Section: UTMB On-line Documentation Subject: Healthcare Epidemiology Policies and Procedures Topic: Intravascular Devices and Infusion Systems

1.18 - Policy 11.15.07 - Revised 1994 - Author

1.18 Intravascular Devices and Infusion Systems

Purpose		To provide infection control guidelines for the proper placement and management of intravascular devices and infusion systems
Audience		All employees of UTMB hospitals and clinics, contract workers, volunteers, and students
Hand Hygiene Documentation Surveillance		• Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based hand rubs. Observe hand hygiene before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. • Use of gloves does not obviate the need for hand hygiene. • Record the operator, date, and time of catheter insertion and removal, and dressing changes on a standardized form. • Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis, depending on the clinical situation of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local infection or bloodstream infection (BSI), the dressing should be removed to allow thorough examination of the site.
Aseptic Technique During Catheter Insertion and Care		• Maintain aseptic technique for the insertion and care of intravascular catheters. • Wear clean or sterile gloves when inserting an intravascular catheter. Wearing clean gloves rather than sterile gloves is acceptable for the insertion of peripheral intravascular catheters if the access site is not touched after the application of skin antiseptics. Sterile gloves must be worn for the insertion of arterial and central catheters. • Wear clean or sterile gloves when changing dressings on intravascular catheters.
Catheter Insertion		• Do not routinely use arterial or venous cutdown procedures as a method to insert catheters.
Catheter-site Care		• Cutaneous antisepsis - Disinfect clean skin with 2% chlorhexidine antiseptic before catheter insertion and during dressing changes. - Allow the antiseptic to remain on the insertion site and to air dry before catheter insertion. - Do not apply organic solvents (e.g., acetone and ether) to the skin before insertion of catheters or during dressing changes.
Catheter-site Dressing Regimens		• Use sterile, transparent, semipermeable dressings to cover venous catheter sites. • Replace transparent semipermeable catheter-site dressings if they become damp, loosened, or visibly soiled or at least weekly. Replace sterile gauze dressings on arterial lines every 48 hours. • If the patient is diaphoretic, or if the site is bleeding or oozing, a gauze dressing is preferable to a transparent, semi-permeable dressing. Replace this dressing every 48 hours. • Tunneled central venous catheters (CVC) sites that are well healed do not require dressings. • Arterial lines that are placed in the Operating Room may have a polyurethane dressing. Arterial lines that are placed in the Intensive Care Unit will be dressed with gauze and tape. Arterial line dressings need to be changed every 48 hours. Any patient who had an arterial line placed in the OR should have their dressing changed to gauze and tape after admission to the ICU and then every 48 hours. • Do not use topical antibiotic ointment or creams on insertion sites because of their potential to promote fungal infections and antimicrobial resistance. • Do not submerge the catheter under water. Showering may be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower.
Selection and Replacement of Intravascular Devices		• Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy. • Promptly remove any intravascular catheter that is no longer essential. • Do not routinely replace central venous or arterial catheters solely for the purposes of reducing the incidence of infection. • Replace peripheral venous catheters at least every 72 hours in adults to prevent phlebitis. Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis and infiltration) occur. • When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours. • Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do not routinely replace catheters in patients whose only indication of infection is fever). Do not routinely replace venous catheters in patients who are bacteremic or fungemic if the source of infection is unlikely to be the catheter. • Replace any short-term CVC if purulence is observed at the insertion site, which indicates infection. • Replace all CVCs if the patient is hemodynamically unstable and catheter-related bloodstream infection (CRBSI) is suspected. • Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related infection.
Replacement of Administration Sets and Intravenous Fluids
Administration Sets	• Replace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected or documented. • Replace tubing used to administer blood, blood products or lipid emulsions (those combined with amino acids and glucose in a 3-in-1 admixture) within 24 hours of initiating the infusion. If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours. • After completing infusion of lipids, discard bag and administration set. This should be done within 12 hours. • Replace tubing used to administer propofol infusions every 6 or 12 hours, depending on its use, per the manufacturer's recommendation.
