Preventing Complications of Central Venous Catheterization

1
Preventing Complications of Central Venous
Catheterization

• By
• Sivaruban Kanagaratnam,
• General Surgery Resident, R1.
• University of Saskatchewan
• September, 22, 2006.

2
Central Venous Catheters

• By definition, a CVC is one whose tip is located
  in a central vessel (i.e. the thoracic vena cava)
• Peripherally Inserted Central Catheter (PICC) is
  a catheter inserted via a peripheral vein whose
  tip terminates in the vena cava.

3
Central Venous Catheters

• gt5 Million catheters inserted each year
• Used for many things, including hemodynamic
  support to nutritional support
• But, adverse events which are hazardous to the
  patient and also expensive to treat.
• gt15 of the patients develop complications.
• Preventing Complications of Central Venous
  Catheterization

4
Indication for Use

• Long term IV therapy-chemo, Antibiotic therapy,
  TPN, blood products.
• Recurrent blood draws
• Dialysis

5
Advantages?

• Immediate access
• Easy access
• High flow and dilution of concentrated solutions
• Outpatient care

6
Disadvantages and Contraindications?

• More invasive
• Potential for more complication
• Contraindications
• Sepsis
• Coagulopathy

7
Types of Central Venous Catheters?

• Central Line

• Tunneled Catheters

• PICC Line

• Subcutaneous Ports

8
Device Choice?

• Patients disease and status
• Number and types of solutions
• Flow required- internal vs external diameter
• Frequency required? i.e. tunneled vs port.
• Duration of use-days vs months.
• gt 7 days-PICC line
• 1-12 weeks-PICC line/tunneled catheter
• 12 weeks-6 months or greater- tunneled catheter
• gt6 months-Port.
• Preference- Dr./Patient.

9
Catheterization Internal Jugular Approach
10
Catheterization Subclavian Approach
11
Central Venous Catheter Tip Position A
Continuing Controversy
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Central Venous Catheter Tip Position A
Continuing Controversy

• Superior Vena Cava vs upper right atrium?
• Concern for patient safety vs optimal catheter
  performance.
• Against R-atrial placement
• Cardiac performation and tamponade,
• Cardiac arrhythmias
• Catheter induced thrombosis
• For R-atrial placement
• Optimal performance and superior functional
  durability
• The incidence of catheter related problems
  depends on the method used for diagnosis
• Complications that occur during catheter
  insertion vs placement

13
Central Venous Catheter Tip Position A
Continuing Controversy

• Superior Vena Cava
• 1989-FDA
• 1996-Oncology Nursing Society
• 2000-Infusion Nurses Society
• Nurses were taught to not use CVC positioned in
  the right atrium, will be held liable if
  complications occurs.

• Right Atrium
• 1998-National Association of Vascular Acc.
  Networks
• PICC close to or in R-atrium
• 2001 Kidney Disease Quality Outcome Initiative
  (K/DOQI)
• Cuffed-tunneled hemodialysis catheters in
  R-atrium
• Non tunneled temp. in SVC/atrial junction

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Central Venous Catheter Tip Position A
Continuing Controversy

• Insufficient evidence to support or condemn-
  R-atrium
• Variables such as catheter type, insertion site,
  the patients body habitus, and the intended use
  of catheter are important.
• On a CXR, the right tracheobronchial angle is the
  best landmark to delineate the borders of the SVC
  and the SVC/atrial junction.

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Central Venous Catheter Tip Position A
Continuing Controversy

• Important majority of the time, a catheter moves
  extending 2-3cm.
• So, a properly placed catheter within the
  inferior (caudal) segment of the SVC will likely
  move in and out of R-atrium as patient moves.
• The most feared complications such as vascular
  complications( Cardiac arrhythmias or
  perforations) are rare(0.4-0.9) and occur
  usually due to physician errors and during
  catheter insertion.

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CVC Tip Position Summary.

• No clear evidence to state one way or another.
• A Continuing Controversy!!!

17
Interventions to Prevent Complications

• Infection
• Mechanical
• Thrombotic

18
Infection The use of Antimicrobial-Impregnated
Catheters

• Figure Kaplan-Meier estimate of the cumulative
  risk for catheter-related bloodstream infection.
• The differences between groups are highly
  significant (P 0.01, log-rank test).

