Chapter 239. Catheter-Associated Infections

Intravascular catheters are used for a wide range of adjunctive therapies in pediatric patients, such as administering total parenteral nutrition and chemotherapy and facilitating blood drawing. For the purposes of discussing complication risks and preventive strategies, these catheters can be subdivided into short-term, intermediate-term, and long-term devices. Approaches to catheter device placement and care that prevent infection are discussed in Chapters 34 and 107.

The pathogenesis of bloodstream infections for both short-, intermediate-, and long-term devices includes migration of potential pathogens from the skin at the exit site along the external surface of the catheter to the catheter tip, intraluminal migration of organisms from the catheter hub, contaminated infusates, and rarely, seeding of the catheter hematogenously from a distant focus.1 The true incidence of bowel translocation of microorganisms with subsequent seeding of the catheter is unknown, but this is proposed as a potential mechanism of catheter-related bloodstream infections (CR-BSI) in patients with dysfunctional bowel. Short-term and intermediate-term, noncuffed, nontunneled catheters are more prone to migration of organisms along the external surface of the catheter, and as a result they are infected by a greater proportion of skin flora including coagulase negative staphylococci and Staphylococcus aureus.2-5 Long-term, cuffed, tunneled catheters are less likely to be infected by organisms along the external catheter surface because the cuff acts as a fibrotic dam to migration. The definitions of different types of catheter-related infections are presented in Table 239-1.

Risk factors for catheter-associated bloodstream infections include prolonged use of systemic antimicrobials and the selective pressure for resistant organisms that results, catheter location (short- and intermediate-term lines placed in the femoral vein were more prone to infection in some pediatric studies),6-9 infusion of hyperalimentation with lipids, prolonged duration of catheterization, age < 2 years (especially premature infants with immature skin integrity), burn patients, immunocompromised patients, and those with intestinal integrity issues.1,10

Prevention of Catheter-Related Infections

Maximal barrier precautions during insertion, including the use of sterile masks, gowns, gloves, and large sterile fields, have been shown to significantly reduce the incidence of catheter infections.11-14 Antisepsis with chlorhexadine should be used before insertion of a catheter.15,16 Prior to manipulation of the catheter, hand hygiene and hub antisepsis are mandatory to reduce the incidence of catheter contamination. Sterile gauze, a transparent dressing,17 or a chlorhexadine patch18can be used to cover the site. Preference is usually given to the transparent dressing either coated with or without chlorhexadine because it is easier to evaluate the exit site. Dressings should only be changed when they are loose, soiled, or damp.1 The exit site should be cleansed with chlorhexadine in 70% alcohol, although povidone iodine is still used.19-22 Detailed sample management programs for the care of central venous catheters and peripherally inserted central catheters (PICC lines) are provided on the DVD (Appendix 239-2). To reduce infections, these catheters have been coated with either external chlorhexadine-silver sulfadiazine23 or internal and external minocycline/rifampin.24,25 Both types of catheters have proven effective in reducing the incidence of catheter-related infections in prospective randomized trials in adults when compared to catheters without antibiotic coating, but a recent comparison has found the minocycline/rifampin catheter superior in this respect.24 However, second-generation antiseptic-coated catheters may be more effective in this regard.26-28 A recent meta-analysis found little data indicating that these catheters can be used for durations greater than 2 weeks.29 They have not been extensively studied in children.

The care of long-term central venous catheters is detailed in Chapter 39 and on the DVD (Appendix 239-1). Recent work has shown that vancomycin instilled into the catheter lumen and allowed to dwell for a period of time (antibiotic lock) is effective in reducing the number of Gram-positive infections in these long-term lines.30 The largest prospective study performed in a pediatric population evaluated the use of ciprofloxacin/vancomycin in a similar manner to reduce Gram-negative infections but failed to show any further reduction in infections when compared to vancomycin alone.31

Diagnosis of Catheter-Related Infection

Our ability to accurately diagnose these infections has evolved over time but remains imperfect. Typically, blood cultures are drawn from patients with intravascular catheters if they develop a fever. In the past nontunneled lines were removed immediately if a blood culture became positive. The line tip was then cultured, and if there were ⩾ 15 colonies of the same organism on the catheter tip as in the blood, a line-associated infection was diagnosed.2 This method is accurate, but it requires the removal of the catheter, and with the advent of tunneled and totally implanted catheters, a diagnostic strategy that did not require removal of the catheter was sought. Initially, blood cultures were drawn from the catheter and a peripheral vein. If both cultures grew the same organism, a catheter-associated bloodstream infection was diagnosed, and an attempt to clear the line with appropriate antimicrobials was made as long as the patient remained clinically stable.Recently, experimental evidence has revealed that it is possible to differentiate between a line-associated infection and bacteremia from another source by utilizing equal-volume quantitative blood culture methods.32-37 If the infection is truly line related, then the largest burden of organisms would be at the catheter tip. As organisms are shed into the bloodstream, they are filtered through the lungs, and as a result, they have a lower concentration in the peripheral blood. Studies have shown that there should be 5 to 10 times the number of colonies from a blood culture drawn through the catheter than that drawn from a peripheral vein in order to diagnose a line-related infection.38 This method is sensitive and specific, but it is not widely used because of its labor intensiveness and expense. It may have its greatest utility in specific patient populations, such as those with bowel dysfunction, where one might expect a greater incidence of bacterial translocation to take place.A new method has been proposed. Newer blood culture analyzers are capable of storing time of entry and time of positivity in the computer; therefore, it is possible to generate standard curves with known quantities of specified organisms. In this way an approximate organism burden can be generated once the machine has categorized a bottle as positive.39-44 This method could become the gold standard after further validation because it is less labor intensive and cheaper than the current quantitative methods.

