Sepsis Prevention: Vascular Access Care and Laboratory Testing in the Intensive Care Unit

SEPSIS PREVENTION: VASCULAR ACCESS CARE AND LABORATORY TESTING IN THE INTENSIVE CARE UNIT

JASSIN M. JOURIA, MD

DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY SCHOOL OF MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING HOSPITALS THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY.

Abstract

When patients are brought to the Intensive Care Unit, extensive laboratory testing and monitoring is often considered necessary in order to diagnose and treat critical conditions. However, laboratory tests and monitoring are not without risk. Results can be misleading, and the testing itself can be harmful, such as potentially causing anemia and infection. Health professionals need to take a sensible approach to laboratory testing and monitoring for patients in the Intensive Care Unit, focusing on the benefits and risks of each procedure and being mindful of the probability of disease.

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Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Clinicians caring for patients in the Intensive Care Unit are required to interpret laboratory tests and care for vascular access monitoring devices, and be able to manage safe and appropriate guidelines when caring for critically ill patients. Health professionals working with critically ill patients need to take an evidenced-based and rational approach to vascular access for laboratory testing and continuous monitoring including an understanding of the benefits and risks of each procedure relative to a disease process.

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Course Purpose

To provide health clinicians with knowledge of different types of laboratory testing and monitoring for patients in the Intensive Care Unit as well as the benefits and risks of varied procedures.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

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1. A catheter lock is an approach where an antimicrobial solution is used to fill the lumen of the catheter

a. to flush the lumen prophylactically. b. to prophylactically sterilize the lumen for a period of time. c. to flush the lumen if a patient has a bloodstream infection. d. between uses.

2. It is recommended that peripherally inserted central venous catheters (PICC) and central venous catheters (CVC) should

a. not be removed on the basis of fever alone. b. be removed on the basis of fever alone. c. be routinely replaced to prevent catheter-related infections. d. be removed based clinical judgment.

3. To prophylactically sterilize the lumen of the catheter, a commonly used antiseptic is

a. cefazolin. b. ancomycin. c. alcohol. d. amikacin.

4. In peripheral catheters in children, the recommendation on replacing peripheral catheters in children is:

a. every 72–96 hours. b. before 72 hours. c. only when clinically indicated. d. there is no recommendation.

5. With respect to frequent, scheduled replacement of central venous catheters (CVCs), which of the following statements best describe whether this practice reduces the frequency of infection or the rate of thrombophlebitis?

a. It does reduce the rate of these conditions b. Frequent replacement is recommended to reduce the rate of these conditions c. Replacement should be based on the presence of fever alone d. There is no evidence that it reduces the rate of infection or phlebitis

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Introduction

Practice guidelines inform health clinicians to make best practice and safe decisions in the Intensive Care Unit. Appropriate measures for specific clinical procedures for critical patients involve national safety goals related to sepsis prevention, recognition and treatment. All clinicians need to be updated on the latest recommendations for peripheral and central catheter insertion, maintenance, laboratory testing and prevention of infection at the site of a catheter when obtaining laboratory tests and monitoring patient outcomes.

Decision-Guides In The Intensive Care Unit

The Acute Physiology and Chronic Health Evaluation II (Apache II), the Sequential [Sepsis-Related] Organ Failure Assessment (SOFA) system and the Simplified Acute Physiology Score (SAPS) II are used to classify the severity of illness, estimate prognosis, guide decision making and predict mortality or morbidity in critically ill patients. These scoring systems are widely used in Intensive Care Units. This section considers various reviews and recommendations for the use of scoring systems relative to infection prevention and infection morbidity and mortality.1-5,11,12

A number of recent reviews have examined these various scoring systems for various populations of patients. It has been found that elderly patients (median age 81) had been evaluated using the APACHE II, SOFA and SAPS II scoring systems for predicting mortality. Patients with arrhythmias or ischemic heart disease were excluded. Using the APACHE II system, the sensitivity, specificity and accuracy

nursece4less.com nursece4less.com nursece4less.com nursece4less.com were 75%, 63% and 69% respectively. Using the SOFA system, the sensitivity, specificity and accuracy were 73.1%, 62.8% and 68.4%, respectively, and using the SAPS II scoring system, the sensitivity, specificity and accuracy were 73.1%, 76.7% and 74.7%, respectively.

The Logistic Organ Dysfunction (LOD) score was also compared to the APACHE II, SOFA and SAPSII scores and analyzed with respect to nosocomial infections: 291 patients older than 16 years and admitted to an Intensive Care Unit (ICU) for at least 3 days were studied, and 41 patients were excluded because of missing data points. Of the 250 patients studied, 18.4% developed at least one nosocomial infection. Mortality was 23.9% in the patients diagnosed with nosocomial infections as compared to 23.0% of patients without a diagnosis of infection. The results indicated that SOFA score (≥H48) was most effective in predicting the risk of nosocomial infection.

Patients in the ICU with Acute Respiratory Distress Syndrome (ARDS) were analyzed in one study; 110 adults (median age 38) with a median duration of illness before admission to the ICU was 6 days and with the median ICU stay 27 days, comparing the APACHE III, APACHE II, SOFA and SPASII scoring systems. Researchers concluded that none of the scoring systems were adequate, but the APACHE II/III scoring system was superior to that of the other systems.

Overall, there does not appear to be a single scoring system for all circumstances found in ICU patients. A combined APACHE II, SAPS II and SOFA calculator can be used. Health clinicians can also use individual APACHEII, SAPS II, and SOFA calculators as well. 6

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Prevention And Reduction Of Catheter-Related Infections

The Center for Disease Control and Prevention (CDC) has a number of recommendations for the prevention and reduction of intravascular catheter-related bloodstream infections (CRBSIs). The main recommendations from the CDC are highlighted below.

Prophylaxis

Prophylactic antimicrobial lock solution should be used in patients with long-term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique. A catheter lock is an approach where an antimicrobial solution is used to fill the lumen of a catheter to prophylactically sterilize the lumen of the catheter for a period of time (as opposed to simply flushing the catheter with the solution). Either microbial specific or a broad-spectrum antibiotic solution can be used. Antibiotics used include ancomycin, gentamicin, ciprofloxacin, minocycline, amikacin, cefazolin, cefotaxime, and ceftazidime.

Antiseptic solutions can be used as well. Commonly, the antiseptic used is alcohol. Both antimicrobial and antiseptic solutions may be combined with anticoagulants such as heparin or EDTA.

The recommendation regarding routine use of anticoagulants suggest that anticoagulant therapy not be used routinely in order to reduce the risk of catheter-related infection in the general patient population. For individuals with a central venous catheter, there is a relationship

nursece4less.com nursece4less.com nursece4less.com nursece4less.com between central venous catheter-associated infections and thromboses. Efforts to reduce the risk of infections and thromboses by combining the use of antimicrobials and anticoagulants have been raised; however, large meta-analyses did not support evidence that the use of anticoagulants as a prophylactic reduces the rate of infections.

More recent studies have indicated that heparin may reduce the risk of CRBSI; however, since the heparin was in solution with preservatives with antimicrobial activity, it was not clear that the decrease in CRBSI was due to the heparin alone. The use of heparin is also associated with heparin-induced thrombocytopenia. Trisodium citrate, which has both anticoagulant and antimicrobial properties, may be a rational alternative.

Replacement of Catheters (Midline and Peripheral)

It is recommended that there is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated. In children, replacement of peripheral catheters should be only when clinically indicated.

