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Running head: CAT AND DOG IV CATHETER CONTAMINATION FACTORS 1

Contributing Factors of Contamination of Peripheral Intravenous Catheters in Cats and Dogs

Rachel Romo

Tarleton State University

VETE 4208: Veterinary Research and Writing

Sunday, December 3rd, 2017


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Abstract

In order to appreciate the significance of intravenous catheter issues that lead to a

decrease in patient care, understanding the level of protocol necessary to eliminate all potential

contaminants may find difficult to achieve to the general private practice. Other research has

been completed to find that the removal of hair around the IVC site, using a sterile prep and

cleanser prior to the insertion of the intravenous catheter greatly decreases the percentage of

microorganism growth in the site of insertion and also general phlebitis and dermatitis.

This study provides a larger number of patient data results giving a larger percentage of

intravenous catheter positive cultures, which may give the most accurate percentage to this day.

Many studies prior had a smaller number of patients within the study that may not reflect the

majority of the public. The results of this study also provide that the more the intravenous

catheter is manipulated, maintenanced close to the site and or contaminated resulted in the most

positive results for problems or microorganism growths.


CAT AND DOG IV CATHETER CONTAMINATION FACTORS 3

Table of Contents

Introduction..4

Statement of Problem...6

Purpose of Study..6

Hypothesis6

Research Questions..7

Definitions7

Assumptions.....7

Limitations...8

Delimitations....8

Literature Review.9

Methodology..10

Data Analysis.13

Findings.....13

Summary and Conclusions14

Implications of Findings14

Recommendations..15

References..16

Appendix17
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 4

Introduction
The resistance from veterinary technicians for additional infection prevention measures

enforced during peripheral intravenous catheter placements increases every year from the latest

studies pointing in a generalized direction towards any culprit. The truth is, without spending lots

of money and time, it doesnt seem worth more than the study of postoperative infections of

patients since these are much more detrimental. All the while, this is a small fight in a much

larger picture of excelling in the highest of quality patient care.

The highest quality of patient care is seen in patients that have veterinary technicians

consistently at their sharpest in prolonged care, i.e. the intensive care unit. One of the most

common, most popular issues seen in patients is with peripheral intravenous catheters. Could you

imagine how much time, money and discomfort would be saved if this skill was mastered? This

including quantifiable reasons for peripheral intravenous catheter infections.

There are some serious variables to consider with this goal including the fact that the

highest incidence of inflammation at the catheter site in a study of dogs and cats was found in

immune-mediated compromised patients. Fractious animals also posed problems such as

increased risks to inflammation and bacterial infection. In human studies, it has been found that

bacterial colonization is common, however septicemia following is approximately less than 5%

(Rhh Tan, 2003).

Other important variables that are important to consider are the standard skin preparation

protocols and how it truly affects the infection rate. A study in 1998 found that just a one-minute

skin preparation using a 4% chlorhexidine gluconate solution resulted in a significantly

decreased bacterial growth and dermatitis than without (Coolman, 1998). The issue with this

information is that the young millennials of our times, are reluctant to trust studies that date too
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 5

far from their present day. Hence the desperate need for a current, applicable and thorough study

for a common skill seen in any veterinary practice type.

By utilizing the variety of studies referenced in this study, many opportunities for

potential error are eliminated making this study as accurate as possible to defeat any room for

rebuttal. The idea for eliminated as many possible reasons for error are to find as many

controlled elements as possible when the action of placing a peripheral intravenous catheter

(IVC). The place of practice will be at Texas A&M University Veterinary Medical Teaching

Hospital Small Animal Emergency Receiving by no more than 5 veterinary technicians that have

from 2 to 6 years of experience in this area with only one as a studied registered veterinary

technician. By limiting the number of people, tracking the patients included in the study and

independent variables will be better monitored. Keeping the study within one service will

provide a control of training backgrounds. The trained practice at this location includes the

following; Always remove the hair least 1 inch above and below the area intended for catheter

introduction. Use a 2% chlorhexidine gluconate solution with at least a 30 second contact time

allowance as per manufacture recommendations. Always wear clean nitrile gloves for IVC

placement. Never touch the catheter or stylet (any portion that will remain inside the patient).