Controversy remains as to the optimal combination of central and of peripheral blood cultures to obtain in pediatric patients. Studies looking at the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of central versus peripheral blood cultures have been predominantly performed in adults.45-47 The simultaneous acquisition of equal volumes of blood from a peripheral vein and from a potentially infected catheter provides the best combination of sensitivity, specificity, PPV, and NPV; however, central cultures have greater sensitivity while peripheral cultures have greater specificity and PPV. In an adult patient, where adequate blood volume is generally assured, the use of multiple peripheral blood cultures to diagnose a catheter-related bloodstream infection might be sufficient. The greater sensitivity of the central culture would be expected to occur as a result of colonization or contamination, while the greater specificity and PPV as well as the equivalent NPV of the peripheral cultures would lead to a more accurate diagnosis of a catheter-related bacteremia.In children, especially infants and toddlers, equal blood volume is not always guaranteed. As a result, because volume of blood has been shown to predict culture positivity,48 inadequate peripheral cultures could lead to a high false-negative rate compared to a central culture, where blood volume is not as important an issue. Consequently, it has become more common in children to draw blood cultures only from the catheter. The optimal combination of central and peripheral blood cultures must take into consideration the age of the child, the type of catheter, the number of catheter lumens and ability to draw from each lumen, the clinical status of the patient, and the type of blood culture vial (pediatric blood culture vials have an optimal liquid medium–to–blood ratio for smaller volumes of blood). Every effort should be made to obtain an adequate peripheral culture before antimicrobials are initiated as per recommendations. As always, clinical judgment is paramount in interpreting results and in deciding on the appropriate management strategy.

Treatment

Short- or immediate-term catheters should ideally be removed when a catheter-associated infection is documented.49 A great deal of attention has been paid to the duration of catheterization and its role in the pathogenesis of catheter-related infections. It has been shown that the colonization rate of these catheters increases with the duration of catheterization, but it has also been shown that the rate of infection does not change over time while the absolute number of infections increases.50 In clinical studies as well, there has been no clear reduction in infectious complications if one compares scheduled periodic changing of short-term catheters via guidewire exchange versus removal and replacement of these devices as needed.51 Removal of a long-term catheter may not be practical in some clinical situations since this risks the loss of life-saving venous access. It is now routine practice to attempt to treat an infection in a long-term catheter while the catheter is in place. Guidance on decisions for immediate versus delayed removal of a catheter are provided in Table 239-2. A proposed algorithm49 for the management of short- and intermediate-term catheters suggests: (1) removal of catheters when they are no longer needed for patient care and (2) replacement over a guidewire if clinically indicated, ie, mechanical difficulty or suspected but as yet undocumented infection. Replacement by guidewire exchange has been shown to reduce insertional complications. If a line is exchanged because of presumed infection, the old line should be cultured, and if positive, the new line should be removed and another new catheter placed in a different location. If a catheter is removed because of a documented infection, then a new line should be placed in a different location. An alternative approach would be removal of all malfunctioning lines with reinsertion at a different location.

Decisions regarding whether to remove a long-term line secondary to recrudescence of infection is more problematic and should be decided by the pathogenicity of the offending organism, the status of the patient, and the need to maintain appropriate access; however, most experts would recommend line removal in such situations.

The choice of empiric antibiotics depends upon the host, previous history of bloodstream infection, and nosocomial versus community acquired pathogens. There are a large variety of acceptable regimens chosen by the likely organisms and patient status, as shown in eTable 239.1. In a neutropenic or unstable patient, combination Gram-negative antibiotic coverage should be initiated with agents that work by different mechanisms (ie, a pencillin derivative and aminoglycoside or a quinolone and aminoglycoside) until the patient has stabilized and an organism is identified.

Duration of antibiotic therapy depends on the clinical status of the patient and the laboratory findings. If the catheter culture is positive and the peripheral culture is negative, then a short course (3–5 days for coagulase negative staphylococci and 7 days for most other bacterial pathogens) is acceptable as long as the host does not have an underlying immunodeficiency. If the patient is also bacteremic, then the duration of antimicrobials depends on the ability to clear the organism and may prolong therapy by at least a week. Repeat cultures should be drawn before starting therapy if a coagulase negative staphylococcus is isolated because of the possibility of contamination from a skin site; however, this might not always be practical in patients with an underlying immunodeficiency when empiric therapy is initiated quickly. A workup for bacterial dissemination to other sites (spontaneous bacterial endocarditis, bone) be initiated for all patients who fail to clear their peripheral blood culture despite line removal or who remain persistently symptomatic despite negative blood cultures. If this workup is negative at the end of a standard 2-week course of antimicrobial therapy, then it is reasonable to discontinue treatment. In addition, bloodstream infection with Candida (spp) should prompt a search for additional foci of infection, especially in neutropenic patients. It should include an ophthalmology exam, echocardiogram, and CT scan of chest and abdomen (head if appropriate shunting might occur across the heart).

