ESPEN Congress Brussels How to take care of central venous access devices (CVAD)? Eva Johansson

Transcription

1 ESPEN Congress Brussels 2005 How to take care of central venous access devices (CVAD)? Eva Johansson

2 How to take care of central venous access devices (CVAD)? Eva Johansson, RN, PhD Division of Hematology Karolinska University Hospital and Institutet SWEDEN

3 Central venous access device issues Totally implantable subcutaneous port system (PORT) or tunnelled CVC? Dressing protocols? Heparin or flushing? Use of antibiotic lock?

4 Prevention of complications Infections exit site tunnel blood stream infection (BSI) Occlusion Thrombosis

5 Catheter-associated blood stream infections, ICUs USA central line-associated BSI/year 5.3 central line-associated BSI/1000 catheter-days 3% attributable mortality rate 1. Mermel LA. Ann Intern Med 2000;132:391

6 Factors associated with CVAD related complications The physical condition of the patient Type of CVAD and connections used CVAD location Organisational factors Hygiene and management

7 PORT or Tunnelled CVC

8 CVAD-removal due to complication in randomised trials PORT CVC n (%) n (%) p-value Kappers-Klunne 6 / 20 (30) 10 / 23 (43) NS acute leukaemia Carde 3 / 50 (6) 18 / 46 (39) <0.001 solid tumours Mueller 11 / 46 (24) 11 / 46 (24) NS leukaemia, lymphoma, solid tumours Johansson 4 / 17 (24) 9 / 20 (45) NS acute leukaemia 2. Kappers-Klunne M et al. Cancer 1989;64: Carde P et al. Eur J Cancer Clin Oncol 1989;25: Mueller B et al. J Clin Oncol 1992;10: Johansson E et al. Support Care Cancer 2004;12:99

9 PORT vs CVC Catheter survival Proportion of catheters in use PORT (n=17, solid line) p=0.15 CVC (n=20, dotted line) Time (days) 5. Johansson E et al. Support Care Cancer 2004;12:99

10 PORT vs CVC Time to first CNS positive blood culture Proportion of patients remaining CNS blood culture negative PORT (n=17, solid line) p= Time (days) CVC (n=20, dotted line) 5. Johansson E et al. Support Care Cancer 2004;12:99

11 Patient satisfaction 23 item questionnaire PORT CVC Items yielding > 25% difference (n=15) (n=17) INFORMATION (1/2 items) I know how my CVAD works 73% 100% DISCOMFORT (1/6 items) After a while you do not think of that you have got a CVAD 100% 54% ANXIETY (0/6 items) RESTRICTIONS IN DAILY ACTICITIES (3/6 items) The CVAD disturbs me when I am: taking a shower 50% 92% dressing myself 0% 46% I am sitting in a a special position so that the CVAD will not change its location 11% 43% 6. Johansson E et al. (Abstract) European Haematology Association 1999, Barcelona, Spain

12 Dressing protocols Transparent polyurethane dressing or gauze and tape dressing no difference Replace dressing when it becomes damp, loosened or soiled transparent: every 7 days gauze: every 2 days 7. Gillies D et al. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD O'Grady N et al. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10):1-29.

13 Dressing protocols Proper hand hygiene Maintain aseptic technique for the insertion and care a no-touch technique use of forceps or sterile gloves the use of gloves has given a false sense of security 8. O'Grady N et al. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10): Centers for Disease Control and Prevention, Guideline for hand hygiene in health-care settings: MMWR 2002;51(No. RR-16):1-45.

