Vascular Access Device (VAD) Management Page 1 of 21

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

TABLE OF CONTENTS

Definitions………………………………....…………………………....………………………………………….. Page 3
CVAD Post-Insertion Dressing Care………….………………………………………………………………….. Page 4
VAD Maintenance Care………….………………………………………………………………………………... Pages 5-8
Dressing Care …………………………………………………………………………………………………. Page 5
Flush Management …………………………………………………………………………………………. Page 6
Needleless Connector Management………………………………………………………………………….. Page 7
Tubing Management………………....…………….……………………………...………………………….. Page 8
Implanted Venous Ports: Access and Management……….…………………………………………………….. Page 9
VAD Complications………………………………………………………………………….…………………….. Pages 10-13
Skin Impairment…….………………………………………………………………………………………… Page 10
Site Complication/Infection…………………………………………………………………………………… Page 11
Phlebitis …………………………....…………….……………………………...……………………………... Page 12
CVAD Device-Related …………………………....…………….……………………………...……………… Page 13

CVAD = central venous access device

PICC = peripherally inserted central catheter
CICC = centrally inserted central catheter

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 Vascular Access Device (VAD) Management Page 2 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

TABLE OF CONTENTS - continued

APPENDIX A: CLABSI Bundle……………….....…………………………………………….………................ Page 14

APPENDIX B: Flush Panel .……………………………………………………………………………………… Page 15
APPENDIX C: Venous Access Procedure Orders……………………………………………………………….. Page 15
APPENDIX D: Pediatric Routine Catheter Flush……………………………………………………………….. Page 16
APPENDIX E: Skin Prep Allergy Recommendations..………………………………………………………….. Page 16
APPENDIX F: Alternative Adhesive Dressing Recommendations……………………………………………... Page 17
APPENDIX G: Infusion Nurses Society Phlebitis Scale ..…………………………………………….………..... Page 18
Suggested Readings …………...……………………………………………………………...…………………..... Pages 19-20
Development Credits ……………...………………………………………………………………...……………… Page 21

CLABSI = central line-associated blood stream infection

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 Vascular Access Device (VAD) Management Page 3 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

DEFINITIONS

Acute Care Procedure Team: A team comprised of specialized Advanced Practice Providers (APP) that are trained in placement, management, and removal of central venous access devices.

Apheresis catheter: A large bore CVAD that is typically greater than 10 French or more in size that is used for apheresis procedures as well as other infusions as indicated.

Central Venous Access Device (CVAD): Includes peripherally inserted central catheter (PICC) and all centrally inserted catheters including non-tunneled, tunneled, or implanted catheter with the
catheter tip ending in the vena cava, such as a subclavian, femoral, and internal jugular.

Centrally Inserted Central Catheter (CICC) [also known as central venous catheter (CVC)]: Includes tunneled or non-tunneled central venous catheters.

Infusion Therapy Team (ITT): A team comprised of registered nurses who are skilled and educated in the management and care of central and peripheral venous access devices.

Implanted venous port: A surgically placed central venous catheter that is attached to a reservoir located under the skin.

Non-Tunneled Centrally Inserted Catheter (Non-Tunneled CICC): A catheter inserted by direct venous puncture through the skin in the subclavian, jugular or femoral areas without tunneling.

Peripherally Inserted Central Catheter (PICC): A central venous catheter inserted into an upper extremity vein that is threaded within the superior vena cava.

Tunneled Centrally Inserted Catheter (Tunneled CICC): A catheter that is tunneled under the skin before entering the venous system which can either be cuffed or non-cuffed. Cuffed indicates that
the catheter has a small cuff promoting tissue growth for catheter adherence.

Vascular Access Device (VAD): Any device utilized for venous access regardless of location. These include peripheral intravenous catheter (PIV), peripherally inserted central catheter (PICC),
centrally inserted central catheter (CICC), and implanted venous port.

Vascular Access Team (VAT): A team that is comprised of the Acute Care Procedure Team and the Infusion Therapy Team engaged in the planning and management of patients requiring vascular
access.

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 Vascular Access Device (VAD) Management Page 4 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

CVAD POST INSERTION DRESSING CARE1

MANAGEMENT

Yes Dressing change should occur 7 days post insertion or if clinically indicated 2
Is a sterile
Post-CICC/ transparent dressing
PICC with CHG impregnated
insertion disc used?
No To ensure gauze dressing is removed3,4, initiate dressing change within 2 days
post-insertion or as clinically indicated1

For post-procedure
Apply sterile transparent patient education,
Dressing and needle must be changed after 7 days or
dressing with CHG
if clinically indicated2,5 refer to patient
Yes impregnated disc education materials6
Post-implanted
Is port accessed
venous with needle in
port insertion place? Steri-Strips™ or surgical glue should not physically
Yes
be removed during the first two weeks post-surgery
No
Is site
open to air?
If a sterile transparent or non-transparent dressing is
No
present, remove after 2 days and leave open to air