Granulocytopenic oncology patients without positive cultures can be started on dual therapy with pipericillin/tazobactam or cefipime and an aminoglycoside; however, if local epidemiology is consistent with increased isolation of methicillin-resistant S aureus, then vanocmycin should be added to empiric therapy until culture results are known. Possible community-acquired infections may be covered with a combination of oxacillin and an aminoglycoside or third-generation cephalosporin. Nosocomial infections are usually covered with vancomycin and pipericillin/tazobactam or cefipime. Once a pathogen is identified, antibiotics can be narrowed, and special attention should be given to removing vancomycin as soon as possible. A workup for bacterial dissemination to other sites (spontaneous bacterial endocarditis, bone) should be initiated for all patients who fail to clear their peripheral blood culture despite line removal or who remain persistently symptomatic despite negative blood cultures. If this workup is negative at the end of a standard 2-week course of antimicrobial therapy, then it is reasonable to discontinue treatment. In addition, bloodstream infection with Candida spp. should prompt a search for additional foci of infection, especially in neutropenic patients. It should include an ophthalmology exam, echocardiogram, and CT scan of chest and abdomen (head if appropriate shunting might occur across the heart).

Adjunctive Treatment Strategies

In addition to the use of antibiotic locks for the prevention of catheter-related bloodstream infections, antibiotic and ethanol locks have been used as an adjunct in the treatment of catheter-related infections. Antibiotic lock therapy has been recommended in the Infectious Diseases Society of America guidelines for the treatment of catheter infections,49 and ethanol lock therapy is a promising new technique for the treatment of such infections.53,54 The major complication of ethanol lock therapy is catheter occlusion, presumably from biofilm destruction. This results in the use of catheter declotting procedures but rarely requires catheter removal (see DVD: Appendix 239-3).

Treatment of Exit/Tunnel Infections

The treatment of more localized exit/tunnel infections depends on the catheter in use.49 For short-term catheters, an exit site infection associated with bacteremia should prompt catheter removal and the introduction of systemic as well as topical antimicrobials. If the exit site infection is not associated with bacteremia, then an attempt can be made to treat the infection with topical agents alone. The treatment of long-term catheter exit site infections is essentially the same, except that unlike the short-term catheter, long-term catheters can be salvaged, even in the face of bacteremia, if the infection responds to appropriate antimicrobial therapy with sterilization of the blood culture and resolution of the local infection. Tunnel tract infections are generally seen with long-term catheters only. They require systemic antimicrobial therapy and usually necessitate catheter removal. Unless bacteremia is present, a trial of empiric therapy for S aureus and Pseudomonas aeruginosa is warranted if the patient is stable. If no improvement is noted, then the catheter should be removed and the tract cultured. Antibiotics can then be tailored to the identified pathogen. Pocket infections require catheter removal for eradication of the offending organism.

Prognosis

Major complications of central line infections include sepsis, septic emboli, endocarditis, endovascular infection, abscess formation, and death. The true incidence of these complications is unknown in the pediatric population, but prompt removal of the catheter and initiation of long-term antibiotic therapy are required to ensure a good outcome. Certain organisms, including Candida (spp) Pseudomonas (spp) and S aureus, have greater metastatic potential; thus, early consideration should be given to removing central lines when these pathogens are present. Studies analyzing the outcomes of central line–related infections have shown increased length of stay with associated increases in medical costs, and morbidity and mortality rates as high as 10–20%.55-57 Complications in immunocompromised patients would be expected to be greater and to carry a larger morbidity and mortality burden. However, there is a need for studies of this kind in pediatric patients, with special attention given not only to the differences in organisms, but to the outcomes of the different catheter types.

Sample: Central Venous Catheters: Maintenance Care Procedure

Purpose:

To outline the care and management of central venous catheters as follows:

A. Change of dressing, extension set, and cap

B. Medication administration and flushing

C. Conversion to a capped lumen

Applicability:

All inpatient areas, ambulatory areas, and Emergency Department

Policy Statement:

A. General Information

• 1. Central venous catheter tip location must be verified by X-ray and confirmed by a radiologist’s report with the specific tip location documented by the MD/NP/PA prior to using the central venous catheter.
• 2. The procedures described herein will be performed by registered nurses educated in the care of central venous catheters.
• 3. The infection control policy on Prevention of Intravascular Catheter-Related Infections provides standards for the frequency for changing IV tubing and add-on devices.
• 4. The nursing procedure for Implanted Port or Implanted Venous Access Device (IVAD), Use and Maintenance of will be implemented for care specific to IVADs.
• 5. The nursing procedure for Intermittent Hemodialysis via Dialysis Central Venous Catheter CVC-HD will be implemented for the care of dialysis catheters (ie Vascaths). Dialysis catheters should ONLY be accessed by a hemodialysis RN, a renal attending/fellow/NP, or an ICU RN administering CRRT who has demonstrated competency.