Midline catheters should only be replaced when there is a specific indication based on the following rationale:

• A number of studies have indicated that the rates of infection and thrombophlebitis increase if the CVC is left in place for more 8

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than 72 hours. The effect of removing and replacing CVCs every 72 hours on the rates of infections is significantly greater than the effect of removing/replacing CVCs on the rates on thrombophlebitis.

• Midline catheters have been associated with lower rates of thrombophlebitis than short peripheral catheters.

Replacement of CVCs, PICCs and Hemodialysis Catheters

It is recommended to not routinely replace central venous catheters (CVCs), peripherally inserted central catheters (PICCs), hemodialysis catheters, or pulmonary artery catheters to prevent catheter related infections. CVCs or PICCs should not be removed on the basis of fever alone. Clinical judgment needs to be used regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Additionally, the following are recommended:

• Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection.

• Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection.

• Use a guidewire exchange to replace a malfunctioning non- tunneled catheter if no evidence of infection is present.

It is also recommended new sterile gloves be used before handling a new catheter when guidewire exchanges are performed. While it would appear logical that frequent replacement of CVCs on a schedule should reduce the rate of infection and/or phlebitis, there is no evidence that

nursece4less.com nursece4less.com nursece4less.com nursece4less.com this will actually reduce the frequency of infection or the rate of thrombophlebitis. However, there have been few recent studies addressing this issue. Similarly, studies of routine scheduled guidewire exchange of CVCs have not shown a decrease in the rates of infection.

In pediatric patients, including neonates, the difficulty with which CVCs are placed must be taken into account when considering replacement of these catheters. CVC occlusion is a particular concern in pediatric and neonatal populations. One study evaluated whether a continuous heparin infusion (0.5 units/kg/hour) could extend the catheterization lifespan as compared with a placebo infusion. The rate of catheter occlusion that necessitated catheter removal and replacement was lower in the heparin group (6% vs. 31%). Rates of infection (CRBSI) were similar. However, the study was not adequately powered to evaluate CRBSI rate differences.

In hemodialysis catheters there is a significant risk of infection. Catheters are the most common factor in developing sepsis in dialysis patients, with 7 times the risk for bacteremia as compared to patients with arteriovenous (AV) fistulas or grafts. AV fistulas and grafts are the preferred approach for patients in chronic renal failure. For temporary access, a tunneled cuffed catheter is preferred in all settings.

Pulmonary artery catheters, most of which are heparin-bonded, stay in place, on average, for 3 days. While heparin-bonded catheters reduce both thrombosis and microbial colonization, the rate of CRBSI is 3.7

nursece4less.com nursece4less.com nursece4less.com nursece4less.com per 1000 catheter days and is somewhat higher than non-medicated catheters (2.7 per 1000 catheter days). In general, colonization of the introducer occurs earlier (within 3-4 days) than the risk of CRBSI (generally after day five). There is no evidence that replacement of the catheter on a schedule reduces the rate of infection and there is no evidence that patients benefit by replacing the catheter more frequently than every 7 days. For those patients that require pulmonary catheters for monitoring more than 7 days, there is no specific recommendation other than careful monitoring of the patient for signs of infections.

In peripheral catheters there is no need to replace the catheters more frequently than every 72–96 hours to reduce risk of infection and phlebitis in adults. There is no recommendation made regarding replacement of peripheral catheters in adults only when clinically indicated. However, in children peripheral catheters should be replaced only when clinically indicated.

Midline catheters should only be replaced when there is a specific indication. Umbilical catheterization is often utilized in newborns, before extensive colonization has taken place. Umbilical catheterization risks vary depending on position (above or below the diaphragm and above the aortic bifurcation) and type (arterial or venous). CBRSI rates are similar regardless of position. However, umbilical catheters placed higher have lower rates of vascular complications. Low birth weight neonates who also received antibiotic treatment (for more than 10 days) have been found to be at increased risk for umbilical artery

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CRBSIs while higher birth weight neonates receiving parenteral nutrition were at increased risk of umbilical venous CBRSI.

Arterial/Venous Catheterization And Pressure Monitoring Devices For Adult and Pediatric Patients

Arterial and venous catheterization are indicated for adult and pediatric patients in the ICU setting where continuous monitoring and testing may be indicated to trend treatment outcomes and a disease process. This section highlights varied aspects of arterial and venous monitoring, including infection prevention considerations.6,11-16

Arterial Catheterization

For the most part, arterial catheterization is utilized in unstable patients who require contemporaneous pressure or arterial blood gas (ABG) measurements. Arterial lines may be placed in the radial, ulnar, brachial, axillary, posterior tibial, femoral, and dorsalis pedis arteries.

The radial artery is preferred in both adults and in pediatric patients because of the artery’s superficial and easily accessible and consistent location. In addition, radial artery catheterizations have a low rate of complications. If a larger artery is required, the femoral artery has a larger diameter and is relatively easily palpable. The overall complication rate is approximately the same for the radial and femoral arteries, though femoral arterial catheterization has a decreased risk of thrombosis and accidental removal. Indications for arterial catheterization include continuous and direct monitoring of blood pressure (note that arterial catheter Mean Arterial Pressure (MAP) 12

nursece4less.com nursece4less.com nursece4less.com nursece4less.com measurements are more accurate than sphygmomanometric BP readings in patients who are Class III obesity, very thin, with severe burns to one or more extremities, and severely hypotensive), and those patients for whom frequent blood sampling is required. Contraindications for arterial catheterization include 1) Infections of the skin and soft tissue, 2) Severe peripheral vascular disease, 3) Impaired collateral circulation, 4) Severe coagulopathy, and 5) Synthetic vascular graft.

For catheterization at the radial artery, the initial puncture site should be as distal as possible; commonly over the radial pulse at the proximal flexor crease. Care should be taken that the puncture is at least 1 cm proximal to the styloid process as to avoid inuring the retinaculum flexorum and the small superficial branch of the radial artery. For catheterization at the femoral artery, found between the femoral nerve (lateral) and the femoral vein (medial), the femoral artery should be accessed at approximately 2.5 cm below the inguinal ligament, in the laterosuperior portion of the inguinal triangle. The femoral arterial pulsation can be palpated between the anterior superior iliac spine and the pubic symphysis.

A number of considerations irrespective of the location of the specific placement of the arterial catheter include:

• Patient position:

The patient should be as comfortable as possible and positioned in such a way as to facilitate catheter placement.

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• Radial artery catheterization:

For radial artery catheterization, the Allen test should be performed before attempting to place the catheter. Additionally, both the ulnar and radial arteries should be compressed for a few seconds and released. Reperfusion should occur within 7-8 seconds in order to ensure that there is satisfactory collateral flow in the event of radial occlusion.

• Pressure over the puncture site:

Pressure should be maintained over any puncture site for 5-7 minutes. Longer duration may be necessary in some patients.

• Guidewire or catheter insertion:

A guide wire or the catheter should not be forced against any resistance. If resistance to advancement is encountered, there are a number of approaches that may prove useful: − A small incision at the intended puncture site may allow for easier advancement of the catheter and may help prevent any kinking. − Rotating the needle may allow the needle to avoid an intimal flap that may be preventing advancement of the needle. − The liquid stylet method may prove useful, which involves filling a syringe (10 mL) with 5 mL of sterile saline, attaching the syringe to the catheter hub and aspirating 1- 2mL of blood. Then, while slowly injecting the saline the catheter is pulled along behind the fluid wave.

