Dressing a Central Line Properly

Welcome to one-of-maybe-more series of pearls based off my pet peeves.

Tim’s Pet Peeves Pearls

Magnificent.

Anyways as many of our residents know, central lines placed in the emergency department are frequently changed shortly after transfer to the ICU out of concern that lines were not placed under sterile technique. Not an ideal situation, as repeat catheter placement results in additional risk and discomfort to the patient. 

A year ago I asked one of our (now graduated) ICU fellows about this practice, and he mentioned that when he sees an improperly dressed central line (e.g. dressing partially falling off, not completely sealed), he feels obligated to change the line as it seems less clear whether or not that line was placed under sterile technique and has remained sterile.

While lines may still be exchanged regardless once patients have left our care, we should learn how to best dress and maintain sterility on our central lines. Let’s prevent those catheter-related bloodstream infections!

The lesson today was taught to me a couple years ago by our fabulous resus nurse Minh Duong. 

How to Dress a Central Line

Huzzah, you nailed your central line. Fantastic! Sutured down and everything. Now while you still have your sterile gown and mask on, you open your central line dressing kit. Inside you see a dressing, chlorhexidine swabs, barrier film, and extra PPE.

1. Use your chlorhexidine swabs and clean from inside to outside along the length of the catheter. Clean the line itself! 

2. Flip the swab and go back and forth over the surrounding skin. 

3. Repeat with the remaining swabs (there are multiple swabs in the kit)

4. Allow the site to dry. No need to fan or blow on the site.

5. Take your Sureprep Protective Wipe and draw a rectangle around the catheter site. The dressing will not stick well to the chlorhexidine, but will stick well to the SurePrep barrier film. This is important to make sure the dressing seals properly.

6. Place the dressing over the catheter so that the chlorhexidine-impregnated gel layer overlies the entrance of the catheter into the skin. Important for preventing those catheter infections!

7. Remove the sides of the dressing and press firmly along the sides to ensure that the dressing lies flat along the skin. For IJs, this often requires pulling a small amount of tension along the skin to have the dressing lay flush against the skin along the curves of the neck.

8. Take the next largest piece of the dressing (from the wings of the initial piece) and place it UNDER the catheter but OVER the dressing to create a closed loop around the catheter. Press firmly so the dressing lies flush against the skin.

9. Take the final thin piece of dressing from the remaining wing and apply it overtop the area where the catheter exits the dressing. Label the final piece with the current date.

If applied properly you now have a sealed dressing around a CVC. Do this properly, take a little extra time and your nurses and ICU will love you. Congrats!

Sources

https://www.youtube.com/watch?v=BVZq4WgfzQ4

https://www.youtube.com/watch?v=aMxahVmCR2E

https://www.youtube.com/watch?v=DGL8CzKTgVo

POTD: Felon

POTD: Felon

• Subcutaneous pyogenic infection of the pulp space compartment of the distal finger

• Can often be confused with paronychia or herpetic whitlow (fingertip pain but should not cause taut erythema) which can sometimes present with volar erythema

• High risk to progress to osteomyelitis, Flexor Tenosynovitis!

Clinical Features:

• Erythematous, edematous, tense distal pulp space with significant pain and tenderness

• May see necrotic appearing tissue distally due to increased pressure in space 

Work Up:

• Usually diagnosed clinically

• XR: No foreign body, soft tissue swelling pulp of thumb

• US: Use the water bath technique to see a potential fluid collection

• Digital Nerve Block

• I & D is the cornerstone of management: 

• Apply a latex glove finger tourniquet

• If the felon is on patient’s index, middle or ring finger, make the incision of the ulnar aspect

• If the felon is on patient’s thumb or pinky, make the incision of the radial aspect

• Using your #11 blade start your incision 5mm distal to flexor DIP crease and end 5mm proximal to nail plate border. Digital arteries and nerves arborize near DIT. Avoid those!

• Blunt dissect and break any loculations until the abscess is decompressed

• Avoid the "fishmouth" incision. Potentially can cause an unstable finger pad, neuroma or loss of sensation

• Antibiotics: Cover for Staph (MRSA) and strep

Disposition: 

• Home with follow up in the hand clinic or ED in 1-2 days. 

Check out this video to see it done:  

• www.emrap.org/episode/felonincision/felonincision 

Stay well,

TR Adam

Hello, World!

POTD: Dog Bites

In celebration of the Year of the Dog, we wanted to cover management of dog bites.

According to CDC data from 2015, there are approximately 4.5 million dog bites per year in the United States with 1 out of 5 requiring medical attention. The wounds tend to be crush injuries with a greater risk of underlying fracture due to the strength of the dog’s jaws. Pay attention to distal neurovascular status, tendon involvement, joint violation and the presence of foreign bodies. A low threshold to x-ray is valuable. These wounds should be debrided and cleaned with well pressured irrigation.

Classically tested, the most common pathogen that creates infection in wounds is Pasteurella Canis (and other Pasteurella species). Immunosuppressed, alcoholics, smokers or asplenic patients should raise concern for Capnocytophagia canimorsus (a gram-negative rod) that causes particularly devastating illness with meningitis and septic shock reported.

Antibiotic prophylaxis/treatment of choice is with amoxicillin-clavulanate 875/125mg twice a day for 10-14 days. Other bacteria of interest include staphylococci, streptococci, and anaerobes. Remember this isn't your run of the mill cellulitis, cephalexin will not cut it.

Repairing these bites has been a subject of debate. REBEL-EM did a great job covering the myths for these wounds with two of the major studies. (link below)

Using 3-7% as a normal wound infection rate for all lacerations, the thought is that you can attempt a closure on some of these wounds for cosmesis. Good indications for closure would be a clean appearing wound that can receive significant irrigation that is <8 hours old. Wounds greater than 8 hours old had greater than a 20% chance of infection if closed in a study by Paschos et al.

Well vascularized areas perform better with closure – the face/scalp. We use non-absorbable sutures and no buried sutures to reduce the burden of foreign bodies present – minimizing infectious risk.

Tetanus should be given to patients suffering dog bites if they have not received it in the past 5 years. Rabies vaccination + rabies immunoglobulin should be considered for dog bites occurring in the USA from dogs that cannot be monitored and/or are unvaccinated. People previously vaccinated against the rabies virus do not need the immunoglobulin but can take part in the 0, 3, 7, 14 series tailored per local infectious disease recommendations.

Dog bites that return to the ED with infection should be cultured (with peripheral smear added for patients at risk of Capnocytophagia). The area should be imaged to assess the integrity of the bone.

Happy year of the dog!

Read More

Centers for Disease Control and Prevention. Preventing Dog Bites. http://www.cdc.gov/features/dog-bite-prevention/index.html. May 18, 2015.

Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A radomised controlled trial. Injury 2014 45(1): 237-40. PubMed ID: 23916901

Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bite (Review). Cochrane Database of Systematic Reviews 2008 (3); PubMed ID: 11406003

Butler T et al. Capnocytophaga canimorsus: an emerging cause of sepsis, meningitis, and post-splenectomy infection after dog bites. Eur J Clin Microbiol Infect Dis. 2015 34(7): 1271-80. PubMed ID: 25828064

http://rebelem.com/myths-management-dog-bites/