Journal of Parenteral and Enteral
The online version of this article can be found at:
2011 35: 588 JPEN J Parenter Enteral Nutr
and Geert Wanten
Getty Huisman-de Waal, Michelle Versleijen, Theo van Achterberg, Jan B. Jansen, Hans Sauerwein, Lisette Schoonhoven
on Home Parenteral Nutrition
Device Related Complications in Patients
Psychosocial Complaints Are Associated With Venous Access
On behalf of:
The American Society for Parenteral & Enteral Nutrition
can be found at:
Journal of Parenteral and Enteral Nutrition
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Journal of Parenteral and
Volume 35 Number 5
September 2011 588-595
© 2011 American Society for
Parenteral and Enteral Nutrition
Clinical Relevancy Statement
Our data show a clear association between the pres-
ence of psychosocial complaints (eg, depression, fatigue,
social impairment, experienced quality of life [QOL]) and
previously experienced venous access–related complications
From the 1Department of Gastroenterology and Hepatology; 2IQ
Healthcare, Nursing Science, Radboud University Nijmegen
Medical Center, Nijmegen; 3Department of Endocrinology and
Metabolism, University Medical Center Amsterdam, The Netherlands.
Received for publication September 24, 2009; accepted for
publication July 15, 2010.
Address correspondence to: Getty Huisman-de Waal, Radboud
University Nijmegen Medical Center, 455 Department of
Gastroenterology and Hepatology; PO Box 9101, 6500 HB
Nijmegen, The Netherlands; e-mail: email@example.com.
in a substantial number of Dutch patients with long-term
intestinal failure who are treated by means of home par-
enteral nutrition (HPN). These findings underscore the
need for the development of additional preventive and
therapeutic measures regarding both types of problems in
Parenteral nutrition (PN) has been used for nearly 4 dec-
ades to prevent or correct malnutrition in patients with
severe intestinal failure. In cases of long-term intestinal
failure, patients may administer PN in the home setting
(HPN). Whenever possible, HPN patients in the
Netherlands are trained in the 2 academic referral cent-
ers in Nijmegen and Amsterdam to become autonomous
with regard to HPN practices.
Background: Complications related to venous access devices
(VADs) remain the major drawback of home parenteral nutrition
(HPN) support. In addition to technical issues, patients also
experience psychosocial problems. The aim of this study is to
present an overview of VAD-related complications in patients on
long-term HPN and to assess whether these adversities are
related to experienced psychosocial problems and quality of life
(QOL). Methods: Information on VAD-related complications was
collected from the medical charts of 110 adult HPN patients who
were followed by the 2 major referral centers in the Netherlands.
In addition, a survey was conducted in this group to characterize
psychosocial problems and assess their association with tech-
nique-related complications; 75 patients (68%) responded.
Results: At the time of survey, the majority of patients (76%) had
developed 1 or more episodes of catheter-related sepsis at some
point during their HPN treatment. The overall incidence of
VAD-related blood stream infections (BSIs) was 3 per 1,000
venous access days. The incidence of VAD occlusions was 0.8 per
1,000 venous access days. During the observation period, there
was a highly significant association between the incidence of
VAD-related complications and the occurrence of psychosocial
complaints (eg, depression, fatigue, social impairment, and
decreased QOL). Conclusions: Psychosocial complaints are asso-
ciated with previously experienced VAD-related complications in
patients on HPN therapy. Although only an association, and not
a causal relationship is demonstrated by these findings, our
results underscore the need for preventive and therapeutic meas-
ures regarding both types of problems in these patients. (JPEN J
Parenter Enteral Nutr. 2011;35:588-595)
Keywords: home parenteral nutrition; venous access device–
related complications; psychosocial problems
Psychosocial Complaints Are
Associated With Venous Access–Device
Related Complications in Patients on
Home Parenteral Nutrition
Getty Huisman-de Waal, PhD, RN1,2; Michelle Versleijen, MD, MSc1;
Theo van Achterberg, PhD, RN2; Jan B. Jansen, MD, PhD1;
Hans Sauerwein, MD, PhD3; Lisette Schoonhoven, PhD, RN2;
and Geert Wanten, MD, PhD1
Financial disclosure: None declared.
