central line audit cycle dr coralie carle b med sci bmbs frca, spr 4 anaesthesia & icm dr...
TRANSCRIPT
Central Line Audit Cycle
Dr Coralie Carle B Med Sci BMBS FRCA, SpR 4 Anaesthesia & ICM
Dr Ibrahim Ibrahim, MBChB ST 2 Anaesthesia
Dr Simon Mills, MBChB MRCP FRCA, Consultant Anaesthetist
Outline
trigger for audit
background
service evaluation
intervention
re-audit
future plans
Audit Trigger
Patient in PACU…
37 year old male
post-op exploration of bleeding pseudoaneurysm / ileofemoral bypass
PMH• IVDU• Hep C +ve• PE
(patient consent for presentation obtained)
…in extremis
acutely SOB in PACU
ABC approach with simultaneous consideration of diagnoses
• pneumothorax
• PE
• transfusion reaction
• air embolism
CVC inspection
3-way stopcock aligned so it was potentially open to the atmosphere
partially loose (cross threaded) red replacement cap
air aspirated from lumen < 1 ml
lumen flushed & cap tightened
Venous Air Embolism (VAE) Suspected
left lateral decubitus position
distal lumen of CVC aspirated• No further air withdrawn
AP mobile erect CXR taken to aid diagnosis
reduction in upper zone vascular markings
7mm x 19mm gas shadow region of the left main pulmonary artery
Supportive Management
sat up as most comfortable
100% oxygen
gradual improvement over 30 minutes
discharged at 90 minutes• oxygen
• level 2 care
follow up revealed no persistent problems
Venous Air Embolism
VAE development
open communication • between vein & atmosphere
pressure gradient enabling air entrainment• Vessel lumen : atmospheric pressure
volume and rate of air entrained• size of communication• pressure gradient
100mls can be fatal1
100mls: • 14G cannula• 1 second
• 5cm H20 pressure gradient2
90mls: • 8F PAC introducer needle• 1 second
• 5.4cm H20 pressure gradient3
§ Yeakel AE. Lethal air embolism from plastic blood-storage container. Journal of the American Medical Association 1968; 204: 267-9.
§ Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus – a lethal complication of subclavian venipuncture. New England Journal of Medicine 1969; 218(9): 488-9.
§ Conahan TJ. Air embolization during percutaneous Swan-Ganz catheter placement. Anesthesiology 1979; 50: 360-1.
Pressure gradient relative position of open communication
in relation to the RA• sitting position reduced CVP• resulted in the open communication of CVC
lying above RA
hydration status• Hypovolaemia decreases intravascular
pressure
mode of ventilation• Spontaneous inspiration decreases
intravascular pressure
CVP gasp reflex
Gasp reflex
VAE during spontaneous ventilation
10% obstruction to the pulmonary circulation can cause GASP REFLEX
reduces RA pressures and results in further air entrainment1
1. Palmon SC, Moore LE, Lundberg J, Toung T. Venous Air Embolism: A Review. Journal of Clinical Anesthesia 1997; 9: 251-7.
Central Line Service Evaluation
Outline R & D permission obtained
Phase 1• Assess current practice of CVC care in
relation to prevention of VAE in all locations throughout the hospital
• Presentation of results
Phase 2• Assess need for standard setting• Implement agreed standard
Phase 3• Audit at 1 & 6 months post intervention
Data collection proformaAudit ID number: Location: Bed number:
CVC
Site R L IntJug Subclavian Femoral
Lumens in total 1 2 3 4 5
Lumens in use 1 2 3 4 5
Reason for CVC
Speciality/Grade of Dr inserting line Insertion date
Sutures
Fixed connector sutured Y N
Adjustable connector present Y N & sutured Y N
Comments
Dressing
Covering insertion site Y N
Clean Y N
What position should the patient be in when removing the CVC?
(ask nurse looking after patient)
Bung Bionector Tap position Clip open Clip Closed X Leave blank if no clip
If single bionector attached to lumen then write BIONECTOR across diagram
Data collection
Wed 28th Oct 2009
all wards in hospital• ICU, HDU, CICU, CCU, medical & surgical
wards, PACUs.
all patients with CVC in situ included in the evaluation
data collection proforma completed for each CVC
Results: common errors
Patient
IVI
Patient
Patient
3 way Tap
CVC lumen
IVI
Patient
Intervention
Intervention
presentation locally• raised awareness
• ensure CVC chosen is appropriate
• use of three-way taps?
hospital standard set
re-education• Poster
CVC insertion site:
CVC sutured to the skin at all times
Insertion site covered by an occlusive dressing
Removal:
Follow trust guidelines but remember to:
Lie the patient head down
Apply a sterile occlusive dressing
Prevent air from entering CVC:
Prime all syringes & IV giving sets
Use needle-free access devices if possible
Ensure bungs are not cross-threaded
Ensure correct 3-way-tap alignment:
1. Service evaluation Oct 09:
✗ ✗ ✗
Prevention of Venous Air Embolism (VAE):Central Venous Catheter (CVC) Care
% of CVCs with errors potentially leading to VAE
2. Intervention: Points to remember
3. Re-audit planned summer 2010
64% of CVCs had an error
64% of CVCs at risk of VAE
✓✓
Re-audit
What next?
What next?
repeat education / updated posters
CVC insertion site:
CVC sutured to the skin at all times
Insertion site covered by an occlusive dressing
Removal:
Follow trust guidelines but remember to:
Lie the patient head down
Apply a sterile occlusive dressing
Prevent air from entering CVC:
Prime all syringes & IV giving sets
Use needle-free access devices if possible
Ensure bungs are not cross-threaded
Ensure correct 3-way-tap alignment:
1. Current practice:
✗ ✗ ✗
Prevention of Venous Air Embolism (VAE):Central Venous Catheter (CVC) Care
% of CVCs with errors potentially leading to VAE
2. Intervention: Points to remember
3. Re-audit planned Nov 2010
Oct 09: 64% of CVCs at risk of VAE
May 10: 35% of CVCs at risk of VAE
✓✓
What next?
repeat education / updated posters
needle-less valves?
re-audit 6 months
Summary
Summary
raised awareness relating to VAE
• prevention
• management
our hospital’s approach
consider…
• need for CVC?
• lumens required?
• needle-free valves?
ANY QUESTION
S?