Yes, Virginia, Aseptic Technique Is Very Important: Maximal Barrier Precautions during Insertion Reduce the Risk of Central Venous Catheter-Related Bacteremia

Yes, Virginia, there is a Santa Claus. -Frances Pharcellus Church There long has been controversy over the level of sterile barrier precautions that should be used during the insertion of a short-term, noncuffed central venous catheter. Most authorities stress the need for good aseptic technique, stringent asepsis, or asepsis, and many explicitly advocate use of maximal sterile barriers,1-9 namely the use of sterile gloves, a long-sleeved surgical gown, a large sterile drape, and possibly a surgical cap and mask as well. However, most authors have not addressed the issue explicitly or endorsed the widespread practice of using only sterile gloves and drapes.1~19 Even the expert panel that wrote the first Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Intravascular Infections could not bring itself to recommend sterile barriers beyond gloves and drapes.20 No cardiologist performing a cardiac catheterization would use less than complete barrier precautions, despite the fact that the catheter remains in place for only an hour or two in most cases and rarely for more than 24 hours, even when the introducer is left in place for a percutaneous transcoronary angioplasty the following day. Realizing that a short-term, percutaneously inserted, noncuffed central venous catheter is the intravascular device most likely to cause nosocomial bloodstream infection,8,21,22 I have long believedadmittedly without conclusive supportive data-that maximal sterile barrier precautions should be mandat ry during the insertion of any central venous catheter (realizing that such precautions are unnecessary and would not be cost-effective for insertion of peripheral venous catheters or intraarterial catheters used for hemodynamic monitoring in an ICU).8 The problem with imposing such a standard on the 5 million short-term central venous catheters placed in U.S. hospitals each year has been the lack of scientific data affirming clearcut benefits in terms of reduction of device-related infection and, in the maelstrom of impending healthcare reform, economic cost-benefit. As a consequence, central venous catheters currently are inserted by physicians who wear sterile gloves, but often use little else in terms of barrier precautions. Personally having inserted hundreds of central venous catheters and supervised the insertion of several thousand over the past 20 years using a long floppy guidewire (as is the common practice), I would submit that without maximal sterile barriers-including a longsleeved gown and a large sterile sheet-drape-touch contamination of the guidewire, the catheter, or both is very common (but rarely appreciated).