Psychosocial Complaints and Venous Access–Related Complications / Huisman-de Waal et al 589
HPN is most frequently delivered by means of a venous
access device (VAD) such as a tunneled catheter or a subcu-
taneous port, which is positioned in a large-bore central
vessel, often the subclavian or internal jugular vein.
Despite substantial clinical experience, VAD-related com-
plications remain the most serious threat for both the
patient and the survival of HPN as a technique.1–3 Of
these, catheter-related bloodstream infections (CR-BSIs)
are the most common complication. Howard and Ashley4
reported that, on average, adult HPN patients in the
United States experienced CR-BSIs once every 2 to 3
years (0.34 episodes per catheter year). Other studies
mentioned BSI rates in central venous catheters (CVCs)
ranging from 0.17 to 2.19 episodes per year.2,3,5–7 CR-BSIs
can ultimately be responsible for the loss of central
venous access or cause severe septic complications.6
Evidently, the prevention of CR-BSIs is of key importance
for the survival of any HPN program. A summary of our
protocols for CR-BSIs and occlusions is given in Boxes 1
and 2. Recently, we published an in-depth analysis of all
venous access–related complications observed in the
HPN population from Nijmegen that showed the use
of arteriovenous fistulas (AVFs) for the administration of
HPN is feasible, with a significantly decreased rate of
infectious complications when compared with CVCs
(Hickman type or subcutaneous ports).8
Box 1. Criteria for Diagnosis and Treatment
In both Dutch HPN centers, patients who are suspected
of having catheter-related sepsis are evaluated in the
• Blood cultures are taken from the VAD device as well
as from peripheral sites.
• PN administration is aborted and only restarted after
a period of 24 hours without fever.
• Treatment is started with broad-spectrum antibiotics
infused through the catheter (eg, flucloxacillin in
hemodynamically stable patients; ceftriaxone and
gentamicin in hemodynamically unstable patients).
• The therapeutic regimen thereafter is tailored accord-
ing to culture results.
• In addition, in Nijmegen, patients are treated by the
administration of the fibrinolytic agent urokinase
into the catheter (5.000 U/2.5 mL) before antibiotic
therapy is initiated.
• Catheters are only immediately removed in cases of
septic shock, fungal infection, or treatment failure,
as evidenced by culturing the same organism from
the VAD twice within 6 weeks following the discon-
tinuation of antibiotic. VADs are also removed in
cases of tunnel (ie, subcutaneous pocket formation)
or persistent exit-site infections.
Box 2. Criteria for Diagnosis and
Treatment of Occlusion
Apart from infection, catheter or AVF occlusion is the
most common VAD-related problem, often necessitating
catheter removal, AVF surgery, or angioplasty. These latter
events interrupt HPN treatment and also expose the
patient to the risks associated with catheter replacement
and the loss of valuable access sites.
CVC occlusion can be caused by thrombus forma-
tion, lipid deposition, or drug precipitation. CVC throm-
bosis generally results from disruption of the vein and
development of a fibrin sheath around the catheter. If
catheter thrombosis is unrecognized and untreated, it
may lead to the need for catheter removal and long-term
loss of a venous access site.
• In case of suspected lipid deposition or drug precipi-
tation, patients are treated by means of sodium
hydroxide (0.1 mol/L, 25 mL) infusion.
• Catheter thrombosis may be treated with urokinase
• If treatment is unsuccessful, removal of the catheter
• AVF occlusion may occur during episodes of dehy-
dration or in cases of an underlying prothrombotic
disease, but mostly is related to stenosis of the vascu-
lar anastomosis. The latter problem mostly develops
gradually and can be suspected when an increased
pitch of the murmur can be heard over the AVF.
Patients are therefore trained to check their AVF
using a stethoscope. In addition, periodic ultrasonog-
raphy is performed to detect any abnormalities.
