HISTORICAL PERSPECTIVES
Fluid optimisation using a peripherally inserted central catheter (PICC) following proximal femoral fracture: Lessons learnt from a feasibility study

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Summary

The aim of this study was to test the feasibility of using peripherally inserted central catheters (PICCs) in older people to enable fluid optimisation. Fourteen patients were randomised to three groups: (i) usual care, insertion of short peripheral intravenous cannulae and normal fluid prescription; (ii) PICC insertion and normal fluid prescription; (iii) PICC insertion and guided fluid prescription based on measurements of central venous pressure (CVP). A range of outcome measures were undertaken, plus two focus groups with ward staff and an interview with the research nurse to ascertain views concerning the implementation of the study. Descriptive findings identified that PICC use in this group of patients was extremely difficult. The practical issues affecting the feasibility of this study were: (i) the physical and psychological frailty of the patients, proxy consent, difficulties measuring outcomes, unsuccessful PICC placement due to aged veins, intolerance to lines; (ii) staff concerns relating to patient vulnerability, competent use of new technology, limited resources and work capacity. Most aspects of the trial were made more difficult due to the frailty of the patient group.

Section snippets

Background

Fluid depletion in older adults living with proximal femoral fracture is common. They are often dehydrated on arrival, frail and have poor venous access. Dehydration may be compounded by poor fluid management and inadequate monitoring of fluid balance (Cullum et al., 1999). Fluid optimisation for frail older people living with proximal femoral fracture is an under researched area. A systematic review identified that in perioperative studies of fluid optimisation this group of patients required

Aim

The aim of this randomised controlled trial was to test the feasibility of using PICCs in older people living with a proximal femoral fracture to enable fluid optimisation.

Design

The study design was a randomised controlled trial with three groups; one control and two intervention groups. The three groups were: (i) usual care, insertion of short peripheral intravenous cannulae and normal fluid prescription; (ii) PICC insertion by a vascular access specialist nurse and normal fluid prescription; (iii)

Discussion

Despite the rationale that these patients were likely to be under perfused and stand to gain most from having an adequate level of hydration there remains many barriers to the use of PICCs for fluid optimisation with frail older people. A significant aspect of this is the degree of frailty in this group of patients. Frailty is a complex concept encompassing many different facets but helps to identify health and life changes that differ from those expected from normal aging (Levers et al., 2006

Conclusions

This study has highlighted, with regard to this group of frail older people, the challenges of using PICCs as a means of fluid optimisation, the difficulty of using a randomised trial approach and the demands of introducing a different technology into a ward area. The feasibility of routinely using PICCs in this population for fluid optimisation is problematic due to their high degree of mental and physical frailty. Consenting older patients for randomised controlled trials in stressful

Acknowledgements

In addition to the authors, the research team that undertook this study were: Dr. James Price (Consultant Geriatrician and Chief Investigator), Helen Hamilton (Senior Nurse, Vascular Access Services), Professor Sallie Lamb (Kadoorie Professor of Trauma Rehabilitation), Debbie Langstaff (Matron), Professor Keith Willett (Professor of Orthopaedic Trauma Surgery).

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