INFECTION CONTROL & DISEASES DISORDER

INFECTION CONTROL

Nosocomial infection is a major problem in the ICU leading to prolonged stay, increasing morbidity and mortality, and increased coasts.

The following guidelines aim to reduce the transmission of infection:
• Everyone who comes into contact with the patient MUST WASH his or her hands before and after handing the patient. The ICU nurses have given the authority to ensure this practice is carried out.
• All staff should be appropriately gowned, gloved and masked when carrying out invasive procedures.
• To reduce the traffic flow in ICU, the ICU round by doctors of other units should be limited to 4 persons.

NOSOCOMIAL INFECTION CONTROL
GENERAL MEASURES

1. PROPER HAND WASHING before and after each patient contact.
2. Practice aseptic technique for all invasive procedures.
3. Take standard precautions when handling all body secretions.
4. Isolate all infectious patient.

SPECIFIC MEASURES

Venous Lines

1. Insertion under aseptic technique.
2. Apply sterile transparent dressings at insertion sites.
3. Use minimum number of three-way-taps and stop-cocks.
4. Use triple lumen for multiple drug infusion.
5. Inspect the catheter site daily. Avoid blood residue to stagnate in the lines or three-way-tap.
6. Replace lines
• After 5 to 7 days routinely
• Any signs of inflammation at sites
• Any unexplained fever, increased TWDC or sepsis
• If staphylococci is isolated in the blood
7. TPN line must be dedicated line.


Arterial line

1. To be done under aseptic technique.
2. Do not push blood back into the line.
3. Do not allow blood residue to stagnate in line or 3 way tap.
4. Replace line after 5 to 7 days or at any time of signs of inflammation at puncture site.

Urethral Catheterisation

1. To be done under aseptic technique.
2. To use a closed drainage system to collect urine.
3. To remove as soon as possible/weekly change of catheter.

Equipment

1. Ventilator
• Change of ventilator tubings/ humidifier/ resuscitation bag/oxygen apparatus every 48-72 hours.
2. Suction catheters to be used once only.
Suction tubings
• Tip must be covered when not in use.
• To be discarded daily and every new admissions.

3. Suction liner to be discarded when full/every admissions.
4. Wipe surroundings daily and on discharge
• Bed/ mattress / cables/ stethoscope/ monitors / perfusors / drip stand/etc.

Staffing
1. minimize number of visiting doctors/nurses in ICU to 4 doctors per discipline.
2. all ICU staffs to be well-versed with nosocomial infection control protocol.

Visitors
1. Discourage casual visitors
2. Educate close relatives to wash hands before and after touching the patients.


BARRIER NURSING

To be carried out for patients who present a risk to others or vice versa.

1. Nursing patient in isolated area.
• To wear gown and gloves when attending to patient.
• To remove gown and gloves and wash hands before leaving the room.
• The staff in-charge to remain in the isolated room.

2. Minimize visitors.
3. Do not overstock equipment.
• Necessary equipments only to be kept in the room.
4. Linen to be sent separately to laundry unit. Dressings and waste to be disposed according to protocol e.g. to pour hydrogen peroxide before disposal of gas gangrene dressings.
5. Once the room is vacated
• Disinfect and clean the equipments in the room thoroughly.
• To clean and disinfect the room.
• Linen used to pack and label separately before sending to laundry unit.



PROTECTION YOURSELF AND OTHERS

HEALTH HAZARDS ON THE JOB

Tuberculosis , Hepatitis. AIDS. As a healthcare worker in today’s world, it may seem that all you hear about are communicable diseases and the increasing risks they pose to your health.
Although you shouldn’t be overly alarmed, you need to be aware of the risks and the simple ways in which you can avoid them-----to protect yourself as well as your coworkers and patients.

Hidden Dangers

Some health risks in your workplace are obvious. Others are not. Infectious organisms may be anywhere around you. From needle sticks to coughing patients, a variety of accidents and situations can expose you to infection----and lead to life-threatening consequences. How should you deal with these possible dangers? Start by understanding which infectious diseases can be spread in your workplace.

