Devices and dressings to secure peripheral venous catheters: A Cochrane systematic review and meta-analysis

BackgroundPeripheral venous catheterisation is the most frequent invasive procedure performed in hospitalised patients; yet over 30% of peripheral venous catheters fail before treatment ends.ObjectivesTo assess the effects of peripheral venous catheter dressings and securement devices on the incidence of peripheral venous catheter failure.Data sourcesWe searched the Cochrane Wounds Group Register, The Cochrane Central Register of Controlled Trials, MEDLINE; EMBASE and CINAHL for any randomised controlled trials comparing different dressings or securement devices used to stabilise peripheral venous catheters. The reference lists of included studies were also searched for any previously unidentified studies.ResultsWe included six randomised controlled trials (1539 participants) that compared various dressings and securement devices (transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster). Trial sizes ranged from 50 to 703 participants. The quality of evidence ranged from low to very low. Catheter dislodgements or accidental removals were lower with transparent dressings compared with gauze (two studies, 278 participants, risk ratio (RR) 0.40; 95% confidence interval (CI) 0.17–0.92, P = 0.03%). However, the relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47–1.68) and infiltration (RR 0.80; 95% CI 0.48–1.33) are unclear. A single study identified less frequent dislodgement or accidental catheter removal with bordered transparent dressings compared to a securement device (RR 0.14, 95% CI 0.03–0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03–64.02). A comparison of a bordered transparent dressing and tape found more peripheral venous catheter failure with the bordered dressing (RR 1.84, 95% CI 1.08–3.11) but the relative effect on dislodgement was unclear.ConclusionsThere is no strong evidence to suggest that any one dressing or securement product for preventing peripheral venous catheter failure is more effective than any other product. All of the included trials were small, had high or unclear risk of bias for one or more of the quality elements we assessed, and wide confidence intervals, indicating that further randomised controlled trials are necessary. There is a need for suitably powered, high quality trials to evaluate the newer, high use products and novel – but expensive – securement methods, such as surgical grade glue.     

Central Line Care and Management: Adopting Evidence-Based Nursing Interventions

Central line–associated bloodstream infections occur not only in the intensive care unit but also the non–intensive care units of the hospital. The purpose of this article is to review current evidence to guide perianesthesia nurses in the care of a patient with a central vascular access device (CVAD). The CVAD bundle focuses on five key elements: hand hygiene, maximal sterile barrier, chlorhexidine antiseptic, catheter site selection, and daily evaluation of the need for the device. Once the CVAD is placed, evidence-based care and maintenance are the responsibility of the nurse. Ensuring proper maintenance and care of a CVAD falls within nursing practice and interventions can significantly reduce the patient's risk of central line–associated bloodstream infection. The single most crucial step a nurse can take to help prevent central line–associated bloodstream infections is performing proper hand hygiene. Other interventions focus on dressing management, bathing practices, access of intravenous infusion sets, blood draws, and management of port line occlusions. Familiarity and adoption of best practice interventions in the maintenance and care of patients with CVADs will help the perianesthesia nurse protect patients and prevent harm.     

Chlorhexidine-impregnated gel dressing compared with transparent polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients: A pilot randomised controlled trial

BackgroundIn patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections.ObjectivesThe objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC.MethodsOne hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip.ResultsOf 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes.ConclusionsOur preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.     

A pilot randomised controlled trial of dressing and securement methods to prevent arterial catheter failure in intensive care

BackgroundCritically ill patients in an intensive care setting often require arterial catheters for blood pressure monitoring and arterial blood collection. Arterial catheter failure, which manifests in both mechanical and infective forms, remains common. Dressing and securement inadequacies may impact this failure; however, the best method for dressing and securing arterial catheters is yet to be determined.ObjectivesThe objective of this study was to establish the feasibility of a definitive randomised controlled trial comparing methods for dressing and securing arterial catheters and to prevent device failure in an adult intensive care setting.MethodsA pilot, parallel-group, randomised controlled trial was conducted between April 2017 and June 2018. Patients receiving treatment in two adult intensive care units (Queensland, Australia) were eligible for inclusion and were allocated to receive either (i) an integrated securement dressing or (ii) a simple polyurethane dressing (with gauze/foam), applied to their newly inserted arterial catheters.Main outcome measuresPrimary outcomes were (i) feasibility (defined by pre-established criteria: patient eligibility, consent, protocol adherence, retention, and staff acceptability) and (ii) all-cause arterial catheter failure (a composite of local and bloodstream infection, occlusion, dislodgement, infiltration/extravasation, arterial inflammation, thrombosis, and/or inaccurate trace). Secondary outcomes included: failure type, dwell time, dressing adhesion, adverse event profiles, and staff acceptability.ResultsIn total, 109 patients were studied (n = 53 integrated securement dressing; n = 56 simple polyurethane). The feasibility criterion was met by most patients (including rates of consent [86%], protocol adherence [93%], and retention [100%]); however, the criteria for patient eligibility were not met (73%). All-cause device failure did not differ significantly between the integrated securement device group (n = 12/53, 23%) and the simple polyurethane group (n = 6/56, 11%) (hazard ratio = 2.39, 95% confidence interval = 0.89–6.37, p = 0.083).ConclusionsFindings indicate a larger study is feasible, with minor alterations to recruitment methods required. Arterial catheter failure remains unacceptably common; further research to determine optimal dressing/securement practices is urgently needed.     

