Modern Vascular Access: The Relationship Between Insertion...

Modern Vascular Access: The Relationship

Between Insertion and Maintenance

Jack LeDonne MD, VA-BC, FACS Medical Director Chesapeake Vascular Access Baltimore, Maryland

SPONSORED BY

Jack Le Donne MD, VA-BC, FACS

The Relationship between Insertion

and Care and Maintenance:

Is the Dressing Important?

Disclosures

• Eloquest Healthcare

• Ethicon (BioPatch)

• Teleflex

• SonoSite

Topics

• Philosophy of Practice

• Non-standard Access

• Care and Maintenance begins at the

Insertion

• What else can we do to prevent infections?

We have to make it easy to do the right

thing and hard to do the wrong thing.

- Faisal Masud MD

We have to do what is right for the

patient, not what is convenient for us.

- Mauro Pittiruti MD

change practice

Non Standard Access:

Emergency Dept

our challenge

The Problem

GrLatToV

BrIV:

Video 1

Little Princess, an unhappy human being:

Video 2

Is this the Era of

Evidence-based Medicine?

• Keystone Project, NEJM 2008, vol. 355 no. 26

• Timsit, CCM 2012, vol.40 no. 6

• SHEA Guidelines 2014

• CDC Guidelines 2011

Before 2007

isolated reports that some hospitals

had reduced CR-BSI to 0

generally regarded..

Top Gun: Video 3

May, 28 -29th, 2015

Hong Kong

What was the intervention?

How did Dr. Pronovost work this magic?

The Insertion Bundle

Hand Hygiene

Chlorhexidine Skin Antisepsis

Maximal Barrier Precautions Upon Insertion

Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for

Non-Tunneled Catheters

Implement the Central Line Bundle

Hand Hygiene

Chlorhexidine Skin Antisepsis

Maximal Barrier Precautions Upon Insertion

Daily Review of Line Necessity with Prompt

Removal of Unnecessary Lines

Avoid the Femoral Site

0 sec

30 sec

30 sec

30 sec

30 sec

How did we achieve such

incredible results by

focusing on 2 minutes?

1 Conclusion: Insertion practices

must have been pretty bad

See if you can spot the

deviation:

Video 4

What else can we do? (beside the bundle, national standard)

the lament of IC practitioner

We can insert the catheters properly

We can care for them properly

We can get out of our silos and work as a team

We can dress them properly

Trick-Le Donne Hypothesis

Marks the end of the Insertion phase and the

beginning of Care and Maintenance

30 min

6 days (8600 min)

30/8640 = 0.35% Insertion Phase:

How long does it take to place a CVC?

How long is a CVC in place?

The Dressing is Vital

Without denigrating the importance of a

clean insertion (1% of the life),

the main goal has to be placing the

device in a position for

proper care and maintenance (99%).

How Important is

the Dressing?

67% of dressing changes were performed before

the planned date because of soiling or undressing

The number of dressing disruptions was related

to increased risk for colonization of the skin

around the catheter at removal (p<.0001)

Results

• Dressing disruption was a common event in ICU

• More than 2 dressing disruptions was associated

with 3x increase in CR-BSI

• Final dressing disruption is associated with a 12x

colonization or infection rate

Conclusion: Disruption of catheter

dressings was common and was an

important risk factor for catheter-related

infections.

Subclavian access protected

from dressing disruption.

This study adds major arguments to include

dressing integrity in catheter bundles.

A new area in CR-BSI prevention should

be opened for the development, validation

and use of more adherent dressings.

not only common sense, but an important study…

Infusion Therapy Standards, 2016

VAD Assessment, Care & Dressing

Changes Standard: “Secure dressings to reduce the risk of

loosening/dislodgement, as more frequent dressing

changes are associated with increased risk for

infection; more than 2 dressing changes for disruption

were associated with a greater than 3-fold increase in

risk of infection.”

What can we do to ensure a proper dressing?

If the Dressing is so Important…

Lynchburg, VA

What are the components

of a good dressing?

(make it easy…)

• Easy to clean: not hubbed or sutured

• No skin incision: minimize bleeding

• Dressing Adhesive

• Flat surface

• Minimal motion

Flat Surface, Minimal Motion

30cm

So, where are we going to

place these CVCs?

No, No…

Video 5

What is my objection

to the IJ Vein?