As reported previously by our group, HPN patients
also experience a wide range of psychosocial and physical
problems in their daily lives in addition to VAD-related
complications.9,10 Anxiety and fear are common reactions
in HPN patients and have been associated with realistic
threats such as catheter infection, thrombosis, air embo-
lism, and liver damage,9,11 and anger, negative self-image,
being dependent on HPN and professionals and diarrhea
have also been reported.4,9,12–14
The most commonly reported VAD-related psy-
chocial and physical problems are fatigue, depression,
and social impairment, which have a major impact on
patient QOL. Fatigue may result from lack of sleep15
due to the noise of the infuser pump or from sleep dis-
ruptions due to frequent urination during fluid infu-
sion.16 In our previous study,16 fatigue was the most
frequent general complaint in HPN patients and con-
sistently interfered with daily activities such as work and
590 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 5, September 2011
An important underlying question that sparked the
present investigation was whether the occurrence of psy-
chosocial problems is associated with VAD-related com-
plications, which are essentially preventable, or with the
underlying disease that led to intestinal failure, which
mostly cannot be prevented. This is relevant because such
a notion would further bolster the indication for preven-
tive measures in this respect.
The aim of the present study was: (1) to provide an
assessment and characterization of VAD-related compli-
cations in patients on HPN in the Netherlands, and (2) to
relate these complications to observed psychosocial com-
Materials and Methods
We included all long-term adult HPN patients from the 2
Dutch specialized university centers who received HPN
for at least 3 months at the time of patient selection, in
December 2006. Patient medical charts were retrospec-
tively reviewed by 2 independent reviewers. Whenever
data from medical charts were unclear, nursing files were
screened as well. In each patient, all VADs placed for
HPN purposes between the start of HPN treatment and
December 2006 were analyzed for complications. VAD-
related BSIs were defined by the presence of symptoms
(eg, fever, chills) associated with positive blood cultures
in the absence of other evident infectious foci that likely
could explain the BSI. Episodes of fever and/or chills
without positive blood cultures were considered BSIs
when blood samples were drawn during antibiotic therapy
or when patients showed signs of sepsis (eg, fever with
cold chills, low blood pressure requiring intravenous fluid
support, or oliguria) and other infectious foci that could
explain the symptoms were excluded. Concerning the
occlusions, the time span of development (ie, slowly and
partial, with a spontaneous flow of <100 drops/min [con-
sidered to be mainly due to precipitation of infused sub-
strates] vs acute [(nearly) complete obstruction, mainly
due to thrombus formation]) was frequently not docu-
mented, and ultrasonography or contrast venography was
not always performed. Therefore, it was, impossible to
distinguish thrombotic occulsions from nonthrombotic
occlusions. For this reason, and in accordance with other
studies on CVC-related complications,8,17 we report over-
all occlusion rates in the present study.
Of note, in our patients, CVCs were used solely for
the administration of PN or fluids.
A standardized record was used for data extraction.
Extracted information included age, sex, underlying dis-
ease, indication for HPN, years on HPN therapy, type of
CVC (external tunneled vs implanted port vs AVF),
comorbidity, type of complications (eg, infection, occlu-
sion), and their treatment, including those observed in
both the inpatient and outpatient settings. VADs that were
in situ but not used, and, therefore, not likely to cause
complications (n = 8), and VADs with missing data con-
cerning the precise utilization period or the exact number
of complications during use (n = 4) were excluded from
the analysis. In total, 509 VADs were placed in 110
All adult patients monitored by the nutrition support
teams at the university centers in Nijmegen and
Amsterdam in October 2006 (n = 110) were invited to
participate in the study. Based on previous reports, we
estimated that these patients represented 85% of all
patients receiving long-term HPN in the Netherlands
during that period (n = ±130).18 The study protocol was
approved by the Medical Ethics Committee of the
Radboud University Nijmegen Medical Center. All
patients gave their written informed consent before inclu-
sion in the study.
To address the secondary aim of the present study, in
October 2006, study patients were surveyed using
questionnaires based on our previous research.10 The ques-
tionnaires addressed general and HPN-related characteris-
tics, including medication use, QOL, social impairment,
depression, fatigue, physical complaints, coping, self-effi-
cacy, social support, sexual disorders, and anxiety (Table 1).
