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Thinking about physics…. and IV therapy: The pressure’s on!
Melissa M. Otoya RNC
University of Virginia Children’s Hospital: Neonatal ICU
Introduction
As care and technology for our most vulnerable neonatal
population improves, so does our dependence upon centrally
placed vascular access devices. The use of these devices,
along with the multiple options and variables associated with
tubing adjuncts and infusion pumps, has potential to create
practice variation, knowledge gaps, and confusion for caregivers
in the NICU. Just how much does the typical NICU nurse know
about catheters, tubing adjuncts, infusate solutions, infusion
pump devices, and the potential relationships to complications
of intravenous therapies? Do our educational efforts, either
associated with product training, new hire orientation, or staff
development provide for a clear understanding? With recent
emphasis on reduction of morbidities associated with infusion
therapy, the tools and framework of knowledge that the nurse
has is imperative to the ability to minimize risks associated with
long term IV therapy. Beyond the emphasis on reduction of
catheter associated blood stream infection, this focus on
product selection, nursing knowledge, and practice patterns will
hopefully engage further thought into the associated physics,
pathophysiology of thrombus/ thromboembolism formation and
relationship to patient outcomes such as interrupted
fluid/medication
delivery,
catheter
occlusion,
bio-film
development, and catheter related blood stream infection.
Ah-ha! The clot thickens!!!!!!
Neonatal Thrombosis / Thromboembolism
 “Relative” prothrombotic state of newborn is balanced by other factors
that prevent a term or relatively well premature infant from experiencing
spontaneous thromboses.
 When this “balance” is disrupted, the neonate is at high risk for
thromboses development.
 Specifically, infection promotes clotting activation and catheters
provide a center for thrombus formation.
 Alternatively, the plastic CVC surface promotes platelet activation and
thrombus formation. The thrombus and its ligands promote adherence of
local bacteria.
 Clinical significance of neonatal thrombosis varies from asymptomatic
incidents to life or limb-threatening events.
The Problem
Infusion device characteristics and differences
Prescription for the problem
Over a six month period in the NICU at the University of Virginia
Children’s Hospital, the incidence and prevalence of line
occlusion, as well as thromboembolism (TE) requiring long term
anticoagulant therapy had increased.
Large volume pump – peristaltic flow device
Staff Education: Mandatory annual skills fair venue
In addition to application of IHI - Central Line Care bundle,
practice changes in the months preceding these outcomes
included:
• Abandonment of the practice of locking central vascular catheters (CVC,
PICC, UVC).
• Use of KVO rate to maintain patency if maintenance of catheter is deemed
necessary, thereby reducing number of entries into IV system.
• Reduction of standard KVO rate from 2ml/hr to 1ml/hr .
• Standardization of tubing configuration inclusive of closed medication
delivery system.
• Sterile procedure for tubing assembly and change procedures.
• Placement of needleless injection cap on any point in tubing configuration
likely to be entered and specific injection cap antiseptic prep procedures.
 Data from three international registries demonstrated that
approximately 90% of venous thromboses in neonates were associated
with CVC’s.
 Overall size of catheter in relation to small vessel lumen creates risk
for obstruction of blood flow and can be mechanical source of endothelial
damage to vessel wall.
Whereas daily re-evaluation of need for CVC or umbilical catheter as
well as use of heparinized solutions have been recommended in the
medical literature as preventative strategies, our findings suggest that
infusion therapy devices, product characteristics, and user interface may
well have a significant relationship to outcomes.
Syringe infusion pump
• Typically offer +/- 2% delivery accuracy.
• Positive linear displacement device that utilizes a gear reduction mechanism
and a lead screw.
• Computer controlled motor turns the screw that ultimately provides positive
force to the plunger on a syringe.
• Specifically designed to deliver small volumes and low flow rates.
• Mechanism allows for enhanced continuity of flow with shorter frequency
intervals and minimal relaxed time.
• “Mechanical gap” or “slack” can have a significant impact on start up time,
resulting in delay of infusion unless specific priming procedures are consistently
understood and employed.
