Central Venous Access Device (CVAD) Insertion: Best Practice Review And Critique Of Evidence-Base

Case Study: Joseph Russo

The insertion of a central venous access device (CVAD) was an essential component of care for Joseph Russo; however, the rate of complications for this procedure 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.

Joseph Russo was born on the 7th of July 1950 in Manarola, Italy. The youngest of six children, Joseph described his upbringing as ideal and he was very close to his parents and enjoyed school. At the age of 17, Joseph met Sophia and they married a year later. Joseph’s father encouraged him to move to Australia to work for his uncle who had emigrated 20 years previously.

Although somewhat reluctant, Joseph thought Australia sounded exciting and thought it would be a great start for both he and Sophia. Sophia was not as keen to move but wanted to do what would make Joseph happy.

They arrived in Australia in 1970 and were excited to find they were expecting their first child (Antonio was born in 1971, followed by a daughter Emma in 1972).  Joseph was overjoyed to be a father and while still working for his Uncle started to explore the idea of starting his own smallgoods business. This happened quite quickly when a nearby shop became vacant.  Joseph wanted to work close to home as he was worried about Sophia, since arriving in Australia she had only made a few friends in the Italian community and only spoke one or two words of English. Joseph tried to encourage her to learn English but each time she became frustrated.  Joseph recalls that Sophia cried frequently after the children were born - he felt it was because she was homesick.

While he was concerned about his wife, he felt that they needed to remain in Australia as his small business was becoming hugely successful, customers would travel long distances to buy his smallgoods. He worked hard, sometimes over 80 hours per week. He was well known in the community as a happy, hard-working and very likable man. His hospitality was well known and the family home was host to many memorable events and parties. Sophia was an excellent cook and no-one ever went hungry, although she preferred to stay in the kitchen cooking and washing up, while  Joseph entertained the guests with his stories and singing.

Sophia discovered in 1979 that she was pregnant again, although shocked she was excited; however the baby boy was stillborn at full term. Sophia felt deep sadness and a sense of failure, she lost her appetite (and as a result lost a significant amount of weight) and started smoking heavily (60 cigarettes per day). She rarely left the house.  Joseph said little and instead worked harder and spent the remainder of his time in his shed, working on old cars.

In 1990 after dropping out of university Antonio decided to work for his father – for Joseph  this was a defining moment as he now had a family business – this had been his dream and to celebrate he had the front of the shop repainted with “Russo & Son Family Butchery”.  Joseph was content and his daughter completed her education and was awarded a Bachelor of Science and worked for a number of years as a research assistant. Emma started a family with her partner Steven. Emma gave birth to Thomas in 2006 and started to notice he was ‘different to other children’ at around the age of two. Thomas was diagnosed with ASD. Steven left shortly after his diagnosis and returned to work in the west.

Complications Associated with Central Venous Access Device Insertion

Joseph subdivided his very large block and built a house for Emma and Thomas next door. It was around this time that Sophia’s health started to deteriorate.  Joseph spent more time at home helping both Sophia and Emma. Antonio took over the running of the business and convinced his father to expand the business by buying second shop.  Joseph was incredibly proud and told everyone what a good business head his son had. However,  Joseph was unaware that Antonio had a gambling problem and was taking large sums of money from the business. In 2008 during the global financial crisis, Antonio left Australia and  Joseph and Sophia have not heard from him despite their efforts to trace and contact him. Due to the debts that Antonio accumulated in Joseph’s name, he lost the business and almost lost his family home.

Joseph now cares for Sophia full-time, she has COPD and heart failure.  Joseph now cooks, cleans and provides Sophia’s personal care. He has declined all offers of assistance from healthcare providers, family and friends, as it is “his job to care for his wife not a stranger”.  Joseph had planned a retirement in which they could both travel and enjoy their children and grandchildren –  Joseph had saved hard for retirement but the debts from the business took all of their savings and they now rely solely on the pension. Sophia has not left the house in over a year. The financial struggles, losing contact with his son and caring for his wife have taken an emotional toll on Joseph.

