Infusión de furosemida intravenosa domiciliaria, continua y prolongada en insuficiencia cardiaca refractaria por pericarditis constrictive / Long-term home-administered continuous intravenous furosemide infusion in refractory heart failure from constrictive pericarditis

Presentamos dos casos clínicos de pacientes con pericarditis constrictiva en insuficiencia cardiaca refractaria a tratamiento diurético combinado y dosis elevadas de furosemida, con disnea de pequeños-mínimos esfuerzos y grandes dificultades para abandonar el hospital por dependencia al tratamiento parenteral. Fueron tratados con infusión continua intravenosa de furosemida mediante infusores elastoméricos. La técnica se mantuvo a largo plazo en domicilio de forma eficaz, con muy buena tolerancia y sin efectos secundarios reseñables

We present two clinical cases about constrictive pericarditis in advanced heart failure refractory to combined diuretic therapy and high dose of furosemide. Patients had small-minimum efforts dyspnea and difficulties to be discharged because of parenteral treatment dependency. They were treated with intravenous continuous furosemide infusion administered by elastomeric pumps. Long-term use at home was effective, well-tolerated and without remarkable secondary effect

Allergic contact dermatitis caused by isobornyl acrylate in the Enlite glucose sensor and the Paradigm MiniMed Quick-set insulin infusion set.

BACKGROUND: The FreeStyle Libre glucose sensor has caused many cases of allergic contact dermatitis, and isobornyl acrylate (IBOA) in this sensor has been identified as one of the culprit allergens. OBJECTIVES: To report on the presence of IBOA in devices produced by Medtronic, namely, the Enlite sensor and the insulin infusion set Paradigm MiniMed Quick-set. PATIENTS AND METHODS: Five patients reacting to the glucose sensor Enlite and/or the insulin infusion set Paradigm MiniMed Quick-set observed in three clinics (two Belgian and one Swedish) were patch tested with the baseline and other series, as well as with IBOA; four of them also with pieces of adhesive patches from the devices, and two with a thin layer chromatogram of Enlite glucose sensor extracts. Gas chromatography-mass spectrometry (GC-MS) analyses were performed. RESULTS: Four patients reacted to IBOA and one to colophonium, a known allergen in Enlite, and three to the adhesive part of the sensor or the insulin infusion set. IBOA was identified in the sensor by GC-MS, and its presence was indicated in the infusion set. CONCLUSIONS: IBOA is a contact allergen in Enlite glucose sensor, and likely also in the infusion set. Therefore, these devices are not suitable alternatives for patients sensitized to the FreeStyle Libre sensor.

Flow rate accuracy of ambulatory elastomeric and electronic infusion pumps when exposed to height and back pressures experienced during home infusion therapy.

Background: Elastomeric infusion pumps are widely used in the delivery of parenteral medications in the home, but real-life conditions may not match calibration or standardised testing conditions. This study investigated the impact of changes in infusion pump height and/or back pressure on infusion pump function. Methods: Volume delivered after one day, infusion duration, average and peak flow rates and time spent within stated accuracy were determined for four elastomeric and one electronic pump using gravimetric technique. Experiments were repeated after altering the height of the pump relative to the output (±40cm, ±20cm) and/or adding a back pressure (10-30mmHg) to the output of an attached catheter. Results: Under ideal operating conditions, the flow rate deviated from that specified by the manufacturer and between 88.5% and 99% of the total infusion volume was delivered. Varying the height or applying back pressure led to further changes in average flow rates and the volume of infusion solution delivered by the elastomeric pumps, but had little effect on the electronic pump. Conclusions: Clinicians should consider potential impact on drug delivery, safety and therapeutic effect for home infusion patients given variations in infusion pump performance observed in this study.

Catheter Occlusion in Home Infusion: The Influence of Needleless Connector Design on Central Catheter Occlusion.

