INS 2011 S55-S96

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or blood products should be changed no more fre-quently than every 96 hours. There is strong evi-dence that changing the administration sets more fre-quently does not decrease the risk of infection.2-3_(I)

B. Extending the administration set change to every 7 days may be considered when an anti-infective central vascular access device (CVAD) is being used or if fluids that enhance microbial growth are not administered through the set.3,4_(II)

C. If a secondary administration set is detached from the primary administration set, the secondary administration set is considered a primary inter-mittent administration set and should be changed every 24 hours (see Practice Criteria III, Primary

Intermittent Infusions).1_(V)

D. When compatibility of infusates is verified, use of secondary administration sets that use back-prim-ing infusion methods are preferred due to reduced need for disconnecting secondary intermittent administration sets.1_(V)

Practice Criteria

III. Primary Intermittent Infusions

A. Primary intermittent administration sets should be changed every 24 hours. When an intermittent infusion is repeatedly disconnected and reconnect-ed for the infusion, there is increasreconnect-ed risk of cont-amination at the catheter hub, needleless connec-tor, and the male luer end of the administration set, potentially increasing risk for catheter-related bloodstream infection. There is an absence of studies addressing administration set changes for intermittent infusions. In a meta-analysis of 12 randomized, controlled trials that supported increasing the time interval for administration set changes to 96 hours, at least 2 of the studies excluded administration sets used for heparin-locked catheters and in sets disconnected for more than 4 hours. In several others, exclusions were not stated.1,5_(V)

B. A new, sterile, compatible covering device should be aseptically attached to the end of the adminis-tration set after each intermittent use. The practice

43. ADMINISTRATION SET

CHANGE

Standard

43.1 Administration set changes shall be performed rou-tinely, based on factors such as type of solution adminis-tered, type of the infusion (continuous versus intermittent), immediately upon suspected contamination, or when the integrity of the product or system has been compromised. 43.2 The administration set shall be changed whenever the peripheral catheter site is rotated or when a new central vascular access device is placed.

43.3 Add-on devices used as part of the administration set, such as single- and multilumen extension sets and filters, shall be changed at the same time as the administration set. 43.4 The frequency of performing administration set changes and the system used to promote adherence to administration set change (eg, labeling/electronic) shall be established in organizational policies, procedures, and/or practice guidelines.

43.5 A vented administration set shall be used for solutions supplied in glass or semi-rigid containers, and a nonvented administration set shall be used for plastic fluid containers. 43.6 All administration sets shall be of luer-lock design to ensure a secure junction.

Practice Criteria I. General

A. The use of add-on devices for administration sets should be minimized as each device is a potential source of contamination, misuse, and disconnection; it is preferable to use an administration set with devices as an integral part of the set (see Standard 26, Add-on Devices).1_(V)

Practice Criteria

II. Primary and Secondary Continuous Infusions

A. Primary and secondary continuous administration sets used to administer fluids other than lipid, blood,

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of attaching the exposed end of the administration set to a port on the same set (“looping”) should be avoided.1,5_(V)

Practice Criteria

IV. Parenteral Nutrition

A. Administration sets used for nonlipid-containing par-enteral nutrition (PN) solutions should be routinely changed no more often than every 96 hours.2,6_(I)

B. Administration sets used for total nutrient admix-tures (TNA) containing intravenous fat emulsions (IVFE) with the amino acid and dextrose solution should be routinely changed every 24 hours.2,6_(III)

C. When primary administration sets used for PN are exposed to IVFE, consideration should be made to changing the administration set every 24 hours. Limited evidence suggests an increased risk for infection when duration of administration sets is extended beyond 24 hours.7_(III)

Practice Criteria

V. Intravenous Fat Emulsions (IVFE) and Other Lipid Product Infusions

A. When units of IVFE are administered intermit-tently, the administration set should be changed with each new container; the characteristics of IVFE (iso-osmotic, near neutral-alkaline pH, and containing glycerol) are conducive to the growth of microorganisms.6,8_(III)

B. When units of IVFE are administered consecutive-ly, the administration set should be routinely changed every 24 hours.6_(III)

C. A dedicated administration set should be used to administer propofol infusions and should be replaced every 12 hours, when the vial is changed, and according to the manufacturer’s directions for use.8_(Regulatory)

D. Administration sets used to administer lipid-based infusates, such as IVFE or TNA, should be free of di-ethylhexyl-phthalate (DEHP). DEHP is lipophilic and is extracted into the lipid solution with commonly used polyvinyl chloride administration sets and con-tainers. DEHP is considered a toxin, and studies have demonstrated increased DEHP levels in lipid solu-tions, which is especially a risk with neonatal, pedi-atric, and long-term home care patients.6,9-13_(IV)

Practice Criteria

VI. Blood and Blood Components

A. Administration sets used for blood and blood com-ponents should be specific to blood transfusion and

include a filter; the administration sets should be replaced every 4 hours (see Standard 28, Filters).14

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Practice Criteria

VII. Hemodynamic and Arterial Pressure Monitoring

A. The disposable or reusable transducer and/or dome and other components of the system, includ-ing the administration set, continuous flush device, and flush solution used for invasive hemodynamic pressure monitoring, are considered a closed sys-tem and should be changed every 96 hours, imme-diately upon suspected contamination, or when the integrity of the product or system has been compromised. The number of manipulations and entries into the system should be minimized.15_(III)

REFERENCES

1. Hadaway L. Infusion therapy equipment. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO:

Saunders/Elsevier; 2010:391-436.

2. Gillies D, O’Riordan L, Wallen M, Morrison A, Rankin K, Nagy S. Optimal timing for intravenous administration set replace-ment. Cochrane Database Syst Rev. 2005;(4):CD003588. 3. Rickard CM, Lipman J, Courtney M, et al. Routine changing of

intravenous administration sets does not reduce colonization or infec-tion in central venous catheters. Infect Control Hosp Epidemiol. 2004;25;650-655.

4. Raad I, Hanna HA, Awas A, et al. Optimal changing of intra-venous administration sets: is it safe to prolong use beyond 72 hours? Infect Control Hosp Epidemiol. 2001;22(3):136-139. 5. Institute for Safe Medication Practices. Failure to cap IV tubing

and disconnect IV ports place patients at risk for infections.

Medication Safety Alert! Published July 26, 2007. Accessed June

17, 2010.

6. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenter-al nutrition. J Parenter Enterparenter-al Nutr. 2004;28(suppl):S39-S70. 7. Matlow AG, Kitai I, Kirpalani H, et al. A randomized trial of

72-versus 24-hour intravenous tubing set changes in newborns receiv-ing lipid therapy. Infect Control Hosp Epidemiol. 1999;20(7):487-493.

8. Diprivan injectable emulsion [package insert]. Wilmington, DE: Astrazeneca; 2008. http://www.accessdata.fda.gov/drugsatfda_ docs/label/2008/019627s046lbl.pdf. Accessed January 30, 2010. 9. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phthalate from perfusion lines of various material, length, and brand by lipid emulsions. J Pediatr Gastroenterol Nutr. 2004;39(4): 341-345.

10. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phthalate by home total parenteral nutrition from polyvinyl chlo-ride infusion lines commonly used in the home. J Pediatr

Gastroenterol Nutr. 2008;47(1):81-86.

11. Pak VM, Nailon RE, McCauley LA. Controversy: neonatal expo-sure to plasticizers in the NICU. MCN Am J Maternal Child

Nurs. 2007;32(4):244-249.

