Vascular Access Guidelines

 

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSA, eviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

In 2013, CNSA and eviQ, a program of the Cancer Institute of New South Wales formed a collaborative CVAD Review Group consisting of adult and paediatric oncology and haematology nurses, nurse researchers, academics, infection control experts, CVAD specialist nurses and eviQ content authors. The CVAD Review Group using a systematic review methodology, critically appraised published CVAD guidelines using a modified AGREE II Appraisal Tool. The total of 349 guidelines were identified and the final 35 were either endorsed (n=3), partially endorsed (n=8) or not endorsed (n=24) via consensus by the Review Group.

On completion of this project, it was highlighted the 2007 CNSA CVAD Guidelines were a unique resource for cancer nurses because they provided the only, comprehensive set of clinical guidelines for the specific and diverse needs of caring for the different types of CVADs for a patient with cancer. In January 2019, the CNSA VAD&IT SPN) commenced revision of the CNSA Central Venous Access Device: Principles for Nursing Practice and Education Guidelines. The revised scope of the guidelines was endorsed by the CNSA Board of Directors including to:

1. Broaden the scope and change the title to ‘CNSA Vascular Access Devices: Evidence-Based Clinical Practice Guidelines’.
2. Update the guidelines, topic by topic with Patency, occlusion prevention and management elected as the first topic.
3. Include graded recommendations to guide clinical practice.
4. Guidelines will be open access.
5. Guidelines will be a living document, incorporating newly published research at regular intervals over the year.

Search strategy

A systematic review methodology was utilized including

1. identification of relevant clinical questions, using the PICO format
2. developing inclusion and exclusion criteria
3. performing an extensive literature search
4. screening of the articles according to the criteria and establishing a PRISMA chart (9).

The search strategy is devised in consultation with an expert medical librarian until the search results contain an accurate reflection of studies to answer the clinical questions with a minimal number of less relevant articles. Secondly inclusion and exclusion criteria are established, and the date range of the last 10 years. All study designs are included except for case studies/reports, editorials, conference abstracts and educational material as there are many gaps in high quality research for VAD maintenance practices. Thirdly, a database search is undertaken in Medline, Embase and CINAHL Complete.  

All answers and recommendations were reviewed by the VAD&IT SPN members.Grading for the recommendations was completed (NG), and independently reviewed by the primary author (KC).

Strength of Evidence for Clinical Recommendations:

Recommendations to guide clinical practice based on well-designed research is ideal (15). In Australia, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is recommended by the National Health and Medical and Research Commission for appraisal of evidence for clinical guidelines (16). This process includes studies with control and comparator groups. However, there is an absence of studies or a wide variety of study designs for CVAD and PIVC management for patients with cancer. In order to capture all available evidence for our cancer cohort, a wider range of study designs was included.

A wider range of study designs was included in the body of evidence for these guidelines to capture all available evidence for our cancer patient cohort. Inclusion of a wider range of studies aligns with the appraisal of evidence in the Infusion Therapy Standards of Practice (17) with the application of the appropriate evidence rating based on the highest level of evidence. The strength of evidence ranges from level 1 meta-analyses and randomised controlled studies to level IV cohort and descriptive studies, and anatomy and pathophysiology and consensus. A Grade Ib has been added to include guidelines using the RAND/UCLA Appropriate Methods, for example The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) (18) and The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC (19).

Table 2. Strength of body of evidence (17)

This body of evidence of the latest vascular access research for patients with cancer is supported by international vascular access standards and vascular access expert consensus guidelines for all patient cohorts where high quality research was absent. This will be noted when included in the recommendations.

In developing these guidelines for patients diagnosed with cancer we have highlighted the need for more research to ensure that our vascular access care is based in evidence. These guidelines can be used by future researchers to highlight the research gaps.

1. Chopra V, Anand S, Hickner A, Buist M, Rogers MAM, Saint S, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382:311-25.

2. Yap YS, Karapetis C, Lerose S, Iyer S, Koczwara B. Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. European Journal of Cancer Care. 2006;15(4):342-7.

