Management of central venous catheters in pediatric onco-hematology using 0.9% sodium chloride and positive-pressure-valve needleless connector
Introduction
The increasing complexity of hospitalized patients has led, over the past thirty years, to widespread use of central venous catheters (CVC), even outside the context of specialized intensive care units (Bowers et al., 2008). In particular, CVC use was implemented to ensure a medium to long term venous access in order to avoid repeated cannulation of peripheral veins (especially in children) and to administer sclerosing or hyperosmolar chemotherapy (Hoffer et al., 1999). The benefits associated with the use of such devices are widely demonstrated even if their use is not without risks (Mayo, 2001, Fuentes i Pumarola et al., 2007, Baskin et al., 2009, Cesaro et al., 2009).
Occlusion is one of the most frequent non-infectious complication related to the use of CVC and ranks among the leading causes of morbidity, mortality and rehospitalization for both adults and children (Krzywda, 1999, Polderman and Girbes, 2002, Ryder, 2006). It has been estimated that occlusion occurs in up to 25–29% of the CVCs (Stephens et al., 1995, Jacobs et al., 2004, Fratino et al., 2005, Schilling et al., 2006, Mitchell et al., 2009). The loss of luminal patency is associated with delays and interruptions in delivery of therapy thus compromising the quality of therapeutic care (Polderman and Girbes, 2002).
In literature, available evidence on preventive interventions to maintain patency of CVCs is weak. Systematic reviews, addressing flushing solutions (0.9% sodium chloride pure or supplemented with heparin), heparin bonded catheters and positive pressure caps, concluded that evidence on these interventions is small. Published studies are of low quality and include small sample sizes (López-Briz and Ruiz-García, 2005, Mitchell et al., 2009). Thus, it is unclear what is the more effective intervention to prevent CVC occlusive complications and further research is needed (López-Briz and Ruiz-García, 2005, Mitchell et al., 2009). As a result of this uncertainty, procedures on CVC management are based mainly on professional consensus and on manufacturer recommendations, and vary substantially between institutions (Mitchell et al., 2009).
The aim of this observational study is to describe, in pediatric onco-hematological patients, the rate of occlusions in unused CVC flushed once a week with a 0.9% sodium chloride solution through a positive-pressure-valve needleless connector. Secondary objectives are to assess the effectiveness of disocclusion interventions and to evaluate the association between some possible explanatory variables and the emergence of the occlusion.
Section snippets
Materials and methods
This retrospective cohort study was conducted at the Pediatric Onco-Hematology unit of the Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, a third level scientific research institute located in Trieste (North-eastern Italy).
Through a manual search in medical and nursing records of the Pediatric Onco-Hematology unit, subjects with the following criteria were identified and included in the cohort:
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children, aged 0–17 years, with onco-hematological malignancy and treated in Day
Results
Fifty-one patients were identified and included in the cohort. Table 1 describes the main characteristics of the identified patients and of the their CVCs.
During the follow up period, 247 outpatient (Day Hospital) visits were carried out. The median duration of follow-up was 169 days (IQR 111–305). During the follow up period, in 17 subjects (33%) the CVC was removed (15 ended the chemotherapy, 1 presented a CVC displacement and 1 a CVC infection) and nine children (18%) resumed continuous
Discussion
The results of this study show that a protocol for the prevention of endoluminal occlusions, including the flushing with 0.9% sodium chloride using a pulsatile technique followed by catheter closure with a positive pressure valve, is associated with a percentage of occlusion of 27%. Complete occlusion occurred in 4% of the children included in the study. These findings are consistent with those reported in literature (Stephens et al., 1995, Jacobs et al., 2004, Fratino et al., 2005, Schilling
Limitations
The main limitation of the study is related to its observational and retrospective design. A loss of information on variables and outcomes of interest is possible due to incomplete filling of the medical and nursing records. Furthermore, families could go to other hospitals of our Region for problems related to the CVC. However, we believe that this risk is very low, given that ours is the only pediatric onco-hematological ward in our Region (Friuli Venezia Giulia). So, we assume that the CVCs
Implications for clinical practice
This study, entirely designed and conducted by clinical nurses, shows the adequate performance of the adopted protocol for the prevention of endoluminal occlusions: 1) the occurrence of occlusions is consistent with data reported in literature; 2) only a limited number of children had a complete occlusion; 3) all the occlusions were resolved with pharmacological treatment, without the need for catheter removal, avoiding a possible discontinuation of treatment and the need for new CVC insertion.
Implications for research
To clarify the role of maintenance procedure for central venous access devices, such as flushing with saline and the use of pressure valves, prospective studies, well designed and of adequate sample size, are needed.
Conclusions
The prevention of CVC occlusions is a strategic key to improve health care outcomes and quality of care in onco-hematological children. Consequently, maintaining the patency of central lines is a primary objective of care for these children and represents a specific nursing competence. Different interventions have been proposed to achieve this goal but evidence available from systematic literature reviews is scanty and inconsistent, making it difficult to identify the most effective
Conflicts of interest statement
None declared.
Role of the funding source
The study was part of a Research Project (n° 26/11) funded with internal funds from the Institute for Maternal and Child Health – IRCCS “Burlo Garofolo”, Trieste, Italy.
Acknowledgment
The authors thank for the collaboration ensured all the nurses and the doctors of the Pediatric Hematology Oncology Unit of the Institute for Maternal and Child Health – IRCCS “Burlo Garofolo”.
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