The authors are grateful to Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript. The authors would like to thank the communication department of Rouen University Hospital and the teams of the Medical Training Center for their participation in the video shoot.

1. Preparation of connectors and infusion lines
<ol>
	<li>Sterilely retrieve the connectors.</li>
	<li>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.</li>
	<li>Take the infusion manifold. Unscrew each single-use cap. Screw 1 connector into each socket of the manifold to replac...

<ol>
	<li>Worth, L. J., McLaws, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+it+possible+to+achieve+a+target+of+zero+central+line+associated+bloodstream+infections.">Is it possible to achieve a target of zero central line associated bloodstream infections.</a> Current Opinion in Infectious Diseases. 25 (6), 650-657 (2012).</li><li>Kelly, L. J., Jones, T., Kirkham, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Needle-free+devices:+keeping+the+system+closed.">Needle-free devices: keeping the system closed.</a> British Journal of Nursing (Mark Allen Publishing). 26 (2), 14-19 (2017).</li><li>Casey, A. L., Karpanen, T. J., Nightingale, P., Elliott, T. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+risk+of+microbial+contamination+associated+with+six+different+needle-free+connectors.">The risk of microbial contamination associated with six different needle-free connectors.</a> British Journal of Nursing (Mark Allen Publishing). 27 (2), 18-26 (2018).</li><li>Salgado, C. D., Chinnes, L., Paczesny, T. H., Cantey, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Increased+rate+of+catheter-related+bloodstream+infection+associated+with+use+of+a+needleless+mechanical+valve+device+at+a+long-term+acute+care+hospital.">Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital.</a> Infection Control and Hospital Epidemiology. 28 (6), 684-688 (2007).</li><li>Jarvis, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+care-associated+bloodstream+infections+associated+with+negative-+or+positive-pressure+or+displacement+mechanical+valve+needleless+connectors.">Health care-associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors.</a> Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 49 (12), 1821-1827 (2009).</li><li>Btaiche, I. F., Kovacevich, D. S., Khalidi, N., Papke, L. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+needleless+connectors+on+catheter-related+bloodstream+infections.">The effects of needleless connectors on catheter-related bloodstream infections.</a> American Journal of Infection Control. 39 (4), 277-283 (2011).</li><li>Chernecky, C., Waller, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+evaluation+of+five+needleless+intravenous+connectors.">Comparative evaluation of five needleless intravenous connectors.</a> Journal of Advanced Nursing. 67 (7), 1601-1613 (2011).</li><li>. Infusion Resource Library - BD Available from: <a target="_blank" href="https://www.bd.com/en-us/offerings/capabilities/infusion/infusion-resource-library?contenttype=22_productline=115">https://www.bd.com/en-us/offerings/capabilities/infusion/infusion-resource-library?contenttype=22_productline=115</a> (2019)</li><li>Kim, S. C., Klebach, C., Heinze, I., Hoeft, A., Baumgarten, G., Weber, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraclavicular+fossa+ultrasound+view+for+central+venous+catheter+placement+and+catheter+change+over+guidewire.">The supraclavicular fossa ultrasound view for central venous catheter placement and catheter change over guidewire.</a> Journal of Visualized Experiments. (94), 52160 (2014).</li><li>Clavier, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+MaxZeroTM+needle-free+connector+on+the+incidence+of+central+venous+catheter-related+infections+in+surgical+intensive+care+unit.">Impact of MaxZeroTM needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit.</a> Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses. , (2018).