CVL/PICC dressing change procedure

A central line or central vascular access device (CVAD) is a tube that goes through one of your child’s large veins that leads to the heart, to deliver medications or fluids. Types of CVADs include central venous lines (CVLs) and peripherally inserted central catheters (PICCs).

The place where the CVL/PICC leaves the skin is called the exit site. It is covered with a sterile dressing, which protects it from germs. Once per week (every seven days), you must clean the exit site and the area under the sterile dressing with antiseptic solutions and apply a new sterile dressing. You will need to look through the clear dressing daily to examine the area for any drainage, puffiness or redness. Report any changes to your child’s health-care team.

If your child has a chest CVL you will also look at the entry site in the neck as part of your daily routine when first inserted, checking for anything that does not appear as perfectly healed skin.

Dressing changes are done regularly to keep the exit site clean and prevent infection. Unless given specific instructions from the health-care team, you will need to change the dressing every seven days for a clear dressing and every two days for a gauze dressing. Change the dressing when it becomes wet or loosened. Only perform this procedure if you have been instructed to do so by your child’s health-care provider.

You may be instructed to start using a gauze dressing instead of a clear dressing on your child’s CVL or PICC. This dressing will be shown and described to you. A gauze dressing is changed much more frequently than a clear dressing. Your child’s health-care team will give you instructions on how to care for a gauze dressing.

Whenever the dressing becomes wet, dirty or no longer sticks to the skin, you need to change it.

What to look for while changing the dressing

Signs of infection

Check your child’s exit site and surrounding skin daily, including when you change the dressing, for signs of infection. Start at the exit site and follow the path of the CVL/PICC all the way to the neck (including the vein insertion site on a chest line).

Examine the exit site and area under the dressing closely for:

• swelling
• redness
• irritation
• drainage or discharge
• bad smell

If you see any drainage or discharge, crust or redness at or around the exit site or the insertion site, tell your child’s health-care team right away. Let them know the amount, size, colour and smell. You can also take a picture to show your child’s health-care team. Take your child’s temperature to find out if it is higher than normal.

Skin reaction

A skin rash or irritation may develop from the tape or the antiseptic solution. Chlorohexidine may cause some redness if a dressing is placed on the skin before it has completely dried. Changing to a different type of dressing or cleaning solution may help this problem. If you see redness, contact the health-care team for suggestions.

Loose dressing

The dressing may not stick well in warm weather, or if the antiseptic solution has not completely dried before putting the dressing on. If the dressing tape becomes loose or falls off, you will need to do another complete dressing change to keep germs away from the exit site.

Setting up your environment

Before you begin the dressing change procedure, you will need to set up your environment for the procedure. A central line dressing change requires two caregivers: a main person and a support person. Before beginning the procedure, decide who will take the main and supporting role, and plan where you will perform the procedure.

Follow these steps outlined in the video above to set up your environment:

1. Locate an area to perform the procedure. Find a quiet space and remove any pets or other children. You can limit air drafts by closing windows and doors and turning off fans. Remove any clutter. Do not use your child’s bed as a work surface. Do not use a changing table as this is not a clean area.
2. Find a stable, wipeable work surface, within arm’s reach, to place your supplies. You can set aside an item like an unused, dedicated cookie sheet for this purpose since it will be easy to sanitize. This is your general aseptic field. Clean the surface with a disinfectant wipe before each use and allow it to dry. 
3. Place a garbage bin and hand sanitizer within reach. You will also need a clock or cell phone to use as a timer. Make sure to remove any jewelry and tie back long hair before starting the procedure. 
4. Wash your hands thoroughly using soap and water. You may use hand sanitizer if your hands are not visibly soiled.
5. Gather your supplies and place all materials within reach on your clean work surface. You will need:
• Antiseptic wipes containing alcohol
• 2 pairs clean (non-sterile) gloves
• 1 pair sterile gloves
• 3 chlorhexidine gluconate (CHG) 2% swabsticks or 3 ChloraPrep
• Sterile transparent (clear) dressing (e.g. Tegaderm™, IV 3000)
• An appropriate securement device (e.g. Statlock)
• Masks for everyone in the room including the child
• Sterile drape (optional)
6. Keep all supplies in their packages until you are ready to use them. This is known as the micro critical aseptic field.
7. Wash your hands and put on a mask to prevent the spread of germs from your mouth and nose. Wash your hands again after touching your face. Have your child wear a mask if they are able or have the second person support your child in turning their head away from the CVAD or place a barrier between their mouth/nose and the procedure.
8. Wash your hands again and put on clean gloves to reduce the possibility of adding more germs from your hands to the skin under the dressing. The second person also needs to wash their hands and put on clean gloves, in case they need to hold the line during the procedure.

