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

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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. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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 5 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 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
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