Dosage of heparin for patency of the totally implanted central venous catheter in cancer patients

OBJECTIVE

to analyze the evidence available in the literature about the lowest necessary dose of heparin to maintain the patency of the totally implanted central venous catheter in adult cancer patients.

METHOD

an integrative literature review, carried out in the following databases: Literatura Latino-Americana e do Caribe em Ciências de Saúde, Sciverse Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, including thirteen studies.

RESULTS

the evidence showed that the dose of heparin (300 IU/ml) is the most used in maintaining the patency of the totally implanted central venous catheter.

CONCLUSION

according to the selected studies, the lowest dose of heparin found in maintaining the patency of the totally implanted central venous catheter in cancer patients was 10 UN/ml with a volume of 5 ml of the heparin solution.

Phase II Trial on Extending the Maintenance Flushing Interval of Implanted Ports

PURPOSE

Retrospective studies suggest that it may be safe to extend the maintenance flushing interval of implanted ports from once every month, as recommended by the manufacturer, to once every 3 months, but no prospective cohort studies have been done specifically assessing the safety and feasibility of this intervention.

METHODS

This was a phase II study in oncologic patients who retained a functional port after completion of systemic chemotherapy. Patients enrolled in the study had their port flushed once every 3 months and were observed until completion of five scheduled flushes (one on enrollment and four additional flushes, one every 3 months) or development of any port-related complication, including infections, thrombosis, and occlusions. The primary end points were frequency of port-related complications and port failure requiring removal.

RESULTS

A total of 87 patients were enrolled in the study. The median follow-up time was 308 days, accounting for a total of 24,202 catheter-days. There were 10 port-related complications (11.49%; 95% CI, 4.85% to 18.14%). No infection or symptomatic thrombosis occurred. The mean time to port-related complication was 184 days. No patients developed port failure while on protocol, but on subsequent medical record review, four patients developed a complication that required port removal or port revision within 30 days of being removed from the trial (4.6%; 95% CI, 0.4% to 8.8%; 0.17/1,000 catheter-days).

CONCLUSION

Extending the maintenance flushes of implanted ports in adult oncologic patients to once every 3 months is safe, effective, and likely to increase patient adherence and satisfaction while decreasing the associated cost.

Normal saline versus heparin solution to lock totally implanted venous access devices: Results from a multicenter randomized trial

PURPOSE

Our aim was to determine the non-inferiority of normal saline flushing compared to heparin flushing in maintaining the patency of totally implanted venous access devices (TIVADs).

METHOD

Four hundred and thirty patients were recruited from 14 Italian centres. Patients were randomized to heparin group or to normal saline group. The primary outcome of the study was TIVAD occlusion.

RESULTS

After randomisation, 203 patients were assigned to normal saline group and 212 to heparin group. Median follow up time was 204 days in normal saline group and 294 in the heparin group. We observed 24 withdrawal occlusions (5.78%): 10 in the heparin group and 14 in the normal saline group. One total occlusion was observed in the normal saline group. Taking as reference the arm treated with heparin, the absolute risk difference was 2.67 with the 90% CI including the non - inferiority margin of 4%. No significant difference between hazards of occlusion was found.

CONCLUSIONS

This study failed to demonstrate that normal saline flushing is not inferior to heparin flushing, even if a significant difference between the two treatments was not found. The use of heparin is controversial and other prospective trials are necessary in this field.

TRIAL REGISTRATION

EudraCT number: 2009-013620-22.

Variability in management of implantable ports in oncology outpatients

PURPOSE OF THE RESEARCH

To describe the variability in practice regarding the management of vascular access ports in adult oncology patients at Spanish outpatient clinics and to evaluate its compliance with the recommended procedural guidelines.

METHODS AND SAMPLE

Three e-mailings or three postal mail-outs were sent to all Spanish outpatient clinics, in accordance with the hospital's preference. An additional fourth postal mail-out was made to all units. In total 185 units at Spanish outpatient clinics out of a total 256 completed the survey questionnaire.

KEY RESULTS

A number of variations exist in the techniques used for insertion, withdrawal of needle from vascular access ports, blood sampling and unblocking procedure. There is considerable agreement in relation to the use of a special beveled needle, the use of gloves in the access and withdrawal procedures and checking of reservoir permeability by aspirating blood. In most cases, sterile gloves are used but there is a lesser occurrence of both scrubbed hands and correct antiseptic use.