Each person in allowed only 2 attempts at IVC placement. Use clean, hair/debris-free 1/2-inch

cloth tape (2 to 3 pieces). Using proper sterile technique, collect blood with a syringe and place a

flushed T-port. If necessary, use an alcohol soaked pad to siphon any remaining blood from the

T-port and IVC junction. Place clean and debris-free bandaging material that may include: roll

cotton cast padding, roll gauze (2 inch) and vet wrap.

The plan further from these steps are to monitor otherwise healthy dogs and cats (non-

immunocompromised) for a period of 72 hours while considering the following: location of


CAT AND DOG IV CATHETER CONTAMINATION FACTORS 6

patient holding, technician skill and experience on each case, animal behavior (fractious, docile,

etc.), IVC placement difficulty and number of attempts, how IVC materials are handled and

stored and IVC replacement (if applicable).

Problem Statement

The main issue is peripheral intravenous catheter infection and coinciding issues that

could include dermatitis, phlebitis, digital edema and discomfort at any level. There are many

opinions and beliefs for the potential reasons for causing IVC infections and complications.

However, because there are only studies that focus on one variable, enforcing better practices can

be difficult for people to adopt. This being that because there are other opportunities to cause

error and maybe that they do not get the opportunity to see IVC infection themselves, adoption

of better practices for IVC placements fail.

Purpose of Study

To find contributing factors that affect the risk rate of infection over the period within

seventy-eight hours, found at the site of a peripheral intravenous catheter site initially, placed

upon emergency triage in the emergency room and by an emergency receiving veterinary

technician.

Hypothesis

Proper site preparation of, personal protection equipment use with, proper sterile

technique execution, securing of, proper placement of clean managing for the protection of and

adequate site monitoring of peripheral intravenous catheter placements congruently result in less

than 1% of infection rates.


CAT AND DOG IV CATHETER CONTAMINATION FACTORS 7

Research Questions

1. Does wearing gloves, shaving hair with a cleaned (not necessarily new) clipper blade

(#40), and using sterile technique with site cleansing with three 2% chlorhexidine gluconate

swabs prior to the introduction of an intravenous catheter weigh heavily on the IVC site infection

rate over 3 days?

2. Does enforcing the two attempts per person rule, have an effect on infection rate and

comfort level over 3 days?

3. Are patients more prone to contracting IVC infections in the Emergency Room kennels

versus ICU wards?

4. Does placing the IVC the first attempt reduce the predicted results?

5. Does storing the bandaging material in a sealed container reduce infection rates?

Definitions

IVC; intravenous catheter.

Assumptions

The need for a detailed scrutinizing of intravenous catheter placements and bacterial

growth over a three days period. That the tape used to secure the intravenous catheter (IVC) is

free of debris and bacteria upon placement. The condition of the equipment and the sterility of

the items used. Although the survey was anonymous and secured from tampering, the sincerity

and honesty of the survey answers are in question since these individuals may not feel safe

giving their truth in fear of reprimanding. These individuals are those responsible for

maintenance of the equipment and inventory handling of the materials used. All potential IVC

issues must be considered and assuming that each is recognized in a timely manner for
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 8

troubleshooting the IVC before the problem progresses into a more severe situation, therefore

compromising the IVC.

Limitations

Although the same veterinary technician will be placing, troubleshooting and keeping up

with the maintenance of each IVC, it is up to the ICU technician to monitor the IVC for the time

in between these sessions. Depending on the time of day, there is a different technician and

requesting the same technician(s) for each case is quite impossible to achieve consistently to

remove all room for error. However, the number of technicians will be kept to a minimum,

schedule permitting. Within the department of the hospital used to facilitate this study there is a

severe shortage of veterinary technicians which decreases the accuracy and quality of patient

care. To assist with this, the same technician that will be placing each IVC will be on call for the

ICU technician to utilize if the IVC needs maintenance and troubleshooting to keep the quality of

care as consistent as possible. The same nitrile gloves were used to prepare for and place the

IVC.

