Transcript Central Venous Catheter Occlusion and Thrombosis

Prevention of Catheter-Related
Infections in the Adult and
Pediatric Population
Darcy Doellman RN BSN
PICC/CVC Resource Nurse
Cincinnati Children’s Hospital Medical Center
Central Venous Catheters
Background & Complications
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Essential in managing chronic & critically ill
patients
41% of PICU patients have 1 or more CVC
57% of adult ICU patients have 1 or more CVC
Complications:
 Mechanical (migration, hole in catheter)
 Catheter obstruction, occlusion & thrombosis
 Catheter-Related BSI
Catheter-Related Infections
Clinical Implications
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Medical costs up to $25,000 to treat a
Catheter-related infection
Average rate of CR-BSI is 5.3/1,000
catheter days in the ICU, approx 80,000
CR-BSI occur annually in the US
Morbidity
Mortality
Terminology
Noscomial Infections
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Vast majority of noscomial
infections are device or
procedure related
Twenty fold increase of
candida since 1965
Site Preparation
Infection Control Issues
Short-term
CVCs
PICCs
Dwell Times
Reported
mean
30+ days
4 days
1+ years
6 weeks
1+ years
6 months
3+ years
3 years
Rate of
CR-BSI
5.3/1000
catheter
days
0.51/1000
catheter
days
2.77/1000
catheter
days
0.21/1000
catheter
days
Bedside
Medical
Providers
Bedside
Nurses
IR/OR
Medical
Providers
IR/OR
Medical
Providers
Insertion
Issues
Tunneled
Catheters
Implanted
Ports
CSR-BSI Considerations and Central Venous Access
Devices
Sources: CDC 2002, Moreau, 2002, Ryder, 1996, Lowenthal et. Al. 2002, Skiest, 2000, Thiagajarian,
1997,Alhimyary, 1996, Abi-Nader, 1993, Ng, 1997, Graham, 1991
Practice Issues
Desired Outcomes:
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Provide best care
possible
Evidence-based practice
Minimize complications
of central lines
Reality
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We use what’s available
Unaware of
complications
Limitations of literature
Do not consider overall
costs
Challenge for Clinicians
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Multi-tasking
Information overload
Time intensive
Staffing issues
Experienced personnel
Catheter Occlusion
Prevention – CCHMC Studies
Simple
(n=150)
Valve
(n=149)
PPV1+
Heparin
(n=150)
PPV1+
Saline
(n=150)
PPV2+
Saline
(n=161)
Patient Age (Months)
45.67.5
53.67.6
36.16.6
41.86.4
55.48.0
Catheter Type:
Non-Tunneled
PICC
Tunneled
63 (66%)
31 (32%)
2 (2%)
64 (71%)
23 (26%)
3 (3%)
76 (89%)#
9 (11%)#
0
69 (79%)
18 (21%)
0
56 (73%)
20 (26%)
1 (1%)
9.70.7
8.20.6*
7.40.7#
7.40.5*
8.30.9*
18 (12.0%)
2 (1.3%)$
5 (3.3%)#
6 (4%)*
6 (3.7%)*
Partial Occlusions
7 (4.7%)
11 (7.4%)
6 (4%)
6 (4%)
13 (8.1%)
Complete + Partial
Occlusions
25 (16.7%)
13 (8.7%)
10 (6.7%)*
12 (8%)*
19 (11.8%)
Catheter Duration (days)
Complete Occlusions
INCIDENCE OF CR-BSI
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Catheter duration (Raad et al J Hosp Infect 1993)
Insertion Site ( IJ site associated with fourfold
increase as compared to subclavian site)
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Geography (Mermel et al Am J Med 1991)
High risk patients
Multiple lumens/catheters
Catheter material (polyvinyl chloride or polyethyl)
Thrombogenicity/phlebitis
CR-BSI
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Microbes colonize
skin at the
insertion site and
the catheter hub
(Mermel et al Am J Med
1991)
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Sutures go through
skin, inflammation
Biofilm Basics
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Planktonic and sessile cells interact
As sessile bacteria attach to a surface, they
begin to excrete a slimy material (biofilm).
