Evidence-Based Practice: Sodium Citrate versus Heparin - Research Proposal Example

Evidence-Based Practice: Sodium Citrate versus Heparin Introduction In the current age where there are so many available medical treatment options in the health care industry, patients and health care professionals often face the dilemma of deciding which among these options are the best choices for the patient. As the world is now facing financial problems in health care services, evidence-based practice (EBP) is now being considered by various medical and financial experts as a very appropriate option. This paper shall discuss the application of evidence-based practice, more particularly, the use of sodium citrate 4% locking solution for central venous dialysis against the use of the more costly heparin. This paper shall analyse the relevance of theoretical and research-based knowledge. It shall also evaluate evidence of critical discussion of the various perspectives on the use of either sodium or heparin for central venous dialysis. Discussion Theoretical and Research-based Practice Theoretical and research-based knowledge is defined by Dawes (2005, p. 4, as quoted by Taylor, et.al., 2007, p. 10) as the practice which “aims to provide the best evidence at the point of clinical (or management) contact”. In other words, it seeks to apply the most efficient or the most effective intervention for the patient based on particular qualities of the patient. It implies individual and patient-based care because the reckoning point of care is the point of contact, and the point of contact, in this instance, is when the patient and professional care giver come in contact with each other. Evidence or research-based practice in healthcare finds its roots in medical researchers in Canada who wanted to make sure that medical practice is actually based on research evidence. “Since that time, EBP has become firmly established in the USA, United Kingdom, Europe and southern hemisphere countries” (Taylor, et.al., 2007, p. 10). Advocates of EBP or research-based practice emphasize on best evidence, on expertise in clinical decision-making techniques, and in considering the patient’s values and needs. Each patient is different; and even if he shares the same symptoms or even the same diagnosis with another patient, it does not mean that the same interventions should be applied to him. Hence, there is now the need for evidence or research to establish proof of the applicability of a particular form of treatment to a particular patient. Evidence-based practice is also based on the needs of the ‘informed’ consumer. The informed consumer is usually “seeking an evidence base to the health care practices in which they take part” (Crisp, et.al., p. 7). The health care consumers are now more conscientious of the interventions that are being suggested or being undertaken on their person. They now have learned to question and to ask for proof from the medical health professionals that the interventions being applied to them are the best and the most appropriate interventions. As a result, the medical health practitioners are seeking ways to keep themselves informed about the latest and the best interventions available. Evidence-based practice in the nursing practice is focused on its changing nature based on “new information originating from research, practice trends, technological development, and social issues affecting clients” (Crisp, et.al., p. 7). This practice also seeks to combine the best evidence-based practice with the clinical skills of the health care giver and the specific needs of the patient. Crisp, et.al., (p. 7) emphasize that the nursing practice is about making sound decisions largely based on critical thinking in the delivery of the health care needs of the patients. In relation to the concept of evidence-based practice is the concept of evidence-based medicine. This is a more holistic concept as it covers the entire medical practice – from patient treatment administered by doctors to medical research conducted by scientists. Nevertheless, evidence-based medicine captures important descriptions about the “systematic process of evaluating scientific research that is used as the basis for clinical treatment choices” (Claridge & Fabian, as cited by Stankos & Schwarz, 2007). They are based on essential elements which essentially boil down to scientifically-based choices in the health care practice. Evidence Base: Sodium citrate versus Heparin Clinical and scientific evidence on the use of sodium citrate 4% instead of heparin as a locking solution for central venous dialysis catheters has been demonstrated in a study conducted by Wiejmer, et.al., (2002) when they attempted to assess the in vitro antimicrobial activity of trisodium citrate (TSC) as compared with heparin and iso-osmolal sodium