Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters in haematology and oncology patients (PASSPORT 2).

BACKGROUND: Central venous catheter dysfunction may be associated with intraluminal clots, drug precipitates and lipid residues or extra luminal causes such as fibroblastic sleeve, tip malposition, pinch-off syndrome and venous thrombosis at the tip of central venous catheter. Failure to restore patency after addressing these causes, empirical treatment with thrombolytic agents should be considered. Urokinase is used widely as a thrombolytic agent but very few outcome studies have been published. METHODS: A multicentre group conducted a prospective audit of management of central venous catheter dysfunction after exclusion of common causes using in centre standardised doses of urokinase from September 2017 to February 2018 in haematology and oncology units. Data of catheter blood flow were collected anonymously following administration of 5000- to 25,000-IU urokinase in dysfunctional central venous catheter. RESULTS: A total of 117 patients were recruited from eight centres, 54 females and 63 males, median age was 60 (46-68). In total, 53% presented as partial withdrawal occlusion and 47% total occlusion. In partial withdrawal occlusion, patency was restored in 80% of interventions, in 82% of interventions using push lock and in 76% using dwell lock. In total occlusion, patency was restored in 88% of the interventions. The central venous catheter clearance rate was dose dependent; patency was restored in 83% of central venous catheter with 5000 IU, 89% with 10,000 IU and 92% with high dose of 25,000 IU. No adverse events were recorded. CONCLUSION: In this study, treatment of dysfunctional central venous catheter using standardised urokinase doses was safe and effective in restoring patency when no other mechanical causes could account for central venous catheter dysfunction.

Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis.

Tunnelled central venous access devices (CVADs) are defined as any intravenous multipurpose catheters placed within the central veins for use in haemodialysis and administration of blood products or chemotherapy in oncology and haematological conditions. Frequent complications include thrombosis and catheter-related infection, which may lead to significant adverse patient outcomes. Once thrombosis is suspected correction should be attempted empirically with thrombolytic agents. Commonly available thrombolytic agents in the UK include urokinase (Syner-Kinase) and alteplase (Cathflo). It is well recognised that urokinase usage differs widely and concerns were raised by clinicians about the variation of dose regimens nationally. The objective of the CVAD Focus Group was to address this issue and offer guidance in the management of suspected thrombosis of CVAD with urokinase using two algorithms for renal and non-renal dysfunctional CVAD and to audit prospectively the outcomes of intervention.

Improving outcomes of short peripheral vascular access in oncology and chemotherapy administration.

A short peripheral intravenous catheter or cannula (PIVC) is frequently used to deliver chemotherapy in oncology practice. Although safe and easy to insert, PIVCs do fail, leading to personal discomfort for patients and adding substantially to treatment costs. As the procedure of peripheral catheterization is invasive, there is a need for greater consistency in the choice, insertion and management of short PIVCs, particularly in the oncology setting where there is a growing trend for patients to receive many different courses of IV treatment over a number of years, sometimes with only short remissions. This article reviews best practice with respect to PIVCs in cancer patients and considers the necessity for bundling these actions. Two care bundles, addressing both insertion and ongoing care and maintenance, are proposed. These have the potential to improve outcomes with the use of short PIVCs for vascular access in oncology practice.

Influencing organisational culture: a leadership challenge.

In the wake of the Francis report, the need for NHS trusts and hospitals to adopt a culture of learning, safety and transparency has been highlighted. This article considers different aspects of culture in health care, and hones in on the link between culture and safety for patients in putting the patient first, embedding the 6Cs and considering the options to measure and influence organisational culture. The article reflects more deeply on how leadership across all levels can influence and inspire change in organisational culture, ensuring that the patient remains the focus of any changes in care delivery.

Plane and practice parallels: our journey to AVA 2013.

It was an unremarkable start to our trip to Nashville for the 27th annual meeting of the Association of Vascular Access (AVA). Poster (check), presentation (check), meeting point at the airport (check), luggage within weight limit (check), hand luggage minus sharp items and liquids (check).

Intravenous therapy in older patients.

Intravenous therapy is available in a variety of settings and for patients of all ages. Therefore, it is essential that nurses have the clinical knowledge and technical expertise to carry out this procedure and care for patients, particularly those who are vulnerable, such as older people. This article provides an overview of the anatomy and physiology of the skin and veins. Considerations for improving venous access, selection and insertion of a peripheral cannula, and recognition, prevention and management of complications in older people are discussed. Alternative routes for the administration of fluids and medications are also explored.

