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Blood Reflux:

Has your line been slimed?

Accreditation/Disclosure

Accreditation - Provider approved by the California Board of Registered

Nursing, provider number CEP 15005, for 1 contact hour.

Non-endorsement of products - Approval as a provider refers only to this

continuing education activity and does not imply California Board of

Registered Nursing endorsement of any commercial products.

Commercial Support for this activity is provided by Smiths Medical ASD,

Inc.

Conflicts of Interest - Presenter is a full time employee or paid consultant

for Smiths Medical ASD, Inc.

Off-label use of a product for a purpose other than that for which it was

approved by the Food and Drug Administration will not be presented in

this learning activity.

Requirements for Successful

Completion

To earn contact hours for this activity:

� Attend the entire program no partial credit will be awarded

� Complete all required forms

� Return all forms to the program facilitator

� Certificate of Attendance will be provided upon receipt of completed forms

Documentation

� Secured confidential records for this learning activity will be maintained for six (6) years

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Objectives

� Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections.

� List two quality initiatives to prevent blood reflux complications.

� Identify two strategies for preventing complications created by blood reflux in the vascular access catheter.

Reflux & Bloodstream Infections

“Theoretically, blood reflux into either the IV

catheter or needleless connector increases both the

risk of occlusion and biofilm formation. Both also

increase the risk of Health Care Associated Blood

Stream Infections”.

Infection Control Today August 2010 Vol. 14 No 8, “Choosing the Best Design for Intravenous

Needleless Connector to Prevent HA-BSI” By: William R. Jarvis, MD

Blood Reflux

Uncontrolled backflow of

blood into the catheter

lumen

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Blood Reflux

Because the catheter tip is

inside the body and not

visible, we are not always

aware when reflux occurs

Backflow and Biofilm

■ Blood attaches to catheter lumen and begins

coagulation process

■ Blood reflux may cause catheter-associated

venous occlusion and thrombosis

VA

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Dynamics of Vascular Pressure

■ All blood vessels have blood

forced through them by

contraction of the heart muscle

■ This forward flow is often called

vascular pressure and is

measured in units of force such

as mmHg and PSI

Dynamics of Vascular Pressure

■ If vascular pressure becomes higher than infusion

pressure, increased pressure pushes blood into

catheter tip

■ The blood remains in catheter lumen until vascular

pressure drops below pressure of the infusing fluid

Dynamics of Vascular Pressure

Pressure

mm Hg

Example

(rounded pressure values)

Pressure

psi

2 - 20mm Hg Central Venous pressure range 0 - 0.4 psi

10 - 30mm Hg Peripheral Venous pressure range0.2 - 0.6 psi

80-100mm Hg Extravasation risk > 2 psi

75mm HgGravity pressure of fluid 100cm

(39 inches) above cannulation site1.5 psi

36” height above the heart = 1.33 psi overcomes the patients vascular pressure with gravity infusion

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TH

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OSIS

Type of Thrombotic Occlusions:

• Fibrin sheath thrombus

• Fibrin tail

• Mural thrombus

• Intraluminal thrombus

Hypercoagulability of blood

Vessel Wall Damage

Hemodynamic changes in blood flow

Virchow’s Triad

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Blood Coagulation

Acquired

■ Pregnancy

■ Diabetes

■ Trauma or Surgery

■ Cancer

■ Obesity

■ Prolonged immobility

■ Nephrotic Syndrome

■ Dehydration

Genetic

■ Genetic clotting factor

disorders

■ Hemoglobin

deficiencies

Vessel Wall Damage

■ Injuries or trauma

■ Hypertension, chronic inflammation

■ Catheter placement and size

■ Catheter composition

Hemodynamics: Influencing

Factors

■ Syringe connection/ disconnection

■ Syringe plunger rebound

■ IV bag run dry

■ Low infusion rates

■ External pressure from ventilators and other hospital equipment

■ Patient Movement

■ Coughing

■ Crying

■ Sneezing

■ Respiration

■ Vomiting

Mechanical Physiological

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OSIS A

ND

INFE

CT

ION

Relationship between

Thrombosis and Infection

“Shortly after insertion, intravascular catheters are

coated with a conditioning film, consisting of fibrin,

plasma proteins, and cellular elements, such as

platelets and red blood cells. Microbes interact with

the conditioning film, resulting in colonization of

the catheter. There is a close association between

thrombosis of central venous catheters and

infection.”

