NIVAS 2019: facing the future in vascular access and infusion therapy

Katherine Ajdukiewicz, Consultant in Infectious Diseases and Tropical Medicine, Pennine Acute Hospitals NHS Trust

In this era of increasing antimicrobial resistance there is a need to develop new antibiotics with novel mechanisms of action. Although the development of new antibiotics has been slow, Dr Ajdukiewicz noted that odilorhabdins are a novel class of natural antibacterial agents produced by enzymes of the nematode-symbiotic bacterium Xenorhabdus nematophila. Odilorhabdins interfere with protein synthesis and are ribosome-targeting. They act against both Gram-positive and Gram-negative bacteria and carbapenemase-producing enterobacteriaceae, and have demonstrated promising efficacy in mouse models.

Dr Ajdukiewicz continued by detailing the threat posed by biofilms, which are often difficult to detect, resistant to desiccation, tolerant of biocides and are rarely treatable with antimicrobials. In a recent study of 75 patients who had experienced a stroke, 79% had oral bacterial DNA in their cerebral thrombus. The DNA was identified as being mainly from the Streptococcus viridans group, which form biofilms, bind to platelet receptors and increase the risk of developing blood clots. Therefore, good oral health and dental hygiene may be more important than previously thought. In addition, Dr Ajdukiewicz outlined the results of a retrospective study conducted between 2000 and 2013 (Dayer et al, 2015) that demonstrated that during this period, owing to the National Institute for Health and Care Excellence (NICE) 2008 guidance that advised against the use of antibiotic prophylaxis for infective endocarditis for people undergoing dental procedures, the incidence of infective endocarditis increased significantly. Following these results, NICE revised its guidance in 2016 to state that the use of antibiotic prophylaxis for infective endocarditis for people undergoing dental procedures is not ‘routinely’ recommended, which Dr Ajdukiewicz noted as being too unclear.

In patients with periprosthetic joint infection where surgery is not an option, Dr Ajdukiewicz highlighted the usefulness of continuous antibiotic suppression to manage the infection. Ideally, continuous antibiotic suppression should be associated with high bone penetration, low cumulative toxicity, low risk of drug–drug interactions, long half-life, minimal effect on the gut microbiome and be relatively convenient to take. In the UK, doxycycline, quinolones and cotrimoxazole are commonly used for continuous antibiotic suppression. However, there are limited data available to support the length of time that patients should receive continuous antibiotic suppression; this may contribute to the development of antibiotic resistance. In addition, Dr Ajdukiewicz outlined the role of multi-drug resistant (MDR) plasmids in the development of antibiotic resistance. MDR plasmids are small DNA molecules found in bacterial cells that develop as a result of gene mutations or by acquisition of resistance genes via horizontal gene transfer. Some MDR plasmids also promote biofilm development, thus improving the persistence of MDR plasmids.

Dr Ajdukiewicz highlighted the development of genetically modified bacteriophages for the treatment of chronic bacterial infections such as Pseudomonas aeruginosa; bacteriophages have been shown to successfully penetrate the associated thick, black slime inside the lungs and clear the infection.

Dr Ajdukiewicz concluded with the mantra ‘right drug for the right bug’, and for health professionals to consider the following when making treatment decisions for bacterial infections:

James Gilbert, Consultant Transplant and Vascular Access Surgeon, Oxford University Hospitals NHS Foundation Trust

Dr Gilbert's presentation detailed the challenges associated with vascular access and their associated solutions. With the increasing demand for vascular access in the clinic, end-stage vascular access (ESVA) failure is becoming more common. As peripherally inserted central catheters (PICCs) and midlines are associated with the development of thromboses, infections and central venous stenosis/occlusion, there is a need to develop novel strategies for vascular access that avoid ESVA failure.

In patients with central venous pathology or ESVA failure, the Haemodialysis Reliable Outflow (HeRO) device is a better long-term option than central venous catheters (CVCs) and is cost effective at £3000 when compared with alternative strategies. In patients with thoracic central vein obstruction, the Surfacer system has demonstrated an ability to re-establish vascular access.

