Central venous catheter related sepsis
Harri Jones DICM FRCA
Advanced Trainee Intensive Care Medicine
Focus on central venous catheter related sepsis
Central venous catheterisation is a core component of intensive care patient management. An estimated two hundred thousand central venous catheters are inserted annually in the UK. Ten percent develop catheter related sepsis and have an attributable mortality of up to 20%.
Catheter related infections arise by extra-luminal and intra-luminal routes in the majority of patients. Infections occurring within the first week are usually caused by the migration of bacteria from the skin down the external surface of the catheter (extra-luminal route). Infections arising after the first week are a consequence of improper (non-sterile) handling of the hubs, locks and other catheter components and cause intra-luminal contamination.
The following procedural issues are relevant when considering central venous catheter related sepsis:
- There are no published randomised control trials that compare the site of insertion and subsequent catheter related sepsis rates. Observational studies suggest a lower rate with the subclavian approach.
- Ultrasound is now recommended to guide the insertion of central venous catheters because of their association with decreased failure and lower complication rate. The most serious complications associated with a blind (landmark) technique are pneumothorax (incidence up to 3%) and carotid artery puncture (incidence up to 9.4%).
- Antibiotic impregnated catheters are now available which reduce the incidence of extra-luminal contamination. However, these catheters are more expensive. Randomised controlled trials have demonstrated a reduced incidence of infection. There is little evidence to support the use of one type of impregnated catheter over another. It has been proposed that antibiotic impregnated catheters are probably most cost effective where the incidence of catheter related infection is high.
- Antiseptic skin preparation and a strict aseptic insertion technique are essential to reduce extra-luminal contamination. A meta-analysis by Chaiyakunaprak et al of six randomised control trials demonstrated that chlorhexidine skin preparation had a significantly lower incidence of catheter colonisations (and therefore catheter infection) than povodine-iodine (Betadine).
Key learning points
There is a duty of care to our patients which involves not doing them harm. This duty of care extends to common, everyday procedures such as central line insertion.
The development of new evidence based guidelines should facilitate a reduction in central line catheter related sepsis.
If doubts exist about the sterility of a line then consideration should be made about its removal
In circumstances where line insertion technique may be sub-optimal (ward environment and emergency department) there may be grounds to consider the use of an antibiotic impregnated line.
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