Essentials of Infusion Nursing
Infusion Nursing is a specialty branch that provides nurse care by infusing fluids, medication and blood products through injections into patients' veins or by maintaining arterial catheters. Infusion nurses also hold the responsibility of monitoring patients, maintaining their tubing and recognizing potential drug interactions and complications. Infusion nurse care is complex due to factors such as HIV, HBV and HCV that are transmitted by blood transfusion, the fatal acute haemolytic reactions caused by ABO incompatibility, contamination of red cells (Carson et.al, 1999) and nerve injuries during venipunctures (Masoorli, 2004). Thus, infusion nurses need to develop a protocol to address infusion reactions and ensure patient safety (Carney and Ollom, 2008).
Recent Risks in Infusion Nursing
Cytokines, Monoclonal Antibodies and Immunomodulators have become the preferred treatment option for many complex medical conditions, especially in the areas of oncology and immunology. Many of them have been approved for administration by parenteral biologic therapy and have their own clinical applications, mechanisms of action and side effects (Vizcarra and Belcher, 2006). Novel biologic infusion agents such as rituximab and infliximab are being prescribed to patients with vasculitis who do not respond to conventional intravenous glucocorticosteroid therapy (Sejismundo, 2006). Infusion nurses have to be aware of the anaphylaxis and anaphylactoid consequences of such agents (Scarlet, 2006). Intravenous immunoglobulin is a preparation of immunoglobulins containing antibodies given intravenously to patients with both inherited and acquired immunodeficiency disorders such as, Primary Immune Deficiency Diseases, Idiopathic Thrombocytopenia Purpura, Chronic Lymphocytic Leukemia and Bone Marrow Transplantation. Although most patients tolerate IVIG, potential side effects include headache, myalgias, tachycardia, renal tubule necrosis, and hyperviscosity, stroke, myocardial infarction, anaphylaxis, and hemolysis (Koski and Patterson, 2006). Subcutaneous infusion of immunoglobulin has emerged as an alternative administration method for both children and adults (Kirmse, 2006). Heparin-induced thrombocytopenia is a serious complication of heparin therapy that frequently leads to thrombosis (Cypher, 2006). Nurse interventions include discontinuation of heparin, initiation of a direct thrombin inhibitor and therapy with warfarin (Swanson, 2007).
Fluid management is a vital component in the resuscitative care and the goal of fluid resuscitation is to restore tissue perfusion without compromising the body's natural compensatory mechanism. But, the timing, type, and amount of fluid administration during the resuscitative phase have always been a controversy especially, while managing a pediatric resuscitation. Nursing interventions should aim at establishing vascular access via peripheral intravenous, central venous or intraosseous catheters. Fluid resuscitation in the early phase of nurse care aims at perfusing critical organs, such as the brain and heart focusing on perfusion of vital structures with enough oxygen and energy substrates to maintain cellular function to avoid tissue ischemia (Schweer, 2008). Cortical hyperostosis is a frequent, often asymptomatic, side effect of prolonged prostaglandin E1 (PGE1) infusion in infants awaiting cardiac transplantation (Woo et.al, 1994).
Complications in Oncology
Complications of implantable venous access devices such as Port-a-Cath during intermittent continuous infusion of chemotherapy investigated recently has shown major complications such as infection, occlusion, thrombosis, extravasation and migration (Poorter et.al, 1996). Although monoclonal antibodies (mAb) used in oncology care are well tolerated, a major complication with mAbs is the development of mild to life threatening infusion reactions (Carney and Ollom, 2008). A study to evaluate the incidence and causes of complications associated with balloon-occluded arterial infusion chemotherapy (BOAI) for pelvic malignancies has shown that infusion from the anterior division induces neurological complications more frequently and cystitis-like symptoms are common during balloon-occluded arterial infusion (Sugimoto et.al, 1999). Complications of subcutaneous infusion port have also been investigated recently. These SIPs display delayed complications, frequently related to clinical conditions of the neoplastic patients and immediate complications, often due to the placement technique. Infection and thrombosis are the two major complications of SIP in general oncology patients. Nurse interventions include a therapy with antibiotics and fibrinolytic agents. Although neurological complications following stem cell infusion are rare, cerebral infarction and transient global amnesia episodes have been documented (Hoyt et.al, 2000).
