UPDATE ARTICLE

Prevention of infections relating to the short-term, non-implanted, central-line catheter

Thamyres Morgado de Almeida^I, Cristiane Helena Gallasch^II, Helena Ferraz Gomes^III, Bianca de Oliveira Fonseca^IV, Ariane da Silva Pires^V, Ellen Márcia Peres^VI

^I Nurse. Resident in Clinical Nursing, State University of Rio de Janeiro. Brazil. E-mail: thamyresmorgado@live.com
^II Nurse. PhD in Nursing. Adjunct Professor, University of the State of Rio de Janeiro. Brazil. E-mail: cristiane.gallasch@gmail.com
^III Nurse. PhD Student in Nursing. Assistant Professor, University of the State of Rio de Janeiro. Brazil. E-mail: helenafg1@yahoo.com.br
^IV Nurse. PhD student in Microbiology from the University of the State of Rio de Janeiro. Brazil. E-mail: bianca.micro@gmail.com
^V Nurse. PhD Student in Nursing. Assistant Professor, University of the State of Rio de Janeiro. Brazil. E-mail: arianepires@oi.com.br
^VI Nurse. PhD in Nursing. Associate Professor, University of the State of Rio de Janeiro. Brazil. E-mail: ellenperes@globo.com

ABSTRACT

Objective: to present the state of scientific knowledge about nursing care in prevention and control of infections relating to the short-term, non-implanted, central-line catheter. Content: the study highlighted the importance of evidence-based nursing care supported by current legislation on professional practice: identification of signs and symptoms of colonization and/or infection, care for the insertion site and maintenance of the device, including use of antiseptics, topical products and infusion solutions for maintaining permeability and preventing infection. Conclusion: prevention of complications resulting from catheter insertion and maintenance requires that the health team have evidence-based technical and scientific training in care practices, and work in a synchronized and consistent manner for the purpose of ensuring effective, safe care.

Descriptors: Nursing process; catheters; catheter-related infections.

INTRODUCTION

Central venous cannulation or catheterization (CVC) is defined as the placement of a vascular access device with its distal extremity inserted in the inferior or superior vena cava to provide safe access to the systemic circulation, so as to allow the administration of irritating medications and/or vasopressor vesicants and hyperosmolar solutions. It is also of use for monitoring central venous pressure and to collect blood samples ¹.

These catheters have been increasingly used in inpatient and outpatient settings, as an option for long-term venous access. However, as they disrupt skin integrity, they increase the risk of bacterial and/or fungal infections and their dissemination in the bloodstream may lead to hemodynamic changes and organic dysfunctions².

The most recent data in Brazil indicate that 19,941 cases of primary bloodstream infections (PBSIs) associated with CVC were reported in 2014 in the intensive care units of 1,692 Brazilian hospitals. Among these case, 15,434 were diagnosed in laboratory (PBSIL) and were associated with 22,989 microorganisms reported as etiological agents³. In the state of Rio de Janeiro, in 2015, 1,637 cases of clinical PBSIs and 2,751 cases of PBSIL were reported⁴.

In view of the risk of catheter-related bloodstream infections (CRBSIs), nursing assistance requires skilled and evidence-based care plans. Thus, the objective of the present study is to present the state of the art of the scientific knowledge about nursing care for prevention and control of short term non-implanted central line-associated bloodstream infection

Nursing care for patients using CVC

The application of systematized care established by evidence-based guidelines promotes patient safety and quality of work of the health team, effectively impacting on reducing the rates of Health Care-Related Infections (HCRI), including the PBSIs⁵.

According to the Federal Nursing Council (Cofen) system and the Regional Nursing Councils (Corens), it is the responsibility of nurses to evaluate and prescribe care for patients using CVC and remove the device ^6,7. Although the nursing team has the responsibility to prevent and control of PBSIs, this task should be shared among the different professionals involved in health care provision. Professional training and continuing education programs are important, as well the elaboration and adherence to protocols for handling the device, ensuring a safe practice, reduced length of hospital stay and related costs⁸.

Identifying signs and symptoms suggestive of infection

The evaluation, at least once a day, of the insertion site of central catheters, by visual inspection and palpation on the intact dressing⁹ is a task of the nursing team. Nurses must be able to identify signs and symptoms of bloodstream infection¹⁰ such as hyperemia and drainage of exudate at the catheter insertion site, associated with fever, device malfunction, bradycardia, oliguria, among others^8,11,12.

The diagnosis of PBSIs can be established based on inflammatory (local and systemic) clinical signs such as hyperemia or fever, or based on laboratory data, where the microbiological infection is confirmed^13,14. Some researchers describe a low sensitivity for detecting local inflammation around the CVC insertion site based on clinical findings (pain, erythema, edema and purulence), reporting that the colonization of the vascular device takes place even in the absence of symptoms and signs of infection¹⁵.

