Care of Intravascular Catheters

Dr.T.V.Rao MD

Dr.T.V.Rao MD @ TMC Kollam 1

We are in a Complex Situation

Dr.T.V.Rao MD @ TMC Kollam 2

ICU patients • Sickest patients (multiple diagnoses,

multi-organ failure, immunocompromised, septic and trauma)

• Move less

• Malnourished

• More obtunded (Glasgow coma scale)

• Diabetics and Heart failure

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ICU Care is Invasive

• More invasive lines and procedures including surgeries

• Longer length of stay

• More IV and parenteral drugs

• More tube feeding and Parenteral nutrition

• More ventilation

Dr.T.V.Rao MD @ TMC Kollam 4

Know about the Purpose and Consequences of Catheter Use • Healthcare personnel should be educated

regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-

related infections. Knowledge of and adherence to these guidelines should be assessed periodically for all personnel

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Inserting Catheters have consequences

• Central venous catheters (CVCs) are being increasingly used in the inpatient and outpatient settings to provide long - term venous access. CVCs disrupt the integrity of the skin, making infection with bacteria and/or fungi possible.

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Catheters are Very Near to our Hearts

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Why we Insert a Catheter

•Aims • 1. To gain peripheral venous access in

order to:

• • administer fluids

• • administer blood products, medications and nutritional components

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Who Should Perform • 1.Only nurses who have been certified as

competent in the insertion of IV cannula will perform this procedure.

• 2. Where the patient is less than 14 years of age, the IV cannula will be inserted by a medical personal or experienced Nurse?. The exception will be in the case of neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer

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What barrier precautions to follow

• Maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves,

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Choosing IV catheter Size • Age

< 1 year: 22, 24 gauge (g)

1-8 years: 18, 20,

22 gauges > 8 years: 16. 18,

20 gauges

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How to prepare the Skin • Skin preparation entails preparing clean skin

with a more than 0.5% chlorhexidine preparation with alcohol before CVC and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophores, or 70% alcohol can be used as alternatives

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Microbiology of the Skin

• 80% of the resident bacteria exist within the first 5 layers of the stratum corneum of the epidermis

• The remaining 20% of the resident bacteria are found in biofilms within the hair follicles and sebaceous glands

• Complete recolonization of surface bacteria can occur within 18 hours of antiseptic application

Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal. 2005;5(3) ©2005 Medscape Posted 08/18/2005 . http://www.medscape.com/viewarticle/508109.

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Hand Hygiene • Use of waterless

alcohol-base hand rub –Most effective and

efficient method for hand antisepsis against bacterial pathogens

• When hands are visibly soiled, they should be washed with soap and water

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Proceed with action

• Use universal precautions (glove and eye protection)

• Allergies (beta dine or latex)

• Explain procedure to Pt.

• Prepare all material

• Select vein. Apply tourniquet above the elbow.

• Prepare site Dr.T.V.Rao MD @ TMC Kollam 16

Procedure (cont.)

• Warn the patient of possible pain

• Bevel up at 30 degree above horizontal

• Look for flashback of blood into catheter

• Upon seeing flashback, advance catheter another millimeter or two

• Advance the sheath completely into the vein and release tourniquet

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IV Procedure (cont.)

• Connect the IV tubing/heplock

• Secure catheter and tubing

• Dispose of needles in sharps container

• Document the IV site, catheter size and date on the patient’s chart

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Chlorhexidine-impregnated sponge dressing

• A chlorhexidine-impregnated sponge

dressing should be used for temporary short-term catheters in patients older than 2 months if the CRBSI rate is not decreasing, despite adherence to basic prevention measures

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Cutaneous Antisepsis CR Infection Prevention w/ Chlorhexidine Cath colonization CRBSI

CHX Control CHX Control

2.3% 7%*† 0.5% 2.6% (Maki `91)

2% 7%* 0.6% 0.6% (Sheehan`93)

4.7% 9.3%* 0 0.5% (Garland `95)

12/103 31/103* 0.1/103 0.9/103 (Minoz`96)

34% 27%* 3.5/103 4.1/103 (Humar`97)

red values = p<0.05 *= povidone iodine † = alcohol

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Procedure for Insertion of Peripheral IV Catheter

