Intermittently delivered IV medication and pH: reevaluating the evidence.

The Infusion Nurses Society's Infusion Nursing Standards of Practice has treated pH as a critical factor in the decision-making process for vascular access device selection, stating that an infusate with a pH less than 5 or greater than 9 is not appropriate for short peripheral or midline catheters. Because of the Standards, drug pH is not an uncommon factor driving the decision for central vascular access. In this era of commitment to evidence-based practice, the pH recommendation requires reevaluation and a critical review of the research leading to infusate pH as a decisional factor. In this narrative literature review, historical and current research was appraised and synthesized for pH of intermittently delivered intravenous medications and the development of infusion thrombophlebitis. On the basis of this review, the authors conclude and assert that pH alone is not an evidence-based indication for central line placement.

[Routine nursing measures for thrombosis prevention in a university hospital]. / Thromboseprävention im pflegerischen Alltag an einer Universitätsklinik.

A literature search on the subject of thrombosis prevention showed that there have been changes in preventive nursing measures in the last three decades. Data on preventive measures as actually employed at the different Clinics of the Innsbruck Medical University were gathered with the help of written questionnaires (completed by 192 staff nurses and 111 nursing students) with the aim of instituting improvements in such measures in actual practice. Our investigation showed that 56.9% of the participants did not know what the appropriate time was for discarding graduated elastic compression stockings for antithrombotic prophylaxis; 72.7% reported that they measured patients' legs for proper fit only seldom or not at all. 77.5% said that patients refused to wear the elastic stockings during the night. Only 22.3% reported that the compression device was worn by patients 24 hours a day. 82.5% had not participated in any continuing education programmes on thrombosis prophylaxis in the past five years. According to 42.3% of study participants, nursing measures for thrombosis prevention must be carried out jointly by physician and nurse. Based on this investigation, we have compiled a booklet of guidelines to be used for teaching nursing students and for continuing education of staff nurses, and have raised our internal standards to comply with the state of the art in thrombosis prevention. We plan to investigate antithrombotic measures currently in place in the area of intensive care. It is also planned to invite the opinion of patients on the matter of wearing compression stockings for thrombosis prophylaxis in order to gain some understanding of the reasons why patients refuse to wear them at night.

Deep vein thrombosis in pregnancy.

This article provides a review of the incidence, pathophysiology, and treatment of deep vein thrombosis (DVT) in pregnancy, a rare but serious complication of pregnancy. The incidence of DVT in pregnancy varies widely, but it is a leading cause of maternal morbidity in both the United States and the United Kingdom. Risk factors during pregnancy include prolonged bed rest or immobility, pelvic or leg trauma, and obesity. Additional risk factors are preeclampsia, Cesarean section, instrument-assisted delivery, hemorrhage, multiparity, varicose veins, a previous history of a thromboembolic event, and hereditary or acquired thrombophilias such as Factor V Leiden. Heparin is the anticoagulant of choice to treat active thromboembolic disease or to administer for thromboprophylaxis, but low molecular-weight heparin is being used with increasing frequency in the pregnant woman. Perinatal nurses should be aware of the symptoms, diagnostic tools, and treatment options available to manage active thrombosis during pregnancy and in the intrapartum and postpartum periods.

Critical care nurses be aware: Lemierre's syndrome is on the rise.

Lemierre's syndrome (LS) typically occurs in previously healthy young adolescents and young adults who become acutely ill following an attack of pharyngotonsillitis. Also known as post anginal sepsis, those afflicted develop pyrexia, rigours and multiple metastatic abscesses that lead to septic thrombophlebitis of the internal jugular vein. In the pre-antibiotic era this particularly virulent syndrome had a mortality rate in excess of 90%, but since the introduction of antibiotics and the widespread treatment of throat infections, it has became almost unknown. However, due to a number of factors, including a reduction in the use of antibiotics for the treatment of sore throats, misdiagnosis and/or improvements in microbiology diagnostic techniques, several reports have indicated a resurgence of the condition. This has major ramifications for critical care nurses as LS is still associated with significant morbidity and mortality. This paper discusses the aetiology, pathophysiology, bacteriology, diagnosis and management aspects of this syndrome. A case study of a young woman is presented to illustrate the complexity of the condition, and highlight how early diagnosis and prompt initiation of appropriate intravenous antibiotic therapy ensured a favourable clinical outcome.

