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ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 7  |  Page : 2013-2020

Study on the timing of first dressing change with alginate dressing application in PICC placement among tumor patients


1 School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University; Nursing Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
2 Nursing Department, The First Affiliated Hospital of Shandong First Medical University, Jinan, China

Date of Submission03-May-2022
Date of Decision11-Sep-2022
Date of Acceptance12-Oct-2022
Date of Web Publication11-Jan-2023

Correspondence Address:
Hong Ji
School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, No.44, Wenhuaxi Road, Lixia 250012, Jinan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.jcrt_941_22

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 > Abstract 


Objective: To explore how the timing of the initial dressing change influences bacterial growth when alginate dressings were used after peripherally inserted central catheter (PICC) line insertion in tumor patients.
Methods: In total, 186 tumor patients who had an alginate dressing after PICC insertion were randomly divided into a control group, observation group one (OG1), and observation group two (OG2). The control group had their first dressing change 48 h after PICC insertion, while OG1 was after 72 h and OG2 was after 96 h after. Samples were taken at the dressing change from the insertion site and surrounding skin. The results of the bacterial culture were compared to investigate how the timing of the first dressing change affected catheter infection.
Results: Of the 186 patients, 29 had a positive bacterial culture. Of these, 10 were in the control group, 9 were in OG1, and 10 were in OG2. IBM SPSS Statistics 21.0 was adopted to analyze the correlation between the timing of the first dressing change and insertion site infection. No statistical significance between the timing of the first dressing change and insertion site infections was found (P > 0.05).
Conclusions: The condition of each tumor patient should be comprehensively evaluated after PICC placement to determine when the first dressing change should occur, but it can likely be extended to 96 h after insertion to promote wound healing, reduce clinical workload, and lower patient economic burden.

Keywords: Alginate dressing, bacterial culture, first dressing change, insertion site infection, PICC, placement


How to cite this article:
Zhao J, Ruan Z, Zhao J, Yang Y, Xiao S, Ji H. Study on the timing of first dressing change with alginate dressing application in PICC placement among tumor patients. J Can Res Ther 2022;18:2013-20

How to cite this URL:
Zhao J, Ruan Z, Zhao J, Yang Y, Xiao S, Ji H. Study on the timing of first dressing change with alginate dressing application in PICC placement among tumor patients. J Can Res Ther [serial online] 2022 [cited 2023 Jan 27];18:2013-20. Available from: https://www.cancerjournal.net/text.asp?2022/18/7/2013/367480

Authors Jinyan Zhao and Zhen Ruan contributed equally to the article.





 > Introduction Top


A peripherally inserted central catheter (PICC) provides long-term, safe, and painless vein access via catheter insertion into a peripheral vein, with the catheter tip located in the superior or inferior vena cava.[1],[2],[3],[4] PICC lines have been widely used in clinical practice and effectively avoid the pain caused by repeated venipuncture and reduce the incidence of chemical phlebitis.[5] In China, PICC lines have been used for many years and have been widely used in, for example, chemotherapy, parenteral nutrition, and critically ill patients.[6],[7],[8] PICC placement involves an invasive operation and damages the innate immune barrier (i.e., skin), thus providing a pathway to microorganisms from the skin into the blood. Infection is one of the most common PICC complications, with catheter-related bloodstream infections being the most common nosocomial infection and most serious complication caused by long-term catheter maintenance.[1],[9],[10] Central line-associated bloodstream infections increase mortality, morbidity, and medical costs.[7]

White blood cell count, placement duration, and operator experience are the main risk factors associated with catheter-related bloodstream infections. Additional important risk factors include the number of puncture attempts, patient age, and pre-existing chronic conditions (e.g., diabetes).[11],[12] Clinical staff believe that extending the dressing change interval may increase the risk of infection due to the increase of skin colonies under the dressing.[13] Most specialized intravenous infusion therapy regulation literature states that dressing changes should be performed in an interval of three to seven days during PICC placement.[14] One study recommends dressings to not be changed before the seventh day after PICC placement or even less frequently unless the PICC line is loose, damp, or soiled with blood.[15] There are currently no clear guidelines for the timing of the first dressing change after a PICC insertion and no clear correlation between the timing of the first dressing change and catheter-related blood infections.

