Central venous cathetersCentral venous catheters

February 2010February 2010

Anne AspinAnne Aspin

Central venous catheterCentral venous catheter

• Central venous access is the Central venous access is the placement of a venous catheter in a placement of a venous catheter in a vein that leads directly to the heart.vein that leads directly to the heart.

SiteSite

• Basillic or long saphenous vein preferred.Basillic or long saphenous vein preferred.

• NB. Blood or blood products should not be NB. Blood or blood products should not be infused. Catheter may rupture or block.infused. Catheter may rupture or block.

• Catheter should always be flushed with Catheter should always be flushed with

10 ml syringe10 ml syringe

Which vein to cannulateWhich vein to cannulate

• Veins commonly lie close to arteries Veins commonly lie close to arteries and nervesand nerves

• Subclavian vein lies close to dome of Subclavian vein lies close to dome of pleura, damage lead to pleura, damage lead to pneumothoraxpneumothorax

Types usedTypes used

• Percutaneous long linesPercutaneous long lines

• Percutaneous multi lumen linesPercutaneous multi lumen lines

• Peripheral inserted central catheter Peripheral inserted central catheter (PICC)(PICC)

• Broviac and Hickman linesBroviac and Hickman lines

• PortacathPortacath

Length of time to useLength of time to use

• Percutaneous line.Percutaneous line.

• 10 – 12 weeks10 – 12 weeks

• Percutaneous multi lumen linePercutaneous multi lumen line

• 5 – 10 days post operation5 – 10 days post operation

• PICC linePICC line

• 10 / 12 weeks10 / 12 weeks

• Broviac / Hickman line / PortacathBroviac / Hickman line / Portacath

• For long term useFor long term use

Percutaneous long linePercutaneous long line

• TPNTPN

• Clear fluidsClear fluids

• Medications - infuse slowlyMedications - infuse slowly

PICCPICC

• TPNTPN

• Clear fluidsClear fluids

• Blood transfusionBlood transfusion

• MedicationsMedications

• Flush offFlush off

Broviac / Hickman / Broviac / Hickman / PortacathPortacath

• TPNTPN

• Clear fluidsClear fluids

• Blood transfusionBlood transfusion

• MedicationsMedications

Percutaneous Multi lumen Percutaneous Multi lumen lineline

• TPNTPN

• Clear fluidsClear fluids

• Blood transfusionBlood transfusion

• MedicationsMedications

• Caution, ports 1, 2, 3 Caution, ports 1, 2, 3

ComplicationsComplications

• SepsisSepsis

• EmbolusEmbolus

• MalpositionMalposition

• OcclusionOcclusion

• Fibrin sheath Fibrin sheath formationformation

• DislodgeDislodge

• rupturerupture

• ThrombusThrombus

• PneumothoraxPneumothorax

• Perforation of vesselPerforation of vessel

• Cardiac tamponadeCardiac tamponade

• EndocarditisEndocarditis

• Vent arrythmiaVent arrythmia

• PhlebitisPhlebitis

• Cuff erosionCuff erosion

SepsisSepsis

• Pyrexia, >38cPyrexia, >38c

• Labile temperatureLabile temperature

• Labile sugarsLabile sugars

• Shock, pallorShock, pallor

• ApnoeaApnoea

• tachycardiatachycardia

• BradycardiaBradycardia

• Capillary venous Capillary venous return > 4 secsreturn > 4 secs

• GreyGrey

• QuietQuiet

• thrombocytopeniathrombocytopenia

InfectionInfection

• Life threatening where neutriphil Life threatening where neutriphil counts <500 cells/mm.counts <500 cells/mm.

• Local infection – exit site, port pocket Local infection – exit site, port pocket and tunnel infection.and tunnel infection.

