Preventing Nosocomial Intravascular related Device Infection And Managing Complications of IV Therapy.

Nosocomial Infection in the Health Care Setting

Introduction Nosocomial infection comes from Greek words nosus meaning disease and komeion meaning to take care of. Traditionally referred as HOSPITAL - ACQUIRED INFECTION Also known as healthcare associated infection. Infections that develop during hospitalization.

A NOSOCOMIAL INFECTION is: One of the leading causes of death and increased morbidity for hospitalized patients. Of which are mostly caused by drug resistant strains of bacteria. Infections are considered nosocomial if they first appear 48hrs or more after hospital admission or within 30 days after discharge.

Rise in nosocomial infection as a result of four factor Crowded hospital conditions New microorganism Increasing number of people with compromised immune system Increasing Bacterial resistance

AGENTS OF NOSOCOMIAL INFECTIONS The diseases are usually caused by bacteria, virus, fungus and parasites and can be spread by human-to -human contact, human contact with an infected surface, airborne transmission through tiny droplets of infectious agents suspended in the air, and finally, by a common vehicle such as food and water.

COMMON SITES OF INFECTION 1. Urinary Tract 2. Respiratory Tract 3. Surgical wounds 4. Skin 5. Bacteria The four most common nosocomial infections of which comprise approximately 80% of all nosocomial infections: o o o o Urinary tract infection Surgical site infection Pneumonia Intravascular device-related bloodstream infection -- are related to invasive procedures or the use of invasive devices

PROBLEMS OF NOSOCOMIAL INFECTIONS Nosocomial infections will become more important as public health problems as it causes: Nosocomial suffering Prolonged hospital stay Increase the cost of care significantly

NOSOCOMIAL PNEUMONIA The most important are patients on ventilators in ICU. Recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum and recent onsite fever.

NOSOCOMIAL PNEUMONIA The most important are patients on ventilators in ICU. Recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum and recent onsite fever.

NOSOCOMIAL BACTERAEMIA The incidence is increasing particularly for certain organisms such as multi resistance coagulase negative staphylococcus and candida.

Infections may occur at the skin entry site of the IV device or in the sub cutaneous path of catheter.

URINARY TRACT INFECTIONS It is the most common cause of nosocomial infections 80% of the infections are associated with indwelling catheters.

CHAIN OF INFECTION CONTROL

There are six links in the chain of infection: 1st - The Infectious Agent -any disease-causing microorganism (pathogen). 2nd - The Reservoir Host - the organism in which the infectious microbes reside.

What are Carrier Hosts? Hosts that do not show any outward signs or symptoms of a disease but are still capable of transmitting the disease are known as carriers. 3rd - The Portal of Exit - route of escape of the pathogen from the reservoir. Examples: respiratory secretions, blood exposure, breaks in skin. 4th - The Route of Transmission - method by which the pathogen gets from the reservoir host. The primary routes of transmission for infections are through the air, blood (or body fluid), contact (direct or indirect), fecal oral route, food, animals, or insects. 5th - The Portal of Entry -route through which the pathogen enters its new host. The primary entry points for microorganisms are mucosal surfaces, such as respiratory, gastrointestinal, and genitourinary tract, breaks in protective skin barrier. 6th - The Susceptible Host -the organism that accepts the pathogen. The support of pathogen life & its reproduction depend on the degree of the hosts resistance. Organisms with weakened immune systems are more vulnerable to the support & reproduction of pathogens. Organisms with strong immune systems are better able to fend off pathogens. to the new

Breaking the Chain of Infection Levels of Aseptic Control

The essential part of patient care & self-protection.

