1 18 th AVA Conference, Vancouver, Sept 19, 2004 AVA TRANSPARENT POLYURETHANE IV CATHETER DRESSING WORKSHOP Dennis G. Maki, MD Section of Infectious Diseases Department of Medicine Center for Trauma and Life Support University of Wisconsin [email protected]SHORT-TERM INTRAVASCULAR DEVICES • Defined: usually used <10 days • Types: – Peripheral IV catheters – Arterial catheters for hemodynamic monitoring – Noncuffed and nontunnelled CVCs • Multilumen CVCs • PA Swan-Ganz catheters • Dual-lumen hemodialysis catheters
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AVA 2004 PU Dressing Workshop Sept 19, 2004 MOD testMULTIVARIATE ANALYSIS Anti-infective catheter surface 9. 0.2 - 0.6 Tunneled short-term ICU CVC 3 0.4 - 15.1 Systemic antimicrobial
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18th AVA Conference, Vancouver, Sept 19, 2004AVA TRANSPARENT
0.2 - 0.33Cutaneous antisepticChlorhexidine vs Povidone-Iodine
1.6 - 9.07Guidewire exchange
2.7 - 4.37Access: IJ > Subclavian
5.5 - 13.25Heavy colonization (>103CFU) of insertion site
Risk RatioNo. StudiesFactor
Safdar N and Maki DG, Medicine (2002)
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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MICROBIAL PROFILE OF IVD-RELATED BSI Meta-analysis of 159 Studies
Hickmans, ports, PICCs, cuffed HD CVCs
% of Total
3501325865Long-term CVCs:
PIVCs, non-cuffed CVCs, Art lines
11152640592Short-term, percutaneous:
Yeasts
GNRs
S. aureus
CNSNo. IVD-Related
BSIs
Kluger DM and Maki DG (2000)
LINE SEPSIS IN 2004Prevention
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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Trends in BSI rates*, by ICU type and year –NNIS, U.S. 1990-1999
CDC-NNIS. MMWR 49:149-53 (2000).*Per 1000 days a central line was used.
2002 HICPAC GUIDELINE FOR PREVENTION OF INTRAVASCULAR DEVICE-RELATED INFECTIONS
GENERALHCW education IASurveillance: hospital rates; patients IA
INSERTIONGloves for all handling of the device IBSpecial IV Teams desirable IASterile gloves, gowns, drapes for CVCs IAAlcohol, Pov-I2 , Tincture I2 or Tinct Chlorhex IASterile gauze or polyurethane dressings IACVCs: Subclavian preferred to IJ IANo prophylactic antibiotics IA
Use of anti -infective-coated CVC, if high rate IVD BSI IAUse of anti -infective lock solution for permanent IVDs, if recurrent IVD BSIs IB
Remove device ASAP IAFOLLOW-UP CARE
Daily surveillance of patient, site IBReplacement of catheters
PIVCs every 48- 72 hrs IAArterial catheters > 7d IBNoncuffed CVCs: NOT routinely IB
Guidewire exchangesNo evidence infection: OK IBDocumented infection: avoid IA
Compound admixtures in central pharmacy IB
Infect Control Hosp Epidemiol, Am J Infect Control, Crit Care Med (2002)
IB. Strongly recommended,…moderate supportive data
IC. Required by State or Federal regulations
II. Suggested for implementation,…theoretical rationale…
Unresolved Issue. No recommendation
us344425
This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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2002 HICPAC GUIDELINE FOR PREVENTION OF INTRAVASCULAR DEVICE-RELATED INFECTIONSGENERAL
HCW education IASurveillance: hospital rates; patients IA
INSERTIONGloves for all handling of the device IBSpecial IV Teams desirable IASterile gloves, gowns, drapes for CVCs IAAlcohol, Pov-I2 , Tincture I2 or Tinct Chlorhex IA
Sterile gauze or polyurethane dressings IACVCs: Subclavian preferred to IJ IANo prophylactic antibiotics IAUse of anti -infective-coated CVC, if high rate IVD BSI IAUse of anti -infective lock solution for permanent IVDs, if recurrent IVD BSIs IB
Remove device ASAP IAFOLLOW-UP CARE
Daily surveillance of patient, site IBReplacement of catheters
PIVCs every 48- 72 hrs IAArterial catheters > 7d IBNoncuffed CVCs: NOT routinely IB
Guidewire exchangesNo evidence infection: OK IBDocumented infection: avoid IA
Compound admixtures in central pharmacy IB
Infect Control Hosp Epidemiol, Am J Infect Control, Crit Care Med (2002)
us344425
This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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Why Would We Switch From Gauze to a Transparent Film Dressing?