The first dressing change is usually performed 24 h after PICC insertion in clinical practice, which has shown that such dressing changes often cause complications, including scab loss, puncture site bleeding, puncture site pain during disinfection, a slower healing process, and an increased incidence of catheter removal.[16] Frequent dressing changes increase the incidence of medical adhesive-related skin injury and the economic burden on patients. Bleeding is the most common complication during the first dressing change after PICC insertion among patients with hematologic tumors.[5] A randomized controlled trial investigating the frequency of dressing changes after chest tube insertion illustrated that dressing changes every three days reduced patient pain, skin injury, economic cost, and nurse workload compared to daily dressing changes.[17]

Nurses consider increased infection rates to be the greatest risk factor associated with delayed dressing changes.[13] Replacing sterile gauze dressings with alginate dressings over the puncture site after PICC insertion in tumor patients has been shown to lower the dressing change interval to one week and to reduce postoperative blood flow and puncture site infection rates.[18] A histological examination of mice found that alginate dressings reduce inflammation at the wound site and promote re-epithelialization, angiogenesis, and collagen deposition.[19] To date, no clear evidence has been provided to support the safety of delayed dressing changes when using alginate dressings over PICC line puncture sites in tumor patients. In this study, the initial dressing change after PICC insertion was delayed by different lengths of time when alginate dressings were used on patient puncture sites. Consequently, bacterial growth was measured at the puncture site and surrounding skin to predict infection rate differences caused by the varied dressing change timings.


 > Materials and Methods Top


Research subjects

In this study, 186 patients who underwent PICC placement in the oncology department of a grade A tertiary hospital in Shandong province from March 2020 to March 2021 were enrolled as research subjects. Patients were included if they were conscious with an assessed Barthel index of slightly dependent or not dependent if their PICC line was inserted successfully on the first try, if the guidewire was removed at the appropriate time after the electrocardiogram-guided positioning of the terminal tip of the PICC line, and if the patient participated voluntarily with signed, informed consent. Patients were excluded when they had poor treatment compliance, their transparent film dressing was removed, the guidewire was pulled out, and the catheter was placed for a second time after the PICC line and guidewire were placed, or when patients had an infection prior to PICC insertion. Patients were eliminated when there was bleeding at the puncture site or the dressing was changed ahead of the prescribed change, when the patient was discharged early from the hospital and did not undergo the required dressing change, and when the patient took antibiotics or immunosuppressants before collection of the specimen for culture. The study has been approved by the Ethics committee. Ethics: YXLL-KY-2022(057).

Grouping

Block randomization was used in this study, with each block consisting of three patients according to the timing of their PICC insertion. Each block group was randomly divided based on the random number table. Finally, the subjects were divided into three groups, including the control group, observation group one (OG1), and observation group two (OG2).

Research method

The guidewire was removed immediately after electrocardiogram-guided positioning of the terminal tip during PICC placement. The puncture site was covered with 2 × 2 cm triple-layered alginate dressing made from a 2 × 6 cm double-folded alginate dressing that was covered with a 3.3 × 3.3 cm nine-layer gauze dressing made from a 10 × 10 cm gauze dressing (four-folded). A sterile, transparent dressing was pasted to the outermost layer with the catheter properly fixed. The first dressing was changed 48 h after PICC insertion in the control group, 72 h after PICC insertion in OG1, and 96 h after PICC insertion in OG2. During the initial dressing change after PICC insertion, the transparent film dressing was removed via an aseptic technique and a 5 × 5 cm sterile sampling plate was applied to the skin above the catheter. With the puncture site as the center, a sampling swab was applied to the puncture site and 5 × 5 cm of skin around the puncture site. Afterwards, the swab was submitted and cultured in a timely manner. The differences in bacterial growth between the three groups were recorded. Details are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: The puncture site was covered with 2 × 2 cm triple-layered alginate dressing that was covered with a nine-layer gauze dressing

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Figure 2: A sterile, transparent dressing was pasted to the outermost layer with the catheter properly fixed

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Figure 3: A 5 × 5 cm sterile sampling plate was applied above the skin with the puncture site as the center, and a sampling swab was applied to the skin within the sterile sampling plate

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Figure 4: The swab was submitted and cultured in a timely manner

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Quality control

The subjects were all inpatients in the department of oncology. They did not leave the hospital during this study and were subjected to the same hospitalization environment. PICC insertion was performed jointly by two specialized nurses from the department of oncology with national and provincial PICC insertion certification. The PICC insertion process was done under strict aseptic conditions. The PICC dressing changes and bacterial cultures were performed by nurses from the department of oncology who had been strictly trained in this operation and who were qualified by the specialist nurse that had national PICC insertion certification. The homogenization of PICC insertion and dressing change for all the research objects was maximized to prevent confounding variables from interfering with the research.

Evaluation index

Primary outcome indicators: Bacterial culture

At the first dressing change, a sterile swab was applied to the PICC insertion site and the surrounding skin in 5 cm squares. The specimen was cultured for three days. A positive bacterial culture was considered a potential risk factor for catheter-related infection.

