Mosul Journal of Nursing

Bone marrow transplantation (BMT) is currently considered as a practiced and a well-established modality for the treatment of several hematological diseases and malignancies. Central venous catheters (CVCs) have a crucial role in patients who are undergoing such therapeutic procedure. Their insertions could be effectively used in the infusion of chemotherapeutic drugs, stem cells, blood products, electrolyte supplements, antibiotics, and frequent venous samplings (Elgendy, et al, 2020). On other hand, CVCs represent an important target of investigation in the effort to improve patient safety and quality outcomes, particularly with respect to decreasing complication rates associated with the use of this necessary but invasive medical device (Bell et al, 2020).

DISCUSSION

The analysis of the socio-demographic variables of the patients recruited in this study showed that the age of more than half was between 40 – 60 years old, most were male, more than one-third were primary school graduates, and almost all were from urban.

On other hand, the most medical diagnosis was multiple myeloma, followed by Hodgkin lymphoma, and acute myeloid leukemia, while the proportion of non-Hodgkin lymphoma and acute lymphoid leukemia was about ten and four percent respectively. The type of transplant for almost three-quarters was autologous. Hickman and peripheral insert central (PICC) with single lumen were the most used catheter type.

Moreover, the Internal jugular and basilic were the most used veins for catheter insertion. Furthermore, the length of stay with the catheter was 2 to 3 weeks for most of the participants, and the dressings were performed twice a week for more than three-quarters of them. As stated before, the BMT has been performed more for patients with multiple myeloma, this may be related to the fact that the multiple myeloma had fewer complications than another medical diagnosis, this result is supported by Rajkumar, (2020) reported that the treatment of newly diagnosed with multiple myeloma is guided by eligibility for Autologous stem cell transplantation and the absence of any risk of graft versus host disease with ASCT.

The age of patients who underwent BMT was between forty to sixty years and from urban, this may be because multiple myeloma which was the medical diagnosis of most is common in people over 40 years old and, the urban people had a better opportunity to have BMT this may result from the rural area having lower access to health care and may have poorer knowledge regarding the procedure.

Furthermore, the type of transplant for more than three-quarters was autologous transplant in the present study because this type of BMT has less complication, the rate of rejection is low, and requires a shorter time than Allogenic. Giralt et al., (2015) found that Autologous transplants have a lower risk of life-threatening complications; there is no risk of Graft versus host disease (GVHD) and no need for immunosuppressive therapy to prevent GVHD and graft rejection.

Hickman line was the most used CVC type; therefore, the internal Jugular vein was the best-inserted vein for the Hickman line. Using a single lumen catheter for most of the participants may be related to simplifying such kind of catheter. An Italy study conducted by Morano et al., (2014) found that the Hickman catheter was the most usually utilized, representing an advance in the management of cancer patients, especially those who require HSCT, in addition, a Japan study explained that the internal jugular vein (IJV) is one of the suggested locations for safe insertion of a central venous catheter, Ishizuka et al., (2010).

In the current study more than two-thirds of patients received 2 bags of Fresenius (hematopoietic stem cell), more than half had a blood transfusion and the majority received platelet. This finding was in line with Akahoshi et al., (2016) who found that the majority of a patient undergoing BMT require platelet transfusion to avoid secondary failure of platelet recovery and almost half needs a blood transfusion.

The current study's result revealed that the incidence of delayed CVC- related complications among patients who underwent BMT was high, the finding indicated that nearly two-thirds of participants complained from CVC-related complications.        The incidence of complications was varied; accumulation of the fibrin around the site of catheter insertion was highest which was observed in more than one-third, followed by an infection which was nearly one-third, the occlusion has occurred in less than one-tenth, finally, hematoma around the site of insertion was the least CVC-related complication, Table (4). Regarding the number of complications almost one-third of patients had no complications, more than one-third had only one complication, nearly one-fifths had two, and about four percent had 3 complications together, Figure 2.

The delayed complications of a central venous catheter include infection and device dysfunction. These complications are much more gradual in onset and can occur in the weeks to months after a central line insertion (Kornbau et al, 2015). Patel et al (2019) found that device dysfunction happens when there is a problem with the mechanical components of the central line. A dysfunction of one of them can lead to delayed complications like a fibrin sheath, a catheter fracture, a thrombosis, stenosis, or an infection. The rate of device dysfunction is directly related to the central line site, the duration, and the underlying patient comorbidities.

