A central venous catheter is a thin flexible tube used to give fluids, blood and nutrients to patients and inserted through the neck or arm until it reaches a vein near the heart. Although the CVCs do enable administration of a life supporting medication to patients, the use of these catheters can place patients at a risk of catheter related bloodstream infections which can be very fatal. The staff, methods and techniques used during catheter insertion and the management of the CVCs by the medical staff are quiet important in prevention of any kind of infection and any central line associated bacteraemia.  The following is a research proposal that will examine possible ways used to reduce complications of the central venous catheters. It will look at findings regarding the nursing management of CVCs to prevent infection.

Background information

A central venous catheter (CVC) also called the vascular access device is a long thin flexible tube used to give medicines, fluids, nutrients or blood to patients over relatively a long period time which can be several weeks or months. A CVC is used to give long term supply of medicine or to supply nutrition. They can also be used to give medicine to the heart usually when quick response is required. Usually there are several types of catheters and they include; implanted port, PICC line and tunneled catheter. PICC line is periphery inserted usually into a vein in the arm. A tunneled catheter is a surgically inserted catheter into a vein in the neck or chest and passed under the skin. The catheter is passed under the skin to help keep it in place and less visible, only the end f the catheter is brought to the skin where the medicines can be given. The implanted catheter is like the tunneled catheter only that it is left under the skin and medicines are given through the skin to the catheter (McGee D. and Gould M. 2003).

In the US alone, more than 5 million catheters are inserted yearly. They are liked because like the central catheters do allow accurately the measurement of hemodynamic variables that cannot be accurately measured by noninvasive means. But with all this pride, the use of catheters is associated with various complications. More than 15% of the patients who use catheters have complications in which 5-26% of these patients have infectious complications, 5-19% mechanical problems and another 2-26% have thrombotic complication (Frasca D., Dahyot-fizelier C. and Mimoz O. 2010).

The possible complications that can arise from the use of CVC includes; bleeding which is caused by inserting the catheter into the vein. Collapsed lungs otherwise called pneumothorax caused during insertion of the catheter in the chest although this depends on the skill of the inserter and the site of insertion. Other complications include infection that may require the removal of the catheter or treatment by use of antibiotics (Nursing care of Central Venous Catheters in Adult Intensive Care).  Blockage or kinking of the catheter may occur prompting flushing of the catheter to unblock it or repositioning the kinked catheter. Pain may sometimes be experienced at the position where the catheter is placed or where it is under the skin. Lastly but not least involves the shifting of the catheter when it has moved out place or replacing it if repositioning does not work (WebMD. 2010).

The use of central venous catheters has been associated with various adverse effects that are hazardous to the patients and are very expensive to treat. Infection has been the main complication of intravascular catheters in sickly patients. These infections have been known to cost around $300 million to $2.3 billion with more than 80, 000 cases being reported. Other financial costs may be as much as $ 30,000 for each survivor while mortality rates range from as low as 0% to 35% depending on the severity of the illness. Fortunately the physiotherapy of the catheter infection is now known and better understood. The infection of the catheter arises by two main pathways; the extralumina and the intaluminal routes. For short term CVCs, the migration of skin organisms occur from the point where the catheter is inserted to the cutaneous catheter tract. Colonization at the tip of the endovascular tip of the catheter is then infected. For long term catheters i.e. these staying in the body for more than 15 days, the cause of colonization is by the manipulation of the venous line and the migration of organisms along the lumen of the catheter (Frasca D., Dahyot-fizelier C. and Mimoz O. 2010).

The CDCP has identified this catheter associated effects as one of its health care safety challenges and wants to reduce its prevalence by 50% in the next 5 years. Some preventive measures are known to reduce these infections. The effective measures have been those that reduce the colonization of the point where the catheter enters the skin. This may include; knowledge on how to use the care protocols, administration by qualified personnel, use of biomaterials that inhibit microorganism growth, good hygienic conditions, use of skin disinfectants and manipulation of the vascular line.

Mechanical complications

The most common mechanical complications include arterial puncture, hematoma and pneumothorax which do occur during insertion of the central venous catheters. The internal jugular catheterization and the subclavian venous catheterization carry similar risks of mechanical complications although subclavian catheterization is more likely to be associated arterial puncture. Because the mechanical complications are likely to occur during catheterization at the femoral site it is advisable to to chose internal jugular or subclavian venous routes unless contraindicated (McGee D. and Gould M. 2003).  

Infectious complications

Catheter related infections arise from by several mechanisms that include infecting the exit site by which the pathogens migrate along the external catheter surface, contamination of the catheter hub which leads to catheter colonization and hematogenous seeding of the catheter. A study carried out found that a subclavian venous catheterization was associated with a lower rate of infectious complications than femoral venous catheterization and also a lower rate of suspected catheter related bloodstream infections (McGee D. and Gould M. 2003).

