Course Access
Hi Phillipa,
a) PICC (and other CVAD) dressings, if a transparent semi-permeable
dressing is used, should be changed every 7 days or as required i.e
blood or moisture under dressing, poor skin adherence due to
diaphoresis, etc.
b) Antiseptic impregnated patch or sponge dressing should be
changed with the dressing or unless saturated with blood or fluid, based
on the manufacturers guidelines and evidence-based literature..
I would be looking at the current practice guidelines CDC, INS, AVA,
CNSA and ONS to support your practice, which should be evidence-based.
Here is the standards from INS (Infusion Nurses Society – USA 2011)
below.
Please feel free to contact me directly should you require further
information.
Tim..
46. VASCULAR ACCESS DEVICE SITE CARE AND DRESSING CHANGES
Standard
46.1 Vascular access device (VAD) site care and dressing
changes, including frequency of procedure and type
of antiseptic and dressing, shall be established in organizational
policies, procedures, and/or practice guidelines.
46.2 The nurse shall be competent in performing VAD
site care and dressing changes.
46.3 VAD site care and dressing changes shall be performed
at established intervals and immediately if the
dressing integrity becomes compromised, if moisture,
drainage, or blood is present, or if signs and symptoms
of site infection are present.
46.4 A sterile dressing shall be applied and maintained
on VADs.
Practice Criteria
A. Routine site care and dressing changes are not
performed on short peripheral catheters unless
the dressing is soiled or no longer intact.1 (V)
B. Central vascular access device (CVAD) site care
and dressing changes should include the following:
removal of the existing dressing, cleansing of
the catheter-skin junction with appropriate antiseptic
solution(s), replacement of the stabilization
device if used, and application of a sterile dressing
(see Standard 36, Vascular Access Device
Stabilization).2-4 (V)
C. Chlorhexidine solution is preferred for skin antisepsis
as part of VAD site care. One percent to two percent
tincture of iodine, iodophor (povidone-iodine),
and 70% alcohol may also be used. Chlorhexidine
is not recommended for infants under 2 months of
age.2,5-8 (I)
D. For infants under 2 months of age or pediatric
patients with compromised skin integrity, dried
povidone-iodine should be removed with normal
saline wipes or sterile water.9 (V)
E. CVAD site care frequency is based on the type of
dressing; transparent semipermeable (TSM) dressings
should be changed every 5-7 days, and gauze
dressings should be changed every 2 days. While
the evidence does not support one type of dressing
over another, gauze is preferable to TSM if the
patient is diaphoretic, or if the site is oozing or
bleeding. In the event of drainage, site tenderness,
other signs of infection, or loss of dressing integrity,
the dressing should be changed sooner, allowing
the opportunity to closely assess, cleanse, and
disinfect the site.2,3,8,10 (II)
F. Placement of a gauze dressing under a transparent
dressing should be considered a gauze dressing
and changed every 2 days. If gauze is used to
support the wings of a noncoring needle in an
implanted port and does not obscure the insertion
site, it is not considered a gauze dressing.3
(V)
G. The use of a chlorhexidine-impregnated dressing
with short-term CVADs should be considered in
patients older than 2 months of age as an additional
catheter-related bloodstream infection
(CR-BSI) prevention measure.2,11-13 (I)
H. With a well-healed tunneled CVAD, consideration
may be given to no dressing.14 (III)
I. The catheter-skin junction site should be visually
inspected or palpated daily for tenderness through
the intact dressing; for patients receiving outpatient
or home care, the patient should be instructed
to check the VAD site and dressing every day
for signs of infection and to report such changes or
dressing dislodgment immediately to the health
care provider.1,3 (V)
J. Gauze, bandages, or any dressing material that
may obstruct visualization of the catheter-skin
junction and/or constrict the extremity should not
be used (see Standard 38, Site Protection).1,4 (V)
K. The dressing should be labeled with the following
information: date, time, and initials of the nurse
performing the dressing change.1,3,4 (V)
L. Sterile gloves should be worn when performing
CVAD site care. The use of a mask during access
is often recommended; however, it remains an
unresolved issue due to lack of research.2,3,15,16
(IV)
REFERENCES
1. Perucca R. Peripheral venous access devices. In: Alexander M,
Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion
Saunders/Elsevier; 2010:456-479.
