Evidence Summaries

Gavin NC, Webster J, Chan RJ, Rickard CM. Frequency of dressing changes for central venous access devices on catheter-related infections. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD009213. DOI: 10.1002/14651858.CD009213.pub2.

Authors' conclusions
The best available evidence is currently inconclusive regarding whether longer intervals between CVAD dressing changes are associated with more or less catheter-related infection, mortality or pain than shorter intervals.

Bradford NK, Edwards RM, Chan RJ. Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children. Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD010996. DOI: 10.1002/14651858.CD010996.pub2


Authors' Conclusions
The review found that there was not enough evidence to determine the effects of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Ullman AJ, Cooke ML, Mitchell M, Lin F, New K, Long DA, Mihala G, Rickard CM. Dressings and securement devices for central venous catheters (CVC). Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD010367. DOI:10.1002/14651858.CD010367.pub2.


Authors' conclusions
Medication-impregnated dressing products reduce the incidence of catheter-related BSI relative to all other dressing types. There is some evidence that CGI dressings, relative to SPU dressings, reduce catheter-related BSI for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of catheter-related BSI. A multiple treatment meta-analysis found that sutureless securement devices are likely to be the most effective at reducing catheter-related BSI though this is low quality evidence. Most studies were conducted in intensive care unit (ICU) settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVCs. Future research may adjust the estimates of effect for the products included in this review and is needed to assess the effectiveness of new products.

Marsh N, Webster J, Mihala G, Rickard CM. Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD011070. DOI: 10.1002/14651858.CD011070.pub2.


Authors' conclusions
It is not clear if any one dressing or securement device is better than any other in securing peripheral venous catheters. There is a need for further, independent high quality trials to evaluate the many traditional as well as the newer, high use products. Given the large cost differences between some different dressings and securement devices, future trials should include a robust cost-effectiveness analysis.

Moureau NL, Flynn J. Disinfection of needleless connector hubs: Clinical Evidence Systematic Review. Nursing Research and Practice, 2015, Article ID 796762. doi:10.1155/2015/796762
url: http://www.hindawi.com/journals/nrp/2015/796762/

Moureau and Flynn (2015) published a systematic review related to disinfection of needleless connectors (NC). Literature meeting inclusion criteria was rated according to the National Health and Medical Research Council Guidelines (NHMRC 2009). The review yielded a large number of studies with 67 papers and 34 abstracts meeting requirements for inclusion and grading. The studies and abstracts were grouped for NC disinfection practices prior to access, the impact of hub contamination on infection, and measures of education and compliance that promote aseptic access. Results of this study indicated a lack of compliance with disinfection of access sites despite educational initiatives and improved disinfecting agents. Use of passive disinfection caps resulted in the greatest effectiveness when more than 80% compliance was achieved with the products.

Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD011447. DOI:10.1002/14651858.CD011447.

Authors' conclusions
On the basis of available data, we conclude that two-dimensional ultrasound offers small gains in safety and quality when compared with an anatomical landmark technique for subclavian (arterial puncture, haematoma formation) or femoral vein (success on the first attempt) cannulation for central vein catheterization. Data on insertion by inexperienced or experienced users, or on patients at high risk for complications, are lacking. The results for Doppler ultrasound techniques versus anatomical landmark techniques are uncertain.

López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Marti S, Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD008462. DOI: 10.1002/14651858.CD008462.pub2.

Authors' conclusions
We found no conclusive evidence of important differences when heparin intermittent flushing was compared with 0.9% normal saline flushing for central venous catheter maintenance in terms of efficacy or safety. As heparin is more expensive than normal saline, our findings challenge its continued use in CVC flushing outside the context of clinical trials.

Robertson-Malt S, Malt GN, Farquhar V, Greer W. Heparin versus normal saline for patency of arterial lines. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD007364. DOI: 10.1002/14651858.CD007364.pub2.

