Infection from Invasive Infection from Invasive procedures procedures

Prepared by : Rasha Prepared by : Rasha MuslehMusleh20082008

NNeonatal babies in NICU departments are at eonatal babies in NICU departments are at high risk of infection, as those neonates high risk of infection, as those neonates came from sterile environment with low came from sterile environment with low immunity to any pathogensimmunity to any pathogens..

AllAll health care personnel who health care personnel who participate in invasive procedures should participate in invasive procedures should always use appropriate sterile barrier always use appropriate sterile barrier precautions to prevent transmitting precautions to prevent transmitting infection to neonatesinfection to neonates . .

By:By: proper hand washingproper hand washing

Sterile gloves &Surgical masksSterile gloves &Surgical masks Sterile Gowns and other protective Sterile Gowns and other protective

apparelapparel

HHealth-care institutions purchase millions of ealth-care institutions purchase millions of intravascular catheters each yearintravascular catheters each year . .

Intravascular cathetersIntravascular catheters provide necessary provide necessary vascular access; their use puts neonates vascular access; their use puts neonates at risk for local and systemic infectious at risk for local and systemic infectious complicationscomplications

. .Blood-stream infectionBlood-stream infection related related to the catheter is the most serious type to the catheter is the most serious type of catheter infectionof catheter infection..

Definition:Definition: isolation of the same micro- isolation of the same micro-organism from culture of a catheter organism from culture of a catheter segment or blood drawn from the catheter segment or blood drawn from the catheter and from blood preferably drawn from a and from blood preferably drawn from a peripheral vein of a patient with peripheral vein of a patient with accompanying clinical symptoms of BSI accompanying clinical symptoms of BSI and no other apparent source of infectionand no other apparent source of infection

The incidence of BSI varies The incidence of BSI varies considerably byconsiderably by type of catheter type of catheter frequency of catheter frequency of catheter

manipulation, manipulation, and patient-related and patient-related

factors (e.g., underlying factors (e.g., underlying disease and acuity of disease and acuity of illnessillness))

Other catheter related Other catheter related infectionsinfections

Colonized catheterColonized catheter Exit –site infectionExit –site infection : erythema : erythema

tenderness, induration or purulence within tenderness, induration or purulence within 2 cm of the skin at the exit site of catheter.2 cm of the skin at the exit site of catheter.

Tunnel infection : erythema tenderness : erythema tenderness and induration in the tissues overlying the and induration in the tissues overlying the catheter and > than 2 cm from the exit sitecatheter and > than 2 cm from the exit site

Infusate blood stream infectionInfusate blood stream infection. .

Catheter related blood stream Catheter related blood stream infectionsinfections

Catheter related blood stream infection Catheter related blood stream infection [CR-BSI] are associated with: [CR-BSI] are associated with:

Increased morbidity Increased morbidity Increased mortality Increased mortality Prolonged hospitalization.Prolonged hospitalization. Increased medical cost Increased medical cost

Peripheral venous cathetersPeripheral venous catheters are are the devices most frequently used the devices most frequently used for vascular accessfor vascular access . .

Although the incidence of (BSIs) Although the incidence of (BSIs) is rarely associated with these is rarely associated with these catheters but serious infectious catheters but serious infectious complications may occur.complications may occur.

In general complications In general complications occurred; occurred; up to one-fourthup to one-fourth of of catheters that can result in catheters that can result in serious morbidity & mortality.serious morbidity & mortality.

PCVCs CathetersPCVCs Catheters::

These catheters are the These catheters are the commonest cause of commonest cause of hospital-acquired hospital-acquired bloodstream infectionbloodstream infection..

Peripheral Arterial CathetersPeripheral Arterial Catheters::

Peripheral arterial catheters are Peripheral arterial catheters are usually inserted into the radial ,or usually inserted into the radial ,or femoral artery and permit continuous femoral artery and permit continuous blood pressure monitoring and blood blood pressure monitoring and blood gas measurementsgas measurements . .

Umbilical venous Umbilical venous catheter catheter::

InIn neonatal practice an neonatal practice an umbilical venous umbilical venous catheter can be used catheter can be used to deliver parenteral to deliver parenteral nutrition, particularly nutrition, particularly during the first week of during the first week of lifelife..To reduce the risk of To reduce the risk of infection maximum infection maximum sterile precautions sterile precautions should be used during should be used during the insertionthe insertion..

