CVAD antiseptic solution and cleaning of the skin and catheter

Section Recommendation statement Grading of recommendations
8.
  • Single use 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is the preferred antiseptic agent for insertion and dressing of CVADs (1-3).
  • If this is not available, chlorhexidine 0.5% in 70% alcohol or iodine in alcohol should be used (4-9).
  • Solutions must not be decanted into smaller containers and unused portions must be discarded.
  • Where a patient demonstrates chlorhexidine sensitivity, topical povidone iodine 10% in 70% alcohol may be used.
NSW Policy
9. Avoid organic solvents (e.g. acetone, ether or adhesive remover wipes) on the CVC or surrounding skin (9, 10). Grade B
10. Prior to cleaning with chlorhexidine in alcohol, Sterile 0.9% saline is to be used to remove dried blood and/or other fluids from around the catheter and under the securement hub. Consensus
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Based on available evidence alcohol-containing antiseptics, particularly those with chlorhexidine, are recommended for preparing for CVAD interventions as they are associated with a significantly lower risk of CRBSI compared with the use of aqueous solutions. The concentration of chlorhexidine in relation to infection is currently being examined in a randomised controlled trial in Dublin, Ireland. The research findings should be available to inform this recommendation in 2014. The following solutions are recommended in PD 2011_060 in preferential order:

  1. topical chlorhexidine 2% in 70-80% alcohol (lower concentrations of chlorhexidine (0.5­­‑1%) may also be used (e.g. for infants)
  2. topical povidone iodine 10% in 70% alcohol.

Other antiseptic alternatives for use on keratinised skin are inferior to the above products but include:

  1. topical chlorhexidine 1-2% in water (aqueous preparation)
  2. topical povidone iodine 10% in water.

All solutions must be allowed to dry before CVAD interventions to ensure optimal antimicrobial effect is achieved. Alcohol-based solutions will dry faster. Alcohol has an immediate antiseptic action, whereas chlorhexidine has a residual antimicrobial action for around seven days. Sterile saline or water solutions alone are not acceptable antiseptic solutions and should only be used to clean the skin of gross contaminants prior to applying antiseptic solution.

Safety alert - Antiseptic allergy

Before applying any antiseptic agent clinicians must check for the presence of allergies.

Aseptic non-touch technique

There are a number of ways that clinicians refer to and practise in relation to maintaining asepsis when accessing and touching attachments to the CVAD . Aseptic technique aims to prevent pathogenic organisms from being introduced to susceptible sites by hands, surfaces and equipment. Aseptic non-touch technique involves using an aseptic technique while also protecting the CVAD and insertion site by undertaking appropriate hand hygiene, touching the minimum number of parts required to perform an intervention (non-touch technique), using sterile equipment and/or cleaning existing parts so that asepsis is achieved prior to use (11). Confusion often arises about when sterile gloves should be used during practice. This is clearly identified in the Australian Guidelines for the Prevention and Control of Infection in Healthcare 2010(12) and should be referred to for further information. For more information about Aseptic non-touch technique (ANTT®) refer to the Association for Safe Aseptic Practice.

Grading of Recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (13)

References

  1. National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare 2010.
  2. Bishop L, Dougherty L, Bodenham A, Mansi J, Crowe P, Kibbler C, et al. Guidelines on the insertion and management of central venous access devices in adults. International Journal of Laboratory Hematology. 2007;29(4):261-78. PubMed PMID: 17617077.
  3. Infection Control Guidelines Steering Committee. Australian Guidelines for the Prevention and Control of Infection in Healthcare Executive Summary. In: Healthcare ACoSaQi, editor.: Australian Government; 2010.
  4. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis.[Summary for patients in Ann Intern Med. 2002 Jun 4;136(11):I26; PMID: 12044142]. Annals of Internal Medicine. 2002;136(11):792-801. PubMed PMID: 12044127.
  5. Astle CM, Jensen L. A Trial of ExSept® for Hemodialysis Central Venous Catheters. Nephrology Nursing Journal. 2005;32(5):517-25. Epub Sep/Oct 2005.
  6. Mimoz O, Villeminey S, Ragot S, Dahyot-Fizelier C, Laksiri L, Petitpas F, et al. Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care. Archives of Internal Medicine. 2007;167(19):2066-72. PubMed PMID: 17954800.
  7. Parienti J-J, du Cheyron D, Ramakers M, Malbruny B, Leclercq R, Le Coutour X, et al. Alcoholic povidone-iodine to prevent central venous catheter colonization: A randomized unit-crossover study. Critical Care Medicine. 2004;32(3):708-13. PubMed PMID: 15090951.
  8. Valles J, Fernandez I, Alcaraz D, Chacon E, Cazorla A, Canals M, et al. Prospective randomized trial of 3 antiseptic solutions for prevention of catheter colonization in an intensive care unit for adult patients. Infection Control & Hospital Epidemiology. 2008;29(9):847-53. PubMed PMID: 18665819.
  9. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2007;65 Suppl 1:S1-64. PubMed PMID: 17307562.
  10. Simonova G, Rickard CM, Dunster KR, Smyth DJ, McMillan D, Fraser JF. Cyanoacrylate tissue adhesives - effective securement technique for intravascular catheters: in vitro testing of safety and feasibility. Anaesthesia & Intensive Care. 2012;40(3):460-6. PubMed PMID: 22577911.
  11. Australian Commission on Safety and Quality in Health Care. Australian Guidelines for the Prevention and Control of Infections in Healthcare. In: Government A, editor. 2010.
  12. Care ACoSaQiH. Australian Guidelines for the Prevention and Control of Infection in Healthcare. 2010.
  13. Hillier S, Grimmer-Somers K, Merlin T, Middleton P, Salisbury J, Tooher R, et al. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology. 2011;11:23. PubMed PMID: 21356039.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.