1
See Appendix A for Central Line-Associated Blood Stream Infection (CLABSI) Bundles
2
Immediate dressing change is required when dressing is soiled, damp, reinforced, or no longer intact. Refer to CVAD Maintenance Dressing Change on Page 5.
3
Best practice indicates that gauze should only be used when clinically appropriate; sterile transparent dressing with CHG impregnated disc is recommended post-insertion
4
If unable to determine if gauze is present, initiate CVAD Dressing Care: Maintenance Dressing Change within 2 days post-insertion or as clinically indicated
5
Needle change is only required if port has been accessed greater than 7 days
6
Central Line (CVC/PICC) Patient Checklist (https://www.mdanderson.org/patient-education/Infusion-Therapy/Central-Line-(CVC-PICC)-Patient-Checklist-Infusion-Therapy_docx_pe.pdf)
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 Vascular Access Device (VAD) Management Page 5 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

VAD MAINTENANCE CARE: DRESSING CARE1

DRESSING TYPE AT PRESENTATION MANAGEMENT

Transparent chlorhexidine
gluconate (CHG)
impregnated dressing or
transparent dressing with
CHG impregnated disc 2
● Change dressing using institutional standard dressing change process4 at least every 7 days or as clinically indicated5
● If skin or site related complications are noted, refer to Pages 10-11 for management
Note:
Non-transparent dressing with
● For patients with CHG allergy, follow CHG allergy standard of care dressing deviation protocol:
Patient presents CHG impregnated disc 3
○ First line: alternative bordered transparent dressing with equivalent skin prep; change every 7 days or as clinically
for dressing indicated
change
○ Second line: non-transparent dressing with equivalent skin prep; change every 2 days or as clinically indicated
Transparent dressing
without CHG
impregnated disc

Gauze dressing
(i.e., any non-transparent
● Change dressing using institutional standard dressing change process5 at least every 2 days or as clinically indicated4
dressing without CHG
● If skin or site related complications are noted, refer to Pages 10-11 for management
impregnated disc or gauze and
tape)

1
See Appendix A for Central Line-Associated Blood Stream Infection (CLABSI) Bundles
2
Institutional standard; considered best practice and recommended as dressing of choice for standard of care
3
Avoid in patients with implanted ports, receiving vesicants, or inability to verbalize pain or discomfort
4
Immediate dressing change is required when dressing is soiled, damp, reinforced, or no longer intact (i.e., dressing corners are lifted to the extent that allows access to the insertion site, or exposure of catheter wings)
5
Refer to Infection Control Associated with Vascular Access Devices (VADs) Policy (#CLN0441)

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 Vascular Access Device (VAD) Management Page 6 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

VAD MAINTENANCE CARE: FLUSH MANAGEMENT - ADULT1,2

CATHETER TYPE MANAGEMENT

PIV Flush with preservative-free (PF) 0.9% NS 10 mL before and immediately after each use, and every 12 hours when not in use

● Inpatient: Flush each lumen with PF 0.9% NS 10 mL before and immediately after each use, every 12 hours for all lumens not in use, and
Adult CICC 10 French or
all lumens upon hospital discharge
less (excluding implanted ● Outpatient: Flush each lumen with PF 0.9% NS 10 mL before and immediately after each use, and upon completion of outpatient treatment
venous ports)4,5 ● Home care: Flush each lumen with PF 0.9% NS 10 mL daily
Routine
● Inpatient: Flush each lumen with PF 0.9% NS 10 mL before and immediately after each use, every 12 hours for all lumens not in use, and
catheter
all lumens upon hospital discharge
flush3
● Outpatient: Flush each lumen with PF 0.9% NS 10 mL before and immediately after each use, and upon completion of outpatient treatment
Yes ● Home care: Flush each lumen with PF 0.9% NS 10 mL daily for CICC and monthly for implanted venous port

Implanted venous ports

or CICC greater than Heparin CICC
10 French (i.e., apheresis allergy? ● Inpatient: Flush each lumen with PF 0.9% NS 10 mL before and immediately after each use. Flush with PF 0.9% NS 10 mL

catheters)4,5 followed by a heparin 2 mL (100 units/mL) daily for lumens not in use and upon hospital discharge.
● Outpatient: Flush each lumen with PF 0.9% NS 10 mL and heparin 2 mL (100 units/mL) upon completion of treatment
No ● Home care: Flush each lumen with heparin 2 mL (100 units/mL) daily
Implanted venous port
● Inpatient: Flush with PF 0.9% NS 10 mL before and immediately after each use, or every 12 hours when not in use.
For pediatric flush management, see Appendix D Upon discharge and deaccess, flush with PF 0.9% NS 10 mL and heparin 2 mL (100 units/mL).
Pediatric Routine Catheter Flush ● Outpatient: Flush with PF 0.9% NS 10 mL before and after each use, and heparin 2 mL (100 units/mL) upon completion
of treatment
● Home care: Flush with PF 0.9% NS 10 mL and heparin 2 mL (100 units/mL) monthly

1
See Appendix A for Central Line-Associated Blood Stream Infection (CLABSI) Bundles
2
For flushing/locking arterial catheters, dialysis catheters, or implanted peritoneal ports, follow specific institutional orders as directed by physician
3
Order appropriate flush from Flush Panel, see Appendix B
4
Manage CVAD as clinically indicated, see Appendix C for Venous Access Procedure Orders
5
See Catheter Patency Problems in Appendix C (Venous Access Procedure Orders) and Central Vascular Access Devices (CVAD) – Restoring Patency Due to Thrombotic or Precipitant Occlusion Policy (#CLN0859)