B. Change of dressing, extension set, and cap

• 1. Dressing changes:
  • a. Biopatch (USED ONLY IN ICU) and transparent dressings must be changed every 7 days and PRN if damp, soiled, and loose. NOTE: PATIENTS WITH BIOPATCH DRESSINGS UPON TRANSFER OUT OF ICU ARE TO HAVE BIOPATCH REMOVED UPON NEXT DRESSING CHANGE.
  • b. If gauze dressing was used initially for a bleeding or oozing site, the dressing must be changed within 48 hours.
  • c. If transparent dressings cannot be used due to skin sensitivity, gauze and tape dressings are used and must be changed every 48 hours.
  • d. If sutures have been used to secure the catheter, use steri-strips over the sutures before placing a transparent dressing. Do not place steri-strips over the insertion site.
• 2. DO NOT use scissors or a sharp clamp to remove the dressing because this can cause perforation of the catheter or catheter fracture.
• 3. Report signs and symptoms of infection immediately to the MD/NP/PA for assessment.
• 4. For extension set change: Apply a new luer-lock extension set to each lumen with each dressing change if lumens do not have a clamp.
• 5. For cap change:
  • a. A new valve/injection site is applied to each lumen each time the lumen is opened.
  • b. Change valve/injection site every week if the lumen is capped and not used.

C. Medication Administration and Flushing

• 1. When flushing a central venous catheter, use a 10-mL syringe or larger for patients > 10 kg and a 5-mL syringe or larger for patients < 10 kg.
• 2. Patency of the catheter is maintained as follows:
  • a. Intermittent use: Flush using SASH (saline/additive/saline/heparin) after each IV medication administration or at a minimum of every 12 hours. NOTE: Groshong/PSAV catheters do not requireheparin.
  • b. Capped lumen(s): Refer to Appendix 239-5.
  • c. Continuous use: No flush is necessary unless administering multiple meds sequentially. If more than one IV medication is administered sequentially, instill 0.9% sodium chloride flush between each medication, and then instill heparin flush/lock solution after the LAST medication.
• 3. In the neonate and pediatric patients, preservative-free 0.9% is used for flushing.
• 4. For pediatrics, when an IV line for medication administration is ordered, this line is to be used to flush following each IV medication. No heparin flush is necessary. The line should not be disconnected in between medications. Refer to Appendix 239-5 for flush volume.

Supportive Data:

• 1. Central venous catheters reside in the central venous circulation and include:
  • a. Percutaneous catheters—inserted directly into subclavian, internal jugular, or femoral veins.
  • b. PICC catheters—inserted into the basilic or cephalic vein and threaded into the superior vena cava.
  • c. Tunneled catheters—inserted surgically under the skin and tunneled into the superior vena cava.
• 2. Manufacturer guidelines for a particular central catheter can be referenced for additional information about catheter care.
• 3. When patients are unable to cooperate with sterile technique, consider having 2 staff members at bedside to preserve sterile technique.

Procedure:

A. Change of Dressing, Extension Set, and Cap

Equipment:

Sterile dressing change kit contains:

• 1. One towel polylined
• 2. One roll tape, 1 × 36”
• 3. One pair sterile gloves
• 4. One mask
• 5. One sponge dressing, 2 × 2
• 6. One swab stick, skin protectant
• 7. One transparent dressing
• 8. One biopatch
• 9. One cap/injection site per lumen flush as below in section 3

Additional Supplies Include:

• 1. One prepstick (ChloraPrep*)
• 2. One sterile luer-lock valve with cap, with or without extension set per lumen if no clamp on lumen
• 3. One mask per person at the bedside
• 4. Alcohol prep swabs or pads
• 5. Steri-strips if catheter is sutured

*For infants < 2 months, use 70% isopropyl alcohol.

Procedure:

• 1. Position patient comfortably, supine with head turned away from the central venous catheter, if applicable.
• 2. Don mask.
• 3. Perform hand hygiene and don nonsterile gloves.
• 4. Remove old dressing carefully by peeling transparent dressing toward the exit site and discard old dressing and gloves.
• 5. Assess catheter insertion site for redness, swelling, discharge, or tenderness.
• 6. If any signs/symptoms of infection are present, notify MD/NP/PA. If sutures are present, ensure that suture sites are intact. Ifsutures are not intact, contact MD/NP/PA for resuturing.
• 7. Don sterile gloves.
• 8. Cleanse catheter site 2 cm beyond the minimum perimeter of the dressing as follows:
  • a. For patients > 1 kg:
    • i. Remove the ChloraPrep from package.
    • ii. Pinch wings on the applicator to break ampule and release antiseptic. NOTE: Do not touch the sponge.
    • iii. Wet sponge by repeatedly pressing and releasing the sponge against the treatment area until liquid is visible on the skin.
    • iv. Using friction, cleanse the skin insertion site using repeated back-and-forth strokes of the sponge for approximately 30 seconds.
    • v. Allow to air dry for approximately 30 seconds, never waving or blotting the area to speed the drying process.
  • b. For infants < 1 kg:
    • i. Remove 70% isopropyl alcohol swab or pad from package.
    • ii. Cleanse site, using friction; repeat with 2 remaining alcohol swabs.
    • iii. Allow to air dry for approximately 30 seconds, never waving or blotting the area to speed the drying process.
    • iv. Once dry, repeat as above using two additional alcohol swabs or pads.
• 9. Apply protectant skin prep to intact skin 1 inch away from the exit site, working toward dressing perimeter.
• 10. When no clamp exists on lumen, take the following steps:
  • a. Briskly swab the outside of catheter hub/extension junction with alcohol prep for 30 seconds and air dry.
  • b. Clamp lumen by pinching it onto itself, disconnect extension set or valve/cap, and discard.
  • c. Attach sterile-primed luer-lock extension set and/or valve/cap, ensuring that no air enters the lumen.
  • d. Flush according to sets in section B below.
• 11. A pply biopatch around catheter at the exit site, foam side next to the skin, blue/grid side up. (Applies only in ICUs)
• 12. Secure the catheter with transparent dressing, covering a minimum of 2 inches around the insertion site.
• 13. Place steri-strips over catheter hub to secure to extremity.
• 14. Loop and tape any external portion of catheter to skin upward and away from the transparent dressing.
• 15. Label dressing with dressing change date.

