Table 17.6 Example of central venous catheter CVC maintenance bundle
Care practice Bundle recommendations
Hand hygiene Hand hygiene performed before and after CVC insertion, care, and catheter entry or
after contact with any inanimate object; use clean gloves for all CVC access as needed; glove use does not preclude use of hand hygiene
Surface disinfection Clean work surfaces with germicidal wipe prior to CVC care
Use of maintenance kitsCVC cart
Procedure kitscarts containing supplies help to ensure all required supplies are available at the time of the procedure, including those required for insertion, dressing
change and CVC removal Insertion
Bundle recommendations Hand hygiene
Hand hygiene is followed by waterless surgical scrub application Maximal sterile barrier
precautions Patient is covered from head to toe with sterile drapes; mask, cap, sterile gown and
sterile gloves during insertion procedure; all staff including the assistant and family members to wear regular face mask and cap when within 3 ft of sterile fi eld
Skin antisepsis Skin disinfected with chlorhexidine gluconate; apply back and forth friction scrub
for 30 s and allow to dry completely for 30 s 2 min scrub for wet sites, such as the groin; site must be dry before skin puncture
Universal protocol utilized Staff observers are skilled in monitoring elements of sterile technique; staff
empowered to stop non-emergent procedure if sterile technique not followed Assessment
Bundle recommendations Ongoing assessment of
catheter site Inspect catheter site for cleanliness and dressing integrity; assess CVC site for
complications hourly when infusing solutions and every 4 h when locked Daily assessment of need for
CVC Discuss ongoing need for CVCs daily with medical team during rounds; assess
patient for appropriateness of their vascular access device based on infusateslength of therapy and available vessels; promptly remove unnecessary CVCs
Catheter site caremanagement Bundle recommendations Skin antisepsis
Use clean gloves for all CVC access; maintain clean disposable towel or 4 × 4 gauze under CVC access port before accessing; skin disinfected with chlorhexidine
gluconate; apply back and forth friction scrub for 30 s and allow to dry for 30 s 2 min scrub for wet sites, such as the groin
CVC dressing assessment and change
Routine dressing changes performed by clinicians with demonstrated competency; use of catheter securement device with PICC dressing changes; mask and sterile
gloves for dressing changes; dressing change frequency: transparent dressing, every 7 days and as needed for soiled dressing or loss of integrity; gauze and non-
occlusive dressing, every 48 h and as needed
Antisepsis of needleless connectors, IV junctions and
catheter hub Vigorously scrub needleless connectors, IV junctions and hub diaphragm and
sides prior to accessing with an alcohol swab using friction for a minimum of 15 s CRBSI criteria
Bundle recommendations Blood culture sampling
Consider DTP protocol when drawing blood cultures with signifi cant time differential of CVC culture versus peripheral culture positivity of 2 h; generally
peripheral blood cultures are not drawn on oncology patients who have central lines see Chap.
1 Administrative
Bundle recommendations Education
Education of clinicians responsible for managing CVCs to include: care and maintenance strategies, identifi cation and management of complications
Routine surveillance of CVCs Collect and benchmark outcome data with the National Healthcare Safety Network PICC
peripherally inserted central catheter, IV
intravenous, CRBSI
catheter-related bloodstream infection, DTP differential time to positivity
Adapted from Mermel 2000
, Marschall et al. 2008
, Horan et al. 2011
17.7.5.2 Antiseptic Needleless Connectors and Antiseptic
Port Barrier Caps Contamination of the CVC hub is the main
source of CLABSI 10 days after insertion. Novel products are now available to decrease
the incidence of this complication. Three such devices are currently marketed.
V-link with VitaShield
protective coating Baxter is a needleless connector with an antimicrobial
coating silver on the interior and exterior sur- face. Curos® port protector is a barrier cap with
a sponge saturated with 70 isopropyl alcohol IPA. Disinfection occurs 3 min after being
threaded onto the connector. The cap may be left in place up to 7 days protecting the connec-
tor from airborne and contact contamination. Caps should be placed on all needleless injec-
tion sites and changed after each access. Saralex-CL Menyhay is an antimicrobial bar-
rier cap that threads onto the needless connector bathing the connector in 2 chlorhexidine glu-
conate in 70 IPA. Disinfection occurs in 5 min and may be left in place up to 96 h. The
cap protects the connector from airborne and contact contamination. A new cap is applied
after each access.
A prospective simulation study by Menyhay and Maki
2006 evaluated the effi cacy of cleans-
ing a CVC hub with 70 alcohol compared to the use of a Saralex barrier cap. One hundred
fi ve needleless connectors from three manufac- turers were tested. The septum of each device
was contaminated with
Enterococcus faecalis and allowed to dry for 24 h. A control group of
15 connectors were not disinfected, 30 were cleansed with a 70 alcohol swab and 60 had a
Saralex barrier cap applied and removed after 10 min. Nutrient broth was injected through each
connector, collected and cultured. Cultures from all control connectors were positive. Twenty
connectors 67 with conventional disinfec- tion with 70 alcohol were culture positive,
whereas only 1 1.6 of the connectors disin- fected with use of the Saralex cap was culture
positive. Further study through randomized trials is needed to determine if practice changes are
indicated.
17.8 Summary
CVCs are a central component in the care of pediatric oncology patients and allow for safe
and effective administration of chemotherapeutic agents in addition to antibiotics, blood products,
parenteral nutrition and multiple additional medi- cations. Blood can be easily drawn from exter-
nally tunneled CVCs and in accessed implanted ports. Infection and thrombosis are the most
common risk factors with CVC placement, and practitioners must be aware of the clinical signs
and symptoms associated with these complica- tions, methods to prevent these side effects, and
treatment of these problems. Generally, practice and management are based on consensus guide-
lines and expert opinion as robust evidence is lacking, especially in pediatric patients.
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