshong™. The nurse caring for a patient with an STCVC catheter produced by another company can base their care on these guidelines. They should however make every effort to ensure that they are aware of any variance in the care requirements of the product before attempting to use the catheter.

If there are any major changes in the specification or maintenance requirements of Bard Groshong™ catheters, the authors of these guidelines will endeavour to disseminate this information and update these guidelines as soon as is practicably possible. In any event these guidelines will be reviewed within three years of their publication.

1.4 Options

Should the patient have an STCVC other than a Groshong™ and there be no literature available for guidance of care the following personnel may be contacted for advice:

Lead Nurse for Oncology and Haematology

Bleep 3127

Haematology Clinical Nurse Specialist

Bleep 2044

Ward staff, Pembroke Suite

ext. 3157

Ward staff, Pembroke Ward

ext. 3181

Or the patient's consultant

Via switchboard or their Bleep

top

2. Clinical Management

2.1 Preparing patient for insertion and recovery post insertion

The X-ray department will contact outpatients giving instructions on how to prepare and what time to attend. The X-ray department will arrange a bed for the patient to recover in.

Inpatient wards should ensure that the patient notes are available and liase with the X-ray department to confirm the time of line insertion. In-patients should be prepared for STCVC insertion on the ward.

2.1.1 Staff

Any member of staff (registered or untrained) who is competent and confident in preparing and recovering patients for minor surgery can perform these aspects of care.

2.1.2 Equipment

Patient in a theatre gown

Two name bands with correct patient details

Medical notes

2.1.3 Method/procedure

Consent forms are usually completed in the x-ray department, though all patients should ideally have had the procedure fully explained to them prior to arrival at x-ray. As sedation is given to relax the patient fully during insertion day case patients must be told that they will unable to drive home following placement of the catheter.

The following pre-insertion care should be followed when the patient is an in-patient. If the patient is attending as a day case x-ray will advise the patient on what time to attend and how long to starve for.

Pre insertion care

Intervention

Rationale

Ensure patient is wearing two name bands, is in a gown and that notes are available

Safety of patient

Starve patient for 4 hours prior to x-ray appointment

Reduce risk of patient vomiting and aspirating during sedation

Ensure that TPR, BP and O2 saturation have been recorded

Baseline recordings in case of later problems.

Escort patient to x-ray once called for

Safe and prompt delivery

Post insertion care

If required by x-ray, escort patient from x-ray once called for

Safe and prompt return

Get full hand over from x-ray staff

Ensure that you are aware of any problems, or special care that may be required.

Ensure that patient is regularly observed and is given assistance if required

Until the effects of the sedation have fully worn off the patient may well be still quite drowsy and disorientated.

Do TPR, BP and O2 saturation and repeat every 30 minutes on three occasions (or longer or more frequently if deemed appropriate).

Detect any signs of shock, haemorrhage or breathing difficulties

Clean hands thoroughly according to Trust hand hygiene policy

Prevent introduction of infection

Observe both wound dressings and tunnel

To detect any haemorrhage

Ensure that patient is written up for analgesia and enquire about discomfort. Observe patient for any non-verbal signs of pain.

Although just a minor op, patients often experience significant discomfort for several days post insertion.

All care is documented and evaluated

Continuity of care. NMC/UKCC guidelines on records and record keeping

2.1.4 Potential complications/ Risk Management

From the insertion

Haemorrhage, haematoma, pleural effusion, cardiac tamponade, infection, pneumothorax, haemothorax, misplacement, air embolism and Millwheel murmur [6]

From the sedation

Respiratory depression, drowsiness, lack of co-ordination, confusion [14]

2.1.5 After care

Patients can often be a little disorientated or confused post insertion, they may not remember having the line put in due to the sedation. Following sedation patients should not attempt to drive a car or use any potentially dangerous machinery.

Patients should be discouraged from excessive movement of the shoulder, to lessen bruising; they will usually experience discomfort around the catheter and their shoulder for a few days, and possibly up to a week.[6] The pain is normally well controlled with oral analgesics such as Paracetamol, Dihydrocodeine, or similar. Subcutaneous, IM or IV analgesics are rarely required. If any significant discomfort persists beyond a week or if oral analgesics fail to control the discomfort medical advice should be sought.

The dressing should left alone and intact for 24 hours, unless there is good reason to remove it or change it.

A pneumothorax is a very unlikely, though possible, event when the line is inserted via the jugular vein. It is might more likely to occur following insertion via the subclavian vein. In Salisbury the lines are nearly always inserted via the jugular vein, however should the patient develop any chest pain or breathlessness, a pneumothorax should be suspected and medical assistance called for immediately.

2.2 Dressing and cleaning the Groshong™ catheter exit site

2.2.1 Staff

Any member of staff (registered or untrained who is competent and confident in basic wound care can perform these aspects of care.

2.2.2 Equipment

Clean dressing trolley or tray.

  1. Sterile Gloves and Medium sterile dressing pack

  2. Alcoholic 2% Chlorhexidine swabs

  3. Transparent semi-permeable dressing

  4. Adhesive dressing tape and/or fixing device e.g. Micropore or Skin Fix™

  5. Sterile Gauze or non-adherent dressing if required

  6. Sterile microbiology swab if infection suspected

2.2.3 Method/procedure

+TSP:   Transparent Semi-Permeable dressing e.g. Tegaderm or Opsite. Those allergic to the adhesive used in TSPs should use an adhesive tape and gauze.

