Chlorahexadine and PICC management

iluvivt, BSN, RN · Sep 23, 2010

are you practicing in the united states? phlebitis (esmp) is usually caused by a mechanical problem and not the prep...such as trauma to the vein on insertion..trauma to the vein b/c picc was placed at an area of flexion...picc too large for that part of the vein and an inflammatory process is set up. there is a possibility that if you have not allowed the chg to completely dry you are tracking some in and it irritates those fragile little veins and sets up the phlebitis. are you washing off the chg with ns?....yes at first that seems strange but that is what ins recommends.. have you changed any of your products or has the catheter material changed b/c it sounds like you are very experienced. we sometimes will see an increase in our phlebitis rate with a newly trained clinician . check this out fromtiny patients, tiny dressings: a guide to the neonatal picc dressing change elizabeth l. sharpe arnp, msn, nnp-bc

jay s. greenspan md

ksenia zukowsky rnc, phd, crnp

advances in neonatal care - [color=#d02200]featured journal

june 2008

volume 8 number 3

pages 150 - 162

a number of organizations have recognized the advantages of chg for cutaneous antisepsis. numerous studies in the adult population support that chlorhexidine is superior in providing immediate, residual, and cumulative antimicrobial effects.48 the cdc has made a category ia recommendation for the use of a 2% chlorhexidine-based preparation as preferred over iodine or alcohol; however, this does not apply to infants younger than 2 months.1 the institute for healthcare improvement includes chg skin antisepsis in its group of evidence-based interventions called the central line bundle for improving outcomes in patients with intravascular central catheters.49 the california perinatal quality care collaborative, in its toolkit for preventing hospital-acquired infections, acknowledges no superior antiseptic agent for skin antisepsis.50 the use of chg over povidone-iodine as a skin preparation is associated with substantially reduced incidence of device-related infection.38,51 one analysis concluded that the use of chg for vascular site care was even cost-effective, calculating a $113 saving per catheter.52 despite compelling evidence for its use in adult and pediatric populations, chg remains without approval for use in neonates younger than 2 months. there have been reports of blistering, burns, and sloughing from povidone-iodine and alcohol.53 erythema has been reported with chg in both the alcohol-based and aqueous products.53

in a comparison of 10% povidone-iodine with 0.5% chg, chg was more efficacious in preventing colonization in piv sites in neonates with no adverse effects reported.54 thousands of neonates in developing countries have received chg for either full-body and/or umbilical cord cleansing. its use is associated with decreased colonization and decreased risk of oomphalitis and mortality.55 although absorption was reported in a minimal number of infants, there were no reported adverse effects as a result. numerous studies have addressed chg use in neonates in varied settings now but the inconsistencies in concentration studied or endpoints have left many questions unanswered.55 at this time, despite anecdotal reports of increasing off-label utilization, the use of chlorhexidine in neonates remains an unresolved issue.

in a national survey of 305 nicus published in 1999, 36% of respondents reported using povidone-iodine and 48% reported using povidone-iodine and alcohol in combination.56 in a survey of 15 nicus in 4 states also published in 1999, all reported using povidone-iodine for antimicrobial skin preparation.57 these surveys conducted, prior to the availability of chg in the united states, reflect our continuing curiosity with the practices of our peers, yet there remains a lack of standardization.56,57 current practice seems to be changing. in an informal electronic survey of nicus across the country in 2007, results showed the majority reporting use of chg, with the remainder using the povidone-iodine preparation. this reflects a growing confidence in its perceived value despite lack of food and drug administration approval for use in neonates younger than 2 months.

any antimicrobial agent should be applied to already-cleansed skin to achieve optimal efficacy.1,36 the area to be prepared should be of sufficient size to minimize risk of contamination.14 the specific method of application is unique to each agent. alcohol is more efficient with more than 1 consecutive 10-second exposure and the use of 2 consecutive cleanings or longer duration of cleaning is recommended for more effective skin sterilization.58 povidone-iodine is applied beginning at the insertion site, in a circular outgoing motion away from the intended insertion site, for 30 seconds, and is allowed to dry for at least 2 minutes. two percent chg is recommended for application using a back-and-forth friction scrub for 30 seconds and is allowed to dry for 2 to 3 minutes.46 anecdotally, some of those reporting its off-label use in neonates are describing a lighter application with minimal friction in lieu of the manufacturer's instructions for use. in an early study of chg 0.5% with alcohol in neonates, 2 consecutive 10-second applications significantly reduced colony count compared with a single application.58 aqueous chlorhexidine is applied using 2 x 2 sterile gauze and must be removed to allow the dressing to adhere. the infusion nurses society recommends that the utilization of povidone-iodine or chg solution requires complete removal with sterile water or sterile 0.9% sodium chloride after the procedure.16

picclineman · Sep 23, 2010

That is an inservice in and of itself. Thanks

iluvivt, BSN, RN · Sep 24, 2010

Too good not to post and it explained the controversy and benefits so well.