Safety of positive-pressure valve connectors in arterial catheters inserted into critically ill patients

Application Analysis of Positive-Pressure Connector in Invasive Blood Pressure Monitoring in Coronary Interventional Therapy

Background: In order to reduce the risk of invasive blood pressure monitoring and improve the safety and efficiency, this article mainly analyzes the effectiveness and safety of using positive-pressure connector for invasive blood pressure monitoring in patients with coronary artery interventional therapy, so as to improve the invasive blood pressure monitoring method. Aim: To study and analyze the application of positive-pressure connector in invasive blood pressure monitoring in coronary interventional therapy. Methods: From October 2017 to October 2019, a total of 120 patients admitted to Cangzhou Central Hospital, Cangzhou, Hebei, China, for coronary interventional therapy with invasive blood pressure monitoring were selected and divided into a control group and an experimental group by drawing lots with 60 patients in each group. Positive-pressure connector was used for invasive blood pressure detection in the experimental group, and heparin cap connector was used for invasive blood pressure detection in the control group. The effectiveness and safety of blood pressure monitoring in the two groups were compared, and the influence of different joints on invasive blood pressure monitoring was analyzed. Results: The influencing factors of puncture efficiency in the experimental group (6.67%) were significantly lower than those in the control group (30.00%) (P < 0.05). There was no significant difference in catheter bending between the experimental group and the control group (P > 0.05). The experimental group exhibited a remarkably higher puncture safety rate (93%) compared to the control group (67%) (P < 0.05). There was no significant difference in arterial blood pressure between the two groups with different indwelling time (P > 0.05). The frequency of extubation and reinsertion in the experimental group was significantly lower than that in the control group (P < 0.05). Factors influencing puncture safety in the experimental group were significantly lower than those in the control group (P < 0.05). Conclusion: The use of positive-pressure connector for invasive blood pressure monitoring in patients with coronary artery interventional therapy can greatly improve the safety of blood pressure monitoring and reduce the suffering of patients. Therefore, the application of positive-pressure connector in invasive blood pressure monitoring is worthy of promotion and application in clinical practice.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Impact of needle-free connectors compared with 3-way stopcocks on catheter-related bloodstream infection rates: A meta-analysis

BACKGROUND

Needle-free connectors (NFCs) were introduced to eliminate the use of needles in intravascular catheters, and their newest generations were designed to improve patient safety and reduce catheter-related bloodstream infection (CRBSI) risks. The aim of this meta-analysis was to compare NFCs with 3-way stopcocks (3WSCs) and their effects on CRBSI rates.

METHODS

A meta-analysis was conducted using a research protocol consistent with the PRISMA statement for reporting meta-analyses. The Cochrane Database of Systematic Reviews and MEDLINE were searched for relevant randomized studies published from January 2000 to September 2018.

RESULTS

We identified and selected for the meta-analysis 8 studies comparing CRBSI rates (according to the Centers for Disease Control and Prevention's National Healthcare Safety Network definition) associated with NFCs utilizing negative-displacement, neutral-displacement, or positive-displacement devices with rates for 3WSCs. Relative risk was 0.53 with a 95% CI of 0.28 to 1.00, and the relative difference was -0.018 with a 95% CI of -0.039 to 0.004.

CONCLUSIONS

CRBSI risk was statistically higher for 3WSCs compared to NFCs.

Clinical impact of needle-free connector design: A systematic review of literature

The objective of this systematic review is to analyze types of needle-free connectors and open systems and their effects on central line–associated bloodstream infection rates and other adverse outcomes through a research protocol consistent with the Preferred Reporting Items for Systematic Reviews’ recommendations. MEDLINE and Cochrane databases of systematic reviews were searched for relevant comparative studies published from January 2000 to September 2017. Eighteen studies compared central line–associated bloodstream infection (according to the Centers for Disease Control and Prevention/National Healthcare Safety Network definition), internal microbial contamination, occlusions, phlebitis, and other outcomes associated with needle-free connectors with a positive displacement device, negative displacement device, neutral displacement device, or three-way stopcock. Ten studies reported central line–associated bloodstream infection rates, which were lower with positive displacement devices versus negative displacement devices/neutral displacement devices (one study) and with negative displacement devices versus three-way stopcocks (three studies), but varied with different positive displacement device and negative displacement device/neutral displacement device designs (four studies). Seven studies reported internal microbial contamination rates, which were higher with three-way stopcocks versus negative displacement devices (two studies) and positive displacement devices (two studies), lower when positive displacement devices were used versus neutral displacement devices (one study), and varied with different types of negative displacement device (one study). Central line–associated bloodstream infection rates and most other outcomes analyzed were statistically significantly higher with three-way stopcocks (open devices) versus positive displacement device, negative displacement devices, and neutral displacement devices, but varied among closed device designs.

