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Dressings for the Management of Catheter Sites: A Review
Dressings for the Management of Catheter Sites -I
REVIEW
-
Ann i e Abstract
Introduction
A number ofdifferent types of dressings are available for the management of vascular access sites. Vapor-permeable dressings differ in relation to their thickness, weight, extensibility, gaseous permeability, and moisture vapor transmission rate (MVlR). MVlR may be important in preventing the accumulation of sweat and bacteria on intact skin. The current review examines the available literature and the advantages and disadvantages ofsome ofthe dressings in use in clinicalpractice.
Intravascular and central venous catheters (CVCs) have become widely used in the past two decades in order to administer total parenteral nutrition (TPN), chemotherapeutic agents, blood and blood products, and inotropes (Table n. The use of evcs also allows the measurement of hemodynamic variables that cannot be accurately measured by non-invasive means. Unfortunately, the use of CVCs is associated with both mechanical complications in 5 to 19 percent of patients, thrombotic complications in 2 to 26
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percent, and bloodstream or access site infection in 5 to 26 percent of patients. 1 The risk of infection varies with catheter type. Peripheral venous catheters are associated with a low risk of local or bloodstream infection, while nontunnelled CVCs are associated with the highest risk. In the United States, a total of 250,000 cases of CVC-associated bloodstream infections (BSIs) occur annually, with an attributable mortality of 12 to 25% for each infection, and a cost to the health-care system of $25,000 per episode. 2 In order to address this situation, general rec-
Table 2: Catheters used for venous and arterial access3 Catheter Type Peripheral venous catheters Peripheral arterial catheters Midline catheters Nontunneled central venous catheters Pulmonary artery catheters Peripherally inserted central venous catheters (PICCs) Tunneled central venous catheters (CYCs) Totally implantable
Umbilical catheters
Entry site
Comments
Usually inserted in the veins of the forearm or hand Usually inserted in radial artery; can be placed in femoral, axillary, brachial, posterior arteries. Inserted via antecubital fossa into proximal basilic or cephalic veins; does not enter central veins. Percutaneously inserted into central veins.
Phlebitis with prolonged use. Rarely associated with bloodstream infection. Low infection risk. Rarely associated with bloodstream infection. Lower rates of phlebitiS than with the use of short peripheral catheters. Account for majority of CRBSlt
Inserted through Teflon@ introduced into central vein.
Usually heparin bonded. Similar rates of bloodstream infection as CYCs:f:.
Inserted through basilic, cephalic or brachial veins and enter the superior vena cava
Lower rate of infection than nontunneled CYCs
Implanted into subclavian, internal jugular or femoral veins
Cuff inhibits migration of organisms into catheter tract. Lower rate of infection than nontunneled CYCs. Lowest risk for CRBSI. Improved patient self-image. No need for local catheter site care. Surgery required for removal. Risk for CRBSI similar with catheters placed in vein or artery.
Tunnelled beneath skin; subcutaneous port accessed with needle. Implanted in subclavian or internal jugular vein. Inserted into umbilical vein or artery.
tCRBSI; catheter-related bloodstream infection :f: CYC; central venous catheter
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Figure I: Summary of the CDC Guidelines for the prevention of intravascular CRI. 3 General Recommendations
(Adapted from CDC Recommendations for the prevention of nosocomial intravascular device related infections. available via the Internet at http://www.cdc.gov ) Education and Training Conduct ongoing education and training of health care workers regarding the management of intravascular devices and appropriate infection control measures. (Category A) Surveillance For Catheter Related Infection • Conduct surveillance for intravascular device-related infections to determine rates of infection. (Category 18) • Palpate catheter insertion site for tenderness. daily through dressing. (Category 18) • Visually inspect catheter site if tenderness has developed at insertion site. (Category 18) • If dressing prevents palpation or visualization of catheter insertion site. remove dressing and visually inspect site at least daily. Replace with new dressing. (Category 18) • Record the date and time of catheter insertion in an obvious location near catheter insertion site. (Category 18) • Do not routinely perform surveillance cultures of patients or devices used for intravascular access. (Category 18)
on intravascular devices. (Category 18) • No recommendation for the use of sterile versus nonsterile clean gloves during dressing changes. (Unresolved issue) Replacement of Intravascular Device • Remove any intravascular device as soon as its use is no longer clinically indicated. (Category lA) Intravenous Injection Ports • Clean injection ports with 70% alcohol or pOVidone-iodine before accessing the system. (Category lA) Preparation and Quality Control of Intravenous Admixtures • Admix all parenteral fluids in the pharmacy in a laminar-f1ow hood using aseptic technique. (Category 18) • Check all containers or parenteral fluid for visible turbidity leaks. cracks. particulate matter, and the manufactureris expiration date before use. (Category lA) • Use single-dose vials for parenteral additives or medications when possible. (Category 11) In-Line Filters Do not use in-line filters routinely for infection control purposes. (Category lA)
Handwashing • Wash hands before and after palpating. inserting. replacing. or dressing any intravascular device. (Category lA)
Intravenous Therapy Personnel Designate trained personnel for the insertion and maintenance of intravascular devices. (Category 18)
Catheter Insertion • Do not routinely use cutdown procedures as a method to insert catheters. (Category lA)
Needleless Intravascular Devices No recommendation for use, maintenance. or frequency of replacement of needleless IV devices. (Unresolved issue)
Barrier Precautions During Catheter Care • Wear non-latex or latex gloves when inserting an intravascular device. (Category lA) • Wear non-latex or latex gloves when changing the dressings
Prophylactic Antimicrobials Do not administer antimicrobials routinely before insertion or during use of an intravascular device to prevent catheter colonization or bloodstream infection. (Category 18)
ommendations from the Centers for Disease Control and Prevention (CDC) have been developed for the prevention of nosocomial intravascular infection (Figure 1).3 Standardization of aseptic care, insertion and maintenance of catheters by experienced staff and continuing education have all been found to reduce the incidence of catheter related infections in both adult and pediatric patients. 3 Intravenous (IV) therapy carries an appreciable risk of bacteremia, septicemia and thrombophlebitis, which is associated with an increased risk of localized infection.4-7 Catheterrelated infections (CRIs) can be divided into two different groups: those that
are local and those that are bacteremic. Local infections affect only the insertion site and are evident by pericatheter inflammation. A diagnosis of a local infection is usually given after evidence of an infection is present (e.g., purulence at the exit site). In contrast, bacteremic catheter-related infections are defined as a positive blood culture with microbiologic or clinical evidence that strongly indicates the catheter as the source of infection.
