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МЕаииПНСКПЕ НАУКИ
PORT-A-CATH-INDICATIONS FOR USE AND NURSING EDUCATION
Sherbanov Ognyan
Medical Doctor, Philosophy Doctor, Chief assistent Ruse University ' 'Angel Kanchev ", Ruse, Bulgaria
SUMMARY
Hospitalized patients frequently require vascular access for different clinical indications. This access can be through peripheral or central vein. Well known fact is that central catheters have many advantages over the peripheral ones, but also more complications concerning insertion and maintenance. Their insertion allows infusing large volumes of fluids, blood products, drugs. They can be maintained long period of time. Totally Implantible Venous Access Devices (TIVAD) or port-a-caths are subcutaneous devices which are inserted for several indications. The technique is a surgical procedure. It has contraindications and many complications. Once implanted, the port requires special maintenance and managing by the nursing team and patient himself. For this purpose a well training and nursing education are necessary. In the article bellow we share the literature review and our experience on teaching future nurses and midwifes how to care about patients having ports.
Key words: education, nursing care, port-a-cath, totally implantable venous access devices, training
ПОРТ-А-КЯТ -
ПОКАЗАНИЯ ДЛЯ ИСПОЛЗОВАНИЯ И МЕДСЕСТРИНСКОЕ ОБУЧЕНИЕ
Шербанов Огнян
Врач, доктор по медицине, главный асистент Русенский университет "Ангел Кънчев', Русе, Болгария
АННОТАЦИЯ
Сосудистый доступ требуется у больных, госпитализированных по различным клиническим показаниям. Он может быть периферической или центральной вены. Центральные катетеры имеют много преимуществ по сравнению с периферийным. Они надежный метод вливание больших объемов жидкостей, продуктов крови, и лекарственных средств. Они могут быть сохранены в течение длительного периода времени. Полностью Имплантируемые Венозные Устройства или порт-а-кят,представляют подкожные устройства, которье вставляются в течение нескольких показаний. Методика является хирургическая процедура. Сама по себе она имеет противопоказания и много осложнения. После имплантации, порт должен быть в хорошем состоянии и надо управляется медсестер. Для етого хорошей подготовки и образования необходимы. В статье мы разделяем данньй литературе и наше преподавания будущих медсестер и акушерок, как заботиться об этих устройствах.
Ключевые слова: медсестрински уход, обучение, порт-а-кят, имплантируемые венозные устройства, поддерживание
INTRODUCTION
Vascular access is often required in hospitalized patients, for plenty of clinical indications. During the last decades technologic advances in vascular catheters give medical specialists many options for vascular access. In pediatric and adult population, they are the following : Peripheral intravenous (IV) access; peripherally inserted central catheter (PICC); percutaneous polyethylene catheter or silicone central venous catheter (eg. Hickman, Broviac, Leonard, Groshong, Quinton); implantable vascular access device (ports, port-a-cath, Infusaport, Mediport); intraosseous; venous cutdown. The first two accesses devices are for a short period of use and the other three are for a long term usage. The last two modes of access are mainly used in emergency cases. The decision to obtain vascular access sometimes is a major challenge to the medical team. Physicians must consider the indications for catheter's use or factors such as patient's age, size of vessel, availability of venous access sites and the anticipated length of use. Peripheral vascular catheters may be used for various indications: samplings for laboratory tests, infusion of
fluids, blood and medications. They cannot be used for a long period of time for chemotherapy and total parenteral nutrition (TPN) because of local venous irritation, destruction and infections. As general, vascular access is considered a safe procedure, but with many complications, some of which can be life threatening [11].
PRESENTATION:
Well known fact is that central venous catheters (CVCs) have many advantages over peripheral lines. Their insertion is a reliable method of infusing large volumes of fluids, blood products, TPN, different kind of drugs and they can me maintained for rather long time. Another advantage is a possibility to e use them for critical - care monitoring. The history is old. In 1973 the first long- term CVC was used for parenteral nutrition. The Hickmann catheter was used for chemotherapy for the first time in 1979.
General indications for central venous access may include administration of the following:
• Critical- care monitoring (of pulmonary wedge pressure) and medications (inotropes)
• Emergency access (for managing trauma or cardiopulmonary arrest)
• Chemotherapy
• Treatment of chronic pain
• Total parenteral nutrition
• Repeated venous punctures in chronically ill, for blood sampling and medications
• Long - term antibiotics (more than 3 -4 weeks)
• Patients with haemophyllia and other blood disorders
• Chronic haemodyalisis
• Patients with immunodeficiency
• Need for stem cell collection, plasmapheresis and bone marrow reinfusion
• In bariatric surgery
• Patient preference
Totally Implantible Venous Acess Devices (TIVAD), called also Port - a - Cath or subcutaneous ports, are used in patients who need repeated long term intravenous therapy. In most of the cases other forms of venous access are impossible or very difficult. Ports eliminate many of the problems associated with CVCs: infection, restriction of daily activities, altered body image, need of frequent dressing changes, etc. The use of implantible ports has grown tremendously since their first use in 1981. The first recipients of these ports were the oncology patients.
