Nancy	  L.	  Moureau,	  BSN,	  RN,	  CRNI,	  CPUI,	  VA-­‐BC	  	  	  	  	  	  	  	  	  	  	  	  	                         ...
Disclosure	  •  Nancy	  Moureau	  •  No	  conflict	  with	  this	  topic	  	  •  Clinician	  at	  Greenville	  Memorial	  H...
ObjecFves	  •  IdenGfy	  factors	  that	  increase	  risk	  of	  central	     venous	  catheter	  infecGon	  in	  relaGon	...
IntroducFon	  •  InfecGon	  is	  the	  #1	  most	  serious	  complicaGon	  for	  any	  vascular	     access	  device	  •  ...
Central	  Line	  Bundle	  PracFces                                          	  •  Hand	  Hygiene	  •  Site	  SelecGon	  • ...
Site	  SelecFon	  Emphasis	  •  Primary	  message:	      –  Avoid	  femoral	      –  Use	  subclavian	  over	  internal	  ...
Pathophysiology	  and	  Risk	  Factors	  for	                      InfecFon	  	  ColonizaGon	  of	  a	  central	  venous	 ...
Commonly	  Used	  (non	  tunneled)	  Central	  Venous	                                            	                    Cat...
Exit	  Site	  OpFons                                            	     #4 Thorax 1X105        Head/Scalp 1X106Axilla 5X106#...
Bacterial	  DistribuFon	  on	  Skin	  •  Number	  of	  bacterial	   •  Lower	  colonizaGon	   •  Higher	  colonizaGon	    ...
Exit	  Site	  Risk	  •  Local	  infecGon	  and	  CRBSI	  are	  related	  to	     risk	  of	  contaminaGon	  at	  the	  exi...
Exit	  Site	  Risk	  •  Other	  non-­‐infecGve	  complicaGons	    (thrombophlebiGs,	  venous	  thrombosis,	    dislodgemen...
Best	  PosiFon	  on	  Arm/Thigh/                 Abdomen/Chest       	  •  Flat	  posiGon	  •  Low	  moisture	  •  Good	  ...
Effect	  of	  Dressing	  Adherence	  •  Avoid	     –  Moisture	  and	  areas	  with	  hair,	        consider	  tunneling	  ...
Issues	  with	  Femoral/Inguinal	  Site	  •  Moisture	  •  Hair	  •  Highest	     temperature	  •  Difficulty	  with	     dr...
PICC	  Upper	  Arm	  vs	  Antecubital                                            	  •  Upper	  arm	  best	  locaGon	      ...
Internal	  Jugular	  with	  Chest	                       Dressing   	  •  InserGon	  at	  base	  of	  neck	      –  Stable...
Axillary	  Access	  as	  OpFon	  •  InserGon	  into	  axillary	      –  Stable	  and	  flat,	  without	         movement	  ...
Risk	  ReducFon	  Strategies                                        	  •  Apply	  all	  5	  steps	  of	  central	  line	  ...
Clinical	  ImplicaFons	  •  Evaluate	  central	  venous	  catheters	  with	  all	  opGons   	     of	  exit	  site	  using...
Future	  Study	  ConsideraFons                                       	  •  Compare	  ultrasound	  guided	  PICC/   Axillar...
QUESTIONS?	                       Speaker	  Contact	  InformaGon:	                           Nancy	  Moureau	             ...
