Management of functional complications of totally implantable venous access devices by an advanced practice nursing team: 5 Years of clinical experience

Maintenance of totally implantable ports in Zhongshan Hospital: a best practice implementation project

BACKGROUND

The totally implantable port is a common central venous access device. The cost of implantation and maintenance however is very expensive. At present, the biggest problem regarding the promotion and the use of implantable ports in China is lack of well trained professional healthcare providers. Furthermore, maintenance of totally implantable ports by nurses is poor and patients may easily get complications.

AIMS/OBJECTIVES

This project aimed to reduce the incidence of complications among general surgery patients with implantable ports, and improve healthcare safety and the care process, strictly in compliance with current evidence-based criteria.

METHODS

A baseline audit on maintenance of totally implantable ports utilizing the Joanna Briggs Institute Practical Application of Clinical Evidence System program was undertaken from 1 April to 15 May 2015 that involved 25 nurses and 25 patients. An intervention including education, demonstration, clinical practice and assessment was conducted from 16 May to 15 July 2015. A post-implementation re-audit was completed from 16 July to 10 August 2015.

RESULTS

The results of the audit for the nine audit criteria for totally implantable port maintenance were as follows: the compliance rate for Criteria 2 and 3 increased from 0% to 100%, Criterion 1 from 80% to 100%, Criterion 4 from 92% to 100%, Criterion 5 from 68% to 100%, Criterion 6 remained as 100%, Criterion 7 from 12% to 100%, Criterion 8 from 0% to 96% and Criterion 9 from 88% to 100%. During implementation we found four barriers and undertook measures to address them.

CONCLUSIONS

This project achieved a significant improvement in establishing evidence-based practice regarding maintenance of totally implantable ports in the general surgery ward. Strategies in sustaining best practice should be developed in the future.

Comparison between Saline Solution Containing Heparin versus Saline Solution in the Lock of Totally Implantable Catheters

BACKGROUND

There are only 3 studies comparing the efficacy of 2 different types of lock used in totally implantable catheters regarding occlusion or reflux dysfunction. The present study contains the largest published casuistry (862 patients) and is the only one that analyzes 3 parameters: occlusion, reflux dysfunction, and flow dysfunction.

METHODS

This was a retrospective study of patients operated at a large oncology center and followed up in the outpatient clinic between 2007 and 2015. The patients were divided into 2 groups according to the type of lock: the Hep group (heparine), whose lock was composed of saline solution 0.9% with heparin (100 IU/mL) and the SS group (saline solution), whose lock was composed of saline solution 0.9%.

RESULTS

The Hep group was composed of 270 patients (31%) and the SS group of 592 patients (69%). Regarding occlusion, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to reflux dysfunction, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to flow dysfunction, there was 1 case in the Hep group (0.37%) and 4 cases in the SS group (0.68%; P = 1).

CONCLUSIONS

There was no statistically significant difference between the groups regarding occlusion, reflux dysfunction, and flow dysfunction.

Chest radiograph-based algorithm for managing malfunctioning ports

PURPOSE

To evaluate a chest x-ray-based algorithm for managing malfunctioning ports.

MATERIALS AND METHODS

A review of interventional radiology procedures on malfunctioning ports during the period 2000-2012 was performed. Events were divided into two periods: before and after implementation of an algorithm beginning with tip position evaluation using a chest x-ray. Time to return to usability, frequency of interventions to restore function, and frequency of malfunctioning ports remaining in use after the procedure were calculated.

RESULTS

The review included 303 procedures before implementation of the algorithm on 237 access sites in 227 patients (mean age, 56 y; 38% male) and 155 procedures after implementation of the algorithm on 131 access sites in 130 patients (mean age, 55 y; 35% male). Implementation of the algorithm was associated with significantly fewer repeat checks on the same access (27% before algorithm, 9% after algorithm, P < .001) and reduced frequency of a malfunctioning port remaining in use after the interventional radiology procedure (43% before algorithm to 14% after algorithm, P < .001). Median time from consultation to revision was significantly less after implementing the algorithm (13 days before algorithm, 1 day after algorithm, P < .001). Median time from consultation to port usability was also less after implementing the algorithm (2.7 days before algorithm, 1 day after algorithm, P < .001).

CONCLUSIONS

Implementation of the algorithm was associated with significantly less frequent repeat procedures on the same port and a lower frequency of malfunctioning ports remaining in place. Use of the algorithm was associated with significantly reduced time from consultation to revision and to return to usability. These findings suggest the algorithm allows triage of patients with malfunctioning ports to the appropriate intervention before undergoing a procedure.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial

BACKGROUND

Heparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking.

PATIENTS AND METHODS

We randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as 'easy injection, impossible aspiration' at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4.

RESULTS

Three hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%-4.69%) and 3.92% (95% CI 3.09%-4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%-1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group.

CONCLUSION

NS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.