Download Central venous catheters

Central venous catheters
February 2010
Anne Aspin
Central venous catheter
• Central venous access is the placement of
a venous catheter in a vein that leads
directly to the heart.
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
Which vein to cannulate
• Veins commonly lie close to arteries and
nerves
• Subclavian vein lies close to dome of
pleura, damage lead to pneumothorax
Types used
• Percutaneous long lines
• Percutaneous multi lumen lines
• Peripheral inserted central catheter (PICC)
• Broviac and Hickman lines
• Portacath
Length of time to use
• Percutaneous line.
• 10 – 12 weeks
• Percutaneous multi lumen line
• 5 – 10 days post operation
• PICC line
• 10 / 12 weeks
• Broviac / Hickman line / Portacath
• For long term use
Percutaneous long line
• TPN
• Clear fluids
• Medications - infuse slowly
PICC
• TPN
• Clear fluids
• Blood transfusion
• Medications
• Flush off
Broviac / Hickman / Portacath
• TPN
• Clear fluids
• Blood transfusion
• Medications
Percutaneous Multi lumen line
• TPN
• Clear fluids
• Blood transfusion
• Medications
• Caution, ports 1, 2, 3
Complications
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Sepsis
Embolus
Malposition
Occlusion
Fibrin sheath
formation
Dislodge
rupture
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Thrombus
Pneumothorax
Perforation of vessel
Cardiac tamponade
Endocarditis
Vent arrythmia
Phlebitis
Cuff erosion
Sepsis
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Pyrexia, >38c
Labile temperature
Labile sugars
Shock, pallor
Apnoea
tachycardia
• Bradycardia
• Capillary venous
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return > 4 secs
Grey
Quiet
thrombocytopenia
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
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
• 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.
• 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.
Catheter occlusion
• Cannot draw back nor solutions infuse
• Usually clotted blood, precipitate
• Flush well after sampling
• Streptokinase, Urokinase – fibrinolytic agents.
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5000 units per 1 cc
1ml each lumen, 4 hours. Check pharmacy.
Takes 27 minutes, leave 60 mins.
Extravasation
• Leakage from vein into subcutaneous
space
• Pain, irritation in chest, swelling, necrosis
• Crying, fussy, distressed.
Catheter malposition
• Painful phlebitis
• Thrombosis
• Backtracking
• Pericardial effusion
• Cardiac tamponade chest pain, shortness
of breath.
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.
Percutaneous CVC
• infants <1000g 28g single lumen, 20cm
long maximum flow 38mls / hr.
• Premicath 27g, markings every 5cm, max
flow rate 30ml / hr
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.
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
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.
Dressings
• Evidence.
• Transparent / gauze / no dressing
• Change dressing daily until dry then
change twice weekly.
• Chlorhexidine 1:200, 70% alcohol
Portacath
• Chemotherapy
• Medications
• For cancer or leukaemia
• Soft plastic tube, disc between 2.5-4cm.
• Catheter tunneled
• Years. Discreet
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
Result
• Twenty RCTs
• Sample size small
• < ten pounds per procedure
• For every 1000 procedures, ?save 2000
• Improved failure and complication rate.
References
• Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J, Levy I
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(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/1018395overview
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