In June of this year, Emma saw the lights on in her father’s shed and thought she would go and have a chat as her father seemed quite down in the past few months. As she approached the shed she saw him sitting in his beloved 1962 EJ Holden, at first she thought he was sleeping but something didn’t seem right, when she opened the car door she found Joseph unresponsive and ran inside to call 000.

When the ambulance arrived,  Joseph was not responsive. He wasn't breathing but the ambulance officers could feel a faint carotid pulse. They inserted an oropharyngeal airway, intravenous (IV) cannula and provided ventilation with bag/valve/mask using 100% oxygen. 

The ambulance officers reassured Emma who was distraught after finding her beloved father in such a terrible state. After calling the ambulance, she had turned off the engine and pulled her dad out of the car toward fresh air – this was a difficult task as Joseph is 171 cms tall and weighs 89kgs. Emma kept saying ‘I didn’t know what to do? How could I have saved him?’ They asked Emma to travel to the hospital with them, but she declined, as she was worried about who would look after her mum and son Thomas.

On arrival at the Emergency Department (ED),  Joseph remained unconscious and was not breathing spontaneously. The ED Registrar, Dr Jaram, intubated Joseph so he could be mechanically ventilated. He was hypotensive despite 1.5 Litres of IV crystalloid, so an infusion of IV metaraminol was commenced with an aim of increasing his Mean arterial pressure greater than 65mm Hg. Joseph’s hypotension continued to be an issue, so Dr Jaram inserted a three lumen central venous catheter into Joseph ’s right subclavian vein using surgical aseptic non touchtechnique (ANTT). Inotropes in the form of IV noradrenaline was commenced and titrated to maintain MAP > 65.  Joseph was transferred to the intensive care unit for ongoing care and close monitoring.

Current Evidence-Base on Central Venous Access Device Insertion

Emma arrived at the ED to see her father and was directed to the ICU. She was terribly frightened about how her father would be when she arrived. When she got the ICU, staff asked her to stay in the waiting room until  Joseph was ready for visitors. It was over an hour before the nurse came to get her and during this time, Emma imagined terrible things that could be happening to her dad. She felt guilty for worrying how she was going to manage without Joseph in her life. Her mum Sophia’s health was worsening and she relied heavily on Joseph for all of her personal care and management of her medications. Emma’s son Thomas is now 12 and becoming increasingly challenging in terms of behaviours related to his ASD. Since her partner left, Emma has managed everything by herself, and it was becoming increasingly challenging to juggle the responsibilities of work, her son, her home and her parents alone. She felt so guilty that her dad had come to this desperate state and she had not recognised it.

When Emma finally walked into her father’s ICU room, she saw a pale, frail man who was attached to a breathing machine which made his chest rise and fall at a strangely regular rate. There were tubes everywhere, which were attached to machines delivering medications and a tube down his nose which delivered nutrition to his stomach. The intensive care specialist Dr Prince, spoke to Emma about Joseph’s situation. She said that Joseph was stable at the moment but he wasn’t breathing on his own and medications were keeping his blood pressure up. Dr Prince explained that they didn’t know how long Joseph had been exposed to the carbon monoxide from the car which can cause damage to the brain, and they would need to wait and see if Joseph gained consciousness over the next 24 hours.

Emma had to return home to her mother and son who were being cared for by a neighbour. She wished she could contact her brother Antonio. Despite everything he had done, he was still her brother and she desperately wanted to share the current pressures and responsibilities.

On day two, Joseph had not regained consciousness.  He was not opening his eyes, although he was moving his limbs spontaneously but not with any purpose. Joseph ’s temperature was documented at 38.8 degrees Celsius, with an increased heart rate and he remained hypotensive. On assessment, the insertion site of his CVC was very red and warm.  No other site of infection was found so a diagnosis of Central Line Associated Bloodstream Infection (CLABSI) was made. A swab was taken from the site as well as peripheral and central blood cultures. A new CVC was inserted into the Left internal jugular vein under strict surgical ANTT and the suspected source of the infection, the original CVC was removed. Broad spectrum IV antibiotics were commenced and then changed when sensitivities were available.