How Health Care Workers Break the Chain of Infection. Link Infectious or Causative Agent Intervention Accurate and rapid identification of microorganisms Early recognition of sign and symptoms of infection Employee health examinations and screenings Environmental sanitations Disinfection / Sterilization of instruments Standard Precautions, Medical Asepsis, Proper Hygiene Clean gowns, linens, towels, Clean wound dressing Portal of Exit Handwashing, use of PPE, proper waste disposal, standard precautions Handwashing, Standard Precautions, Safe food handling, isolations, use of PPE, transmission based precautions Aseptic technique, medical or surgical asepsis, wound / catheter care, proper disposal, maintain skin integrity, standard precautions Treatment of Disease, Recognition of clients at risk, immunization, exercise, proper nutrition

Reservoirs

Method or Mode of Transmission Portal of Entry

Susceptible Host

COMPLICATIONS OF IV THERAPY: Local Complications, such as 1. Infiltration / Extravasation 2. Phlebitis 3. Thrombosis 4. Thrombophlebitis 5. Infection of venipuncture site 6. Hematoma

7. Venous spasm Systemic Complications, such as 1. Circulatory Overload 2. Air Embolism 3. Catheter Embolism 4. Speed shock 5. Septicemia 6. Allergic reaction 1. Infiltration / Extravasation The terms infiltration and extravasation are often used interchangeably. Infiltration is the inadvertent administration of a nonvesicant solution into surrounding tissue. Extravasation is the inadvertent administration of a vesicant solution into surrounding tissue. Examples include chemotherapy agents, certain electrolyte solutions (e.g. potassium and calcium), antibiotics (e.g. vancomycin), promethazine, diazepam, and phenytoin, and radiographic contrast media. Infiltration - leakage of fluid from a vein into surrounding tissue. Most common complication. First sign is complaints of tightness. Discomfort, swelling, and cool to touch. Chemo will cause tissue to slough off if infiltrated. Treatment: > Discontinue and relocate. > Elevate extremity and fluid should absorb in 2 or 3 days.

Prevention: > Monitor IV closely, use appropriate size catheter, dont start at joint flexions, securing well with tape, relocate according to policy, if in doubt, relocate.

2. Phlebitis This is an inflammation of a vein due to bacterial, chemical or mechanical irritation. Symptoms: 1. Pain. 2. Redness. 3. Warmth along the area. 4. Vein feels hard or cordlike. Prevention: Rotate infusion according to local policy. Meticulous asepsis. Treatment: Discontinue IV infusion. Warm compress to the area. Antibiotics as ordered. 3. THROMBOSIS Is the formation or presence of a blood clot in the vein. The thrombosis usually occludes the vein. Causes: 1. Poor venipuncture technique, 2. Blood backing up in the system of a hypertensive patient 3. Low flow rate, which limits fluid movement to maintain patency 4. Flow rate obstruction due to compressing the site 5. I.V line remains dry (no fluids ) for an extended time. Signs and Symptoms: The drip rate slows, or the line does not flush easily, and resistance is felt. Prevention:

a. Use I.V infusion pump to control the rate. b. Avoid flexion areas for placement if I.V cannula. Intervention and treatment modalities: a. Discontinue the I.V and restart the cannula in a new vein. b. Do not irrigate. * Irrigation of an occluded line with saline can push the clot into the circulatory system and cause an embolism. 4. THROMBOPHLEBITIS Thrombophlebitis denotes twofold injury, thrombosis and inflammation. Signs and symptoms of thrombophlebitis: a. Sluggish flow rate b. Edema of the limb c. Vein tender, hard and cord like d. Site warm to touch e. Red line visible above venipuncture site Intervention and treatment modalities: > Remove the entire I.V line and restart with a fresh one. > Notify Physician Prevention: 1. Use veins in forearm and avoid hands when infusing any medication. 2. Do not use veins in joint flexion. 3. Anchor the cannula securely to prevent its manipulation. 4. Infuse solutions at prescribed rate. 5. Use the smallest size cannula that meets patients needs. 5. LOCAL INFECTION Local infections are one of the most frequent complications of I.V. Therapy. It consists of those related to microbacterial contamination of the cannula or infusate.