Intravascular device infections The most commonly occurring organisms that cause intravascular device infections are Staphylococci species, Gram-negative rods, and Can-
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dida species. These organisms are introduced by several methods, the most common of which involve the skin insertion site and the catheter hub (Figure 2).8 Bacteria migrate from the insertion site on the skin along the external surface of the catheter and then colonize the distal tip of the intravascular device. 9 The hub of the device also can be a factor in CRIS.9 Infection can also occur when healthcare workers fail to properly wash their hands 10 or properly cleanse the port prior to accessing the system. 9 In these cases, bacteria migrate along the inner surface of the catheter lumen and may result in bacteremia. A number of studies have been per-
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Figure 2: Pathogenesis of vascula....cathete....related colonization and infection, as originally diagrammed by Raad (1998).9 CATHETER • Surface change and hydrophobicity • Thrombogenicity • Type of polymer
HOST • Proteins (e.g. fibronectin • Platelets • Neutrophil function (phagocytosis and hemotaxis
MICRO-ORGANISM • Surface change and hydrophobicity • Slime and biofilm formation
Sterility of insertion Hub contamination
Catheter location Dwell time I TPN used
Multiplication and release of freefloating organisms
TPN =
total parenteral nutrition
Catheter-related Bloodstream Infection
formed on the impact of different dressing protocols on CVC-associated infection. Risk factors associated with the development of catheter-related infection include l1 : • the patient's underlying condition; • lack of use of the aseptic technique; • degree of skin cleansing; • type of infusate being delivered via the device; • type of device used; • material from which the device is made; and • whether the device has a Single or multiple lumen.
tion site, allowing the early detection of inflammation. s A number of different dressings are available for the management of vascular access sites. These fall into three broad categories: tape and gauze (T&G); non-permeable polyurethane transparent' dressings (NPTD); and highly permeable transparent dressings (HPTDs). The criteria for appropriate insertion site dressings are rather concise (Table II).
Tape and Gauze Dressings
evidence to suggest that the use of non-sterile tape is associated with an increased risk of bacterial contamination and associated infection. 18•19 In an assessment of adhesive tape and the risk of infection, it was noted that while 74% of specimens of tape collected in one hospital were colonized by 'Pathogenic bacteria, this could be reduced by discarding the outer layer of the roll. 20 Campbell & Carrington21 reviewed the different types of catheter site dressings and compared and contrasted conventional dressings with transparent, polyurethane dressings. Conventional gauze dreSSings were found to have a number of disadvantages, such as:
This type of fixation system has now largely been replaced in clinical pracDressings are applied to vascular tice by transparent dressings; however, access sites in order to minimize the gauze dressings are recommended if contamination of the insertion site and blood is oozing from the catheter inserprovide stability of the device. The tion site. 13 Tape and gauze dressings • daily changes are required; ideal dressing should provide an effec- must be changed every one to two • materials/nurSing staff time can tive barrier to bacteria, allow the days. Unfortunately, frequent dressing increase costs; catheter to be fixed securely, be sterile changes lead to manipulation and • frequent changes can lead to and easy to apply and remove, and be movement of the cannula and thus are manipulation and movement of the comfortable for the patient. 12 Studies associated with an increasing risk of catheter; consequently increasing have indicated that twice weekly phlebitis, which can occur in up to the risk of phlebitis; dressing changes reduce the number 17% of patients. 14 • passage of micro-organisms when of infective episodes, lengthen the On the positive side, gauze dressings wet; and time to first infection, and reduce the prevent pooling of moisture, which can • do not allow continuous observaoverall need for extra dressings in allow the passage of bacteria when tion of the catheter site. patients requiring permanent catheteri- wet. The use of gauze has not been zation. 6 Transparent dressings allow associated with an increased risk of Nelson et af-2 implied that the use of visual inspection of the catheter inser- bloodstream infections,IS-17 but there is dressings not specifically designed for
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Table 11: Criteria for insertion site dressings 21
Table Ill: Vapor permeable film dressing characteristics, adapted from Morgan (1999).56 Dressing Bioclusive Bioclusive Select Cutifilm Epiview:j: IV3000t Mefilm Niko-Derm Opsite Flexigrid Polyskin MR Tegaderm Tegaderm HP
peripheral cannulas was associated with an increase in inflammation around the cannula site. There have been reports from other investigators that the use of tape is associated with both skin damage and pain upon removal 23 ,24
Transparent dressings have some of the following advantages over opaque dressings2l : • inspection of the catheter site;
Inverted MVTR
Johnson & Johnson
IVIWD IV WD WD IV WD IVIWD WD IV IVIWD IVIWD
553 553
nIt
Smith & Nephew Convatec Smith & Nephew Molnlycke Nikomed Smith & Nephew Kendal 3M Health Care
885 11140 1580 5606 725 5044 743 1156
* Personal Communication Smith & Nephew (Data on File) :j: Discontinued t Formerly OpSite IV3000 IV intravenous WD wound nit not tested
= = =
Transparent Dressings Transparent dressings (TDs) have become the most frequently used material to dress catheter insertion sites. Despite widespread use, many transparent dressings are unsuitable for IV access sites because they retain moisture, which promotes colonization and contributes to increased infection rates in central venous catheters. ll ,17,25 The advantage of TDs is that they permit visualization of the insertion site while the dressing is in situ, and therefore do not require remova1.'6,27 Most of these dressings are also waterproof, alloWing the patient to bathe or shower without concern about the dressing integrity and reducing the potential number of dressing changes. Recent research has investigated the infection risks and frequency of dressing changes of both sterile gauze and transparent dressings. While some studies indicate that there is no significant difference between tape and gauze and transparent dressings in terms of incidence of infection,28 others describe slightly higher levels of bacterial colonization with the use of non-permeable transparent dressings (NPTDS)'17
Manufacturer
Type
g/m2/24h*
Sterile Capable of preventing moisture accumulation Allow visual inspection Easy to apply and fix securely to insertion site Easy to remove Cost effective
• • • • • • • • •
being hypoallergenic; sterile; semi-permeable; providing a bacterial barrier; allowing moisture vapor transmission; reliably securing the catheter; being comfortable and conformable to skin; waterproof (allowing bathing); and extended length of wear time.
