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The insertion of a central venous access device (CVAD) was an essential component of care for Jim Karas, however the rate of complications is high. In
this assessment task, you will undertake a review of the literature to explore and critique the evidence-base surrounding this aspect of care and argue what is considered best practice. Your essay will need to address the following

specific complications experienced by Mr. Karas:


• CVAD (central venous catheter line) associated bloodstream infection – how could this have been prevented?

• Occlusion – how could this have been prevented? And now it has occurred, how could it be best managed?

• Local skin irritation - how could this have been prevented?
 

Factors Contributing to CVAD Occurrence in Jim Karas

The essay will illustrate the factors that might have contributed to the occurrence of CVAD in Jim Karas and will use evidences from literatures to identify possible measures that can be implemented to prevent the onset of associated complications. Upon admission to the hospital, Jim was showed symptoms of hypotension that present as a major issue. Further complications were associated with delirium, agitation, infection and difficulty in breathing. He had developed CVAD infection that can be attributed to the insertion of central venous catheter in the left internal jugular vein. Thus, the potential role of evidences in managing the complications will be discussed in the following sections.

The term CVAD encompasses different types of catheters that are inserted and positioned inside the veins of the body for delivering therapies to the bloodstream. These catheters have an end outside the body (Hadaway 2012). On the other hand, ports are surgically placed beneath the skin and can be accessed using special needles (Cotogni and Pittiruti 2014). In the case scenario, Jim Karas, the patient was brought to the hospital, after being found unconscious inside his car. He was initially manifested symptoms of unconsciousness, and breathing difficulties. On assessment, he was diagnosed with hypotensive symptoms and was administered with ventilation masks that used 100% oxygen, for ventilation. An intravenous (IV) cannula and oropharyngeal airways were also used to treat him. Although he demonstrated symptoms of hypertension after being put under mechanical ventilation and started becoming stable, the medications were still continued. There was an elevation observed in his heart rate and he also demonstrated an increased body temperature (38.8 °C). There are several evidence based research knowledge that if applied accurately, can prevent the onset of bloodstream infections. The intrinsic risk factors that increase the susceptibility of acquiring these infections are namely, gender and age of the patient, and underlying conditions or diseases (Rinke et al. 2013). 


However, there are a range of extrinsic factors that govern the prevalence of such infections. These are associated with parenteral nutrition, heavy colonization of microbes at the catheter insertion site, lack of minimum sterile barriers for the insertion and internal jugular or femoral access site (Chopra et al. 2013). Furthermore, prolonged hospitalization of the patient before such insertion procedures and multilumen CVC also increase risks of complications. According to the guidelines formulated by the Centre for Disease Control and Prevention that are based on post-insertion care of such catheters, there are several aspects that should be emphasized upon for prevention of these infections (Mutalib et al. 2015). The guidelines focus on the following aspects:

  • Scrubbing of the hub or the access port with an antiseptic before the insertion
  • Usage of sterile equipments for accessing the catheters and ports
  • Changing the dressings at the site of infection using gloves and under aseptic or sterile conditions
  • Showing adherence to hand hygiene
  • Regular replacements of soiled dressings

Prevention Strategies for CVAD Complications

Use of Aseptic Non-touch Technique (ANTT) is an intravenous technique that focuses on the procedure that involves easy and hassle-free handling of sterile equipments and instruments that are brought in direct contact with the hub or port access sites. This technique is advised for such complications owing to its non-touch nature, which helps to maintain asepsis (Mutalib et al. 2015). The clinical guidelines and steps related to the dressing policies and hygiene maintenance should be followed for eliminating associated health complications. A wide range of research evidences emphasise on the application of central line procedures during utilization of aseptic techniques for catheter insertion (Conley 2016). Failure to selecting sterile gloves is also contentious issue in these therapies. Demonstrating poor practice in following aseptic techniques are considered as the primary reasons that contribute to healthcare acquired infections.

An action plan can be formulated for preventing and managing the onset of complications that were observed in Jim, as mentioned below:

  • Showing compliance to hand washing procedures and always using sterile gloves while administering catheters at the veins.
  • Maintaining adequate dry periods during the time interval between insertion of two catheters. This will facilitate easy and rapid wound healing and would reduce the chances of associated infections.
  • Scrubbing the access ports and hub for a minimal time duration of 15 seconds that should be succeeded by a drying time of 30 seconds (Blot et al. 2014).
  • Using alcohol wipes that contain 70% isopropanol, in combination with 2% chlorhexidine for cleaning the ports (Khawaja et al. 2013).
  • Sterilising all instruments that are meant to be used for the insertion, by usage of aseptic techniques. This would prevent entry of pathogens at the access port, thereby preventing further microbial infections.
  • An additional step that can be implemented in the action plan involves creating provisions for providing adequate training to the healthcare staff that would help them realize the necessity of zero central line. 

The occurrence of the wound can be attributed to the fact that the catheter was probably inserted in the jugular vein through the stratum corneum (dermis) and the epidermis. Central insertion of the catheters usually involves their insertion in the trunk or neck regions. However, incisions are made in the limb or most often the scalp, in cases that encompass their peripheral administration. Pathogen entry into the site of injury and their colonization can be effectively prevented by emphasizing on the use of coated catheters and antimicrobial catheters. Owing to the fact that Jim suffered from carbon monoxide poisoning, it can be suggested that using catheters that are coated with alloys will reduce the infection rates to zero (Busscher et al. 2012). Furthermore, increased efficacy of medical grade liquids such as, LINORel in preventing the formation of pathogen biofilm in hospital-acquired infections also emphasise on their use as an effective intervention (Goudie, Pant and Handa 2017). Infection rates can also be reduced by monitoring the adherence to aseptic techniques for removing hair from the skin surface at the site where the catheter is meant to be inserted.

