The observed median duration of catheter use of 55 days and the catheter failure rate of 32% are similar to the findings of other studies of Hickman catheter use. Adverse events were more frequent among individuals with high body mass index, among males and in patients with leukaemia. Left sided catheter insertion was associated with a high risk of thrombosis and should be avoided if possible.
The results emphasise the need for the judicious use of these devices, particularly for the high risk groups. Non-tunnelled catheter types may be preferable for obese people to reduce the risk of catheter displacement. The need for explicit protocols for catheter maintenance and use, and also for the management of complications is apparent. Special emphasis and advice regarding exit site care should be given to male patients. Maximal sterile precautions during catheter use are justified for patients with leukaemia. Further research, aimed at refining practice in this area should be
undertaken. Newer intravascular devices, such as non tunnelled silastic catheters, and antibiotic impregnated cuffs should be tested, preferably in randomised trials. Studies on the relative cost-effectiveness of fully implanted ports are also required. Prophylactic antibiotics at the time of insertion or as regular "flushes" require careful evaluation, particularly in view of the potential risk of stimulating microbial resistance. Such studies will provide the stimulus for improvement to be made in the management of patients requiring durable venous access. Based on the findings of this study, the patient's BMI, gender, and the site of catheter insertion should be recorded, along with the underlying disease type, in new studies of Hickman or similar catheters.
This study, with others, demonstrates the imperfection of the currently available devices and methods. In people with a major illness such as
cancer or leukaemia, Hickman catheter complications may seem to be mostly only of nuisance value. Clinicians easily underestimate the frequency and severity of these types of adverse events. Prospective studies of a selected "series" of patients in which a new device or technique is tested tend to systematically underestimate the risk of adverse events which will be observed when the technology is subjected to general, non-trial, use. The adverse events observed in this study, particularly nosocomial catheter
infection and catheter related thrombosis, form part of a silent epidemic of iatrogenic illness which has accompanied the transfer of new intensive medical therapies into general use.
Ongoing, high quality, institutional surveillance of the complications of these devices should be seen a part of standard care in patients with malignant disease. Such surveillance would then become a criterion for any proposed accreditation process developed for institutions treating cancer.
Consolidation of information across a group of collaborating institutions might be expected to lead to the timely identification of group wide trends and also of problems occurring within a single treatment centre. Such a program could lead to a greater dividend in terms of quality of life and cost savings than many technologically complex clinical innovations under current
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