Central venous catheters (CVCs) are necessary during treatment of intestinal failure to maintain adequate hydration, nutritional status, and delivery of medications. A CVC is defined as an intravascular catheter that terminates at or close to the heart or in one of the great vessels and is used for infusion, withdrawal of blood, or hemodynamic monitoring.1 Various types of CVCs are used in the pediatric population, including peripherally inserted central catheter (PICC), nontunneled or tunneled CVC, implanted venous access devices, hemodialysis catheters, and apheresis catheters. Despite the necessity for CVCs, postinsertion CVC complications are common and include central line associated blood stream infections (CLABSI), catheter dislodgment or migrations, catheter breaks, local site infections, skin integrity issues, and/or mechanical occlusions.2–4 Roughly 8% of all hospitalized pediatric patients require care with a CVC, equating to approximately 5 million placed each year.2,5
CVCs require adequate securement and coverage to prevent them from dislodging or becoming contaminated.6 The Centers for Disease Control (CDC) guidelines recommend using a transparent dressing for CVC securement and protection; however, they do not endorse a specific brand or type of dressing.7 Bundled approaches to caring for a CVC are described to prevent infections but lack guidance when the patient has additional complications. Despite recommendations, pediatric patients may have contraindications to transparent dressings requiring alternative dressings and CVC maintenance regimens. Gauze dressings are recommended when a transparent dressing is contraindicated.7
Intestinal failure, or short gut syndrome is a malabsorption disorder, usually as the result of surgical resections, leading to loss of function of the small and/or large intestine. Intestinal failure treatment, with concomitant use of a CVC, may take months to years increasing the patient's risk for central line associated blood stream infections (CLABSI). The short gut syndrome patient population has a higher incidence of gram-negative and enteric pathogens, with rates ranging from 35% to 59% due to the risk factors related to the proximity of the CVC catheter to areas of excessive secretions and stooling.8
Case description
At 1 month of age, the patient was diagnosed with short gut syndrome after multiple surgeries to treat a malrotation and midgut volvulus. The patient received the first of many CVCs after a laparoscopic appendectomy and duodenocolonic dissociation procedure. Soon after the patient began total parenteral nutrition (TPN). Because of the variability of intestinal rehab, the patient required long-term TPN thus requiring a permanent central venous access for the TPN. The patient received a peripherally inserted central catheter (PICC) in the upper extremity.
Health history
Following a second bowel resection a gastrotomy tube was placed for the purpose of stomach decompression. The gastrotomy tube was converted to a MIC-KEY button (Avanos Medical, Inc, Alpharetta, GA), and from the time of insertion began to leak copiously. For this small infant the CVC was near the leaking gastrotomy tube site, and the large amount of secretions significantly increased the potential for contamination of the CVC. The leakage was managed by using split gauze to absorb the drainage. Apart from the high risk of a CLABSI associated with TPN infusions, the patient had multiple other risk factors including an ileostomy, gastrostomy, wound vac, and skin conditions.
The patient was transferred from the Pediatric Intensive Care Unit to the Gastroenterology Service weeks after surgery in stable condition. Upon admission to the Gastroenterology Service, he had an ileostomy, multiple fistulas, and an open abdomen. A complicated abdominal dressing change regimen was required every 3 hours. In addition to the intestinal fistulas and open abdomen, the patient had multiple sites of skin breakdown with weeping and crusty drainage.
The frequent dressing changes with the potential for cross-contamination from his open abdomen, and the draining fistulas and skin breakdown further increased the patient's risk of a CLABSI.
Skin issues
After several months of TPN via a PICC, the patient developed an apparent chlorhexidine gluconate (CHG) allergy, which was noted in the electronic health record after use. Of note, formal CHG allergy testing was not routinely done at this facility, therefore the patient was not tested. Prior to development of the CHG allergy, the standard transparent dressing regimen was used (Figure 1). The standard regimen included cleansing the skin with CHG, using a Biopatch (Medline Industries, LP, Northfield, IL) to cover the CVC insertion site, and securing the site with a transparent dressing. The allergic reaction caused severe skin irritation that ultimately led to the removal of the patient's CVC and the placement of a new one. This would be the second CVC placed in a matter of months.