Needleless Intravascular Devices	• Change the needleless components at least as frequently as the administration set. • Change caps no more frequently than every 72 hours or according to manufacturers' recommendations. • Ensure that all components of the system are compatible to minimize leaks and breaks in the system. • Minimize contamination risk by wiping the access port with an appropriate antiseptic and accessing the port only with sterile devices.
Parenteral Fluids	• Complete the infusion of lipid-containing solutions (e.g., 3-in-1 solutions) within 24 hours of hanging the solution. • Complete the infusion of lipid emulsions alone within 12 hours of hanging the emulsion. • Complete infusions of blood or other blood products within 4 hours of hanging them.
IV Injection Ports	• Clean injection ports with 70% alcohol or an iodophor before accessing the system. • Cap all stopcocks when not in use.
Preparation and Quality Control of Intravenous Admixtures	• If possible, admix all routine parenteral fluids in the pharmacy in a laminar-flow hood using aseptic technique. • Do not use any container of parenteral fluid that has visible turbidity, leaks, cracks, or particulate matter or if the manufacturer's expiration date has passed. • Use single-dose vials for parenteral additives or medications when possible. • Do not combine the leftover content of single-use vials for later use. • If multidose vials are used - Refrigerate multidose vials after they are opened, if recommended by the manufacturer. - Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial. - Use a sterile device to access a multidose vial and avoid touch contamination of the device before penetrating the access diaphragm. - Discard multidose vial if sterility is compromised.
In-line filters	• Do not use in-line filters routinely for infection-control purposes.
IV-Therapy Personnel	• Designate trained personnel for the insertion and maintenance of intravascular devices.
Prophylactic Antimicrobials	• Do not administer intranasal or systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or BSI.
Peripheral Venous Catheters, Including Midline Catheters, in Adult and Pediatric Patients
Selection of Peripheral Catheter	• Select catheters on the basis of the intended purpose and duration of use, known complications (e.g., phlebitis and infiltration), and experience of individual catheter operators. • Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs. • Use a midline catheter or PICC when the duration of IV therapy will likely exceed 6 days.
Selection of Catheter-insertion Site	• In adults, use an upper- instead of a lower-extremity site for catheter insertion. Replace a catheter inserted in a lower-extremity site to an upper-extremity site as soon as possible. • In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site. • Replacement of catheter - Evaluate the catheter insertion site daily, by palpation through the dressing to discern tenderness and by inspection if local tenderness or other signs of possible catheter-related bloodstream infection (CRBSI) are suspected. - Remove peripheral venous catheters if the patient develops signs of phlebitis (e.g., warmth, tenderness, erythema, and palpable venous cord), infection, or a malfunctioning catheter. - In adults, replace short, peripheral venous catheters at least every 72 hours to reduce the risk for phlebitis. If sites for venous access are limited and no evidence of phlebitis or infection is present, peripheral venous catheters can be left in place for longer periods, although the patient and the insertion sites should be closely monitored. - Do not routinely replace midline catheters to reduce the risk for infection. - In pediatric patients, leave peripheral venous catheters in place until IV therapy is completed, unless a complication (e.g., infection, phlebitis or infiltration) occurs.
Catheter and Catheter-site Care	Do not routinely apply prophylactic topical antimicrobial or antiseptic ointment or cream to the insertion site of peripheral venous catheters.
Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters, in Adult and Pediatric Patients
General Principles	• Use a CVC with the minimum number of ports or lumens essential for the management of the patient. • Designate personnel who have been trained and exhibit competency in the insertion of catheters to supervise trainees who perform catheter insertion. • Use totally implantable access devices for patients who require long-term, intermittent vascular access. For patients requiring frequent or continuous access, a PICC or tunneled CVC is preferable. • Use a cuffed CVC for dialysis if the period of temporary access is anticipated to be prolonged (e.g., >3 weeks). • Use a fistula or graft instead of a CVC for permanent access for dialysis. • Do not use hemodialysis catheters for blood drawing or applications other than hemodialysis except during dialysis or under emergency circumstances.
