CENTRAL VENOUS CATHETER (CVC): UMBILICAL CATHETER REMOVAL: PROCEDURE POLICY Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days . Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed aseptically . (CDC, 2011). Umbilical Arterial Catheters (UAC) should be removed when there are signs of vascular compromise (blanching, cyanosis distal to the umbilicus) When determining the vascular access requirements for the infant please refer to: Vascular Access: Anticipated Access Requirements: Algorithm Umbilical Catheter (UC) removal is performed by a health care provider with training, knowledge and skill to perform this task safely. This includes physicians and neonatal nurse practitioners. In most cases UCs can be removed without the use of scissors to avoid cutting the catheter. Due to the risk of bleeding and retention of the umbilical catheter in the blood vessel if the umbilical catheter is inadvertently cut during suture removal, it is recommended that UCs are removed without the use of scissors. UC removal is a two person procedure. One person must be an experienced practitioner, skilled in UC removal. (CDC, 2011). Applicability: UC removal occurs in the Neonatal Program. PROCEDURE Gather equipment: 1. Forceps (Hemostat) 6. 0.9% NaCl 2. Surgicel Hemostat 7. Sterile Gloves 3. 3- 2X2 Gauze 8. Light Source 4. Eye Protection 9. Fine tipped suture cutting scissors (if 5. Dressing Tray necessary) Preparation Note 1. Identify patient and confirm order for UC removal 2. Gather Equipment 3. Wash Hands NN.11.01 Neonatal Program Policy & Procedure Manual Effective Date: May-01-2017 Page 1 of 4 CENTRAL VENOUS CATHETER (CVC): UMBILICAL CATHETER REMOVAL: PROCEDURE 4. Open dressing kit and place required equipment on • Sterile Gauze tray. • Hemostat • Forceps • 0.9% NaCl 5. Use light source to examine the umbilical stump • Protect infant’s eye from light 6. Assess the umbilical cord stump. • If cord stump is dry, removal of the catheter through the suture may be difficult 7. Soak the cord stump with sterile gauze soaked with • Soaking the cord stump facilitates easier 0.9% NaCl for 20 minutes catheter removal, reduces the need to use scissors and improves visualization of the catheter 8. Confirm length to be removed • Check insertion documentation to confirm depth of insertion Removal (scissor-less) Note 9. For UC being removed; discontinue fluid infusion 10. Obtain assistance from a second care provider to • This may include swaddling, facilitated support infant with comfort care measures tucking and/or non-nutritive sucking • The second provider can gently hold legs to allow minimize movement and allow for improved visualization 11. Wash hands, don eye protection and sterile gloves 12. Remove tape from catheter being removed • If UAC and UVC are both being discontinued; remove UAC first • If bleeding from the UAC occurs, the umbilical venous catheter is available for fluid or blood administration 13. Cleanse umbilical stump with 2% Chlorhexidine • Clean/prepare site with Dexidin solution for gluconate in 4% isopropyl alcohol (Dexidin) 30 seconds using side to side motion. • Allow to air dry for 60 seconds • Immediately after the cleaning remove residual Dexidin solution on skin using sterile normal saline or sterile water. 14. Loosen the suture by applying gentle traction • If suture cannot be loosened, soak stump for around the knot another 10 minutes • If suture cannot be loosened and catheter cannot be withdrawn refer to ‘UC: Removal with Scissors’ below 15. Apply gentle traction to the UC and in a slow • Slow removal promotes vasoconstriction and continuous motion remove the line until there is may minimize bleeding after the line is only 2cm remaining in the vessel. Slowly remove removed over 3-5 minutes. NN.11.01 Neonatal Program Policy & Procedure Manual Effective Date: May-01-2017 Page 2 of 4 CENTRAL VENOUS CATHETER (CVC): UMBILICAL CATHETER REMOVAL: PROCEDURE 16. Assess the UAC to ensure the pulsations have ceased in the catheter prior to removal 17. Remove catheter and immediately apply pressure • Do not lift dressing during this time to observe over the vessel with the gauze for at least 5 site as this may cause re-bleeding minutes 18. If there is still blood oozing after 5 minutes apply • Umbilical ties may be tightened around the pressure for an additional 5 minutes stump if there is continued oozing • Consider applying Surgicel hemostat if stump is oozing 19. Position infant so umbilical stump can be observed • Umbilical tie can be removed after 12 hours if for further blood loss. Keep stump visible for a there is no further oozing noted minimum of four hours. 20. Inspect and measure the length and integrity of the • If abnormalities are noted, or the full length umbilical catheter upon removal was not removed, do not discard catheter • Apply forceps to stump (being cautious not to pinch skin) if the catheter broke at that point • Report findings to colleague or staff physician to determine next steps 21. Document time and reason for catheter removal in infant’s medical record UC Removal with Scissors Note 22. See steps 1-14 above • One person must be an experienced practitioner, skilled in UC removal. 23. Obtain sterile fine tipped suture removal scissors • Do not use a scalpel 24. Obtain assistance from a second care provider to • This may include swaddling, facilitated support infant with comfort care measures tucking and/or non-nutritive sucking • The second provider can gently hold legs to allow minimize movement and allow for improved visualization 25. Apply forcep (Hemostat) around the catheter at a • The forcep (Hemostat) will also prevent point below the suture to provide hemostasis in the catheter migration in the event the catheter is event of a catheter transection. accidentally cut. 26. Use light source available to fully visualize catheter 27. Point the sharp edge of scissor away from the catheter and cut the suture with sterile scissors 28. Continue with steps 14-20 above NN.11.01 Neonatal Program Policy & Procedure Manual Effective Date: May-01-2017 Page 3 of 4 CENTRAL VENOUS CATHETER (CVC): UMBILICAL CATHETER REMOVAL: PROCEDURE DOCUMENTATION Physician’s notes Nurses’ Notes Central Venous Catheter (CVC), Peripherally Inserted Central Catheter (PICC), Central Arterial Catheter: Assessment and Tracking: NICU REFERENCES Center for Disease Control (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf The Hospital for Sick Children, Toronto Ontario (2016) Umbilical Catheter Removal. NN.11.01 Neonatal Program Policy & Procedure Manual Effective Date: May-01-2017 Page 4 of 4 .