Central venous catheters

1. Central venous catheters February 2010 Anne Aspin

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

3. Site • Basillic or long saphenous vein preferred. • NB. Blood or blood products should not be infused. Catheter may rupture or block. • Catheter should always be flushed with 10 ml syringe

4. Which vein to cannulate • Veins commonly lie close to arteries and nerves • Subclavian vein lies close to dome of pleura, damage lead to pneumothorax

5. Types used • Percutaneous long lines • Percutaneous multi lumen lines • Peripheral inserted central catheter (PICC) • Broviac and Hickman lines • Portacath

6. Length of time to use • Percutaneous line. • 10 – 12 weeks • Percutaneous multi lumen line • 5 – 10 days post operation

7. PICC line • 10 / 12 weeks • Broviac / Hickman line / Portacath • For long term use

8. Percutaneous long line • TPN • Clear fluids • Medications - infuse slowly

9. PICC • TPN • Clear fluids • Blood transfusion • Medications • Flush off

10. Broviac / Hickman / Portacath • TPN • Clear fluids • Blood transfusion • Medications

11. Percutaneous Multi lumen line • TPN • Clear fluids • Blood transfusion • Medications • Caution, ports 1, 2, 3

12. Sepsis Embolus Malposition Occlusion Fibrin sheath formation Dislodge rupture Thrombus Pneumothorax Perforation of vessel Cardiac tamponade Endocarditis Vent arrythmia Phlebitis Cuff erosion Complications

13. Pyrexia, >38c Labile temperature Labile sugars Shock, pallor Apnoea tachycardia Bradycardia Capillary venous return > 4 secs Grey Quiet thrombocytopenia Sepsis

14. Infection • Life threatening where neutriphil counts <500 cells/mm. • Local infection – exit site, port pocket and tunnel infection. • Systemic infection, colonised thrombi or fibrin sleeves • Intraluminal or extraluminal colonisation

15. Infection • Gram –ve aerobes from gastro intestinal tract • E. coli, klebsiella, pseudomonas 25-33pc • Gram pos aerobes, Staph aureus,staph epidermis, strep 50pc • Candida 5-7pc

16. Greater risk infection with multi lumen catheter • In one study removed 139 days earlier. • Implanted port less infections • Extraluminal clot at catheter tip –related to cath related sepsis.

17. Pseudomonas difficult to eradicate • Antibiotics down the line • Locking catheter for two hours could eradicate pseudomonas, not confirmed in human studies. • ?Trial, Benefit / risk antibiotic resistance.

18. Catheter occlusion • Cannot draw back nor solutions infuse • Usually clotted blood, precipitate • Flush well after sampling • Streptokinase, Urokinase – fibrinolytic agents. 5000 units per 1 cc • 1ml each lumen, 4 hours. Check pharmacy. • Takes 27 minutes, leave 60 mins.

19. Extravasation • Leakage from vein into subcutaneous space • Pain, irritation in chest, swelling, necrosis • Crying, fussy, distressed.

20. Catheter malposition • Painful phlebitis • Thrombosis • Backtracking • Pericardial effusion • Cardiac tamponade chest pain, shortness of breath.

21. Cochrane review 2004 • Perc CVC versus peripheral cannula • RCTs • 3 trials for inclusion • CVC does improve nutrient input • No evidence of CVC increased risk of adverse events, ie infection.

22. Percutaneous CVC • infants <1000g 28g single lumen, 20cm long maximum flow 38mls / hr. • Premicath 27g, markings every 5cm, max flow rate 30ml / hr

23. Percutaneous CVC • Infants > 1000g, 24g, 30cms long, max flow 50 ml/hr • PICC, 20g, silicone, 50cm long • Epicutaneo Neocath, silicone, 30cm and 50cm length. Max flow 100ml/hr.

24. Perc CVC removal • Use no longer justified • Bacteraemia beyond 48-72 hrs despite appropriate antibiotics • Septicaemia due to fungal infection • Evidence of septic emboli or endocarditis

25. Broviac / Hickman line • Soft silicone • Tunneled • Buried under skin • Tissue grows around cuff to secure in place. • Cuff acts as barrier to infection • Can be flushed off.

26. Dressings • Evidence. • Transparent / gauze / no dressing • Change dressing daily until dry then change twice weekly. • Chlorhexidine 1:200, 70% alcohol

27. Portacath • Chemotherapy • Medications • For cancer or leukaemia • Soft plastic tube, disc between 2.5-4cm. • Catheter tunneled • Years. Discreet

28. Ultrasound devices • Systematic review 2003 • Objective. To investigate clinical and cost- effectiveness of ultrasonic locating devices. • Ultrasound – two dimensional image • Dopplers – audible sound from venous blood flow

29. Result • Twenty RCTs • Sample size small • < ten pounds per procedure • For every 1000 procedures, ?save 2000 • Improved failure and complication rate.

30. References • Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J, Levy I (2005). Infectious complications for implantable parts and Hickman catheters in paediatric haematology oncology patients. Journal of Hospital Infection. 62 : 358 - 365 • Alexander N (2010). Question 3. Do Portocaths or Hickman lines have a higher risk of catheter-related bloodstream infections in children with leukaemia. Archives of Disease in Childhood. 95 : 239 - 241. doi:10.1136/adc2009.176545 • Larson S, Hebra A, Raju R, Lee S (2010). Vascular Access, Surgical treatment. http://emedicine.medscape.com/article/1018395-overview • McIntosh W (2003). Central venous catheters : reasons for insertion and removal. Paediatric Nursing. Vol 15, No 1 • Simon A, Ammann R, Wiszniewsky G, Bude U, Fleischhack G, Besuden M (2008). Taurolidine-citrate lock solution (Taurolock) significantly reduces CVAD - associated grampositive infections in paediatric cancer patients. BMC Infectious Diseases. 8 : 102