Additional relevant practices / observations include:
• Standard needleless injection cap is a split-septum, low prime volume
product that exerts a negative pressure upon de-access.
• Large-volume, peristaltic flow infusion pumps are used primarily for infusion
of maintenance IV fluids, and TPN, and frequently at KVO rate.
• Syringe infusion pumps are used for continuous drip medication delivery,
intermittent medication, and intralipid infusions.
• Routine practice of addition of heparin to IV solution for all central venous
lines and arterial lines. (0.5 – 1 unit/ml)
• Syringe pump event logs indicated non-compliance with priming procedures
as well as presence of alarms indicating increasing pressure in system
preceding occlusion outcomes. (early occlusion detection system)
• Routine prophylactic flushing of CVC, PICC devices is not a standard
practice for NICU patient population.
• Moderate nursing turnover with continuous new hire orientation and
preceptor variability.
• Some use of agency (travel) nursing staff with abbreviated orientation
provided.
Analysis of problem and contributing factors
 With acute rise in catheter occlusion rates as well as incidence of
thromboembolism, practice patterns and knowledge gaps are suspect as
contributory.
 Investigation of specifications and operational details of infusion devices provided
insight to understanding variability in flow continuity of these devices, especially at
low rate infusions.
 Survey of staff revealed that pump selection was inconsistent and did not convey
operational understanding of differences between the devices and safety features.
 Survey also provided concerning insight regarding staff knowledge gaps and
practice relevant to needleless injection cap. (Increased incidence of catheter
occlusion, particularly in smaller lumen catheters where longer length of catheter is
filled by reflux displacement of blood upon disconnection, has been previously
reported.)
 Event log reports from infusion devices demonstrated non-compliance with pump
priming procedures as well as lack of understanding and significance of “early”
occlusion alarms.
 To proceed with staff education and changes in practice, the project would require
budgetary allocation for nursing education, system changes in computerized order
entry, medical staff engagement and pharmacy leadership involvement.
Given anecdotal observations, detail gleaned from
infusion device event logs, and a couple of well thought out assumptions, we
developed a survey of “suspect” infusion practices and product choices that
validated some of our concerns regarding practice inconsistencies and well as
knowledge gaps. (68% response rate) The following selected questions and
responses provided us with some direction.
• Explained differences in pump features, specifications, and
recommendations to improve flow continuity for low flow rates as well as
high risk medication delivery.
• Specific attention given to procedure for “pump priming” to overcome
mechanical slack and improve start-up time and avoid stasis in catheter as
well as delayed delivery of fluid/medications. Lots of visuals are helpful to
create understanding of this concept.
• Infusion pump manufacturer recommendations for improving flow
accuracy; choice of syringe size and use of low volume tubing sets.
• Discussion of negative pressure feature of the needleless injection port
with “live” demonstration of “reflux” that occurs upon disconnect. This was
very effective!
• Tubing change procedures and steps involving disconnect from injection
cap, with specific emphasis on clamping prior to disconnect to prevent
reflux into catheter.
System and practice changes
• Standardized steps in initiation of infusion or tubing change to always
include pump priming procedure prior to connect to patient.
• Computerized physician order system changed to include specification of
KVO fluid orders to be dispensed in a syringe. (Syringe size chosen based
upon flow rate)
• Extension sets, CVL, or tubing always clamped upon de-access from
needleless injection ports.
Outcomes
• Although methods of catheter complication data collection (at the time of
problem identification and 1 year following) are not conducive to scientific
analysis, anecdotal and reported catheter occlusion rates declined.
• There has been significant reduction of CVC related thromboembolism
outcome . (almost eliminated)
• Staff orientation and training relevant to infusion therapy has consistent
elements.
• Identification for need to implement systematic central line outcome data
collection for quality and performance improvement purposes. To be
developed within EMR. (process currently underway)
Conclusions and implications for nursing
 Upon de-access or disconnect from the needless injection cap,
 Neonatal population has unique IV therapy needs and potential for
morbidities.
