PENCEGAHAN DAN PENGENDALIAN PLEBITIS Disampaikan Maria Hayati. S.Kep.Ns

POKOK BAHASAN Pendahuluan Pengertian Faktor –faktor yang mempengaruhi plebitis Pencegahan dan pengendalian

PENDAHULUAN Pemasangan infus melalui vena perifer dapat berisiko terjadinya plebitis The incidence of infusion phlebitis is estimated to be as high as 62% of patients with an intravenous access device in place (Lundgren, Jordfeldt & Ek 1993).

Insioden Rate Plebitis Perseribu Hari Pemakaian Alat ( ‰ ) di RS Jantung Harapan Kita Periode Tahun 2005 s/d 2012

PENGERTIAN Plebitis sering dihubungkan dengan Peradangan pada vena perifer Plebitis sering dihubungkan dengan pembentukan bekuan darah (trombosis)  Tromboflebitis Secara klinis adanya keluhan nyeri, nyeri tekan, bengkak, pengerasan, eritema dan hangat pada vena oleh karena peradangan, infeksi dan/atau trombosis

TANDA –TANDA PLEBITIS Secara klinis : Ada nyeri, nyeri tekan,bengkak,pengerasan, eritema dan hangat pada vena Jika infeksi : Kemerahan, demam, sakit, bengkak, adanya pus atau kerusakan pada kulit

Faktor etiologi plebitis Patofisiologi Faktor etiologi plebitis (spontan, komplikasi , p’sangan infus) Tidak diatasi Pengaruh penurun histamine, bradikinin, dan serotonin Terbentuknya faktor procoagulan di endothelial Inflammatory continued Menyebabkan Kerusakan dan iritasi PB A thrombus ‘ll form in vein Mengaktifasi proacugulan Permeabilitas kapiler me ↑ Nyeri Penumpukan cairan & protein di intertitial space Collect leukosit Edema dan tenderness Hipertermia

FAKTOR –FAKTOR YANG MEMPENGARUHI PLEBITIS Usia Jenis kelamin Kondisi dasar ( diabetes melitus, infeksi, luka bakar ) Faktor kimia seperti obat atau cairan yang iritan Faktor mekanis seperti bahan, ukuran kateter, lokasi dan lama kanulasi Agent infeksius

Catheter Related Infection Risk Fibrin sheath, Thrombus HEMATOGENOUS, From distant local Infection Contaminated Infusate

INS Visual Infusion Phlebitis (V.I.P.) Score, 2006 IV site appears healthy No pain at IV site, no erythema, No swelling No palpable venous cord (all ages) No signs of phlebitis OBSERVE CANNULA Erythema at access site With or without pain 1 Stop infusion if possible Identify additional resources for management Remove IV if symptoms persist Erythema Pain at access site With or without edema 2 Streak formation Palpable venous cord 3 Remove IV Notify primary service Palpable venous cord > 1 inch Purulent drainage 4 Stop infusion and establish alternate IV site Remove IV and culture site and catheter tip Phlebitis scale with grade according to the most severe presenting indicator (INS Standard 53). Assess IV per management of peripheral intravenous catheter policy, following the corresponding intervention guidelines. These guidelines are not intended to establish a protocol for all patients, nor are they intended to replace a clinician’s clinical judgement. Protocol of Actions based from Children’s Hospital Boston.

Infiltration Scale (INS 2006) No symptoms Skin blanched Edema < 1 inch in any direction Cool to touch With or without pain 1 Edema 1 – 6 inches in any direction 2 Skin blanched, translucent Gross edema > 6 inches in any direction Mild to moderate pain Possible numbness 3 Skin tight, leaking Skin discolored, bruised, swollen Deep pitting tissue edema Circulatory impairment Moderate – severe pain Infiltration of any amount of blood product, irritant, or vesicant 4 The infusion should be discontinued at the first sign of infiltration, and the device removed (INS 2006). Treatment should be dependent upon the severity of the infiltration. Ongoing observation and assessment of the infiltrated site, including, but not limited to motion, sensation, and circulation in the extremity, should be performed and documented in the patient’s permanent medical record.

