A Systematic Review of Central Venous Catheter Dressings in Patients Undergoing Hematopoietic Stem Cell Transplantation Renata Cristina de Campos Pereira Silveira* Karina Dal Sasso Mendes* Cristina Maria Galvão* *UNIVERSITY OF SÃO PAULO AT RIBEIRÃO PRETO COLLEGE OF NURSING, Brazil
Good morning My name is Renata Silveira. We did a systematic review about the dressing used in long-term central venous catheter in patients undergoing Hematopoietic Stem Cell Transplantation. The other authors are Karina Dal Sasso Mendes and Cristina Maria Galvão. Cristina and I are professors at the University of São Paulo at Ribeirão Preto College of Nursing, in Brazil. Karina is a nurse at the same College.
Introduction Hematopoietic Stem Cell Transplantation (HSCT) consists in the infusion of hematopoietic stem and progenitor cells, which are used to restore the hematopoiesis or treat malignant diseases. However, this procedure is considered risky, due to its complications, whose frequency depends on the type of transplant performed, as well as the age, baseline disease, advanced disease state and patients clinical condition. Bishop, 2007
Introduction Patients need a safe venous access to go through HSCT; nevertheless, the presence of long-term central venous catheter can lead to complications, of which infection is the most preoccupying. Dressing is a procedure that contributes to reduce this complication, on the other hand, depending on the kind of dressing and its frequency of change, injuries may occur on patients skin due to its adherence.
Polyurethane transparent film Requires less frequent changes, but there are doubts if it favors the accumulation of steams (Hoffman et al.; 1992; Lau, 1996; Gillies et al., 2003) In transplantation it reduces skin injuries related to the adherence of the CVC dressing (Rasero et al. 2000; Benhamou et al., 2002) Increases the satisfaction and comfort of the client reducing the costs with material and the nursing team (Silveira; Galvão, 2005)
Objectives The study aimed to identify evidences about the most effective kind of dressing used in long-term central venous catheter in cases of intravascular catheterrelated infection and skin toxicity in patients undergoing hematopoietic stem cell transplantation.
Material and Method Type of study: Systematic Literature Review recommendations of the Cochrane Collaboration http://www.cochrane.org/resources/handbook/hbook.htm question formulation; literature searching; literature selection; appraisal of the quality of the studies; data collection; data synthesis. Galvão; Sawada; Trevizan, 2004; Higgins; Green, 2006
PICO strategy (P) patients submitted to HSCT with CVC AND (I) polyurethane transparent film AND (C) sterile gauze with adhesive tape AND (O) incidence of catheter-related infection and/or adhesiveness-related skin toxicity
Clinical question of the Systematic Review: What is the most effective type of coverage used as dressing in indwelling, tunneled, Hickman-type CVC exit site, in the reduction of the incidence of catheter-related infection and/or decrease of the adhesiveness-related skin toxicity in patients submitted to HSCT?
Sample December 2007 Electronic sources: CINAHL, EMBASE, Cochrane Library, MEDLINE, LILACS, Bone Marrow Transplantation Search strategy in the databases and journals: controlled descriptors: hematopoietic stem cell transplantation, bone marrow transplantation, central venous catheterization, bandages and occlusive dressings non-controlled descriptors : central venous catheter, Hickman catheter, tunneled catheter, indwelling catheter, dressings
Literature selection title, abstract and key words/ doubtful cases were included Studies population - patients at any age submitted to HSCT with indwelling, tunneled, Hickman-type CVC Type of intervention of the studies CVC dressing Studies outcomes incidence of catheter-related infection and/or adhesiveness-related skin toxicity
Studies found n = 42 Eligible studies n = 15 Duplicate studies n = 7 Relevant studies n = 8 Duplicate studies published in different languages n = 2 Sample n = 6
Results and Discussion The review sample consisted of 6 randomized controlled clinical trials. The common outcome observed was the CVCrelated infection and the skin toxicity.
Table 1. Methodological quality of the studies included in the systematic review, Ribeirão Preto, 2007 Study Shivnan et al. (1991) Freiberger et al. (1992) Described as randomized Randomization method described and appropriate Patient losses and exits described Jadad score Random allocation Yes Yes Yes 3 Appropriate 0 CRI Yes No No 1 Not described 0 CRI Brandt et al. (1996) Yes No Yes 2 Not described 0 CRI Rasero et al. (2000) Benhamou et al. (2002) Chambers et al. (2005) Results Yes No Yes 2 Not described 0 ST/GA + ST/GB Yes Yes Yes 3 Appropriate 0 CRI/<ST with longer change intervals Yes No Yes 2 Not described + CRI + - statistically significant difference 0 - no statistically significant difference CRI - catheter-related infection ST - skin toxicity GA - patient with tunneled catheter, Hickman type GB - patient with non-tunneled catheter
Results and Discussion The Jadad (1996) score was applied to the evaluation of the methodological quality of the randomized controlled clinical trials. Two studies obtained 3 points (moderate score), three had two points and one 1 point (weak score).
Results and Discussion Regarding the catheter-related infection measured in 5 studies, 4 did not find statistically significant difference in the incidence of infection both in the use of polyurethane dressing and in its use in longer time interval. In 1 study there was statistically significant reduction in the incidence of catheter-related infection with polyurethane dressing impregnated with CHX.
Results and Discussion Regarding the skin toxicity assessed in 2 studies, 1 indicated statistically significant difference in the reduction of skin injury when the polyurethane dressing was changed at longer time interval. The other study showed statistically significant difference in the group with polyurethane dressing changed at a shorter time interval.
Conclusions Systematic Review There are few evidences indicating difference in the incidence of infection between gauze and tape and/or transparent polyurethane film dressings in indwelling central venous catheter in patients undergoing hematopoietic stem cell transplantation. Future studies are needed to evaluate skin toxicity.
Conclusions Systematic Review It was not possible to carry out meta-analysis, since the interventions and the outcomes in the studies included in the review were measured in different ways.
References CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm. Rep., v. 51, n. RR-10, p. 1-29, 2002. FLETCHER, R. H.; FLETCHER, S. W.; WAGNER, E. H. Epidemiologia clínica: elementos essenciais. Porto Alegre: Artmed, 2006. GALVÃO, C. M.; SAWADA, N. O.; TREVIZAN, M. A. Revisão sistemática: recurso que proporciona a incorporação das evidências na prática da enfermagem. Rev. Latino-am. Enfermagem, v. 12, n. 3, p. 549-56, 2004. HIGGINS, J. P. T.; GREEN, S. Cochrane Handbook for Systematic Reviews of interventions 4.2.6 [updated September 2006]. Disponível em: http://www.cochrane.org/resources/handbook/hbook.htm. Acesso em: (20 fev. 2008). SILVEIRA, R. C. C. P.; Galvão, C. M. O cuidado de enfermagem e o cateter de Hickman: a busca de evidências. Acta Paul. Enferm., v. 18, n. 3, p. 276-84, 2005.
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