Reducing Central Line-Associated Blood Stream Infections

Reducing Central Line-Associated Blood Stream Infections Literature Review: Reducing Incidences of Central Line-Associated Blood Stream Infections A bundle is a group of interventions related to a disease process, that when executed together, produce better outcomes than when implemented individually. Numerous studies done in the developed countries have shown that proper implementation of evidence based practices grouped together as central venous catheter bundle had brought a dramatic reduction in the incidence of CLABSI. Studies in developing countries had also shown high incidence of CLABSI and reduction in CLABSI rate albeit lesser than that of developed countries. Studies from India have a shown a higher incidence of CLABSI and poor adherence to central line catheter bundle. Morbidity and mortality due to CLABSI is considerably high despite underreporting of such events. The development and publication of guidelines often does not lead to changes in clinical behavior and guidelines are rarely if ever, integrated into bedside practice in a timely fashion. The most effective means for achieving knowledge transfer remains an unanswered question across all medical disciplines. Our study aims to determine the compliance with CVC bundle in management of patients in medicine wards and ICU at All India Institute of Medical Sciences New Delhi and the impact of intervention in the form of periodic physician education and feedback in compliance with CVC bundle and central line catheter related complications. Review of literature Ever since the introduction of central venous catheters in the early 1950s, it had varied uses and later numerous studies revealed that it was associated with a varied number of complications. Although mechanical complications were common in the early years of CVC use CLABSIs quickly became recognized as a serious complication associated with their usage. Central venous catheter is defined as a catheter whose tip terminates in the great vessels. The great vessels are the aorta, pulmonary artery, superior vena cava,inferior vena cava, brachiocephalic veins, internal jugular veins,subclavian veins, external iliac veins, common iliac veins,femoral veins, and, in neonates, the umbilical artery/vein. Types : Common types of central venous catheters are Non tunneled catheters, Tunneled catheters, Implantable ports, PICC. A peripherally inserted central catheter (PICC) is peripherally placed, but is considered a central catheter because its tip terminates in the central circulation. These venous catheters can also have single, double or triple lumens although single lumens are frequently used and are for intermediate to long term therapy for blood draws or infusions. Complications of CVC: Mechanical complications(4,9)include Pneumothorax is a common complication with subclavian and IJV cannulations without the use of ultrasound. The use of real time ultrasound reduces the number of attempts and associated with a significantly lower failure rate with internal jugular vein ( Relative risk 0.14, 95% confidence interval 0.06 to 0.33). Limited evidence also exists for sublclavian and femoral routes in this metanalysis. Thus the chances of pneumothorax will be greatly reduced. Pneumothorax is usually apparent immediately on Chest X rays and management may vary from simple observation to ICD placement with needle drainage needed for tension pneumothorax as emergency(11). Delayed pneumothorax is also known to occur with an incidence of 0.4%, more common with subclavian and with multiple attempts(12). Bedside ultrasonography allows diagnosis of pneumothorax to be made immediately with high sensitivity by clinician but is operator dependent(13). Misplacement of catheters occur commonly such as tip malposition or rarely such as within artery. It is common practice to assess tip position lying above carina for right sided catheters assuming pericardial reflection below carina and below carina for left sided catheters in view of acute angulation to superior venacava(14). Management varies depending on the complication such as repositioning of tip for tip malposition lying below carina or when lying with an artery, interventional radiologist or vascular surgeon opinion is sought and removed accordingly(15). Arterial injuries are more common with femoral and internal jugular rather than subclavian approach. A systematic review of complications of central venous catheters revealed significantly more arterial punctures (3.0% vs 0.5%) and less malpositions(5.3% vs 9.3%) with jugular access(16). It leads to hematoma in approximately 40% of patients. The best way to prevent arterial injury is by ultrasound assistance during cannulation(17). Other rarer complications are local hematomas,cerebrovascular accidents mostly seen with arterial injuries via internal jugular access, arrhythmias, perforation of the vein or right atrium, chylothorax, pseudo aneurysm, AV fistulas, cardiac tamponade, guidewire loss and catheter embolisation etc. have been reported. These complications largely depend on the site of insertion and on operator experience. Such complications can be prevented by ultrasound guidance and proper techniques. Infectious complications are most dreaded as it is associated with mortality rates upto 25% and in developing countries even up to 60% and prolong the duration of hospital stay and are largely preventable. Evidence based guidelines have been developed as the central venous catheter bundle which significantly decreases the incidence of infections as shown in below studies.CVC use in non ICU settings is associated with at least a 2 fold rise in infection rate than in ICU settings. However studies are very limited on the infection rates as well as on the preventive measures in non ICU settings. Thrombotic complications range from 1.2 to 3 % in subclavian veins to up to 8 to 34% in femoral cannulations. Merrer et al in a randomized control trial found significantly increased incidence of thrombotic complications(21.5% vs1.9%,p