Central Venous Access-Associated Bloodstream Infection Prevention
CASE STUDY
Central venous access can be linked with adverse events that can be hazardous to the patient, and can also increase the rate of hospital readmissions (Ullman et al. 2015). Infection is the main complication in most of the intravascular catheters in critically ill patients. Blood stream infections due to catheters are found in 3 to 8 % of the inserted catheters and have been one of the main causes of the nosocomial blood steam infections in the intensive care unit (Gillanders et al. 2014). This essay focuses on the central line associated blood stream infection, the strategies to prevent the blood stream infection, probable strategies to manage occlusion, and the ways to maintain skin integrity in patients with CVAD.
Central line associated blood stream infection (CLABSI) is a blood stream infection that is laboratory confirmed blood stream infection that indirectly indicates the quality of care (Sweet et al. 2012). As seen from the case study, Jim Kares had been a central line for a period of 48 hours. Infection might have occurred while inserting the three lumen central venous catheter in to the right subclavian vein of Jim (Ogston-Tuck 2012). It is evident from the case study that the technique involved aseptic on touch technique, hence the infection would not have occurred, Further more infection could have spread by the insertion of a new CVC in to the left internal jugular vein. As stated by (Chopra et al. 2012), which belongs to the level of evidence II, Central lines can get contaminated leading to infection by the following ways- Contamination of the catheter may occur before the insertion. Pathogenic skin organisms might migrate from the site of insertion to the cutanous catheter tract, leading to the colonization of the microbes at the tip of the catheter. Hence in case of Jim Karas the pathogens might have contaminated the catheter tip or might have inoculated the site of insertion in the above mentioned ways.
Catheter can be contaminated by direct contact with hands or contaminated devices. Catheters can become contaminated with other sources of infection through the bloodstream. Another contamination can occur through IV fluid contamination (Ralls et al. 2012). CVAD insertion site should be checked every shift for any early signs of infection, hence in case of Jim it was necessary to check his site of insertion of the CVC every now and then. If any tenderness found at the site of infection suggesting blood stream or local infection the dressing has to be removed for the thorough examination of the site (Chopra et al. 2012). Aseptic techniques have to be maintained while managing the CVAD. In order to reduce the risk of contamination, sterile gloves and aseptic fields are required. According to Ogston-Tuck (2012) CVAD infection can be prevented by following the five moments of hand hygiene. The different moments of the hand and hygiene are relevant as the paper belonged to number one evidence. Clinicians should be able to evaluate the risk of exposure of the body fluid while caring for the patient having a CVAD (Ge et al. 2012). One has to wear sterile gloves for the insertion of the peripheral intravascular catheters. It is advisable not to touch the access site after the application of the skin antiseptics (Ogston-Tuck 2012). It is important to wear sterile and clean gloves for the insertion of central catheter as in case of Jim. This can be prevented by the use of gloves, face shields and aprons. It is evident from the case study that there had been some mistake from the clinician’s side which led to a blood stream infection. This indicates the inferior quality of care that he received in this respect. According to Ge et al. (2012), hand and hygiene should have been maintained before touching of the patient; just before the procedure, after touching the patient’s surroundings, after the procedure, after touching the patient and after touching the patient’s surroundings. Hence, in order to prevent CVAD associated infection, hygiene should have been maintained in case of Jim Karas by using alcohol rubs or soap solutions (Ogston-Tuck 2012). This paper belongs to level II of evidence; hence it relevant to the topic of discussion. The skin preparation of the patient is necessary before the insertion of the catheter to avoid any infections. It is advisable to clean the skin with antiseptics like alcoholic chlorohexidine gluconate solution (Ge et al. 2012). Catheter site dressing regimen is another important step that should be done with utmost care for preventing further infections. Sterile gauze, semi permeable dressing should be used to cover the catheter site. It is advisable to change the dressing if the site becomes damp or soiled. Topical antibiotics should not be applies as they can promote fungal infections (Ogston-Tuck 2012).
Causes of Bloodstream Infection in CVAD
During the clinical procedure it is necessary to maintain an aseptic and a controlled working space. As stated by Gavin et al. (2016) a single line change can be performed by using a dressing pack and the multiple lines needs sterile drapes along with the dressing pack. The case study also reveals that Jim had also suffered from occlusion. Occlusion can be identified as one of the complications related to CVD (Gavin et al. 2016). A CVAD occlusion is the complete or the partial obstruction of the catheter tube that makes it impossible to withdraw blood or flush or give medications through the catheter tube (Ogston-Tuck 2012). This can be a serious complication as it can interrupt or delay the IV therapy and can also make processes like catheter removal and catheter replacement difficult, just as in case of Jim. (Hadaway 2012). According to Gillanders et al.(2013) the main approach to prevent occlusion is to understand the types of catheters. For example the non tunnelled CVADs that are inserted through the subclavian veins can be kept for days to weeks. CVAD catheters with open ended tips have to be clamped. Proper flushing assists in maintaining the patency (Hadaway 2012). Once the occlusion had already occurred in the patient, it is advisable to flush the lumen with sterile 0.9% saline solution and attempt should be made to aspirated blood from the lumen to determine aspiration and the ease of flush. (Bertelino et al. 2012). At first it is important to assess the type of occlusion caused. In case of the managing the mechanical occlusion, at first any add in devices such as needleless connectors/cap are removed and the catheter is flushed with saline solution (Bertelino et al. 2012). The placement of the non-coring needle is verified, the clogged in line filter it replaced. In case of thrombotic occlusion, thrombolytic agents are administered for restoring the CVAD patency in catheter lumens (Ogston-Tuck 2012). Thrombolytic agents are instilled in the occluded lumens. Negative pressure technique is used with stop cock method or single syringe method for managing complete occlusions (Sona, Prentice and Schallom 2012).