• Systemic infection, colonised thrombi Systemic infection, colonised thrombi or fibrin sleevesor fibrin sleeves

• Intraluminal or extraluminal Intraluminal or extraluminal colonisationcolonisation

InfectionInfection

• Gram –ve aerobes from gastro Gram –ve aerobes from gastro intestinal tractintestinal tract

• E. coli, klebsiella, pseudomonas 25-E. coli, klebsiella, pseudomonas 25-33pc33pc

• Gram pos aerobes, Staph aureus,staph Gram pos aerobes, Staph aureus,staph epidermis, strep 50pcepidermis, strep 50pc

• Candida 5-7pcCandida 5-7pc

• Greater risk infection with multi Greater risk infection with multi lumen catheterlumen catheter

• In one study removed 139 days In one study removed 139 days earlier.earlier.

• Implanted port less infectionsImplanted port less infections

• Extraluminal clot at catheter tip –Extraluminal clot at catheter tip –related to cath related sepsis.related to cath related sepsis.

• Pseudomonas difficult to eradicatePseudomonas difficult to eradicate

• Antibiotics down the lineAntibiotics down the line

• Locking catheter for two hours could Locking catheter for two hours could eradicate pseudomonas, not confirmed eradicate pseudomonas, not confirmed in human studies.in human studies.

• ?Trial, Benefit / risk antibiotic ?Trial, Benefit / risk antibiotic resistance. resistance.

Catheter occlusionCatheter occlusion

• Cannot draw back nor solutions infuseCannot draw back nor solutions infuse

• Usually clotted blood, precipitateUsually clotted blood, precipitate

• Flush well after samplingFlush well after sampling

• Streptokinase, Urokinase – fibrinolytic Streptokinase, Urokinase – fibrinolytic agents. 5000 units per 1 ccagents. 5000 units per 1 cc

• 1ml each lumen, 4 hours. Check pharmacy.1ml each lumen, 4 hours. Check pharmacy.

• Takes 27 minutes, leave 60 mins.Takes 27 minutes, leave 60 mins.

ExtravasationExtravasation

• Leakage from vein into subcutaneous Leakage from vein into subcutaneous spacespace

• Pain, irritation in chest, swelling, Pain, irritation in chest, swelling, necrosisnecrosis

• Crying, fussy, distressed.Crying, fussy, distressed.

Catheter malpositionCatheter malposition

• Painful phlebitisPainful phlebitis

• ThrombosisThrombosis

• BacktrackingBacktracking

• Pericardial effusionPericardial effusion

• Cardiac tamponade chest pain, Cardiac tamponade chest pain, shortness of breath.shortness of breath.

Cochrane review 2004Cochrane review 2004

• Perc CVC versus peripheral cannulaPerc CVC versus peripheral cannula

• RCTsRCTs

• 3 trials for inclusion3 trials for inclusion

• CVC does improve nutrient inputCVC does improve nutrient input

• No evidence of CVC increased risk of No evidence of CVC increased risk of adverse events, ie infection. adverse events, ie infection.

Percutaneous CVCPercutaneous CVC

• infants <1000g 28g single lumen, infants <1000g 28g single lumen, 20cm long maximum flow 38mls / hr.20cm long maximum flow 38mls / hr.

• Premicath 27g, markings every 5cm, Premicath 27g, markings every 5cm, max flow rate 30ml / hrmax flow rate 30ml / hr

Percutaneous CVCPercutaneous CVC

• Infants > 1000g, 24g, 30cms long, Infants > 1000g, 24g, 30cms long, max flow 50 ml/hrmax flow 50 ml/hr

• PICC, 20g, silicone, 50cm longPICC, 20g, silicone, 50cm long

• Epicutaneo Neocath, silicone, 30cm Epicutaneo Neocath, silicone, 30cm and 50cm length. Max flow 100ml/hr. and 50cm length. Max flow 100ml/hr.

