The ideal management of theexit site: antisepsis, dressing,          securement        Giancarlo Scoppettuolo       Cathol...
Targeting ZeroTargeting Zero is the philosophy that everyhealthcare institution should be working toward agoal of zero hea...
VAD SELECTIONAND HEALTHCARE WORKERS                       INSERTIONEDUCATION AND TRAINING                        CRBSI Pre...
Prevention of extra and intraluminal               colonization                 CHG Skin                   CHG Eluting Dis...
Why Proper CL Maintenance is CriticalInsertion Period= 30 min = 0.3%                Maintenance Period = 167.5h = 99.7%   ...
Manteinance of Exit Site• Which antiseptic?• Which Dressing?• When to change?• Is there any indication for chlorhexidine  ...
Guidelines for CRBSI Prevention•   CDC Atlanta 2002•   RCN 2005•   INS 2006•   BCSH 2006•   EPIC 2007•   SHEA/IDSA 2008•  ...
WHICH ANTISEPTIC?
Advantages of chlorhexidine• Bactericidal• Broad activity against Gram positive and Gram  negative bacteria, facultative a...
Figure 1                                                 Prospective, randomized trial of two antiseptic solutions for pre...
Premature Infant Skin• Stratum corneum  poorly developed or  absent• Thin epidermis• Dermis not fully  formed and deficien...
Full Term Infant Skin Healthy infants • Well-formed stratum   corneum…..note   multiple layers • Thick epidermis • Structu...
CHG Safety in Premature Infants  • Issues: systemic absorption, skin toxicity  • Concern: hexachlorophene caused neurotoxi...
CHG versus PI in Neonates  • Pilot parallel comparison: 2% CHG (alcohol) vs. 10% Povidone    Iodine  • 48 neonates ≥ 1500 ...
CHG Use in NICUs    • A survey of 90 NICU training units found:       55        Used CHG, central venous catheter care    ...
2010
WHICH DRESSING?AND WHEN TO CHANGE?
Advantages of Semipermeable        Transparent Dressing• Visibility of insertion site• Better stabilization of catheter, a...
Is there any indication forchlorhexidine impregnated          dressing?
WHICH SECUREMENT?
Disadvantages of sutures• Sutures disrupt the skin around the catheter exit site,  causing inflammation and heavy coloniza...
RCN 2005 RCN 2010  INS 2006  INS 2011BCSH 2006CDC 2011
Conclusions• A proper care of the catheter exit site is critical for  CRBSI prevention• The preferred antiseptic for skin ...
Last Conclusion…• All this works and is really effective  not as an isolate strategy, but only if  it is part of a bundle ...
• Hands hygiene and maximal barrier precautions• Ultrasound guided insertion• Use of 2% chlorhexidine, for skin antisepsis...
Targeting zero CLABSI in patients with    PICC lines: a case-control studyG. Scoppettuolo§, L. Dolcetti§, C. Taraschi§, C....
Results                                            CASES            CON TROLS              P                              ...
Thank you for your attention!Giancarlo Scoppettuolo, MDCatholic University“ A. Gemelli” Hospital, RomeE-mail: g.scoppettuo...
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
14.30 15.00 giancarlo scoppettuolo - publiceren copy
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14.30 15.00 giancarlo scoppettuolo - publiceren copy

  1. 1. The ideal management of theexit site: antisepsis, dressing, securement Giancarlo Scoppettuolo Catholic University, Rome
  2. 2. Targeting ZeroTargeting Zero is the philosophy that everyhealthcare institution should be working toward agoal of zero healthcare-associated infections(HAIs). While HAI prevention is challenging andcomplex, APIC believes that all organizationsshould set the aspirational goal of elimination andstrive for zero infections. Every HAI impacts thelife of
  3. 3. VAD SELECTIONAND HEALTHCARE WORKERS INSERTIONEDUCATION AND TRAINING CRBSI Prevention DISINFECTION OF CATHETER HUBS, CARE OF EXITE SITE CONNECTORS AND INJECTION PORTS
  4. 4. Prevention of extra and intraluminal colonization CHG Skin CHG Eluting Disk Preparation (applied after catheter insertion and with every (applied before catheter dressing change) insertion and with every Swabable dressing change) Needleless Connector Intraluminal colonizationExtraluminalcolonization Modified, Courtesy of R. Garcia, MD
  5. 5. Why Proper CL Maintenance is CriticalInsertion Period= 30 min = 0.3% Maintenance Period = 167.5h = 99.7% 0 1 2 3 4 5 6 7 Average Central Line Days Modified, courtesy of J. LeDonne, MD
  6. 6. Manteinance of Exit Site• Which antiseptic?• Which Dressing?• When to change?• Is there any indication for chlorhexidine impregnated dressing?• Which securement?
  7. 7. Guidelines for CRBSI Prevention• CDC Atlanta 2002• RCN 2005• INS 2006• BCSH 2006• EPIC 2007• SHEA/IDSA 2008• ESPEN 2009• RCN 2010• INS 2011• CDC 2011
  8. 8. WHICH ANTISEPTIC?
