Win the battle against thrombosis and infection
Win the battle against thrombosis and infection
Follow this simple 'DIET'
What's a home infusion nurse to do when it comes to preventing thrombosis and infection? The problem is, nobody knows all the answers. And until more research is done, there is no sure-fire way to combat the problem. In the second part of a two-part series, Marcia Ryder MS, BSN, RN, CNSN, a vascular access nurse consultant based in San Mateo, CA, presents her recommendations on critical elements to battle both thrombosis and infection, presented as an acronym she calls the MR DIET.
"The MR stands for minimizing risk and maximizing outcomes," she says. "The cornerstone strategies call for a quality improvement program that covers the aspects in DIET."
D is for device selection. he goal is to make the best choice for the best results with the least cost. The type and duration of therapy dictates the position of the catheter tip, avoiding venous thrombosis, while the risk of infection drives the decision for the catheter insertion site.
I is for insertion technique which Ryder says should involve stringent preoperative skin preparation, maximum sterile barrier, and catheter stabilization.
E is for elimination of bacteria hrough steps such as hand washing, dressing management, and hub disinfection.
T is for thrombus prevention which requires maintaining catheter and vessel patency and the possible use of prophylactic urokinase. A relatively new concept, pilot studies point to a possible benefit of such use.
"I have spent some time reviewing the concept of prophylactic urokinase as a strategy in preventing both infection and thrombosis," says Ryder. "Urokinase is obviously effective in clearing fibrin occlusions, and we know bacteria attaches to catheter surfaces by fibrin. Therefore, if you can eliminate the fibrin, you can remove their attachment sites. Only pilot studies have been done, but we are proposing more studies on that."
Holly Bagnall-Reeb RN, MN, clinical nurse specialist in pediatric hematology/oncology at the Doernbecher Children's Hospital of the Oregon Health Sciences University in Portland, OR, notes that such questions beg for more research.
"There is a relationship between fibrin and biofilm formation and a higher risk of developing an infection," she says, "but we don't know if prophylactic urokinase therapy actually reduces the risk of catheter infection."
But even without the answer to that question, Gary R. Jones MD, associate professor of pediatrics at Doernbecher Children's Hospital, notes that there is one simple task infusion providers can perform to help combat catheter-related infections.
"Any time a patient has a positive blood
culture, and I don't care what it is from, that patient needs to have antibiotic therapy given through the catheter," he says. "First, this ensures that if the infection is truly related to the catheter itself, then antibiotics are being delivered to that environment; and second, it prevents the possibility that contaminated blood drawn up into the catheter will allow organisms to become colonized and become a catheter infection."
This may require a paradigm shift for some infusion providers.
"I emphasize that you need to think of two very separate environments: the patient's systemic circulation and the internal lumen of the catheter," says Jones. "If the catheter is in the patient's body, it is important to conceptualize that the internal lumen does not have the same exposure to the body's infectious defenses. The catheter is being flushed, so there is not a continuous exposure to blood and the products in the blood."
Jones notes that more research on the prophylactic use of urokinase in catheters could give infusion providers more guidance.
"Giving antibiotics through the catheter will often be enough to not only eradicate the infection in the patient, but also within the lumen of the catheter," he says.
However, more research is needed to study the possible causes in patients who have persistent infections, either by presentation of a persistent positive culture, or when infection is cleared but the same microorganism returns later.
While there is some evidence that suggests fibrinolytic agents may help deal with persistent or recurrent bacterial infections in central catheters, there is a need for studies that examine the use of these agents in combination with antibiotics to combat catheter-related infections that don't clear quickly or are recurrent.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.