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10.00 10.30 nancy moureau - publiceren


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10.00 10.30 nancy moureau - publiceren

  1. 1. Nancy  L.  Moureau,  BSN,  RN,  CRNI,  CPUI,  VA-­‐BC                           PICC  Excellence,  Inc.   Hartwell,  GA  USA  
  2. 2. Disclosure  •  Nancy  Moureau  •  No  conflict  with  this  topic    •  Clinician  at  Greenville  Memorial  Hospital  prn  PICC/IV  Team,   30  years  of  vascular  access  experience  •  Owner  of  PICC  Excellence,  Inc,  vascular  access  educaGonal   company  18  years  •  EducaGonal  provider,  speaker  and  consultant  with  Teleflex,   Cook,  3M,  Excelsior,  Angiodynamics,  STI,  Access  ScienGfic,   Genentech  •  Legal  consultant    
  3. 3. ObjecFves  •  IdenGfy  factors  that  increase  risk  of  central   venous  catheter  infecGon  in  relaGon  to  exit   site  •  Evaluate  preventaGve  measures  and  how  they   apply  to  the  central  line  bundle  and  site   selecGon  •  List  two  ideal  exit  site  locaGons  according  to   stability,  lowest  moisture/hair  and  beQer   dressing  adherence  
  4. 4. IntroducFon  •  InfecGon  is  the  #1  most  serious  complicaGon  for  any  vascular   access  device  •  Recent  efforts  worldwide  have  focused  on  prevenGon  and   applicaGon  of  the  central  line  bundle  to  reduce  CVC  infecGons  
  5. 5. Central  Line  Bundle  PracFces  •  Hand  Hygiene  •  Site  SelecGon  •  Chlorhexidine  disinfecGon  of  skin  •  Maximum  barriers  during  inserGon  •  Prompt  removal  of  catheter  with  compleGon   of  therapy  CDC, 2011www.IHI.orgBerenholtz, Crit Care 2004Pronovost, NEJM 2006
  6. 6. Site  SelecFon  Emphasis  •  Primary  message:   –  Avoid  femoral   –  Use  subclavian  over  internal  jugular   –  Is  it  the  vein  or  the  locaGon?   –  Which  has  lowest  risk?  Risk  on  inserGon  or  risk  of   infecGon???  •  Lack  of  substanGal  evidence  to  be  definiGve   for  one  specific  vein  or  veins  as  best;  too   many  variables   Merrer, et al, JAMA 2001 Ruesch, et al Crit Care 2002 Parienti, et al JAMA 2008
  7. 7. Pathophysiology  and  Risk  Factors  for   InfecFon    ColonizaGon  of  a  central  venous  catheter  arises  from:   –  ContaminaGon  -­‐  Failure  to  maintain  asepGc  technique  during  inserGon  or  access   –  Skin  flora  -­‐  Inadequate  skin  disinfecGon  for  inserGon  and  weekly  dressing   management   –  ManipulaGon  or  poor  securement  of  a  catheter  causing  movement  in/out   –  Poor  dressing  management,  non-­‐adhesive  dressing,  moisture  and  hair   –  Bacterial  growth  -­‐  Needleless  connectors/ports  that  harbor  bacteria;  poor   disinfecGng.  Residual  blood  in  catheter  or  tubing;  poor  flushing/clearing   –  Factors  that  contribute  to  thrombosis  development  and  subsequent  infecGon  
  8. 8. Commonly  Used  (non  tunneled)  Central  Venous     Catheter  Exit  Sites–  Exit  site  in  the  antecubital   –  Exit  site  in  the  supraclavicular   area     area   •  Blind  approach  to  PICCs  (w/o   •  Blind  approach  to  IJ  (‘lateral’)   US)   or  subclavian  vein   •  US  guided  approach  to  IJ,  EJ,  –  Exit  site  in  the  upper  mid   subclavian  or  brachiocephalic     arm  (above  the  elbow)     •  US  guided  PICCs  (Dawson,   –  Exit  site  in  the  infraclavicular   2011)   area   •  Blind  approach  to  subclavian   vein  –  Exit  site  at  mid  neck   –  US  guided  approach  to   •  Blind  approach  to  internal/ cephalic  vein  or  axillary  vein   external  jugular  vein   •  US  guide  approach  to  IJ   –  Exit  site  in  the  groin  –  Exit  site  at  base  of  neck   •  Blind  or  US  guided  approach   to  the  femoral  vein  or   •  US  guide  approach  to  IJ,   saphenous  vein   bracheocephalic  
  9. 9. Exit  Site  OpFons   #4 Thorax 1X105 Head/Scalp 1X106Axilla 5X106#1 ARM 1X102 #3 AbdomenGroin 2X106 5X104#2 Thigh 4X104 Ryder, AVA 2011, SHEA 2011
  10. 10. Bacterial  DistribuFon  on  Skin  •  Number  of  bacterial   •  Lower  colonizaGon   •  Higher  colonizaGon   cells  on  skin  averages   –  Dry   –  Moist,  humid   between  10 2-­‐108   –  Cooler  than  core   –  Unable  to   mulG-­‐layers  deep   –  Flat,  stable   maintain  •  Bacterial  density  on   adherence  of   –  Minimal  hair   dressing   skin  varies  from  100   colonies/cm2  on  dry   –  Hair  follicles   surface,  to  100%   –  Sebaceous  glands   increase  in  moist   areas   When catheters are contaminated Grice, Science 2009 Ruocco, Derm Clin 2007 Li, Hulying, Metagenomics 2011
