Thực bành điều dưỡng, quy trình rút catheter lọc máu Practice Standard Skill Level (Nursing): Specialized The following Registered Nurses (RNs) may perform this procedure: 1. RNs who have completed the required hemodialysis (HD) specialty education and who provide nursing care in a BC InCentre andor Community Renal Program AND have received the appropriate training for removal of nontunneled CVCs; 2. Designated RNs who have received the appropriate training for central venous catheter care including removal of temporary CVC lines (e.g., inpatient, home care or ambulatory care RNs or LPNs). Need to Know: 1. Nurses may remove nontunneled catheters upon the order of a physician. Physicians remove tunneled catheters. 2. Standardroutine precautions are used for removing nontunneled catheters to reduce the risk of transmission of bloodborne and other pathogens. Removal of NonTunneled CVC Approved Aug 15, 2011Rev Dec 16, 2011Rev Jun 13, 2012 Page 2 Wash hands before and after manipulation of the CVC and administration lines. If hands visibly soiled, wash with antimicrobial soap; if not, may use either an antimicrobial soap or alcohol hand sanitizer. Wear gloves (nonsterile to remove the dressing and sterile for the rest of the procedure), nonsterile gown and nonsterile maskface shield during catheter removal procedures. 3. Medicalclean aseptic technique is used for removing nontunneled catheters, with additional precautions as follows: Use sterile equipment and supplies and a “no touch” technique when handling the catheter and catheter ports and performing exit site care. Maintain a sterile drape under the catheter ports. 4. Recommended antiseptic solutions, in order of priority: Solution Required Drying Time Chlorhexidine gluconate 2% with alcohol 30 seconds (persistent antimicrobial activity, up to 48 hours) Chlorhexidine gluconate without alcohol 2 minutes Sodium hypochlorite 0.11% (ExSept Plus®) or Amuchina 10% 2 minutes Povidoneiodine 10% (Betadine) 2 minutes 5. Air embolus is a potential catastrophic complication during CVC removal. Two ways to reduce the risk include: Place the patient supine in as flat a position as the patient can comfortably tolerate. Instruct the patient to take a deep breath and to breath out while the catheter is being removed (increases the intrathoracic pressure which minimizes the possibility of air being accidentally drawn into the systemic venous circulation and creating an air embolus).
Removal of Non-Tunneled Central Venous Catheter (CVC) (Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012) Vascular Access Guideline Table of Contents This procedure is posted on the BC Provincial Renal Agency website – Health Professionals Channel – Vascular Access – http://www.bcrenalagency.ca/professionals/VascularAccess/ProvGuide.htm 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Practice Standard Equipment Assessment & Interventions Patient Education & Resources Documentation References Developed By Reviewed By 1.0 Practice Standard Skill Level (Nursing): Specialized The following Registered Nurses (RNs) may perform this procedure: RNs who have completed the required hemodialysis (HD) specialty education and who provide nursing care in a BC In-Centre and/or Community Renal Program AND have received the appropriate training for removal of non-tunneled CVCs; & Designated RNs who have received the appropriate training for central venous catheter care including removal of temporary CVC lines (e.g., inpatient, home care or ambulatory care RNs or LPNs) Need to Know: Nurses may remove non-tunneled catheters upon the order of a physician Physicians remove tunneled catheters Standard/routine precautions are used for removing non-tunneled catheters to reduce the risk of transmission of blood-borne and other pathogens Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page Removal of Non-Tunneled CVC Wash hands before and after manipulation of the CVC and administration lines If hands visibly soiled, wash with antimicrobial soap; if not, may use either an antimicrobial soap or alcohol hand sanitizer Wear gloves (non-sterile to remove the dressing and sterile for the rest of the procedure), non-sterile gown and non-sterile mask/face shield during catheter removal procedures Medical/clean aseptic technique is used for removing non-tunneled catheters, with additional precautions as follows: Use sterile equipment and supplies and a “no touch” technique when handling the catheter and catheter ports and performing exit site care Maintain a sterile drape under the catheter ports Recommended antiseptic solutions, in order of priority: Solution Chlorhexidine gluconate 2% with alcohol Required Drying Time 30 seconds (persistent antimicrobial activity, up to 48 hours) minutes minutes Chlorhexidine gluconate without alcohol Sodium hypochlorite 0.11% (ExSept Plus®) or Amuchina 10% Povidone-iodine 10% (Betadine) minutes Air embolus is a potential catastrophic complication during CVC removal Two ways to reduce the risk include: Place the patient supine in as flat a position as the patient can comfortably tolerate Instruct the patient to take a deep breath and to breath out while the catheter is being removed (increases the intra-thoracic pressure which minimizes the possibility of air being accidentally drawn into the systemic venous circulation and creating an air embolus) 