Care of intravascular catheters


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Care of Intravascular catheters

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Care of intravascular catheters

  1. 1. Care of IntravascularCathetersDr.T.V.Rao MDDr.T.V.Rao MD @ TMC Kollam 1
  2. 2. We are in a Complex SituationDr.T.V.Rao MD @ TMC Kollam 2
  3. 3. ICU patients• Sickest patients (multiple diagnoses,multi-organ failure,immunocompromised, septic andtrauma)• Move less• Malnourished• More obtunded (Glasgow coma scale)• Diabetics and Heart failureDr.T.V.Rao MD @ TMC Kollam 3
  4. 4. ICU Care is Invasive• More invasive lines andprocedures includingsurgeries• Longer length of stay• More IV and parenteraldrugs• More tube feeding andParenteral nutrition• More ventilationDr.T.V.Rao MD @ TMC Kollam 4
  5. 5. Know about the Purpose andConsequences of Catheter Use• Healthcare personnel should be educatedregarding the indications for intravascularcatheter use, proper procedures for theinsertion and maintenance of intravascularcatheters, and appropriate infection controlmeasures to prevent intravascular catheter-related infections. Knowledge of andadherence to these guidelines should beassessed periodically for all personnelDr.T.V.Rao MD @ TMC Kollam 5
  6. 6. Inserting Catheters haveconsequences• Central venous catheters (CVCs)are being increasingly used in theinpatient and outpatient settingsto provide long - term venousaccess. CVCs disrupt the integrity ofthe skin, making infection withbacteria and/or fungi possible.Dr.T.V.Rao MD @ TMC Kollam 6
  7. 7. Catheters are Very Near to ourHeartsDr.T.V.Rao MD @ TMC Kollam 7
  8. 8. Why we Insert a Catheter•Aims• 1. To gain peripheral venous access inorder to:• • administer fluids• • administer blood products, medicationsand nutritional componentsDr.T.V.Rao MD @ TMC Kollam 8
  9. 9. Who Should Perform• 1.Only nurses who have been certified ascompetent in the insertion of IV cannula willperform this procedure.• 2. Where the patient is less than 14 years ofage, the IV cannula will be inserted by amedical personal or experienced Nurse?. Theexception will be in the case of neonateswhere neonatal trained nurses may insert anIV cannula if directed by a medical officerDr.T.V.Rao MD @ TMC Kollam 9
  10. 10. What barrier precautions to follow• Maximal sterilebarrierprecautions,including the useof a cap, mask,sterile gown,sterile gloves,Dr.T.V.Rao MD @ TMC Kollam 10
  11. 11. Choosing IV catheter Size• Age< 1 year: 22, 24gauge (g)1-8 years: 18, 20,22 gauges> 8 years: 16. 18,20 gaugesDr.T.V.Rao MD @ TMC Kollam 11
  12. 12. Dr.T.V.Rao MD @ TMC Kollam 12
  13. 13. How to prepare the Skin• Skin preparation entails preparing clean skinwith a more than 0.5% chlorhexidinepreparation with alcohol before CVCand peripheral arterial catheterinsertion and during dressing changes. Ifthere is a contraindication to chlorhexidine,tincture of iodine, an iodophores, or 70%alcohol can be used as alternativesDr.T.V.Rao MD @ TMC Kollam 13
  14. 14. Microbiology of the Skin• 80% of the resident bacteriaexist within the first 5 layers ofthe stratum corneum of theepidermis• The remaining 20% of theresident bacteria are found inbiofilms within the hairfollicles and sebaceous glands• Complete recolonization ofsurface bacteria can occurwithin 18 hours of antisepticapplicationRyder, MA. Catheter-Related Infections: Its All About Biofilm. Topics in Advanced Practice NursingeJournal. 2005;5(3) ©2005 Medscape Posted 08/18/2005 . MD @ TMC Kollam 14
  15. 15. Hand Hygiene• Use of waterlessalcohol-base handrub–Most effective andefficient method forhand antisepsisagainst bacterialpathogens• When hands arevisibly soiled, theyshould be washedwith soap and waterDr.T.V.Rao MD @ TMC Kollam 15
  16. 16. Proceed with action• Use universal precautions (glove and eyeprotection)• Allergies (beta dine or latex)• Explain procedure to Pt.• Prepare all material• Select vein. Apply tourniquet above theelbow.• Prepare siteDr.T.V.Rao MD @ TMC Kollam 16
