When contending with a cancer diagnosis or chronic illness, the patient's journey is fraught with obstacles that must be overcome. Each day, attempting to navigate such obstacles requires the ability to manage the illness, the treatment, and the effects of both. Adding unnecessary trips to the emergency department (ED), skin breakdown and anxiety about the security of the vascular access device (VAD) may all cause added distress for the patient.
VADs are often a lifeline for the delivery of chemotherapeutic agents, medications, nutritional requirements or antimicrobial infusions (Turner and Hankins, 2010). Having the right VAD placed is the first collaborative decision between the patient, physician and their vascular access specialist. Keeping the VAD secure, preserving skin integrity and reducing risk of infection should be equally important, but the choice of device is often determined by traditional procedural practice or clinical convenience (Czaplewski, 2010).
In this article, the clinical and patient perspectives on a subcutaneous engineered securement device (SESD) used to preserve catheter stability, decrease irritation caused by adhesives and reduce infection risks will be presented. This article will provide nurses with an additional securement option when faced with unnecessary catheter replacement, medical adhesive-related skin injury (MARSI) and the patient's need to perform activities of daily living without fear of catheter dislodgement (Zhao et al, 2018).
Clinician perspective
As the vascular access specialist at a rural hospital in southern Indiana, the author collaborated with oncologists and patients to determine the appropriate long-term VAD for patients receiving a new diagnosis of cancer. Often the appropriate short-term (3–6 months) VAD was a peripherally inserted central catheter (PICC). During this initial phase of the patient's treatment the oncology nurse could safely administer the chemotherapy agent and monitor laboratory results using a PICC.
Many medications infused in oncology may cause cellular damage to the inner layers of the peripheral vasculature. In many cases it is necessary to infuse chemotherapy into the lower one third of the superior vena cava (SVC) in order to get the rapid dilution necessary and preserve vessel health (Gorski et al, 2021). Maintaining this catheter tip placement for all central vascular access devices (CVADs) is required throughout the therapeutic regimen (Gorski et al, 2021).
In the first 6 months of work at the hospital's cancer centre, the author discovered that multiple patients were requiring replacement of their PICC or, at a minimum, a repeat chest X-ray to determine if the tip of the catheter was deep enough in the SVC after an accidental retraction. Often the tip placement was found to be suboptimal, outside of the lower one third of the SVC, while technically located in the SVC. Leaving a PICC tip in this position, regardless of the infusate, increases the likelihood of thrombus formation in a patient already at risk of this damaging consequence (Vidal et al, 2014).
Replacement of the PICC or placing an implanted vascular access device (IVAD) before the initial phase of treatment was complete were unfortunate outcomes of the securement failure (Macklin and Blackburn, 2015; Ullman et al, 2015; Huang et al, 2018). Introducing an SESD to stabilise the PICCs for the long term reduced the complication of accidental retraction or removal to zero in the first year. The only SESD currently on the market is SecurAcath® manufactured by Interrad Medical, Minnesota, USA (Interrad Medical Inc, 2019).
Case study 1
John Anderson, aged 72, was diagnosed with lung cancer and was unable to undergo general anaesthesia for an IVAD placement. At that time conscious sedation for placing an IVAD was not available at this rural hospital.
A PICC was placed with an SESD, a chlorhexidine gluconate-impregnated disc and a silicone-based adhesive transparent semipermeable membrane (3M Healthcare, 2016; Ethicon Inc, 2019; Interrad Medical Inc, 2019). The patient was a farmer and continued to be actively involved in farm work.
The patient had his PICC removed 1 year later after his treatment was complete. At the end of a year of chemotherapy Mr Anderson had experienced no migration of the PICC, no skin breakdown, and no central line-associated bloodstream infections (CLABSIs). Without using the SESD it is unlikely that the PICC could have maintained its optimal position or that the patient would have remained infection free with his active lifestyle. Recently published research has shown that, when comparing an SESD with adhesive engineered securement devices (A-ESDs), the patient had a 288% increase in risk of CLABSI when adhesive stabilisation was utilised (Rowe et al, 2020).
Case study 2
Jessica Brown is a 35-year-old female with a diagnosis of mast cell activation secondary to an allergy caused by ingesting water. During the search for treatments for this rare allergy, the patient needed daily fluid infusions to maintain hydration without activating the allergy.
After 14 months of attempting to maintain her PICC while continuing an active lifestyle, the patient sought out options on her own to improve the securement of her PICC. Ms Brown reported problems during activities of daily living:
‘The line was always being pushed and pulled, causing me irritation and discomfort.’
The pistoning action of the line with its adhesive-based securement and dressing caused constant discomfort and risk of insertion site infection. The patient stated:
‘I was in the emergency room almost weekly to correct dressing change issues.’
These included stabilisation and securement problems.
