Successful Infusion Therapy in Older Adults

Subcutaneous edema as a potential cause of catheter failure in older inpatients receiving peripheral parenteral nutrition

Malnutrition is a common problem among hospitalized older patients. Peripheral parenteral nutrition (PN) can improve patient outcomes but can also lead to complications that affect future treatment. Older inpatients, in particular, are expected to be prone to these catheter-related complications. However, the impact of peripheral PN on older inpatients has been rarely investigated. In the current study, the impact of PN on short peripheral catheters (SPCs) was evaluated by comparing signs and symptoms at the time of catheter removal between 22 patients with PN and 27 without. In addition to external clinical assessment, sonographic investigations of the SPC site were performed. The prevalence of external signs and symptoms of complications was similar between the patients (all P > 0.05). However, subcutaneous edema was found by ultrasound in > 80% of patients with PN, compared with 55.6% of those without PN (P = 0.051). Unlike cases without PN, all patients with PN who presented with external signs and symptoms developed subcutaneous edema (P = 0.022). Multivariate analysis demonstrated that administration of PN was independently associated with subcutaneous edema (adjusted odds ratio = 6.88, 95% confidence interval = 1.083-75.486, P = 0.040). For several decades, phlebitis has been the primary focus of complications related to peripheral PN in clinical settings. However, our results imply that peripheral PN causes subcutaneous edema, which can lead to catheter failure in older inpatients. This study contributes to understanding the etiology of catheter failure during peripheral PN in this population.

Radiopharmaceutical extravasation in bone scintigraphy: a cross-sectional study

OBJETIVES

Tc-99m Hydroxymethylene diphosphonate (HMDP) bone scintigraphy is commonly used to diagnose bone disorders. We aimed to quantify and characterize the occurrence of radiopharmaceutical extravasation in bone scintigraphy, using Tc-99m HMDP, as well as to compare the visual classification of the events with an independent analysis using image processing software.

METHODS

We conducted a cross-sectional study, using data from a total of 400 (9.1%) exams, randomly selected from all the procedures performed in 2018 in the Portuguese Institute of Oncology of Porto, Portugal. Prevalence estimate and the corresponding 95% confidence interval (CI) was computed for the presence of extravasation. Odds ratios and 95% CI were computed to quantify the association between demographic and clinical characteristics, and the occurrence of extravasation.

RESULTS

The prevalence of Tc-99m HMDP extravasation was 26.5% (95% CI: 22.4-31.0). Those from an inpatient setting had almost seven-fold higher odds of extravasation than those from an outpatient setting. When the wrist was used for administration, there was three times more odds of extravasation when compared to the use of hand. There were statistically significant differences in the median scores of extravasations severity obtained from image processing software according to the different grades attributed by visual appreciation ( P  < 0.001).

CONCLUSION

Tc-99m HMDP extravasation occurred in one out of four patients, being more frequent among those from an inpatient setting and when the wrist was used for administration. Visual appreciation of the extravasation seems to be acceptable to classify its severity.

Impact of terminal tip location of midline catheters on catheter-related complications and indwelling duration in elderly patients

AIM

To investigate the relationship between the position of the midline catheter tip and the frequency and type of complications associated with its placement.

DESIGN

A cohort study was performed on patients between May 2018 and December 2021 who underwent midline catheter placement at our institution. Patients were divided into two groups, superficial implementation and deep implementation, based on the midline catheter tip location relative to the clavicle.

METHODS

Clinical data and outcome parameters, including the numbers and types of midline catheter-related complications, day of occurrence and catheter indwell duration, were recorded.

RESULTS

Catheter-related complications occurred in 14 individuals. Compared with the superficial implementation group, the incidence of complications in the deep catheterization group was significantly reduced, with a delayed first occurrence time, and a prolonged catheter indwelling time. The results suggested that locating the midline catheter tip in the distal segment of the axillary vein may reduce catheter-related complication incidence and prolong the indwelling duration.

The burden of peripheral intravenous catheters in older hospital inpatients: A national cross-sectional study part of the ONE MILLION GLOBAL PERIPHERAL INTRAVENOUS CATHETERS COLLABORATION

OBJECTIVES

To investigate the burden of peripheral intravenous catheters (PIVCs) in older hospitalised patients.

