Procedure for flushing central lines, PICC lines and Hickman lines

NHS Ayrshire & Arran guidelines
NHS Ayrshire and Arran

This procedure should be carried out the day following CVAD insertion and once a week following the dressing change. Strict aseptic technique must be used for all CVAD manipulations (appropriately cleaned trolleys must be used in the hospital and trays in the community).  The CVAD must be flushed before and after each intravenous drug administration, blood sampling and/or blood and platelet transfusion.

Hickman and PICC lines should not be used for chemotherapy delivery on the same day as insertion due to the risk of extravasation, especially if more than one puncture has been required at line insertion.

The Vygon TKO needle free device at the end of each line should be changed weekly or when damaged, leaking or soiled followed by a port protector. Octopus extension sets must not be used on PICC or Hickman Lines.

No smaller than a 10ml syringe should be used for drug administration or flushing into the CVAD. This is to prevent excessive pressure being exerted on the lumen which might cause it to rupture.

If you are unable to aspirate from the CVAD or flush the CVAD please refer to appendix 1.

Equipment required

  • sterile dressing pack
  • one pair of sterile gloves
  • plastic apron
  • disposal bag and sharps bin
  • antiseptic hand hygiene product*
  • chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe
  • Vygon TKO needle free device (one per lumen – only needs changed once per week at routine line care and maintenance). Do not use needle free devices with extension sets
  • 0.9% sodium chloride (10mls per lumen). 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile
  • 10iu heparinised 0.9% sodium chloride, (2mls per lumen) – only for Hickman or PICC lines with clamps (do not use in central lines)
  • 10ml Luer-Lok syringes (number depends on how many lumens and if blood sampling required)
  • blunt needles
  • oncology patients only: Curos port protector for each lumen (not sterile, therefore do not place this onto the sterile area)

Procedure for flushing the line

Please note: if your hands are not socially clean and you need to wash your hands with soap and water (rather than alcohol gel), this must be carried out a minimum of 2 meters away from the working surface/dressing trolley and any CVAD equipment.

Procedure

  1. Clean working surface/dressing trolley with detergent wipe and allow to dry completely for at least 30 seconds. Clean hands with alcohol gel as per the WHO 5 moments for hand hygiene. Put on a plastic apron.
  2. Open dressing pack onto clean area and open the necessary equipment onto the dressing pack aseptically.
  3. Clean hands with alcohol gel as per the WHO 5 moments for hand hygiene and apply sterile gloves.
  4. Draw up 0.9% sodium chloride solution for flushing using an aseptic non touch technique (10mls per lumen) or 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile. If the CVAD has clamps draw up heparin sodium solution 10iu/ml using an aseptic non touch technique (2mls per lumen). Heparin should only be used in Hickman and PICC lines with clamps. Heparin should not be used in central lines.
  5. Remove the curos port protector (oncology only). Remove the old Vygon TKO needle free device(s) using sterile swabs and clean the end of the lumen thoroughly with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe for 30 seconds and allow to dry completely for at least 30 seconds. Put on new Vygon TKO needle free devices securely. Do not use needle free devices with extension sets.
  6. Attach a 10ml syringe, open clamp (if applicable) and withdraw 5-10ml stagnant blood, close clamp and discard stagnant blood appropriately. Remember when withdrawing blood from a CVAD without clamps (valved CVAD) gently pull back 1-2mls wait 2-5 seconds for the valve to open and blood to start gently flowing through, prior to aspirating the full amount. If infection is suspected this blood must be sent for blood culture as well as a separate peripheral blood culture sample (see section of this guideline for blood culture procedure). If other laboratory blood samples are required they can be taken once initial 5-10mls of stagnant blood is removed. Do not withdraw any blood if the patient has the CVAD insitu for TPN feeding, unless for blood cultures. TPN lines must not be used for blood samples or the administration of any product other than TPN feeding.
  7. (Open clamp if applicable) and flush with 10mls of 0.9% sodium chloride using a brisk push/pause action, closing the clamp on the last push to create positive pressure in the line.
  8. (If the Hickman or PICC line has a clamp) Attach syringe with heparin sodium solution into needle free device, open clamp and inject the solution with a brisk push/pause action closing the clamp as the last of the solution is inserted. Remove the syringe from the needle free device. Do not use heparin in central lines.
  9. Repeat step 4, 5 & 6 for each lumen.
  10. Oncology patients only: Apply a curos port protector onto the end of each lumen.
  11. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene. Dispose of all waste appropriately as per waste management guidelines.
    1. NHS Ayrshire & Arran segregation of waste.
    2. Hyperlink to waste policy.
  13. Document procedure any problems, action taken and review date in the care bundle DRS 6104 (Appendix 5) and appropriate notes.

Troubleshooting

If there are any problems with CVAD occlusion refer to appendix 1 of the guideline.

If there are any signs of systemic CVAD infection or fracture of the CVAD i.e. fluid leaking from the CVAD when flushing or aspirating refer to appendix 2.