Long-Term Central Venous Catheters PINDA - Luis Calvo Mackenna Hospital Santiago - Chile 2008

1. RN. Lorena Segovia W. RN. Paola Viveros L. Long-Term Central Venous Catheters PINDA - Luis Calvo Mackenna Hospital Santiago - Chile 2008

2. Objectives: • Define what is a long-term central venous line • Determine the uses of long-term central venous lines • Identify the characteristics of commonly used long- term central venous lines • Describe advantages and disadvantages of various long-term central venous lines • Identify the most frequent complications associated with the use of long-term central venous lines • Describe the nursing care of long-term central venous lines

3. Definition: • A percutaneous device that goes through the jugular or subclavian vein down to the union of the superior vena cava and the right atrium

4. General Information • Inserted in surgical room • Sterile procedure • Verify proper placement with chest radiography • Use immediately “Use and maintenance requires strict aseptic techniques and should only be handled by trained nurses.”

5. Uses for Long-Term Central Venous Catheters • Infusion of: • Chemotherapy • Parenteral nutrition • Antibiotics • Antifungal • Antiviral • Blood products • All intravenous medications • Take blood samples for lab tests • Monitoring of central venous pressure

6. Classification • Implantable: • Port – a – cath • Implanto Fix • Externally tunneled: • Hickman – Broviac • Cook • Groshong

7. Port – A – Cath

8. PORT – A – CATH • Self-septum • May puncture up to 2000 times • Heparin flush: • Without use : Every 28 days • In use: Only if it is to remain sealed • Purge: 1.5ml • Run time: 1 to 2 years

9. HICKMAN – BROVIAC / COOK

10. HICKMAN – BROVIAC / COOK • Lumen: 1, 2, or 3 • Change Dressing: • Without use: once a week • In use: twice a week • Heparin flush: • Without use: once a week • In use: only if it is to remain sealed • Run time: 1 to 2 years • Purge: 1.8ml

11. Comparative Table

12. COMPLICATIONS

13. Infection • Causal agent: S. Aureus • The impact depends on: • Host factors: immunocompromise • Catheter factors: Equipment, method of insertion • Intense manipulation • Pathophysiology: • Microorganism migration from the insertion site (short- term lines) • Pollution of the line connections and endoluminal colonization (Long-term lines) • Pollution of fluid infusion

14. Prevention Measures Prevention Measures • Education • Individuals responsible for insertion • Individuals who will use and maintain the line • Skin preparation prior to catheter insertion: • Antiseptic (3” / Chlorhexidine 2%) • Protect insertion site with a sterile dressing • Change circuit every 72 hours • Except PN, lipids , blood products (every 24 hours)

15. Prevention Measures (con’t) • Use heparin flushes • Disinfect port before accessing the intravenous infusion systems • Keep circuit sealed • Handle line with aseptic technique (handwashing, sterile gloves) according to professional standards National Consensus about Central Vascular Access Device Associated Infections, 2003

16. Diagnostics Diagnosis of a central line infection: • Catheter tip with positive culture matching the same microorganism found in the blood cultures • Simultaneous central and peripheral quantitative blood cultures in a proportion > or = 4:1 (central vs peripheral) • Differential time of bacterial growth is at least 2 hours between the peripheral and central blood culture Rev Chil Infect (2003); 20 (1): 41 - 50

17. National Consensus about Central Vascular Access Device Associated Infections, 2003

18. National Consensus about Central Vascular Access Device Associated Infections, 2003

19. Treatment • Follow recommendations of experts, clinical guidelines (Type III), etc. • Attempt to rescue line with antibiotics associated or not with systemic "antibiotic-lock" (The rate of eradication with the therapy for both ways is 80% (BIII)) Antibiotic-lock: Introduce a solution with a high concentration of antibiotics into the lumen of the catheter for a period of 12 hours a day, usually at night.

20. Solutions frequently used with the “antibiotic – lock” system • Cefazolin: cefazolin 1ml + heparin 0.5 ml + NS 0.2ml • Cefazolin + Gentamicin : gentamicin 0.5ml + cefazolin 1ml + heparin 0.5ml • Gentamicin: gentamicin 0.5ml + heparin 0.5ml + NS 1ml • Vancomycin: vancomycin 1ml+ heparin 0.5ml + NS 0.5ml • Vancomycin + Gentamicin: vancomycin 1ml + gentamicin 0.5ml + heparin 0.5ml Antibiotics concentrations: Vancomycin 5mg/ml, gentamicin 4mg/ml, Cefazolin 10mg/ml Rev Chil Infect (2003); 20 (1): 71

21. Recommendation for Central Venous Catheter Removal • Infection of the tunnel or at the site of departure • Hemodynamic or respiratory compromise • Local infection at the port site • Systemic infections • Infections caused by: • Candida sp • Burkholderia sp • Bacillus sp • Corynebacterium sp • Mycobacterium sp • Pseudomonas sp no aeruginosa Rev Chil Infect (2003); 20 (1): 72

22. Other Complications • OCCLUSION • Mechanical • Chemical • Cluster

23. Nursing Management Mechanical supine position, raised arms, push – pull technique Cluster Use a thrombolitic agent Chemical occlusion Bicarbonate 8.4% Lipids occlusion Ethanol 70%

24. Other Complications • AIR EMBOLISM

25. Symptoms: Signs of respiratory distress Tachycardia Anxiety Neurological compromise Management : Clamp the catheter Trendelenburg position Oxygen Management of the symptoms

26. Other Complications • MIGRATION OF THE CATHETER TIP

27. Thank you very much!