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Many home TPN consumers are preparing to travel to San Diego next week for
the annual Oley Foundation meeting (www.oley.org). Others are planning summer vacations to
beaches, camping, and even abroad. Contact your home infusion pharmacy and let them know your
plans. They will advise you on whether they can ship to your travel location,
or if you have to take supplies with you.
Call ahead to your hotel to check refrigerator availability and size,
and check with airlines for rules about traveling with pumps, medications, and
TPN bags. Create a zip lock baggie of supplies for each day with a
couple extra. Include flushes, syringes,
alcohol swabs, tubing, etc. When it is
time to hook up, just grab the baggie and you will have everything you need
without digging and searching in a suitcase. Take a non-porous tray for a work surface to prepare and
setup TPN. These can be purchased from
any variety, grocery, or home store.
Stainless steel bakery trays or smooth plastic trays (usually with the
summer table items) are good. They are
easy to pack at the bottom of a suitcase and can be easily washed with soap and
water or other antiseptic. Hotels and
camping areas may not have a clean work surface other than the bathroom, which
is not
a good choice. Make sure you have plenty of Purell™ hand sanitizer in the
car, camper, hotel room….everywhere you go! There may not be paper towels or
adequate soap where you are staying.
Avoid hand sanitizers with extra additives and fragrances. Remember friction X 15-30 seconds and allow
to completely dry. Don’t forget to pack the catheter repair kit. Hopefully you
won’t have to use it, but if you have a tear or break in the line, you will be
prepared to visit any hospital or clinic with what you need to get the line
functioning again. Remember, that the
instructions for repair can be easily removed from the outer wrap of the kit
without contaminating the sterile contents.
This will come in handy if the health care provider is not familiar with
the procedure. Lastly, I hope everyone has a memorable summer vacation and
I look forward to seeing everyone at Oley next week!
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Many different types of end caps or adapters are available for home TPN consumers to use on the hub (open) end of their central venous access device. There are needleless, dead end, injection ports, and split septum system caps. All connectors and caps need to be changed on a routine basis. The CDC and INS standards recommend cap change at least once weekly. In some cases, a more frequent change may be indicated.
Before removing, it is important to clean the area where the cap is screwed onto the catheter. Use an antiseptic such as alcohol or chlorhexidine + alcohol in a swab or pad form. Both of these antiseptics are highly effective against bacteria and fungi that may be harboring at the connection. Apply the antiseptic with friction using a twisting motion for at least 15 seconds and allow to completely dry. Cleaning the connection before removing and unscrewing the end cap helps to prevent bacteria from spreading into the open catheter lumen.
Next remove the old end cap. Use a new swab/pad to clean the hub. Use friction and a twisting motion for at least 15 seconds and allow completely dry. Apply the new, sterile end cap.
Remember, when accessing the end cap or hub for infusions, flushing, or medication administration, swab the entire area with friction and a twisting motion for at least 15 seconds and allow to completely dry. Use a new swab for each access. For example, if you flush, give a medication, flush again you have used at least 3 antiseptic swabs/pads!
Excellent hub/end adapter care is a vital, yet easy step a home TPN consumer can take to prevent catheter related blood stream infection.
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On April 15 the Infusion Nurse's Society (INS) sponsored an on-line Webinar entitled "Current Guidelines for Flushing Vascular Access Devices." This was a live presentation by Lynn Hadaway M.Ed., RN, BC, CRNI. Lynn is a well known expert in infusion related topics and has an informative website www.hadawayassociates.com. The Webinar was accessed via personal computer and slides could be viewed while Lynn lectured. E-mailed questions were addressed following the presentation. What a great way to to attend an informative seminar from your home or office!
Lynn identified three patency problems seen with vascular access devices. The first is thrombus or clot material that forms near, within, or around the catheter tip and lumen. Diagnosis for this is sometimes difficult, and requires contrast injection and fluoroscopy. Negative displacement needleless devices and compression of the rubber plunger gasket at the completion of flush can contribute to reflux of blood into the lumen increasing risk of thrombus formation.
In addition, excessive coughing, vomiting and heaving, straining, or heavy lifting can cause blood reflux. Reflux can be reduced by use of a neutral needleless end adapter, or postive pressure flushing technique. This is achieved by maintaining pressure on the plunger near the end of flush, clamping the device, then removing the syringe. Leaving a small amount of fluid in the syringe helps to prevent compression of the rubber plunger gasket into the empty syringe.
