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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.
b.
c.
d.
to flush the lumen prophylactically.
to prophylactically sterilize the lumen for a period of time.
to flush the lumen if a patient has a bloodstream infection.
between uses.
2. It is recommended that peripherally inserted central venous
catheters (PICC) and central venous catheters (CVC) should
a.
b.
c.
d.
not be removed on the basis of fever alone.
be removed on the basis of fever alone.
be routinely replaced to prevent catheter-related infections.
be removed based clinical judgment.
3. To prophylactically sterilize the lumen of the catheter, a
commonly used antiseptic is
a.
b.
c.
d.
cefazolin.
ancomycin.
alcohol.
amikacin.
4. In peripheral catheters in children, the recommendation on
replacing peripheral catheters in children is:
a.
b.
c.
d.
every 72–96 hours.
before 72 hours.
only when clinically indicated.
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
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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.
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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
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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
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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 nontunneled 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
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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
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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)
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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 12mL 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, post15
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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, nontunneled 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 catheterrelated 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.
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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
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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
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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 intraarterial 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 first22
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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
venous
catheters
Usually inserted in veins of
forearm or hand
<3 inches
Phlebitis with prolonged
use; rarely associated with
bloodstream infection.
Peripheral
arterial
catheters
Usually inserted in radial
artery; can be placed in
femoral, axillary, brachial,
posterior tibial arteries
<3 inches
Low infection risk; rarely
associated with
bloodstream infection.
Midline
catheters
Inserted via the
antecubital fossa into the
proximal basilic or cephalic
veins; does not enter
central veins, peripheral
catheters
3 to 8 inches
Anaphylactoid reactions
have been reported with
catheters made of
elastomeric hydrogel; lower
rates of phlebitis than short
peripheral catheters.
Nontunneled
central
venous
catheters
Percutaneously inserted
into central veins
(subclavian, internal
jugular, or femoral)
≥8 cm
depending
on patient
size
Account for the majority of
CRBSI.
Pulmonary
artery
catheters
Inserted through a Teflon
introducer in a central vein
(subclavian, internal
jugular, or femoral)
≥30 cm
depending
on patient
size
Usually heparin bonded;
similar rates of bloodstream
infection as CVCs;
subclavian site preferred to
reduce infection risk.
Peripherally
inserted
central
venous
catheters
Inserted into basilic,
cephalic, or brachial veins
and enter the superior
vena cava
≥20 cm
depending
on patient
size
Lower rate of infection than
nontunneled CVCs.
Tunneled
central
venous
catheters
Implanted into subclavian,
internal jugular, or femoral
veins
≥8 cm
depending
on patient
size
Cuff inhibits migration of
organisms into catheter
tract; lower rate of infection
than non-tunneled CVC.
Totally
implantable
Tunneled beneath skin and
have subcutaneous port
accessed with a needle;
implanted in subclavian or
internal jugular vein
≥8 cm
depending
on patient
size
Lowest risk for CRBSI;
improved patient selfimage; no local cathetersite care; surgery required
for catheter removal.
Umbilical
catheters
Inserted into either
umbilical vein or umbilical
artery
≥6 cm
depending
on patient
size
Risk for CRBSI similar with
catheters placed in
umbilical vein versus
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
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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
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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
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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 verylow-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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fluid challenge or blood lactate concentration ≥ 4 mmol/L) during the
first 6 hours of resuscitation include:
•
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 betalactam 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
be used (i.e., percutaneous
rather than surgical drainage
of an abscess).
 If intravascular access devices
are a possible source of severe
sepsis or septic shock, they
should be removed promptly
after other vascular access
has been established.

Infection Prevention
 Selective oral decontamination and
selective digestive
decontamination should be
introduced and investigated as a
method to reduce the incidence of
ventilator-associated pneumonia;
this infection control measure can
then be instituted in health care
settings and regions where this
methodology is found to be
effective.
 Oral chlorhexidine gluconate can
be used as a form of
oropharyngeal decontamination to
reduce the risk of ventilatorassociated pneumonia in ICU
SURVIVING SEPSIS
CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN
3 HOURS:
1) Measure lactate level
2) Obtain blood cultures
prior to administration of
antibiotics
3) Administer broad
spectrum antibiotics
4) Administer 30 mL/kg
crystalloid for
hypotension or lactate
4mmol/L
TO BE COMPLETED WITHIN
6 HOURS:
1) Apply vasopressors (for
hypotension that does
not respond to initial
fluid resuscitation) to
maintain a mean arterial
pressure (MAP) ≥ 65 mm
Hg
2) In the event of persistent
arterial hypotension
despite volume
resuscitation (septic
shock) or initial lactate 4
mmol/L (36 mg/dL):
a. Measure central
venous pressure
(CVP)
b. Measure central
venous oxygen
saturation (ScvO2)
3) Remeasure lactate if
initial lactate was
elevated
Targets for quantitative
resuscitation included in the
guidelines are CVP of≥8 mm
Hg, ScvO2 of 70%, and
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, postsurgically 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 sepsisinduced 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
requirements. Low Fio2 requirements, which can be met
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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 lowmolecular 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.
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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.
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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.
b.
c.
d.
to flush the lumen prophylactically.
to prophylactically sterilize the lumen for a period of time.
to flush the lumen if a patient has a bloodstream infection.
between uses.
2. It is recommended that peripherally inserted central venous
catheters (PICC) and central venous catheters (CVC) should
a.
b.
c.
d.
not be removed on the basis of fever alone.
be removed on the basis of fever alone.
be routinely replaced to prevent catheter-related infections.
be removed based clinical judgment.
3. To prophylactically sterilize the lumen of the catheter, a
commonly used antiseptic is
a.
b.
c.
d.
cefazolin.
ancomycin.
alcohol.
amikacin.
