The aim of intravenous management is safe, effective delivery of treatment without discomfort or tissue damage and without compromising venous access, especially if long-term therapy is proposed
Elaine Lennan RN BN MSc DClinP
Consultant Chemotherapy Nurse,
University Hospital Southampton;
Academic Practitioner,
University of Southampton, UK
The aim of intravenous management is safe, effective delivery of treatment without discomfort or tissue damage and without compromising venous access, especially if long-term therapy is proposed.1
The intravenous route is used for many reasons, including:
- Fluid and electrolyte replacement
- Administration of medicines
- Administration of blood/blood products
- Administration of total parenteral nutrition
- Haemodynamic monitoring
- Blood sampling.
Access to an intravenous route is particularly important for patients undergoing chemotherapy because of the frequency and longevity of intravenous treatment. Occasionally the chemotherapy itself will determine a device to be used, that is, some can only be used centrally, and in addition, the condition of the peripheral veins and patient preference must be taken into consideration.
Vascular access devices
There are several ways to access the intravenous route and the treatment or procedure required should determine the required method. The most common device of choice is the peripheral intravenous catheters (PIVCs). According to a study performed at the Mayo Clinic, PIVCs are now the most commonly used type of device for vascular access, with more than 300 million used each year in US hospitals alone.2 However, central venous access devices are also used in the form of peripherally inserted central catheters (PICCs), tunnelled central catheters (such as Hickman lines) and implantable ports (portocaths). Table 1 shows the advantages and disadvantages for these devices.
Gaining experience in, and using, intravenous access is routine in health care but complications can occur. As a result, much emphasis has been placed on education on preventing complications in recent years.
Complications
Phlebitis and infection
Phlebitis, defined as an inflammation of the vein, is among the most common complications of IV therapy. Studies estimate that anywhere from 20-80% of patients receiving IV therapy develop phlebitis.3,4 Although central access does not eliminate the risk of phlebitis, the issue is mainly of concern in peripheral cannulas. Good insertion technique using principles of asepsis is the first key requirement for an patent uncomplicated cannula.5
The development of phlebitis is multifactoral and causes can be chemical, mechanical or infective. By far the most common cause is chemical. Many chemotherapy agents are irritant to veins because of the extremes of pH of the solutions and such drugs require large bore access devices and concurrent normal saline infusions to dilute the drug.
Duration of cannula in situ is the most pertinent risk factor for the development of mechanical phlebitis. The longer the device is in place, the higher the risk. Indeed, this also applies to infective phlebitis. Clinical guidance now recommends changing peripheral cannula after 48–72 hours.1
Most chemotherapy is now delivered in the outpatient setting, where fresh cannulas are inserted each time for those without central access; however, it is important for those patients on inpatient wards, who are often receiving additional drugs as well as chemotherapy, that cannulae are frequently assessed and observed.
Importance of assessment
Assessment is important and a scale has been developed to guide practice.6 Anyone scoring grade 2 or above should have the cannula re-sited and assessments made regarding the need for antibiotic therapy (Table 2).
It is important to re-site any device at the first signs of phlebitis, but also to monitor the site after removal as inflammation responses are often delayed.
Occlusion
A concern with any device, but particularly central devices, is the risk of occlusion, be it thrombotic or infective. It is important therefore that these devices are only handled by staff aware of the care required. Should a thrombotic occlusion occur, it might be possible to remove it with the use of anticoagulants or a desheathing procedure, but these are costly and not without their own risks. An occluded catheter is distressing to all. Not only is removal and another insertion required, but it also potentially delays chemotherapy treatment.
This is costly for the organisation. However, compared with the consequences of the possibility of clot dislodgment and serious clinical events such as a pulmonary embolus, these are secondary in severity. In addition, infective occlusions represent a significant threat to patient outcomes, given that the purpose of the central catheter placement is access to the bloodstream. Remembering that the chemotherapy treatment is likely to cause a degree of neutropenia, it is clear that infective complications can lead to septicaemia, which can sometimes result, at best, in loss of the device but, at worst, septic shock and death. All chemotherapy units will have guidance in the management of central venous devices.
Infiltration or extravasation
Extravasation is a concern for all healthcare workers administering chemotherapy. Extravasation is more common in peripheral administration but it can also occur with central access devices. Extravasation is the inadvertent infiltration of the drug into the surrounding tissues, the consequences of which will depend on the drug being administered. Most occurrences cause no long-term damage but some commonly used drugs can cause blistering and burning and result in necrosis of the tissue.7 All chemotherapy units will have extravasation policies in place, which will differ from unit to unit. However, in all cases, suspected extravasation is a medical emergency and must be dealt with immediately. For the nurse administering the drug, the first principle is, if in doubt stop. Many chemotherapy drugs cause reactions at the delivery site and it can be difficult to distinguish between a serious and a less serious event (Table 3).
