Catheter Related Thrombus Management

Karen Williford RN, CRNIBeebe Medical CenterTunnell Cancer CenterLewes, Delaware

Objectives

•Discuss the pathophysiology of catheter related thrombosis

•Discuss thrombosis prevention strategies related to vascular access device assessment and insertion

•Discuss current research findings as they relate to vascular access device thrombosis

Upper Extremity Deep Vein Thrombosis (UEDVT)

• Increasing prevalence with potential for considerable morbidity

• Increased use of CVC/PICC• Chemotherap

y

• Bone Marrow Transplant

• Parenteral Nutrition

• Dialysis

Types of Thrombus

Intra-

luminal

•Within the lumen of the catheter

•Accounts for 60% of occlusions

Extra-

luminal

•On the outside of the Catheter

•Usually a Fibrin Sheath

Venous Thrombus

•Within the vein

•Concern for systemic complications

Assessment

• History of a previous device

• Fluid Status

• Sepsis

• Duration of Catheter

• Cancer

• Hypercoaguability

• Improper Maintenance

Blood viscosity can be affected by:

• Hematocrit

• Temperature

• Low flow

• Diabetes

• Pregnancy

• Cancer

Hypercoagulability

Risk Factors

Venipuncture by unskilled professional

Multiple Venipuncture attempts

Use of a catheter that is larger than the vein lumen

Poor circulation with venous stasis

Risk Factors

• Administration of incompatible solutions and medications

• Administration of solutions or medications with high pH or tonicity

• Ineffective filtration

• Thrombogenic catheter materials

• Malpositioned catheter

Virchow’s Triad

Anatomy

Physiology of Clotting

Thrombus

Conversion of Thrombin to Fibrin

Creation of Factor X

Intrinsic Pathway

Extrinsic Pathway

Physiology

Endothelial Injury

• Larger stiffer catheters pose a higher risk of endothelial injury on insertion

• Infusion of irritants or vesicants

• Sub Optimal Catheter Tip Locations carry larger risk of endothelial injury

Does Size Matter??

King et al. (2006)

Increased incidence in oncology population

Overall 2% incidence of thrombosis

Increased incidence with larger diameter catheters

No decrease in incidence with prophylactic anticoagulation

Increased incidence in polyurethane vs. silicone catheters

Blood Flow Dynamics

Pouissille’s Equation

• This law describes the relationship between pressure, flow and resistance through a cylindrical tube (blood vessel)

• The amount of blood that flows is in terms of the difference in pressure between the arteries and the veins X the quantity known as the total peripheral resistance.

Laminar Flow Characteristics

Blood flows in concentric sheets

There is no overlap or mixing

The flow is steady through the vessel

Poiseuille’s Law

Flow Dynamics

Introduction of a catheter into the blood vessel will slow the flow in

the vessel at least 50%

The larger the catheter the greater the

amount of stasis

Optimally vein to catheter ratio

should be at least 3:1 (2:1

minimum)

Evans et al (2010)

• Previous DVT history increases risk

• Large sample size-2014 PICC’s

• Single double and triple lumen catheters

• 60 of 2014 patients developed DVT

• 0.6% Single lumen DVT rate

• 2.9% Double lumen DVT rate

• 8.8% Triple lumen DVT rate

Factors leading to Thrombus Formation

Endothelial Injury

Vasoconstriction, Platelet Adherence &

Aggregation, Coagulation activation

Thrombus FormationFibrinolysis

Reperfusion & Vascular Healing

Seeley et al. (2007)

Multiple venipunctures associated with 38%

thrombosis rates

Patients with DVT history are at higher risk of new

thrombosis

High levels of factor II, factor VIII, factor IX and XI are

associated with increased risk

Stiffer catheter materials produce more intimal damage

that leads to thrombus formation

• Swelling of extremity

• Pain with infusions

• Fluid leaking at insertion site

• Ultrasound of extremity

• Anticoagulation

• Possible catheter removal

Catheter Thrombosis

Burns 2009

• CVC thrombosis results in:

• Vascular and catheter occlusion

• Infection

• Pulmonary embolus

• Right heart thrombo-emboli

• Incidence underestimated

• Synergy of events

Fibrin Sheath

Courtesy of :http://www.konez.com/CentralCatheter_fibrin%20sheath_dialysis.JPG

Does Tip Location Matter?

Standard Infusion Nurses Society 2011 Standard of Practice

Lower 1/3 of SVC to the junction of the RA

Guideline 2011 ONS Access Device Guideline

Distal third of the SVC

Guideline NKF KDOQI Guideline Long Term:RAShort Term: SVC(dialysis access)

Guideline SIR 2003 Quality Improvement Guidelines for CVC

Cava Atrial Region

Guideline AVA 2006 Position Statement

Distal SVC close to the RA

Statement FDA/CVC Working Group 1989, 1994

Lower 1/3 of the SVC

Standards

Central vascular access devices with tiplocations other than the vena cava should beaddressed in collaboration with members ofthe healthcare them. Standard 42, 49.