It is necessary the medical staff, patients and their careres to have knowledge and training to use these systems in home. (Cochrane Library 2010). Percutaneous tunneled external catheters are preferable for patients who require continuous or frequent venous access for blood drawing, supportive therapy or receiving potentially toxic drugs. Peripherally placed central venous access devices are useful in patients who need single, continuous infusion therapy such as antibiotics, fluid rehydration, pain medication. They are very suitable in cancer palliative care.
Ports consist of three parts: The portal - a small plastic or titanium chamber, sealed at the top with a sil-icone septum, with single or double lumen. It withstands from 1000 to almost 3600 punctures with a Huber point needle preferably. The gauge of the needle is selected dependent on type and rate of infusions and the port placement. Plastic and titanium ports are compatible with MRI [9]. The catheter - it is thin, flexible made from silicone or polyurethane. The catheter connector - is a small part which connects the catheter to the port.
The design and the materials used for each components of the system, depend on the producer choice and indications of use. There are various size of catheters depending on patients age. The duration of stay vary due to the frequency of use, number of punctions and complications. According to some publications TIVAD are used for 2 or more years or 2000 to 3000 punctures, [1,7,8]. The insertion sites can be: the right and left internal jugular vein; subclavian vein; the femoral vein; the brachial and cephalic veins.
The main purpose of a port is to infuse directly into a vein, different types of medicines and fluids for
a long period of time. The advantages of using such a device include:
• The port can stay in place from months to years. This eliminates pain and reduces the time spent for accessing a suitable vein
• All kind of drugs can be administered through the port - antibiotics, chemotherapy, parenteral nutrition, etc. The system is placed in a large vein and the medicines get diluted quickly and efficiently, causing less damage to the surrounding tissues. Another important fact is that more than one type of medication can be administered at the same time using double port system
• Frequent blood samples can be get
• The risk of infections is lower compared with IV that sticks out through the skin
• The patient's blood can be easily accessed for any kind of treatment at less pain and discomfort
It is always inserted in the hospital operation theatre or in outpatient surgical clinic, diagnostic imaging and X- ray department. The device placement should always be an elective procedure performed under sterile conditions. The insertion may be performed under general or local anesthesia. General anesthetic techniques include conscious sedation with opiates and benzodiazepines or general anesthesia with different types of drugs. It is preferable in children. This technique can be combined with local anesthesia. The choice of anesthesia type depends on patient's condition preference and doctor's experience. The catheter is thread into the vein under x- ray and ultrasound guidance. The doctor must be sure that the tip of the catheter reaches the superior vena cava. Then a reservoir is placed under the skin through an incision and is connected with the catheter. The reservoir looks like a bump under the skin. It can be placed under the clavicular bone or on the arm, which depends on the access. A chest x- ray is recommended after the end of the procedure. It makes the clinicians sure the catheter is placed exactly in the right place and no lung complications appeared during the manipulation. Most of people go home in the same day after the insertion unless they need to stay in hospital for any other medical reasons. About 10 to 14 days are needed to heal the operation wound after the port placement, a period in which patient's daily activities are a little restricted. Thus people should be well informed about the discomfort, pain and need for some special actions.
Inserting port is mostly a safe procedure. Like any surgical intervention, it may have some risks and complications connected with patient's general condition and the team training. The physicians should have thorough knowledge of the anatomy or the chosen region and of the potential complications from the procedure. Patient's preoperative evaluation should be undertaken. Special attention desires coagulation studies and to the placement of previous vascular access devices. All collected data should be documented on patient's chart and informed consent must be obtained. Other measures to reduce complications include: proper patient positioning on the operation table, adequate assistance, fluoro-scopic or ultrasound guidance. Patient preference for insertion site, lifestyle and activities are very important
as these devices remain in place for several years. TIVAD (ports) require minimal care when they are not accessed. Port should be very well managed in aseptic manner in order to prevent late complications. The catheter must be flushed after each use with heparin sodium solutions (3- 5 ml, 100U/ml) or monthly during periods of nonuse. As for the time between flushing, the data is controversial. The care and management of the catheter is usually performed by nurses/midwifes. They should be educated and trained. In all clinics in which ports are used (most often in medical oncology, hae-modyalisis, intensive care units) algorhythms and guidelines for all these procedures are recommendable.