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
VAD MAINTENANCE CARE: NEEDLELESS CONNECTOR MANAGEMENT1

EVALUATION MANAGEMENT

● Scrub needleless connector injection sites before and in between each access using a CHG antiseptic swab 3 per
manufacturer’s recommendations, unless contraindicated by patient allergy
○ If contraindicated, scrub needleless connector with alcohol for a minimum of 30 seconds and allow to dry for a minimum
of 30 seconds. Refer to Infection Control Associated with Vascular Access Devices (VAD) Policy (#CLN0441) for
Yes additional considerations (i.e., blood culture collection).
● Access the needleless connector using only sterile devices and with clean technique
4
● Change needleless connectors during primary tubing change
● Needleless connectors are not to be changed earlier than 4 days, unless blood is visible or needleless connector is removed
Is connector
accessed?

● Change un-accessed needleless connector at least every 7 days

Yes
No ○ Needleless connectors are not to be changed earlier than 4 days, unless blood is visible or needleless connector is removed
for therapy
Is needleless 4
● For any un-accessed needleless connectors or unused y-sites or ports, use a single-use passive disinfecting port protector
connector
(i.e., Curos cap) according to manufacturer’s recommendations
present2?

No

● Forlumens without needleless connector: clamp lumen and attach new needleless connector
● Contact Vascular Access Team for decontamination procedure prior to use

1
See Appendix A for Central Line-Associated Blood Stream Infection (CLABSI) Bundles
2
A neutral needleless connector should be used with all vascular access devices
3
CHG antiseptic swab is comprised of 3.15% chlorhexidine gluconate and 70% isopropyl alcohol
4
Currently only used for inpatient CVAD maintenance care. Refer to Infection Control Associated with Vascular Access Devices (VAD) Policy (#CLN0441).

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 Vascular Access Device (VAD) Management Page 8 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
VAD MAINTENANCE CARE: TUBING MANAGEMENT1

EVALUATION MANAGEMENT

● Aseptically connect new primary tubing to VAD lumen

needleless connector
2
● Use extension tubing minimally and only when
Change primary and secondary tubing at least every
indicated [i.e., outpatient self-care or for procedure(s)] 4 days unless otherwise indicated3
Yes
● If applicable, use new secondary tubing
Will the
VAD be used
immediately?
Yes
No
Is this a
new VAD Refer to Flush Management on Page 6 and VAD Needleless Connector Maintenance on Page 7
insertion?
No
Change primary tubing and secondary tubing at least every 4 days unless otherwise indicated3

1
See Appendix A for Central Line-Associated Blood Stream Infection (CLABSI) Bundles
2
Change extension tubing in the inpatient setting every 4 days during manifold change when in use. In the outpatient setting, or when not in use, change within 7 days. Change as clinically
indicated if blood is noted in the tubing or needleless connector.
3
Change tubing:
● Every 24 hours if used for intermittent infusions when directly connected to VAD lumen
● Every 24 hours if used for blood products, total parenteral nutrition (TPN), or lipid emulsions
● Every 6-12 hours if used for propofol (dependent on indication and per manufacturer’s recommendation)
● Every 3 days if used for Interleukin-2

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
IMPLANTED VENOUS PORT: ACCESS AND MANAGEMENT

● Port ready for use

PRESENTATION
Patient presents with
an implanted port and
requires access1,2
MANAGEMENT
● For pain or swelling during infusion:
○ Stop infusion, assess site, and
contact primary team
○ For suspected infiltrations or
extravasations, initiate
infiltration/extravasation
Yes protocol immediately. Refer to
● Proceed with port access 5 Vascular Vesicant/Irritant
● For dressing management,
Administration and Extravasation
see Page 5 Policy (#CLN0986).
Is port ● Port can remain accessed for
Yes ● For flushing, needleless
patent? sequential daily treatment but
Is access connector and tubing
maintenance, see requires a needle change every
3 site intact and
Verify port placement 7 days
free of signs4 Pages 7-8
and documentation No
of infection?

No Contact Vascular Access Team

Port cannot be used until
and/or primary team
patency has been restored6,7

1
Manage, access, and de-access implanted ports as clinically indicated
2
For patients requiring a topical anesthetic, see Appendix B Venous Access Procedure Orders
3
Refer to Central Vascular Access Device (CVAD) Assessment and Tip Position Verification Policy (#CLN1036)
4
Pain, swelling, tenderness, and redness
5
Needle selection based on:
● Appropriate gauge for therapy or testing (i.e., 20 gauge is considered standard of care; some diagnostic imaging studies require a 19 gauge needle)
● Appropriate length based on reservoir palpation (i.e., 3/4 inch, 1 inch, 1 ½ inch)
● Appropriate needle type: access power injectable ports with power rated needles
6
Refer to Central Vascular Access Devices (CVAD) – Restoring Patency Due to Thrombotic or Precipitant Occlusion Policy (#CLN0859)
7
For orders, see Catheter Patency Problems in Appendix C (Venous Access Procedure Orders)

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
VAD COMPLICATIONS: SKIN IMPAIRMENT

