Febrile Tunneled Catheter Patient With Unsafe Medication Practices
A 46-year-old man with end-stage kidney disease has a tunneled right internal jugular catheter that was placed 5 months ago. During the first 45 minutes of hemodialysis he develops rigors, fever of 38.9°C, and BP 102/60 mmHg with heart rate 112. The exit site is erythematous with purulent drainage; the dressing is soiled. The unit has six chairs and one isolation room, which is occupied by a patient who is hepatitis B surface antigen positive. A staff member is preparing saline flushes for several patients on one tray and has a multidose vial of heparin on the cart. The patient's blood cultures are pending. The nurse wants to finish dialysis and send him home with oral antibiotics. He has no known history of MRSA or hepatitis.
1. What is the immediate clinical management of this possible catheter-related bloodstream infection?
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Treat this as a possible catheter-related bloodstream infection. Stop the session, obtain two sets of blood cultures-one from the catheter and one peripheral-before antibiotics, plus CBC and lactate. Notify the nephrologist immediately; start empiric IV antibiotics after cultures according to unit protocol. Give oxygen, monitor BP and heart rate, and provide fluids cautiously if hypotensive.
Do not send the patient home on oral antibiotics. The catheter should not be used for routine dialysis until reviewed; if the patient is unstable or cultures grow Staphylococcus aureus or Pseudomonas, catheter removal is likely. The exit-site drainage needs culture and a sterile dressing change.
2. What infection prevention and control actions are required in the unit, including placement and medication practices?
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Place the patient in a single room or dedicated area with contact precautions; the hepatitis B surface antigen-positive patient's room is not appropriate for this patient, so cohorting should follow transmission risk and unit policy. Staff must perform hand hygiene and use gloves and a gown for drainage.
Immediately correct the medication tray practice: one patient per tray, no shared multidose heparin vial unless the unit has a strict policy and the vial is dedicated, and use single-dose flushes. Clean and disinfect the cart. Review catheter hub disinfection, dressing technique, and staff training.
3. What documentation, communication, and follow-up should the nurse complete?
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Document vital signs, cultures, antibiotics, catheter assessment, and who was notified. Complete an incident report and notify infection control and the medical director. Communicate with the patient and family about admission and catheter plans, and with receiving staff at handover.
Review 30-day catheter infection rates and medication-preparation audits. Ensure the patient's next facility knows about the infection and pending cultures; avoid blaming staff in the initial report.