The possible complications concerning insertion of ports can be divided into two main groups: Anesthe-siological and Surgical. According to the time of their appearance, they may also be two groups: acute, procedural or early (during the insertion period or to 30 days after it) and long - term, delayed (more than 30 days after the implanting).
Risks of general anesthesia include: allergic reaction, nausea, vomiting, urinary retention, cut lips, chipped teeth, sore throat, headache and more serious risks are: arrhythmia, blood pressure changes, very seldom sudden death; blood clots, pneumonia, etc.
Surgical complications, discussed in the literature are: [1,4,5,6,12]:
1. Early complications:
• Local tissue damage or trauma- formation of hematoma, brachial plexus injury
• Pneumothorax - reported rate of up to 5%, especially via the subclavian vein approach. The higher incidence is reported in: nutritionally compromised and emaciated people; the number of attempts required to access the vein and the operators experience. For reducing the risk, use of venous ultrasound and chest radiograph to guide placement of the venipuncture needle into the initial point of entry, is advisable. Usually uncomplicated, small pneumothoraxes do not require immediate evacuation. They only should be monitored to ensure that they resolve satisfactorily. The resorbtion is spontaneous at a rate of approximately 1% daily. Failure of a small pneumothorax to resolve, a presence of a compromised ventilation and enlarging pneumothorax are indication for immediate evacuation. The risk of acute pneumothorax is lower when implanting the catheter in brachial veins, but the the thrombogenic complications in arm ports than in chest ports are more frequent.
• Hemothorax- less than 1%. It is a result of injuring a major vessel with the venipuncture needle, guidewire, dilator and peel- away introducer sheath. It can be a life threatening condition
• Vascular damage
• Thoracic duct injury
• Hemorrhage
• Surgical emphysema
• Accumulation of fluid at the implant site
• Air embolism
• Persistent pain and discomfort
• Device- related complications: Aberrant catheter placement, catheter tip malposition, catheter compression, fracture, embolization
• Cardiac complications - arrhythmia, cardiac irritation, cardiac perforation, tamponade
2. Long term complications: the risk increases with the duration of catheterization [2,3,5,6,9,10,12,13]
• Infection of the catheter exit, tunnel or port pocket infection, sepsis. The long- term access devices are prone to become infectious at least once. The incidence of infection depends on the catheter's type, the patient age, the location placement of the device. A higher rate of infections is observed in neonatal population, patients with short- bowel syndrome, neutro-penia. Catheter infection is suspected in patients with fever and an identifiable bacterium isolated either from blood samples or catheter device. Local symptoms may be erythema, edema, ulceration, necrosis. Irritative skin changes may be due to extravasation of chemothera-peutic drugs, when the needle is not well connected to the port. It is important to determine if the catheter is truly the source of infection. Erythema surrounding the device exit site may represent only irritation of the skin. When infection is proved, the advice is to remove the catheter. This act usually eliminates the source of infection. In critically ill, with signs of sepsis, empiric antibiotics are recommended. They should cover coagulase - negative Staphylococcus bacteria because they are the most frequently identified organisms for CVC infection together with Candida species. Administration of antibiotics should continue at least 48 hours or until cultures results are available. In this period, patient's clinical condition needs reassessment. Duration of antibiotic administration depends on the patient's clinical condition and antimicrobial resistance. High priority for the health care workers, should be prevention of catheter- related infection. Prevention strategies include strict hand- washing protocols, meticulous care of the catheter site and aseptic techniques for catheter handling. Catheter removal is necessary in case of: tunnel or port infection, persistent sepsis/bacteraemia, relapse of infection after antibiotic therapy, metastatic complications, unstable patient.
• Phlebitis of the cannulated vessel
• Thrombosis: pulmonary embolism, deep venous thrombosis, portal or catheter thrombosis - 12 and 64% [14]. Etiologic factors related with these complications are: the size, location and type of the catheter and patient's underlying conditions. Cancer patients are at increased risk of venous thrombosis and placement of TIVAD (ports) further increases that risk. Catheter associated thrombi vary in size, from small to large and they may be potentially fatal. Significant thrombosis can occlude: the lumen of the catheter or of the vessel; cause thromboembolism or vena cava superior syndrome. The complication, venous thrombosis, may be asymptomatic or present with swelling or ipsilateral neck and arm pain. When a venous obstruction is suspected, CT, echocardiography or venography should be made. Vascular thrombosis are treated with anticoagulants. To reduce the incidence of thrombotic occlusions ports should be flushed regularly with heparin sodium. Some studies evaluated antithrombotic prophylaxis
with low molecular weight heparin (LMWH) or warfarin administered after the catheter placement [2,3,5,6,13]. They found no statistically significant difference in the incidence of thrombosis between patients receiving anticoagulants after the insertion and those who did not received.