The second patency problem identified is drug or lipid precipitate formation. It is very important to notify your infusion pharmacy to check compatibilities of prescribed intravenous medications and TPN solution. Very few drugs can be given simultaneously with TPN. Flushing with 10 ml of sodium chloride between IV medications can help reduce or prevent precipitate. Alcohol flush has been sucessfully used to clear suspected lipid precipitate.
Mechnical causes can affect patency also. These can include kinking, tight sutures, pinch-off syndrome, ballooning, and malpositioned central venous catheters and ports. Each of these problems needs to be assessed and treated individually depending upon the circumstances.
Unfortunaltely there is a lack of solid research supporting flushing practices to prevent or decrease patency complications. We do know that flushing is necessary at the completion of infusions, between and after IV medication administration, and after blood sampling. Sodium chloride is used to flush out medication, blood, or infusion solution residue from catheters. It can be used alone in valved devices or with approved needleless end adapters. Heparin flush is used as a lock to prevent clot formation in the catheter tip. Heparin is available in 10 Unit to 100 Unit concentrations and is usually given in 3-5 ml amounts depending upon the type of catheter used. Several concerns to consider with heparin usage are drug incompatibilities, recent recalls of contaminated heparin vials and syringes, and heparin induced thrombocytopenia. Multiple dose vials for sodium chloride and heparin flushing should be avoided because of their potential for bacterial contamination.
Any of the above three complications will cause resistance when flushing is attempted. Excessive pressure and force may cause catheter ballooning or rupture. A 10 ml syringe should be used for flushing because it generates the least amount of pressure on the catheter wall. Smaller syringes produce a greater flushing force and should be used cautiously.
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Total parenteral nutrition (TPN)
has been identified as a risk factor for catheter related blood stream
infection (CRBSI). Central
venous access devices (CVAD) used to administer TPN provide a direct pathway
for pathogens to enter the blood stream either from skin or hub migration.
TPN solutions are susceptible to
microbial growth because of the necessary nutritional components they contain.
Fat emulsions, amino acids, and dextrose support microbial growth. Temperature, pH, and infusion time may
contribute to bacterial and fungal proliferation. Contamination during compounding is
rare when hospital and home care facilities follow the American Society of
Health-System Pharmacists guidelines for sterile admixing. Microorganisms are usually introduced into the
sterile system from manipulations by clinicians and caregivers during the
administration process.
Intraluminal microbial biofilm
begins to develop shortly after CVAD insertion, gradually forming a denser
matrix over time. Biofilm is a substance in which bacteria and fungi live and grow. Long term
catheters may develop a fibrin sheath or tail at the distal catheter tip and
daily infusion of TPN may contribute to development of central venous
thrombosis. These conditions
involving clot create prime sites near or on the catheter surface for microbial
seeding and eventual infection. Many home
TPN consumers also develop chronic urinary tract infections, or have ostomies
and gastrostomy tubes which are potential CVAD contaminates. Psychosocial issues such as, non-compliance,
drug use, and depression have been shown to increase the home TPN consumer’s
risk for infection.
Coagulase-negative staphylococcus
can be attributed to approximately 60% of CRBSI in the home TPN population,
followed by Klebsiella pneumoniea, staphylococcus aureus, and enterococcus. Candida
parapsilosis, glabrata, and albicans
are frequently cultured from long term central lines used for TPN. Diligent hub care with alcohol and friction
over 15-20 seconds with each flush or tubing hook up has been shown to kill
these bacteria and fungi. Also, use a
new alcohol pad each time a surface is swabbed.
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Several Nutrishare pharmacists, our dietician, and I attended the American Society for Parenteral and Enteral Nutrition (ASPEN) Clinical Nutrition Week in Chicago, IL last month. This conference focuses on topics related to nutritional support in the hospital and outpatient settings. Nutrition experts present a wealth of knowledge for clinicians to take back to their practice.
I presented a nutrition practice poster entitled “Self-Administered Alteplase in a Home Total Parenteral Nutrition Population.” This was awarded Abstract of Distinction and 2nd place in the Home Care section. I will highlight the “take home” information from this poster.