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12. Kambia K, Gressier B, Bah S, et al. Evaluation of childhood expo-sure to di(2-ethylhexyl) phthalate from perfusion kits during long term parenteral nutrition. Int J Pharm. 2003;262(1-2):83-91. 13. US Food and Drug Administration. FDA public health notification:

PVC devices containing the plasticizer DEHP, 2002. http://www. fda.gov/MedicalDevices/Safety/AlertsandNotices/Public HealthNotifications/UCM062182. Accessed March 2, 2010. 14. AABB. Standards for Blood Banks and Transfusion Services. 26th

ed. Bethesda, MD: AABB; 2009.

15. Centers for Disease Control and Prevention (CDC). Guidelines for the prevention of intravascular catheter-related infections.

MMWR Morb Mortal Wkly Rep. 2002;51(RR-10):18.

44. VASCULAR ACCESS

DEVICE REMOVAL

Standard

44.1 Removal of a vascular access device (VAD) shall be performed upon the order of the licensed indepen-dent practitioner (LIP), in accordance with the rules and regulations as promulgated by the state’s Board of Nursing, organizational policies, procedures, and/or practice guidelines, or immediately upon suspected con-tamination or complication.

44.2 The nurse shall be competent in the process of VAD removal, including identification of potential complica-tions, and appropriate nursing interventions and/or emer-gency measures as needed, and patient and caregiver edu-cation.

44.3 VADs shall be removed upon unresolved compli-cation, therapy discontinuation, or if deemed unneces-sary.

44.4 VADs placed in an emergency situation shall be replaced as soon as possible and not later than 48 hours. 44.5 The frequency of short peripheral catheter removal for the purpose of site rotation shall be established in organizational policies, procedures, and/or practice guide-lines.

44.6 Removal of an implanted port shall be considered a surgical procedure and shall be performed by an LIP with validated competency operating within the state’s rules and regulations for professional practice, and according to organizational policies, procedures, and/or practice guidelines.

Practice Criteria

I. Short Peripheral Catheters

A. The nurse should consider replacement of the short peripheral catheter when clinically indicated and when infusion treatment does not include peripheral parenteral nutrition. The decision to replace the short peripheral catheter should be

based on assessment of the patient’s condition; access site; skin and vein integrity; length and type of prescribed therapy; venue of care; integrity and patency of VAD; dressing; and stabilization device.1-10_(I)

B. The nurse should not routinely replace short peripheral catheters in pediatric patients.11_(IV)

C. Caution should be used in the removal of a short peripheral catheter. Digital pressure should be applied until hemostasis is achieved, and a dress-ing should be applied to the access site.1_(V)

D. With any patient reports of discomfort or pain related to the short peripheral catheter, the catheter should be removed. The LIP should be notified if unable to restart the short peripheral catheter or a delay in medication administration occurs.1,12_(V)

E. If a catheter-related bloodstream infection (CR-BSI) is suspected, consideration should be given to culturing the catheter after removal (see Standard 49, Infection).2,12_(V)

F. If a vesicant medication has extravasated, treatment should be determined prior to catheter removal. The nurse should aspirate the remaining drug from the catheter prior to removal (see Standard 48,

Infiltration and Extravasation).2,13_(V)

Practice Criteria II. Midline Catheters

A. The midline catheter is indicated for those periph-eral infusion therapies prescribed for a duration of 1-4 weeks. For therapies requiring catheter dwell times greater than 4 weeks, extension of catheter dwell should be based on the profession-al judgment of the nurse after consideration of the following factors including, but not limited to, length and type of therapy remaining, peripheral vascular status, condition of the vein in which the catheter is indwelling, skin integrity, and patient condition.2,14_(V)

B. Removal of a midline catheter should be deter-mined by patient condition, completion or change of therapy administered, presence of infectious or inflammatory process, catheter malposition, or catheter dysfunction. Midline catheters should be removed if the tip location is no longer appropri-ate for the prescribed therapy.1,2,12_(V)

C. Caution should be used in the removal of a mid-line catheter. Digital pressure should be applied until hemostasis is achieved, and a petroleum-based ointment and a sterile dressing should be applied to the access site to seal the skin-to-vein tract and decrease risk of air embolus.1_(V)

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occur. If unable to resolve the complication, or the complication warrants removal, after collabo-ration with the health care team, the midline catheter should be removed.1_(V)

E. With any patient reports of discomfort or pain related to the midline catheter, the patient and catheter should be assessed and appropriate inter-ventions performed. The LIP should be notified. When interventions are unsuccessful, the catheter should be removed.1,2,12_(V)

Practice Criteria

III. Nontunneled Central Vascular Access Devices (CVADs)*

A. Daily assessment of CVAD need and removal when no longer needed are components of the central line bundle known to decrease risk of infection. The maximum dwell time of a nontunneled CVAD is unknown; ongoing and daily monitoring of the device necessity should be performed.12,15-17_(II)

B. Removal of a nontunneled CVAD should be deter-mined by patient condition, completion of therapy, presence of infectious or inflammatory process, catheter malposition, or catheter dysfunction.12,17

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C. The decision to remove or salvage a catheter due to suspected or confirmed catheter-related blood-stream infection (CR-BSI) should be based on blood culture results, specific type of cultured organism, patient’s current condition, available vascular access sites, effectiveness of antimicro-bial therapy, and LIP direction (see Standard 49,

Infection).12_(V)

D. The CVAD should be removed after patient assessment and in collaboration with the health care team if a catheter-related complication is sus-pected and interventions are unsuccessful.17_(V)

E. A CVAD with a malpositioned catheter tip loca-tion that cannot be reposiloca-tioned to a central vein should be removed.17_(V)

F. Caution should be used in the removal of a non-tunneled CVAD, including precautions to prevent air embolism. Digital pressure should be applied until hemostasis is achieved by using manual compression and/or other adjunct approaches such as hemostatic pads, patches, or powders that are designed to potentiate clot formation. The nurse should apply petroleum-based ointment and a sterile dressing to the access site to seal the skin-to-vein tract and decrease the risk of air embolus. When removing the CVAD, the nurse should position the patient so that the CVAD insertion site is at or below the level of the heart

to reduce the risk of air embolus (see Standard 50,

Air Embolism).17-22_(IV)

G. If resistance is encountered when the catheter is being removed, the catheter should not be forcibly removed, and the LIP should be notified and dis-cussion should occur related to initiating appropri-ate interventions for successful removal.2,23,24_(V)

H. With any patient reports of discomfort or pain related to the CVAD, the patient and CVAD should be assessed, appropriate interventions performed, and the LIP notified. When interventions are unsuc-cessful, the CVAD should be removed.17-18_(V)

I. Coagulation studies, such as the International Normalized Ratio (INR), are not routinely neces-sary for the removal of a CVAD.25_(IV)

Practice Criteria

IV. Surgically Placed CVADs: Tunneled/Implanted Ports

A. The maximum dwell time of a surgically placed CVAD is unknown; ongoing and frequent monitor-ing of the access site should be done as well as ongo-ing assessment of need. When no longer necessary, the surgically placed CVAD should be removed.17_(V)

B. The decision to remove or salvage a CVAD due to suspected or confirmed CR-BSI should be based on blood culture results, specific type of cultured organ-ism, patient’s current condition, available vascular access sites, effectiveness of antimicrobial therapy, and LIP direction (see Standard 49, Infection).11,13_(V)

C. If a catheter-related complication occurs (eg, cuff exposure, dislodgment, infection) and interven-tions are unsuccessful, the catheter should be removed after patient assessment and in collabo-ration with the health care team.2,11-13_(V)

D. If resistance is encountered when the tunneled CVAD is being removed, the device should not be forcibly removed, and further collaboration with the health care team should occur.17,23,26_(IV)

E. After removal, the nurse should continue to mon-itor the site, implement interventions as necessary, provide patient education, and document obser-vations and actions in the patient’s permanent medical record.17,18_(V)

F. Coagulation studies, such as the International Normalized Ratio (INR), are not routinely necessary for the removal of a tunneled catheter or implanted port.25_(IV)

Practice Criteria V. Arterial Catheters

A. Arterial catheters should not be routinely removed or replaced.27_(V)

*Includes PICCs.