Causes of local infection: Cannulae contamination is the most common source of local infections. Ways in which cannulae tip may acquire bacteria are: a. During introduction or venipuncture. b. During removal of the inner needle. c. Contamination of I.V fluids. d. The practice of manipulating the I.V system for the administration of medication, tubing changes, dressing changes etc. e. Ineffective hand washing technique can result in cross contamination. Signs and symptoms Local Infection: 1. Redness at the site 2. Pain and Swelling at the site. 3. Elevated temp. 4. Possible exudates of purulent material. 5. Increased White Blood Cells count. (WBCs) Treatment: 1. Stop the infusion. 2. Remove the cannula and initiate the I.V therapy in a new site. 3. Send the tip of the cannula to lab for culture and sensitivity. 4. Send sample of drainage if any to the lab for culture and sensitivity. 5. Clean the infected site with disinfectant, apply antibiotic ointment if prescribed. 6. Monitor patients temperature if pyrexial.

Prevention of Local Infection: 1. Practice rigid aseptic technique when inserting a cannula. Consider the procedure a minor operation.

2. Thoroughly cleanse the infusion site, and follow this with iodine - base antiseptic. 3. Avoid the use of aqueous benzalkonium chlorides, as they ineffective against some gram-negative organisms, especially pseudomonas. 4. Anchor the cannulae firmly to prevent excessive movement that might traumatize the vein. 5. Maintain hand washing technique. 6. ECCHYMOSIS AND HAEMATOMA -Is the localized mass of blood outside the blood vessel, usually found in a partially clotted state. Causes of Hematoma: 1. Poor venipuncture technique. 2. Discontinuation of I.V Cannula or needle without pressure held over the site after removal of the needle. 3. Applying a tourniquet too tightly above a previously attempted, venipuncture site, or left too long on the patient extremity. 4. Susceptible patients with bleeding disorders or prone to easy bruising. Signs and symptoms of hematoma: > Discoloration of the skin surrounding the venipuncture (ecchymosis). > Site swelling and discomfort. Prevention: 1. Use an indirect method for starting an I.V until technique is perfect for direct insertion of cannula. 2. Apply the tourniquet just before performing venipuncture. 3. For elderly patients; use small gauge cannula, and BP cuff instead tourniquet to fill the vein. 4. Be very gentle in venipuncture technique. Treatment: 1. Apply direct pressure with sterile gauze over the site, after cannula is removed.

2. Instruct the patient to elevate arm over head or pillow to maximize venous return. 3. Place ice compression the area of hematoma. 7, VENOUS SPASM Venous spasm can occur suddenly and for a variety of reasons. Causes of Venous Spasm: 1. Administration of a cold infusate, irritating solutions, or viscous solutions such as blood products. 2. Too rapid administration of I.V solutions. Signs and symptoms: 1. Sharp pain at IV site traveling up the arm. 2. Slowing of the infusion. Treatment venous spasm: 1. Apply warm compresses to warm the extremity and decrease flow rate until spasm subsides. 2. Restart the I.V infusion if venous spasm continues. Prevention: 1. Dilute medication additive as per manufactures instructions. 2. Keep I.V solution at room temperature. 3. Warm extremity with warm compresses during infusion.

SYSTEMIC COMPLICATIONS
1. CIRCULATORY OVERLOAD The patient receives an excessive amount of solution (usually occurs in the elderly or in infants, or patients with impaired renal function or cardiopulmonary function. Causes of Circulatory Overload: 1. Too rapid I.V rate, either as ordered or because of an incorrect setting. 2. Positional I.Vs that markedly increase the infusion rate when the patient moves the extremity.

Signs and symptoms: 1. Headaches, flushed skin, rapid pulse. 2. Venous distention (engorged neck veins). 3. Raise in blood pressure. 4. Coughing, shortness of breath, increased RR. 5. Syncope, shock 6. Pul. edema leading to dyspnea and cyanosis. Intervention and treatment modalities: 1. Notify the physician. 2. Slow infusion to a "keep-open" rate. 3. Raise the head of the bed. 4. Keep the patient warm to promote peripheral circulation. 5. Monitor vital signs and urine output carefully. 6. Administer Oxygen if necessary. Prevention: > Know whether patients has existing heart condition. > Monitor solution flow, especially NaCl, and maintain flow. > Place patient in semi-sitting position during infusion. > Be especially attentive to the elderly and the infant, > Use the proper tubing.

