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Best Exit Sites for CVCs Have Low Moisture and Hair
- 1. Nancy L. Moureau, BSN, RN, CRNI, CPUI, VA-‐BC PICC Excellence, Inc. Hartwell, GA USA
- 2. Disclosure • Nancy Moureau • No conflict with this topic • Clinician at Greenville Memorial Hospital prn PICC/IV Team, 30 years of vascular access experience • Owner of PICC Excellence, Inc, vascular access educaGonal company 18 years • EducaGonal provider, speaker and consultant with Teleflex, Cook, 3M, Excelsior, Angiodynamics, STI, Access ScienGfic, Genentech • Legal consultant
- 3. ObjecFves • IdenGfy factors that increase risk of central venous catheter infecGon in relaGon to exit site • Evaluate preventaGve measures and how they apply to the central line bundle and site selecGon • List two ideal exit site locaGons according to stability, lowest moisture/hair and beQer dressing adherence
- 4. IntroducFon • InfecGon is the #1 most serious complicaGon for any vascular access device • Recent efforts worldwide have focused on prevenGon and applicaGon of the central line bundle to reduce CVC infecGons
- 5. Central Line Bundle PracFces • Hand Hygiene • Site SelecGon • Chlorhexidine disinfecGon of skin • Maximum barriers during inserGon • Prompt removal of catheter with compleGon of therapy CDC, 2011 www.IHI.org Berenholtz, Crit Care 2004 Pronovost, NEJM 2006
- 6. Site SelecFon Emphasis • Primary message: – Avoid femoral – Use subclavian over internal jugular – Is it the vein or the locaGon? – Which has lowest risk? Risk on inserGon or risk of infecGon??? • Lack of substanGal evidence to be definiGve for one specific vein or veins as best; too many variables Merrer, et al, JAMA 2001 Ruesch, et al Crit Care 2002 Parienti, et al JAMA 2008
- 7. Pathophysiology and Risk Factors for InfecFon ColonizaGon of a central venous catheter arises from: – ContaminaGon -‐ Failure to maintain asepGc technique during inserGon or access – Skin flora -‐ Inadequate skin disinfecGon for inserGon and weekly dressing management – ManipulaGon or poor securement of a catheter causing movement in/out – Poor dressing management, non-‐adhesive dressing, moisture and hair – Bacterial growth -‐ Needleless connectors/ports that harbor bacteria; poor disinfecGng. Residual blood in catheter or tubing; poor flushing/clearing – Factors that contribute to thrombosis development and subsequent infecGon
- 8. Commonly Used (non tunneled) Central Venous Catheter Exit Sites – Exit site in the antecubital – Exit site in the supraclavicular area area • Blind approach to PICCs (w/o • Blind approach to IJ (‘lateral’) US) or subclavian vein • US guided approach to IJ, EJ, – Exit site in the upper mid subclavian or brachiocephalic arm (above the elbow) • US guided PICCs (Dawson, – Exit site in the infraclavicular 2011) area • Blind approach to subclavian vein – Exit site at mid neck – US guided approach to • Blind approach to internal/ cephalic vein or axillary vein external jugular vein • US guide approach to IJ – Exit site in the groin – Exit site at base of neck • Blind or US guided approach to the femoral vein or • US guide approach to IJ, saphenous vein bracheocephalic
- 9. Exit Site OpFons #4 Thorax 1X105 Head/Scalp 1X106 Axilla 5X106 #1 ARM 1X102 #3 Abdomen Groin 2X106 5X104 #2 Thigh 4X104 Ryder, AVA 2011, SHEA 2011
- 10. Bacterial DistribuFon on Skin • Number of bacterial • Lower colonizaGon • Higher colonizaGon cells on skin averages – Dry – Moist, humid between 10 2-‐108 – Cooler than core – Unable to mulG-‐layers deep – Flat, stable maintain • Bacterial density on adherence of – Minimal hair dressing skin varies from 100 colonies/cm2 on dry – Hair follicles surface, to 100% – Sebaceous glands increase in moist areas When catheters are contaminated Grice, Science 2009 Ruocco, Derm Clin 2007 Li, Hulying, Metagenomics 2011
