Implementation of Ultrasound-Guided Cannulation Training Across Eight NHSBT Therapeutic Apheresis Units in England

Ultrasound-guided cannulation (USGC) of a peripheral vein reduces the need for central vascular access device (CVAD) placement to perform a successful apheresis procedure. Effective training of healthcare professionals to acquire this skill is essential. Here, we report on the implementation of the USGC training across eight apheresis units in England. A 3-h introductory training program was devised with theoretical and practical elements. This was followed by supervised USGC practices on any patient ≥ 18 years old, regardless of venous status. Data on all supervised USGC attempts were recorded and analyzed. Over an 11-month period, 11 nurses were trained to USGC competency with another six nurses still in training, resulting in seven out of eight units having at least one USGC-competent nurse. In one unit, USGC training has not started yet. Three hundred sixty-one supervised USGC episodes on 168 patients and donors took place; of these, 178 were done for training purposes only on patients who had visible and palpable veins, 179 USGC were done on patients with difficult venous status and four were not recorded. The period from first supervised USGC to competency was a median of 45 days (Range: 17-166 days), with a median of 15 successful (Range: 10-30) and two unsuccessful (Range: 1-15) USGC being performed per trainee. The placement of 57 CVADs and 41 multiple cannulation attempts have been avoided. USGC is a useful tool to reduce the need for CVAD. Training across multiple apheresis units is a lengthy procedure, but it can be successfully implemented.

Recent insights into extracorporeal photopheresis for graft-versus-host disease

INTRODUCTION

Extracorporeal Photopheresis (ECP) may be considered the unique large-scale cell therapy currently available. It is currently employed mainly as second-line treatment, especially in steroid-resistant or steroid-dependent Graft versus Host Disease (GvHD) with good results and very few limitations.

AREAS COVERED

Many points need to be clarified regarding the ECP mechanism of action, that conditions the lack of uniqueness among the different centers, essentially cycle frequency, treatment duration, and the number of cells to be treated to obtain a response, according to the organs involved. Moreover, reliable biomarkers for prediction of response are lacking, as well as the best pharmacological combination. We will focus on the recent advances concerning ECP for GvHD treatment. We performed a systematic literature research in Pubmed and Embase as of September 2023.

EXPERT OPINION

The recent studies on ECP mechanism of action along with the promising biomarkers of response, and the synergistic benefit of ECP in association with the new drugs render this therapy an important weapon for GvHD resistant to conventional treatment and can be proposed as a valid first-line therapy option with promising results. We believe that it should be used early in all categories of patients, considering its high safety profile.

Apheresis collection of mononuclear cells for chimeric-antigen receptor therapies

Collections of lymphocytes to be genetically modified to treat hematologic malignancies have seen a dramatic increase over the last few years as commercial products have been approved. Reports of new products in development that can possibly treat solid organ malignancies represent a massive change in the field. Apheresis is at the center of the collection of cells for the manufacture of these chimeric-antigen receptor therapy products. The expansion of these collections represents one of the areas of apheresis procedures growth. This review will summarize concepts important to this type of collection and variables that need to be optimized to obtain desired cell yields while increasing patients' safety.

Extracorporeal Photopheresis in Graft-versus-Host Disease

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity following allogeneic hematopoietic stem cell transplantation. Extracorporeal photopheresis (ECP), which exposes mononuclear cells to ultraviolet A irradiation in the presence of a photosensitizing agent, has shown efficacy in the treatment of GVHD. Recent observations in molecular and cell biology have revealed the mechanisms by which ECP can reverse GVHD, including lymphocyte apoptosis, differentiation of dendritic cells from circulating monocytes, and modification of the cytokine profile and T cell subpopulations. Technical innovations have made ECP accessible to a broader range of patients; however, logistical constraints may limit its use. In this review, we scrutinize the development of ECP from its origins to recent insights into the biology underlying ECP efficacy. We also review practical aspects that may complicate successful ECP treatment. Finally, we analyze how these theoretical concepts translate into clinical practice, summarizing the published experiences of leading research groups worldwide.