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− If the artery is in spasm, either allowing some time for artery recovery or using lidocaine (1%) will help to reduce arterial spasm. − In pediatric patients and neonates, papaverine (30mg/250mL) can be added. Papaverine may help maintain the catheter patency

Pulmonary Artery Catheterization and Monitoring

Pulmonary artery catheterization (PAC) and monitoring is less commonly used for a number of reasons including a lack of evidence that mortality and morbidity are significantly affected. In fact, PAC has been associated with increased mortality, though it is not clear if complications or the procedure itself is implicated. PAC has been described as a diagnostic and hemodynamic monitoring tool but not a therapeutic intervention. Moreover, the use of PAC has not been found to change mortality in the general ICU or hospital, or the cost for adult patients in intensive care. More studies are needed to determine if there are optimal PAC-guided management protocols for ICU patients that could lead to benefits, for example shock reversal, improved organ function and less vasopressor use. Newer, less-invasive hemodynamic monitoring tools need to be validated against PAC prior to clinical use in critically ill patients.

Pulmonary artery catheterization is often used to determine cardiac output and preload. PAC may be indicated for cardiac disorders such as acute valvular regurgitation, cardiac tamponade, complex heart failure or myocardial infarctions, and ventricular septal rupture. PAC may also be indicated for the assessment of volume state, post- 15

nursece4less.com nursece4less.com nursece4less.com nursece4less.com surgical monitoring, in some cases of pulmonary embolism and hypertension. The most common complications include temporary occlusion, hematomas and bleeding. Less common complications include localized infections, sepsis, ischemic damage (which rarely may be permanent), thrombosis, femoral artery dissection and air emboli. Neurological complications can occur and include compartment syndrome, carpal tunnel syndrome, paralysis and nerve injury. Very rare complications can include pseudoaneurysm formation and suppurative thromboarteritis.

In general, arterial catheterization is associated with a lower rate of infection than those associated with non-coated, uncuffed, non- tunneled short term CVCs. However, the rates of infection in arterial catheterizations are similar when using coated, uncuffed, non-tunneled short term CVCs, with insertion at the femoral artery resulting in the highest rates of infection.

The risk of infection increases with duration of catheterization, though there is no supporting evidence indicating that replacement of catheters more frequently with no evidence of infection, benefits the patient or decreases the risk of infection.

In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of catheter insertion to reduce the risk of infection. In children, the brachial site should not be used; the radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion.

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A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion. During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. The following are also recommended:

• Replace arterial catheters only when there is a clinical indication.

• Remove the arterial catheter as soon as it is no longer needed.

• Use disposable, rather than reusable, transducer assemblies when possible.

• Do not routinely replace arterial catheters to prevent catheter- related infections.

• Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced.

• Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile.

• Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (i.e, continuous flush), rather than an open system (i.e, one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters.

• When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system.

• Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit.

• Sterilize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible. 17

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Replacement of Administration Sets

In patients not receiving blood, blood products or fat emulsions, replacement of administration sets continuously used, including secondary sets and add-on devices should occur no more frequently than at 96-hour intervals, but at least every 7 days. However, no recommendation can be made regarding the frequency for replacing intermittently used administration sets or the frequency for replacing needles to access implantable ports.

Tubing should be replaced that is used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. Tubing used to administer propofol infusions should be replaced every 6 or 12 hours, when the vial is changed, according to the manufacturer’s recommendation. No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place.

Needleless Intravascular Catheter Systems

It is recommended to change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours; and, change needleless connectors no more frequently than every 72 hours or according to manufacturers’ recommendations for the purpose of reducing infection rates. It should be ensured that all components of the system are compatible to minimize leaks and breaks in the system.

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Contamination risk should be minimized through scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. A needleless system should be used to access IV tubing. When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves. Stopcocks have not been shown to be significant entry points for microbes. Nevertheless, it is recommended that stopcocks be capped when not in use. So-called piggyback systems, which utilize a port on a primary infusion set to deliver secondary infusions, pose an increased risk of infection. Modified piggyback systems may prevent infections, depending on the specific modification.

Purpose of Vascular Access

Vascular access is frequently used to monitor vital signs, deliver medications such as antibiotics or chemotherapy, allow blood to be drawn, deliver nutrients or transfusions, allow for monitoring blood gas levels, electrolyte balance and other critical values or allow for hemodialysis. In general, catheterization allows a thin, flexible, sterile plastic tube to be inserted into a vein or artery.

Venous catheterization is commonly used; and, the use of automatic monitoring has somewhat decreased the use of arterial catheterization with the exception of patients requiring minute-to-minute monitoring or who require frequent blood draws to measure arterial blood gas (ABG). Venous catheterization may involve peripheral or central

nursece4less.com nursece4less.com nursece4less.com nursece4less.com venous access. Peripheral access is adequate for many patients and can be accomplished with a percutaneous peripheral venous catheter. In other cases, a venous cutdown may be needed.

Central Venous Cutdown

The most common sites for a venous cutdown are at the cephalic or saphenous veins. The Seldinger (wire) technique has been compared with venous cutdown to place totally implantable venous access ports (TIVAPs), such as comparing the Seldinger technique (subclavian vein access) with cephalic vein cutdown, Seldinger technique utilizing the internal jugular vein with cephalic vein cutdown, Seldinger technique and venous cutdown both at the cephalic vein, and also the Seldinger technique at the subclavian vein with a Seldinger technique at the internal jugular vein. The evidence (moderate-quality) indicated that the Seldinger technique had a higher primary implantation success rate compared with the venous cutdown technique.

When the Seldinger technique was compared to the venous cutdown technique there were no significant differences with the overall complication rate; however, subclavian access utilizing the Seldinger technique was associated with higher frequency of complications.

Contraindications for central venous catheterization include the existence of adequate peripheral access. Relative contraindications can also include coagulopathies, thrombosis or injury of the target vein and assisted ventilation with high end-expiratory pressure. For the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com subclavian approach, additional complications include the use of thrombolytic medication.

Potential Complications of Venous Catheterization

Common complications of venous catheterizations include local infection, venous thrombosis, thrombophlebitis and interstitial fluid extravasation. These complications can generally be avoided by using sterile techniques methodically and meticulously and by replacing or removing the catheters within 72 hours. However, common and less common complications can result in various sequelae, such as:

• Carotid artery injuries can lead to bleeding, respiratory compromise and various neurologic events. • Puncture of the lung or the pleura can lead to pneumothorax. • Puncture of the vein can lead to bleeding, fluid extravasation, hemodynamic compromise. • Injury of the subclavian artery can lead to bleeding, vascular compromise of the extremity, hemothorax, and hemodynamic compromise. • Air embolisms can lead to cardiac arrhythmias and arrest. • Injury to the brachial plexus can compromise the extremity. • Catheter erosion can lead to bleeding, fluid extravasation, hemodynamic compromise. • Local infection can lead to sepsis or bacteremia. • Mechanical injury to the clavicle, the rib or vertebrae can lead to osteomyelitis. • Injury to the lymphatics can lead to chylothorax. • Endocarditis can be caused by valvular injury.

