1. Chapter 9 Preventing Infection Associated with Intravascular Therapy

2. INTRODUCTION Indispensible part of medical care
Used to administer fluids, blood products, nutritional support, and medications
Most patients admitted to hospital will have vascular access by either IV line or Saline/Heparin Lock
Critically ill patients will most likely have central lines
Management of IV devices has important incidence on bloodstream infections (BSI)

3. Bloodstream Infections
Blood stream is a sterile are
Microorganisms detected will always be an abnormal finding
Infections can start in a different place and then migrate to IV site and enter blood stream
If started at IV site considered a primary BSI
Risk of IV infection will depend on the patient, type of catheter, duration, how often manipulated

4. Bloodstream Infections
The critically ill are more vulnerable to BSI
Most common to have a BSI with a central vascular device
Even though peripheral lines are less likely to become infected the possibility is still there
Symptoms are systemic such ass fever, hypertension, chills and in children 1 year of age can have hypothermia, apnea, bradycardia
Once bacteria is in bloodstream it possible bacterial will lodge on other tissues and might cause endocarditis or osteomyelitis

5. Sepsis
Presence of severe infection can disrupt the immune system so severely can cause organ function to break down
Early signs might be non-specific; feeling unwell, altered mental state, difficulty breathing, low urine output and possibly fever, but could have hypothermia especially in the elderly; dangerously low blood pressure and increase serum lactate
The elderly, immunosuppressed, and cancer are most at risk
Bloodwork will include a variety of tests that will assess the organ functions such as liver panel, renal panel, platelets, arterial blood gases among others

6. Insertion Site Infection
Superficial infection may develop at the point of insertion will be looking for erythema or presence of pus
Phlebitis may develop in peripheral lines but not necessarily with central lines
Other signs and symptoms include swelling, tenderness, and able to palpate the vein
Risk of phlebitis maybe influenced due to the catheter material, and size, quality of insertion, length of time inserted
Usually phlebitis happens due to mechanical irritation or chemical irritation

7. Sources of Intravascular Device Infection
Two main routes of microorganisms gaining access to bloodstream
Migrating along the catheter from insertion site
Contamination of the device, hub from hands contaminated fluids, or hands
Bloodstream infections for short duration usually due to contamination at the insertion site; for long duration the catheter hub is usually the contamination point

8. Catheter Colonization
Bacteria associated with infections are usually one of the following
Staphylococcus aureus, Staphylococcus epidermidis, candida, pseudomonas among others

9. Diagnosis of Intravascular Device Infection
Bacteriaemia is diagnosed by culturing blood
Will 10 mL of blood inoculated in each culture bottle
One is anaerobic and the other is aerobic
Will usually need two cultures to be done one from the device and the other from a separate vein
If microorganism is cultured from both sites suggestions are made it is bloodstream infection

10. Types of Catheters
Peripheral Catheters associated with very few infections, but phlebitis is a greater risk if vein in hand is used
Peripheral arterial catheters used to measure arterial pressure and oxygenation and frequent manipulation increases risk of bloodstream infection
Central Vascular Catheters are inserted into subclavian, internal jugular, or femoral vein; usually used on patients in ICU or other critical care units

11. Types of Catheters
Pulmonary Arterial Catheters (Swan-Ganz)-balloon tipped catheters are inserted over the heart valves and used to manage critically ill patients whose hemodynamics are unstable
The trauma they cause to the valves and endocardium increase the risk of endocarditis
Risk is low but increases significantly with duration of catherization

12. Types of Catheters
Pressure monitoring systems-used to assess pressure monitoring within arteries
Hickman, Porta-Cath, or Broviac-used when prolonged venous access for more than 30 days is required like patients receiving chemotherapy. Inserted into subclavian vein can be tunneled under the skin or implanted totally under the skin and accessed by using special needles

13. Types of Catheters
Peripherally Inserted Central Vascular Catheters (PICC)-used for medium to long term access especially for outpatient treatment; does not require a surgical procedure. Can be associated with phlebitis, lesser than peripheral catheters

14. Duration of Catherization
Length of time influences the risk of infection because more opportunities exist for possible contamination each time device is handled and chances of being able to become colonized over time.

15. Insertion of Catheter
Technique should be done using aseptic technique because contamination can come from the patient’s site of even the hands of the person inserting the catheter
Considered an open wound and should use high standards when a central vascular catheter is being inserted
IV catheter should be securely anchored to prevent movement of device; tape used directly contacting insertion site should be sterile

16. Skin preparation
Chlorhexidine has shown to be more effective for cleaning the insertion site
Cleaning material should be applied 30 seconds and should be allowed to completely dry before insertion
Shaving can cause microabrasions and should be avoided if possible
Area should be cleaned from center outward about 2 inches or as per protocol

17. Care of the Insertion Site
Controversy has existed over this particular issue. The site should be visible to inspect site and be able to assess for possible signs of infection or phlebitis
Semipermeable transparent dressings are preferred and needs to be sterile; dressings should be changed every 7 days or if moisture collects underneath the dressing or if they become loose, but to ensure following procedures should follow facility policies

18. Care of the Insertion Site
When cleaning the site should use 2% chlorhexidine in alcohol each time dressing is changed
Inspect the site according to facility policies or at least once per shift for signs of infection or phlebitis

19. Management of Catheters and Fluid Administration Sets
Aseptic management of the catheter hub, connection ports, and administration sets is essential to prevent contamination of the system
Cleaning ports or hubs with alcohol based solution to decrease microbial contamination; ports should be cleaned at least 15 seconds prior to use and after use
Fluids and administration sets have been known to become contaminated
Hand hygiene is imperative when handling IV lines of any kind
Tubing is changed as per facility policies