Maki, D. G. et. al. Ann Intern Med
1997127257-266
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Infection The use of Antimicrobial-Impregnated
Catheters
Maki, D. G. et. al. Ann Intern Med
1997127257-266
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Infection The use of Antimicrobial-Impregnated
Catheters

• Use of these catheters decreases blood stream
  infection
• 4.6 regular catheter
• 1.0 antibiotic impregnated catheters
• Cost effective analysis save about
  196USD/catheter inserted.
• Chlorhexidine-Silver sulfadiazine and
  Minocycline-Rifampin impregnated catheters
• The Use of antibiotic impregnated catheters
  should be considered at all circumstances!
• The emergence of resistance is certainly of
  concern.

N ENGL J MED 348 12, 2003
21
Infection Insertion of Catheters at the
Subclavian Venous Site

• The risk of catheter-related infection is lower
  with subclavian catheterization than with
  internal jugular or femoral catheterization

22
Infection The Use of Maximal Sterile-barrier
precautions during catheter insertion

• The use of mask, cap, sterile gown, sterile
  gloves, and large sterile drape.
• Has shown to reduce the rate of catheter-related
  bloodstream infections and to save an estimate of
  167 per catheter inserted.

Infect Control Hosp Epidemiol, 1994 15231-8
23
Infection Avoiding the use of Antibiotic
Ointments

• The Use of ointments such as bacitracin,
  mupirocin, neomycin, and polymyxin to catheter
  insertion sites show
• Increase the rate of colonization by fungi
• Promote bacterial resistance
• Has not shown to affect the risk of catheter
  related bloodstream infection.

N ENGL J MED 348 12, 2003
24
Infection Disinfecting Catheter Hubs
Microbes migrate intraluminally from colonized
hubs, less often from contaminated infusate.

• Catheter hubs are common sites of catheter
  contamination

Annals of Internal Medicine, 132(5), 2000.
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Infection Disinfecting Catheter Hubs
TEGO CONNECTOR

• Reduces hub related infection
• High flow rate-600ml/min
• 7 days of microbial efficacy.

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Kaplan-Meier estimates of the cumulate likelihood
of freedom from CRBSI in the 2 treatment groups
Garland, J. S. et al. Pediatrics
2005116e198-e205
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Infection Routine Catheter Changes?

• Scheduled, routine replacement of central venous
  catheters at a new site does not reduce the risk
  of catheter related infection.
• Scheduled, routine exchange of cathetres over
  guide wire is associated with a trend toward
  increased catheter related infections and
  mechanical complications.
• META analysis of 12-RCTs do not support.
• CVC should not be replaced on a scheduled basis.

N ENGL J MED 348 12, 2003
28
Infection Remove when no longer needed.

• The probability of colonization and
  catheter-related bloodstream infection increases
  over time.

NON-Antiseptic Impregnated catheter
Antiseptic Impregnated catheter
Collin, G. R. Chest 19991151632-1640
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Infection Summary.

• Use antimicrobial-impregnated catheters
• Avoid inserting catheters at femoral venous site
• Use maximal sterile barrier precautions
• Avoid antibiotic ointments
• Disinfect catheter hubs
• Do not schedule routine catheter changes
• Remove catheter when no longer needed

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Interventions to Prevent Complications

• Infection
• Mechanical
• Thrombotic

31
Mechanical Recognizing Risk Factors for
Difficult Catheterization

• A history of failed catheterization attempts or
  the need for catheter at sites of prior surgery,
  skeletal deformity or scarring suggests that
  catheterization may be difficult

N ENGL J MED 348 12, 2003
32
Mechanical Seek experienced help!

• Physician gt50 catheterization has 50 less
  mechanical complications than someone who
  performed lt50.

N ENGL J MED 348 12, 2003
33
Mechanical Avoid Femoral Venous Catheterization

• The frequency of mechanical complication
• femoral gtgt subclaviani. jugular catheterization

N ENGL J MED 348 12, 2003
34
Mechanical The use of U/S during Internal
Jugular Catheterization

• The use of U/S guided internal jugular
  catheterization
• Reduces time required for insertion
• Reduces number of unsuccessful catheterization
• Carotid artery puncture
• Hematoma formation

N ENGL J MED 348 12, 2003
35
Mechanical Scheduling of Routine Catheter Changes

• Routine replacements at new sites increases
  mechanical complications.

