A few simple precautions can help you make your patient safer when placing a central venous catheter
So simple yet so effective:
In a landmark study involving over 100 ICUs in Michigan, Pronovost and colleagues included five evidence-based practices, including removing unnecessary catheters. Other interventions included: hand hygiene, using full-barrier precautions during central venous catheter insertion, cleansing the skin with chlorhexidine and avoiding the femoral site for central venous catheters when possible. Within three months, they found central line associated blood stream infections were reduced by two-thirds. Furthermore, the rate of CLABSIs were reduced so much they became rare events in the participating ICUs.
Choosing the best site:
Selecting the best site can help reduce the risk of infection. It is generally recommended to avoid the femoral vein when placing a CVC in adults and to preferentially place the catheter in the subclavian vein rather than the internal jugular vein as the subclavian vein has the lowest risk of infection. However, in patients with kidney disease who may require dialysis, it is recommended to avoid the subclavian site. Additionally, subclavian cannulation is associated with an increased risk of pneumothorax – a potentially life-threatening complication. The risks and benefits for each site will have to be accounted for when selecting a cannulation site for any individual patient.
Central line insertion is a sterile procedure and proper hand hygiene should be practiced. The Centers for Disease Control (CDC) recommends either conventional soap and water hand-washing or use of an alcohol-based gel prior to insertion of a CVC.
When placing a central line, several steps should be taken to ensure sterility. These include wearing a hat, mask, sterile gown and sterile gloves and using a full-body sterile drape which completely covers the patient. It is, effectively, a surgical procedure. These steps reduce the likelihood that the catheter could become contaminated during placement.
Chlorhexidine Skin Preparation:
Unless there is a contraindication such as an allergy, chlorhexidine-based skin preparation should be used. It has been shown to have superior efficacy to other agents. In the event that an alternative must be used, the CDC recommends iodine-based agents or 70% alcohol.
Simple precautions that can keep a patient with a central line from developing an infection
Careful attention to how you maintain the dressing which secures a central line in place can help prevent the development of infections. Historically, dressings were changed frequently according to a fixed schedule. However, current practice recommendations suggest that the dressing should only be changed evey seven days unless is it visibly soiled or soaked with blood. A transparent, semi-permeable dressing is best as it allows for daily assessment of the insertion site without the need for removal of the dressing. Sterile gauze is an acceptable alternative (although it is recommended that the dressing be changed every two days if this option is used). Placement of a chlorhexidine-soaked sponge at the catheter insertion site is also recommended to help reduce the rate of CLABSI.
Daily chlorhexidine bathing:
A newer strategy, daily bathing with chlorhexidine, has been shown to help decrease the rate of CLABSI as well as protect patients from other hospital acquired infections, including vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. It is well-tolerated by most patients but should be avoided in patients who have an allergy to chlorhexidine.
Accessing the catheter:
Aseptic technique should be used when accessing any port of a central line or tubing connected to it. This includes practicing hand antisepsis, using clean gloves, and disinfection with 70% alcohol prior to accessing hubs, connectors, or stopcocks. New devices are now available to assist with this step including caps that contain a small alcohol-soaked sponge that can be connected to ports on IV tubing sets to increase compliance.