In the Absence of Standard Guidelines, Here Are the Recommendations and Best Practices for Vascular Access Devices
Lack of standardized selection and maintenance regarding vascular access devices (VADs) across institutions creates challenge for nurses caring for patients with these devices, Dawn Camp-Sorrell, MSN, CRNP, AOCN®, of Children’s of Alabama in Birmingham, said during a session held at the ONS BridgeTM virtual conference on September 14, 2021. To help guide oncology nurses in preventing and managing complications, she provided best practices for central line bundles.
Although the wide variety of VADs are all similar in function, the designs and maintenance requirements are different, Camp-Sorrell explained, which makes standardization difficult and presents challenges in care.
Oncology nurses typically use three types of long-term catheter designs:
- Peripherally inserted central catheter (PICCs), which are inserted by a specialty trained nurse, are used in patients who are critically ill and unable to undergo surgery or anesthesia to receive IV therapy over weeks or months. They are commonly used in patients with chest tumors and are available with triple lumens.
- Tunnel catheters, used in patients receiving long-term therapy and those with prolonged myelosuppression, and are available with three lumens.
- Implanted ports, which have double lumens, offer the advantages of potentially reducing infection, require no maintenance when not accessed, and do not have as many restrictions in terms of patient activities.
Camp-Sorrell noted that very few randomized controlled trials have assessed the devices’ maintenance, so practice standards are usually driven by manufacturers, government regulations, historical data, and individual institutions. Use of central line bundles provides a helpful guideline for preventing infection. Camp-Sorrell recommended including the following techniques as part of a central line bundle of evidence-based practices (https://www.ons.org/access-device-standards) to reduce infection (https://doi.org/10.1186/s12913-020-05221-6).
- Maximal sterile barrier for insertion
- Avoidance of femoral or axilla insertion
- Frequent hand washing before and after care
- Chlorhexidine skin antisepsis
- Daily review of the line necessity and remove if not needed
- Alcohol decontamination prior to hub access
Even with a central line bundle, however, certain areas are subject to different interpretations. For example, no current definitive recommendation is available for maintaining a sterile environment. In addition, use of gloves, masks, and gowns is not addressed.
Camp-Sorrell provided basic infection prevention guidelines that should also be included in central line bundle recommendations.
- Consistent maintenance procedures
- Strict aseptic technique
- Routine surveillance for infection rates
- Nurse, patient, and caregiver education
- Close monitoring of patients with comorbid diseases
When ensuring that dressings are maintained, nurses should protect the exit site, use securement devices, and use an antiseptic, no-touch technique, Camp-Sorrell said. Data are inconsistent to guide standardized care regarding flushing techniques to decrease occlusions, so she recommended using a positive pressure locking technique and flushing after drawing blood samples or administering medications with a 5–10 ml pulsatile technique.
For blood draws from central lines, the most common method is to discard 3–5 ml of blood, draw the specimen, and flush with 10–20 ml of normal saline. However, the best method has not been determined and is an area for future study.
“VADs are a standard component of caring for patients with cancer in all settings,” Camp-Sorrell said. “Despite the common use, current standardized procedure for maintenance care and managing complications are still lacking.”