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B. When a peripheral arterial catheter is removed, digital pressure should be applied until hemostasis is achieved by using manual compression and/or other adjunct approaches such as hemostatic pads, patches, or powders that are designed to potenti-ate clot formation. A sterile dressing should be applied to the access site. Prolonged digital pres-sure and adjunct hemostatic approaches may need to be applied in patients with coagulation abnor-malities or femoral arterial catheters.2,20-22_(IV)

C. The nurse should assess and document the circu-latory status distal to the area of cannulation after removal of the peripheral arterial catheter.2_(V)

REFERENCES

1. Perucca R. Peripheral venous access devices. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:

2. Camp-Sorrell D, ed. Access Device Guidelines: Recommendations

for Nursing Practice and Education. 2nd ed. Pittsburgh, PA:

Oncology Nursing Society; 2004.

3. Gallant P, Schultz A. Evaluation of a visual infectious phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. J Infus Nurs. 2006;9(6):338-345. 4. White S. Peripheral intravenous therapy-related phlebitis rates in

an adult population. J Infus Nurs. 2001;24(1):19-24.

5. Idvall E, Gunningberg L, Idvall E, Gunningberg L. Evidence for elective replacement of peripheral intravenous catheters to pre-vent thrombophlebitis: a systematic review. J Adv Nurs. 2006; 55(6):715-722.

6. Webster J, Osborne S, Rickard C, Hall J. Clinically indicated replacement versus routine replacement of peripheral venous catheters. In: The Cochrane Collaboration. Chichester, England: John Wiley & Sons, The Cochrane Library; 2010(3).

7. Lee W, Chen H, Tsai T, et al. Risk factors for peripheral intra-venous infections in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control. 2009;37(8):683-686. 8. Powell J, Tarnow KG, Perucca R. The relationship between

peripheral intravenous catheter dwell time and the incidence of phlebitis. J Infus Nurs. 2008;31(1):39-45.

9. Zingg W, Pittet, D. Peripheral venous catheters: an under-evalu-ated problem. Int J Antimicrob Agents. 2009;34S:S38-S42. 10. Bregenzer T, Conen D, Sakiman P, Widmer A. Is routine

replace-ment of peripheral intravenous catheters necessary? Arch Int

Med. 1998;158(2):151-156.

11. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’s

Principles & Practice of Intravenous Therapy. 7th ed. Philadelphia,

PA: Lippincott Williams & Wilkins; 2007:621.

12. Mermel l, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Disease Society of America. Clin Infect Dis. 2009;49:1-45.

13. Schulmeister L. Antineoplastic therapy. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

14. Infusion Nurses Society [position paper]. Midline and midclavic-ular catheters. J Infus Nurs. 1997;20(4):175.

15. Institute for Healthcare Improvement. 100,000 Lives campaign, 2005-2006. www.ihi.org. Accessed January 30, 2010.

16. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reduc-tions in catheter related bloodstream infecreduc-tions in Michigan inten-sive care units: observational study. Br Med J. 2010;340:c309. 17. Gorski L, Perucca R, Hunter M. Central venous access devices:

care, maintenance, and potential complications. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

18. Managing central venous catheter therapy. In: Doyle R, Nale P, eds. Handbook of Infusion Therapy. Springhouse, PA: Springhouse; 1999:114-141.

19. Boer W, Hene R. Lethal air embolus following removal of a dou-ble lumen jugular vein catheter. Nephrol Dial Transplant. 1999;14(8):1850-1852.

20. Wang DS, Chu LF, Olson SE, et al. Comparative evaluation of noninvasive compression adjuncts for hemostasis in percutaneous arterial, venous, and arteriovenous dialysis access procedures. J

Vascular Intervent Radiol. 2008;19(1):72-79.

21. Pahari M, Moliver R, Lo D, et al. QuikClot interventional hemo-static bandage (QCI): a novel hemohemo-static agent for vascular access. Cath Lab Digest. January 2010.

22. Kheirabadi BS, Scherer MR, Estep S, et al. Determination of effi-cacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine. J Trauma Inj Infect Crit Care. 2009;67(3): 450-460.

23. Makhiza N, Choudhury M, Kiran U, et al. The stuck central venous catheter: a word of caution. Heart Lung Circ. 2008;17: 417-436.

24. Petit J, Wyckoff M. National Association of Neonatal Nurses.

Peripherally Inserted Central Catheter Guidelines for Practice.

2nd ed. Glenview, IL: National Association of Neonatal Nurses; 2007.

25. Stecker M, Johnson M, Ying J, et al. Time to hemostasis after traction removal of tunneled cuffed central venous catheters.

J Vascular Intervent Radiol. 2007;18(10):1232-1239.

26. Lee AC. Elective removal of cuffed central venous catheters in children. Support Care Cancer. 2007;15:897-901.

27. Centers for Disease Control and Prevention (CDC). Guidelines for he prevention of intravascular catheter-related infections.

MMWR Morb Mort Wkly Rpt. 2002;51(RR-10):1-26.

45. FLUSHING AND LOCKING

Standard

45.1 Vascular access devices shall be flushed prior to each infusion as part of the steps to assess catheter function.

45.2 Vascular access devices shall be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompati-ble medications.

45.3 Vascular access devices shall be locked after com-pletion of the final flush solution to decrease the risk of occlusion.

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and/or practice guidelines and in accordance with manu-facturers’ directions for use.

Practice Criteria

A. Single-use systems include single-dose vials and prefilled syringes and are the preferred choices for flushing and locking. If multiple-dose containers must be used, each container should be dedicated to a single patient.1-3_(IV)

B. Flushing is accomplished with preservative-free 0.9% sodium chloride (USP). When the medication is incompatible with preservative-free 0.9% sodi-um chloride (USP), 5% dextrose in water should be used and followed by flushing with preservative-free 0.9% sodium chloride (USP) and/or heparin lock solution. Dextrose should be flushed from the catheter lumen because it can provide nutrients for biofilm growth.4_(IV)

C. Bacteriostatic 0.9% sodium chloride contains ben-zyl alcohol as the preservative. The maximum vol-ume that can be tolerated by adult and pediatric patients is undetermined; however, one study sug-gests that this should not exceed 30 mL in a 24-hour period for adults.1,2_(IV)

D. The minimum volume of preservative-free 0.9% sodium chloride (USP) for catheter flushing depends upon the type and size of catheter, age of the patient, and type of infusion therapy being given. A minimum volume of twice the internal volume of the catheter system is recommended; however, a larger volume may be needed for blood sampling or blood transfu-sion procedures.3-5_(V)

E. The nurse should aspirate the catheter for blood return as a component of assessing catheter function prior to administration of medications and solutions (see Standard 61, Parenteral Medication and Solution

Administration)6-8_(V)

F. Due to varying degrees of physiologic maturity for drug metabolism and excretion in the neonate, solutions used for flushing and/or locking catheters should not contain the preservative benzyl alco-hol.5,7,8_(IV)

G. If resistance is met and/or no blood return noted, the nurse should take further steps to assess patency of the catheter prior to administration of medications and solutions. The catheter should not be forcibly flushed (see Standard 56, Catheter

Clearance).3,6_(V)

H. To prevent catheter damage, the size of the syringe used for flushing and locking should be in accor-dance with the catheter manufacturer’s directions for use. Patency is assessed with a minimum 10-mL syringe filled with preservative-free 0.9% sodium chloride (USP). Flush syringes holding a smaller volume and/or designed to generate lower amounts of pressure may also be used to assess patency.

