cdc guidelines for central line removal

Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. Numerous quality improvement studies have been published during the past several years that have used various methods, such as education of healthcare personnel, audit and feedback, organizational change, and clinical reminders [811, 69, 70, 202, 365367]. a central venous catheter cart that contained all the necessary supplies; a checklist to ensure adherence to proper practices; stoppage of procedures in non-emergent situations, if evidence- based practices were not being followed; prompt removal of unnecessary central catheters identified during daily patient rounds; feedback to the clinical teams regarding the number of CRBSI episodes and overall rates; and. peripheral intravenous line, PIV, peripherally inserted central catheter, PICC, CPN, hyperalimentation Table of Contents Page Number I. The risk of CRBSI for arterial catheters is lower than that associated with non-coated, uncuffed, non-tunneled short term CVCs (1.7 versus 2.7 per 1,000 catheter days) [6]. Reports spanning the past four decades have consistently demonstrated that risk for infection declines following standardization of aseptic care [7, 12, 14, 15, 239241] and that insertion and maintenance of intravascular catheters by inexperienced staff might increase the risk for catheter colonization and CRBSI [15, 242]. Chlorhexidine impregnated sponge dressings were associated with localized contact dermatitis in infants of very low birth weight. Central lines are different from IVs because central lines access a major vein that is close to the heart and can remain in place for weeks or months and be much more likely to cause serious infection. Proper hand hygiene can be achieved through the use of either an al-cohol-based product [255] or with soap and water with adequate rinsing [77]. These infections can cause long-term harm and life-threatening conditions such as sepsis. If so, ask them to help you understand the need for it and how long it will be in place. In several studies, an estimated 40%55% of umbilical artery catheters were colonized and 5% resulted in CRBSI; umbilical vein catheters were associated with colonization in 22%59% of cases [147, 148, 340] and with CRBSI in 3%8% of cases [148]. Make sure the line is not tunneled and does not have to be taken out by interventional radiology. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. Another type of second-generation needleless system addressed the occlusion issue by incorporating positive or neutral fluid displacement to either flush out aspirated blood or prevent its aspiration into infusion catheters. Observational studies suggest that a higher proportion of pool nurses or an elevated patientto-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs [2931]. The reasons for these associations are not known and it is also not known if this is a device-specific or class association, particularly as physical and mechanical properties of needleless connectors vary from device to device. Use a sterile sleeve to protect pulmonary artery catheters during insertion [81]. Remove the arterial catheter as soon as it is no longer needed. Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed aseptically [155, 156]. Physician recognizes catheter is no longer needed 3. The second largest study in hemodialysis subjects examined the effect of a catheter lock solution containing cefazolin, gentamicin, and heparin compared with control patients receiving only heparin [135]. Two well-designed studies evaluating the chlorhexidine-containing cutaneous antiseptic regimen in comparison with either povidone iodine or alcohol for the care of an intravascular catheter insertion site have shown lower rates of catheter colonization or CRBSI associated with the chlorhexidine preparation [82, 83]. A luer-activated device, which incorporates a valve preventing the outflow of fluid through the connector, was designed to eliminate this problem. 20,49,42-46 RM (2003) Cardiothoracic ITU removal of a central line guideline Clarke (2013) Nursing protocol for the removal of epicardial pacing . If blood is oozing from the catheter insertion site, gauze dressing is preferred. Catheter insertion over a guidewire is associated with less discomfort and a significantly lower rate of mechanical complications than are those percutaneously inserted at a new site [327]. Minimize the number of manipulations of and entries into the pressure monitoring system. Catheters Used for Venous and Arterial Access, Epidemiology and Microbiology in Adult and Pediatric Patients, Strategies for Prevention of Catheter-Related Infections in Adult and Pediatric Patients, U.S. Department of Health & Human Services. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. Maximal sterile barrier precautions during insertion of CVC were compared with sterile gloves and a small drape in a randomized controlled trial. Instruct the patient to continuously hum or Valsalva; simultaneously and swiftly remove the line. At present, guidelines suggest that for enterococcal and gram-negative bacillus CLABSIs, retaining the central venous catheter . In 120 subjects, the rate of CRBSI was significantly lower in those receiving the antibiotic lock solution (0.44 BSI/1,000 CVC days vs. 3.12 BSI/1,000 CVC days, P = .03) [135]. [105]. Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI [114]. By creating an account, I agree to receive occasional communications from Guideline Central. The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with arteriovenous (AV) fistulas [336]. In the largest multicenter randomized controlled trial published to date comparing chlorhexidine impregnated sponge dressings vs standard dressings in ICU patients, rates of CRBSIs were reduced even when background rates of infection were low. Meta-analysis indicates that the CRBSI rate associated with pulmonary artery catheterization is 3.7 per 1,000 catheter days and somewhat higher than the rate observed for unmedicated and non-tunnelled CVCs (2.7 per 1,000 catheter days)[6, 45]. REMEMBER: deep inspiration on removal will increase negative pressure in the thorax (increasing risk of air embolism). Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI [102104]. Three meta-analyses have all demonstrated that catheter lock solutions reduce risk of CRBSI in hemodialysis patients [297299]. In the largest of these studies, 291 subjects were enrolled in a prospective randomized comparison of 30% trisodium citrate versus heparin [133]. In addition, no relation was found between duration of catheterization and the daily probability of infection (r = 0.21; P > .1), suggesting that routine replacement of CVCs likely does not reduce the incidence of catheter-related infection [250]. Catheters that need to be in place for >5 days should not be routinely changed if no evidence of infection is observed. Because phlebitis and catheter colonization have been associated with an increased risk for catheter-related infection, short peripheral catheter sites commonly are replaced at 7296 hour intervals to reduce both the risk for infection and patient discomfort associated with phlebitis. However, other studies have not confirmed reduced thrombosis and still others have found untoward interactions in patients receiving 5-FU [319, 320]. Patients who get a CLABSI have a fever, and might also have red skin and soreness around the central line. No recommendation can be made regarding the frequency for replacing intermittently used administration sets. Catheter lock is a technique by which an antimicrobial solution is used to fill a catheter lumen and then allowed to dwell for a period of time while the catheter is idle. Category II. However, one analysis has suggested that the use of chlorhexidine/silver sulfadiazine catheters should lead to a cost savings of $68 to $391 per catheter [271] in settings in which the risk for CRBSI is high, despite adherence to other preventive strategies (e.g., maximal barrier precautions and aseptic techniques). Stopcocks used for injection of medications, administration of IV infusions, and collection of blood samples represent a potential portal of entry for microorganisms into vascular access catheters and IV fluids. Replacement of temporary catheters over a guidewire in the presence of bacteremia is not an acceptable replacement strategy because the source of infection is usually colonization of the skin tract from the insertion site to the vein [37, 327]. Additionally, infection risk increases with nursing staff reductions below a critical level [30]. Site selection should be guided by patient comfort, ability to secure the catheter, and maintenance of asepsis as well as patient-specific factors (e.g., preexisting catheters, anatomic deformity, and bleeding diathesis), relative risk of mechanical complications (e.g., bleeding and pneumothorax), the availability of bedside ultrasound, the experience of the person inserting the catheter, and the risk for infection. If temporary access is needed for dialysis, a tunneled cuffed catheter is preferable to a non-cuffed catheter, even in the ICU setting, if the catheter is expected to stay in place for >3weeks [59]. Most commonly a temporary central line is placed for dialysis (blood filtration to remove chemicals and waste . Chapter 1 reviews the types of central venous catheters and describes the risk factors for and pathogenesis of central line-associated bloodstream infections (CLABSIs). Replace arterial catheters only when there is a clinical indication. Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. You will be subject to the destination website's privacy policy when you follow the link. The use of catheters for hemodialysis is the most common factor contributing to bacteremia in dialysis patients [334, 335]. Catheter stabilization is recognized as an intervention to decrease the risk for phlebitis, catheter migration and dislodgement, and may be advantageous in preventing CRBSIs. Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit [163, 173, 174]. CRBSI rate was higher (20%) among long term catheterized neonates when compared with short term catheterized neonates (13%). More recent studies have examined this approach in high-risk patients, particularly those undergoing hemodialysis [116119]. Proper technique is essential to prevent air embolism. However, a number of outbreak investigations have reported increases in CRBSIs associated with a switch from external cannulae activated split septum needleless devices to mechanical valve devices [197, 198, 200, 359]. In one study, neonates with very low birth weight who also received antibiotics for >10 days were at increased risk for umbilical artery CRBSIs [148]. CDC: Central Line-associated Bloodstream Infection CDC: MDRO Prevention and Control CDC: Clostridioides difficile Infection CDC: Healthcare Infection Control Practices Advisory Committee IDSA: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections Little data exist regarding the length of time a needle used to access implanted ports can remain in place and the risk of CRBSI. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. This has prompted investigators to assess the utility of topical mupirocin, a potent anti-staphylococcal agent. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. Data are limited; although low dose warfarin decreases the risk of thrombus formation in cancer patients, it has not been shown to reduce infectious complications. Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragm interface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to withdraw blood [199]. In non-oncology patients, no benefit was associated with vancomycin administration prior to catheter insertion in 55 patients undergoing catheterization for parenteral nutrition [281]. In addition, the group using MSB precautions had infections that occurred much later and contained gram negative, rather than gram positive, organisms [76]. Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators [3335]. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced [37, 161]. However, these studies did not address the issue of CRBSI, and the risk of CRBSIs with this strategy is not well studied. See the Updated Recommendations on Chlorhexidine-Impregnated Dressings for more information. Central lines should be used for the shortest duration possible and removed as soon as they are no longer required. However, the use of steel needles frequently is complicated by infiltration of intravenous (IV) fluids into the subcutaneous tissues, a potentially serious complication if the infused fluid is a vesicant [34]. However, these results can be misleading particularly in the absence of concomitant peripheral and central line blood cultures. In this study, MSB precautions use increased and CRBSI decreased [14]. bolism and central line-associated bloodstream infec-tion (15-17). To receive email updates about this page, enter your email address: Centers for Disease Control and Prevention. In addition, there are no FDA approved formulations approved for marketing, and most formulations have been prepared in hospital pharmacies. Because of the increased difficulty obtaining vascular access in children, attention should be given to the frequency with which catheters are replaced in these patients. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Speak up about any concerns so that healthcare personnel are reminded to follow the best infection prevention practices. Prolonged anti-infective activity provides improved efficacy in preventing infections [265]. In a study in which survival analysis techniques were used to examine the relation between the duration of central venous catheterization and complications in pediatric ICU patients, all of the patients studied (n = 397) remained uninfected for a median of 23.7 days [250]. Hand hygiene. The duration of catheter placement in one study ranged from 5.1 to 11.2 days [264]. Central venous catheterization (CVC) is a procedure frequently required in acute or critical care resuscitation. While chlorhexidine has become a standard antiseptic for skin preparation for the insertion of both central and peripheral venous catheters, 5% povidone iodine solution in 70% ethanol was associated with a substantial reduction of CVC-related colonization and infection compared with 10% aqueous povidone iodine [259]. No recommendation can be made regarding the frequency for replacing needles to access implantable ports. A recent randomized trial (n = 210) evaluated whether long-term umbilical venous catheterization (up to 28 days) would result in the same or fewer CRBSIs when compared with neonates who were randomized to short-term umbilical venous catheterization for 710 days followed by percutaneous central venous catheterization. Vascular access sites can be even more limited among neonates. However, in selected patients with tunneled hemodialysis catheters and bacteremia, catheter exchange over a guidewire, in combination with antibiotic therapy, is an alternative as a salvage strategy in patients with limited venous access [328331]. Data were recorded on 151 CVCs in 106 patients giving a total of 721 catheter days. Category II Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. There were insufficient data to evaluate the risk of selection for vancomycin resistant organisms. In a study of 166 catheters, patients who were randomly assigned to have their catheters self-contained within this sleeve had a reduced risk for CRBSI compared with those who had a pulmonary artery catheter placed without the sleeve (P = .002) [81]. Two trials demonstrated that use of these catheters significantly reduced CRBSI compared with uncoated catheters [110, 111]. Category II. Appropriate disinfectants must be used to prevent transmission of microbes through connectors [357]. Femoral catheters have been demonstrated to have high colonization rates compared with subclavian and internal jugular sites when used in adults and, in some studies, higher rates of CLABSIs [40, 