Secondary outcome indicators: The average cost of dressing changes

A data book for PICC dressing changes was established to record each subject's expenses for each PICC dressing change during hospitalization. The subjects' total expenses for the PICC dressing changes were obtained at discharge. Accordingly, the average PICC dressing change cost for the subjects in each group was calculated and compared between the three groups.

Secondary outcome indicators: The average total time spent on dressing changes

The working hours of the nurses who performed each PICC dressing change were recorded. The total working hours needed for PICC dressing changes for each subject were obtained when the subjects were discharged. Accordingly, the total nurse working hours needed for the PICC dressing changes in each group were calculated and compared between the different groups.

Data collection method

The general subject information and related PICC insertion information was collected by a researcher. Before data collection, the researcher systematically trained the nurses who were qualified in PICC dressing changes in the protocols for this study, which included the rigorous and precise recording of the expenses and length of time spent on each dressing change. Another researcher controlled the data quality.

Statistical analysis

All data were analyzed by the statistical software IBM SPSS Statistics 21.0. Normally distributed measurement data were expressed as “x ± s” and enumeration data were represented by a percentage. The Chi-square test was adopted to investigate the relationship between the timing of the first dressing change and a positive bacterial culture at the puncture site. The correlation between the timing of the first dressing change and the growth of the bacteria at the puncture site and the surrounding skin was predicted with a statistical significance at P ≤ 0.05.


 > Results Top


Comparison of general information

This study evaluated 250 participants who underwent PICC insertion. Of these, 186 patients were enrolled in this study, with 63 patients in the control group, 63 patients in OG1, and 60 patients in OG2 [Table 1] and [Figure 5]. There was no significant difference among the three groups in gender (p = 0.107), age (p = 0.260), or tumor type (p = 0.327). Thus, it is meaningful to make a comparison of the three groups.
Table 1: Comparison of general information between the three groups of patients at different times of the first dressing change after PICC insertion

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Figure 5: Flow diagram for the phases of a parallel-controlled, randomized clinical trial of three groups

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The results of bacterial culture at the puncture site and surrounding skin

A total of 29 bacterial cultures were positive (excluding bacterial colonizers of skin), which included 10 cases from the control group, 9 cases from OG1, and 10 cases from OG2. There was no significant correlation between the timing of the first dressing change and a positive bacterial culture from the skin at the insertion site (p = 0.933). The results are shown in [Table 2] and [Figure 6].
Table 2: Bacterial culture results of the skin at the insertion site between three groups of patients (cases)

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Figure 6: Bacterial culture results of the three groups of patients with different intervals until the initial dressing change after PICC insertion (cases)

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Of the 29 positive bacterial cultures, 22 (76 %) were positive for Staphylococcus epidermidis, 4 were positive for Staphylococcus hominis, and 1 each was positive for Streptococcus viridans, Escherichia coli, and gram-positive bacilli, respectively. Details are shown in [Table 3] and [Figure 7].
Table 3: General information for patients with positive bacterial cultures

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Figure 7: Constituent ratio of different types of bacteria in positive culture results

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Comparison of the cost and nurse working hours of PICC dressing changes

The average cost and time spent on the dressing changes for the patients in each group were analyzed and a comparison was made of the three groups. The results are shown in [Table 4]. With the extension of the interval between the first dressing changes, the cost of dressing changes in the hospital and the total time of dressing changes in patients decreased significantly.
Table 4: Cost of dressing change and nurse workload among the three groups of patients

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 > Discussion Top


PICC lines are the most common venous access pathway used in tumor patients, and its advantages have been accepted by patients and medical staff. It has been widely accepted by nursing staff changing the PICC line dressing 24 h after insertion easily leads to bleeding and pain at the insertion site and that catheter-related bloodstream infections are the greatest potential risk associated with delayed dressing changes in clinical practice.

Analysis of the bacterial culture results from the PICC insertion site and surrounding skin

This study showed that S. epidermidis accounts for a major proportion of bacterial cultures. S. epidermidis is a kind of gram-positive cocci bacterium that lives on human skin and in the vagina. Although it is recognized that S. epidermidis is nonpathogenic, its pathogenicity has seen a gradual increase in recent years. Previous studies have also verified that S. epidermidis is the most common bacterium found in the bacterial culture of patients with catheter-related bloodstream infections.[20],[21],[22] Tumor-triggered wasting syndrome and the side effects associated with antitumor drugs help to weaken patient immune systems and increase the chance of infection when combined with PICC insertion, which provides germs with a pathway into the body. Thus, attention should be paid to bacterial infections caused by the normal flora living on human skin, even if the infections are found in other body parts. At the same time, nursing staff should improve their hand hygiene and use a sterile technique to perform all PICC procedures.