The Risk of Infection
Healthcare workers are at risk of exposure to infectious diseases such as:
 Tuberculosis ( TB ), a bacterial infection that effects the lungs, but can also be present in other parts of the body;
 Hepatitis B virus ( HBV ), a virus that can cause severe liver damage and even death; and
 Human immunodeficiency virus ( HIV ), a virus that causes acquired immunodeficiency syndrome ( AIDS )

Other common health risks in your workplace include hepatitis C, malaria, syphilis, lice, scabies, measles, cytomegalovirus, chickenpox, herpes, ‘staph’ infections, colds, ‘ flu and diarrheal infections. If you suspect that you or a patient has been infected, be sure to report it according to your employer’s policies.

Simple Steps to Protection

Once you are aware of the risks around you, you need to know the steps for preventing exposure to those risks. This booklet will show you how to protect yourself and others against several specific infections by using precautions.
No matter what you come into contact with, two of your best defenses are handwashing and the use of personal protective equipment ( PPE )-----specialized clothing or equipment worn for protection against hazards.

Wash Your Hands Often

Removing germs by handwashing provides vital protection against many types of infection. Always wash your hands before and after you have contact with a patient or anything a patient has touched.
Remember the following:
 Wash your hands immediately after removing gloves---and before eating, drinking , smoking, applying makeup or handling contact lenses.
 Work up a good lather with nonabrasive soap and running water. Clean between your fingers and around your nails. Then rimes well.
 If your hands or any other part of your body fluids, immediately wash exposed skin thoroughly.


Use PPE ( Personal protective equipment )
Designed to protect you from a variety of hazards, PPE helps guard your skin, eyes, mouth and personal clothing from exposure to infectious germs. Your employer will provide the type of PPE that is most effective for your particular job. Never wear PPE that’s damaged or soiled. After use, remove PPE and palace it in the proper container for cleaning, decontamination or disposal.

TUBERCULOSIS

An infectious disease that usually begins in the lungs, TB may spread to the brain, kidney or spine. Most people who are infected with TB will never develop the active disease, but the disease can develop at any time if it is not treated with medication.

How TB Infection Occurs

TB can be spread when a person with active TB disease coughs, shouts, or laughs, spraying bacteria-contaminated droplets into the air. The infection is most likely to be spread in small, poorly ventilated rooms, and usually results from prolonged exposure.
Inactive TB

In most people, infectious TB bacteria remain inactive for a lifetime---their immune systems prevent the infection from progressing. A person who is infected with inactive TB isn’t sick, doesn’t have symptoms, and can’t infect others. In fact, the only way to know if you’ve been infected is to get tested. That’s why it’s vital for healthcare workers to have a TB skin test once or twice a year. If you are infected, medication can help ensure that you will not develop active disease.

Active TB

Inactive infection becomes active disease if the TB bacteria grow and begin to attack a body organ, often the lungs. Symptoms may include persistent coughing, fatigue, weight loss, fever, loss of appetite and night sweats. If left untreated, TB can be fatal. Fortunately, when taken properly, medication can completely cure the disease. People who stop their medications or who take them irregularly may develop drug-resistant TB, which is sometimes impossible to cure.

Using the Right PPE

When working in or visiting areas with suspected or confirmed cases of TB, use appropriate masks, such as HEPA ( high-efficiency particulate air ) filter respiratory masks or dust-fume-mist masks. Your employer’s respiratory protection policy may recommend other types of PPE, as well.

Controlling TB
You and your facility can use a variety of methods to limit the spread of TB:

• Place TB patients in negative-pressure isolation rooms with a minimum of six air changes per hour ( preferably 10 – 12 air changes per hour ).
• Ask TB patients to cover their noses and mouths with tissue when they cough or sneeze. When transporting TB patients outside of their rooms, be sure they wear surgical masks.
• Use a HEPA filter hood to prevent the spread of TB germs when inducing and collecting sputum.


BLOODBORNE PATHOGENS

Whether or not you work directly with patients, you need to protect yourself from expose to bloodborne pathogens ie, disease-causing germs carried by blood or certain body fluids. Knowing how these infections are spread will help you prevent them.

How Bloodborne Diseases Are Spread

Many infectious germs are carried in blood and in other body fluids in which blood may be present such as saliva, semen, fecal matter, and amniotic fluid. If infected blood comes into contact with any opening or break in your skin, you may be exposed to disease. Two of the most common and dangerous types of bloodborne disease that may infect healthcare workers are caused by the hepatitis B virus ( HBV ) and the human immunodeficiency virus ( HIV ).