Use of a 1-piece chlorhexidine gluconate transparent dressing on critically ill patients

Background New transparent dressings with chlorhexidine gluconate in the dressing are available. Objectives To compare the effectiveness of a new 1-piece occlusive dressing that incorporates chlorhexidine gluconate with that of a dressing plus a chlorhexidine gluconate patch in maintaining the low rate of catheter-related bloodstream infections in the intensive care unit and to evaluate nurses' satisfaction with and cost of the new dressing. Methods A quality improvement observational study was done in an adult medical-surgical intensive care unit. All patients with a central venous catheter had initial and/or subsequent dressing changes done with the new dressing. The central catheter bundle elements of the Institute for Healthcare Improvement were followed. Patients were monitored for catheter-related bloodstream infections, and the rate of infection was calculated. Results During the study period of 1881 device days, the infection rate was 0.051 per 1000 device days, compared with a rate of 0.052 in 2008. Nurses preferred the new dressing. Cost savings were $3807. Conclusion A low rate of catheter-related bloodstream infections can be maintained, nurses' satisfaction achieved, and cost savings realized with the new dressing.     

A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients

PurposeTo improve jugular central venous access device (CVAD) securement, prevent CVAD failure (composite: dislodgement, occlusion, breakage, local or bloodstream infection), and assess subsequent trial feasibility.Materials and MethodsStudy design was a 4-arm, parallel, randomized, controlled, nonblinded, pilot trial. Patients received CVAD securement with (i) suture + bordered polyurethane (suture + BPU; control), (ii) suture + absorbent dressing (suture + AD), (iii) sutureless securement device + simple polyurethane (SSD + SPU), or (iv) tissue adhesive + simple polyurethane (TA + SPU). Midtrial, due to safety, the TA + SPU intervention was replaced with a suture + TA + SPU group.ResultsA total of 221 patients were randomized with 2 postrandomization exclusions. Central venous access device failure was as follows: suture + BPU controls, 2 (4%) of 55 (0.52/1000 hours); suture + AD, 1 (2%) of 56 (0.26/1000 hours, P = .560); SSD + SPU, 4 (7%) of 55 (1.04/1000 hours, P = .417); TA + SPU, 4 (17%) of 23 (2.53/1000 hours, P = .049); and suture + TA + SPU, 0 (0%) of 30 (P = .263; intention-to-treat, log-rank tests). Central venous access device failure was predicted (P < .05) by baseline poor/fair skin integrity (hazard ratio, 9.8; 95% confidence interval, 1.2-79.9) or impaired mental state at CVAD removal (hazard ratio, 14.2; 95% confidence interval, 3.0-68.4).ConclusionsJugular CVAD securement is challenging in postcardiac surgical patients who are coagulopathic and mobilized early. TA + SPU was ineffective for CVAD securement and is not recommended. Suture + TA + SPU appeared promising, with zero CVAD failure observed. Future trials should resolve uncertainty about the comparative effect of suture + TA + SPU, suture + AD, and SSD + SPU vs suture + BPU.     

