Central venous access devices in patients with haematological malignancies care, complications and home treatment

Detta är en avhandling från Stockholm : Karolinska Institutet, Department of Medicine

Sammanfattning: A well functioning central venous access device (CVAD) that will remain in situ free from complications during the entire treatment period, is highly desirable in the management of patients with aggressive haematological malignancies. Unfortunately, such a goal is not likely to be achieved due to the high rate of CVAD-related complications. The CVAD should also be acceptable for the patient and easy to manage by health care personnel. Self- administration of intravenous therapy is an option for patients who prefer staying at home with ongoing treatment. This mode of treatment should be safe and of value to the individual patient. The overriding goal of this study was to improve CVAD use and ambulatory selfadministration of i.v. therapy in patients with malignant blood disorders. Adult patients were allocated to have their central venous catheter (CVC) dressings changed once a week (OAW; n=20) or twice a week (TAW; n=19). A significantly higher proportion of positive cultures during erythema and more CVC tip positive isolates were obtained in the OAW group. Change of transparent CVC dressings TAW appears to be superior to OAW. Forty-two patients received a long-term dialysis CVC (dCVC) to ensure harvesting of peripheral blood stem cells (PBSC) and subsequent high dose therapy and autografting. The long-term dCVC cannot be recommended due to that half of the longterm dCVCs were removed because of dCVC related infection or thrombosis. Additionally, we evaluated 101 harvests of PBSC regarding effectiveness and complication rate between four types of venous access devices (VAD). The number of harvesting occasions did not differ between the types of VAD used. The collection of PBSC was stopped due to poor blood flow in four patients with a dCVC whereas in none of the patients having peripheral venous cannulae (PVC). We recommend to use PVCs for collection of PBSC. If this is not feasible, a short-term dCVC is advocated. Forty-three adult patients with acute leukaemia (AL) were randomised to receive a double lumen totally implanted subcutaneous port system (PORT) or a double lumen CVC. Five patients with a PORT experienced an extensive local bleeding/haematoma after placement which led to a premature stop of patient accrual. The PORT cannot be advocated in AL patients undergoing induction chemotherapy. CVAD use was associated with discomfort, feelings of anxiety and restrictions on daily life activities with a tendency of fewer problems among PORT patients. Eleven patients with AL or aggressive lymphoma performed self-administration of i.v. antibiotic therapy during 16 episodes of fever/infection. Self-administration appears to be feasible and valuable during the last days of feverlinfection in selected patients. All patients stated that they would prefer home treatment again during subsequent i.v. antibiotic therapy. Self-administration of pamidronate (Self-A-Pam) was offered to 62 patients with multiple myeloma. Thirteen patients performed Self-A-Pam of whom 12 participated in an interview focusing on experiences of self-administration. All patients who started in the program completed all three courses of Self-A-Pam during the study period. A gain in feelings of freedomlindependence and saving time was experienced. However, the responsibility to handle the venous access device was associated with feelings of uncertainty or anxiety. This should be considered in self-administration programmes.

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