Tunneled Cuffed Catheters

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Tunneled Cuffed Catheters
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Hemodialysis access

• The number of patients with end-stage renal
  disease (ESRD) has increased steadily
• The creation and maintenance of functioning
  vascular access, along with the associated
  complications, constitute the most common cause
  of morbidity, hospitalization, and cost in
  patients with end-stage renal disease.

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Vascular Access via Percutaneous Catheters

• useful method of gaining immediate access to the
  circulation.
• associated with higher risks.
• the use-life of this type of access is shorter
  than that of AVFs.

• Noncuffed catheters
• Short term lt3 weeks

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Vascular Access via Percutaneous Catheters
cuffed catheters

• Cuffed catheters
• Patients who will require long-term access should
  have a tunneled catheter placed.
• allow so-called no-needle dialysis with high flow
  rates
• eliminate the problem of vascular steal

• placed in a subcutaneous tunnel under
  fluoroscopic guidance

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Vascular Access via Percutaneous Catheters
cuffed catheters

• The Dacron cuff allows tissue ingrowth that helps
  reduce the risk of infection when compared with
  noncuffed catheters.

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Hemodialysis access complications

• A chest radiograph must be taken after catheter
  placement to rule out pneumothorax and injury to
  the great vessels and to check for position of
  the catheter.
• The incidence of pneumothorax is 1 to 4,the
  incidence of injury to the great vessels is less
  than 1.
• Thrombotic complications occur in 4 to 10 of
  patients
• Infection may occur soon after placement (3 to 5
  days) or late in the life of the catheter and may
  be at the exit site or the cause of
  catheter-related sepsis.
• Rate of infection between 0.5 and 3.9 episodes
  per 1000 catheter-days.
• Catheter thrombosis increases the incidence of
  catheter sepsis.

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PRESERVING CATHETER FUNCTION
CATHETER
ACCESS
TREATMENT
PLACEMENT
CARE
POSITIONING
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Types of central lines

• Open-ended tunneled catheters
• Tunneled valved catheters
• Implanted ports
• Nontunneled central venous catheters (CVCs)
• Peripherally inserted central catheters (PICCs)

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Central Line Complications

• Infections
• Air embolus
• Dislodgement of catheter
• Catheter occlusion

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Central Line Flow Control

• Volume in ML x Drop factor DEVIDED BY no. of
  hours to be infused x 60
• Drop factors are 15 drops / cc OR 60 drops / cc

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ADVANTAGES OF CENTRAL VENOUS ACCESS

• 1. Immediate access
• 2. High flow and dilution of hyper tonic
  solutions
• 3. Easy access
• 4. Permits outpatient care

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DISADVANTAGES OF CENTRAL VENOUS ACCESS

• More invasive - potentially more complications
  and pain

Acute
Chronic
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CENTRAL VENOUS ACCESSINDICATIONS

• 1. Long term IV therapy
• Chemo
• Antibiotics
• TPN
• Blood products
• 2. Recurrent blood draws
• 3. Dialysis/Pharesis

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CONTRAINDICATIONS

• 1. Sepsis
• 2. Coagulopathy

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TYPES OF CENTRAL VENOUS ACCESS

• 1. Non tunneled external catheters
• a. Central line
• b. PICC line
• 2. Tunneled catheters
• 3. Subcutaneous Ports
• a. chest
• b. arm

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CHOOSING THE ACCESS DEVICE

• Patients disease and status
• Number and type of solutions, osmolality
• Flow required
• Frequency accessed
• Duration of use- days vs months
• Preferences - Dr. / Patient

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NUMBER AND COMPATIBILITY OF INFUSATES

• Determine true number of lumens that are required
  based on the number of infusates when they are
  given and if they are compatible

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FLOW

• Internal Diameter (ID) vs Outer Diameter (OD)
• The outer diameter is not always directly
  proportional to flow. Some catheters are just
  thick walled and although large yield slow flow.
  For high flow - check the ID. Remember, larger
  catheters cause more irritation potentiating
  stenosis and thrombosis.

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DURATION

• gt 7 days - PICC Line
• 1- 12 Weeks - PICC line / tunneled catheter
• 12 weeks - 6 months or greater - tunneled
• catheter
• gt 6 months - Port

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FREQUENCY OF ACCESS

• Frequent access and infusion - tunneled catheter
• Infrequent access (every week or month)-port

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MATERIAL

• Silastic
• thicker, softer, larger for same flow, more
  friction over a wire
• Polyurethane
• stiffer, thinner wall, smaller for same flow,
  less friction

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PREFERENCES

• Patient
• Some patients may prefer a port for aesthetics,
  no restrictions on activities
• Operator
• If the operator cant place a port
• choose an alternative!!!!!!!