Educating health professionals in ultrasound guided peripheral intravenous cannulation: A systematic review of teaching methods, competence assessment, and patient outcomes

BACKGROUND

Peripheral intravenous cannula insertion is the most common invasive healthcare procedure, however failure rates remain unacceptably high, particularly in patients with difficult intravascular access. This leads to treatment delays and increased complication risk, causing poorer outcomes among this patient subset. Ultrasonographic guidance reduces these risks and is therefore becoming a competency required of health professionals. However, there is no consensus on how to design teaching sessions to achieve this competency.

METHODS

Systematic review was conducted to identify characteristics of effective teaching sessions for current and training health professions to achieve ultrasound guided peripheral intravenous cannulation competency. Secondary outcomes included defining competency and to assess benefits to patients and healthcare systems. Eligibility for inclusion required description of teaching of ultrasound guided peripheral intravenous cannulation to qualified or training health professionals who went on to perform it in human patients or volunteers with reported outcomes or success rates. Studies were excluded if not accessible in full, not peer-reviewed or presented research that had been presented elsewhere previously. Of the 1085 records identified on review of 6 databases, 35 were included for final review based on eligibility criteria.

RESULTS

Almost all (97.1%) used mixed modality teaching comprising of didactic and simulation portions, although time allocated varied widely. A median of 5 proctored procedures was required for competency. Competency was independent of previous experience or staff seniority. Mean reported insertion attempts was 1.7, success rate was 82.5% and first-time success rate was 75.5%. All included studies described improvement in their participants or healthcare system including significantly reduced midline insertion rates, central venous catheter insertion rates and associated bacteremia and sepsis, self-reported cannulation difficulty, specialist input, therapy delays and premature catheter failure rates. Further, there was significantly improved procedural confidence, knowledge and competence.

CONCLUSION

Simple teaching interventions can lead to competent ultrasound guided peripheral intravenous cannula insertion by novices, resulting in numerous positive outcomes for patients and healthcare systems.

Nationwide practices in the use of central venous catheters for therapeutic plasma exchange in the inpatient setting

INTRODUCTION

Therapeutic plasma exchange (TPE) is often impacted by difficulties in obtaining an adequate and safe vascular access. This study evaluated the rates, predictive factors, and clinical outcomes associated with central venous catheter (CVC) use during the inpatient TPE procedures.

METHODS

The Nationwide Readmissions Database, 2016 to 2017 was used to identify hospitalizations with TPE with and without CVC insertion.

RESULTS

During the study period, there were 35 429 hospitalizations with TPE (pediatric 6.1%, mean ± standard deviation (SD) age 50.9 ± 20.0 years, female 52.7%). CVC insertion was documented in 24 414 (73.4%) adult and 1596 (73.5%) pediatric hospitalizations. In pediatric patients, age >15 years, higher disease severity, and private insurance were associated with higher odds of CVC insertion. In adults, female sex, obesity, concurrent hemodialysis, and higher disease severity were associated with CVC insertion. Adults with private insurance and both adult and pediatric hospitalizations at the teaching hospitals had lower odds of CVC placement. All patients with CVC insertion had longer length of hospital stay, and adults with CVC insertion also had higher hospital charges, higher in-hospital mortality, and lower likelihood of being discharged to home.

CONCLUSION

CVC insertion is performed for the majority of inpatient TPE procedures and CVC use appears to correlate with worse clinical outcomes.

Ultrasound-based criteria for adequate peripheral venous access in therapeutic apheresis procedures

BACKGROUND

Apheresis procedures require adequate vascular access to achieve adequate inlet flow rates. Central dialysis-type catheters are often used in apheresis, despite their multiple risks. Peripheral venous access is a safe and effective option for many patients.

AIM

We previously demonstrated that ultrasound guidance reduces central venous catheter use in apheresis patients; however, no validated criteria for preprocedural evaluation of peripheral veins exist. Here, we hypothesized that ultrasound-based criteria could predict the adequacy of a peripheral vein for apheresis procedures.

PATIENTS/METHODS

In this pilot cohort study, we reviewed the procedural outcomes for 50 cases of peripheral venous procedures that used our ultrasound-based criteria.

RESULTS

Of the procedures that met our criteria, 96% (46/48) were successfully completed. Overall, our criteria had 100% sensitivity, 50% specificity, 96% positive predictive value, and 100% negative predictive value.

CONCLUSION

Our criteria justify an evidence-based ultrasound-guided standard for evaluation of peripheral venous access for apheresis procedures.