IJ Dressings:

Video 6

Strategies to Prevent Central Line–Associated Bloodstream

Infections in Acute Care Hospitals:

2014 Update

Jonas Marschall, MD;1,2,a Leonard A. Mermel, DO, ScM;3,a Mohamad Fakih, MD, MPH;4

Lynn Hadaway, MEd, RN, BC, CRNI;5 Alexander Kallen, MD, MPH;6 Naomi P. O’Grady, MD;7

Ann Marie Pettis, RN, BSN, CIC;8 Mark E. Rupp, MD;9 Thomas Sandora, MD, MPH;10

Lisa L. Maragakis, MD, MPH;11 Deborah S. Yokoe, MD, MPH12

infection control and hospital epidemiology july 2014, vol. 35, no. 7

s h e a / i d s a p r a c t i c e recommendation

SHEA Guidelines 2014

s h e a / i d s a p r a c t i c e recommendation

1. Prolonged hospitalization before catheterization

2. Prolonged duration of catheterization

3. Heavy microbial colonization at the insertion site

4. Heavy microbial colonization of the catheter hub

5. Internal jugular catheterization

6. Femoral catheterization in adults

III. Independent risk factors for CLABSI (in at least 2 published

studies)20-25

10. Total parenteral nutrition

A. Factors associated with increased risk.

Not Flat, Motion,

Gravity (inexorable)

Open System

Extraluminal

Intraluminal

IJ, Gravity:

Video 7

LIJ Acute HD:

Video 8

1. Insert the CVC in the Proper Location

What does the CDC say

about

the choice of vein?

© 2011 Teleflex Incorporated. All rights reserved. 2011-0158 v1 53

• As read on page 11 and 27

Insertion Site Procedure -Subclavian Access

3. Use a subclavian site, rather than a jugular or a

femoral site, in adult patients to minimize infection

risk for nontunneled CVC placement [50-52].

Category 1B

7. Use ultrasound guidance to place central venous

catheters (if this technology is available) to

reduce the number of cannulation attempts and

mechanical complications. Ultrasound guidance

should only be used by those fully trained in its

techniques. [60-64]. Category 1B

3. Subclavian + 7. Ultrasound = Axillary Vein

Anatomy of the Human

Venous System…

Assessment PL:

Video 9

SCV

AXV

Braciocephalic

Approaching

AXV steeply

avoids

RAX (1:07):

Video 10

What are the components

of a good dressing?

(make it easy…)

• Flat surface

• Minimal motion

• No skin incision: minimize bleeding, barrier to

infection



Skin is the Barrier to

Infection

Jack LeDonne MD 2009

Many others

Do not Violate the Skin

with Incisions or Sutures

as much as possible

itty, bitty nick

Grand Canyon

Don’t Cut:

Dilate without Incision:

Video 11

What can we do to help the

dressing stay intact for 7 days?

• Flat surface

• Minimal motion




The Hubbing Monster

70

Video 12

How long is a 20cm

catheter?

1.5cm

Antimicrobial Cath

No Hubbing:

Video 13

Sutureless Securement

Securement SL:

Video 14

Subcutaneous Securement

Video 15

What is the life expectancy of the dressing?

7 Days

What can we do to help the

dressing stay on for 7 days?

(make it easy…)

• Flat surface

• Minimal motion




Dressing Adhesive:

Video 16

What is Mastisol?

A gum mastic water insoluble adhesive

Dries as a resin

Tackifier

• Non-Water Soluble: Can be used on

diaphoretic patients. Secures

dressings in moist areas.

• Non-Staining: Product will not stain

skin, bed sheet, or clothing

• Sterile Applicator: Can be used in

the sterile field

Mastisol® Liquid Adhesive

Mastisol® Liquid Adhesive

• Improved Patient Safety: Recent

data suggests that dressing

disruptions are a major risk factor for

catheter-related infections.*

Mastisol minimizes risk of infection

by reinforcing dressing barrier.

*Timsit J, et al. Dressing disruption is a major risk factor for catheter-

related infections. Crit Care Med. 2012; 40(6): 1707-1714.

• Effective Adhesive Remover: Easily

dissolves adhesive, reducing the amount

of pressure that must be applied to clean

residue off the skin

• Gentle Removal: Alcohol- and acetone-

free product that improves patient

comfort. Will not dry out the skin.

Detachol® Adhesive Remover

• Reduced Risk: Easy adhesive removal

helps reduce the chance of skin tears or

skin irritation

• Complete Removal: With Detachol,

adhesive residue in which bacteria can

breed, will not be left behind

• Sterile Applicator: Can be used in the

sterile field

Detachol® Adhesive Remover

Dressing Change

Video 17

Adversary:

Video 18

Summary: An Intact Dressing is a

Vital Component against CLABSI

• Insert the CVAD so it can be cared for properly

• Flat Surface, minimal motion (chest),

avoid the neck and groin

• Do not incise, hub the catheter or suture

• Antimicrobial catheters and dressings

• Apply Mastisol to help the dressing stay intact

Questions? • Type your questions into the Question Box, located at the lower left-hand

portion of your screen. Email us: [email protected]

Modern Vascular Access: The Relationship Between Insertion...

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