Dr Gilbert concluded by providing a few key recommendations:

Andrew Barton, NIVAS Chair and Advanced Nurse Practitioner IV Therapy and Vascular Access, Frimley Health NHS Foundation Trust

For the majority of cases that require vascular access, a visible, palpable vein is sufficient to achieve successful cannulation. To avoid damaging patients' vasculature, Mr Barton highlighted that a nurse should only attempt cannulation twice before asking a colleague to have a maximum of two further attempts. If successful cannulation is still not achieved, then technological assistance should be sought, for which there are a number of options available:

In addition to novel technologies that aid successful cannulation, technology is beginning to permeate multiple aspects of the workplace for vascular access nurses. Hospify is an NHS-approved, secure application for mobile phones that NHS employees can use to share patient data, and should be used instead of less secure applications that provide similar services, such as WhatsApp. The recent emergence of virtual reality has led to numerous applications in the healthcare sector, and one of the future applications that Mr Barton anticipates is as a distraction tool for children and the needle-phobic to take their mind off the cannulation procedure.

Mr Barton reiterated the substantial benefits that technology can bring to the field of vascular access, but warned that it is important that vascular access nurses are sufficiently trained to exploit these new opportunities. He concluded by noting the pillars of the ideal vascular access technology of the future: comfort, safety, stability, painlessness and convenience.

Angela Dennison, Clinical Nurse Specialist, IV Therapy and Vascular Access, Frimley Health NHS Foundation Trust

Ms Dennison provided an inspiring overview of her career path from joining Frimley Health NHS Foundation Trust as a healthcare assistant in 2002 to her current role as a clinical nurse specialist in vascular access. She appreciated the autonomy and control that she had over her career that ultimately led to her passion for vascular access nursing. Ms Dennison concluded by noting that it has been an amazing journey for her so far, she loves working with new technologies and meeting new people, and that she is excited to learn more in her constantly advancing role.

Phoebe Curson-Endicott, IV Access Team Leader, East Kent Hospitals University NHS Foundation Trust

Ms Curson-Endicott presented her journey from joining the Viking Day Chemotherapy Unit in 2011 as a healthcare assistant to her current role as IV access team leader. Together, her team aims to provide timely, reliable, first-time venous cannulation in line with the Vessel Health Preservation (VHP) framework. Ms Curson-Endicott noted that her dedicated vascular access team has a high success rate for first-time venous cannulation, freeing up doctors and nurses to undertake more role-appropriate tasks. It is hoped that her team will continue to drive excellence in vascular access and develop innovative and thoughtful vascular access care.

Steve Hill, Procedure Team Manager, Ibon Zuzuarrequi, Procedure Nurse Specialist, Sviatlana Vasileuskaya, Procedure Nurse Specialist, and Samantha Brady, Procedure Nurse Specialist, The Christie NHS Foundation Trust

Matt Jones, NIVAS board member, Consultant Anaesthetist, East Kent Hospitals University NHS Foundation Trust, Jackie Nicholson, Nurse Consultant Vascular Access, St George's University Hospitals NHS Foundation Trust and Fiona Nadin, OPAT Lead, Frimley Health NHS Foundation Trust

Three interesting case studies were discussed this year: fibrin sheaths, damaged skin tunnelled catheters, and how to deal with patients who may have factitious disorder. The cases emphasised the importance of collaboration, not making assumptions and thinking outside the box. This interactive session sparked engaging discussions among the attendees and was informative for all health professionals regardless of their level of training.

James Bennett, Consultant Anaesthetist, Birmingham Children's Hospital

Dr Bennett presented an informative account of his experience in paediatric vascular access, and the associated challenges of working with blood vessels that are much thinner and smaller in diameter. The importance of accurate and comprehensive imaging before and during vascular access was emphasised to reduce the risk of vascular damage and complications. Dr Bennett provided guidance on which catheter should be used, and concluded that all paediatric patients deserve the highest quality venous access, and that sharing experiences and expertise can reduce the risk of complications for these vulnerable patients.