Administration of small quantities of medication should be given in a syringe appropriately sized for the dose required following confirmation of catheter lumen patency.9-11_(V)

I. Prefilled syringes filled with preservative-free 0.9% sodium chloride (USP) should not be used for dilution of medications. Due to risk of serious medication errors, syringe-to-syringe drug trans-fer is not recommended.12-14_(V)

J. Short peripheral catheters should be locked with preservative-free 0.9% sodium chloride (USP) fol-lowing each catheter use in adults and children.15-17_(I)

K. No specific recommendation can be made about the use of heparin lock solution or preservative-free 0.9% sodium chloride (USP) for locking short peripheral catheters in neonatal patients. Data are inconsistent and inadequate to make specific recom-mendations.18-21_(V)

L. The nurse should assess for contraindications for the use of heparin lock solution including, but not lim-ited to, presence or risk for heparin-induced throm-bocytopenia, heparin’s impact on laboratory studies drawn from the catheter, and systemic anticoagula-tion. Heparin-induced thrombocytopenia (HIT) has been reported with the use of heparin flush solu-tions, although the exact rates are unknown. All patients should be monitored closely for signs and symptoms of HIT. If present or suspected, heparin and all sources of heparin (ie, heparin-coated catheters) should be discontinued.22-30_(IV)

M.For postoperative patients receiving heparin lock solutions of any concentration, monitoring platelet counts for heparin-induced thrombocy-topenia (HIT) is recommended every 2 to 3 days from day 4 through day 14 or until the heparin is stopped. For medical patients receiving heparin lock solutions, routine platelet count monitoring is not recommended.31_(II)

N. The use of preservative-free 0.9% sodium chloride (USP) for locking catheters with an integral pres-sure-sensitive valve system is recommended by manufacturers’ directions for use, although the continued use of heparin lock solution has also been suggested. There are multiple designs of these valves located on the internal catheter tip and the external catheter hub. Available data are inconclu-sive and conflicting.32-38_(II)

O. While many studies report equivalent outcomes in central vascular access catheters when locked with heparin lock solution or preservative-free 0.9% sodium chloride (USP), others have report-ed greater complications with saline locking. Due to the risk and costs associated with central vas-cular access device (CVAD) insertion, heparin lock solution 10 units/mL is the preferred lock solution after each intermittent use.26,39-44_(III)

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P. Before removal of an access needle from an implanted port and/or for periodic access and flushing, the device should be locked with heparin lock solution 100 units/mL.3,45_(V)

Q. Catheters used for hemodialysis should be locked with heparin lock solution 1000 units/mL after each use.30,46_(IV)

R. Catheters used for apheresis procedures are large-bore catheters and require rapid flow rates; the procedure has an impact on coagulation factors. The flushing and locking procedures for these catheters should follow the same practices as hemodialysis catheters.47,48_(V)

S. Patency of arterial catheters used for hemody-namic monitoring is greater when heparin solu-tion is infused, although existing studies are inconclusive due to variations in the catheter’s location (peripheral versus pulmonary), duration of catheter use, and differences in patency mea-surement. The decision to use preservative-free 0.9% sodium chloride (USP) instead of heparin infusion should be based on the clinical risk of catheter occlusion, the anticipated length of time the arterial catheter will be required, and patient factors such as heparin sensitivities.49_(II)

T. Concentrations of heparin than or equal to 1 unit/mL should be used as an infusion in umbilical arterial catheters in neonates; however, heparinized flush or locking solution is not effective.50_(II)

U. Positive fluid displacement within the lumen of the catheter should be maintained to prevent reflux of blood upon luer disconnection. This is accom-plished with either a flushing technique or a needleless connector designed to overcome blood reflux.11,51_(V)

V. Alternative locking solutions may be considered in patients with HIT including, but not limited to, ethanol, sodium citrate, taurolidine, ethylenedi-amine-tetraacetate (EDTA), or combinations of these solutions. These solutions are not commer-cially available in single-use containers and do not have a labeled indication for maintaining catheter patency. These locking solutions should be obtained from a compounding pharmacy.52-63_(II)

W. Antibiotic lock solution may be used for salvage of an infected long-term CVAD in the absence of a tunnel or port-pocket infection. High concen-trations of vancomycin, ceftazidime, cefazolin, ciprofloxacin, gentamicin, and ampicillin have been reported to be effective when used in con-junction with systemic antibiotics. Drug precipita-tion is possible when heparin is added to these lock solutions. The length of dwell time for the lock solution and the duration of treatment depends on the need to use the catheter for infu-sion and the clinical response. Use of antibiotic

lock solution is not recommended as a routine prophylactic measure due to the possibility of development of resistant strains of microorgan-isms and adverse reactions to the high concentra-tion of lock soluconcentra-tion. Prophylactic use may be considered in patients with a history of catheter-related bloodstream infections or those with other risk factors such as a prosthetic heart valve.63-66_(I)

REFERENCES

1. Kimura E, Darby T, Krause R, Brondyk H. Parenteral toxicity stud-ies with benzyl alcohol. Toxicol Appl Pharmacol. 1971;18:60-68. 2. Gahart B, Nazazreno A. Intravenous Medications. 26th ed. St

Louis, MO: Mosby/Elsevier; 2010.

3. Gorski L, Perucca R, Hunter M. Central venous access devices: care, maintenance, and potential complications. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

5. Frey A, Pettit J. Infusion therapy in children. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

6. Polovich M, Whitford J, Olsen M, eds. Chemotherapy and

Biotherapy Guidelines and Recommendations for Practice. 3rd

ed. Pittsburgh, PA: Oncology Nursing Society; 2009.

7. Wickham R, Engelking C, Sauerland C, Corbi D. Vesicant extravasation part II: evidence-based management and continu-ing controversies. Oncol Nurs Forum. 2006;33(6):1143-1150. 8. Hadaway L. Emergency: infiltration and extravasation: preventing a

complication of IV catheterization. Am J Nurs. 2007;107(8):64-72. 9. Hadaway LC. Major thrombotic and nonthrombotic complica-tions: loss of patency. J Intraven Nurs. 1998;21(5S):S143-S160. 10. Macklin D. What’s physics go to do with it? J Vasc Access

Devices. 1999;4(2):7-13.

11. Hadaway L. Technology of flushing vascular access devices. J

Infus Nurs. 2006;29(3):137-145.

12. Cohen M, Smetzer J. ISMP Medication Error Report Analysis.

Hospital Pharm. 2008;43(2):81-84.