2. Marschall J, Mermel LA, Classen D, et al; Society for Hospital
Epidemiology. Strategies to Prevent CLABSI. Strategies to prevent
central line-associated bloodstream infections in acute care
hospitals. Infect Control Hosp Epidemiol. 2008;29 (suppl 1):
S22-S30.
3. Gorski L, Hunter M. Central venous access devices: care, maintenance
and potential complications. In: Alexander M, Corrigan A,
Gorski L, Hankins J, Perucca, R. eds. Infusion Nursing: An
Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;
2010:496-498.
4. Phillips, LD. Techniques for initiation and maintenance of
peripheral infusion therapy. In: Manual of I.V. Therapeutics:
Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia,
5. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine
compared with povidone-iodine solution for vascular catheter-site
care: meta-analysis. Ann Intern Med. 2002;136(11):792-801.
6. Hibbard JJ. Analysis comparing the antimicrobial activity and safety
of current antiseptic agents. J Infus Nurs. 2005;28(3):194-207.
7. National Kidney Foundation/Dialysis Outcomes Quality
Initiative. Clinical practice guidelines for vascular access: update
2000. Am J Kidney Dis. 2001;37(suppl 1):S137-S181.
8. Safdar N, Kluger DM, Maki DG. A review of risk factors for
catheter-related bloodstream infection caused by percutaneously
inserted, noncuffed central venous catheters: implications for
preventive
strategies. Medicine (Baltimore). 2002;81(6):466-479.
9. Doellman D, Pettit J, Catudal P, Buckner J, Burns D, Frey AM;
Association for Vascular Access. Best practice guidelines in the
care and maintenance of pediatric central venous catheters. 2010;
PEDIVAN.
10. Gilles D, O’Riordan L, Carr D, et al. Gauze and tape and transparent
polyurethane dressings for central venous catheters.
Cochrane Review. In: The Cochrane Library, Chichester, UK:
John Wiley & Sons; 2004.
11. Yong-Gang L, Hong-Lin D, Wang L. Chlorhexidine-impregnated
sponges and prevention of catheter-related infections. JAMA.
2009;302(4):379.
12. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to
prevent vascular and epidural catheter colonization and infection:
a meta-analysis. J Antimicrob Chemother. 2006;58:281-287.
13. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing
povidone-iodine to a chlorhexidine gluconate-impregnated
dressing for prevention of central venous catheter infections in
neonates. Pediatrics. 2001;107(6):1431-1436.
14. Olson K, Rennie RP, Hanson J, et al. Evaluation of a no-dressing
intervention for tunneled central catheter exit sites. J Infus Nurs.
2004;27(1):37-44.
15. Phillips, LD. Techniques for initiation and maintenance of central
venous access. In: Manual of I.V. Therapeutics: Evidence-Based
Practice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis;
2010:458-545.
16. Oncology Nursing Society (ONS). Access Device Guidelines:
Recommendations for Nursing Practice and Education. 2nd ed.
Pittsburgh, PA: ONS; 2004.
Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of
Medicine | University of NSW
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au
Behalf Of Parsons, Phillipa
Dear All,
Could people please advise on the management of PICC line dressings when
an antiseptic impregnated patch is used in regards to
a) frequency of PICC line dressings
b) antiseptic impregnated patches
We have two streams guiding our discussion and management of PICC lines
at the moment.
I am receiving arguments that the ‘exist site’ cannot be observed
properly with the patch insitu and the patch “always” requires changing
next day as blood soaked. The patch product use recommends changing if
blood stained.
Is anyone dealing with a similar issue and how have they managed this?
Regards
Phillipa Parsons
Infection Prevention and Control Clinical Coordinator
Cabrini Health
183 Wattletree Rd
Malvern Vic 3144
03 9508 1577
0400 369 741
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