RED BLOOD CELL EXCHANGE IN
SICKLE CELL DISEASE
Technical And Nursing Aspects
Cathy Hulitt, BSN, RN, HP(ASCP)
The Children’s Hospital of Philadelphia
May 5, 2015
DISCUSSION POINTS

Impart knowledge on Technical Aspects of Intravenous Vascular
Access with Red Blood Cell Exchange procedures





What are the Access options for Acute and Chronic RBCx
What are the options for implantable ports along with their advantages
and disadvantages, accessing issues, durability, and effects on patient
lifestyles
What are the optimal anticoagulants and techniques for flushing and
locking access lines
Sedation verses no sedation in children receiving RBCx
Review Nursing aspects in caring for a patient with Red Blood
Cell Exchange
TECHNICAL ASPECTS
INTRAVENOUS ACCESS
Informal Survey Data
N = 14
• Adult patients - 40%
• Pediatric
- 20%
• Both
- 40%
Peripheral IV
•
What percentage of
Erythrocytapheresis
procedures are performed
with PIV access?
% of PIV Usage
0 to 24%
25 to 49%
50 to 74%
75 to 100%
Respondents
0
10
20
30
40
50
TECHNICAL ASPECTS
INTRAVENOUS ACCESS
Central Venous Access
Devices
•
What percentage of
Erythrocytapheresis procedures
are performed with CVL access
% of Central Venous Catheter
Usage
0 to 24%
25 to 49%
50 to 74%
•
•
Flexible Catheters – 30%
Implantable Ports – 70%
75 to 100%
Respondents
0
10
20
30
40
50
PERIPHERAL IV ACCESS
Access – Draw line
• 16g to 20g
• Steel Needle
o Medisystem® fistula needle
o Meditech®
o Sysloc®
• Flexible needle – 18/20g
o Angiocath™, Insyte™, Jelco®
Access – Return line
•
•
•
18g to 22g
Steel needles
Flexible needles
Acute Usage
• Emergent
Chronic Usage
• Adequate Veins
PERIPHERAL IV ACCESS
Advantages
•
•
•
•
Short term
No home care
Low risk of infection
Maneuverability
Disadvantages
•
•
•
•
•
•
Poor veins
Dehydration
Scar tissue
Sclerotic veins
Excessive weight gain
Needle phobia
CENTRAL VENOUS ACCESS
Flexible Catheters
Draw/Return
•
•
•
•
7 Fr to 13 Fr
Double lumen
Quinton™, Arrow®,
Medcomp®, Permacath™
Any dialysis-type catheter
Acute Usage
•
Short term non-tunneled
Chronic Usage
•
Long term tunneled cuffed
Silicone or Polyurethane material
CENTRAL VENOUS ACCESS
Flexible Catheters
Advantages
• Easy access
• No needle to access
• Better flow rate
Disadvantages
•
•
•
•
External line
Risk infection/thrombus
Hinders ADL
Home care
CENTRAL VENOUS ACCESS
Totally Implantable Ports
Draw/Return
•
•
•
•
•
Angiodynamics® Vortex™ port
7.5 Fr, 9.6Fr and 11.4Fr
Single lumen or Double lumen
Bard Access System port
Norfolk Medical SportPort™
Acute Usage
•
No Indication
Chronic Usage
•
Intermittent Therapy
CENTRAL VENOUS ACCESS
Totally Implantable Ports
Advantages
•
•
•
•
Totally implanted
Less risk of infection
No home care
Normal ADL
Disadvantages
• Slower Inlet flow rate
• Large gauge non-coring needle to access
• Risk of infection/thrombus
• Location of port
• Hospitalization Usage
CENTRAL VENOUS ACCESS
Flushing And Locking
Flushing – after medication or
blood transfusions
• Long term flexible catheter
o Solution/amount
o Pulse flush
o Syringe pressure
• Implantable Port
o Solution/amount
o Pulse flush
o Syringe pressure
Locking – anticoagulant
• Long term flexible Catheter
o Heparin
o Sodium Citrate
o Positive pressure
clamping
• Implantable Port
o Heparin
o tPA
o Positive pressure
clamping
GUIDELINES FOR CENTRAL VENOUS ACCESS FOR
RED CELL EXCHANGE PROCEDURES
The Children’s Hospital Of Philadelphia
Acute Access
Chronic Access
Weight
(kg)
Medcomp
Catheter
10 – 15
7Fr
16 – 20
7Fr
21 – 30
9Fr
SL 7.5Fr
(If another access available)
31 – 40
9Fr
SL 7.5Fr
(If another access available)
41 - 50
11Fr
DL 11.4Fr
SL 9.6Fr
(If another access available)
>50
11Fr
DL 11.4Fr
SL 9.6Fr
(If another access available)
Vortex Port
Cahill-Kim V1.1 140730
NURSING ASPECTS
Central Venous Line Concerns
• Site
o Acute – Flexible Catheter
o Chronic – Flexible Catheter, Implantable Port
• Catheter Tip placement
• Port usage
Procedure Concerns – Staff Competency
•
•
•
•
•
Knowledge of Apheresis instrument - troubleshooting
Competence in PIV/Central Venous Lines
Citrate toxicity
Transfusion reaction
Blood prime
NURSING ASPECTS
Psychosocial Concerns
• External/Internal Central Venous Catheters
• Needle phobia
• Sedation
Patient Education
•
•
•
•
•
•
•
Understanding of Procedure/Compliance
PIV/Central Venous Line
Home care for Central Venous Line
Nutrition/Hydration
Signs/Symptoms of a Transfusion Reaction
Signs/Symptoms of CVL complication
Contact information
REFERENCES
Andropoulos, D., Bent, Bent, S., et al. The Optimal Length of Insertion of Central Venous Catheters for Pediatric
Patients. Anesthesia Analogue 2001; 93:883-886
Bishop, L., dougherty L. Guidelines on the Insertion and Management of Central Venous Access Devices in Adults.
International Journal of Laboratory Hematology 2007, 29, 261-278
Christianson, D. Caring for a Patient Who Has an Implanted Venous Port. American Journal of Nursing 1994, 40-44
Hadaway, L. Comparison of Vascular Access Devices. Seminars in Oncology Nursing 1995, Vol 11, No 3 154-166
Jeng, M., Feusner, J., et al Central Venous Catheter Complications in Sickle Cell Disease. American Journal of
Hematology 2002, 69:103-108
Krishnamurthy, G., Keller, M. Vascular Access in Children. Cardiovascular Interventional Radiology 2011 34:14-24
Lorch, H., Zwann, M., et al. Central Venous Access Ports Placed by Interventional Radiologists: Experience with 125
Consecutive Patients. Cardiovascular Interventional Radiology 2001 24:180-184
Schutz, J., Patel, A., et al. Relationship between Chest Port Catheter Tip Position and Port Malfunction after
Interventional Radiologic Placement. Journal of Vascular Interventional Radiology 2004; 15:581-587
Swerdlow, P. Red Cell Exchange in Sickle Cell Disease. ASH Education Book January 1, 2006 Vol. 2006 No 1 48-53
Thompson, L. Central Venous Catheters for Apheresis Access. Journal of Clinical Apheresis 1992; 7:154-157
Vesely, T. Central Venous Catheter Tip Position: A Continuing Controversy. Journal of Vascular Interventional
Radiology 2003; 14:527-534
Walser, E. Venous Access Ports: Indications, Implantation Technique, Follow-Up, and Complications. Cardiovascular
Interventional Radiology 2012; 35:751-764
Thank You