Pre‐procedure

ActionRationale

1. 1.Show
   Check the patient's full blood count and clotting profile for that day.
   To ensure that the patient is not at risk of bleeding or infection from this invasive procedure. The patient's platelets should be above 100 × 10⁹/L, their white blood count should be above 2 and their international normalized ratio (INR) should be less than 1.3. In haematology patients, the platelets should be above 50 and the INR less than 1.5 (Dougherty [123], E). Note platelet transfusion guidelines and always follow local policy.
2. 2.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
3. 3.Show
   Screen the bed and ask the patient to remove their clothing down to the waist.
   To ensure ease of access to the patient's chest. E
4. 4.Show
   Ask the patient to lie as flat as possible with their arms by their sides.
   To minimize the risk of bleeding from gravitational pressure and to dissuade the patient from touching the sterile field (Dougherty [129], E; Drewett [134], E).

Procedure

1. 5.Show
   Wash or decontaminate hands as per World Health Organization guidelines.
   To reduce the risk of infection (DH [117], C; Fraise and Bradley [156], E; WHO [469], E).
2. 6.Show
   Palpate and identify the position of the cuff in the patient. This can be done by gently pulling on the catheter and observing for skin pucker.
   To locate the area for the incision (Drewett [134], E; Galloway and Bodenham [165], E).
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   If the cuff cannot easily be felt, measure up from the bifurcation or hub at the end of the catheter distal to the patient, dependent on the type of catheter in situ, then palpate again. If it still cannot be felt, ask for assistance from a more experienced colleague.
   The cuff will be positioned differently depending on the type of catheter. To locate the probable site of the cuff. To guard against malplaced incisions (Dougherty [123], E).
4. 8.Show
   Open the outer bag of the minor operation pack.
   To gain access to the contents. E
5. 9.Show
   Put on a plastic apron and wash hands with soap and water, or an alcohol‐based handrub. Dry hands on the sterile towel provided in the pack.
   To reduce the risk of infection (DH [117], C; Fraise and Bradley [156], E).
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   Put on sterile gloves and assemble all necessary equipment on the sterile pack.
   To maintain asepsis, prepare for the procedure and maximize efficiency (DH [117], C).
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   Advise the patient that you will explain each step of the procedure as you go along if the patient wishes.
   This should take into account the patient's individual wish for information. E
8. 12.Show
   Clean the area directly over the cuff with 2% chlorhexidine in 70% alcohol, using back‐and‐forth strokes, working out from the centre directly over the cuff. Allow the area to dry.
   To reduce the risk of infection. To enable the disinfection process to be completed. To prevent stinging on insertion of the needle (Dougherty [123], E).
9. 13.Show
   Apply a fenestrated drape.
   To create a sterile field to operate within and thereby reduce the risk of infection (Dougherty [123], E).
10. 14.Show
    Inform the patient that you are about to administer the local anaesthetic and that this will cause a stinging sensation.
    To prepare the patient. The first injection can be painful and causes a stinging sensation (BNF [42], C, P).
11. 15.Show
    With a 25 G needle, administer the first millilitre of local anaesthetic intradermally directly over the cuff site, causing a raised bleb.
    To commence the numbing of the area to be incised. To provide a raised area for the next injection and identification of the site (Macklin and Chernecky [287], E).
12. 16.Show
    Give a further 1–2 mL of local anaesthetic subcutaneously, using the bleb as the area for insertion of the needle but directing the needle out and around the area of the cuff site.
    To reduce pain for the patient with repeated injections. To ensure the whole incision area is numb (Dougherty [125], E).
13. 17.Show
    Attach the 23 G needle and with the remaining 4 mL of local anaesthetic give two deeper injections to either side of the cuff area.
    To ensure anaesthesia at a deeper level during the blunt dissection around the cuff (Macklin and Chernecky [287], E).
14. 18.Show
    Test the area above the cuff for numbness and then make the incision over the cuff site (but slightly to the side of the cuff site in very thin patients). The incision should be longitudinal and about 2 cm in length. Ensure that the incision is through the epidermis and dermis.
    To ensure that the patient will not experience any pain. To facilitate identification and removal of the cuff. To allow access to the cuff, which is situated below the dermis. To reduce the risk of cutting through the cuff before the cuff has been identified (Dougherty [123], E; Drewett [134], E).
15. 19.Show
    With one pair of small artery forceps, commence blunt dissection of tissue from around the cuff. At intervals, place your finger (if possible) into the site and feel the cuff.
    To free the cuff from the surrounding fibrous tissue. To assess the mobility of the cuff. To reduce the risks of bleeding and damaging the catheter (Dougherty [123], E; Drewett [134], E).
16. 20.Show
    Continue with blunt dissection around and under the cuff until it feels mobile.
    To facilitate the loosening of the cuff (Dougherty [123], E).
17. 21.Show
    With one pair of artery forceps or the dissecting hook, loop under the cuff and lift it up out of the incision.
    To identify the catheter so as to allow removal (Dougherty [123], E).
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    Once the cuff is free, still maintaining a grip on the cuff, gently and carefully peel away the thin straw‐coloured tissue from the catheter with the blade, ensuring the blade is pulled away from the catheter.
    To free the catheter from the anchoring fibrous bands and enable removal. To reduce the risk of accidental incision of the catheter (Dougherty [123], E).
19. 23.Show
    As the last strands of fibre are separated, the catheter should become free and the white material of the catheter should become visible.
    To ensure that the catheter is completely freed for removal (Dougherty [123], E).
20. 24.Show
    Ask the patient to perform the Valsalva manoeuvre as the proximal portion of the catheter is withdrawn from the vein. Apply gentle pressure at the vein exit site.
    To remove the catheter and prevent bleeding or air entry (Drewett [134], E).
21. 25.Show
    Cut through the catheter using a blade or scissors and remove the distal portion via the skin exit site.
    To remove the distal half of the catheter below the cuff (Dougherty [123], E).
22. 26.Show
    If the catheter has been removed because of infection, carefully cut off the tip (approximately 5 cm) of the catheter using sterile scissors and place it in a sterile container for microbiological investigation.
    To detect any infection related to the catheter and thus provide necessary treatment (DH [117], C).
23. 27.Show
    Close the incision with three sutures (3‐0 prolene). Commence the first suture in the middle of the incision, with the remaining sutures evenly on either side.
    To close the incision efficiently. To ensure that the skin edges and insert are brought together in alignment (Dougherty [123], E).
24. 28.Show
    If there continues to be any bleeding, Steri‐Strips can be applied across the incision over the sutures.
    To minimize blood loss (Dougherty [123], E).
25. 29.Show
    It is not usually necessary to suture the exit site.
    To leave the exit site to granulate without a suture (Drewett [134], E).

