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Venous acess care
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Learning objectives
– Learn about different cetral venous access devices
(CVAD)
– Catheter related complications of infectious and
mechanical origin
– Strategy to prevent problems and treatment of
complications
Summary
Home parenteral nutrition (HPN) is a technical complex
procedure that requries a central line. Although well
trained in aseptic techniques patients will face infectious
and other complications. This presentation deals with
selecting the appropiate CCAD, prevention and
management of complications.
Refrences,
links
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Slide from
course
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McGee et
al, N Engl
J Med
(PDF file)
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Slide from
course
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Smith et
al, JPEN
(PDF file)
•
Slide from
course
Venous access care
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Considerations when choosing catheter
Intravenous acess for HPN
Insertion of catheters
Catheter related complications
– Infectious
– Venous thrombosis
– Catheter obstruction
Considerations when selecting a
venous access device (VAD)
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The number of infusions to be given
Type and length of therapy
Available resources and expertise
The age and diagnosis
Specific vascular problems
The VAD history
Patients preference if long term treatment
Venous access devices
• Peripherally inserted central catheter
(PICC)
• Central venous catheter (CVC)
• Hickman or Broviac, tunnelled catheter
• Port-a-cath
Peripherally inserted central
catheter (PICC)
• Inserted in the cubital or upper arm
region
• Intravenous nutrition and other infusion
therapies
• No risk of trauma to neck structures, low
risk of thrombosis
• For short term (3-4 weeks) use only
• Mostly for in patients
Horattas MC et al. 2004; 10:2419-22
Tunnelled catheter
• A central catheter inserted in the
subclavian or femoral vein with the tip in
the vena cava or right atrium
• The distal part of the catheter is
tunnelled in subcutaneous tissue
• Exit of tunnel with a position visible for
the patient allowing self care
Broviac catheter for parenteral nutrition
Broviac or Hickman catheter
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Commonly used for HPN
Different types with more lumens
Blood draws should be avoided (infection)
Covered by transparent dressing
Patient may need help for dressing change
Body image
Shower and bathing possible
Broviac catheter
Port-a-Cath
• A stainless steel chamber with a
membrane implanted in a subcutaneous
pocket in the chest wall
• Accessed with a needle
• Not visible, body image
• If infected – remove – antibiotics will not
clear the infection*
*Kuizon, D et al. Arch Intern Med 2001; 161:406-10
Prevention of complications
• Recognize difficult catheter insertion
– Previous failed attempts
– Scaring, skeletal deformity
• Experience
– Insertion of >50 catheters reduces complication
risk significantly
• Ultrasound
– For jugular access, lower rates of complications
– For subclavian, no difference
McGee D, Gould MK. N Engl J Med 2003; 348:1123-33
Insertion of catheter at the subclavian site:
• Lower risk of infection compared to internal
jugular or femoral catherisation
• Lower risk of catheter related thrombosis
compared to femoral or jugular insertion
• The rates of serious complications are similar
for femoral and subclavian vein access
Merrer J, De Jonghe B, Golliot F et al. JAMA. 2001; 286:700-7
Position of the distal tip
• Review of 141 cases of CVAD
– Catheter tip location only factor predictive
for malfunction (x-ray or fluoroscopy)
– Significant increase in malfunction if tip
more superior than 4 cm from junction of
atrium and caval vein
– Malfunction minimized in cases where tip
in right atrium
Petersen J, Delaney JH, Brakstad MT et al. Am J Surg. 1999;178:38-41
Catheter related complications
• Infectious
– General measures
– Impregnated catheters
– Use of dressing
– Patient support and education
– ESPEN HAN survey on sepsis
– Treatment
General measures
• Use of sterile barrier precautions
reduces the rate of infections
• Disinfect catheter hubs – common site
of contamination
• Remove catheters when no longer
needed
• Routine changes of catheters do not
reduce infectious complications
McGee D, Gould MK. N Engl J Med 2003; 348:1123-33
Impregnated catheters
The use of catheter impregnated with
anti-microbial agents:
• Reduces the risk of catheter related
bloodstream infections
• May lower cost of treatment
• Short term effect and probably not
relevant to HPN population
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Raad I, Darouiche R, Dupuis J, et al Ann Intern Med. 1997; 127:267-74
Central venous catheter dressings
• Different types of dressings available
• 25 studies, controlled/uncontrolled
• 15 studies included in meta-analysis
– Comparison of gauze with dressings
– Comparison of different dressings
• Conclusion
– No difference in infectious complications rate
between any dressing type
– Small patient samples – lack of power
Gillies D, O’Riordan E, et al, J Adv Nurs. 2003;44:623-32
Patient support and education
Patient affiliation to ongoing HPN education
interactive video-based for 18 months
(randomised controlled), 39 patients
– Significantly fewer hospitalisations for line
infection at 6 and 18 months
– Better quality of life score
– Lower rate of depression
– Patients better at defined problem solving
Smith CE, Curtas S et al, JPEN 2003; 27:137-145
ESPEN-HAN survey sepsis 2002
• 12 centres, 447 patients, a total of
110869 catheter days
• About 25 % had problems, about 50 %
of infectious origin and removal of
catheter in half the cases
• Risk factors port-a-cath and daily use of
catheter
Bozzetti F, Mariani L, Bertinet DB et al. Clin Nutr. 2002; 21:475-85.
Catheter associated infection
• Colonisation
– The presence of organisms in the catheter by
culture
• Blood stream infection
– Culture of the same organism in the catheter and
blood stream and no other source of infection
• Exit site infection
– Erythema and tenderness or purulence within 2
cm of the exit site
Suspected catheter related infection
• Blood cultures drawn from catheter and
a peripheral site
• Culture from the hub
• Inspect catheter site for signs of
infection – if erythema or pus consider
removal
• Antibiotic treatment
Catheter related infection
• Antibiotic treatment according to microbiology
• *Catheter lock ?
– Antibiotics to disinfect
– Alcohol to dissolve organic debris
– Urokinase to lyse fresh thrombus
• Save catheter when possible
• Remove immediately in case of septic shock
*Case reports and small studies in support
Catheter related complications
• Thrombosis
• Mechanical
Catheter related venous thrombosis
• In 33 % of ICU patients by Doppler
• Risk higher with insertion at femoral > jugular
> subclavian site
• If diagnosed in the HPN patient population
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Removal of catheter, anticoagulant treatment
Thrombolytic medication ?
Loss of venous access
Probably under diagnosed
Clinical studies warranted
Catheter occlusion
• Common problem
• Random and unpredictable event
• Can be associated with:
– Catheter life span
– Type of catheter
– Handling
– Blood flushing back
– Composition of parenteral nutrition
Catheter occlusion
• Management
– Use of thrombolytic agents
– Flush with saline
– Flush with alcohol
– Flush with acid
– Mechanical rinsing with brush
References, available, mostly case reports
Summary slide
• Chose access for CVAD carefully
• General use aseptic techniques are of
paramount importance
• Support patients educationally to
minimise line related complications
• In case of complications use protocols
to treat patients
• Support clinical studies in this field