C03048v3 Nursing Research

Answer

Jim Karas Case Study

Introduction

The case study suggests that Jim Karas was admitted to the hospital and some of his presenting complaints was hypotension, delirium, infection, breathing difficulty, and agitation. The CVAD infection had developed central venous catheter insertion in left internal jugular vein. This essay will elaborate on the underlying factors that might have played an important role in the onset of CVAD in the patient Jim Karas. This will be supported by scientific evidences that will help in the recognition of measures that can be implemented for averting clinical complications in the patient.

Central Line Associated Bloodstream Infection (CLABSI) prevention and management

Central venous access device (CVAD) refers to a wide range of catheters that are primarily introduced and placed in the veins, with the aim of administering targeted therapies to the circulating bloodstream. The catheters are placed in a way that the end is present outside the human body (Hadaway, 2012). In contrast, surgical placement of ports underneath the skin are typically gained access to by means of special needles (Cotogni & Pittiruti, 2014). Jim Karas, was admitted hospital, following his comatose state inside a car. His initial complaints were that of insentience and difficulty in breathing. A detailed medical assessment led to the diagnosis of hypotension, followed by administration of ventilation masks. Jim was subjected to treatment by oropharyngeal airway (OPA) and intravenous (IV) cannula. Despite demonstrating symptoms of hypertension, following mechanical ventilation, the medications were not immediately stopped. Other noticeable effects were heart rate elevation and an increase in body temperature (38.8 °C). There is mounting evidence for the fact that a range of intrinsic risk factors are responsible for governing the likelihood of a person getting affected by bloodstream associated infections such as, age, gender, and other comorbidities (Rinke et al. 2013). Nonetheless, according to Chopra et al. (2013) a plethora of extrinsic factors namely, parenteral nutrition that encompasses administration of carbohydrate, protein, fat, electrolytes, minerals, and vitamins, microbe colonization at catheter insertion site, and absence of sterile barriers for the catheter insertion also control the onset of infections. Additionally, extended hospitalization prior to multi-lumen CVC and insertion procedures also increases complication risks.

The Centre for Disease Control and Prevention has formulated guidelines the need to be followed before catheter insertion procedures, in order to prevent the patients from acquiring the infections. According to the guidelines, the hub and access port must be scrubbed with antiseptics, prior to insertion. The guidelines also emphasise on the use of sterile equipment for port and catheter access, dressing changes with glove usage, hand hygiene, soiled dressing replacement, and maintenance of sterile and/or aseptic conditions. Recent evidences suggest that use of the intravenous technique, Aseptic Non-Touch Technique (ANTT) consists of hassle-free management of sterile instrument that are in contact with port access regions, helps in management of aseptic conditions (Mutalib et al. 2015). There is also a need to show adherence to the clinical steps that are associated with hygiene and dressing policies, for preventing infections. It has also been confirmed by evidences that central line procedures should be applied while establishing aseptic condition during insertion of catheters (Conley, 2016). Sterile glove selection plays an important role under these circumstances. Often the professionals fail to demonstrate accurate practice that contributes to the incidence of healthcare associated or nosocomial infections.

The complications observed upon admitting Jim to the hospital can be effectively managed by following certain procedures such as, hand hygiene maintenance, sterile glove usage during catheter insertion, and dry period maintenance between catheter insertion periods. Adherence to the aforementioned procedures are imperative for enhancing rapid wound healing, thereby lowering chances of HAIs. Furthermore, it is vital to scrub the hub and access port for at least fifteen seconds, followed by a thirty seconds drying time (Blot et al. 2014). Use of 70% isopropranol impregnated alcohol wipes, along with 2% chlorhexidine are essential for port cleaning. Additionally, in the words of Khawaja et al. (2013) sterilisation of the insertion instruments under aseptic conditions would avert germ entry through the access port, thus reducing chances of acquiring microbial infections. Furthermore, adequate provisions must be created for training and educating the nursing professionals on the importance of preventing catheter associated infections and the importance of attaining a zero central line associated infection.

Prevention of local skin irritation

The fact that Jim acquired the infection can be accredited to the insertion of the catheter through stratum corneum and epidermis into the jugular vein (Busscher et al. 2012). The procedure of catheter central insertion typically comprises of placement in the neck and/or trunk regions. However, incisions are also made in scalp or limb during peripheral administration. Antimicrobial and coated catheters have also been found beneficial in thwarting the entry of pathogen at site of injury, and their subsequent colonization. Alloy coated catheters can also be used for lowering the rates of infection to zero.