● Consider using an alternative dressing that is non-irritating and non-sensitizing, see Appendix F
● Ensure skin prep solution is completely dry before applying dressing
Yes
● Ensure skip barrier is applied to area of skin where dressing is placed (do not apply at insertion site)
● If skin injury not resolved within 1 week, contact primary team/Vascular Access Team for further evaluation

Skin injury1 Is the skin

intact?
● Consult Vascular Access Team
○ Assess and approximate size of skin injury
Patient No ○ Use a non-alcohol containing antiseptic agent and an alternative dressing that is non-irritating, see
presents Appendix E and Appendix F
with skin ● If skin injury not resolved within 3 days, contact primary team/Vascular Access Team for further evaluation
impairment
(i.e., MARSI)
● Rule out other skin complications (i.e. infiltration/extravasation, phlebitis, or other skin conditions)
● Change type of skin prep solution, see Appendix E for Skin Prep Allergy Recommendations and reassess in

Skin irritation2 24 hours or if symptoms worsen. In the inpatient setting, notify VAT. In the outpatient setting, instruct
(i.e., contact patient to return to Vascular Access Clinic for reassessment.
dermatitis) ● If unresolved, consider changing type of dressing and reassess in 24 hours or if symptoms worsen, see
Appendix F for Alternative Adhesive Dressing Recommendations
● Contact primary team/Vascular Access Team if symptoms have not improved in 3 days. Dermatology
consult or referral may be warranted for persistent skin irritation.

MARSI = medical adhesive-related skin injury

1
Presence of skin tears, blistering, irregular shiny skin, appearance or lesions lasting longer than 30 minutes
2
Redness, burning, presence of lesions, and/or pruritis

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

VAD COMPLICATIONS: SITE COMPLICATION/INFECTION

● Outpatient nursing:
○ Notify primary team or send patient to Emergency Center for evaluation
● Inpatient nursing:
Yes
○ Notify covering provider/primary team immediately
3
○ Use sterile non-woven gauze and a transparent dressing if exudates present
○ Monitor for signs of bloodstream infection

Yes Is the patient ● Outpatient nursing:

febrile? ○ Notify Vascular Access Team for further evaluation. For after clinic hours and on
weekends, notify primary team.
3
○ Use sterile non-woven gauze and a transparent dressing if exudates present
○ If site impairment worsens or requires more than 2 dressing changes within
Patient No
Are there 2 days, notify primary team/Vascular Access Team immediately
presents ● Inpatient nursing:
signs of site
with site ○ Use sterile non-woven gauze and a transparent dressing if exudates present
3
infection2?
complication1 ○ Monitor for signs of bloodstream infection
○ Notify covering provider/primary team

● Assess site, apply new gauze dressing, and notify primary team/Vascular Access Team
No ● If site impairment worsens or requires more than 2 dressing changes within 2 days, notify
primary team/Vascular Access Team for further interventions

1
Lymphatic drainage and/or bleeding
2
Redness, warmth, induration, and/or purulent drainage
3
Follow VAD Maintenance Care: Dressing Care on Page 5

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
VAD COMPLICATIONS: PHLEBITIS

POTENTIAL CAUSE(S) MANAGEMENT

● For PICC:
○ Notify primary team to consider alternative vascular access and order removal of PICC
Suppurative2
○ Post-catheter removal, assess exit site daily for 2 days
● For PIV: Remove catheter immediately and monitor site for 2 days

● Assess site and then stabilize catheter, if appropriate3

● Apply heat, elevate limb, and monitor for 2 days
Mechanical
○ If signs or symptoms worsen, notify primary team and Vascular Access Team
Patient presents with for possible removal or other vascular access options
suspected phlebitis1

● Stop infusion
During infusion
● Contact primary team for further interventions

Chemical
● Assess site and notify primary team. Other pharmacologic interventions may be warranted.
Post infusion
● For PICC:
(up to 2 days
○ Consider alternative vascular access and removal. Assess site daily for 2 days.
after completion)
● For PIV: Remove catheter immediately and monitor site for 2 days

1
Use phlebitis scale to grade; see Appendix G
2
Thrombophlebitis associated with fever, purulent drainage, or positive culture
3
Refer to Care of Phlebitis Associated with PICC and Peripheral Venous Catheter Device Policy (#CLN0857)

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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
VAD COMPLICATIONS: CVAD DEVICE-RELATED

Notify primary team and Vascular Access Team for further

Yes
interventions
Severed, ruptured, or
Assess for symptoms of embolism1 and Is patient
leaking catheter
clamp catheter above the severed or hemodynamically
(CICC, PICC,
ruptured portion (if applicable and visible) stable?
implanted port) ● Immediately position patients showing symptoms of air embolism
onto left side in Trendelenburg and place patient on oxygen
No
● Notify Merit team/Code Blue (Rapid Response) team
● Notify primary team and Vascular Access Team

Ballooning catheter
(CICC, PICC)
(Do not use catheter
unless approved by
provider)
● Stop any infusion and clamp catheter. Assess catheter integrity if severed or ruptured (if present,
refer to Severed, ruptured, or leaking catheter pathway above).
● Notify primary team for further interventions
● Exchange or removal must occur immediately, consult Vascular Access Team for recommendations

