Dressing of CVAD and insertion sites

Section Recommendation statement Grading of recommendations
11. A sterile transparent semi-permeable dressing or sterile gauze and hypoallergenic tape must be used to cover the CVC
insertion site. An alternative dressing must be used if allergy is suspected (1, 2) (PD2010_036).
Grade B
12.

Regardless of the dressing type used for the CVAD, the dressing should:

  1. be positioned so the catheter insertion site is in the centre of the dressing
  2. cover the catheter from the insertion site and the first securement
  3. create a complete seal from the securement through to the insertion site.
Consensus
13.

Transparent dressings must be changed every seven days or sooner if (1, 3-6):

  1. the dressing is not intact (i.e. there is no longer a seal)
  2. there is evidence of inflammation
  3. there is excessive accumulation of blood and/or moisture under the dressing.
Grade A
14.

Sterile gauze and hypoallergenic tape dressing is preferable to a transparent dressing if the patient is diaphoretic or if the site is bleeding or oozing (1, 7).

  • If a patient is oozing post insertion (e.g. thrombocytopaenic), use a sterile gauze square on top of the insertion site and cover with semi-permeable dressing.
  • Consider use of a calcium alginate fibre dressing to achieve haemostasis if oozing is problematic.
Consensus
15. Sterile gauze and hypoallergenic tape dressing should be changed every 48 hours and whenever loose, soiled or moist. Grade B
16. A chlorhexidine impregnated sponge must be placed around the catheter at the insertion site after insertion. It should be replaced at each dressing change (8-13). Grade A
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.

A Cochrane Review indicated that although current evidence for the choice of dressing is poor and estimates of effect are wide, gauze and tape have a lower risk of a central line associated blood stream infection (CLABSI) compared to transparent semi-permeable membrane dressings (7). In a secondary analysis of a large randomised controlled trial, Timsit et al (14) examined the risk of CLABSI related to dressing disruption and found that dressings were often performed before the scheduled time, and there was an increased risk of BSI the more often the dressing was disrupted (15). The pragmatic approach of the Guideline Development Network was to consider that the standard practice of using a semi-permeable transparent membrane dressing was supported in favour of gauze and tape dressings until there is stronger evidence available. Semi-permeable transparent membrane dressings are also possibly preferable because the dressing can be used in conjunction with chlorhexidine impregnated sponges.

The use of commercially available chlorhexidine gluconate (CHG)-impregnated sponge dressings was considered in the 2007 version of the guideline. Since then, there is now substantial support for routine use at the time of insertion and at each dressing change. It was widely supported within the Guideline Development Network that this practice be recommended in this subsequent version. A study by Timsit (13) found that the use of CHG sponge dressings significantly reduced the incidence of major catheter related infections (CRI) even when baseline rates were already low (<1/1000 catheter days). There was no benefit in changing unsoiled dressings any more frequently then every seven days (15). Using data from the same study, Schewebel (12) subsequently found that the use of CHG sponges was a more cost effective practice when measured by the reduction in infections (and associated costs), as well as the costs associated with the dressing materials. Levy (10) found the use of CHG sponges decreased catheter colonisation and Ruschulte (11) showed a reduction in documented CRBSI , mainly at the internal jugular vein site. There was some evidence to support the use of transparent semi-permeable dressings impregnated with chlorhexidine gel but little has been published comparing these with chlorhexidine impregnated sponges, so it is unknown whether these provide equivalent infection prevention effect (16). Whichever dressing is in use, asepsis must be maintained.

Practice point - Dressings

  • Refer to the Australian Guidelines for the Prevention and Control of Infection in Healthcare 2010 (17) related to aseptic non-touch technique.
  • Clean skin around the insertion site to disinfect the total area covered by the dressing.
    * Allow appropriate drying times for the disinfectant applied. For example, the manufacturer recommends the following times for various products:
    • chlorhexidine/alcohol wipes: approximately 30 seconds
    • chlorhexidine/alcohol swabsticks and maxi swabsticks: approximately 1 minute
    • aqueous chlorhexidine swabsticks and Maxi Swabsticks: approximately
      2-3 minutes
  • Use of single-use adhesive spray/wipe to improve dressing adherence may be considered where needed.

