Dressings and securement devices for central venous catheters (CVC)

Amanda J Ullman, Marie L Cooke, Marion Mitchell, Frances Lin, Karen New, Debbie A Long, Gabor Mihala, Claire M Rickard, Amanda J Ullman, Marie L Cooke, Marion Mitchell, Frances Lin, Karen New, Debbie A Long, Gabor Mihala, Claire M Rickard

Abstract

Background: Central venous catheters (CVCs) play a vital role in the management of acute and chronic illness. Dressings and securement devices must ensure CVCs do not dislodge or fall out, provide a barrier protection from microbial colonisation and infection, and be comfortable for the patient. There is a large range of dressing and securement products available for clinicians to use.

Objectives: To compare the available dressing and securement devices for CVCs, in terms of catheter-related bloodstream infection (BSI), catheter colonisation, entry- and exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing condition and mortality.

Search methods: In June 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); NHS Economic Evaluation Database (NHSEED); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; six clinical trial registries and reference lists of identified trials. There were no restrictions based on language or date of publication or study setting.

Selection criteria: We included randomised controlled trials that evaluated the effects of dressing and securement devices for CVCs. All types of CVCs were included, i.e. short- and long-term CVCs, tunnelled and non-tunnelled, port-a-caths, haemodialysis catheters, and peripherally-inserted central catheters (PICCs).

Data collection and analysis: We used standard Cochrane Collaboration methods including independent review of titles and abstracts for relevance, data extraction, and risk of bias assessment of the included studies by two review authors. Results are expressed using risk ratio (RR) for categorical data with 95% confidence intervals (CIs). For outcomes best presented as a rate-per-time-period, rate ratios and standard errors have been used. We performed multiple treatment meta-analyses to rank the effectiveness of each intervention for each outcome.

Main results: We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. The extent of blinding of outcome assessment was unclear in most studies. The quality of evidence varied between different comparisons and outcomes. We mainly downgraded the quality of evidence for imprecision, indirectness, risk of bias and inconsistency.It is unclear whether there is a difference in the rate of catheter-related BSI between securement with gauze and tape and standard polyurethane (SPU) (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated (CGI) dressings and SPU (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of catheter-related BSI relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93).There is moderate quality evidence that CGI dressings reduce the frequency of catheter-related BSI per 1000 patient days compared with SPU dressings (RR 0.51, 95% CI 0.33 to 0.78).There is moderate quality evidence that catheter tip colonisation is reduced with CGI dressings compared with SPU dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and SPU are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). It is unclear if there is a difference in rates of skin irritation or damage when CGI dressings are compared with SPU dressings (moderate quality evidence) (RR 11.17, 95% CI 0.84 to 149.48).A multiple treatment meta-analysis found sutureless securement devices as likely to be the most effective at reducing the incidence of catheter-related BSI (low quality evidence), with CGI dressings ranked second (low quality evidence).

Authors' conclusions: Medication-impregnated dressing products reduce the incidence of catheter-related BSI relative to all other dressing types. There is some evidence that CGI dressings, relative to SPU dressings, reduce catheter-related BSI for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of catheter-related BSI. A multiple treatment meta-analysis found that sutureless securement devices are likely to be the most effective at reducing catheter-related BSI though this is low quality evidence. Most studies were conducted in intensive care unit (ICU) settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVCs. Future research may adjust the estimates of effect for the products included in this review and is needed to assess the effectiveness of new products.

Conflict of interest statement

Griffith University received an unrestricted educational grant from 3M (a manufacturer of CVC dressings and securement devices) to assist with the costs of Claire Rickard's (CR) research nurses' travel to a conference in 2014. Griffith University received a consultancy payment from 3M in 2013 for CR to present an educational lecture based on her independent research. Griffith University received an unrestricted investigator initiated research grant from 3M in 2014 to support a research study on which CR is an investigator, but this study was unrelated to CVC dressings and securement. Studies involving 3M's CVC dressings (Tegaderm range) are included in this review but the conclusions do not recommend these over competitor products. Griffith University received an unrestricted investigator‐initiated research grant from Centurion Medical (manufacturer of CVC dressings) as part‐funding for the CASCADE Pilot Trial led by CR, and for a PhD student scholarship Top Up for Amanda J Ullman. No trials investigating Centurion Medical's dressings were included in this review.

Marie L Cooke: nothing to declare Marion Mitchell: nothing to declare Frances Lin: nothing to declare Karen New: has received a research grant from The University of Queensland for research related to preconception and early pregnancy care; has been paid for preparing and delivering education on obtaining informed consent for research; and as the Professional Officer of the Australian College of Neonatal Nurses has been supported by an unrestricted eduction grant from Johnson and Johnson Pacific to deliver education on the AWHONN skin care guidelines and the Every Newborn Action Plan. Debbie A Long: nothing to declare Gabor Mihala: nothing to declare

Editorial base comment: this review is not currently compliant with Cochrane's Commercial Sponsorship policy. The review is expected to be updated within the next twelve months and the majority of authors and the Lead Author will be free of conflicts of interest for this new update.