CDC Guidelines for the Prevention of Intravascular Catheter-Related Infection, 2011

What is Biofilm?

■ Bacteria ■ Yeast ■ Algae ■ Fungi

Dynamic ecosystem of microorganisms embedded in a matrix of extracellular polymeric substances (Slimy Matrix)

– Biofilm Bacteria Are 1000X more resistant to antibiotics than free-floating bacteria

– Share and transfer resistance to other organisms

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The Five Stages of Biofilm Formation

1. Initial reversible attachment of free swimming micro-organisms to surface

2. Permanent chemical attachment, single layer, bugs begin making slime

3. Early vertical development

4. Multiple towers with channels between, maturing biofilm

5. Mature biofilm with seeding / dispersal of more free swimming micro-organisms

Graphic by Peg Dirckx and David Davies © 2003 Center for Biofilm Engineering Montana State University.

Relationship Between

Thrombosis and Sepsis

“The presence of CRS or significant catheter

colonization was more frequent in patients whose

catheter-related central vein thrombosis was

diagnosed.”

Chest 1998; 114;207-213

Central Vein Catheter-Related Thrombosis in Intensive Care Patients: Incidence, Risk Factors,

and Relationship with Catheter-Related Sepsis.

By: Jean-Francois Timset, MD, PhD

IMP

LICA

TIO

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Implications of Occlusion

■ Patient discomfort

■ High risk of DVT

■ Increased risk of embolism

■ Delay in treatment

■ Increased length of stay

■ Nursing time

■ Increase in medication and supply cost

■ Increased risk of infection

Impact of CLABSI

• In the United States, 15 million central vascular

catheter (CVC) days occur in intensive care units

(ICUs) each year

• Outcomes associated with hospital-acquired

CLABSI

• Mortality rate of 12%-25%

• Increased length of hospital stay 6-10 days

• Excess Healthcare cost of $16,550

Morbidity and Mortality Weekly Report, Vital Signs: Central Line–Associated Blood Stream Infections —

United States, March 1, 2011, Vol. 60

Bloodstream Infections: By Device

No. of

Prospective

Studies

Pooled Mean

per/1000

catheter days

Arterial catheters 6 2.9

Short-term non-medicated CVC 61 2.3

Long-term tunneled and cuffed CVC 138 1.2

Peripheral venous catheters 13 0.6

Peripherally inserted CVC (PICC) 8 0.4

Subcutaneous central venous port 13 0.2

Crnich, CJ, Maki DG, The Promise of Novel Technology for the Prevention of Intravascular Device-Related Bloodstream Infections. I Pathogenesis and Short-Term Devices. CID 2002

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CMS Guideline Changes and Impact

on Hospitals:

2005 Deficit Reduction Act’s Hospital-Acquired Conditions (HACs) and Present On Admission (POA) Program

CMS Never Event and Public

Reporting

Central Line Associated Bloodstream

Infections

2011 CMSRequirements

Association for Professionals in Infection Control and Epidemiology, Inc. 3/31/10.

