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