B. Medication Administration and Flushing Equipment:

• 1. One pair nonsterile gloves cap/injection site as needed per lumen
• 2. Two prefilled 0.9% sodium chloride syringe per lumen
• 3. One heparin lock flush (prefilled if available) per lumen
• 4. One IV administration set, primed per lumen as necessary
• 5. One sterile luer-lock valve with cap, with or without extension set per lumen without clamp
• 6. Two alcohol preps per lumen

Procedure:

• 1. Briskly swab the cap and outer part of valve with sterile alcohol prep for 30 seconds.
• 2. Attach syringe with 0.9% sodium chloride for injection; gently aspirate for blood return to confirm catheter placement.
• 3. Using the same syringe, instill 5 mL of 0.9% sodium chloride for injection using a pulsating technique (push/stop/push/stop). Ifany resistance is met or complication occurs at any timeduring flushing, do not force: discontinue and notifyMD/NP/PA.
• 4. Administer medication as ordered:
  • a. IV Drip: Attach primed IV administration tubing and administer medication at prescribed rate, using an infusion or syringe pump.
  • b. IV Push: Attach syringe and follow the nursing procedure for intravenous push (IVP) medication administration.
• 5. When the infusion is complete, cleanse the connection site with sterile alcohol prep and remove the administration set/syringe.
• 6. Cleanse the end of lumen or extension set and outer part of the cap with alcohol prep.
• 7. Attach 0.9% sodium chloride syringe. Instill volume as per Appendix 239-5 using a pulsating technique (push/stop/push/stop).
• 8. Remove empty syringe and attach the prepared heparin lock flush solution. Instill volume as per Appendix 239-5 into lumen using a pulsating technique (push/stop/push/stop).
• 9. Clamp lumen as flushing finishes.
• 10. For a multiple-lumen central venous catheter, repeat steps 1–9 for each lumen used for medication administration.

C. Conversion to a capped lumen equipment:

• 1. One pair nonsterile gloves cap/injection site as needed per lumen
• 2. One prefilled 0.9% sodium chloride syringe per lumen
• 3. One heparin lock flush (prefilled if available) per lumen
• 4. Two alcohol preps per lumen

Procedure:

• 1. Perform hand hygiene and don gloves.
• 2. Close the roller clamp to the IV tubing.
• 3. Clamp the catheter lumen and/or extension tubing.
• 4. Briskly swab the connection with alcohol pad/prep for 30 seconds.
• 5. Remove IV tubing and cleanse catheter hub with alcohol prep/pad.
• 6. Attach 0.9% sodium chloride syringe and open the clamp on the catheter.
• 7. Instill amount of 0.9% sodium chloride as per Appendix 239-5 and reclamp the catheter.
• 8. Remove syringe and cleanse hub with alcohol prep/pad.
• 9. Attach syringe containing heparin flush/lock solution and instill amount as per Appendix 239-5 using a pulsating technique (push/stop/push/stop).
• 10. Clamp catheter, remove syringe, and attach cap/injection site if appropriate.

Documentation:

Document in the patient’s medical record:

A. Change of dressing, extension set, and cap

• 1. Time and date of procedure
• 2. Assessment of central venous catheter site
• 3. Description of any drainage
• 4. Resuturing by MD/NP/PA if required
• 5. Type of dressing applied
• 6. Patient’s response to procedure
• 7. Patient education provided

B. Medication administration and flushing of catheter

• 1. Medication(s) administrated on MAR
• 2. Any complications with follow-up nursing interventions
• 3. Date, time, and amount of 0.9% sodium chloride or heparin lock flushes used on MAR

C. Conversion to a capped lumen

• 1. Time and date of procedure
• 2. Date, time, and amount of 0.9% sodium chloride or heparin lock flushes used on MAR

Sample: Peripherally Inserted Central Catheter (PICC)

Care of the Patient with a PICC

PURPOSE: To outline the care and management of patients with a PICC line.

• SUPPORTIVE DATA:
• 1. A PICC may remain in place as long as it is patent and remains in the proper position and the patient is free of catheter-related complications.
• 2. Blood pressures, venipunctures, and IVs should not be performed in the arm with a PICC.
• 3. All infusions into PICC lines (including piggyback) must be on an infusion pump.
• 4. Blood and blood products may be administered via a PICC only when no other IV access is available:

• Adults: By gravity using a 4 Fr or larger catheter.
• Pediatrics and neonates: Via a pump through an appropriate-sized PICC line.