Catheters can become infected in several Catheters can become infected in several different waysdifferent ways::

1.1. through infection at the insertion site through infection at the insertion site which migrates along the catheter surface which migrates along the catheter surface

2.2. via contamination of the catheter ports via contamination of the catheter ports with subsequent colonization of the lumen with subsequent colonization of the lumen of the catheter of the catheter

3.3. or through hematogenous spread of or through hematogenous spread of infection arriving at the catheter from infection arriving at the catheter from pathogens entering the bloodstream from pathogens entering the bloodstream from other sources.other sources.

4.4. Administration of contaminated infusateAdministration of contaminated infusate

SSoo::

A number of guidelines A number of guidelines including skin prep should including skin prep should be reviewed and be reviewed and implemented as part of a implemented as part of a comprehensive program to comprehensive program to reduce infectionreduce infection . .

Each unit should have a Each unit should have a written policy on the written policy on the procedures governing the procedures governing the use of these cathetersuse of these catheters

General recommendations for General recommendations for IV device use ( AAP)IV device use ( AAP)

Health care workers education and trainingHealth care workers education and training Surveillance for catheter related infectionSurveillance for catheter related infection Proper hand washingProper hand washing Barrier precautions during catheter Barrier precautions during catheter

insertion and care insertion and care Selection and replacement of intravascular Selection and replacement of intravascular

device device Replacement of administration sets and Replacement of administration sets and

intravenous fluids.intravenous fluids. Preparation and quality control of Preparation and quality control of

intravenous admixture.intravenous admixture.

TThe first step that used to reduce coetaneous colonization of the skin he first step that used to reduce coetaneous colonization of the skin & to reduce infection especially those extremely low birth weight & to reduce infection especially those extremely low birth weight infants ( less than 1000 gm) are particularly at risk. includes:infants ( less than 1000 gm) are particularly at risk. includes:

1- disinfecting the site prior to insertion1- disinfecting the site prior to insertion 2-preventing colonization from other areas 2-preventing colonization from other areas

getting near the insertion site getting near the insertion site

3- and care of the site after insertion. 3- and care of the site after insertion.

Barrier precautionsBarrier precautions (--(--Appropriate Appropriate

washing To Alter washing To Alter the infectionthe infection) )

The current standard The current standard is the use of is the use of alcohol alcohol based solution with based solution with ethanol 60-85 %ethanol 60-85 % [[ManugelManugel] in ] in addition to hand addition to hand washingwashing..

----Patient skin Patient skin preparationpreparation

CCleans the skin with an leans the skin with an appropriate antiseptic appropriate antiseptic that include that include 70% 70% alcohol, or 10% alcohol, or 10% Povidone-iodinePovidone-iodine oror alcohol based alcohol based solution to solution to chlorhexidinechlorhexidine..

Do not palpate the insertion site after Do not palpate the insertion site after the skin has been cleaned.the skin has been cleaned.

Use Use sterile gauze for cleaning for cleaning Avoid contaminating catheter Avoid contaminating catheter Use transparent dressingUse transparent dressing Better to wear mask even when Better to wear mask even when

applying a peripheral venous catheter.applying a peripheral venous catheter. It is often necessary to remove the It is often necessary to remove the

catheter in order to clear the catheter in order to clear the infection).infection).

Surveillance for catheter Surveillance for catheter related infectionrelated infection

Conduct studies in your unit concerning Conduct studies in your unit concerning incidence of CR-BSI . incidence of CR-BSI . ( The reported incidences of catheter-( The reported incidences of catheter-

related sepsis in the NICU vary from) related sepsis in the NICU vary from) 5% to 5% to

nearly 40%nearly 40% Palpate the catheter insertion site daily Palpate the catheter insertion site daily

through intact dressing.through intact dressing. Visually inspect catheter site Visually inspect catheter site [better than [better than

to inspect it every hourto inspect it every hour] ]

RRedness or swelling if seen at any edness or swelling if seen at any time stop the infusion and establish time stop the infusion and establish a new IV line in a different vein or a new IV line in a different vein or artery & apply sterile gauze to artery & apply sterile gauze to prevent infection prevent infection

Record the date & time of catheter Record the date & time of catheter insertion in an obvious location near insertion in an obvious location near the catheter insertion site and on the catheter insertion site and on patient’s record patient’s record

Replacement of administration Replacement of administration set and intravenous fluidsset and intravenous fluids

CChange the IV infusion fluid bag hange the IV infusion fluid bag every 24 hoursevery 24 hours; even if the bag still ; even if the bag still contains IV fluid (they can be a contains IV fluid (they can be a major source of infectionmajor source of infection

RReplace IV tubings including eplace IV tubings including stopcocks & extension tubes using stopcocks & extension tubes using sterile techniquesterile technique no more no more frequently than frequently than 72 72 hours intervals hours intervals unless clinically indicated .unless clinically indicated .((Stopcock Stopcock contamination occurring contamination occurring in in 45% - 50%45% - 50% They are a potential They are a potential portal for entry of microorganisms portal for entry of microorganisms

Replace tubing used for lipid within Replace tubing used for lipid within 24 hours & Complete infusions of 24 hours & Complete infusions of lipid containing parenteral nutrition lipid containing parenteral nutrition within 24 hours also.within 24 hours also.

these products have been identified as these products have been identified as independent risk factors for BSI. independent risk factors for BSI.

