Tunneled Cuffed Catheters

Hemodialysis access The number of patients with end-stage renal disease (ESRD) has increased steadily The creation and maintenance of functioning vascular access, along with the associated complications, constitute the most common cause of morbidity, hospitalization, and cost in patients with end-stage renal disease.

Vascular Access via Percutaneous Catheters useful method of gaining immediate access to the circulation. associated with higher risks. the use-life of this type of access is shorter than that of AVFs. Noncuffed catheters Short term: <3 weeks

Vascular Access via Percutaneous Catheters: cuffed catheters Cuffed catheters Patients who will require long-term access should have a tunneled catheter placed. allow so-called no-needle dialysis with high flow rates eliminate the problem of vascular steal placed in a subcutaneous tunnel under fluoroscopic guidance

Vascular Access via Percutaneous Catheters: cuffed catheters The Dacron cuff allows tissue ingrowth that helps reduce the risk of infection when compared with noncuffed catheters.

Hemodialysis access: complications A chest radiograph must be taken after catheter placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter. The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%. Thrombotic complications occur in 4% to 10% of patients Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis. Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days. Catheter thrombosis increases the incidence of catheter sepsis.

PRESERVING CATHETER FUNCTION CATHETER CARE PLACEMENT TREATMENT ACCESS POSITIONING

Types of central lines Open-ended tunneled catheters Tunneled valved catheters Implanted ports Nontunneled central venous catheters (CVCs) Peripherally inserted central catheters (PICCs)

Central Line Complications Central Line Complications Infections Air embolus Dislodgement of catheter Catheter occlusion

Central Line Flow Control Central Line Flow Control Volume in ML x Drop factor DEVIDED BY no. of hours to be infused x 60 Drop factors are 15 drops / cc OR 60 drops / cc

ADVANTAGES OF CENTRAL VENOUS ACCESS ADVANTAGES OF CENTRAL VENOUS ACCESS 1. Immediate access 2. High flow and dilution of hyper tonic solutions 3. Easy access 4. Permits outpatient care

DISADVANTAGES OF CENTRAL VENOUS ACCESS More invasive - potentially more complications and pain Acute Chronic

1. Long term IV therapy: ChemoAntibioticsTPN Blood products 2. Recurrent blood draws 3. Dialysis/Pharesis CENTRAL VENOUS ACCESS: INDICATIONS

CONTRAINDICATIONS 1. Sepsis 2. Coagulopathy

TYPES OF CENTRAL VENOUS ACCESS 1. Non tunneled external catheters a. Central line a. Central line b. PICC line b. PICC line 2. Tunneled catheters 3. Subcutaneous Ports a. chest a. chest b. arm b. arm

CHOOSING THE ACCESS DEVICE Patients disease and status Patients disease and status Number and type of solutions, osmolality Number and type of solutions, osmolality Flow required Flow required Frequency accessed Frequency accessed Duration of use- days vs months Preferences - Dr. / Patient Preferences - Dr. / Patient

NUMBER AND COMPATIBILITY OF INFUSATES Determine true number of lumens that are required based on the number of infusates when they are given and if they are compatible

FLOW Internal Diameter (ID) vs Outer Diameter (OD) The outer diameter is not always directly proportional to flow. Some catheters are just thick walled and although large yield slow flow. For high flow - check the ID. Remember, larger catheters cause more irritation potentiating stenosis and thrombosis.

DURATION > 7 days - PICC Line Weeks - PICC line / tunneled catheter 12 weeks - 6 months or greater - tunneled catheter > 6 months - Port

FREQUENCY OF ACCESS Frequent access and infusion - tunneled catheter Infrequent access (every week or month)-port

MATERIAL Silastic thicker, softer, larger for same flow, more friction over a wire Polyurethane stiffer, thinner wall, smaller for same flow, less friction

PREFERENCES Patient: Some patients may prefer a port for aesthetics, no restrictions on activities Operator: If the operator can’t place a port choose an alternative!!!!!!! choose an alternative!!!!!!!

NON-TUNNELED EXTERNAL CATHETERS NON-TUNNELED EXTERNAL CATHETERS

TUNNELED CATHETERS 1. Single or multiple lumens 2. Flow - variable 3. Long term 4. Easy access (no skin puncture) 5. Cuff - Dacron, vita

Tunneled catheter with cuffs

Tunneled catheter with cuff

Tunneled catheter

SITES OF ACCESS 1. Upper extremity 2. Subclavian and Internal Jugular Vein 3. Collaterals and Thrombosed veins 4. IVC – trans hepatic, trans lumbar 5. Hepatic vein 6. Intercostal veins 1. Upper extremity 2. Subclavian and Internal Jugular Vein 3. Collaterals and Thrombosed veins 4. IVC – trans hepatic, trans lumbar 5. Hepatic vein 6. Intercostal veins

LOWER EXTREMITY Most commonly femoral vein Easily contaminated from proximity to groin Complication of DVT less tolerated than upper extremity

