ASPEN Clinical Guidelines for CVADs in Home Parenteral Nutrition

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Questions and Answers

What was the minimum age requirement for the target adult patients in the ASPEN clinical guidelines?

>25 years

>15 years

>20 years

>18 years (correct)

How many abstract citations were scanned for relevance in total?

400

600

700

564 (correct)

What percentage of the studies addressed at least one of the 6 guideline-related questions?

10%

20%

2.3% (correct)

What was the criterion used to assess the quality of study design and execution?

GRADE criteria Signup and view all the answers

How many studies compared the best solutions for routine flushing of lumens?

0 Signup and view all the answers

What was the outcome of the literature search regarding studies on CVAD mechanical or infectious complications?

No studies were found Signup and view all the answers

What was the purpose of defining language used for the routine care and complications associated with CVADs?

To develop key questions for the literature search Signup and view all the answers

Who approved the final clinical guidelines?

The ASPEN Board of Directors Signup and view all the answers

What is the primary purpose of implanted ports?

For therapeutic purposes Signup and view all the answers

What is a benefit of implanted ports in terms of infection prevention?

Reduced handling or manipulation Signup and view all the answers

Why is salvaging a long-term catheter beneficial to the patient?

It limits the number of remaining viable veins that can be used to reinsert a new CVAD Signup and view all the answers

What is a limitation of using antibiotics to treat central line-associated bloodstream infections?

They may not adequately infiltrate the biofilm Signup and view all the answers

What is a benefit of using ethanol to treat central line-associated bloodstream infections?

It is bactericidal as well as fungicidal and can penetrate the biofilm Signup and view all the answers

What is a goal of HPN care?

To teach patients to become independent in their care Signup and view all the answers

What is a characteristic of tunneled central venous access devices (CVADs)?

They are appropriate for extended periods of parenteral nutrition Signup and view all the answers

What is a risk factor for central line-associated bloodstream infections (CLABSI) in paediatric patients with cancer?

Prolonged neutropenia Signup and view all the answers

What is a recommendation for patients with long-term CVADs who have a history of multiple CLABSIs despite optimal maximum adherence to aseptic technique?

Prophylactic antibiotic lock solutions Signup and view all the answers

Why is it important for clinicians to be knowledgeable about the best CVAD on the market and the most effective treatment options?

To achieve the goals of HPN care Signup and view all the answers

What was the first step in developing the clinical guideline?

Developing the key questions Signup and view all the answers

How many citations were yielded from the MEDLINE database?

350 Signup and view all the answers

What was the criteria for reviewing the abstracts of the citations?

Only studies that included HPN and met the 3 criteria Signup and view all the answers

What type of data was abstracted from the articles that met the criteria?

Relevant outcome data including type of catheter material and lumen number Signup and view all the answers

What is the maximum duration of HPN therapy for adults?

3 months-34 years Signup and view all the answers

What is the most common complication of HPN therapy?

CVAD mechanical complications and CLABSIs Signup and view all the answers

What is the primary concern with using PICCs for HPN?

Higher likelihood of deep vein thrombosis Signup and view all the answers

What is the typical treatment for CLABSI after CVAD removal?

Administering several days of intravenous antibiotics Signup and view all the answers

Why is the location of the exit site a concern for PICCs?

It is difficult to perform self-care Signup and view all the answers

What is the advantage of using PICCs for HPN?

They are suitable for acute care as well as short-term and medium-term PN Signup and view all the answers

Study Notes

ASPEN Clinical Guidelines for CVAD Selection and Care in Adult HPN Patients

The guidelines target adults >18 years of age who require HPN infused via a CVAD.
The guidelines exclude case studies, non-English studies, and studies of CVADs no longer available in the United States.
A total of 564 abstract citations were scanned for relevance, resulting in 13 studies that addressed at least one of the 6 guideline-related questions.

Methodology

The GRADE process was used to develop key questions and plan data acquisition and conflation for the guidelines.
The task force of experts defined language used for routine care and complications associated with CVADs and keywords for the literature search.
The search strategy yielded 564 citations, with 350 from MEDLINE and 214 from PubMed/non-MEDLINE databases.

Results

The 13 studies included were observational, and none were prospective and randomized.
The evidence grade was adjusted based on the assessment of the quality of study design and execution using the GRADE criteria.

HPN Therapy and CVAD Complications

HPN therapy requires patients to have a CVAD, which can be associated with mechanical and infectious complications.
The duration of HPN therapy varies from 3 months to 34 years for adults, making it essential to select the appropriate CVAD to minimize complications.
The most common complications for HPN therapy are CVAD mechanical complications and central line-associated blood stream infections (CLABSIs).

Types of CVADs

Implanted infusion venous access devices (VADs), PICCs, and tunneled catheters are used for HPN infusion, each with unique risks.
PICCs are commonly used for HPN but are suitable for acute care, short-term, and medium-term PN, with a higher likelihood of deep vein thrombosis.
Tunneled CVADs (Hickman, Broviac, Hohn types) are appropriate for extended periods of parenteral nutrition, with a cuff within the tunnel preventing microbial movement and reducing the likelihood of device displacement.
Implanted ports have a dwell time of 6 months to several years, are used for therapeutic purposes, and are linked to the lowest risk of CLABSI due to decreased handling or manipulation.

Salvaging CVADs

Salvaging a long-term catheter is defined as trying to save or keep the catheter in place while treating mechanical or infectious complications.
This approach is beneficial to the patient, as every CVAD insertion limits the number of remaining viable veins that can be used to reinsert a new CVAD in the future.
Infusion of concentrated antibiotics sensitive to the offending organisms into the CVAD lumen was one of the first alternatives used to avoid venous access removal.
Ethanol has been used for treatment as well as prophylaxis in HPN populations, with the ability to penetrate the biofilm and being bactericidal as well as fungicidal.

Goals of HPN Care

The goals of HPN care are to teach patients to become independent in their care, keep patients in their home, and maintain their quality of life by avoiding hospitalizations or unnecessary resource utilization.
Clinicians must be knowledgeable in regard to the best CVAD on the market and the most effective treatment options that minimize risk of mechanical or infectious complications.

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Description

Learn about the best practices for selecting and caring for central venous access devices for home parenteral nutrition in adult patients. This quiz covers the ASPEN clinical guidelines for HPN administered via CVADs.