These dressings meet the requirements listed in the guidelines for intravenous site care. 29 ,30
Non-permeable Polyethylene Transparent Dressings The first transparent dressings to become available were non-permeable. Since an important factor related to infection is moisture (the collection of moisture enhances the proliferation of micro-organisms), so it is essential to maintain a dry, sterile, intact IV site dressingY This is a disadvantage of NPTDs, in that they allow the accumulation of moisture around the insertion site, which may potentiate bacterial growth. This factor may be significant in the early reports of an increased incidence of infection associated with the use of transparent dressings,7
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which later reviews and meta-analyses have failed to support. 16,27,32
Semi-permeable Film Dressings Semi-permeable film dressings first became available in the early 1970s with the launch of OpSite'" (Smith & Nephew), originally available as an Incise drape (971) and then in 1974 as a wound dressing. OpSite was the first of a plethora of film dressings that offered the significant advantage over polyethylene of being gas and vapor permeable, self adhesive, impermeable to liquid and micro-organisms, as well as transparent, elastometric and conformable. Tegaderm™ (3M Health Care Ltd) also is described as an intravenous dressing,33 although it is also indicated for the management of treatment of minor burns, pressure areas, donor sites, post-operative wounds, and a variety of minor injuries, including abrasions and lacerations. 34 Other semipermeable film dressings include Bioclusive (J&]), Epiview (ConvaTec) and Mefilm (Molnlycke). These dressings also have multiple indications but, although indicated for the management of IV sites, were not specifically developed for this purpose. 35 Vapor permeable film dressings dif-
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fer in relation to their thickness, weight, extensibility, moisture vapor transmission rate (MVTR), and gaseous permeability.36 The typical semi-permeable dressing is composed of a film (polyurethane, either extruded or solvent cast at approximately 30g/m2) and an adhesive (acrylic, solvent cast at 30g/m2).37 A number of semi-permeable dressings have since been developed, and while the various products differ, the general range of physical properties is37 : MVfR 400 - 900 glm2/24h; Oxygen permeability.. 0.2 - 3.0 Vm2/24h; Carbon dioxide permeability 100 - 200 Vm2/24h.
An MVTR ranging from 400 to 900 g/m2/24h is adequate to cope with the normal evaporation loss from skin; however, excess sweating may lead to moisture build-up. An accumulation of sweat and skin secretions may lead to the failure of the adhesive bond or the formation of wrinkles, through which bacteria may reach the dressing or catheter, may cause irritant dermatitis,38 or tissue maceration associated with an increase in bioburden of the skin, thereby increasing the possibility of wound infection. 39 It is in this context that differences in the MVTR of the various films may be important (Table III);33 however, there is a lack of gcxxi quality, randomized stud-
ies comparing different types of transparent dressings in the literature.
Highly permeable transparent dressings More recently, transparent dressings designed to improve moisture-vapor permeability have been produced. The N3000™ (formerly OpSite N3000) dressing (Smith and Nephew UK) is a reactive hydrophilic polyurethane film coated with a water-based hypo-allergenic acrylic adhesive, which is up to 8 times more permeable than earlier films. The manufacturers maintain that the increased permeability will lead to improved adhesion, resulting in less
Table IV: Studies of dressing type and incidence of eVe-related blood stream infection Author
Dressing Type
Infection rate (%) Gauze Transparent
Powell 198545
GO vs. OpSite
5/ 111(4.5)
8/262 (3.0)
Andersen 1986t5
GO vs. OpSite
1/75 (1.3)
2160 (3.3)
Young 198647
GO vs. OpSite
1/36 (2.8)
21132 (1.5)
Conley 1989" Oickerson 198<)46
GO vs. 0psite GO vs.TO
0/57 (0) 1/33 (3.0)
7/58 (16.7) 3/36 (8.3)
Shivnan 1991 *50
GO vs. Tegaderm
1/47 (2.1)
2151 (3.9)
Maki 1994t48
GO vs. Tegaderm
4/134 (3.0)
7/222 (3.1)
Maki 199649
GO vs. Tegaderm
8/191 (3.1)
5/204 (2.5)
Brandt 199651
GO vs. OpSite IV3000 Tegaderm vs. OpSite IV3000
1/53 (2.0)
5/48 (10.4)
NR
NR
Reynolds 1997*JJ
Treston-Aurand 1997 32
GO vs.TO vs OpSite IV3000
116/1374 (8.5%)
6/1677 (3.3)
Little 1998 11
GO vs. OpSite IV3000 Hydrocolloid vs. transparent
4/75 (5.3)
3/86 (3.4)
24/77 (36)
12174 (19)
Nicoletti 199957
GO = gauze TO = transparent dressing HPTP = highly permeable transparent dressing
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Remarks No significant difference in infection. Aseptic technique more important than type of dressing. No significant difference in CR-BSls, although a statistically significant difference was reported in the incidence of positive tip culture (p = 0.01) No significant difference was found between the dressing groups, despite differences in duration of wear time. Use of OpSite significantly increased CR-BRls The difference between the two groups was not significant (p = 0.34). No statistically significant difference in infection (exit-site). TOs associated with significant decrease in nursing time, local skin irritation and dressing costs No statistically significant difference between the two regimens No significant difference in CR-BSI, although cutaneous colonization was significantly greater in the Tegaderm group (p = 0.03). No significant difference was found in the rate of definite or suspected CVC sepsis 23/36 (64%) Tegaderm and 21/39 (54%) OpSite IV3000 had positive skin cultures (p = >0.1).There was no significant difference between the two dressings A significant difference existed in the rate of catheter-related infections using HPTOs vs. GOs or TOs.The rate of catheter related infection decreased by 25% using HPTOs. No significant difference between the two groups. Mean duration of catheterization was 8.5 - 1I days Use of a hydrocolloid dressing increased the risk of catheter colonization.
t Catheter related blood stream infections (CR-BSI) * Local skin culture NR = not reported
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Table V: Advantages and disadvantages of commercially available cannula dressings, adapted from Campbell and Carrington (1999).21 Promotes moisture vapor transmission Ease of application Ease of removal Allows visual inspection Cost t
tt
IV3000
Tegaderm
Veca-C
Nico-gard
~~~
~~
(II,OOOg/m
(735g/m
~~~
~~~
~
~~
~~~
~
~
~
~
~~~
~~
~
~~
~~~
~~
~~
~~~
~~~
~~~
mid-price range
mid-price rangett
inexpensive
inexpensive
inexpensive
Dermafilm
~
(SOOg/m
Data on file Smith & Nephew Although the 6 x 7 cm size is the most inexpensive of the Tegaderm range, further tape or bandage is often necessary to preserve the cannula.
dressing lift-up, longer wear times, and reduced handling. The IV3000 was specifically developed for use on intravenous access sites, and has an average MVP in excess of 11,000 glm2/24h.
Comparative Clinical Studies It is important to note that the properties of these dressings may have changed over time without a change in the branded name, making retrospective comparisons and systematic reviews in this area particularly problematic. A recent review of central venous catheter site care for blood and bone marrow recipients also reported that the heterogeneity of published studies with regard to patient population, frequency of dressing change and skin antisepsis as limiting factors in the ability to determine optimal catheter care practice. 40 A meta-analysis performed on studies using non-permeable or semi-permeable transparent dressings published between 1982 to 1989 reported a 53% increased risk of catheter tip infection associated with the use of these dressings. 17 Four additional studies published between 1985 to 1992 also raised the possibility that TDs might increase the risk of CRI.28,41-43 Interestingly, the study by Craven et alY noted a statistically ,significant higher rate of CRI in the summer months. Richet et al. 41 noted a higher rate of fever and bacteremia associated with central versus peripheral catheters. These studies illustrate that, in addition to the type of dressing used to secure the catheter in place, there are several variables that may affect the incidence of CRI.