Thrombotic complications

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Patients requiring CVCs are at a high risk for catheter-related thrombosis. The risk of catheter-related thrombosis varies according to the site of insertion. The risk of thrombosis associated with internal jugular insertion is about four times the risk associated with subclavian insertion (McGee D. and Gould M. 2003).   

Catheter care protocols

Instituting programs that will help health care providers to successfully monitor and evaluate care can be crucial for the success of preventive measures. Training these health care professionals on catheter insertion and helping them with written protocols and manuals will be of importance. Catheter insertion can include; preparation of the equipment, skin antisepsis, insertion techniques while catheter manipulation involves; manipulation of taps and hand hygiene and catheter care combines type and frequency of dressing, catheter replacement technicalities, and line repair. Emergency catheter insertions should immediately be replaced when the patient's condition stabilizes as it increases non-compliance in insertion protocol.

Clearly, catheter maintenance should be insisted. Every catheter used should be removed when not needed since catheter related infections increase with time especially after the fifth day since the first use (Frasca D., Dahyot-fizelier C. and Mimoz O. (2010).

Health care providers who do insertion and maintenance of CVCs should be educated and trained on how best to do the exercise so as to avoid catheter related infections and improve patient outcomes. This will in turn reduce the healthcare costs. It has been shown that on educating in the catheter insertion, improves patient outcomes. Studies show that if the number of nurses taking care is reduced to a certain critical level, then the catheter related infections will increase thus showing that well trained enough nurses must be available for the best patient care (Dahyot-fizelier C. and Mimoz  2010).

Catheter insertion site

Due to the differences of skin density in different parts of the body, the site of catheter insertion will likely influence the risk of catheter related infections. Catheters inserted at the femoral veins have a higher colonization rate but with no increase in bloodstream infections while the use of catheters at the internal jugular vein is associated with non-significant increase in bloodstream infection risk. Colonization also increases with patients whose body mass index is 24.2 but decrease with patients whose body masses are greater than 28.8. Thus from this information, the subclasvian site is preferred for infection control purposes but for body masses, the internal jugular vein should be used especially when the subclavian route is contraindicated. The insertion site must be maintained to ensure that it is germ free. The following ways can be useful to maintaining the insertion site; application of antibiotics to the insertion site does increase the rate of catheter colonization and promotes emergence of antibiotic resistant bacteria neither does not lower catheter related bloodstream infection thus the use of these ointments should not be used (Herndon D. N. 2007).  

Skin antisepsis is a preventive measure that will cleanse microorganisms at the catheter insertion site which is a major risk factor for the catheter related infections. Most commonly used antiseptic agents include povidone iodine and chlorhexidine.

Antibiotic prophylaxis

Although studies have not yet shown that antibacterial or antifungal drugs can reduce CVC infection rates but they have confirmed that antibiotic administration in patients with CVC does reduce the risk of catheter colonization and that of bloodstream infections

Another way of reducing catheter infection is by subcutaneous tunneling of short term CVCs. This is due to increase of the distance between the venous entry site and that of skin emergence and also by less colonization by pathogens of the skin area by catheter emergence. Tunneling has also the advantage of better fixation of the catheter in turn reducing the chances of CVC infections with short term devices. Although it is shown that tunneling does reduce catheter infection, routine subcutaneous tunneling of short term venous catheters should not be tried unless subclavian access is not possible and the duration of catheterization is to be more than 7 days.

Dressings on the insertion site should be carefully done as it has been shown that occlusive dressings trap moisture on the skin and provide an ample environment for micro-flora growth. Incase blood does ooze from the insertion site, a gauze dressing is preffered. Although the optimal frequency for routine change of catheters is not known, it is of importance to change the catheters if it gets soiled with blood or moisture or when the dressing is stuck. The dressing site shoukd be kept clean and be disinfected with antiseptics (Herndon D. N. 2007).

Venous line maintenance

The optimal time for routine replacement of venous administration sets is recommended at around after 72 hours after initiation of use, this is a safe and cost effective method. Tubing used to administer blood, blood products and lipid emulsions should be replaced after 24 hours or immediately after the end of administration. Tubing should be done after cleaning hands with alcohol based solution.  The continued use of the catheter should be assessed daily and removal done when the catheter is no longer needed (Frasca D., Dahyot-fizelier C. and Mimoz O. (2010).

The catheter related bloodstream infections is one of the most serious complications of the central venous access and it is also a leading cause of nosocomial infection in the ICU. Thus the prevention of catheter related infections is vital to the patients. Prevention involves some measures that include adequate staff training, a guide to catheter insertion and maintenance, an adequate patient to nurse ratio and the use of subclavian vein if possible. The use of clean hands is emphasized, a preference for a chlorhexidine-based solution for skin antisepsis and the removal of any catheters that are not in use is encouraged so as to reduce any complications that may result from the use of the CVCs.  Where the incidence of catheter related infection remains high, the use of antimicrobial-coated CVCs should be reversed despite adherences to guidelines and the recommended measures. The health care workers who care for the patients with CVCs need to be adequately trained and assessed as to whether they are competent to using CVCs and adhere to infection prevention practices.

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