• Neck insertion sutures should be removed after 7 days (Hickman lines only);
• Guidance regarding suture removal at the catheter must be sought from the specialist centre where the line was inserted;
• Never remove sutures from non-tunnelled central venous catheters (central lines) unless the line is being removed.

Children and young people who have Hickman and PICC lines inserted must have their site dressing removed 24 hours following the insertion of the line to allow the wound site to be checked. The exit site should only be swabbed if there are clinical signs of infection, e.g. inflammation or pus.

Note: Immunocompromised children and those undergoing chemotherapy may not show external signs of infection around their exit site due to lack of circulating white blood cells or neutropenia. A raised temperature or discomfort may be the only indicator of infection.

• The line must be kept clean and dry around the exit site;
• The dressing on Hickman lines, PICCs and non-tunnelled central lines must be changed on a weekly basis, or when soiled or insecure;
• An antimicrobial disc dressing should be used and changed weekly on PICC and Hickman lines (they are not routinely used on Portacaths)
• Some PICC/Hickman lines may require a securement device such as a SecurAcath or Griplock. If these securement devices are not available then secure line with Broad steri strips. Discussion should be made about when these securement devices get changed.
• Needle free device should be changed twice a week. If they are damaged they must be replaced immediately to ensure line integrity and safety.

Equipment required:

• cleaned trolley or tray
• sterile dressing pack
• sterile swab for culture (only if signs of infection for example, redness and heat, pus or foul smelling exudate)
• a pair of correct size sterile surgical gloves
• a pair of non sterile gloves
• plastic apron for personal protection
• chlorhexadine 2% in 70% alcohol (Chloraprep) swab. Note: 0.5% chlorhexadine in 70% alcohol must be used in infants under 8 weeks old)
• semi permeable dressing
• disposal bag
• antiseptic hand hygiene product as per NHS Ayrshire & Arran Infection Control Guideline
• chlorhexadine gluconate 2% or chlorhexadine gluconate BP 2% & isopropyl alcohol 70% wipe (0.5% chlorhexadine with 70% alcohol must be used in infants under 8 weeks old)
• antimicrobial chlorhexadine sponge disc dressing (not required for a Portocath)

Procedure:

1. Explain and discuss the procedure with the child or young person and ensure that they understand fully and are comfortably positioned. Consent must be obtained verbally. See AthenA for consent protocol. The use of distraction therapy or the play leader assistance can help with the procedure;
2. Put on a plastic apron for personal protection;
3. Clean and dry working surface. Perform hand hygiene as per the World Health Organisation (WHO) 5 moments for hand hygiene (see – Hand Hygiene Policy of the control of infection manual);
4. Open dressing pack onto clean area using an aseptic technique and open the necessary equipment onto the dressing pack using an aseptic technique;
5. Apply non-sterile gloves and remove the old dressing from the site using sterile adhesive remover (a child may wish to remove the dressing themselves). Remove the antimicrobial disc dressing and dispose of this as per infection control guidelines. Remove non-sterile gloves;
6. Perform hand hygiene as per the WHO 5 moments for hand hygiene and apply sterile gloves;
7. A swab for bacteriology should be taken from the exit site if clinical signs of infection are present or in the case of immunosuppressed neutropenic children where infection is suspected;
8. Clean the exit site for 30 seconds with Chloraprep using the appropriate technique which is circular motions moving away from the exit site and allow to dry for 30 seconds. Note: Chloraprep is not recommended in the use of infants under 8 weeks old due to possible skin reactions;
9. Inspect the line, noting integrity of line and clamps and, from the exit site, clean downwards moving away from the exit site with chlorahexidine gluconate 2% solution (for lines that are not compatible with alcohol). Or chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe (preferred option) and allow to dry for 30 seconds. 0.5% chlorhexadine and 70% alcohol should be used in infants under 8 weeks of age. Make sure the clamp has been cleaned.
10. Position antimicrobial chlorhexidine sponge disc dressing (blue side upwards) around the line at exit site as per manufacturer’s guidance. Ensure that Hickman lines are coiled before dressings are applied. This ensures that the line has some give if it gets pulled. Apply semi permeable dressing over the exit site, touching only the corners, to minimise skin irritation and reduce the risk of the dressing peeling or becoming damaged;
11. Remove personal protective equipment and perform hand hygiene as per the WHO 5 moments for hand hygiene.
12. Dispose of all waste management appropriately as per Waste Management Procedure.
13. Document procedure and note review date, including the length of the line, any problems and action taken in the appropriate notes. Document in the child or young person’s records and any other appropriate notes.