chloride (NaCl) solutions. Previous studies have revealed that haemodialysis catheters which are being used for vascular access face complications related to infection. The potential of sodium citrate as a better and less infection-risky alternative to heparin has been proposed by previous studies. This study by Wiejmer, et.al. (2002) revealed that higher concentrations of TSC successfully killed off staphylococcus strains in patients included in their study. They were able to offer substantive proof that, as compared to heparin, TSC provides superior antimicrobial activity in patients with haemodialysis catheters. There was complete killing of E.coli and P. aeruginosa bacteria and there was also inhibited growth of C. albicans with the use of TSC 30%. On the other hand, the antimicrobial effect of heparin did not manifest any significant changes in antimicrobial effect. A study by Branson, et.al., (1993, pp. 882-885) attempted to measure the efficacy of a 1.4% solution of sodium citrate in the maintenance of arterial catheter patency in medical ICU patients. This study sought to compare the efficacy of sodium citrate with heparin in maintaining the patency of the catheters in medical ICU patients. After patients underwent the research process for this paper, results revealed that a larger percentage of patients whose catheters were flushed with sodium citrate proved functional after 48 hours. The patency of catheters for patients whose catheters were flushed with heparin registered a lesser percentage of patency. Based on the results of the study, it was also concluded that arterial catheter flush solutions with sodium citrate are more effective and are safer alternatives to heparin in maintaining catheter patency (Branson, et.al., 1993, pp. 882-885). It is important to maintain the patency of catheters for patients in critical care units because they help ensure “accurate hemodynamic measurements, arterial blood sampling, and cardiac output determinations” (Halm, 2008). In another research, this time conducted by Grudzinski, et.al. (2006), they attempted to evaluate the effectiveness of using sodium citrate 4% locking solution for central venous dialysis catheters. In their study, they used sodium citrate 4% instead of heparin to lock all central venous haemodialysis catheters. They assessed the rate of growth of bacteria and the annual cost of this locking agent. They eventually established that the use of sodium citrate is far more pharmacologically and economically beneficial for the patient. They were also able to definitively establish that citrate does offer clinical advantages over heparin and that sodium citrate is able to prevent bleeding complications often seen in heparin users (Grudzinski, et.al., 2006). This study therefore, presents more evidence proving that the sodium citrate locking solution is actually a better alternative or even the best evidence-based alternative which can be used for patients who are undergoing haemodialysis. In an attempt to shed more light to the issue, Power and colleagues (2008) conducted their study where they assessed an open label randomized controlled trial of 2 catheter locks. This study also attempted to determine if sodium catheter locks would be able to reduce catheter-related bacteria and infection (Power, et.al., 2008). They were able to cover 232 patients in their study with half of the patients placed on sodium citrate locks and the other half placed on heparin locks. This paper presented a result which did not support the comparative effectiveness of sodium citrate with heparin. This study revealed that the widespread and long-term use of citrate catheters is not justified. However, it is important to note that this study had low baseline catheter-related bacteraemia and exit-site infection; and this situation may have affected the results. If there were higher rates of infection, there may have been a link made to the high concentration of citrate used as a locking mechanism (Power, et.al., 2008). The study appropriately recommends more researches to be conducted on the same topic while making the necessary adjustments to make the study less constrained and less affected by limitations. In a study conducted by renal pharmacist Jenkins, et.al. (2009, pp. 119-120), she reviewed the incidence of bacteraemia on patients placed on haemodialysis with TSC locked catheters. Patients admitted from January to June 2006 were administered the heparin-locking solutions, and those admitted from September 2006, to February 2007 were administered with TSC. Her study was able to reveal that out of the 12 haemodialysis patients who were administered with heparin-locking solutions, 11 of them later registered with haemodialysis catheter infections. This represents about 91% of the population. For those administered with TSC