The advantages and application status of alginate

Alginate dressings are functional dressings of high absorbability. Alginate is a natural, nontoxic carbohydrate extracted from seaweed. When use as a dressing, alginate forms a soft hydrogel that releases calcium ions in contact with the wound exudate, thus providing a moist environment and optimal wound healing conditions and also protects new tissues and reduces wound pain. It is also convenient and painless to change alginate dressings without causing further wound damage. Germs and viruses can be prevented when alginate dressing is in the intact state and no wound exudate is produced. Alginate dressings also have a certain capacity to absorb bacteria and reduce the incidence of wound infection.[23]

An observational study in France illustrated that compression using alginate dressings has a good effect on hemostasis in vascular access cannulation.[24] Many studies have confirmed that covering the insertion site with an alginate dressing could prevent infection.[18] One study explored the application of alginate dressings in pressure ulcers and showed that the alginate dressings accelerated the growth of granulation tissue and wound healing and significantly reduced the amount of localized bacterial infections without any adverse reactions in the treatment of patients with stage II pressure ulcers.[25] Alginate dressings on incisions have been shown to reduce pain and adhesions and to promote wound healing.[26],[27] When alginate dressings are used postoperatively in nasal cavities and paranasal sinuses, wound healing was accelerated, including epithelization, changes in the mucous membrane of the paranasal sinuses, and the reduction of postoperative edema.[28] All of the above studies show that the application of alginate dressings in the skin promotes wound healing and prevents infection.

The effect of dressing change timing on wound healing

Normal wound healing is achieved through a basic process that includes inflammation, proliferation, scar formation, and the regeneration of the epidermis and tissues. In skin, wound healing begins immediately after injury to the skin, with a large amount of granulation tissues produced 72 h after the injury.[29] A study exploring the dressing change frequency of central venous catheters illustrated that a dressing change interval of 15 days did not lead to an increase in premature catheter removal due to infection when compared to a dressing change interval of 4 days.[30] Another study suggested that dressing changes should be based on patient and wound status since unnecessary dressing changes have a negative effect on patient health and medical resources by increasing the financial cost of the dressing changes and nursing care and because increased dressing changes likely increase the risk of complications due to m more frequently exposed wounds.[31] In addition, the misdiagnose of wounds has an influence on healing and increases the incidence of complications and nursing difficulties.[32] Too-frequent dressing changes slow down wound healing, whereas less frequent dressing changes have no obvious effect on infection rates. Thus, the frequency of dressing changes could be reduced by considering patient status, which would promote wound healing and reduce skin irritation from disinfectant.

Research status of the timing of the first dressing change after PICC insertion

No research was found to suggest the optimum time for the first dressing change after PICC insertion; however, one study showed that PICC migration and bleeding mostly occurred within three days after PICC insertion.[17] In this study, no significant difference was found in the bacterial cultures taken during the first dressing change in the three groups when an alginate dressing was used to cover the insertion site after PICC insertion (P = 0.933). In addition, the three groups displayed no significant difference in bacterial growth within 96 h of PICC insertion; however, if the dressing is changed too frequently under conditions that did not fully comply with the specifications of this study (including medical environment and nurse operation), then exogenous bacteria could easily enter the patient's puncture site and the body, causing complications (e.g., infection). With increased dressing changes, the risk of infection and medical adhesive-related skin injuries rises gradually.

The results of this study illustrated that a delay in the first dressing change after PICC line insertion negatively correlated with nurse working times, patient financial expense, and medical resource consumption. Accordingly, alginate dressings could be used to cover the insertion site in clinical practice, with the timing of the first dressing change after PICC line insertion based on a comprehensive evaluation of each patient's condition. In order to reduce the disinfectant irritation, pain, and skin injury from dressing and catheter removal during the dressing change, the first dressing change could likely be delayed until 96 h after insertion unless hypersensitivity reactions have occurred in patients or the dressing is soiled, damp, or loose. Strict asepsis must be adhered to during PICC maintenance. In addition, effective health education should be provided to increase each patient's knowledge of infection prevention during PICC placement.[33]


 > Conclusions Top


Alginate dressings effectively avoid infection at the PICC insertion site of tumor patients. A comprehensive evaluation of each patient's condition after PICC insertion could likely result in a delay in the first dressing change, a decrease in insertion site bleeding and pain, improved wound healing, and reduced medical resource consumption, patient financial burden, and nurse workload, which has a significance in clinical practice. The results of this study were from a limited time period without the consideration of long-term effects. In addition, the sample size was not accurately calculated prior to the study begin. Other confounding factors, such as personal hygienic habits, were not removed from this study, and the subjects, researchers, and analysts were not blind, which may have resulted in performance bias. Thus, the results should be further validated in additional clinical nursing research.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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