  9. 9. Advantages of chlorhexidine• Bactericidal• Broad activity against Gram positive and Gram negative bacteria, facultative anaerobes, yeasts and some lipid-enveloped viruses, including HIV (but not sporicidal)• Rapid onset of activity• Prolonged antimicrobial effect• Synergistic effect with alcohol• Lack of inactivation when exposed to blood and serum
  10. 10. Figure 1 Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Mi moz, Ol ivier; Pi eroni, Laurence; La wrence, Christine; Edouard, Alain; Costa, Ya nnick; Samii, Ka mran; Brun-Buisson, Christian Cri ti ca l Care Medicine. 24(11):1818-1823, November 1996. Fi gure 1 . Ti me to occurrence of ca theter colonization i n the chl orhexidine group (closed s quares) and the povi done iodine group (open squares). The risk of ca theter colonization was significantly greater in the povi done iodine group than in the chlorhexidine group (p < .01, Log-ra nk test).© Wi l liams & Wilkins 1996. All Rights Reserved. Published by Li ppincott Williams & Wi lkins, Inc. 5
  11. 11. Premature Infant Skin• Stratum corneum poorly developed or absent• Thin epidermis• Dermis not fully formed and deficient of structural proteins“Shaping the Future of Pediatric Vascular Access 2012”
  12. 12. Full Term Infant Skin Healthy infants • Well-formed stratum corneum…..note multiple layers • Thick epidermis • Structural proteins present in the dermis“Shaping the Future of Pediatric Vascular Access 2012”
  13. 13. CHG Safety in Premature Infants • Issues: systemic absorption, skin toxicity • Concern: hexachlorophene caused neurotoxicity • Hexachlorophene: – Bacteriostatic – disrupts bacterial cell wall – slow onset efficacy • CHG: – Bacteriocidal – increases cell membrane permeability – rapid onset – binds to SC proteins Chapman A, et al. J Perinatol (2012); 32(1):4-9“Shaping the Future of Pediatric Vascular Access 2012”
  14. 14. CHG versus PI in Neonates • Pilot parallel comparison: 2% CHG (alcohol) vs. 10% Povidone Iodine • 48 neonates ≥ 1500 g (~ 30wks GA) and ≥ 7 days • No catheter related BSIs in either group • No dermatitis - CHG or PI (i.e., ≥ 2,no pink-red all area) • CHG absorption occurred: • 7 of 10 had blood CHG between 13 – 100 ng/ml • No neurotoxicity Studies needed in younger preterms Garland J, et al. J Perinatol (2009); 29:808-813“Shaping the Future of Pediatric Vascular Access 2012”
  15. 15. CHG Use in NICUs • A survey of 90 NICU training units found: 55 Used CHG, central venous catheter care 27 No restrictions 28 Restrictions: GA, actual age or birth weight 28 Reported adverse reactions, all skin related 17 burns, 2 erosions, 9 erythema 55 Had concerns: Off label use, Immature skin, Limited safety data Tamma P, et al. Infect Control Hosp Epidemiol (2010);31(3):846-849“Shaping the Future of Pediatric Vascular Access 2012”
  16. 16. 2010
  17. 17. WHICH DRESSING?AND WHEN TO CHANGE?
  18. 18. Advantages of Semipermeable Transparent Dressing• Visibility of insertion site• Better stabilization of catheter, avoiding “in and out” movements• Better protection against secretions, mostly if catheter’sexit site is near tracheostomy or oral and nose secretions• Longer time between dressing changes (7 days vs 2 days)
  19. 19. Is there any indication forchlorhexidine impregnated dressing?
  20. 20. WHICH SECUREMENT?
  21. 21. Disadvantages of sutures• Sutures disrupt the skin around the catheter exit site, causing inflammation and heavy colonization• Bad securement of catheter, with movement of “in and out” and increased risk of thrombosis and infection• Patient discomfort• Risk of sharps injury to healthcare workers from inadvertent needlestick injury
  22. 22. RCN 2005 RCN 2010 INS 2006 INS 2011BCSH 2006CDC 2011
  23. 23. Conclusions• A proper care of the catheter exit site is critical for CRBSI prevention• The preferred antiseptic for skin during the dressing change is 2% chlorhexidine (preferably in isopropyl alcohol)• To cover and protect the exit site , you can use gauze and tapes or semipermeable transparent dressing, taking into account the differences in terms of replacing (2 vs 7 days)• To secure the catheter, use sutureless devices instead of sutures.
  24. 24. Last Conclusion…• All this works and is really effective not as an isolate strategy, but only if it is part of a bundle of recommendations…
  25. 25. • Hands hygiene and maximal barrier precautions• Ultrasound guided insertion• Use of 2% chlorhexidine, for skin antisepsis before insertion and for continous or discontinous antisespis of exit site• Use of sutureless devices for catheter securement, whenever possible• Use of transparent dressings, whenever possible• Prompt removal of unnecessary lines
  26. 26. Targeting zero CLABSI in patients with PICC lines: a case-control studyG. Scoppettuolo§, L. Dolcetti§, C. Taraschi§, C. Chiarini§, C. Donato§, S. Lardo§, A. La Greca*, M. Pittiruti* § Clinic of Infectious Diseases, * Dpt. of Surgey, Catholic University, Rome AVA 2011
  27. 27. Results CASES CON TROLS P ( I nfe ct ious ( Ot h e r w a r ds) D ise a se s)CRBSI 0 14 < 0.001CLABSI / 1 0 0 0 ca t h e t e r da y s 0 2.66 < 0.001D ia gn osis · D TP 10 · Blood cu lt u re + t ip 4 cult ur eM e dia n t im e for CLABSI NA 21+12on se tEt iology of CLABSI NA · Ca n dida a lbica n s 3 · Ca n dida pa r a psilosis 2 · CON S 3 · S. a u r e u s 1 · E. coli 3 · K. pn e u m on ia e 2CLABSI r e la t e d de a t h s 0 0 NS
  28. 28. Thank you for your attention!Giancarlo Scoppettuolo, MDCatholic University“ A. Gemelli” Hospital, RomeE-mail: g.scoppettuolo@rm.unicatt.itWeb: www.gavecelt.infowww.evanetwork.infowww.policlinicogemelli.it
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