HBV

HBV infection can lead to liver damage, cancer ,and even death. Symptoms may be mild and flulike. Some people have no symptoms are all.
A vaccination series is available to prevent hepatitis B infection. Your employer provides the hepatitis B vaccination free of charge to employees who are at risk for bloodborne exposure. HIV
Although HIV is much less likely than hepatitis B to be spread in the workplace, it could potentially be spread anywhere that blood is present. HIV weakens the body’s immune system and causes AIDS. Symptoms may include weight loss, night sweats, fever, fatigue, gland pain and swelling, and muscle or joint pain. There is currently no vaccine for HIV and no cure for AIDS. Other Bloodborne Diseases
Blood may carry other serious infections, such as hepatitis C, malaria , and syphilis. If discovered early enough, these conditions can usually be treated with medication.


Exposure Control Plan

Your employer’s exposure control plan is a document that describes when or where an exposure could occur, standard precautions, exposure reporting procedures, and training requirements. You have the right to see that plan at any time. Ask your supervisor for more information.

Standard Precautions

The idea behind standard precautions is simple but effective: Since you don’t always know whose blood is carrying infectious germs, treat all blood and certain body fluids as potentially infectious. Protective controls to help you avoid bloodborne hazards include the following:

Engineering controls, such as safely mounted sharps containers, are your company’s technological means of isolating or removing hazards from the workplace to reduce your exposure to blood.
Work practice controls, such as avoiding contact with blood, are ways that you can perform your job more safely to prevent exposure to bloodborne pathogens

Engineering Controls

By making the work environment safer, your employer can greatly reduce your risk of exposure to bloodborne infections. Sharps containers and medical safety devices are examples of protective engineering controls.

Sharps Containers

Immediately after using sharps, dispose of them in containers are:
• Puncture-resistant
• Leak proof on sides and bottom
• Labeled or color-coded as biohazardous
• Closable
• Located in areas that can be safely and conveniently reached

Safer Medical Devices

Many needles and other medical instruments now have safety features to help prevent accidents and exposure to disease. These devices include:
• Self – sheathing needles
• Needless IV connectors or connectors with recessed needles
• Phlebotomy devices and lancets with safety features such as retractable blades
• Face masks used for mouth – to – mouth resuscitation or cardiopulmonary resuscitation ( CPR )

Work Practice Controls
Engineering controls alone won’t do much good unless you follow safe work practices. Proper waste disposal, safe needle handling and thorough cleaning are a few important ways to help ensure on – the – job safety.

Marking Infectious Materials
Any potentially infectious materials must be labeled or color – coded as biohazardous. Labels must also be placed on cabinets, refrigerators, freezers or any other containers holding blood or other potentially infectious materials.

Disposing of Waste
Whether you’re disposing of used needles, blood-stained towels, tissue specimens, or other contaminated materials, always follow your facility’s waste disposal guidelines. All medical waste should be stored in labeled, closed containers that can hold the contents without leakage during handling, storage, and transportation.


More Work Practice Controls

Handling Needles

One of the most important ways to prevent exposure to infection is to handle needles carefully. Keep the following guidelines in mind.
• Never bend or break needles;
• Never remove needles from disposable syringes;
• Do not recap needles. If you do, use an approved recapping method.
• Always dispose of needles in proper sharps containers.
• If a needlestick occurs, wash the affected area thoroughly with soap and running water. Then report it according to your employer’s policies.

Removing Gloves
To prevent contact with any blood that may be on your gloves, remove them carefully, using the following steps:
Peel one glove off from wrist to fingertips and hold it in the other, gloved hand.
Peel the other glove off from the inside with your exposed hand, holding the first glove inside the second.
Properly dispose of the gloves. Then wash your hands thoroughly.

Staying Aware
Throughout the working day, pay attention to your activities and your environment. Do not eat, drink, apply cosmetics, or handle contact lenses in patient care areas of possible contamination.

Housekeeping
When cleaning any contaminated materials or surfaces, remember the following:
• Wear gloves and protective covering over your clothing.
• When cleaning up blood spills, use disposable towels and an approved disinfectant. Dispose of waste properly. If splashing may occur, wear protection for your eyes and face.
• Separate contaminated laundry into leak proof, biohazard-labeled bags or containers.


