Preventing line infections
Please note that each institution follows slightly different protocols. It is important to check with your CVC team for specific instructions regarding line care. Also, note that this list includes tips from many different families, but any given family may use just a subset of these tips and avoid infections.
- Use scrubbing friction when cleaning anything.
- The cap at the end of the broviac is key, and must be kept as clean and protected as possible.
- Use tegaderm, parafilm, or similar product (see comparisons below) wrapped around the junction between the cap and the broviac.
- Use lots of alcohol and rubbing during the cap change (including before removing the old cap -- pour alcohol squeezed from a wipe into the junction to prevent anything from sneaking in there!).
- When off TPN, some families keep the exposed cap covered with an alcohol wipe, but some institutions recommend against this and Bo's mom (industrial microbiologist) explains why below. If there is significant risk of the cap coming into contact with stool, covering may be preferable. In this case, scrub the cap as if you were going to connect and then cover it immediately with parafilm or alcohol wipe package (without the pad) crimped in place.
- When infusing, cover the connection with a snack baggie (or parafilm).
- Use positive pressure caps that keep out microbial contamination.
- Avoid talking when doing procedures -- a simple step that could reduce infection risk. Some people secure broviacs over the shoulder so that the cap is behind the child, to reduce infection risk from the child coughing, laughing, or spitting during procedures.
- Some families wear masks and gloves, others do not.
Link to photos: LINE CARE PHOTOS
- Parafilm vs. tape/tegaderm: Bo's mom explains that adhesive is like superfood for bateria, so that parafilm (which sticks to itself without adhesive) is preferable to tegaderm or cloth/silk tape at tubing threads and junctions.
- Chloraprep vs. alcohol: Chloraprep is the preferred antiseptic for skin preparation because it continues to kill bugs after it dries. Bo's mom prefers alcohol for cleaning the cap to get the most friction, to leave you with a chemically neutral site, and to minimzie exposure to chlorapreps to prevent sensitivity (allergic reaction) from developing so they can be used for their designed purpose on the skin.
- Swabs vs. pads: To help avoid touching the cap, you can use alcohol or chloraprep swabs (rather than pads), which allow you to keep your skin further from the surfaces you are cleaning than pads do. However, pads allow you to get more of the friction that is critical for cleaning.
Other tips for preventing/minimizing Infection
- Sterilize work surfaces, and ideally work somewhere other than the kitchen or bathroom.
- I would not ever recommend covering the cap with alcohol pad. As a microbiologist who used to support sterile injectibles manufacturing, we know that textiles are the kiss of death and a sure way to promote microbial growth. The alcohol will evaporate, leaving you with a great place for bugs. For that matter, I would also strongly discourage the use of tape at connections; adhesives=food for bacteria. Instead, I use Parafilm M http://www.sigmaaldrich.com/catalog/search/ProductDetail/SIGMA/P7793 for all of Bo's connection sites; it seals off the threads from poopy diapers, has no adhesive, and conforms to the odd shapes these junctions present. This is the material we use in the lab to seal up petri dishes, flasks and the like. And, I would also pose (less stridently) that covering the cap with anything is not a great idea. In the manufacturing area, the more aseptic a workspace needs to be, the more airflow we have. This is known to discourage microbial growth. So sealing your cap from airflow, allowing it to steep in moisture (next to a warm sweaty baby), may yield more bacteria than less. Your infusion company should be able to find Parafilm for you. It's cheap and will help keep your kid infection-free longer. Any laboratory supplies vendor (SigmaAldrich, VWR and Fischer all come to mind) will have it. Send the above link to your supply company if they are still unclear what you need. We have a 4" x 250' roll (~$30), which I estimate will last us 5 years; we parafilm the TPN and lipid connection using at most 1" each.
- Hand-washing: Scrubbing is more important than what kind of soap you use. Well, okay, for hand washing, it's the mechanical motion of hand over hand and the running water washing away contaminants on the skin's surface. You actually don't want to apply too much pressure to the skin when "scrubbing" since bacteria live in the deeper layers of epidermis, so scrubbing too hard can actually expose more of your internal microflora. Enough grandstanding about hand-washing technique; I do it only because this is truly the single most important tool we have to prevent infection.