To determine whether experienced psychosocial problems
(in October 2006) and VAD-related complications were
related, we included complications that occurred between
January 1, 2005, and September 30, 2006.
Completion of the survey took 45 to 75 minutes and
was accomplished by 75 patients (68%).
Fatigue severity was measured using a subscale of the
Checklist Individual Strength (CIS).19,20 The Beck
Depression Inventory for Primary Care (BDI-PC) was
used to measure the severity of depression,21 and the
social behavior subscale of the Sickness Impact Profile
68 (SIP68) was used to evaluate social impairment.22,23
QOL was measured with the Cantril Ladder of Life,
a 1-item questionnaire, based on a visual analogue scale
from 0 to 10, where 0 stands for the worst possible QOL
and 10 for the best possible QOL.24 The Cantril Ladder
has acceptable psychometric characteristics. Both relia-
bility and validity were found to be reasonable.25
Information on hospital admissions was provided
from 2002 to 2006 because of the highly improved com-
puter registration of patient data in this period.
HPN patients who experienced VAD-related compli-
cations between January 1, 2005, and September 30,
2006, were compared with those who did not have VAD-
related complications during the same period.
Descriptive statistics were computed for all variables.
These data are given as mean (standard deviation [SD])
Psychosocial Complaints and Venous Access–Related Complications / Huisman-de Waal et al 591
or medians. Pearson product moment correlations were
used to analyze associations between VAD complications
and psychosocial problems and QOL. To compare patients
with and without complications, t tests, or Mann-Whitney
U tests were used, where appropriate. Analysis of variance
was used to analyze differences between VAD types. A P
value < .05 was considered significant in all analyses. All
statistical tests were performed using SPSS statistical
software (version 16.0; SPSS Inc, Chicago, IL).
In total, 110 medical charts could be retrieved for review
(ie, there were no missing records). Patients recruited
were treated at the Radboud University Medical Center
Nijmegen (n = 64) or at the Academic Medical Center
Amsterdam (n = 46) in the Netherlands. In October
2006, the patients’ mean age was 51 years (SD 12.4
years; range, 18–81 years), and 72 patients (65.5%) were
female (Table 2). The cumulative duration of HPN treat-
ment in all patients was 627 years, ie, 228.855 VAD days,
with a mean of 5.7 years (SD 5.6 years; range, 3 months
to 30 years). Four patients (4%) only used fluids; all other
patients (n = 106) used PN, from which 53 patients used
PN combined with fluids. Two patients (1%) used
The majority of patients (n = 84 [76%]) experienced
infectious complications (n = 391) at some point during their
HPN treatment. The overall incidence of VAD-related
Table 1. Set of Questionnaires
Topic Instrument Information
General characteristics Own development9 items
HPN-related characteristicsOwn development
Cantril Ladder of Life24
Quality of life
1-item questionnaire on a visual analogue
scale. The Cantril Ladder has acceptable
psychometric characteristics. Both
reliability and validity were found to be
Extent of problems
Fatigue Fatigue severity, subscale of the
Checklist Individual Strength
8 items, score 8–56
Clinically severe fatigue present when
Validated in various populations. The inter-
nal consistency of the CIS is good:
Cronbach α for fatigue severity was 0.88.
Convergent validity is satisfactory.
Depression Beck Depression Inventory for Primary
The BCI-PC is a 7-item questionnaire with
each item rated on a 4-point scale (0–3).
It is scored by the sum of ratings for each
item (range 0–21). Items are symptoms
of sadness, pessimism, past failure, loss
of pleasure, self-dislike, self-criticalness,
and suicidal thoughts and wishes.
Patients were asked to describe their
symptoms for the “past 2 weeks, includ-
ing today.” A cutoff score of >4 is given a
diagnosis of major depressive disorder.
The internal consistency is high (α =
0.86). With regard to the convergent
validity, the BDI-PC was positively asso-
ciated with the diagnosis of major
depressive disorders (r = 0.66, P < .001).
Social impairment Social behavior, subscale of the Sickness
Impact Profile68 (SIP68)22,23
12 items, dichotomous. The internal con-
sistency of the SIP68 is high (Cronbach
α = 0.92).