Protective isolation precautions for the prevention of nosocomial colonisation and infection in burn patients: A systematic review and meta-analysis

ObjectivesTo assess the impact of protective isolation precautions on nosocomial colonisation and infection rates in burn patients.Research methodologyA systematic review and meta-analysis were performed of studies identified through Pubmed and Web of Science. Only articles in English were considered. The Downs and Black tool was used to evaluate their methodological quality. Random-effects meta-analysis obtained pooled risk ratios (RRs) and 95% confidence intervals (CIs) of nosocomial colonisation and infection rates.ResultsFive eligible before-after studies were identified, encompassing a total of 3033 patients (1192 in the experimental group; 1841 in the control group). Varying protective isolation precautions were investigated, resulting in high clinical heterogeneity. Quality assessment revealed overall poor methodological quality. Protective isolation significantly reduces combined colonisation and infection rates compared to baseline care (RR 0.52, 95% CI 0.40–0.69; P < 0.0001). Subgroup analyses indicated significant reductions in both nosocomial colonisation (RR 0.65, 95% CI 0.51–0.83; P = 0.02) and infection rates (RR 0.53, 95% CI 0.49–0.58; P < 0.0001).ConclusionsProtective isolation precautions appear to decrease the risk of colonization and infection in burn patients. Because of the absence of higher quality study designs, clinical heterogeneity and the small number of studies involved, these results must be interpreted cautiously.     

The value of chlorhexidine gluconate wipes and prepacked washcloths to prevent the spread of pathogens—A systematic review

BackgroundUse of chlorhexidine gluconate wipes and pre-packed washcloths has been described for preventing pathogen spread in healthcare settings.AimTo assess the impact of chlorhexidine washcloths/wipes in preventing the spread of pathogens.MethodsExtensive and structured literature search from studies in Google Academic, Cochrane Library, Web of Science, Pubmed and Cinahl from their inception until November 2012.FindingsFinal analysis included 15 studies, 9 of which were randomised controlled trials. The most frequent setting was the intensive care unit. In intensive care units, a significant reduction of bloodstream infection was associated with intervention and 3 studies revealed a decrease in blood culture contamination. One study showed a decrease in staff and environmental contamination and no increase in chlorhexidine resistance with intervention. Positive blood cultures for multiple pathogens also declined with intervention. In a paediatric intensive care unit, intervention decreased bacteraemia and catheter-associated bloodstream infection. In hospital wards, intervention was associated to a 64% reduction of pathogen transmission. One study had no statistically significant results. Pre-surgical chlorhexidine use significantly decreased bacterial colonisation but had no impact on surgical site infections. Regarding maternal and perinatal setting, one study did not show reduction of early onset neonatal sepsis and pathogen transmission. Another study of vaginal and neonatal decolonisation with chlorhexidine wiping revealed significant reduction in colonisation. One study concluded that single and multiple umbilical cord cleansing reduced the likelihood for a positive swab in 25% and 29%, respectively. Neonatal wiping maintained low levels of skin colonisation for a 24 h period, for multiple pathogens.ConclusionCurrent evidence supports the usefulness of chlorhexidine washcloths and wipes in an intensive care, hospital and pre-surgical setting. More studies are required to encourage its use for prevention of perinatal and neonatal transmission of pathogens.     

Selection and implementation of a transparent dressing for central vascular access devices

The selection of new central venous access devices (CVADs), line dressing, and nursing clinical practices was guided by the Center for Advanced Nursing Practice's Evidence-Based Practice Model. The model's evidence-triggered, evidence-supported, evidence-observed, and evidence-based phases provided structure that guided a systematic process in which best practice was incorporated into the clinical setting, based on clinician insights, evaluation of authoritative literature, and examination of three CVAD dressings as an intervention using various study methods. This article discusses study findings, recommendations, and implications for nursing practice. CVAD dressing integrity has clinical practice applicability in multiple settings along the care continuum.     

Central venous catheter use

Central venous catheters (CVCs) are used with increasing frequency in the intensive care unit and in general medical wards. Catheter infection, the most frequent complication of CVC use, is associated with increased morbidity, mortality, and duration of hospital stay. Risk factors in the development of catheter colonisation and bloodstream infection include patient factors (increased risk associated with malignancy, neutropenia, and shock) and treatment-related factors (increased risk associated with total parenteral nutrition, ICU admission for any reason, and endotracheal intubation). Other risk factors are prolonged catheter indwelling time, lack of asepsis during CVC insertion, and frequent manipulation of the catheter. The most important factor is catheter care after placement. Effects of CVC tunnelling on infection rates depend to a large extent on indwelling time and the quality of catheter care. Use of polyurethane dressings can increase the risk of colonisation compared to regular gauze dressing. Thrombus formation around the CVC tip increases the risk of infection; low-dose anticoagulants may decrease this risk. New developments such as CVC impregnation with antibiotics may reduce the risk of infection. Reducing catheter infection rates requires a multiple-strategy approach. Therefore, ICUs and other locations where CVCs are used should implement strict guidelines and protocols for catheter insertion, care, and maintenance.     