Catheter resuture2,3
Consult Vascular Access Team3 to evaluate for resuture if loose, tight or missing sutures are noted
(CICC, PICC)

CVAD tip
malposition4,5
(Do not use catheter Consult Vascular Access Team to evaluate/recommend appropriate intervention
unless approved by
provider)
1
Catheter embolism symptoms: changes in blood pressure, arrhythmias, cough, shortness of breath, chest pain, or weak pulse
2
See Appendix C for Venous Access Procedure Orders
3
Catheter resuture may be performed by specially trained provider
4
Malposition refers to when catheter tip is not located in acceptable position for infusion. Refer to policy Central Vascular Access Device (CVAD) Assessment and Tip Position Verification Policy (#CLN1036).
5
Obtain new chest x-ray if malposition is greater than 30 days from insertion confirmation x-ray
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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.
APPENDIX A: Central Line-Associated Blood Stream Infection (CLABSI) Bundles
Central Line Insertion Bundle
● Choose the best insertion site, catheter type, and number of lumens based on individual patient assessment to minimize infections and other related noninfectious complications. For adult patients,
the femoral vein should be avoided unless other sites are unavailable.
● Adhere to a strict hand hygiene protocol
● Use a Standardized Central Line Insertion Checklist
● Use a Standardized Central Line Insertion Supply Kit
● Insert catheter using aseptic technique, which includes maximum sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile full body drape)
● Prepare the insertion site using greater than 0.5% chlorhexidine with alcohol skin prep; allow prep solution to completely dry before inserting the catheter
TM
● If a CHG skin prep solution is contraindicated, use an alcohol combined with an alternative skin prep solution (i.e., Duraprep )
● Proper application of a sterile dressing placement with a chlorhexidine disc. A transparent dressing with a chlorhexidine disc is standard of care for all CVADs or accessed implanted ports post
insertion
● Application of an institutionally approved needleless connector post insertion
Central Line Maintenance Bundle
● Adhere to strict hand hygiene practice when handling any VAD
● Standardized catheter hub, needleless connector, and administration tubing care:
○ Use only sterile devices to access the catheter
○ Scrub the access port of the needleless connector using friction with a CHG device swab prior and in between each access (i.e., between each syringe attachment) and allow to dry per
manufacturer’s recommendations
TM
○ Use a passive disinfecting port protector (i.e., Curos cap) on all unused lumens or open ports according to manufacturer’s recommendation
○ Aseptically change needleless connector and administration sets per policy
○ Maintain a closed administration system by limiting tubing disconnections
● Standardize flushing care:
○ Daily maintenance flushing of each lumen ○ Use push-pause technique when flushing
● Standardized dressing change care:
○ Perform daily site inspection and dressing integrity audits
○ Perform routine dressing change using aseptic technique including the use of sterile gloves and mask, CHG skin prep scrub for a minimum of 30 seconds and allow to dry per manufacturer’s
recommendation
○ Change gauze dressing (i.e., any type of dressing where gauze has been applied over the insertion site or non-transparent dressing without a CHG disc) every 2 days
○ Change all transparent dressing without gauze or non-transparent dressing with a CHG disc every 7 days
○ Immediately replace dressings that are soiled, damp, no longer intact, have been reinforced, have corners that are lifted allowing accessibility to insertion site, or expose catheter wings
● Perform daily audits regarding VAD necessity
● Patient education on personal and oral hygiene (i.e., CHG bathing)
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Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

APPENDIX B: Flush Panel1 APPENDIX C: Venous Access Procedure Orders1

Adult VAD Flush Panel Procedure Per Parameter: No Cosign Required
PIV insertion and implanted Lidocaine/Prilocaine 2.5/2.5% cream
● Preservative-free (PF) 0.9% Normal Saline (NS) 10 mL flush syringe
venous port access
● 0.9% NS 50 mL
● 0.9% NS 100 mL
PICC insertion/non-tunneled Adult/Pediatric CVAD Flush Panel
● 0.9% NS 250 mL
CICC exchange Lidocaine 1% 10 mL (buffered or non-buffered)
● 0.9% NS 500 mL
2 Chest x-ray (2 view preferred)
● Lock-flush heparin solution 2 mL (100 units/mL)
● Dextrose 5% in water (D5W) injection flush syringe 10 mL Non-tunneled CICC insertion Adult/Pediatric CVAD Flush Panel
● D5W 50 mL Lidocaine 1% 30 mL (buffered or non-buffered)
● D5W 100 mL Chest x-ray (2 view preferred)
● D5W 250 mL INR, platelets

Pediatric CVAD Flush Panel PIV insertion and implanted Adult/Pediatric CVAD Flush Panel
venous port access and
● Preservative-free (PF) 0.9% Normal Saline (NS) 10 mL flush syringe deaccess/routine CVAD flush
● For patients less than or equal to 10 kg: Resuture Lidocaine 1% 10 mL (buffered or non-buffered)
2
○ Lock-flush heparin solution 2 mL (10 units/mL)
● For patients greater than 10 kg: Catheter patency problems Adult/Pediatric CVAD Flush Panel
2
○ Lock-flush heparin solution 2 mL (100 units/mL) Alteplase (CathfloTM Activase®) 2 mg/2 mL
● 0.9% NS 25 mL Chest x-ray (2 view preferred)
● 0.9% NS 100 mL
Suspected site infection Mupirocin 2% ointment (Bactroban®)
● D5W 50 mL
Non-tunneled CICC/PICC Single dose petrolatum-based ointment packet
1
removal
Selection of supply is dependent on manufacturer’s availability
2
If patient has heparin allergy, may use alteplase (tPA) or saline as directed by physician Adult/Pediatric CVAD Flush Panel
Malposition/rapid saline power
flush Chest x-ray (2 view preferred)

