American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration

Abstract

This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non‐English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non‐MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline‐related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.

Repair of Central Venous Catheter in a Single‐Center Adult Home Parenteral Nutrition Cohort

“…Additionally, younger patient age at catheter start has also been noted to be associated with increased catheter damage . Loss of the integrity of the external part of the catheter can pose an increased risk of CLABSI; therefore, close inspection and examination of the catheter by the HPN team is recommended by ASPEN . In cases of confirmed catheter rupture, replacement is recommended, and in all other cases in the absence of infection, catheter repair can be performed .…”

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition

“…Standards of care were drafted from the identified evidence‐based literature to guide day‐to‐day practice and reduce variation of care between HPN centers. These are intended to link closely with quality indicators, with the intention of translating established international CIF and HPN guidelines for local implementation …”

Repair of Central Venous Catheters in Home Parenteral Nutrition Patients

“…For HPN patients requiring long‐term PN, CVCs are the mainstay because they provide access to the central veins and can be used long‐term. The CVCs often used for HPN include tunneled cuffed catheters (eg, Hickman, Broviac, or Groshong), peripherally inserted central catheters (PICCs), and implanted port . Although all 3 types of CVCs are acceptable for use in HPN, a recent publication by the American Society for Parenteral and Enteral Nutrition (ASPEN) recommended selection of a tunneled cuffed CVC over the other CVC types for long‐term HPN patients because of lower rates of central line–associated bloodstream infections (CLABSIs) …”

“…Tunneled cuffed catheters were developed in the 1970s as an alternative to the use of an arteriovenous fistula for the administration of PN . The cuff on the tunneled catheter serves a dual purpose: inhibition of bacterial migration as well as securement of the catheter and prevention of accidental dislodgement . Tunneled cuffed CVCs have been utilized extensively since their development in the HPN field.…”

“…The advantage of PICCs is the ease of placement in a variety of locations with low risk of complication. Disadvantages of PICCs include the need for care assistance, usually by a home health agency (or family member) or office visit for site care, activity limitations, and increased risk of deep venous thrombosis . Implanted ports are useful for intermittent access, which is ideally suited for treatments such as chemotherapy.…”