Home Intravenous Therapy

Home intravenous (IV) therapy programs started in the 1970s and are spreading annually as the cost savings compared to hospitalization increase.Advances in technology have resulted in the ability to manage patients at home safely with IV  therapy.Many patients prefer to receive infusion at home rather than the hospital.Infusion therapies include antibiotics,pain therapy,chemotherapy,and parenteral nutrition (PN).Blood transfusions and blood products tend to be given in the hospital because of the higher risk of complications.The physician is the medical case manager with responsibility for ordering the plan of care and usually writes the orders.

Peripheral PN regimens can only be used for low-osmolarity solution (300-900 mOsm/L). Higher osmolarity solutions must be larger veins with faster blood flow to avoid sceloris and inflammation of the vein wall. Central lines may be placed percutaneously and the pheriperally inserted central catheters (PICC lines) are increasingly being used for intermediate (days to weeks) usage. Central lines also may be surgically inserted, often with a subcutaneous tunnel to reduce the chance of skin bacteria infecting the vein. The Hickman and Broviac catheter can be inserted surgically of through a needle. Catheters such as the mediport or portacath may be implanted under the skin. These catheters are best used when there is interminttent need fo IV infusion, such as a course of antibiotics or chemotherapy. The Groshong catheter has a patented 3-position valve near the closed tip which opens inward during blood  withdrawal and outdward during infusion. The valve closes automatically when not in use because venous pressure is not enough to spontaneously open the valve inward. The result is that if the catheter becomes disconected, blood loss or air embolus is prevented.

Catheter-related complications are not uncommon. It is important to check the position of the tip or the catheter before solutions are infused. Air embolus is an infrequent complication as filters and connections have reduced this occurrence. Thrombophlebitis is common with peripheral catheter and thrombus formation may occur with statis associated with central catheters. Infection related to central catheters is a major complication. If there is fever, catheter-related sepsis must be considered. Blood cultures can be drawn from the line and peripherally at the same time. If there is evidance of fungal line sepsis, the catheter needs to be removed. Sometimes antibiotic treatment can be given to eradicate bacterial colonization of the catheter, but it is often necessary to remove the catheter.

Monitoring of laboratory paremeters needs to be planned. Blood levels of antibiotics or other medications should be checked at appropriate intervals and hematology and biochemical studies can be drawn during a home visit or the patient can go for blood drawing at a clinic or hospital.

IV tubing should be changed every 24-48 hours. Central catheters should be flushed monthly to reduce the potential for blocking off by thrombus formation.

The gravity system is the simplest for home infusion therapy. The solution is hung on a pole and the rate of flow is adjusted by using an in-line clamp and by watching the number of drips in a drip chamber to estimate the rate. This is not an accurate method and there are no alarms. Some systems use an ambulatory infusion pump which is portable and battery-powered. Complications of IV therapy can be minimized with careful protocols. Infiltration of periheral lines is common in children with pain and swelling at the site. Phlebitis is more common if the fluid is hypertonic or irritating.

If antibiotics are to be continued for more than 3 weeks, some form of central line is necessary. If there is a history of allergy, the initial dose of an antibiotic should be given in an environment where anaphylaxis can be treated.

Patients with diseases involving kidneys, liver, heart, lungs, or blood should be monitored more closely for side effects. Chemotherapy is usually administered in an infusion center initially and some chemotherapy medications should always be administered in the presence of personnel who can handle emergency situations. Unused drugs should not be disposed of down the drain or toilet but should be treated as hazardous waste.

Pain medications can be administered by IV, IM, subcutaneously, intrathecally and by epidural catheter. Infusion pumps for narcotics can be set up so that the patient can activate the pump at intervals depending on the need for pain control. The pumps are called patient-controlled activation (PCA).