4547, 50, 51, 246]. Replace peripheral catheters in children only when clinically indicated [32, 33]. This module, titled "Central Line -Associated Bloodstream Infection: An Introduction" will provide background information on what constitutes a central venous catheter, the definition and burden of CLABSI and Catheter location, infusion of parenteral nutritional fluids with continuous IV fat emulsions, and length of ICU stay before catheter insertion, have all increased pediatric patients risk for phlebitis. Studies of short peripheral venous catheters indicate that the incidence of thrombophlebitis and bacterial colonization of catheters increases when catheters are left in place >72 hours [258]. Pay attention to the bandage and the area around it. Generally a temporary central line is in place for less than two weeks. Additionally, silver-coated connector valves have been FDA approved; however, there are no published randomized trials with this device and no recommendation can be made regarding its use. A central line (also known as a central venous catheter) is a catheter (tube) that doctors often place in a large vein in the neck, chest, or groin to give medication or fluids or to collect blood for medical tests. Data from prospective studies indicate that the risk of significant catheter colonization and CRBSI increases the longer the catheter remains in place. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site [99101]. In a meta-analysis evaluating the benefit of heparin prophylaxis (3 units/mL in parenteral nutrition, 5,000 units every 6 or 12 hours flush or 2,500 units low molecular weight heparin subcutaneously) in patients with short-term CVCs, the risk for catheter-related central venous thrombosis was reduced with the use of prophylactic heparin [139]. Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Recently, the method was also used . Here are some ways patients can protect themselves from CLABSI: Research the hospital, if possible, to learn about its CLABSI rate. In 601 cancer patients receiving chemotherapy, the incidence of CRBSI was reduced in patients receiving the chlorhexidine impregnated sponge dressing compared with standard dressings (P = .016, relative risk 0.54; confidence interval 0.31.94) [262]. Specialized IV teams have shown unequivocal effectiveness in reducing the incidence of CRBSI, associated complications, and costs [1626]. In all, 323 breaches in care were identified giving a failure rate of 44.8%, with significant differences between intensive care unit (ICU) and non-ICU wards. Approaches not recommended for CLABSI prevention are also briefly reviewed. A recent meta-analysis reviewed these studies in oncology patients [114]. Studies have shown that heparin-bonded catheters reduce risk of thrombosis and risk of CRBSI [306, 308 310], but are less effective at reducing catheter colonization than catheters impregnated with chlorhexidine/silver sulfadiazine [311]. Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange [14, 75, 76, 80]. [39, 187193]. Ensure appropriate nursing staff levels in ICUs. Pulmonary artery catheters are inserted through a Teflon introducer and typically remain in place an average of 3 days. Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. Category IA. buy-in from the chief executive officers of the participating hospitals that chlorhexidine gluconate products/solutions would be stocked prior to study initiation. Clean the injection cap on your catheter using disinfectant wipes or other supplies, as directed by your healthcare team. This topic last updated: Jun 17, 2022. A multifaceted catheter care maintenance bundle consisting of educational programs for nurses, update of hospital policies, visual aids, a competency assessment, process monitoring, regular progress reports, and consolidation of supplies necessary for catheter maintenance. In light of this, a firm recommendation for or against the use of these catheters cannot be made. In addition, one investigation found CRBSIs increased with the switch from a luer-activated negative displacement mechanical valve to a luer-activated positive fluid displacement mechanical valve [199]. A small trial demonstrated a reduced risk of skin colonization at the insertion site when MSB precautions were used [OR 3.40, 95%CI 1.32 to 3.67] [80]. A study of pulmonary artery catheters also secondarily demonstrated that use of MSB precautions lowered risk of infection [37]. The rate of catheter occlusion requiring catheter removal was lower in the heparin group (6% vs. 31%, P = .001: NNT = 4). A meta-analysis has assessed studies that compared the risk for CRBSIs using transparent dressings versus using gauze dressing [260]. When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system [163]. In 98 neonates with very low birth weight, 15 (15%) developed localized contact dermatitis; four (1.5%) of 237 neonates weighing >1,000 g developed this reaction (P < .0001). Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance [88, 89]. Warfarin has been evaluated as a means to reduce CVC thrombus formation and, hence, infection [314318]. Hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation, provides protection against infection [12]. Midline catheters are associated with lower rates of phlebitis than short peripheral catheters and with lower rates of infection than CVCs [322324]. No antiseptic or antimicrobial impregnated catheters currently are available for use in infants weighing <3kg. Therefore, anticoagulants have been used to prevent catheter thrombosis and presumably reduce the risk of infection. As in adults, the use of peripheral venous catheters in pediatric patients might be complicated by phlebitis, infusion extravasation, and catheter infection [243]. In a prospective, randomized, double blind study in hemodialysis patients, use of interdialytic heparin (5,000 U/mL) was associated with a significantly greater rate of CRBSIs compared with use of 30% trisodium citrate (4.1 BSI/ 1,000 CVC days vs. 1.1BSI/1,000 CVC days [313]. Once practices have been determined to be effective and economically efficient, the next step is to implement these evidence-based practices so they become part of routine clinical care. Results INDICATIONS FOR USE 2 III. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site [8487]. In addition, a prospective observational study of over 2,900 arterial catheters that were inserted using maximum barrier precautions demonstrated an almost 8-fold increase in the incidence of CRBSI when the femoral site was used compared with the radial site [343]. Trisodium citrate has been recommended as a catheter lock solution because it possesses both anticoagulant and antimicrobial properties [133]. and date and time of catheter removal . No single trial has satisfactorily compared infection rates for catheters placed in jugular, subclavian, and femoral veins. However, they also pose a risk for contamination of the intravascular fluid if the device entering the rubber membrane of an injection port is exposed to air or if it comes into direct contact with nonsterile tape used to fix the needle to the port. Within the 6-month study period, there were 13 deaths in the placebo group as compared with three deaths in the bacitracin/gramicidin/ polymyxin B group (P = .004). Scheduled guidewire exchange of CVCs is another proposed strategy for preventing CRBSI. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Similarly, extending perioperative prophylactic antibiotics in cardiovascular surgery patients did not reduce central venous catheter colonization [282]. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. The results of a meta-analysis of 12 randomized, controlled trials assessing CVC management failed to demonstrate any reduction of CRBSI rates through routine replacement of CVCs by guidewire exchange compared with catheter replacement on an as needed basis [326]. Remove a central line as soon as it is no longer needed. You may be familiar with intravenous catheters (also known as IVs) that are used frequently to give medicine or fluids into a vein near the skins surface (usually on the arm or hand), for short periods of time. Change the needleless components at least as frequently as the administration set. The MSB group had fewer episodes of both catheter colonization (RR = .32, 95% CI, .10.96, P = .04) and CR-BSI (RR = .16, 95% CI, .021.30, P = .06). The rates of catheter colonization and CRBSI appear similar between the radial and dorsalis pedis sites [157]. (Taurolidine and trisodium citrate are not approved for this use in the United States). A central line insertion cart should include all the components and equipment needed to insert a central line. Some studies have suggested that planned removal at 72 hours vs. removing as needed resulted in similar rates of phlebitis and catheter failure [142144]. A study to assess practice and staff knowledge of CVC post-insertion care and identify aspects of CVC care with potential for improvement revealed several areas of opportunity to improve post-insertion care [370]. At least 10 studies regarding catheter flush or lock solutions have been performed in hemodialysis patients [128, 129, 131 138]. Thus, there is evidence from one study in hemodialysis patients that bacitracin/gramicidin/ polymyxin B ointment can improve outcome, but no similar data exist for use in other patient populations [296]. Shortly after insertion, intravascular catheters are coated with a conditioning film, consisting of fibrin, plasma proteins, and cellular elements, such as platelets and red blood cells [213, 302]. CVC occlusion due to thrombus formation is one of the most common reasons for CVC removal in neonates. Ask a healthcare provider if the central line is absolutely necessary. Some luer devices require a cap to be attached to the valve when not in use, which can be difficult to maintain aseptically, and therefore they may be prone to contamination. Please read the Disclaimer at the end of this page. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. A significant decrease in colonization, exit-site infection, or bloodstream infection was observed. Healthcare providers can take the following steps to help prevent CLABSIs: Here are some ways patients can protect themselves from CLABSI: See the library of Various methods have been tried to prevent catheter occlusion. The Centers for Disease Control and Prevention (CDC) has released a report detailing interventions to help prevent central line bloodstream infections in hospitals. Methods: This qualitative descriptive study involved semi-structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal .

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