Infection from Invasive procedures

1. Infection from invasive procedures Guidelines for prevevetion of intravascular device related infection in NICU Infection from Invasive procedures prepared by : Rasha Musleh Prepared by : Rasha Musleh 2008 Supervised By: Dr. Hania Al-Jouzy Mrs:Amal Abu njma

2. Introdution: Neonatal babies in NICU departments are at high risk of infection, as those neonates came from sterile environment with low immunity to any pathogens. All health care personnel who participate in invasive procedures should always use appropriate sterile barrier precautions to prevent transmitting infection to neonates.

3. By: • proper hand washing • Sterile gloves &Surgical masks • Sterile Gowns and other protective apparel gloves mask& gown

4. Health-care institutions purchase millions of intravascular catheters each year. Intravascular catheters provide necessary vascular access; their use puts neonates at risk for local and systemic infectious complications

5. . Blood-stream infection related to the catheter is the most serious type of catheter infection. Definition: isolation of the same micro-organism from culture of a catheter segment or blood drawn from the catheter and from blood preferably drawn from a peripheral vein of a patient with accompanying clinical symptoms of BSI and no other apparent source of infection

6. The incidence of BSI varies considerably by • type of catheter • frequency of catheter manipulation, • and patient-related factors (e.g., underlying disease and acuity of illness)

7. Other catheter related infections • Colonized catheter • Exit –site infection : erythema tenderness, induration or purulence within 2 cm of the skin at the exit site of catheter. • Tunnel infection : erythema tenderness and induration in the tissues overlying the catheter and > than 2 cm from the exit site • Infusate blood stream infection.

8. Catheter related blood stream infections • Catheter related blood stream infection [CR-BSI] are associated with: • Increased morbidity • Increased mortality • Prolonged hospitalization. • Increased medical cost

9. Peripheral venous catheters are the devices most frequently used for vascular access. • Although the incidence of (BSIs) is rarely associated with these catheters but serious infectious complications may occur. • In general complications occurred; up to one-fourth of catheters that can result in serious morbidity & mortality.

10. PCVCs Catheters: These catheters are the commonest cause of hospital-acquired bloodstream infection.

11. Peripheral Arterial Catheters: Peripheral arterial catheters are usually inserted into the radial ,or femoral artery and permit continuous blood pressure monitoring and blood gas measurements.

12. Umbilical venous catheter: In neonatal practice an umbilical venous catheter can be used to deliver parenteral nutrition, particularly during the first week of life. To reduce the risk of infection maximum sterile precautions should be used during the insertion.

13. Catheters can become infected in several different ways: • through infection at the insertion site which migrates along the catheter surface • via contamination of the catheter ports with subsequent colonization of the lumen of the catheter • or through hematogenous spread of infection arriving at the catheter from pathogens entering the bloodstream from other sources. • Administration of contaminated infusate

14. So: A number of guidelines including skin prep should be reviewed and implemented as part of a comprehensive program to reduce infection. Each unit should have a written policy on the procedures governing the use of these catheters

15. General recommendations for IV device use ( AAP) • Health care workers education and training • Surveillance for catheter related infection • Proper hand washing • Barrier precautions during catheter insertion and care • Selection and replacement of intravascular device • Replacement of administration sets and intravenous fluids. • Preparation and quality control of intravenous admixture.

16. The first step that used to reduce coetaneous colonization of the skin & to reduce infection especially those extremely low birth weight infants ( less than 1000 gm) are particularly at risk. includes: • 1- disinfecting the site prior to insertion • 2-preventing colonization from other areas getting near the insertion site • 3- and care of the site after insertion.

17. Barrier precautions --(Appropriate washing To Alter the infection ) The current standard is the use of alcohol based solution with ethanol 60-85 % [Manugel] in addition to hand washing.

18. --Patient skin preparation Cleans the skin with an appropriate antiseptic that include 70% alcohol, or 10% Povidone-iodineoralcohol based solution to chlorhexidine. chlorhexidine chlorhexidine povidone iodine

19. Do not palpate the insertion site after the skin has been cleaned. • Use sterile gauze for cleaning • Avoid contaminating catheter • Use transparent dressing • Better to wear mask even when applying a peripheral venous catheter. • It is often necessary to remove the catheter in order to clear the infection).

20. Surveillance for catheter related infection • Conduct studies in your unit concerning incidence of CR-BSI . ( The reported incidences of catheter-related sepsis in the NICU vary from) 5% to nearly 40% • Palpate the catheter insertion site daily through intact dressing. • Visually inspect catheter site [better than to inspect it every hour]

21. Redness or swelling if seen at any time stop the infusion and establish a new IV line in a different vein or artery & apply sterile gauze to prevent infection • Record the date & time of catheter insertion in an obvious location near the catheter insertion site and on patient’s record

22. Replacement of administration set and intravenous fluids • Change the IV infusion fluid bag every 24 hours; even if the bag still contains IV fluid (they can be a major source of infection • Replace IV tubings including stopcocks & extension tubes using sterile technique no more frequently than 72 hours intervals unless clinically indicated .(Stopcock contamination occurring in 45% - 50%They are a potential portal for entry of microorganisms

23. Replace tubing used for lipid within 24 hours & Complete infusions of lipid containing parenteral nutrition within 24 hours also. these products have been identified as independent risk factors for BSI. • Infusion of blood products should be completed within 4 hours of hanging the product.

24. Preparation and quality control of intravenous admixture • Admix all parenteral fluids in a laminar flow hood using aseptic technique. • Check all containers of parenteral fluid for visible therapy, leaks, cracks, and the manufacturer’s expiration date before use. • Use single dose vials for parenteral additives or medications whenever possible.

25. If multi-dose vials are used - Refrigerate multidose vial after they are opened, if recommended by the manufacturer. - Clean the rubber diaphragm with alcohol before use. - Use a sterile device each time a multidose vial is accessed, and avoid touch contamination of the device before penetrating the rubber diaphragm. - Discard multi-dose vials when empty, when suspected or visible contamination occurs, or when the manufacturer’s stated expiration date is reached Additional specific risk factors include prolonged use of parenteral nutrition [ lipid emulsion] (Mathieu 2006).

26. Preparation of parenteral nutrition under laminar flow at HFH

27. Conclusion So it is very important to handle the invasive procedures in sterile wayand to adopt a special guidelines in performing any invasive procedure (sterile way in care, giving any medication, IV fluids administrations)

28. PCVC insertion at HFH

29. Thank you

30. References: -Exposure to invasive procedures in neonatal intensive care unit admissions,DP Barker and N Ruttera ,archives of Disease in Childhood - Fetal and Neonatal edition, Vol 72, November 1, 2006; 91(6): F448 - F453, www.http://fn.bmj.com/PDF. - Journal of Research in Nursing, Mathieu, September 1, 2006; 330 – 353, www .http://fn.bmj.com/. -Do WE STII hurt Newborn babies, Mangureten, S.H. Scott and C.E. Guzetta et al ,2003,F54-F55, www.http://archpedi.ama-assn.org/.pdf -Neonatal Sepsis, (Adapted from Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A) November 2005 ,http://www.merck.com/.html -Infection Control Program Moderator , October , 2006, http://www.apic.org/ source/. -Infection control program, sepsis, AAP, http: /www.apic.com