Central venous catheters: preventing infection and occlusion

As central venous catheters (CVCs) become more widely used in today's healthcare environment, nurses require expert knowledge in relation to CVC maintenance to prevent complications and maximize efforts to optimize the individual's health status. This is especially so since CVCs have begun to be used outside intensive care units, e.g. in general wards, and can be associated with high incidences of infection, occlusion and subsequent compromise in patient health. Nurses are responsible for the maintenance and use of central access devices, such as CVCs, resulting in a need for literature specific to the nursing aspects of CVC management. This article addresses many nursing issues pertaining to care of the central line, focusing on evidence- and research-based literature, and also reviews the literature to make recommendations for practice.     

Central venous catheter management in patients with cancer

This article provides a summary on the management of central venous catheters (CVCs) in the person with cancer. The use of CVCs is becoming more commonplace with the emphasis on home-based cancer therapies and the increasing use of high-dose chemotherapy regimens and stem cell rescue. The different types of CVC are examined and the potential complications and nursing management are discussed in this article. Nurses are leading practice in this area, undertaking a holistic assessment of the patient before inserting a CVC that meets their specific medical and personal requirements. A thorough understanding of the use of CVCs, potential complications and patient issues is crucial for sensitive assessment and treatment.     

Central venous catheters: choosing the most appropriate access route

Intravenous therapy and care is a complex and intricate area of practice, which is being subsumed into the core role of registered nurses. As more patients become recipients of a vascular access device (VAD), particularly those requiring intermediate to long-term central venous access, it is important to ensure that not only the device but also the most appropriate vein meets their clinical physiological and psychological needs. There is much research and literature on the insertion and care of central venous catheters (CVCs) as well as the detection and treatment of complications. However, apart from a few small studies comparing the performance of devices placed either in the subclavian or jugular veins, there is little to guide doctors or nurses as to which vein is preferable, if secondary complications are to be avoided. This article will describe a number of primary and secondary complications associated with both the subclavian and internal jugular veins and how these can be minimized by selecting the most appropriate vessel. The article concludes with the author's suggestions for correct patient assessment in order that the correct vein is utilized.     

Anti-infective-treated central venous catheters: a systematic review of randomized controlled trials

Objective This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in the acute care setting. Methods Randomized controlled trials were retrieved from Medline and the Cochrane Library up to 15 January 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model. The impact of the risk for CRBSI in the control group (baseline risk) on the benefit of anti-infective CVCs was studied by using meta-regression based on the binomial normal bivariate meta-analysis model. Results Twenty-one trials were included in the review. Mainly intensive care (IC) patients were studied. Eighteen trials showed that anti-infective CVCs reduced the risk of CRBSI. The number needed to treat (NNT) varied from 182 to 12, with baseline risks ranging from 1% to 10%. Nearly all trials had serious methodological shortcomings. Three trials comparing minocycline-rifampicin-treated catheters with antiseptic-treated catheters showed inconsistent results. One trial suggested that there is not any difference in CRBSI between heparin- and antiseptic-treated CVCs. Conclusion Because the NNT is large when the baseline risk is low, the use of anti-infective-treated CVCs in the acute care setting should only be considered in situations in which background rates of CRBSI are high. The magnitude of benefit as calculated in this review should be interpreted with caution because of strong arguments in favor of a systematic overestimation of the effect. Which type of anti-infective catheter is most effective could not be established from the available data. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Central venous catheter infections: Concepts and controversies

Central venous catheters (CVCs) are widely used in critically ill patients in intensive care units. However, infectious complications are common and may limit their utility. We critically review the literature to determine the impact of CVC design amd composition, insertion site selection, insertion procedures, care and removal of temporary CVCs on infectious complications. Relevant articles were identified and selected for review using a database search (Medline and manual of the English language literature) based upon study design and sample size with an emphasis on prospective randomized trials. To minimize infectious complications and maintain a reasonable cost-benefit ratio, we recommend: i) use a single lumen catheter unless clear indications for a multi-lumen catheter exist; ii) insert the catheter via the subclavian vein if no relative contraindication exists (bleeding diathesis, positive pressure ventilation); iii) disinfect the insertion site employing sterile technique; iv) apply a dry, sterile dressing and change the dressing every other day; v) inspect the insertion site for signs of infection and remove the catheter if pus is present; vi) if a catheter-related infection is suspected, change the catheter over a guidewire and culture the distal segment. The replacement catheter should be removed if an original catheter segment culture is positive.     