Of the comparative clinical trials of dressings included in a recently published review,40 only one study44 showed a statistically significant increase in CRBSIs associated with the use of a semipermeable dressing (Table IV). It is important to note that this study was conducted in patients with central venous catheters in place for more than three days, and that only 115 patients were included in the study. Four other studies5.4>-47 included in an analysis by Zitella 40 failed to show any significant difference among the use of gauze, semi-permeable dressings, or highly permeable transparent dressings. In studies comparing Tegaderm to gauze,48-SO there was no significant difference in infection between the two regimens, although the study by ShivnanSO reported a significant decrease in nursing time and skin irritation in favor of the transparent dressing. Three comparative studies",33,S1 of the highly-permeable transparent dressing IV3000 also have shown no significant difference between dressing type and infection. One more recent large comparative study has reported a significant reduction of CRIs when HPTDs (IV3OOO) were utilized, in comparison to TDs and tape-gauze methodsY The use of IV3000 was associated with a significantly lower CRI rate (p=
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more than 178 extra patient days avoided with the use of the HPTD,
Discussion Transparent dressings have a number of advantages over tape and gauze dressings (Table V), including the fact that they allow visual inspection of the catheter site and are waterproof. The more recently developed HPTDs may also promote moisture vapor transmission and maintain a dry access site. 27 In vitro data 36,39 and one clinical study 52 have shown that there is less pooling of moisture tinder HPTDs, such as IV3000, and fewer incidences of the dressing becoming detached. Both of these factors may be important in avoiding unnecessary contamination of the access site and the development of CRIs,2,30,53 although clinical studies are needed to confirm these hypotheses. Important factors in the development of CRI are catheter material and location of the catheter. 54 A warm moist environment, conducive to a high microbial bioburden, may also increase the risk of infection,'6 and this would appear to be supported by the literature relating to newer HPTDs and their ability to prevent moisture accumulation under the dressing. 32,55 The large study by TrestonAurand et al.,32 which reported a 25% reduction in the rate of CRIs associated with the use of IV3000 compared with either gauze or Tegaderm, supports the use of HPTDs over other types of dressing. Further well controlled randomized studies are needed to investigate the reproducibility of these data, both in terms of infection rates and potential
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cost savings. Other published studies comparing catheter site dressings in clinical practice are limited by their small sample size and other confounding variables, such as aseptic technique and access site.
Conclusion Highly permeable transparent dressings are well tolerated by patients21 ,32.55 and are easy to apply and remove. 55 Despite initial concerns about an association with the use of transparent dressings and the risk of CRI, this risk would seem to only be associated with the use of occlusive film dressings 7 •
The development of higWy permeable film dressings has been a significant advance for the management of catheter sites, allowing the observation of the catheter site without the need for dressing removal and an increased level of patient comfort. Insertion site dressings are important in preventing trauma and the extrinsic contamination of the site of entry. In chOOSing an intravenous dressing, medical staff needs to be aware of the advantages and disadvantages of the dressings on the market to make an informed choice about the type to use.• AnnieJones is a Dphil student at the
Department of Health Sciences, York University, York, UK. Director: Magus Strategic Communications Ltd. Consultancy: Bayer AG, Bayer Corp., British Journal of Nursing, Chiron Corp., Gensoft Corp., PAREXEL MMS, Roche Corp., Smith & Nephew, Wyeth Pharmaceuticals. William Hirsch, MS is a Field Sales Development Manager with Boston Scientific Oncology Division with over 20 years experience in the development and manufactUring of medical devices. William seroed as a member of the Board ofDirectorsfor the Society ofPlastics Engineeringfor over 10 years.
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1996; 32(1): 65-69. 23. Tripepi-Bova KA, Woods KD, Loach
and of skin preparation on the force required to dislodge angiocatheters. Can] Anaesth 1994; 41(8): 738--741. 25. Holm C, Petersen JS, Groboek F, Gottrup F. Effects of occlusive and conventional gauze dressings on incisional healing after abdominal operations. European Journal of Surgery 1998; 164(3): 179-183. 26. Baranowski 1. Central venous access devices: current technologies, uses, and management strategies. ] Intraven Nurs 1993; 16(3): 167-194. 27. Keenlyside D. Avoiding an unnecessary outcome: a comparative trial between N3000 and a conventional film dressing to assess rates of catheter-related sepsis. Professional Nurse 1993; 8(5): 290-291. 28. Petrosino B, Becker H, Christian B. Infection rates in central venous catheter dressings. Oncol Nurs Forum 1988; 15(6): 709-717. 29. Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection 2001; 47(1): S47-s67. 30. O'Grady NP, Alexander M, Dellinger EP, et at. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. .MMW1? Recomm Rep 2002; 51(RR-10): 1-29. 31. Perucca R. Obtaining vascular access, in Intravenous Therapy: Clinical Principles and Practices, ]. Terry, et al., Editors. 1995, W.B. Saunders: Philadelphia. pp. 37T391. 32. Treston-Aurand J, Olmsted RN, AllenBridson K, Craig CP. Impact of dressing materials on central venous catheter infection rates. ] Intraven Nurs 1997; 20(4): 201-206. 33. Reynolds MG, Tebbs SE, Elliott TS. Do dressings with increased permeability reduce the incidence of central venous catheter related sepsis? Intensive Crit Care Nurs 1997; 13(1): 26-29. 34. Thomas S. Tegaderm SMTL Dressings Datacard. Wounds.org. Available at: http://www.dressings.orglDressings/teg aderrn.htrnl. Accessed 5 Nov 2003. 35. British National Formulary. Vo!. 46. 2003: British medical Association, London, UK and Royal Pharaceutical Society of Great Britain, London, UK. 36. Thomas S, Loveless P, Hay NP. Compara-
tive riview of the properties of six semipermeable film dressings. The Pharmaceutical]ournaI1988; 240: 785-789. 37. Richardson MC. Film Dressings: A review. in Wound healing: New treatment, measurement and wound product review. 1994. Cardiff, Wales: IBC Technical Services Ltd. 38. Mertz PM, Marshall DA, Eaglstein WH. Occlusive wound dressings to prevent bacterial invasion and wound infection. ] Am Acad Dermatol 1985; 12(4): 662-