If the CVC tip is located outside the venacava, the catheter is no longer consideredcentrally located and should be removed.Standard 49.

Removal of PICC determined by…catheter

malposition. Standard 49.

Define Central

Anything in the Chest

Mid Chest vs. Midline

Superior Vena Cava

Cava Atrial Junction

Right Atrium

Luciani et al. (2001)

• Prospective US study

• 3/62 (5%) with tips at CAJ developed thrombosis

• 5/7 (71%) at SCV/BCV junction developed thrombosis

Lobo et al. (2009)

38 of 777 adult patients studied developed DVT

4.89% symptomatic DVT rate

Incidence increased 2.6 times when tip located outside the

SVC

Incidence increased 10 times for previous

DVT history

Cadman, Lawrance, Fitzsimons,Spencer-Shaw, Swindell (2004)

• Relationship between tip position andvenous thrombosis

• 428 tunneled catheters

• 72 days

• 5/91 in lower 1/3 (2.6%)

• 5/95 in middle 1/3 (5.3%)

• 20/48 in upper 1/3 (41.7%)

Verhey, Gosselin, Primack,Blackburn, Kraemer (2008)

SVC 7.6 cm (5-10.5cm)

Most superior right cardiac border is Right Atrial Appendage (RAA)

Distance from RAA to CAJ: 1.8cm(1-3cm)

Distance from carina to CAJ: 4.7cm(2.5-7.2cm)

Trerotola et al 2010

Prospective study to evaluate outcomes Triple Lumen PICCs in the ICU

6F TL PICCs placed at bedside by Nursing Team with IR back-up

Placement & longterm complications were recorded

On removal US done to detect DVT

Catheters were cultured for colonization

Tretola Study 2010

• Stopped at 50 of 167 planned patients

• Scheduled interim US showed an DVT rate of 20% (10 of 50)

• Venous Thrombosis (symptomatic or asymptomatic) 58%

• 0% CRBSI

• Colonization 10%

• Malfunction & Dislodgement in 1 patient

Duke University 2011

Purpose: Evaluate the effectiveness of practice changes to reduce PICC thrombus risk

Retrospective analysis of adult patients

1307 charts reviewed January 2008, October 2008, and August 2010. Clinical Practice change to include US & tip in SVC

Duke University 2011

PICC related DVT rates decreased from

4.8% to 2.9% (January 2008-October 2008)

October 2008-August 2010 practice change to

measure & document native vein diameters prior to PICC insertion -2X outer cath diameter

PICC related DVT decreased from 2.9% to 1.4%

INS National Standards

Medications with a pH <5 or >9

OROsmolarity

greater than 600mOsm/L

can cause vein irritation,

phlebitis, infiltration or extravasation.

pH <5Ciprofloxin 3.3-4.6Dopamine 2.5-5.0Doxycycline 1.8-3.3Dopamine 2.5-5.0Morphine 2.5Pentamidine 4.1-5.4Phenergan 4.0Potassium 4.0Taxol 4.4-5.6Vancomycin 2.4Zofran 3.0-4.0

pH >9Acyclovir 10.5-11.6Ampicillin 8.0-10Bacterium 10Cerebyx 8.6-9.05FU 9.2Ganciclovir 9-11Phenytoin 12Protonix 9-10.5

Extreme pH IV MedicationspH <5 or >9

AcyclovirAmiordaroneAmpho BAmpicillinBactrimCalcium chlorideCalcium Gluconate 10%CiprofloxacinCerebyxContrast mediaAramine

DaptinomycinDextrose >10%DigitoxinDobutamineDopamineDoxapramDoxycyclineEpinephrineErythromycinGanciclovirGentamycin

Vesicants

LevophedLorazepramMagnesium sulfateMannitol 10% and 20%MorphineNafcillinNorepinephrinePhenerganPhenytoinPhenylephrinePentamadine

LevophedLorazepramMagnesium sulfateMannitol 10% and 20%MorphineNafcillinNorepinephrinePhenerganPhenytoinPhenylephrinePentamadine

Vesicants

Hypertonic

Hypertonic solution has an osmolality of

350 mOSM/liter and above.

The osmolality of PPN is about 750

mOSM/liter and above.

Hypertonic solutions cause phlebitis

peripherally in less than 24 hours

Examples

• D25W (1330mOSM/liter).

• D40W (2020mOSM/liter).

• D50W (2525mOSM/liter).

• Literature states hypertonic drugs withan osmolality over 600mOSM/liter resultin phlebitis in 24 hours with shortperipheral catheters.

• Consider central venous administration

Assessment is the Key!

Through ultrasound assessment

Correct vein to catheter ratio (Bigger veins are better!)

Advocate for single lumen catheters if possible

Consider softer catheters for long term therapies

Consider baseline sedimentation rate

Take this Home!!

• History and Physical/Physician Collaboration

• Limit Catheter Manipulation*Catheter Exchange can increase thrombosis and infection risk

• Prevent catheter related infections

• Get the tip in the right place!