Handling a central venous line port

[ddexter]

I have a few doubts lurking in my mind regarding the handling a CV line port during IV administration for which I could not find satisfactory/consistent answers by searching. Hence I'm asking them here.

1. Is hand hygiene and a 'no touch technique' of the ports sufficient or is a sterile glove mandatory prior to every use of the port?
   
2. Is cleaning of the ports with an alcohol/chlorhexidine based antiseptic solution mandatory before every use of the port?
   
3. How can the cap (which has been removed from the port for an IV infusion) of the CV line port kept sterile till the IV infusion gets completed? Is it safe to use it again or a new cap is required after each infusion?
   
4. Is it the usual practice everywhere to have the individual lines (lumens) of the CV line (for example the three lines of a triple lumen catheter) 'dressed' with a sterile gauze pack? Not doing so makes the lumens gets separated in different directions and sometimes they get contaminated by reaching unsterile areas like the hairy chest.
   

[SoldierNurse22, BSN, RN]

Is hand hygiene and a 'no touch technique' of the ports sufficient or is a sterile glove mandatory prior to every use of the port?

I'm assuming you mean for flushing or using an already accessed port with this question...?

Let me put it this way:

Accessing a port is ALWAYS a sterile procedure. (Accessing = inserting the Huber needle through the skin into the port).

Using an already accessed port for a med push (for example) would entail washing your hands, donning gloves, scrubbing the hub of the port, attaching your syringe and injecting the medication per protocol.

Is cleaning of the ports with an alcohol/chlorhexidine based antiseptic solution mandatory before every use of the port?

Yes. And you use an alcohol wipe to scrub the hub before you use it. It's the same as a PIV.

Chlorhexidine is used to prep the skin before accessing a port.

How can the cap (which has been removed from the port for an IV infusion) of the CV line port kept sterile till the IV infusion gets completed? Is it safe to use it again or a new cap is required after each infusion?

Again, the terminology here is kinda fuzzy. By cap, I'm assuming you mean the hub on the end of the port.

The cap/hub is NEVER removed from the port for an infusion. EVER. You don't remove it for lab draws, either. The only time you remove the hub is to change it between infusions (for instance, between blood infusions), between lab draws, when it is visibly soiled or cracked/compromised.

If you are using a cap of some sort that screws onto the end of the hub to protect it, then yes, you should replace it after it is removed.

Is it the usual practice everywhere to have the individual lines (lumens) of the CV line (for example the three lines of a triple lumen catheter) 'dressed' with a sterile gauze pack? Not doing so makes the lumens gets separated in different directions and sometimes they get contaminated by reaching unsterile areas like the hairy chest.

I have never heard of "dressing" the lines with sterile gauze. Ever. With a hub in place, there is no reason that a line should be "dressed" as the hub on the end of the line protects it from exposure to gunk. This makes it difficult to use, wastes supplies and is just entirely unnecessary.

There are, in some hospitals, little green caps that twist onto the hub of a line. They are alcohol impregnated on the inside and they are available to be placed on the end of a line in order to offer extra protection. However, they are by no means necessary and shouldn't be substituted for a good scrubbing of the hub before giving a med.

I sense that you have a poor understanding of what needs to be kept sterile, how a port is protected by a hub and how to handle a CVC in general.

CVC use (aside from accessing/deaccesing) follows many of the same basic principles that guide PIV use. You always scrub the hub before giving a med. The hub protects the line from the "dirt" in the external, unsterile world.

[Corey Narry, MSN, RN, NP]

First, always refer to your hospital or healthcare facility's policy and procedure when caring for patients with central venous catheters. I am 100% certain that every hospital in the nation has a strategy for avoiding Central Line Associated Bloodstream Infections (CLABSI) as the incidence of these have a huge impact on hospital revenue. Medicare and Medicaid will not reimburse hospitals for the additional cost of care from a CLABSI. Incidence of late CLABSI (positive blood cultures more than 5 days after CVC placement) have been associated with poor disinfection of access ports (needleless connectors) during medication administration.

Second, standards are developed from research evidence and these are definitely evolving still. Currently the standards are:

1. Handwashing prior to contact with any part of the central line system is a must.

2. Sterile gloves are not required in handling the central line system except for when cleansing the insertion site and changing the dressing. In that case, a mask should also be worn.

3. Cleaning the access port or needleless connectors with alcohol or chlorhexidine is not only absolutely mandatory but the technique of cleaning is so much more important. The standard is that the port be scrubbed with vigorous friction for 15 seconds (like "juicing an orange"). See: Keeping needleless connectors clean, part 1 : Nursing2013

4. A new cap (or access port) is not required each time it is accessed. However, commercially available barrier cap covers have been studied (see: Curos® Port Protector – The Green Disinfection Cap That Is Making A Difference | Curos). There are studies that support them: http://www.menyhaymedical.com/23.pdf).

5. For your last question, I am not aware of this being standard. Again, the nurse should inspect the entire Central Venous Catheter and where the lumens lie. Are they exposed to oral secretions? is there blood left on the line? Use your judgement and steer these access ports away from contact with possible contaminants. The commercially available cap covers have been quite effective and many hospitals are using them.