UNIVERSAL PRECAUTIONS

Hospital staff must use precautions with blood and body fluids from all patients to protect themselves from blood borne pathogens.

These precautions also protect against other infectious organisms.

All patients are to be treated as potential source of infection e.g. HIV, Hepatitis B etc.

Wash hands before and after all patients or specimen contact. Proper handwashing with ordinary soap and water is sufficient except for invasive procedures when antiseptic soap is necessary.

Handle the blood and body fluids of all patients as potentially infectious.

Wear gloves for potential contact with blood and body fluids or when there is direct contact with non-intact skin or mucous membrane.

Place used syringes immediately in nearby 100% puncture resistant container, do NOT recap or manipulate needle in any way.

Wear protective eyewear and mask if there is a possibility of splatter with blood or body fluids ( e.g. bronchoscopy, oral surgery )

Wear gowns or apron when splash with blood or body fluids is anticipated.

Handle all linen soiled with blood and/or body secretions as potentially infectious.

Process all laboratory specimens as potentially infectious. Autoclave/heat treat where necessary before disposing.

Any spillage should be treated with 0.5-1% sodium hypochlorite before cleaning.

Wear masks for protection against airborne infections.

It takes up to six months after exposure for a person to develop HIV antibodies.




INVASIVE MONITORING [ PART TWO ]

Background

Invasive pressure monitoring systems are widely used for bedside monitoring of hemodynamic changes in the critically ill patients.
One component of an intravascular monitoring system is a fluid-filled catheter, one end of which is placed within the vascular system. The catheter is connected to a transducer, which is an electronic device that converts physiological events
( alternation in pressure ) to electronic signals that can be displayed on an oscilloscope. To ensure accuracy and to allow for changes in atmospheric pressure, the transducers are periodically balanced and recalibrated. When measuring pressures, the transducer should be positioned at the level of the cardiac chamber in which the catheter tip is positioned. Too high a position of the transducer will results in erroneous low reading. A falsely high reading will results if the transducer is placed too low because of hydrostic pressure on the transducer. For accurate monitoring the transducer should be positioned at the phlebostatic axis, which is measured from the fourth intercostal space in the midaxillary line, which corresponds to the level of the right atrium. Mark this point with a magic marker to establish a consistent 0 reference point.
Use a carpenter’s level to check the position of the transducer in relation to the mark on the chest. Reading can be taken in any position, although the supine position is preferred. Take serial readings in the same position.

A variety of equipment is used for pressure monitoring and much of this equipment is disposable. A continuous low-pressure flush systems is used to prevent clot formation within arterial catheter. Clot formation inhibits free transmission of the pressure waves and increases the risk of embolisation.
To minimize the risk of comtamination or air leaks and to increase accuracy, use high pressure tubing with as few connections and stopcocks as possible.



Haemodynamic Parameters

Haemodynamic parameters that are commonly used to assess critically ill patients include the peripheral arterial pressure, central venous pressure, pulmonary artery wedge pressure, cardiac output and mixed venous oxygen saturation.

Continuous arterial pressure is monitored by cannulating a peripheral artery by using an intravenous
( IV ) cannula and connecting to the transducer system. An arterial waveform is displayed on the oscillioscope if the system is free of air bubbles, clots and kinks.

The normal range for arterial pressure in adults :-

Systolic pressure : 100mmHg – 140mmHg
Diastolic pressure : 60mmHg - 80mmHg
Mean arterial pressure (MMP ) 70mmHg – 90mmHg

Ø TRANSDUCER SETUP – To continuously monitor a single pressure or two pressures alternatively.
Ø ARTERIAL LINE – Insertion of a cannula into the artery. To maintain continuous beat monitoring of blood pressure in the critically ill patient. To obtain repeated arterial blood samples with minimal discomfort to the patient.
- Reference Point
- Arterial monitoring Setup
Ø CENTRAL VENOUS PRESSURE – is a measurement of the volume status of patient. It also indicates the competence of the right heart to accept and expel the blood returned. It assesses how well the right ventricle functions as a pump. It can be measured using either a simple fluid manometer or a transducer.
- To assess haemodynamic changes occurring in the right side of the heart.
- To administer fluids or medications directly to the central veins.
- To obtain central venous blood samples.
- To assess volume status of a patient in shock and the response to treatment.
- To provide an early recognition of congestive cardiac failure ( CCF ).