668. 39. Thomas S, Leigh !M. Wound dressings, in Wounds: Biology and management, DJ Leaper and K.G. Harding, Editors. 1998, Oxford University Press: Oxford, UK. p. 166-183. 40. Zitella 1. Central venous catheter site care for blood and marrow transplant recipients. Clin] Oncol Nurs 2003; 7(3): 289-298. 41. Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. ] Clin Microbioll990; 28(11): 2520-2525. 42. Craven DE, Lichtenberg DA, Kunches LM, et a!. A randomized study comparing a transparent polyurethane dressing to a dry gauze dressing for peripheral intravenous catheter sites. Infect Contro11985; 6(9): 361-366. 43. Callahan JL, Wesorick B. Bacterial growth under a transparent dressing. Am]Infect Control 1987; 15(6): 231-237. 44. Conly JM, Grieves K, Peters B. A prospective, randomized study comparing transparent and dry gauze dressings for central venous catheters. ] Infect Dis 1989; 159(2): 310-319. 45. Powell CR, Traetow MJ, Fabri PJ, Kudsk KA, Ruberg RL. Op-Site dressing study: a prospective randomized study evaluating povidone iodine ointment and extension set changes with 7-day OpSite dressings applied to total parenteral nutrition subclavian sites. ] Parenter Enteral Nutr 1985; 9(4): 443-446. 46. Dickerson N, Horton P, Smith S, Rose RC. Clinically significant central venous catheter infections in a community hospital: association with type of dressing. ] Infect Dis 1989; 160(4): 720-722. 47. Young GP, Alexeyeff M, Russell DM, Thomas R]. Catheter sepsis during par-
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enteral nutrition: the safety of long-term OpSite dressings. ] Parenter Enteral Nutr 1988; 12(4): 365-370. 48. Maki DG, Will 1. Colonization and infection associated with transparent dressing for central venous, arterial and Hickman catheters: A comparative trial (Abstract). in 34th Interscience Conference on Antimicrobial Agents and Chemotherapy. 1994. Washington, DC. 49. Maki DG, Merrnel LA, Martin M, Berry D. A highly semi-permeable polyurethane dressing does not increase the risk of CVC-related BSI: A propective multi-center, investigator blinded trial (Abstract). in 36th Interscience Conference on Antimicrobial Agents and Chemotherapy. 1996. New Orleans, LA. 50. Shivnan JC, McGuire D, Freedman S, et at. A comparison of transparent adherent and dry sterile gauze dressings for longterm central catheters in patients undergoing bone marrow transplant. Oncol Nurs Fornm 1991; 18(8): 1349-1356. 51. Brandt B, DePalma J, Irwin M, Shogan J, Lucke JF. Comparison of central venous catheter dressings in bone marrow transplant recipients. Oncol Nurs Fornm 1996; 23(5): 829-836. 52. Joyeux B. Opsite N 3000 versus Tegaderm on peripheral venous catheters: Improving catheter site care. Royal Society of Medicine, London. 1991. 53. Polderman KH, Girbes AR. Central venous catheter use. Part 2: infectious complications. Intensive Care Med 2002; 28(1): 18--28. 54. Darouiche RO. Prevention of vascular catheter-related infections. The Netherlands Journal ofMedicine 1999; 55(3): 92-99. 55. Wille JC. A comparison of two transparent film-type dressings in central venous therapy. (Effect of OpSite and OpSite N3000 on catheter-related sepsis. Research). Journal ofHospital Infection 1993; 23(2): 113-121. 56. Morgan DA. Wound management products in the drug tariff. Pharmaceutical ]ournall999; 263(7072): 820-825. 57. Nikoletti S, Leslie G, Gandossi S, Coombs G, Wilson R. A prospective, randomized, controlled trial comparing transparent polyurethane and hydrocolloid dressings for central venous catheters. Am] Infect Control 1999;
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REVIEW
-
Ann i e Abstract
Introduction
A number ofdifferent types of dressings are available for the management of vascular access sites. Vapor-permeable dressings differ in relation to their thickness, weight, extensibility, gaseous permeability, and moisture vapor transmission rate (MVlR). MVlR may be important in preventing the accumulation of sweat and bacteria on intact skin. The current review examines the available literature and the advantages and disadvantages ofsome ofthe dressings in use in clinicalpractice.
Intravascular and central venous catheters (CVCs) have become widely used in the past two decades in order to administer total parenteral nutrition (TPN), chemotherapeutic agents, blood and blood products, and inotropes (Table n. The use of evcs also allows the measurement of hemodynamic variables that cannot be accurately measured by non-invasive means. Unfortunately, the use of CVCs is associated with both mechanical complications in 5 to 19 percent of patients, thrombotic complications in 2 to 26
Jones,
MSc
percent, and bloodstream or access site infection in 5 to 26 percent of patients. 1 The risk of infection varies with catheter type. Peripheral venous catheters are associated with a low risk of local or bloodstream infection, while nontunnelled CVCs are associated with the highest risk. In the United States, a total of 250,000 cases of CVC-associated bloodstream infections (BSIs) occur annually, with an attributable mortality of 12 to 25% for each infection, and a cost to the health-care system of $25,000 per episode. 2 In order to address this situation, general rec-
Table 2: Catheters used for venous and arterial access3 Catheter Type Peripheral venous catheters Peripheral arterial catheters Midline catheters Nontunneled central venous catheters Pulmonary artery catheters Peripherally inserted central venous catheters (PICCs) Tunneled central venous catheters (CYCs) Totally implantable
Umbilical catheters
Entry site
Comments
Usually inserted in the veins of the forearm or hand Usually inserted in radial artery; can be placed in femoral, axillary, brachial, posterior arteries. Inserted via antecubital fossa into proximal basilic or cephalic veins; does not enter central veins. Percutaneously inserted into central veins.
Phlebitis with prolonged use. Rarely associated with bloodstream infection. Low infection risk. Rarely associated with bloodstream infection. Lower rates of phlebitiS than with the use of short peripheral catheters. Account for majority of CRBSlt
Inserted through Teflon@ introduced into central vein.
Usually heparin bonded. Similar rates of bloodstream infection as CYCs:f:.
Inserted through basilic, cephalic or brachial veins and enter the superior vena cava
Lower rate of infection than nontunneled CYCs
Implanted into subclavian, internal jugular or femoral veins
Cuff inhibits migration of organisms into catheter tract. Lower rate of infection than nontunneled CYCs. Lowest risk for CRBSI. Improved patient self-image. No need for local catheter site care. Surgery required for removal. Risk for CRBSI similar with catheters placed in vein or artery.
