Recommendations on Prevention of Intravascular Catheter

General Aspects
1.1 Hand hygiene
Perform hand antisepsis with water and antiseptic soap or with alcohol
hand rub for catheter site care and accessing the system, including before
and after catheter insertion, touching the catheter insertion sites, dressing
and the infusion system. (1, 3, 4, 5)
1.2 Use aseptic technique for catheter insertion and catheter site care
1.2.1 Disinfect skin properly before catheter insertion, with sufficient
contact time, (alcohol-based antiseptics require contact time about
30 seconds; non-alcohol-based antiseptics require longer contact
time usually around 2 min) (6). For examples, 70% alcohol for
peripheral line insertion. Chlorhexidine-based preparation is
preferred for central line insertion (1, 7, 8)
1.2.2 Do not use arterial and venous cutdown as a routine method of
catheter insertion. (1)
1.2.3 Use clean gloves and apply “non-touch” technique for peripheral
intravascular catheter insertion after the application of skin
antiseptics. Wear sterile gloves for the insertion of arterial and
central venous catheters. (1)
1.3 Quality assurance, education and surveillance
1.3.1 Implementation of educational programs regarding the indications
for intravascular catheter use, proper procedures for the insertion
and maintenance of intravascular catheters, and appropriate
infection control measures to prevent CABSI. (1, 9, 10)
1.3.2 Ensure persons who insert or manage intravascular catheters are
trained and competent for the procedure.
1.3.3 Well-organized surveillance program that can monitor and
evaluate the performance of care is one of the tools for the
prevention of the CABSI. (1, 9). Both process and outcome
measures on the care of intravascular catheter should be
monitored. For the infection rate, it is preferable to express it by
an incidence density such as “CABSI per 1000 catheter patient
days”. (11)
1.3.4 Do not routinely culture catheter tips unless the source of
infection is likely to be the catheter. (1)
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1.4 Catheter and site care
1.4.1 Use sterile gauze or transparent dressings to cover the catheter
site. (1). The choice of materials of transparent dressings should
prefer increased durability, improved security of the catheter,
visibility of the wound site, provision of an effective barrier to
micro-organisms or increase the rate of evaporation of fluid. (12,
13)
1.4.2 A gauze dressing is preferred if the site is bleeding, oozing or the
patient is diaphoretic. (1, 14)
1.4.3 Change dressings at least weekly or when clinically indicated
(removal or replacement of catheter; damp, loosened or visibly
soiled dressings). (1)
1.4.4 Secure the catheter after insertion. (1)
1.4.5 Do not apply topical antibiotic ointment or creams to the catheter
insertion site except for dialysis catheters. (1)
1.4.6 Remove the catheter when it is no longer used. (1, 13)
2 Care of Specific Catheters
2.1 Central venous catheters (CVCs), including peripherally inserted
central venous catheters (PICCs), haemodialysis and pulmonary
artery catheters
The central line bundle approach is a group of evidence-based
interventions for patients with intravascular central venous catheters
that, when implemented together, result in better outcomes than when
implemented individually. The central line bundle consists of 5 key
components:
a) Hand hygiene
b) Maximal barrier precautions
c) 2% Chlorhexidine skin antisepsis
d) Optimal catheter site selection, with subclavian vein as the
preferred site for non-tunneled catheters
e) Daily review of line necessity, with prompt removal of unnecessary
lines.
This is not intended to be a comprehensive list of all elements of care
related to central lines. Other elements of care, such as daily site care
and selection of dressing material, are not excluded for any purpose
other than to have a bundle that is focused. (15)
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2.1.1 A subclavian site is preferred to a jugular or femoral site in adult.
(16, 17, 18, 19) Use a jugular or femoral catheter rather than a
subclavian one for haemodialysis or pheresis. (1)
2.1.2 Use maximal sterile barrier precautions (including the use of cap,
mask, sterile gloves, sterile gown and one large sterile drape) for
insertion of central line. (1, 19, 20)
2.1.3 Minimal numbers of ports and lumens of central venous catheters
essential for management of patients should be used. (1, 21)
2.1.4 Designate a CVC line or one port of a multi-lumen CVC for
exclusive use of parenteral nutrition. (1, 22)
2.1.5 Replace gauze dressing every 2 days and transparent dressing
every 7 days for short-term CVC. The risk of catheter dislodging
should be weighed for changing of dressing in paediatric patients.
(1)
2.1.6 Routine replacement of intravascular catheters is not necessary if
they are functioning and have no evidence of causing local or
systemic complications. (1, 23)
2.1.7 Do not replace intravascular catheters over guidewire if CABSI is
suspected. (1, 23)
2.1.8 Prepare skin with antiseptic chlorhexidine 2% in 70% isopropyl
alcohol which has been proven to provide better skin antisepsis
than other antiseptic agents such as povidine-iodine solutions (1,
15)