locking solutions, none of the patients admitted registered with haemodialysis catheter infections. Jenkins (2009, pp. 119-120) further extrapolates from the data that that such figures represent a 67% drop in infections related to haemodialysis catheters. Although the number of patients only represents a small part of the population, they help support the results of previous studies undertaken on the subject matter which suggest that the use of TSC or sodium citrate as a locking solution for haemodialysis catheters help reduce the incidence of infection (Jenkins, et.al., 2009, p. 119). Moran & Ash (2008, pp. 490-492) attempted to assess the effectiveness of using heparin or sodium citrate as locking solutions for haemodialysis catheters. They cited studies which said that both heparin and sodium citrate are suitable choices in maintaining the patency of central venous catheters for dialysis patients. This study however did not compare the use of these two solutions; instead it compared the use of these two solutions with other solutions in general (Moran & Ash, 2008, pp. 490-492). Nevertheless, it still produced viable results which help support the use of sodium citrate as a preferred locking solution over other locking solutions. There is a need for other studies to support and specify the results of this study. A study conducted by MacRae, et.al. (2008), was another clear attempt at coming up with evidence or research which would help prove or disprove the effectiveness of sodium citrate as a locking solution in haemodialysis catheters. They included 61 haemodialysis (HD) patients with tunnelled cuff HD catheters in their randomized study. Their patients were given either heparin 5000 U/ml or citrate 4% as a locking agent after haemodialysis. In their study, they assessed the development of catheter dysfunction and catheter-associated bacteraemia. They also sought to assess the development of exit-site infections or bleeding complications (MacRae, et.al., 2008). Their study revealed that citrate produced lesser catheter dysfunction instances as compared to heparin. There were 13 out of 32 cases of catheter dysfunction seen in patients with citrate locking solutions, and 12 out of 29 cases for those with heparin. No differences were seen in the two groups with regard to bacteraemia-related catheter use. There were also no differences seen in exit-site infection in the two groups. This study was able to conclude that 4% citrate, as compared to heparin, is more effective in maintaining catheter patency and it does not appear to increase the incidence of infection in patients undergoing HD. Since the use of citrate is actually much cheaper that heparin, it is potentially the better alternative. It carries the same (or even better) advantages that heparin carries, and yet it is still at a lower cost than heparin. Karaaslan, et.al., (2001) attempted to determine the risk of heparin lock-related bleeding when using indwelling venous catheters in haemodialysis. They included 20 HD patients with Dual-Cath® . In order to prevent coagulation, a bolus of dalteparin was injected. The activated partial thromboplastin time (aPTT) was assessed after the session before and ten minutes after undiluted heparin was used as a locking solution. Catheter patency was also assessed. The study revealed that aPTT values were almost normal; and all patients had uncoagulable blood 10 minutes after locking with heparin. As a whole, the study was able to conclude that the risk of inducing serious bleeding occurs at a lower frequency with the use of heparin locking especially in postoperative patients. This study also recommended sodium citrate, polygeline, or urokinase as possible alternatives to heparin (Karaaslan, et.al., 2001). Although, this study does not compare the use of sodium citrate and heparin as locking solutions, it sets forth important results relating to the use of sodium citrate as an alternative to heparin. The use of locking mechanisms in the catheters of HD patients is an important part of medical and nursing practice which the nurse and the medical health professional should consider at all times. Simon, et.al., (2008) sought to assess the use of a citrate (TauroLock TM) lock solution with broad spectrum antimicrobial activity in order to prevent bloodstream infection (BSI) in pediatric cancer patients with long-term central venous access devices (CVAD). In their 48-month cohort study, they compared all patients given heparin locks (Wales) with patients given citrate locks (Germany). In the course of their research, they were able to uncover that in the heparin group, 14 out of the 30 patients tested primary Gram positive BSI due to coagulase-negative staphylococci (CoNS); in the citrate group, only 3 out of the 25 patients presented with BSI caused by CoNS. They