2.0 Equipment Non-sterile gloves Non-sterile gown Non-sterile mask/eye protection (2) Sterile gloves (2 pair) Sterile dressing tray Sterile suture scissors x sterile gauzes (several) Antiseptic solution, preferably chlorhexidine gluconate 2% with alcohol 2x C&S containers (for exit site and catheter tip swabs), if suspect infection Tape Garbage receptacle Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page Removal of Non-Tunneled CVC 3.0 Assessment & Interventions Preparation: Place the patient supine in as flat a position as the patient can comfortably tolerate Wash hands with antimicrobial soap Don non-sterile gown (staff) Don non-sterile mask (staff and patient) Open the tray and add supplies Don non-sterile gloves Remove dressing: Remove exit site dressing and discard dressing Take C&S around the exit site, if ordered or if suspect a local infection Remove gloves and wash hands with antimicrobial soap 10 Don sterile gloves Exit site care: 11 Using a sterile 4x4 gauze soaked in an antiseptic solution, cleanse the catheter exit site skin in a circular motion (exit-site outward to cover a diameter of 10 cm) Discard used gauze 12 Using sterile scissors, carefully remove the sutures that anchor the temporary catheter in place (usually two sutures) 13 Place a dry, sterile 4x4 gauze, folded into four, over the exit site (to help stop the bleeding when the catheter is removed) 14 Instruct the patient to take a deep breath and to breathe out while the catheter is being removed 15 Using a dry, sterile 4x4 gauze, grasp the catheter at its exit site from the skin Remove the catheter, pulling straight out and parallel to the vein while maintaining gentle, constant traction If resistance is encountered, contact the physician Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page Removal of Non-Tunneled CVC 16 Apply pressure to the exit site for a minimum of 10 minutes (longer if bleeding persists) Do not lift the 4x4 gauze to determine if bleeding has stopped (could cause an air embolus) 17 Apply occlusive dressing over venipuncture site 18 Send catheter tip for C&S if ordered or if a systemic infection is suspected 4.0 Patient Education & Resources Occlusive dressing will be in place for at least 24 hours (usually removed at the next dialysis treatment) Notify kidney doctor (nephrologist) or dialysis unit for any of the following: Oozing or drainage from catheter exit site Noticeable swelling or itching around neck Shortness of breath Feverish and any of the above symptoms Resource: Care of Your Catheter http://www.bcrenalagency.ca 5.0 Documentation Document date, time, procedure, integrity of the catheter, condition of the exit site, any bleeding and patient tolerance of the procedure Document if an exit site swab and/or catheter tip is sent for C&S Document the procedure in Dialysis Access module in PROMIS 6.0 References Besarab, A., and Brouwer, D (2004) Aligning hemodialysis treatment practices with the National Kidney Foundation’s K/DOQI vascular access guidelines Dialysis & Transplantation, 33 (11): 694 – 702 BC Provincial Renal Agency Guideline, Prevention, Treatment, & Monitoring of VA Related Infection in HD Patients (March 2008) http://www.bcrenalagency.ca Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page Removal of Non-Tunneled CVC BC Provincial Renal Agency Patient Teaching Pamphlet, Your Catheter (2008) http://www.bcrenalagency.ca Canadian Society of Nephrology Guidelines: Vascular access (2006) Journal of American Society of Nephrology, 17: S18 - S21 O’ Grady et al (2011) Guidelines for the prevention of intravascular catheter- related infections Centre for Disease Control (US) 51 (RR-10): 1-26 Counts, Caroline (Ed) (2008) Core Curriculum for Nephrology Nursing American Nephrology Nurses’ Association; Pitman, NJ Marschall, Jonas et al (2008) Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals, Infection Control and Hospital Epidemiology, 29: supp 1, S22-S30 National Kidney Foundation (2006) KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access Am J Kidney Dis 48:S1-S322, 2006 (suppl 1) O’Grady, Naomi et al (2002) Prevention Guidelines for Catheter-Related Infections, Clinical Infection Diseases, 24: 1281-307 10 Registered Nurses Association of Ontario, Care and Maintenance to Reduce VA Complications (2008) http://rnao.ca/sites/rnaoca/files/Care_and_Maintenance_to_Reduce_Vascular_Access_Complications.pdf 11 Safer Healthcare Now! Campaign (2006) How-to-Guide: Prevent Central Line Infections http://www.saferhealthcarenow.ca 7.0 Developed By BCs Vascular Access Educators Group (VAEG) Adapted from Fraser Health Renal Program guidelines/standards 8.0 Reviewed By British Columbia Renal Educators Group (BCREG) BC Provincial Renal Agency – Medical Advisory Committee (MAC) Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page .. .Removal of Non- Tunneled CVC Wash hands before and after manipulation of the CVC and administration lines If hands visibly soiled, wash... sanitizer Wear gloves (non- sterile to remove the dressing and sterile for the rest of the procedure), non- sterile gown and non- sterile mask/face shield during catheter removal procedures Medical/clean... Tape Garbage receptacle Approved Aug 15, 2011/Rev Dec 16, 2011/Rev Jun 13, 2012 Page Removal of Non- Tunneled CVC 3.0 Assessment & Interventions Preparation: Place the patient supine in as flat