The ins and outs of inotrope infusion therapy
The ins and outs of inotrope infusion therapy
Special considerations for critical patients
With the advancement of home health care in general and home infusion in particular, patients are returning home earlier than ever during their disease states. Along those lines, it’s not unusual for home infusion providers to receive referrals for cardiac patients receiving inotrope therapy.
Providing inotrope therapy in and of itself is not dangerous, but Kellie Hayes, RN, director of clinical services for Baylor HomeCare in Dallas notes there are numerous problems somewhat unique to inotrope therapy that home infusion providers should be aware of.
"We get calls from different providers in the community who have received a referral, and they are not well-versed in what the drugs are and how to deal with those patients," she says.
Hayes adds there are also discrepancies within the medical community.
"Within the cardiology community, there is no one way to provide inotrope therapy," she says. "We see both intermittent and continuous, so we see it used in a lot of different ways. There have been multiple studies that attempt to show which way is the best way, and no one agrees."
It’s not a rarity
Although Hayes points out that inotrope therapy is infrequent, it’s not a rare occurrence, either. In the Baylor HomeCare cardiovascular program, at any given time, up to 5% of patients are receiving inotrope therapy.
"It’s essentially a last-resort drug," says Hayes. "It’s an end-stage treatment that is sometimes used as a bridge to transplantation for patients. Generally speaking from a nursing perspective, the physician should have maxed out all regimens before going to an IV inotrope."
Know the risks
There are several risks involved in providing the therapy. With those in mind, Hayes says any provider accepting an inotrope therapy patient should be aware of these hazards and pitfalls:
1. Fibrin sheath formation
"You have a low cardiac output syndrome with these patients and an increased potential for fibrin sheath formation at the end of the catheter," says Hayes.
Baylor HomeCare has documented three instances of fibrin sheath formation. To identify the problem, the nurse must tell the doctor she suspects a fibrin sheath has formed, and before the line is pulled, a radiogram is performed to confirm the problem.
Because of this danger, Baylor HomeCare’s protocols for flushing these lines are different than for the maintenance of normal central venous catheters. The first difference, according to Hayes, is that the procedure is a daily vigorous flush of 10cc-20cc of saline.
"If there is a chance of some formation around the catheter, that may be lessened by a vigorous flushing," she says. "Rather than 3cc-4cc going through the catheter every hour, we push 2cc, stop, and push 2cc more."
This creates turbulence at the end of the catheter to prevent a fibrin sheath formation. However, there are dangers in the procedure as well.
"You’re also trying to balance that with the fact that there may be something in there you don’t want to embolize," says Hayes.
2. Staff training
Hayes suggests, before you accept an inotrope therapy patient, your nurses be familiar with the drug, its administration and how to assess the patient.
At Baylor HomeCare, all nurses hired to treat cardiac patients have previous experience. Nurses dealing with inotropes also receive IV training.
Ann Frantz, RN, a Pontiac, MI-based independent health care consultant specializing in alternate-site cardiovascular care, agrees cardiac experience is critical in providing appropriate care to patients receiving inotrope therapy. To assist providers in establishing policies and procedures, Frantz and Hayes were on an independent consensus panel established to create cardiac homecare practice guidelines.
Final guidelines
"This particular version of the guidelines does not deal specifically with patients receiving inotropic therapy. It does state that to take care of a heart failure patient in the home, the nurse should have at least three to five years of experience in a cardiovascular care setting, then have competency within the agency as well," says Frantz.
Guidelines can be ordered from the Home Healthcare Nurses Association by calling (800) 558-HHNA.
3. Arrhythmia
Patients receiving inotrope therapy often suffer from arrhythmia, particularly those on continuous infusion in the home. In such instances, a pump malfunction could be disastrous for the patient. To combat the problem, Baylor HomeCare places an extra pump in every such patient’s home.
4. Patient/caregiver education
Because of the critical nature of inotrope therapy patients, patient/caregiver education is of utmost importance. Education includes changing cassettes and hooking up a new pump.
"In the home, we’re looking at a population that if it’s end-stage disease they are generally 65 and older. But in managed care, we are looking at a bridge to transplantation and it’s generally a younger population," says Hayes.
"We’re teaching skills that don’t come naturally to them and they need to understand that if something goes wrong with this drug, they need to act appropriately and quickly or bad things could happen."
5. Payer driven
Many times a payer source will determine who gets the referral. That means a provider without cardiac experience may find itself suddenly caring for a cardiac patient.
"A physician may know that he has to find someone to care for the patient, but it may be more driven by who is going to pay for it than by who can appropriately care for the case," says Hayes.
Rather than allowing managed care dictate what is needed, it should be up to professionals to dictate what is, advises Frantz.
6. Infection
Because you have a central venous catheter in the body, you have to deal with infection. The more critical the patient, the more dangerous any infection can be.
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