Tunnelled beneath skin; subcutaneous port accessed with needle. Implanted in subclavian or internal jugular vein. Inserted into umbilical vein or artery.
tCRBSI; catheter-related bloodstream infection :f: CYC; central venous catheter
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Figure I: Summary of the CDC Guidelines for the prevention of intravascular CRI. 3 General Recommendations
(Adapted from CDC Recommendations for the prevention of nosocomial intravascular device related infections. available via the Internet at http://www.cdc.gov ) Education and Training Conduct ongoing education and training of health care workers regarding the management of intravascular devices and appropriate infection control measures. (Category A) Surveillance For Catheter Related Infection • Conduct surveillance for intravascular device-related infections to determine rates of infection. (Category 18) • Palpate catheter insertion site for tenderness. daily through dressing. (Category 18) • Visually inspect catheter site if tenderness has developed at insertion site. (Category 18) • If dressing prevents palpation or visualization of catheter insertion site. remove dressing and visually inspect site at least daily. Replace with new dressing. (Category 18) • Record the date and time of catheter insertion in an obvious location near catheter insertion site. (Category 18) • Do not routinely perform surveillance cultures of patients or devices used for intravascular access. (Category 18)
on intravascular devices. (Category 18) • No recommendation for the use of sterile versus nonsterile clean gloves during dressing changes. (Unresolved issue) Replacement of Intravascular Device • Remove any intravascular device as soon as its use is no longer clinically indicated. (Category lA) Intravenous Injection Ports • Clean injection ports with 70% alcohol or pOVidone-iodine before accessing the system. (Category lA) Preparation and Quality Control of Intravenous Admixtures • Admix all parenteral fluids in the pharmacy in a laminar-f1ow hood using aseptic technique. (Category 18) • Check all containers or parenteral fluid for visible turbidity leaks. cracks. particulate matter, and the manufactureris expiration date before use. (Category lA) • Use single-dose vials for parenteral additives or medications when possible. (Category 11) In-Line Filters Do not use in-line filters routinely for infection control purposes. (Category lA)
Handwashing • Wash hands before and after palpating. inserting. replacing. or dressing any intravascular device. (Category lA)
Intravenous Therapy Personnel Designate trained personnel for the insertion and maintenance of intravascular devices. (Category 18)
Catheter Insertion • Do not routinely use cutdown procedures as a method to insert catheters. (Category lA)
Needleless Intravascular Devices No recommendation for use, maintenance. or frequency of replacement of needleless IV devices. (Unresolved issue)
Barrier Precautions During Catheter Care • Wear non-latex or latex gloves when inserting an intravascular device. (Category lA) • Wear non-latex or latex gloves when changing the dressings
Prophylactic Antimicrobials Do not administer antimicrobials routinely before insertion or during use of an intravascular device to prevent catheter colonization or bloodstream infection. (Category 18)
ommendations from the Centers for Disease Control and Prevention (CDC) have been developed for the prevention of nosocomial intravascular infection (Figure 1).3 Standardization of aseptic care, insertion and maintenance of catheters by experienced staff and continuing education have all been found to reduce the incidence of catheter related infections in both adult and pediatric patients. 3 Intravenous (IV) therapy carries an appreciable risk of bacteremia, septicemia and thrombophlebitis, which is associated with an increased risk of localized infection.4-7 Catheterrelated infections (CRIs) can be divided into two different groups: those that
are local and those that are bacteremic. Local infections affect only the insertion site and are evident by pericatheter inflammation. A diagnosis of a local infection is usually given after evidence of an infection is present (e.g., purulence at the exit site). In contrast, bacteremic catheter-related infections are defined as a positive blood culture with microbiologic or clinical evidence that strongly indicates the catheter as the source of infection.
Intravascular device infections The most commonly occurring organisms that cause intravascular device infections are Staphylococci species, Gram-negative rods, and Can-
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dida species. These organisms are introduced by several methods, the most common of which involve the skin insertion site and the catheter hub (Figure 2).8 Bacteria migrate from the insertion site on the skin along the external surface of the catheter and then colonize the distal tip of the intravascular device. 9 The hub of the device also can be a factor in CRIS.9 Infection can also occur when healthcare workers fail to properly wash their hands 10 or properly cleanse the port prior to accessing the system. 9 In these cases, bacteria migrate along the inner surface of the catheter lumen and may result in bacteremia. A number of studies have been per-
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Figure 2: Pathogenesis of vascula....cathete....related colonization and infection, as originally diagrammed by Raad (1998).9 CATHETER • Surface change and hydrophobicity • Thrombogenicity • Type of polymer
HOST • Proteins (e.g. fibronectin • Platelets • Neutrophil function (phagocytosis and hemotaxis
MICRO-ORGANISM • Surface change and hydrophobicity • Slime and biofilm formation
Sterility of insertion Hub contamination
Catheter location Dwell time I TPN used
Multiplication and release of freefloating organisms
TPN =
total parenteral nutrition
Catheter-related Bloodstream Infection
formed on the impact of different dressing protocols on CVC-associated infection. Risk factors associated with the development of catheter-related infection include l1 : • the patient's underlying condition; • lack of use of the aseptic technique; • degree of skin cleansing; • type of infusate being delivered via the device; • type of device used; • material from which the device is made; and • whether the device has a Single or multiple lumen.
tion site, allowing the early detection of inflammation. s A number of different dressings are available for the management of vascular access sites. These fall into three broad categories: tape and gauze (T&G); non-permeable polyurethane transparent' dressings (NPTD); and highly permeable transparent dressings (HPTDs). The criteria for appropriate insertion site dressings are rather concise (Table II).