Intervention

Rationale

Principles of asepsis must be maintained, the dressing should be performed wearing sterile gloves

To prevent introduction of infection

Ensure the patient understands the procedure

Maintain patient's co-operation

Change dressing only as required, daily for gauze, weekly for transparent semi-permeable dressing

To prevent introduction of infection

Observe wound for any redness, swelling or discharge

To detect early signs of infection

Send swab if signs of infection (erythema, pain or exudate are present

Early identification of pathogens

Wash hands thoroughly according to Trust policy before touching the dressing, wound or skin tunnel

Prevent introduction of infection

Open the dressing pack and arrange equipment on the sterile inner wrap.

Have all you equipment in one place and minimise the risk of infection

Pour one capful of alcoholic Chlorhexidine solution on to the gauze

Only a small amount is required

Don the sterile gloves and place sterile towel under the catheter access ports

Provide sterile field in which to work

Clean skin I inch of skin around exit site and first 1 inch (2.5cm) of the line with 2%Chlorhexidine swabs

Reduce bacterial skin flora Maximise disinfectant action

If required apply transparent semi-permeable dressing +/- gauze or non-adherent  dressing

Observation of wound/provide effective barrier

Dispose of equipment safely and appropriately

Maintain infection control.

All care is documented and evaluated

Continuity of care. NMC guidelines on records and record keeping

For the first week the exit site should be cleaned and dressed daily, each time the dressing is lifted to view the exit site or when the gauze becomes soiled or wet. Gauze or a non-adherent dressing, held down with tape or a transparent semi-permeable dressing, is the most suitable covering.[15],[11] This is so that any exudate or blood is absorbed and the wound can be protected from any source of infection.

After a week or once there is no bleeding, a transparent semi-permeable dressing alone can be used and left for a week. After two to three weeks once the line is established a dressing can be dispensed with, provided the wound is clean and free from any exudate. [8],[16],[17] If the patient prefers a dressing covering the exit wound a transparent semi-permeable dressing is preferable as this allows the wound to be observed without disturbing the dressing. In addition, they do not need to be changed daily, will last a week and are associated with fewer exit site infections. [15]

The entry site (neck wound) usually heals very quickly, the dressing from x-ray can be left intact for two or three days, then removed and the wound cleaned. If the patient desires, or there is some weeping from the wound, a small sticking plaster can be placed to stop the suture catching on the patent's clothes. The suture can be removed after 5-7days.

If there is no dressing the exit site wound should be cleaned with alcoholic 2% Chlorhexidine swabs [4],[15],[18] to reduce the bacterial flora around the exit site; the subcutaneous cuff provides a barrier to the entry of bacteria. With an intact transparent dressing the wound needs cleaning weekly. Any dressing, which becomes damaged so as to impair its ability to protect the wound, should be replaced immediately. If an infection is suspected then a wound swab should be sent to microbiology and the patient's doctor should be informed.

The suture at the entry site can be removed after 7-10 days. [7],[8] Exit site sutures should remain in place for at least three weeks. If not infected the suture can remain in until it falls out; this will help to prevent the line falling out. If the sutures appear to have become infected then they should be removed straight away, a wound swab taken and the patient's doctor informed. If the exit site sutures are removed before 3 weeks it may be appropriate to replace the sutures with Steri strips™ to provide additional support to the line. Beyond 3 weeks there should be no reason for using Steri-strips to further secure the line as the cuff will secure the catheter.

In addition the line should be looped further secured with an adhesive fixing device such as Skin Fix™ or a piece of dressing tape e.g. Micropore. The aim is if the Groshong™ is accidentally pulled the loop, tape or device will yield rather than pulling directly on the catheter and the wound itself.

2.2.4 Potential complications/ Risk Management

Groshong™ catheters are most likely to have problems within the first two weeks: infection or bleeding at the exit site is most likely. Other complications include catheter fracture, puncture, and dislodgement.

Groshong™ catheters require similar considerations, as traditional CVCs. Complications are unlikely to arise during dressing the exit site. Infection is the most likely long-term complication 20 and is the result of poor dressing or insertion technique. [4] Exit site infection if left unchecked may lead to a tunnel infection, bacteraemia and septicaemia. A persistently infected line may either fall out or require removal as the only way of resolving the patient's infection. Staff should observe the exit wound and the course of the tunnel for any exudate, erythema, ulceration, inflammation and pain, which may indicate an infection.

Scissors and scalpel blades should not be brought into contact with the catheter unless removing sutures. The catheter can easily be cut or punctured. Pulling the catheter may lead to catheter dislodgement. Infection, damage and dislodgement of the catheter can all lead to the catheter being removed prematurely before treatment has been completed.

2.2.5 After care

A minimum of after care should be necessary if no infection is suspected. Once the cleaning and/or dressing is completed the catheter should ideally then be formed into a loop and further secured with tape or a dedicated securing device. The aim being, if the Groshong™ is accidentally pulled the loop, tape or device will yield rather than pulling directly on the catheter and the wound itself.

Patients should be encouraged to report any temperature they may develop whilst the line is in place as well as any pain, irritation, swelling, or other discomfort associated with the catheter.