Positive-pressure needleless connectors did not increase rates of catheter hub colonization respecting the use of neutral-pressure needleless connectors in a prospective randomized trial

INTRODUCTION

The aim of this study was to compare the colonization rates of central venous catheter (CVC) and arterial catheter (ArtC) hubs fitted with two types of needleless connectors (NCs).

METHODS

We designed a prospective randomized study to compare rates of catheter hub colonization of CVC and ArtC hubs fitted with two types of needleless connectors: neutral-pressure NCs (NP-NCs) and positive-pressure NCs (PP-NCs) in critically ill patients. All NCs were replaced every 7 days of use.

RESULTS

We obtained 326 cultures from 146 catheters (81 CVC and 65 ArtC) in 70 patients. The total cumulative days of risk were 1250 catheter-days. Global swab cultures were positive in NP-NCs in 29/198 (14.6%) versus 17/128 (13.3%) in PP-NCs during catheter use. We did not observe any cases of CRBSI.

CONCLUSIONS

In our experience, the use of PP-NCs did not result in significantly more frequent hub colonization with respect to NP-NCs.

Reduction of Central Line-Associated Bloodstream Infection Rates in Patients in the Adult Intensive Care Unit

Central line-associated bloodstream infections (CLABSIs) prolong hospital stays and increase cost, morbidity, and mortality. An intensive care unit (ICU) in a suburban Baltimore hospital reduced CLABSI rates to zero in 2012, by revising central venous access device policies and initiatives, which included a bloodstream infection alert system, bundle compliance monitoring and routine evaluation, and use of positive displacement needleless connectors. The hospital's ICU infection rate decreased from 2.9/1000 central-line days in 2010 to 0.8 by 2011, 0 by 2012, and 0.91 in 2013. The utilization ratio was 0.64 in 2011, 0.60 in 2012, and 0.58 in 2013. CLABSI prevention involves all disciplines and requires staff accountability for patient safety.

In Vitro Evaluation of Fluid Reflux after Flushing Different Types of Needleless Connectors

Purpose

To evaluate fluid reflux, when disconnecting syringe, for different needleless connectors.

Materials

Nine connectors were tested; 540 measurements were carried out.

Results

The connectors tested showed very different performances, about reflux, on disconnection of the syringe used for flushing. The calculated reflux volumes are: Max Zero® - BD: 6.90 (±2.47) mm3; MicroClave Clear® - ICU Medical: 6.14 (±1.46) mm3; Bionecteur® - Vygon: 1.24(±0.73) mm3; Neutron® - ICU Medical: 0.12 (±0.15) mm3; SmartSite® Carefusion: 33.51 (±11.50) mm3; Safe Plus® - Cremascoli: 23.54 (±3.56) mm3; NeutraClear® - Cair: 9.36 (±1.87) mm3; NeutroX® - Cair: 0.33 (±0.31) mm3; Dasa® BTC: 2.38 (±1.67) mm3. Differences between investigated devices were statistically significant (p<0.001).

Discussion

It is difficult to establish the best quality-price ratio for needleless connectors. It is important to consider several variable factors: continuous or discontinuous infusion, catheter type, usage environment and caliber of catheter used. It would therefore be useful to have an indication of the intraluminal space potentially affected by blood reflux in relation to a specific device.

Conclusions

Needleless connector is one of the main factors involved in keeping catheter patency. It is important to perform the best choice among the connectors available. An empirical reflux measurement, relative to the needleless connector and the catheter in use, can be obtained using an 18G cannula.

Closed blood conservation device for reducing catheter-related infections in children after cardiac surgery

BACKGROUND

Arterial catheters are potential sources of nosocomial infection.

OBJECTIVE

To investigate use of a closed blood conservation device in preventing catheter-related bloodstream infections in children after cardiac surgery.

