I have been asked for some resources regarding recommended access device for the administration of continuours 5FU. Our nursing staff is advocating for central line access (PICC) for a continuous 5 day therapy. The oncology medical staff are saying that the risks associated with a central line outweigh the risks for peripheral infusion of 5FU. What is the "standard of practice" and can anyone provide me with resources?
I am hearing that in many instances Oncology focused clinicians prefer the peripheral access until the patient just runs out of veins. While Vascular Access focused clinicians think vein preservation as priority.
Ann Zonderman, BSN, JD, CRNI
Surely one 5-day infusion is not all the patient must receive. You should look at the entire requirements for infusion therapy, the number and type of courses of chemotherapy, not just a single course length. Second, it should always be a matter of what the patient prefers, not the doctor or the nurses, but the patient!! Intravenous Medications, the handbook by Mosby, has warnings about extravasation of 5FU and recommends that each PIV be changed every 48 hours. The new ONS Chemo Guidelines do not list this drug as a vesicant. So this appears to be conflicting information. I do not think that a PICC for 5 days and then removal is a good idea. But if this is to be given every 3 to 4 weeks for several months, an implanted port would be the top of my list. But again, it is the responsibility of all healthcare professionals to educate the patient about the options - PIV, PICC, tunneled catheter and implanted port - and then to follow their preferences! This has always been a soapbox of mine. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think a CVAD of some kind is called for when giving 5 day continous 5FU. Especially if the patient goes home with the Baxter Infusor. The risk of extravasation is too high with a PIV.
The question, as I see it, is what CVAD. Why would you recommend a port above a PICC, Lynn? Surely the duration 3-6 months is just right for a PICC? If additional infusions are needed a multiple lumen device (port or PICC) could be used. I would see quite a lot to the patient's prognosis: if the line probably could be pulled after completed therapy and the patient would probably not need a new line in a year or so, I would go for a PICC. If shorter (or no) therapy free period seemed probable, I would also go for a port. Patient preference is of course paramount, I agree.
Mats
I would look at the total number of chemo courses being planned for that patient. Usually these are several weeks apart but will be repeated for several months, leaving time intervals where there is nothing being infused. With an implanted port, the patient is free of any external catheter and there is no care required for the catheter. They can easily shower, swim, or do other activities without worry about the external catheter. With a PICC or tunneled catheter, there will always be external catheter that must be considered with any activity. It must be frequently flushed and dressed as well. So intermittent course of any infusion therapy is a clear indication for an implanted port in my opinion. But the patient preferences are the single most important factor! Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
First, a knowledge of regimen, frequency, duration, etc. is crucial for making CVC determination. Is 5FU the only drug pt is rec'g? Secondly, there may be a patient preference for a type of line, when given a choice, but medical condition, social situation, or therapy may require a different approach. (e.g. Preference is not to have ports in a radiation field.) All the reasons should be discussed with the patient and hopefully, this can be negotiated. Third, volume the drug is administered in may also make a difference in the amount of phlebitis (not sure about this, but we have a med onc who always wants the 24 hr drug in 2 L--difficult volumes to manage with home pt). Maybe someone can comment on this and provide a reference. Fourth, I have pics of a patient who had a continuous 5FU infusion going via PIV--she was to have her CVC placed within a day or two. Within 24 hrs, it had infiltrated. I have pics at 24 hrs and 1 month later--I'll send them to Sarah to post in the gallery. Also had another pt with several PIV infiltrations during his 5 day infusion. I would think PIV 5FU in the home would be very difficult to manage--restarts at all hours. Although many chemo agents are not listed as vesicants, that does not mean that they don't result in some tissue effect, potentially long-term, if infiltrated.