Note:-
Avoid using subclavian approach in patients with coagulopathy as it would be difficult to control any bleeding, especially if subclavian artery is inadvertently punctured.


Ø PULMONARY ARTERY (SWAN – GANZ ) CATHETER – Pulmonary Artery Pressure ( PAP ) is measured using a balloon tip flow directed catheter.
- To measure intracardiac pressures e.g. CVP, PAP, PAWP
- To measure cardiac output and derived variables ( SVR, PVR)
- For mixed venous blood sampling
- For cardiac pacing.
Ø NON – INVENSIVE MONITORING – Blood Pressure – Manually ( Sphygmomanometer and stethoscope ) . Electronic / automatic – DINAMAP. Monitoring peripheral pulse using DOPPLERS ‘ ultrasound.
Ø MONITORING PERIPHERAL PULSES USING DOPPLER ULTRASOUND – techniques can be used to amplify and assess peripheral blood flow. Transmitting crystals in the probe emit ultrasound beams that collide with red blood cells moving through the blood cells to a receiver.
The change in sound is converted into an audible sound that is amplified to be heard. If the blood flow is less than 5 cm per second or is shielded by bone, or is located deep below the skin surface, it cannot be heard.
- to assess blood flow in peripheral vessels
- to diagnose peripheral vascular disorders.
- To amplify the blood pressure when it cannot be auscultated using traditional methods.



MECHANICAL VENTILATION ( PART THREE )

Introduction

A large number of patients in ICU are unable to maintain adequate ventilation. They will require the use of ventilatory support. It is thus essential that the nurse caring for these patients have a basic working knowledge on ventilator function and management of ventilated patient.

Principles of Mechanical Ventilation

Spontaneous of normal ventilation will establish airflow into the lungs by creating negative pressure
Within the thoracic cage. This negative pressure occurs when the respiratory muscles expand and slightly raise the ribs, while stimultaneously lowering the diaphragm. The net effect is an increase in the intrathoracic volume which is associated with an increased negative pressure.
Air is then automatically ‘ sucked’ in to fill this space. The larger the space created, the greater the volume of air that is drawn in.
These explains our ability to vary the size of our inspirations from those of a huge sigh to shallow, quiet breathing. Conversely, inspiration during the mechanical ventilation is achieved by means of positive pressure. The gas is driven into the lungs by an external force, i.e. the mechanical ventilator. In both spontaneous and mechanical ventilation, expiration is passive i.e. it depends on the elastic recoil of the lungs.

This illustrates the difference in intrathoracic pressure changes during spontaneous ventilation and mechanical ventilation. It is important to understand the fundamental difference here as it is the key to identifying and predicting potential problems for the mechanically ventilated patients.


Types of Positive Pressure Ventilators

Positive pressure ventilators inflate the lungs with a positive pressure ( compare normal breathing where inspiration is by a negative airway pressure ) then, allow expiration to occur to the atmosphere by the natural elastic recoil of the lungs and the chest wall.

2 most common types of ventilators used in adult critical care are:-
Ø Volume cycle ventilators
Ø Pressure cycle ventilators

Mode of Ventilation

1. Controlled Mandatory Ventilation ( CMV )
Is provided regardless of the patient’s ability to breathe. The major disadvantage is that the ventilator is totally unresponsive and independent of patient’s effort or responses.

2. Assist / control
Patient’s initiated breaths will receive the same preset tidal volume as ventilator initiated breaths.

3. Intermittent Mandatory Ventilation ( IMV )
It is a controlled mode ( with a low preset rate ) which allows spontaneous breathing in between controlled breaths. The two breathing patterns ( ventilator and Patient ) are not synchronized.

4. Synchronized Intermittent Mandatory Ventilation ( SIMV )
The patient breaths through a circuit that allows for independent spontaneous ventilation and the mandatory ventilator breaths ( which are triggered by the patient ) or synchronized to the patients breaths.

5. Pressure Support
Is spontaneously breathing mode, and if the patient does not make an inspiratory effort, apnea will occur. This mode is usually for weaning the patient from the ventilator because the patient must initiate breaths ( by creating a negative pressure to the patient by trigger value ) and pressure support assists the patient by delivering a flow of gas up to the preset pressure level.
6. PEEP / CPAP
Positive End-Expiratory Pressure ( PEEP ) is a maneuver used during IPPV where a prescribed pressure is applied during expiration so that a minimum positive pressure always occur during expiration. The aim is to maintain a minimum positive intrapulmonary pressure throughout the respiratory cycle.