Perc CVC removalPerc CVC removal

• Use no longer justifiedUse no longer justified

• Bacteraemia beyond 48-72 hrs Bacteraemia beyond 48-72 hrs despite appropriate antibioticsdespite appropriate antibiotics

• Septicaemia due to fungal infectionSepticaemia due to fungal infection

• Evidence of septic emboli or Evidence of septic emboli or endocarditis endocarditis

Broviac / Hickman lineBroviac / Hickman line

• Soft siliconeSoft silicone

• TunneledTunneled

• Buried under skinBuried under skin

• Tissue grows around cuff to secure in Tissue grows around cuff to secure in place.place.

• Cuff acts as barrier to infectionCuff acts as barrier to infection

• Can be flushed off.Can be flushed off.

DressingsDressings

• Evidence.Evidence.

• Transparent / gauze / no dressingTransparent / gauze / no dressing

• Change dressing daily until dry then Change dressing daily until dry then change twice weekly.change twice weekly.

• Chlorhexidine 1:200, 70% alcoholChlorhexidine 1:200, 70% alcohol

PortacathPortacath

• ChemotherapyChemotherapy

• MedicationsMedications

• For cancer or leukaemiaFor cancer or leukaemia

• Soft plastic tube, disc between 2.5-4cm.Soft plastic tube, disc between 2.5-4cm.

• Catheter tunneledCatheter tunneled

• Years. DiscreetYears. Discreet

Ultrasound devicesUltrasound devices

• Systematic review 2003Systematic review 2003

• Objective. To investigate clinical and cost- Objective. To investigate clinical and cost- effectiveness of ultrasonic locating devices.effectiveness of ultrasonic locating devices.

• Ultrasound – two dimensional imageUltrasound – two dimensional image• Dopplers – audible sound from venous blood Dopplers – audible sound from venous blood

flowflow

ResultResult

• Twenty RCTsTwenty RCTs

• Sample size smallSample size small

• < ten pounds per procedure< ten pounds per procedure

• For every 1000 procedures, ?save For every 1000 procedures, ?save 20002000

• Improved failure and complication Improved failure and complication rate.rate.

ReferencesReferences• Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J, Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J,

Levy I (2005). Infectious complications for implantable parts Levy I (2005). Infectious complications for implantable parts and Hickman catheters in paediatric haematology oncology and Hickman catheters in paediatric haematology oncology patients. patients. Journal of Hospital Infection. Journal of Hospital Infection. 62 : 358 - 36562 : 358 - 365

• Alexander N (2010). Question 3. Do Portocaths or Hickman Alexander N (2010). Question 3. Do Portocaths or Hickman lines have a higher risk of catheter-related bloodstream lines have a higher risk of catheter-related bloodstream infections in children with leukaemia. infections in children with leukaemia. Archives of Disease in Archives of Disease in Childhood. Childhood. 95 : 239 - 241.95 : 239 - 241.

doi:10.1136/adc2009.176545doi:10.1136/adc2009.176545• Larson S, Hebra A, Raju R, Lee S (2010). Vascular Access, Larson S, Hebra A, Raju R, Lee S (2010). Vascular Access,

Surgical treatment. Surgical treatment. http://emedicine.medscape.com/article/1018395-overviewhttp://emedicine.medscape.com/article/1018395-overview

• McIntosh W (2003). Central venous catheters : reasons for McIntosh W (2003). Central venous catheters : reasons for insertion and removal. insertion and removal. Paediatric Nursing. Paediatric Nursing. Vol 15, No 1Vol 15, No 1

• Simon A, Ammann R, Wiszniewsky G, Bude U, Fleischhack Simon A, Ammann R, Wiszniewsky G, Bude U, Fleischhack G, Besuden M (2008). Taurolidine-citrate lock solution G, Besuden M (2008). Taurolidine-citrate lock solution (Taurolock) significantly reduces CVAD - associated (Taurolock) significantly reduces CVAD - associated grampositive infections in paediatric cancer patients. grampositive infections in paediatric cancer patients. BMC BMC Infectious Diseases. Infectious Diseases. 8 : 1028 : 102