1. See the site at all times
2. More comfortable for most patients3. Not going to saturate the site for
washing/showering4. May help immobilize the device more
effectively than a gauze dressing
Components of Transparent Dressings
PolyurethaneFilm
HypoallergenicAdhesive
50 um {
Are Transparent Dressings Permeable or Occlusive?
• Are commercial Polyurethane dressings Semi -permeable or Occlusive?
• Amount of moisture vapor which passes through a membrane in a given time period
• Measured under controlled conditions
• Not a single value – dependent on test method and conditions of test
• No ideal MVTR has been identified
Occlusive PorousSemi-Permeable
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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Weighing the Test Beaker
Beakers in the Oven
Final Weighing of the Test Beaker
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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Direct Evaporimetery
What Does This Mean in the Clinical Setting?
• Studies have shown no material differences between various MVTR numbers and skin colonization under the dressing, IV catheter colonization or, especially, CRBSI.
What Do The Clinical Outcome Studies
of Polyurethane Dressings on IV Catheter Insertion Sites—
the Prospective Randomized Trials—Show?
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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EPISODES OF LOCAL CATHETER-RELATED INFECTIONS AND CATHETER-RELATED SEPSIS
IN 115 PATIENTS RECEIVINGDRY GAUZE OR TRANSPARENT DRESSING
.0150/347/42 (16.6)Catheter -related sepsis
.0028/34 (24)26/42 (62)Local catheter related
PGauzeTransparentInfection
No. of infected patients/no. who
received dressing (%)
Conly, et al. J Infect Dis (1989)
PROSPECTIVE RANDOMIZED TRIAL OF POLYURETHANE VS GAUZE DRESSINGS ON PERIPHERAL IV CATHETERS
Dressing Regimen
2.55+1.412.85+2.091.83+0.492.41+1.5Mean log CFUs + SD on infected catheters
Weighted RR 1.06 CI95 0.59 – 1.90 P = 0.85Maki et al., SHEA (1997)
“Super-permeable” IV Dressings
• There are no data to support claims/inferences that higher MVTR numbers, vis-a-vis, “super-permeable dressings” correlate to:– Significantly less bacterial colonization on the skin
beneath the dressing
– A significantly lower incidence of catheter colonization
– A reduced incidence of CRBSI
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This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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PROSPECTIVE RANDOMIZED STUDY OF TWO POLYURETHANE DRESSINGS FOR PA CATHETERS
PROSPECTIVE MULTCENTER TRIAL OF A HYPERPERMEABLE POLYURETHANE DRESSING
1Candida species
1Gram-negative bacilli21Staphylococcus aureus
33Coagulase-neg staphylococciBSI organisms:
0.765 (2.5%)6 (3.1%)CVC-related BSI
.1331 (15.2%)19 (10.0%)>103 cfu
.0346 (22.5%)26 (13.6%)Sonication >102 cfu
.00667 (32.8%)39 (20.4%)SQ > 15 cfuColonized CVCs
204191No. catheters studied
P-ValueTegaderm™
HPGauze
Maki, Mermel, and Martin, ICAAC (1995)
2002 HICPAC GUIDELINE FOR PREVENTION OF INTRAVASCULAR DEVICE-RELATED INFECTIONSGENERAL
HCW education IASurveillance: hospital rates; patients IA
INSERTIONGloves for all handling of the device IBSpecial IV Teams desirable IASterile gloves, gowns, drapes for CVCs IAAlcohol, Pov-I2 , Tincture I2 or Tinct Chlorhex IA
Sterile gauze or polyurethane dressings IACVCs: Subclavian preferred to IJ IANo prophylactic antibiotics IAUse of anti -infective-coated CVC, if high rate IVD BSI IAUse of anti -infective lock solution for permanent IVDs, if recurrent IVD BSIs IB
Remove device ASAP IAFOLLOW-UP CARE
Daily surveillance of patient, site IBReplacement of catheters
PIVCs every 48- 72 hrs IAArterial catheters > 7d IBNoncuffed CVCs: NOT routinely IB
Guidewire exchangesNo evidence infection: OK IBDocumented infection: avoid IA
Compound admixtures in central pharmacy IB
Infect Control Hosp Epidemiol, Am J Infect Control, Crit Care Med (2002)
us344425
This material is being provided as educational support of the Dr. Maki program sponsored by 3M and is not to be used for other purposes.
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Places Where Dr. Maki Does Not Use a Transparent Dressing