Delimitations

Breed was not restricted due to the lack of case flow for a timely study. Because of the

increase of risk in immunity compromise, age of the animal was restricted to 1 year through 8

years; making note that some breeds may be considered seniors at this age. Feline patients were

welcomed in the study, although they tend to be more difficult when placing, maintaining and

troubleshooting the IVC. This is because felines have loose skin, are unpredictable with

behavior, and can easily conceal IVC manipulation; disqualifying their IVC from the study.

Using the same clipper blade through as many IVC placements as possible, beginning with a new

one and having the veterinary technician placing the IVCs keep up with the maintenance
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 9

themselves. The sharpness of the blade must be considered as the blade is used more often; this

can cause unwanted irritations on the skin by cutting the skin, plucking the hair instead of cutting

it and catching and pinching the skin. All of which must be included in the results in order to

determine if these errors increased the risk of infection of the IVC.

Literature Review

The most recent and relevant literature on this subject was published in 2011 that focused

on the bacterial and fungal growth colonization of peripheral intravenous catheters in dogs and

cats. Limitations for this study that were influential included: only using the cephalic or

saphenous veins, using the same insertion protocol for all placements, the same clinician

performed all IVCs, hair was clipped (details not given about dimensions), skin prepped with

gauze soaked chlorhexidine (percentage of solution not mentioned) and rinsed with alcohol

(dryness of the skin before IVC placement not mentioned). Also, the clinician washed hands for

one minute (soap type not included), no gloves worn, and no drapes used. A 2-cm wide stripe of

Adheroplaste, BSN Medical, France tape was used to secure the IVC in place; the length was not

noted. An injection cap or fluid lines were attached, but sterility of the item or sterile technique

used/completed were not recorded. IVCs and body temperature (location not noted) were

checked twice a day. Replacement or removal of IVCs occurred when the IVC became

nonfunctional, fluid therapy discontinued, fever occurred, or complications arose (erythema,

phlebitis, swelling).

The 100 IVCs tested were of an average of 1.75 days in length with the data collected

over ten days. Twenty-three animals (18 dogs and 5 cats) were suspected to be

immunosuppressed from either a drug received, or disease related to their reason for the hospital

visit. Local complications and hypothermia were observed in 11 dogs and 1 cat. Nineteen IVCs
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 10

from 14 animals were tested positive for microbiologic culture resulting in an overall 15.4% with

twenty different organisms isolated. Nineteen yielded one organism and one yielded two:

Candida glabratea and Staphylococcus pseudointermedius; noting that molecular testing to

identify Staphylococcus pseudintermedius was not carried out.

High prevalence of catheter-related colonization has been associated with the

administration of a dextrose solution and indwelling of greater than 72 hours in both human and

veterinary medicine. No notes were made with association between IV-line changes or

administration of drugs through IV-line ports with positive microbial culture (Seguela & Pages,

2011).

Methodology

Research Design

A mix of both qualitative and quantitative approaches were carried out for this study,

however the most important being qualitative. A qualified patient arriving in the Emergency

Room was clipped, cleaned, and IVC placed by the same technician in either the cephalic,

forelimb accessory or lateral saphenous veins via the study protocol. A clean #40 clipper blade

was used to clip the hair approximately two inches above and below the anticipated insertion site

of the IVC, taking care that any remaining hair was clear of the insertion site and minimized on

the tape to secure the IVC. Nitrile gloves were worn to prepare all equipment to minimize

contamination potentials; this includes pulling tape pieces, rerolling vet wrap and opening any

sterile items all on a freshly wiped mayo-stand. After any residual hair was brushed or wiped

from the area, three chlorhexidine swab sticks 2% were used on the insertion site; two scrubbing

as a dirty prep and the last swab in a bullseye technique starting at the insertion site. Nitrile

gloves were changed if too much hair existed on them, and again after the IVC was placed if too
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 11

much blood bore threat to stick on any of the bandaging material to house bacteria. The IVC was

securely placed with two attempts or less, blood was drawn from the IVC if applicable before the

T-port attachment was secured. The IVC at the colored hub was taped to the patient using inch

cloth tape in two or three strips and a last three-inch strip just over the IVC and T-Port junction

to secure them together. A light layer of cast padding was placed, then rolled gauze lightly

wrapped, followed by vet wrap. A two-inch piece of one-inch white tape was used for the T-Port

adapter line to secure it to the top of the vet wrap with the time, date, IVC size and initials of the

technician.