On day four, Joseph regained consciousness. He opened his eyes to voice, responded to requests to move his arms/legs appropriately. He had reduced limb strength but there was equal and purposeful movements.  Joseph was weaned from the ventilator and extubated. Nasal prong oxygen was administered to maintain SPO2 > 93%. Joseph’s blood pressure continued to be reliant on inotropes, so he remained in the ICU. Emma was relieved her dad didn’t seem to have brain damage. She tried to talk to her father about what had happened but he refused and would avoid eye contact whenever she brought the subject up. He did not ask how Sophia was, which surprised Emma.

On the evening of day five, Joseph suddenly became agitated and restless and persistently tried to remove tubes and lines. When he wasn’t demonstrating this behaviour, he appeared withdrawn, apathetic, avoiding conversations and eye contact. Nursing staff suspected he was experiencing delirium, and implemented non-pharmacological protocols in an attempt to reassure Joseph and re-orientate to the environment. Interventions included encouraging communication and repeated reorientation, ensuring visible daylight, consistency of nursing staff, mobilisation activities and range of motion exercises. When Emma visited  Joseph in the morning, she was very distressed, thinking that Joseph had terrible brain damage. Nursing and medical staff reassured Emma and informed her of the strategies they were putting in place to support him during this period of delirium. During this period, Joseph's CVC became occluded, this was managed without having to remove the CVC.

On day eight, Joseph was no longer reliant on inotropes and was mentally alert and orientated. He transferred to the medical ward to continue IV antibiotics and follow up with the psychiatric team. On admission to the medical ward staff noted an intact fluid filled blister on Joseph 's left heel, measuring 3 cm by 3 cm.   

Five days later, Emma met with the Psychiatrist and Joseph’s physician who informed her that Joseph was ready for discharge.  Joseph was keen to be discharged from hospital however he refused to participate in any discussions around residential care for either Sophia or himself. Emma wanted her father to return home but acknowledged that additional services were required and Joseph agreed to this request. Joseph's CVC line was removed prior to discharge.

Case Study: Joseph Russo

CVAD (central venous access device) is a device that installed for into the body of patients who require severe fluid intake (Martin et al. 2017). CVAD is inserted in the patient who required the large amount of the intravenous fluid such as blood product or reduction, administration of the hyperosmolar drugs such as Noradrenaline, long-term access for prolonged applications and monitoring central venous patients of the patients (Sasaki et al. 2016). However, the insertion of CVAD may result in the infection. The infection is called central line-associated bloodstream infection where CVAD is a potential source of microorganism, which causes bloodstream infection (Joseph et al. 2016). The case study represents health issues of Joseph who was admitted o the hospital due to the state of unresponsiveness. Since Joseph was not conscious, a three-lumen central venous catheter into Joseph’s right subclavian vein using surgical aseptic technique and Inotropes in the form of IV noradrenaline was administrated. However, after monitoring it was observed that CVAD was the source of infection that caused bloodstream infection. Later occlusions occurred due to the infection which affected his health. This paper will illustrate the action plan for the management and prevention of CVAD associated bloodstream infection and occlusion.  

