0:03 welcome to part 4 the smartpen video
0:06 series today's program focuses on venous
0:09 catheter selection care and complication
0:12 prevention my name is Pat Worthington
0:13 I'm a nutritional support clinical nurse
0:15 specialist at Thomas Jefferson
0:17 University Hospital in Philadelphia
0:22 Pennsylvania I'd like to point out that
0:24 Aspen does not endorse any products that
0:28 may appear during this presentation this
0:30 is a scenario that we all commonly
0:32 encounter the pharmacy receives an order
0:34 to begin parenteral nutrition for a
0:36 patient the peon indication appears to
0:38 be appropriate but what about the
0:41 vascular access there are many options
0:44 for vascular access available to us each
0:45 with distinct advantages and
0:47 disadvantages many factors come into
0:49 play in the decision which we'll take a
0:51 look at us and go along but it's
0:53 important to keep in mind that the
0:54 selection of the most appropriate
0:57 vascular access is the foundation for
1:01 safe and effective PN therapy decisions
1:03 regarding the most appropriate vascular
1:05 access device should be individualized
1:06 based on a number of patient centered
1:08 criteria and these include the health
1:10 care setting where PN therapy will take
1:13 place the risks versus benefits of each
1:15 device and clinical factors such as the
1:18 presence of an infection the need for
1:21 concurrent IV therapies or the presence
1:23 of a condition such as renal failure
1:24 where it's important to preserve the
1:26 upper extremity veins in case that
1:29 dialysis is needed in the future the
1:31 patient's developmental stage is another
1:33 factor what works for an adult may be
1:35 totally inappropriate for a baby or
1:38 child the anticipated duration of
1:41 therapy is factor and the complexity of
1:43 post insertion care should be taken into
1:46 consideration for long-term TPN the
1:49 patient's views concerning what type of
1:51 device they would like is also an
1:53 important consideration in this decision
1:57 and now let's go back to our scenario
1:59 remember the pn indication seemed
2:01 appropriate but now you learn that the
2:03 patient has only a peripheral IV and
2:05 that raises the question is pn
2:07 administration by peripheral vein ever
2:10 appropriate historically peripheral pian
2:13 or p pn has been viewed on favor
2:15 because formulations are often
2:17 hypocaloric this is due to the
2:19 osmolarity limits imposed by peripheral
2:21 veins and it stands out as the primary
2:24 disadvantage of ppm on the other hand
2:26 PPN has the advantage of avoiding the
2:28 need for central line which has become
2:30 an important priority in today's
2:33 healthcare environment in addition the
2:35 current osmolality limit of 900 million
2:38 moles per liter allows better nutrient
2:40 pervasion than we were able to do in the
2:43 past but PPN still requires relatively
2:45 large fluid volumes and the formulation
2:48 cannot be concentrated the osmolality
2:50 constraints still restricting
2:53 electrolyte content of the formulations
2:55 and a frequently overlooked but
2:57 fundamental component is that PPN
3:03 requires adequate venous integrity so
3:05 what recommendations can we make about
3:08 the appropriate use of ppm first PPN
3:10 should be used to prevent rather than
3:12 correct nutritional deficits it's
3:14 important for clinicians to conduct an
3:16 assessment of protein and energy needs
3:19 before starting PPN in some cases PPN
3:24 can meet patient's needs but we want to
3:25 make sure that we're not under feeding
3:28 patients consider PPN as a bridge
3:30 therapy during transitions for example
3:32 when oral or a neural intake is
3:35 suboptimal when there's a need to avoid
3:38 central venous catheter placement for
3:40 example in patients who have fever or
3:44 coagulopathy or when the anticipated
3:47 duration of PPN is no more than 10 to 14
3:51 days we want to avoid PPN in-home care
3:53 due to the difficulty of maintaining IV
3:56 access and there's there's an
3:58 interesting question about whether or
4:00 not a midline catheter which has a
4:02 longer dwell time than a traditional IV
4:06 would serve as a good option for PPN
4:08 however that question requires further
4:10 study and we really don't have an answer
4:15 at this point now let's look at
4:17 guidelines for choosing the most
4:19 appropriate vascular access for central
4:21 pn there's a few general principles that
4:24 apply choose the smallest device with