COMPLICATION OF MECHANICAL VENTILATION

1. Mechanical – equipment malfunction
2. Physiological
a) Respiratory – barotraumas , atelectasis , infection
b) Cardiovascular – decreased venous return and cardiac output
c) Gastrointestinal – gastric ulcerations, micro aspirations
d) Renal / Hepatic – decreased urine output, sodium and water retention, decreased portal blood flow
e) CNS – decreased cerebral perfusion pressure following excessive PEEP


NURSING MANAGEMENT OF VENTILATED PATIENTS

Nursing Responsibilities can be grouped into 3 basic sections :-

1. Assessment and monitoring of the patients physical status and haemodynamic parameters.
2. Monitoring the ventilation parameters. The nurse should be able to recognize and trouble-shoot ventilator problems.
3. Nursing care. This includes skills such as suctioning via ETT, repositioning and securing an ETT, use of artificial airways. ( See airway management )

It must be emphasized that the most important monitor is the nurse.

Patient on life support system such as a ventilator should never be left unattended because failure of the system or development of life threatening complications such as pneumothorax may occurs.
The nurse must be alert to any sudden changes in system performance, or any acute development, distress, cyanosis, tachycardia and unequal breath sounds in the patient. When ventilation is completely controlled with sedation and paralysis, nursing will be the same as that of an unconscious patient.
The nurse must assume the protective reflexes for the patient until he is aware of himself and can function in his own. Patient communication is important and he must always be spoken to as if he is awake. A brief explanation should be given prior to any procedure to be performed.

1. OBSERVATION
1.1 PATIENT :-Conscious state, Colour ,BP, Pulse, Respiratory Rate, CVP
- Chest movement , Oxygen Saturation ( SpO2 )

1.2 VENTILATOR :- Mode , FiO2 , Set tidal volume , Rate , Airway pressure , Airway temperature

2. Alarm limits be set appropriately. Apnea alarm must NEVER be disabled.
3. Disconnection from ventilator requires IMMEDIATE reconnection.
4. in event of machine failure or power failure, commence manual ventilation immediately. Therefore a self-inflating bag with oxygen source must always be available at every bed.
5. drugs may be necessary when the patient is unable to settle with reassurance and inadequate ventilation.

Drugs used in management of ventilated patients
Commonly used drugs include:

Sedatives / analgesics
- Midazolam
- Morphine
- Propofol

Neuromuscular Blocking Agent ( NMBA )
- Suxamethonium ( Scoline )
- Vecuronium ( Norcuron )
- Atracurium ( Tracium )


The use of NMBA in the management of patients on a mechanical ventilator has decreased over the years. They are usually reserved for patients who are more difficult to settle and during the initial stages of stabilization, and for cerebral protection of patients with very high intracranial pressure ( ICP ).

It is important to remember that muscle relaxants have no sedative and analgesic effects – the patient can still hear and experience pain but will be unable to respond . therefore they must be adequately sedated while on muscle relaxants.



WEANING OF MECHANICAL VENTILATION

The process of weaning off the ventilator implies a gradual withdrawal of mechanical ventilatory support. It may take a number of forms and is affected by a number of physiological factors.

Factors To Consider Before weaning

1. Resolution of underlying pathologic condition initially requiring ventilatory support.
2. CXR shows good lung expansion and clear lung fields.
3. Acceptable ABGs with low ventilatory support.
4. Sepsis under control.
5. Awake with intact respiratory drive.
6. Minimal inotropic support.
7. Good hydration status with normalized serum electrolytes electrolytes and acid base status.
8. Adequate nutrition and energy.
9. Intact gag and cough reflex before extubation


Respiratory Criteria for Weaning

PARAMETER CRITERIA

Respiratory Rate 8 – 25 / min.

Vital Capacity 10 – 15 ml / kg

Maximum Inspiratory Force > - 20 cm H2O Pressure

PaO2 > 80 mm hg with FiO2 <>
PaCO2 35 – 45 mm hg
( except in cases of chronic hypercapnia )

Tidal Volume > 5 ml / kg