Intravascular devices are an integral part of contemporary anesthesia care. However, catheter-related infections are associated with significant morbidity and mortality.^1-3 Infectious complications associated with the use of intravascular devices range from minor local inflammation to life-threatening septic complications, including septic thrombophlebitis, endocarditis and bloodstream infections with infection at distant sites (e.g., osteomyelitis, endophthalmitis, arthritis) resulting from hematogenous seeding of another body site by a colonized catheter.

In fact, there are an estimated 200,000 nosocomial bloodstream infections annually,⁴ though the rates of device-related bloodstream infections vary considerably by hospital size, hospital unit and the type of device used. Certainly, most nosocomial bloodstream infections are related to the use of an intravascular device, and the incidence is substantially higher among patients with intravascular devices.⁵ Further, the incidence as well as the potential risk factors for intravascular device-related infections may vary considerably with the type of device and therapy it is used to render.

Intravascular-device infection rates vary between short-term, temporary vascular access devices and long-term, indwelling vascular devices. Devices used for short-term vascular access include short peripheral venous catheters, peripheral arterial catheters, midline catheters, nontunneled central venous catheters, central pulmonary arterial catheters and peripherally inserted central venous catheters. Devices used for long-term vascular access include tunneled central venous catheters and totally implantable intravascular devices.

The Centers for Disease Control and Prevention (CDC) has recently published guidelines for prevention of intravascular device-related infections.⁶ It provides an overview of the evidence for recommendations considered prudent by consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) members and updates the previously published guidelines.⁷ The document discusses many of the issues and controversies in intravascular device use and maintenance. These include the definition and diagnosis of catheter-related infection, appropriate barrier precautions to be used during catheter insertion, intervals for replacement of catheters, fluids and administrations sets, catheter-site care and the use of prophylactic antimicrobials, flush solutions and anticoagulants. HICPAC bases its recommendations on published data with adequate scientific documentation. The CDC guidelines focus on the intravascular devices most commonly used in health care settings, including arterial catheters, central venous and arterial catheters, peripherally inserted central venous catheters and pressure monitoring systems. In addition, recommendations related to intravascular device-related infections in pediatric patients and infections associated with parenteral nutrition and hemodialysis were also addressed.

The CDC guidelines outline strategies for the prevention of catheter-related infections. Clearly, strict adherence to hand-washing and aseptic technique remains the cornerstone of prevention of catheter-related infections. However, other factors to be considered in formulating preventive strategies include the selection of an appropriate site of catheter insertion and type of catheter material, use of barrier precautions during catheter insertion, replacement of catheters, administration sets, and I.V. fluids at appropriate intervals, appropriate catheter-site care and the use of filters, flush solutions, prophylactic antimicrobials and newer intravascular devices, including impregnated catheters and needleless infusions systems.

One of the controversial areas relevant to current anesthesia practice was the recommendation by HICPAC of the preferred site for central venous catheter insertion. In the draft guidelines published in the Federal Register on September 27, 1995, it was proposed that clinicians "use subclavian rather than jugular or femoral sites for central venous catheter placement unless medically contraindicated (e.g., coagulopathy)."⁸ In response, the ASA Task Force on Infection Control of the Committee on Occupational Health of Operating Room Personnel commented to the CDC that infectious complications are but one potential hazard of central venous catheter placement, and other factors must be considered when selecting a cannulation site. The final document incorporated the ASA concerns such that "several factors should be assessed when determining the site of catheter placement, including patient specific factors (e.g., pre-existing catheters, anatomic deformity, bleeding diathesis), relative risk of mechanical complications (e.g., bleeding, pneumothorax) and the risk of infection."⁶ Thus, while central venous catheters inserted via the subclavian vein have a lower risk for infection than do those inserted using either the jugular or femoral veins, the mechanical complications associated with catheterization of the internal jugular vein are less common than with subclavian vein insertion. Therefore, it is important for the anesthesiologist to weigh the risks and benefits of placing a device at a recommended site to reduce infectious complications against the risk of mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, hemothorax, thrombosis, air embolism, catheter malposition). So, while internal jugular insertion sites may pose a greater risk for infection because of their proximity to oropharyngeal secretions and difficulty in immobilizing the catheter, the mechanical complications are less and may be the site of choice for perioperative central venous catheter placement.

The CDC has recommended maximal barrier precautions during central venous catheter insertion. These precautions include the use of sterile technique using a sterile gown and gloves, a mask and a large sterile drape. Maximal barrier precautions should also be used even if the catheter is inserted in the operating room. The use of submaximal barrier precautions (i.e., gloves, small fenestrated drape) has been shown to increase the incidence of catheter colonization and be associated with subsequent bloodstream infections compared to catheters inserted on the ward or in the intensive care unit with maximal barrier precautions.^9,10 The CDC suggested, based on the current literature, if maximal barrier precautions are used during central venous catheter insertion, catheter contamination and subsequent catheter-related infections could be minimized, regardless of whether the catheter was inserted in the operating room or at the patient's bedside. Unfortunately, few data exist defining the specific risk factors for infection of catheters with use limited to the perioperative period.

