Central Lines A Primer

Report
Central Lines:
A Primer
• Tamara Simon, M.D.
• July 2004, updated August 2005
Types of Lines
• Non-tunneled (jugular, femoral, subclavian)
• External Tunneled Catheters
–
–
–
–
–
Broviac
Quinton (dialysis)
Hickman
Cook
Groshong
- Leonard
- Corcath
• Internal (Totally Implantable) Catheters
–
–
–
–
Mediport
Infus-a-port
Port-a-cath
Pas-port
• Peripherally Inserted Central Catheters
External Tunneled Catheters
• Examples:
– Broviac, Quinton, Hickman, Cook, Groshong
– Have a portion exits the skin and a Dacron cuff just
inside the insertion site (fibrosis) with ends in female
Luer lock with needleless cap
• Insertion/Removal:
– Surgically under sterile procedure
– Inserted into external jugular, subclavian, or cephalic
vein with tip on right atrium; other end is tunneled
subcutaneously along anterior chest wall
• Home Care
– Dressing changes and heparin irrigation 3x/week
– No swimming in oceans, lakes, and rivers
External Tunneled Catheters
• Uses
– Long term up to several years
– Blood draws, medication/TPN/blood administration
• Complications
– Infection (site or bacteremia), air embolus, clotted
catheter, damage
• Advantages
– Alleviates blood draws, use immediately (after xray
confirmation)
• Disadvantages
– Requires home care
– Ever-present source of infection, ever-present on body
Internal Catheters
• Examples:
– Mediport, Infus-a-port, Port-a-cath, Pas-port
– Tunneled beneath the skin to a subcutaneous infusion
port or reservoir attached to silastic catheter that enters
a central vein- reservoir is self-sealing and accessed
with tapered 20-22 gauge Huber needle
• Insertion/Removal:
– Surgically under sterile procedure
– Catheter inserted into central vein with tip on right
atrium; other end is tunneled subcutaneously and
attached to reservoir
• Home Care
– None if de-accessed
– Occlusive dressing if accessed
Internal Catheters
• Uses
– Long term up to several years
– Blood draws, medication/TPN/blood administration
• Complications
– Infection (bacteremia), air embolus, clotted catheter
– Lower rates of complications compared to external
devices
Internal Catheters
• Advantages
– No home care required, except when accessed
– Protective barrier of skin, hardly noticeable
– Use immediately (after xray confirmation)
• Disadvantages
– Needle stick to access device
– Needle change every 7 days for infection control if
accessed for continual use
PICCs
• How to get it done
– Deb King, Vascular Access Coordinator, office phone is
860-4312.
– Interventional radiology- over 5 kg, call IR
– Newborn center- under 5 kg, call NBC
– Surgery- on weekends, call consult pager
• Insertion/Removal
– Under sterile procedure
– Small caliber silastic catheter is inserted in antecubital
vein and advanced so that the tip is in the SVC/RA
• Home Care
– Dressing changes weekly or if wet or soiled
– heparin irrigation after each use or 3x/week
PICCs
• Uses
– Short term, up to 6-8 weeks
– Average dwell time 21 days
– Blood drawing if 4 Fr or larger; medication/ nutrition/
blood administration
• Complications
– Infection (site or bacteremia- 2.2%), phlebitis, air
embolus, clotted catheter (8%), damage
PICCs
• Advantages
– Alleviates blood draws, use immediately (after xray
confirmation)
• Disadvantages
– Requires home care
– Ever-present source of infection
– Not tunneled, so dislodgement more likely if
precautions are not taken
Complications:
Causes of Catheter Loss
• Persistent infection (4-60%)
– Pediatric 22%
– Adult 27%
• Inability to clear occlusion
– Pediatric 8%
– Adult 17%
• Mechanical, dislodgement, and damage
– Pediatric 15%
– Adult 12%
Complications: Infection
• Most common complication of central venous
access