Procedure for flushing Portacath is in the Portacath section.

The line must be flushed after each intravenous administration, blood sampling and blood and platelet transfusion. Strict aseptic technique should be used for all catheter interventions and appropriately cleaned trolleys must be used in the hospital and trays in the community. They must be cleaned according to NHS Ayrshire &Arran guidelines on the control of infection.

Consideration must be taken when using a paediatric PICC line. The line is very small in diameter and pressure is needed to administer IV medications/infusions. Although pressure is required to administer medication, practitioners must not use force. Where more than a gentle resistance is noted the patency of the line must be discussed with medical staff and a decision should be made for continued use.

Note: PICC lines must not be used until the child or young person has had an x-ray to confirm the line is correctly placed and/or medical personnel have documented that the line safe to use.

Note: Some Paediatric PICC line can be used for blood sampling but you must check before trying to sample the line.

Please consider using Heparin (10iu/1ml) daily or after every flush if using a small gauge PICC line. This must be discussed with the medical staff.

• The needle free device at the end of each line should be changed weekly or when damaged, leaking or soiled.
• Oncology patients only: Curos port protector for each lumen (not sterile, therefore do not place this onto the sterile area)
• A 10ml luer lock syringe only or larger should be used for drug administration or flushing the catheter. This is to prevent excessive pressure being exerted on the lumen which may cause it to rupture.
• Reposition clamps on a different part of the line to prevent damage to the lumen from repetitive and continuous pressure. Ensure that the clamp on a Hickman line is placed on the reinforced part of the line.

Equipment required:

• cleaned trolley or tray
• sterile dressing pack
• sterile gloves
• 2 x 10 ml luer lock syringes
• green needle
• 10mls of 0.9% sodium chloride
• filter needle
• 2 x chlorhexidine 2% in 70% alcohol (Chloraprep)

Procedure:

1. Perform hand hygiene as per the WHO 5 moments for hand hygiene. Put on sterile gloves using an aseptic technique.
2. Draw up 0.9% sodium chloride solution for flushing (10mls per lumen).
3. Remove the old needle free device(s) and clean the end of the line thoroughly for at least 30 seconds and allow to dry. Clean with chlorhexidine gluconate 2%(for lines that are not compatible with alcohol) or chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe (preferred option). Allow to dry for 30 seconds. Attach new needle free device securely.
4. Insert a 10ml luer lock syringe filled with 10mls of 0.9% sodium chloride and open clamp (if applicable). Aspirate line slightly so that you see a flashback. You only need to see a slight discolouration of fluid with blood. If you do not see a flashback, ask the child or young person to change their position by sitting forward or raising their arm behind their back. If a positional change does not result in a flashback then you must stop the procedure and consult the Advanced Paediatric Nurse Practitioner (APNP) or Nurse in Charge for advice. There must be documentation in the child or young person’s notes if a line does not flashback but still flushes and has been deemed safe to use by a senior member of nursing or medical staff;
5. Flush the line with 0.9% sodium chloride using a brisk push/pause action, closing the clamp on the last half ml push to create positive pressure in the line.
6. Repeat steps 4, 5 & 6 for each lumen.
7. Oncology patients only: Curos port protector for a each lumen (not sterile, therefore do not place this onto sterile area)
8. Dispose of all waste management appropriately as per Waste Management Procedure.
9. Remove personal protective equipment and perform hand hygiene as per the WHO 5 moments for hand hygiene.
10. Document procedure, review date, any problems and action taken regarding the line in the appropriate notes. Document in the child and young person’s notes.
11. Note: Heparin should only be used for routine maintenance and not daily flushing.

Note: Blood sampling must not be done through a paediatric PICC line unless it has been documented that it can be used for sampling.

An aseptic technique must be adhered to when taking blood samples. Check the child and young person’s notes to ensure that the line has been bleeding back. Some lines do not bleed back; therefore you cannot take samples from the line.

Equipment required:

• cleaned trolley or tray;
• sterile dressing pack ;
• a pair of correct size surgical gloves;
• plastic apron for personal protection;
• disposal bag;
• chlorhexadine gluconate 2% & isopropyl alcohol 70% wipe x 2;
• The correct amount of syringes depending on how much blood you need to take. Ensure there is one for discard, sample blood and one for flushing line with 0.9% Sodium Chloride. If cultures are being taken use discard blood for culture. Note: Do not use anything smaller that a 10ml syringe;
• 2 green needles (1 for drawing up 0.9% sodium chloride and 1 for culture bottle if required);
• appropriate laboratory bottles;
• needle free device (should be changed) after blood sampling.

