Cuestiones sobre cuidados de catéteres

Los profesionales nos planteamos con frecuencia interrogantes acerca de los cuidados indicados en el manejo de catéteres, de cara a prevenir la infección de los mismos y garantizar su correcto funcionamiento.

En la Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 desarrollada por el CDC se ofrecen numerosas respuestas a esas cuestiones.

Veamos algunas, a modo de ejemplo:

¿Debemos usar guantes estériles o no para la canalización de vías?

Pues NO para periféricos y SI para el resto.

1.     Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics. Category IC

2.     Sterile gloves should be worn for the insertion of arterial, central, and midline. Category IA

¿Yodo o clorhexidina?

Pues yodo, clorhexidina o alcohol para periféricos.

1.     Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. Category IB

Clorhexidina en accesos centrales, salvo que esté contraindicada.

2.     Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IA

3.     No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Unresolved issue.

4.     No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue

Eso sí, dejándolos secar.

5.     Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter. Category IB

¿Apósito de gasa o transparente?

Pues parece que da igual…

1.     Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. Category IA

Salvo en pacientes que suden mucho, sangren o exuden, en los que se optará por apósitos de gasa:

2.     If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved. Category II

Y ¿Cada cuánto cambiar los apósitos?

Siempre que se humedezcan, se suelten o se ensucien:

3.     Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. Category IB

Y de forma rutinaria, cada 2 días los de gasa estéril.

4.     Replace dressings used on short-term CVC sites every 2 days for gauze dressings. Category II

Y hasta 7 días en los apósitos transparentes.

5.     Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. Category IB

6.     Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II

En cualquier caso, deberá monitorizarse regularmente su normalidad y sobre todo en pacientes que refieran dolor en la zona de inserción, fiebre, etc.

7.     Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. Category IB

Y animar a los pacientes a que comuniquen cualquier cambio que consideren relevante.

8.     Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II

Y ¿Cada cuánto cambiar los catéteres?

Los periféricos, no antes de 72-96 horas.

1.     There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. Category 1B

Los centrales, no deben cambiarse de forma rutinaria.

2.     Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB

3.     Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II

¿Cada cuánto cambiar los sets de administración?

De forma general, entre 4 y 7 días.

1.     In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days. Category IA

Sistemas de administración de productos sanguíneos, o con emulsiones grasas, a las 24 horas del inicio de la infusión.

2.     Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. Category IB

Sistemas de administración de propofol, entre 6 y 12 horas o al cambiar cada vial.

3.     Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendation (FDA website Medwatch). Category IA

¿Y en los catéteres arteriales?

Elegir preferentemente la arteria radial, braquial o pedia.

1.     In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection. Category IB

Usar al menos gorro, mascarilla y guantes estériles con un paño fenestrado para su canalización.

2.     A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion. Category IB

Retirar el catéter en cuanto no sea necesario. Y no cambiarlos de forma rutinaria.

3.     Remove the arterial catheter as soon as it is no longer needed. Category II

4.     Do not routinely replace arterial catheters to prevent catheter-related infections. Category II

Cambiar los kits de monitorización cada 4 dias.

5.     Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced. Category IB

Desde este enlace puedes descargar la guía completa, en la que se detallan todas las recomendaciones anteriores, se profundiza en ellas y se recogen todas las referencias que avalan estas y otras recomendaciones presentes en el texto.