Care of the insertion ostium

Due to the continuous solution flow in the ostium where the catheter is inserted, a sterile occlusive dressing must be used to protect this site, especially the extraluminal part of the catheter¹⁶. In this sense, new technologies have emerged to reduce the rates of catheter-related infection complications.

Dressings available in the market consist of gauze and adhesive tape, and transparent polyurethane film (TPF) impregnated with chlorhexidine^14,17,18. The last manual of the Centers for Disease Control and Prevention (CDC) recommends using sterile gloves when changing the dressing of intravascular catheters and preparing the skin with a 0.5% solution of alcoholic chlorhexidine during changes^11,12. It is important to emphasize that dressings should be inspected daily, as well as the insertion site^{9,11,12,16,19-21}.

The CDC and the National Health Surveillance Agency (ANVISA) recommend that catheter ostium occlusion can be performed with both sterile gauze and tape and with polyurethane film, with preference for sterile gauze in the case of patients with heavy sweating, bleeding or local exudation. Sterile gauze dressings need to be replaced within 24 to 48 hours, while polyurethane film dressings have to be changed every three to seven days, or when there is dirtiness, wrinkling, loosening, or some other impairment.

Regarding the adherence, CHG-impregnated dressings have more satisfactory fixation, because transparent dressings need to be changed early in relation to the stipulated time due to bad fixation and accumulation of exudate under the film, exposing the patient to a greater risk of colonization and CRBSIs^14,16,17.

A number of randomized studies with adult and pediatric groups have shown varying reductions in CRBSIs resulting from the use of these dressings. A meta-analysis of five randomized studies showed a significant reduction in catheter-tip colonization and a non-significant trend towards a reduction in CRBSIs²².

It should be emphasized that the focus of prevention actions for CVC-related sepsis should not only include the use of specific products for care with catheters but also the implementation of CVC insertion and maintenance processes with well established criteria, so as to achieve better results in the prevention of this problem²³.

A study that evaluated the use of Biopatch to surround the CVC before placement of the clear dressing with chlorhexidine gluconate-impregnated Tegaderm^® (transparent film) highlighted the impossibility to see the site of insertion and to manipulate the CVC and/or sutures to apply foam around the catheter, but a decreased rate of infection²⁴.

Regarding the dressing change routine, a study showed that the professionals exchange dressings according to the institutional recommendation, thus adhering to a Nursing Care Systematization (SAE) step, but without registration in medical records²⁰. Daily surveys are fundamental for the nursing management team to make sure that the dressings are occlusive and dated²⁵. The CVC and the insertion site should not be wetted; impermeable covers should be used during the bath ^9,11,12 to reduce the probability of entrance of moisture and consequently contaminants into the catheter and infusion lines^26.

According to the latest manual published by ANVISA on health care-related infection prevention measures with the 2011 CDC manual, the use of antimicrobial ointments at the insertion site should be limited to hemodialysis catheters after each dialysis session^9,11,12.

Care related to handling the CVC

One of the main recommendations for professionals, patients and family members is the previous hand hygiene by means of friction for 15 seconds with antiseptic solution (preferably alcohol). However, it is possible to use other solutions such as antiseptic soaps when organic matter is present. For disinfection of the connectiors, ANVISA recommends the use of alcohol-based solutions; the indication of chlorhexidine is not explicit ^10,19,20,27.

The administration of intravenous medications in hospitalized patients is most often performed through already installed accesses, represented by closed systems, which require specific care to be accessed. The use of equipment with specific entries for the administration of medicines is mandatory, as well as the disinfection of connections, connectors with valves and ports for addition of drugs with alcohol-based antiseptic solution, with movements applied in order to generate mechanical friction from 5 to 15 seconds⁹. However, this action has been neglected by health professionals⁸.

A study conducted to evaluate the predominant factors of CRBSIs found that 31% of the nurses did not disinfect the unthreaded connectors before accessing them and 17% of the blood samples "discarded" from the blood collected by these connectors without needles had microbial growth²⁸.

Connectors began to be used due to an imposition to reduce the number of accidents with sharp and cutting objects. Although their use allows the closure of the vascular system, an increase in CRBSI rates in many institutions soon after their introduction was paradoxically observed^9,28.

Several factors cause vulnerability to contamination of catheters and increase the risk of developing CRBSIs including inconsistent disinfection practices, recontamination after use, and lack of leveling of the septal surface of the valve as the only barrier between the bloodstream and external contaminants. If the septal surface is not properly disinfected prior to use, contaminants from the septal surface will be forced into the intraluminal fluid pathway and into the bloodstream. In turn, once the septal space (inner chamber) is contaminated, it is impossible to disinfect it.