- 11. Exit Site Risk • Local infecGon and CRBSI are related to risk of contaminaGon at the exit site – Increased risk -‐ Moisture, warmer areas of body, hair distribuFon, failure of dressing to adhere – Very high risk -‐ exit site at groin (moisture +hair+warm) – RelaFvely high risk -‐ exit site in the neck/ chest area (moisture+hair; close to oral/ nasal/tracheal secreGons). Higher on neck = higher risk (more hair) – Low risk -‐ exit site at base of neck, on chest (dry, stable), at mid upper arm (dry, stable) Garnacho-Montero, Int Care Med 2008 Goetz, Inf Cont Hosp Epid 1998
- 12. Exit Site Risk • Other non-‐infecGve complicaGons (thrombophlebiGs, venous thrombosis, dislodgement, etc) – Related to stability of catheter, terminal Gp posiGon, vein vs catheter size – ProblemaGc securement/dressing -‐ exit site at mid neck or higher – Ideal securement/dressing maintains adherence and limits movement -‐ exit site at upper mid-‐arm or in the infraclavicular area/base of neck
- 13. Best PosiFon on Arm/Thigh/ Abdomen/Chest • Flat posiGon • Low moisture • Good dressing adherence • Minimal hair
- 14. Effect of Dressing Adherence • Avoid – Moisture and areas with hair, consider tunneling – Ideal locaGon on chest even with IJ, turn it down onto chest
- 15. Issues with Femoral/Inguinal Site • Moisture • Hair • Highest temperature • Difficulty with dressing • Consider tunneling to move exit locaGon to increase stability, reduce moisture Merrer, et al, JAMA 2001 Goetz, Inf Cont Hosp Epid 1998 Marschall, Inf Cont Hosp Epid 2008
- 16. PICC Upper Arm vs Antecubital • Upper arm best locaGon – Stable and flat, without joint movement – Dry, less hair – Larger vein diameter – If inserGon close to axillary moisture area consider tunneling – Using ultrasound with upper arm placement Dawson, JAVA 2011 reduces complicaGons and Doellman, JAVA 2009 Falkowski, Nursing 2006 infecGon Hockley, Crit Care Res 2007 Nichols, JIN 2008 Royer, JIN 2001 Simcock, JAVA 2008
- 17. Internal Jugular with Chest Dressing • InserGon at base of neck – Stable and flat, without movement – Drier, less hair – Ultrasound reduces inserGonal risk
- 18. Axillary Access as OpFon • InserGon into axillary – Stable and flat, without movement – Drier, less hair – Less inserGon risk away from pleura – Ultrasound reduces inserGonal risk
- 19. Risk ReducFon Strategies • Apply all 5 steps of central line bundle • Consider use of anGmicrobial catheter and sponge dressing, both proven to reduce infecGon • Choose vein and exit site independently, relate to risk • When moisture/humidity are present at site of vein access consider tunnel or alternate site: – Axillary – Upper arm – Tunnel catheter • Focus on securement and dressing adherence Timsit, 2009 CDC, 2011 Ruschulte, 2008 Maki, 2008 Maki, 2000 HTA UK Assessment, 2008
- 20. Clinical ImplicaFons • Evaluate central venous catheters with all opGons of exit site using ultrasound for placement • Consider zones or areas with least risk of infecGon based on evidence • Understand complicaGons are directly correlated with exit site related to moisture, temperature and dressing adherence • Establish new terminology and classificaGon of CVCs with focus on exit site and risk reducGon
- 21. Future Study ConsideraFons • Compare ultrasound guided PICC/ Axillary/Infra and Supraclavicular venous access device with specific area of inserGon/exit on skin. Evaluate risk for inserGon and post inserGon complicaGons • Evaluate infecGon rates for non-‐ tunneled catheter according to precise area of exit site • Study each catheter/vein complicaGon rate based on exit site (Dawson, 2011)
- 22. QUESTIONS? Speaker Contact InformaGon: Nancy Moureau Email: nancy@piccexcellence.com Website informaGon: www.piccexcellence.com THANK YOU!!