4:26 the fewest number of lumens that
4:28 meet the patients and Fusion needs
4:31 dedicate one lumen of the device for P
4:33 an administration whenever possible and
4:35 this serves two purposes first it
4:37 decreases the amount of manipulation the
4:39 line will receive and second it avoids
4:42 Co infusion of potentially incompatible
4:44 medications with the complex peon
4:47 formulation there's there's no need to
4:51 insert a new lines for PN and finally
4:53 the tip of the catheter should rest in
4:55 the distal superior vena cava at the
4:57 junction between the vena cava and the
5:02 right atrium as I noted earlier there
5:04 are many options available for vascular
5:06 access for administering central PN and
5:09 we're going to we will go over a few of
5:11 them here first is the percutaneous non
5:14 tunneled central catheter these can be
5:16 inserted easily at the bedside and
5:18 replaced over a guide wire if needed
5:20 they're most appropriate for use in
5:22 acute care settings and they're the
5:25 preferred access for up to about 14 days
5:27 however they're not suited for home care
5:29 they require sutures or a securement
5:32 device to prevent dislodgement and they
5:33 carry a high risk for catheter related infections
5:35 infections
5:37 next is the tunneled cuffed catheter
5:39 these are catheters most frequently
5:42 referred to as Hickman or broviac type
5:44 catheters they're placed surgically or
5:46 with fluoroscopic guidance and they're
5:48 inserted through a tunnel a subcutaneous
5:50 tunnel in the chest wall there's a
5:53 Dacron cuff under the skin that adheres
5:56 to the subcutaneous tissue and the
5:57 primary advantage of these catheters is
6:00 that the cuff within the tunnel may
6:02 decrease the risk of infection from
6:04 migrating organisms along the outside of
6:06 the catheter and helps to prevent
6:08 dislodgement there's no restrictions on
6:10 upper extremity activity and the
6:12 position the position of the catheter on
6:15 the chest wall facilitates self-care it
6:17 can be easily hidden under clothing as
6:20 well these are best used for long-term
6:23 TPN three months up two years the
6:25 disadvantage of these devices is that
6:28 they require a surgical procedure at the
6:31 bedside or in an outpatient suite for
6:32 removal I'm not gonna be a big
6:36 disadvantage to patients who are at home
6:40 on TPN so this is an illustration
6:42 of a percutaneous non tunnel catheter
6:44 you can see this one is a double-lumen
6:47 device and it uses an approach through
6:50 the subclavian vein which is common but
6:52 you also see these catheters placed
6:55 through the internal jugular vein that
6:59 you see there in the neck here's an
7:01 illustration of a tunneled cuffed
7:04 catheter the dotted portion you see on
7:05 the chest wall represents the
7:08 subcutaneous tunnel with the small cuff
7:10 there at the end this is a single lumen
7:14 device also using a subclavian approach
7:17 but an internal jugular approach is also
7:22 possible with this type of device now we
7:24 come to two more categories of central
7:26 lines the first is the peripherally
7:28 inserted central catheter these devices
7:31 have been come really common through it
7:32 on all healthcare settings
7:35 largely due to the ease and safety with
7:36 which they can be inserted and removed
7:40 they are appropriate for short and
7:43 medium-term TPN and they can be removed
7:46 simply either at the bedside or even at
7:48 home when the line is no longer needed
7:51 the key disadvantage of the PICC line is
7:53 that it increases the risk for upper
7:56 extremity deep vein thrombosis the in
7:58 addition to that the antecubital
8:01 placement of the insertion site hinders
8:03 self-care it's hard for patient to
8:06 manage dressing procedures when one of
8:08 their hands using just one hand and in
8:11 some cases there may be activity
8:14 restrictions on the arm that has the
8:17 line in place so that can be a big
8:19 disadvantage for certain patients
8:22 finally we come to implanted ports with
8:25 an implanted port the central catheter
8:29 is attached to a chamber that's that's
8:32 inserted into a pocket and into the
8:35 subcutaneous tissue usually on the chest
8:38 wall these devices are ideal for low
8:40 frequency intermittent access and they
8:42 carry the lowest risk for central line
8:44 infection primarily because they're
8:46 covered by a skin barrier and not open
8:49 to the environment these are suitable