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Intraosseous Cannulation And Infusion

Intraosseous (IO) access has experienced a resurgence of use since the 1980s after a number of studies indicated that it could be effective in delivering emergency medications, especially in those patients for whom intravenous access is difficult or impractical. IO access is often beneficial in pediatric populations as well. IO delivery has some distinctive advantages. Firstly, intraosseous access can be achieved quickly and generally more easily than intravenous (IV) or intra- arterial access. This can be especially critical in cases of cardiac arrest in the ICU or for patients in transport to the emergency department. IO access can be used in adult, pediatric and neonatal populations.

Administration of resuscitation medications via an IO route achieve peak plasma concentrations more quickly than by either tracheal administration or by IV administration. Recent research has found that the infection rates for IO access were 0.6%. For the most part, the infections were correlated with prolonged administration or the existence of pre-existing bacteremias. Regarding volume resuscitation, the IO approach is equivalent to IV access. IO access can be used to obtain blood samples after discarding the initial 1-2 mL of aspirate.

Placement of Intraosseous Cannulation

Most IO cannulation is at the proximal tibia. Other sites include the humerus and the medial malleolus. Historically, the sternum was preferred, but is not recommended for pediatric patients because of the proximity of the great vessels and the small marrow cavity. The proximal tibia and the humerus have been compared; and, the first-

nursece4less.com nursece4less.com nursece4less.com nursece4less.com attempt success rate for the proximal tibia group was higher than the first-attempt success rate at the humerus (91% versus 51%) as well as a faster insertion time (4.6 min versus 7.0 min).

In newborns, the needle should be inserted 10 mm distal to the anterior tibial tuberosity. It should be aimed in a slight posterior and inferior direction. This is done to avoid damaging the growth plate. In children, possible sites include the proximal or distal tibia, the proximal humerus or the distal femur. The anterior iliac spine is less commonly used for access. In adults, possible sites are the proximal or distal tibia, the proximal humerus, the distal femur, the anterior iliac spine, the sternum and the distal radius. In children and adults, the needle insertion site should be 2 cm below the tibial tuberosity and 1 cm medially on the tibial plateau. For the humerus, the insertion site is located 2 cm distal to the acromion process.

Contraindications for IO cannulation include: 1) previous fracture, 2) at the site of an unsuccessful previous attempt, and 3) indwelling hardware. Relative contraindications include local skin or soft tissue infection and underlying bone disease. Complications are relatively minor or rare with IO cannulations. A major complication includes compartment syndrome. Risk factors include total fluid volume and infusion rate, bone fracture, dislodgement of the needle, use of hypertonic fluid, recent cortical puncture in the same bone, infection, fat- or bone-marrow embolic events and bone injury. The following table itemizes the varied risk factors associated with the types of catheter insertions and sites.

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Catheter Type Entry Site Length Comments

Peripheral Usually inserted in veins of <3 inches Phlebitis with prolonged venous forearm or hand use; rarely associated with catheters bloodstream infection.

Peripheral Usually inserted in radial <3 inches Low infection risk; rarely arterial artery; can be placed in associated with catheters femoral, axillary, brachial, bloodstream infection. posterior tibial arteries

Midline Inserted via the 3 to 8 inches Anaphylactoid reactions catheters antecubital fossa into the have been reported with proximal basilic or cephalic catheters made of veins; does not enter elastomeric hydrogel; lower central veins, peripheral rates of phlebitis than short catheters peripheral catheters.

Nontunneled Percutaneously inserted ≥8 cm Account for the majority of central into central veins depending CRBSI. venous (subclavian, internal on patient catheters jugular, or femoral) size

Pulmonary Inserted through a Teflon ≥30 cm Usually heparin bonded; artery introducer in a central vein depending similar rates of bloodstream catheters (subclavian, internal on patient infection as CVCs; jugular, or femoral) size subclavian site preferred to reduce infection risk.

Peripherally Inserted into basilic, ≥20 cm Lower rate of infection than inserted cephalic, or brachial veins depending nontunneled CVCs. central and enter the superior on patient venous vena cava size catheters

Tunneled Implanted into subclavian, ≥8 cm Cuff inhibits migration of central internal jugular, or femoral depending organisms into catheter venous veins on patient tract; lower rate of infection catheters size than non-tunneled CVC.

Totally Tunneled beneath skin and ≥8 cm Lowest risk for CRBSI; implantable have subcutaneous port depending improved patient self- accessed with a needle; on patient image; no local catheter- implanted in subclavian or size site care; surgery required internal jugular vein for catheter removal.

Umbilical Inserted into either ≥6 cm Risk for CRBSI similar with catheters umbilical vein or umbilical depending catheters placed in artery on patient umbilical vein versus size artery.

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Sepsis And Blood Transfusion

There is generally insufficient data to support high recommendations on the topic of red blood cell (RBC) transfusion in sepsis. The transfusion needs for each septic patient must be assessed individually since optimal transfusion triggers in sepsis patients are not known and there is no clear evidence that blood transfusion increases tissue oxygenation.7-10

Acute Lung Injury and Acute Respiratory Distress Syndrome

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are common clinical sequelae of massive transfusion. Prior studies have suggested that RBC transfusion is associated with respiratory complications, including ALI and ARDS that remains even after adjusting for potential confounders. There exists insufficient data to support high recommendations on this topic. All efforts should be initiated to avoid RBC transfusion in patients at risk for ALI and ARDS after completion of resuscitation.

Efforts should also be made to diagnose and report transfusion-related ALI (TRALI) to the local blood bank because it has emerged as a leading cause of transfusion-associated morbidity and mortality, despite underdiagnosis and underreporting.

Neurologic Injury and Diseases

There is insufficient data to support high recommendations on RBC transfusions in patients with neurologic injury and diseases.

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Specifically, no benefit exists for a ‘liberal’ transfusion strategy (transfusion when Hb <10 g/dL) in patients with moderate-to-severe traumatic brain injury. Decisions regarding blood transfusion in patients with subarachnoid hemorrhage (SAH) must be assessed individually since optimal transfusion triggers are not known and there is no clear evidence that blood transfusion is associated with improved outcome.

Red Blood Cell Transfusion Risks

Insufficient data exists to support high recommendations regarding RBC transfusion risks. RBC transfusion is associated with increased nosocomial infection (wound infection, pneumonia, sepsis) rates independent of other factors. RBC transfusion is also an independent risk factor for multiple organ failure (MOF) and systemic inflammatory response syndrome (SIRS).

There is no definitive evidence that pre-storage leukocyte depletion of RBC transfusion reduces complication rates, but some studies have shown a reduction in infectious complications. RBC transfusions are independently associated with longer ICU and hospital length of stay, increased complications, and increased mortality. As mentioned, there is a relationship between transfusion and ALI and ARDS.

Alternatives to Red Blood Cell Transfusion

Insufficient data exists to support high-level recommendations on alternatives to RBC transfusion. However, recombinant human erythropoietin (rHuEpo) administration improves reticulocytosis and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com hematocrit and may decrease overall transfusion requirements. Hemoglobin-based oxygen carriers (HBOCs) are undergoing investigation for use in critically ill and injured patients but are not yet approved for use in the United States.

Strategies to Reduce Red Blood Cell Transfusion

Insufficient data exists to support high-level recommendations on strategies to reduce RBC transfusion. The use of low-volume adult or pediatric blood sampling tubes is associated with a reduction in phlebotomy volumes and a reduction in blood transfusion. The use of blood conservation devices for reinfusion of waste blood with diagnostic sampling is associated with a reduction in phlebotomy volume.

Intraoperative and postoperative blood salvage and alternative methods for decreasing transfusion may lead to a significant reduction in allogeneic blood usage. Reduction in diagnostic laboratory testing is associated with a reduction in phlebotomy volumes and a reduction in blood transfusion.