</li><li>Lehn, R. A., Gross, J. B., McIsaac, J. H., Gipson, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Needleless+connectors+substantially+reduce+flow+of+crystalloid+and+red+blood+cells+during+rapid+infusion.">Needleless connectors substantially reduce flow of crystalloid and red blood cells during rapid infusion.</a> Anesthesia and Analgesia. 120 (4), 801-804 (2015).</li><li>Ferroni, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pulsative+flushing+as+a+strategy+to+prevent+bacterial+colonization+of+vascular+access+devices.">Pulsative flushing as a strategy to prevent bacterial colonization of vascular access devices.</a> Medical Devices (Auckland, N.Z). 7, 379-383 (2014).</li><li>Flynn, J. M., Keogh, S. J., Gavin, N. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sterile+v+aseptic+non-touch+technique+for+needle-less+connector+care+on+central+venous+access+devices+in+a+bone+marrow+transplant+population:+A+comparative+study.">Sterile v aseptic non-touch technique for needle-less connector care on central venous access devices in a bone marrow transplant population: A comparative study.</a> European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society. 19 (6), 694-700 (2015).</li><li>Merrill, K. C., Sumner, S., Linford, L., Taylor, C., Macintosh, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+universal+disinfectant+cap+implementation+on+central+line-associated+bloodstream+infections.">Impact of universal disinfectant cap implementation on central line-associated bloodstream infections.</a> American Journal of Infection Control. 42 (12), 1274-1277 (2014).</li><li>Mermel, L. A., Bert, A., Chapin, K. C., LeBlanc, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+stopcock+and+manifold+colonization+of+newly+inserted+peripheral+intravenous+catheters.">Intraoperative stopcock and manifold colonization of newly inserted peripheral intravenous catheters.</a> Infection Control and Hospital Epidemiology. 35 (9), 1187-1189 (2014).</li><li>Rosenthal, V. D., Maki, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+study+of+the+impact+of+open+and+closed+infusion+systems+on+rates+of+central+venous+catheter-associated+bacteremia.">Prospective study of the impact of open and closed infusion systems on rates of central venous catheter-associated bacteremia.</a> American Journal of Infection Control. 32 (3), 135-141 (2004).</li><li>Bouza, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+needleless+closed+system+device+(CLAVE)+protects+from+intravascular+catheter+tip+and+hub+colonization:+a+prospective+randomized+study.">A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study.</a> The Journal of Hospital Infection. 54 (4), 279-287 (2003).</li><li>Tabak, Y. P., Jarvis, W. R., Sun, X., Crosby, C. T., Johannes, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+on+central+line-associated+bloodstream+infections+associated+with+a+needleless+intravenous+connector+with+a+new+engineering+design.">Meta-analysis on central line-associated bloodstream infections associated with a needleless intravenous connector with a new engineering design.</a> American Journal of Infection Control. 42 (12), 1278-1284 (2014).</li><li>Wallace, M. C., Macy, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+Central+Line-Associated+Bloodstream+Infection+Rates+in+Patients+in+the+Adult+Intensive+Care+Unit.">Reduction of Central Line-Associated Bloodstream Infection Rates in Patients in the Adult Intensive Care Unit.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 39 (1), 47-55 (2016).</li><li>Btaiche, I. F., Kovacevich, D. S., Khalidi, N., Papke, L. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+needleless+connectors+on+catheter-related+thrombotic+occlusions.">The effects of needleless connectors on catheter-related thrombotic occlusions.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 34 (2), 89-96 (2011).</li><li>Williams, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+Occlusion+in+Home+Infusion:+The+Influence+of+Needleless+Connector+Design+on+Central+Catheter+Occlusion.">Catheter Occlusion in Home Infusion: The Influence of Needleless Connector Design on Central Catheter Occlusion.</a> Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society. 41 (1), 52-57 (2018).</li></ol>