In clinical practice, the central venous access device is a life-saving therapy for treating many patients. However, in the majority of cases it becomes a source of bloodstream infection due to aseptic insertion of the CVAD in patient’s body.  An intravenous catheter is integral part of modern practice, which is inserted in the critically ill patients for administrating fluids (Mardegan et al. 2016). However, due to aspect handling of the intervenes cathedral and negligence in following proper protocol for intensive care patient, it becomes a potential source of the nosocomial infection bacteraemia and septicaemia (Gavin et al. 2018). Buckley et al. (2018), suggested that the risk of developing CVAD bloodstream infection with CVAD is 64 the time huge than peripheral cathedral insertion. Gavin et al. (2018), stated that approximately 12% to 25 %the death rate because of nosocomial infection is associated with the CVAD bloodstream infection which also increases the ICU staying of the patients. The associated risk factors of the infection are including presence of multi-luminal catheter, catheter-related thrombosis, anatomical site of insertion and hospital lasting before insertion. a randomized trail control suggested that the main pathogen for giving rise to the CVAD bloodstream infection are Staphylococcus aureus, Enterococcus sp, Candida sp.,  Klebsiella pneumonia. S. aureus is coagulase negative gram-negative microorganisms that colonize at the catheter tip. When it inserted in the patients for fluid, transmitted to the bloodstream and causes infection. The catheters are mainly contaminated by the hands of the health professionals with the intraluminal dissemination up to the catheter tip (Kovacevich et al, 2018). However, these microbes also present in the cutaneous layers, nasal mucous and insertion may provide the opportunity to access the bloodstream (Colvine, Thomson and Duerksen 2017). As observed in this case study, Joseph was suffering from the CVAD blood infection due to CVAD insertion due to his health issues when he arrived at the hospital. Diagnosis test confirmed the infection and further, it gives rise to the occlusion. Majority of these microbes shows the resistance towards braid spectrum antibiotics and require narrow-spectrum antibiotics.

Complications Associated with Central Venous Access Device Insertion

The primary prevention technique for the CVAD bloodstream infection is to follow the strict protocol for specific insertion of the catheter. Moreover, in order to prevent the infection, stringent infection control practice should be followed in every clinical setting, especially intensive care unit each time they change the uniform or check the catheter line (Garcia et al. 2018). Other central line infections practices are also are in practice for preventing the blood stream infection. These practices involve the performance of hand hygiene, application appropriate skin antiseptic, ensuring the agents applied for the hand hygiene should be dried before inserting the catheter (Colvine, Thomson and Duerksen 2017). Five all maximal sterile barriers precautions should be taken such as the use of sterile gloves, sterile gown, sterile drape, and sterile masks (Garcia et al. 2018).  Once central line is  placed,  the infection can be prevented by maintenance of the central line practice and washing hands with alcohol-based agents to remove the infection. Moreover, in order to minimize the infection, the catheter should be removed immediately when it is no longer needed.

The blockage is the most common non-infectious complication of CVAD blood stream infection and in the majority of the causes, the catheter completely blocked so that it cannot be flushed at all. A study by Gavin et al. (2018) suggested that fibrin search is one of the most common cause thrombotic obstructions, which usually occurs after CVAD placement and developed within 2weeks. Therefore, if the catheter were blocked, forced action would be required to remove them. As observed in the case study, joseph’s catheter become occluded and admitted to the medical ward to continue IV antibiotics and on admission intact, the fluid-filled blister was observed in the left leg of the Joseph prevention and management plan can be developed for the residential support of Joseph.

Assessment of the catheter occlusion required to identify if the thrombosis obstruction causes the occlusion. Three possible strategies can be used for managing the occlusion.   These strategies involved administration of thrombolytic agents, removal of thrombi and removal of catheter followed by administration anticoagulants. According to Hallam et al. (2018), the current practice of occlusion is the installation of alteplase with the concentration of 2 mg/2mL for initiating fibrinolysis. According to Takashima et al. (2018), the current recommendation includes administration of thrombolytic agents into the lumen with a dwell time for at least 30 minutes. Thrombi should be removed for managing occlusion of Joseph. Lastly, Anticoagulation prophylaxis can be given to the Joseph for the normal flow of blood where occlusion observed (Colvine, Thomson and Duerksen 2017). However, anticoagulants have several side effects that may affect the other parts of the body (Colvine, Thomson and Duerksen 2017). Therefore, nurses should contact physicians before administrating the anticoagulants to the Joseph for avoiding any severe side effects Moreover, for green leafy vegetable, mustard greens, fish, liver, and cereal can be incorporated in Joseph’s diet for healing faster (Garcia et al. 2018). Cayenne paper can be incorporated in the diet of Joseph since it is known as a natural blood thinner, which helps in smooth circulation of blood and helps to prevent a blood clot (Ullman et al. 2018).  