Tape and Gauze Dressings
evidence to suggest that the use of non-sterile tape is associated with an increased risk of bacterial contamination and associated infection. 18•19 In an assessment of adhesive tape and the risk of infection, it was noted that while 74% of specimens of tape collected in one hospital were colonized by 'Pathogenic bacteria, this could be reduced by discarding the outer layer of the roll. 20 Campbell & Carrington21 reviewed the different types of catheter site dressings and compared and contrasted conventional dressings with transparent, polyurethane dressings. Conventional gauze dreSSings were found to have a number of disadvantages, such as:
This type of fixation system has now largely been replaced in clinical pracDressings are applied to vascular tice by transparent dressings; however, access sites in order to minimize the gauze dressings are recommended if contamination of the insertion site and blood is oozing from the catheter inserprovide stability of the device. The tion site. 13 Tape and gauze dressings • daily changes are required; ideal dressing should provide an effec- must be changed every one to two • materials/nurSing staff time can tive barrier to bacteria, allow the days. Unfortunately, frequent dressing increase costs; catheter to be fixed securely, be sterile changes lead to manipulation and • frequent changes can lead to and easy to apply and remove, and be movement of the cannula and thus are manipulation and movement of the comfortable for the patient. 12 Studies associated with an increasing risk of catheter; consequently increasing have indicated that twice weekly phlebitis, which can occur in up to the risk of phlebitis; dressing changes reduce the number 17% of patients. 14 • passage of micro-organisms when of infective episodes, lengthen the On the positive side, gauze dressings wet; and time to first infection, and reduce the prevent pooling of moisture, which can • do not allow continuous observaoverall need for extra dressings in allow the passage of bacteria when tion of the catheter site. patients requiring permanent catheteri- wet. The use of gauze has not been zation. 6 Transparent dressings allow associated with an increased risk of Nelson et af-2 implied that the use of visual inspection of the catheter inser- bloodstream infections,IS-17 but there is dressings not specifically designed for
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Table 11: Criteria for insertion site dressings 21
Table Ill: Vapor permeable film dressing characteristics, adapted from Morgan (1999).56 Dressing Bioclusive Bioclusive Select Cutifilm Epiview:j: IV3000t Mefilm Niko-Derm Opsite Flexigrid Polyskin MR Tegaderm Tegaderm HP
peripheral cannulas was associated with an increase in inflammation around the cannula site. There have been reports from other investigators that the use of tape is associated with both skin damage and pain upon removal 23 ,24
Transparent dressings have some of the following advantages over opaque dressings2l : • inspection of the catheter site;
Inverted MVTR
Johnson & Johnson
IVIWD IV WD WD IV WD IVIWD WD IV IVIWD IVIWD
553 553
nIt
Smith & Nephew Convatec Smith & Nephew Molnlycke Nikomed Smith & Nephew Kendal 3M Health Care
885 11140 1580 5606 725 5044 743 1156
* Personal Communication Smith & Nephew (Data on File) :j: Discontinued t Formerly OpSite IV3000 IV intravenous WD wound nit not tested
= = =
Transparent Dressings Transparent dressings (TDs) have become the most frequently used material to dress catheter insertion sites. Despite widespread use, many transparent dressings are unsuitable for IV access sites because they retain moisture, which promotes colonization and contributes to increased infection rates in central venous catheters. ll ,17,25 The advantage of TDs is that they permit visualization of the insertion site while the dressing is in situ, and therefore do not require remova1.'6,27 Most of these dressings are also waterproof, alloWing the patient to bathe or shower without concern about the dressing integrity and reducing the potential number of dressing changes. Recent research has investigated the infection risks and frequency of dressing changes of both sterile gauze and transparent dressings. While some studies indicate that there is no significant difference between tape and gauze and transparent dressings in terms of incidence of infection,28 others describe slightly higher levels of bacterial colonization with the use of non-permeable transparent dressings (NPTDS)'17
Manufacturer
Type
g/m2/24h*
Sterile Capable of preventing moisture accumulation Allow visual inspection Easy to apply and fix securely to insertion site Easy to remove Cost effective
• • • • • • • • •
being hypoallergenic; sterile; semi-permeable; providing a bacterial barrier; allowing moisture vapor transmission; reliably securing the catheter; being comfortable and conformable to skin; waterproof (allowing bathing); and extended length of wear time.
These dressings meet the requirements listed in the guidelines for intravenous site care. 29 ,30
Non-permeable Polyethylene Transparent Dressings The first transparent dressings to become available were non-permeable. Since an important factor related to infection is moisture (the collection of moisture enhances the proliferation of micro-organisms), so it is essential to maintain a dry, sterile, intact IV site dressingY This is a disadvantage of NPTDs, in that they allow the accumulation of moisture around the insertion site, which may potentiate bacterial growth. This factor may be significant in the early reports of an increased incidence of infection associated with the use of transparent dressings,7
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which later reviews and meta-analyses have failed to support. 16,27,32
Semi-permeable Film Dressings Semi-permeable film dressings first became available in the early 1970s with the launch of OpSite'" (Smith & Nephew), originally available as an Incise drape (971) and then in 1974 as a wound dressing. OpSite was the first of a plethora of film dressings that offered the significant advantage over polyethylene of being gas and vapor permeable, self adhesive, impermeable to liquid and micro-organisms, as well as transparent, elastometric and conformable. Tegaderm™ (3M Health Care Ltd) also is described as an intravenous dressing,33 although it is also indicated for the management of treatment of minor burns, pressure areas, donor sites, post-operative wounds, and a variety of minor injuries, including abrasions and lacerations. 34 Other semipermeable film dressings include Bioclusive (J&]), Epiview (ConvaTec) and Mefilm (Molnlycke). These dressings also have multiple indications but, although indicated for the management of IV sites, were not specifically developed for this purpose. 35 Vapor permeable film dressings dif-
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fer in relation to their thickness, weight, extensibility, moisture vapor transmission rate (MVTR), and gaseous permeability.36 The typical semi-permeable dressing is composed of a film (polyurethane, either extruded or solvent cast at approximately 30g/m2) and an adhesive (acrylic, solvent cast at 30g/m2).37 A number of semi-permeable dressings have since been developed, and while the various products differ, the general range of physical properties is37 : MVfR 400 - 900 glm2/24h; Oxygen permeability.. 0.2 - 3.0 Vm2/24h; Carbon dioxide permeability 100 - 200 Vm2/24h.
An MVTR ranging from 400 to 900 g/m2/24h is adequate to cope with the normal evaporation loss from skin; however, excess sweating may lead to moisture build-up. An accumulation of sweat and skin secretions may lead to the failure of the adhesive bond or the formation of wrinkles, through which bacteria may reach the dressing or catheter, may cause irritant dermatitis,38 or tissue maceration associated with an increase in bioburden of the skin, thereby increasing the possibility of wound infection. 39 It is in this context that differences in the MVTR of the various films may be important (Table III);33 however, there is a lack of gcxxi quality, randomized stud-
ies comparing different types of transparent dressings in the literature.
Highly permeable transparent dressings More recently, transparent dressings designed to improve moisture-vapor permeability have been produced. The N3000™ (formerly OpSite N3000) dressing (Smith and Nephew UK) is a reactive hydrophilic polyurethane film coated with a water-based hypo-allergenic acrylic adhesive, which is up to 8 times more permeable than earlier films. The manufacturers maintain that the increased permeability will lead to improved adhesion, resulting in less
Table IV: Studies of dressing type and incidence of eVe-related blood stream infection Author
Dressing Type
Infection rate (%) Gauze Transparent
Powell 198545
GO vs. OpSite
5/ 111(4.5)
8/262 (3.0)
Andersen 1986t5
GO vs. OpSite
1/75 (1.3)
2160 (3.3)
Young 198647
GO vs. OpSite
1/36 (2.8)
21132 (1.5)
Conley 1989" Oickerson 198<)46
GO vs. 0psite GO vs.TO
0/57 (0) 1/33 (3.0)
7/58 (16.7) 3/36 (8.3)
Shivnan 1991 *50
GO vs. Tegaderm
1/47 (2.1)
2151 (3.9)
Maki 1994t48
GO vs. Tegaderm
4/134 (3.0)
7/222 (3.1)
Maki 199649
GO vs. Tegaderm
8/191 (3.1)
5/204 (2.5)
Brandt 199651
GO vs. OpSite IV3000 Tegaderm vs. OpSite IV3000
1/53 (2.0)
5/48 (10.4)
NR
NR
Reynolds 1997*JJ
Treston-Aurand 1997 32
GO vs.TO vs OpSite IV3000
116/1374 (8.5%)
6/1677 (3.3)
Little 1998 11
GO vs. OpSite IV3000 Hydrocolloid vs. transparent
4/75 (5.3)
3/86 (3.4)
24/77 (36)
12174 (19)
Nicoletti 199957
GO = gauze TO = transparent dressing HPTP = highly permeable transparent dressing
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Remarks No significant difference in infection. Aseptic technique more important than type of dressing. No significant difference in CR-BSls, although a statistically significant difference was reported in the incidence of positive tip culture (p = 0.01) No significant difference was found between the dressing groups, despite differences in duration of wear time. Use of OpSite significantly increased CR-BRls The difference between the two groups was not significant (p = 0.34). No statistically significant difference in infection (exit-site). TOs associated with significant decrease in nursing time, local skin irritation and dressing costs No statistically significant difference between the two regimens No significant difference in CR-BSI, although cutaneous colonization was significantly greater in the Tegaderm group (p = 0.03). No significant difference was found in the rate of definite or suspected CVC sepsis 23/36 (64%) Tegaderm and 21/39 (54%) OpSite IV3000 had positive skin cultures (p = >0.1).There was no significant difference between the two dressings A significant difference existed in the rate of catheter-related infections using HPTOs vs. GOs or TOs.The rate of catheter related infection decreased by 25% using HPTOs. No significant difference between the two groups. Mean duration of catheterization was 8.5 - 1I days Use of a hydrocolloid dressing increased the risk of catheter colonization.