Infusion of blood products should be Infusion of blood products should be completed within 4 hours of hanging completed within 4 hours of hanging the product. the product.

Preparation and quality control Preparation and quality control of intravenous admixtureof intravenous admixture

Admix all parenteral fluids in a laminar Admix all parenteral fluids in a laminar flow hood using aseptic technique.flow hood using aseptic technique.

Check all containers of parenteral fluid Check all containers of parenteral fluid for visible therapy, leaks, cracks, and for visible therapy, leaks, cracks, and the manufacturer’s expiration date the manufacturer’s expiration date before use.before use.

Use single dose vials for parenteral Use single dose vials for parenteral additives or medications whenever additives or medications whenever possible.possible.

If multi-dose vials are If multi-dose vials are usedused

- Refrigerate multidose vial after they are opened, if - Refrigerate multidose vial after they are opened, if recommended by the manufacturer.recommended by the manufacturer.

- Clean the rubber diaphragm with alcohol before use.- Clean the rubber diaphragm with alcohol before use. - Use a sterile device each time a multidose vial is - Use a sterile device each time a multidose vial is

accessed, and avoid touch contamination of the accessed, and avoid touch contamination of the device before penetrating the rubber diaphragm.device before penetrating the rubber diaphragm.

- Discard multi-dose vials when empty, when suspected - Discard multi-dose vials when empty, when suspected or visible contamination occurs, or when the or visible contamination occurs, or when the manufacturer’s stated expiration date is reached manufacturer’s stated expiration date is reached

Additional specific risk factors include prolonged use of Additional specific risk factors include prolonged use of parenteral nutrition [ lipid emulsion]parenteral nutrition [ lipid emulsion] ( (MathieuMathieu 2006 2006).).

Preparation of parenteral Preparation of parenteral nutrition under laminar flow at nutrition under laminar flow at

HFHHFH

ConclusionConclusionSSo it is very important to handle the o it is very important to handle the invasive procedures in invasive procedures in sterile waysterile way and to and to adopt a special guidelinesadopt a special guidelines in performing any invasive in performing any invasive procedureprocedure

))sterile way in care, giving any sterile way in care, giving any medication, IV fluids medication, IV fluids administrationsadministrations))

PCVC insertion at PCVC insertion at HFHHFH

ReferencesReferences::--Exposure to invasive procedures in neonatal intensive care unit Exposure to invasive procedures in neonatal intensive care unit

admissions,admissions, DP Barker and N Ruttera ,archives of Disease in DP Barker and N Ruttera ,archives of Disease in Childhood - Fetal and Neonatal edition, Vol 72, November 1, 2006; Childhood - Fetal and Neonatal edition, Vol 72, November 1, 2006;

91(6): F448 - F45391(6): F448 - F453 , ,www.http://fn.bmj.com/PDFwww.http://fn.bmj.com/PDF..

- -Journal of Research in NursingJournal of Research in Nursing, Mathieu, September 1, 2006; 330 – 353, , Mathieu, September 1, 2006; 330 – 353, www .http://fn.bmj.comwww .http://fn.bmj.com ./ ./

--DDo WE STII hurt Newborn babies, WE STII hurt Newborn babies, Mangureten, S.H. Scott and C.E. Mangureten, S.H. Scott and C.E. Guzetta et al ,2003,F54-F55Guzetta et al ,2003,F54-F55 , ,www.http://www.http://archpedi.ama-assn.orgarchpedi.ama-assn.org/.pdf/.pdf

--Neonatal SepsisNeonatal Sepsis, (Adapted from Schrag S, Gorwitz R, Fultz-Butts K, , (Adapted from Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A)Schuchat A) November 2005 , November 2005 ,http://www.merck.com/.htmlhttp://www.merck.com/.html

--Infection Control Program ModeratorInfection Control Program Moderator , October , 2006,  , October , 2006, http://www.apic.org/http://www.apic.org/ sourcesource././

--Infection control program, sepsis,Infection control program, sepsis, AAP, AAP, http: /www.apic.comhttp: /www.apic.com