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12.15 12.30 lynn hadaway - publiceren
 

12.15 12.30 lynn hadaway - publiceren

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    12.15 12.30 lynn hadaway - publiceren 12.15 12.30 lynn hadaway - publiceren Presentation Transcript

    • Peripheral  Venous  Catheter  (PVC)   Infec6ons   Lynn  Hadaway   Lynn  Hadaway  Associate,  Inc.   Milner,  GA,  USA  
    • Financial  Disclosure  •  Disclosure   –  Literature  search  commissioned  and  funded  by  BD   Medical,  Inc.     –  Lynn  Hadaway  is  a  paid  consultant  for  BD  Medical,   Inc.    
    • Peripheral  IV  Catheters  •  1.7  Billion  sold  worldwide   –  330  million  sold  annually  in  the  USA  •  Even  small  rates  equal  large  number  of  infec6ons  •  Many  unanswered  ques6ons  about  outcomes  with   their  use   –  Very  liPle  aPen6on  to  infec6on  risks  •  Integra6ve  literature  review  to  thoroughly  evaluate   what  is  known  
    • Literature  Review  Process  •  Search  Terms   –  Peripheral  catheter   –  Peripheral  catheter   complica6on   –  Peripheral  IV  catheter   –  Peripheral  catheter  &   infec6on   –  Peripheral  venous   catheter   –  Peripheral  catheter  &   phlebi6s   –  Peripheral  IV  catheter   inser6on   –  Suppura6ve   thrombophlebi6s  &   –  Peripheral  venous   catheter   catheter  inser6on   –  Bacteremia  &  catheter   –  Venipuncture   –  Bloodstream  infec6on  &   catheter  
    • Literature  Review  1400   4  case  reports  abstracts  reviewed, 45  met   22  descrip6ve  studies   inclusion   1  cohort  study  588  studies   3  case  controlled  studies  examined   criteria   1  correla6on  study   9  randomized  controlled  trials   4  systema6c  literature  reviews   1  meta-­‐analysis  Final  report  will  be  published  in  Journal  of  Infusion  Nursing,  July/August  2012  
    • Literature  Review  •  22  countries   –  Canada   –  Lebanon   –  Spain   –  Scotland   –  Taiwan   –  Israel   –  Uganda   –  Chile   –  Korea   –  Germany   –  Barxil   –  USA   –  United   –  Switzerland   –  Italy   Kingdom   –  Netherlands   –  Australia   –  Turkey   –  England   –  Austria   –  New  Zealand   –  Japan  
    • Types  of  Infec6ons   •  Local  infec6ons  (case  reports)   •  Celluli6s  and  sob  6ssue  infec6ons   •  Osteomyeli6s   •  3  children  with  osteomyeli6s  in  close   proximity  to  peripheral  catheter  site;  skin   organisms  lead  to  thrombophlebi6s  and   then  osteomyeli6s  
    • Types  of  Infec6ons  •  Phlebi6s/thrombophlebi6s   –  Ranges  from  2%  to  80%   –  5%  to  25%  of  peripheral  catheters   colonized  with  bacteria  at  removal   –  No  data  on  rates  of  each  type  of   phlebi6s  •  Suppura6ve  thrombophlebi6s-­‐   purulent  drainage  from  inser6on  site  
    • Types  of  Infec6ons  –  BSI/Bacteremia  Systema6c  Literature  Review  (Maki,  2006)   •  Studies  from  January  1966-­‐July  1,  2005   •  110  studies  of  plas6c  catheters   •  10,910  catheters;  28,720  device-­‐days   •  13  BSIs  =  pooled  mean  rate  of  0.1  event  per  100  devices   •  0.4  pooled  mean  events  per  1000  device  days   •  Lowest  rates  of  all  devices  by  percentage  
    • Types  of  Infec6ons  –  BSI/Bacteremia  Lowest  Rates  but  High  Absolute  Numbers  •  330  million  catheter  sold  annually  in  USA  •  2  aPempts,  2  catheters  per  site    •  165  million  inserted  •  165,000  pa6ents  with  BSI  annually  