13. Institute for Safe Medication Practices. Errors with injectable medications: unlabeled syringes are surprisingly common! ISMP

Acute Care Newsletter. Nov 15, 2007.

14. Hadaway L. Misuse of prefilled flush syringes: implications for medication errors and contamination. Infect Control Resour. 2008;4(4):2-4.

15. Goode C, Titler M, Rakel B, et al. A meta-analysis of effects of heparin flush and saline flush: quality and cost implications. Nurs

Res. 1991;40(6):324-330.

16. Frey A, Pettit J. Infusion therapy in children. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

17. Mok E, Kwong TK, Chan MF. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs

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18. Shah PS, Ng E, Sinha AK. Heparin for prolonging peripheral intravenous catheter use in neonates. Cochrane Database Syst

Rev. 2005;(4):CD002774.

19. Flint A, McIntosh D, Davier M. Continuous infusion versus inter-mittent flushing to prevent loss of function of peripheral intra-venous catheters used for drug administration newborn infants.

Cochrane Database Syst Rev. 2005;19(4):CD004593.

20. American Society of Health-System Pharmacists. Policy

Recommendation: The Safey and Effective Use of Heparin in Neonatal Patients. Bethesda, MD: ASHP; 2009.

21. Klenner A, Fusch C, Rakow A, et al. Benefits and risk of heparin for maintaining peripheral venous catheters in neonates: a place-bo-controlled trial. J Pediatr. 2003;143(6):741-745.

22. Dai M, Hsieh A, Chao T. Catastrophic heparin-induced thrombo-cytopenia/thrombosis syndrome related to the use of a Port-A-Cath in a breast cancer patient receiving chemotherapy. Support Care

Cancer. 2004;12(7):537-539.

23. Hong A, Cook D, Sigouin S, Warkentin T. Central venous catheters and upper-extremity deep-vein thrombosis complicating immune heparin-induced thrombocytopenia. Blood. 2003;101(8):3049-3051. 24. Muslimani A, Ricaurte B, Daw H. Immune heparin-induced thrombocytopenia resulting from preceding exposure to heparin catheter flushes. Am J Hematol. 2007;82(7):652-655.

25. McNulty I, Katz E, Kim KY. Thrombocytopenia following heparin flush. Prog Cardiovasc Nurs. 2005;20(4):143-147. 26. Mitchell M, Anderson B, Williams K, Umscheid C. Heparin

flush-ing and other interventions to maintain patency of central venous catheters: a systematic review. J Adv Nurs. 2009;65(10):2007-2021.

27. Mayo DJ, Dimond EP, Kramer W, McDonald KH. Discard vol-umes necessary for clinically useful coagulation studies from heparinized Hickman catheters. Oncol Nurs Forum. 1996;23(4): 671-675.

28. Hinds P, Quargnenti A, Gattuso J, Srivastava D. Comparing the results of coagulation tests on blood drawn by venipuncture and through heparinized tunneled venous access devices in pediatric patients with cancer. Oncol Nurs Forum. 2002;29(3):E26-E34. 29. Lambert C, Deneys V, Pothen D, Vermylen C, Hermans C.

Inadvertent anticoagulation of a haemophiliac child with routine line flushing. Haemophilia. 2006;12(5):548-550.

30. Yevzlin AS, Sanchez RJ, Hiatt JG, et al. Concentrated heparin lock is associated with major bleeding complications after tun-neled hemodialysis catheter placement. Semin Dial. 2007;20(4): 351-354.

31. Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians. Evidence-based clinical practice guidelines. 8th ed. Chest. 2008;133(suppl 6):340S-380S. 32. Hoffer E, Borse J, Santulli P, Bloch R, Fonteine A. Prospective

ran-domized comparison of valved versus nonvalved peripherally inserted central vein catheters. Am J Roentgenography. 1999;173: 1393-1398.

33. Carlo JT, Lamont JP, McCarty TM, Livingston S, Kuhn JA. A prospective randomized trial demonstrating valved implantable ports have fewer complications and lower overall cost than non-valved implantable ports. Am J Surg. 2004;188(6):722-727. 34. Tolar B, Gould J. The timing and sequence of multiple

device-related complications in patients with long-term indwelling Groshong catheters. Cancer. 1996;78(6):1308-1313.

35. Mayo D, Horne M, Summers B, Pearson D, Helsabeck C. The effects of heparin flush on patency of Groshong catheter: a pilot study. Oncol Nurs Forum. 1996;23(9):1401-1405.

36. Biffi R, Braud Fd, Orsi F, et al. Totally implantable central venous access ports for long-term chemotherapy: a prospective study analyzing complications and costs of 333 devices with a mini-mum follow-up of 180 days. Ann Oncol. 1998;9:767-773. 37. Biffi R, Corrado F, Braud FD, et al. Long-term, totally implantable

central venous access ports connects to a Groshong catheter for chemotherapy of solid tumours: experience from 178 cases using a single type of device. Eur J Cancer. 1997;33(8):1190-1194. 38. Biffi R, Braud FD, Orsi F, et al. A randomized, prospective trial of

central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients. Cancer. 2000;92(5):1204-1212. 39. Stephens L, Haire W, Tarantolo S, et al. Normal saline versus heparin flush for maintaining central venous catheter patency during apheresis collection of peripheral blood stem cells (PBSC).

Transfusion Sci. 1997;18(2):187-193.

40. Schilling S, Doellman D, Hutchinson N, Jacobs B. The impact of needleless connector device design on central venous catheter occlusion in children: a prospective controlled trial. J Paren

Enteral Nutr. 2006;30(2):85-90.

41. Jacobs B, Schilling S, Doellman D, Hutchinson N, Rickey M, Nelson S. Central venous catheters occlusion: a prospective, con-trolled trial examing the impact of a positive-pressure valve device. J Parenter Enteral Nutr. 2004;28(2):113-118.

42. Rotello LC, Albrant D, Purcell T, et al. Incidence of triple lumen catheter and port occlusion utilizing normal saline flushes. Chest. 2007;132(4):493a.

43. Cesaro S, Tridello G, Cavaliere M, et al. Prospective, randomized trial of two different modalities of flushing central venous catheters in pediatric patients with cancer. J Clin Oncol. 2009;27(12):2059-2065.

44. Bowers L, Speroni K, Jones L, Atherton M. Comparison of occlu-sion rates by flushing solutions for peripherally inserted central catheters with positive-pressure luer-activated devices. J Infus

Nurs. 2008;31(1):22-27.

45. Arch P. Port navigation: let the journey begin. Clin J Oncol Nurs. 2007;11(4):485-488.

46. Moran JE, Ash SR. Locking solutions for hemodialysis catheters; heparin and citrate: a position paper by ASDIN. Semin Dial. September/October 2008;21(5):490-492.

47. Linenberger ML, Price TH. Use of cellular and plasma apheresis in the critically ill patient: part 1: technical and physiological con-siderations. J Intensive Care Med. 2005;20(1):18-27.

48. Schonermarck U, Bosch T. Vascular access for apheresis in inten-sive care patients. Ther Apher Dial. 2003;7(2):215-220. 49. Halm MA. Flushing hemodynamic catheters: what does the

sci-ence tell us? Am J Crit Care. 2008;17(1):73-76.