2.3 Clinical Management-Flushing the Groshong™ catheter

(Accessing for blood sampling or administering IV boluses or infusion and changing the injection caps)

2.3.1 Staff

Staff without IV training, including phlebotomists and HCSWs can also use these catheters for blood sampling under the direct supervision of a suitably trained registered nurse. Only those registered nurses that are IV trained should administer IV bolus or infusion therapies.

2.3.2 Equipment

Clean dressing trolley or tray.

Sterile Gloves and Medium sterile dressing pack

Alcoholic 2% Chlorhexidine swabs

For each lumen:

Empty10ml syringe

10ml syringe filled with 0.9% Sodium Chloride for injection

Vacutainer blood sampling equipment if required: Bottles, luer adapter and holder.

IV boluses if required, and at least 5ml of 0.9% Sodium Chloride (or other appropriate fluid) for injection to flush between each drug and 10ml 0.9% Sodium Chloride as a final flush

If the line does not have Posiflow™ (or similar needle-less bung system), then a blue needle (21 gauge) will be required for each syringe used to access each lumen

IV infusion and giving set if required

Two Posiflow™ injection caps if they require changing.

2.3.3 Method/procedure

Intervention

Rationale

Ensure the patient understands the procedure

Maintain patient's co-operation

Principles of asepsis must be maintained

To prevent introduction of infection

Clean hands thoroughly according to Trust hand hygiene policy

Prevent introduction of infection

Open the dressing pack and arrange equipment on the sterile inner wrap.

Have all you equipment in one place and minimise the risk of infection

Don the sterile gloves and place sterile towel under the access ports of the Groshong™ catheter

Provide sterile field in which to work

Clean bungs with 2% Chlorhexidine swabs and allow to dry.

Remove any potential source of infection

Attach empty 10ml syringe and withdraw 10ml of blood and discard

If blood cannot be aspirated please follow the flow chart

Establish patency. Remove contents of lumen which may harbour infection, or affect any blood specimens

As per prescription or pathology request form

Flush catheter with at least 10ml of 0.9% Sodium Chloride

Establish patency of the lumen. Ensure no blood or drugs that may cause blockage of lumen are left in the catheter.

Attach infusion if required, setting it at the prescribed rate

As per prescription

Dispose of equipment safely and appropriately

Maintain infection control and prevent any needle stick injury.

All care is documented and evaluated

Continuity of care. UKCC guidelines on records and record keeping

The injection caps require changing regularly; every 100 actions [43] according to the manufacturer, this could take a year if the line is only accessed weekly. To ensure that the caps get changed regularly the following should be used as a guideline; outpatients should have the caps changed once a month, inpatients weekly.

2.3.4 Potential complications/ Risk Management

Groshong™ catheters require similar considerations, as traditional CVCs. Complications are unlikely to arise during accessing or flushing the catheter if care is taken. Complications associated with these aspects of care include infection, rupture of the catheter, thrombus formation, complete or partial blockage of the lumen, dislodgement of the catheter and air embolism.

Bard only recommends the use of 0.9% Sodium Chloride to regularly flush a Groshong™ catheter. The valve prevents the flow of blood into the catheter and should not need instilling with any heparin to prevent any clots forming. [5] As with other vascular access devices clots do still form in a Groshong™ catheter [20] and many believe that heparin should be used in the maintenance of Groshong™ catheters. [21],[22]

Certain drugs require flushing with fluids other than 0.9% Sodium Chloride, for example cyclizine is not compatible with 0.9% Sodium Chloride so water for injection should be used, and Amphotericin is only compatible with 5% glucose . On such occasions before using a fluid other than 0.9% Sodium Chloride, the nurse should ensure that an appropriate prescription is present on the patient's drug chart.

When flushing a Groshong™ catheter (or any IV device) care should be taken, if there is any obstruction of the lumen high pressures can develop which can cause a puncture in the line. If this damage occurs in the portion of the catheter which is outside the patient it may be possible to repair it, if the damage occurs in the tunnel or vein the line may need to be removed and replaced. The smaller the bore of the syringe, the more likely a high pressure will develop; 1 to 5ml syringes in particular can cause a high pressure to develop. A syringe no smaller than 10ml should be used to establish catheter patency. [5],[6] Once patency is confirmed any size syringe can be used to administer drugs or flushes, as long as undue resistance is not felt.

2.3.5 Difficulties in aspirating or flushing the line

If you are unable to draw out any blood from a line placed in a jugular vein this could be because the line is kinked (and occluded) where it bends as it enters the jugular. If the patient turns their head away from the entry site wound this will usually relieve the kinking and allow blood to be aspirated.

In a line placed in the subclavian vein a similar phenomenon, "pinch-off", occurs. This develops when the line is compressed between the first rib and the clavicle, causing intermittent occlusion when administering or aspirating. Raising the arm or bringing the shoulder forward will usually relieve this. If this fails, try to flush the line gently with the 1-2ml of 0.9% Sodium Chloride, there may be a little resistance at first, but keep pushing gently. If this fails it is worth trying to rapidly alternately push and pull on the syringe this sometimes can unblock the lumen of the line, Do not try to force 0.9% Sodium Chloride into the line as it can be damaged if too great a force is applied.

If a small amount of Sodium Chloride is aspirated, but then no more there could well be some debris in the Posiflow™ cap, this should be replaced and then another attempt should be made to aspirate the line.

If you are still unable to inject any 0.9% Sodium Chloride the line may well be blocked and require unblocking (for details see section 2d).

