Wading through VAD dressing protocol

How to respond to changes in VAD protocols

By Nancy Moureau, BSN, CRNI

President

PICC Excellence

Infusion Insights Newsletter

Orange Park, FL

Recent publications by the Centers for Disease Control (CDC) and the Oncology Nurses Society (ONS) have provided alternatives to the standard peripheral or central line dressing change protocols. The CDC has released two publications in the last two years that address intravascular infection, identification, and prevention issues relating to vascular access devices (VADs).1,2

The ONS provides detailed information on technology, definitions of devices, insertion, usage and maintenance, in addition to cost comparisons, complications, advantages and disadvantages related to VADs.3 This is the most complete, current document specific to VADs.

Organizations such as the Intravenous Nurses Society (INS), the American Society for Enteral and Parenteral Nutrition (ASPEN), and the National Association of Vascular Access Networks (NAVAN) have practice recommendations or standards available or in the works for VADs.

Traditional nursing dressing change protocols have used variations on alcohol and betadine prepping, with some form of dressing cover for all VADs. INS Standards of Practice advocate the use of 70% alcohol, tincture of iodine, 1% to 2% iodophors or chlorhexidine to be used as prepping agents for VAD insertion or maintenance. INS encourages the use of alcohol first, then betadine, without blotting or wiping off the betadine. ONS guidelines do not recommend a single method, but compare research findings for dressing changes to common practice. The CDC lists INS’ prepping agents, but specifies 2% chlorhexidine. The 70% alcohol, tincture of iodine, 10% providone iodine and 2% chlorhexidine were all listed as effective antiseptic agents by the CDC, ONS, and INS. Whichever single prepping agent or combination of agents are used, each reference points to the need for thorough skin cleansing with antimicrobial agents for catheter insertion or dressing care:

Alcohol 70% — Used as an antiseptic, alcohol cleans the skin, removing organic materials, i.e. dirt, blood, and other body contaminants. Alcohol’s antiseptic action continues until dry, with no residual action. The removal of organic substances by alcohol can enhance the action of iodophor prepping agents.

Iodophor solutions — Once dry, iodophor solutions act as an antimicrobial, killing Gr+, Gr-, TB, Fungi, and viral contaminants. Residual activity of iodophors continue up to eight hours. Iodophor in 10%, tincture or 1% to 2% iodine, has long been considered a skin irritant. Mixing alcohol with 10% iodophor results in a tincture composition, which may cause a higher rate of irritation. Some institutions remove iodophor with alcohol to reduce irritation and allow for better site visualization. When the iodophor solution is removed with alcohol or by blotting, little to no residual antimicrobial effect remains.

Chlorhexidine — A widely used antimicrobial solution in Europe and Britain, recommended 2% chlorhexidine solutions are not yet available in the United States. 0.5% solutions of chlorhexidine, in the form of Hibiclens (soapy scrub) or Hibistat are available in bulk form (non-sterile). Chlorhexidine promotes active cell wall destruction with Gr+, Gr-, fungal and viral pathogenic action.3 Residual activity of chlorhexidine continues for up to 72 hours, with action enhanced after subsequent applications.4 A chlorhexidine gluconate impregnated patch is available. The Biopatch is a disc with timed released chlorhexidine antimicrobial action lasting for seven days. The Biopatch may be indicated for immunocompromised patients and those at great risk if an infection develops. The CDC does not recommend chlorhexidine as a catheter site care agent.

Upon completion of a prepping procedure for site maintenance, a covering is applied to protect the site from pathogens and secure the VAD. Steristrips or sterile tape may also be necessary when dressing for Midlines or peripherally inserted central catheters (PICCs). Transparent dressings have provided a reliable means of securing all types of VADs. These dressings are semipermeable, allowing moisture to be released through the dressing. Some dressings such as Smith and Nephew’s OpSite 3000 and 3M’s Tegaderm HP are specifically designed as moisture-releasing transparent covers for IV sites. Both CDC and INS list length of optimal time for a transparent dressing to cover a VAD as unknown. Other data suggests that transparent dressings can safely cover a VAD for up to seven days ONS illustrates the most common policy for dressing changes for VAD, specific to central access, at five to seven days, or as needed.5

Gauze and tape can be used in place of transparent dressings, but require more frequent changes. The ONS, CDC, and INS agree that gauze dressings should be changed at least every 48 hours. Inability to visualize the site, moisture absorption and a prime environment for bacterial growth are considered the basis for 48-hour-change rule. Studies demonstrate bacteria growth in 4.6% of gauze dressings and 5.7% in transparent.6 Gauze dressings allow greater airflow to the insertion site but can be difficult to maintain with adherence to the skin.

Study finds no difference between two groups

A Canadian study found no significant difference between two dressing groups of HIV patients with different types of dressing regimens.7 One group used the traditional transparent dressings, changed once a week, and as needed. The other group used no dressing after the first week of site care. The no dressing group found a 15.7% local infection rate, compared with a 20% local infection rate with the transparent dressings in this high-risk group. The CDC lists the frequency of dressing changes as an unresolved issue. It makes no recommendation for the routine replacement of dressings on central catheter sites. Other studies are in progress in which patients wear clean cloth coverings, such as socks, over peripheral sites and PICCs. The findings to date have demonstrated very low infection rates.

Vascular access devices can be maintained with dressings based on the frequency of need for outer cover and securement. Transparent central VAD dressings maintain support for change every five to seven days and gauze dressings every 48 hours. Peripheral site VAD dressings are changed with each site rotation. All dressings should be changed whenever loose, damp, or soiled. Site preps include 70% alcohol, tincture of iodine, 10% iodophor or chlorhexidine solutions, with an effort to maximize the residual effects by leaving the iodophor or chlorhexidine as the last agent on the site. Whichever prepping method or dressing regimen is followed, outcome monitoring is needed to demonstrate acceptably low infection rates.

References

1. Centers for Disease Control and Prevention. Part II Intravascular Device-Related Infections Prevention Draft Guideline Availability Notice. Department of Atlanta or Washington, DC., Health and Human Services. Federal Register:(September 1995) vol. 60.

2. Pearson ML. Guideline for the prevention of intravascular-device-related infections. Infect Control and Hosp Epidemiol 1996; 17:438-473.

3. Oncology Nurses Society. Access Device Guidelines: Recommendations for Nursing Practice and Education. Pittsburgh; Fall 1996.

4. Maki DG., et.al. Prospective Randomized Trial of Providone Iodine, Alcohol and Chlorhexidine for Prevention of Infection Associated with Central Venous and Arterial Catheters. Lancet 1991; 338:339-343.

5. Young GP, et.al. Catheter Sepsis During Parenteral Nutrition: The Safety of Long-term OpSite Dressings. Journal of Parenteral and Enteral Nutrition 1988; 12:365-370.

6. Maki DG, M Ringer. Evaluation of Dressing Regimes for the Prevention of Infection with Peripheral Intravenous Catheters. JAMA 1987; 258:2,396-2,403.

7. LaPlume M, et.al. A One Year Comparative Evaluation of Two Dressing Techniques for Central Venous Catheters in HIV Patients. Immunodeficiency Clinic, Toronto (Ontario) Hospital; 1994.