8:51 for PN and selected circumstances
8:53 motivated patients can wear
8:57 access procedures with with ports the
8:58 body image remains intact because
9:02 nothing is visible when the line is not
9:04 accessed and it requires no local sight
9:07 care when the device is not accessed the
9:09 biggest disadvantage of the of the
9:12 device of an implanted port is that
9:16 needle access is required so for daily
9:18 use this procedure can be difficult for
9:20 many patients dislodgement of this
9:22 needle can result in infiltration so
9:25 that's a risk factor the need for an
9:27 indwelling catheter for continuous or
9:30 daily TPN generally offsets the reduced
9:32 infection benefit because now you have a
9:34 needle that's that's exposed to the
9:38 outside environment ports requires
9:40 surgical a surgical procedure for
9:44 removal so if there's a high infection
9:46 rate physicians will be reluctant to
9:48 insert a port with the idea that the
9:51 patient will need this to be removed
9:53 potentially in a short time in the
9:59 future this drawing shows a PICC line
10:02 notice how far this catheter travels
10:03 within the vein to reach the central
10:05 venous circulation this is the biggest
10:07 difference between this device and other
10:09 types of central venous catheters
10:12 despite all the advantages that PICC
10:14 lines bring it would not be accurate to
10:15 assume that they represent the gold
10:18 standard for IV therapy this is because
10:19 PICC lines pose a greater risk for deep
10:21 vein thrombosis than other types of
10:23 central lines this can be a serious
10:26 complication opera Stremme aney
10:27 thrombosis can lead to pulmonary
10:30 embolism and patients with upper
10:32 extremity DBT may require therapeutic
10:35 anticoagulation for several months for
10:37 patients who are PN dependent repeated
10:39 episodes of thrombosis can lead to the
10:42 loss of sites for vascular access which
10:45 is a common reason for referral to too
10:48 small bowel transplant centers here we
10:50 have an implanted port the dotted
10:52 portion the drawing represents the
10:54 portion of the device that's under the
10:57 skin this also depicts a single lumen
10:58 port but they're available in double
11:00 lumen where you have two chambers that
11:06 to move on to central venous catheter
11:08 complications in general these problems
11:11 can be divided into two categories those
11:13 related to the insertion of the device
11:15 and problems that arise during the
11:18 maintenance phase of care in terms of
11:20 insertion related complications the
11:23 first we see our bloodstream infections
11:25 that occur in the first five days after
11:28 insertion these infections are thought
11:30 to occur due to breaks and technique
11:32 during during the insertion itself and
11:34 they're much less common now with the
11:36 development of very explicit insertion
11:38 guidelines you may have heard of
11:41 insertion bundles and they spell out a
11:43 series of steps that should be in place
11:46 during insertion and they've made this
11:48 type of infection much less common
11:51 injuries can occur during insertion such
11:53 as pneumothorax or arterial puncture and
11:56 these risks have been reduced with the
11:58 widespread use of ultrasound for
12:01 insertion catheter tip placement occurs
12:03 with certain amount of frequency and
12:05 although it's not immediately dangerous
12:07 to the patient it does require
12:09 repositioning of the catheter and an
12:11 unnecessary manipulation which could
12:14 lead to complications down the road in
12:16 terms of maintenance complications the
12:18 greatest risk we have is bloodstream
12:20 infection that occurs more than five
12:23 days after infection in this case the
12:25 bacteria rather than migrating along the
12:27 outside of the catheter are actually
12:29 found in the lumen of the catheter and
12:31 that's the mechanism of infection about
12:34 72 percent of central line infections
12:36 occur through contamination of the hub
12:40 and an internal migration of organisms
12:43 this highlights the importance of hand
12:46 hygiene and aseptic management of the
12:48 hub and injection ports which we'll talk
12:52 about it and a little bit finally there
12:54 are mechanical complications which can
12:59 occur at any time during during the life
13:00 of the line and these can include
13:03 catheter occlusion which may respond to
13:05 treatment or breakage which probably
13:13 so now let's turn attention to
