Prevention of Intravascular

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???????????????????????????????????? ?????????????
? Prevention of Intravascular Related
Infection
??????? ???????? ICN sujinda1672_at_yahoo.com
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• ??????????????????????? 13

Meier P.A. et al. Am J infect Control
199826(4)388-392
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1. Peripheral venous catheter ????????????????
????????? ????????????????????????????
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2. Central line ?????????????????????????????
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• Cut down
• Subclavian, femoral, jugular
• Hemodialysis catheter
• Pulmonary catheter Swan ganz, angiography
• Umbilical vein ???? artery

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• Migration of skin organisms
• Colonization of catheter tip
• skin flora, hands, antiseptics
• Contamination of catheter hub
• Hematogenous seed from another focus
• Infusate contaminated

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Migration of skin organisms at site
Hub Colonization

• Hematogenous seeding from distant site of
  infection

Skin
fibrin sheath
vein
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Contaminated Infusate
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??????????????????????? ???????????
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?? 1992 1999

• Coagulase neg Staphylloccoci 37
• Staphylococcus aureus 16
• Streptococci 13
• Enterococci 14
• Candida 8

NNISCDC 1992-1999
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• Extremes of Age
• Pre-existing comorbidities
• Underlying disease
• Severity of illness
• Malnutrition
• Burn
• On immunosuppressive drug
• Immunocompromised Host

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• Duration of Cannulation gt 72 hrs.
• Type of Catheter And Material
• Site of Insertion
• Number of Lumen
• Emergency Placement
• Personal Education and Skill Level

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Type of Catheter Material

• ??????????? Polyvinyl Chloride ???? risk of
  
• Mechanical Complication
  ??????????????????
• ???????? BSI Teflon / Polyurethrane
  ???????????
• ????????? Polyvinyl Chloride /
  Polyethylene

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???????????????????????????????????? IVD
increase Risk of BSI when

• Route Peripheral lt Central
• Site upper limb lt lower limb , hand lt arm or
  wrist
• Number of Lumen Single lt Multiple
• Parenteral Nutrition Administration
• Hemodynamic Monitoring Use
• Time gt 72 hrs.

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Reduce Duration
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• Enviromental factor
• - Exogenous factor
• - Admission to ICU
• - nurse to patient ratio

• Microbiologic factor
• - Type of organism
• - Bacterial inoculum
• - Host colonization
• process
• - Antimicrobial resistance

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Bloodstream Infection
Laboratory-confirmed
Clinical sepsis
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Laboratory-confirmed bloodstream infection
(BSI-LCBI)

• 1. Positive H/C, ???????????????????????
• ??????????????????????
• 2. ????? gt38o, chill,hypotension
• ???? Temp lt37o, apnea, bradycardia
• Positive H/C x 2
• Positive H/C , ???????? ATB ?????
• ?? Antigen ???????

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Clinical sepsis (BSI-CSEP)

• ????? gt38o, hypotension, oligulia
• ???? Templt37oC ,apnea, bradycardia
• Negative H/C ?????????????
• ???????? ATB ????? Sepsis
• ???????????????????????????

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1. PHLEBITIS

• Inflammation of vein, caused by chemical
• in infusate or mechanical irritation of
  cannula
• Infection may subsequently develop Septic
• Thrombophlebitis (increase risk of CRI )

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2. Catheter Colonization

• gt 15 colonies
• No symptoms
• negative blood culture

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• gt 15 colonies
• Local symptoms
• negative blood culture

Local Catheter Infection
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3. Local Catheter Infection
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• Exit-site Infection
• Erythema, tenderness induration or purulence
  
• within 2 cm of the skin at the exit site

• Tunnel Infection
• Erythema, tenderness, or site induration gt
  2 cm
• from exit site along the subcutaneous
  tract of
• a tunneled (Hickman or Broviac)

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3. Local Catheter Infection
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• Pocket Infection
• Purulent fluid in the subcutaneous pocket of
• a totally implanted intravascular catheter
  
• drainage or necrosis of the overlying skin

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4.CR- Bloodstream Infection
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• Isolation of the same organism from culture of
• a catheter segment and from the blood with
• accompanying clinical symptoms and no
• other apparent source of infection

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5. Infusate - Related BSI
?????????????????????????????????????