METHODS

A cross-sectional prospective observational study (2014/2015) to describe the characteristics, indications and outcomes of PIVCs among patients aged ≥65 from 65 Australian hospitals.

RESULTS

Amongst 2179 individual PIVCs (in 2041 patients, mean age 77.6 years, 45% female, 58% in NSW), 43% were inserted by doctors and 74% used that day, meaning 25% were 'idle'. Overall, 18% (393/2179) exhibited signs of PIVC-related complications. Most commonly exhibited PIVC-related complications were tenderness (4.1%) and local redness (1.8%). Nearly one in three (29.1%) dressings was soiled, loosened or had come off, and only 36.8% had the time and date documented on the dressing. Both infusing IV medications (aOR 1.74, 95% CI 1.28-2.38, p < 0.001) and inserting the PIVC in a non-upper limb vein (aOR 3.40 compared to forearm [reference site], 95% CI 1.62-7.17, p < 0.001) were independently associated with PIVC failure. Phlebitis was exhibited in 7% (154) of the patients. Only infusing intravenous medications increased the likelihood of developing symptoms of phlebitis (aOR 1.61, 95% CI 1.01-2.57, p = 0.05). Increasing age was inversely associated with symptoms of phlebitis. Among the 1575 patients (79%) who rated their PIVC experience using the Likert scale 0-10 (where 10 = 'best possible'), the median score was 8 (IQR 6-10). Age in highest quartile (>84 years) was independently associated with lower likelihood of a high score (aOR 0.71, 95% CI 0.54-0.94, p = 0.02).

CONCLUSIONS

Given 1 in 5 PIVCs were identified with having complications, further research should focus on optimising PIVC use in older patients.

Characteristics of expert nurses' assessment of insertion sites for peripheral venous catheters in elderly adults with hard-to-find veins

AIM

To clarify the characteristics of expert nurses' assessments when selecting an insertion site for a peripheral venous catheter (PVC).

METHODS

Participants were 11 competent (control group) and 13 expert nurses. Using a simulated patient, we recorded the procedures participants followed when selecting a site for a PVC insertion. The researchers interviewed the nurses after the procedure by asking targeted questions about the site selection to clarify the factors influencing that selection. During the interview, a video of that nurse's procedure was observed, and each step performed during the procedure was investigated.

RESULTS

We identified three assessment characteristics specific to expert nurses that influenced their PVC site selection: (a) focusing on a patient's unique characteristics and choosing the appropriate procedure for that individual; (b) avoiding complications and paying attention to the patient's daily self-care needs; and (c) carefully considering the patient's fear and fatigue during site selection and catheter insertion. Other assessments, based on the general knowledge and skill acquired by nurses in selecting a PVC site, were common to both groups: arm selection based on the patient's preference and site selection to avoid nerve injuries or complications. The control group's approach was assessed on the basis of their confidence in selecting a site for a PVC insertion.

CONCLUSIONS

Expert nurses assessed the patient's individual characteristics and daily self-care needs and helped mitigate the patient's anxiety. Our findings provide a basis for educational programs that share how expert nurses assess sites for a PVC insertion.

Peripheral Intravenous Access: Applying Infusion Therapy Standards of Practice to Improve Patient Safety

The most common invasive procedure performed in the hospital setting worldwide is the insertion of a peripheral intravenous catheter. Although use of peripheral intravenous access is common, its presence is far from benign, with a reported 35% to 50% failure rate, even in facilities with a dedicated infusion team. Significant complications related to the presence of a peripheral intravenous site include localized infection, bacteremia, phlebitis, and infiltration or extravasation. Consistent application of evidence-based standards of practice in all aspects of peripheral intravenous catheter care is essential to provide infusion therapy that delivers safe and quality care. Management of peripheral intravenous access in the complex setting of critical care is examined in this article. A case study approach is used to illustrate application of infusion therapy standards of practice in peripheral intravenous catheter insertion, indications for catheter placement, and assessment parameters to enhance early recognition of peripheral intravenous access-related complications.