Polyhexamethylene biguanide discs versus unmedicated dressings for prevention of central venous catheter–associated infection in the intensive care unit: A pilot randomised controlled trial to assess protocol safety and feasibility

BackgroundCentral venous catheters are prone to infectious complications, affecting morbidity, mortality and healthcare costs. Polyhexamethylene biguanide-impregnated discs at the catheter insertion site may prevent local and bloodstream infection; however, efficacy has not been established in a critical care setting.ObjectiveThe objective of this study was to pilot test polyhexamethylene biguanide–impregnated discs compared to standard unmedicated dressings for central venous catheter infection prevention in critically ill patients.MethodsThis was a single-centre pilot randomised controlled trial. Adults admitted to intensive care requiring a central venous catheter for >72 h were eligible. Patients with a current bloodstream infection, concurrent central venous catheter, chlorhexidine or polyhexamethylene biguanide allergy, or sensitive skin were excluded. Patients were randomised to receive standard central venous catheter dressings with/without polyhexamethylene biguanide discs.Outcome measuresThe primary outcome was feasibility, defined by patient eligibility, recruitment, retention, protocol adherence, missing data, and staff satisfaction. Secondary outcomes included: central line–associated infection; primary bloodstream infection; local infection; skin complications; device/dressing dwell time; serious adverse events, and cost-effectiveness.ResultsOf 309 patients screened, 80 participants were recruited with 98% (n = 78) receiving an internal jugular catheter which dwelled for a median of 5 days (interquartile range = 4.0, 6.0). Feasibility criteria were predominantly met (recruitment 88%; retention 100%; protocol fidelity 91%); however, eligibility criteria were not met (32%; most commonly owing to short predicted catheter dwell). Staff acceptability criteria were met, with 83% of staff scoring dressing application and removal ≥7 on a numerical rating scale. There were no central line–associated bloodstream infections and no local infections. Insertion site itch occurred in 4% (control [n = 0], intervention [n = 3]) of participants, while 32% (24/76) reported pain, and 46% (35/76) tenderness.ConclusionsPolyhexamethylene biguanide discs appear safe for central venous catheter infection prevention. Feasibility of a large efficacy trial was established with some modifications to screening processes. Large, adequately powered randomised controlled trials are needed to test the infection prevention hypotheses.     

A systematic review of foam dressings for partial thickness burns

BackgroundPartial thickness burns are the most common form of thermal burns. Traditionally, dressing for these burns is simple gauze with silver sulfadiazine (SSD) changed on a daily basis. Foam dressings have been proposed to offer the advantage of requiring less frequent dressing change and better absorption of exudates.ObjectiveTo compare the impact of silver-containing foam dressing to traditional SSD with gauze dressing on wound healing of partial thickness burns.MethodsWe performed a systematic literature search using PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library database and Google Scholar for trials comparing traditional SSD dressings to that of silver-containing foam dressing on wound healing in partial thickness burns <25% of the body surface area. We excluded studies that enrolled burns involving head, face, and genitals; burns older than or equal to 36 h, non-thermal burns, and immunocompromised patients. Quality of trials was assessed using the GRADE criteria. The main outcome, complete wound healing, is reported as percentages of wound with complete epithelialization after the follow up period. Relative risks of complete healing are also reported with respective 95% CI. Time to healing and pain score before, during, and after dressing change at each follow up visit are compared between the groups (means with standard deviation or medians with quartiles).ResultsWe identified a total of 877 references, of which three randomized controlled trials (2 combined pediatric and adult trials and 1 adult trial) with a total of 346 patients met our inclusion criteria. All three trials compared silver-containing foam dressing to SSD and gauze on partial thickness burns. Moderate quality evidence indicated no significant difference in wound re-epithelialization between the groups across all three trials as confidence intervals for the relative risks all crossed 1. Although pain scores favored foam dressing at the first dressing change (7 days), there was no significant difference between the groups at the end of the treatment period at 28 days. Time to wound healing was also similar across the three trials with no statistical difference. Infection rates favored the foam-dressing group, but data were inconsistent.ConclusionModerate quality evidence indicates that there is no significant difference in wound healing between silver-containing foam dressing and SSD dressing. However, foam has the added benefit of reduced pain during the early treatment phase and potentially decreased infection rates.     