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NON-TUNNELED EXTERNAL CATHETERS
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TUNNELED CATHETERS

• 1. Single or multiple lumens
• 2. Flow - variable
• 3. Long term
• 4. Easy access (no skin puncture)
• 5. Cuff - Dacron, vita

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Tunneled catheter with cuffs
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Tunneled catheter with cuff
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Tunneled catheter
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SITES OF ACCESS
1. Upper extremity 2. Subclavian and
Internal Jugular Vein 3. Collaterals and
Thrombosed veins 4. IVC trans hepatic, trans
lumbar 5. Hepatic vein 6. Intercostal veins
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LOWER EXTREMITY

• Most commonly femoral vein
• Easily contaminated from proximity to groin
• Complication of DVT less tolerated
• than upper extremity

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SUBCLAVIAN VEIN

• ACUTE
• Senagore - 10 incidence of art. Puncture
• Mansfield - 12.2 unsuccessful access
• CHRONIC
• Cimchowski - 50 stenosis SCV, 10 IJV
• Shillinger - 42 stenosis SCV, 10 IJV
• Uldall - 10-30 thrombosis, 10-40
• stenosis

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SUBCLAVIAN VEIN COMPLICATIONS
PINCH-OFF SYNDROME
STENOSIS
THROMBOSIS
Subclavian vein (SCV) access is prone to more
complications than internal jugular vein (IJV)
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ADVANTAGES OF THE RIGHT IJ

• 1. Larger
• 2. More superficial
• 3. Further from the lung
• 4. More direct route to the heart
• 5. Acute and chronic complications are reduced

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CENTRAL VENOUS CATHETER PLACEMENT

• 1. Prep
• 2. Access
• 3. /- Tunnel
• 4. Secure

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PREP

• Alcohol scrub to remove surface oils
• Chlorhexidine scrub
• Betadine prep (allow to dry)
• Ioban dressing and drapes

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PREP

• Maximum Sterile Barrier -
• Surgical hats, gowns, masks gloves
• 3 - 5 min. surgical scrub
• Antibiotics (controversial) 30-60 min. prior
• Cefazolin (Kefzol, Ancef) 1 gm IV or
• Gentamycin 80 mg IV

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ACCESS

• Ultrasound (US) or venography to localize vein
• Micropuncture technique
• 21 ga needle
• .018 wire
• Dilate to appropriate size for peel
• away sheath

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TUNNEL

• Some evidence suggests it should exceed
• 6 cm for best results
• Tunnel using sharp or blunt device
• Avoid bleeding !!!!!!
• Position and place through peel away

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SECURE

• A small exit site should retain cuff
• If using suture, place 2-3cm away from exit site
  to reduce potential for infection
• DO NOT secure suture too tightly around catheter

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COMPLICATIONS

• 1. Acute Procedural
• 2. Sub-acute Infection
• 3. Chronic
• Infection
• Catheter fragmentation
• Non-function

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COMPLICATIONSACUTE

• 4. PNEUMOTHORAX
• 5. MALPOSITION
• 6. AIR EMBOLUS

• 1. SPASM
• 2. ACCESS FAILURE
• 3. ARTERIAL PUNCTURE

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PREVENTING ACUTE COMPLICATIONS

• 1. Micropuncture - 21ga needle, .018wire
• 2. Imaging - US, Fluoro, Contrast, CO2
• 3. Right Internal Jugular vein approach
• 4. Tilting table, Valsalva, Pinch Sheath

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AIR EMBOLUS SYMPTOMS

• 1. Respiratory distress
• 2. Increased heart rate
• 3. Cyanosis
• 4. Poor pulse
• 5. Change in the level of consciousness

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AIR EMBOLUS TREATMENT

• 1. Left lateral decubitus (Durants) Position
• 2 100 O2
• 3. Vasopressin if necessary
• 4. Chest compression
• 5. Aspiration through catheter /-
• Mortality decreases from 90 to 30 with
  conventional treatment

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COMPLICATIONSCHRONIC

• 1. Infection
• 2. Catheter fragmentation
• 3. Non-function

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PREVENTING INFECTION

• 1. Sterile environment
• 2. Periprocedural antibiotics
• 3. Number of lumen incidence of infection
• 4. Prep
• 5. Skin fixation
• 6. Dry dressing vs. Occlusive dressing
• 7. Ointments - Iodophor vs antibiotic
• 8. Special instructions

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TYPES OF INFECTION

• EXIT SITE, TUNNEL/POCKET or CATHETER
• 1. Cutaneous - pain, erythema, swelling,
• /- exudate
• 2. Bacteremia - fever, leukocytosis and
• positive blood cultures
• 3. Septic thrombophlebitis - bacteremia,
• thrombosis and purulent discharge

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INFECTION CAUSATIVE ORGANISMS

• Staph epidermidis 25-50
• Staph aureus 25
• Candida 5-10

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INFECTIONCATHETER REMOVAL

• 1. Exit site - 15.4
• 2. Tunnel - 69
• 3. Septic thrombophlebitis - 100

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INFECTION

• 1. Septic thrombophlebitis - remove catheter
• 2. Cutaneous - local treatment
• 3. Bacteremia -
• 1. IV antibiotics 48 -72 hours
• if improved - keep catheter
• if no change, worse or recurs
• remove catheter
• or
• 2. Exchange catheter over wire,
• 85 cure with treatment

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INFECTION

• Continue to treat infection for 10 - 14 days
• If ineffective - try locking with thrombolytics
  between antibiotic doses and administer
  antibiotics through catheters

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INFECTIONCATHETER REPLACEMENT

• 1. Afebrile
• 2. Negative blood culture

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CATHETER FRAGMENTATION

• 1. Power injection - gt 2 cc/sec
• 2. Port injection - 10 cc syringe or greater
• 3. Catheter withdrawal
• 4. Pinch Off Syndrome

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NON - FUNCTIONCATHETER MALPOSITION

• 1.Intravascular vs. Extravascular
• 2. Infuses but doesnt aspirate
• 3. Check the CXR

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CORRECTING MALPOSITION

• 1. Imaging guidance
• 2. Redirecting catheters

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THANK YOU !