concluded that the citrate lock (TauroLock TM) was able to reduce significantly the incidence of primary catheter-related blood stream infections in paediatric cancer patients. The results of this study once again help to support the results of previous studies on the use of sodium citrate as a better locking solution in HD patients (Simon, et.al., 2008). These results are important because they cover paediatric patients who are under long-term care. It is important to note that all the necessary efforts are being taken to ensure that the children receive the best possible interventions to help improve their condition. Steczko, et.al. (2009, pp. 1937-1945) sought to establish the microbial inactivation properties of a new antimicrobial/antithrombotic catheter lock solution which contains citrate. Its effects against planktonic bacteria and sessile bacteria within a biofilm were evaluated. And these results were then compared to heparin. This study revealed that the new citrate locking solution, as compared to heparin was able to kill most tested planktonic microorganisms within an hour of incubation. The citrate solution was also able to kill almost all sessile bacteria in biofilm growth on plastic or glass discs within one hour of incubation. The researchers then concluded that the new multicomponent lock solution (with citrate) has strong microbial properties against sessile and planktonic microorganisms. Heparin, on the other hand, has weak antimicrobial properties against sessile and planktonic bacteria. Consequently, citrate, as compared to heparin is the much better choice in haemodialysis patients in terms of diminishing the incidence of catheter-related bacteraemia. A recent study by Ko, et.al., (2009, pp. 127-128) attempted to assess the broader effectiveness of trisodium citrate with or without antimicrobials for preventing infections in vascular access catheters in any clinical setting. This study is basically a literature review of studies from Evidence-based Medicine, from the Cochrane database, the EMBASE, and the CINAHL. The studies that they were able to review revealed statistically significant reductions in catheter-related bloodstream infections for each patient for each catheter day. In patients with ESRD undergoing HD, the use of heparin and citrate seemed to indicate no significant differences in results; however, the study pointed out a high degree of bias and conflict of interest in the studies included. This bias, on the whole, affects the results of the study since the number of patients included is not sufficient for applicability to the general population. The literature review emphasized that the use of trisodium citrate at any concentration, as compared to the use of heparin, still has inconclusive results. They point out that the quality of the research which has so far been conducted on the subject matter is poor; hence no definitive recommendations on the problem can be made after their thorough review of literature (Ko, et.al., 2009, pp. 127-128). They recommend more researches on the subject matter; these researches have to make the necessary adjustments after duly considering the limitations of the previous studies. In a research by Girolami, et.al., (2003), they attempted to assess the incidence of heparin-induced thrombocytopenia (HIT) in hospitalised patients. Platelet counts were performed at baseline and every 3 days in 598 consecutive patients admitted to two medical wards. The study revealed that HIT was seen in 5 patients, all of them belonging to the subgroup of patients receiving heparin prophylactic indications. The incidence of thromboembolic complications in patients with HIT registered at high levels. Although the incidence of HIT in the patients treated with heparin is lower in the clinical setting, this is still considered a high risk complication associated with an even higher risk for thromboembolic events (Girolami, et.al., 2003). These risks associated with heparin use cannot be ignored. They must be considered well before the choices in medical intervention for the patient are made. Patients carry enough risk as it is from their diagnosed diseases; the medical community will not be doing them any favours if medical health risks are increased while they are in the care of the medical health professional. Hartman, et.al., (2008, pp. 39-49) attempted to study anticoagulation in combined membrane/adsorption systems. Their study revolved around the concept that that for extracorporeal blood purification treatments to work, an effective anti-coagulation measure is needed in order to avoid contact activation through the intrinsic pathway of the blood-clotting system. They point out that although heparin is the standard anticoagulant in dialysis, it carries certain disadvantages which must be evaluated in