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KEY POINTS

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  • Intravascular access device–associated infections may be either local or bacteremic, and the risk of developing an infection varies with the patient population, the type of device, the microbe, and the patient-microbe-device interaction.

  • The status of all indwelling vascular access devices should be reviewed daily by the critical care team, with attention to the duration of placement, appearance of the exit site, and continued clinical indication for the intravascular device.

  • Central venous catheters account for over 90% of all intravascular device–related bacteremias.

  • Most intravascular device–related bacteremias are caused by endogenous skin flora at the catheter insertion site that migrate along the transcutaneous portion of the catheter with subsequent colonization of the catheter tip.

  • Coagulase-negative staphylococci and Staphylococcus aureus account for just over 50% of all intravascular device–related bacteremias, followed in frequency by gram-negative bacilli and yeast.

  • Diagnosis of intravascular device–related infection, either local or bacteremic, is best approached using a combination of clinical and laboratory criteria.

  • Although treatment of central-line infections due to coagulase-negative staphylococci may be successful without catheter removal, infections caused by S aureus necessitate catheter removal.

  • Central intravascular catheter infections are essentially preventable infections. Successful prevention entails attention to a careful needs assessment for the device, careful site selection, maximal barrier precautions and sterile technique on insertion, insertion by the most skilled operators, rigorous catheter-site care, and interrupting the integrity of the system as little as possible.

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The use of intravascular access devices has become an integral part of modern patient care, and nowhere is this more evident than the intensive care unit (ICU). Over the years, an increasing array of devices other than the original peripheral and single-lumen central catheters have been introduced. There is currently no standardized nomenclature for vascular access devices and they may be differentiated based on the number of lumens, site of insertion, use of cuffs or tunneling, category, or even by name. From a generic perspective they may be classified as percutaneously inserted peripheral or central lines and totally implantable devices. Central lines may be further distinguished as tunneled or nontunneled and noncuffed or cuffed. The most frequently encountered devices are single lumen peripheral lines, noncuffed, nontunneled multilumen central venous catheters (CVCs), tunneled and cuffed CVCs, flow-directed pulmonary artery catheters (PACs), peripherally inserted central and midline catheters, peripheral arterial catheters, and implantable devices. Intraosseous vascular access lines may occasionally be encountered.

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These intravascular access devices provide a route for the administration for fluids, blood products, nutritional products, and medications; allow the monitoring of hemodynamic functions; and permit bloodletting and the maintenance of emergency access. However, vascular access devices may be associated with several complications, including local site infection, bacteremia, clinical sepsis without bacteremia, line fracture and extravasation of fluids or drugs, obstruction by medication, thrombosis, thrombophlebitis, and septic thrombophlebitis. Infectious complications are the most frequent and among the most serious of these complications. The magnitude of CVC-related infectious complications can be appreciated when one realizes there are ...

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