Ms Brown received a wide variety of sterile and non-sterile dressing changes from home-care nurses. Additionally, the PICC was stabilised with a variety of A-ESDs (Figure 1) and simple tape as supplied by the company delivering the IV fluids (Figure 2).
Figure 1. Case study 2: Ms Brown received an adhesive engineered securement device under a chlorhexidine gluconate disc, which caused a pistoning action, leading to discomfort and an infection risk
Figure 2. Case study 2: clear porous tape was used to stabilise Ms Brown's PICC, but still led to pistoning issues and discomfort
Once the SESD was placed to secure her new PICC, the issue of pistoning during activities of daily living and dressing change securement variability ceased (Figure 3). Ms Brown reported that, in the 14 months prior to placement of the SESD, she visited the ED for issues four times a month and after placement of the SESD her trips to the ED for PICC complications stopped completely.
Figure 3. Case study 2: Ms Brown's subcutaneous engineered securement device in place. The device and the PICC remained in place until the end of therapy, with no pistoning or retraction problems
During the current pandemic crisis, adding ED visits for avoidable issues such as these is even more important. Patients with chronic health issues are more likely to have negative outcomes because of the additional infections they are exposed to with each visit to the ED. The average cost of an ED visit according to Consumer Health Ratings is US$1700 [approximately £1229], with a median cost of US$830 [approximately £600] (Dahlen, 2019).
The patient was able to maintain her PICC in optimal position for 14 months before having a tunnelled cuffed CVAD placed for long-term use. The tunnelled cuffed catheter was also maintained with an SESD, in addition to the built-in cuff for added stability.
Case study 3
Sarah Gray, aged 30, had multiple chronic illnesses requiring long-term vascular access. The patient developed an allergy to adhesives, causing skin breakdown. This patient was not a candidate for an IVAD or tunnelled cuffed catheter because her doctor was not expecting the need for daily infusions to be long term. The condition was deemed chronic after almost 10 months and three different PICCs. During the course of infusate treatment, the patient experienced PICC migration and MARSI, dramatically increasing her risk of infection in addition to her chronic illnesses and compromised immune system. MARSI often occurs when a patient has an obvious reaction to the adhesive or with repeated adhesive application and removal. Each removal of an adhesive dressing tears the superficial skin layers (Zulkowski, 2017). Ms Gray was also pregnant.
Ms Gray searched for a solution to her PICC securement dilemma on her own and found the SESD. She reported that multiple versions of transparent dressings and skin protection barriers were applied in an effort to minimise the effects of MARSI. It was important that her PICC remained in place to keep her, and her baby, as healthy as possible while securing the PICC through her labour.
Ms Gray's baby girl was born safely at home and she was able to keep her PICC in place for 6 months while caring for her newborn with no migration, no infection, no discomfort, and dramatically less skin irritation. Ms Gray had an adhesive transparent semi-permeable membrane covering the insertion site and SESD, but she needed no additional adhesive device to secure the PICC. She said:
‘SecurAcath® (SESD) was the best choice for me to make sure my line [PICC] was safe and stayed in place without having anything with adhesives.’
Eventually Ms Gray received an IVAD to manage her chronic illnesses.
Conclusion
At the time this article was submitted for publication there was only one subcutaneous engineered securement device (SESD) on the market but there are multiple forms of adhesive engineered securement devices (A-ESDs). The three case studies reported here highlight the need to discuss with patients their securement options and present an alternative to A-ESDs.
It is imperative that health professionals caring for patients with VADs are aware of options for optimal securement and do not rely on ‘what we have always done’, what is conveniently in the kit, or what is provided to patients at home by a pharmaceutical company unaware of the potential negative outcomes. The choice of securement should be weighed against the patient's activity level, duration of the catheter placement, infection risks and the high risk of skin irritation caused by repeated replacement of adhesive securement.
A patient who will be living with a new, possibly devastating, diagnosis should be informed about vascular access catheter securement options and not be expected to search for alternatives on their own. The VAD should be a useful device to navigate life with the disease and not another source of anxiety.
KEY POINTS
- Securing a vascular access device (VAD) is as crucial as choosing the right VAD
- A subcutaneous engineered securement device (SESD) reduces the risk of catheter dislodgement with activities of daily living
- Minimising catheter complications is key to optimising outcomes
- Using an SESD has been shown to reduce the risk of central line-associated bloodstream infections by 288%
- Convenience and tradition are not the best practice for choosing a VAD securement method
CPD reflective questions
- Consider the risk to patients with a vascular access device (VAD) of central line-associated bloodstream infections. How might the use of a subcutaneous engineered securement device reduce this risk?
- Think about patients in your clinical setting who have problems with repeated adhesive dressing application and removal—what steps do you currently take to overcome these, and are they effective?
- Think about how your practice would change if you consider the securement of the VAD as a vital part of the long-term function of the VAD