• Superior vena cava syndrome
• Catheter dislodgement, migration, occlusion or malfunction of the catheter. Often catheter fracture is asymptomatic. But rare serious complications following the fracture, like arrhythmia, cardiac arrest and cardiac perforation may pursue. Catheter malfunction is two types: Inability to withdraw blood from it and Inability to infuse through it. The first complication is frequently caused by a fibrin sheath at the catheter's tip which causes one- way valve effect. It may be due to a positioning of the tip against the side wall of the venous structure within which it resides. In such cases, repositioning the patient or Valsalva maneuver are recommended. Mechanical reasons may cause complications such as: catheter tip malposition, kinking of the catheter, catheter lumen thrombosis, venous thrombosis and intraluminal medications precipitation. In such cases very useful are: chest X-ray, contrast venography, CT, MRI, venous duplex Doppler ultrasonography [12].
• External catheter damage
• Suture disruption
• Extravasation of drugs and fluids
• Heparin delayed hypersensitivity after device heparinisation
• Hydrothorax
• Intolerance reaction to implanted device
Contraindications and precautions for port implantation [4,12]:
• Neutropenia
• Thrombocytopenia
• Clotting factor abnormalities
• Active infection, bacteremia, septicemia are an absolute contraindication for port insertion. It can be possible after antibiotic treatment.
• Known or suspected allergic reactions to materials of the device
To improve patient safety, outcomes and experiences provision of highest quality of care is needed. Nurses have very important role in it. As ports are the most expensive VAD, perfect nurse maintenance and management are necessary for long and proper use of the catheters. Nurses who care about those devices should be well informed and trained. All the procedures concerning maintenance of the port should be described in a guideline for nursing care and must be observed by the staff in each clinic. General points of nursing care and responsibilities include: care and use of the port after initial surgical implantation; needle size and type determination; observation of complications before accessing the port; accessing and de- accessing the port; performing infusions and taking blood samples; frequency and type of flushing with heparin after use; management of compilcations of use; record comments in the documentation about the procedures with the
catheter. Patients must be well informed and have instructions about their duties for the catheter either. They must always carry the device passport.
One of the major priorities of medical professionals is the need of adequate and immediate patients care in line with the global trends. In last decades the quality of health care is changing dynamically and is improved continuously in relation to the provision of good clinical practice in the contest with the established quality standarts. As a teaching staff in the department of "Health care" in the University of Ruse "Angel Kan-chev", we make efforts to form a good theoretical and practical knowledge of our students so they can meet these growing demands and changing trends either in Bulgaria or outside our country. We are motivated to conduct research and training for some modern therapeutic techniques and treatment regiments, one of which is the implantation and care about different kinds of TIVAD.
When revising the current Bulgarian literature, we found that there are no much studies concerning the competence of the students- nurses and midwifes, on implantation and management of ports. This was a good enough reason for us, to conduct a survey, in October 2015, among the Students from the department of "Health care", RU "Angel Kanchev'' from speciality "Nurse" and ''Midwife'', regarding their awareness of indications, contraindications, compilcations and care about TIVAD. As a method of collecting data we used open written inquiry.
Implanting TIVAD was a very rare technique in Bulgaria at that time. Only a few clinics in our capital Sofia, performed insertion of ports. The majority of our students did not have any information about such devices, so they had no competence about use and care of such catheters. But all of them showed interest and liked to have basic knowledge and training on these techniques. We made a presentation about indications and care of TIVAD. Our students opinion was that this was a modern and effective technique. They desired to pass an education and participate in care teams for patients with implanted ports. They were convinced that it could improve the quality of life of chronically ill patients.
Analyzing the results of our survey, we conclude that our teaching team must hold education and training for volunteering students who want to have theoretical and practical knowledge concerning TIVAD. Connected with this we made a pilot training of future nurses and midwifes in March - May 2016. At the end of June, we provided application during clinical practice, of the knowledge and skills in small appropriate group of patients. From 2017, in the lection courses in our curriculum of Anestesiology and intensive care and in Nursing care for oncology patients, were included lectures about different types of totally implantable access devices, indication, contraindications and maintenance and nursing care. In March 2018 we organized an education conference "Special nursing and midwifery care for patients with implanted permanent systems for infusion therapy", for students and nurses in
both University hospitals in our town Ruse, with leading specialist on this field from Sofia. Sharing of experiences among participants was accepted as beneficial.