N ENGL J MED 348 12, 2003
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Mechanical Summary

• Recognize risk factors
• Seek assistance with difficult cases
• Avoid femoral venous catheterization
• Use U/S guided jugular catheterization
• Dont schedule routine catheter changes

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Thrombosis

• Intermittently used catheters need to be replaced
  frequently due to obstruction and or infection.
• Clot formation is a major source of obstruction

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Thrombotic Insertion of the Catheter at the
Subclavian Site

• Subclavian catheterization carries a lower risk
  of catheter related thrombosis than femoral or
  internal jugular catheterization.

N ENGL J MED 348 12, 2003
39
Keeping Central Venous Lines Open

• The use of anti-obstructive flushes such as
  heparin, citrate and Vitamin C (Germans), have
  associated complications
• Bleeding,
• Thrombocytopenia-heparin induced
• Arrhythmia (citrate)

Intensive Care Med. 2002 281172-6
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Keeping Central Venous Lines Open a prospective
comparison of Heparin, Vit. C, and NaCl blocks

• Signif. longer patency with heparin(5000IU/ml)
• Vitamin C ineffective
• Group of 25 low dose heparin flushes(200IU/ml)
  flushes showed catheter survival closer to saline
  group.
• So, high concentration of heparin flushes
  recommended.

Intensive Care Med. 2002 281172-6
41
PICC lines
Radiologists
Nurses
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PICC Indications

• Patient comfort (less pokes)
• Convenience
• Decreased risk (pneumothorax or bleeding)
• Long term access (0-432 days)
• Home therapy (safe, reliable, easy to manage)

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PICC Contraindications

• ABSOLUTE
• Peripheral venous obstruction
• Inadequate line care management
• Need for extensive blood products

• RELATIVE
• Septicemia
• Coagulopathy
• Ipsilateral paralysis or mastectomy
• Chronic central venous occlusion
• End stage renal disease
• Skin conditions-burns, infections.

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Venous Thrombosis Associated with the placement
of PICC lines.

• Comparison of left and right arms developing
  thromboses after the placement of the initial and
  subsequent PICCs.
• All patients with history of PICC line placement
  requiring dialysis access should undergo
  venography prior to placement of permanent access

JVIR Nov-Dec 2000, 1309-1314
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Venous Thrombosis Associated with the placement
of PICC lines.

• Incidence of venous thromboses by vein developing
  after PICC placement.
• High rate of venous thrombosis, especially
  cephalic thrombus.

JVIR Nov-Dec 2000, 1309-1314
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Complications and Cost for patients receiving TPN
via Subclavian or PICC access.

• Patients with the PICC line encountered more
  complications sooner than the standard subclavian
  approach
• PICC have higher rate of thrombophlebitis and
  more difficult to insert for standard TPN
  patients
• Cost
• PICC- US22.32- 2.74 per day.
• Subclavian US16.20-2.96 per day.

Clinical Nutrition, 2000, 19(4)237-243
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Complications of PICC in patients with solid
tumors
41

• Higher rate of serious complications (infection
  and thrombosis)
• solid tumor (29)
• non( 9)
• PICC lines should be used with caution solid
  tumor malignancy

59
Internal Medicine Journal, 2004 34234-238
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PICC Fracture and Embolization

• may pose a potential risk of serious
  consequences.
• Rare 11/ 1650 children
• Non-factor
• Catheter size, and
• meds infused via catheter.
• Significance
• duration of placement, line complications
  blockage or
• leaking line
• Prudent to list fracture as a potential
  complication when obtaining consent.

J. Pediatr 2003 142141-4
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SUMMARY

• There are many complications associated with
  Central Venous Catheters
• Infectious, Mechanical, and Thrombotic causes.
• There isnt one defined approach that works for
  all
• Need to have a case based approach.
• Shouldnt be trigger happy with PICC lines
• Not a fool proof method
• Perhaps not the savior that once we believed it
  to be.