Liquid-infused nitric oxide-releasing silicone (LINORel) have recently proved their effectiveness in developing ultra-low fouling region and also help in preventing pathogen proliferation, thus establishing their usage as an intervention (Goudie, Pant & Handa, 2017). Efforts can also be taken for reducing rates of infection by adhering to aseptic techniques for hair removal from skin at the site of insertion of catheter. Mimoz et al. (2015) affirmed that disinfectants containing iodopovidone or mild alcohol also helps in disinfection of skin. Nonetheless, there is a need to check the patient’s medical records for gaining an awareness of previous allergy and/or anaphylaxis. The medical charts of Jim must also be reviewed for gaining an insight into medications that need to be avoided. Catheter insertion should be preceded by removal of skin lipids and prevention of pathogen contact with the instrument. Antimicrobial therapy such as, carbapenem and piperacillin-tazobactam will also prove effective (Sawyer et al. 2015). The infection can also be prevented with the use of β-lactam and inhibitor (Pickard et al. 2012).

Prevention and management of occlusion

The blockage of blood vessel due to presence of a clot is commonly referred to as vascular occlusion (Chong et al. 2013). This can be cited as a major issue in the case study, which in turn increased Jim’s chances of suffering from cardiovascular complications. Efforts must be taken to ensure that the catheter patency guidelines are being followed by healthcare professionals (Chong et al. 2013). Flushing the CVAD lumens with normal saline prior to and after blood test, and use of minimum volume that is twice the internal catheter volume will also prove effective in preventing vascular occlusion (Bolton 2013). CVAD clamping with the use of suitable sequences also help in preventing reflux of blood reflux in catheter tips. Jim should also be repositioned for avoiding mechanical occlusion. Syringes having capacity more than 10ml must be inserted in the catheters. Use of thrombolytic agents, such as, urokinase, alfimeprase, and tenecteplase will also facilitate complication prevention (Balami et al. 2013).  

The administration of new medications must be done after receiving consent from Angela. This can be accredited to the fact that Jim current health status will not permit him to demonstrate treatment compliance. This calls for the need of including his daughter in the clinical decision-making process (Barry and Edgman-Levitan 2012). ANTT guidelines that emphasise on absence of contamination in regions that have not been touched upon, should also be followed (Pans et al. 2015). This in turn will create a significant impact on reduction of infection rates. Adequate precaution must be taken while using isopropanol wipes for access hub cleansing, during old catheter removal, followed by new insertion (Khawaja et al. 2013).

Administration of low pH drugs namely, piperacillin and vancomycin, and HCl will also prevent CVAD occlusion (Witkin et al. 2015). Fluid locked non-valved CVAD usage following normal saline flushing also enabled complication management (Fiebach et al. 2012). Nevertheless, hypersensitive reaction developmed was largely responsible for increased the severity of the complications. Prolonged catheter attachment to the skin surface might have contributed to occlusion onset for another time (Fiebach et al. 2012).

Conclusion

To conclude, though nosocomial infection onset in Jim can be thought of as an interaction between different factors, implementation of evidence based strategies would prove operative in averting and treatment of the symptoms presented by Jim. There is a need for the healthcare professionals to implement the aforementioned interventions, with the aim of effectively managing the signs and symptoms manifested by the patient, Jim Karas.

References

Balami, JS, Chen, R, Sutherland, BA & Buchan, AM 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), vol. 12, no. 2, pp. 145-154.

Barry, MJ & Edgman-Levitan, S 2012, ‘Shared decision making—the pinnacle of patient-centered care’, New England Journal of Medicine, vol. 366, no, 9, pp. 780-781.

Blot, K, Bergs, J, Vogelaers, D, Blot, S & Vandijck, D 2014, ‘Prevention of Central Line–Associated Bloodstream Infections Through Quality Improvement Interventions: A Systematic Review and Meta-analysis’, Clinical Infectious Diseases, vol. 59, no. 1, pp. 96-105.

Bolton, D 2013, ‘Preventing occlusion and restoring patency to central venous catheters’, British journal of community nursing, vol. 18, no. 11, pp. 539-544. 