• Isolation of the same organism from infusate
• and from separate percutaneous blood
• cultures, with no other source of infection

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Line associated bloodstream infection
???????? ?????
Hemo c/s ????
1- 14 colony No sign infection ?????
Negative
gt 15 colony No sign infection ?????
Colonization
gt 15 colony sign infection
????? Local infection




gt 15 colony sign infection ??
CR-BSI


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• Guideline for the Prevention of
• Catheter related BSI 2002
• Center for Disease Control and prevention
  CDC
• Hospital Infection Control Practice Advisory
• Committee HICPAC

IA ?????????????? ??????? RCT
???????????????? ???????? ??. IB
????????????? ??. ???????????????????????????????
II ???????????? ??. ????????
?????????????????????????? No recommended
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Hand Hygiene

• ??????????????? ???????????????????? (IA)
• ????????? /??????????????????
• ???????????????????????????????? dressing
• Hygienic handwashing (IA)
• hibiscrub
• alcohol-based handrub
• ???????????????????? (IA)

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General principles

• Do not routinely use cut down procedure (IA)
• ?????? CVC ????? ports ???? lumens ??????????
• ????????????? (IB)

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Insertion Site

• nontunneled CVC - Use subclavian vein rather
• than femoral or jugular sites (IB)
• Hemodialysis - Use jugular or femoral vein
• rather than subclavian vein (IA)
• ????????????????????????????????????? (IA)

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Site
Jugular
Subclavian
Radial
Wrist
Groin
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Cutaneous Antisepsis - Insertion

• 2 Chlohexidine (IA) ????
• 10 povidone iodine
• 2 tincture iodine
• 70 alcohol
• Allow adequate contact time
• Povidone iodine , 2 min contact time (IB)

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Dressing Regimens - All Catheters (1)

• Use sterile gauze or transparent (IA)
• Use gauze dressing ,if the site is bleeding,
• oozing (II)
• Change dressing if damp, loose, soiled (IA)

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Dressing Regimens - All Catheters (2)

• Change dressing regularly (II)
• (Adults and adolescent pts.)
• Frequency determined by hospital,
• at least weekly (II)
• Permit showering (II)
• protect catheter from water
• use impermeable coving

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Dressings - Central Lines(1)

• Frequency of dressing change
• Short term catheter (IB)
• gauze 2 d
• transparent 7 d
• Tunneled or implanted catheter
• no more than 1X wk (IB)

exception pediatric patients
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3.2
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Barriers Precaution

• Peripheral IV (IC)
• Non-sterile gloves
• Central line
• Sterile gloves, gown, large drape,
• mask cap (IA)

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Catheter Replacement

• PIVC 72- 96 hr (IB)
• Arterial gt 5 d (IB)
• CVC No change (IB)
• PICC No change (IB)
• Umbilical cath Up to 14 days (II)
• Emergency insertion
• change lt 48 hours if break in aseptic
  technique

adults and adolescents
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Administration Sets and Fluids

• Replace tubing gt 96 hr (unless CRI) IA
• ( include secondary set, add-on device)
• add-on device Stopcocks, extension set,
• injection port, needleless system)
• Do not use any container of parenteral fluid
  with
• visible turbidity,leaks,crack, particulate
  matter or
• expiration date has pass IB

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Administration Sets and Fluids

• Parenteral fluids
• Lipids (lt 24 hours) IA
• Blood lt 4 hours IC
• Other fluids Unresolved

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Flushing(Infusion Nursing Standard of Practice)

• Before and after administration of incompatible
  medication and/or solution
• 0.9 NSS flush at least twice of volume of
  catheter
• or add-on device
• Positive end pressure prevent reflux of blood /
  clot
• Heparin flush 1-10 u/ ml. for pediatric pts.
• Single use flushing system

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Medications

• Multidose vials
• single use needles syringes (IA)
• disinfect with alcohol (IA)
• store per manufacturer (IA)
• discard if visible contamination or expired (IA)

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Injection Hubs and Ports

• Disinfect with 70 alcohol
• or iodophor (IB)
• Cap all stopcocks when not in use (IB)

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Measures NOT Recommended

• Routine cultures of catheter tips (IA)
• Daily tubing and/or dressing changes
• Topical antimicrobial ointment promote (IA)
• (promote fungal infections and
  antimicrobial resistance)
• Cut down procedure (IA)
• In-line filters routinely for IC (IA)
• Prophylactic antimicrobials (IA)

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Objectives are clear . . .

• Limit insertion shorten duration
• Focused surveillance/feedback rates
• Maximal barriers (insertion)
• Improved skin antisepsis
• Dressing changes less frequently

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Thank you for your attention