membrane/adsorption-based blood purification systems. At present, the better alternative is citrate which is an effective anticoagulant as it reduces ionized calcium concentration in the extracorporeal circuit. The study was able to show that by pre-coating the adsorbents with heparin, they were able to significantly reduce the adsorptive removal of heparin. The more significant results of this study are related to heparin-induced thrombocytopenia and other contraindications for heparin anticoagulation which now makes citrate the better and the more elegant alternative primarily because of its additional ability to suppress complement activation (Hartman, et.al., 2008, pp. 39-49). The results of this study are important because they point out more favourable anticoagulation properties of citrate which make it the safer and more effective alternative choice in haemodialysis patients. Application of theory to student practice The theories of evidence-based or research-based practice are applicable to this student’s practice in the sense that they serve as basis or rationale for the application of a particular intervention. There are a variety of interventions that a student may opt to apply to the patient; the evidence that the practice can now present can help guide the student and the nurse towards the best choices in patient care. Melnyck & Fineout-Overholt, (2005, p. 2) outline important steps in the process of reaching and applying evidence-based practice. First and foremost they start off with the burning clinical question (Melnyck & Fineout-Overholt, 2005, p. 2). In this case the burning clinical question is on whether or not sodium citrate is a better choice as a locking solution in the catheterization of HD patients. The next step in the process would be to collect the most relevant and the best evidence (Melnyck & Fineout-Overhold, 2005, p. 2). This process was undertaken by searching through various databases of researches in relation to this subject matter. The best evidence was chosen based on the credibility of the authors and the elements of reliability and validity applied in the course of the research. The next step covered the critical appraisal of the evidence (Melnyck & Fineout-Overholt, 2005, p. 2). This was conducted in this paper when the evidence gathered was evaluated and assessed in terms of substance and also reliability. The results were also assessed for duplication and applicability to a wider population. The next step of the process is about the “integration of evidence with one’s clinical practice, patient preferences, and values in making a practice decision or change” (Melnyck & Fineout-Overholt, 2005, p. 2). This step will now be expected of the student nurse or the nurse in the actual clinical practice. In this instance, the nurse or the clinician has to assess the clinical evidence gathered and choose to apply them to the patient after duly considering the latter’s preferences and values. The particular characteristics of the patient have also to be considered in this instance because each patient is unique. His individual characteristics may require qualities of care different from other patients. Lastly, an evaluation of the practice decision or change is needed (Melnyck & Fineout-Overholt, 2005, p. 2). This evaluation will help perfect patient care. Through evaluation, the nurse and other medical practitioners now assess the application of a particular practice and decide, in retrospect, how this practice may or may not fit the patient. The evidence-based practice as applied in this paper has yet to undertake the fourth and the fifth steps for this student. However, the important process has already been laid out for this student to follow. Many nurses and clinicians are often criticised for their lack of confidence in synthesizing information and data which they can later use in patient care. It is important for this student to associate herself with other nurses and practitioners who possess the expert knowledge on the subject matter. In evidence-based practice, a student would best apply this practice by measuring patient outcomes “related to the intervention they implement and to publish their protocols in clinical journals” (Burns, et.al., 2005, p. 641). This would help build evidence and proof on the subject matter and on a particular application in patient care. Evidence-based or research-based practice emphasizes the importance of applying the best interventions for patients based on proof of effectiveness of care. Various researches have been presented above supporting the effectiveness of sodium citrate over heparin as a locking solution for catheterization in haemodialysis patients. The researches and evidence cited above still do not offer definitive answers to the issue posed by this research. More evidence and research is