Catheter Related Complications
Intravenous catheter outcomes are important for nurses in patients receiving intravenous medications on account of catheter-related bloodstream infections (Leone and Dillon, 2008). Central venous catheters have been used for vascular access since the 1970s and peripherally inserted central catheters have been in use since the 1990s (Earhart et.al, 2007). A study to determine the relationship between peripheral IV catheter indwell time and phlebitis in hospitalized adults has shown a significant association between phlebitis and indwell time (Powell et.al, 2008). Studies have also shown that approximately 150 million peripheral intravenous (PIV) catheters are inserted annually in the United States, with a 5% incidence rate of phlebitis. It is hence, recommended to change peripheral intravenous sites and administration sets every 96 hours. A Visual Infusion Phlebitis Scale has been evaluated recently to determine the time for a PIV to be removed (Gallant and Schultz, 2006). A prospective, sequential clinical trial to investigate if new catheter securement devices like StatLock for peripheral IV catheter securement could extend the average survival time of such catheters sufficiently to allow the implementation of the 96-hour PIV change-protocol has shown that the use of mechanical catheter securement devices like StatLock instead of tape or die-cut tape, enables the implementation of the 96-hour PIV change protocol (Smith, 2006).
Nerve injuries related to the insertion of peripheral IV catheters, venipuncture for blood collection, and the insertion of peripherally inserted central catheters are the most commonly reported insertion complications. Nerve compression injury can cause compartment syndrome due to large infiltrations and extravasations. Selection of appropriate sites for insertion of vascular access devices and use proper venipuncture techniques can prevent such injuries (Masoorli, 2007). Ultrasound-guided placement of peripherally inserted central catheters has been proved safe in infusion therapy (Nichols and Doellman, 2007). A study to investigate the practice of transfusion with infusion pump for peripherally inserted central catheters and other vascular access devices has shown that the use of infusion pump does not cause any PICC failure and results in shorter transfusion times ( Houck and Whiteford, 2007). Standard practice guidelines recommend that insertion and removal of an implanted port or pump shall be performed only by an Advanced Practice Nurse using sterile techniques to access the implanted port or pump (Gorski et.al, 2008). Cardiac tamponade occurs during central venous catheter placements when the pressure of the fluid within the pericardial sac is high enough to impair the venous return to the heart (Forauer, 2007).
Infusion nurses need to develop a protocol to address infusion reactions and ensure patient safety. Nerve injuries related to the insertion of peripheral IV catheters and the insertion of peripherally inserted central catheters are the most common complications. Infusion complications in oncology need to be addressed seriously. Adherence to the Infusion Nursing Standards of Practice like site selection and change protocol ensures safe infusion practice.
- Andrew R. Forauer (2007). Pericardial Tamponade in Patients with Central Venous Catheters. Journal of Infusion Nursing.30 (3); 161 - 167.
- Ann Earhart Christine Jorgensen and Darlene Kaminski (2007). Assessing Pediatric Patients for Vascular Access and Sedation. Journal of Infusion Nursing.30 (4); 226 - 231.
- Bonnie Smith (2006). Peripheral Intravenous Catheter Dwell Times: A Comparison of 3 Securement Methods for Implementation of a 96-Hour Scheduled Change Protocol. Journal of Infusion Nursing.29 (1); 14 - 17.
- C. Ballarini, M. Intra, A. Pisani Ceretti, A. Cordovana, M. Pagani, G. Farina, S. Perrone, M. Tomirotti, A. Scanni, G.P. Spina. Complications of Subcutaneous Infusion Port in the General Oncology Population. Oncology .56:97-102.
- Carol Lee Koski and Jardiolyn Valino Patterson (2006). Intravenous Immunoglobulin Use for Neurologic Diseases. Journal of Infusion Nursing.29 (3) S; 21-23.
- Carson J.L et.al (1999). Risk Of Bacterial Infection Associated With Allogenic Blood Transfusion Among Patients Undergoing Hip Fracture Repair. Transfusion. 39(694).
