Course Access
Tony,
The papers and discussion in the articles below may help you work your way through the issues relating to some of these valves (negative- or positive-pressure or displacement mechanical valve needleless connectors). To comment further I would need to know which valve you are using.
Problems can include the following; stagnant fluid in the bung chamber(not always visible as the chambers are not always transparent), some bungs with concertina valves which fit snugly over the internal channel in the bung chamber are not sealed and this may result in communication between the stagnant fluid in the bung chamber with the fluid in the infusion channel when the hydrostatic pressure in the system is increased, accumulation of fluid(wet) on the bung surface after accessing a bung(after removal of the syringe), risk of user contamination when accessing the bung(some bung surfaces are smooth and the syringe tip can slip off the surface when trying to access), some bungs surfaces cannot be adequately disinfected before accessing and finally poor technique.
Stagnant fluid in a dead space of any component of an intravascular device is vulnerable to contamination either during manipulation or when accessing the system with a syringe. Best to aseptically change the bungs on a regular basis to reduce the risk of microbial growth as microorganisms can migrate along a stagnant fluid pathway.
A case I followed up in the past was a transplant patient who represented to hospital with Chryseobacterium sepsis. On investigation the patient had a multilumen hickmans catheter insitu. The patient had repeated positive BCs and was noted to spike a fever following flushing or accessing the lines. When I spoke with the patient about how the line was being managed at home it was established that the patient had not received the instruction to change the bungs and they had remained in situ since discharge(3-4 weeks). The patient had also been showering but was covering the Hickman and lines as instructed. All bungs were removed and cultured and all grew Chryseobacterium. Assume the bungs had become contaminated during showering as it is difficult to keep something covered and dry on the chest wall during showering.
Jarvis et al. Health CareAssociated Bloodstream Infections Associated with Negative- or Positive-Pressure or Displacement Mechanical Valve Needleless Connectors
Clin Infect Dis. (2009) 49 (12): 1821-1827.
http://cid.oxfordjournals.org/content/49/12/1821.abstract
Menyhay SZ, Maki DG. Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier cap. Infect Control Hosp Epidemiol 2006; 27:238.
Happy to discuss further off line if needed.
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426
—–Original Message—–
[Cross-posted from OzBug with permission on behalf of Tony Allworth – Moderator. I will copy any list replies to him.
NB I tried posting this a few days ago but it seems not to have been emailed?]
A question has been raised that I would appreciated consolidated opinion on (I expect total consensus as usual): We have traditionally left the positive displacement valves (“bungs”) on PICCs from the time they go in unless there is obvious blood build-up or other contamination. The basis of this is to maintain a closed system to minimise infection. It has been pointed out that the positive displacement valves according to the manufacturer should be changed either after a certain number of accesses or time frame eg 3 days. When asked for the rationale for this no answer has been forthcoming. I can find no help in the literature. I am concerned that changing them “routinely” will compromise the microbial integrity of the system.
What do others do, and think we should be advising?
Cheers,
Tony Allworth
Dr Tony Allworth
Director, Infectious Diseases
Royal Brisbane & Women’s Hospital
(No vested interest in PICCs or bungs)
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