TC, PG and BV previously conducted a study on PPNC valves. BD provided the connectors for this previous work but had no role in the trial initiation, study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit. The other authors have nothing to disclose. The drafting of this protocol was formalized in 2013 with validation by Carefusion consultants.

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...

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 &#34;zero catheter related infection&#34;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.

<table>
	<tbody>
		<tr>
			<td>BD MaxZero&#8482;&#160;needle-free connector</td>
			<td>Becton Dickinson</td>
			<td>MZ1000-07</td>
			<td>we present the installation of the connector with MaxZero but this protocol is applicable with any positive displacement valve.</td>
		</tr>
		<tr>
			<td>4-port mannifold with PE/PVC extension</td>
			<td>Cair-LGL</td>
			<td>RPB4310A</td>
			<td></td>
		</tr>
		<tr>
			<td>PE/PVC extension line with 3-way stopcock</td>
			<td>Cair-LGL</td>
			<td>PE3302M</td>
			<td></td>
		</tr>
		<tr>
			<td>NaCl 0.9% 250 ml</td>
			<td>Baxter</td>
			<td>2B1322</td>
			<td></td>
		</tr>
		<tr>
			<td>BD&#160;Plastipak&#8482; 50mL Luer-Lock Syringe</td>
			<td>BECTON DICKINSON MEDICAL</td>
			<td>613-3925</td>
			<td></td>
		</tr>
	</tbody>
</table>

a protocol to set up needle-free connector with positive displacement on central venous catheter in intensive care unit

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 &#34;opening&#34; once it has been sterilely installed.

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...

Watch this Scientific Journal Video about A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit at JoVE.com

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

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

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest ...

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggests that the latest generation of connectors with positive displacement may have an interest in reducing central venous line infections. New generation positive pressure connectors are now widely used and there are many reports of their use in similar context, ICU, oncology, or parenteral nutrition.Currently, there is no practical description of how to place these connectors on the catheters. Thus, it's possible that each team uses them differently. Therefore, we proposed a formalized protocol for the installation of these connectors on central venous line in ICU.We present the installation of the connector that we did use in our ICU, but this protocol is applicable with any positive displacement valve. We are going to show you a protocol to set up needle-free connector with positive displacement on central venous catheter in intensive care unit. Sterilely retrieve the connectors.Screw one connector into each socket of the three way extension stopcock and screw one connector into the end of the extension line. Then, purge the connectors with sterile saline serum. Each connector should be purged.Then, reproduce the procedure three times. At the end of the procedure, there should be three extensions with connectors. Take five more connectors and one four port manifold.Unscrew each single use cap from the manifold. Then, screw one connector into each socket of the manifold to replace the single use caps. Purge the infusion line through each connector by turning each stopcock sequentially.At the end of this step, there are three extensions with three way stopcock with purged connectors and a four port manifold with purged connectors. Place the central venous catheter sterilely according to usual practice in the unit or hospital. Check the permeability of each line, and then re-inject saline serum.Clamp the line after this injection. Screw the connectors of the three way extension stopcock into the catheter line. Then, remove the clamps.These three connectors are the proximal connectors. Screw the extension of the four port manifold into one of the connectors of the three way stopcock of the distal line. Now, all of the connectors are set up on the catheter and the catheter can be used.Before each infusion, disinfect the end of the connector for three seconds with a sterile compress, soaked in 70%isopropyl alcohol. Then, wait 10 seconds for the connector to dry. When the connector is dry, connect the syringe directly to the connector, and inject.After injection, or infusion, unscrew the device, but do not remove the connector. Leave the proximal valve in place, even if the line is not perfused. In case of microscopic contamination after disinfection, and when the connector is dry, rinse the connector with saline.In a previously published study, including 1, 633 catheterized ICU patients we observed a decrease in catheter related infections after protocol implementation, from 6.2 infections per 1, 000 catheter days to 2.7 infections per 1, 000 catheter days. Setting up the connectors increases little of the total time required to place a catheter. However, their use has several advantages.No need for a for non-infused lines, rapid stopping of infusion of the lines if necessary, no need to use single use caps several times a day to close the infusion lines. During, or for your experience with these connectors, we didn't have any problem. There is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications, but given the advantages and the absence of serious complications described in large series, the use of positive displacement connectors appears to be a good alternative to single use caps in ICU.

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11.7K visualizações.  Rouen University Hospital. Os conectores livres de agulhas foram inicialmente projetados e promovidos para evitar a exposição sanguínea aos profissionais de saúde. Alguns dados recentes sugerem que a última geração de conectores com deslocamento positivo pode ter interesse em reduzir infecções de linha venosa central. Os conectores de pressão positiva da nova geração são hoje amplamente utilizados e há muitos relatos de seu uso em contexto semelhante, UTI, oncologia ou nutrição parenteral.Atualme...