CONCLUSIONS

There are considerable differences in the management of the vascular access ports in terms of the recommendations published in the main international guidelines, though these are based on low level evidence. The results highlight the need for further quality studies in ports use and manipulation to lessen the variability between published recommendations and clinical practice.

IV Catheter Care and Maintenance Minimizes Catheter-Related Blood Stream Infection

The elimination of catheter-related bloodstream infections (CR-BSI) requires meticulous intravenous (IV) catheter care. There are three different types of needlefree connectors and one intraluminal protection device that require different care regimens, including the correct usage of disinfectants, flushing techniques, and clamping sequences. The nurse must be able to identify which connector is in use and select the appropriate care. This care must be followed not only in the inpatient unit by the bedside nurse but also in areas that are providing diagnostic procedures such as the cardiac cath lab. Since bacterial adhesion to the intraluminal catheter wall is the primary building block of a CR-BSI, which may not present until days after initial inoculation, preventing intraluminal fluid pathway contamination is paramount with every access. In addition, many institutions have more than one type of connector available. This complicates the provision of consistent safe care. Split septum, negative mechanical valves, positive pressure mechanical valves, and intraluminal protection devices have specific care and maintenance requirements. This article discusses the different connector types, why each requires special care, how intraluminal fluid pathway contamination can lead to CR-BSI, and how simple nursing care and maintenance practices of connector septum swabbing and catheter flushing by the cardiac cath nurse can help prevent this serious complication.

The late complications of totally implantable central venous access ports: the results from an Italian multicenter prospective observation study

PURPOSE

The principal aim of this study is to analyze the incidence of late complications in oncologic patients with totally implanted central venous access ports.

METHODS

A prospective multicenter observational study was conducted in 26 Italian oncologic outpatient clinics. 1076 cancer patients with Totally Implanted Central Venous Access Ports (TIAP) were observed. 515 devices were observed in patients under treatment and 561 in patients who went to the outpatient clinic only for flushing.

RESULTS

Late complications observed in patients under treatment were: 3 pocket infections (0.09/1000 days of port observation), 1 cutaneous infection (0.03/1000 days of port observation), 8 occlusions (0.24/1000 days of port observation) and 12 others. In patients using the device only for flushing we observed 4 cases of device related bacteremia (0.04/1000 days of port observation), 1 pocket infection (0.01/1000 days of port observation), 1 cutaneous infection (0.01/1000 days of port observation), 3 occlusions (0.03/1000 days of port observation) and 7 other complications.

CONCLUSIONS

The low incidence of complications suggests that TIAP is safe and reliable for long term intermittent venous access. Our results support the use of TIAP in the oncology patients.

The Impact of IV Connectors on Clinical Practice and Patient Outcomes

It has only been during the past decade that contamination of the intraluminal fluid pathway has gained recognition as a cause of CR-BSI. The IV connector is the gate keeper of the intraluminal fluid pathway. The care and maintenance of catheters is the complete responsibility of the primary nurse. The primary CR-BSI causative agent is biofilm formation. Biofilm formation depends on the number of cells, the presence of surface conditioning and the flow rate of the solution. Staph epidermis, and Staph aureus have surface cell receptors which assist in fibrin, fibrinogen location enabling the microorganisms to successfully adhere. Therefore, intraluminal contamination prevention strategies must be two-pronged - to prevent active and passive microorganism migration into the intaluminal fluid pathway and to prevent microorganism adhesion by minimizing fibrin build-up on the internal surface. The two care and maintenance procedures nurses use to protect the intraluminal pathway are swabbing the connector septum and flushing the connector after use. Individualizing the care based on the patient has not been studied. Since every patient is unique, different catheters and connectors are used, and even the nurse's experience and knowledge are different, achieving consistent positive outcomes using a one-size-fits-all approach has shown to have inconsistent outcomes. An overview of swabbing and flushing is discussed and then how IV connector design affects these practice and outcomes is reviewed. It is imperative to recognize what procedures are performed for improved patient outcomes, versus what procedures are performed to overcome IV connector design features. If flushing and swabbing procedures are standardized to general time requirements alone and connector design is overlooked, it should be understood that outcomes may vary and this variance may not be related to inconsistent nursing adherence to IV connector related swabbing and flushing procedures.