Thrombotic catheter occlusion is a common complication associated with central venous catheters (CVCs). A wide variety of needleless connectors that differ greatly in design and function are available for use with CVCs; however, there are a limited number of studies comparing the catheter occlusion rate associated with differently designed needleless connectors. This retrospective observational study compared occlusion rates associated with a split-septum neutral-displacement needleless connector versus those of a solid-surface neutral-reflux needleless connector in patients undergoing home infusion therapy. The neutral-reflux needleless connector was associated with a significant reduction in occlusion rate and thrombolytic use versus the neutral-displacement needleless connector.

Safer healthcare at home: Detecting, correcting and learning from incidents involving infusion devices.

OBJECTIVE: Complex medical devices such as infusion pumps are increasingly being used in patients' homes with little known about the impact on patient safety. Our aim was to better understand the risks to patient safety in this situation and how these risks might be minimised, by reference to incident reports. DESIGN: We identified 606 records of incidents associated with infusion devices that had occurred in a private home and were reported to the UK National Reporting and Learning Service (2005-2015 inclusive). We used thematic analysis to identify key themes. RESULTS: In this paper we focus on two emergent themes: detecting and diagnosing incidents; and locating the patient, lay caregivers and their family in incident reports. The majority of incidents were attributed to device malfunction, and resulted in the patient being under-dosed. Delays in recognising and responding to problems were identified, alongside challenges in identifying the cause. We propose a process model for fault diagnosis and correction. Patients and caregivers did not feature strongly in reports; we highlight how the device is in the home but of the care system, and propose an agent model to describe this; we also identify ways of mitigating this disjoint. CONCLUSION: Devices need to be appropriately tailored to the setting in which they are employed, and within a system of care that ensures they are used optimally and safely. Suggested features to improve patient safety include devices that can provide better feedback to identify problems and support resolution, alongside greater monitoring and technical support by care providers for both patients and frontline professionals. The proposed process and agent models provide a structure for reviewing safety and learning from incidents in home health care.

Infusion therapy.

Essential facts [Figure: see text] Many patients admitted to hospital or receiving care in other settings, including their own homes, are recipients of one or more infusion therapies. Total parenteral nutrition, chemotherapy, parenteral antimicrobial therapy, pain relief and other infusion therapies are increasingly delivered in community settings. While the move away from hospital helps meet patients' lifestyles and clinical needs, it can have implications for patient care and safety.

From a Suspect Victim to the Holmes: The Unexpected Value of a Home-Made Mobile Chemotherapy Medication Administration System.

Nurse used to be the first one to be investigated in a drug adverse event. Our newly hospital-wide implemented home-made mobile chemotherapy medication support system, which has released our nurses from the traditional heavy 2-nurse-double-checking loading, was unexpectedly used to protect our nurses from being suspected in a recent event of over delivery of infusion. The outcome turned us to reexamine the device maintenance and test protocols.

The use of syringe drivers in the community: considerations for palliative care providers.

'Caring for him at home was such a sad, challenging but rewarding and special time ... we wouldn't have wanted him to die anywhere else ... things improved after the syringe driver was started as he seemed more at ease and was not suffering anymore ... the twinkle returned to his eyes for a while ... it made such a positive difference and allowed us to carry on at home until the end.' These words from the family of a dying patient recently cared for by the author remind us of how special the care given at the end of life is.

Using syringe drivers in palliative care within a rural, community setting: capturing the whole experience.

The aim of this research was to understand how the introduction of a syringe driver, which is considered routine practice in many palliative care settings, impacted on patients, carers and community nurses within a rural, community setting. A phenomenological study was conducted exploring the experiences from the perspective of patients (n=4), carers (n=9) and community nurses (n=12) when syringe drivers are used at home. We interviewed patients and carers in their own homes and conducted two focus groups with community nurses who had an interest in palliative care but were not specialists. Despite the wide use of syringe drivers within palliative care, our study found their use among community nurses, particularly in rural areas can be variable with frequent time lapses between a nurse's exposure, impacting on both their technical abilities and knowledge. In-depth interviews with patients revealed few barriers to their use, but carers clearly identified areas where their expectations and experiences differed and where more information setting realistic goals of care would have been helpful. The authors conclude that although nurses require competencies related to syringe drivers, they also need an in-depth knowledge of the actions of the drugs and the likely changes which occur physiologically as patients approach the end of their life. This will ensure accurate information is delivered, and facilitate meaningful dialogue.