HPN, home parenteral nutrition.
592 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 5, September 2011
BSIs was 3 per 1,000 venous access days. VAD-related
BSIs were mainly caused by Gram-positive bacteria (57%,
mostly Staphylococcus sp). Gram-negative bacteria, mostly
Escherichia coli or Klebsiella sp, were found in 27%. Fungi,
mostly Candida sp, were responsible for VAD-related BSIs
less often (7%) (Table 3).
In 54% (n = 211) of all catheter infections, urokinase
was used as part of the treatment protocol, with the
intention of eliminating a (potentially infected) throm-
bus. Ninety-five percent of all episodes (n = 371) were
treated with antibiotics, and in 5% of these (n = 20), the
catheter was removed immediately. In 57% of all infec-
tions (n = 223), the VAD was eventually replaced.
VAD occlusions occurred in 42% of patients (n = 46),
and the overall incidence of VAD occlusions was 0.8 per
1,000 venous access days. Eighty-four percent of these
(n = 176) were treated via infusion of a caustic solution
(0.1 mol/L, 25 mL sodium hydroxide)26 (Box 2). In 44%
of all catheter occlusion (n = 92), this strategy failed to
open the catheter, and a new catheter had to be placed.
Almost one-third of all patients (n = 34) experienced
other complications such as accidental removal (n = 12)
and tearing of the catheter (n = 9). These latter complica-
tions occurred at a rate of 0.65 per 1,000 venous access
days. In 69% of these cases (n = 84), placement of a new
catheter or AVF was mandatory.
Table 4 shows our data on hospital admissions due to
VAD-related complications. The mean (SD) length of stay
in days per patient per year in the hospital significantly
decreased from 21.5 (34.9) in 2002 to 8.9 (17.5) in 2006
(P < .001).
The response rate in our survey was 68% (n = 75). No
evidence of selection bias, as suggested by differences in
gender, age, duration of HPN therapy, and indication for
HPN, was found in respondents or in patients who
refused to participate.
Severe fatigue was reported by 66% of all respondents
(severe fatigue present when CIS-Fatigue score is >35;
Table 5). There was a significant association between the
degree of fatigue and the occurrence of VAD-related com-
plications (r = 0.30, P = .009). Fatigue severity was not
correlated with the number of hospital admissions.
According to the BDI-PC, almost 57% of the HPN
patients had depressive disorders (major depressive disor-
der present when BDI-PC score is >4; Table 5). There was
a significant association between depressive disorders and
the number of experienced VAD-related problems (r =
0.30, P = .011). In addition, depression was clearly asso-
ciated with the number of hospital admissions due to
VAD-related problems (r = 0.43, P = .002).
The results of the SIP68 questionnaire showed raised
levels on the social behavior subscale (Table 5). There
was a highly significant association between social behav-
ior and VAD-related complications (r = 0.34, P = .003).
We also found an association between social impairment
and the number of hospital admissions due to VAD-
related complications (r = 0.31, P = .026).
For QOL, patients scored a mean (SD) 5.7 (1.72).
Forty-three percent of the patients scored below 6. QOL
was clearly associated with the number of VAD-related
problems (r = –0.38, P = .001) and the number of hospi-
tal admissions due to these problems (r = –0.41, P =
.002). In cases with more VAD-related problems and
related admissions, patients reported decreased QOL.
Low QOL was also strongly related (P < .02) with more
intense fatigue (r = –0.59), more severe depression (r =
–0.68), and greater social impairment (r = −0.45).
There was no significant correlation between length
of hospital stay and QOL or experienced problems, except
for social impairment (r = 0.04, P = .291).
There were no significant correlations between the
type of venous access (AVF vs implanted port vs CVC)
and QOL, depression, fatigue, and social impairment.
Table 2. Characteristics of HPN Patients (n = 110)a
Age, y, mean (SD)
Female gender, n (%)
Underlying disease, n (%)
Indication HPN: short bowel
syndrome (vs motility disorders)
Years on HPN, mean (range)
Type of venous access at start of HPN
Central venous catheter
5.7 (SD 5.6)
HPN, home parenteral nutrition; CIIP, chronic idiopathic intes-
tinal pseudoobstruction; SD, standard deviation.
aData are given as n (%), unless otherwise specified.
