A 76-year-old man with chronic obstructive pulmonary disease is admitted to the intensive care unit for pneumonia. On presentation in the emergency department, he had hypercapnia and hypoxic respiratory failure. He was intubated and sedated. After intubation, the patient's blood pressure dropped to 85/58 mm Hg and did not recover with intravenous fluid resuscitation. A central venous catheter was placed and he was started on pressors.
Which of the following procedures is most likely to improve outcome in this patient?

Question

A 76-year-old man with chronic obstructive pulmonary disease is admitted to the intensive care unit for pneumonia.  On presentation in the emergency department, he had hypercapnia and hypoxic respiratory failure.  He was intubated and sedated.  After intubation, the patient's blood pressure dropped to 85/58 mm Hg and did not recover with intravenous fluid resuscitation.  A central venous catheter was placed and he was started on pressors.
Which of the following procedures is most likely to improve outcome in this patient?

Quizplus · Accepted Answer

Central venous catheters (CVCs) are the most common cause of iatrogenic bloodstream infection, which can significantly worsen patient outcomes. Recommendations to reduce the incidence of central line-associated blood stream infections (CLABSIs) include the following: Hand hygiene prior to catheter insertionUse of a catheter cart/kit that includes all necessary items for insertionChlorhexidine for insertion site cleaningMaximal sterile precautions (gown, cap, mask, gloves, sterile full-body drape)Removal of nonessential CVCs ("idle CVCs") Hand hygiene prior to catheter insertion Use of a catheter cart/kit that includes all necessary items for insertion Chlorhexidine for insertion site cleaning Maximal sterile precautions (gown, cap, mask, gloves, sterile full-body drape) Removal of nonessential CVCs ("idle CVCs") CLABSI risk increases with each additional day that the catheter remains in place. A recent study of patients not in the intensive care unit showed that health care providers did not know the reason that a CVC was maintained in >8% of patients. (Choices A, C, and D) Routine clinical testing can increase health care costs, has not proven beneficial for patient care, and may occasionally cause harm (eg, induce anemia requiring transfusion). Unnecessary testing may also lead to workup of incidental and non-clinically significant results. Daily routine laboratory testing is not advised; instead, testing should be performed based on specific clinical indications. (Choice E) Starting enteral nutrition in critically ill but hemodynamically stable patients within 48 hours has been shown to improve outcomes. However, it is recommended that enteral nutrition not be started in hemodynamically unstable patients who have not been fully resuscitated as it may lead to bowel ischemia. Educational objective: Risk for central line-associated bloodstream infections increases the longer a catheter remains in place. Critically ill patients should be assessed daily for the need for continued central venous access. __________ References: Making health care safer II: an updated critical analysis of the evidence for patient safety practices. (http://www.ncbi.nlm.nih.gov/pubmed/24423049)

A 76-Year-Old Man with Chronic Obstructive Pulmonary Disease Is Admitted