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PENCEGAHAN DAN

PENGENDALIAN PLEBITIS

Disampaikan
Pada Pelatihan PPI Dasar
PERSI
Jakarta, 26 29 Nopember 2013

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

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
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

TANDA TANDA
PLEBITIS

Secara klinis :
Ada nyeri, nyeri
tekan,bengkak,pengerasan,
eritema dan hangat pada
vena
Jika infeksi :
Kemerahan, demam, sakit,
bengkak,

Patofisiologi
Faktor etiologi plebitis
(spontan, komplikasi ,
psangan infus)
Pengaruh
penurun
Menyebabkan
histamine,
Kerusakan
bradikinin, dan
dan iritasi PB
serotonin

Nyeri

Tidak diatasi
Terbentuknya
faktor
procoagulan
di endothelial

Permeabilitas
kapiler me
Penumpukan cairan & protein
di intertitial space
Edema dan
tenderness

Mengaktifasi
proacugulan
Collect
leukosit

Hipertermi
a

Inflammato
ry
continued

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

Catheter Related Infection


Risk
Catheter site
SKIN ORGANISMS
Endogenous Flora
Extrinsic
HCW
Contam Disinfectant
Invading Wound

CONTAMINATION OF
CATHETER HUB
Extrinsic (HCW)
Endogenous (Skin)

CONTAMINATED
INFUSATE
Fluid
Medication
Contaminated
Extrinsic
Infusate

CONTAMINATION OF DEVICE
PRIOR TO INSERTION
Extrinsic

Skin
Vein

Fibrin
Fibrinsheath,
Sheath
Thrombus
Thrombus

HEMATOGENOUS
HEMATOGENOUS,
From
Distant
Local
Infection
From
distant
local
Infection

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)
Erythema at access site
With or without pain
Erythema
Pain at access site
With or without edema
Erythema
Pain at access site
With or without edema
Streak formation
Palpable venous cord
Erythema
Pain at access site
With or without edema
Streak formation
Palpable venous cord > 1 inch
Purulent drainage

No
Nosigns
signsof
ofphlebitis
phlebitis
OBSERVE
CANNULA
OBSERVE CANNULA

Stop
Stopinfusion
infusionififpossible
possible
Identify
additional
Identify additionalresources
resources
for
management
for management
Remove
RemoveIV
IVififsymptoms
symptomspersist
persist

Stop
Stopinfusion
infusionififpossible
possible
Identify
additional
Identify additionalresources
resources
for
management
for management
Remove
RemoveIV
IVififsymptoms
symptomspersist
persist

Stop infusion if possible


Stop infusion if possible
Identify additional resources
Identify additional resources
for
formanagement
management
Remove IV
Remove IV
Notify primary service
Notify primary service

Stop infusion and establish alternate


Stop infusion and establish alternate
IV
IVsite
site
Remove IV and culture site and cathe
Remove IV and culture site and cath
tip
tip
Notify primary service
Notify primary service

Infiltration Scale (INS 2006)


No symptoms

Skin blanched
Edema < 1 inch in any direction
Cool to touch
With or without pain

Skin blanched

Edema 1 6 inches in any direction


Cool to touch
With or without pain

Skin blanched, translucent


Gross edema > 6 inches in any direction
Cool to touch
Mild to moderate pain
Possible numbness

Skin blanched, translucent


Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema > 6 inches in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate severe pain
Infiltration of any amount of blood product, irritant, or vesicant

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 m.

Pemilihan material kateter


intravaskuler yang
digunakan silikon dan poliuretan
kurang bersifat
iritasi dibanding politetrafluoroetilen

Himpunan Perawat Pencegah dan


Pengendali Infeksi Indonesia
(HIPPII)- Pusat

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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

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

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

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
CDC, Centre
for Disease Control
and Prevention,
Guidelines
forfor
prevention
of Intravascular
dressing
and
72
hour
transparent
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 PICCs )
INS standards, 2006
Single use flushing systems to be used, that is, do not use
multiple use vials

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

The Peripheral Vascular Catheter


(PVC) Bundle
1. Performed hand hygiene before and
after all PVC procedures
2. Checking the PVCs insitu are still
requared
3. Removing PVCs where there is extra
vasation or inflamation
4. Checking PVC dressing are intact
5. Considering removal of PVCs insitu
longer than 72 hours

Pengumpulan data setiap hari


Perhitungan setiap bulan
Laporan setiap bulan,triwulan,semester,
tahunan
Insiden rate Plebitis:
Jumlah plebitis
--------------------------------)

Hari pemakaian IV Kateter

X 1000 =

Himpunan Perawat Pencegah dan


Pengendali Infeksi Indonesia
(HIPPII)- Pusat

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