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Canada Communicable Disease Report

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Canada Communicable Disease Report - Supplement
Volume: 23S8
December 1997

INFECTION CONTROL GUIDELINES

Preventing Infections Associated with Indwelling Intravascular Access Devices

Care of Intravascular Therapy System Components

The components of intravascular therapy delivery systems (see Figures 2and 3) can become contaminated, leading to growth of potential pathogens on the system's inner surfaces(2). Measures to prevent contamination (asepsis), to prevent growth of contaminants (antisepsis) and to prevent microbial growth from reaching dangerous levels are proven methods to prevent intravascular device-associated infections. Complex intravascular systems, such as pressure monitoring systems, present more opportunities for contamination and are well documented as reservoirs of infection(79,80). Various guidelines have been issued(81). Current data indicate that for most purposes 72 hours is a safe duration of use. Longer durations may become acceptable if proven equally safe. Recent studies have suggested that the use of needle-less injection systems may compromise the sterility of the lumenal contents of the injection port (Figure 3) and lead to an increased risk of intravascular-device related infections(82,83). Further evaluation of these devices is required. Data regarding use of materials for longer than 72 hours are discussed in detail in the recommendations.

RECOMMENDATIONS

Administration Sets and Delivery Systems

  1. With six exceptions, all intravascular delivery system components up to the hub should be changed at 72 hour intervals(84-87). This applies to all intravascular lines, including those used for total parenteral nutrition. Scheduled changes should be planned to minimize the number of times that the closed fluid path is opened. (Category A; Grade I)

  2. The six exceptions are:

    1. administration of blood products (tubing and administration sets should be changed as soon as possible after administration)(Category C);

    2. administration of lipid emulsion (total system in 24 hours) (Category B; Grade III);

    3. a suspected epidemic of infusion-related septicemia (total system in 24 hours)(Category B; Grade III);

    4. on site compounded solutions or admixtures with a high rate of contamination (total system in 24 hours) (Category B; Grade III);

    5. arterial pressure monitoring, for which 96 hours is acceptable (see Section D below) (Category B; Grade II); and

    6. administration of commercially prepared admixtures (recommendations of the manufacturers to be followed) (Category C).

  3. Solutions other than blood, blood components, lipids, or those with time-limited stability should be completely used or discarded at the time of delivery system change (72 hours). If excessive infection rates appear to be associated with fluid contamination, then all solutions should be completely used or discarded within 24 hours of starting the infusion. (Category A; Grade III)

  4. Blood specimens should not be drawn through single-lumen peripheral or central venous lines intended for infusions except when essential to obtain a specimen or when catheter-associated bacteremia is suspected. A specific lumen from a multi-lumen line should be dedicated for blood-letting. (Category B; Grade III)

  5. The entire intravascular system (cannula, administration set, and fluid) should be changed immediately if purulent thrombophlebitis, cellulitis, or intravascular device-related bacteremia is diagnosed or strongly suspected in a patient with a peripheral or non-tunnelled central line (Table 2). If an intravascular system is to be discontinued because of suspected device-related infection, appropriate cultures of the fluid and cannula should be obtained. Blood and other clinical material should also be obtained for culture as appropriate. If infection is suspected or documented in a patient with a tunnelled central venous line (CVL) for long-term venous access, depending on the organism an attempt may be made to treat the infection with antibiotics without removing the line, provided that the patient remains hemodynamically stable. (Category A; Grade III)

  6. Ideally, sterile components should not be assembled until actually needed(88). Sterile intravenous equipment components should be stored in a clean, dry and secure environment without spiking or priming with intravenous solutions. (Category B; Grade III)

Hubs, Stopcocks and Other Connectors (Figures 1, 2 and 3)

  1. Systems should be set up to minimize the numbers of ports, connections, and blind stagnant columns of fluid as much as possible(24,89,90). (Category A; Grade II)

  2. Staff who have exudative dermatitis or other open lesions should wear gloves when manipulating intravascular lines and junctions for the protection of both the patient and themselves(91). (Category B; Grade III)

  3. The frequency of handling and manipulation of the cap should be minimized to reduce the risk of contamination. The optimal timing for changing hub caps is not known. (Category C)

