CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 1
CVAA Clinical Resource Guide Site Care and Maintenance – Central Venous Access Devices (CVADs)
Organization Insertion Site Preparation Site Care Pediatric Considerations
Standards Intravenous Nurses Society Single dose antiseptic solutions should be used Using friction, apply antiseptic solution For neonates, isopropyl alcohol or (INS) 2006 to disinfect insertion sites. Recommended products containing isopropyl alcohol solutions include: If using alcohol, apply friction for a are not recommended for access site (pg S44) minimum of 30 seconds preparation. Alcohol If using chlorhexidine gluconate, use Chlorhexidine gluconate friction according to manufacturer’s Povidone-iodine or chlorhexidine Povidone-iodine labeled use and directions gluconate solution is recommended Tincture of iodine but requires complete removal after the preparatory procedure with sterile Do not disinfect with aqueous benzalkonium- Only one application is necessary. water or sterile 0.9% sodium chloride like compounds or hexachlorophene. (USP) to prevent product absorption. Allow antiseptic to air dry. Allow antiseptic to air dry.
Royal College of Nursing (RCN) Antimicrobial solutions in a single-unit use Antimicrobial solutions that should be used 2010 configuration should be used whenever possible. for site care are 2% chlorhexidine, as a single agent or in combination with alcohol (Pg 30 & 33) Antimicrobial solutions that should be used or aqueous solution. include 2% chlorhexidine as a single agent or in combination. Where alcohol is used, check manufacturers’ recommendations for any Skin should be rubbed for approximately 30 potential damage to the catheter material seconds with the antimicrobial disinfection solution in order to decontaminate the skin effectively.
The solution(s) should be allowed to air-dry completely (at least 30 seconds) before proceeding with the vascular access device insertion procedure.
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 2
Organization Insertion Site Preparation Site Care Pediatric Considerations
Guidelines Disinfect the skin with an appropriate antiseptic Disinfect the skin with an appropriate No recommendations can be made for Centre for Disease Control (CDC) before catheter insertion. antiseptic during dressing changes the use of chlorhexidine in infants 2002 aged < 2 months. Although a 2% chlorhexidine-based preparation (Appendix B, pg 29) is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used
Allow the antiseptic to remain on the insertion site and to air dry before catheter insertion
Allow povidone iodine to remain on the skin for at least 2 minutes, or longer if it is not yet dry before insertion
Department of Health (2001) Clean the skin site with an alcoholic Do not apply antimicrobial ointment to chlorhexidine gluconate solution prior to CVC CVC insertion sites as part of routine (pg S38) insertion. catheter site care
Use an alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity.
Allow the antiseptic to dry before inserting the catheter
Do not routinely apply antimicrobial ointment to the catheter placement site prior to insertion
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 3
Organization Insertion Site Preparation Site Care Pediatric Considerations
Epic 2: National Evidence-based Guidelines for Preventing Decontaminate the skin site with a single use An alcoholic chlorhexidine gluconate Healthcare- Associated Infections application of alcoholic chlorhexidine gluconate solution (preferably 2% chlorhexidine in NHS Hospitals in England solution (preferable 2% chlorhexidine gluconate gluconate in 70% isopropyl alcohol) in 70% isopropyl alcohol) prior to the insertion should be used to clean the catheter Journal of Hospital Infection (2007) of a central venous access device. insertion site during dressing changes, and 655 S1-S64 allowed to air dry.
(pg S41 – S42) Use a single patient use application of alcoholic An aqueous solution of chlorhexidine povidone-iodine solution for patients with a gluconate should be used if the history of chlorhexidine sensitivity. Allow the manufacturer’s recommendations prohibit antiseptic to dry before inserting the central use of alcohol with their product. venous access device.
Do not apply organic solvents, e.g., acetone, Individual single use sachets of antiseptic ether, to the skin before the insertion of a central solution or individual packages of single venous access device. use antiseptic impregnated swabs for wipes should be used to disinfect the insertion site.
Do not routinely apply antimicrobial ointment to No not apply antimicrobial ointment to the catheter placement site prior to insertion catheter insertion sites as part of routine catheter site care.