I contacted a group of 36 Nutrishare home TPN consumers who had physician’s orders for alteplase administration in the home setting. Alteplase is a fibrinolytic agent that has been shown to be safe and effective in restoring catheter patency.
Thirteen consumers in Group 1 used alteplase on a routine monthly basis and 23 consumers in Group 2 used alteplase as needed to treat catheter sluggishness or clotting. Group 1 had one clotting episode and 15 sluggish events, and Group 2 experienced 4 clotting and 31 sluggish episodes. All incidences were successfully treated without catheter loss, and no adverse effects were noted. Without home self-administration, a trip to the MD office or emergency room would be necessary, thus delaying treatment. The average distance to treatment was 20 miles with an estimated wait time of 2-6 hours.
Although the difference between the two groups was not statistically significant, this study demonstrates that TPN consumers who are knowledgeable in troubleshooting catheter dysfunction can safely manage this therapy in the home setting. This avoids timely and costly hospital admissions, and reduces exposure to hospital acquired infections and health care providers who are not familiar with access devices. Based on this preliminary data, monthly vs. as needed treatment seem to be equally effective.
Home TPN consumers who experience occasional catheter sluggishness, pump occlusion alarms, and clotting should discuss this therapy with their physician. With instruction and oversight from a nurse or pharmacist, self-administered alteplase is a safe and effective home therapy.
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Access devices are becoming more and more complex with various materials and configurations. A new product recently developed by Bard Access Systems™ (C.R. Bard, Inc. Salt Lake City, Utah) is called a PowerPICC Solo Catheter™. This catheter is inserted in the same manner as other peripherally inserted central catheters (PICC's) and is made of polyurethane. This PICC has a valve in the hub that simplifies care and maintenance. It can be maintained by flushing with sodium chloride (normal saline) once weekly when not in use. Following infusion of TPN, antibiotics, or other medications, it is flushed with sodium chloride only. Heparin is not needed because of the valve, which reduces blood reflux. This may also limit the risk of heparin induced thrombocytopenia (HIT). In addition, there is no clamp and neutral or positive pressure end caps may be used. It comes in single, double, or triple lumens and is purple and blue in color. Home TPN consumers often have PICC’s placed for short term therapy or during catheter related bloodstream infection until a permanent catheter can be replaced. With all the different catheters now available, it is very important to get an identification card any time a new line is placed. Never assume that the PICC you had placed last year is the same make and model as the one you get today. Knowing exactly what catheter you have helps to define the type of care and flushing it needs.
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One of the most common complications associated with TPN is catheter related blood stream infection. In most instances this requires hospitalization. This always has been and will continue to be a hospital stay that is covered by insurance benefits. In October 2008, Medicare is changing reimbursement for preventable complications that occur during hospitalization. This means that if a home TPN consumer is admitted for another reason and a catheter related blood stream infection occurs during the hospitalization, Medicare considers this episode preventable and will not reimburse the institution for care associated with this infection. The hospital cannot bill the consumer for these un-reimbursed charges. A hospital acquired blood stream infection increases length of stay an average of 7 days, with an estimated cost of $10,000 - $30,000. Not receiving reimbursement for this extra care has created an incentive to hospitals nation-wide to identify strategies to reduce hospital acquired blood stream infections. This becomes a win-win situation for the home TPN consumer who commonly sees health care providers in hospital and clinic settings use poor aseptic technique during catheter care and accessing. Over the last several years, hospitals have begun to implement “Care Bundles” which are evidence based best practices that when applied as a group have shown to significantly improve care and reduce complications. The key components of the “Central Line Bundle” are: - Hand Hygiene
- Maximal barrier precautions during catheter insertion
- Chlorhexidine skin antisepsis
- Optimal catheter site selection
- Daily review of line necessity and prompt removal of unnecessary lines
- Scrupulous hub care
These apply to short term, hospital appropriate central lines, but are applicable to a home TPN consumer who is in the hospital and needs an additional short term line or temporary access until a tunneled catheter or port can be placed. In the home, hand hygiene is also the first defense against infection. Maximal barrier precautions include work area and surface preparation, which is so important with admixing and hook up. Hub care with friction, 10-20 seconds, and drying should be practiced with each device access, and chlorhexidine is superior for exit site and port access site care. I recently heard presentations from several hospitals who have achieved significant reduction in infection rates by implementing catheter care bundles: Johns Hopkins, University of Pittsburgh Medical Center, Missouri Baptist Medical Center, St. Joseph’s Hospital, and Sutter Roseville Medical Center. These “back to the basics” strategies are not new to health care providers, but extensive re-education along with surveillance and commitment from hospital administrators have allowed these hospitals to achieve nearly zero infection rates in their intensive care units and with their catheter insertion and care teams. Implementation of catheter care bundles should increase awareness of health care providers and allow HPN consumers to receive safer, quality access device care when hospitalization is necessary.
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Silicone tunneled catheters may develop ballooning or bulging during infusion and flushing which indicates a weakened catheter wall. This ballooning is usually noticed at the end of the catheter before the thickened area at the hub, or on double lumen catheters at the “Y” area. Polyurethane catheters (PowerLines™) are made of a more durable material and will not balloon.
A weakened wall may occur on new as well as old catheters. The weakening may be a result of forceful flushing, sluggishness, or clotting, but most of the time it is unclear why it happens.
If a home TPN consumer notices bulging or ballooning of their catheter, a repair should be scheduled as soon as possible. The catheter may be gently and cautiously flushed. Observe the tubing during infusion. If bulging is large, you may need to lengthen the TPN cycle so that the solution goes in at a slower rate, creating less pressure on the catheter wall.
Repair requires a kit ordered from your catheter manufacturer. When a new catheter is placed, obtain the identifying information and order your repair kit from your home infusion pharmacy.
A catheter repair procedure can be performed by a skilled home nurse, a physician’s office, hospital radiology department, or emergency room. This is a sterile procedure that usually requires two people to complete. Unfamiliar clinicians have easy access to the instruction sheet located on the top of the package. Removing the sheet does not compromise the sterility of the repair kit contents. Additional supplies such as flushes, gloves, and masks will need to be assembled before starting.
It is a good practice to observe your tunneled catheter tubing and site frequently, even when flushing and infusing TPN. A watchful eye can many times prevent a full tear or hole.
For additional information on catheter repair see my "Springing a Leak" blog dated 9/20/06.
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Securing a tunneled catheter that hangs from the chest or
abdominal area can be challenging for the home TPN consumer. There is a very high risk for contamination
and subsequent catheter related blood stream infection when catheter tubing
hangs near an ostomy, gastrostomy tube, or diaper. Tubing that gets tangled in clothing or
caught on various household furnishings can cause chronic pulling at the exit
site with eventual irritation or infection.
Numerous different methods are available to secure a
tunneled catheter. A securing loop can
be placed under a transparent dressing or taped into place. Catheter securing devices are available with
snaps or Velcro strips. These have a
sticky backing and should remain in place for about a week. Sometimes the devices are rather large, but
can be trimmed to fit a smaller frame.
Some consumers like to secure their catheter to the shoulder area and
route the tubing down their back or arm.
This keeps the catheter totally away from ostomies and tubes. For children and infants, there are a few
cloth wrap-type devices that have been created by parents for their
children. For women, a bra works nicely
for coiling and tucking tubing. Men
should avoid shaving chest hair and instead, trim the hair with scissors before
applying tapes.
These are just a few ideas that are available to assist with
catheter positioning. Keeping the tubing
as clean and isolated as possible, and away from fecal or gastric contamination
greatly reduces the risk for catheter related blood stream infection.
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Home TPN consumers self-administer a highly technical
infusion therapy. They are very
knowledgeable about pumps, tubings, syringes, medications, aseptic technique,
and complication troubleshooting. Many
HPN consumers perform all aspects of their care independently, without the help
of a back-up caregiver. Although, taking
charge of one’s health and well being is admirable, it is always a good idea to
have another person who is also familiar with the procedures and routines.
Illness or injury can occur unexpectedly at any time. There may be occasions when a HPN consumer
may not be able to communicate or care for themselves, and a back-up caregiver
becomes invaluable. Choose someone who
lives with or near you and is available and willing to accept responsibility
for your care in the event of an emergency. Spend time reviewing the regimen
and actually let them perform the TPN hook up from time to time so it remains
familiar.
Never assume that friends and family who watch you with
TPN could actually administer it without your help. Plan today to identify and train your
emergency back-up helper
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