As in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability and economic impact. However, the previous CDC system for categorizing recommendations has been modified as follows:⁸

Category IA: Strongly recommend for all hospitals and strongly supported by well-designed experimental or epidemiologic studies.

Category IB: Strongly recommend for all hospitals and viewed as effective by experts in the field and a consensus of Hospital Infection Control Practices Advisory Committee (HICPAC), based on strong rationale and suggestive evidence, even though definitive scientific studies may not have been done.

Category II: Suggested for implementation in many hospitals. Recommendations may be supported by suggestive clinical or epidemiologic studies, a strong theoretical rationale or definitive studies applicable to some, but not all, hospitals.

No recommendation; unresolved issue: Practices for which insufficient evidence or consensus regarding efficacy exist.

Current Recommendations Regarding Central Venous and Arterial CathetersI. Selection of catheter

1. Use a single-lumen central catheter, unless multiple ports are essential for the management of the patient. Category IB
2. Use either a peripherally inserted central venous catheter, a tunneled catheter (e.g., Hickman or Broviac) or an implantable vascular access device (i.e., port) for patients 4 years of age or older in whom long-term vascular access (>30 days) is anticipated. Consider use of a totally implantable access device for younger pediatric patients (age <4) who require long-term vascular access. Category IA

II. Selection of catheter-insertion site

1. Weigh the risks and benefits of placing a device at a recommended site to reduce infectious complications against the risk of mechanical complications. Category IA
2. Use subclavian, rather than jugular or femoral, sites for central venous catheter placement unless medically contraindicated. Category IB
3. No recommendation on preferred site for insertion of pulmonary artery catheters. Unresolved issue

III. Barrier precautions during catheter insertion

1. Use sterile technique, including a sterile gown and gloves, a mask, and a large sterile drape (i.e., maximal barrier precautions) for the insertion of central venous and arterial catheters. Use these precautions even if the catheter is inserted in the operating room. Category IB

IV. Replacement of catheter

1. Do not routinely replace nontunneled central venous catheters as a method to prevent catheter-related infections. Category IA
2. Replace pulmonary artery catheters at least every five days. Category IB
3. Guide wire exchange
   1. Use guide wire-assisted catheter exchange to replace a malfunctioning catheter or to convert an existing catheter if there is no evidence of infection at the catheter site. Category IB
   2. If catheter-related infection is suspected, but there is no evidence of local catheter-related infection, remove the existing catheter and insert a new catheter over a guide wire. Send the removed catheter for culture. Leave the new catheter in place if the culture is negative. If the catheter culture indicates colonization or infection, remove the newly inserted catheter and insert a new catheter at a different site. Category IB
   3. Do not use guide wire-assisted catheter exchange whenever catheter-related infection is documented. If the patient requires continued vascular access, remove the implicated catheter and replace it with another catheter at a different insertion site. Category IA

V. Catheter and catheter site care

1. Do not use single-lumen parenteral nutrition catheters for purposes other than hyperalimentation. Category IB
2. Routinely flush indwelling central venous catheters with an anticoagulant. Groshongs may not require routine flushing with an anticoagulant. Category IB
3. Do not routinely apply antimicrobial ointment to central venous catheter-insertion sites. Category IB
4. Do not apply organic solvents to the skin before insertion of parenteral nutrition catheters. Category IA
5. Replace catheter site dressings when the device is replaced, when the dressing becomes damp, loosened or soiled, or when inspection of the site is necessary. Category IB
6. No recommendation for the frequency of routine replacement of dressings used on central catheter sites. Unresolved issue

References:

1. Smith RL, Meixler SM, Simberkoff MS. Excess mortality in critically ill patients with nosocomial bloodstream infections. Chest. 1991; 100(1):164-167.
2. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients: Excess length of stay, extra costs and attributable mortality. JAMA. 1994; 271(20):1598-1601.
3. Arnow PM, Quimosing EM, Beach M. Consequences of intravascular catheter sepsis. Clin Infect Dis. 1993; 16(6):778-784.
4. Maki DG. Infections due to infusion therapy. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston, MA: Little, Brown and Co; 1992.
5. Jarvis WR, Edwards JR, Culver DH, et al. Nosocomial infection rates in adult and pediatric intensive care units in the United States. National Nosocomial Infections Surveillance System. Am J Med. 1991; 91:185S-191S.
6. Simmons BP. CDC guidelines for the prevention and control of nosocomial infections. Guideline for prevention of intravascular infections. Am J Infect Control. 1983; 11(5):183-199.
7. Pearson ML. Guideline for prevention of intravascular device-related infections. Part I. Intravascular device-related infections: An overview. The Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1996; 24(4):262-277.
8. Part II Department of Health and Human Services Centers for Disease Control and Prevention. Intravascular Device-Related Infections Prevention; Guideline Availability; Notice. Federal Register, September 1995.
9. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: A prospective study utilizing molecular subtyping. Am J Med. 1991; 91:197S-205S.
10. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infection Control Hosp Epidemiol. 1994; 15:231-238.

Morris Brown, M.D., is Professor of Anesthesiology at Wayne State University School of Medicine, and Chair of the Department of Anesthesiology at Sinai Hospital, Detroit, Michigan.
E-mail the author.

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