14 Dressing protocols Skin disinfection Use an appropriate antiseptic: 2% chlorhexidine-based preparation 10% povidone-iodine 70% alcohol 70% alcohol and 0.5% chlorhexidine 8. O'Grady N et al. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10): Centers for Disease Control and Prevention, Guideline for hand hygiene in health-care settings: MMWR 2002;51(No. RR-16): Chaiyakunapruk N et al. Ann Intern Med 2002;136:792

15 Flushing The push-pause technique Amount Karolinska University Hospital CVAD-protocol (in adult patients not under fluid restrictions) before use ml 0.9% sodium chloride immediately after: iv fluids (non-lipid) ml 0.9% sodium chloride immediately after: blood products, lipid emulsions or drawing blood samples ml 0.9% sodium chloride 11. Hadaway L. Nursing 2000;30:74

16 Heparin to maintain catheter patency Systemic therapy Heparin decreased catheter-related thrombosis and bacterial colonization Heparin in parenteral nutrition did not reduce catheterrelated thrombosis Warfarin or dalteparin decreased catheter-related thrombosis Intermittent flushes (peripheral venous and arterial catheters) Heparin (10 U/ml) did not decrease catheter clot formation Heparin (100 U/ml) reduced catheter clot formation 12. Randolph A. Chest 1998;113: Klerk C. Arch Intern Med 2003;163: Randolph A et al. BMJ 1998;316:969

17 Heparin to maintain catheter patency Complications bleeding complications allergic reactions heparin-induced thrombocytopenia Drug incompatibilities Cost

18 Use of antibiotic lock Seems to be effective BUT development of bacterial resistance is a concern Prevention or treatment Antibiotic concentration Dwell time Heparin in the antibiotic solution Concurrent systemic antibiotics 8. O'Grady N et al. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10): van de Wetering MD et al. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD Bagnall-Reeb H. Journal of Infusion Nursing 2004;27:118

19 Other lock strategies Ethanol to prevent infection Minocycline and edetic acid (M-EDTA) Citrate Taurolidine 16. Bagnall-Reeb H. Journal of Infusion Nursing 2004;27: Metcalf S. Journal of Infection 2004;49: Jurewitsch B et al. Clinical Nutrition 2005;24:462

20 Summary/conclusions PORT or tunnelled CVC? PORT Dressing protocols? transparent or gauze Heparin or Flushing? flushing with 0.9% sodium chloride is the primary method Use of antibiotic lock? not recommended routinely

21 References 1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132: Kappers-Klunne M et al. Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection. Cancer 1989;64: Carde P et al. Classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: a randomized trial in 100 patients with solid tumours. Eur J Cancer Clin Oncol 1989;25(6): Mueller B et al. A prospective randomized trial comparing the infectious and noninfectious complications of an externalized catheter versus a subcutaneously implanted device in cancer patients. J Clin Oncol 1992;10(12): Johansson E et al. Totally implantable subcutaneous port system versus central venous catheter placed before induction chemotherapy in patients with acute leukaemia a randomized study. Support Care Cancer 2004;12: Johansson E et al. Totally implantable catheter system versus central venous catheter placed before induction chemotherapy in patients with acute leukaemia. (Abstract) European Haematology Association 9-12 June 1999, Barcelona, Spain 7. Gillies D et al. Gauze and tape and transparent polyurethane dressings for central venous catheters. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD DOI: / CD O'Grady N et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-10): Centers for Disease Control and Prevention, Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. MMWR 2002;51(No. RR-16):1-45.

22 References 10. Chaiyakunapruk N et al. Chlorhexidine compared with povidone-iodine solution for vascular cathetersite care: a meta-analysis. Ann Intern Med 2002;136: Hadaway L. Flushing to reduce central catheter occlusions. Nursing 2000;30:74, Randolph A. Benefit of Heparin in central venous and pulmonary artery catheters. Chest 1998;113: Klerk C. Thrombosis prophylaxis in patient populations with a central venous catheter. Arch Intern Med 2003;163: Randolph A et al. Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials. BMJ 1998;316: van de Wetering MD et al. Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD DOI: / CD Bagnall-Reeb H. Evidence for the use of the antibiotic lock technique. Journal of Infusion Nursing 2004;27: Metcalf S. Use of ethanol locks to prevent recurrent central line sepsis. Journal of Infection 2004;49: Jurewitsch B et al. Taurolidine lock: The key to prevention of recurrent catheter-related bloodstream infections. Clinical Nutrition 2005;24:462-65