Disinfectants that contain mild concentrations of alcohol or iodopovidone can be used for skin disinfections (Mimoz et al. 2015). However, the medical records of the patient need to be checked for identifying previous history of anaphylactic reactions. The doctor should evaluate Jim’s medical charts to avoid any medication errors that might worsen his situation. Airborne bacteria should be prevented from coming in contact with the instrument to be used for the CVAD process and the skin lipids should also be removed from Jim’s skin, before the catheter is inserted. Another prevention strategy includes usage of antimicrobial therapy such as, piperacillin-tazobactam, carbapenem (Sawyer et al. 2015). A combination of β-lactam and its inhibitor that can prevent the ICU acquired infection (Pickard et al. 2012). 

Managing CVAD Complications in Jim Karas

Vascular occlusion refers to blocking a blood vessel by the presence of a clot. This was a major issue that was observed in Jim and might increase cardiovascular complications in him. Several strategies that could prevent CVAD occlusion in Jim are related to ensuring that the healthcare professionals responsible for administering the CVAD adhere to the principles of catheter patency (Chong et al. 2013). The CVAD lumens should be flushed with normal saline before and after conducting blood tests. Using minimum volume of 2 times the internal volume of catheter system will also help in preventing occlusion (Bolton 2013). Research evidences have further suggested that clamping the CVAD using appropriate sequences will prevent blood reflux into the catheter tips. Repositioning Jim is also an accurate step that will help in preventing mechanical occlusion.

No syringes of capacity less than 10ml should be used in the catheters. Certain thrombolytic agents, such as, alfimeprase, urokinase and tenecteplase have also been found effective in preventing the complications (Balami et al. 2013).  Thus, they can be administered on Jim as an appropriate intervention. Angela should also be informed of introduction of this new medication as Jim is not in a condition to opine his views on compliance to treatment. Therefore, his daughter should be involved in the shared decision making process (Barry and Edgman-Levitan 2012). Showing adherence to the ANTT guidelines that illustrate the absence of contamination in a body part if it is not touched can also be followed as a prevention strategy (Pans et al. 2015). Thus, the chances of infection will get reduced significantly. In addition, another precautionary measure is related to usage of isopropanol wipes for cleansing the access hub while removal of an old catheter, which is soon followed by insertion of a new one (Khawaja et al. 2013). The CVAD occlusion can also be prevented by using HCl or low pH drugs like vancomycin and piperacillin (Witkin et al. 2015). 


Using fluid locked nonvalved CVAD after flushing with normal saline solution initially helped in managing the condition (Fiebach et al. 2012). However, development of hypersensitive reactions acted as a major factor that increased the complications. Attachment of the catheter to the surface of the skin for a prolonged time period might be responsible for developing the occlusion for a second time.

Conclusion

Thus, it can be stated that although rates of occurrence of nonsocomial infection in Jim was due to interplay of a variety of factors, there are certain evidence based strategies, which when applied in this context, will prove effective in preventing and managing his symptoms. The healthcare professionals can apply the discussed interventions for treating the health complications that are observed in the patient, Jim Karas 

References

Balami, J.S., Chen, R., Sutherland, B.A. and Buchan, A.M., 2013. Thrombolytic agents for acute ischaemic stroke treatment: the past, present and future. CNS & Neurological Disorders-Drug Targets (Formerly Current Drug Targets-CNS & Neurological Disorders), 12(2), pp.145-154.

Barry, M.J. and Edgman-Levitan, S., 2012. Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine, 366(9), pp.780-781.

Blot, K., Bergs, J., Vogelaers, D., Blot, S. and Vandijck, D., 2014. Prevention of Central Line–Associated Bloodstream Infections Through Quality Improvement Interventions: A Systematic Review and Meta-analysis. Clinical Infectious Diseases, 59(1), pp.96-105.

Bolton, D., 2013. Preventing occlusion and restoring patency to central venous catheters. British journal of community nursing, 18(11), pp.539-544. 

Busscher, H.J., Van Der Mei, H.C., Subbiahdoss, G., Jutte, P.C., Van Den Dungen, J.J., Zaat, S.A., Schultz, M.J. and Grainger, D.W., 2012. Biomaterial-associated infection: locating the finish line in the race for the surface. Science translational medicine, 4(153), pp.153rv10-153rv10.

Chong, L.M., Chow, Y.L., Kong, S.S.C. and Ang, E., 2013. Maintenance of patency of central venous access devices by registered nurses in an acute ambulatory setting: an evidence utilisation project. International Journal of Evidence?Based Healthcare, 11(1), pp.20-25.

Chopra, V., O'horo, J.C., Rogers, M.A., Maki, D.G. and Safdar, N., 2013. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infection Control & Hospital Epidemiology, 34(9), pp.908-918.

Conley, S.B., 2016. Central Line-Associated Bloodstream Infection Prevention: Standardizing Practice Focused on Evidence-Based Guidelines. Clinical journal of oncology nursing, 20(1), pp.23-26.

Cotogni, P. and Pittiruti, M., 2014. Focus on peripherally inserted central catheters in critically ill patients. World journal of critical care medicine, 3(4), p.80.

Fiebach, J.B., Al-Rawi, Y., Wintermark, M., Furlan, A.J., Rowley, H.A., Lindstén, A., Smyej, J., Eng, P., Warach, S. and Pedraza, S., 2012. Vascular occlusion enables selecting acute ischemic stroke patients for treatment with desmoteplase. Stroke, 43(6), pp.1561-1566.

Goudie, M.J., Pant, J. and Handa, H., 2017. Liquid-infused nitric oxide-releasing (LINORel) silicone for decreased fouling, thrombosis, and infection of medical devices. Scientific reports, 7(1), p.13623.

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