State of the science of oncology vascular access devices.

OBJECTIVE: To present an overview of long-term vascular access devices (VADs), current maintenance care, controversies of care, and the need for VAD research. DATA SOURCES: Current research and published literature. CONCLUSION: Over the last four decades, VADs have become a standard part of caring for patients in all clinical settings. Despite the common use of VADs, current standardized procedures for maintenance care and managing complications are not available. IMPLICATIONS FOR NURSING PRACTICE: The key to establishing evidence-based practice is to create a network of researchers, clinicians, and policy makers in a consortium to secure funding and implement multisite research. Only through research will traditional practice be challenged.

Features and selection of vascular access devices.

OBJECTIVE: To review venous anatomy and physiology, discuss assessment parameters before vascular access device (VAD) placement, and review VAD options. DATA SOURCES: Journal articles, personal experience. CONCLUSION: A number of VAD options are available in clinical practice. Access planning should include comprehensive assessment, with attention to patient participation in the planning and selection process. Careful consideration should be given to long-term access needs and preservation of access sites. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses are uniquely suited to perform a key role in VAD planning and placement. With knowledge of infusion therapy, anatomy and physiology, device options, and community resources, nurses can be key leaders in preserving vascular access and improving the safety and comfort of infusion therapy.

Insertion and placement of central catheters in the oncology patient.

OBJECTIVES: To review the current up-to-date recommendations for insertion and placement of central venous access devices and discuss the prevention of complications during and post-placement of central catheters. DATA SOURCES: Journal articles, electronic articles, organizational position papers, personal experience. CONCLUSION: There are numerous types of vascular access catheters that play an important role in the management of complex treatments for the oncology patient. Cancer patients with a catheter have a higher rate of thrombosis and infection as part of their disease process and treatment; hence, nursing care can eliminate or minimize complications. IMPLICATIONS FOR NURSING PRACTICE: Nurses must be educated on the correct procedures and rationale for insertion and placement as well as for the care and maintenance of each specific device.

An overview of suprapubic catheter care in community practice.

This paper gives a broad overview of suprapubic catheterization. Community nurses can often feel they lack experience with suprapubic catheter general care and routine changes. This paper sets out the advantages and disadvantages of suprapubic catheters, the procedure for routine change and the golden rules for general care. The paper contains an introduction on trouble shooting.

Tracheal intubation, tracheal tubes and laryngeal mask airways.

Tracheal intubation is used when a clear airway is difficult to achieve with a face mask or laryngeal mask, or if there is a risk of dislodgement of other forms of airway control. Tracheal intubation is considered to be an important part of patient management when a major intraoperative complication develops (for example anaphylaxis, massive haemorrhage or malignant hyperpyrexia).

Transposición de vena basílica en el brazo, para acceso vascular en pacientes sin lecho venoso superficial / Transposition of basilic vein of the arm, for vascular access in patients without superficial veinbed

La provisión de acceso vascular duradero, en pacientes con insuficiencia renal en hemodiálisis, sin lecho venoso superficial, es difícil. Tradiocionalmente, se recurre al uso de prótesis vascular. Entre mayo de 1998 y abril de 1999, se confeccionan 8 fístula arteriovenosas humerobasílicas con transposición subcutánea de la vena basílica en el brazo, en igual número de pacientes con antecedentes de múltiples accesos vasculares ocluidos; dos pacientes con accesos vasculares protésicos trombosados (PTFE). Hubo 100 por ciento de utilización de vena basílica. Cinco pacientes de sexo masculino, y tres, femenino. con edad promedio de 40 años (rango: 23-65 años). Entre las complicaciones destacan: hematoma (1), linforrea (1), edema del brazo (2), estenosis de vena basílica (1), aneurisma (1). Una fístula se ocluyó a los 30 días. Ningún paciente se infectó. Al 30/6/99 se mantienen permeables y funcionales 6 fístulas. En nuestra breve experiencia, y por razones económicas y mayor duración, consideramos a la fístula arteriovenosa humerobasílica con transposición venosa subcutánea, nuestra primera alternativa en este tipo de pacientes. Los accesos vasculares protésicos corresponden a la última alternativa

Temporary vascular access for extracorporeal therapies.

