4. injection caps

Injection Caps

Continuing Education

Injection Caps/Needleless Connectors

Needleless connectors (NCs) are devices used to connect catheters, administration sets, and/or syringes to deliver IV therapy.

They were introduced about 20 years ago to prevent needle stick injury to healthcare workers.

A Needless Connector automatically seals when the IV set or syringe is removed so that blood or fluids cannot leak out, air cannot enter in and introduction of microorganisms introduced can be minimized.

Other terms used to refer to NCs are ports, caps, split septum devices, mechanical valves, IV connectors, and IV access devices.

Types of Needless Connectors

The simple connector is a split septum device and has no internal mechanism. o It allows fluid to flow

straight through the device lumen.

The complex connector has a leur lock valve with various internal mechanisms which controls flow of fluid within the system.

PHOTO REFERENCE: http://t1.gstatic.com/images?q=tbn:ANd9GcQkWLCgA6ztOgcPx0Iox2pBI3_HcgU5-ZudZCgyhq0hF2JClTYSnTwYCI-O

There are two types of connectors:

Simple and Complex.

PHOTO REFERENCE: http://www.hpnonline.com/inside/2010-07/1007/OR-RyeMed-InVisionPlus-cutaway-connector.jpgPHOTO REFERENCE: http://medicaldesign.com/products/IV-connectors.jpg

To further categorize the needleless connector is the manner in which they function, thus displacing fluid inside the device.

Many devices allow for negative fluid displacement, meaning that blood reflux will occur into the catheter lumen while an administration set is attached and upon disconnection of an administration set or syringe.

Blood reflux allowed to reside inside the lumen can lead to full or partial occlusion of the catheter, biofilm formation and increased risk of HA-BSIs (Health associated blood stream Infections).

Negative pressure connectors necessitate the use of positive pressure flushing to overcome the blood reflux.

Functions of Needless Connectors

Some connectors contain mechanical valves designed to produce a positive fluid displacement upon disconnection of an administration set or syringe.

These valves contain a reservoir for holding a small amount of fluid that is pushed out to the catheter lumen upon disconnection of an administration set or syringe thus overcoming blood reflux.

This displacement of fluid only occurs during disconnection from the device, thus allowing blood reflux to occur should an empty IV container remain connected.

Functions of NC’s Cont.

Mechanical valves labeled as neutral devices prevent blood reflux upon connection and disconnection. o Some studies show there can be a very small amount of blood reflux

indicating it is not entirely neutral.

Though the term negative pressure and positive pressure have been associated with the needless connector, there is no pressure or force generated when the fluid movement occurs; it is a displacement of fluid within the device and catheter.

Functions of NC’s Cont.

Needleless Connector Devices

Brand of Device

Type of Displacement

Priming Volume

Luer Access or Luer Activated

Internal Mechanism

Antimicrobial CLAVE ®, ICU Medical, Inc

Negative 0.06mL/0.04mL

Luer Activated Mechanical valve with internal blunt cannula

CLEARLINK® V-Link,Baxter

Negative 0.25mL Luer Activated Mechanical Valve

INTERLINK®, Baxter

Negative 0.2mL No luer – blunt cannula access

None

Q-Syte™, BD Medical

Negative 0.10mL Luer Access None

SmartSite®, CareFusion

Negative 0.1mL Luer Activated Mechanical Valve

CLC2000®, ICU Medical, Inc

Positive 0.09mL Luer Activated Mechanical Valve

FLOLINK®, Baxter


MaxPlus®/MaxPlus Clear®/ MaxGuard®, Maximus Medical

Positive 0.28mL (all)

Luer Activated Mechanical Valve

Reference: AJN 2010 Vol 33. Needless Connectors: A Primer on Technology. Pg3

Needleless Connector Devices Cont.

Brand of Device

Type of Displacement

Priming Volume

Luer Access or Luer Activated

Internal Mechanism

Posiflow™, BD Medical


SmartSite® Positive Bolus, CareFustion


Ultrasite®/Ultrasite® Ag, B Braun Medical

Positive 0.35mL (both)

Luer Activated Mechanical Valve with internal spring

Bionector®, Vygon

Neutral 0.018mL Luer Activated Mechanical valve with internal blunt cannula

Invision-Plus®/ InVision-Plus® Junior ™, RyMed Technologies Inc

Neutral 0.027mL/0.022mL

Luer Activated Mechanical valve with internal blunt cannula

LifeShield TKO™LifeShield TKO™With split septumLifeShield TKO™ with CLAVE®, Hospira

Neutral <0.10mL0.10mL0.15mL

Requires addition of another connector No luer – blunt cannula access. Luer activated.