1. Obtain and review the order

2. Ascertain allergies

3. Gather Equipment

4. Verify patient’s identity using two patient identifiers

5. Explain procedure, benefits, care management, and potential complications to patient

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Procedure for Insertion of Peripheral IV Catheter (cont)

6. Perform hand hygiene

7. Assemble equipment

8. Apply Tourniquet

9. Assess veins, keeping in mind the rational for therapy and duration of therapy

10. Apply Non sterile gloves

11. Wash intended insertion site with antiseptic soap and water. (as needed)

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Procedure for Insertion of A Peripheral IV Catheter (cont)

13.Clean intended insertion site with antiseptic solution, working outward using back-and-forth motion

14. Allow site to dry 15.Perform venipuncture while

stabilizing skin with the no dominate hand

Use left hand right handers

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Procedure for Insertion of A Peripheral IV Catheter (cont)

16.Enter skin at a 10- to- 30 degree angle. Decrease angle when the skin has been penetrated. When blood is obtained in the flash back chamber, advance catheter 1/16 inch, and then slightly pull stylet back, advancing catheter gently into vessel. Continue to advance catheter into vein until the catheter hub is against the skin.

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Procedure for Insertion of A Peripheral IV Catheter (cont)

17. Release tourniquet

18. Occlude tip of catheter by pressing finger of non dominant hand over vein to prevent blood spillage.

19. Activate needle safety device before removing stylet. Connect IV administration set or injection cap/needless device. Begin infusing solutions slowly.

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Procedure for Insertion of A Peripheral IV Catheter (cont)

22.Discard stylet in sharps container

23. Remove gloves. Perform hand hygiene

24. Document procedure in the patient’s medical record.

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At every stage Document your results

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When you fail in insertion

• In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts the assistance of a medical practitioner will be sought.

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When you Wish to Keep the Catheter Longer

• A chlorhexidine/silver sulfadiazine or minocycline/rifampicin "impregnated CVC should be used in patients whose catheter is expected to remain in place for more than 5 days if, after successful implementation of a comprehensive strategy to reduce rates of CRBSI, the CRBSI rate is not decreasing

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Prevention of CR-BSI

Dressing

• Gauze dressings every 2 days

• Transparent dressing every 7 days on short term catheter

• Replace dressing when catheter is replaced or dressing becomes damp or loose.

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Risk Factors

• Four major risk factors are associated with increased catheter-related infection rates: –Cutaneous colonization of the insertion site

–Moisture under the dressing

–Prolonged catheter time

– Technique of care and placement of the central line

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Strategies for Prevention of CR Infections

• Antibiotic/Antiseptic Ointments – Povidone-iodine ointment – Mupirocin ointment

• Antibiotic Lock Prophylaxis – Flushing and filling the lumen of the catheter with an

antibiotic solution and leaving the solution to dwell in the lumen of the catheter.

– Heparin plus 25 micrograms/ml of Vancomycin – Vancomycin/ciprofloxacin/heparin combination

– Minocycline and ethylenediaminetetraraacetic acid (EDTA)

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Complications of IV Therapy

• Classified according to their location

–Local complication: at or near the insertions site or as a result of mechanical failure

–Systemic complications: occur within the vascular system, remote from the IV site. Can be serious and life threatening

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Local complications • Occur as adverse reactions or trauma to the

surrounding venipuncture site • Assessing and monitoring are the key

components to early intervention • Good venipuncture technique is the main

factor related to the prevention of most local complications associated with IV Therapy.

• Local complications include: hematoma, thrombosis, phlebitis, post infusion phlebitis, thrombophlebitis, infiltration, extravasation, local infection, and veno spasm.

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Hematoma • Subcutaneous hematoma is the most common

complication

• Can be a starting point for other complications: thrombophlebitis and infection

• Related to:

– Nicking the vein

– Discontinuing the IV without apply adequate pressure

– Applying the tourniquet to tightly above a previously attempted venipuncture site.

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Hematoma • Signs and

symptoms: – Discoloration of the skin

– Site swelling and discomfort

– Inability to advance the cannula all the way into the vein during insertion

– Resistance to positive pressure during the lock flushing procedure

• Document

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Hematoma Prevention

• Use of an indirect method

• Apply tourniquet just before venipuncture

• Use a small need in the elderly and patients on steroids, or patients with thin skin.