Continuous at-home postoperative analgesia using a catheter in the case of hand surgery: preliminary study about 40 cases.

In hand surgery, ever since continuous at-home postoperative analgesia (CPA) was implemented, procedures which cause pain for more than 24h can now be performed in ambulatory surgery. The aim of our work was to study the feasibility of CPA. Our series comprised 40 patients with a mean age of 50 years. Twenty-four patients had an ASA score of 1 and 16 patients had an ASA score of 2. Indications were osteoarthritis and rheumatoid diseases. Three steps were involved: preoperative (patient screening and information), peroperative (placement of a peripheral nerve catheter through an axillary approach using an elastomeric device) and postoperative (at-home patient care provided by visiting nurses). Evaluation was rated using a CPA score (0 to 10) based on analgesia quality and network organization data. The global CPA score was 1.85. The quality of analgesia (2.6) scored less than the quality of organization (1.1). In the case of analgesia, sleep obtained the lowest score, followed by pain, and lastly, unwanted events. As far as organization was concerned, the network obtained the lowest score, followed by patient satisfaction, and lastly, patient information. Problems were encountered due to insufficient nurse training, analgesia failures, as well as unwanted events related to the oral antalgic treatment. However, technical success was almost always achieved. Our results show that the indications for ambulatory surgery could be extended and hospital-private practice networks be further developed. CPA appears to be a promising technique for analgesia and ambulatory surgery.

Central venous access devices for paediatric patients with haemophilia: a single-institution experience.

Use of a central venous access device (CVAD) can facilitate early introduction of home-based infusion of factor concentrate for long-term prophylaxis or immune tolerance therapy in children with bleeding disorders. The aim was to review outcomes associated with use of CVAD. Retrospective review of paediatric patients with bleeding disorders was observed at the Mayo Clinic Comprehensive Hemophilia Center. Thirty-seven CVAD were placed in 18 patients (haemophilia A [n = 15], type 3 von Willebrand disease [n = 2] and haemophilia B [n = 1]). Follow-up was for 45 952 CVAD days, and median time that CVAD remained in place was 1361 days per device. Factor VIII (FVIII) inhibitors were present in 4 of the 15 patients. Ten CVAD-related infections occurred (median, 672 days; range, 72-1941 days), of which six were in one patient with FVIII inhibitors. Overall infection rate was 0.22 (95% confidence interval [CI], 0.10-0.40) per 1000 CVAD days, with 0.11 infections in patients without FVIII inhibitors compared with a pooled incidence of 0.66 (95% CI, 0.44-0.97) reported in the literature. Indications for removal of 27 CVAD were blockage, change to peripheral venous access, catheter displacement, infection, leak in the port septum, short catheter and skin erosion. No clinically apparent thrombosis or sequelae of thrombosis were observed. Infection is the most common complication associated with CVAD use and is increased in patients who have inhibitors. The low rate of clinically apparent thrombosis reflects our practice of not screening for thrombosis. The low infection rate reflects our practice of using and reinforcing the aseptic technique.

[Continuous infusion of baclofen and an antibiotic for treating meningitis related to refilling of an intrathecal infusion pump reservoir]. / Infusión continua de baclofeno con antibiótico para el tratamiento de meningitis asociada a relleno del reservorio de la bomba de perfusión intratecal.

Baclofen via intrathecal infusion pump is a widely used treatment severe spasticity. Complications are rare and usually mild, though they can also be serious. The sudden discontinuation of intrathecal baclofen may have significant adverse effects. We report the case of a 59-year-old man with chronic spasticity and torsion dystonia who developed meningitis due to Staphylococcus epidermidis due to contamination of the intrathecal, infusion pump reservoir during refilling. It was decided to treat the patient by administering vancomycin through the pump, together with the baclofen. We believe that changing the intrathecal perfusion pump is not necessary as the first measure to take in these cases. Combined infusion of baclofen and an antibiotic through the pump makes it possible to maintain antispastic treatment, sterilize the pump reservoir and tubes, and effectively treat infections that develop during use of these systems.