First time Adult/Pediatric CVAD Flush Panel

CVAD assessment Chest x-ray (2 view preferred)

Department of Clinical Effectiveness V4

Approved by The Executive Committee of the Medical Staff on 04/30/2019
 Vascular Access Device (VAD) Management Page 16 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

APPENDIX D: Pediatric Routine Catheter Flush1 APPENDIX E: Skin Prep Allergy Recommendations
Pediatric PICC/CVAD/Accessed Implanted Port (excluding hemodialysis catheters)2 ● Allergy to CHG:
○ Intact skin: Use 70% isopropyl alcohol3 followed by
● For patients greater than 10 kg:
povidone-iodine4 or a combination of alcohol and iodine
○ Flush before and immediately after each use with PF 0.9% NS 10 mL
solution5
○ Flush each unused lumen once daily with PF 0.9% NS 10 mL and 4
○ Non-intact skin: Use povidone-iodine only
PF heparin 2 mL (100 units/mL)
● Allergy to alcohol:
○ Prior to discharge/de-accessing, flush all lumens with PF 0.9% NS 10 mL and
○ Use a non-alcohol containing chlorhexidine gluconate prep
PF heparin 2 mL (100 units/mL)
solution if available or povidone-iodine4
○ Un-accessed Implanted ports should be flushed monthly with PF 0.9% NS 10 mL and 4
○ If CHG allergy, use povidone-iodine only
PF heparin 2 mL (100 units/mL)
● Allergy to povidone-iodine and CHG:
○ May flush with a minimum PF 0.9% NS 5 mL when clinically indicated 3
○ Use 70% isopropyl alcohol only
● For patients less than or equal to 10 kg: ○ Do not use CHG impregnated dressing or disc
○ Flush before and immediately after each use with PF 0.9% NS 5 mL ● Allergy to all skin prep dilutions (CHG, povidone-iodine, and
○ Flush each unused lumen once daily with PF 0.9% NS 5 mL and alcohol):
6
PF heparin 2 mL (10 units/mL) ○ Use sterile saline
○ Prior to discharge/de-accessing, flush all lumens with PF 0.9% NS 5 mL and ○ Do not use CHG impregnated dressing or disc
PF heparin 2 mL (10 units/mL)
○ Un-accessed Implanted ports should be flushed monthly with preservative-free 0.9% NS 5 mL and
PF heparin 2 mL (10 units/mL)
○ May flush with a minimum of PF 0.9% NS 3 mL when clinically indicated

Pediatric Peripheral Intravenous Catheter (PIV)

Preservative-free 0.9% Normal Saline (NS)
● Flush with PF 0.9% NS 10 mL before and immediately after use and every 12 hours when not in use
● May flush with a minimum PF 0.9% NS 5 mL based on patient when clinically indicated

1 4
Selection of supply is dependent on manufacturer’s availability Scrub site with povidone-iodine for a total of 60 seconds or per manufacturer’s recommendations, and
2
For flushing/locking arterial catheters, hemodialysis catheters, or implanted peritoneal ports, allow to dry for 2 minutes
5
follow specific institutional orders as directed by physician Refer to manufacturer’s recommendations
3 6
Scrub site using friction with isopropyl alcohol for a total of 60 second, and allow to dry High risk for infection related to sterile saline use

Department of Clinical Effectiveness V4

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 Vascular Access Device (VAD) Management Page 17 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

APPENDIX F: Alternative Adhesive Dressing Recommendations1

Dressing Skin Injury Skin Irritant Other Considerations Dressing Change Frequency

Sobraview ● SkinIntact: 1st choice dressing 1st choice 1st choice dressing for patients ● Every 7 days with or without presence of
Shield ● Non-Intact Skin: Contact Vascular Access Team for usage dressing that are diaphoretic and are Biopatch
Dressing unable to tolerate Tegaderm with ● Every 2 days if gauze is present over insertion
CHG site with or without presence of Biopatch
Covaderm Plus ● SkinIntact: Contact Vascular Access Team for usage 3rd choice 1st choice dressing if patient ● If used as pressure dressing: change every
Vascular ● Non-Intact Skin: Contact Vascular Access Team for usage dressing requires pressure dressing 2 days with or without presence of Biopatch
Access ● If used due to patient irritant: change every
Dressing1 7 days if Biopatch is present

Allevyn ● SkinIntact: 2nd Choice dressing (preferred when patient diaphoretic) 2rd choice N/A ● Every 7 days with presence of Biopatch
dressing 1 st
● Non-Intact Skin: 1 choice dressing (preferred when patient diaphoretic) dressing ● Every 2 days if no Biopatch is present

Mepilex Border ● Skin Intact: 2nd choice dressing 2rd Choice N/A ● Every 7 days with presence of Biopatch.
Dressing1 st
● Skin Non-Intact: 1 choice dressing Dressing ● Every 2 days if no Biopatch is present.