4. In peripheral catheters in children, the recommendation on
replacing peripheral catheters in children is:
a.
b.
c.
d.
every 72–96 hours.
before 72 hours.
only when clinically indicated.
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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6. ______________________ are the preferred approach for
dialysis patients in chronic renal failure.
a.
b.
c.
d.
AV fistulas or grafts
Tunneled cuffed catheter
Hemodialysis catheters
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.
b.
c.
d.
lower regardless of position of catheterization.
lower if catheterization is placed above the aortic bifurcation.
lower if catheterization is placed below the diaphragm.
similar regardless of position of catheterization.
9. Umbilical catheters placed higher in the patient
a.
b.
c.
d.
have
have
have
have
lower rates of vascular complications.
lower CBRSI rates.
higher rates of infection.
higher rates of vascular complications.
10. The preferred site for catheter insertion in children include
a.
b.
c.
d.
the
the
the
the
brachial artery.
femoral artery.
posterior tibial.
axillary artery.
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11. Which of the following is NOT one of the preferred sites for
catheter insertion in adults?
a.
b.
c.
d.
Brachial artery
The dorsalis pedis
The posterior tibial
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.
b.
c.
d.
only when there is a clinical indication.
as soon as it is no longer needed.
at 96-hour intervals.
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.
b.
c.
d.
or above the diaphragm
the aortic bifurcation
a posterior tibial site
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.
b.
c.
d.
parenteral nutrition fluids
blood
fat emulsions
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.
b.
c.
d.
administration sets used continuously
intermittently used administration sets
needles to access implantable port
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.
b.
c.
d.
if there is a clinical indication
every 24 hours
at 96-hour intervals
every 6 or 12 hours
19. Which of the following is correct regarding the use of
stopcocks in administration?
a.
b.
c.
d.
Stopcocks are a significant entry point for microbes
Stopcocks should be capped when not in use
Stopcocks are only used in needleless systems
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.
b.
c.
d.
minute-to-minute monitoring.
parenteral nutrition fluids.
concomitant monitoring.
All of the above
21. The most common sites for a venous cutdown procedure
are at the
a.
b.
c.
d.
femoral artery.
femoral artery or cephalic.
cephalic or saphenous veins.
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.
b.
c.
d.
lower.
the same.
undetermined.
higher.
23. True or False: When replacing administration sets and addon 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.
b.
c.
d.
Apache II test
Allen test
SAPS test
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.
b.
c.
d.
Intraosseous (IO) access
Seldinger (wire) technique
The cutdown approach
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.
b.
c.
d.
papaverine (30mg/250mL)
propofol (2%)
fat emulsions
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.
b.
c.
d.
1 cm below retinaculum flexorum
2.5 cm below retinaculum flexorum
2 cm below the tibial tuberosity
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.
b.
c.
d.
A heparin infusion
Propofol (1%)
Oral chlorhexidine gluconate
Lidocaine (1%)
30. Septic patients who have a contraindication for heparin use
should not receive ___________________, but should
receive appropriate, mechanical prophylactic treatment.
a.
b.
c.
d.
warfarin sodium
pharmacoprophylaxis
lepirudin
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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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?
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.”
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.
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 addon 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.”
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.
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 ventilatorassociated 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.
2.
3.
4.
5.
6.
7.
8.
9.
Band, Jeffrey (2016). Treatment of intravascular catheter-related
infection. Up To Date. Retrieved online at
https://www.uptodate.com/contents/treatment-of-intravascularcatheter-relatedinfections?source=search_result&search=sepsis%20and%20cathe
ter%20related%20infection&selectedTitle=1~150.
Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU
is there a reason? Chest. 1995; 108:767–71.
Dolman, HS., et al, Impact of minimizing diagnostic blood loss in
the critically ill., Surgery, 158(4), 1083-1088, 2015.
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.
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-adultsepidemiology-definitions-clinical-presentation-diagnosis-andprognosis?source=search_result&search=sepsis%20and%20cathe
ter%20related%20infection&selectedTitle=7~150.
Baird, G., The laboratory test utilization management toolbox.
Biochemia Medica 2014;24(2):223-34.
Flegel, WA., Natanson, C., Klein, HG. Does prolonged storage of
red blood cells cause harm? Accessed at http://rdcr.org/wpcontent/uploads/2012/08/BJH-2014.pdf (9/2016)
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)
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/ajrccm57
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
10.
11.
12.
13.
14.
15.
16.
17.
18.
conference.2013.187.1_MeetingAbstracts.A5322 (Accessed
10/2016)
American Association of Critical Care Nurses (2016). Choosing
Wisely. Retrieved online at
http://www.choosingwisely.org/societies/critical-care-societiescollaborative-critical-care/.
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-locktherapy-for-treatment-of-catheter-related-bloodstreaminfections?source=search_result&search=sepsis%20and%20cathe
ter%20related%20infection&selectedTitle=5~150.
Centers for Disease Control and Prevention (2016). Assessment
Control Assessment Tools. Health-associated infections. Retrieved
online at https://www.cdc.gov/hai/prevent/infection-controlassessment-tools.html.
Merck Manual (2016). Retrieved online at
https://www.merckmanuals.com/professional/nutritionaldisorders/nutritional-support/total-parenteral-nutrition-tpn.
Lew, CC., et al, Association Between Malnutrition and Clinical
Outcomes in the Intensive Care Unit: A Systematic Review. J
Parenteral Nutrition, Feb, 2016.
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.
Band, J. and Gaynes, R. (2016). Prevention of intravascular
catheter related infection. Retrieved online at
https://www.uptodate.com/contents/treatment-of-intravascularcatheter-relatedinfections?source=search_result&search=sepsis%20and%20cathe
ter%20related%20infection&selectedTitle=1~150.
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.
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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