Review of literature
CVAD refers to a device named central venous access device that is used among patients to give them relief from multiple puncture during insertion of the catheter (Martinet al. 2017). In this method, a central venous cannula (CVC)is used. However, this technique is very much prone to create infection in the patients. In this case study, it is seen that Joseph Russo was admitted to the emergency department of hospital as he was discovered senseless by his daughter. Before admitting to the hospital he was given oropharyngeal airway, ventilation with mask using 100% bag and intravenous cannula. After taking to the hospital he was given IV metaraminol to enhance the Mean arterial pressure (MAP). He was inserted a three lumen catheter in the right subclavian vein using a special technique named aseptic non touch technique (ANTT).Noradrenaline was given to him in order to maintain the MAP under the 65 mm hg.Joseph was diagnosed with central line associated bloodstream infection (CLABSI).In this essay, the risk factors associated with the CVAD and the prevention strategy of blood stream infection is discussed. In addition to this, the prevention and managing strategy of occlusion is highlighted in the later part of the essay.
CVC technique is used to take care of the patient of the critical care and CLABSI refers to the patient who is having a central catheter and in addition to this the patient may have high fever, hypotension and various other infection. The central line catheter is mainly placed in the vein that are close to the heart such as Jugular vein. In comparison with other catheter technique, CVC is mostly used to give liquid medicines. World Health Organization also has declared CVC as a serious cause of infection (WHO 2015). In case of Joseph it was seen that, Joseph had given the catheter in his Jugular vein and he also had the hypotension and high body temperature as his body temperature was 38.8 degree centigrade. A study by Bowdle (2014) showed that CVC can cause injury to the arteries and to the intrathoracic veins and they may cause death of the patient as well. Moreover this type of injury may result in catastrophic hemorrhage to the veins that communicate with the crucial areas of that region. They also stated that, the internal perforation of the blood vessels due to the catheter insertion may pose serious risks to the patients. Insertion of the central line catheter is associated with complications that is occurred during the use and maintenance of the CVC during the time of treatment. The complications that is quite frequent with the insertion of the catheter inside the body are wrong positioning of the catheter, puncture of the blood vessels of the patients, cardiac arrhythmia, sepsis and other type of metastatic infection. In a study it was seen that, the multi lumen catheter insertion has more risks than that of the mono lumen puncture.In this study, the 55 patient subject was examined with the multi-lumen puncture and 53 patient was examined with the mono lumen puncture. This study result showed that, the multi lumen puncture is more risky than that of the mono lumen puncture. According to the result, CVC caused heart arrhythmia among the 23.33% of subjects who had multi-lumen catheter and it was greater than that of the mono lumen cardiac arrhythmia patients. The rate of artery puncture was also high in case of multi lumen puncture in comparison with the mono lumen puncture. Another finding from this was that the bacteria occurrence was higher in case of multi lumen catheter (Hodzic et al. 2014). In case of Joseph multi lumen catheter was inserted in to the central line vein of Joseph. So it can be said the chances of infection was high in Joseph. The study of kornbau et al. (2015), also supported the risks of the CVC and from their study it was observed that, the CVC has immediate and delayed risk factors. The immediate effect of the CVC is cardiac, pulmonary, vascular and placement complications. In case of delayed effect, there may be infection and dysfunction of the device as well. In addition to this, prolonged catheterization can cause neurological deficits, thrombus production. In some cases it was also seen that, the CVC placement in the right atrium can cause local myocardial irritation that may cause serious problems like supraventricular arrhythmias. However, if such conditions are kept untreated may create life threatening condition of the patient. Hematoma formation is another serious condition that is related to the insertion of catheter in the central line blood vessels. The infection source of the catheter may be the contamination from the infused catheters. The study also supported the fact that the multi lumen catheter insertion has higher risk factors than that of the mono lumen puncture catheter. Occlusion is another problem of CVC and it is estimated that, up to 25% CVCs have become occluded and there are mainly three type of occlusion. They include thrombotic, non-thrombotic and mechanical occlusion (Doellman2017).
Prevention
Prevention and care of CVC related infection patients are a crucial factor but it helps in easing the process of treatment that needs multiple intravenous delivery of drugs. Ultrasound guidance technique is very much effective in decreasing the risks of hazards related to the CVC technique. This technique allows to detect the exact location of the intra jugular vein (IJV)and as a result the real time ultrasound may help the in the placement of the catheter during the insertion process. Study showed higher success rate in ultrasound guidance insertion than that of the traditional method and ultrasound had no role in creating complication among the patients. The measurement of the needle is another technique that can help in safer catheter insertion in the patients. Moreover, it can be used along with the ultrasound guidance technique and that would give better result. Thus pressure measuring technique is very much helpful as it is capable of detecting all the arterial punctures due to insertion of catheter(Bowdle 2014).
According to a study of Colvine, Thomson and Duerksen(2017) it was found that the flushing techniques and aseptic infusion practice may decrease the risk of producing occlusion in the patients. A proper assessment of the catheter before insertion by the nurses can help in avoiding occlusion and infection (Kovacevichet al, 2018). In addition to this, it is seen that a regular basis exercise can prevent the occlusion (Mardeganet al. 2016). According to Garvin et al. (2018), loosely fitted socks, cloths, can prevent the chances of occlusion. It can be applied in case of Joseph. In addition to this, nurses should allowed the patients to do various activities so that they can be engaged in activities and it will reduce the chances of occlusion (Mardeganet al.2016). In addition to this, the physical activities will also reduce the psychological problems like agitation, irritation and anxiety. The position of the catheter of Joseph should also be changed by the nurses. The consumption of salt should be omitted from the diet of Joseph to prevent the occlusion that was noted previously. According to Martin et al. (2017), the consumption of the salt may cause the more damage of the blood vessels and it will cause the more negative consequences of to the patients. In addition to this, the nurses will contact to the physician if there is any serious consequences of the patients. This technique can also be applied to Joseph as well.