Over the three-day stay, all kennels were cleaned and steamed before use, and all IVC

catheters were maintenanced by the same technician. This would include IVC troubleshooting,

replacement or bandage material adjustment and replacement.

Sample Population

Gathering more patients to test increases the accuracy of the result, however it is most

important that all limitations and protocols are followed in order for quality results. Since

patients for this study were admitted through the Emergency Service, widening of the patient

pool was necessary. Most patients were admitted into the hospital with presenting problems that

may have the patient in an immunity compromising situation. the age limitation was however,

followed; 6 months to 8 years.

Informed Consent

A form was presented to the client with detailed description of the study purpose and

methodology. Approved by the University of Texas A&M University research administration

and Emergency Service clinicians and supervisor, this study was fitting for maintaining the

highest quality of patient care while caring for animal welfare.


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Confidentiality

Patient confidentiality is a withstanding protocol for all Texas A&M University staff and

faculty of the Veterinary Medical Teaching Hospital. All patients are safe and secure within our

watch and care within or without a study throughout the hospital.

Geographic Limitations

This study data was collected all within the hospital which remains at 62 to 73 degrees

Fahrenheit and approximately 35% to 45% humidity. No other geographic limitations were set.

Data Collection

A survey was used to gather information on the perception of the study problem and

realistic IVC placement protocol outside of such high-quality limitations. For the purpose of

setting up IVC problems up for the best success rate, every action possible was taken to avoid as

many possibilities for contamination to narrow down the list of contaminants. If the IVC needed

any maintenance whatsoever, two culturette swabs were collected from the insertion site of the

IVC; aerobic and anaerobic. All notes were documented by the same technician who placed the

IVCs, maintenanced and collected samples. Clinical Microbiology department was called in at

any hour to have the sample plated within two hours of collection. The person who performed

the plating in Clinical Microbiology was noted.

Instrumentation

Instruments used included, #40 clipper blade, standard battery-operated clipper handle,

chlorhexidine 2% swabsticks, nitrile gloves, Monoject IVC, BD syringe 1mL - 5mL, T-Port

extension set, inch cloth tape, 1-inch waterproof white tape, cast padding, cloth gauze roll,

vetwrap.
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 13

Data Analysis

Out of 300 patients (263 dogs and 37 cats), 87 IVCs were tested positive for bacterial

growth. 20 organisms were identified, 8 of which were resistant to one or more antibiotic used to

treat the patient. Factors thought to have influence on the presence of the bacteria include: the

location the patient was housed and cleaning protocol, infusion of dextrose solution of any

percentage, immunosuppression of the patient, times of manipulation of the IVC or bandage at

any point within the three-day period.

Data from the culture growth plates were collected from a microbiologist and results

were emailed to the study researcher.

Table 1. Bacterial and fungal species isolates


from 87 intravenous catheters
Species Numbers
Staphylococcus epidermidis 23
Staphylococcus intermedius 8
Staphylococcus aureus 6
Enterobacter species 9
Escherichia coli 9
Pseudomonas species 8
Klebsiella species 8
Non-haemolytic Streptococcus
species 8
Candida glabrata 8

Findings

Staphylococcus was the most prominent bacteria found to be present with the total

percentage of problematic IVCs 34.4%. 423 patients began the study and 123 were disqualified

due to premature IVC replacement, patient death, patient discharged from the hospital prior to

the 72-hour limit or break of other study limitations. Other considerations that must be taken into

note for future studies; 178 IVCs were rebandaged more than once per day, 54 were completely
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 14

re-taped with minimal site cleaning. All of the causes for extra IVC maintenance were mostly

due to bandage contamination from IVC fluids, saliva, urine, drinking water or feces. Some

bandaging maintenance, 100 (57 cats), were necessary due to patient behavioral issues. IVC

bandages that remained clean from the time of IVC placement and after each bandage change,

had the lowest number of contaminate results that grew.