• Use blood pressure cuff to apply pressure

• Be gentle

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Hematoma Treatment

• Apply direct, light pressure for 2-3 minutes after needle removed

• Have patient elevate extremity

• Apply Ice

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Thrombosis

• Catheter-related obstructions can be mechanical or non-thrombotic

• Trauma to the endothelial cells of the venous wall causes red blood cells to adhere to the vein wall, forms a clot or Thrombosis

• Drip rate slows, line does not flush easily, resistance is felt

• Never forcible flush a catheter

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Thrombosis • Signs and Symptoms

– Fever and Malaise – Slowed or stopped infusion

rate – Inability to flush

• Prevention – Use pumps and controllers

to manage flow rate – Micro drip tubing for rate

below50mL/hr – Avoid areas of flexion – Use filters – Avoid lower extremities

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Never forcible flush a catheter

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Thrombosis

Treatment – Never flush a cannula

to remove an occlusion

– Discontinue the cannula

– Notify the physician and assess the site for circulatory impairment

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Phlebitis • Inflammation of the vein

in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammation-induced phlebitis

– Tender to touch and can be very painful

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Phlebitis • Mechanical:

– To large a catheter for the size of the vein

– Manipulation of the catheter: improper stabilization

• Chemical: vein becomes inflamed by irritating or

vesicant solutions or medication

– Irritation medication or solution

– Improperly mixed or diluted

– Too-rapid infusion

– Presence of particulate matter

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Phlebitis

• Chemical (cont): – The more acidic the IV solution the greater the

risk

– Additives: Potassium

– Type of material

– Length of dwell:

• 30% by day 2, 39-40% by day 3 (Macki and Ringer)

– The slower the rate of infusion the less irritation

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Catheter removal indications

• Severe sepsis

• Hemodynamic instability

• Endocarditis or evidence of metastatic infection

• Erythema due to Suppurative thrombophlebitis

• Persistent bacteremia after 72 hrs abx to which organism is susceptible

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CRBSI - Pathogenesis

• 4 major sources:

• a. colonization from skin

• b. intraluminal or hub contamination

• c. secondary seeding from a bloodstream

• infection

• d. rarely contamination of the infusate

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What infections are ……

• A survey of 112 medical ICUs in the United States: • CoNS, mostly Staph epidermidis (36%) • Enterococci (16%) • Gram-negative aerobic bacilli (16%) • (Pseudomonas aeruginosa, Klebsiella pneumoniae, E

coli, etc) • Staph aureus (13%) • Candida species (11%) • Other organisms (8%)

• Richards M, Edwards J, Culver D, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. Crit Care Med 1999(5);

27:887-892

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Severe Consequences

• 75% of all catheter-related infections are due to the use of a central line

• >250,000 CVC-related infections per year

• Mortality may be up to 35%

• The CDC estimates that attributable costs due to catheter-associated infections range from $34,508 to $56,000.

HICPAC. CDC Guideline on the Prevention of Intravascular Associated Infections, 2002.

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Studies prove the Infection Rate

• A study in HSA ICU 2005:

• 80.6% Gram –ve bacteria: K. pneumoniae (38.9%)

• P. aeruginosa (19.4%)

• A. baumanii (13.9%)

• Enterobacter spp (8.3%)

• 19.4% Gram +ve bacteria: MRSA (13.9%)

• MSSA (2.8%)

• CoNS (2.8%)

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Blood under dressing

Key Strategy: Monitor dressing protocols

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Loose Dressing Dr.T.V.Rao MD @ TMC Kollam 53

Diagnosis of Catheter related Infections

• The diagnosis of catheter-related infections relies on the presence of clinical manifestations of infection and the evidence of colonization of the catheter tip by bacteria, mycobacteria, or fungi. The reference method to confirm the latter requires the withdrawal of the catheter for culturing, which frequently turns out to be inconvenient, unnecessary and costly.

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Comparative quantitative blood cultures

• Comparative quantitative blood cultures with a marked increase (> or = 5) in colony counts between blood obtained from the catheter lumen and from a peripheral vein simultaneously is one of those methods. It has a high sensitivity (>80%) and specificity (94-100%) but it is cumbersome and requires both an easy backflow of blood in the catheter and the existence of bacteraemia. • Catheter-related infections: diagnosis and intravascular

treatment.Bouza E, Burillo A, MuñozP.