It is widely recognised that early detection and intervention is critical to the prevention of potentially serious adverse outcomes. Failure to detect infiltration or extravasation promptly can leave the patient with permanent disfigurement and loss of function, and potentially result in litigation.
Benefits of infusion devices
Historically, the use of infusion pumps had been frowned upon in chemotherapy clinics because of the potential risk of extravasation. However, modern technology has advanced leaps and bounds to include sensitive pressure sensors to detect early any resistance in the vein. This has helped change thinking but it is still clear the responsibility for preventing extravasation remains with the nurse whether using a pump or not. An added advantage of a pump is the ability to consistently deliver the drug at a controlled rate. This may help prevent phlebitis because the administering nurse is unlikely to be able to deliver a consistent concentration but rather use a stop/start technique.8
Hypersensitivity
Hypersensitivity reactions to chemotherapy agents are common. The severity ranges from mild to life-threatening but they are difficult to predict. It is known, for example, that platinum-containing drugs build a hypersensitivity with repeated cycles whereas the use of taxanes and monoclonal antibodies is associated with reactions at first or second exposure.9 Given the frequency of hypersensitivity in clinical practice, is important that nurses are not only aware of the risk but competent in the management of reactions across the spectrum. Initial strategies to manage a mild reaction include stopping the infusion, administration of antihistamines and steroids and close observation. Once settled, with careful observation the infusion may be re-commenced at a slow rate. For more severe reactions, discontinuation of the treatment is often indicated, usually with the consent of the patient who can be traumatised after such an event. For those patients in whose best interest it is to continue the treatment, desensitisation protocols are available but this procedure is labour intensive, costly and not without risk.10,11
Importance of controlled rates
Controlled rates are important for drugs associated with a high risk of hypersensitivity. Modern infusion pumps are now available to titrate rates over time. For example, a desensitisation programme starts with 1ml/mg/hour followed by 5ml/mg/hour and incremental rises until the full dose is given or symptoms of hypersensitivity occur. This controlled rate is extremely important in this instance and the value of the pump cannot be underestimated. In addition, the pump is able to accurately calculate the actual amount administered before any discontinuation, which might be crucial in determining the schedule and timeframe(s) of alternative treatment.
Conclusions
Infusion therapy is fraught with complications. While most are not serious, complications are associated with significant patient morbidity and considerable cost to healthcare organisations. Choice of infusion device is key in optimal care and most complications can be managed with adherence to principles of care with regard to infection and assessment. Infusion pumps can help in the prevent of phlebitis by offering a constant concentration of drug rather than a ‘push-pull’ technique employed by the nurse. Prevention of extravasation remains the key concern of the chemotherapy unit but the increasing hypersensitivity reactions with the advent of repeat treatments and antibody therapy are equally of concern. Ongoing education in the management of these events are crucial to ensure safety is always at the forefront of care.
Key points
- The aim of intravenous (IV) management is safe, effective delivery of treatment without discomfort or tissue damage and without compromising venous access, especially if long-term therapy is proposed.
- Most chemotherapy is now delivered in out patient settings
- Correct choice of intravenous access device is essential; peripheral canulas are the device most commonly used.
- Phlebitis rates range from 20-80%.
- Nurses need skills in the management extravasation and hypersensitivity reactions.
References
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- Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81(9):1159–71.
- Panadero A et al. A dedicated intravenous cannula for post operative use. Anaesthesia 2002;57:921–5.
- Uslusoy E, Mete S. Predisposing factors to phlebitis in patients with peripheral intravenous catheter. J Am Acad Nurse Practitioners 2008;20:172–80.
- Higginson R, Parry A. Phlebitis: treatment, care and prevention. Nurs Times 2011;107(36):18–21.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs 2006;29:S1–91.
- European Oncology Nurses Society. Extravasation guidelines;2008. EONS
- Kirkbride G, Vermace B. Smart pumps: implications for nurse leaders. Nurs Admin Q 2011;35(2):110–18.
- Hallquist Viale P. Management of hypersensitivity reactions: A nursing perspective. Oncology 2009;23(2 Suppl 1):26–30.
- Lenz H. Management and preparedness for infusion and hypersensitivity reactions. Oncologist 2007;12:601–9.
- McElroy TM, Gruenigen VE, Waggoner SE. A case of prolonged carboplatin therapy in a patient with carboplatin hypersensitivity. Gynecol Oncol 2003;91(2):435–7.
