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JoseDelp
AV graft use for TPN....

We currently ahve a patient that has been repeatedly infected with MRSA via her CVCs over the last few years. (Don't go there --- I know). the physicians currently are planning to put a new hickman in and treat for bacteremia for several weeks. When cultures are negative they want to do AV graft with the intent of using it for TPN.  Rationale is that the AV graft is the least likely to get infected and has fewer complications then other CVCs and even AV fistula. I see case reports in the literature of 3 patients that this was done successfully - but they were all on short term TPN for bowel rest. This patient will be on TPN forever for short gut.

I am concerned about the logisitics of this approach for the staff, patient and husband in the home environment.  I am interested in everyone's thoughts on this ...

lynncrni
Wow, what a thought-provoking

Wow, what a thought-provoking situation! My initial question - is this planned for cyclic TPN on a nighly basis? Does she plan to remove the access needle and reinsert it daily? Who will be doing this procedure - patient, family, nurses? When used for dialysis, these grafts would be accessed about 3 times a week. This is quite different from every day. I am not sure what the expected life of the graft is. Other issues would be the smaller vein diameter in the arm compared to the SVC and the subsequent risk of thrombosis. Infection may be lower but these grafts do clot off easily. Add the extreme osmolarity of TPN and this will increase the risk. What was the concentration of those 3 patients with TPN for bowel rest? Was it truly the total PN with high osmolarity or was it a partial or "peripheral" formula? What will your patient be receiving? If her other catheters have become infected so easily, then what is to say that this graft will also not become infected? What is the source of the MRSA? Is she a carrier herself? If I were the patient, I have serious doubts about whether I would agree to this. She definitely needs to have ful disclosure of the risks associated with this along with the other alternatives. It should be the patient's decision, not the doctors preference. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JoseDelp
AV graft for TPN

A lot of your questions are mine as well. It would definately be a cycled patient. Who accesses the graft etc. would remain questions to be answered also. I also wonder who would accept this patient for home TPN to start with... The issue of vein diameter.... if the graft matures the vessel diameter would definately be much larger. Her TPN also contains a fair amount of replacement hydration. Currently she runs a final osmo of 750-900 depending on formula....She had less than ideal managment in treating her infections until the last one..... She was treated aggressively with antibiotics and line was removed as well. She was then sent home on no TPN.... (I know, I know) to try and maintain on PO for two and a half months. Of course during that time she became severly malnourished. They brought her back. Apparently AV grafts have the lowest infection rate of all access and lower complication rates for malfunction and thrombosis. If the material is autogolus the hope is that it will not easily be seeded and biofilm will not be a factor as well.... I am not saying I believe in this or advocate any of this plan... just putting it out there for others to ponder on and comment... Thanks for the commentary so far....

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

timspencer
Hi, Not sure if you might

Hi,

Not sure if you might have read these articles yet (but if you havent),

Naber A.H.J., Tongeren van J.H.M. Complications, use and lifespan of central venous catheters and arteriovenous shunts in home parenteral nutrition. Gastroenterology 1989, 96, A358.

 Engels LG, Skotnicki SH, Buskens FG, van Tongeren JH. Home parenteral nutrition via arteriovenous fistulae. Journal of Parenteral & Enteral Nutrition. 1983 Jul;7(4):412-414

The success of AV fistulae for PN is quite poor - generally a 2-3 yr lifespan.
This is an unusual alternative vascular access 'device' for PN administration - certainly holds some moderate risk.
How are the surgeons planning to use the fistula? Are they going to infuse through a short peripheral cannula, midline (or modified midline) or an alternative device?
What type of solution are they using? PPN, TPN - hyperosmolality of the solution will be the biggest imposing factor on the fistula.
Thrombosis (from the hyperosmolality) and infection can be quite high.
You mention that the patient has had several CVC infections over a few yrs - have you used a D/L PICC for this patient at all?
Interested to hear more on this case.

Tim Spencer
Clinical Nurse Consultant
Central Venous Access & Parenteral Nutrition
Department of Intensive Care
Liverpool Hospital
Locked Bag 7103
Liverpool BC NSW 2170
AUSTRALIA
Ph: +61 2 9828 3603
Fax: +61 2 9828 3551
Email: Tim.Spencer@swsahs.nsw.gov.au

Timothy R. Spencer, RN, APN, DipAppSci, BH, ICU Cert, VA-BC™
Vascular Access Consultant
That CVC guy from Australia :-}

amaguila2009
AV graft use for TPN

What about a translumbar approach?

Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
amaguila2009@gmail.com

JoseDelp
AV Graft for TPN

I suggested translumbar approach.... Got no takers. I might suggest to patient so that she would look into it herslef....

Thankd you for the references on this topic as well! I think the plan to access the graft has not been fully worked out.We have used multiple PICCs on this woman and she has left subclavian vein occlusion now as well. If we really do end up with AV graft I will keep you all updated. I really hope we don't go this route though.

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

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