Post‐procedure

1. 30.Show
   Apply a small pressure dressing and cover with an airtight dressing.
   To absorb any slight bleeding and to maintain a clean site (Dougherty [129], E; Scales [400], E).
2. 31.Show
   Advise the patient that there might be some oozing and to reapply a dry dressing after 24 hours and thereafter once a day until the sutures are removed. Advise the patient that the sutures should be removed in 7–10 days.
   To ensure that the incision has fully closed and healed (Dougherty [123], E; Drewett [134], E).
3. 32.Show
   Dispose of the equipment in the appropriate containers.
   To reduce the risk of environmental contamination (DH [117], C). To ensure safe disposal in the correct containers and avoid laceration or injury of other staff. To prevent reuse of equipment (NHS Employers [346], [347], C).
4. 33.Show
   Ask the patient to rest on the bed for the next 30–60 minutes, or longer if required, especially patients who are prone to bleeding.
   To reduce the risk of bleeding and air embolism as the patient sits or gets up (Dougherty [123], E; Dougherty [129], E).
5. 34.Show
   Liaise with the nursing team and document the date, time and reason for removal; type of local anaesthetic used (volume and percentage); and any problems in the nursing and medical notes.
   To ensure there is good communication between all teams and a written record of the procedure (NMC [356], C).