Vascular Access Devices:APatient's Perspective

Talulah Ruger. RN, MSN, RneN

AbstractVarious vascular access devices are

available and widely used in the hospi­tal and home setting for the treatment ofpatients with acute and chronic illnesses.Many cancer patients, in particular,require Sh011- or long-term centralvenous access for the intravenousadministration Cl! chemotherapy,immunotherapy, bloodproducts, antibi­otics, total parental nutrition, and othermedications. This author, a breast can­cer survivor and a nurse, examines thebenefits and drawbacks ofvenous accessdevices, the satisfaction and dissat4!ac­tion with their use, and the ejj(xts thesedevices have on treatment and quality Clllife from a patients perspective.

IntroductionAccording to American Cancer Soci­

ety estimates, 1,372,910 new cases ofcancer will be diagnosed in the UnitedStates in 2005.' Patients with a newdiagnosis of cancer face uncenaintiesabout their monality, the course theirillness will take, their treatment and itspotential adverse effects, their ability tocare for themselves, and the effectstheir treatment and disease will haveon their families and quality of life. Theinitial diagnosis marks the beginning ofan emotionally stressful and over­whelming peJiod as the patient tIies to

Correspondence concerning this articleshould be addressed totruger@mdanderson.org

adapt and understand all the informa­tion proVided by physicians, nurses,and other health care providers.

When I learned that I had breastcancer in 2001, I was a 21-year veteranoncology nurse who in a matter ofweeks became the patient. Soon afterthe diagnosis, I was told that my treat­ment plan would include chemother­apy and the insertion of a venousaccess device (VAD) for long-term ther­apy. The ovelwhelming and immediatesense of powerlessness and loss ofcontrol that had been communicatedto me by patients during my careerbecame my reality. Fortunately, theclear, accurate, and thorough informa­tion that I received about my diseaseand its treatment allowed me to beactively involved in the decision-mak­ing process and to make informeddecisions about my care. One of thosedecisions involved the type of VAD touse for chemotherapy administration.

More than 10 years ago, it was esti­mated that approXimately 500,000long-term venous access catheterswere placed each year in the UnitedStates.' Today, this number hasincreased, as have the types of VADsavailable. As a result, physicians andpatients now can choose the methodby which chemotherapy, total par­enteral nutrition, blood products,antibiotics, and other intI-avenous med­ications are administered. In addition,the major shift in the delively of healthcare that has occurred over dle past 15years-from a primarily acute, inpa-

tient setting to an outpatient or "out-of­hospital-care" setting1-has made VADseven more attractive because of theirconvenience, higher level of patientcomfort, and positive effects onpatients' quality of life.

The OptionsThe available options were ex­

plained to me in a dl0rough but Simpleway that was easy to understand. I wastold, for example, that the centralvenous catheter is a device insertedinto dle brachial or cephalic vein in thearm, the subclavian vein in the chest,or the jugular vein in the neck. Theimplanted pon is inselted into a subcu­taneous pouch in the chest, just underthe skin, and dlreaded into the superiorvena cava. I cannot overemphasize theimponance of using easy-to-understandterms and avoiding the use of complexmedical terms that patients may notunderstand. Many patients will not tellthe physician or nurse that they do notunderstand.

My oncologist provided the initialpatient teaching about central venousaccess devices (CVADs) by discussingthe various types available for my treat­ment. The clinic nurse also providedwritten information, and I viewed therequired preplacement video on cen­tral venous access and informed con­sent. The many potential risks andbenefits of CVAD insertion were dis­cussed in the video and reviewed ver­bally before Signed the formconsenting to treatl1lent.

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complications were directly related tothe skill of the practitioner inserting thecatheter. Therefore, I asked the surgeonhow many catheters she had insertedduring the past year. Pleased with herresponse, I relaxed.

With the exception of the injectionof the local anesthetics, the procedurewas quick and painless. I only recallfeeling pressure with the insertion of

Figure I. CVAD dressing change.

explanation of the insertion processand postinsertion maintenance candecrease patient anxiety and improvepatient compliance with care. Duringthe insertion of my subclavian catheter,while I was sterilely draped and in afixed position, I tested my recall ofpotential complications of CVADs.Pneumothorax was the first item thatcame to mind. I recalled reading that

Before selecting a CVAD, I under­went a standard assessment that con­sidered my disease process, therecommended treatment, the durationof treatment, my lifestyle, my post­insertion care, and my ability to under­stand and willingness to perform thehome care needed. The cost of careand my financial ability to purchaserequired supplies were also importantconsiderations.