Nursing Assessment and Care:

• 1. Admission of patients with existing PICC line.
  • a. Notify the IV team of the patient’s admission.
  • b. The PICC line must not be used until TIP placement is verified and documented in the medical orders/record by MD/NP/PA. Specific tip location can be confirmed by written documentation provided by the patient, a patient’s PICC line information booklet, or a CXR specifying tip location.
  • c. A written physician’s order is required before a PICC can be used.
  • d. The PICC team RN performs and documents an assessment and initial external catheter measurement in the medical record.
• 2. PICC line inserted while hospitalized.
  • a. The PICC must not be used until specific tip location is verified by a radiologist report or specific tip documentation is in the MD/NP/PA’s order.
• 3. Ongoing care.
  • a. A laminated sign may be placed over the bed or in a location designated by the nursing unit stating “No BPs orvenipuncture in ___extremity.”
  • b. Assess daily the PICC dressing is dry and intact and there are no signs or symptoms of phlebitis (see Table 1).
  • c. Notify MD/NP/PA for any signs that phlebitis is present.
  • d. Monitor patient for signs and symptoms of potential complications (see Table 2).
  • e. The primary nurse will alert procedural areas about the existence of a PICC when the patient leaves the unit.

Patient Teaching:

• a. Report to nurse any discomfort at site, leaking, redness, or swelling or a loose dressing.
• b. Ensure patient/family has information about catheter care postdischarge.

Documentation:

• a. Assessment of any signs or symptoms of PICC complications.
• b. Treatments or interventions performed.
• c. Patient’s response to procedure.
• d. Evaluation of patient teaching.

Sample: Antibiotic Lock Therapy (ALT) and Ethanol Lock Therapy (ELT) for the Management of Central Venous Catheter–Related Infections

Purpose:

To develop guidelines for the use of antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) in the treatment and prevention of catheter-related infections in adult and pediatric patients.

Background Information:

The use of central venous catheters (CVCs) has increased dramatically in recent years. As use has increased, so has the rate of catheter-related infections. Infection remains one of the most devastating complications associated with vascular access devices, especially with long-term total parenteral nutrition (TPN) use.1CVCs are expensive and difficult to implant and remove, and vascular access sites may be limited, especially in the pediatric population.2 Antibiotic lock therapy and ethanol lock therapy have been proposed as means of managing catheter-related infection. Antibiotic lock therapy involves instilling an antibiotic solution into a catheter hub and allowing the solution to dwell for a set period of time. The goal of the therapy is to eradicate organisms from an infected line and to prevent colonization of a sterile line. Several antibiotics, with or without heparin, have been suggested for use in antibiotic lock therapy. Because of the role of host proteins such as fibrin, fibrinogen, and fibronectin as adhesins in the catheter lumen, heparin may be a beneficial additive in such therapies.4The main concern of using heparin in antibiotic lock therapy is drug stability. Large concentrations of heparin used in antibiotic lock therapy can lead to inadvertent systemic heparinization, especially in the pediatric population. In addition, heparin must not be used in patients with a history of heparin-induced thrombocytopenia (HIT) or who have an active hypocoagulable state. Therefore, formulations are provided that do (and do not) contain heparin (Table 1) (note: ethanol is INCOMPATIBLE with heparin).

Similar to antibiotic lock therapy, ethanol lock therapy consists of filling and closing a catheter lumen with an ethanol solution to prevent or treat catheter-related infections. The advantages of ethanol lock therapy include the prevention/eradication of colonization of the offending organism irrespective of the sensitivity of the organisms to an antibiotic. A 70% ethanol lock is adequate for prevention of infection because an ethanol concentration above 40% is able to inhibit bacterial growth in established biofilms. However, a 70% ethanol lock must dwell in the catheter for a minimum of 2 hours in order to be effective.5A recent retrospective study involving pediatric hematology-oncology patients showed a benefit from ethanol lock therapy in treating and preventing central venous catheter infections.6Most patients in the study received one 5-day course of lock therapy. However, one patient received 7 courses safely, and a case in the literature cites the successful and safe use of lock therapy for 3 years in a patient dependent on total parenteral nutrition.7