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Standards of Evidenced-Based

and Best Practice

■ Infusion Nurses Society – INS

■ Association for Vascular Access – AVA

■ Centers for Disease Control and Prevention - CDC

■ Society for Healthcare Epidemiologist of America - SHEA

■ Manufacture’s Recommendations

Guidelines for Peripheral and

CVCs

Needleless Connectors Add-On/ Administration

Sets

Site and Dressing Changes

CDC

2011

Split septum valve

preferred over

mechanical valve

No more frequently

than 96-hours intervals,

but at least every 7 days

Peripheral catheters :

72-96 hours

SHEA

2008

(CVCs only)

Do not routinely use

positive pressure

needleless connectors

No longer than 96

hours

Non-tunneled CVCs,

change transparent

dressings every 5-7 days

INS

2011

Needleless connectors

shall be Luer-lock

design

Change with site

rotation: up to 96

hours dependent on infusate

When clinically indicated

Peripheral Device Selection

Appropriate catheter should accommodate

patient’s vascular access based on:

■ Prescribed therapy and duration of treatment

■ Vascular integrity and comorbidities

■ Use of smallest gauge size and length

■ Ability and resources to care for the device

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Peripheral Site Selection

■ Preferred sites are those found on dorsal

and ventral surfaces of upper extremities

■ Avoid –

� Areas of flexion, bifurcation and valves

� Lateral/ventral surface of the wrist due to

potential nerve damage

� Extremities with lymphedema

� Previously used sites

Central Catheter Placement

Right-sided placement is preferred:

� Results in shorter catheter length

� Catheter lies parallel in the right internal jugular vein resulting in less damage to the intima

� Ideal tip location - lower 1/3 of the superior vena cava

Stabilization

Reduce Mechanical Phlebitis

• Preserve integrity of access device

• Minimize catheter movement at

insertion site

• Prevent catheter dislodgement

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Needleless Technology

Negative displacement: Upon syringe

disconnection, blood refluxes into catheter tipAction: clamp BEFORE syringe disconnection

Positive displacement: Upon syringe disconnection,

small amount of fluid pushes out end of catheter

tipAction: clamp AFTER syringe disconnection

Neutral displacement: Designed to minimize blood

reflux into catheter tip upon syringe disconnection Action: clamp BEFORE syringe disconnection

Clamping sequence and fluid displacement

Clamping does NOT

stop all blood reflux potentials

Positive Needleless Connectors

• SHEA – Do not routinely use positive-pressure needleless connectors with mechanical valves

• FDA Alert – Initiated post market surveillance and supports SHEA’s recommendations

• CDC – Split septum valve may be preferred over some mechanical valves

Risk Benefits Education

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EX

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Are you doing what it takes

to decrease the occurrence of

blood reflux?

Clinical Practice: Policy and

Protocol

Policy must reflect facility specific flush protocol:

■ Proper flush-clamp sequence according to connector being used

■ Proper flush solution, technique, frequency of flush, and volume of flush

■ Treat partial and complete occlusion in central catheters PROMPTLY

Clinical Practice: Needleless

Connectors

• Negative Fluid Replacement Needleless

Connector

Flush Clamp Remove Syringe

• Positive Fluid Replacement Needleless

Connector

Flush Remove Syringe Clamp

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Clinical Practice: Data

■ Number of PIV catheters placed■ Number of PIV catheter days■ Mean, Median and Average dwell time

■ Complications:� Phlebitis� Infiltration and Extravasation

� Infection� Air Embolism� Catheter Embolism

� Thrombosis and Occlusion

Education and TrainingOut with the Old in with the New

See One

Do One

Teach One

Hospital Protocols/Policies and

Infection Prevention

■ Hand hygiene and aseptic technique

■ Site care and maintenance

■ Catheter site dressing regimens

■ Assessment for complications

■ Access connector decontamination

■ IV administration set and add-on device

■ Vascular access devices removed when no longer required

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SUM

MIN

G IT

UP

Strategies to Prevent Blood

Reflux

� Standards of Best Practice

� Education

� Data – Continuous Quality Improvement

� Technology

Objectives

• Describe how blood reflux in vascular access catheters contributes to thrombotic catheter occlusions and bloodstream infections.

• List two quality initiatives to prevent blood reflux complications.

• Identify two strategies for preventing complications created by blood reflux in the vascular access catheter.

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Questions?

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