10/2/2013

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Evolving Your Vascular

Access Practice

Rita Larson, RN, BSN,

CRNI, MBA, VA-BC

Beyond the Status Quo

Defining the Risk of

Malpositioned Catheters

Inadvertent Arterial Puncture, Azygos, Upper

SVC

Disclosure

• Employee of Teleflex, Incorporated.

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OBJECTIVE

• Define catheter tip malposition

• Describe five evidence-based publications describing the risks of catheter tip malposition

• Define clinical risks of malpositioned CVC catheters

• Discuss use of evidence to drive process improvement with the aim of reducing the risk of inadvertent arterial, azygos, and upper CVC catheter tips

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Present Standards, RecommendationsPosition Papers - Catheter Tip Placement

Group Guideline

AVA (1998) Lower 1/3 of SVC – RA Junction

ONS (2004) Lower 1/3 of SVC - CAJ

INS (2006) Lower 1/3 of SVC - CAJ

FDA CVC Working Group (1998,1994) Lower 1/3 of SVC – Catheter should not be allowed to migrate in RA

SIR (2000) SVC / RA Junction

NKF DOQI (2001) SVC / RA Junction or RA

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Optimal Final Tip Location

• Cavoatrial Junction (CAJ) or the adjacent lower 1/3 of the superior vena cava

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Hostetter, et al. Precision in CVC Tip Placement. 2010. JAVA 2010;15(3):112-125.

DataStudy Type Complication Detection Results

Schummer Observationalprospective

Malposition ECG Cardiac reflectionresults in malposition

Cadman Randomized, retrospective

Thrombosis Ultrasounds, Venograms

Thrombosis 16X higher when position high

Lozano Prospective Malposition Tomography Malposition reduced by 89% when cath in distal

SVC

Hostetter LiteratureReview

Malposition Landmarktechniques

Accuracy rate for first time placements

Gravenstein In-vitro Perforation In-vitro Perforation greater when not in distal SVC

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Why the Lower 1/3 SVC-CAJ?

Ideal Tip Position Characteristics

• Best drug distribution and dilution

• Lowest occlusion rates

• Lowest tip related DVT

• Least catheter tip interference with venous and RA

walls

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Why the Lower 1/3 SVC-CAJ?Q = k x П x r4 x ∆P Poiseuille’s Law

8 x L x η

Q = k x r2 x (П x r2) x ∆P

L x 8 x η

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r

Pi

PfL

Why the Lower 1/3 SVC-CAJ?• Relative Effect of Vessel Size on Blood Flow

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Cephalic 34

Basilic 44

Axillary 84

Subclavian 9.54

SVC 12.54

Radius of

Vessel (mm)4

Approx.

mL/Min.

2-4 mm

4-6 mm

16 mm

19 mm

20 mm

Actual

Diameter

38 cm

24 cm

13 cm

6 cm

7 cm

Length

(cm)

1

3.2

50

100

301.4

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Why the Lower 1/3 SVC-CAJ?

• Irritating Medications• pH

• Concentration of hydrogen ions

• Osmolality

• Measurement of number of particles

dissolved in water (the concentration)

• Vesicant

• Toxic to the vein and can cause tissue

necrosis if extravasated

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Why the Lower 1/3 SVC-CAJ?

• Evidence defines lowest risk here

• Large vein diameter

• High blood flow velocity

• Significant turbulent blood flow elements

• Catheter tip distant from the wall

Timsit, JF et al. Central vein catheter-related thrombosis in intensive care patients. Incidence, risk factors,

and relationship with catheter-related sepsis. Chest 1998; 114(1):207-213

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Why the Lower 1/3 SVC-CAJ?

• 82 power injections

• 62% proximal tip positions resulted in displacement

• 10.14% distal tip positions resulted in displacement

• When tip is distal SVC, risk of displacement is reduced by 89%

Lozano,A, Marn, C, Goodman, L. (2012). Power Injectable Peripherally Inserted Central Venous

Catheter Lines Frequently Flip After Power Injection of Contrast. J Comput Assist Tomogr2012 Jul;36(4):427-30.

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Why the Lower 1/3 SVC-CAJ?

• Legal Implications

• New case studies emerging of catheter tips in

the incorrect location

• Reduce liability by developing processes that promote the most consistent outcome

Orme,R, McSwiney, M, Chamberlein-Webber, R (2007) Fatal Cardiac Tamponade as a Result of a Peripherally

Inserted Catheter: A Case Report and Review of Literature. British Journal of Anesthesia 384-388.

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Why the Lower 1/3 SVC-CAJ?

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Cadman, A, Lawrance, JL, Fitzsimmons, L, Spencer-Shaw A and Swindell R (2004). To clot or not to clot? That is the question in central venous catheters. Clinical Radiology, 59: 349-355

Why the Lower 1/3 SVC-CAJ?

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Arm movement, adduction and abduction

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Why the Lower 1/3 SVC-CAJ?

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Parallax

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Parallax is the apparent

shift in the position of an

object by a change in the

observation position

Pericardial Reflection

•Pericardial Reflection, rather than entry into the SVC may cause P Wave Spike

• X Ray is unable to detect pericardial reflection

• Doppler is unable to mistake pericardial reflection as a P Wave Spike

Schummer, et al. Central venous catheters—the inability of ‘intra-atrial ECG’ to prove adequate positioning. British Journal of Anesthesia 93 (2): 193-8 (2004).

