Best Practices in Catheter Care
Helpful Hints for Preventing Catheter-Related Infections
Two of the treatments available for pulmonary hypertension, epoprostenol (Flolan and Veletri) and treprostinil (Remodulin), are delivered by continuous infusion into the body. Flolan and Veletri are administered via a special catheter that delivers medication directly into the vein (intravenously), and Remodulin is administered beneath the skin (subcutaneously) or intravenously. For intravenous administration, a soft hollow tube, or central venous catheter (CVC), is placed into a large vein leading to the heart which comes out through a small opening in the chest area. Three types of CVCs are available: Hickman, Groshong and Broviac.
Unfortunately, catheter site infections and blood infections (bacteremia) are some of the risks associated with having a CVC and continuous infusion therapy. Infections can cause serious illness, require hospitalization for antibiotic therapy for several weeks, and require replacement of the CVC. In addition, infections may worsen pulmonary hypertension and can be fatal. Patients, caregivers and health care providers must be constantly mindful of following appropriate procedures and practices and strive to prevent CVC infections and emergencies.
One of the best ways to prevent CVC infections is through regular and thorough hand washing. Our hands come in contact with bacteria constantly throughout the day. So hands and nails must be washed thoroughly with antibacterial soap and dried with a new clean cloth or paper towel prior to CVC care, medication preparation or changing the infusion system. Wearing gloves can also be helpful but does not eliminate the necessity of excellent hand hygiene.
The catheter hub, or the end of the CVC, is a place where microorganisms can enter the catheter and cause infection in the blood. One method of protecting the end of the catheter is to consider a closed hub system, or a needleless end-cap on the end of the CVC. With the closed hub system, the catheter hub is only opened and exposed to the environment weekly when the endcap device is changed. In contrast, without a closed hub system, the CVC is opened to the environment with every tubing change. When using a closed hub system, it is very important to thoroughly cleanse the end-cap with alcohol and allow the alcohol to dry before connecting new tubing.
All infusion system connections may be exposed to water-borne organisms during showering. A recent increase in catheter related blood stream infections (CR-BSI) at The Children’s Hospital in Denver prompted the consultation of a plastics engineer regarding the possible way in which the bacteria were entering the infusion system. It was discovered that when any connection to the catheter hub is exposed to water (e.g., showering), water is able to track along the threads of the connection. If the catheter hub is disconnected from a needleless device or tubing while the threads are wet, water migrates to the end of the catheter hub allowing bacteria from the water to enter the catheter. Therefore, it is strongly recommended that connections be protected from water at all times, and it is critical that the connections are never opened if wet. While many impermeable covers for the connections have been tried, most patients find Glad Press and Seal to be the easiest, cheapest and most effective.
Catheter Insertion Site
The catheter insertion site is also a potential entry point for microorganisms. There are many options for central line dressings and cleaning solutions for the skin. The goal is to keep the catheter site clean, dry and free of any skin reactions and infection at all times. ChloraPrep is the preferred antiseptic. However, Betadine and alcohol can also be used. The use of a semi-permeable dressing such as Tagaderm (changed every seven days) or sterile gauze (changed every two days) is also recommended. Many patients face unique challenges with skin sensitivities to cleaning solutions and dressings. Since skin reactions and rashes can lead to skin and CVC-site infections, it is critical that patients report any skin reactions immediately to their PH nurses.
The medication and mixed infusion solution must remain sterile within the reservoir or cassette. Thus, it is critical to precisely follow the mixing and administration protocol taught by your PH center. If an accidental contamination occurs during the mixing of the medication, the solution should be discarded. Maintaining the integrity of the vial of medication is also essential. If accessing the vial with a needle, it is important to insert the needle with the bevel (needle opening) up at a 45% degree angle to the top of the vial to avoid coring the rubber diaphragm. For needleless access using a vial adaptor, it is important to use a vial adaptor with a flat surface that can be thoroughly disinfected with alcohol prior to access. In addition, it is now recommended that all open vials be stored in a refrigerator.
Recognition of CVC Infections
Early recognition of catheter site infections or blood infections is crucial since early recognition and treatment can impact the severity of the infection and survival. Notify your PH physician or nurse immediately if you experience any of the following signs of infection:
- Drainage, warmth or odor around the catheter site.
- Redness or tenderness at the catheter site and/or extending under the skin along the CVC track.
- Fever of 100.5° F (38° C) or greater or chills.
- Unexplained malaise or flu-like symptoms. While CVC infections are generally rare, even one infection can have serious consequences.
Other Catheter-Related Emergencies
In addition to infections, patients on intravenous medication and their caregivers should also know what to do in the event of the following catheter-related emergencies.
If the Catheter Comes Out
If the catheter falls out or is pulled out, call 911 immediately. Flolan and Veletri each have a half-life of between two and six minutes. If you stop the medicine for more than a few minutes, it can be fatal. Remodulin has a half-life of between two and four hours. Although the half-life is longer, you must still treat this as an emergency. Tell 911 you have a life-threatening emergency and ask them to dispatch an ambulance immediately. While waiting for help to arrive, minimize physical activity and put oxygen on if you have it at home. Cover the area where the catheter came out (with your hand) and apply pressure if bleeding. When help arrives, advise emergency personnel of your condition and that they must start an IV in your arm to ensure that you continue to receive your life-sustaining medication. Learn more about what you need to know when working with emergency personnel
If the Catheter is Leaking or Cracked
If the catheter is leaking or cracked, call 911 immediately. Your medicine may be leaking out, and a doctor must repair or replace the catheter as soon as possible. Tell 911 you have a life-threatening emergency and ask them to dispatch an ambulance immediately. If blood is backing up the catheter or leaking out, use the clamp to close off the catheter to stop blood from backing up. Try to wrap the crack or hole tightly with tape, but if it is still leaking you must clamp off the line. When help arrives, advise emergency personnel of your condition and that they must start an IV in your arm to ensure that you continue to receive your life-sustaining medication. Learn more about what you need to know when working with emergency personnel
If the Catheter is Loose
If you notice a fuzzy raised area where your catheter comes out of the skin, call your PH doctor immediately. The catheter has a small "cuff" under the skin that is designed to hold the catheter in place. Over time, this cuff sits under the skin and forms a bond between the skin and muscle. Sometimes the catheter can come loose, and you will see this cuff start to appear outside the skin. The catheter cannot safely be "pushed" back in. A doctor must repair or replace it. If this happens to you, secure the catheter with dressing, using extra tape, and make several "safety loops” to prevent the catheter from accidentally pulling out. Call your PH doctor or clinic and ask how you should proceed.
PHA is grateful to Aimee Doran, MS, RN, CPNP, Pulmonary Hypertension Program, The Children’s Hospital, Aurora, Colo., and Traci Stewart, RN, MSN, CHFN, Cardiomyopathy Treatment Program, University of Iowa, for their contributions and medical review.
To review Conflict of Interest Disclosures for PHA's medical leadership, visit: Disclosures
Last reviewed: February 2012