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Cytocentrifugation and acridine orange staining

• Cytocentrifugation and acridine orange staining of blood withdrawn from an infected catheter lumen has a sensitivity and a specificity of over 90% for the diagnosis of tip colonization. 'Superficial cultures' comprise the semi quantitative culture of the hub, of the skin surrounding the catheter entrance and of the first subcutaneous portion (1 cm) of the catheter after swabbing. The sensitivity of this method is >90%, specificity is >80%, and positive and negative predictive values for catheters (considering together those with and without clinical data of infection) are 66 and 97%, respectively.

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Antimicrobial-coated catheters

The use of antimicrobial-coated catheters becomes more prevalent, the existing definitions of catheter colonization and catheter-related infection may need to be modified, because such coatings may lead to false-negative culture results. Many catheter infections, diagnosed without catheter withdrawal, can be handled nowadays with the so-called 'antibiotic lock-in technique', which consists in 'locking' the infected catheter lumen with a solution containing antibiotics.

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Changing trends • A high proportion of infected catheters, mainly

those with coagulase-negative staphylococci, can be maintained in place and sterilized with this technique, including catheters in patients with therapeutic failure after receiving conventional intravenous antibiotic therapy. New diagnostic and therapeutic techniques may avoid the unnecessary withdrawal of thousands of efficient, difficult to replace and expensive intravascular lines.

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Personal safety of Health Care Workers

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Steps to prevent needle sticks

• Wear gloves

• Do Not Bend or Break Needles

• Never RECAP!!!

• If you must, use the One Handed technique

• Take your time

• Dispose of contaminated needles immediately in puncture-resistant containers

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Risks to you - if Careless

• Risks after needle Sticks Exposure

• Hepatitis B: 10-30%

• Hepatitis C: 2%

• HIV: 0.4 %

• Other blood borne pathogens

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POLICY ON ACCIDENTAL NEEDLE STICKS

• Immediately wash injured area.

• Report all needle sticks immediately to your instructor or immediate supervisor.

• Complete an incident report and report to employee health or ED.

• Determine if the needle was clean or dirty.

• Cleansing wound with antiseptic.

• Request that the identified patient be tested for Hepatitis B surface antigen and HIV antibodies.

• Have your blood tested for Hepatitis B and HIV antibodies as soon as possible.

• Begin drug treatment (if necessary) & counseling.

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Diagnosis of CRBSI • • Catheter removal required

• (i) Semi-quantitative culture method • - catheter segment is rolled across surface of an • agar plate and cfu are counted after overnight • Incubation • • >15 cfu is significant • • limitation: cultures organisms from the external • surface of the catheter • • intraluminal colonisation, after prolonged and • excessive use of the catheter hub not evaluated

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CDC (HICPAC) Guidelines for References

• Issued 8/9/02

• Evidence-based

• Recommendations categorized

• Peer reviewed

www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm Dr.T.V.Rao MD @ TMC Kollam 64

Establish Credibility

• Recruit Physician & Nurse Champions

• Key areas: – ER – ICUs – Anesthesiology

• All must be committed to same goals

• Leaders must convince their own

• Appoint “CLAB Leader” for each patient unit

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Performance-Based Training

• Educational focus is on the continuous improvement of worker performance

• Worker skills and competencies are identified to achieve the department mission

• Curriculum is organized around learner needs and regulatory mandates. A collaborative approach is used with manager, worker, and educator input.

• The evaluation measures the workers’ abilities to meet standard; it also determines if learned skills are enough to perform the job effectively.

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Training on Mannequins • Held weekly

• All first-year residents are required to attend

• Conducted by IC and Surgical Attending

• Walk-through on insertion steps Dr.T.V.Rao MD @ TMC Kollam 67

Summary

Infection Prevention Guidelines –Record date of insertion & removal of

the device –Keep number of lines, lumens &

stopcocks to minimum –Maintenance and inspection of I.V.

line/site –Quality control of infusion/additives –Cleanliness of equipment

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Never Forget to Update the Records on Catheritizated Patients

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Talk less and Do more Hand Washing in Patient Care Areas

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• Programme Created by Dr.T.V.Rao MD for Benefit of Medical and Paramedical

Professionals for better services in Hospital Practice, Kindly forward to all

your friends in the Profession

• Email

• doctortvrao@gmail.com

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