50. Barrington K. Umbilical artery catheters in the newborn: effects of heparin. Cochrane Database Syst Rev. 2000;(2):(CD000507). 51. Hadaway L. Infusion therapy equipment. In: Alexander M,

Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

52. Winnett G, Nolan J, Miller M, Ashman N. Trisodium citrate (TSC) 46.7% selectively and safely reduces staphylococcal catheter-related bacteraemia (CRB). Nephrol Dial Transplant. 2008;23(11):3592-3598.

53. Macrae J, Dojcinovic I, Djurdjev O, et al. Citrate 4% versus heparin and the reduction of thrombosis study (CHARTS). Clin J

Am Soc Nephrol. 2008;3(2):369-374.

54. Maharaj AR, Zelenitsky SA, Vercaigne LM. Effect of an ethanol/ trisodium citrate hemodialysis catheter locking solution on iso-lates of Candida albicans. Hemodial Int. 2008;12(3):342-347.

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55. Raad II, Fang X, Keutgen XM, Jiang Y, Sherertz R, Hachem R. The role of chelators in preventing biofilm formation and catheter-related bloodstream infections. Curr Opin Infect Dis. 2008;21(4):385-392.

56. Rioux JP, De Bortoli B, Troyanov S, Madore F. The effect of sodi-um citrate 4% locking solution for central venous dialysis catheter on the international normalized ratio (INR) value. Nephrol Dial

Transplant. 2008;23(5):1772-1773.

57. Steczko J, Ash SR, Nivens DE, Brewer L, Winger RK. Microbial inactivation properties of a new antimicrobial/antithrombotic catheter lock solution (citrate/methylene blue/parabens). Nephrol

Dial Transplant. 2009;24:1937-1945.

58. Percival S, Kite P, Eastwood K, et al. Tetrasodium EDTA as a novel central venous catheter lock solutions against biofilm.

Infect Control Hosp Epidemiol. 2005;26(6):515-519.

59. Raad I, Buzaid A, Rhyne J, et al. Minocycline and ethylenedi-aminetetraacetate for the prevention of recurrent vascular catheter infections. Clin Infect Dis. 1997;25(1):149-151. 60. Raad I, Chatzinikolaou I, Chaiban G, et al. In vitro and ex vivo

activities of minocycline and EDTA against microorganisms embedded in biofilm on catheter surfaces. Antimicrob Agents

Chemother. 2003;47(11):3580-3585.

61. Maiefski M, Rupp M, Hermsen E. Ethanol lock technique: review of the literature. Infect Control Hosp Epidemiol. 2009;30:1096-1108.

62. Bradshaw JH, Puntis JW. Taurolidine and catheter-related blood-stream infection: a systematic review of the literature. J Pediatr

Gastroenterol Nutr. 2008;47(2):179-186.

63. Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial

Transplant. 2008;23(5):1666-1672.

64. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1-45.

65. Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30. 66. Barsanti MC, Woeltje KF. Infection prevention in the intensive

care unit. Infect Dis Clin North Am. 2009;23(3):703-725.

46. VASCULAR ACCESS DEVICE

SITE CARE AND DRESSING

CHANGES

Standard

46.1 Vascular access device (VAD) site care and dress-ing changes, includdress-ing frequency of procedure and type of antiseptic and dressing, shall be established in orga-nizational policies, procedures, and/or practice guide-lines.

46.2 The nurse shall be competent in performing VAD site care and dressing changes.

46.3 VAD site care and dressing changes shall be per-formed at established intervals and immediately if the dressing integrity becomes compromised, if moisture,

drainage, or blood is present, or if signs and symptoms of site infection are present.

46.4 A sterile dressing shall be applied and maintained on VADs.

Practice Criteria

A. Routine site care and dressing changes are not performed on short peripheral catheters unless the dressing is soiled or no longer intact.1_(V)

B. Central vascular access device (CVAD) site care and dressing changes should include the follow-ing: removal of the existing dressing, cleansing of the catheter-skin junction with appropriate anti-septic solution(s), replacement of the stabilization device if used, and application of a sterile dressing (see Standard 36, Vascular Access Device

Stabilization).2-4_(V)

C. Chlorhexidine solution is preferred for skin antisep-sis as part of VAD site care. One percent to two per-cent tincture of iodine, iodophor (povidone-iodine), and 70% alcohol may also be used. Chlorhexidine is not recommended for infants under 2 months of age.2,5-8_(I)

D. For infants under 2 months of age or pediatric patients with compromised skin integrity, dried povidone-iodine should be removed with normal saline wipes or sterile water.9_(V)

E. CVAD site care frequency is based on the type of dressing; transparent semipermeable (TSM) dress-ings should be changed every 5-7 days, and gauze dressings should be changed every 2 days. While the evidence does not support one type of dress-ing over another, gauze is preferable to TSM if the patient is diaphoretic, or if the site is oozing or bleeding. In the event of drainage, site tenderness, other signs of infection, or loss of dressing integri-ty, the dressing should be changed sooner, allow-ing the opportunity to closely assess, cleanse, and disinfect the site.2,3,8,10_(II)

F. Placement of a gauze dressing under a transpar-ent dressing should be considered a gauze dress-ing and changed every 2 days. If gauze is used to support the wings of a noncoring needle in an implanted port and does not obscure the inser-tion site, it is not considered a gauze dressing.3

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G. The use of a chlorhexidine-impregnated dressing with short-term CVADs should be considered in patients older than 2 months of age as an addi-tional catheter-related bloodstream infection (CR-BSI) prevention measure.2,11-13_(I)

H. With a well-healed tunneled CVAD, considera-tion may be given to no dressing.14_(III)

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the intact dressing; for patients receiving outpa-tient or home care, the paoutpa-tient should be instruct-ed to check the VAD site and dressing every day for signs of infection and to report such changes or dressing dislodgment immediately to the health care provider.1,3_(V)

J. Gauze, bandages, or any dressing material that may obstruct visualization of the catheter-skin junction and/or constrict the extremity should not be used (see Standard 38, Site Protection).1,4_(V)

K. The dressing should be labeled with the following information: date, time, and initials of the nurse performing the dressing change.1,3,4_(V)

L. Sterile gloves should be worn when performing CVAD site care. The use of a mask during access is often recommended; however, it remains an unresolved issue due to lack of research.2,3,15,16

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REFERENCES

2. Marschall J, Mermel LA, Classen D, et al; Society for Hospital Epidemiology. Strategies to Prevent CLABSI. Strategies to pre-vent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 (suppl 1): S22-S30.

3. Gorski L, Hunter M. Central venous access devices: care, mainte-nance and potential complications. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca, R. eds. Infusion Nursing: An

Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;

2010:496-498.

4. Phillips, LD. Techniques for initiation and maintenance of peripheral infusion therapy. In: Manual of I.V. Therapeutics:

Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia,

PA: FA Davis; 2010:303-401.

5. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: meta-analysis. Ann Intern Med. 2002;136(11):792-801. 6. Hibbard JJ. Analysis comparing the antimicrobial activity and

safe-ty of current antiseptic agents. J Infus Nurs. 2005;28(3):194-207. 7. National Kidney Foundation/Dialysis Outcomes Quality

Initiative. Clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis. 2001;37(suppl 1):S137-S181.

8. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for pre-ventive strategies. Medicine (Baltimore). 2002;81(6):466-479. 9. Doellman D, Pettit J, Catudal P, Buckner J, Burns D, Frey AM;

Association for Vascular Access. Best practice guidelines in the care and maintenance of pediatric central venous catheters. 2010; PEDIVAN.

