Evidence Based Practice Associated with CLAB - Coursework Example

Since the patient already has been diagnosed with sepsis, it is important to explain the necessity of taking extra care of the central venous catheter. Central line-associated bloodstream infection (CLAB) is an important cause of mortality in the critically ill patient, and this should be clearly explained. Taking adequate precautions and care will prevent this dreaded complication. Evidence-based practice “Evidence-based practice is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (AORN, n.d.) Nursing care essentially involves the use of a wide range of medical interventions, which is evidence based (Craig, 2002). It is therefore important that nurses develop specific key skills to develop evidence-based practice (Craig, 2002). Whenever evidence is not available, they should learn to make careful decisions (Craig, 2002, p.3). The process of evidence-based practice involves the application of research evidence, clinical skills, and interpreting the patient’s needs and perspectives in making decisions (Craig, 2002.) Evidence Based Practice associated with CLAB The morality rates associated with Central line-associated bloodstream infections (CLAB) is between 12% and 25% (Posa, Harrison, Vollman, 2006). The main organisms associated with CLAB are coagulase negative staphylococci, enterococci, and staphylococcus aureus (Heard, 2001). The main route of infection is migration of microorganisms from the skin along the outer surface of the catheter and through the subcutaneous catheter tract into the bloodstream (Kruse & Shah, 1993). It is usually difficult to diagnose CLAB because, frequently, there are no signs of inflammation around the catheter (Salzman & Rubin, 1995). Therefore, a positive quantitative catheter culture is required to diagnose the condition. A diagnosis of CLAB can also be made if antimicrobial therapy does not cure the sepsis but the condition improves after removal of the catheter (Salzman & Rubin, 1995). CLAB can be reduced or eliminated by using a central line-associated bloodstream infection prevention program (Posa, Harrison, Vollman, 2006). This includes: staff education, hand hygiene, chlorhexidine gluconate skin antisepsis, avoidance of femoral lines, stopping the procedure if sterile technique is broken, and daily assessment of the need for a central line (Posa, Harrison, Vollman, 2006) use of the subclavian insertion site, catheter insertion and catheter maintenance with chlorhexidine sponges (Heard, 2001.) The strongest evidence to prevent CLAB exists for the following procedures (Mermel, 2000) a. Full barrier precautions during central venous catheter insertion. b. Subcutaneous tunneling. c. Short-term catheters inserted in the internal jugular or femoral veins when catheters are not used for drawing blood. d. Contamination shields for pulmonary artery catheters. e. Povidone-iodine ointment applied to insertion sites of hemodialysis catheters. f. Specialized nursing teams caring for patients with short-term peripheral venous catheters (especially at institutions with a high incidence of CLAB). g. No routine replacement of central venous catheters. h. Antiseptic chamber filled hub or hub-protective antiseptic sponge for central venous catheters. i. Use of chlorhexidine-silver sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term central venous catheters if infection occurs despite maximal barrier precautions. Some recent methods for preventing CLAB include “topical antibiotics or antiseptics at the catheter insertion site, flush solutions containing vancomycin, and bonding antimicrobial agents to the catheter”(Salzman & Rubin, 1995). Adjunctive treatments include the use of urokinase (Salzman & Rubin, 1995). In case of tunneled silicone catheters, CLAB can be managed by infusing antimicrobial therapy through the catheter without removing the catheter (Salzman & Rubin, 1995). Compared to coagulase-negative staphylococci, staphylococcus aureus is more aggressive and associated with more complications (Salzman & Rubin, 1995). If infection is due to candida and bacillus species, then the catheter has to be usually removed (Salzman & Rubin, 1995). Sepsis “Severe sepsis is an infection-induced syndrome resulting in a systemic inflammatory response that is complicated by dysfunction of at least one organ system”(Cunha, 2006) Pathophysiology Sepsis has a complex pathophysiology resulting from sustained bacteremia and the effects of circulating bacterial products, mediated by cytokine release. Excessive cytokine release leads to increased coagulation and decreased fibrinolysis as well as impaired pulmonary, hepatic, or renal function (Cunha, 2006) (see fig 1.) Demographics/risk factors Sepsis is a common cause of mortality and morbidity globally. There is no racial or sexual predisposition (Cunha, 2006). Up to 50% of patients die of complications related to severe sepsis (Cunha, 2006). The prognosis depends on the immune status of the host and the appropriate medical and surgical therapy (Cunha, 2006). Patients with diabetes, systemic lupus erythematosus (SLE), alcoholism, or who are taking steroids are at an increased risk for developing sepsis (Cunha, 2006). Clinical manifestations The systemic inflammatory response varies from mild to severe sepsis. Hyperventilation is a an early sign. Disorientation, confusion, and other signs of encephalopathy may also develop early, especially in the elderly. Hypotension and DIC lead to acrocyanosis and ischemic necrosis of the peripheral tissues, most commonly the digits. Seeding of the bacteria and fungi in the skin or underlying soft tissue can give rise to cellulitis, pustules, bullae, or hemorrhagic lesions. Neisseria meningitidis or less commonly, H.influenzae can cause cutaneous petechiae or purpura. Acute gastroenteritis can lead to nausea, vomiting, diarrhea and ileus. Gastrointestinal bleeding can occur from stress ulceration. Cholestatic jaundice can precede other signs of sepsis. As hypoperfusion develops, tissue hypoxia leads to metabolic acidosis. The blood glucose concentration often increases, especially in diabetics (Munford, 1998.) Management A pair of blood cultures is obtained after the first elevation in temperature, followed by a second pair within the next 24 hours (Micek, Shah, Kollef, 2003). If the lung is the suspected source of infection, one sample of lower respiratory tract secretions for direct examination and culture is obtained (Micek, Shah, Kollef, 2003). The sample could be expectorated sputum, induced sputum, tracheal secretions, or bronchoscopically obtained (Micek, Shah, Kollef, 2003). If the patient has diarrhea, one stool sample is evaluated (Micek, Shah, Kollef, 2003). Other cultures include urine, pus from implanted catheter site and cerebrospinal fluid evaluation by cytology, Gram stain, and culture (in patients with unexplained altered consciousness or focal neurologic signs) (Micek, Shah, Kollef, 2003). It is critical to identify failing organs, as early as possible. The most common organ system to fail is the pulmonary system, followed by the cardiovascular, renal, and hematologic systems (Micek, Shah, Kollef, 2003). Respiratory failure is diagnosed when the ratio of partial pressure of oxygen: forced inspiration of oxygen is less than or equal to 250 (or Read More