1. Plebitis Kimia 2. Plebitis Mekanis 3. Plebitis Bakterial JENIS – JENIS PLEBITIS 1. Plebitis Kimia 2. Plebitis Mekanis 3. Plebitis Bakterial

1.Plebitis Kimia pH dan osmolaritas cairan infus yang ekstrem  pH ↓, osmolaritas ↑ Mikropartikel yang terlarut  yang terbentuk bila partikel obat tidak larut sempurna selama pencampuran  pemberian obat intravena menggunakan filter 1 sampai 5 µm. Pemilihan material kateter intravaskuler yang digunakan  silikon dan poliuretan kurang bersifat iritasi dibanding politetrafluoroetilen (teflon), polivinil klorida atau polietilen resiko tertinggi

Himpunan Perawat Pencegah dan Pengendali Infeksi Indonesia (HIPPII)- Pusat

2. PLEBITIS MEKANIS Penempatan kateter intravaskuler yang tidak tepat Ukuran kateter intravaskuler yang tidak sesuai dengan ukuran vena Cara pemasangan, pengawasan dan perawatan yang kurang baik Laju pemberian yang tidak sesuai

3. PLEBITIS BAKTERIAL Hand hygiene tidak dilakukan Preparasi kulit tidak baik sebelum pemasangan infus Teknik aseptik tidak baik saat akan pemberian obat atau cairan Kateter dipasang terlalu lama Tempat Tusukan Kateter tidak/ jarang diinspeksi secara visual Alat – alat yang di gunakan rusak atau bocor atau kadaluarsa Larutan infus terkontaminasi karena teknik aseptik yang kurang baik pada saat pencampuran larutan Faktor virulen instrinsik dari mikroorganisme itu sendiri

PENATALAKSANAAN PENCEGAHAN PLEBITIS 1.HAND HYGIENE

2. PREPARASI KULIT Use alcohol followed by application of main disinfectant 10% Povidone Iodine or 2% Chlorhexidine prep. Provides immediate kill as well as residual activity For Iodophor - 2-3 hrs For Chlorhexidine prep. - 6 hrs Process - 2 Steps Apply alcohol in circular motion outwards, allow it to dry Apply Povidone Iodine or Chlorhexidine in circular motion outwards, allow it to dry

3. DRESSING / PENUTUP INFUS Use either sterile gauze or sterile transparent, semi permeable dressing to cover the catheter site Replace catheter dressing if the dressing becomes damp, loose, or visibly soiled Replace dressings at every 2 days for gauze dressing and 72 hour for transparent dressing CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR, 2002: 51 ( No. RR 10 )

4.Catheter care - Flushing All vascular access devices used should be flushed with 0.9% sodium chloride (normal saline) or heparin to* Maintain catheter patency Prevent contact between incompatible fluids and medications Appropriate Flushing helps to reduce catheter thrombosis and thus CR-BSI risk** As thrombi or fibrin deposits could serve as a nidus for microbial colonization When catheter flushing is to be performed Just after catheter insertion Before and after each administration of medication od sampling Every 6-8 hours when catheter is not in use (Once a day - home care PICC’s ) INS standards, 2006 Single use flushing systems to be used, that is, do not use multiple use vials 8% Syringes prepared by nurses are contaminated - Syringe tip, Fluid*** Touch contamination Multiple use vials or their inappropriate usage page 394, ** CDC, Centre for Disease Control and Prevention, Guidelines for prevention of IV catheter related Infections, MMWR, 2002: 51, Page 9 ( No. RR 10 ), ** APIC, Lynn Hadaway, Webinar series 2006 Infusion Therapy in clinical practice Judy Hankins et al, 2nd Edition, The Infusion Nursing Society,

5. Appropriate use of equipment 1. Intravasular Access Monitor and inspect catheter site regularly, the site should be observed for any signs of inflammation, infection or malfunction 2.For any intravascular access Replace IV tubing and add on devices no more frequently than 72 hours Replace tubing used to administer blood products or lipids with in 24 hrs Clean injection ports with 70% alcohol or an iodophor before accessing 3.IVD replacement Peripheral Venous : 72-96 hrs in adults / first signs of phlebitis, In pediatric patients, Do not routinely replace peripheral venous catheters unless clinically indicated CVC’s / PICC / Hemodialysis / PA / Peripheral Arterial : NOT routinely*

The Peripheral Vascular Catheter (PVC) Bundle Performed hand hygiene before and after all PVC procedures Checking the PVCs insitu are still requared Removing PVCs where there is extra vasation or inflamation Checking PVC dressing are intact Considering removal of PVCs insitu longer than 72 hours NHS

SURVEILANS Pengumpulan data setiap hari Perhitungan setiap bulan Laporan setiap bulan,triwulan,semester, tahunan Insiden rate Plebitis: Jumlah plebitis --------------------------------- X 1000 = ( ‰ ) Hari pemakaian IV Kateter

Himpunan Perawat Pencegah dan Pengendali Infeksi Indonesia (HIPPII)- Pusat