  17. 17. Procedure (cont.)• Warn the patient of possible pain• Bevel up at 30 degree above horizontal• Look for flashback of blood into catheter• Upon seeing flashback, advance catheteranother millimeter or two• Advance the sheath completely into the veinand release tourniquetDr.T.V.Rao MD @ TMC Kollam 17
  18. 18. IV Procedure (cont.)• Connect the IVtubing/heplock• Secure catheter andtubing• Dispose of needles insharps container• Document the IV site,catheter size and dateon the patient’s chartDr.T.V.Rao MD @ TMC Kollam 18
  19. 19. Chlorhexidine-impregnatedsponge dressing• A chlorhexidine-impregnated spongedressing should be used fortemporary short-term catheters inpatients older than 2 months if theCRBSI rate is not decreasing, despiteadherence to basic preventionmeasuresDr.T.V.Rao MD @ TMC Kollam 19
  20. 20. Cutaneous AntisepsisCR Infection Prevention w/ ChlorhexidineCath colonization CRBSICHX Control CHX Control2.3% 7%*† 0.5% 2.6% (Maki `91)2% 7%* 0.6% 0.6% (Sheehan`93)4.7% 9.3%* 0 0.5% (Garland `95)12/103 31/103* 0.1/103 0.9/103 (Minoz`96)34% 27%* 3.5/103 4.1/103 (Humar`97)red values = p<0.05*= povidone iodine † = alcoholDr.T.V.Rao MD @ TMC Kollam 20
  21. 21. Procedure for Insertion ofPeripheral IV Catheter1. Obtain and review the order2. Ascertain allergies3. Gather Equipment4. Verify patient’s identity using two patientidentifiers5. Explain procedure, benefits, caremanagement, and potential complications topatientDr.T.V.Rao MD @ TMC Kollam 21
  22. 22. Procedure for Insertion ofPeripheral IV Catheter (cont)6. Perform hand hygiene7. Assemble equipment8. Apply Tourniquet9. Assess veins, keeping in mind the rational fortherapy and duration of therapy10. Apply Non sterile gloves11. Wash intended insertion site with antisepticsoap and water. (as needed)Dr.T.V.Rao MD @ TMC Kollam 22
  23. 23. Procedure for Insertion of APeripheral IV Catheter (cont)13.Clean intended insertion site withantiseptic solution, working outwardusing back-and-forth motion14. Allow site to dry15.Perform venipuncture whilestabilizing skin with theno dominate handUse left hand right handersDr.T.V.Rao MD @ TMC Kollam 23
  24. 24. Procedure for Insertion of APeripheral IV Catheter (cont)16.Enter skin at a 10- to- 30 degree angle.Decrease angle when the skin has beenpenetrated. When blood is obtained inthe flash back chamber, advance catheter1/16 inch, and then slightly pull styletback, advancing catheter gently intovessel. Continue to advance catheter intovein until the catheter hub is against theskin. Dr.T.V.Rao MD @ TMC Kollam 24
  25. 25. Procedure for Insertion of APeripheral IV Catheter (cont)17. Release tourniquet18. Occlude tip of catheter by pressingfinger of non dominant hand over vein toprevent blood spillage.19. Activate needle safety device beforeremoving stylet. Connect IVadministration set or injectioncap/needless device. Begin infusingsolutions slowly.Dr.T.V.Rao MD @ TMC Kollam 25
  26. 26. Procedure for Insertion of APeripheral IV Catheter (cont)22.Discard stylet insharps container23. Remove gloves.Perform handhygiene24. Documentprocedure in thepatient’s medicalrecord.Dr.T.V.Rao MD @ TMC Kollam 26
  27. 27. At every stage Document your resultsDr.T.V.Rao MD @ TMC Kollam 27
  28. 28. When you fail in insertion• In the case of two unsuccessfulattempts at insertion, the operatorwill seek the assistance of anotherexperienced nurse for one additionalattempt. After a total threeunsuccessful attempts the assistanceof a medical practitioner will besought.Dr.T.V.Rao MD @ TMC Kollam 28
  29. 29. When you Wish to Keep the CatheterLonger• A chlorhexidine/silver sulfadiazine orminocycline/rifampicin "impregnatedCVC should be used in patients whosecatheter is expected to remain in placefor more than 5 days if, after successfulimplementation of a comprehensivestrategy to reduce rates of CRBSI, theCRBSI rate is not decreasingDr.T.V.Rao MD @ TMC Kollam 29
  30. 30. Prevention of CR-BSIDressing• Gauze dressings every 2days• Transparent dressingevery 7 days on shortterm catheter• Replace dressing whencatheter is replaced ordressing becomes dampor loose.Dr.T.V.Rao MD @ TMC Kollam 30