Fiona Nadin, OPAT Lead, Frimley Health NHS Foundation Trust

A strong relationship and good communication between health professionals and patients is essential for optimal patient care. Ms Nadin highlighted that patient non-compliance can be deliberate (usually owing to a lack of trust in their health professional or treatment plan) or non-deliberate (usually owing to a comorbidity that causes the patient to misunderstand, such as a learning disability). As this has a large impact on patient care, it is important for professionals to identify patients who are at risk of compliance prior to initiating outpatient parenteral antimicrobial therapy (OPAT) by considering the following factors:

Ms Nadin then provided an informative summary of the devices and dressings that are available for OPAT, and included an overview of those devices that are tailored for use with non-compliant patients, such as PICC Guard—a tamper-evident device for intravenous drug users. Ms Nadin concluded her presentation by reiterating the need to take a holistic view of patients when assessing their eligibility for OPAT, and to tailor the devices used to the patients' needs.

Jecko Thachil, Consultant Haematologist, Manchester Royal Infirmary

A blood clot is one of the body's natural responses to prevent infection, but the disadvantage of this strategy is reduced or halted blood flow. Dr Thachil's presentation focused on the risk of a blood clot developing as a result of catheter placement, and how we can treat them if they do occur. The types of blood clots that can occur as a result of catheter placement are fibrin sheaths, intraluminal clots, mural thrombi and venous thrombi; two-thirds of these patients are asymptomatic. Dr Thacil noted that blood clots should be treated with anticoagulants (routine prophylaxis is not recommended) and that if the patient responds to the treatment then the catheter can be kept in place as long as it is functional, well-positioned and not infected.

Matt Jones, NIVAS board member, Consultant Anaesthetist, East Kent Hospitals University NHS Foundation Trust, Steve Hill, Procedure Team Manager, The Christie NHS Foundation Trust and James Bennett, Consultant Anaesthetist, Birmingham Children's Hospital

The session began with a brief presentation that covered the principles of ultrasound-guided cannulation, and was followed by an extended training session allowing attendees to interact with ultrasound systems and cannulation training blocks. Sharing of knowledge was encouraged, which led to a highly interactive experience for all attendees.

Gemma Oliver, Nurse Consultant Integrated IV Care, East Kent Hospitals University NHS Foundation Trust and Nicola York, Clinical Nurse Manager Vascular Access, Oxford University Hospitals NHS Foundation Trust

Ms Oliver and Ms York provoked engaging discussions about peripheral vascular access, with topics including the types of lines/ports, challenges associated with venous access, and common mistakes associated with the use of technology in peripheral vascular access. Attendees enjoyed analysing a photo of Andy Murray's cannula and discussing the possible errors associated with his cannulation, and all agreed that they had taken some key learning points from this interactive and informative workshop.

Tim Jackson, NIVAS Vice-Chair and Consultant Anaesthetist, Calderdale and Huddersfield NHS Foundation Trust

Vascular access procedures are currently the most common invasive procedures in acute care in the UK. Despite this, Dr Jackson noted that awareness among health professionals about the importance of VHP is low, leading to unnecessary harm for patients. Although the VHP framework has been established and is undergoing its first major revision, there is still a lot of work to be done before vascular access can be achieved for all patients in accordance with the VHP framework. For example, in its current state (https://bit.ly/2Jyscbm), it would not be cost-effective to apply this across the NHS.

Dr Jackson concluded his presentation by highlighting some potential avenues to explore to improve the reach of the VHP framework and the awareness of VHP in general including:

Andrew Barton, NIVAS Chair and Advanced Nurse Practitioner IV Therapy and Vascular Access, Frimley Health NHS Foundation Trust

Mr Barton thanked the attendees for striving to make a difference and improve outcomes for patients, B Braun for the company's partnership and the other sponsors for their support, as well as OPEN Health Medical Communications for their secretariat support. Mr Barton concluded the conference by underlining the informative and engaging discussions that took place among a diverse group of health professionals.