Performing the procedure

Follow these steps outlined in the video above to perform the dressing change:

1. Your support person can help keep your child as calm and still as possible, if needed.  If they need to hold your child still, they can dedicate one hand for holding, and keep the other hand clean to help hold the central line during the procedure. The support person may find it helpful to hold that hand up.
2. Loosen the old dressing starting at the outer edges. From the outside of the dressing, make sure you are gently but firmly holding the PICC or CVL at the exit site to reduce any possible tugging on the line while removing the old dressing. If possible, keep the securement device in place until after the dressing has been changed.
3. Remove the old dressing.
4. Look for signs of infection such as redness, swelling or drainage at the exit site, tunnel site, surrounding skin and insertion site (neck area for chest CVL). If you notice any problems, finish the dressing and inform your child’s health-care team.
5. Do not touch the exit site or skin under the dressing with your non-sterile gloves. Protecting the area under the dressing helps reduce the risk of infection.
6. Remove the clean gloves, wash your hands and put on a new pair of clean gloves. You need to wash your hands because the old dressing you just removed is dirty.
7. Use the CHG sponge or swabstick to cleanse the area. if you are using the sponge, open it up and while pointing the sponge downwards, crack the sponge so it fills with the liquid. If you are using the swabstick, carefully take it out of the packaging.
• If the line is out of the securement device, the second person can lift the CVAD off skin to keep it elevated. Remember not to touch the key site with your hands.
8. Scrub the skin using friction around the CVAD from the exit site to approximately 5 cm beyond the dressing borders in a back-and-forth motion in two directions for 30 seconds. For example, up and down and side to side, for 30 seconds. Vigorous scrubbing will allow the solution to effectively clean the skin.  Make sure the area that will be under the dressing has been cleaned. Then throw the sponge or swabstick into the garbage.
9. Open two additional chlorhexidine sponges or swabsticks. Use the two swabsticks to clean both sides of the central line, starting closest to the child and moving up the catheter for an additional 30 seconds. If the CVAD is looped when placed against your child's skin, a longer portion of the CVAD must be cleaned. Make sure not to tug the CVL/PICC at the exit site. Cleaning from the exit site and moving up the line helps to decrease the risk of infection.
10. Allow the area to dry completely for at least 2 minutes. Do not fan or blow on the newly cleaned area as this may introduce new germs to the area. Allowing the area to dry will ensure germs have been killed and the dressing will adhere to the skin. Leaving skin damp may cause redness and irritation.
11. Remove your gloves and throw them away. Wash your hands.

The next steps of the procedure are considered critical steps because the key site (the entry site) is exposed. This means they need to be free from any contamination. Take care as you perform each step. 

12. Open sterile dressing package making sure not to touch the dressing inside. Wash hands again. You can choose to leave the sterile dressing inside the sterile packaging or open sterile glove package and carefully drop sterile dressing into the sterile glove field using aseptic non-touch technique. Wash your hands again.
13. Put on your sterile gloves. For instructions on how to properly put on sterile gloves, please watch the video Sterile Gloving Procedure.  Make sure you do not contaminate your sterile gloves.
14. Loop the CVL/PICC if possible. Keeping a loop allows for extra slack if the line is accidentally pulled.
15. Peel off the paper backing of the dressing.  Apply the dressing using ANTT, making sure the site and catheter loop are covered. It is important to position the CVAD so that the key site is visible through the window of the dressing. Pay careful attention not to stretch the dressing when applying it, and make sure the dressing is well adhered to the skin.
16. Place your hand over the entire dressing for 15-30 seconds to help it stick to the skin. The heat from your hands help the adhesive tape stick to the skin.
17. Remove the CVAD from the securement device. Use additional pieces of the dressing, or another adhesive tape, to cover any openings around the catheter by placing one strip under the line, and another over the line. 
18. Remove the securement device from the skin and apply a new one. If using a securement device, it can be helpful to secure the line in the new device first, and then stick it to the skin.
19. Remove your gloves, perform hand hygiene, and then remove your mask. Wash your hands again.
20. Discard the used supplies into the garbage and clean your general aseptic field.