From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Nadine Nakazawa
Sent: Monday, July 31, 2006 10:15 PM
To: [EMAIL PROTECTED]; [EMAIL PROTECTED]
Subject: Re: 24 hour dressing after PICC insertion
Even with MST (modified Seldinger technique) many PICC exit sites ooze a bit of blood for a few hours. Certainly patients with thrombocytopenia, on anticoagulant therapy or patients in liver failure with high INRs will nearly always have some bleeding that requires a gauze over the exit site. we ask the nurses to change the PICC dressing within 24 hours (actually after any newly placed central line), removing the gauze, THEN apply the Biopatch (chloraprep, etc first as Marcia has described). This allows for the Biopatch to be placed on dry exit site after hemostasis has been achieved. As PICC inserters, we don't always know which PICC exit sites will continue to ooze and which will achieve hemostasis right away. This policy covers all the different patient scenarios and puts the responsiblity on the bedside nurses especially since our PICC volume continues to grow every year.
From: [EMAIL PROTECTED]
To: [EMAIL PROTECTED], [EMAIL PROTECTED], [EMAIL PROTECTED]
Subject: Re: 24 hour dressing after PICC insertion
Date: Sat, 29 Jul 2006 16:59:00 EDT
In my opinion, you are both correct.
The 24 hour dressing change recommendation came about as a result of the through the needle design that was used in the first PICC designs. There was usually some residual bleeding or drainage from the enlarged skin tract from the needle which was larger than the catheter. We were not thinking about biofilm (didn't know then what I know now when I published that recommendation) nor CHG because we did not have it other than Hibiclens which I did recommend.
Ten plus years later we now know much more about biofilm and CHG. Here is the recommended "bundle" for prevention of extraluminal colonization and CRBSI:
1. Skin antisepsis:
a. Clean skin: 2 minute scrub with Hibiclens (preferred) or antimicrobial soap
b. Disinfection: One application ChloraPrep
2. Maximum sterile barrier
3. Application of BioPatch AT TIME OF INSERTION (for continued antisepsis 24/7)
The first week is the most vulnerable time for colonization and biofilm formation in the sub-q space during the inflammatory phase and presence of edema/drainage. The Biopatch absorbs moisture and continues antiseptic protection. Gauze has NO antimicrobial protection, in fact will grow biofilm quite well in the gauze fibers. Put gauze on top of Biopatch if absolutely necessary.
4. Secure catheter at insertion site (either securement device or proper suturing technique)
5. Continued antisepsis 24/7:
Repeat cleaning (3 alcohol or CHG swabsticks), disinfection (ChloraPrep) and Biopatch at least every 7 days (if not using Biopatch, change dressing every 48 hours as you have no more antiseptic protection and surface bacterial growth will occur).
All of this is explained and referenced in:
Ryder, M. Evidence-based practice in the management of vascular access devices for home parenteral nutrition therapy. JPEN. 2006;30(1):S82-S93.
Cheers
Marcia Ryder
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