Catheter outcomes in home infusion.

Intravenous catheter outcomes are a prominent topic for healthcare providers whose patients receive intravenous medications. There are thousands of products being marketed today claiming to improve catheter outcomes, thus improving overall patient outcomes and reducing provider costs associated with catheter infections and replacement. Catheter-related bloodstream infections (CR-BSIs) cost hospitals between $5000 and $34,000 per infection, and 12% to 25% of bloodstream infections are attributable to patient mortality. Products that claim to prevent CR-BSIs and subsequently reduce the number of bloodstream infections are a multimillion-dollar industry.

Choosing the right intravenous catheter.

Infusion therapy in the home has been common for many years. The therapies appropriate for home infusion are numerous. The type of access device provided for the infusion is an important consideration for safe and effective care. That choice will take into consideration physician and patient preference and length of therapy. However, paramount to this decision are the characteristics of the infusate. It is essential to know the pH and osmolality of the drug as well as its potential vesicant properties. The nurse needs to act as the patient advocate to ensure that proper catheter selection is made. Patient teaching should be aimed at recognition of complications and immediate interventions to avoid problems.

Disposable infusion pumps.

PURPOSE: The properties, performance, and applications of nonelectric disposable infusion pumps are reviewed. SUMMARY: All nonelectric disposable infusion pumps exploit the same physical principle: mechanical restriction within the flow path determines the speed of pressurized fluid. The pressure generated by disposable pumps on fluid is 250-600 mm Hg, compared with 5-1200 mm Hg of pressure for electric pumps. There are several types of disposable infusion pumps, including elastomeric, positive-pressure (spring-powered and gas-pressure-powered), negative-pressure (vacuum), and patient-controlled analgesia (PCA) pumps. The accuracy of each pump's flow rate is dependent on several factors, including temperature, fluid viscosity, atmospheric pressure, back pressure, partial filling, and storage. Disposable infusion pumps can be used in many areas, including home care, PCA, patient-controlled epidural analgesia, continuous peripheral analgesia, continuous epidural analgesia, continuous i.v. analgesia, and pediatrics applications. The advantages of disposable infusion pumps include their light weight, small size, simplicity of use, independence from an external power supply, elimination of programming errors, and disposability. Disadvantages include the possibility of inaccurate flow rates, fixed reservoir volume, lack of a facility to change the flow rate and bolus-dose volume to provide adequate analgesia, inability to trace the history of the analgesia demand by patients, inability to combine PCA with background continuous infusions, and long-term cost. CONCLUSION: Despite some disadvantages and limited areas of applicability, disposable infusion pumps provide patients with advantages, such as portability, simplicity, and disposability, especially for the administration of analgesia. Understanding their physical and mechanical characteristics and their appropriate application may optimize patient care.

[Outpatient parenteral antimicrobial therapy (OPAT) in bone and joint infections]. / Antibiothérapie parentérale ambulatoire (APA), par voie intraveineuse dans les infections ostéoarticulaires.

The medical treatment of many bone and joint infections (including chronic osteomyelitis, prosthetic joint infection, and septic arthritis) requires prolonged intravenous antimicrobial therapy. For some patients, this treatment could be administered outside the hospital in a program that offers outpatient parenteral antimicrobial therapy (OPAT). In France, we have no registry of patients receiving OPAT. Initiation of this program requires specific criteria based on a patient evaluation and selection, and an interdisciplinary team of professionals committed to high-quality patient care. Various vascular access devices and infusion pump therapy are used to administer OPAT. The most common parenteral agents for OPAT are beta-lactams and glycopeptids (specifically vancomycin). Antimicrobial courses are stopped prematurely in 3 to 10% of the cases because of an adverse reaction or vascular access complications. Several published studies demonstrate the effectiveness of OPAT and higher patient satisfaction than hospital care. In addition, OPAT is clearly more cost-effective than intravenous therapy provided in the hospital setting. Some diagnoses, such as cellulites, community-acquired pneumonia, and endocarditis may be managed with OPAT.