Bench-to-bedside review: Challenges of diagnosis,care and prevention of central catheter-related bloodstream infections in children

Central venous catheters (CVCs) are indispensable in modern pediatric medicine. CVCs provide secure vascular access, but are associated with a risk of severe complications, in particular bloodstream infection. We provide a review of the recent literature about the diagnostic and therapeutic challenges of catheter-related bloodstream infection (CRBSI) in children and its prevention. Variations in blood sampling and limitations in blood culturing interfere with accurate and timely diagnosis of CRBSI. Although novel molecular testing methods appear promising in overcoming some of the present diagnostic limitations of conventional blood sampling in children, they still need to solidly prove their accuracy and reliability in clinical practice. Standardized practices of catheter insertion and care remain the cornerstone of CRBSI prevention although their implementation in daily practice may be difficult. Technology such as CVC impregnation or catheter locking with antimicrobial substances has been shown less effective than anticipated. Despite encouraging results in CRBSI prevention among adults, the goal of zero infection in children is still not in range. More high-quality research is needed in the field of prevention, accurate and reliable diagnostic measures and effective treatment of CRBSI in children.     

Clinical review: new technologies for prevention of intravascular catheter-related infections

Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.     

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.     

Clinical review: New technologies for prevention of intravascular catheter-related infections

Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.     

Strategic patient education program to prevent catheter-related bloodstream infection

Central venous catheters (CVCs) are used commonly for venous access during treatment, and catheter-related bloodstream infection (CRBSI) is a frequent, yet highly preventable, hospital-acquired infection. One of the performance elements of the Joint Commission's 2012 National Patient Safety Goals addresses the education of patients and family members on CVC care and management, as well as CRBSI prevention before a central catheter is inserted. This article presents the history and roles of the Infusion Therapy Team at the University of Texas MD Anderson Cancer Center in CVC care and describes an organized patient education program that plays a key part in the institution's strategy to reduce and prevent CRBSI. Institutional standard policies and procedures for patient care should be in compliance with guidelines of the Centers for Disease Control and Prevention and the Joint Commission before any patient educational initiative is implemented. Such standards will serve as a guide to set up, organize, and implement an effective program.     

Central venous catheter infection in adults in acute hospital settings

As well as the human cost, central venous catheter (CVC)-related bloodstream infections significantly inflate hospital costs, mainly through increased length of stay in hospital, particularly in intensive care. This literature review appraises recent research on measures used to minimize CVC-related infection and compares it with current best practice. Randomized controlled trials and systematic reviews published on the subject between 2000 and 2005 were reviewed, concentrating on non-tunnelled, short-term CVCs in the acute hospital setting. The new evidence mainly backs up current best practice. However, skin disinfection could be improved by using alcoholic chlorhexidine followed by aqueous povidone-iodine before CVC insertion. Also, alcoholic chlorhexidine is the preferred solution for cleaning the hubs/connectors before accessing the CVC. Good hand hygiene and quality control and education programmes are vital to improve patient care. More research is needed to clarify the effectiveness of certain interventions and technologies, such as antimicrobial CVCs.     

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.     

Elective removal of cuffed central venous catheters in children

Background Subcutaneously tunneled, cuffed central venous catheters (CVCs) are commonly used in children undergoing cytotoxic chemotherapy or hematopoietic stem-cell transplantation. When their use is no longer indicated or precluded by mechanical or infectious complications, CVCs have to be removed. General instructions on how cuffed CVC should be removed are available in the medical texts but none is adapted for use in children. Materials and methods A literature search from the MEDLINE and EMBASE to identify articles describing the procedure of removing CVC or complications arising from the procedure was carried out. Results Specific guidance on the removal of CVC in children was not found. Venous air embolism appeared to be the most common complication associated with catheter removal but none involved pediatric patients. On the other hand, three out of the five incidents of catheter fracture with or without embolization happened in children. Conclusion Further studies are needed to define the optimal management of CVC removal in pediatric patients. A sequence of positioning the child, use of sedation, dissecting out the cuff, pulling off the catheter, closing the exit wound, and handling of the removed catheter is suggested.     