Cardiac Monitoring In The Intensive Care Unit

Most critical care patients commonly have their cardiac activity routinely monitored using automated systems with alarms. Continuous cardiac monitoring (CCM) is often ordered without regard to the medical necessity. As with other laboratory tests and patient monitoring routines in the ICU, continuous cardiac monitoring has its

nursece4less.com nursece4less.com nursece4less.com nursece4less.com advantages and its disadvantages, especially in the setting of potential risk or sepsis and other cardiac complications.19

The advantages of CCM include:

• Detection of arrhythmias • Monitoring for myocardial ischemia • QT-interval monitoring

However, CCM also has some significant disadvantages:

• Alarm fatigue − As a corollary, some ICU patients and their loved ones can suffer alarm fatigue as well • Lack of specificity • Increased cost

The main indications for CCM are a diagnosis (or concern) for an acute cardiac condition and for critical illness. The most recent recommendations from the American Heart Association suggest the following best practices, which also include those patients for whom CCM is not recommended such as low-risk, post-operative patients, patients with rate-controlled atrial fibrillation, and patients currently undergoing hemodialysis but without other indications for monitoring. The recommendations also include guidelines for time-limited CCM: indefinite CCM as well as 24- and 48 hour CCM. Patients are assigned to one of three classes based on clinical characteristics.

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Class I patients require CCM and include all patients at risk of an immediate, life-threatening arrhythmia. This class includes a number of categories:

• Patients who have been resuscitated from a cardiac arrest

• Patients in the early phase of Acute Coronary Syndromes − ST-Elevation or Non–ST-Elevation MI − Unstable Angina − To Rule-Out MI

• Patients with unstable coronary syndromes and/or recently diagnosed high-risk coronary lesions

• Patients with a history of cardiac surgery − This category includes both adults and children

• Patients with a history of non-urgent percutaneous coronary intervention, but who experienced complications

• Pacemaker dependent patients or those who have undergone the implantation of an automatic defibrillator or pacemaker lead

• Patients with: − A temporary pacemaker − AV block − Long-QT syndrome and associated ventricular arrhythmias − Arrhythmias complicating Wolff-Parkinson-White syndrome with rapid anterograde conduction over an accessory pathway − Acute heart failure and/or pulmonary edema − A need for intensive care including patients with “major trauma, acute respiratory failure, sepsis, shock, acute pulmonary embolus, major noncardiac surgery (especially in older adult patients with a history of coronary artery disease or coronary risk factors), renal failure with 29

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electrolyte abnormalities (i.e., hyperkalemia), drug overdose (especially from known arrhythmogenics, i.e., digitalis, tricyclic antidepressants, phenothiazines, antiarrhythmics)” − Concurrent diagnostic or therapeutic procedures that require conscious sedation or anesthesia

Class II patients may benefit from CCM, but CCM is not expected to be a life-saving procedure. Class II patients also are divided into a number of subgroups. These subgroups include patients with:

• Post-acute MI

• Chest pain syndromes − The Goldman risk-assessment tool can be used to categorize patients into high-, moderate-, low- and very- low-risk groups. This categorization is based on patient history and physical examination. These predictors (risk factors) are: MI is suspected on initial ECG ST-segment elevation of ≥1 mm or pathological Q waves in ≥2 leads Ischemia suspected on initial ECG ST-segment depression of ≥1 mm or T wave inversion in ≥2 leads Systolic blood pressure <110 mm Hg Rales heard above the bases bilaterally History of unstable ischemic heart disease Worsening of previously stable angina New onset of post-MI angina

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Angina after a coronary revascularization procedure Pain that is the same as that associated with a previous MI

Currently, the recommendation from the American Heart Association is to utilize CCM for patients with any sign of ischemia or infarction on initial ECG evaluation and one or more of the following risk factors:

• Uncomplicated, non-urgent percutaneous coronary interventions.

• Patients on antiarrhythmic drugs or those with chronic atrial tachyarrhythmias and who require medication adjustment to control heart rate.

• Pacemakers but who are not dependent on the pacemaker.

• A history of uncomplicated ablations of an arrhythmia, routine coronary angiography, subacute heart failure or those who are currently be evaluated for syncope.

• A terminal diagnosis or Do-Not-Resuscitate (DNR) order. • Class III patients are post-operative patients at low risk for cardiac events.

Resuscitation Of The ICU Patient And Infection Prevention

This section discusses protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion.17,18

Initial Resuscitation

The goals of initial resuscitation of the patient with sepsis-induced tissue hypoperfusion (defined as hypotension persisting after initial

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• Central venous pressure 8–12 mm Hg

• Mean arterial pressure (MAP) ≥ 65 mm Hg

• Urine output ≥ 0.5 mL/kg/hr

• Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively. − In patients with elevated lactate levels targeting resuscitation to normalize lactate. • Screening for Sepsis and Performance Improvement − Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy. − Hospital–based performance improvement efforts in severe sepsis. • Diagnosis − Cultures as clinically appropriate before antimicrobial therapy if no significant delay (>45 mins) in the start of antimicrobial(s): At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted. − Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.

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− Imaging studies performed promptly to confirm a potential source of infection. • Antimicrobial Therapy − Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock as the goal of therapy. − Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis. − Antimicrobial regimen should be reassessed daily for potential de-escalation. − Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection. − Combination empirical therapy for neutropenic patients with severe sepsis and for patients with difficult-to-treat, multidrug-resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia. A combination of beta- lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections.

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Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known. − Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia. − Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin. − Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause. • Source Control − A specific anatomical diagnosis of infection requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hour after the diagnosis is made, if feasible. − When infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred. − When source control in a severely septic patient is required, the effective intervention associated with the

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least physiologic insult should SURVIVING SEPSIS be used (i.e., percutaneous CAMPAIGN BUNDLES

rather than surgical drainage TO BE COMPLETED WITHIN of an abscess). 3 HOURS: 1) Measure lactate level − If intravascular access devices 2) Obtain blood cultures prior to administration of are a possible source of severe antibiotics 3) Administer broad sepsis or septic shock, they spectrum antibiotics 4) Administer 30 mL/kg should be removed promptly crystalloid for after other vascular access has hypotension or lactate 4mmol/L been established. TO BE COMPLETED WITHIN • Infection Prevention 6 HOURS:

− Selective oral decontamination and 1) Apply vasopressors (for hypotension that does selective digestive not respond to initial decontamination should be fluid resuscitation) to maintain a mean arterial introduced and investigated as a pressure (MAP) ≥ 65 mm Hg method to reduce the incidence of 2) In the event of persistent arterial hypotension ventilator-associated pneumonia; despite volume resuscitation (septic this infection control measure can shock) or initial lactate 4 then be instituted in health care mmol/L (36 mg/dL): a. Measure central settings and regions where this venous pressure (CVP) methodology is found to be b. Measure central venous oxygen

effective. saturation (ScvO2) 3) Remeasure lactate if − Oral chlorhexidine gluconate can initial lactate was be used as a form of elevated

oropharyngeal decontamination to Targets for quantitative resuscitation included in the reduce the risk of ventilator- guidelines are CVP of≥8 mm Hg, ScvO2 of 70%, and associated pneumonia in ICU normalization of lactate. patients with severe sepsis.