_____?______ pressure is created.
Negative pressure
Positive pressure
Neutral pressure
• Discussion of survey findings and conclusions regarding product,
practice, and knowledge gaps as potential contributing factors in
development of occlusion, thrombus / thromboembolism outcomes.
• Syringe infusion pumps to be used for KVO rates.
When in doubt………..SURVEY!
 Incidence has been reported between 2.4 – 5.1 per 1000 newborns
admitted to NICUs . (1995, 1997)
Incidence statistics are expected to have increased since these earlier
reports as a result of ever increasing use of central venous catheters
(CVC, PICC), as well as umbilical catheters (UVC, UAC) .
• Typically offer +/- 5% delivery accuracy.
• Most common mechanism is a linear peristaltic device which uses fingerlike
projections to occlude tubing successively in a rippling wave–like motion.
• Tubing is held against a stationary plate and is alternately compressed and
released by moving fingers, forcing fluid flow.
• At low infusion rates this may result in longer frequency intervals with significant
“relax” time.
• Fluid flow is “cyclic” and may cause significant fluctuations in flow rate and
continuity.
77.5%
16.9%
5.6%
 Nursing staff education needs to address these unique differences in both
practical and didactic components of orientation and in-service training.
 When I de-access – disconnect tubing or syringe during routine tubing
or syringe changes, I will ______________.
Clamp the catheter or extension set
91.5%
Not clamp the CVC or extension set if it has an injection cap
4.2%
Sometimes clamp, depends upon what medication is infusing
4.2%
 Products used with infusion therapy need to be implemented with
thorough staff education, including skill and knowledge competency validation.
 When I am running fluids through a central line or PICC at KVO rate, the
infusion pump I typically use is…….
Large volume (peristaltic flow) pump 45.1%
Syringe pump 32.4%
Choice depends on total fluid volume and MD orders 23.9%
Whatever pump available
2.8%
Further studies of the pathophysiology of thrombosis and infection are
warranted with emphasis on preventative interventions inclusive of variables
associated with infusion devices, and infusion system tubing adjuncts,
especially needleless injection caps.
Acknowledgements
I would like to specifically acknowledge Danielle Ottinger MSN, NNP for her assistance with creation and conduction of
the staff survey. Additionally, it is the honor of working with such a dedicated medical and nursing staff in the NICU at the
University of Virginia’s Children’s Hospital that supports and celebrates continuous inquiry of practice to improve care to
our most vulnerable patients and their families.
 Infusion product selection and implementation processes must have
representation by end users. Failure Mode and Effects Analysis Model (ISMP)
provides a good framework for product and practice analyses.
References:
1.
2.
ECRI Institute. Needleless Connectors. Health Devices. Sept 2008: 262 – 318
ECRI Institute. HealthCare Product Comparison System: Infusion Pumps, general purpose. 2007. Accessed
8/11/2010. http://www.ecri.org/Documents/HPCS_Infusion_Pumps.pdf
3. Neff SB, Neff TA, Gerber S, Weiss MM. Flow rate, syringe size, and architecture are critical to start up performance of
syringe pumps. European J Anaesthesiology. 2007; 24(7): 602-608
4. Ryder M. Evidence-based practice in the management of vascular access devices for home parenteral nutrition
therapy. JPEN. 2006; 30(1):S82-S93.
5. Saxonhouse MA, Burchfield DJ. The evaluation and management of postnatal thromboses. J Perinatology. 2009;29:
467-478.
6. Thornburg CD, Smith PB, Smithwick ML, Cotton CM, Benjamin DK, Jr. Association between thrombosis and
bloodstream infection in neonates with peripherally inserted catheters. Thrombosis Research. 2008;122: 782-785.
7. Veldman A, Nold, MF, Michel-Behnke I. Thrombosis in the critically ill neonate: incidence, diagnosis, and
management. Vascular Health and Risk Management. 2008;4(6): 1337-1348.
For further information:
Contact: Melissa Otoya RNC
[email protected]