A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit

요약

We present a protocol to show the installation of a needle-free connector with positive displacement on a central venous catheter.

초록

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

서문

Central venous catheter-related infections (CRI) are a severe complication of central venous catheters in intensive care unit (ICU). The decline in CRI remains an ever-present objective, with a final goal of "zero catheter related infection"¹. Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. There are two main designs of connectors: split septum (no internal moving parts) and closed valve systems (internal moving components) but both designs can be combined in one connector². Needle-free connectors are categorized according to the type of fluid displacement that occurs after disconnection of a male Luer valve: negative (blood reflux into the catheter), neutral, and positive (with a push of blood out of the catheter lumen)^2,3.

Some connectors have been described as a cause of catheter-related infections, in particular in the intensive care unit (ICU)^4,5,6. A new generation of needle-free connectors with minimal internal complexity, a reduction or elimination of interstitial or dead space, a visible fluid path to help assess proper flushing technique, and a flat access surface, etc. has been designed to lower the risk of infection. In vitro, these connectors have shown low bacterial colonization⁷. There are global recommendations from the laboratory manufacturing these connectors; however, there is no practical description of how to install them on catheters⁸. Hence, it is possible that each team uses them differently. Therefore, we propose a formalized protocol for the installation of these connectors on central venous lines in the ICU.

We present the installation of a positive pressure needleless connector (PPNC) with an internal silicone piston in our ICU but this protocol is applicable with any positive displacement valve. This valve is a mechanical needle-free connector with positive displacement.

프로토콜

1. Preparation of connectors and infusion lines

1. Sterilely retrieve the connectors.
2. On the 3-way extension stopcock, screw 1 connector into each socket of the stopcock and 1 connector into the end of the extension line. Take 0.9% NaCl with a 50 mL syringe to purge the extension and the lines. Purge each 3-way extension with 0.9% NaCl through the 2 connectors of the stopcock.
3. Take the infusion manifold. Unscrew each single-use cap. Screw 1 connector into each socket of the manifold to replace the caps. Purge the infusion line through each connector by turning each stopcock sequentially.
   NOTE: At the end of this step, there are 3 extensions with 3-way stopcock with purged connectors and an infusion manifold with purged connectors.

2. Placement of the catheter

1. Place the central venous catheter sterilely according to usual practice in the unit or a previously described protocol⁹.
2. Check the permeability of each line by aspiration of blood and then reinjection of 0.9% NaCl serum. Clamp the lines.

3. Installation of the connectors

1. Screw the extension’s connector of each 3-way extension stopcock into each catheter line. These connectors, directly connected to the lines of the catheter, are the "proximal connectors". Unclamp the lines.
2. Connect the infusion manifold line to one of the connectors of the 3-way stopcock of the distal line.
   NOTE: There is no need to place a vein guard on the manifold or extensions.

4. Use of connectors and infusion lines

1. Before each infusion, disinfect the end of the connector for 3 s with a sterile compress soaked in 70% isopropyl alcohol. Connect the syringe or tubing directly to the connector by screwing and injecting. After injection or infusion, unscrew the device. Do not remove the connector.
2. If needed, rinse an unused line with 3 mL of saline. There is no need to clamp or infuse an unused line with a vein guard. Leave the proximal valve in place even if the line is not perfused.

5. Replacement and maintenance of connectors and infusion lines

1. Always change the connectors every 7 days except for the proximal connectors. Thus, every week, the nurse prepares the extensions with 3-way stopcock and the infusion manifold in sterile conditions (see step 1).
2. Unscrew the used extensions at the proximal valve and screw the new sterile and purged extensions to the catheter on the proximal connector (see step 3).
3. Only change a proximal connector if it is soiled (to maintain the catheter in a "closed" system).
4. In case of macroscopic contamination, rinse the connector with 10 mL of 0.9% NaCl. If there is still contamination, replace the connector. In the event of transfusion, infusion of lipid solution (e.g. propofol) or parenteral nutrition, change the tubing and connectors of the line concerned every 24 hours.
5. Change other infusion lines and tubing according to the practices and protocols of each unit.

결과

Once all the elements are in place, the catheter has connectors on almost all the junctions between two infusion lines (Figure 1). Thus, it has proximal connectors on each line and two connectors on the sockets of the 3-way extensions (Figure 2). Each infusion line has connectors at all its female sockets (Figure 3). Once the assembly is in place, any injection or infusion (continuous or discontinuous) must be made, after disinfecti...

토론

Setting up the connectors slightly increases the total time required to place the catheter. However, their use has several advantages: no need to maintain a continuous saline perfusion for non-infused lines, rapid stopping of infusion of the lines if necessary (in case of urgent transport of the patient for example), no need to use single-use caps several times a day to close the infusion lines. The use of connectors simplifies the daily use of catheter infusion lines without any particular complications. It should be no...

자료

Name	Company	Catalog Number	Comments
BD MaxZero™ needle-free connector	Becton Dickinson	MZ1000-07	we present the installation of the connector with MaxZero but this protocol is applicable with any positive displacement valve.
4-port mannifold with PE/PVC extension	Cair-LGL	RPB4310A
PE/PVC extension line with 3-way stopcock	Cair-LGL	PE3302M
NaCl 0.9% 250 ml	Baxter	2B1322
BD Plastipak™ 50mL Luer-Lock Syringe	BECTON DICKINSON MEDICAL	613-3925