Central venous catheters provide at the present time the basic and ideal method to perform acute extracorporeal blood purification. Rapid launch of extracorporeal therapy is indicated in two situations: first, renal conditions presenting as a recognized acute organic renal failure (ARF) and acute decompensation of end stage renal disease (ESRD) without permanent vascular access; second, non-renal conditions presenting as urgent clinical situations requiring isolated ultrafiltration for chronic congestive heart failure, plasmapheresis or selective immunoadsorption for immune diseases, cytapheresis for hematological disease, and selective detoxification for certain types of poisoning. Central venous catheters are classified into 2 categories according to the duration of use: temporary catheter (less than 90 days) and permanent catheter (more than 90 days). A temporary catheter, including rigid (polyethylene, teflon) and semirigid (polyurethane) material, is indicated in emergency situations and for short-term use. A permanent catheter, made usually of soft silicone rubber with a subcutaneous anchoring system, has a subcutaneous tunnel and is indicated in medium and long-term use. Catheter design has benefited greatly from technical advances and material hemocompatability. However, catheter-related morbidity still remains high and is associated with an unacceptable incidence rate of infection and/or vein thrombosis. This article covers our present knowledge regarding catheter indications, technical aspects of catheter insertion and care, functional limitation of central venous catheters, and catheter-related complications. It is also our intent to provide the reader with optimal indication and catheter care in order to prevent and reduce the burden of catheter-related morbidity.

Selection of vascular access devices and nursing care.

OBJECTIVE: To provide an overview of the patient selection criteria for a vascular access device (VAD) and its maintenance care. CONCLUSIONS: The availability of different types of devices had led to confusion on the part of many health care professionals as to which device is the best for their purpose. Selecting the appropriate VAD is an interdisciplinary decision based on patient characteristics, type of therapy, support system availability, and cost. Numerous controversial issues surround the care of VADs, and research results have not yet resolved these practice issues. Although various procedures are used throughout the country, it can be reasonably concluded that the fundamental requirement for successful maintenance of a VAD is strict adherence to established care protocols. IMPLICATIONS FOR NURSING PRACTICE: Assessment of the need for a VAD is an ongoing process. Nurses are in a perfect position to assess the factors that precede device selection, including the frequency of access, type of intravenous therapy, and the condition of the patient's peripheral veins. The vast array of devices demands specialized knowledge in selecting the appropriate VAD, providing correct care, and evaluating the device once inserted or implanted.

Comparison of vascular access devices.

OBJECTIVE: To provide an overview of venous access device designs and methods of insertion and removal. CONCLUSIONS: Venous access devices are indicated for many patients who require reliable long-term venous access. Three types of venous access devices are available including nontunneled, tunneled, and implanted ports. Since their introduction into clinical practice, the widespread use of these devices has had an enormous impact on cancer treatment by decreasing the overuse of peripheral veins while allowing for more flexibility and choice of the type of device used. Although numerous devices are available, each offers unique designs and performance expectations. Each type of device has similar features and can be used for intravenous drug and nutritional therapy, administration of blood products, and withdrawal of blood. IMPLICATIONS FOR NURSING PRACTICE: Even if only a single device is used in a given setting, the nurse must have a basic understanding of all types of venous access devices. It is imperative that the nurse be fully cognizant of the anatomic position and structure of the major vessels associated with the central venous system, especially for the insertion of peripheral central catheters. Understanding the venous system and venous access design can assist in preventing or assessing potential complications.

Arterial, peritoneal, and intraventricular access devices.

OBJECTIVE: To provide an overview of access devices used to treat cancers through the arterial, peritoneal, and intraventricular body systems. CONCLUSIONS: Short-term and long-term devices have been developed over the last 35 years for cancer treatment. Although less amenable to standard methods of therapy, the various access devices available to access the arterial, peritoneal, and intraventricular systems have provided a safe and reliable means for drug therapy. Access devices assist in delivering high concentrations of drugs directly to the center of the tumor. Complications and toxicities are inherent with these devices from the drug therapy as well as the device. Nursing assessment can provide early identification of potential problems and implementation of appropriate interventions. IMPLICATIONS FOR NURSING PRACTICE: As the availability of these devices increases, so must the nurse's knowledge base to provide optimal safe care. Oncology nurses are challenged to know the differences between the devices, the device of choice for the individual patient, insertion procedures, and maintenance protocols.