Maintenance antisepsis in reducing the rate of late-onset central venous catheter-related bloodstream infection: A comparison of 0.05% and 1% chlorhexidine

BackgroundBundled measures have been recommended to reduce the risk of central venous catheter (CVC)-related bloodstream infection. However, the importance of each procedure involved in CVC insertion/management for preventing catheter-related bloodstream infection (CRBSI) has not been thoroughly assessed. We aimed to analyze the effectiveness of maintenance antisepsis at the CVC insertion site in reducing the CRBSI risk through comparing the use of 0.05% chlorhexidine to 1% chlorhexidine.Patients and methodsIn the South Miyagi Medical Center, Japan, 372 patients with a CVC who had undergone antisepsis maintenance using 0.05% chlorhexidine swabs 12 months prior to implementing 1% chlorhexidine swabs, and 344 patients at 12 months post-implementation of 1% chlorhexidine swabs, were followed prospectively for the development of CRBSI and signs of infection, and their data compared.ResultsPost-implementation of the 1% chlorhexidine swabs, the CRBSI rate decreased from 3.64/1000 catheter-days to 1.77/1000 catheter-days. The risk of CRBSI decreased to 0.465 (95% confidence interval [CI]: 0.216–1.001). Furthermore, the risk of CRBSI ≥20 days after CVC insertion decreased to 0.200 (95% CI: 0.049–0.867); however, we found no difference between 0.05% and 1% chlorhexidine use within 19 days of CVC insertion. The increased number of patients with insertion site tenderness after implementing 1% chlorhexidine indicated a possible adverse effect of chlorhexidine.ConclusionMaintenance antisepsis with 1% chlorhexidine decreased the risk of developing CRBSI ≥20 days after CVC insertion, indicating the effectiveness of antisepsis with 1% chlorhexidine. Our data highlight the importance of maintenance antisepsis in reducing the rate of late-phase CRBSI.     

Preventing pressure ulcers—Are pressure-redistributing support surfaces effective? A Cochrane systematic review and meta-analysis

ObjectivesTo undertake a systematic review of the effectiveness of pressure redistributing support surfaces in the prevention of pressure ulcers.DesignSystematic review and meta-analysis.Data sourcesCochrane Wound Group Specialised Register, The Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL. The reference sections of included trials were searched for further trials.Review methodsRandomised controlled trials and quasi-randomised trials, published or unpublished, which assessed the effects of support surfaces in preventing pressure ulcers (of any grade), in any patient group, in any setting compared to any other support surface, were sought. Two reviewers extracted and summarised details of eligible trials using a standardised form and assessed the methodological quality of each trial using the Cochrane risk of bias tool.ResultsFifty-three eligible trials were identified with a total of 16,285 study participants. Overall the risk of bias in the included trials was high. Pooled analysis showed that: (i) foam alternatives to the standard hospital foam mattress reduce the incidence of pressure ulcers in people at risk (RR 0.40, 95% CI 0.21–0.74) and Australian standard medical sheepskins prevent pressure ulcers compared to standard care (RR 0.48, 95% CI 0.31–0.74). Pressure-redistributing overlays on the operating table compared to standard care reduce postoperative pressure ulcer incidence (RR 0.53, 95% CI 0.33–0.85).ConclusionsWhile there is good evidence that higher specification foam mattresses, sheepskins, and that some overlays in the operative setting are effective in preventing pressure ulcers, there is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. More robust trials are required to address these research gaps.     

Efficacy and safety of hydroxychloroquine/chloroquine against SARS-CoV-2 infection: A systematic review and meta-analysis

IntroductionHydroxychloroquine (HCQ)/Chloroquine (CQ) has been evaluated for treatment and prophylaxis against SARS-CoV-2 infection in various studies with conflicting results. We performed a systematic review to synthesize the currently available evidence over the efficacy and safety of HCQ/CQ therapy alone against SARS-CoV-2 infection.MethodsWe searched Embase, PubMed, Web of Science, and Cochrane central for randomized controlled trials (RCTs) and prospective cohort studies published until October 15, 2020 and assessing the efficacy of HCQ alone against SARS-CoV-2 infection. We included studies evaluating HCQ/CQ alone as intervention and placebo/standard care as a control group. Retrospective studies and studies using other drugs (namely azithromycin, corticosteroids, immunomodulators, etc.) we excluded. Thirteen RCTs and three prospective cohort studies were included in this review. We pooled data using a random-effect model.ResultsPooled data from 12 studies (9917 participants) showed that HCQs increase mortality as compared to placebo/standard of care (RR 1.10; 95% CI:1.00–1.20). Hydroxychloroquine did not reduce the need for hospitalization in out-patients (RR 0.57; 95% CI 0.31–1.02). HCQ group has a significantly higher rate of any adverse event (RR 2.68; 95% CI 1.55–4.64), as compared to the control group. Also, using HCQ for prophylaxis against SARS-CoV-2 infection did not reduce the risk of acquiring SARS-CoV-2 infection (RR 1.04; 95% CI 0.58–1.88).ConclusionsHCQ therapy for COVID-19 is associated with an increase in mortality and other adverse events. The negative effects are more pronounced in hospitalized patients. Therefore, with the available evidence, HCQ should not be used in prophylaxis or treatment of patients with COVID-19.     