  4. Any open stopcock or injection port (Figure 3) should be protected with an appropriate cover. (Category B; Grade III)

  5. Injection ports (Figure 3) and stoppers should be decontaminated with 70% isopropyl alcohol or other appropriate disinfectant (see Appendix III) prior to puncturing. If iodophors are selected, a disinfectant rather than an antiseptic formulation should be used(92,93). Swabs used for skin antisepsis should not be used. The current and commonly used antiseptic formulations are not considered adequate for this purpose (concentration: 30-50 mg free iodine/litre). (Category B; Grade III)

  6. Novel hub and connector designs that improve the security of junctions may promote lower risk of infection(94-96). Their evaluation should be encouraged. (Category C)
  7. Appropriate alternatives should be used to ensure safety in providing intravascular therapy when latex allergy is of concern(97). (Category B; Grade III)

Filters

  1. In line filters should not be used as an infection prevention measure(98,99). (Category E; Grade II)

Pressure Transducers

  1. If disposable transducers (see Appendix III) and chamber-domes (Figure 2) are used for hemodynamic monitoring, there appears to be no need to replace the entire transducer assembly or other delivery system components, including flush solutions, more frequently than every 4 days(41), and it may be safe to adopt a "no-routine change" policy(100). (Category B; Grade II)

  2. Reusable intravascular pressure transducers and domes should be sterilized between uses(101-105). (Category A; Grade II)

  3. Ideally, sterile components should not be assembled until actually needed. When assembled, the space between the transducer head and dome membrane (see Figure 2) should be left dry or, if fluid is required, filled with bacteriostatic normal saline, bacteriostatic water, or 70% alcohol (if this will not cause damage). Glucose-containing solutions should not be used. If equipment must be assembled in advance of use, equipment should be stored in a clean, dry and secure environment. (Category B; Grade III)

  4. The patency of pressure-monitoring cannulae should be maintained through use of a closed flush system rather than use of a syringe and stopcock. (Category B; Grade III)

Admixture of Solutions

  1. Parenteral fluids should be admixed (compounded) using the equivalent of the good manufacturing practices that are standard in commercial preparation of pharmaceuticals. These include aseptic technique, a closed fluid path, terminal filtration with positive rather than negative pressure, and appropriate laminar flow. (Category B; Grade III)

  2. All containers of parenteral fluid should be checked for visible turbidity, leaks, cracks, particulate matter, and expiry date before use. If a problem is found, it should be reported to the appropriate authority and the fluid should not be used. (Category B; Grade III)

  3. Injection ports (Figure 3) and stoppers should be decontaminated with 70% isopropyl alcohol or other appropriate disinfectant prior to puncturing. If iodophors are selected, a disinfectant rather than an antiseptic formulation should be used(92). The current and commonly used antiseptic formulations (concentration: 30-50 mg free iodine/litre) are not considered adequate for this purpose. Clean vial stoppers may be wiped with alcohol(106). (Category B; Grade III)

  4. Single-use containers should be used for admixture whenever possible. (Category B; Grade III)

  5. A distinctive supplementary label should be attached to each admixed parenteral fluid giving, as a minimum, the additives and their dosage, the date and time of compounding, the expiration time, and the person who did the compounding. (Category B; Grade III)

  6. Routine culture of parenteral fluids, as a check on sterility, should not be adopted as an infection prevention measure. (Category D; Grade III)

  7. Admixed parenteral fluids not used immediately should be stored at 4° C. They may be used for up to 1 week unless a shorter duration is indicated by drug instability(107). (Category B; Grade III)

Other Sources of Contamination

Bacteremia has been attributed to contamination from ice used to chill syringes that were used to sample blood from stopcocks(108). Ice used for this purpose should not be brought to the bedside. Other outbreaks were attributed to contaminated fluids used to flush central lines(109,110) and to reuse of pre-filled retrograde medication syringes(111). Care should be taken to avoid contamination in the storage and use of any devices and supplies associated with intravascular care. (Category A; Grade II)

Figure 1
Sources of infection of a percutaneous intravascular device(2). (Figure is used with permission of author and publisher.)Figure 1

Figure 2
Components of pressure monitoring system

Figure 2

Figure 3
Diagram of IV tubing containing IV fluid roller clamp, injection port and IV cannula

Figure 3

 

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