Policy Statement

• 1. For inpatients, use of antibiotic lock therapy/ethanol lock therapy requires approval from the Infectious Diseases (ID) service.
• 2. Antibiotic lock therapy/ethanol lock therapy is NOT recommended as monotherapy for active systemic infection. Antibiotic lock therapy/ethanol lock therapy is not intended for concurrent or sequential therapy. Therefore, three scenarios for their use are intended:
  • a. For active infection, concurrent with systemic antibiotics. The data for this scenario is mostly derived from small, uncontrolled, observational trials using a variety of different antibiotic solutions in patients receiving total parenteral nutrition. As such, no definitive conclusions regarding efficacy can be made at this time.4
  • b. As “mop-up” therapy in patients with central venous catheter–associated infection, but in whom replacement of the line is not feasible. Lock therapy in these patients is intended to increase the likelihood that the line will be eradicated of organism colonization.
  • c. Preventive therapy in patients with recurrent central venous catheter–associated infection. Such therapy may in some cases be long-term (even lifelong). Although total parenteral nutrition–dependent patients are the most common candidates for preventive therapy, most of the data is derived from studies in hematology/oncology patients. In addition, most of these studies did not use lock solutions per se, but rather antibiotic flushes.4
• 3. The lock may be performed by a registered nurse or at home by a patient or caregiver who has demonstrated competency in line care. It must be ordered by a physician or other authorized prescriber.
• 4. Patient candidate criteria:
  • a. General lock therapy eligibility
    • i. Patients who have experienced multiple bacterial infections of their central line within a short period of time OR
    • ii. Patients in whom replacement of infected central venous catheter is not feasible.
  • b. Ethanol lock therapy
    • i. Patients age ⩾ 6 months OR if < 6 months, must be ⩾ 6 kg, have normal hepatic function tests, and be inpatient during the course of ethanol treatment.
    • ii. Negative history of allergy to ethanol.
    • iii. Patient has not received oral or IV: metronidazole (Flagyl, 48 hours), disulfiram (Antabuse, 7 days), isoniazid (Nydrazid, 24 hours) previously within the designated hours. These agents interact with alcohol and cause severe nausea and vomiting and are therefore contraindicated when alcohol is being administered.
    • iv. Patients whose catheter hardware is NOT composed of polyurethane (see section 6 below).
  • c. Antibiotic lock therapy
    • i. Patients without documented allergies to requested antibiotics.
    • ii. If heparin is to be used, patient must not have history of heparin-induced thrombocytopenia (HIT) or have an active hypocoagulable state.
• 5. Lock therapy should be initiated and instilled without dwell disruption for the duration of the therapy. It should not be used as a flush/lock solution concurrently when the central line is being accessed for multiple daily doses of intravenous medications because the patient could receive multiple doses of ethanol/antibiotic.
  • a. If patient has a single lumen catheter or port, another line (peripheral or PICC) may need to be placed for intravenous antibiotic courses.
  • b. If patient has a double-lumen catheter, the lock solution can be placed in one lumen for 24 hours while the other lumen is used for infusions. During the next 24-hour period, the other lumen can be locked with a lock solution “dwell” while the first lumen is used for infusions.
• 6. Type of catheter
  • a. Ethanol lock therapy: The PICCs currently used are manufactured by Bard Access Systems. These catheters are made of polyurethane, and there have been reports of catheter breakage and cracking when exposed to ethanol. As such, ethanol lock therapy will be used ONLY when the catheter/port hardware that will be exposed to ethanol is not composed of polyurethane (unless proven compatible). The most common alternate material is silicone. It is the responsibility of the ordering practitioner to verify that the catheter hardware is not composed of polyurethane.8
  • b. Antibiotic lock therapy: Hickman, Groshong, Mahukar, Hohn, Broviac, Permcath, Mediport, Port-a-Cath, and PICCs.
    • i. Data suggests that antibiotic lock therapy is less effective in treating infections in implantable ports than in infections in other types of central venous catheters.4
    • ii. Only intraluminal infections are candidates for lock therapy, because lock therapy would be ineffective in extraluminal infection.
• 7. Recommended antibiotic lock therapy formulations (Table 1):

• 8. Catheter volumes and dosages9
  • a. Doses are determined by the catheter volume with a maximum volume of 5 mL. In general, the literature is consistent in recommending 2-mL to 5-mL lock volumes in adult patients on antibiotic lock therapy. In these patients, if the catheter volume cannot be determined, it appears appropriate to approximate. Ethanol lock therapy volumes should be more precisely determined, if possible, with a maximum volume of 2 mL. Please recall that ethanol lock therapy should not be used in patients age < 6 months, unless the patient weighs ⩾ 6 kg. The following approximations for heparin lock flushes are used:

If the catheter volume cannot be precisely determined, practitioners may use the following recommendations derived from reference 9:

Physician Ordering:

• 1. Ethanol lock therapy
  • a. The practitioner will write an order for ethanol lock therapy denoting the exact volume and duration of each dwell of 74% ethanol solution to be instilled into the catheter.
    • i. Example Order: “ETHANOL LOCK THERAPY—Please instill ____ mL of 74% ethanol solution into the patient’s catheter lumen after TPN is cycled off. Withdraw the ethanol solution prior to administration of other medications or reinitiation of TPN. Flush before and after with 5 mL of normal saline.”
    • ii. When writing total parenteral nutrition (TPN) for patients on the ethanol lock, the practitioner will delete the heparin from the TPN to avoid possible incompatibility issues.
    • iii. The practitioner will also verify that the catheter material is compatible with ethanol.
• 2. Antibiotic lock therapy
  • a. The practitioner will write an order for antibiotic lock therapy denoting the specific solution requested, the exact volume of solution to be instilled into the catheter, duration of each dwell, and the number of dwells per day.
    • i. Example Order: “ANTIBIOTIC LOCK THERAPY—Please instill ____ mL of ____ solution into the patient’s catheter lumen in between antibiotic infusions. Withdraw the antibiotic solution prior to administration of other medications. Flush before and after with 5 mL of normal saline.”

Pharmacy Preparation and Dispensing:

Table 2, provides guidance in preparation of antibiotic and ethanol lock solutions.