METHODS

Children with an indwelling arterial catheter after cardiac surgery were randomly assigned to 2 groups: a control group with a conventional 3-way stopcock in the catheter system and an interventional group with the conservation device in the catheter system. Catheter tips, catheter intraluminal fluid, and blood samples obtained from the catheter and peripherally were cultured for microbiological analysis. RESULTS Intraluminal fluid contamination was significantly lower (P = .03) in the interventional group (3 of 147 catheters) than in the control group (10 of 137 catheters). The 2 groups did not differ significantly in the rate of tip colonization (9 of 147 vs 12 of 137; P = .40) or in the number of catheter-related bloodstream infections (0 of 147 vs 2 of 137; P = .21).

CONCLUSION

Use of a closed blood conservation device could decrease the incidence of catheter-related contamination of intraluminal fluid.

Comparison of bacterial contamination of blood conservation system and stopcock system arterial sampling lines used in critically ill patients

BACKGROUND

Commonly placed to monitor blood pressure and to aspirate blood, arterial lines frequently cause complications. The blood conservation system (BCS) forms a closed infusion line and may be expected to reduce complications caused by intraluminal contamination. We compared microbial contamination resulting from use of BCS and 3-way stopcock catheterization.

METHODS

Patients who required arterial catheterization for at least 24 hours in our intensive care unit were randomly assigned to receive an arterial pressure monitoring system either with the BCS (test group) or with a 3-way stopcock (comparator group). To evaluate arterial line contamination, we qualitatively assessed the contamination of the catheter tip and intraluminal fluid.

RESULTS

We analyzed microbial contamination for a total of 216 arterial catheters: 109 in the test group and 107 in the comparator group. We found no difference in the incidence of catheter tip colonization in the 2 groups (test group, 8/109 vs comparator group, 11/107; P = .48). There was a statistically significant correlation between catheter tip colonization and duration of arterial line utilization. We found statistically significantly lower intraluminal fluid contamination in the test group (test group, 2/109 vs comparator group, 9/107; P = .03). There was no relationship between intraluminal fluid contamination and catheter tip contamination.

CONCLUSION

There was less microbial contamination of intraluminal fluid when BCS was used for arterial catheterization.

The effects of needleless connectors on catheter-related bloodstream infections

Needleless connectors, including the standard split septum and the luer-activated mechanical valve connectors, have been introduced into clinical practice to eliminate the risk of needlestick injuries by avoiding the use of needles when accessing the intravascular catheters. Negative and positive displacement mechanical valves have been associated with increased rates of catheter-related bloodstream infections as compared with split septum connectors. Based on available data, split septum connectors should be preferentially used instead of mechanical valves. Adequate disinfection by scrubbing the access port preferably with chlorhexidine is recommended to minimize the risk of catheter microbial contamination along with proper infection control practices. Large prospective randomized clinical trials are needed to evaluate further the possible causes and effects of different types of mechanical valve needleless connectors on bloodstream infections.

Clinical use of disinfectable needle-free connectors

BACKGROUND

In 1992, the United States Food and Drug Administration required health care services to adopt needle-free devices to prevent health care workers' exposure to bloodborne pathogens resulting from needlestick injuries, and several systems of disinfectable needle-free connectors (DNC) were introduced.

STUDIES

MICROBIAL COLONIZATION: Experimental studies showed that DNCs designed with a split septum (SS-DNCs) and mechanical valve systems (MLV-DNC) prevented endoluminal colonization as effectively as needles or conventional caps. A comparison of the microbiologic barrier effect of SS-DNCs, MLV-DNCs, and passive positive-pressure (PPV)-DNCs found that PPV-DNCs were least effective in providing protection under experimental conditions of poor handling practices and high microorganism concentrations. PREVENTION OF CATHETER-RELATED BLOODSTREAM INFECTIONS: Some randomized trials show a positive or neutral effect of DNC use on the prevention of catheter-related bloodstream infections (CR-BSIs); however, some investigators have reported outbreaks of CR-BSIs following the introductions of DNCs that could be related to noncompliance with DNC handling recommendations or the use of PPV-DNCs.

CONCLUSION

Strategies focused in the implication of the nurse staff in CRBSI surveillance increase compliance with DNC handling recommendations and minimize the risk of developing a CR-BSI. DNCs can be used safely if staff complies with recommendations for use.