• Increased risk with external devices and multiple
lumens
• When suspected (fever, redness, swelling, and/or
drainage), get CBC, CRP, central blood culture,
+/- DIC panel, peripheral blood culture, site
drainage Gram stain and culture
Complications: Infection
• Microbiology
–
–
–
–
–
–
Coagulase negative staph*
38%
Gram negative rods
25%
Enterococcus
10%
Candida*
9%
Staph aureus
* lipids increase risk, especially of slime
producers
MMWR 2002, 51:12
Complications: Infection
• Pathogenesis
– Migration of skin flora from insertion site to
catheter tip
– Contamination of hub leading to intraluminal
infection
– Catheter materials differ in bacterial adherence
• Infection Rate
– Non-tunneled > Tunneled > Implanted
– Central > Peripheral
Complications: Infection
• Types of infection:
–
–
–
–
Tunnel or pocket infection
Exit site infection
Catheter-related bacteremia
Phlebitis
Tunnel or pocket infection
• Redness, swelling, and purulent drainage from
tunnel of pocket around port or external CVC
(beyond 2 cm)
• Organisms usually Gram positive (Staph epi,
Staph aureus), can be Gram negative
(Pseudomonas)
• Treatment consists of removal of CVC, IV
antibiotics (vancomycin initially), debridement or
drainage of pocket/tunnel
Exit site infection
• Originates at site where CVC exits skin (within 2
cm)
• Pain, redness, or swelling around port or external
CVC without systemic signs of infection
• Organisms usually Gram positive (Staph epi,
Staph aureus)
• Treatment consists of aggressive site care and
oral/IV antibiotics; if Dacron cuff is visible, it is
very difficult to clear infection and removal of
CVC is usually necessary
Catheter-related
Bacteremia/Sepsis
• No other source of infection found, despite
extensive search
• Positive blood culture drawn from CVC which
shows a 5-10 fold or higher concentration of
organisms than in the peripheral blood; usually
multiple blood cultures (Todd says two
consecutive cultures from central line suffices)
• Temporal relationship between catheter
manipulation and development of symptoms
Catheter-related
Bacteremia/Sepsis
• Gram positive and Gram negative organisms
• Treatment consists of IV antibiotics (vancomycin
plus Gram negative +/- Pseudomonas coverage
initially); depending on organisms and duration of
persistence, it is very difficult to clear infection
and removal of CVC is usually necessary
• Consideration of distant complications such as
endocarditis and metastatic abscesses
Phlebitis
• Inflamed, palpable, thromobosed vein
• Often due to physiochemical factors rather
than infection
• Increases the risk of infection, observed
with insertion-site infections
Accessing CVC’s
• Damaging:
– Tincture of Iodine damages Silastic
– Clamps and hemostats with teeth damage catheters
– Small syringes generate too much pressure so use 5-10
ml catheters (central lines are delicate)
• Establish patency before infusing meds/ fluids
• Close clamps when circuit is open (air emboli)
• Withdraw 3 ml blood from external tunneled CVC
and 5 ml from internal CVC before sampling for
lab tests
• Force fluid into catheter against significant
resistance
• Use HCl in polyurethane catheters
Complications: Thrombosis
• Complete occlusion: inability to flush or aspirate
CVC
Differential diagnosis:
• Fibrin sheath formation around tip
• Venous thrombosis beyond tip of CVC (more common if tip in
high SVC or above compared to low SVC or RA
• Catheter or tip migration (consider CXR)
• Intraluminal clot
• Intraluminal drug precipitation
• Mechanical such as kinking or pinching off between
clavicle/rib (consider CXR)
Complications: Thrombosis
• Partial occlusion: ability to flush but not to
aspirate blood
Differential diagnosis:
• Fibrin sheath at tip of CVC acting as ball-valve
• Tip up against vessel wall- positional
– Reposition patient (reverse Trendelenberg), then have
them valsalva, cough, take deep breaths, raise arms over
head
• Tip migration too low, CVC compressed as AV
valve closes
Catheter Declotting
• Assessment: determine if occlusion was caused by
blood or drug precipitate
• Blood clot
– Treatment of choice is TPA 1 mg/ml (Alteplase) at max
dose 0.4 mg/kg; also can use urokinase 5000 U/ml
– Instill per nursing protocol (see website)
• Drug precipitate (completely preventable)
– Success of restoring patency is variable
– HCl can be used to lower pH and NaBicarb to raise pH
– 70% ethanol can treat lipid precipitates
Catheter Declotting
Infusion
Deposit
Un-occluder
Lipid
waxy
Basic drug
high pH ppt
(phenytoin)
70% ethanol
1 hour, 1x
7.5 % NaBicarb
1 hr, 1-2 x
Acidic drug
low pH ppt
(Ca, PO4)
0.1 N HCl
20 min, 3x/2 hrs
None
blood clot
fibrinolytic
2 hrs, 1x/24 hrs
Technique: Lock Technique
• Volume for lock technique equal to priming
volume of catheter (3 ml/5 ml, and/or check box
of similar device) plus add on devices
• Clamp catheter or T-connector
• Disconnect IV tubing
• Remove needle-less cap
• Remove all add-on devices
• Attach 5 ml syringe with un-occluding agent,
unclamp
Technique: Lock Technique
•
•
•
•
•
Infuse proper volume gently with push-pull action
Clamp catheter or T-connector
Wait designated time based on un-occluding agent
Aspirate un-occluding agent and discard
Infuse saline flush to test catheter patency
Technique: Lock Technique
• …but you can’t infuse un-occluder or can’t
aspirate it back…
• Clamp catheter
• Attach empty 10 ml syringe
• Pull plunger back 8-9 ml to create controlled
negative pressure
• Re-clamp catheter
• Attach 5 ml syringe with un-occluding agent or
saline (if unable to aspirate it back)
Technique: Lock Technique
• Un-clamp catheter and allow fluid to flow
into catheter
• Wait appropriate dwell time
• Aspirate un-occluder
• Test for catheter patency
• If it’s TPA, be sure to dilute it with NS
Complications: Mechanical
• Dislodgement
– Suspect if:
• No blood returns
• Dacron cuff outside skin surface- don’t push it in!
• Subcutaneous swelling at site of implanted port
– Associated with:
• cuff placement 0.5-2 cm from exit site
• smaller lumens (6 Fr or less)
• young age (<3 years)
– X-ray to locate catheter tip
– Dye study
Complications: Mechanical
• Damage to internal/external parts of CVC
–
–
–
–
–
More common in external devices
Trauma, detachment needle puncture, wear and tear
Clamp catheter to avoid exsanguination
Associated with young age (<3 years)
Leaks/breaks can occur anywhere on external segment
• repair is possible if there is adequate length of old catheter to
splice on the new segment
• each CVC has a permanent repair kit, be sure to get the correct
one- external segment, male connector, glue
• Repair is a strict sterile technique by specially trained RN or
MD
Complications: Rare
• Air embolism- left Trendelenburg, oxygen, clamp
catheter
• Catheter embolism – visible on xray, happens with
longer duration and occlusion, invasive retrieval
• Exsanguination
• Respiratory decompensation- catheter tip in
pulmonary artery
• Cardiac tamponade- erosion of atrial wall
References
• Central Lines Used at UNC Hospitals, September
1999.
• Konsler GK. Management of Central Venous
Catheters: Troubleshooting, August 1999.
• Band JD. Central venous catheter-related
infections: Types of devices and definitions. Up To
Date, January 15, 2002.
• Teoh DL. Tricks of the Trade: Assessment of
High-Tech Gear in Special Needs Children.
Clinical Pediatric Emergency Medicine. 3(1),
March 2002.

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