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 4
Organization Insertion Site Preparation Site Care Pediatric Considerations
Pedivan (2010)
Best Practice Guidelines in the See Pediatric Considerations See Pediatric Considerations Apply chlorhexidine preparation with Care and Maintenance of Pediatric a repeated back and forth / side to Central Venous Catheters. side motion with friction to obtain sufficient antisepsis; allow to dry Association for Vascular Access completely prior to applying dressing.
(pg 44) For patients with chlorhexidine allergy or sensitivity, consider use of povidone iodine.
When using povidone iodine, apply using concentric circles, beginning at the point of insertion, and moving outward or per hospital policy. Allow povidone iodine to dry completely (minimum of 2 minutes) prior to applying dressing.
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 5
Organization Insertion Site Preparation Site Care Pediatric Considerations
Registered Nurses Association of Antiseptics should remain on the insertion site The antiseptic solution must be compatible Ontario, Best Practice Guidelines. and be allowed to air dry before catheter with the catheter material. Acetone (2005) insertion. products should be avoided as they may cause irritation and affect the integrity of Care and Maintenance to Reduce the catheter; and alcohol-based solutions Vascular Access Complications are not recommended for certain devices.
(Pg 23) Antiseptics should remain on the insertion site and be allowed to air dry before dressing change.
The Society for Healthcare Use a chlorhexidine-based antiseptic for skin Perform site care with a chlorhexidine- Chlorhexidine products are not Epidemiology of America. preparation in patients older than 2 months of based antiseptic every 5-7 days. approved by the US Food and Drug age. Administration for children younger Strategies to Prevent Central Line– than 2 months of age; povidone- Associated Bloodstream Infections iodine can be used for children of this in Acute Care Hospitals. age group. Before catheter insertion, apply an alcoholic Infection Control and Hospital chlorhexidine solution containing a Epidemiology 2008; 29:S22–S30 concentration of chlorhexidine gluconate greater than 0.5% to the insertion site. (pg S24-S25)
The antiseptic solution must be allowed to dry before making the skin puncture.
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 6
Discussion:
Antimicrobial solutions should be used in accordance with manufacturers’ guidelines. Protocols for site preparation should be set out in organizational policies and procedures.
Prior to peripheral, midline, arterial, and peripherally inserted central catheter placement insertion, the intended site should be decontaminated with the appropriate antimicrobial solution using aseptic technique (RCN, 2010).
The most common skin antisepsis for site care used to decrease infection is chlorhexidine gluconate/alcohol combination solution. Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone- iodine. Chlorhexidine preparations have residual antibacterial activity of 48 to 72 hours (Pedivan, 2010). The product is currently not labeled for patients< 2 months of age, although there is evolving evidence of chlorhexidine safety and efficacy for all age groups (Pedivan, 2010).
The technique for skin preparation with chlorhexidine 2% in 70% isopropyl alcohol is as follows: Apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes) (SHN, 2007).
Nurses must be knowledgeable about the type of device in order to make appropriate care decisions around the skin antiseptic to be used during catheter care. Some antiseptic solutions may not be compatible with the catheter material and should be avoided.
March 2011 CVAA Clinical Resource Guide – Site Care and Maintenance (CVADs) 7
References:
Centers for Disease Control and Prevention (CDC) (2002). Guidelines for the prevention of intravascular catheter-related infections. Morbidity and Mortality Weekly Report (MMWR) 51 (RR-10), 1-29
Department of Health (DH) (2001). Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection, 47 (Supplement) S47-S67
Evidence-Based Practice in Infection Control (epic2). National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection (2007), 65S, S1-S64
Intravenous Nurses Society (2006). Infusion Nursing: Standards of Practice. Journal of Intravenous Nursing, 29 S1-S92
Pedivan (2010). Best Practice Guidelines in the Care and Maintenance of Pediatric Central Venous Catheters. Association for Vascular Access
Registered Nurses Association of Ontario (RNAO) (2008). Nursing Best Practice Guidelines: Care and maintenance to reduce vascular access complications. Review
Royal College of Nursing (RCN) (2010). Standards for infusion therapy. London: Author
Safer Healthcare Now (SHN) : Central Line Infections (2007) Safer Healthcare Now Campaign. How to Guide: Prevent Central Line Infections.
The Society for Healthcare Epidemiology of America (2008). . Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology, 29 S22–S30. Accessed September 2010 @ http://www.journals.uchicago.edu/doi/full/10.1086/591059.
March 2011