Table 3. Pathogenesis of Infections (n = 391)a
Pathogen n (%)
Gram-positive bacteria and Gram-Negative bacteria
Gram-positive bacteria and fungi
Gram-negative bacteria and fungi
aValues are given as n (%).
Psychosocial Complaints and Venous Access–Related Complications / Huisman-de Waal et al 593
Patients without VAD-related complications between
January 1, 2005, and September 30, 2006 (n = 29), expe-
rienced significantly fewer psychosocial problems and
reported a better QOL compared with those who did have
VAD-related complications during the same period (n =
46) (Table 6).
To our knowledge, this is the first study that shows that,
in a substantial (70%) proportion of HPN patients, at
least in the Dutch situation, the number of VAD-related
complications and hospital admissions due to these
complications is strongly associated with impaired
QOL and the presence of depression, fatigue, and social
In our opinion, these data underscore the need for
adequate measures to prevent VAD-related problems and,
if possible, to treat psychosocial problems. Our results also
confirm that VAD-related complications are experienced at
some point by the vast majority of these patients, despite
the fact that all these patients or their caregivers in the
home setting have been trained to administer HPN in
accordance with current practice guidelines.
In our 2 major Dutch HPN referral centers, special-
ized PN nurses teach all patients to work in an aseptic
manner and also to recognize relevant symptoms of all
VAD-related complications in an early stage, thus enabling
adequate treatment at an early stage of any problem.
Patients can contact their PN center on a 24-hour basis.
The CR-BSI rates in our HPN population are comparable
with those in recent studies, which have shown incidence
rates between 0.44 and 6 per 1,000 venous access
days.2,3,5–7 Occlusion rates in other studies are also compa-
rable with our finding of 0.9 per 1,000 catheter days.26–28
Evidence indicates that the risk of developing a
CR-BSI is reduced by the use of tunneled and implanted
catheters, proper education and specific training of the
staff, an adequate policy of hand washing, and regular
change of administration sets.29 Recently, the use of an
antibiotic lock solution containing 2% taurolidine was
compared with our previous standard practice (Box 1)
and has been shown to dramatically (>90%) reduce the
recurrence of CR-BSIs.30 In the future, we plan to evalu-
ate whether this policy translates into improved QOL as
well as psychosocial outcomes measures.
Several implications of our findings for clinical prac-
tice can be noted. Apart from measures to decrease VAD-
related complications, there are other therapeutic options
to improve QOL are at hand. For example, the level of
fatigue in HPN-dependent patients approximate the level
observed in patients on hemodialysis and in patients with
multiple sclerosis,31 and even surpasses the level seen in
patients with functional bowel disorder or cerebrovascu-
lar accidents.20 It has been suggested that antifatigue
therapy should be included in the standard care for most
chronic fatigue-associated conditions.15 Yurtkuran et al32
found a yoga-based exercise program had a positive effect
on sleep disturbance and fatigue in hemodialysis patients.
Liu33 reported that depression and age significantly both
predict fatigue in hemodialysis patients. Identifying and
Table 4. Hospital Admissions From 2002 to 2006
2002 (n = 46) 2003 (n = 53)2004 (n = 64) 2005 (n = 81)2006 (n = 110)
patient per year,
Total admissions per
Length of stay per
patient per year,
d, mean (SD)
Total length of stay,
days per year, n
74 4168 8379
987505 656 879986
Table 5. Problems Experienced by HPN Patients
Problem Mean (SD)Range
HPN, home parenteral nutrition; CIS, Checklist Individual
Strength; BDI-PC, Beck Depression Inventory for Primary
Care; QOL, quality of life; SD, standard deviation; SIP, Sickness
594 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 5, September 2011
treating depression on a routine basis, as suggested by
Wuerth et al34 might be an effective strategy for decreas-
ing levels of fatigue.33-34 O’Sullivan and McCarthy31 con-
cluded that, while physical functioning increased, fatigue
decreased. The results from the latter study highlight the
importance of focusing nursing care on fatigue and
physical functioning ability in practice. To our knowl-
edge, no studies looking at the effect of psychosocial
interventions on clinical outcomes in HPN-dependent
patients have been performed.