Barreta et al, (2016) found catheter-associated infections, with a reported incidence varying between 42.5 and 50.6%, another complication was thrombosis after autologous or allogeneic bone marrow transplantation reveals a rate of thrombosis varying from 4.8% to 18.1%.

Furthermore, Khouzam et al, (2013) reported that the development of a fibrin sheath can occur within the first week of central line insertion and can create blockages at the distal openings. This will reduce the ability to draw blood from the line. For treatment, fibrinolytic such as alteplase can be prescribed to dissolve the fibrin sheath, and where fibrinolytic fails, line stripping can be attempted.  Hematoma formation has been reported by Vats (2012) in about 4.7% of all central line insertions. Most hematomas formed during central line insertions are benign but some can become sources of infection in patients and lead to abscess formation. Blood can collect in the thorax or in the mediastinum leading to hemothorax or hem mediastinum, respectively (Patel et al, 2019).

Participants, age, gender, education, and residency had no effect on the occurrence of CVC-related complications. this result is similar to a finding of the study done by Okyere et al., (2021), they clarify that there were no significantly associated between sociodemographic characteristics with the type of CVCs complications,

The incidence of complications as general was higher among leukemic patients; (acute lymphoid leukemia and acute myeloid leukemia) when compared to Hodgkin and Non-Hodgkin lymphoma, and multiple myeloma. On other hand, the complications were observed more in patients who underwent Allogeneic transplantation than Autologous significantly. Our explanation for this finding is may due to receiving high dose immunosuppression chemotherapies as a conditioning regimen, receiving induction of chemotherapy for getting remission before transplant, and the type of transplant for all leukemic patients was Allogeneic transplant in Shahid Shaswary Garmian Hospital. There are two recent studies revealed that leukemic patients who underwent allogeneic transplants are at great risk for CVC-related complications compared to patients with another medical diagnosis. (Beck et al., 2019; Heidenreich et al., 2020).

The CVC-related complications were most common in patients who had Hickman and single lumen, and the internal jugular vein was used for catheter insertion, this may result from that, Hickman lines insertion procedure is more difficult, needs two-incision, and it needs a tunneled site; which increases the risk for complications such as hematoma and infection. This finding is supported by results of a study conducted by Dix et al, (2012) which demonstrated that central venous catheters inserted within the internal jugular or femoral vein had a significantly higher rate of infection compared with those inserted in the subclavian veins.

Furthermore, the patients who had catheters for a long time and who had fewer dressings for catheter insertion sites complained from CVC-related complications more. This finding was expected because increasing the length of stay with catheters and few dressing numbers per weak increase the opportunity for catheter-related infection. This finding was in line with Leistner et al., (2013) results, they found a significantly prolonged stay with catheters in the ICUs associated with CVCs infection.

CONCLUSIONS

The incidence of central venous catheter-related complications was high, almost two-thirds had at least one complication. The most common complications were fibrin and infection. The incidence of complications affects by patients' medical diagnosis, type of transplant and catheter, vein used for insertion of the catheter, the duration of stay with a catheter, and the number of dressings for catheters insertion site. Central Venous Catheter is frequently associated with a number of complications, including device malfunction and/or greater patient morbidity related to longer hospital stays and more expensive medical care. Therefore, handling and monitoring CVC is a very important and responsible aspect of the nurses’ work. The complications can be prevented by high-quality nursing care.

ETHICAL CONSIDERATIONS COMPLIANCE WITH ETHICAL GUIDELINES

An administrative agreement was obtained from head of the clinical nursing department, and approved by the College of Nursing, University of Sulaimani, Iraq. The participants were informed about the research’s purpose and ensured anonymity and confidentiality of the information. A written informed, voluntary participation consent was obtained from each participant. 

FUNDING
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

AUTHOR’S CONTRIBUTIONS

Study concept; Writing the original draft; Data collection; Data analysis and Reviewing the final edition by all authors.

DISCLOSURE STATEMENT: The authors report no conflict of interest.

ACKNOWLEDGEMENTS

We thank the anonymous referees for their useful suggestions.

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