The relationship between methodological trial quality and the effects of impregnated central venous catheters

OBJECTIVE: We assessed the methodological trial quality of individual randomized controlled studies on chlorhexidine silver sulfadiazine impregnated catheters and the effect on catheter-related infection (CRI). DESIGN: Only the studies identified in the Medline database from 1966 to December 2001 were considered, abstracts being excluded. The outcome of this investigation centered on bloodstream CRI. The trial quality of the 11 studies identified and published (total 3,131 catheters) was assessed using a scoring system based on allocation, patient selection, patient characteristics, blinding of the intervention and the diagnosis of CRI (range 0-2 points, 10 points maximum). RESULTS: The mean methodological quality score was 7.1 (range 5-9). The relative risk reduction for bloodstream CRI ranged from -0.14 to 1.0. No association between trial quality and the impact of chlorhexidine silver sulfadiazine impregnated catheters on CRI was found. The summary odds ratio for CRI was 0.69 (95% CI 0.46-1.03). Taking only those studies with 2 points for diagnosis of CRI a summary odds ratio of 0.87 (95% CI 0.44-1.72) resulted, whereas studies with a diagnosis score of only 1 point led to a summary odds ratio of 0.60 (95% CI 0.35-1.02). CONCLUSIONS: The quality of the studies seems to have had no influence on the outcome, according to the results of this investigation, but the use of only a single quality score may not be sufficient to investigate the prevention effect of impregnated catheters.     

Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis

OBJECTIVES: Vascular and epidural catheter-related infections cause significant morbidities and mortality in hospitalized patients. This meta-analysis assessed the effect of chlorhexidine-impregnated dressing on the risk of vascular and epidural catheter bacterial colonization and infection. METHODS: Literature search was based on MEDLINE (1966 to 1 November 2005), EMBASE and Cochrane Controlled Trials Register (2005 issue 3) databases. Only randomized controlled clinical trials comparing chlorhexidine-impregnated dressing with placebo or povidine-iodine dressing were included in this meta-analysis. Two reviewers reviewed and extracted the data independently. RESULTS: Eight studies assessing a single type of chlorhexidine-impregnated dressing were identified and subjected to meta-analysis. The chlorhexidine-impregnated dressing reduced the risk of epidural [3.6% versus 35%, odds ratio (OR) 0.07, 95% CI: 0.02-0.31, P=0.0005] and intravascular catheter or exit-site bacterial colonization (14.8% versus 26.9%, OR 0.47, 95% CI: 0.34-0.65, P<0.00001) (overall 14.3% versus 27.2%, OR 0.40, 95% CI: 0.26-0.61; P<0.0001). The use of chlorhexidine-impregnated dressing was associated with a trend towards reduction in catheter-related bloodstream or CNS infections (2.2% versus 3.8%, OR 0.58, 95% CI: 0.29-1.14, P=0.11). Local cutaneous reactions to chlorhexidine-impregnated dressing were reported in 5.6% of the patients in three studies (OR 8.17, 95% CI: 1.19-56.14, P=0.04), and 96% of these reactions occurred in neonatal patients. The number needed to prevent one episode of intravascular catheter-related bloodstream infection was 142 for an average period of catheter in situ of 10 days and a change of dressing every 5 days. The cost of preventing one vascular catheter-related bloodstream infection was estimated to be pound298 (US$532.5). CONCLUSIONS: Chlorhexidine-impregnated dressing is effective in reducing vascular and epidural catheter bacterial colonization and is also associated with a trend towards reduction in catheter-related bloodstream or CNS infections. A large randomized controlled trial is needed to confirm whether chlorhexidine-impregnated dressing is cost-effective in preventing bacterial infection related to vascular and epidural catheters.     

Focus on peripherally inserted central catheters in critically ill patients

Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care.