Social impairment has a major impact on the daily
lives of HPN patients. In our previous study,16 between
35% and 43% of patients experienced social impairment
due to HPN. HPN administration takes time, sometimes
more than 14 hours per day, and many of the respondents
had to hook up to HPN 5 times a week or more. Freedom
to choose and the ability to make simple daily life deci-
sions were sharply reduced and social contact and inter-
action decreased because of the catheter, the schedule of
HPN, mobility problems, and physical complaints.16
Skerrett and Moss-Morris35 have shown that the ways in
which patients interpret and respond to their symptoms
as part of their underlying disease (coping style) have a
significant impact on their level of social impairment. The
most important correlates of social adjustment were
embarrassment cognitions and avoidance/resting behav-
iors. Skerrett and Moss-Morris35 also found that depres-
sion explained a moderate amount of the variance in
social impairment and fatigue levels.
Depression also can have a marked impact on many
aspects of life. Depression is often accompanied by
impairment in one’s functional capacity to work and as
well as in role functioning in nonwork domains.36 Our
previous review showed that depression was a common
emotional response to HPN treatment in many studies.16
Severity of depression ranged from mild to severe and was
observed in 10% to 80% of the HPN patients.
The limitations of the present investigation have to
be considered. Its retrospective character carries a risk for
misinterpretation of documented relevant data. We tried to
overcome this by using 2 independent reviewers, both of
whom had a medical background and expertise in this field.
Given the study design, we cannot be sure that psy-
chosocial problems truly resulted from complications.
First, data on psychosocial problems were collected fol-
lowing the collection of data on VAD complications.
While this suggests a favorable time order, complications
could have been resolved at the time of data collection. In
the near future, we have planned a prospective study to
ascertain that preexisting psychosocial issues do not
affect the patient’s ability to care for their catheter and
increase the incidence of infectious complications.
Furthermore, psychosocial problems may be partly due to
underlying diseases. However, Carlsson et al12 showed
that short bowel syndrome patients on HPN therapy
experience decreased QOL compared with short bowel
syndrome patients not on HPN therapy, and HPN patients
worry more about fatigue and feeling alone. In our study,
patients without VAD-related complications also experi-
enced significantly fewer psychosocial problems and
reported better QOL compared with those who did have
VAD-related complications. Although firm conclusions on
causal relationships could not be made in this study, the
results support our hypothesis that VAD-related compli-
cations do contribute to psychosocial problems.
Another limitation of the current study is the small
population size, which precluded certain subgroup analy-
ses. Despite this, a strength of the study is the high
response rate. Therefore, we assume that our results are
representative for the total population of HPN patients in
the Netherlands. Future research should include new
HPN patients to determine whether psychosocial com-
plaints are mainly caused by the underlying disease, or as
we think, are deteriorated by VAD-related complications.
Taking the limitations of our studies into account and
given the mentioned questions regarding the interpretation
of our data, the correlations we have identified still stand.
Taken together, the results from the present study show
Table 6. Comparison of VAD-Related Complications vs No Complications
Quality of LifeBDI-PC CIS-FatigueSIP-Social Impairment
YesNo YesNoYes No YesNo
5.4 (1.7)6.2 (1.7)4.4 (3.6) 2.4 (2.5)43.1 (11.8)34.1 (13.9)
6.6 (3.0)4.2 (3.8)
P value.029 .012.004 .004
VAD, venous access device; BDI-PC, Beck Depression Inventory for Primary Care; CIS, Checklist Individual Strength; SIP, Sickness
Impact Profile; SD, standard deviation.
aYes, n = 46; no, n = 29.
Psychosocial Complaints and Venous Access–Related Complications / Huisman-de Waal et al 595
that, in patients on HPN therapy, depression, fatigue,
social impairment, and QOL are closely related to previ-
ously experienced VAD-related complications. This notion
should bolster our efforts to prevent such adversities and to
further optimize the quality of HPN care.
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