10. Gilles D, O’Riordan L, Carr D, et al. Gauze and tape and trans-parent polyurethane dressings for central venous catheters. Cochrane Review. In: The Cochrane Library, Chichester, UK: John Wiley & Sons; 2004.

11. Yong-Gang L, Hong-Lin D, Wang L. Chlorhexidine-impregnated sponges and prevention of catheter-related infections. JAMA. 2009;302(4):379.

12. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother. 2006;58:281-287. 13. Garland JS, Alex CP, Mueller CD, et al. A randomized trial

com-paring povidone-iodine to a chlorhexidine gluconate-impregnat-ed dressing for prevention of central venous catheter infections in neonates. Pediatrics. 2001;107(6):1431-1436.

14. Olson K, Rennie RP, Hanson J, et al. Evaluation of a no-dressing intervention for tunneled central catheter exit sites. J Infus Nurs. 2004;27(1):37-44.

15. Phillips, LD. Techniques for initiation and maintenance of central venous access. In: Manual of I.V. Therapeutics: Evidence-Based

Practice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis;

2010:458-545.

16. Oncology Nursing Society (ONS). Access Device Guidelines:

Recommendations for Nursing Practice and Education. 2nd ed.

Pittsburgh, PA: ONS; 2004.

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C. When any VAD is removed, the nurse should monitor the vascular access site for 48 hours to detect postinfusion phlebitis; or upon discharge, the patient and/or caregiver should be given instructions about signs and symptoms of phlebitis and the person to contact if this occurs.6_(V)

D. The nurse should use a standardized phlebitis scale that is valid, reliable, and clinically feasible. Two phlebitis scales have demonstrated validity and reli-ability and have been used for adult patients. The population for which the scale is appropriate should be identified: adult or pediatric patients.1,2,6,9,17-21_(IV)

1. The Phlebitis Scale has concurrent validity, inter-rater reliability, and is clinically feasible (below).22_(IV)

2. The Visual Infusion Phlebitis (VIP) scale has con-tent validity, inter-rater reliability, and is clinically feasible. This scale includes suggested actions matched to each scale score.2,23 _(IV)

E. The nurse should participate in quality improvement activities or outcomes evaluation regarding the occur-rence and reporting of phlebitis with infusion therapy (see Standard 7, Quality Improvement).6,9,10,15,20,24-28_(V)

47. PHLEBITIS

Standard

47.1 The assessment and treatment of phlebitis shall be established in organizational policies, procedures, and/or practice guidelines.

47.2 The nurse shall assess the vascular access site for phlebitis; determine the need for and type of intervention; educate the patient and/or caregiver about phlebitis, the intervention, and any follow-up; and assess patient response to treatment.

47.3 The nurse shall document in the patient’s permanent medical record the signs and symptoms of phlebitis using a standardized scale, interventions implemented, and patient response to treatment.

Practice Criteria

A. The nurse should routinely assess all vascular access sites for signs and symptoms of phlebitis based on patient population, type of therapy, type of device, and risk factors. Signs and symptoms of phlebitis include pain, tenderness, erythema, warmth, swelling, induration, purulence, or palpable venous cord; the number or severity of signs and symptoms that indicate phlebitis differ among published clinicians and researchers.1-9_(IV)

B. If phlebitis occurs, the nurse should:

1. Assess the vascular access site for signs, symptoms, and severity of phlebitis using a standardized scale.6,8,9_(V)

2. Determine the possible etiology of the phlebitis— chemical, mechanical, bacterial, or postinfusion— and implement appropriate interventions for midline and peripherally inserted central catheters. Remove the short peripheral catheter (see Standard 44, Vascular Access Device

Removal).1,6,10-15_(V)

3. Assess and document patient response to inter-vention(s).6,8_(V)

4. When the vascular access device (VAD) is removed, consider the need to collaborate with the licensed independent practitioner (LIP) regarding the need for continued or alternative vascular access.6,13,16_(V)

Infusion-Related Complications

The Art and Science of Infusion Nursing

TABLE 1

Phlebitis Scale

Grade Clinical Criteria

0 No symptoms

1 Erythema at access site with or without pain 2 Pain at access site with erythema and/or edema 3

Pain at access site with erythema Streak formation

Palpable venous cord

4

Pain at access site with erythema Streak formation

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F. The nurse should advocate for ongoing improve-ment in phlebitis rates.2,14,17,20-25,28-31_(IV)

G. The nurse should use a consistent, standard, and clinically feasible calculation for short peripheral catheter phlebitis, which may be reported as a phlebitis rate based on point prevalence of short peripheral catheters.2,8,17,18,28,32_(V)

One clinically feasible calculation for point prevalence (measurement at 1 point in time) of peripheral VAD phlebitis rate is:

REFERENCES

1. Finlay T. Safe administration and management of peripheral intra-venous therapy. In: Dougherty L, Lamb J, eds. Intraintra-venous Therapy

in Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:143-166.

2. Gallant P, Schultz A. Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. J Infus Nurs. 2006;29(6):338-345. 3. Gorski L. Intravenous therapy. In: Ackley BJ, Ladwig GB, Swan BA,

Tucker SJ. Evidence-Based Nursing Care Guidelines: Medical-Surgical

Interventions. St Louis, MO: Mosby/Elsevier; 2008:482-488.

4. Lamb J, Dougherty L. Local and systemic complications of intra-venous therapy. In: Dougherty L, Lamb J, eds. Intraintra-venous Therapy

in Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:167-196.

5. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. Ann Int Med. 1991;114:845-854. 6. Perucca R. Peripheral venous access devices. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/

Elsevier; 2010:456-479.

7. Tagalakis V, Kahn SR, Libman M, Blostein M. The epidemiolo-gy of peripheral vein infusion thrombophlebitis: a critical review.

Am J Med. 2002;113(2):146-151.

8. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluat-ed problem. Int J Antimicrob Agents. 2009;34S:S38-S42. 9. Dougherty L, Bravery K, Gabriel J, et al. Standards for Infusion

Therapy: The RCN IV Therapy Forum. 3rd ed. London,

England: Royal College of Nursing; 2010:17,35,60-61,80. 10. Di Giacomo M. Comparison of three peripherally-inserted

cen-tral catheters: pilot study. Br J Nurs. 2009;18(1):8-16. 11. dos Reis P, Silveira R, Vasques C, de Carvalho E. Pharmacological

interventions to treat phlebitis: a systematic review. J Infus Nurs. 2009;32(2):74-79.

12. Eppert H, Goddard K. Administration of amiodarone during resusci-tation of ventricular arrhythmias. J Emerg Nurs. 2010;36(1):26-28. 13. Gabriel J. Long-term central venous access. In: Dougherty L,

Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:321-351.

14. Liu H, Han T, Zheng Y, Tong X, Piao M, Zhang H. Analysis of complication rates and reasons for nonelective removal of PICCs in neonatal intensive care unit preterm infants. J Infus Nurs. 2009; 32(6):336-340.

15. Slim A, Roth J, Duffy B, Boyd S, Rubal B. The incidence of phlebitis with intravenous amiodarone at guideline dose recom-mendations. Milit Med. 2007;172(12):1279-1283.

Number of Phlebitis Incidents

Total Number of IV Peripheral Catheters"100 # % Peripheral Phlebitis

16. Joanna Briggs Institute. Management of peripheral intravascular devices. Austral Nurs J. 2008;16(3):25-28.

17. Powell J, Tarnow KG, Perucca R. The relationship between peripheral intravenous catheter indwell time and the incidence of phlebitis. J Infus Nurs. 2008;31(1):39-45.