Duoderm Extra ● SkinIntact: Not recommended, contact Vascular Access Team 4th choice N/A ● Every 7 days with presence of Biopatch.
Thin Dressing ● Non-Intact Skin: Not recommended, contact Vascular Access Team dressing ● Every 2 days if no Biopatch is present (Gauze
must be placed over insertion site)
Kerilex Gauze ● Skin Intact: Contact Vascular Access Team for usage Contact N/A ● Dressingmust be changed daily by Vascular
Dressing ● Non-Intact Skin: Contact Vascular Access Team for usage Vascular Access Team
Access
Team for
usage

1
Perform and document assessment every 12 hours in inpatient setting

Department of Clinical Effectiveness V4

Approved by The Executive Committee of the Medical Staff on 04/30/2019
 Vascular Access Device (VAD) Management Page 18 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

APPENDIX G: Infusion Nurses Society Phlebitis Scale

Grade Clinical Criteria

0 No symptoms

1 Erythema at access site with or without pain

2 Pain at access site with erythema and/or edema

● Pain at access site with erythema and/or edema

3 ● Streak formation
● Palpable venous cord

● Pain at access site with erythema and/or edema

● Streak formation
4
● Palpable venous cord greater than 1 inch in length
● Purulent drainage

Infusion Nurses Society. (2016). Infusion nursing standards of practice. Journal of Infusion
Nursing: The Official Publication of the Infusion Nurses Society, 39(1), S1-92.96.

Department of Clinical Effectiveness V4

Approved by The Executive Committee of the Medical Staff on 04/30/2019
 Vascular Access Device (VAD) Management Page 19 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

SUGGESTED READINGS

Alexander, M. (2016). Infusion standards: A document without borders. Journal of Infusion Nursing, 39(4), 181–182. doi: 10.1097/NAN.0000000000000181.
Alexander, M., Corrigan, A., Gorski, L. (Eds.). (2014). Core Curriculum for Infusion Nursing, (4th ed). Philadelphia, PA: Wolters Kluwer Health and Lippincott Williams & Wilkins.
Alexander, M., Corrigan, A., Gorski, L., Hankins, J., Perucca, R. (Eds.). (2010). Infusion nurses’ society: Infusion nursing an evidence-based approach (3rd ed). St. Louis, MO: Saunders Elsevier.
Androes, M. P., & Heffner, A. C. (2018). Placement of jugular venous catheters. In K. Collins (Ed.), UpToDate. Retrieved March 19, 2019, from https://www.uptodate.com/contents/placement-of-jugular-
venous-catheters
ASWCS (Avon, Somerset and Wilthshire Cancer services) Chemotherapy Handbook, May, 2005
Bertoglio, S., van Boxtel, T., Goossens, GA., Dougherty, L., Furtwangler, R., Lennan, E., … Stas, M. (2017). Improving outcomes of short peripheral vascular access in oncology and chemotherapy
administration. Journal of Vascular Access, 18(2), 89-96. doi:10.5301/jva.5000668.
Bhutani, G., El Ters, M., Kremers, W. K., Klunder, J. L., Taler, S. J., Williams, A. W., ... & Hogan, M. C. (2017). Evaluating safety of tunneled small bore central venous catheters in chronic kidney
disease population: A quality improvement initiative. Hemodialysis International, 21(2), 284-293.
Broadhurst, D., Moureau, N., & Ullman, A. J. (2017) Management of central venous access device-associated skin impairment. J Wound Ostomy Continence Nurs, 44(3), 211-220.
Camp-Sorrell, D. (Ed.). (2017). Access device guidelines: Recommendations for nursing practice and education (3rd ed). Pittsburgh, PA: Oncology Nursing Society.
Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., O'Grady, N. P., Safdar, N., ... & Pittiruti, M. (2015). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a
multispecialty panel using the RAND/UCLA appropriateness method. Annals of Internal Medicine, 163(6_Supplement), S1-S40.
DeVries, M., & Strimbu, K. (2019). Short peripheral catheter performance following adoption of clinical indication removal. Journal of Infusion Nursing, 42(2), 81–90.
doi: 10.1097/NAN.000000000000318
El Ters, M., Schears, G. J., Taler, S. J., Williams, A. W., Albright, R. C., Jenson, B. M., ... & Rule, A. D. (2012). Association between prior peripherally inserted central catheters and lack of
functioning arteriovenous fistulas: a case-control study in hemodialysis patients. American Journal of Kidney Diseases, 60(4), 601-608.
Flynn, J., Rickard, C., Keogh, S., & Zhang, L. (2017). Alcohol Caps or Alcohol Swabs With and Without Chlorhexidine: An In Vitro Study of 648 Episodes of Intravenous Device Needleless
Connector Decontamination. Infection Control & Hospital Epidemiology, 38(5), 617-619. doi:10.1017/ice.2016.330
Gorski, L, Hadaway, L, Hagle M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy standards of practice (Revised 2016). In M. Alexander (Ed.), Journal of Infusion Nursing,
39(1S). Retrieved from: https://source.yiboshi.com/20170417/1492425631944540325.pdf
Heffner, A. C., Androes, M. P., & Cull, D. L. (2016). Overview of central venous access. Disponible en: http://www. uptodate. com [Acceso: Enero 2016]. http://www.uptodate.com/contents/
overview-of-central-venous-access?detectedLanguage=en&source=search_result&search=central+venous+catheters&selectedTitle=1%7E150&provider=noProvider. Retrieved 7/15/2013
Heffner, A. C., Androes, M. P., & Wolfson, A. B. Placement of subclavian venous catheters. http://www.uptodate.com/contents/placement-of-subclavian-venous-catheters?detectedLanguage=
en&source=search_result&search=subclavian+central+line&selectedTitle=1%7E150&provider=noProvider Retrieved 7/15/2013