It is evident from the case study that Jim Kares had been suffering from skin irritation. Potential risk factors for the CVAD skin damage includes age of the patients, type of the comorbid conditions, irritation of the CVAD site. It can also be seen from the case study that Jim had already turned old. It has to be remembered that skin thins with age and can become very weak with age (Ogston-Tuck 2012). Skin injury might take place and it may take longer time to heal. Nutritional imbalance, anxiety, pain and incontinence can cause sores or skin damages (Ullman et al.2012). It is necessary to keep the skin clean and hydrated. Keeping the patient mobile, providing the patient with cushions, air mattresses or booties can ease the sore spots. The clinicians inspect the skin colour at the CVAD site for assessing the texture, integrity and uniformity. It is necessary to classify the lesions and the exudates by their types (Ogston-Tuck 2012). Chlorohexidine gluconate is normally used as the preferred antiseptic solution for cleaning the CAVD sites (Ullman et al 2012). In case of contact dermatitis, the sensitivity of the product has to be measured. Adhesives in the CVAD may also cause skin damages; in that case considerations have to be made while selecting the brand. Appropriate dressing may help in hastening the wound healing and mange the exudates (Ullman et al.2012). Hence, Jim should be cared with proper cleansing agents and hydrocolloid dressings to avoid any local dermal irritations.
Prevention of Bloodstream Infection in CVAD
It is evident from the case study that Jim had been vulnerable to blood stream infections which might have occurred through the site of insertion. It can be easily understood that CLABSI are the negative determinants of health and indicates towards negligence of the clinical staffs. Proper surveillance of the clinical staffs could have prevented the occlusion of the catheter, which has probably disrupted his medicine uptake. It can be said that proper maintenance of hand and hygiene, maintenance of aseptic environment while preparing the central lines can mitigate the risks of CVAD infections. Furthermore, proper flushing and application of appropriate thrombolytic agents can also reduce the chance of occlusion. Skin irritation is a basic problem in aged under CVAD, which can be reduced by the application of the antiseptic and antimicrobial agents.
References
Bertolino, G., Pitassi, A., Tinelli, C., Staniscia, A., Guglielmana, B., Scudeller, L. and Luigi Balduini, C., 2012. Intermittent Flushing with Heparin Versus Saline for Maintenance of Peripheral Intravenous Catheters in a Medical Department: A Pragmatic Cluster?Randomized Controlled Study. Worldviews on Evidence?Based Nursing, 9(4), pp.221-226.
Chopra, V., Anand, S., Krein, S.L., Chenoweth, C. and Saint, S., 2012. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. The American journal of medicine, 125(8), pp.733-741.
Gavin, N.C., Webster, J., Chan, R.J. and Rickard, C.M., 2016. Frequency of dressing changes for central venous access devices on catheter?related infections. The Cochrane Library.
Ge, X., Cavallazzi, R., Li, C., Pan, S.M., Wang, Y.W. and Wang, F.L., 2012. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. The Cochrane Library.
Gillanders, L., Angstmann, K., Ball, P., O’Callaghan, M., Thomson, A., Wong, T. and Thomas, M., 2012. A prospective study of catheter-related complications in HPN patients. Clinical nutrition, 31(1), pp.30-34.
Hadaway, L., 2012. Short peripheral intravenous catheters and infections. Journal of Infusion Nursing, 35(4), pp.230-240.
Ogston-Tuck, S., 2012. Intravenous therapy: guidance on devices, management and care. British journal of community nursing, 17(10).
Ralls, M.W., Blackwood, R.A., Arnold, M.A., Partipilo, M.L., Dimond, J. and Teitelbaum, D.H., 2012. Drug shortage–associated increase in catheter-related blood stream infection in children. Pediatrics, 130(5), pp.e1369-e1373.
Sona, C., Prentice, D. and Schallom, L., 2012. National survey of central venous catheter flushing in the intensive care unit. Critical care nurse, 32(1), pp.e12-e19.
Sweet, M.A., Cumpston, A., Briggs, F., Craig, M. and Hamadani, M., 2012. Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American journal of infection control, 40(10), pp.931-934.
Ullman, A.J., Marsh, N., Mihala, G., Cooke, M. and Rickard, C.M., 2015. Complications of central venous access devices: a systematic review. Pediatrics, 136(5), pp.e1331-e1344.
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