Nancy  L.  Moureau,  BSN,  RN,  CRNI,  CPUI,  VA-­‐BC                          PICC  Excellence,  Inc.  

Hartwell,  GA  USA  

Disclosure  

•  Nancy  Moureau  

•  No  conflict  with  this  topic    •  Clinician  at  Greenville  Memorial  Hospital  prn  PICC/IV  Team,  

30  years  of  vascular  access  experience  

•  Owner  of  PICC  Excellence,  Inc,  vascular  access  educaGonal  company  18  years  

•  EducaGonal  provider,  speaker  and  consultant  with  Teleflex,  Cook,  3M,  Excelsior,  Angiodynamics,  STI,  Access  ScienGfic,  Genentech  

•  Legal  consultant    

ObjecFves  

•  IdenGfy  factors  that  increase  risk  of  central  venous  catheter  infecGon  in  relaGon  to  exit  site  

•  Evaluate  preventaGve  measures  and  how  they  apply  to  the  central  line  bundle  and  site  selecGon  

•  List  two  ideal  exit  site  locaGons  according  to  stability,  lowest  moisture/hair  and  beQer  dressing  adherence  

IntroducFon  

•  InfecGon  is  the  #1  most  serious  complicaGon  for  any  vascular  access  device  

•  Recent  efforts  worldwide  have  focused  on  prevenGon  and  applicaGon  of  the  central  line  bundle  to  reduce  CVC  infecGons  

Central  Line  Bundle  PracFces  

•  Hand  Hygiene  •  Site  SelecGon  •  Chlorhexidine  disinfecGon  of  skin  • Maximum  barriers  during  inserGon  

•  Prompt  removal  of  catheter  with  compleGon  of  therapy  

CDC, 2011 www.IHI.org Berenholtz, Crit Care 2004 Pronovost, NEJM 2006

Site  SelecFon  Emphasis  •  Primary  message:  

– Avoid  femoral  

– Use  subclavian  over  internal  jugular  –  Is  it  the  vein  or  the  locaGon?  – Which  has  lowest  risk?  Risk  on  inserGon  or  risk  of  infecGon???  

•  Lack  of  substanGal  evidence  to  be  definiGve  for  one  specific  vein  or  veins  as  best;  too  many  variables   Merrer, et al, JAMA 2001

Ruesch, et al Crit Care 2002 Parienti, et al JAMA 2008

Pathophysiology  and  Risk  Factors  for  InfecFon    

ColonizaGon  of  a  central  venous  catheter  arises  from:  

–  ContaminaGon  -­‐  Failure  to  maintain  asepGc  technique  during  inserGon  or  access  

–  Skin  flora  -­‐  Inadequate  skin  disinfecGon  for  inserGon  and  weekly  dressing  management  

–  ManipulaGon  or  poor  securement  of  a  catheter  causing  movement  in/out  

–  Poor  dressing  management,  non-­‐adhesive  dressing,  moisture  and  hair  

–  Bacterial  growth  -­‐  Needleless  connectors/ports  that  harbor  bacteria;  poor  disinfecGng.  Residual  blood  in  catheter  or  tubing;  poor  flushing/clearing  

–  Factors  that  contribute  to  thrombosis  development  and  subsequent  infecGon  

Commonly  Used  (non  tunneled)  Central  Venous  Catheter  Exit  Sites  

–  Exit  site  in  the  antecubital  area    •  Blind  approach  to  PICCs  (w/o  

US)  

–  Exit  site  in  the  upper  mid  arm  (above  the  elbow)    •  US  guided  PICCs  (Dawson,  

2011)  

–  Exit  site  at  mid  neck  •  Blind  approach  to  internal/

external  jugular  vein  •  US  guide  approach  to  IJ  

–  Exit  site  at  base  of  neck  •  US  guide  approach  to  IJ,  

bracheocephalic  

–  Exit  site  in  the  supraclavicular  area  •  Blind  approach  to  IJ  (‘lateral’)  

or  subclavian  vein  •  US  guided  approach  to  IJ,  EJ,  

subclavian  or  brachiocephalic    

–  Exit  site  in  the  infraclavicular  area  •  Blind  approach  to  subclavian  

vein  

–  US  guided  approach  to  cephalic  vein  or  axillary  vein  

–  Exit  site  in  the  groin  •  Blind  or  US  guided  approach  

to  the  femoral  vein  or  saphenous  vein  

Exit  Site  OpFons  #4 Thorax 1X105

#3 Abdomen 5X104

#2 Thigh 4X104

Groin 2X106

#1 ARM 1X102

Axilla 5X106

Head/Scalp 1X106

Ryder, AVA 2011, SHEA 2011

Bacterial  DistribuFon  on  Skin  •  Number  of  bacterial  

cells  on  skin  averages  between  102-­‐108  mulG-­‐layers  deep  

•  Bacterial  density  on  skin  varies  from  100  colonies/cm2  on  dry  surface,  to  100%  increase  in  moist  areas  

•  Lower  colonizaGon  –  Dry  –  Cooler  than  core  –  Flat,  stable  –  Minimal  hair  