A great Powerpoint reference:

http://www.avainfo.org/website/download.asp?id=281140

[ddexter]

@SoldierNurse22

I am sorry if I've been unclear in my question. By 'Central line' I meant a triple lumen catheter inserted into the SVC. I see that you have understood it to be a subcutaneous port accessed via a Huber needle.

Examples: The triple lumen catheter; The triple lumen catheter in place

As you can see, each lumen of the CV line ends in a luer port, to this a valve is connected, followed by a cap.

I gather that all three (hand wash, sterile gloves and scrubbing the luer port) is mandatory before injecting any medication through the port.

Suppose you are giving an infusion over 4-6 hours, you have to remove the blue cap and give the the infusion via the valve/luer port. Once the cap is removed, how is it kept sterile till the infusion ends and is it safe to replace? If it is unsafe to replace, should the valve be left open (although it will not allow backflow)?

I have seen some people wrapping the 3 lumens with a sterile guaze rather then letting them lie like this. That's why I asked. Another thing, at the entry site a biopatch is usually used instead of the guaze as shown in the picture. However this makes daily inspection of the site impossible. What is your stand on this?

[ddexter]

@ juan de la cruz

Your statement that "Hand washing alone is sufficient and sterile gloves are not necessary for administering IV" is contradictory to that of SoldierNurse22.

Thanks for the info on the disposable caps.

[ddexter]

Once again thanks for the responses!

[Corey Narry, MSN, RN, NP]

@ juan de la cruz

Your statement that "Hand washing alone is sufficient and sterile gloves are not necessary for administering IV" is contradictory to that of SoldierNurse22.

Thanks for the info on the disposable caps.

Again, you'll have to refer to your hospital's policy. I've never worked in a hospital where sterile gloves are required when administering IV meds through needleless access ports in central venous lines. It's not standard of care.

Sent from my iPhone using allnurses.com

[Corey Narry, MSN, RN, NP]

Biopatch are impregnated with Chlorhexidine. They are becoming standard of care as well and there are studies that support their use. You could still see skin erythema around them if it exists and they should be replaced when soiled and per your facility's protocol.

http://jac.oxfordjournals.org/content/58/2/281.full

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[SoldierNurse22, BSN, RN]

Most of the links you included didn't open for me. As best I can tell you, sterile gloves are not needed with PICCs/ports/Hickmans etc unless you are actually inserting a line or changing a dressing.

Does the end hub on the PICC have a luer option? Because if it's a closed system, you don't need to add anything on the end. Yes, the caps with alcohol impregnated pads in the ends have been shown to be effective in reducing exposure to germs, but they aren't necessary if you're doing a good scrub.

As long as the end of this cap isn't open to air (and as best I can tell, it isn't), there is nothing wrong with letting them lie out like they are in this photo http://drugline.org/img/term/venous-catheter-central-15887_1.jpg.

If you have an infusion flowing into a PICC/port, the infusion should be sterile. After you scrub the hub and connect the tubing, you have a closed sterile system (bag to tubing to patient) and you don't need to worry about protecting the patient's line while the infusing is going.

Biopatches have been shown to greatly reduce infection when used properly. With a biopatch, you don't need to change the dressing but every 7 days unless you are seeing s/s of infection. With gauze, most institutions require a dressing change every 48-72 hours. With nothing in place, some places require a dressing change every 24 hours.

Yes, it is difficult to directly visualize the actual insertion site with a biopatch. But if there are s/s of infection, you can see it around the patch (redness, oozing, pain, etc). I have spotted infections budding around biopatches without difficulty.

End story, using a Biopatch is a safe, effective way of reducing infection risk, even though you can't directly visualize the site. Without it, you are exposing that area to infection twice as often as you would with the actual patch. Repeated dressing changes are a huge risk for infection simply because it exposes the site to air. Biopatches (chlorhexidine impregnated) deliver a constant amount of antiseptic to the site of insertion for 7 days and decrease the need to change the dressing. We used them on our oncology patients, one of the most immunocompromised groups of people out there, with great results.

[SoldierNurse22, BSN, RN]

@ juan de la cruz

Your statement that "Hand washing alone is sufficient and sterile gloves are not necessary for administering IV" is contradictory to that of SoldierNurse22.

Thanks for the info on the disposable caps.

Not sterile gloves--just regular clean gloves. Sterile gloves are needed for changing a dressing or accessing a port. Clean gloves are used when pushing meds.

[ParvulusPuella]

When you've seen the ends wrapped with gauze, are you sure its not a dialysis catheter? Those usually are dressed in some fashion like that, and they are not meant for access other than dialysis unless you have a special order, and even then its usually just for the pigtail catheter. Not all dialysis caths have the pigtail.

[Corey Narry, MSN, RN, NP]

Not sterile gloves--just regular clean gloves. Sterile gloves are needed for changing a dressing or accessing a port. Clean gloves are used when pushing meds.

I agree with you and know what you mean. However, for the OP's benefit "accessing a port" in your statement means inserting a Huber Needle through an implanted Medaport or Infusaport. We should make that distinction so as not to cause confusion.