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Laboratory Testing and Management of Sepsis

Routine laboratory screening for infection and sepsis prevention measures and complications from sepsis should be continuous in the ICU setting. If tissue hypoperfusion has been resolved and there are no special circumstances (i.e., myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic coronary artery disease), the target Hgb concentration is recommended to be between 7-9g/dL.

• Erythropoietin is not recommended to treat the anemia associated with sepsis.

• Fresh frozen plasma (FFP) is not recommended for correct clotting abnormalities.

• Antithrombin administration is not recommended in the treatment of severe sepsis or septic shock.

• Platelets should be administered when platelet counts are≤10,000/mm3 when there is no apparent bleeding. The target is ≥50,000/mm3 if there are signs of active bleeding, post- surgically and before invasive procedures. • Intravenous immunoglobulins are not recommended in the treatment of severe sepsis or septic shock. • Intravenous selenium (Se) is not recommended in the treatment of severe sepsis or septic shock. • If mechanical ventilation of sepsis-induced Acute Respiratory Distress Syndrome is required: - A tidal volume of 6mL/kg predicted body weight in patients with sepsis-induced ARDS rather than12 mL/kg should be targeted.

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- Plateau pressures should be measured in patients with ARDS. The goal for initial upper limit goal for plateau pressures in a

passively inflated lung should be ≤30 cm H2O. - Positive end-expiratory pressure (PEEP) should be applied to avoid alveolar collapse at end expiration (atelectotrauma). - Strategies should be based on higher rather than lower levels of PEEP. These should be used for patients with sepsis- induced moderate or severe ARDS. - Recruitment maneuvers should be used in sepsis patients with severe refractory hypoxemia. - Prone positioning should be used in sepsis-induced ARDS

patients with a Pao2/Fio2 ratio ≤100mm Hg in facilities that have experience with such practices. - Mechanically ventilated sepsis patients should be maintained with the head of the bed elevated to 30-45o to limit aspiration risk and to prevent the development of ventilator-associated pneumonia. - Noninvasive mask ventilation (NIV) should be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks. - A weaning protocol should be in place and that mechanically ventilated patients with severe sepsis undergo spontaneous breathing trials regularly to evaluate the ability to discontinue mechanical ventilation when they satisfy the following criteria: 1) Arousable, 2) Hemodynamically stable (without vasopressor agents), 3) No new potentially serious conditions, and 4) Low ventilator and end-expiratory pressure

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safely delivered with a face mask or nasal cannula. (If the spontaneous breathing trial is successful, consideration should be given for extubation).

• The routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS is not recommended.

• A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion is recommended

• In the absence of specific indications such as bronchospasm, using β2-agonists for treatment of sepsis-induced ARDS is not recommended.

Sedation, Analgesia, and Neuromuscular blockade in Sepsis

• Continuous or intermittent sedation should be minimized in mechanically ventilated sepsis patients, targeting specific titration endpoints.

• Neuromuscular blocking agents (NMBAs) should be avoided if possible in the septic patient without ARDS due to the risk of prolonged neuromuscular blockade following discontinuation. If NMBAs must be maintained, either intermittent bolus as required or continuous infusion with train-of-four monitoring of the depth of blockade should be used.

• Provide a short course of NMBA (not greater than 48 hours) for

early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg.

Glucose Control

• A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2

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consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110mg/dL.

• Blood glucose values be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hours thereafter

• Glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values.

Renal Replacement Therapy

• Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure.

• Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients. • Bicarbonate Therapy

• Sodium bicarbonate therapy for the purposes of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH≥7.15 is not recommended.

Deep Vein Thrombosis Prophylaxis

• Patients with severe sepsis should receive daily pharmacoprophylaxis against venous thromboembolism (VTE) This should be accomplished with daily subcutaneous low- molecular weight heparin (LMWH) (versus twice daily UFH, or

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versus three times daily UFH). If creatinine clearance is <30 mL/min, use dalteparin or another form of LMWH that has a low degree of renal metabolism or UFH.

• Patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible.

• Septic patients who have a contraindication for heparin use (i.e., thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) should not receive pharmacoprophylaxis, but receive mechanical prophylactic treatment, such as graduated compression stockings or intermittent compression devices, unless contraindicated. When the risk decreases start pharmacoprophylaxis.

Stress Ulcer Prophylaxis

• Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor should be given to patients with severe sepsis/septic shock who have bleeding risk factors.

• When stress ulcer prophylaxis is used, proton pump inhibitors rather than H2RA

• Patients without risk factors do not receive prophylaxis. • Nutrition

• Administer oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock

• Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (i.e., up to 500 calories per day), advancing only as tolerated. 40

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• Use intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock.

• Use nutrition with no specific immunomodulating supplementation rather than nutrition providing specific immunomodulating supplementation in patients with severe sepsis.

Summary

Patients in hospital intensive care units are at risk of infection, sepsis and other medical conditions. Recommendations and procedures for laboratory testing discussed above will help the clinician incorporate national safety goals related to sepsis prevention, recognition and treatment. This is especially true when it comes to catheter insertion and maintenance. The clinician needs to incorporate the latest recommendations for peripheral and central catheter insertion, maintenance, laboratory testing, cardiac monitoring and prevention of infection at the site of a catheter especially in the setting of needed blood draws to monitor outcomes of ongoing treatment.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.

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1. A catheter lock is an approach where an antimicrobial solution is used to fill the lumen of the catheter

a. to flush the lumen prophylactically. b. to prophylactically sterilize the lumen for a period of time. c. to flush the lumen if a patient has a bloodstream infection. d. between uses.

2. It is recommended that peripherally inserted central venous catheters (PICC) and central venous catheters (CVC) should

a. not be removed on the basis of fever alone. b. be removed on the basis of fever alone. c. be routinely replaced to prevent catheter-related infections. d. be removed based clinical judgment.

3. To prophylactically sterilize the lumen of the catheter, a commonly used antiseptic is

a. cefazolin. b. ancomycin. c. alcohol. d. amikacin.

4. In peripheral catheters in children, the recommendation on replacing peripheral catheters in children is:

a. every 72–96 hours. b. before 72 hours. c. only when clinically indicated. d. there is no recommendation.

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6. ______are the preferred approach for dialysis patients in chronic renal failure.

a. AV fistulas or grafts b. Tunneled cuffed catheter c. Hemodialysis catheters d. Midline catheters

7. True or False: The use of antimicrobials and anticoagulants as a prophylactic reduces the rate of central venous catheter-associated infections.

a. True b. False

8. In umbilical catheterization, catheter-related bloodstream infection (CBRSI) rates are

a. lower regardless of position of catheterization. b. lower if catheterization is placed above the aortic bifurcation. c. lower if catheterization is placed below the diaphragm. d. similar regardless of position of catheterization.

9. Umbilical catheters placed higher in the patient

a. have lower rates of vascular complications. b. have lower CBRSI rates. c. have higher rates of infection. d. have higher rates of vascular complications.

10. The preferred site for catheter insertion in children include

a. the brachial artery. b. the femoral artery. c. the posterior tibial. d. the axillary artery.

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11. Which of the following is NOT one of the preferred sites for catheter insertion in adults?

a. Brachial artery b. The dorsalis pedis c. The posterior tibial d. Radial artery

12. True or False: The use of femoral or axillary sites as preferred site for catheter insertion in adults helps reduce the risk of infection.

a. True b. False

13. During axillary or femoral artery catheter insertion, it is recommended to replace disposable or reusable transducers

a. only when there is a clinical indication. b. as soon as it is no longer needed. c. at 96-hour intervals. d. at least every seven days.

