Page 280 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

184 PART 2: General Management of the Patient

A central venous catheter in place for 3 days and at least one of the
following: suspected infection without another confirmed source,
signs of sepsis, sepsis, septic shock, or exit-site infection

Remove catheter No
Order two blood cultures Catheter needed?
Continue evaluation for infection

Yes

Order two blood cultures

Exit-Site Infection
Yes Remove catheter
Catheter site infected? Insert new catheter at new site
Start empirical antibiotics if sepsis
or septic shock is present
No

Yes
Sepsis or septic shock? Start empirical antibiotics

No No
Septic shock?

Change catheter over guide wire Yes
Culture catheter tip
Source of infection other
Yes than catheter probable?
No
Catheter Infection Unlikely No Remove catheter
Continue evaluation for other Tip culture positive? Culture catheter tip
sources of infection Insert new catheter at new site
Yes

Blood cultures positive?

No Yes

Catheter Colonization Catheter-Related Bloodstream Infection
Remove catheter and insert new catheter Remove catheter and insert new catheter
at new site (if not already done) at new site (if not already done)
Antibiotics are not indicated Antibiotics are indicated
Tailor antibiotics to the sensitivity
of organisms
Treat for 10-14 days

FIGURE 27-3. Management of suspected central venous catheter infection. (Reproduced with permission from McGee DC, Gould MK. Preventing complications of central venous catheter-
ization. N Engl J Med. March 20, 2003;348(12):1123-1133. Copyright © 2003 Massachusetts Medical Society. All rights reserved.)

blood vessel (eg, bright red color, pulsatile blood return) may be unreli- is connected to the needle while it is in the vessel, the tubing is elevated
able in hypotensive, hypoxemic patients frequently encountered in the and the movement of the column of saline is analyzed to reflect either a
ICU. Transduction of the pressure waveform with intravenous exten- venous or arterial waveform. Alternatively, the guide wire can be placed
sion tubing before dilation and placement of a large bore catheter may through the needle into the vessel using the modified Seldinger technique.
reduce the occurrence of this complication. The tubing with a three-way Subsequently, a small, short catheter (eg, 18- or 20-gauge 2-in intrave-
stopcock is filled with sterile saline. After a vessel is entered, this tubing nous catheter) can be placed over the wire into the vessel and the wire

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