Pressure-sensitive valve ir all types

MicroCLAVE®, ICU Medcial, Inc

Neutral 0.02mL Luer Activated Mechanical valve with internal blunt cannula

Reference: AJN 2010 Vol 33. Needless Connectors: A Primer on Technology. Pg3

Complications Associated with Needleless Connectors

While the goal to prevent needle stick injury was ultimately achieved with the use of NCs, other issues have been linked to their use.

Since the 1990’s there has been much concern and controversy that certain types of NCs have contributed to an increased rate in CR-BSIs (catheter related-bloodstream infections) and Thrombotic Occlusions.

These complications can result in: o delays and disruptions in therapy o health riskso lengthy hospital stayso increased costs of care

Preventing Complications

It is difficult to determine the risks associated with each different NC since there have been no recent randomized trials comparing them.

Our focus must remain on o adhering to evidence-based infection control practices and

procedures o strict attention to hand hygiene o device cleaning o infection control surveillance

Enacting improvements in these areas will probably have a greater impact on reducing CR-BSIs then simply changing from one model of NC to another.

Care of the Needleless Connector

The National Patient Safety Goals from Joint Commission now require a standardized protocol for how to clean and disinfect all catheter ports and injection ports.

It is known that scrubbing the NC with mechanical friction is a critical element and it is clear that one swipe is not sufficient.

Before accessing any NC, performing proper hand hygiene must be performed using either antiseptic (preferable) or non-antiseptic liquid soap.

The NC should be disinfected with an appropriate disinfectant such as 70% alcohol by vigorously scrubbing the connector or hub for a minimum of 15 seconds before every connection.

Allow equal time for drying.

Care of the Needleless Connector Cont.

In addition to proper NC access, the correct flushing technique for each type of NC is imperative in preventing blood reflux which increases risk of thrombotic occlusion, biofilm formation and catheter assoc. bloodstream infections.

Different NC types require different sequences of flushing and clamping prior to disconnection of syringe.

Positive displacement needless connectors require clamping after syringe is disconnected. o Clamping before syringe disconnection will prevent the

internal mechanism from working as it is designed.

Flushing the Needless Connector

Negative displacement needleless connectors require flushing with a positive pressure technique.

This can be obtained in several ways. o If using a blunt cannula, this can be accomplished by

withdrawing the cannula as the last ml of solution is being flushed inward.

o Another technique calls for flushing then closing the clamp followed by disconnecting the syringe.

o This requires the finger remaining in place keeping force on the plunger until syringe is disconnected.

Neutral displacement connectors do not depend on any clamping/flushing sequence.

Flushing the Needless Connector Cont.

The optimal time frame for changing the needleless connector has not been determined.

INS guidelines recommend: o changing the needless connector if removed for any

reason o if there is blood or debris within the needless connector o prior to drawing a blood culture sample from the

catheter o upon contaminationo per organizational policies, procedures and/or practice

guidelines; or per the manufacturer’s directions.

Changing the Needleless Injection Cap

Although home infusion is likely safer than hospital infusion as demonstrated by lower CLABSI rates, bacteria are still present in the home and preventing contamination remains a challenge.

Obviously most patients and caregivers lack the extensive training and experience of a clinician.

If the clinician is not knowledgeable in the type and/or care of the needleless connector, even the most meticulous patient becomes at risk for infection, occlusion or other catheter related incident.

Conclusion

For home infusion providers who often rely strictly on patients and caregivers to correctly and consistently perform all the steps of IV self –administration, new technologies to improve and achieve positive patient outcomes are constantly being explored and trialed.

From antimicrobial impregnated needless connectors and central lines to alcohol impregnated caps, without a knowledgeable and competent clinical staff trained in product use and CLABSI prevention these goals will never be achieved.

Conclusion Cont.

And Always Remember:

References Hadaway, L. and Richardson, D. Needless Connectors: A Primer on

Terminology. Journal of Infusion Nursing. 2010;33(1) Jarvis,W. Infection Control Today. Choosing the Best Design for IV

Needleless Connectors to Prevent Healthcare- Associated Bloodstream Infections. 2010; 14( 8)

ECR institute. Health Devices: Evaluation: Needless Connectors 2008; 37( 9)

Leone,M. Preventing Central Line Associated Bloodstream Infections in the Home Through Use of Disinfection caps. NHIA 2011; 17( 6)

Btaiche, I, Kovacevich, D, Khalidi,N, Papke, L. The Effects of Needleless Connectors on Catheter-Related Thrombotic Occlusions. Journal of Infusion Nursing 2011; 34( 2)

Hadaway, L. Needless Connectors: Improving Practice, Reducing Risks. JAVA 2011; 16 ( 1)

CDC.gov Guidelines for the Prevention of Intravascular Related Infections

http://www.docstoc.com/docs/45449330/Scrub-Hub-poster

4. injection caps

Education

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