See Figure 1 for pictures of applied dressings.

Safety alert - Application of dressings

Before applying any dressings or tapes clinicians must check for the presence of allergies.

Figure 1: Securement of CVADs

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Grades 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 (18)

References

  1. 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.
  2. Olson K, Rennie RP, Hanson J, Ryan M, Gilpin J, Falsetti M, et al. Evaluation of a no-dressing intervention for tunneled central venous catheter exit sites. Journal of Infusion Nursing. 2004;27(1):37-44. PubMed PMID: 14734986.
  3. Ishizuka M, Nagata H, Takagi K, Kubota K. Dressing change reduces the central venous catheter-related bloodstream infection. Hepato-Gastroenterology. 2011;58(112):1882-6. PubMed PMID: 22234057.
  4. Le Corre I, Delorme M, Cournoyer S. A prospective, randomized trial comparing a transparent dressing and a dry gauze on the exit site of long term central venous catheters of hemodialysis patients. The journal of vascular access. 2003 Apr-Jun;4(2):56-61. PubMed PMID: 17642061. Epub 2007/07/21. eng.
  5. Laura R, Degl'Innocenti M, Mocali M, Alberani F, Boschi S, Giraudi A, et al. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO). Haematologica. 2000;85(3):275-9. PubMed PMID: 10702816.
  6. Benhamou E, Fessard E, Com-Nougue C, Beaussier PS, Nitenberg G, Tancrede C, et al. Less frequent catheter dressing changes decrease local cutaneous toxicity of high-dose chemotherapy in children, without increasing the rate of catheter-related infections: results of a randomised trial. Bone Marrow Transplantation. 2002;29(8):653-8. PubMed PMID: 12180109.
  7. Webster J, Gillies D, O'Riordan E, Sherriff KL, Rickard CM. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database of Systematic Reviews. 2011 (11):CD003827. PubMed PMID: 22071809.
  8. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. Journal of Antimicrobial Chemotherapy. 2006;58(2):281-7. PubMed PMID: 16757502.
  9. Chambers ST, Sanders J, Patton WN, Ganly P, Birch M, Crump JA, et al. Reduction of exit-site infections of tunnelled intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled trial. Journal of Hospital Infection. 2005;61(1):53-61. PubMed PMID: 16002181.
  10. Levy I, Katz J, Solter E, Samra Z, Vidne B, Birk E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatric Infectious Disease Journal. 2005;24(8):676-9. PubMed PMID: 16094219.
  11. Ruschulte H, Franke M, Gastmeier P, Zenz S, Mahr KH, Buchholz S, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Annals of Hematology. 2009;88(3):267-72. PubMed PMID: 18679683.
  12. Schwebel C, Lucet J-C, Vesin A, Arrault X, Calvino-Gunther S, Bouadma L, et al. Economic evaluation of chlorhexidine-impregnated sponges for preventing catheter-related infections in critically ill adults in the Dressing Study. Critical Care Medicine. 2012;40(1):11-7. PubMed PMID: 21926570.
  13. Timsit J-F, Schwebel C, Bouadma L, Geffroy A, Garrouste-Orgeas M, Pease S, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA. 2009;301(12):1231-41. PubMed PMID: 19318651.
  14. Timsit J-F, Bouadma L, Ruckly S, Schwebel C, Garrouste-Orgeas M, Bronchard R, et al. Dressing disruption is a major risk factor for catheter-related infections*. Critical Care Medicine. 2012;40(6):1707-14 10.097/CCM.0b013e31824e0d46.
  15. Timsit J-F, Bouadma L, Ruckly S, Schwebel C, Garrouste-Orgeas M, Bronchard R, et al. Dressing disruption is a major risk factor for catheter-related infections. Critical Care Medicine. 2012;40(6):1707-14. PubMed PMID: 22488003.
  16. Olson C, vascular Access team of Abbott Northwestern Hospital, Heilman J. Clinical Performance of a New Transparent Chlorhexidine Gluconate Central Venous Catheter Dressing. JAVA. 2008;13(1):13-9.
  17. Care ACoSaQiH. Australian Guidelines for the Prevention and Control of Infection in Healthcare. 2010.
  18. 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.

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