Dressing disruption is a major risk factor for catheter-related infections.

OBJECTIVE: Major catheter-related infection includes catheter-related bloodstream infections and clinical sepsis without bloodstream infection resolving after catheter removal with a positive quantitative tip culture. Insertion site dressings are a major mean to reduce catheter infections by the extraluminal route. However, the importance of dressing disruptions in the occurrence of major catheter-related infection has never been studied in a large cohort of patients. DESIGN: A secondary analysis of a randomized multicenter trial was performed in order to determine the importance of dressing disruption on the risk for development of catheter-related bloodstream infection. MEASUREMENTS AND MAIN RESULTS: Among 1,419 patients (3,275 arterial or central-vein catheters) included, we identified 296 colonized catheters, 29 major catheter-related infections, and 23 catheter-related bloodstream infections. Of the 11,036 dressings changes, 7,347 (67%) were performed before the planned date because of soiling or undressing. Dressing disruption occurred more frequently in patients with higher Sequential Organ Failure Assessment scores and in patients receiving renal replacement therapies; it was less frequent in males and patients admitted for coma. Subclavian access protected from dressing disruption. Dressing cost (especially staff cost) was inversely related to the rate of disruption. The number of dressing disruptions was related to increased risk for colonization of the skin around the catheter at removal (p < .0001). The risk of major catheter-related infection and catheter-related bloodstream infection increased by more than three-fold after the second dressing disruption and by more than ten-fold if the final dressing was disrupted, independently of other risk factors of infection. CONCLUSION: Disruption of catheter dressings was common and was an important risk factor for catheter-related infections. These data support the preferential use of the subclavian insertion site and enhanced efforts to reduce dressing disruption in postinsertion bundles of care.

Infectious risk associated with arterial catheters compared with central venous catheters.

BACKGROUND: Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence. OBJECTIVES: To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters. METHODS: We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data. RESULTS: We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion. CONCLUSIONS: The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement.

Treatment for Anterior Flail Chest With a Vacuum Bell.

We describe a patient with polytrauma that included anterior chest flail caused by a fall while climbing. As the situation was similar to a pectus excavatum, we attempted to stabilize the depressed chest wall by using a vacuum bell. Deep breath, peak flow, and pectus index were increased when the patient used the vacuum bell. Conservative treatment with a vacuum bell during the day and continuous positive airway pressure during the night was undertaken for 6 weeks. This report documents stabilization of an anterior flail chest using a vacuum bell.

Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.

CONTEXT: Use of a chlorhexidine gluconate-impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary. OBJECTIVE: To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes. DESIGN, SETTING, AND PATIENTS: Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer. INTERVENTIONS: Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings. MAIN OUTCOME MEASURES: Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes. RESULTS: Of 2095 eligible patients, 1636 (3778 catheters, 28,931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, -1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001). CONCLUSIONS: Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00417235.