Central Venous Access Device (CVAD)
You will undertake a review of the literature to explore and provide critique of the evidence base surrounding the care of aspects of CVAD management.
CVAD or Central Venous Access Device is a system, which is inserted in the veins of the patient to deliver blood stream to the patient. It is utilized in different medical interventions for the insertion of fluids, resuscitation or blood different hyper-osmolar drugs to the bloodstream (Moureau et al. 2013). This assignment is going to discuss about Jim Karas (59), who was admitted to hospital after being unresponsive and unable to breathe out. He was admitted to the emergency department of the hospital and after his primary health check-up, doctor inserted three central venous catheter into his right subclavian veins using surgical aseptic non touch technique (ANTT). This assignment will be discussing the complications of Jim Karas which is CVAD associated bloodstream infection and the preventive strategy of it, prevention and management of occlusion and local skin irritation because of these medical interventions. These complications, its types, infection process, prevention and management process will be discussed with the help of literatures and the critical discussion will be presented below.
The moment when Jim was found unresponsive, doctors were able to detect a faint cardiac pulse and therefore they inserted an oropharyngeal airway intravenous cannula and provided him with 100 percent oxygen ventilation. He was still unresponsive to the treatments and therefore the doctor Jaram incubated him for mechanical incubation. Finally, the doctor inserted three central venous catheters (CVC) in the veins of Jim to improve his condition However, one day later, a red swollen infection was found near the insertion site of CVC and the infection was detected as the Central Line Associated Bloodstream Infection (CLABSI) (Miller and Maragakis 2012). It is a common factor in the long-term use of catheter in the blood stream. There can be several reasons due to which, the CVAD related infection could occur in patients. Few of such reasons are ruptured catheter, dislocation of the catheter inside the vein, chylothorax and paravasation (Yeoh et al. 2013). In the case study, Jim was also suffering from infection and his swollen site of catheter injection was indicating towards the fact that he was being affected with the CVAD related infection.
There are several preventive measures for the protection from this infection. The primary and most effective one is application of 2 percent chlorhexidine based alcohol solution and continuous skin care after the injection of the catheters in the blood stream, cleaning the injection hub or the connector will be helpful in preventing such disorder in the injection site (Department of Health and Human Services USA, 2018). The ANTT technique or the aseptic not touch technique was used as the preventive measure for Jim, which is effective in preventing the bloodstream related infection after injecting the CVC into his body. The doctors continuously used hand washes and sanitizers to prevent the normal micro flora of the hand to be colonized in the wounds of Jim. Another therapy that can be used in the infection of CVAD is continuous dressing of the site of injection (Department of Health and Human Services USA, 2018). If Jim was provided with continuous dressing of his CVAD insertion site, dressing around the skin tunnel until the wound has healed. Further, after the healing of this site, dressing would be done in the injection port pocket (Hentrich et al. 2014). According to the guidelines from the CDC of USA, the dressing should be semi-permeable and it should be replaced every time it becomes damp or loosened. Two percent chlorhexidine solurton should be used for the cleansing purpose of Jim and this strategy is effective in preventing primary BSIs (Department of Health and Human Services USA, 2018). These are the ways the nursing staff of the organization should be used to provide care to Jim in his CVAD related infection. These researches are based on the level I of the level of evidence and within this, randomized control trial or RCTs and meta-analysis studies are included. The preventive measured that have been used for Jim are depending on the CDC department of the United States of America. Therefore, it was used for Jim to prevent his CVC related bloodstream infections (Lai et al. 2013).
CVAD Associated Bloodstream Infection
The second complication that Jim suffered during the treatment in the healthcare system after his unresponsiveness was occlusion. According to the data, 14 to 36 percent of patients generally suffers from the catheter related occlusion and the time taken for the occurrence of the occlusion is 1 to 2 year after the injection of catheters (Oliveira et al. 2012). The occlusion can be partial in which, the blood is not been able to aspirate but the catheter infusion is possible (Zhang et al. 2014). However, due to occlusion, neither aspiration nor the infusion is possible (Linnemann 2014). The primary reason for occlusion is the usage of low quality catheters for the intervention (Oliveira et al. 2012). The secondary reason can be the several mechanical issues, emerging after the application of the catheter in the bloodstream (Braithwaite et al. 2014). Finally, there can be reaction between the provided drugs, making the flow of liquid through the veins sluggish. Further, if the pH of the infusion is too alkaline or acidic in nature precipitation can also be occurred in the blood stream creating an occluded condition. Even high amount of lipid residues in the nutrition can cause the occlusion condition (Zhang et al. 2014). According to the Bolton (2013), intraluminal clots are one of the reasons due to which, catheter occlusion occurs and according to the statistics, 5 to 26 percent of the catheter occlusions are resulted from it. There are several management strategies of occlusion due to catheter or physiological problems. The first strategy is about the mechanical obstruction of catheter (Lam et al. 2012). These can be of different types, such as kink in the catheter tubing, a tight suture, inadvertently closed clamp, blood vessel wall blocking the tip of the catheter.