- Cora Scarlet (2006). Anaphylaxis. Journal of Infusion Nursing.29 (1); 39-44.
- Cora Vizcarra and Dulce Belcher (2006). Management of the Patient Receiving Parenteral Biologic Therapy. Journal of Infusion Nursing.29 (2); 63-71.
- Dereen Houck and Joan Whiteford (2007). Transfusion with Infusion Pump for Peripherally Inserted Central Catheters and Other Vascular Access Devices. Journal of Infusion Nursing.30 (6); 341-344.
- Hoyt R, Szer J, Grigg A (2000). Neurological Events Associated With The Infusion Of Cryopreserved Bone Marrow And/Or Peripheral Blood Progenitor Cells. Bone Marrow Transplant.25:1285-7.
- Inez Nichols and Darcy Doellman (2007). Pediatric Peripherally Inserted Central Catheter Placement: Application of Ultrasound Technology. Journal of Infusion Nursing.30 (6); 351 - 356.
- Jane Kirmse (2006). Subcutaneous Administration of Immunoglobulin. Journal of Infusion Nursing.29 (3) S; 15-20.
- Jessica Powell, Karen Gahan Tarnow and Roxanne Perucc (2008). The Relationship Between Peripheral Intravenous Catheters Indwell Time and the Incidence of Phlebitis. Journal of Infusion Nursing.31 (1); 39-45.
- Karen Woo, Janet Emery and Joyce Peabody (1994). Cortical Hyperostosis: A Complication of Prolonged Prostagland in Infusion inInfants Await ing Cardiac Transplantation. PEDIATRICS .93(3); 417-420.
- Kimberly Duff (2006). You Can Make a Difference in the Administration of Intravenous Immunoglobulin Therapy. Journal of Infusion Nursing.29 (3) S; 5-14.
- Koji Sugimoto, Shozo Hirota, Kazufumi Imanaka, Tetsuya Kawabe, Yoshiharu Nakayama, Yasuhito Takeuchi(1999). Complications Following Balloon-Occluded Arterial Infusion Chemotherapy for Pelvic Malignancies. CardioVascular and Interventional Radiology. 22(6); 481-485.
- Lisa A. Gorski (2008). Speaking of Standards: Standard 45: Implanted Ports and Pumps. Journal of Infusion Nursing.31 (1); 20-21.
- Lourdes P. Sejismundo (2006). Vasculitis and Biologic Infusion Therapies: Implications for Nursing. Journal of Infusion Nursing.29 (5); 272 - 282.
- Lynn Schweer (2008). Pediatric Trauma Resuscitation Initial Fluid Management. Journal of Infusion Nursing.31 (2); 104-111.
- Melissa Leone and L. Rad Dillon (2008). Catheter Outcomes in Home Infusion. Journal of Infusion Nursing.31 (2); 84-91.
- Pamela H. Carney and Cathy L. Ollom (2008). Infusion Reactions Triggered by Monoclonal Antibodies Treating Solid Tumors. Journal of Infusion Nursing.31 (2); 74-83.
- Paulette Gallant and Alyce A. Schultz (2006). Evaluation of a Visual Infusion Phlebitis Scale for Determining Appropriate Discontinuation of Peripheral Intravenous Catheters. Journal of Infusion Nursing.29 (6); 338 - 345.
- R. L. Poorter, F. N. Lauw, W. A. Bemelman, P. J. M. Bakker, C. W. Taat and C. H. N. Veenhof (1996). Complications of an Implantable Venous Access Device (Port-A-Cath®) During Intermittent Continuous Infusion of Chemotherapy. European Journal of Cancer. 32(13); 2262-2266.
- Sandy Cypher (2006). Treatment of Heparin-induced Thrombocytopenia: A Practical Argatroban Dosing Protocol for Nurses. Journal of Infusion Nursing.29 (6); 318 - 325.
- Sue Masoorli (2007). Nerve Injuries Related to Vascular Access Insertion and Assessment. Journal of Infusion Nursing.30 (6); 346-350.
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Liz Di Bernardo