Selection of Catheter Insertion Site	• Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). • Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for nontunneled CVC placement. • Place catheters used for hemodialysis and pheresis in a jugular or femoral vein rather than in a subclavian vein to avoid venous stenosis if catheter access is needed.
Maximal Sterile Barrier Precautions during Catheter Insertion	• Use sterile technique including the use of a cap, mask, sterile gown, sterile gloves, and a large fenestrated sterile drape, for the insertion of CVCs (including PICCs) or guidewire exchange. • Use 2% chlorhexidine to prep the insertion site. • Use a sterile sleeve to protect pulmonary artery catheters during insertion.
Replacement of Catheter	• Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. • Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. • When catheters are removed, do not routinely culture the tips. • Guidewire exchange - Do not use guidewire exchanges routinely for nontunneled catheters to prevent infection. - Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present. - Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed.
Catheter and Catheter-site Care	• General measures - Designate one port exclusively for hyperalimentation if a multilumen catheter is used to administer parenteral nutrition. • Antibiotic lock solutions - Do not routinely use antibiotic lock solutions to prevent catheter-related bloodstream infection. Use prophylactic antibiotic lock solution only in special circumstances (e.g., in treating a patient with a long-term cuffed or tunneled catheter or port who has a history of multiple catheter- related bloodstream infections despite optimal maximal adherence to aseptic technique). • Catheter-site dressing regimens - Replace the catheter-site dressing when it becomes damp, loosened, or soiled or when inspection of the site is necessary. - Replace dressings used on short-term CVC sites weekly for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter outweighs the benefit of changing the dressing. - Replace dressings used on short term CVC sites every 2 days if a gauze dressing is required. - Replace dressings used on tunneled or implanted CVC sites weekly, until the insertion site has healed. • Ensure that catheter-site care is compatible with the catheter material. • Use a sterile sleeve for all pulmonary artery catheters.
Additional Recommendations for Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients

Insertion of Arterial Catheters	• Insertion of arterial catheters o Wash hands with an antimicrobial soap or apply an alcohol hand rub. o Don sterile gloves o Use 2% chlorhexidine to prep the insertion site. o Use aseptic no touch technique for insertion. o Cover the insertion site with a gauze dressing.
Replacement of Catheter and Pressure Monitoring System	• Replace peripheral arterial catheters every 7 days. • Replace transducers every 7 days with catheter changes. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced.
Care of Pressure Monitoring Systems	• General Measures - Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile. - Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed-flush system (i.e., continuous flush), rather than an open system (i.e., one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters. - When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, wipe the diaphragm with an appropriate antiseptic before accessing the system. - Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit.
Recommendations for Umbilical Catheters
Replacement of Catheters	• Remove and do not replace umbilical artery catheters if any signs of catheter-related bloodstream infection, vascular insufficiency, or thrombosis are present. • Remove and do not replace umbilical venous catheters if any signs of catheter-related bloodstream infection or thrombosis are present. • Replace umbilical venous catheters only if the catheter malfunctions.
Catheter-site Care	• Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone-iodine) can be used. • Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. • Add low doses of heparin (0.25-1.0 F/ml) to the fluid infused through umbilical arterial catheters. • Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days. • Umbilical venous catheters should be removed as soon as possible when no longer needed but can be used up to 14 days if managed aseptically.
References	1. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002;51(No.RR-10):1-32. 2. Farr BM. Nosocomial infections related to use of intravascular devices inserted for short-term vascular access. In: Mayhall CG, ed. Hospital epidemiology and infection control, 3rd Ed. Philadelphia: Lippincott Williams and Wilkins, 2004:231-240. 3. Rijnders BJA, Van Wijngaerden E, Wilmer A, Peetermans WE. Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial. Clin Infect Dis 2003; 36: 743-748.