Please use the flow chart to try to get the line to allow you to aspirate blood from it.

2.3.6 Difficulties in aspirating or flushing the Groshong

There are several reasons why it may not be possible to withdraw blood from the catheter; the most likely reasons include the following:

  1. Fibrin sheath over the Groshong™ valve

  2. Blood clot or precipitated drugs in the catheter lumen

  3. Debris blocking the Posiflow™ cap

  4. Debris blocking the Groshong™ valve

Ensuring the line is flushed properly after each use should reduce the risk of a withdrawal occlusion, because of b, c or d. A fibrin sheath is an inevitable consequence of a central venous catheter.

2.3.7 Persistent Withdrawal Occlusion

PWO (Persistent withdrawal occlusion) occurs when fluid can be infused via the catheter, but no blood can be aspirated. [45] The most likely cause of this is a fibrin sheath over the catheter valve. Other causes of PWO include thrombosis within the lumen of the catheter, catheter malposition due to kinking or the line having been partially pulled out of position, and the vein.

The presence of a fibrin sheath or another cause of PWO can only be confirmed using a venogram. [46]

Fibrin sheaths on central venous catheters have been associated with the extravasation of cytotoxics. [47],[48]

The only 100% guarantee that the lumen is correctly placed in a vein is if you can draw blood back from the lumen. If you cannot draw blood back you cannot be sure that the line is correctly placed and consequently infusing anything down the line may result in extravasation of the fluid.

Once radiological confirmation of a fibrin sheath has been achieved instillation of Urokinase should be used initially to re-establish catheter patency (see section 2d). [46] If this fails then a second instillation of Urokinase can be used.

Should this fail there are other methods that can be used to try to restore the catheter, though they should only be used after discussion with the patient's consultant and a Radiology consultant. An infusion of Urokinase (40,000 units/hour over 6 hours) has been shown to restore patency in 15 out of 17 catheters (with out a malposition) at the first attempt and the other two were successful at the second attempt. [49] Radiological intervention using a snare can also remove the fibrin sheath though it does add extra risk to the patient.

As Urokinase used in this manner will have a systemic thrombolytic effect, an infusion of Urokinase should only be used after discussion with the patient's consultant.

2.3.8 What to do if you cannot aspirate blood from a PICC or Groshong STCVC

2.3.9 After care

Patients should not usually require any care following accessing or flushing the catheter, apart from any care specifically related to any IV medications that have been given.

Staff should however be particularly aware of any patients who may have an infection in the lumen of the catheter. This is most likely in neutropenic patients, those who have not had their catheters flushed for some time or when the patient has had the line in-situ for an extended period. There is always a risk of inoculating the patient with the infected contents of the lumen. In such an instance the patient may develop pyrexia and rigors at any time following flushing the catheter. If an infection is suspected the patient's doctor should be informed, and blood cultures should be taken from all lumens of the catheter.

Any patient developing rigors following flushing of their catheter should be considered at risk of developing septic shock, consequently appropriate measures should be taken to observe, manage and treat for septic shock.

2.4 Clinical Management-Unblocking the Groshong™ catheter

(Re-establish Patency of Lumen, by instillation of Urokinase) and Persistent Withdrawal Occlusion (PWO) due to fibrin sheath

2.4.1 Staff

Only those registered nurses that are IV trained and competent and confident in administering IVs through CVCs or STCVCs should perform these aspects of care. Staff without IV training should not perform these aspects of care.

2.4.2 Equipment

To Instil Urokinase

Clean dressing trolley or tray.

Sterile Gloves and Medium sterile dressing pack

Alcoloic 2% Chlorhexidine swabs

For each lumen:

5,000 IU Urokinase

2ml Water for injection

2ml syringe with 21 gauge needle

Empty 2ml syringe

3-way tap

Sterile injection cap

To remove Urokinase and Re-establish Patency

Clean dressing trolley or tray.

Sterile Gloves and Medium sterile dressing pack

Alcoholic 2% Chlorhexidine swabs

For each lumen:

10ml 0.9% Sodium Chloride for injection

Two 10ml syringes

Sterile injection cap

2.4.3 Method/procedure

2.4.3.1 To Instil Urokinase

Intervention

Rationale

Ensure the patient understands the procedure

Maintain patient's co-operation

Principles of asepsis must be maintained

To prevent introduction of infection

Clean hands thoroughly according to Trust hand hygiene policy

Prevent introduction of infection

Remove bung and clean hub with Alcoholic 2% Chlorhexidine swabs

Remove any potential source of infection

Reconstitute Urokinase with 2ml water for injection and fill 2ml syringe attach this and empty 2ml syringe to 3-way tap and attach to the affected lumen

Withdraw as much as possible from the line with the empty 2ml syringe

Create vacuum

Switch 3-way tap to Urokinase allowing vacuum to draw the Urokinase into the lumen of the catheter

Ensure correct volume of Urokinase is instilled within the lumen of the catheter.

Remove 3-way tap and syringes, attach new bung

Dispose of equipment safely and appropriately

Maintain infection control and prevent any needle stick injury.

Leave Urokinase in-situ for at least 1 hour, preferably 2 hours

Give enzyme enough time to fully break down any debris.

2.4.3.2 To remove Urokinase and Re-establish Patency

Intervention

Rationale

Ensure the patient understands the procedure

Maintain patient's co-operation

Principles of asepsis must be maintained

To prevent introduction of infection

Clean hands thoroughly according to Trust hand hygiene policy

Prevent introduction of infection

Remove bung and clean hub with Alcoholic 2% Chlorhexidine swabs

Bung may hamper removal of debris within the lumen. Remove any potential source of infection

Attach empty 10ml syringe to hub, withdraw at least 10ml if possible, then discard syringe

Remove Urokinase and all debris in lumen

Attach 10ml syringe filled with 0.9% Sodium Chloride to hub, and flush the lumen with all 10 ml

Ensure that only 0.9% Sodium Chloride remains in the line

Remove 10ml syringe and attach new bung

All care is documented and evaluated

Continuity of care. NMC guidelines on records and record keeping

2.4.4 Potential complications/ Risk Management

As previously stated when flushing a Groshong™ catheter a small-bore syringe (1 to 5ml) can cause high pressures to develop within any IV device. Whilst trying to unblock a STCVC only 10ml syringes should be used to push any liquid into the lumen of the catheter. Urokinase is a suitable enzyme for breaking down fibrin or clots, which may have caused and occlusion of the lumen. [7],[1],[23],[24] The 3-way tap method of instilling Urokinase [8]removes the need to push the solution in to the catheter and lessens the risk of creating high pressures within the catheter which may lead to catheter damage. Once patency is re-established any size syringe can be used to administer drugs or flushes as long as undue resistance is not felt.

If the line is still blocked repeating the instillation of Urokinase may prove fruitful, however it may have to be accepted that that use of the blocked lumen is no longer possible.

2.4.5 After care

Patients should not usually require any special care following unblocking of the catheter.

Staff should however be particularly aware of any patients who may have an infection in the lumen of the catheter. This is most likely in neutropenic patients, those who have not had their catheters flushed for some time or when the patient has had the line in-situ for an extended period. There is always a risk of inoculating the patient with the infected contents of the lumen. In such an instance the patient may develop pyrexia and rigors at any time following flushing the catheter. If an infection is suspected the patient's doctor should be informed, and blood cultures should be taken from all lumens of the catheter.

Any patient developing rigors following flushing of their catheter should be considered at risk of developing septic shock, consequently appropriate measures should be taken to observe, manage and treat for septic shock.

Urokinase can only help to clear an occlusion due to build up of fibrin or blood in the catheter. If the occlusion is due to lipid deposition from TPN then 70% alcohol is more appropriate, 0.1N Hydrochloric acid should be used when Calcium and Phosphate precipitation is suspected, and Sodium Bicarbonate is suitable for Alkaline drugs which have precipitated in the lumen. [5]

2.5 Clinical Management-Additional Considerations and General Care

Patients need not allow the line to affect their lifestyle significantly. It should only affect them minimally, in respect of their treatment it should make life easier. Whilst the stitches are in situ the patient should avoid getting the wound wet, a transparent semi permeable dressing will achieve this. Within twenty-one days, following insertion, the cuff should have fully adhered to the tissues creating a physical barrier; they can then shower with or without a dressing. If there is no dressing then the wound should be cleaned after the shower. An intact transparent semi permeable dressing can stay in place whilst showering and need not be replaced. [10]

Whether having a shower or bath it is best not to allow the end of the line from getting wet, or dangling in the bath. A small plastic bag over the end kept in place with a rubber band will do this.

Patients should be advised not go swimming in a pool, river or the sea due to the risk of infection. Once the line is out and the wound healed they can go swimming again. Other forms of exercise should pose little risk to the line. In the first week or so after the line has been put in the shoulder and chest may be too sore. Contact sports such as martial arts, rugby, wrestling are probably best avoided as the line may get pulled. Less vigorous activities such as walking, dancing, cycling, running and tennis should pose little if any risk to the line.

Initially the soreness in the shoulder, neck and chest may mean that patients cannot twist their necks adequately to drive safely, so they should avoid driving until the pain has subsided. They may want to contact their motor insurer as their disease or treatment may affect their liabilities and benefits. The line may be uncomfortable as a result of the seat belt pulling or rubbing on your chest. They should be advised not to interfere with the correct function of the seat belt by fitting any comfort devices that are not recommended by your vehicle manufacturer. Extra gauze over the wound may help, but the Department of the Environment, Transport and the Regions does not advise using padding, or any other modification, to improve seat belt comfort. [25]

Patients can also apply for a "Certificate of Exemption from Compulsory Seat Belt Wearing", from their GP or consultant, if driving with a line is too problematic. [25]

2.6 Catheter removal

Indications for catheter removal:

  1. sepsis,

  2. permanent blockage,

  3. axillary or other venous thrombosis attributable to the line,

  4. irreparable damage to the catheter including that caused by pinch off syndrome,

  5. the end of treatment.

The medical staff will usually remove Groshong lines; one of two methods is used.

Cut down

An incision is made in the skin over the cuff; the subcutaneous tissues around the cuff are released allowing the line to be easily pulled out. A suture will be required to close the wound in this instance, which can be removed 5-7 days later.

Simple traction

The line is gripped firmly and pulled out. The line needs to be checked to ensure that it has come out complete, the cuff may remain in situ, this is thought to be of no significance and may be left in place. [8]

Since the vein closes after the catheter is removed only minimal bleeding occurs at the entry site, although there may be some slight bleeding at the exit site because of the passage of the cuff.

However the line is removed local anaesthetic is used, there should be little if any discomfort as the line is removed and only a minor "bruised" feeling afterwards. The patient should stay long enough to ensure that no further bleeding is taking place before they get up and resume their normal activities.

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3. Patient Information

3.1 Sending the patient home

Patient education is an essential aspect of STCVC care. Educational packages should include practical demonstrations and a clear and succinct handout. [8] Ensuring patient's have a good understanding of the care of their catheters and being involved in the care of their catheters at home, [8],[7] are vital parts of the continuing the care once the patient is outside the confines of the hospital environment.

An information sheet is included, as an appendix explaining what a Groshong™ is, how to look after it, how to flush it and what to do if anything goes wrong.

Section 2 of these guidelines can be given to community nursing staff by way of guidance on care of Groshong lines

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4. Audit

4.1 Audit Indicators

An aspect of patient care

Percentage

Exceptions

Definitions

An aspect of patient care - measurable aspect of care that needs to be fulfilled

The frequency that it should happen. Either 100% for 'all' or 0% for 'none'.

For example due to clinical condition

1. Define any terms

2. the source of this information e.g. patient notes, observation

1 Nursing staff caring for Groshongs will have access to, this protocol

100%

None

Available on ICID

2 Nursing staff on caring Pembroke unit will be aware of how to get this protocol

100%

None

Ask all qualified nursing staff on Pembroke unit

3 Care of Groshongs documented and reviewed

100%

None

Patient notes

4 Patients will have been advised on basic aspects of Groshong care

100%

None

Ask patients if they have received Patient information sheet

4.2 Audit design

The audit indicators have been designed to simply ensure that the foundations are set for care based on the guidelines. Further audits are appropriate looking at complications or aspects of care such as mechanical phlebitis, use or frequency of dressings

4.3 User involvement

The patient information leaflet has been sent to the Patient Information team who have forwarded the leaflet to the Readership Panel for an independent quality check to ensure it is written in Plain English. Amendments to the information sheet were made in light of suggestions made by the readership panel before publishing a final copy.

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5. Evidence Base

5.1 Sources of information

  1. Harrison, M. (1997) Central Venous Catheters: A Review of the Literature. Nursing Standard 11(27) 43-5

  2. http://www.patent.gov.uk/tm/index.htm

  3. Camp, L, D. (1988) Care of the Groshong Catheter. Oncology Nursing Forum 15 (6) 745-749

  4. Department of Health (2001) Guidelines for Preventing infections Associated with the Insertion and Maintenance of Central Venous Catheters Journal of Hospital Infection47 (Supplement) S47-67

  5. Bard (1994) Groshong C.V. Catheters Nursing Procedure Manual. Bard Access Systems, Salt Lake City Utah

  6. Royal College of Nursing of The United Kingdom Leukaemia and Bone Marrow Transplant Forum (1995) Skin Tunnelled Catheters Guidelines for Care Harrow: Royal College of Nursing

  7. BCSH (1997) BCSH Guidelines on the insertion and Management of Central venous lines. British Journal of Haematology 98 1041-7

  8. Mallet, J. and Dougherty, L. (2000) The Royal Marsden Manual of Clinical Nursing Procedures (5th Edition) Oxford: Blackwell Science  (available at /marsden)

  9. Simcock, L. (2001) The uses of Central Venous Catheters For IV Therapy. Nursing Times 97(18) 34-5

  10. Simcock, L. (2001) Central Venous Catheters: Some common Clinical Questions. Nursing Times 97(19) 34-6

  11. Simcock, L. (2001) Complications of CVCs and Their Nursing management. Nursing Times 97(20) 36-8

  12. Simcock, L. (2001) Managing occlusions in Central Venous Catheters. Nursing Times 97(21) 36-8

  13. NMC (2005) Guidelines for records and record keeping London: Nursing and Midwifery Council (Available at http://www.nmc-uk.org/(cgn2wsnxrrldtb554tb45m45)/aFrameDisplay.aspx?DocumentID=223)

  14. British Medical Association and The Royal Pharmaceutical Society of Great Britain (2005) BNF 49.  London: British Medical Association and The Royal Pharmaceutical Society of Great Britain (Also available at http://www.bnf.org).

  15. Cook, N. (1999) Central Venous Catheters: Preventing Infection and Occlusion. British Journal of Nursing 8(15) 981-9

  16. Morris, P., Grace, S., Glakin, V., Ackers, N., McNamara, G., Seale, T., Nicol, A., Robbins, J. and Green, J (1995) Audit of Skin Tunnelled Catheters in Neutropenic Patients Bone Marrow Transplantation 15 (suppl. 2) 168

  17. Lucas, H. and Attard-Montalto, S. (1996) Central Line Dressings: Study of Infection Rates. Paediatric Nursing 8(6) 21-23

  18. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall MH. epic2: National Evidence-based Guidelines for Preventing Healthcare-associated Infections in NHS Hospitals in England. Journal of Hospital Infection February 2007; 65S: S1-S64

  19. Ray, S., Stacey, R., Imrie, J and Filshie, J (1996) A review of 560 Hickman insertions. Anaesthesia 51(10) 981-5

  20. Horne 3rd, M.K., Mayo, D.J. and Wittes, R.E. (1993) Heparinized 0.9% Sodium Chloride to Flush Groshong Catheters. Journal of Clinical Oncology 11(12) 2458

  21. Mayo, D.J., Helsabeek, C.B. and Horne 3rd, M.K. (1996) Intraluminal Clots in Groshong Catheters. Journal of Vascular Access Devices 1(2) 20-2

  22. Mayo, D.J., Horne 3rd, M.K., Summers, B.L., Pearson, D.C. and Helsabeek, C.B. (1996) The Effects of Heparin Flush on Patency of the Groshong Catheter; A Pilot Study. Oncology Nursing Forum 23(9) 1401-5

  23. Drewett, S. (2000) Complications of Central Venous Catheters: Nursing Care. British Journal of Nursing 9(8) 466-79

  24. Ray, C.E., Shenoy, S.S., McCarthy, P.L., Broderick, K.A. and Kaufman, J.A. (1999) Weekly Prophylactic Urokinase Instillation in Tunnelled Central Venous Access Devices. Journal of Vascular Interventional Radiology 10(10) 1330-4

  25. Advice on Keeping Your Vehicle  and http://www.thinkroadsafety.gov.uk/advice/seatbelts.htm

  26. Sariego, J., Bootorabi, B., Matsumoto, T. and Kerstein, M. (1993) Major long term Complications in 1,422 Permanent Venous Access Devices. The American Journal of Surgery 165(2) 249-51

  27. O'Neill, V.J., Jeffrey Evans, T.R., Preston, J., Moss, J. and Kaye, S.B. (1999) A retrospective Analysis of Hickman line-Associated Complications in Patients With Solid Tumours Undergoing Infusional Chemotherapy. Acta Oncology 38(8) 1103-7

  28. Tolar, B. and Gould, J. R. (1996) The Timing and Sequence of Multiple Device-related Complications in Patients with Long Term Indwelling Groshong Catheters. Cancer 78(6) 1308-13

  29. Newman, K.A., Reed, W.P., Schimpff, S.C., Bustamante, C.I. and Wdae, J.C. (1993) Hickman Catheters in Association with Intensive Cancer Chemotherapy. Supportive Care in Cancer 1, 92-7

  30. Fletcher, S.J. and Bodenham, A.R. (1999) Catheter-Related Sepsis: an Overview-Part 1. British Journal of Intensive Care 9 (2) 46-53

  31. Fletcher, J. (1997) Wound Cleansing. Professional Nurse. 12(11) 793-7

  32. Pearson, M. l. (1996) Hospital Infection Control Practices Advisory Committee: Guideline for Prevention of Intravascular-Device-Related Infections Infection Control and Hospital Epidemiology 17(7) 438-73

  33. Little, K. and Palmer, D (1998) Central Line Exit Sites: Which Dressing? Nursing Standard 12(48) 42-4

  34. Henderson, N. (1997) Central Venous Lines. Nursing Standard 11(42) 49-56

  35. Palmer, D. (1998) Fewer Patients Dislodge Peripheral Intravenous Catheters with Transparent Dressings than with Gauze Dressings. Evidence Based Nursing 1 (3) 81

  36. Pratt, R (2001) Preventing Infections associated with Central venous Catheters. Nursing Times97(15) 36-9

  37. Rowley, S. (2001) Aseptic Non-Touch Technique. Nursing Times 97(7) SVI-VIII

  38. Werlin, S.L., Lausten, R., Jessen, S., Toy, L., Norton, A., Dallman, L., Bender, J., Sabilan, L. and Rutowski, D. (1995) Treatment of Catheter Occlusions with Ethanol and Hydrochloric Acid. Journal of Parentral and Enteral Nutrition 19(5) 416-8

  39. Weatherill, K. (1999) Keeping the Lines Open. Nursing Standard 13(52) 41-2

  40. Docherty, B. (2001) Clinical Practice Review: Central Line Management. Professional Nurse 16(7) 1206

  41. Dougherty, L. (2000) Central Venous Access Devices Nursing Standard 14(43) 45-50

  42. Hadaway, L.C (1998) Major Thrombotic and Non Thrombotic Complications. Loss of Patency. J Intravenous Nurse 1998 Sep;21(5Suppl):S143-S160

  43. http://www.bd.com/infusion/products/posiflow/faq.asp

  44. Mayo, D.J (1998) Administering Urokinase. Nursing98 28(12) 50-2

  45. Gould, J. R, Carloss, H.W. and Skinner, W.L. (1993) Groshong associated Subclavian Venous Thrombosis. The American Journal of Medicine 95(4) 419-23

  46. Gabriel, J (1997) Fibrin Sheaths in vascular access devices. Nursing Times 93(10) 56-7

  47. Mayo, D.J. and Pearson, D.C., (1995) Chemotherapy extravasation: A Consequence of Fibrin Sheath Formation around venous access devices. Oncology Nursing Forum. 22(4) 675-80

  48. Mayo, D.J., (1998) Fibrin Sheath Formation and Chemotherapy extravasation: A Case report. Supportive Care in Cancer 6(1) 51-6

  49. Haire, W.D. and Lieberman, R.P. (1992) Thrombosed Central Venous Catheters: Restoring function with a 6-hour infusion after failure of bolus Urokinase. Journal of Parenteral and Enteral Nutrition. 16(2) 129-132