    • Types  of  Infec6on  –  BSI/Bacteremia  •  Retrospec6ve   • 544  cases   analysis  of  S.   • 18  definite,  6  probably  cases  of  bacteremia   aureus   related  to  short  peripheral  IV  catheters   bacteremia   • 12%  of  all  S.  aureus  bacteremias   from  July  2005   • 67%  of  definite  cases  inserted  in  Emergency   thru  March   Dept;  46%  in  right  antecubital,  21%  in  leb   2008   antecubital   • Calculated  rate  of  0.06  bacteremias  per  1000  •  Blood  and   catheter  days   catheter  6p   • Annual  adult  pa6ent  discharge  data  from  USA   cultures   • Es6mated  10,028  S.  aureus  bacteremias   correlated  to   annually  in  hospitalized  adults   clinical  findings  
    • Author,  Year,   Numbers   PVC  Infection  Rates  Reported  Country  Maki,  USA,  2006   110  studies   0.1  BSIs  per  100  devices  Literature  review   10,910  PVCs   0.4  mean  #  BSIs  per  1000  device  days  spanning  38.5  years   28,720  device-­‐days  Pujol,  Spain,  2007   147  patients   PVC=  77  (51%)  or  0.19  cases/1000   patient  days  Descriptive  study  over   CVC=  73  (49%)  or  0.18  cases/1000  18  months   patient  days  Nahirya,  Uganda,  2008   391  PVC  cultured   81  (20.72%)  colonized  PVC  tip   catheter  tip,  hub,  and   44  (11.25%)  colonized  PVC  hub   blood   19  (4.86%)  with  same  organism  at  tip   and  hub   16  (4.09%)  PVC  tip  with  same  organism   as  blood   7  (1.79%)  with  same  organisms  at  tip,   hub  and  in  blood  
    • Author,  Year,   Numbers   PVC  Infection  Rates  Reported  Country  Lee,  Taiwan,  2009   3165  patients  with   160/162  PVCs  (98.8%)  with  phlebitis;   6538  PVCs   showed  no  microbiological  evidence  of   Semi-­‐quantitative   infection   culture  of  all  catheters   No  purulent  exit  site  infection   at  removal.   No  CRBSI  Webster,  Australia,   6  RCTs  comparing   Catheter  related  bacteremia:  2010   routine  change  at   •  Low  risk  population  =  1/1000  device   _ixed  time  interval  vs   days  in  both  groups   when  clinically   •  High  risk  population  =  7/1000     indicated   device  days  in  routine  removal   3455  participants   group;  4/1000  removal  when   1  trial  in  England   clinically  indicated   5  in  Australia   4  published   2  unpublished  
    • BSI/Bacteremia  –  USA    •  Retrospec6ve   • 544  cases   analysis  of  S.   • 18  definite,  6  probably  cases  of  bacteremia   aureus   related  to  short  peripheral  IV  catheters   bacteremia   • 12%  of  all  S.  aureus  bacteremias   from  July  2005   • 67%  of  definite  cases  inserted  in  Emergency   thru  March   Dept;  46%  in  right  antecubital,  21%  in  leb   2008   antecubital   • Calculated  rate  of  0.06  bacteremias  per  1000  •  Blood  and   catheter  days   catheter  6p   • Annual  adult  pa6ent  discharge  data  from  USA   cultures   • Es6mated  10,028  S.  aureus  bacteremias   correlated  to   annually  in  hospitalized  adults   clinical  findings  
    • Pathophysiology  •  Not  well  understood  •  Most  likely  mechanism  of  peripheral  catheter-­‐BSI     –  Coloniza6on  of  the  vascular  catheter  tract   –  Biofilm  forma6on   –  Occurs  during  inser&on  and  manipula&on   –  No  evidence  about  the  connec6on  between   thrombophlebi6s  and  BSI  (Zingg  &  PiPet,  2009)  
    • Iden6fied  Clinical  Issues  –      Catheter  Design  •  Ported  catheters   –  German  study  found  27%  of  pa6ents  with   possible  infec6on  from  ported  catheters   (Grune,  2004)   •  2495  catheters,  1582  pa6ents   •  104  events  per  1000  catheter  days   •  Fever  and  local  signs  and  symptoms   •  No  culture  data  provided  