SUBCLAVIAN VEIN ACUTE ACUTE Senagore - 10% incidence of art. Puncture Senagore - 10% incidence of art. Puncture Mansfield % unsuccessful access Mansfield % unsuccessful access CHRONIC CHRONIC Cimchowski - 50% stenosis SCV, 10% IJV Cimchowski - 50% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Uldall % thrombosis, 10-40% Uldall % thrombosis, 10-40% stenosis stenosis ACUTE ACUTE Senagore - 10% incidence of art. Puncture Senagore - 10% incidence of art. Puncture Mansfield % unsuccessful access Mansfield % unsuccessful access CHRONIC CHRONIC Cimchowski - 50% stenosis SCV, 10% IJV Cimchowski - 50% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Uldall % thrombosis, 10-40% Uldall % thrombosis, 10-40% stenosis stenosis

SUBCLAVIAN VEIN COMPLICATIONS Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV) PINCH-OFF SYNDROME THROMBOSIS STENOSIS

ADVANTAGES OF THE RIGHT IJ 1. Larger 2. More superficial 3. Further from the lung 4. More direct route to the heart 5. Acute and chronic complications are reduced

CENTRAL VENOUS CATHETER PLACEMENT 1. Prep 2. Access 3. +/- Tunnel 4. Secure

Alcohol scrub to remove surface oils Chlorhexidine scrub Betadine prep (allow to dry) Ioban dressing and drapes PREP

PREP Maximum Sterile Barrier - Surgical hats, gowns, masks & gloves min. surgical scrub Antibiotics (controversial) min. prior Cefazolin (Kefzol, Ancef) 1 gm IV or Gentamycin 80 mg IV

ACCESS Ultrasound (US) or venography to localize vein Micropuncture technique 21 ga needle.018” wire Dilate to appropriate size for peel away sheath away sheath

TUNNEL Some evidence suggests it should exceed 6 cm for best results 6 cm for best results Tunnel using sharp or blunt device Avoid bleeding !!!!!! Position and place through peel away

SECURE A small exit site should retain cuff If using suture, place 2-3cm away from exit site to reduce potential for infection DO NOT secure suture too tightly around catheter

COMPLICATIONS 1. Acute Procedural 2. Sub-acute Infection 3. Chronic Infection Catheter fragmentation Non-function

COMPLICATIONS: ACUTE 1. SPASM 2. ACCESS FAILURE 3. ARTERIAL PUNCTURE 4. PNEUMOTHORAX 5. MALPOSITION 6. AIR EMBOLUS

PREVENTING ACUTE COMPLICATIONS 1. Micropuncture - 21ga needle,.018”wire 2. Imaging - US, Fluoro, Contrast, CO2 3. Right Internal Jugular vein approach 4. Tilting table, Valsalva, Pinch Sheath

AIR EMBOLUS: SYMPTOMS 1. Respiratory distress 2. Increased heart rate 3. Cyanosis 4. Poor pulse 5. Change in the level of consciousness

AIR EMBOLUS: TREATMENT 1. Left lateral decubitus (Durant’s) Position 2 100% O 2 3. Vasopressin if necessary 4. Chest compression 5. Aspiration through catheter +/- Mortality decreases from 90% to 30% with conventional treatment

COMPLICATIONS: CHRONIC 1. Infection 2. Catheter fragmentation 3. Non-function

PREVENTING INFECTION 1. Sterile environment 2. Periprocedural antibiotics 3. Number of lumen incidence of infection 4. Prep 5. Skin fixation 6. Dry dressing vs. Occlusive dressing 7. Ointments - Iodophor vs antibiotic 8. Special instructions

TYPES OF INFECTION EXIT SITE, TUNNEL/POCKET or CATHETER EXIT SITE, TUNNEL/POCKET or CATHETER 1. Cutaneous - pain, erythema, swelling, +/- exudate +/- exudate 2. Bacteremia - fever, leukocytosis and positive blood cultures positive blood cultures 3. Septic thrombophlebitis - bacteremia, thrombosis and purulent discharge thrombosis and purulent discharge

INFECTION CAUSATIVE ORGANISMS Staph epidermidis 25-50% Staph aureus 25% Candida 5-10%

INFECTION: CATHETER REMOVAL 1. Exit site % 2. Tunnel - 69% 3. Septic thrombophlebitis - 100%

INFECTION 1. Septic thrombophlebitis - remove catheter 2. Cutaneous - local treatment 3. Bacteremia - 1. IV antibiotics hours if improved - keep catheter if no change, worse or recurs remove catheter or 2. Exchange catheter over wire, 85% cure with treatment

Continue to treat infection for days If ineffective - try locking with thrombolytics between antibiotic doses and administer antibiotics through catheters INFECTION

INFECTION: CATHETER REPLACEMENT 1. Afebrile 2. Negative blood culture

CATHETER FRAGMENTATION 1. Power injection - > 2 cc/sec 2. Port injection - 10 cc syringe or greater 3. Catheter withdrawal 4. Pinch Off Syndrome

NON - FUNCTION: CATHETER MALPOSITION 1.Intravascular vs. Extravascular 2. Infuses but doesn’t aspirate 3. Check the CXR

CORRECTING MALPOSITION 1. Imaging guidance 2. Redirecting catheters

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