3. Abedin S, Kapoor G. Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatr Blood Cancer. 2008;51:251-5.

4. Matsuzaki A, Suminoe A, Koga Y, Hatano M, Hattori S, T. H. Long-term use of peripherally inserted central venous catheters for cancer chemotherapy in children. . Support Care Cancer. 2006;14(153-60).

5. Makary MS, Lionberg A, Khayat M, Lustberg M, AlTaani J, Pan XJ, et al. Advanced stage breast cancer is associated with catheter-tip thrombus formation following implantable central venous port placement. Phlebology. 2019;34(2):107-14.

6. Cotogni, P., Barbero, C., Garrino, C., Degiorgis, C., Mussa, B., De Francesco, A., & Pittiruti, M. (2015). Peripherally inserted central catheters in non-hospitalized cancer patients: 5-year results of a prospective study. Support Care Cancer, 23, 403–409. doi:10.1007/s00520-014-2387-9

7. Rickard, C. M., Marsh, N. M., Webster, J., Gavin, N. C., Chan, R. J., McCarthy, A. L., . . . Playford, E. G. (2017). Peripherally InSerted CEntral catheter dressing and securement in patients with cancer: the PISCES trial. Protocol for a 2x2 factorial, superiority randomised controlled trial. BMJ Open, 7(e015291). doi:10.1136/bmjopen-2016-015291

8. Moss, J., Wu, O., Bodenham, A., Agarwal, R., Menne, T., Jones, B., . . . McCartney, E. (2021). Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial. The Lancet, 398. doi:10.1016/S0140-6736(21)00766-2

9. Larsen, E. N., Marsh, N., O'Brien, C., Monteagle, E., Friese, C., & Rickard, C. M. (2021). Inherent and modifiable risk factors for peripheral venous catheter failure during cancer treatment: a prospective cohort study. Support Care Cancer, 29(3), 1487-1496. doi:10.1007/s00520-020-05643

10. Shintani, Y., Murayama, R., Abe-Doi, M., & Sanada, H. (2022). Incidence, causes, and timing of peripheral intravenous catheter failure related to insertion timing in the treatment cycle in patients with hematological malignancies: A prospective descriptive study. Jpn J Nurs Sci, 19(4), e12484. doi:10.1111/jjns.12484

11. Levi M, Sivapalaratnam S. An overview of thrombotic complications of old and new anticancer drugs. Thromb Res. 2020;191 Suppl 1:S17-s21

12. Greten, F. R., & Grivennikov, S. I. (2019). Inflammation and Cancer: Triggers, Mechanisms, and Consequences. Immunity, 51(1), 27-41. doi:https://doi.org/10.1016/j.immuni.2019.06.025

13. Agency for Healthcare Research and Quality. (2019). About Learning Health Systems. Retrieved from https://www.ahrq.gov/learning-health-systems/about.html     

14. Linares-Espinós E, Hernández V, Domínguez-Escrig JL, Fernández-Pello S, Hevia V, Mayor J, et al. Methodology of a systematic review. Actas Urol Esp (Engl Ed). 2018;42(8):499-506.

15. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence based medicine: how to practice and teach EBM. 2nd ed. London: Churchill Livingston; 2000.

16. GRADE Working Group. GRADE 2021 [2 Aug 2021]. Available from: https://www.gradeworkinggroup.org/.

17. Nickel, B., Gorski, L. A., Kleidon, T. M., Kyes, A., DeVries, M., Keogh, S., Meyer, B., Sarver, R., Ong, J., Clare, S., & Hagle, M. E. (2024). Infusion therapy standards of practice. J Infus Nurs., 47 (suppl1), S1-S285.

18. Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., O'Grady, N. P., Safdar, N., . . . Bernstein, S. J. (2015). The Michigan appropriateness guide for intravenous catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA Appropriateness Method. Annals of Internal Medicine, 163(6 Supplement), S1-S39.

19. Ullman, A. J., Bernstein, S. J., Brown, E., Aiyagari, R., Doellman, D., Faustino, E. V. S., . . . Chopra, V. (2020). The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics, 145(Suppl 3), S269-S284.