Procedure:

1. Explain and discuss the procedure with the child or young person and ensure that they understand fully and are comfortably positioned. Consent must be obtained verbally. See AthenA for consent protocol. The use of distraction therapy or the assistance of the play leader can help with the procedure;
2. Put on a plastic apron for personal protection;
3. Clean and dry working surface. Perform hand hygiene as per the World Health Organisation (WHO) 5 moments for hand hygiene (see section 6 – Hand Hygiene Policy of the control of infection manual);
4. Open dressing pack onto clean area using an aseptic technique and open the necessary equipment onto the dressing pack using an aseptic technique;
5. Perform hand hygiene as per the WHO 5 moments for hand hygiene and apply non sterile gloves.
6. Draw up 10mls of 0.9% sodium chloride solution for flushing.
7. Place all syringes on sterile field ready to use;
8. Clean the needle free device on the line for 30 seconds using a non-touch technique. Ensure the needle free device is cleaned thoroughly. Allow to dry for 30 seconds before attaching the syringe;
9. Attach the empty 10ml syringe and aspirate 3-5ml of blood. If cultures are required then set aside syringe on sterile field;
10. Attach another empty 10ml syringe and aspirate required amount of blood for samples;
11. Attach syringe with 10mls of 0.9% sodium chloride and flush line using push pause action. Clamp line on the last half ml push to create positive pressure in the line;
12. If needle free device needs to be changed then remove the old needle free device and replace ensuring you have primed the line with 0.9% sodium chloride so there are no air bubbles.
13. Decant the blood samples into the appropriate bottles. If culture is needed attach green needle to discard blood syringe and inject into culture bottle. Ensure that the top of the culture bottle has been swabbed with a chlorhexadine gluconate 2% & isopropyl alcohol 70% wipe and allowed to dry for 30 seconds before injecting the discard.
14. Dispose of all waste management appropriately as per Waste Management Procedure.

When obtaining blood cultures, blood must be taken from every lumen of the CVAD and peripherally. The initial 3-5mls of stagnant blood must be used for the blood culture samples for each lumen. Each bottle must be clearly marked with which lumen it has been obtained from, similarly with the peripheral sample.

Important: Peripheral blood cultures should be obtained before central line cultures.

An aseptic technique must be adhered to when commencing an infusion. The giving set must be primed using an aseptic technique. Do not prime a giving set over the sink because there is a risk of contamination from the splash back of organisms within the sink.

Equipment required:

• cleaned trolley or tray;
• sterile dressing pack;
• a pair of correct size surgical gloves;
• plastic apron for personal protection;
• chlorhexadine gluconate 2% & isopropyl alcohol 70% wipe x 2;
• infusion set;
• infusion fluid/drug;
• 10ml syringe with 0.9% sodium chloride;
• 2 green needles.

Giving sets must be primed immediately prior to the procedure.

Procedure:

1. Explain and discuss the procedure with the child or young person and ensure that they understand fully and are comfortably positioned. Consent must be obtained verbally. See AthenA for consent protocol. The use of distraction therapy or the assistance of the play leader can help with the procedure;
2. Put on a plastic apron for personal protection;
3. Clean and dry working surface. Perform hand hygiene as per the World Health Organisation (WHO) 5 moments for hand hygiene (see section 6 – Hand Hygiene Policy of the control of infection manual);
4. Open dressing pack onto clean area using an aseptic technique and open the necessary equipment onto the dressing pack using an aseptic technique;
5. Perform hand hygiene as per the WHO 5 moments for hand hygiene and apply non sterile gloves;
6. Draw up 10mls of 0.9% sodium chloride solution for flushing;
7. Connect infusion fluid to giving set and prime by running the solution through the giving set onto the sterile field.
8. Clean the needle free device on the line for 30 seconds using a non-touch technique. Ensure the needle free device is cleaned thoroughly. Allow to dry for 30 seconds before attaching the syringe;
9. Attach 10ml syringe of 0.9% sodium chloride and aspirate slightly (Hickman non-tunnelled) until you see a flashback then flush the line;
10. Attach primed infusion set to line;
11. Start the infusion.

All equipment should be appropriately disposed of at the end of the procedure. The contents of this trolley should never be kept to be used for disconnecting the infusion, no matter how short the infusion, because this significantly increases the chance of contamination.

A strict aseptic technique must be followed when disconnecting an infusion pump. A trolley should be set in the same way as for connecting an infusion.

If an infusion is being administered into one lumen only, only the one lumen will require flushing. Flush with 0.9% sodium chloride.