The use of access devices in cancer pain control.

OBJECTIVE: To provide an overview of access devices and infusion pumps available for pain management. CONCLUSIONS: Pain still remains a significant problem in patients with cancer. Access devices and infusion pumps have expanded pain management options for patients unable to use simple routes for medication administration. When access devices are selected and used appropriately, pain relief can be accomplished safely. IMPLICATIONS FOR NURSING PRACTICE: Nursing assessment is essential to develop an effective pain management regimen. Because patients are the best source of information about their pain, the nurse is in an excellent position to determine if the placement and use of an access device could be useful in controlling a patient's pain.

Manufactura de catéteres en doble J con material desechable: uso y abuso de los catéteres ureterales / Double J catheters manufacture with discardable material: use and abuse of ureteral catheters

Los materiales utilizados para la manufactura de los catéteres ureterales en doble J, han sufrido modificaciones importantes desde hace 20 años hasta la actualidad. En la mayor parte de los hospitales del mundo en desarrollo no ha sido posible la adquisición de estos dispositivos por carencia de recursos económicos. En la actualidad en el Hospital Regional de Especialidades No. 25, Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México, se cuenta con catéteres en doble J de varias marcas nacionales y extranjeras. Hace más de un año, estos catéteres se manufacturaban en este servicio de urología utilizando los catéteres desechables de los procedimientos cardiológicos. Se colocaron diez de estos catéteres elaborados en el servicio a pacientes con trastornos obstructivos, ya sea intrínsecos o extrínsecos, al azar entre otros 100 catéteres. De estos 110 dispositivos, 43 (30.90 por ciento), se calcificaron, pero entre ellos solamente tres de los elaborados por el personal del hospital. No se efectuó control cronológico de la premanencia de los catéteres, ya que uno s quedaron in situ hasta por 31 meses. Es muy grande el abudo y mal uso de estos catéteres, por lo cual fue elevada la tas de calcificación. Se concluye que los catéteres elaborados en el hospital tienen, aproximadamente, la misma tasa de incrustación cálcica (30 por ciento) que los de marca

Implantable devices for venous access: nurses' and patients' evaluation of three different port systems.

Implantable injection port systems are safe and convenient for long-term venous access. The present investigation comprises nurses' and patients' evaluation of three different types of devices; Port-A-Cath (16.0 g), Cordis Miniport (3.8 g) for implantation in the chest wall and the PAS Port system (5.6 g) for implantation in the forearm. The devices were implanted for chemotherapy. Eighty patients and 17 nurses answered a questionnaire regarding their experience with the devices. Overall, the systems functioned well and were helpful for both patients and nurses. In the patient study few significant differences emerged. Nurses noted that the PAS Port system was more difficult to withdraw blood from (P < 0.001) and its infusion flow capacity was inferior to the two ports in the chest wall (P < 0.001). Port-A-Cath was judged to be the easiest system for needle insertion and the needle position was felt to be more secure (P < 0.001). Fourteen of the 17 nurses preferred Cordis Miniport for cosmetic reasons (P < 0.001). All devices functioned well. The differences in shape, size and site of implantation allow an optimum port selection for each patient. The replies in this study expressed the need for educational programmes in order to spread the injection port concept further.

Long-term central venous catheters: issues for care.

Long-term central venous catheters allow the safe administration of chemotherapy, blood and blood products, total parenteral nutrition, fluids, and other medications. Despite their benefits, the risk of certain complications (e.g., fibrin sleeve and mural thrombus formation, infection, catheter occlusion, extravasation, and catheter malposition) exist for every person who has a catheter. Thus, preventative measures, recognition of early signs and symptoms of complications, and adequate care of utmost importance.