Busscher, HJ, Van Der Mei, HC, Subbiahdoss, G, Jutte, PC, Van Den Dungen, JJ, Zaat, SA, Schultz, MJ & Grainger, DW 2012, ‘Biomaterial-associated infection: locating the finish line in the race for the surface’, Science translational medicine, vol. 4, no. 153, pp. 153rv10-153rv10.

Chong, LM, Chow, YL, Kong, SSC & 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, vol. 11, no. 1, pp. 20-25.

Chopra, V, O’horo, JC, Rogers, MA, Maki, DG & 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, vol. 34, no. 9, pp. 908-918.

Conley, SB 2016, ‘Central Line-Associated Bloodstream Infection Prevention: Standardizing Practice Focused on Evidence-Based Guidelines, ‘Clinical journal of oncology nursing, vol. 20, no. 1, pp. 23-26.

Cotogni, P & Pittiruti, M 2014, ‘Focus on peripherally inserted central catheters in critically ill patients’, World journal of critical care medicine, vol. 3, no. 4, p. 80.

Fiebach, JB, Al-Rawi, Y, Wintermark, M, Furlan, AJ, Rowley, HA, Lindstén, A, Smyej, J, Eng, P, Warach, S & Pedraza, S 2012, ‘Vascular occlusion enables selecting acute ischemic stroke patients for treatment with desmoteplase’, Stroke, vol. 43, no. 6, pp. 1561-1566.

Goudie, MJ, Pant, J & Handa, H 2017, ‘Liquid-infused nitric oxide-releasing (LINORel) silicone for decreased fouling, thrombosis, and infection of medical devices’, Scientific reports, vol. 7, no. 1, p. 13623.

Hadaway, L 2012, ‘Short peripheral intravenous catheters and infections’, Journal of Infusion Nursing, vol. 35, no. 4, pp. 230-240.

Khawaja, RA, Sikandar, R, Qureshi, R & Jareno, RJM 2013, ‘Routine skin preparation with 70% isopropyl alcohol swab: is it necessary before an injection? Quasi study’, JLUMHS, vol. 12, no. 2, p. 109.

Mimoz, O, Lucet, JC, Kerforne, T, Pascal, J, Souweine, B, Goudet, V, Mercat, A, Bouadma, L, Lasocki, S, Alfandari, S & Friggeri, A 2015, ‘Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised controlled, two-by-two factorial trial’, The Lancet, vol. 386, no. 10008, pp.2069-2077.

Mutalib, M, Evans, V, Hughes, A & Hill, S 2015, ‘Aseptic non-touch technique and catheter-related bloodstream infection in children receiving parenteral nutrition at home’, United European gastroenterology journal, vol. 3, no. 4, pp. 393-398.

Pans, SJ, Molmans, E, Marczinski, SC, Bijker, JB & Snijdelaar, DG 2015, ‘Aseptic non-touch technique in the operating room: keep it simple’, Nederlands tijdschrift voor geneeskunde, vol. 159, pp. A9471-A9471.

Pickard, R, Lam, T, MacLennan, G, Starr, K, Kilonzo, M, McPherson, G, Gillies, K, McDonald, A, Walton, K, Buckley, B & Glazener, C 2012, ‘Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial’, The lancet, vol. 380, no. 9857, pp. 1927-1935.

Rinke, ML, Milstone, AM, Chen, AR, Mirski, K, Bundy, DG, Colantuoni, E, Pehar, M, Herpst, C & Miller, MR 2013, ‘Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors’, Pediatric blood & cancer, vol. 60, no. 11, pp. 1882-1889.

Sawyer, RG, Claridge, JA, Nathens, AB, Rotstein, OD, Duane, TM, Evans, HL, Cook, CH, O’Neill, PJ, Mazuski, JE, Askari, R & Wilson, MA 2015, ‘Trial of short-course antimicrobial therapy for intraabdominal infection’, New England Journal of Medicine, vol. 372, no. 21, pp. 1996-2005.

Witkin, AJ, Shah, AR, Engstrom, RE, Kron-Gray, MM, Baumal, CR, Johnson, MW, Witkin, DI, Leung, J, Albini, TA, Moshfeghi, AA & Batlle, IR 2015, ‘Postoperative hemorrhagic occlusive retinal vasculitis: expanding the clinical spectrum and possible association with vancomycin’, Ophthalmology, vol. 122, no. 7, pp. 1438-1451.