The DecisionEach CVAD has benefits and draw­

backs that include the maintenancerequirements, the ease of placementand use, the length of time the cathetercan be left in place, the cost, and theeffect on body image.4 In my case, itwas very important to maintain somesense of normalcy as I continued towork during my therapy and to partic­ipate in activities outside of work, suchas directing the education program atmy church and attending school. I alsohad a new granddaughter who wasonly five months old at the time of mydiagnosis, and I wanted my am1S to befree so I could carry her. In addition,my daughter was a senior in college,and her medical school interviewsrequired that we travel. Therefore, Iwanted to be able to conceal thecatheter and tubing during my therapybecause I interacted with many peopledaily. Although an implanted port isconcealed, it was not a desirableoption for me because I did not wantto undergo surgery.

Although I was very open about mydiagnosis, I did not want my cancerand its treatment to be the center ofconversations or to prevent my normalinteraction with others. Therefore, Ichose subclavian catheter insertionbecause of my personal needs and myability to manage the catheter careindependently at home.

The ExperienceThere is no substitute for thorough

patient education about tl1e CVAD priorto its placement. By the time I anivedin tl1e clinical area where the catl1eterinsertion would take place, I was well­informed. Providing patients with clear,simple information and a step-by-step Figure 2. Radiograph of a CVAD placement at MD. Anderson Cancer Center.

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the needle. A registered nurse, whohad special training in the care ofCVADs, sutured the catheter in placeand applied the dressing (Figure 1).Accompanied by a colleague, I walkedto radiology for a chest radiograph toverify catheter placement and to ruleout pneumothorax (Figure 2). Patients,however, are typically required toremain in the clinical area where thereinsertion took place until the catheterplacement is confirmed.

Home CareThe subclavian catheter dressing

must be changed weekly or biweekly,depending on the type of dressingused. Patient teaching, a repeat demon­stration of the dressing change tech­nique, and a demonstration of thepatient's or family member's ability toperform the heparin flush and injec­tion-cap replacement are required priorto discharge. The patient or familymember should also receive a list indi­cating the necessary supplies and aprescription for daily heparin flushes.Assuring that patients have evelythingnecessary for home care preventsunnecessary anxiety.

CVAD infection can be preventedby teaching the patient to change thedressing, as shown by the nurse; toadhere to the catheter-care procedures;to carefully assess the insertion site forsigns of infection; and to report anysign of infection immediately (Figure3). I have changed many subclaviandressings during my nursing career.However, changing my own subclaviandressing at home for the first timebrought me back to the fundamentalsof nursing. I used a one-hand tech­nique standing in front of a large mir­ror to change my dressing. It wassafety first, speed later.

Shortly after my catheter insertion,the skin around the edge of the dress­ing became red with small blisters. Thisreaction was due to skin sensitivity tothe transparent occlusive dressing. Afterconsultation with the nurse, the dress­ing was changed to a nonocclusivetype (Figure 4). This type dressing ischanged twice weekly. In addition, thesutures were clipped sholter to preventa "sticking" sensation at the insertion

Figure 3. Assessing the site for infection.

site. When chemotherapy was initiated,one of the prescribed medications wasa vesicant with the potential to causemuch tissue damage in the event ofextravasation. However, because I wasvery comfortable with the catheter, Ihad no concerns about receiving ther­apy. There were at least two times dur­ing home chemotherapy that I wokeup during the night, got out of bed,and forgot that I was attached to aportable pump. Fortunately, mycatheter sutures were secure and I didnot accidentally dislodge the catheterfrom the added tension. During theseven months that the catheter was inplace, I would often perspire profuselyat night. On occasion, the perspirationwould loosen the nonocclusive dress­ing, requiring that I change the dressingmore than twice weekly. Othelwise, myhome care was uneventful and mycatheter site was infection free.