  31. 31. Risk Factors• Four major risk factors are associatedwith increased catheter-related infectionrates:–Cutaneous colonization of the insertion site–Moisture under the dressing–Prolonged catheter time–Technique of care and placement of thecentral lineDr.T.V.Rao MD @ TMC Kollam 31
  32. 32. Strategies for Prevention of CR Infections• Antibiotic/Antiseptic Ointments– Povidone-iodine ointment– Mupirocin ointment• Antibiotic Lock Prophylaxis– Flushing and filling the lumen of the catheter with anantibiotic solution and leaving the solution to dwell inthe lumen of the catheter.– Heparin plus 25 micrograms/ml of Vancomycin– Vancomycin/ciprofloxacin/heparin combination– Minocycline and ethylenediaminetetraraacetic acid(EDTA)Dr.T.V.Rao MD @ TMC Kollam 32
  33. 33. Complications of IV Therapy• Classified according to their location–Local complication: at or near theinsertions site or as a result ofmechanical failure–Systemic complications: occur withinthe vascular system, remote from theIV site. Can be serious and lifethreateningDr.T.V.Rao MD @ TMC Kollam 33
  34. 34. Local complications• Occur as adverse reactions or trauma to thesurrounding venipuncture site• Assessing and monitoring are the keycomponents to early intervention• Good venipuncture technique is the mainfactor related to the prevention of most localcomplications associated with IV Therapy.• Local complications include: hematoma,thrombosis, phlebitis, post infusion phlebitis,thrombophlebitis, infiltration, extravasation,local infection, and veno spasm.Dr.T.V.Rao MD @ TMC Kollam 34
  35. 35. Hematoma• Subcutaneous hematoma is the most commoncomplication• Can be a starting point for othercomplications: thrombophlebitis and infection• Related to:– Nicking the vein– Discontinuing the IV without apply adequatepressure– Applying the tourniquet to tightly above apreviously attempted venipuncture site.Dr.T.V.Rao MD @ TMC Kollam 35
  36. 36. Hematoma• Signs andsymptoms:– Discoloration of the skin– Site swelling anddiscomfort– Inability to advance thecannula all the way intothe vein during insertion– Resistance to positivepressure during the lockflushing procedure• DocumentDr.T.V.Rao MD @ TMC Kollam 36
  37. 37. HematomaPrevention• Use of an indirect method• Apply tourniquet just beforevenipuncture• Use a small need in the elderly andpatients on steroids, or patients with thinskin.• Use blood pressure cuff to apply pressure• Be gentleDr.T.V.Rao MD @ TMC Kollam 37
  38. 38. HematomaTreatment• Apply direct, lightpressure for 2-3minutes after needleremoved• Have patient elevateextremity• Apply IceDr.T.V.Rao MD @ TMC Kollam 38
  39. 39. Thrombosis• Catheter-related obstructions can bemechanical or non-thrombotic• Trauma to the endothelial cells of the venouswall causes red blood cells to adhere to thevein wall, forms a clot or Thrombosis• Drip rate slows, line does not flush easily,resistance is felt• Never forcible flush a catheterDr.T.V.Rao MD @ TMC Kollam 39
  40. 40. Thrombosis• Signs and Symptoms– Fever and Malaise– Slowed or stopped infusionrate– Inability to flush• Prevention– Use pumps and controllersto manage flow rate– Micro drip tubing for ratebelow50mL/hr– Avoid areas of flexion– Use filters– Avoid lower extremitiesDr.T.V.Rao MD @ TMC Kollam 40
  41. 41. Never forcible flush a catheterDr.T.V.Rao MD @ TMC Kollam 41
  42. 42. ThrombosisTreatment– Never flush a cannulato remove anocclusion– Discontinue thecannula– Notify the physicianand assess the site forcirculatory impairmentDr.T.V.Rao MD @ TMC Kollam 42
  43. 43. Phlebitis• Inflammation of the veinin which the endothelialcells of the venous wallbecome irritated and cellsroughen, allowingplatelets to adhere andpredispose the vein toinflammation-inducedphlebitis– Tender to touch and canbe very painfulDr.T.V.Rao MD @ TMC Kollam 43
  44. 44. Dr.T.V.Rao MD @ TMC Kollam 44
  45. 45. Phlebitis• Mechanical:– To large a catheter for the size of the vein– Manipulation of the catheter: improper stabilization• Chemical: vein becomes inflamed by irritating orvesicant solutions or medication– Irritation medication or solution– Improperly mixed or diluted– Too-rapid infusion– Presence of particulate matterDr.T.V.Rao MD @ TMC Kollam 45