Dexrazoxane: a management option for anthracycline extravasations.

AIMS: This article reviews the efficacy and place in therapy of dexrazoxane (Savene®) for the treatment of anthracycline extravasation, highlighting the lack of inclusion of Savene in most UK cancer network and organisational treatment guidelines. Here we offer advice to nurses on making a case to ensure the availability of Savene. KEY FINDINGS: In 2010, the UK National Extravasation Information Service (NEXIS) green card scheme reported that anthracyclines were the second most common agent involved in extravasations, but they carry the greatest risk to the patient because of their potentially serious consequences. Anthracycline extravasations therefore require prompt and effective treatment. Due to the infrequent occurrence of anthracycline extravasations, their accidental nature and ethical considerations, conducting randomised controlled clinical trials in this therapy area is not possible. As treatment decisions should always be made on patient-specific factors, health professionals need to demonstrate the rationale for choosing a particular course of action when presented with an anthracycline extravasation, especially when we are moving into an era of increased medical litigation. There are several possible treatment options, some of which require demonstrable local core competencies in order to be considered for a particular patient. Based on the available evidence, Savene-the only licensed antidote-is recommended as an effective management strategy for anthracycline extravasation and should be made available in all settings where chemotherapy is administered. However, a high percentage of nurses administering chemotherapy still do not have access to Savene, as it has not been included in their local guidelines for the management of extravasations. Thus, in a large part of the UK, this important treatment option is not available, leaving a significant unmet need (Figure 1). CONCLUSIONS: As nurses play a key role in the prevention, detection, and management of extravasations, they should also assume a key role in ensuring that their local protocols include all appropriate management strategies. Where appropriate, if Savene is not included in the treatment guidelines, nurses should feel empowered to encourage their trust and Specialist Commissioning Groups (SCGs) to make it available, and thus minimise the serious risks associated with anthracycline extravasations.

Decision-making processes used by nurses during intravenous drug preparation and administration.

AIM: The aim of this study was to explore the decision-making processes that nurses use during intravenous drug administration and how this influences risk taking and errors. BACKGROUND: Intravenous drug errors have been estimated to be a third of all drug errors. Previous drug error research has focused on observation of nurses and errors they make but has not attempted to understand the decision-making processes used during the preparation and administration of intravenous drugs. METHOD: A three-phased ethnographic study was carried out in a specialist cancer hospital in 2007 using focus groups, observation and interviews. This article is concerned with the observation and interview phase. Observation took place on two wards, each over a week. Twenty nurses were observed preparing and administering intravenous drugs; then interviewed about their procedure. Data analysis was carried out using a five stage approach. FINDINGS: Major themes identified include: interruptions; identification and knowing the patient; routinized behaviour, prevention of errors. These represent the findings of the observation and interviews with the nurses. One key finding was the lack of checking of patient identity prior to IV drug administration, which appeared to be based on nurses feeling they knew the patient well enough, although this was in contrast to how they checked even familiar drugs. This article will focus on identification and knowing the patient. CONCLUSION: Implications for practice included: exploring new and effective methods of education based on behavioural theories; involving staff in updating policies and procedures; formal assessment of staff during intravenous preparation and administration.

Extravasation: prevention, recognition and management.

This article provides readers with an overview of extravasation, including risk factors and management strategies. The importance of accurate reporting and documentation is also highlighted, particularly as patients will often require follow-up care and may take legal action as a result of extravasation injury.

The inaugural NIVAS conference.

The inaugural conference of the National Infusion and Vascular Access Society (NIVAS) 'Infusing excellence and expertise' was held on 12th and 13th May 2010 at the Hotel Russell, London. It was attended by over 70 delegates and supported by 16 companies. The first day of the programme focused on reducing risk.

IV therapy: recognizing the differences between infiltration and extravasation.

Infiltration and extravasation are complications that can occur during intravenous therapy administered via either peripheral or central venous access devices. Both can result in problems with the siting of future venous access devices, nerve damage, infection and tissue necrosis. The nurse is the key to reducing the risk of infiltration and extravasation, through her knowledge and skill in cannulation and the intravenous administration of drugs (by bolus injection or infusion). The nurse must also be able to recognize the early signs and symptoms of infiltration and extravasation and act promptly and effectively to limit tissue damage. The first sign of possible leakage of drugs into the tissues is pain and discomfort, so patients must be informed of what symptoms to look out for and be asked to report any change in sensation as soon as they are aware of it. Finally, accurate documentation of the event is vital to facilitate patient care and in case of litigation.