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464 PA R T III / Assessment of Heart Disease

Table 21-1 ■ CR-BSI CONTROL
Steps Comments
Skin antisepsis • Skin antisepsis with a 2% chlorhexidene preparation is superior to 10% povidone–iodine or 70% alcohol in preventing
catheter colonization 27
Insertion technique • Central venous catheter: maximum sterile technique for insertion (cap, mask, sterile gloves, sterile gown, large sterile
drapes)
• Arterial line (not specifically addressed): technique similar to short-term central venous catheter
Hand hygiene • Perform hand hygiene before and after manipulating catheters/catheter site
• Use of gloves does not obviate the need for good hand washing
Location of insertion site • Higher BSI rates associated with internal jugular or femoral vain insertion site compared to subclavian vein insertion site;
avoid lower extremity if possible
• Higher contamination and BSI incidence with femoral artery insertion site compared with radial artery insertion
site 28–30
• Increased BSI with reinsertion over a guidewire at old insertion site
Antimicrobial catheters • Antibiotic-impregnated catheters (minocyclin/rifampicin) decrease the risk of CR-BSIs compared with standard catheters
and chlorhexidene/silver sulfadiazine catheters 31–34
• Catheters coated with chlorhexidene/silver sulfadiazine and heparin bonding may decrease the risk of CR-BSI 31,40–42
• Consider use of antimicrobial catheters if catheter is to remain in place 5 days and current hospital BSI rate exceeds
2% 35 or NNIS standards
Catheter sleeve (PA catheter) • Use sterile sleeve during PA catheter insertion
Frequency of catheter change • Routine catheter replacement is not recommended 36
• Change PA catheters no more frequently than every 7 days 37
• Arterial line (manage similar to short-term central venous catheters)—no specific CDC recommendations for catheters
that need to be in place 5 days.
• Risk for colonization increases wither greater than 4 days in situ; 28,29 however, there are no studies suggesting a need for
routine catheter replacement for infection control prevention
• Evaluate daily the patients need for central and arterial catheters
Dressing • Use sterile gauze or sterile, transparent semipermeable membrane dressing
• Change gauze dressing every 2 days and transparent dressing at least every 7 days, when the dressing becomes, damp,
loose, or soiled or for site inspection
Flush solution • Do not administer dextrose-containing solutions through the pressure monitoring system
Administration set • Continuous-flush device
• Replace pressure transducers and all tubing and flush solution every 96 hours
Obtaining cultures from central • Drawing cultures from only one lumen of a multilumen catheter has a 60% chance of detecting significant colonization.
venous and arterial catheters If only one lumen is sampled a negative culture does not necessarily rule out the CVC as a source of infection. 38 Coloniza-
tion of the medial lumen is an independent risk factor for CR-BSI 39
• Cultures obtained through a central venous or arterial catheter have a lower positive predictive value and similar or better
negative predictive values compared with peripheral cultures, which indicates that additional cases of bacteremia may be
identified from the catheter culture in addition to peripheral cultures 40,41

CDC, Centers for Disease Control and Prevention; NNIS, National Nosocomial Infections Surveillance System

62
Blood Drawing From Arterial and time [ACT]) drawn from heparin-bonded PA catheters, and the
Central Venous Catheters introducer side-port when the PA catheter is present 63 are signifi-
cantly increased compared with specimens obtained from an arte-
Arterial blood gases, serum electrolytes, and coagulation studies rial catheter although baseline specimens can be obtained from
can be drawn from an arterial line. To avoid contamination of the the introducer before placement of the PA catheter. 64
specimen with saline and/or heparin, two times the deadspace vol-
ume (volume from the catheter tip to the aspiration site) or two
times the deadspace plus 2 mL (approximately equivalent to six DIRECT ARTERIAL PRESSURE
times the deadspace) should be withdrawn for arterial blood gases MONITORING
and electrolytes. 56 For coagulation studies (e.g., PT/aPTT), the
discard volume should be four to six times the deadspace vol- Indications
ume. 57,58 If an in-line blood conservation set is used, caution
must be exercised to ensure that an adequate discard volume is ob- Intra-arterial monitoring is indicated when precise and continu-
tained. 59 If heparin is used in the flush solution and the coagula- ous monitoring is required. Examples of clinical conditions war-
tion results are abnormal, consideration should be given to using ranting direct arterial pressure monitoring include acute hyper-
a venipuncture specimen to confirm the results. tensive crises, hypotension, any shock state, frequent drawing of
Serum sodium and glucose can be obtained from the infusion arterial blood samples, monitoring of vasoactive pharmacologic
port of the PA catheter if the dwell volume plus 2 mL of addi- support, and during aggressive respiratory support (e.g., high pos-
tional blood is discarded. 60 No published research was found re- itive end-expiratory pressures [PEEP]).
garding measurement of potassium or other electrolytes from PA
catheters; however, in a study of central venous lines it was found Arterial Catheter Placement
that a discard volume of 3 mL (corresponding to six times the
catheter deadspace) was sufficient after initially flushing the line Important considerations in site selection for arterial catheters in-
with 5 mL of saline. 61 Coagulation studies (Activated clotting clude patient comfort, avoidance of insertion sites at increased risk