- Ethanol locks: Ethanol locks can reduce line infections, as reported in this journal article: Use of Ethanol Lock Therapy to Reduce the Incidence of Catheter-Related Bloodstream Infections in Home Parenteral Nutrition Patients. John Ballard's parents have used a 70% ethanol lock on his central line, he has not had a central line infection for at least 8 months, whereas before he had 3 in 2 months. They instill 1cc of the ethanol (after 1cc heparin)into the central line on Monday, Wednesday and Fridays. The ethanol remains in the line from 9a-8pm, the time at which he is not on TPN. They learned this from Pittsburgh ID doctors. And, from another family on the yahoo short bowel syndrome group: We instill 70% ethyl alcohol into the central line for two hrs, draw back 2mls of blood, flush and hep lock to prevent bio-film from hanging on the line. It clearly has helped with our chronic translocations.
- Biopatch: This product is placed over the CVL site and releases chloroprep continually over 7 days.
- I don't think I can help being OCD. Too much at risk! Here are a couple of tricks I use with AustinRath. One of his line infections occured after his ostomy bag leaked (which occurs several times a week) all over his central line. The stool leaked down in between the Broviac and TPN connection, entering his blood stream. I was told that I could change the cap, but that I couldn't clean the inside of the line. He was deathly ill with 5 "bugs" within several days of this event. So I now cover that connection by wrapping a Tegaderm dressing over the connection point and change it once a week when the home care nurse changes the Broviac dressing and cap. I also use a snack size zip lock bag that I cover the connection with (the two ends of the line exit on the far top ends of the zip lock, with the center snapped together. I then secure the bag with tape on either end. If the bag leaks, I replace the baggy. When Austin is off TPN, I cover the exposed cap with a mini baggy and use a tiny hair elastic from the beauty store to secure it. I use 3 alchol wipes to initially clean the line, then 1 in between saline, etc. We had 4 line infections in 3 months before starting this procedure. Since then, in the last 11 months, not a single line infection! I also put a tab of cloth tape about 12" down on the tubing and use a safety pin to attach the tape to Austin's clothes. So if he pulls on it or the line gets caught, it won't break or pull out the line.
- Another suggestion from a PN clinic nurse that we're currently using for our son (Luke) to keep the tip of the catheter covered is to cut off a finger of your glove and wrap it around the cap and secure it with tape, leaving a tab at the end for easier removal. We use a plastic tape (Transpore) that rips easily. We, too, pin the line as high as is feasible to keep it out of the range of either g-tube leakage or stool. Luke has had 8 line infections (both gram positive and gram negative) in a period of a year, so vigilant line care is a must!
- Cap Change example: For cap changes we do sterile set up, pour alcohol into the junction between the line and cap (hard to explain in email). With masks and sterile gloves we do 12 alcohol swabs, with friction, to the entire area. (again hard to explain in email) We use an alcohol pad to hold the line and also an alcohol pad to hold the cap we are removing. We use yet another alcohol pad to clean all threads for a sufficient amount of time and then put on the primed cap. Sean's cap is covered at all times when not in use, including when he is swimming.
- Dressing Change example: The time just after a line is placed is the most critical for potential infection. Otherwise sterile technique in dressing changes should prevent infections. Sean's entry site is covered by gauze and an opsite. (that's just what works best for him). His line is always secured over his shoulder with smaller opsites strategically placed. For swimming he must wear a snug fitting rash guard shirt.
- Tips specific to Swimming_and_bathing.
- Dental work: The pediatric dental group (AAPD) and Oley recommend prophylactic antibiotics before dental work for children with central lines, because bacteria can enter the bloodstream during dental procedures that cause the gums to bleed, which may lead to sepsis. The antibiotics might be prescribed by the dentist, GI, or primary pediatrician.
[Perhaps people could indicate how long they've been infection-free w/their recipes?]