The new CVC, a PICC, was managed with an alternate hypoallergenic transparent dressing method, OpSite IV3000 (Smith & Nephew, London, UK), that is commonly used. This method consisted of cleansing the skin with betadine, covering the insertion site with PolyMem Silver (Ferris Mfg. Corp., Fort Worth, TX), and using a hypoallergenic dressing to secure the site. Despite using this method, severe skin irritation developed under and around the transparent dressing. Because of the severity of the reaction, the dermatology service was consulted. In addition to the CHG allergy, the patient was diagnosed with irritant dermatitis due to skin adhesives. A recommendation was made to omit the hypoallergenic transparent dressing and use a nonadhesive dressing to secure the PICC. PolyMem Silver (Ferris) and Kerlix™ (Cardinal Health™, Dublin, OH) were used to dress the PICC site. Two weeks later skin improvement was noted, and the decision was made to continue with the nonadhesive dressing.
Central line-associated blood-stream infection
The nonadhesive dressing regimen was used for approximately 2 months, and during this time, the patient was diagnosed with 2 CLABSIs due to the organism Staphylococcus aureus. The CLABSIs were identified via a blood culture of the PICC, and both were treated with intravenous antibiotics. During a review of the first CLABSI, the nonadhesive dressing was considered a contributing risk factor, however, because of the patient's irritant dermatitis it was decided to continue with the nonadhesive dressing.
Two weeks later purulent drainage was found during a dressing change. A second S. aureus infection was diagnosed via blood culture. Given the second CLABSI, the risk factor of the nonadhesive dressing regimen, and the patient's irritant dermatitis, the occlusive transparent dressing was resumed.
The nonadhesive alternative dressing regimen was used for approximately 1 month, and during that time the patient had 2 occurrences of CLABSI with S. aureus. Because of this the CVC was removed per recommendation of the Infectious Disease Department, and a new PICC line was placed 2 days later. The patient was discharged home on TPN with this PICC in place, and the alternate hypoallergenic dressing regimen was used by skilled nursing in the home. After successful bowel rehabilitation, the patient did eventually transition off TPN, and the PICC was removed.
Discussion
CHG allergies
CHG is well tolerated by the vast majority of patients and is typically associated with positive antimicrobial effects.9 The CDC guidelines for the prevention of intravascular catheter related infections1 recommends using CHG in various forms for daily skin cleansing, catheter site CHG impregnated sponges, and during CVC dressing changes. Despite CHG's popularity, it can cause irritation, erosive contact dermatitis, and in rare cases anaphylaxis.9,10 Mild skin reactions can present as localized itching, redness, and swelling after blood sampling or intravenous access and may be overlooked or not communicated by health care providers.10 While this patient was not tested for a CHG allergy, his symptoms were indicative of mild CHG allergy, thus it was eliminated from his CVC regimen.
CVC alternative dressings
CDC guidelines1 recommend the use of a sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. These recommendations allow for the health care provider to assess the site and provide the best dressing for the patient's needs. At our institution the standard occlusive, transparent dressing is a Tegaderm™ (3M™, Saint Paul, MN) When a patient exhibits signs and symptoms of known allergies to the standard dressing, an algorithm guides the nurses' clinical decision making on the best alternative dressing. This algorithm includes transitioning from the standard dressing to a gauze dressing depending on the patient's skin assessment. Due to the nature of this patient's skin reaction, a PolyMem (Ferris) and Kerlix (Cardinal Health™) dressing was recommended.
Risk of nonadhesive dressing and other risk factors
CVC dressings must provide a barrier protection from microbial colonization and infection.3 While the use of PolyMem Silver (Ferris), a medication-impregnated dressing product, does give protection against the aforementioned risk, the use of a nonadhesive dressing exposed this patient to multiple other risk factors for contamination. In addition to an occlusive dressing, adhering to the CLABSI bundle elements of keeping tubing up and away from contamination zones, daily linen changes and baths, and scheduled cap changes can help mitigate these types of risk (Figure 2).
Lessons learned
While the CDC guidelines recommend best practices and important bundle components, alternative CVC maintenance methods to prevent CLABSIs are not addressed.1 An apparent cause analysis was conducted to discuss contributing factors and lessons learned for this CLABSI. When using alternative dressings, such as Kerlix (Cardinal Health™) and PolyMem (Ferris), it was recommended to continually reassess the skin integrity and readiness to reintroduce an occlusive dressing. Use of available resources such as the wound ostomy team, dermatology, infectious disease, and PICC team were instrumental in the approach. This unique scenario highlighted opportunities for patients with CHG allergies or irritant dermatitis to adhesives when standard dressings are not applicable.
Conclusions
When a patient cannot use the standard, best practices for CVC care and maintenance, they are at an increased risk for developing CLABSIs. Future research needs to focus on alternative methods for CVC maintenance when allergies or sensitivities occur. Additional nursing assessment and care need to be applied to complex patients who cannot follow standardized CVC care and maintenance bundles. Reflecting on previous apparent cause analysis for CLABSIs is necessary for process improvement and driving change.