5.2 Other useful/interesting reading

  1. Abi-Said,.D., Raad,I., Umphrey., Gonzalez, V. et al (1999) Infusion therapy team and dressing changes of Central venous catheters, Infection Control and Hospital Epidemiology; 20 (2) 101-105

  2. Dale, J. (1997) Wound Dressings. Professional Nurse Study Supplement 12(12) S12-14

  3. Gillies D. , O'Riordan, E. , Carr, D., O'Brien, I . , Frost, J ., and Gunning, R. (2003) Central venous catheter dressings: a systematic review Journal of Advanced Nursing 44(6), 623–632

  4. Horne 3rd, M.K. and Mayo, D.J. (1997) Low-Dose Urokinase infusions to treat Fibrinous obstruction of Venous Access Devices in Cancer Patients. Journal of Clinical Oncology 15(7) 2709-14

  5. Lange, B., Weiman, M., Feuer, E., Jakobowski, D.,et al (1997) Impact of changes in catheter management on infectious complications among children with central venous catheters Infection Control and Hospital Epidemiology 18 (5) 326-332

  6. Langgartner, J. Linde, H., Lehn, N., Reng, M., Schölmerich, J., and Glück, T. (2004) Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonisation of central venous catheters Intensive Care Med 30:1081–1088

  7. Keung, Y., Watkins, K., Chen, S., Groshen, S., Silberman, H. and Douer, D (1994) Comparative Study of Infectious Complications of Different Types of Chronic Central venous Access Devices. Cancer 73(11) 3832-37

  8. Lazarus, H. M., Trehan, S., Miller, R.M., Creger, R. J., RaffJ.H. (2000) Multi-Purpose Silastic Dual-Lumen Central venous Catheters For Both Collection and Transplantation of Haematopoietic Progenitor Cells. Bone Marrow Transplant 25(7) 779-85

  9. Parker, L. (1999) IV Devices and related infections: Causes and Complications. British Journal of Nursing 8(22) 1491-7

  10. Reynolds, M.G., Tebbs, S.E. and Elliot, T.S.J. (1997) Do Dressings with Increased permeability reduce the Incidence of Central Venous Catheter Related Sepsis. Intensive and Critical Care Nursing (1997) 13 26-29

  11. Rickard, N (2003) Reducing infections associated with central venous catheters British Journal of Nursing; 12 (5) 274-284

  12. Waghorn, D.J (1994) Intravascular Device Associated Systemic Infections: A 2-Year Analysis of Cases in a District General Hospital. Journal of Hospital Infection. 28, 91-101

  13. Wood, S.S., Nass, J. and Deisch, P (2000) Selection and Implementation of a Transparent Dressing for Central Vascular Access Devices. Nursing Clinics of North America 35(2) 385-93

  14. http://www.accessabilitybybard.co.uk/

5.3 Summary of evidence, review and recommendations

There are presently no national guidelines for STCVC care. There is the useful Bard Accessability web-site their own procedure manual [5] which is very comprehensive and reasonably up to date, as are the guidelines for care produced by the Leukaemia and Bone Marrow Transplant Nursing Forum, [6] but these were published in 1994 and 1995 respectively, so must be considered to be obsolete. The British Committee for Standards in Haematology (BCSH) [7] published their guidelines in 1997; they are only intended to be a resource for those producing local policies and protocols. More recent publications include The Royal Marsden Hospital Manual of Clinical Procedures (5th edition), [8] Department of Health Guidelines for Preventing Infections Associated with the Insertion and Maintenance of Central Venous Catheters, [4] and a series of 4 articles written by Liz Simcock and published in May 2001 in the Nursing Times. [9],[10],[11],[12] These most recent sources together with the BCSH guidelines form much of the basis for these guidelines.

A wide range of sources was accessed in preparing these guidelines. Nursing medical and infection control journals from both the USA and UK. Policies developed by other trusts including The Royal Free Hospital and The Royal Marsden Hospital were included. Promotional and product literature provided by Bard, the manufacturer of Groshong™ lines, and other STCVCs were also used. Senior members of the Oncology and Haematology Nursing Teams, Consultant in Haematology, Oncology and Radiology were also approached to provide input, criticism and advice

The majority of articles reviewed are not centred around care of Groshongs, but CVCs in general or the more common STCVC type the Hickman. As there are many similarities between Groshong catheters and other central venous catheters it makes sense therefore to use articles which are not directly about Groshongs to obtain enough evidence to support interventions and care.

Some of the evidence for care of Groshong catheters seems to be cut and dry other evidence less definite and some simply does not exist. Much care is therefore based on a combination of best available evidence relating to traditional and other CVCs, or is based on current practice (or considered opinion) which appears to be both safe effective and not contradicted by any recent research.

Complications probably affect all STCVCs, even if they do not significantly affect the functioning of the catheter. The Complications of STCVCs are well known and well described. [7],[45]  Clots are believed to occur in all Groshongs, causing a detectable problem in about a third.[15] Infections are probably the most likely and serious of complications of STCVC insertion 4 affecting possibly as many as 57% [29] or as little as 19.4%.[27] Of all the infections over half are bacteraemias, [29] that's almost 6,000 patients in the UK yearly.[43],[30] Exit site infection account for nearly a quarter of these and 7% are tunnel infections. [29]

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Document Owner Roy Dear 
Department
Review Date
Document Status
Revision Number
1.3