Management of central venous catheters in intensive care units: Comparative study of guidelines versus practice.

Sir,

An observational study was conducted on 100 nurses with minimum 6 months of experience in various intensive care units (trauma, swine flu, medical, and renal) of the hospital to assess their knowledge and clinical practice. A two-part questionnaire [Table 1] was filled by the nurses after every central venous catheter (CVC) insertion for a period of 2 months. Each correct response was scored 1; incorrect 0. Total number of catheter insertions was 148. Mean score for the study was 53%.

Table 1

Questionnaire

Results from Part A: Standardized equipment set, barrier precaution, filling of the checklist, and an assistant was available in 96%, 95%, 86%, and 98% of the insertions. Two-third were done on monitored beds with head low; only 1% on unmonitored beds. Povidone iodine, 70% alcohol, 2% chlorhexidine-based preparations were preferred in decreasing order for disinfection of skin (60%, 21%, and 19%, respectively). Eighty percent preferred sutures for catheter fixation and transparent bio-occlusive dressing.

Results from Part B: Subclavian, internal jugular and femoral vein were preferred by 66.6%, 25%, and 9%. One-fifth were not aware of use of ultrasound. 98% managed unintended arterial puncture by removal of needle/catheter and application of pressure. 90% opined that chest X-ray confirmed placement of CVC. 96% preferred heparin based solution; 4% used normal saline. Two inspections of CVC/day were made by 50%; one/day were made by 40%. One-fifth wiped access ports with antiseptic before drug administration. Removal of infected CVC was considered by 60%; 25% believed in giving an antibiotic and observing. Three-fourth marked 4 h as maximum infusion time for blood products; 24 h for change of intravascular catheters/sets. Tubings for blood products and lipid emulsions were changed by 80% 12 hourly. Three-fourth believed in no fixed duration for changing CVC; one-fourth believed in the weekly change.

Half believed in administration of antibiotics for central lines inserted in emergency. Only 25% considered a replacement of the catheter within 48 h. The remaining 25% considered replacement only on signs of infection. Routine prophylactic antibiotics was advocated by 36%.

Results show that awareness on the use of chlorhexidine, ultrasound, correct management of arterial punctures and protocol for CVC inserted in emergency departments needs to be increased. Regular training programs with the nursing staff on bundles of care related to insertion and maintenance of CVC are needed.[123]

American Society of Anesthesiologists guidelines[4] are focused on elective insertions of CVC's performed by anesthesiologists, but the Centers for Disease Control and Prevention guidelines[5] also address emergency placements, peripherally inserted central catheters, pulmonary artery catheter and tunneled central lines. Safety or efficacy of chlorhexidine in neonates and infants aged <2 months remains an unresolved issue. Fluid administration sets need to be changed at 96 h intervals and tubings for blood products and lipid emulsions every 24 h. Routine replacement of CVCs on the basis of fever alone and prophylactic administration of systemic antimicrobial agents is discouraged. Mandatory replacement is to be done within 48 h for all catheters inserted in an emergency without aseptic precautions.