  46. 46. Phlebitis• Chemical (cont):– The more acidic the IV solution the greater therisk– Additives: Potassium– Type of material– Length of dwell:• 30% by day 2, 39-40% by day 3 (Macki and Ringer)– The slower the rate of infusion the less irritationDr.T.V.Rao MD @ TMC Kollam 46
  47. 47. Catheter removal indications• Severe sepsis• Hemodynamic instability• Endocarditis or evidence of metastaticinfection• Erythema due to Suppurativethrombophlebitis• Persistent bacteremia after 72 hrs abx towhich organism is susceptibleDr.T.V.Rao MD @ TMC Kollam 47
  48. 48. CRBSI - Pathogenesis• 4 major sources:• a. colonization from skin• b. intraluminal or hub contamination• c. secondary seeding from a bloodstream• infection• d. rarely contamination of the infusateDr.T.V.Rao MD @ TMC Kollam 48
  49. 49. What infections are ……• A survey of 112 medical ICUs in the United States:• CoNS, mostly Staph epidermidis (36%)• Enterococci (16%)• Gram-negative aerobic bacilli (16%)• (Pseudomonas aeruginosa, Klebsiella pneumoniae, Ecoli, etc)• Staph aureus (13%)• Candida species (11%)• Other organisms (8%)• Richards M, Edwards J, Culver D, Gaynes RP. Nosocomial infections inmedical intensive care units in the United States. Crit Care Med 1999(5);27:887-892Dr.T.V.Rao MD @ TMC Kollam 49
  50. 50. Severe Consequences• 75% of all catheter-related infections aredue to the use of a central line• >250,000 CVC-related infections per year• Mortality may be up to 35%• The CDC estimates that attributable costsdue to catheter-associated infectionsrange from $34,508 to $56,000.HICPAC. CDC Guideline on the Prevention of Intravascular Associated Infections, 2002.Dr.T.V.Rao MD @ TMC Kollam 50
  51. 51. Studies prove the Infection Rate• A study in HSA ICU 2005:• 80.6% Gram –ve bacteria: K. pneumoniae (38.9%)• P. aeruginosa (19.4%)• A. baumanii (13.9%)• Enterobacter spp (8.3%)• 19.4% Gram +ve bacteria: MRSA (13.9%)• MSSA (2.8%)• CoNS (2.8%)Dr.T.V.Rao MD @ TMC Kollam 51
  52. 52. Blood under dressingKey Strategy:Monitor dressing protocolsDr.T.V.Rao MD @ TMC Kollam 52
  53. 53. Loose DressingDr.T.V.Rao MD @ TMC Kollam 53
  54. 54. Diagnosis of Catheter relatedInfections• The diagnosis of catheter-related infectionsrelies on the presence of clinicalmanifestations of infection and the evidenceof colonization of the catheter tip by bacteria,mycobacteria, or fungi. The reference methodto confirm the latter requires the withdrawalof the catheter for culturing, which frequentlyturns out to be inconvenient, unnecessary andcostly.Dr.T.V.Rao MD @ TMC Kollam 54
  55. 55. Comparative quantitative bloodcultures• Comparative quantitative blood cultures with amarked increase (> or = 5) in colony countsbetween blood obtained from the catheter lumenand from a peripheral vein simultaneously is oneof those methods. It has a high sensitivity (>80%)and specificity (94-100%) but it is cumbersomeand requires both an easy backflow of blood inthe catheter and the existence of bacteraemia.• Catheter-related infections: diagnosis and intravasculartreatment.Bouza E, Burillo A, MuñozP.Dr.T.V.Rao MD @ TMC Kollam 55
  56. 56. Cytocentrifugation and acridine orangestaining• Cytocentrifugation and acridine orange staining of bloodwithdrawn from an infected catheter lumen has asensitivity and a specificity of over 90% for the diagnosisof tip colonization. Superficial cultures comprise the semiquantitative culture of the hub, of the skin surroundingthe catheter entrance and of the first subcutaneousportion (1 cm) of the catheter after swabbing. Thesensitivity of this method is >90%, specificity is >80%, andpositive and negative predictive values for catheters(considering together those with and without clinical dataof infection) are 66 and 97%, respectively.Dr.T.V.Rao MD @ TMC Kollam 56