Continued on next page

Department of Clinical Effectiveness V4
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 Vascular Access Device (VAD) Management Page 20 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

SUGGESTED READINGS - continued

Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P, … Yokoe, D. S. (2014). Strategies to prevent central-line-associated bloodstream infections in acute care hospitals:
2014 update. Infection Control & Hospital Epidemiology, 35(S2), S89-S107.
MD Anderson Institutional Policy #CLN0441 – Infection Control Associated with Vascular Access Devices (VADs)
MD Anderson Institutional Policy #CLN0537 – Flushing of All Central Venous Catheters & Peripheral Venous Catheter Devices Policy
MD Anderson Institutional Policy #CLN0617 – Central Venous Catheters (CVCs) with Persistent Withdrawal Occlusion (No Blood Return) Policy
MD Anderson Institutional Policy #CLN0655 – Central Venous Catheters (CVC)/Midline Catheters-Percutaneous Removal Policy
MD Anderson Institutional Policy #CLN0656 – CVC Overwire Exchange: Assisting Physicians, Advanced Practice Providers, and Infusion Therapy Nurse-Performed Exchange Policy
MD Anderson Institutional Policy #CLN0857 – Care of Phlebitis Associated with Peripherally Inserted Central Catheter and Peripheral Venous Catheter Devices
MD Anderson Institutional Policy #CLN0859 – Central Venous Catheters (CVCs)-Restoring Patency to CVCs Due to Thrombotic or Precipitant- Occlusion Policy
MD Anderson Institutional Policy #CLN0944 – Central Venous Catheters (CVCs)-Drawing Blood Policy
MD Anderson Institutional Policy #CLN0986 – Vascular Vesicant/Irritant Administration and Extravasation Policy
MD Anderson Institutional Policy #CLN1036 – Central Venous Catheter Assessment and Tip Position Verification Policy
MD Anderson Institutional Policy #CLN1154 – Percutaneous Central Venous Catheter (CVCs) - Suture Securement and Replacement Policy
MD Anderson Institutional Policy #CLN1094 – Clinical Practice Patient Care Management Tools
MD Anderson Institutional Policy #CLN1165 – Central Venous Catheter- Peripherally Inserted Central Catheter (PICC) Insertion
Moureau, N., & Flynn, J. (2015). Disinfection of needleless connector hubs: Clinical evidence systematic review. Nursing Research and Practice, 2015(2015), 20.
doi:10.1155/2015/796762
O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, P., Garland, J., Heard, S. O., … the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Centers for Disease
Control and Prevention (CDC): Guidelines for prevention of intravascular catheter-related infections. Retrieved from https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf
Polovich, M., Olsen, M., Lefebvre, K. (Eds.). (2014). Chemotherapy and biotherapy guidelines and recommendations for practice, (4th ed). Pittsburgh, Pennsylvania: Oncology Nursing Society.
The Joint Commission. (2019). Preventing central line–associated bloodstream infections: useful tools, an international perspective. Retrieved from: https://www.jointcommission.org/topics/
clabsi_toolkit.aspx

Department of Clinical Effectiveness V4

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 Vascular Access Device (VAD) Management Page 21 of 21
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care.

DEVELOPMENT CREDITS

This practice consensus statement is based on majority opinion of the Vascular Access Devices Management experts at the University of Texas MD
Anderson Cancer Center for the patient population. These experts included:

Patricia Amado, BSN, MSN, RN (Nursing – Pediatrics)

Ivy Cocuzzi, MPAS, PA-C (Acute Care Services)
Gina Butler, MSN, RN, CPHQ (Nursing Quality)
Heather Cienfuegos, BSN, RN, OCN (Infusion Therapy)Ŧ
Lucia Del Rosario, RN, CRNI (Infusion Therapy)
Joylynmae Estrella, MSN, RN, OCN, CNL (Nursing Administration)
Stacy Hall, MSN, RN, NE-BC (Infusion Therapy)
Tam Huynh, MD (Thoracic and Cardiovascular Surgery)Ŧ
Elizabeth Natividad, RN, CRNI (Infusion Therapy)
Amy Pai, PharmD♦
Issam Raad, MD (Infectious Disease)Ŧ
Rebecca Salvacion, BSN, MSN, RN, CRNI (Infusion Therapy)Ŧ

Ŧ
Core Development Team
♦
Clinical Effectiveness Development Team

Department of Clinical Effectiveness V4

Approved by The Executive Committee of the Medical Staff on 04/30/2019