t Catheter related blood stream infections (CR-BSI) * Local skin culture NR = not reported
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Table V: Advantages and disadvantages of commercially available cannula dressings, adapted from Campbell and Carrington (1999).21 Promotes moisture vapor transmission Ease of application Ease of removal Allows visual inspection Cost t
tt
IV3000
Tegaderm
Veca-C
Nico-gard
~~~
~~
(II,OOOg/m
(735g/m
~~~
~~~
~
~~
~~~
~
~
~
~
~~~
~~
~
~~
~~~
~~
~~
~~~
~~~
~~~
mid-price range
mid-price rangett
inexpensive
inexpensive
inexpensive
Dermafilm
~
(SOOg/m
Data on file Smith & Nephew Although the 6 x 7 cm size is the most inexpensive of the Tegaderm range, further tape or bandage is often necessary to preserve the cannula.
dressing lift-up, longer wear times, and reduced handling. The IV3000 was specifically developed for use on intravenous access sites, and has an average MVP in excess of 11,000 glm2/24h.
Comparative Clinical Studies It is important to note that the properties of these dressings may have changed over time without a change in the branded name, making retrospective comparisons and systematic reviews in this area particularly problematic. A recent review of central venous catheter site care for blood and bone marrow recipients also reported that the heterogeneity of published studies with regard to patient population, frequency of dressing change and skin antisepsis as limiting factors in the ability to determine optimal catheter care practice. 40 A meta-analysis performed on studies using non-permeable or semi-permeable transparent dressings published between 1982 to 1989 reported a 53% increased risk of catheter tip infection associated with the use of these dressings. 17 Four additional studies published between 1985 to 1992 also raised the possibility that TDs might increase the risk of CRI.28,41-43 Interestingly, the study by Craven et alY noted a statistically ,significant higher rate of CRI in the summer months. Richet et al. 41 noted a higher rate of fever and bacteremia associated with central versus peripheral catheters. These studies illustrate that, in addition to the type of dressing used to secure the catheter in place, there are several variables that may affect the incidence of CRI.
Of the comparative clinical trials of dressings included in a recently published review,40 only one study44 showed a statistically significant increase in CRBSIs associated with the use of a semipermeable dressing (Table IV). It is important to note that this study was conducted in patients with central venous catheters in place for more than three days, and that only 115 patients were included in the study. Four other studies5.4>-47 included in an analysis by Zitella 40 failed to show any significant difference among the use of gauze, semi-permeable dressings, or highly permeable transparent dressings. In studies comparing Tegaderm to gauze,48-SO there was no significant difference in infection between the two regimens, although the study by ShivnanSO reported a significant decrease in nursing time and skin irritation in favor of the transparent dressing. Three comparative studies",33,S1 of the highly-permeable transparent dressing IV3000 also have shown no significant difference between dressing type and infection. One more recent large comparative study has reported a significant reduction of CRIs when HPTDs (IV3OOO) were utilized, in comparison to TDs and tape-gauze methodsY The use of IV3000 was associated with a significantly lower CRI rate (p=
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more than 178 extra patient days avoided with the use of the HPTD,
Discussion Transparent dressings have a number of advantages over tape and gauze dressings (Table V), including the fact that they allow visual inspection of the catheter site and are waterproof. The more recently developed HPTDs may also promote moisture vapor transmission and maintain a dry access site. 27 In vitro data 36,39 and one clinical study 52 have shown that there is less pooling of moisture tinder HPTDs, such as IV3000, and fewer incidences of the dressing becoming detached. Both of these factors may be important in avoiding unnecessary contamination of the access site and the development of CRIs,2,30,53 although clinical studies are needed to confirm these hypotheses. Important factors in the development of CRI are catheter material and location of the catheter. 54 A warm moist environment, conducive to a high microbial bioburden, may also increase the risk of infection,'6 and this would appear to be supported by the literature relating to newer HPTDs and their ability to prevent moisture accumulation under the dressing. 32,55 The large study by TrestonAurand et al.,32 which reported a 25% reduction in the rate of CRIs associated with the use of IV3000 compared with either gauze or Tegaderm, supports the use of HPTDs over other types of dressing. Further well controlled randomized studies are needed to investigate the reproducibility of these data, both in terms of infection rates and potential
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cost savings. Other published studies comparing catheter site dressings in clinical practice are limited by their small sample size and other confounding variables, such as aseptic technique and access site.
Conclusion Highly permeable transparent dressings are well tolerated by patients21 ,32.55 and are easy to apply and remove. 55 Despite initial concerns about an association with the use of transparent dressings and the risk of CRI, this risk would seem to only be associated with the use of occlusive film dressings 7 •
The development of higWy permeable film dressings has been a significant advance for the management of catheter sites, allowing the observation of the catheter site without the need for dressing removal and an increased level of patient comfort. Insertion site dressings are important in preventing trauma and the extrinsic contamination of the site of entry. In chOOSing an intravenous dressing, medical staff needs to be aware of the advantages and disadvantages of the dressings on the market to make an informed choice about the type to use.• AnnieJones is a Dphil student at the
Department of Health Sciences, York University, York, UK. Director: Magus Strategic Communications Ltd. Consultancy: Bayer AG, Bayer Corp., British Journal of Nursing, Chiron Corp., Gensoft Corp., PAREXEL MMS, Roche Corp., Smith & Nephew, Wyeth Pharmaceuticals. William Hirsch, MS is a Field Sales Development Manager with Boston Scientific Oncology Division with over 20 years experience in the development and manufactUring of medical devices. William seroed as a member of the Board ofDirectorsfor the Society ofPlastics Engineeringfor over 10 years.
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