Grice, Science 2009 Ruocco, Derm Clin 2007 Li, Hulying, Metagenomics 2011

•  Higher  colonizaGon  –  Moist,  humid  –  Unable  to  

maintain  adherence  of  dressing  

–  Hair  follicles  –  Sebaceous  glands  

When catheters are contaminated

Exit  Site  Risk  •  Local  infecGon  and  CRBSI  are  related  to  

risk  of  contaminaGon  at  the  exit  site  –  Increased  risk  -­‐  Moisture,  warmer  areas  

of  body,  hair  distribuFon,  failure  of  dressing  to  adhere  

–  Very  high  risk  -­‐  exit  site  at  groin  (moisture+hair+warm)  

–  RelaFvely  high  risk  -­‐  exit  site  in  the  neck/chest  area  (moisture+hair;  close  to  oral/nasal/tracheal  secreGons).            Higher  on  neck  =  higher  risk  (more  hair)  

–  Low  risk  -­‐  exit  site  at  base  of  neck,  on  chest  (dry,  stable),  at  mid  upper  arm  (dry,  stable)  

Garnacho-Montero, Int Care Med 2008 Goetz, Inf Cont Hosp Epid 1998

Exit  Site  Risk  

•  Other  non-­‐infecGve  complicaGons  (thrombophlebiGs,  venous  thrombosis,  dislodgement,  etc)    

–  Related  to  stability  of  catheter,  terminal  Gp  posiGon,  vein  vs  catheter  size    

–  ProblemaGc  securement/dressing  -­‐  exit  site  at  mid  neck  or  higher  

–  Ideal  securement/dressing  maintains  adherence  and  limits  movement  -­‐  exit  site  at  upper  mid-­‐arm  or  in  the  infraclavicular  area/base  of  neck  

Best  PosiFon  on  Arm/Thigh/Abdomen/Chest  

•  Flat  posiGon  •  Low  moisture  

•  Good  dressing  adherence  

• Minimal  hair  

Effect  of  Dressing  Adherence  •  Avoid  

– Moisture  and  areas  with  hair,  consider  tunneling  

–  Ideal  locaGon  on  chest  even  with  IJ,  turn  it  down  onto  chest  

Issues  with  Femoral/Inguinal  Site  •  Moisture  •  Hair  •  Highest  temperature  

•  Difficulty  with  dressing  

•  Consider  tunneling  to  move  exit  locaGon  to  increase  stability,  reduce  moisture  

Merrer, et al, JAMA 2001 Goetz, Inf Cont Hosp Epid 1998 Marschall, Inf Cont Hosp Epid 2008

PICC  Upper  Arm  vs  Antecubital  •  Upper  arm  best  locaGon  

–  Stable  and  flat,  without  joint  movement  

–  Dry,  less  hair  –  Larger  vein  diameter  –  If  inserGon  close  to  axillary  moisture  area  consider  tunneling  

–  Using  ultrasound  with  upper  arm  placement  reduces  complicaGons  and  infecGon  

Dawson, JAVA 2011 Doellman, JAVA 2009 Falkowski, Nursing 2006 Hockley, Crit Care Res 2007 Nichols, JIN 2008 Royer, JIN 2001 Simcock, JAVA 2008

Internal  Jugular  with  Chest  Dressing  

•  InserGon  at  base  of  neck  –  Stable  and  flat,  without  movement  

– Drier,  less  hair  – Ultrasound  reduces  inserGonal  risk  

Axillary  Access  as  OpFon  

•  InserGon  into  axillary  –  Stable  and  flat,  without  movement  

– Drier,  less  hair  –  Less  inserGon  risk  away  from  pleura  

– Ultrasound  reduces  inserGonal  risk  

Risk  ReducFon  Strategies  

•  Apply  all  5  steps  of  central  line  bundle  •  Consider  use  of  anGmicrobial  catheter  and  sponge  dressing,  both  proven  to  reduce  infecGon  

•  Choose  vein  and  exit  site  independently,  relate  to  risk  •  When  moisture/humidity  are  present  at  site  of  vein  access  consider  tunnel  or  alternate  site:    –  Axillary  –  Upper  arm    

–  Tunnel  catheter  •  Focus  on  securement  and  dressing  adherence  

Timsit, 2009 CDC, 2011 Ruschulte, 2008 Maki, 2008 Maki, 2000 HTA UK Assessment, 2008

Clinical  ImplicaFons  

•  Evaluate  central  venous  catheters  with  all  opGons  of  exit  site  using  ultrasound  for  placement    

•  Consider  zones  or  areas  with  least  risk  of  infecGon  based  on  evidence  

•  Understand  complicaGons  are  directly  correlated  with  exit  site  related  to  moisture,  temperature  and  dressing  adherence  

•  Establish  new  terminology  and  classificaGon  of  CVCs  with  focus  on  exit  site  and  risk  reducGon  

Future  Study  ConsideraFons  

•  Compare  ultrasound  guided  PICC/Axillary/Infra  and  Supraclavicular  venous  access  device  with  specific  area  of  inserGon/exit  on  skin.  Evaluate  risk  for  inserGon  and  post  inserGon  complicaGons  

•  Evaluate  infecGon  rates  for  non-­‐tunneled  catheter  according  to  precise  area  of  exit  site  

•  Study  each  catheter/vein  complicaGon  rate  based  on  exit  site  (Dawson,  2011)  

THANK  YOU!!  

Speaker  Contact  InformaGon:  Nancy  Moureau  Email:  nancy@piccexcellence.com  Website  informaGon:  www.piccexcellence.com  

QUESTIONS?