CONCLUSIONS:
Theoretical knowledge and practical management of TIVAD is already a less serious problem for Bulgarian medical community. In our country from 2 years placement of ports is a routine technique especially before chemotherapy. But creating guidelines for nursing care of patients with implanted ports is still recommended, as some departments do not have such rules. They are crucial for improving the patients quality and length of life. A real fact is that nurses and midwifes working with critically and chronically ill patients do not have enough authority to draw up individual plans for comprehensive care for TIVAD (ports). This problem is a challenge for the teaching team in our department. We should consider and include a special emphasis in training programs for Special nursing and midwifes care.
References: Список литературы:
[1]. Amr Mahmoud Abdel Samad, Yosra Abdel-zaher Ibrahim, Complication of Port A Cath implantation: A single institution experience, The Egyptian Journal of Radiology and Nuclear Medicine, Vol. 46, Issue 4, December 2015, p. 907-911
[2]. Couban S, Goodyear M, Burnell M, et al: Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 23:4063-4069, 2005.
[3]. De Cicco M, Matovic M, Balestreri L, et al: Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: A randomized controlled study based on serial venographies. Ann Oncol 20:1936-1942, 2009.
[4]. Garajova I., Nepoti G., Paragona M., Brandi G., Biasco G., Port-a-Cath related complications in 252 patients with solid tissue tumors and the first report of
heparin- induced delayed hypersensitivity after Port-a-Cath heparinisation, Eur J Cancer Care (Engl.), 2013, Jan;22(1):125-32
[5]. GUIDELINES FOR MAINTENANCE AND MANAGEMENT OF A PORTACATH, Nottingham University Hospitals, March 2012
[6]. Port Catheter Insertions, King Abdullag bin Abdulaziz, Arabic Health Encyclopedia, August 2011
[7]. Hadaway, L.C. (2010) Anatomy and Physiology Related to Infusion Therapy. In: Alexander,M.; Corrigan, A. Gorski, L. et al (eds) Infusion Nursing an Evidence Based Approach 3rd Edition: pp 137-177
[8]. Hayden BK and Goodman M (2005) Chemotherapy: principles of administration In: Henke Yar-bro, C. et al (eds) Cancer Nursing - Principles and Practice 6th Edition: pp 351-411
[9]. Jones and Bartlett London. Perucca, R. (2001). Obtaining Vascular Access. In: J. Hankin et al (eds) Infusion Therapy in Clinical Practice 2nd edition: pp 375-388. W.B. Saunders. Philadelphia.
[10]. Nishinari K1, Bernardi CV, Wolosker N, Yazbek G., Retained catheter: a rare complication associated with totally implantable venous ports, J Vasc Access. 2010 Apr-Jun;11(2):159-61
[11]. Shawn D Larson, Vascular Access Overview, Sep 04.2014
[12]. Stephen P. Povoski, Long- Term Central Venous Access, cancernetwork, Cancer Management, May 01, 2014
[13]. Karthaus M, Kretzschmar A, Kröning H, et al: Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: Final results of a double-blind, placebo-controlled phase III trial. Ann Oncol 17:289-296, 2006.
[14]. Verso M, Agnelli G, Bertoglio S, et al: Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: A double-blind, placebo-controlled, randomized study in cancer patients. J Clin Oncol 23:4057-4062, 2005.
MANAGING NAUSEA AND VOMITING IN CANCER PATIENTS -_LITERATURE REVIEW_
Sherbanov Ognyan
Medical Doctor, Philosophy Doctor, Chief assistent Ruse University ' 'Angel Kanchev ", Ruse, Bulgaria
Nedeva Teodora
Medical Doctor, Philosophy Doctor, Associate professor Ruse University ' 'Angel Kanchev ", Ruse, Bulgaria
SUMMARY
Treating nausea and vomiting in oncology patients, sometimes is challenging for the team. Cancer ill people should be assessed completely, the frequency, duration and intensity of nausea/vomiting should be estimated; patient's daily activities and the presence of anorexia and cachexia are also important facts. Another problem is whether nausea/vomiting are independent of cancer treatment or related to chemotherapy or radiation. The complications which are not related to treatment of cancer, are treated more successfully and specifically. For chemotherapy and radiation related nausea and emesis various national and international antiemetic guidelines are developed. Unfortunately the most prescribed antiemetics - dexamethasone, neurokinin-1 receptor antagonists, 5-hydroxytryptamine type 3 receptor antagonists - recommended in them, reduce significantly vomiting but not
