Darcy Doellman

Infiltration and Extravasation: Update on Prevention and Management

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Central venous catheter occlusion: a prospective, controlled trial examining the impact of a positive-pressure valve device

BACKGROUND Central venous catheter (CVC) occlusion occurs frequently in children. This problem is often associated with disruption of intravascular therapy and monitoring. Multiple factors may predispose to catheter occlusion, but reflux of blood into the catheter lumen is a common factor. We hypothesized that use of a positive pressure valve device would reduce the incidence of catheter occlusion. METHODS In phase I of this sequential study design, newly placed CVCs were capped with a standard device. In Phase II, CVCs were capped with a positive-pressure valve device. Data collected included patient demographics, type of catheter, infusate, catheter duration, and complications. Partial and complete catheter occlusions were delineated. A user satisfaction survey was conducted. RESULTS There were 153 children (mean age 48.0 +/- 7.7 months) with 312 CVC lumens enrolled in the study. Mean catheter duration was 9.4 +/- 0.9 days. There were fewer complete occlusions in CVCs capped with the positive pressure valve device than with the standard device [6/161 (3.7%) vs 18/151 (11.9%) occlusions, respectively; p = .012)]. There were no significant differences in partial occlusions, phlebitis, or catheter-related bloodstream infection between the 2 groups. CONCLUSIONS CVCs with a positive-pressure valve cap device have a lower incidence of complete catheter occlusion than those with a standard cap device.

The efficacy and safety of blood sampling through peripherally inserted central catheter devices in children.

Background The peripherally inserted central catheter (PICC) is commonly used in children for medication and fluid administration. In addition, PICCs are used occasionally for blood sampling as an alternative to venipuncture. Blood sampling from these catheters carries the hypothetical risk of catheter occlusion caused by blood remaining in the catheter, and this practice is not supported by PICC manufacturers. Children often undergo multiple needle punctures, which are associated with pain, anxiety, and dissatisfaction with care. The authors hypothesized that blood sampling through 3-Fr PICC devices is effective and safe for children. Methods After placement of a 3-Fr PICC, all the children were sequentially enrolled in one of two groups. The control group included patients that had 3-Fr PICC devices without blood sampling. The blood sampling group included patients with 3-Fr PICC devices through which blood samples were obtained. Demographic data, PICC placement and sampling data, infusate composition, catheter occlusion, mechanical complications, and blood stream infections were recorded. The primary outcome variable was the difference in occlusion rates between the two groups. Results The analysis included 204 children with 3-Fr PICCs (120 in the blood sampling group and 84 in the control group) who had a mean age, 117.7 ± 4.9 months. The mean PICC duration was 15.6 ± 1.0 days. Blood sampling was successful more than 98% of the time from all blood sampling group catheters, with a mean of 4.4 ± 0.5 samples removed from each catheter. There was a higher occlusion rate in the blood sampling group. However, this result did not reach statistical significance. There were no significant differences between the groups in terms of infection or mechanical complication rates. Conclusions Blood sampling is feasible and effective through 3-Fr PICC devices in children. This practice is not associated with a significant increase in occlusion, infection, or mechanical complication rates.

Pediatric peripherally inserted central catheter placement: application of ultrasound technology.

Ultrasound-guided placement of peripherally inserted central catheters has been well documented for adults who require infusion therapy. This same technology is surfacing in the pediatric population to improve outcomes when confronted with the challenges of the smaller vascular system and chubbier body shapes. The scope of practice is addressed in coupling peripherally inserted central catheters with ultrasound imaging, and recommendations are identified for the advancement of nursing practice within the field of imaging technology and application. Obstacles related to successful insertion of peripherally inserted central catheters are defined, and the benefits of ultrasound-guided placement of peripherally inserted central catheters are reviewed.

Peripherally inserted central catheters in children: a survey of practice patterns.

There is little published information describing standards of practice in the placement, use, and maintenance of peripherally inserted central catheter (PICC) devices in children. A Web-based survey tool was designed to query these issues, and 72 intravenous therapy nurses from 72 hospitals provided complete responses to the survey. The respondents were predominantly (81%) from healthcare organizations inserting 40 or fewer PICC devices per month. These hospitals were equally divided in using 0.9% sodium chloride (USP) (saline) or heparinized saline flush to maintain patency, whereas 76% used catheters for blood sampling. Flushing and blood sampling practices were not related to catheter occlusion rates. From their survey, the authors conclude that the standards of practice for 3-Fr PICC devices, the most commonly used for children, are quite variable and in need of standardization for this specific population.

Reducing risk of harm from extravasation: a 3-tiered evidence-based list of pediatric peripheral intravenous infusates.

Extravasation of medications during peripheral intravenous (PIV) therapy can result in harm to pediatric patients. These medications have physical and/or biologic factors that cause tissue damage. To assist in clinical decisions when using these infusates, an evidence-based table of medications stratified by their relative risk of causing harm if extravasated was developed. Local data and experience, a systematic review of the pediatric literature, and measured pH and osmolality of common pediatric preparations of PIV infusates were used to create a 3-tiered table of PIV infusates categorized by relative risk of causing harm if extravasated.

Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric patients.

Central venous catheter occlusions disrupt delivery of needed therapies to vulnerable neonatal and young pediatric patients. Nursing practices that minimize risk of catheter occlusion include proper infusion and flushing techniques. Treatment strategies vary on the basis of the source of the occlusion. Mechanical occlusions can often be resolved by altering the patients position, correcting catheter kinks, or adjusting clamps. Occlusions caused by precipitation can be cleared through instillation of ethanol, hydrochloric acid, or sodium bicarbonate, depending on the chemistry of the infusates. Finally, the thrombolytic agent alteplase is recommended for treatment of catheter occlusion because of thrombus formation.