In case of managing an occlusion that is previously detected, the best practice might be the catheter occlusion. This requires the identification of the condition if there is an occlusion due to the thrombosis formation. There are mainly three strategies that can be used to manage the condition of occlusion and they are administration of anticoagulants along with the removal of the catheter, dismissal of thrombi and administration of the thrombolytic agents. Hallam et al. (2018) stated that, recent occlusion technique is the installation of a component in concentration of 2mg/2ml for starting the process of fibrinolysis. Anticoagulant prophylaxis can be used in order to normalize the blood flow in the area where occlusion is formed (Colvine, Thomson and Duerksen2017). This technique can also be applied to Joseph. However, there are various adverse effects of using anticoagulants as it can affect the other part of the body. In a study by Takashima et al. ( 2018) showed that thrombolytic agents need at least 30 minutes of bowel time to function in the lumen of the blood vessels. In case of joseph, the thrombi should be removed immediately. As the use of anticoagulants may create adverse condition, so before giving any thrombolytic, nurses should inform the doctors. In a study by Garcia et al. (2018) showed that, consumption of green leafy vegetables helps in healing process. So Joseph can be given such diet so that he can have the more fast healing process. A blood thinner may help in smooth circulation (Ullmanet al. 2018).
Management
Conclusion
So lastly, it can be said that, using CVAD may causes serious infection during the insertion of CVC. In this essay, case study of joseph is represented as he was admitted to the hospital by her daughter. He was diagnosed with CLABSI that is the infection due to the insertion of cannula to the central line of blood vessels. However, such kind of infection can be prevented with proper techniques and if the patient like Joseph already had the infection, it should be managed in a systematic way.
References
Bowdle, A., 2014. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. Journal of cardiothoracic and vascular anesthesia, 28(2), pp.358-368.
Colvine, J., Thomson, P. and Duerksen, D.R., 2017. Management of Recurrent Catheter?Related Bloodstream Infections in an Adult Patient Receiving Home Parenteral Nutrition: Dramatic Effect of Ethanol Lock Therapy. Journal of Parenteral and Enteral Nutrition, 41(6), pp.1072-1074.
Doellman, D., 2017 K-hen.com. Available at: https://www.k-hen.com/Portals/16/Education/CAUTI_CLABSI_2017/ImpactofCatheterOcclusion.pdf [Accessed 21 Dec. 2018].
Garcia, R.A., Spitzer, E.D., Kranz, B. and Barnes, S., 2018. A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. American journal of infection control, 46(5), pp.571-576.
Gavin, N.C., Button, E., Castillo, M.I., Ray-Barruel, G., Keogh, S., McMillan, D.J. and Rickard, C.M., 2018. Does a Dedicated Lumen for Parenteral Nutrition Administration Reduce the Risk of Catheter-Related Bloodstream Infections? A Systematic Literature Review. Journal of Infusion Nursing, 41(2), pp.122-130.
Hallam, C., Jackson, T., Rajgopal, A. and Russell, B., 2018. Establishing catheter-related bloodstream infection surveillance to drive improvement. Journal of Infection Prevention, p.1757177418767759.
Hodzic, S., Golic, D., Smajic, J., Sijercic, S., Umihanic, S. and Umihanic, S., 2014. Complications related to insertion and use of central venous catheters (CVC). Medical Archives, 68(5), p.300.
Joseph, S.M., Brisco, M.A., Colvin, M., Grady, K.L., Walsh, M.N., Cook, J.L. and genVAD Working Group, 2016. Women with cardiogenic shock derive greater benefit from early mechanical circulatory support: an update from the cVAD registry. Journal of interventional cardiology, 29(3), pp.248-256.
Kovacevich, D.S., Corrigan, M., Ross, V.M., McKeever, L., Hall, A.M. and Braunschweig, C., 2018. American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration. Journal of Parenteral and Enteral Nutrition.
Mardegan, K., Curtis, K., Radford, S., Cameron, D. and Grayson, L., 2016. Implementation of a Central Venous Access Device (CVAD) maintenance bundle to decrease the rate of organisation wide CVAD related infections. Infection, Disease & Health, 21(3), p.130.
Martin, G.A., Paul, S., Qiao, W., Jabbour, E.J., Kontoyiannis, D.P. and McCue, D.A., 2017. Pneumocystis JiroveciPneunomia Prophylaxis during Maintenance Therapy with Hyper-CVAD Regimens for Adult Acute Lymphoblastic Leukemia.
Takashima, M., Schults, J., Mihala, G., Corley, A. and Ullman, A., 2018. Complication and failures of central vascular access device in adult critical care settings. Critical care medicine, 46(12), pp.1998-2009.
Ullman, A.J., Cooke, M.L., Mitchell, M., Lin, F., New, K., Long, D.A., Mihala, G. and Rickard, C.M., 2016. Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review. International journal of nursing studies, 59, pp.177-196.
World Health Organization. 2015. Guidelines for The Prevention, Care And Treatment of Persons With Chronic Hepatitis B Infection. Available:https://books.google.fi/books?hl=zh- 30 CN&lr=&id=slk0DgAAQBAJ&oi=fnd&pg=PR9&dq=world+health+organization+INFECTION+&ots=_K16YuuR5_&sig=PPFTbDdoVpdYA9TAFR5ipABlmWE&redir_esc=y#v=onepage&q=world%20health%20organization%20INFECTION&f=false.
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