• 1. Ethanol lock therapy
  • a. Ethanol lock solutions will be compounded and dispensed daily.
  • b. A standing order will be used to enter the ethanol lock solution on the patient’s profile.
  • c. Pharmacy will prepare a single-use syringe of 74% ethanol with 24-hour expiration for each patient. (74 percent ethanol solution [ethyl alcohol]).
  • d. Deliver the ethanol lock for the exact volume prescribed, up to 2 mL.
  • e. Label: “For central venous catheter lock use only. Do not infuse into patient. Do not use with heparin flush.”
  • f. Expiration: 24 hours.
• 2. Antibiotic lock therapy
  • a. Antibiotic lock solutions will be compounded and dispensed daily.
  • b. A standing order will be used to enter the antibiotic lock solution on the patient’s profile.
  • c. Pharmacy will prepare 5 mL of the solution in 12-mL syringes and send the syringe(s) to the floor each day. One 12-mL syringe with 5 mL of antibiotic lock solution will be sent for each dwell time. Syringes will be labeled with 24-hour expiration.
  • d. Label: “For catheter lock use only. Do not infuse into patient. Do not use if precipitate seen. Call pharmacy.”
  • e. Expiration: 24 hours.
  • f. For specific pharmacy compounding instructions.

Nursing Management:

• 1. General considerations
  • a. Ethanol and antibiotic lock solutions are not intended for injection directly into the systemic circulation. They are instilled for purposes of “locking” the catheter for the specified period of time and are to be withdrawn prior to administering a dose of a medication or total parenteral nutrition or other infusion.
  • b. The nurse will instill the solution into the catheter lumen(s) using the appropriate volume ordered and allow the solution to dwell for the appropriate time based on the frequency of medications/nutrition (minimum dwell time for ethanol lock therapy = 2 hours). Prior to initiating this procedure, the nurse should carefully check the order for the amount to be instilled (ethanol lock therapy syringes dispensed by the pharmacy should contain the exact amount to be instilled, but antibiotic lock therapy syringes will all contain a volume of 5 mL, which may be different from the volume ordered).
    • i. Instillation of lock solution:
      • 1. Cleanse hands with alcohol-based hand hygiene product or scrub hands for 30 seconds with antimicrobial soap before procedure.
      • 2. Put on sterile gloves; use aseptic technique throughout procedure.
      • 3. Clean injection cap with alcohol for 30 seconds and let dry.
      • 4. Attach a 12-mL syringe filled with 5 mL of normal saline.
      • 5. Unclamp catheter and gently irrigate catheter using push-pause method with normal saline to assure patency of the catheter.
      • 6. Clamp catheter and remove saline syringe.
      • 7. Insert lock syringe into catheter injection cap. Inject appropriate volume of lock solution (per physician’s order) using a slow, push-pause method. Clamp catheter and remove syringe.
      • 8. Label catheter to indicate that the lumen contains either an ethanol or antibiotic lock solution.
  • c. When the lumen is needed for medications/nutrition, the nurse will use the same technique and aseptic procedure as described above to:
    • i. Withdraw the lock solution (the exact same amount of volume as initially instilled in the catheter)
    • ii. Flush with 5 mL of normal saline
    • iii. Administer the ordered medication/nutrition
    • iv. Flush with 5 mL of normal saline
    • v. Instill the new lock solution
    • vi. Label catheter to indicate that the lumen contains either an ethanol or antibiotic lock solution
  • d. As part of the flushing technique, the push-pause method should be used. It creates turbulence to clear the interior lumen(s) of possible blood clots that may be attached without an increase in pressure (push in saline, pause of two seconds, continue with this method until flush is complete).
• 2. Ethanol lock therapy
  • a. Ethanol is INCOMPATIBLE with heparin, so DO NOT use heparinized saline flushes with any patient currently on ethanol lock therapy. To avoid this potential problem further, chronic total parenteral nutrition (TPN) patients receiving ethanol lock therapy will have the heparin removed from their TPN.
• 3. Antibiotic lock therapy
  • a. In regard to stability, antibiotic lock solutions are stable for at least 24 hours at room temperature. However, the nurse should always verify that no precipitate has formed in the solution (to ensure physical compatibility).
• 4. Inadvertent injection of the lock solution into the systemic circulation
  • a. Ethanol lock therapy—In case of an accident, the ethanol may be flushed into the systemic circulation. If the ethanol lock solution cannot be withdrawn from the catheter, unfortunately it will have to be administered to the patient. Ethanol infusions are fairly safe and have been used in pediatric patients for other reasons, such as methanol or ethylene glycol ingestion (for example, antifreeze ingestion). The patient should be monitored for the following signs and symptoms: tiredness, headaches, dizziness, nausea, and light-headedness. Notify the MD/PA/NP of the inadvertent administration.
  • b. Antibiotic lock therapy—In case of an accident, the antibiotic lock solution may be flushed into the systemic circulation. If the lock solution cannot be withdrawn from the catheter, unfortunately it will have to be administered to the patient. In most cases, accidental flushing will not result in significant systemic exposure to the antibiotic, and should be safe. The primary concern with routine flushing of antibiotic lock therapy is exposing the system to low concentrations of antibiotics, and thus facilitating the development of antibiotic resistance. Notify the MD/PA/NP of the inadvertent administration.

Ethanol Lock Preparation: