The case scenario talks about Mr. Joseph Russo who has been diagnosed with Central Line-Associated Bloodstream infection (CLABSI). Mr. Russo’s daughter finds him near his car in an unresponsive state. The patient is not breathing and is hypotensive due to inhalation of carbon monoxide from the car. Emma (the patient’s daughter) calls for an ambulance which ferries him to the hospital. The caregivers insert an oropharyngeal airway and Intravenous cannula to provide ventilation for the patient. Additional remedies to correct his condition include the insertion of a central venous catheter (CVC) and IV noradrenaline to normalize the blood pressure. Joseph also experienced symptoms of delirium such as agitation and restlessness. The insertion of CVC into his left internal jugular vein made him develop a CVAD infection. This essay will discuss the prevention and management of CVAD and Occlusion.
Prevention of CVAD associated BSIs
The diagnosis of Joseph indicated that he had CLABSI which resulted from the insertion of CVC during treatment. The first preventive measure is education to caregivers before they insert the catheter (Alexandrou et al., 2014). The nurses should use a sterile drape which is full-size when inserting a CVC into the system of the patient. The application of sterile drapes reduces the rate of CLABSI in catheter-induced treatments (Ling et al., 2016). The supervisors of the nurses should ensure that caregivers apply the clinical rates to reduce the infections.
The maintenance of hand hygiene is another essential preventive measure when inserting the catheter. The contamination of the hands of the nurses attending to Joseph would result from the removal of a swab from the peripheral and central blood cultures. Healthcare professionals also acquire contamination from the immediate environment or when attending to other contaminated patients. Improvement in hand hygiene decreases the incidences of BSIs such as CVAD (Simonov et al., 2015). Therefore, nurses should maintain hand hygiene when handling Catheter equipment.
Another reason for the development of Joseph’s CVAD infection is unsterile conditions of the caregivers and the hospital environment. Protective clothing and sterile barriers reduce possible colonization and contamination of the new catheter and the site of insertion during the placement of CVC (Taylor, McDonald, and Tan, 2015). The surgeons working on Joseph should ensure that their surgical gowns, cap, mask, drapes, and gloves are sterile before the operational procedures. Additionally, a large sheet of drape minimizes CLABSI more than a small sheet.
Skin antisepsis also prevents the development of CVAD infection that Mr. Russo experienced. The nurses should prepare the skin of the patient by applying antiseptics to eliminate the skin microorganisms at the insertion site of the catheter (Ullman et al., 2016). The caregivers should conduct daily monitoring and care of the catheter site. The nurses can combine 70% alcohol, 2% chlorhexidine, and 10% povidone-iodine to disinfect the site (Ullman, Cooke, and Rickard, 2015). Recent research has indicated that chlorhexidine is more effective than povidone-iodine in CLABSI treatment.
The site of catheter location is also a determinant of preventive measures towards the infection. Accessing the central vein through the femoral vein increases the chances of CLABSI infection (Patel et al., 2017). The colonization of the catheter by the microorganism is excellent when the femoral vein is the accessing site than when the physicians use other veins. Therefore, health care professionals should use the jugular vein to insert the catheter. The insertion of a new CVC into the left jugular vein reduced the severity of Mr. Joseph’s condition.
Caregivers should apply the above strategies to create system-based intervention measures that prevent the progression of CVAD infection. Caregivers should use specific cart standards when placing the CVC. The nurses should also ensure that the treatment equipment and the insertion site are germs-free before the surgical procedures (Ling et al., 2016). The operation should use a large sterile drape to reduce the chances of CLABSI progression. Additionally, the best sterilization chemicals are alcohol and chlorhexidine. A senior nurse should supervise the caregiver operating to avoid contamination.
Proper care after the insertion of the catheter also minimizes the chances of CLABSI. The caregiver should dip a sponge in chlorhexidine and use it to dress the CVC insertion site (Flynn et al., 2017). The treatment reduces the colonization of the site by skin flora. The caregivers should change the dressing after every five to seven days. The nurses should also disinfect the needless connectors, catheter hubs, and pots of injection before application to prevent contamination. The application of antimicrobial locks also reduces the chances of CLABSI.
The surgeons working on Mr. Joseph replaced the old CVC with a new one as a strategy to prevent the infection. Nurses should reevaluate the importance of a catheter in the treatment of CLABSI on a daily basis (Rickard et al., 2015). Caregivers should discontinue CVC that is no longer necessary to prevent the progression of the disease. The process of incorporating the practices of infection-prevention into the maintenance of CVC helps in reducing the risk of the condition. Therefore, a regular replacement of CVCs minimizes the progression of CVAD infections.
Nurses can also use catheters coated with antibiotics to reduce infections during CVAD treatment. The coating of the catheters with antibiotics reduces microbial contamination of the infection site. Antibiotics also prevent the formation of biofilm at the catheter exterior. Examples of antimicrobials useful in coating the catheters are rifampin and minocycline (Wang et al., 2018). Caregivers can also use antiseptics such as silver sulfadiazine and chlorhexidine to coat the catheter before insertion. Nurses should use the antibiotic-coated catheters in patients with a recurrent history of CLABSI.
Prevention and Management of Occlusions
Vascular Occlusions occur when a blood clot blocks a specific blood vessel (Bucciarelli et al., 2017). The physicians observed the incidence with Joseph when they admitted him in the ICU. Numerous strategies can help in the prevention and management of the situation. The catheter obstruction through mechanical means is the first management point. The caregivers should reposition Joseph to eliminate any mechanical obstacles. The nurse can reposition the patient by raising his ipsilateral arm. Additional techniques include rolling Mr. Russo onto a single side or making him stand or sit. Care providers should use a dye study to check for internal catheter kink.
Catheter obstruction and subsequent occlusion can result from parenteral nutrition or medication. The case study indicates that the caregivers connected separate tubes to Joseph that provided medication and nutrition to the stomach. Nurses should check for incompatibility in the food and the drugs that can lead to occlusions (White, and King, 2014). The appropriate method of treatment should depend on the possible causative agents of occlusion. Obstructions can occur due to the precipitation of calcium phosphate medications with low pH values. The physicians should manage such manage such obstructions by administering 0.2% Hydrochloric Acid to Joseph. Caregivers can manage obstacles by medicines of high pH through administering sodium hydroxide or sodium bicarbonate. Lipid-rich nutrition can also lead to obstruction. Nurses can solve the problem by recommending a 70% solution of ethanol to clear the lipid residues.
Catheter obstruction also occurs due to thrombosis. Caregivers can use the catheter study to check for fibrin or intraluminal clot. The treatment of suspected occlusions due to thrombosis is through thrombolytics. A majority of healthcare professionals recommend alteplase in the management of thrombotic occlusions. Alteplase initiates fibrinolysis by catalyzing the production of plasmin from plasminogen (Medcalf, 2015). Urokinase enzyme is also useful but has a slow catalytic action in comparison to Alteplase. Therefore, caregivers can apply the two enzymes to correct the occlusion.
Physicians can also use the new drug called reteplase to prevent occlusions due to thrombosis. The new medication acts in a shorter time than Alteplase. Additionally, reteplase has higher efficacy than urokinase. Reteplase is structurally different from Alteplase; hence it has an increased thrombus penetration and half-life (Asadi, Williams, and Thornton, 2016). Recombinant urokinase is also useful in the management of adult occlusions due to its high rate of efficacy. Alfimeprase can also eliminate catheter occlusions. The drug has a different action site from the other drugs. The advantage of alfimeprase is that it does not depend on plasminogen activation to carry out its therapeutic functions.
Conclusion
Numerous strategies are useful in the prevention and management of Mr. Russo’s CVAD infection and the catheter occlusions. Nurses should acquire proper education on the practical methods of CVC insertion. Additionally, caregivers should observe hand hygiene when handling the catheter to prevent the progression of CLABSI. Care providers should also use appropriate antiseptics on the site of catheter insertion to prevent colonization. Nurses can coat the catheters with antibiotics to avoid contamination and to CVAD progression. Caregivers can use numerous drugs to prevent and manage catheter occlusions. The remedies include hydrochloric acid and sodium hydroxide; useful other medicines include Alteplase, urokinase, and Reteplase.
References
Alexandrou, E., Spencer, T.R., Frost, S.A., Mifflin, N., Davidson, P.M. and Hillman, K.M., 2014. Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates—a report from 13 years of service. Critical care medicine, 42(3), pp.536-543.
Asadi, H., Williams, D., and Thornton, J., 2016. Changing management of acute ischaemic stroke: the new treatments and emerging role of endovascular therapy. Current treatment options in neurology, 18(5), p.20.
Bucciarelli, P., Passamonti, S.M., Gianniello, F., Artoni, A. and Martinelli, I., 2017. Thrombophilic and cardiovascular risk factors for retinal vein occlusion. European journal of internal medicine, 44, pp.44-48.
Flynn, J.M., Rickard, C.M., Keogh, S. and Zhang, L., 2017. Alcohol caps or alcohol swabs with and without chlorhexidine: an in vitro study of 648 episodes of intravenous device needleless connector decontamination. Infection control & hospital epidemiology, 38(5), pp.617-619.
Ling, M.L., Apisarnthanarak, A., Jaggi, N., Harrington, G., Morikane, K., Ching, P., Villanueva, V., Zong, Z., Jeong, J.S. and Lee, C.M., 2016. APSIC guide for the prevention of central line-associated bloodstream infections (CLABSI). Antimicrobial Resistance & Infection Control, 5(1), p.16.
Medcalf, R.L., 2015. What drives “fibrinolysis”?. Hämostaseologie, 35(04), pp.303-310.
Patel, P.A., Boehm, S., Zhou, Y., Zhu, C., Peterson, K.E., Grayes, A. and Peterson, L.R., 2017. Prospective observational study on central line-associated bloodstream infections and central venous catheter occlusions using a negative displacement connector with an alcohol disinfecting cap. American journal of infection control, 45(2), pp.115-120.
Rickard, C.M., Marsh, N.M., Webster, J., Gavin, N.C., McGrail, M.R., Larsen, E., Corley, A., Long, D., Gowardman, J.R., Murgo, M. and Fraser, J.F., 2015. Intravascular device administration sets replacement after standard versus prolonged use in hospitalized patients—a study protocol for a randomized controlled trial (The RSVP Trial). BMJ Open, 5(2), p.e007257.
Simonov, M., Pittiruti, M., Rickard, C.M. and Chopra, V., 2015. Navigating venous access: a guide for hospitalists. Journal of hospital medicine, 10(7), pp.471-478.
Taylor, J.E., McDonald, S.J. and Tan, K., 2015. Prevention of central venous catheter-related infection in the neonatal unit: a literature review. The Journal of Maternal-Fetal & Neonatal Medicine, 28(10), pp.1224-1230.
Ullman, A.J., Cooke, M. and Rickard, C.M., 2015. Examining the role of securement and dressing products to prevent central venous access device failure: a narrative review. Journal of the Association for Vascular Access, 20(2), pp.99-110.
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.
Wang, H., Tong, H., Liu, H., Wang, Y., Wang, R., Gao, H., Yu, P., Lv, Y., Chen, S., Wang, G. and Liu, M., 2018. The effectiveness of antimicrobial-coated central venous catheters for preventing catheter-related blood-stream infections with the implementation of bundles: a systematic review and network meta-analysis. Annals of intensive care, 8(1), p.71.
White, H. and King, L., 2014. Enteral feeding pumps: efficacy, safety, and patient acceptability. Medical devices (Auckland, NZ), 7, p.291.
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