A care bundle for management of central venous catheters

Central venous catheters (CVCs) are an essential tool in paediatric intensive care, providing a means to monitor patient haemodynamics and to administer fluids, nutrition, blood products and medications. Because multiple factors contribute to the high risk of catheter related infection, a multi-strategy approach is required to prevent such infections. Using contemporary literature and clinical audit findings a 'care bundle' was created for use within the PICU at Birmingham Children's Hospital. This care bundle groups together best practices in order to prevent catheter related bloodstream infection.     

A multicentred clinical improvement project among preterm population evaluation of current practices

Sepsis, a potentially life-threatening infection, is a common complication related to the use of central venous catheters (CVCs) in the preterm infant population. Best practice guidelines include successful strategies to prevent infections. Central venous catheter use is a fairly recent intervention in Finnish neonatal intensive care units (NICUs). As part of a quality improvement project to evaluate catheter-related care practices, 4 NICUs collaborated in a multicenter, multiprofessional study aimed at decreasing the incidence of catheter-related sepsis among a population of preterm infants. This article describes the initial phase that evaluated current protocols and practices. The findings were that current protocols need revision to include more detailed and accurately focused instructions on infection prevention associated with CVC. Many challenges in performing certain procedures with catheters were found. Precis CVC protocols and practices in 4 Finnish NICUs were reviewed for infection control measures.     

Use of ultrasound to place central lines

CONTEXT: Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. OBJECTIVE: The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. DATA SOURCES: Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. STUDY SELECTION: Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. DATA SYNTHESIS: Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, -.12, 95% confidence interval [CI], -.18 to -.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15-1.67), and arterial puncture rate (risk difference, -.07, 95% CI, -.10 to -.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference,.24, 95% CI,.08-.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. CONCLUSIONS: Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined.     

Your child has diabetes: hospital or home at diagnosis?

Historically, children with diabetes have been hospitalized at diagnosis, but increasingly, newly diagnosed children are being cared for entirely at home. The management of this chronic condition usually involves the whole family, with children often taking responsibility for much of their own care. However, this article focuses specifically on the needs of parents, forming part of an extensive literature review informing a study exploring parents' experience of home management and coping over the first year with childhood diabetes. A search of the literature revealed a scarcity of evidence overall about hospitalization or home management from a parental perspective, and none in relation to childhood diabetes. This article provides a critical appraisal of the appropriateness of these two approaches to care for parents of children with newly diagnosed diabetes. First, a brief introduction to home management in childhood diabetes is followed by an examination of the small amount of research found about home management and hospitalization from the point of view of parents. Then, the possible benefits and disadvantages of both approaches are discussed and subsequently scrutinized in the context of childhood diabetes. Finally, preliminary conclusions are drawn and suggestions made for the direction of future research in this area.     

Chlorhexidine versus povidone-iodine for central venous catheter site care in children

The number of children receiving central venous catheters (CVCs) for the administration of medications is at an all-time high. Unfortunately, placement of these CVCs is not without risks. Infection of CVC insertion sites is one of the most common, yet often preventable, causes of nosocomial bacteremia in both children and adults worldwide. Throughout the years, multiple practice recommendations have been made regarding the proper site care of CVCs. The most popular antimicrobial solution used for site care has traditionally been povidone-iodine. Chlorhexidine gluconate solution, however, has been shown to be more effective than povidone-iodine in preventing CVC-related infections in adults. There continues to be controversy regarding the efficacy and safety of antimicrobial solutions for pediatric CVC site care. An evidence-based approach was used to determine current recommendations for CVC site care in children.     

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

Purpose

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

Methods

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

Results

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

Conclusions

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.