13:14 preventing these complications
13:17 associated with central lines on the
13:18 slide you see
13:22 categories of intervention that are
13:24 designed to prevent specific
13:26 complications the first component is
13:29 review the necessity of the line in
13:32 acute care this is occurs on a daily
13:34 basis but for those of us who are
13:36 involved in nutritional support it also
13:38 means we need to ensure prompt
13:42 transition to oral an internal intake to
13:45 avoid excess P in days then we have
13:47 management on the infusion system this
13:49 involves the tubing and the connections
13:52 and the primary intervention is to be
13:55 consistent with adherence to hand
13:58 hygiene practices we need to avoid
14:01 manipulation or disconnect disconnection
14:02 of the line for routine care or
14:05 ambulation change the peon
14:07 administration tubing every 24 hours
14:10 which is more frequently than is done
14:13 for standard IV therapy and consider a
14:15 prohibition on blood drawings for PN
14:17 recipients which represents a really
14:19 high-risk form of manipulation of the
14:23 system there's next care of the
14:27 insertion site in in recent years we've
14:30 shifted from skin antisepsis with
14:32 povidone-iodine to chlorhexidine which
14:35 seems to have a significant beneficial
14:37 impact on central line infections and
14:40 they're in acute care particularly in
14:44 ICU chlorhexidine bathing is done to
14:47 prevent central line catheter infection
14:49 sterile dressing should be in place on
14:52 all lines transparent dressings are
14:53 pretty much the standard of care and
14:56 they've changed every 7 days the patient
14:58 can't tolerate a transparent dressing
15:01 godswood be used and they need to be
15:02 changed every two days or if the
15:05 dressing is compromised loose moist or
15:06 with drainage
15:09 it's better to use a securement device
15:12 then then sutures if possible because
15:14 they can serve as an Ida store infection
15:18 and if central line infection rates
15:21 remain high despite all these standard
15:23 measures you might want to consider
15:26 using a chlorhexidine patch or a
15:28 dressing with a chlorhexidine square
15:31 embedded in it
15:34 finally care of injection ports and the
15:36 catheter hub this is the most specific
15:39 intervention to prevent that internal
15:41 contamination that I talked about all
15:43 ports should be cleansed and needleless
15:46 adapters should also be sterilized using
15:50 alcohol or chlorhexidine with every
15:52 access these are known as scrub the hub
15:54 protocols and you'll hear them talked
15:57 about in cases where infection rates
16:00 remain elevated despite these measures
16:02 they now make caps that are impregnated
16:04 with alcohol which could serve as
16:07 passive disinfection for for the
16:09 catheter hub and needleless adapters as
16:12 in terms of flushing and locking
16:15 catheters most organizations have pretty
16:18 much standardized flushing protocols in
16:20 place with saline or heparinized saline
16:23 we use heparin much less now due to
16:25 concerns about heparin induced
16:28 thrombocytopenia all PN and
16:30 administration tubing should be flushed
16:33 beef with sailing before and after
16:35 medications are given before and after
16:38 the parenteral nutrition is initiated
16:41 and then consider using an ethanol lock
16:44 for selected PN recipients or at high
16:46 risk for infection complications and
16:48 this is very commonly used in patients
16:50 and pediatric patients and babies who
16:56 are on long term parenteral nutrition so
16:57 to summarize what we've talked about
16:59 today I'd like to highlight three points
17:01 first selection of the appropriate
17:03 vascular access device for parenteral
17:05 nutrition is the key to safe and
17:08 effective therapy decisions regarding
17:10 the choice of vascular access device
17:12 should be based on many patient centered
17:15 criteria and proper vascular access
17:16 device placement and vigilant
17:18 maintenance is associated with fewer
17:22 complications we've provided references
17:24 here for further information on the
17:29 topics that we've discussed today this
17:31 educational offering was provided to you
17:33 by Aspen and supported by an educational
17:37 grant provided by Baxter healthcare I
17:40 invite you to learn more about Aspen and
17:41 the resources available to you by
17:43 visiting the websites that you see on
17:44 this slide the you
