Central Lines

[capitalsfan83, BSN]

Hello Nurses! I work in a busy Oncology Infusion Center and we are trying to implement a policy of giving vesicants only through a central line. Some of our doctors are having difficulty accepting that because of increased risk of infections and other complications that might happen with central lines. I was wondering if anyone knows of any research papers that would support our cause or any reccomendations from ONS?

Thanks in advance

[KelRN215, BSN, RN]

I've only ever given chemotherapy though a central line. It's not even a question in children. As soon as they are diagnosed, they get either a port, a PICC or a CVL.

[SoldierNurse22, BSN, RN]

Extravasation of systemic hemato-oncological therapies

"Administration of vesicant agents should be carried out through a central line whenever possible, especially if it requires continuous infusion."

http://www.oncologypractice.com/jso/journal/articles/0805212.pdf

"Continuous-infusion vesicants and vesicants given for longer than 1 hour should be administered only via central line".

Clinical

"Avoid using a peripheral IV site for continuous vesicant administration. A central venous access catheter or implanted access device should be used to administer any vesicant infusing for longer than 30–60 minutes."

***

There are mountains of evidence that support the use of central lines for chemo in general, but much more so for vesicants because it decreases the risk of extravasation. If your docs are balking at that...well, wow. Someone should bring them into this century when it comes to modern oncology treatment standards.

Google Scholar and a basic Google search reaped the info above, though as KelRN stated in her post, my floor had protocols in place that mandated the use of central lines unless in extreme cases (patient refused a central line).

[oncnursemsn]

I'm so relieved to see this as a topic- I'm in the process of developing guidelines for our newly diagnosed patients who will be receiving aggressive chemo/radiation and supportive care. What I'm finding is there is a philosophy in my organization *against* ports/PICCS despite our administration of irritants and vesicants via peripheral lines. If anyone has already existing guidelines or protocols that address the issue of central VAD insertion prior to initiation of treatment, I would love to hear about it! In our patients who have ports, we have an almost 0% central line infection rate...

[SoldierNurse22, BSN, RN]

I'm so relieved to see this as a topic- I'm in the process of developing guidelines for our newly diagnosed patients who will be receiving aggressive chemo/radiation and supportive care. What I'm finding is there is a philosophy in my organization *against* ports/PICCS despite our administration of irritants and vesicants via peripheral lines. If anyone has already existing guidelines or protocols that address the issue of central VAD insertion prior to initiation of treatment, I would love to hear about it! In our patients who have ports, we have an almost 0% central line infection rate...

I worked at Walter Reed Bethesda for several years. We had no written policy about central line insertion prior to chemo--just very strict policies about the care of central lines, dressing changes and infection prevention techniques. Otherwise, the culture condoning and encouraging central line use was already in place. Our docs were on the forefront of medicine and working closely with NIH, which made it easy.

Similarly, we had a very low central line infection rate--even in an immunocompromised population--because RNs were properly trained on central line care and patients were taught how to prevent infection from the start.

[capitalsfan83, BSN]

Thanks for your reply SoldierNurse22, those are good references and we have used them before in our talks with the docs, the only problem is that they do not specifically state that we should use central lines with all vesicants, they say that they "highly reccomend" central lines with all vesicant infusions of 30 min or more, which we already do.

[SoldierNurse22, BSN, RN]

True, the evidence does not directly address the tiny piece of the problem you're trying to tackle. However, the sweeping evidence regarding central line usage with chemotherapy--specifically with vesicants--is supported without dispute.

From what I understand, if you're giving an IV push of chemo, physically pushing a syringe puts more pressure on the vein internally than the pump does. So while the infusion may not be as long, you're applying more force over a shorter amount of time. The chances for loss of patency and subsequent infiltration/extravasation are even higher with IV pushes versus continuous/long infusions. Some patients get IV pushes of vesicants every day for certain cycles. Do they really want you to just rotate PIV sites? Ugh. Sometimes, I wish I could make the doc do my job and talk to patients the way I do so they could see what we're dealing with!

[brithoover]

Pushing vesicant a through an IV makes me sweat. Literally. Scary stuff

[Manal Al Humaid]

It seems that a worldwide issue !! Even in our organization does have a written protocol about giving chemo through CVAD but unfortunately solid tumor patients who receive it for a few hours are not included.

[annacat]

I have pushed vesicants through PIV's in the hand before without a problem. (Just be sure to check for blood return before, after, and every 2cc of push!)

I have also had patients who's ports would be clotting every 2 weeks. Nothing is perfect but I do agree, as does the ONS, that central lines are much preferred in general for vesicant administration. Anyone who has seen the effects of vesicant extravasation would most likely agree.

Sounds like you all need the support of those up the chain of command from you to influence the doctors who are resistant.