  57. 57. Antimicrobial-coated cathetersThe use of antimicrobial-coated catheters becomesmore prevalent, the existing definitions of cathetercolonization and catheter-related infection may need tobe modified, because such coatings may lead to false-negative culture results. Many catheter infections,diagnosed without catheter withdrawal, can behandled nowadays with the so-called antibiotic lock-intechnique, which consists in locking the infectedcatheter lumen with a solution containing antibiotics.Dr.T.V.Rao MD @ TMC Kollam 57
  58. 58. Changing trends• A high proportion of infected catheters, mainlythose with coagulase-negative staphylococci, canbe maintained in place and sterilized with thistechnique, including catheters in patients withtherapeutic failure after receiving conventionalintravenous antibiotic therapy. New diagnosticand therapeutic techniques may avoid theunnecessary withdrawal of thousands of efficient,difficult to replace and expensive intravascularlines.Dr.T.V.Rao MD @ TMC Kollam 58
  59. 59. Personal safety of HealthCare WorkersDr.T.V.Rao MD @ TMC Kollam 59
  60. 60. Steps to preventneedle sticks• Wear gloves• Do Not Bend or Break Needles• Never RECAP!!!• If you must, use the One Handed technique• Take your time• Dispose of contaminated needles immediatelyin puncture-resistant containersDr.T.V.Rao MD @ TMC Kollam 60
  61. 61. Risks to you - if Careless• Risks after needle Sticks Exposure• Hepatitis B: 10-30%• Hepatitis C: 2%• HIV: 0.4 %• Other blood borne pathogensDr.T.V.Rao MD @ TMC Kollam 61
  62. 62. POLICY ON ACCIDENTAL NEEDLESTICKS• Immediately wash injured area.• Report all needle sticks immediately to your instructor orimmediate supervisor.• Complete an incident report and report to employee health orED.• Determine if the needle was clean or dirty.• Cleansing wound with antiseptic.• Request that the identified patient be tested for Hepatitis Bsurface antigen and HIV antibodies.• Have your blood tested for Hepatitis B and HIV antibodies assoon as possible.• Begin drug treatment (if necessary) & counseling.Dr.T.V.Rao MD @ TMC Kollam 62
  63. 63. Diagnosis of CRBSI• • Catheter removal required• (i) Semi-quantitative culture method• - catheter segment is rolled across surface of an• agar plate and cfu are counted after overnight• Incubation• • >15 cfu is significant• • limitation: cultures organisms from the external• surface of the catheter• • intraluminal colonisation, after prolonged and• excessive use of the catheter hub not evaluatedDr.T.V.Rao MD @ TMC Kollam 63
  64. 64. CDC (HICPAC) Guidelines forReferences• Issued 8/9/02• Evidence-based• Recommendationscategorized• Peer MD @ TMC Kollam 64
  65. 65. Establish Credibility• Recruit Physician & NurseChampions• Key areas:– ER– ICUs– Anesthesiology• All must be committed tosame goals• Leaders must convincetheir own• Appoint “CLAB Leader” foreach patient unitDr.T.V.Rao MD @ TMC Kollam 65
  66. 66. Performance-Based Training• Educational focus is on the continuousimprovement of worker performance• Worker skills and competencies are identified toachieve the department mission• Curriculum is organized around learner needs andregulatory mandates. A collaborative approach isused with manager, worker, and educator input.• The evaluation measures the workers’ abilities tomeet standard; it also determines if learned skillsare enough to perform the job effectively.Dr.T.V.Rao MD @ TMC Kollam 66
  67. 67. Training on Mannequins• Held weekly• All first-yearresidents arerequired toattend• Conducted by ICand SurgicalAttending• Walk-through oninsertion stepsDr.T.V.Rao MD @ TMC Kollam 67
  68. 68. SummaryInfection Prevention Guidelines–Record date of insertion & removal ofthe device–Keep number of lines, lumens &stopcocks to minimum–Maintenance and inspection of I.V.line/site–Quality control of infusion/additives–Cleanliness of equipmentDr.T.V.Rao MD @ TMC Kollam 68
  69. 69. Never Forget to Update the Records onCatheritizated PatientsDr.T.V.Rao MD @ TMC Kollam 69
  70. 70. Talk less and Do more Hand Washingin Patient Care AreasDr.T.V.Rao MD @ TMC Kollam 70
  71. 71. • Programme Created by Dr.T.V.Rao MDfor Benefit of Medical and ParamedicalProfessionals for better services inHospital Practice, Kindly forward to allyour friends in the Profession• Email• doctortvrao@gmail.comDr.T.V.Rao MD @ TMC Kollam 71