14. The rates of infection in arterial catheterizations are similar to rates of infection when using coated, uncuffed, non-tunneled short-term CVCs, with insertion at ______experiencing the highest rates of infection.

a. or above the diaphragm b. the aortic bifurcation c. a posterior tibial site d. the femoral artery

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15. During axillary or femoral artery catheter insertion, it is recommended that a provider NOT administer ______through the pressure monitoring circuit.

a. parenteral nutrition fluids b. blood c. fat emulsions d. blood products

16. In patients not receiving blood, blood products or fat emulsions, replacement of ______should occur no more frequently than at 96-hour intervals, but at least every 7 days.

a. administration sets used continuously b. intermittently used administration sets c. needles to access implantable port d. tubing

17. True or False: A minimum of a cap, mask, and sterile gloves should be used during peripheral arterial catheter insertion.

a. True b. False

18. Tubing used to administer propofol infusions should be replaced ______, when the vial is changed, per the manufacturer’s recommendation.

a. if there is a clinical indication b. every 24 hours c. at 96-hour intervals d. every 6 or 12 hours

19. Which of the following is correct regarding the use of stopcocks in administration?

a. Stopcocks are a significant entry point for microbes b. Stopcocks should be capped when not in use c. Stopcocks are only used in needleless systems d. All of the above

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20. In spite of the increase in use of automatic monitoring devices, the use of arterial catheterization for monitoring patients is still useful for patients requiring

a. minute-to-minute monitoring. b. parenteral nutrition fluids. c. concomitant monitoring. d. All of the above

21. The most common sites for a venous cutdown procedure are at the

a. femoral artery. b. femoral artery or cephalic. c. cephalic or saphenous veins. d. posterior tibial site or saphenous veins.

22. The Seldinger (wire) technique’s success rate for primary implantation when compared with the venous cutdown technique was

a. lower. b. the same. c. undetermined. d. higher.

23. True or False: When replacing administration sets and add- on devices, no recommendation can be made regarding the length of time a needle, used to access implanted ports, can remain in place.

a. True b. False

24. For radial artery catheterization, perform the ______before attempting to place the catheter.

a. Apache II test b. Allen test c. SAPS test d. reflex test

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25. ______has experienced a resurgence of use since it could be effective in delivering emergency medications, especially in those patients for whom IV access is difficult or impractical.

a. Intraosseous (IO) access b. Seldinger (wire) technique c. The cutdown approach d. The needleless access

26. If resistance to advancement of a guide wire or the catheter is encountered because of an artery spasm, either allow some time for artery recovery or use ______to reduce arterial spasm.

a. papaverine (30mg/250mL) b. propofol (2%) c. fat emulsions d. lidocaine (1%)

27. For catheterization at the femoral artery, found between the femoral nerve (lateral) and the femoral vein (medial), the femoral artery should be accessed at approximately ______, in the laterosuperior portion of the inguinal triangle.

a. 1 cm below retinaculum flexorum b. 2.5 cm below retinaculum flexorum c. 2 cm below the tibial tuberosity d. 2.5cm below the inguinal ligament

28. True or False: When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves.

a. True b. False

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29. ______can be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis.

a. A heparin infusion b. Propofol (1%) c. Oral chlorhexidine gluconate d. Lidocaine (1%)

30. Septic patients who have a contraindication for heparin use should not receive ______, but should receive appropriate, mechanical prophylactic treatment.

a. warfarin sodium b. pharmacoprophylaxis c. lepirudin d. argatroban

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Correct Answers:

1. A catheter lock is an approach where an antimicrobial solution is used to fill the lumen of the catheter

b. to prophylactically sterilize the lumen for a period of time.

“A catheter lock is an approach where an antimicrobial solution is used to fill the lumen of a catheter to prophylactically sterilize the lumen of the catheter for a period of time (as opposed to simply flushing the catheter with the solution).”

2. It is recommended that peripherally inserted central venous catheters (PICC) and central venous catheters (CVC) should

a. not be removed on the basis of fever alone.

“It is recommended to not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter related infections. CVCs or PICCs should not be removed on the basis of fever alone.”

3. To prophylactically sterilize the lumen of the catheter, a commonly used antiseptic is

c. alcohol.

“Antiseptic solutions can be used as well. Commonly, the antiseptic used is alcohol.”

4. In peripheral catheters in children, the recommendation on replacing peripheral catheters in children is:

c. only when clinically indicated.

“In children, replacement of peripheral catheters should be only when clinically indicated.”

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d. There is no evidence that it reduces the rate of infection or phlebitis

“While it would appear logical that frequent replacement of CVCs on a schedule should reduce the rate of infection and/or phlebitis, there is no evidence that this will actually reduce the frequency of infection or the rate of thrombophlebitis.”

6. ______are the preferred approach for dialysis patients in chronic renal failure.

a. AV fistulas or grafts

“Arteriovenous (AV) fistulas and grafts are the preferred approach for patients in chronic renal failure.”

7. True or False: The use of antimicrobials and anticoagulants as a prophylactic reduces the rate of central venous catheter-associated infections.

b. False

“Efforts to reduce the risk of infections and thromboses by combining the use of antimicrobials and anticoagulants have been raised; however, large meta-analyses did not support evidence that the use of anticoagulants as a prophylactic reduces the rate of infections.”

8. In umbilical catheterization, catheter-related bloodstream infection (CBRSI) rates are

d. similar regardless of position of catheterization.

“Umbilical catheterization risks vary depending on position (above or below the diaphragm and above the aortic bifurcation) and type (arterial or venous). CBRSI rates are similar regardless of position.”

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9. Umbilical catheters placed higher in the patient

a. have lower rates of vascular complications.

“… umbilical catheters placed higher have lower rates of vascular complications.”

10. The preferred site for catheter insertion in children include

c. the posterior tibial.

“In children, the brachial site should not be used; the radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion.”

11. Which of the following is NOT a preferred site for catheter insertion in adults?

c. The posterior tibial

“In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of catheter insertion to reduce the risk of infection. In children, the brachial site should not be used; the radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion.”

12. True or False: The use of femoral or axillary sites as preferred site for catheter insertion in adults helps reduce the risk of infection.

b. False

“In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of catheter insertion to reduce the risk of infection.”

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13. During axillary or femoral artery catheter insertion, it is recommended to replace disposable or reusable transducers

c. at 96-hour intervals.

“During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. The following are also recommended: … Replace disposable or reusable transducers at 96-hour intervals.”

d. the femoral artery

“… the rates of infection in arterial catheterizations are similar when using coated, uncuffed, non-tunneled short term CVCs, with insertion at the femoral artery experiencing the highest rates of infection.”

15. During axillary or femoral artery catheter insertion, it is recommended that a provider NOT administer ______through the pressure monitoring circuit.

a. parenteral nutrition fluids

“During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. The following are also recommended: … Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit.”

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16. In patients not receiving blood, blood products or fat emulsions, replacement of ______should occur no more frequently than at 96-hour intervals, but at least every 7 days.

a. administration sets used continuously

“In patients not receiving blood, blood products or fat emulsions, replacement of administration sets continuously used, including secondary sets and add-on devices should occur no more frequently than at 96-hour intervals, but at least every 7 days.”

17. True or False: A minimum of a cap, mask, and sterile gloves should be used during peripheral arterial catheter insertion.

b. False

“A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion.”