needed in order to help establish firm evidence on the issue. However, so far, evidence clearly shows support for the use of sodium citrate as a better alternative to heparin. The questions raised on the reliability of these researches have yet to be settled by future studies on the subject matter. Works Cited Branson, P., McCoy, R., Phillips, B., & Clifton, G., March 1993, Efficacy of 1.4 percent sodium citrate in maintaining arterial catheter patency in patients in a medical ICU, Chest Journal, volume 103, number 3, pp. 882-885 Burns, N., Burns, N., & Grove, S., 2005, The practice of nursing research: conduct, critique, and utilization, Missouri: Elsevier Saunders Crisp, J., Potter, P., Taylor, C., & Perry, A., 2006, Potter & Perrys fundamentals of nursing, New South Wales: Elsevier Health Sciences Girolami, B., Prandoni, P., Stefani, P., Tanduo, C., Sabbiob, P., Eichler, P., Ramon, R., Baggio, G., Fabris, F., Girolami, A., 15 April 2003, The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study, Blood Journal, viewed 12 October 2009 from http://bloodjournal.hematologylibrary.org/cgi/content/full/101/8/2955 Grudzinski, L., Quinan, P., Kwok, S., & Pierratos, A., 2006, Sodium citrate 4% locking solution for central venous dialysis catheters--an effective, more cost-efficient alternative to heparin, Nephrology, Dialysis, Transplantation, volume 22, pp. 471-476 Halm, M., 2008, Flushing Hemodynamic Catheters: What Does the Science Tell Us?, American Journal or Critical Care, volume 17, number 1, pp. 73-76 Hartman, J., Strohl, K., &Falkenhagen, D., 2008, Anticoagulation in combined membrane adsorption systems, Center for Biomedical Technology, viewed 12 October 2009 from http://e20.manu.edu.mk/prilozi/04h.pdf Jenkins, J., Daniels, C., Pritchard, N., April 2009, Changing catheter-locking solutions to reduce infection, British Journal of Clinical Pharmacy, volume 1, viewed 12 October 2009 from http://www.clinicalpharmacy.org.uk/April/sharingpractice1.pdf Karaaslan, H., Peyronnet, P., Benevent, D., Lagarde, C., Rince, M., Leroux-Robert, C., 2001, Risk of heparin lock-related bleeding when using indwelling venous catheter in haemodialysis, Nephrology Dialysis, Transplantation, volume 16, pp. 2072-2074 Ko, H., Garubba, M., & Allen, K., May 2009, Trisodium citrate for prevention of catheter-related infections, Monash University, viewed 12 October 2009 from http://www.mihsr.monash.org/cce/pdf/ers/trisodiumcitratecatheterinfections.pdf MacRae, J., Dojcinovic, I., Djurdjev, O., Jung, B., Shalansky, S., Levin, A., Kiaii, M., 2008, Citrate 4% versus Heparin and the Reduction of Thrombosis Study (CHARTS), Clinical Journal of the American Society of Nephrology, volume 3, pp. 369-374 Melnyck, M. & Fineout-Overholt, E., 2005, Evidence-based practice in nursing & healthcare: a guide to best practice, Pennsylvania: Lippincott Williams and Wilkinson Moran, S. & Ash, S., September 2008, Locking solutions for hemodialysis catheters; heparin and citrate, Seminars in Dialysis, volume 21, number 5, pp. 490-492 Power, A., Duncan, N., Singh, S., Brown, W., Dalby, E., Edwards, C., Lynch, K., Prout, V., Cairns, T., Griffith, M., MacLean, A., Palmer, A., & Taube, D., 2009, Sodium Citrate Versus Heparin Catheter Locks for Cuffed Central Venous Catheters: A Single-Center Randomized Controlled Trial, Science Direct Simon, A., Ammann, R., Wiszniewsky, G., bode, U., Fleischhack, G., & Besuden, M., 2008, Taurolidine-citrate lock solution (TauroLock) significantly reduces CVAD-associated grampositive infections in pediatric cancer patients, UK PubMed Central, viewed 12 October 2009 from http://ukpmc.ac.uk/articlerender.cgi?tool=pubmed&pubmedid=18664278 Stankos, M. & Schwarz, B., January 2007, Evidence-Based Design in Healthcare: A Theoretical Dilemma, Interdisciplinary Design and Research e-Journal, Volume I, Issue I, viewed 12 October 2009 from http://www.idrp.wsu.edu/Vol_1/stankos.pdf Steczko, J., Ash, S., Nivens, D., Brewer, L., & Winger, R., June 2009, Microbial inactivation properties of a new antimicrobial/antithrombotic catheter lock solution (citrate/methylene blue/parabens), Nephrology, Dialysis, Transplantation, volume 6, pp. 1937-1945 Taylor, B., Roberts, K. & Kermode S., 2007, Research in nursing and health care: evidence for practice, New South Wales: Thomson Learning Weijmer, M., Debets-Ossenkopp, Y., van de Vondervoort, F., ter Wee, P., 2002, Superior antimicrobial activity of trisodium citrate over heparin for catheter locking, European Renal Association-European Dialysis and Transplant Association, viewed 12 October 2009 from http://ndt.oxfordjournals.org/cgi/content/full/17/12/2189?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Superior+antimicrobial+activity+of+trisodium+citrate+over+heparin+for+catheter+locking&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Read More