Chapter 17: Vascular access devices: insertion and management
Skip chapter table of contents and go to main content
Post‐procedural considerations
Immediate care
This will depend on the type of VAD that has been inserted (see sections on each individual VAD below in this chapter).
Ongoing care
Discharging patients home with a VAD in situ
Patients may be discharged home with a VAD in situ, which will allow them to receive treatment at home (e.g. continuous chemotherapy or intermittent antibiotics) or allow for easier access on each admission (e.g. via a long‐term CVAD). An early referral to the community nurses is crucial to ensure adequate support for the patient once they are at home (Kayley [239]).
Patients may now receive daily treatment over a 3–5‐day period with an indwelling peripheral cannula (Shotkin and Lombardo [414]). The degree of care is minimal compared with a CVAD, but patients should receive adequate information about the early signs of phlebitis (such as pain, redness and swelling) and what to do in the case of accidental dislodgement or removal of the cannula.
The dressing of choice for PICC and skin‐tunnelled catheter (when required) insertion sites is one that is moisture permeable and transparent (Loveday et al. [278], NICE [350]) and that usually only requires changing once a week (following the initial change within the first 24 hours, if required) (RCN [381], Ryder [393]). This type of dressing may make it difficult for patients to change the dressing themselves and so a carer or community nurse will need to be involved. At the dressing change, the site should be inspected and any signs of erythema or inflammation should be reported to the hospital at once in order for appropriate treatment to be prescribed (DH [117]). The area should be cleaned using an aseptic technique with a 2% chlorhexidine‐based solution (DH [117], Loveday et al. [278], NICE [350]).
If a patient wishes to be self‐caring, the nurse should observe them carrying out the flushing procedure, either in hospital or in the home setting, until they are competent to do so without the supervision of a nurse (Dougherty [123], Gorski et al. [181]). However, some patients prefer the community nurse to take responsibility for maintaining patency. Sufficient equipment (Boxes 17.4 and 17.5) must be supplied to enable the patient or nurse to care for the CVAD from the time of discharge until the patient's next admission (Kayley [239]).
Box 17.4
Example of a CVAD flushing kit
A CVAD flushing kit should contain the following when a patient has a skin‐tunnelled catheter or PICC in situ:
- Needle‐free connectors
- Ampoules of heparinized saline (50 international units heparin in 5 mL 0.9% sodium chloride) or pre‐filled syringes (depending on local practice)
- 2% chlorhexidine in 70% alcohol wipes
- Sterile 10 mL Luer‐Lok syringes
- Blunt drawing‐up needles
- Instruction leaflet to provide both the community nurse and the patient with a point of reference, for example a patient information leaflet on central venous access devices
- Sharps container
Box 17.5
Contents of pack to take home for patients with a PICC
For PICC dressings, a pack containing the following should be sent home with the patient:
- Dressing packs (including gloves)
- Securing device (where required)
- Gauze
- Transparent dressings
- 2% chlorhexidine in 70% alcohol sponges
- Bandages or spare protective sleeves (e.g. tubular bandages)
Education of the patient and relevant others
Patients with long‐term CVADs in situ, such as PICCs or skin‐tunnelled catheters, will require instruction and supervision to ensure adequate understanding of the care and maintenance of their devices (Dougherty [123], Kayley [239]). This must start early within the discharge planning process along with an assessment of the home environment, the patient's manual dexterity, and their physical and medical condition (Kayley [239]). Patient education is one of the most important aspects of care but, to make teaching effective, it is essential to recognize each patient's needs and limitations. It is also vital to acknowledge each patient's past experiences and readiness to learn (Czaplewski [97], Kayley [239]). Education of the patient should encompass care and maintenance of the device as well as signs and symptoms of complications (Kayley [239], RCN [381]). Educational packages should be prepared in the form of practical demonstrations and clear, succinct handouts (Gorski et al. [181], Kayley [239], NICE [351]) (Figure 17.10). It is also important to recognize the need to prepare patients carefully to participate in their own self‐care and therapy (Czaplewski [97]). The patient, their relatives and/or their carers should understand the following:
- how frequently to change the dressing and how to care for the site
- how to maintain patency
- how to inspect for signs of infection or other complications
- how to solve problems and where to seek help (RCN [381]).
Figure 17.10 Patient information booklet on central venous access devices.
Patients should be taught what early signs and symptoms to look out for, what to do if the catheter becomes occluded or damaged, and when and who to contact (along with a contact name and number) if they need professional advice. This will help to alleviate any anxiety (Dougherty et al. [131]). Most problems can be managed at home with the involvement of community nurses and the patient's GP (Kayley [239]).
The most common complications associated with CVADs are infection and thrombosis (Dougherty [123], Kayley [238], RCN [381]). The patient should be told to report:
- signs of redness and tracking at the exit site, along the skin tunnel or up the arm
- any oozing at the exit site
- fevers or rigors.
Patients are no longer routinely prescribed prophylactic warfarin as this has been shown to have no apparent benefit in the prevention of thrombosis (Couban et al. [91], Young et al. [479]). Therefore, it should be stressed to the patient that any of the following signs or symptoms should be reported immediately: breathlessness, pain and/or swelling over the shoulder, across the chest, and/or into the neck and arm. Early reporting will enhance the effectiveness of treatment and may avoid the removal of the device (Bishop [37]).