18. Tubing used to administer propofol infusions should be replaced ______, when the vial is changed, per the manufacturer’s recommendation.

d. every 6 or 12 hours “Tubing used to administer propofol infusions should be replaced every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendation.”

19. Which of the following is correct regarding the use of stopcocks in administration?

b. Stopcocks should be capped when not in use

“Stopcocks have not been shown to be significant entry points for microbes. Nevertheless, it is recommended that stopcocks be capped when not in use.”

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20. In spite of the increase in use of automatic monitoring devices, the use of arterial catheterization for monitoring patients is still useful for patients requiring

a. minute-to-minute monitoring.

“Venous catheterization is commonly used, but the use of automatic monitoring has somewhat decreased the use of arterial catheterization, with the exception of patients requiring minute-to-minute monitoring or who require frequent blood draws to measure arterial blood gas (ABG).”

21. The most common sites for a venous cutdown procedure are at the

c. cephalic or saphenous veins.

“The most common sites for a venous cutdown are at the cephalic or saphenous veins.”

22. The Seldinger (wire) technique’s success rate for primary implantation when compared with the venous cutdown technique was

d. higher.

“The evidence (moderate-quality) indicated that the Seldinger technique had a higher primary implantation success rate compared with the venous cutdown technique.”

23. True or False: When replacing administration sets and add- on devices, no recommendation can be made regarding the length of time a needle, used to access implanted ports, can remain in place.

a. True

“No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place.”

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24. For radial artery catheterization, perform the ______before attempting to place the catheter.

b. Allen test

“For radial artery catheterization, perform the Allen test before attempting to place the catheter.”

25. ______has experienced a resurgence of use since it could be effective in delivering emergency medications, especially in those patients for whom IV access is difficult or impractical.

a. Intraosseous (IO) access

“Intraosseous (IO) access has experienced a resurgence of use since the 1980s after a number of studies indicated that it could be effective in delivering emergency medications, especially in those patients for whom IV access is difficult or impractical.”

26. If resistance to advancement of a guide wire or the catheter is encountered because of an artery spasm, either allow some time for artery recovery or use ______to reduce arterial spasm.

d. lidocaine (1%)

“If the artery is in spasm, either allow some time for artery recovery or use lidocaine (1%) to reduce arterial spasm.”

d. 2.5cm below the inguinal ligament

“For catheterization at the femoral artery, found between the femoral nerve (lateral) and the femoral vein (medial), the femoral artery should be accessed at approximately 2.5cm below the inguinal ligament, in the laterosuperior portion of the inguinal triangle.”

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28. True or False: When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves.

a. True

“When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves.”

29. ______can be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis.

c. Oral chlorhexidine gluconate

“Oral chlorhexidine gluconate can be used as a form of oropharyngeal decontamination to reduce the risk of ventilator- associated pneumonia in ICU patients with severe sepsis.”

30. Septic patients who have a contraindication for heparin use should not receive ______, but should receive appropriate, mechanical prophylactic treatment.

b. pharmacoprophylaxis

“Septic patients who have a contraindication for heparin use (i.e., thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) should not receive pharmacoprophylaxis, but receive mechanical prophylactic treatment, such as graduated compression stockings or intermittent compression devices, unless contraindicated. When the risk decreases start pharmacoprophylaxis.”

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References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Band, Jeffrey (2016). Treatment of intravascular catheter-related infection. Up To Date. Retrieved online at https://www.uptodate.com/contents/treatment-of-intravascular- catheter-related- infections?source=search_result&search=sepsis%20and%20cathe ter%20related%20infection&selectedTitle=1~150. 2. Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU is there a reason? Chest. 1995; 108:767–71. 3. Dolman, HS., et al, Impact of minimizing diagnostic blood loss in the critically ill., Surgery, 158(4), 1083-1088, 2015. 4. Srivastava, R., Bartlett, WA., Kennedy, IM., Hiney, A., Fletcher, C., Murphy, MJ. Reflex and reflective testing: efficiency and effectiveness of adding on laboratory tests. Ann Clin Biochem. 47 (3) 223-227, 2010. 5. Neviere, R. (2016). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis and prognosis. Up To Date. Retrieved online at https://www.uptodate.com/contents/sepsis-syndromes-in-adults- epidemiology-definitions-clinical-presentation-diagnosis-and- prognosis?source=search_result&search=sepsis%20and%20cathe ter%20related%20infection&selectedTitle=7~150. 6. Baird, G., The laboratory test utilization management toolbox. Biochemia Medica 2014;24(2):223-34. 7. Flegel, WA., Natanson, C., Klein, HG. Does prolonged storage of red blood cells cause harm? Accessed at http://rdcr.org/wp- content/uploads/2012/08/BJH-2014.pdf (9/2016) 8. Napolitano, LM., et al, Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Accessed at: http://www.learnicu.org/docs/guidelines/redbloodcell.pdf (9/2016) 9. Iosfina, I. et al, Implementation Of An On-Demand Strategy For Routine Blood Testing In ICU Patients, D23. QUALITY IMPROVEMENT IN CRITICAL CARE. May 1, 2013, A5322-A5322. Accessed at http://www.atsjournals.org/doi/abs/10.1164/ajrccm-

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conference.2013.187.1_MeetingAbstracts.A5322 (Accessed 10/2016) 10. American Association of Critical Care Nurses (2016). Choosing Wisely. Retrieved online at http://www.choosingwisely.org/societies/critical-care-societies- collaborative-critical-care/. 11. Girand, H. (2016). Antibiotic lock therapy for treatment of catheter-related blood stream infections. Up To Date. Retrieved online at https://www.uptodate.com/contents/antibiotic-lock- therapy-for-treatment-of-catheter-related-bloodstream- infections?source=search_result&search=sepsis%20and%20cathe ter%20related%20infection&selectedTitle=5~150. 12. Centers for Disease Control and Prevention (2016). Assessment Control Assessment Tools. Health-associated infections. Retrieved online at https://www.cdc.gov/hai/prevent/infection-control- assessment-tools.html. 13. Merck Manual (2016). Retrieved online at https://www.merckmanuals.com/professional/nutritional- disorders/nutritional-support/total-parenteral-nutrition-tpn. 14. Lew, CC., et al, Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. J Parenteral Nutrition, Feb, 2016. 15. Venecourt-Jackson, Esra, Simon J. Hill, and Russell S. Walmsley (2013). "Successful treatment of parenteral nutrition–associated liver disease in an adult by use of a fish oil–based lipid source." Nutrition 29.1 (2013): 356-358. 16. Band, J. and Gaynes, R. (2016). Prevention of intravascular catheter related infection. Retrieved online at https://www.uptodate.com/contents/treatment-of-intravascular- catheter-related- infections?source=search_result&search=sepsis%20and%20cathe ter%20related%20infection&selectedTitle=1~150. 17. Society of Critical Care Medicine (2013). Surviving Sepsis Campaign: International Guidelines for Surviving Sepsis and Septic Shock. Retrieved online at http://www.survivingsepsis.org/sitecollectiondocuments/impleme nt-pocketguide.pdf. 18. Makara, M., et al (2016). Cardiac Electrical and Structural Changes During Bacterial Infection: An Instruction Model to Study Cardiac Dysfunction in Sepsis. Journal of the American Heart Association. 2016;5:e003820, originally published September 12, 2016. Retrieved online at http://jaha.ahajournals.org/keyword/sepsis.

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