Both vulnerabilities can lead to contamination of the pathway and potential BSI^28,29. In contrast, a study published in 2013 reported that systems of needle-free closed connectors are effective against infections, resulting in a lower incidence not only of CRBSIs but also of needle injuries. However, the results of this research clearly demonstrate that the use of needle-free closed systems have no superiority over the use of the Luer-lock connector systems to prevent the incidence of CRBSIs³⁰.

Disinfection with 70% alcohol does not reliably prevent the entry of microorganisms, which may multiply intraluminally in the connector or colonize the internal surface of the device with the valve. In contrast, the innovative antiseptic barrier Saralex-cl^® was highly effective in the protection of the septum, preventing the entry of any microorganism even in cases of strong contamination²⁹.

The most recent CDC manual recommends the use of needle-free systems to access intravenous (IV) tubing, and in these systems, a split septum valve may be preferred over some mechanical valves because of the increased risk of infection involved in the use of mechanical valves^11,12.

Equipment and transducers are responsible for maintaining the permeability of the central venous pressure (PVC) monitoring system and infusion of medications, NPT, and blood products. Contamination of these systems is significantly reduced when continuous infusion devices are changed within a maximum time every 96 hours⁹, and the devices are changed with a periodicity of 24 to 76 hours, according to their use²⁰. In the case of devices for intermittent administration and in the case of patients receiving lipid emulsions (e.g. parenteral nutrition) and/or blood, the devices should be changed every 24 hours^10-12.

The change of complementary equipment and devices is based on factors such as the type of solution used, infusion frequency (continuous or intermittent), suspected contamination, or when the integrity of the product or the system is compromised. In this case, connectors must be of the luer lock type to ensure injection hold and avoid disconnections^9-12.

Repeated disconnections and reconnections of the system increase the risk of contamination of the luer lock system, catheter hubs, and needle-free connectors with consequent risk of PBSIs. It is essential to protect the tip of the device aseptically with a single-use, sterile protective cap if disconnection is required; protective needles should never be used⁹.

CVC patency maintenance

There has been a major shift in catheter flushing practice since the mid-1990s. Heparin solution was the most commonly used substance to achive patency, but today, saline solution is preferred. This change may be related to the professionals' awareness of the dangerous complications implied by the use of heparin. The recommendation of use of heparin solution instead of saline solution is considered inconclusive for the maintenance of short-term CVC, according to guidelines^9,16,31.

To prevent CRBSIs, a wide variety of antibiotic and antiseptic solutions have been used to release or block catheter lumens. The catheter lock or lock therapy is a technique through which an antimicrobial solution is used to fill the lumen of the catheter for a period of time while the catheter is idle³². Prophylactic antimicrobial blocking solution is adopted in patients who use indwelling catheters and who have a history of multiple CRBSIs despite maximum adherence to aseptic technique. Anticoagulant therapy is not routinelly used to reduce the risk of catheter infection in regular patient populations^11,12.

Ethanol (alcohol) blocking technique is a method proposed to prevent and treat CRBSIs. It consists of infusing an ethanol solution to completely fill the catheter and allow it to remain for a period of time in order to prevent colonization of the catheter lumen(s). This method has low scientific evidence regarding its effectivity to maintain catheter patency, reduce morbidity, prevent antimicrobial resistance associated with the use of antibiotics, and reduce health costs associated to CRBSIs.

It is postulated that ethanol acts by denaturation of non-specific proteins and, therefore, is less likely to promote antimicrobial resistance, which is a concern surrounding the use of systemic antibiotics or antibiotic blockade. Potential toxic effects related to ethanol include central nervous system depression, arrhythmias, local venous irritation, and flushing. Blocking therapy appears to be associated with an ethanol concentration above 50%. However, the efficacy of lower concentrations of ethanol has not been demonstrated in clinical studies, thus creating a clinical enigma³³.

Contexts with increased of CRBSIs despite the implementation of preventive measures, should consider the introduction of trained nursing teams to manage all different types of intravascular devices¹⁰.

CONCLUSION

The prevention and control of bloodstream infections associated with the use of catheters, especially central lines, continues to be an important goal in the care of hospitalized patients at risk for development of these infections.

In a context of high competition such as the current one, cost containment and health care reform, care units should prioritize infection control measures. A variety of strategies are available to guide organizational efforts in favor of change. Common attributes among successful strategies include engagement and motivation to take on and support the proposed interventions, education for health professionals to understand the importance of the proposed interventions, implementation to incorporate interventions, and evaluation of the success of the interventions.

The availability of new catheter and dressing types, which are increasingly safe and present better technical properties, requires professionals to be able to handle them properly, ensuring a safer care. In order to avoid the complications resulting from the insertion and maintenance of a short-term central venous catheter, it is necessary that healthcare teams know the best care practices and work in a synchronized way in order to guarantee a safe care for patients.

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