Current Evidence-Base on Central Venous Access Device Insertion

Central venous catheter occlusion disrupts the delivery of required therapy for vulnerable patients. Therefore, in order to minimize the risk of developing occlusion, nursing practice include aseptic infusion and flushing techniques (Colvine, Thomson and Duerksen 2017). The catheter should assess properly by nurses before inserting it to the patient’s body in order to avoid any infection and occlusion (Kovacevich et al, 2018).  Moreover, wearing loosely fitted clothes, socks during walking or doing daily activities, can prevent occlusion. Therefore, the residential nurse must ensure that the Joseph wears loosely fitted cloth and compression stockings for the prevention of reoccurrence of occlusion (Gavin et al. 2018). A study by Mardegan et al. (2016), suggested that staying active through exercising regularly can successfully prevent the occlusion of the patient. Therefore, nurses should engage him into freehand exercise or walking for at least 20 minutes to prevent the further clotting of (blood Mardegan et al. 2016). It will also prevent his psychological distress such as anxiety, agitation, and irritation. Residential nurses should change the position of Joseph. Moreover, salt should be excluded from Joseph’s diet for preventing the occlusion that previously observed . Martin et al. (2017), suggested that even if the salts do not cause the clotting, it enhances the damage of the blood vessels of the patient which further has negative consequences (Colvine, Thomson and Duerksen 2017).  Lastly, the nurses should monitor the improvement of Joseph on daily basis and contact the physician if any abnormalities observed (Martin et al. 2017). It will help him to heal faster from the occlusion and blood infection.

Conclusion:

Thus, it can be concluded that CVAD is a potential source of microorganism which causes bloodstream infection in the patient which further associated with the morbidity. The case study represents the CVAD bloodstream infection of a patient who was admitted to the hospital because of his unconsciousness. The diagnosis confirmed the bloodstream infection of Joseph. The accumulated evidence identified microorganisms such as Staphylococcus, Klebsiella, candida that are a potential cause of infection. Therefore in order to prevent the infection safety measures such as following strict protocols, hygiene steps should be followed along with respecting handling of the catheter. Te cases study suggested that the occurrence of an occlusion in the place of catheter insertion. in order to manage the occlusion, anti-thrombolytic agents can be given to the patients. For prevention of occlusion, Joseph requires the change of the lifestyle such as sodium-free diet, exercise, loosely fitted clothes with the assistance of the residential nurse.

References:

Buchanan, M.O., Summerlin-Long, S.K., DiBiase, L.M., Sickbert-Bennett, E.E. and Weber, D.J., 2018. The compliance coach: A bedside observer, auditor, and educator as part of an infection prevention department's team approach for improving central line care and reducing central line-associated bloodstream infection risk. American journal of infection control. 63(1), 162-178.

Buckley, B., Dreyfus, J., Prasad, M., Gayle, J., Kendter, J. and Hall, E., 2018. Burden of illness and costs among paediatric haemophilia patients with and without central venous access devices treated in US hospitals. Haemophilia.

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.

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.

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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.

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Sasaki, K., Jabbour, E.J., Ravandi, F., Short, N.J., Thomas, D.A., Garcia?Manero, G., Daver, N.G., Kadia, T.M., Konopleva, M.Y., Jain, N. and Issa, G.C., 2016. Hyper?CVAD plus ponatinib versus hyper?CVAD plus dasatinib as frontline therapy for patients with Philadelphia chromosome?positive acute lymphoblastic leukemia: A propensity score analysis. Cancer, 122(23), pp.3650-3656.

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.