Procedures for Hickman Central Hickman Line/Central Line Flushing

PROCEDURES FOR HICKMAN LINE/CENTRAL LINE FLUSHING

Objectives

To maintain the patency of the Hickman/Central lines by flushing in an aseptic manner. To promote patient and family education if appropriate.

Equipment

Sterile wound care pack.
10ml syringe x 3.
10ml normal saline for injection.
5ml sterile heparinised saline injection 10 units of Sodium Heparin per ml.
CX1 chlorhexidine gluconate in alcohol spray or 2 large alcohol wipes and 1pr sterile forceps. (Sterets are not suitable).
Sterile catheter bung.
Sterile gloves if not contained in wound care pack.

Procedure	Rationale
1. Prepare a clean work surface and wash hands.	To minimise infection risk.
2. Collect together all the equipment required.	To ensure the procedure is completed without interruption.
3. Explain the procedure to the patient.	To provide patient education.
4. Using aseptic technique open the dressing pack. Open onto the sterile field the needles, bung and syringes. If using the Alcowipes, open packets and remove using forceps.	To maintain asepsis.
5. Ask the patient to expose the catheter end and ensure the line is clamped off.	To prevent blood loss of air entry into the catheter.
6. Clean the exposed end of the catheter with an alcohol wipe and discard or spray with the CX1 spray and allow to dry. Place the cleaned catheter on the sterile drape. If using CX1 spray some onto the gauze squares.	To clean the catheter prior to placing on the sterile field.
7. Wash hands. Apply the sterile gloves. Using an aseptic technique, draw up the 10ml of normal saline for injection and the 4ml of heparinised saline injection, place the syringes on the sterile field, needles removed.	To maintain asepsis.
8. Using a second Alcowipe or the gauze squares, pick up and clean the area around the bung. Remove the bung and attach the 10ml syringe.	To clean the catheter.
9. Unclamp the catheter and aspirate 3-5ml of blood from the line. Reclamp the line and discard the syringe and blood into a sharps bin.	To remove any static blood in the catheter and check the position of the catheter tip.
10. Attach the syringe with ten ml of saline, unclamp the line and flush. Reclamp line, remove and discard the syringe.	To clear the line of any blood and check line patency.
11. Attach the 10ml syringe with the heparinised saline, unclamp the line and smoothly inject the heparinised saline, clamping the catheter while instilling the last 1ml.	To instill the hepsaline lock and prevent a vacuum which can pull a small amount of blood into the catheter tip.
12. Clean the hub of the catheter and fit the new bung.
13. Repeat the procedure if required, if the catheter has multiple lumens.

Notes

After insertion and prior to first use all patients must have a chest x-ray to check catheter placement. This must be reviewed by Medical Staff who must document in the medical records the catheter can be used.

All Hickman lines should be flushed twice weekly as a minimum, if problems with blockages develop, the flushing can be increased up to daily.

Central lines can be positional and may not allow aspiration of blood. If this occurs, ask the patient to change position eg. lie on side, take deep breaths or raise their arms above their head. If this fails to result in aspiration of blood, then attempt to flush the catheter with normal saline gently. If no resistance is felt, continue with the heparisation procedure. If there is resistance to flushing notify the Medical Officer and order a chest x-ray to monitor placement.

If Bionector bungs are used, they are replaced weekly and the aspiration and flushing procedure is performed through the bung.

Taking Blood Specimens

To take blood specimens follow the flushing procedure an extra 20ml syringe is needed. At stop 9. after aspirating and discarding the first 5ml of blood, attach the 20ml syringe and withdraw adequate blood for the specimens required and then flush as per procedure.

If a Hickman line infection is suspected, aspirate 10ml of the hepsaline and blood from the catheter do not discard and place in blood culture bottles as per usual protocol. Label clearly Hickman catheter sample.

Connection & Disconnection to an IV Line

To connect to an IV line, the flushing procedure is followed to step 10, the line is attached instead of step 11.

When disconnecting from an IV line, the procedure is followed but at step 8 the IV line is disconnected and the procedure followed from stop 10.

Suspected Hickman Line Infection

If a patient with a Hickman line insitu is febrile or having chills or rigors after any Hickman line manipulation, then infection should be suspected and blood cultures performed.

The procedure for taking pathology specimens is followed but the first hepsaline and blood aspirated is cultured, this is most likely to yield a positive result, all lumens must be separately cultured.

Peripheral blood cultures must be taken at the same time and clearly labelled Peripheral Blood. If antibiotic therapy is commenced, it must be given via the Hickman line with doses alternating down the lines if the catheter if dual lumen.

Following treatment of an infective episode, a set of monitoring cultures should be taken 3 � 7 days after the cessation of antibiotic therapy.

References

Nursing Procedure Manual, Bard Access Systems, June 1994.

British Journal of Haematology 1997 1041�1047 BCSH Guidelines on the Insertion and Management of Central Venous Lines.

Revised July 2001

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