Understanding and preventing deep vein thrombosis and pulmonary embolism.

Deep vein thrombosis and its complications, including pulmonary embolism, are major health problems in the United States, resulting in more than 260,000 hospital admissions and 100,000 deaths each year. Thirty percent of patients diagnosed with deep vein thrombosis will experience at least one recurrence of symptoms. To minimize patient morbidity and mortality and to contain health care costs, prevention, early diagnosis, and treatment of these conditions are essential. In this article the incidence pathophysiology risk factors, and clinical course of deep vein thrombosis and pulmonary embolism are discussed, as well as the clinician's role in prevention and treatment.

Calculating patients' risk of deep vein thrombosis.

Deep vein thrombosis (DVT) constitutes a serious threat to patients' general recovery. DVT in postoperative and bedridden patients is usually preventable and a thromboprophylaxis protocol based on risk assessment categories is strongly recommended. The Autar DVT risk assessment scale was developed to separate risk into no risk, low, moderate and high risk categories. Founded on Virchow's triad in the genesis of DVT, the scale is composed of seven categories of risk factors. When the scale was tested on a trauma/orthopaedic unit a cut-off score of 16 yielded 100% sensitivity, 81% specificity and a correlation coefficient of 0.98. The DVT scale is designed to allow application in diverse clinical specialties. It is recommended that nurses using the Autar DVT scale should evaluate for themselves the best cut-off score to achieve maximum predictive accuracy.

Surveillance of the patient receiving infusional cancer chemotherapy: nursing role in recognition and management of catheter-related complications. The Cancer Center of Boston.

Surveillance of the patient on infusional cancer chemotherapy (ICC) is paramount to patient safety. Key to this issue is diligence in monitoring for complications of infusion catheters. Nursing knowledge and awareness are essential for the early detection of such complications. The following is a composite of the manifestations of commonly experienced catheter-related complications. The incidence, detection and management issues are presented from the perspective of 15 years experience with ICC at The Cancer Center of Boston (TCC).

Nursing assessment of clients at risk of deep vein thrombosis (DVT): the Autar DVT scale.

Deep vein thrombosis (DVT) poses a threat to hospitalized clients' recovery. It is preventable and the cost of treating this problem is considerably more than that of preventative practices. Accurate DVT risk assessment facilitates the application of the most appropriate venous thromboprophylaxis. Founded on Virchow's triad of risk factors in the genesis of deep vein thrombosis, the Autar DVT scale was developed as a predictive index. The DVT scale is composed of the following seven risk categories: increasing age, build and body mass index (BMI), immobility, special DVT risk, trauma, surgery and high risk disease. The DVT scale was tested on two trauma wards and the study was essentially a data generating exercise. Clinical data were gathered on 21 clients to validate the reliability, sensitivity and specificity of the DVT scale. Pearson moment correlation coefficient (r) and total percentage agreement (T%) measurement yielded a value of r at 0.98 and a T% ranging between 70% and 87% respectively for both reliability studies. Predictive validity of the scale calculated from a threshold score of 16 achieved 100% sensitivity and 81% specificity. The Autar DVT scale has produced some interesting results and holds considerable promise as a predictive index. However, as this was a small study further testing in diverse clinical areas of a large client population is recommended.

Undiagnosed hypercoagulable state: a case study.

Vascular nursing presents constant challenges. The natural history of vascular disease coupled with the complexity of the patient population provides an environment for constant learning. Providing care to these unique individuals demands a thorough knowledge of vascular anatomy and physiology, diagnostic interventions, treatment modalities, multidisciplinary resources, and nursing interventions. This case study explores the multifaceted realm of vascular nursing by examining the hospital course and multidisciplinary plan of care of a 22-year-old man whose hospital course began with a lower extremity deep venous thrombosis and progressed to pulmonary embolus, phlegmasia cerulea dolens, compartment syndrome, sepsis, arterial thrombosis, severe coagulopathy, priapism, laryngeal bleeding/laryngospasm, and subsequent notification of having received a unit of blood from a donor whose human immunodeficiency virus status was later determined to be positive. The intent of this article is not to define a specific means of practice but to share with colleagues the wealth of knowledge that was gained from this experience.