Managing these mechanical problems can reduce a huge amount of occlusion occurring in patients with CVC injected (Puiggros et al. 2012). Rearrangement, repositioning of catheters inside the blood vessel is can be done by making patient move from side to side, or making him stand or sit. However, in case of Jim, making him move or stand is not possible, as he is not responding to the medical interventions (Drasler, Pedersen and Ungs 2016). Further, the thrombotic catheter obstruction can be removed, by using a device called lingo gram, a device detects the intraluminal clot or fibrin sheath (Cohen et al. 2013). A drug can also be used to remove the cathedral obstacle. This drug is named as Alteplase and minimal dose of it can treat the thrombotic occlusion after the injection of CVC intravenously (Lam et al. 2012). The experiments or researches included for this complication are level II of level of evidence. It includes RCTs and lower level of meta-analysis studies. The preventive measures that have been used here as preventive instruments for Jim are tried and tested on a large population and are being used in several countries.
Further, the third complication, that Jim suffered while his treatment and after injection of CVC intravenously was Local skin irritation. After the application of the catheter, it can be seen that the insertion site of the catheter has become red and swollen (Timsit et al. 2012). There can be several reason behind this swelling of the catheter insertion region of the patient’s body. One of which is the high density of the microorganisms in the catheter insertion site, due, to which the inflammation and anaphylaxis leading to type 1 hypersensitivity in the body, which can lead to autoimmune disease (Raphael et al. 2015). Further, the preventive measure for such skin treatment is the povidone iodine and chlorhexidine, which can be used as a solution for the CVC related skin irritation. On the other hand, generate irritation can be from the injected catheter and its low quality as mechanical defect in the catheter can also induce type 3 hypersensitivity in the patient leading to autoimmune disorder (Loveday et al. 2014). According to the researches, ()there has been only one comparison based trial has been performed to understand the activity of chlorhexidine-based solution to 5 percent alcoholic povidone iodine (Mimoz et al. 2015).
Prevention and Management of Infection
Chlorhexidine-based solution has been proven 50 percent more active than the povidone iodine solution as it removed the catheter related skin irritation by 50 percent. One factor that should be mentioned in this scenario is the, tolerance level of chlorhexidine-based solution towards the inflammation; anaphylaxis is quite higher than that of the povidone iodine solution. Therefore, this solution should be used in the case of Jim for the preventive and management measures of local skin irritation after the ingestion of CVC catheter in the veins (Hooper, Littman and Macpherson 2012)). One more reason behind the skin irritation of Jim could be his lack of nutrition and weaker immune system, which has made him more sensitive to outer environment (Wahren-Herlenius and Dörner 2013). Further, to prevent skin irritation, the exposed skin should be wiped with soap or some other liquid cleansing solution as it will help to keep the skin dirt free and allergen free. Therefore, preventive measures should include application of medicines to improve his immunological condition and resist the hypersensitive condition of the patient. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate) before peripheral venous catheter insertion. Further, prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives (Department of Health and Human Services USA, 2018). Evidence based analytical studies have been used in this complication description and the level of evidence is level V of evidence.
In the conclusion, it can be said that, Jim suffered from drastic physical complications and after he doctors checked his physiological conditions and did few primary checkups, they inserted a central venous catheter in the right subclavian vein of Jim. After that, there were several physiological conditions occurred in the body of Jim. Three of which has been discussed in this assignment. The first complication was CVAD related bloodstream infections, of which the preventive measures and management skills were mentioned. The second complication was related to catheter occlusion and its preventive measures are been mentioned. The final measurement of local skin irritation due to catheter application was discussed critically and management skills were mentioned as well.
References
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