Single cells – Early structure – Mature biofilm
(nutrients flow through complex structures)
Researchers have shown that bacterium
attached to a surface “turns on” a whole
different set of genes. This makes it a different
organism to deal with
Biofilm Lifestyles
Free Floating
Embedded
Ubiquitous
Planktonic
Rapid growth
Fairly sensitive
Ubiquitous
Sessile Phenotype
Slow growth
Highly resistant
Biofilm Basics
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Researchers at the “Center for Biofilm
Engineering” have discovered a different level
of expression of genes, a division of labor
Some cells use energy turned on by metabolic
pathways and effects the partial degradation
while others use the degradation products to
produce new cells (cell to cell communication)
BIOFILM
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The “Iceberg Effect”
Described by Maki and Mermel
Difficult to treat, best to remove it. Patient may be
asymptomatic
Cultures may grow planktonic cells
Biofilm in “high flow” areas may seed other parts
of the body
FUTURE TREATMENT
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Biofilm inhibitor (RAP, TRAP, RIP is biofilm
inhibitor)
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Biofilm inhibitor plus antibiotic in dacron cuff
With the use of ultrasound, the inhibitor and
antibiotic would be released
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Biofilm inhibitor in antibiotic beads as they
dissolve
Prevention
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Handwashing
Chlorohexidine scrub (1a
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recommendation from the CDC)
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BioPatch (chlorhexidine-
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impregnated synthetic disk)
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Anti-infective lock
solution in long-term
devices
Maximal sterile barriers
Specialty teams
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Multidisciplinary
approach
Transparent dressing
Antimicrobial-infected
catheters
Securement devices
Handwashing
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50% of nosocomial infections could be eliminated
by handwashing alone
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Hands are only washed 50% of the times indicated
Wearing gloves does not eliminate need to wash
hands before or after patient contact
15 second vigorous hand wash with soap and
running water
Primary infection control measure
Chlorhexidine Skin Antiseptic
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Superior efficacy
Rapid onset (30 seconds) and
prolonged antimicrobial
efficacy
Recent meta-analysis suggest
CR-BSI is significantly
reduced in patients receiving
chloraprep vs providineiodine for site disinfection
80% of resident and
transient flora live in the 1st 5
layers of dry skin (1st 10
layers of wet skin) Friction is
necessary
(Chalyakunapruk N, et al. Ann
Intern Med. 2002;135, 792)
BIOPATCH
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Foam patch with chlorhexidrine gluconate with
antimicrobial and antifungal properties
Highly absorbent
Inhibits growth of bacteria for 7 days
Shown to significantly reduce bacterial colonization of
CVC sites (Hanazaki et al, J Hosp Inf 1999)
Associated with localized contact dermatitis in infants
of very low birthweight (Garland et al, Pediatrics 20010
ANTI-INFECTIVE LOCK SOLUTION
Prophylaxis with vancomycin lock
(More studies needed) Risk of VRE
 Ethanol instillation (to be published
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soon) 25% ethanol instilled for one hour
each day
PREVENTION
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The use of maximal sterile barrier, including the
use of hair covering, face mask, sterile gown and
gloves and large sterile drapes, have been shown to
reduce the risk of infection by six to seven times
over the use of sterile gloves and drapes alone
(Maki, 1994)
AHRQ
SPECIALTY TEAMS
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IV Teams/PICC teams
Clinical resource for clinicians
Routine assessment of CVC sites
Monitoring of CVC for potential
complications
Goal is to provide appropriate
access from the start
PREVENTION
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Uniform Guidelines
INS Standards/ CDC
Guidelines
Policies available and
user-friendly
Yearly competencies
Resources available
Process Improvement
Ongoing educational
opportunities
PREVENTION
EDUCATION
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Mandatory education program for ICU nurses and physicians
in a 19-bed medical ICU at Washington University
10-page self-study module on risk factors and practice
modifications relating to CR-BSI and inservices
Pre and post-test. Fact sheets and posters reinforced the
information
Results:
24 months before the education, CR-BSI occurred in
9.4/1,000 catheter days ( 74 in 7,879 catheter days)
After implementing new program, CR-BSI occurred in
5.5/1,000 catheter day (41 in 7,455 catheter days)
Estimated cost savings with decreased CR-BSI was between
$103,600 and 1,573,000.
Warren DK. “The Effect of an Education Program on the Incidence of Central Venous
Catheter-Associated Bloodstream Infections in a Medical Center.” Chest 2004;126: 16121618.
TRANSPARENT DRESSING
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Semi-permeable polyurethane dressings
Dry and intact
Routine dressing changes
Special attention to
immunocompromised patients and
neonates
ANTIMICROBIAL
IMPREGNATED CATHETERS
PREVENTION
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Purpose: Evaluate efficacy of longterm non-tunneled silicone
catheters impregnated with
minocycline and rifampin (M-R) in
reducing CR-BSI
Prospective, randomized, doubleblind study N=356
182 M-R Catheter duration 66.21
days CR-BSI 3
174 control Catheter duration
63.01 days CR-BSI 14
Hanna H, et al. “Long-term silicone central
venous catheters impregnated with minocycline
and rifampin decrease rates of catheter-related
bloodstream infection in cancer patients: a
prospective randomized clinical trial.” J Clin Oncol.
2004 Aug 1;22(15):.3163-71
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CR=BSI rates: M-R 0.25/1,000
catheter days
Control 1.28/1,000 catheter days
P=.003
Gram-positive cocci accounted for the
majority of positive cultures
No allergic reactions
ANTISEPTIC IMPREGNATED
CATHETERS AND CUFFS
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Catheters coated with chlorhexidine/silver sufadiazine
on the catheter surface can reduce the risk for CR-BSI
Antimicrobial activity decreases over time, benefit will
be realized within the 1st 14 days.
Although rare, anaphylaxis has been reported
More expensive than standard catheters, may be cost
effective for high risk patients i.e. patients with burns,
neutropenia
Veenstra DL et al, “Efficacy of antiseptic-impregnated central venous catheters in preventing catheterrelated blood stream infections: a meta-analysis.” JAMA 1999;281;261-7.
SECUREMENT DEVICES
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Decrease irritation
Decrease needlesticks
Decrease catheter migration
Increase patient comfort
Decrease infection (Shears et al, 2000)
ADDITIONAL STRATEGIES
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Catheters inserted into new
sites, not old sites over a
guidewire (avoid routine
replacement of central lines)
Warfarin and Heparin
Prophylaxis (Thrombus formation
on indwelling CVC associated with CRBSI) S. aureus, S. epidermidis,
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and Candida species adhere
to different protein
components of thrombus)
Subcutaneously tunneled
short term catheters (Cuffed
dialysis catheters decreases risk of
CR-BSI by 2/3)
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Minimize hub manipulations
Ointments to insertion site;
may lead to increased
colonization of candida
species. (Ointment to insertion sites
of temporary HD central lines reduces
CR-BSI)
“KEEP ME SAFE”
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Patient campaign from the Oley
foundation
Specific instructions for central line
care
Goal is to prevent infection