Never use macro-drip tubing with elderly or paediatrics patients, whose

circulatory systems may be particularly prone to overload.

2. AIR EMBOLISM Air embolism is a rare but lethal complications, especially involving subclavian central lines. This problem is treatable with prompt recognition, but

prevention is the key. This occurs when air manages to get into the circulatory system. Causes: 1. Air in tubing (such as improper priming at onset of infusion). 2. Empty solution container. 3. Loose connections, allowing air to enter tubing. 4. Administration of blood products under pressure. 5. Poor technique in dressing and tubing changes for central lines Signs and symptomsof Air Embolism * Hypotension, Hypoxia, * Respiratory distress, * Increase venous pressure, * Unconsciousness Prevention of Air Embolism Change the solution container before it empties. Clear the tubing of air prior to starting the infusion. Keep the insertion site below the heart level. Secure all connections. Intervention: Unless prompt action is taken, the patient may die within minutes Immediately turn the patient to the left side, in trendelenberg position. Administer oxygen, if ordered by physician. Notify physician immediately. Check the system for leaks. Monitor vital signs 3. CATHETER EMBOLISM Catheter embolism is an infrequent systemic complication of plastic catheters. This could cause pulmonary embolism, cardiac dysrhythmia, sepsis, endocarditis, thrombosis, and death (yikes!). Causes of Catheter Embolism: a. Attempting to rethread the catheter with a needle b. Unsecured catheter Signs and symptoms:

 Sharp sudden pain at the I.V site Minimal blood return Short, rough, and uneven catheter noted on removal. Cyanosis and Chest Pain. Decreased blood pressure. Weak, rapid pulse. Loss of consciousness Treatment for Cath. Embloism: 1. Apply tourniquet above elbow. 2. Contact physician. 3. Start a new I.V infusion 4. Prepare patient for X-Ray examination. 5. Measure the remainder of the catheter tip to know the length of migrated piece of catheter. Prevention: 1. Never reinsert a needle in an over needle catheter after removal. 2. Avoid inserting the catheter over joint flexion where movement causes catheter to bend back and forth. 3. Splint arm when patient is restless. 4. SPEED SHOCK Speed shock occurs when a foreign substance, usually a medication, is rapidly introduced into the circulation. Causes; Rapid injection of medication, permits the concentration of the medication in the plasma to reach toxic proportions, flooding the organs rich in blood (the heart and the brain). S/S of Speed Shock: > Tachycardia, dizziness, > decreased blood pressure, > progressive syncope, > cardiovascular collapse, > cardiac arrest. Treatment: 1. Stop the infusion immediately 2. Notify the doctor.

3. Give antidote or resuscitation medication as needed Prevention of Speed Shock : 1. Reduce the size of drops; use microdrip sets for medication delivery. 2. Use and electronic flow control for high- risk drugs. 3. Monitor the infusion rate for accuracy. 4. Be careful not to manipulate the catheter, as cannula movements could speed up flow rate. 5. SEPTICEMIA Unlike phlebitis and thrombophlebitis, an I.V. related infection can develop without causing any overt problems at the venipuncture site.

Cause of Septicemia Pathogens entering the blood stream through the I.V. line due to poor aseptic technique. Use of contaminated equipment during the manufacturing and storage or use. Irrigation of a clogged I.V catheters can propel a clot, which is a significant source of bacterial contamination. Signs and symptoms: 1. Abrupt temperature elevation, chills 2. Face flushing, sudden pulse rate change. 3. Complaints of backache, headache 4. Nausea and vomiting 5. Diarrhea, sudden explosive 6. Hypotension - vascular collapse 7. Cyanosis - vascular collapse

Intervention and treatment: Notify the physician immediately. Restart new I.V systems in opposite extremity. Obtain cultures from: Administration set, Container, Catheter tip, Site, Blood. Initiate antimicrobial therapy as ordered

Monitor patient condition closely.