Bayer , et al. Implication of the Anatomy of the Pericardial Reflection on Positioning of the Central Venous catheters”

Journal of Cardiothoracic and Vascular :Anesthesia Vol 20:6 2(2006)

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Pericardial Reflection

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Pericardial Reflection

•It is a location, not an

event or activity

•The extension of the

pericardial tissue is the

reflection

•Heart sits in the pericardial

sac

•Sac attaches around mid

SVC

Malpositioned Central

Lines

• Inadvertent Arterial Placements

• Azygos Placement

• Upper SVC

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Inadvertent Arterial Puncture

• New Case Studies emerging with arterial

puncture

• IV Therapy.net

• Medical Legal Websites

Sumit Parikh, Vinodh Narayanan (2004) Misplaced Peripherally Inserted Central Catheter: An Unusual Cause of Stroke.

Pediatric Neurology, 30:210,212

Nitin Garg, Amit Noheria, Ian R. McPhail, Joseph J. Ricotta II. (2010)Embolic Strokes After Peripherally Inserted Catheter

Placement. Annals of Vascular Surgery, 24: 1133.

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Inadvertent Arterial

PunctureRisks Associated:

• Pseudoanuerysm

• Inadvertent cannulation of Carotid

• Trachael Displacement

• Excessive Bleeding

• Tear in Carotid Artery

• TPN infused in vertebral artery

• Perforation of Aorta

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Azygos Placement

• (Inadvertent) placement of PICC line in azygos vein is probably

the commonest complication associated with this procedure.

(Radiopeadia.org)

Complications Include

• Inaccurate Venous Pressure Measurements

• Thrombophlebitis

• Arrhythmias

• Potentially toxic solutions delivered into Azygos vein

Charles S. Langston. (1971) The Aberrant Central Venous Catheter and Its Complications. Radiology 100:1 55-59.

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Azygos Placement

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P-wave Technology

Normal

P-wave

Range

Maximal

P-wave

Range

Biphasic

P-wave

Range

RA

CAJ

SVC

SVC

2-5 cm

RA

0-3 cm

RA

2-5 cm

Landing

zone lower

1/3 of

SVC-CAJ

Source: Jeon et al, CAN J ANESTH 2006 / 53: 10 / pp 978–983

Rx only

CONFIDENTIAL — NOT FOR DISTRIBUTION © 2013 Teleflex Incorporated. All rights reserved.

2013-2218

Doppler Technology

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Sound Waves determine if sound waves

are moving with blood cells, or against

Driving Best Practices

Precise Catheter Tip Location

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Outline Evidence for Change

Ask the question;

Why is change in practice needed?

• Well documented: Malposition catheter tip = Complications

• Position statements, guidelines, recommendations &

position papers

• Multi-disciplinary collaboration reduces complications

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Plan of Action• Begin with a proposal to consider the benefits of

precise catheter tip technology� Focus on timely start of therapy

� Reduce cost of care (no chest X-ray)

� Optimize vessel health and reduce liability

� Mitigate risks of post-insertion complications

� Improved patient safety and satisfaction with vascular access

device use

� Follow a business model� Identify champions in your healthcare facility

� Educate your team and key influencers

� Initiate performance improvement

� Measure the outcomes…drive change!

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Net Impact of Precise Tip Location

• Reduce complications associated with

catheter malposition

• Reduce liability from terminal tip

complications

• Establish tip in optimum high flow area-CAJ

• Promote patient safety

• Cost-effective healthcare

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Our Call to Action

• First, Do No HARM

• The Lower 1/3 SVC-CAJ every time

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Why the Lower 1/3 SVC-CAJ?-

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ReferencesSchummer, et al. Central venous catheters—the inability of ‘intra-atrial ECG’

to prove adequate positioning. British Journal of Anesthesia 93 (2): 193-8 (2004).

Cadman, A, Lawrance, JL, Fitzsimmons, L, Spencer-Shaw A and Swindell R

(2004). To clot or not to clot? That is the question in central venous

catheters. Clinical Radiology, 59: 349-355

Lozano,A,Mann,C,Goodman,L. (2012). Power Injectable Peripherally

Inserted Central Venous Catheter Lines Frequently Flip After Power

Injection of Contrast. J Comp Assist-Tomogr 2012 Jul;36(4);427-30

Gravenstein N, Blackshear RH. In vitro evaluation of relative perforating

potential of central venous catheters:comparison of materials, selected

models, number of lumens, and angles of incidence to simulated

membrane. J ClinMonit. 1991 Jan;7(1):1-6.

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References•

• Embolic Strokes After Peripherally Inserted Central Catheter Placement

Annals of Vascular Surgery, Volume 24, Issue 8, November 2010, Pages 1133.e1-1133.e4

Nitin Garg, Amit Noheria, Ian R. McPhail, Joseph J. Ricotta II

Charles S. Langston

The Aberrant Central Venous Catheter and Its Complications Radiology July 1971 100:1 55-59; doi:10.1148/100.1.55

•

1 Blaivias M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central

venous access. J Ultrasound Med 2009; 28:1239–1244.

• Kusminsky RE. Complications of Central Venous Catheterization. J Am Coll Surg 2007;204:4,681-696.

3 Petrus LV, Lois JF, Lo WWM. Iatrogenically induced cortical blindness associated with leptomeningeal

enhancement. Am J Neuroradiol 1998;19:1522–1524.

Garg N, Noheria A, McPhai IRl, Ricotta JJ. Embolic strokes after peripherally inserted central catheter placement. Ann

Vasc Surg 2010; 24: 1133.e1-1133.e4.Parikh S, Narayanan V. Misplaced peripherally inserted central catheter: an unusual cause of stroke. Pediatr Neurol

2004;30:210-212.

Hung HL, Chao KY, Tseng LM, Hung FM, Lee TY. Arterial misplacement of a femoral central venous catheter

complicated with acute arterial occlusion. J Chin Med Assoc 2005;68:3:138-141.

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Thank you for your time and attention

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