  11. 11. Exit  Site  Risk  •  Local  infecGon  and  CRBSI  are  related  to   risk  of  contaminaGon  at  the  exit  site   –  Increased  risk  -­‐  Moisture,  warmer  areas   of  body,  hair  distribuFon,  failure  of   dressing  to  adhere   –  Very  high  risk  -­‐  exit  site  at  groin  (moisture +hair+warm)   –  RelaFvely  high  risk  -­‐  exit  site  in  the  neck/ chest  area  (moisture+hair;  close  to  oral/ nasal/tracheal  secreGons).             Higher  on  neck  =  higher  risk  (more  hair)   –  Low  risk  -­‐  exit  site  at  base  of  neck,  on   chest  (dry,  stable),  at  mid  upper  arm  (dry,   stable)  Garnacho-Montero, Int Care Med 2008Goetz, Inf Cont Hosp Epid 1998
  12. 12. Exit  Site  Risk  •  Other  non-­‐infecGve  complicaGons   (thrombophlebiGs,  venous  thrombosis,   dislodgement,  etc)     –  Related  to  stability  of  catheter,  terminal  Gp   posiGon,  vein  vs  catheter  size     –  ProblemaGc  securement/dressing  -­‐  exit  site  at  mid   neck  or  higher   –  Ideal  securement/dressing  maintains  adherence   and  limits  movement  -­‐  exit  site  at  upper  mid-­‐arm   or  in  the  infraclavicular  area/base  of  neck  
  13. 13. Best  PosiFon  on  Arm/Thigh/ Abdomen/Chest  •  Flat  posiGon  •  Low  moisture  •  Good  dressing   adherence  •  Minimal  hair  
  14. 14. Effect  of  Dressing  Adherence  •  Avoid   –  Moisture  and  areas  with  hair,   consider  tunneling   –  Ideal  locaGon  on  chest  even   with  IJ,  turn  it  down  onto  chest  
  15. 15. Issues  with  Femoral/Inguinal  Site  •  Moisture  •  Hair  •  Highest   temperature  •  Difficulty  with   dressing  •  Consider  tunneling   to  move  exit   locaGon  to  increase   stability,  reduce   moisture   Merrer, et al, JAMA 2001 Goetz, Inf Cont Hosp Epid 1998 Marschall, Inf Cont Hosp Epid 2008
  16. 16. PICC  Upper  Arm  vs  Antecubital  •  Upper  arm  best  locaGon   –  Stable  and  flat,  without   joint  movement   –  Dry,  less  hair   –  Larger  vein  diameter   –  If  inserGon  close  to  axillary   moisture  area  consider   tunneling   –  Using  ultrasound  with   upper  arm  placement   Dawson, JAVA 2011 reduces  complicaGons  and   Doellman, JAVA 2009 Falkowski, Nursing 2006 infecGon   Hockley, Crit Care Res 2007 Nichols, JIN 2008 Royer, JIN 2001 Simcock, JAVA 2008
  17. 17. Internal  Jugular  with  Chest   Dressing  •  InserGon  at  base  of  neck   –  Stable  and  flat,  without   movement   –  Drier,  less  hair   –  Ultrasound  reduces   inserGonal  risk  
  18. 18. Axillary  Access  as  OpFon  •  InserGon  into  axillary   –  Stable  and  flat,  without   movement   –  Drier,  less  hair   –  Less  inserGon  risk  away   from  pleura   –  Ultrasound  reduces   inserGonal  risk  
  19. 19. Risk  ReducFon  Strategies  •  Apply  all  5  steps  of  central  line  bundle  •  Consider  use  of  anGmicrobial  catheter  and  sponge   dressing,  both  proven  to  reduce  infecGon  •  Choose  vein  and  exit  site  independently,  relate  to  risk  •  When  moisture/humidity  are  present  at  site  of  vein   access  consider  tunnel  or  alternate  site:     –  Axillary   –  Upper  arm     –  Tunnel  catheter  •  Focus  on  securement  and  dressing  adherence   Timsit, 2009 CDC, 2011 Ruschulte, 2008 Maki, 2008 Maki, 2000 HTA UK Assessment, 2008
  20. 20. Clinical  ImplicaFons  •  Evaluate  central  venous  catheters  with  all  opGons   of  exit  site  using  ultrasound  for  placement    •  Consider  zones  or  areas  with  least  risk  of   infecGon  based  on  evidence  •  Understand  complicaGons  are  directly  correlated   with  exit  site  related  to  moisture,  temperature   and  dressing  adherence  •  Establish  new  terminology  and  classificaGon  of   CVCs  with  focus  on  exit  site  and  risk  reducGon  
  21. 21. Future  Study  ConsideraFons  •  Compare  ultrasound  guided  PICC/ Axillary/Infra  and  Supraclavicular   venous  access  device  with  specific  area   of  inserGon/exit  on  skin.  Evaluate  risk   for  inserGon  and  post  inserGon   complicaGons  •  Evaluate  infecGon  rates  for  non-­‐ tunneled  catheter  according  to  precise   area  of  exit  site  •  Study  each  catheter/vein  complicaGon   rate  based  on  exit  site  (Dawson,  2011)  
  22. 22. QUESTIONS?   Speaker  Contact  InformaGon:   Nancy  Moureau   Email:   Website  informaGon:  THANK  YOU!!  
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