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distal lumen of CVC aspirated• No further air withdrawn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 FemoralLumens in total 1 2 3 4 5Lumens in use 1 2 3 4 5Reason for CVCSpeciality/Grade of Dr inserting line Insertion date

SuturesFixed connector sutured Y NAdjustable connector present Y N & sutured Y NComments

DressingCovering insertion site Y NClean 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 clipIf 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 timesInsertion site covered by an occlusive dressing

Removal: Follow trust guidelines but remember to:Lie the patient head downApply a sterile occlusive dressing

Prevent air from entering CVC:Prime all syringes & IV giving setsUse needle-free access devices if possibleEnsure bungs are not cross-threadedEnsure 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 error64% 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 timesInsertion site covered by an occlusive dressing

Removal: Follow trust guidelines but remember to:Lie the patient head downApply a sterile occlusive dressing

Prevent air from entering CVC:Prime all syringes & IV giving setsUse needle-free access devices if possibleEnsure bungs are not cross-threadedEnsure 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 VAEMay 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?