The past 2 years have seen the use of IV therapy and vascular access devices (VADs) at the forefront of treating COVID-19 patients. Even before the pandemic, VAD use was on the rise. As more intravenous treatments are developed in all areas of medicine, the need for VADs has risen, prompting the need for new guidelines and protocols to avoid complications. Guidelines for the care and maintenance of VADs should always be evidence-based to ensure safe practice. However, since the start of the pandemic, we have had to make difficult decisions and adapt practice to available resources while dealing with a significant rise in demand. Some shortcuts have proved safe and beneficial, such as port flushing being successfully extended to 2 monthly or longer, with anecdotal evidence to-date of no negative outcomes.
However, NIVAS members have recounted some worrying practices during the pandemic. At a recent IV therapy conference, delegates spoke to me about a rise in catheter-related bloodstream infections (CRBSIs) in their hospitals, partly due to increased inappropriate use of personal protective equipment when maintaining VADs. I heard how basic measures to prevent infections, such as scrubbing the hub of needle-free connectors or fully disinfecting the skin before cannulation, were being overlooked in favour of speed. I was told about the increase in inappropriate use of peripheral cannula for administering vesicant drugs, again blamed on the pandemic. Two years from the onset of pandemic we cannot blame poor IV practice on COVID-19. We know what we need to do to reduce the risks while delivering evidence-based care in IV therapy and vascular access, it is always about reducing complications.
In my own practice, the use of adjuncts to prevent catheter-related infections has been a focus for the past 12 months. The use of disinfection caps to protect the needle-free connector and chlorhexidine-impregnated IV dressings to protect the exit site have been recognised as important approaches. Catheter-locking solutions have been another change, in my own practice, to protect VADs, with the most recent additions not only helping prevent CRBSIs but also being used for treatment. Taurolidine-locking solutions are antiseptics, reducing the risk of antibiotic resistance.
There are many ways to prevent complications in vascular access and IV therapy, the simplest being to remember the basics and provide regular updates to staff. NIVAS is looking forward to offering more study days and webinars this year. Look out for upcoming dates on the website and in our emails to members.
International research relevant to UK
In this IV supplement you will find two excellent international articles. The first is an insightful piece from the journal of the Canadian Vascular Access Association on the effectiveness of scheduled vital sign assessment during infliximab infusions in detecting reactions. The study investigated the utility of scheduled vital sign monitoring in detecting reactions to infliximab. This was partly because there is no standardised approach to infusion vital sign recording in Canada or, indeed, worldwide and, partly I suspect, to ensure staff are not redundantly taking vital signs when there is a lack of evidence for this. A multicentre retrospective study found that scheduled vital signs did not detect infusion reactions, which were identified either by visual assessment or reported by the patient. The article is not indication that vital signs should not be recorded: current guidelines in Canada state they should be taken before and after an infusion. I found the article interesting because part of my role is to manage an infusion unit where we infuse infliximab daily. We take baseline observations before and at the end of the process. Recently, I had a patient react to the third infliximab infusion presenting as facial swelling, but her vital observations were not markedly changed.
The second article is from journal of the Association of Vascular Access in the USA, which discusses managing a patient's central venous catheter dressing after a reaction to chlorhexidine-impregnated dressings. It examines why this happened and what was done to ensure the device was covered appropriately to reduce an exit-site infection, while treating the skin reaction. The case resembled a medical adhesive-related skin injury (MARSI), with similar presentation and management. While the UK and US terminology may be different, the challenges faced by our vascular access teams remain the same.
We need to undertake more research into MARSI (BJN presented a webinar on the issues last year). The root cause can often be associated with not allowing chlorhexidine-cleaning solution to dry before adhesive devises are applied to the skin around a VAD.