Summary and Conclusions

Conclusively, the problem of peripheral intravenous catheter placement and maintenance

over a three-day period has proven itself an issue even through careful protocol. Staphylococcus

was the most prominent bacteria found to be present with the total percentage of problematic

IVCs 34.4%. It would be safe to note that cleanliness in any step of IVC placement and

maintenance is beneficial to decreasing the risk of IVC issues even after the first 24 hours. Any

environmental cleaning, safer storage of materials and proper personal hygiene protocols proved

successful throughout the study. Potentially sending the technician performing the IVCs for the

next study to learn better ways of IVC placement may improve these findings.

The question that remains is what further steps need to occur to bring this percentage of

infection rate down? Or is there even a practical and affordable protocol that exists? Is reaching

less than or equal to 1% infection rate of indwelling IVCs realistically attainable? This study will

be repeated with increased limitations to provide a more accurate pool of data to find a common

denominator for the cause of IVC contamination. Allowing more time elapsed over the study

should allow for an increase of patient numbers for a larger data pool.

Implications and Findings

It is important to understand that the research was completed on a generally healthy pet

and within a age range that was most likely to have a better immune system. This brings to light
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 15

the increase of risk of peripheral IVCs if signalment were different than the limitations for this

study.

Recommendations

Further research is encouraged to find the breaking point of 30% of infection rate of IVC

placement. Protocol for wearing at least nitrile gloves during placement is recommended for all

veterinary practices for the prevention of infection. Also, proper skin cleansing is imperative to

the decrease of risk of infection as proven in the study and others in years prior (resource). All

other protocols taken should be valued, but may not be practical for smaller veterinary practices.

For instance, the storage and housing of sterile items may not be available and therefore at rise

for a decrease in the integrity of the package. If the sterile item is at risk for integrity damage,

then this may be a reason for potential infection risk increase.


CAT AND DOG IV CATHETER CONTAMINATION FACTORS 16

REFERENCES

Jones, I. D., Case, A. M., Stevens, K. B., Boag, A., Rycroft, A. N. (2009). Factors

contributing to the contamination of peripheral catheters in dogs and cats. Veterinary Record,

164, 616-618. doi: 10.1136/vr.164.20.616

Marsh-Ng, M. L., Burney, D. P., Garcia, J. (2007). Surveillance of Infections Associated

With Intravenous Catheters in Dogs and Cats in an Intensive Care Unit. JOURNAL of the

American Animal Hospital Association, 43, 13-20.

Burrows, C. F. (1982). Inadequate skin preparation as a cause of intravenous catheter-

related infection in the dog. Journal of the American Veterinary Medical Association, 180(7),

747-749. Retrieved from http://europepmc.org/abtract/med/7085453

Lobetti, R. G., Joubert, K. E., Picard, J., Carstens, J., Pretorius, E. (2002). Bacterial

colonization of intravenous catheters in young dogs suspected to have parvoviral enteritis.

Journal of the American Veterinary Medical Association, 220(9), 1321-1324.

Maki, D. G., Weise, C. E., Sarafin, H. W. (1977) A Semiquantative Culture Methos for

Identifying Intravenous-Catheter-Related Infection. The New England Journal of Medicine,

296(23), 1305-1309.

Ashby, J. (2017). Peripheral intravenous catheter care in hospitalized cats and dogs.

Veterinary Nursing Journal, 32(2), 32-36. doi: 10.1080/17415349.2016.1262322

Seguela, J., Pages, J.-P. (2011). Bacterial and fungal colonization of peripheral

intravenous catheters in dogs and cats. Journal of Small Animal Practice, 52, 531-535. doi:

10.1111/j.1748-5827.2011.01101.x
CAT AND DOG IV CATHETER CONTAMINATION FACTORS 17

Appendix

Table 1. Bacterial and fungal species isolates


from 87 intravenous catheters
Species Numbers
Staphylococcus epidermidis 23
Staphylococcus intermedius 8
Staphylococcus aureus 6
Enterobacter species 9
Escherichia coli 9
Pseudomonas species 8
Klebsiella species 8
Non-haemolytic Streptococcus
species 8
Candida glabrata 8