How does catheter-related infection occur?

Infection of short-term catheters is frequently been due to microbes from the skin moving along the catheter surface where the catheter enters the skin.

Risk Factors Type of catheter used Total parenteral nutrition Duration of catheterization

Catheter site insertion Expertise of the person inserting Management of catheter after insertion Guidewire exchange Use of dressing Use of triple antibiotic ointment

PRINCIPLES OF PREVENTION OF INFECTION Consider every person (patient of staff) infectious. Wash hands the most practical procedure for preventing cross contamination (person to person). Wear gloves before touching anything wet broken skin, mucous membranes, blood or other body fluids (secretions or excretions) or soiled instruments and other items. Use physical barriers (protective goggles, face masks and aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated. Use safe work practices, such as not recapping or bending needles, safely passing sharp instruments and properly disposing of medical waste. Isolate patients only if secretions (airborne) or excretions (urine and feces) cannot be contained. Decontaminate process instruments and other items (decontaminate, clean, high level disinfect or sterilize using Infection Prevention Practices.

REVIEW INFECTION RISK FACTORS AND PRACTICES Infection is the presence and growth of microorganisms that produces tissue death. Wash your hands Routinely clean and disinfect surfaces

Handle and prepare food safely Get immunized Use antibiotics appropriately Keep pets healthy Avoid contact with wild animals

PRINCIPLES OF SAFE IV CARE / PRACTICES Use aseptic technique to avoid contamination of sterile injection equipment. Do not administer medications from a syringe to multiple patients, even if the needle of cannula on the syringe is changed. Use fluid infusion and administration sets for one patient only and dispose after use. Use single dose vials for parenteral medications whenever possible. Use proper personal protective equipment (PPE). Adhere to safety waste protocol according to institutions policy.

Venipuncture Techniques The use of needleless system Proper use of sharp containers Monitoring and Assessment The use of appropriate dressing

General Recommendations for Intravascular Device Use Health Care Worker Education and Training Surveillance for Catheter Related Infection Handwashing Barriers Precautions During Catheter Insertion and Care

Catheter Insertion Catheter Site Care Selection and Replacement of Intravascular Devices Replacement of Administration Sets and Intravenous Fluids Intravenous Injection Ports Preparation and Quality Control of Intravenous Admixtures In line Filters Intravenous Therapy Personnel Needleless Intravascular Devices

References: NOSOCOMIAL INFECTION IN THE HEALTH SETTING Centers for Disease Control and Prevention (CDC), USA Healthcare Infection Control Practices Advisory Committee (HICPAC), USA Hospital Epidemiology and Infection Control, Mayhall 3rd ed. Weinstein, S. Plumers Principles and Practices of IV Therapy, 7th Ed. Ch. 17. Philadelphia: Lippincott, Williams & Wilkins, 2005. Intravenous Nurses Society: "Infusion Nursing Standards of Practice," Journal of Intravenous Nursing. 23(6S), S70-71. 2005. I.V. Therapy. Just the Facts, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2005

References: MANAGING COMPLICATIONS OF BASIC IV THERAPY 1. Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP). 2000. Nursing Standards on Intravenous Practice 7th EDITION. 2. Cahil, Matthew. I.V. Therapy made Incredibly Easy. Springhouse Corporation, Pennsylvania. 3. Dionne, Lynn. Manual of I.V. Therapeutics. Philips, F.A., Davis Co. Philadelphia.

4. Intravenous Nursing Society, Supplement to Journal of Intravenous Nursing, Jan./February 1998 vol.21, Fresh Pond Square, 10 Faucett street, Cambridge, MAO 218. 5. Lippincott Williams and Wilkins. 2005. JUST THE FACTS I.V. Therapy. 6. Nursing Journal May and July 2000.
germancalderon2003@yahoo.com

******************************************************************************* ************