Patient Satisfactionand Quality of Life

The literature is replete with the com­plications of CVADS.5 However, the sub­jective experiences and satisfaction ofpatients and the impact on their qualityof life are not well studied. Dearbom etal 6 compared the satisfaction among

patients and nurses with the three typesof vascular access devices. The resultsindicated that patients with POltS weremost satisfied with their devices. How­ever, these patients reported problemsrelated to the lack of knowledge of theircaregivers in the use of the ports. Inaddition, Goossens et a[,7 studied theexperience of cancer patients with animplanted pon, who cited benefits suchas the avoidance of venipuncture, thegreater convenience, and the ability tomove their am1S freely when pelformingactivities of daily living. Patients werenot pleased with the visibility of the ponand the pain at the inseItion site. Finally,a pilot study of oncology patients' satis­faction and dissatisfaction with venousaccess devices conducted by Chemecky"showed that the patients were generallyhappy with the device and experiencedan improved quality of life. Some of thedissatisfaction involved site soreness,sleep disturbances, and the monthlyheparin injections.

I was very pleased with my subcla­vian catheter, which was in place forseven months. It allowed the safeadministration of my chemotherapywithout the risk of extravasation, keptmy arms free, and enabled me to con­ceal the catheter and tubing during the

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Figure 4. Occlusive (left) and nonocclusive (right) dressings.

months I was receiving treatment. Mychief dissatisfaction was the biweeklyor more dressing changes necessitatedby my skin sensitivity to the transpar­ent occlusive dressing. I was alsoinconvenienced by having to use thehandheld showerhead to avoid wettingmy dressing. After a few weeks, Istopped worrying about dislodging thecatheter during sleep. I was selectiveabout the type of clothing that I wore,being careful to choose items that con­cealed the catheter, as well as pre­vented tension on the infusion tubing.My catheter removal was uneventful.However, the insertion site was tenderfor several weeks, and there is a verysmall scar at the insertion site.

ConclusionMany years ago, CVADs were consid­

ered only as a last resort for patientswith poor venous access. Today,CVADs are used during the initial ther­apy of patients receiving short- andlong-term treatment. Careful assessmentand evaluation of eligible patients andthe participation of these patients in theselection of the appropriate CVAD areessential. Adequate patient teachingabout home care is also a high priority.It is important to create a balancebetween treatment and quality of lifethat ensures that the inconveniences oftherapy do not interfere with thepatients' well being and daily activities.

Talulah Ruger, RN, MSN, AOCN, is aSenior Instructor and Coordinator of

1. American Cancer Society. Cancer Factsand Figures 2005. Atlanta, GA: Ameri­can Cancer Society; 2005.

2. Alexander HR, ed. Vascular Access inthe Cancer Patient. Philadelphia, PA:Lippincou; 1994.

3. Gorski L. Central venous access deviceoutcomes in a homecare agency: a 7­year study.] In/us Ther. 2004;27:104-111.

4. Black ]M, Hawks ]H, Keene AM. Medi­cal Surgical Nursing. Clinical Manage­

ment for Positive Outcomes. 7th ed. St.

Nursing Student Programs in theDepartment of Nursing ProfessionalDevelopment and Education at the Uni­versity of Texas MD. Anderson CancerCenter in Houston, Texas. An oncologynurse for thepast 24 years, Ruger hasworked in various roles during hercareer at MD. Anderson. Her passionfor and expertise in thefield ofoncologyhas been evident in her roles as alicensed vocational nurse, a clinical reg­istered nurse, a nurse manager, a clini­cal nurse specialist, and now aninstructor in nursing education. As

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Louis, MO: Elsevier; 2005:372.5. Yildizeli B, Lacin T, Batirel HF, Yuksel

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2004;5:174-178.6. Dearborn P, Demuth ], Requarth A,

Ward S. Nurse and patient satisfactionwith three types of venous accessdevices. Oncol Nurs Forum.1997;24(suppL 1):34-40.

7. Goossens GA, Vrebos M, Stas M,

Coordinator of Nursing Student Pro­grams, Ruger is responsible for the dailyactivities ofprograms such as the Prqfes­sional Student Nurse Extern program,the placement ofgraduate and under­graduate academic nursing students, thework/schoolprogram, and the onsite cer­tified nursing assistant course for MD.Anderson employees. In addition, sheteaches in departmental nursing orien­tation and other programs. A breastcancer survivor whose disease was diag­nosed in 2001, this nurselpatient writesfrom herpersonalpatientperspective.

DeWever I, Frederickx L. Central vascu­lar access devices in oncology andhematology considered from a differentpOint of view: how do patients experi­ence their vascular access ports? ] In/usNul'S. 2005;28:61-67.

8. Chernecky C. Satisfaction versus dissat­isfaction with venous access devices inoutpatient oncology: a pilot study.Oncol Nurs Forum. 2001;28:1613-1616.

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