18. Van Donk P, Rickard C, McGrail M, Doolan G. Routine replace-ment versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: a randomized con-trolled trial. Infect Control Hosp Epidemiol. 2009;30(9):915-917. 19. Doran DM, Pringle D. Patient outcomes as an accountability. In: Doran DM, ed. Nursing Outcomes: The State of the Science. 2nd ed. Sudbury, MA: Jones & Bartlett Learning; 2011:1-27. 20. Schultz AA, Gallant P. Evidence-based quality improvement

pro-ject for determining appropriate discontinuation of peripheral intravenous cannulas. Evid Based Nurs. 2005;8(1):8.

21. Uslusoy E, Mete S. Predisposing factors to phlebitis in patients with peripheral intravenous catheters: a descriptive study. J Am

Acad Nurse Pract. 2008;20(4):172-180.

22. Groll D, Davies B, MacDonald J, Nelson S, Virani T. Evaluation of the psychometric properties of the phlebitis and infiltration scales for the assessment of complications of peripheral vascular access devices. J Infus Nurs. 2010;33(6):385-390.

23. Bravery K, Dougherty L, Gabriel J, Kayley J, Malster M, Scales K. Audit of peripheral venous cannulae by members of an IV therapy forum. Br J Nurs. 2006;15:1244-1249.

24. Ahlqvist M, Bogren A, Hagman S, et al. Handling of peripheral intravenous cannulae: effects of evidence-based clinical guide-lines. J Clin Nurs. 2006;15:1354-1361.

25. Birk S. Needleless IV access means fewer costs. Mate Manag

Health Care. 2007;16(7):46-48.

26. Biswas J. IV nursing care. Clinical audit documenting insertion date of peripheral intravenous cannulae. Br J Nurs. 2007;16(5): 281-283.

27. Collins AS. Preventing health care-associated infections. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for

Nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency for

Healthcare Research and Quality; March 2008:2–547-2–575. 28. Leone M, Dillon L. Catheter outcomes in home infusion. J Infus

Nurs. 2008;31(2):84-91.

29. Zarate L, Mandleco B, Wilshaw R, Ravert P. Peripheral intra-venous catheters started in prehospital and emergency depart-ment settings. J Trauma Nurs. 2008;15(2):47-52.

30. Barría R, Lorca P, Muñoz S. Randomized controlled trial of vas-cular access in newborns in the neonatal intensive care unit. J

Obstet Gynecol Neonatal Nurs. 2007;36(5):450-456.

31. Bravery K. Paediatric intravenous therapy in practice. In: Dougherty L, Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:408-460.

32. Malach T, Jerassy Z, Rudensky B, et al. Prospective surveillance of phlebitis associated with peripheral intravenous catheters. Am

J Infect Control. 2006;34(5):308-312.

48. INFILTRATION AND

EXTRAVASATION

Standard

48.1 The assessment and treatment of infiltration and extravasation shall be established in organizational policies, procedures, and/or practice guidelines.

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48.2 The nurse shall assess the vascular access site for infiltration and extravasation; determine the need for and type of intervention; educate the patient and/or caregiver about infiltration and extravasation, the inter-vention, and any follow-up; and assess patient response to treatment.

48.3 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of infiltra-tion and extravasainfiltra-tion, interveninfiltra-tions implemented, and patient response to treatment.

Practice Criteria

A. Infiltration and extravasation are reported with all types of peripheral and central vascular access devices (CVADs) and intraosseous devices. The nurse should routinely assess all vascular access sites for signs and symptoms of infiltration and extravasation based on patient population, type of therapy, type of device, and risk factors.1-3_(V)

B. The nurse should determine possible causes of infiltration and extravasation, which include mechanical, pharmacologic, obstructive, and inflammatory factors.1,4,5_(IV)

C. The nurse should immediately stop all infusions when the patient complains of any type of pain, burning, or stinging, at or around the insertion site, catheter tip, or entire venous pathway as this should not be considered within normal limits with any infusion. These symptoms require further assessment to determine appropriate intervention(s).5,6_(IV)

D. The nurse should use a standardized scale for assessing and documenting infiltration/extravasa-tion from all types of vascular access devices (VADs). This measurement should occur initially and regularly until resolution, based on patient con-dition and age; type of fluid; severity of infiltration/ extravasation; type of device; and anatomical loca-tion. Signs and symptoms progress from simple to complex, and the clinical presentation can easily be confused with phlebitis or irritant and flare reac-tions. Early recognition of infiltration/extravasation is critical to limit the amount of fluid that escapes into the subcutaneous tissue and potential subse-quent tissue injury.1,6-10_(III)

E. Frequency of site assessment after infiltration/ extravasation depends upon the drugs involved and the individual patient needs. All changes should be reported to the licensed independent practitioner (LIP).1_(V)

F. The nurse should not rely on alarms from electron-ic infusion pumps to identify infiltration/ extravasation because these alarms are not designed to detect the presence or absence of these complications. Electronic infusion pumps do not cause infiltration/ extravasation; however, they will exacerbate the problem until the infusion is stopped.11,12_(V)

G. All infusions through the peripheral catheter or CVAD should be discontinued at the first sign of infiltration/extravasation, the administration set dis-connected, and all fluid aspirated from the catheter with a small syringe (eg, 3 mL). The peripheral catheter or implanted port needle should be removed after aspiration. Timing of CVAD removal depends on the plan of care. The nurse should notify the LIP about the complication and activate the treatment protocol or other prescribed treatments.6,10,13_(I)

H. The nurse should estimate the volume of fluid that has escaped into the tissue based on the rate of injection or infusion and the length of time since the last assessment. Large volumes (eg, greater than 25-50 mL) of escaped fluid increase the risk of tissue damage, and consultation with a plastic surgeon may be necessary.14_(V)

I. Treatment of infiltration depends on the severity when it is recognized. Treatment may include extremity elevation, thermal manipulation, use of antidotes, and surgical interventions.2_(IV)

J. The nurse should educate the patient and caregiver about the possible progression of the signs and symptoms of infiltration/extravasation, changes that should be reported to the LIP (eg, changes in extremity mobility and sensation, elevated temper-ature, and other signs of infection), to protect the site from sunlight, and the frequency of follow-up visits to the LIP and/or other medical consultants as needed (see Standard 11, Patient Education).1_(V)

K. There is insufficient evidence for the management of infiltration/extravasation in neonates and other pediatric patients. Thermal manipulation is a con-troversial issue, and skin maceration with moist heat is possible.6_(IV)

L. The nurse should monitor clinical outcomes asso-ciated with infiltration, which may include com-partment syndrome with the need for rapid surgi-cal intervention, and nerve injury from excessive compression producing neuropathies and com-plex regional pain syndrome.15-21_(V)

M. The nurse should monitor clinical outcomes asso-ciated with extravasation that may include forma-tion of blisters over a prolonged period (eg, 7-14 days), skin sloughing and tissue necrosis, function-al and sensory loss in the injured area, disfigure-ment and loss of limb, or mastectomy.4,5,22-27_(V)

REFERENCES

1. Polovich M, Whitford J, Olsen M, eds. Chemotherapy and

Biotherapy Guidelines and Recommendations for Practice. 3rd

ed. Pittsburgh, PA: Oncology Nursing Society; 2009.