    • Iden6fied  Clinical  Issues  –      Skin  An6sepsis  •  No  studies  suppor6ng  applica6on   technique   –  Circular  mo6on  or  back  and  forth?    •  Specific  agents,  applica6on  &   drying  6me    •  Venipuncture  for  blood  culture   and  blood  donor  collec6on   focuses  on  skin  an6sepsis  with   chlorhexidine  gluconate  
    • Iden6fied  Clinical  Issues  –      Skill  of  Inserters  Taiwanese  study  (Lee,  2009)   •  By  emergency  dept  nurses  –  3.7%  with  phlebi6s   •  By  IV  nurses  –  2.1%  with  phlebi6s   •  All  phlebi6s  was  considered  to  be  infec6ous   •  160/162  phlebi6s  cases  had  microbial  evidence  of  coloniza6on   •  No  purulence  or  BSIs  reported  USA  study  (Palefski,  2001)   •  639  catheters  inserted  by  IV  nurses;  137  inserted  by  generalists   nurses   •  36%  by  generalist  nurses,  20%  by  IV  nurses  removed  for  complica6on   •  No  reports  of  infec6on  in  either  group  
    • Iden6fied  Clinical  Issues  –      Predisposi6on  to  Phlebi6s   Higher  rates  with  more  than  1  catheter  site  •  1st  catheter  with  phlebi6s  =  5.1  X  more  likely  to  have   phlebi6s  with  subsequent  catheter   •  Pain  on  infusion  with  1st  catheter  =  11.7  X  more  likely   with  subsequent  catheters  (Palefski,  2001)  •  1st  catheter  –  phlebi6s  rates  of  2.7%   •  2  or  more  catheters  =  phlebi6s  rate  of  13.4%   (Gallant,  2006)  
    • Iden6fied  Clinical  Issues  –      Vein  Visualiza6on  Technology  Infrared  light   •  No  infec6on  data  reported  yet   •  ED  physicians  inser6ng  18  g  into  deep  basilic  or  brachial   veins   •  Chlorhexidine  skin  prep,  sterile  coupling  gel,  sterile   transparent  dressing  covering  probe   Ultrasound   •  No  infec6ons,  47%  with  infiltra6ons  within  24  hours   (Dargin,  2009)   –  2  studies   •  Retrospec6ve  data  on  804  ED  pa6ents   •  402  with  tradi6onal  methods;  3  skin/sob  6ssue   infec6ons   •  402  with  ultrasound;  nonsterile  glove  and  nonsterile   bacteriosta6c  lubricant  gel;  2  skin/sob  6ssue  infec6ons   (Adhikari,  2010)  
    • Iden6fied  Clinical  Issues  –      Catheter  Stabiliza6on   Catheter  with   Tradi6onal  catheter  hub   Mul6ple  studies  on  stabiliza6on  plamorm  plus   with  stabiliza6on  device   securement  dressing   added   stabiliza6on  devices   •  None  have  included  data  on   any  type  of  infec6ons   •  Fewer  unplanned  restarts  due   to  phlebi6s  reported  
    • Issues  Iden6fied  •  Many  prac6ce  differences  between  countries  •  Varia6ons  in  study  design  •  Varia6ons  in  data  analysis   –  Infec6ous  episodes  per  1000  catheter  days  vs  1000   pa6ent  days  
    • Issues  Iden6fied  •  No  data  on  each  type  of  phlebi6s   –  Mechanical   •  Catheter  size  in  rela6on  to  vein  diameter   •  Catheter  stabiliza6on   –  Chemical   •  pH   •  Osmolarity   •  Vesicant  nature   –  Infec6ous  
    • Unanswered  Ques6ons  •  Many  aspects  are  NOT  addressed  in  studies     –  Hand  hygiene   –  Catheter  and  site  selec6on   –  Skin  an6sepsis   –  Catheter  stabiliza6on   –  Catheter  dressing   –  Use  of  add-­‐on  devices  (e.g.,  extension  sets,  needleless   connectors)   –  Catheter  removal   –  Tourniquet  use  –  single  pa6ent?   –  Source  of  flush  solu6on  –  single  dose  container?  
    • Peripheral  Catheters  Cause  Infec6on  Exact  number  and  rates  are  hard  to  determine  with  current  studies   Pathophysiology  is  not  well  understood   Many  cases  go  undetected   Preven6on  is  dependent  upon  knowledge  and  skill  of   caregiver  following  published  standards  and  guidelines   More  studies  are  needed!!