Authors' conclusions
The available evidence is of poor quality because of risk of bias and does not provide sufficient information to support the effects of adding heparin (1 to 2 IU/mL) to a maintenance solution (pressurized to deliver 3 mL of flush solution per hour) of 0.9% normal saline in maintaining the patency and functionality of arterial catheters.

Safdar N, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Critical Care Medicine, 2014. 42(7): p. 1703-1712.
url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258905/

Safdar and colleagues (2014) published a meta-analysis of nine clinical trials assessing the efficacy of chlorhexidine (CHG) impregnated dressings in patients with central vascular catheters (CVC) that found 1.2% of patients developed catheter related bloodstream infections (CRBSI) in the CHG group and 2.3% in the comparator group and that CHG impregnated dressings reduced CRBSI (random effects RR 0.57, 95% CI 0.420.79, P=0.002). The authors conclude that the findings support the use of CHG-impregnated dressings in central lines and that the greatest benefit is expected from reduction of extra-luminal infectious complications in short-term catheters.

Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD007798. DOI: 10.1002/14651858.CD007798.pub3.

Authors' conclusions
The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

Ullman AJ, Cooke ML, Gillies D, Marsh NM, Daud A, McGrail MR, O'Riordan E, Rickard CM. Optimal timing for intravascular administration set replacement. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD003588. DOI: 10.1002/14651858.CD003588.pub3

Some evidence indicates that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the risk of infection. Other evidence suggests that mortality increased within the neonatal population with infrequent administration set replacement. However, much the evidence obtained was derived from studies of low to moderate quality.

Lai NM, Chaiyakunapruk N, Lai NA, O'Riordan E, Pau WSC, Saint S. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.:CD007878. DOI: 10.1002/14651858.CD007878.pub2.

Authors' conclusions
This review confirms the effectiveness of antimicrobial CVCs in improving such outcomes as CRBSI and catheter colonization. However, the magnitude of benefits in catheter colonization varied according to the setting, with significant benefits only in studies conducted in ICUs. Limited evidence suggests that antimicrobial CVCs do not appear to significantly reduce clinically diagnosed sepsis or mortality. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

Webster J, Gillies D, O'Riordan E, Sherriff KL, Rickard CM. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD003827. DOI: 10.1002/14651858.CD003827.pub2.

The authors found a four-fold increase in the rate of catheter-related blood stream infection when a polyurethane dressing was used to secure the central venous catheter. However, this research was at risk of bias and the confidence intervals were wide indicating high uncertainty around this estimate; so the true effect could be as small as 2% or as high as 17-fold. More, better quality research is needed regarding the relative effects of gauze and tape versus polyurethane dressings for central venous catheter sites.

Griffith RJ, Jordan V, Herd D, Dalziel SR. Vapocoolants (cold spray) for pain treatment during intravenous cannulation. Cochrane Database Systematic Reviews 2016 Issue 4. Art. No.CD009484. doi: 10.1002/14651858.CD009484.pub2

Authors' conclusions
Moderate-quality evidence indicates that use of a vapocoolant immediately before intravenous cannulation reduces pain during the procedure. Use of vapocoolant does not increase the difficulty of cannulation nor cause serious adverse effects but is associated with mild discomfort during application


Lau CS, Chamberlain RS. Ultrasound-guided central venous catheter placement increases success rates in pediatric patients: a meta-analysis. Pediatr Res. 2016 May 11. doi: 10.1038/pr.2016.74. [Epub ahead of print]

Authors' conclusions
US-guided CVC placement is associated with significantly higher success rates and decreased mean number of attempts required for cannulation. US-guided CVC insertion improves success rates, and should be utilized in pediatric patients.


Ista E, van der Hoven B, Kornelisse R, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis. 2016 Feb 18. pii: S1473-3099(15)00409-0. doi: 10.1016/S1473-3099(15)00409-0. [Epub ahead of print]

Authors' conclusions
Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs.




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