1. Long-Term Central Venous Catheters PINDA - Luis Calvo Mackenna Hospital Santiago - Chile 2008 RN. Lorena Segovia W. RN. Paola Viveros L.

2. Objectives: Define what is a long-term central venous line Determine the uses of long-term central venous lines Identify the characteristics of commonly used long- term central venous lines Describe advantages and disadvantages of various long-term central venous lines Identify the most frequent complications associated with the use of long-term central venous lines Describe the nursing care of long-term central venous lines

3. Definition: A percutaneous device that goes through the jugular or subclavian vein down to the union of the superior vena cava and the right atrium

4. General Information Inserted in surgical room Sterile procedure Verify proper placement with chest radiography Use immediately “U se and maintenance requires strict aseptic techniques and should only be handled by trained nurses. ”

5. Uses for Long-Term Central Venous Catheters Infusion of:  Chemotherapy  Parenteral nutrition  Antibiotics  Antifungal  Antiviral  Blood products  All intravenous medications Take blood samples for lab tests Monitoring of central venous pressure

6. Classification Implantable: Port – a – cath Implanto Fix Externally tunneled: Hickman – Broviac Cook Groshong

7. Port – A – Cath

8. PORT – A – CATH Self-septum May puncture up to 2000 times Heparin flush:  Without use : Every 28 days  In use: Only if it is to remain sealed Purge: 1.5ml Run time: 1 to 2 years

9. HICKMAN – BROVIAC / COOK

10. Lumen: 1, 2, or 3 Change Dressing:  Without use: once a week  In use: twice a week Heparin flush:  Without use: once a week  In use: only if it is to remain sealed Run time: 1 to 2 years Purge: 1.8ml

11. Comparative Table Port-a-CathHickman/Cook Less risk of infectionIncreased risk of infection Increased risk of extravasationLess risk of extravasation Minimum maintenance/care requiredSignificant maintenance/care required by the patient/keeper Possible anxiety / discomfort with needle insertion Eliminates anxiety/discomfort associated with needle insertion Minimum affect on body imageAlteration of body image Minimum limitation of physical activitiesSome limitation of physical activities (swimming) Cannot administer incompatible medications at the same time Able to administer incompatible medications

12. COMPLICATIONS

13. Infection Causal agent: S. Aureus The impact depends on:  Host factors: immunocompromise  Catheter factors: Equipment, method of insertion  Intense manipulation Pathophysiology:  Microorganism migration from the insertion site (short- term lines)  Pollution of the line connections and endoluminal colonization (Long-term lines)  Pollution of fluid infusion

14. Prevention Measures Education  Individuals responsible for insertion  Individuals who will use and maintain the line Skin preparation prior to catheter insertion:  Antiseptic (3” / Chlorhexidine 2%) Protect insertion site with a sterile dressing Change circuit every 72 hours  Except PN, lipids, blood products (every 24 hours) Prevention Measures

15. Use heparin flushes Disinfect port before accessing the intravenous infusion systems Keep circuit sealed Handle line with aseptic technique (handwashing, sterile gloves) according to professional standards National Consensus about Central Vascular Access Device Associated Infections, 2003 Prevention Measures (con’t)

16. Diagnostics Diagnosis of a central line infection:  Catheter tip with positive culture matching the same microorganism found in the blood cultures  Simultaneous central and peripheral quantitative blood cultures in a proportion > or = 4:1 (central vs peripheral)  Differential time of bacterial growth is at least 2 hours between the peripheral and central blood culture Rev Chil Infect (2003); 20 (1): 41 - 50

17. SiteCharacteristics Infection at the site of departureInflammatory signs or secretion within 2 cm. of the skin surrounding the departure point of catheter With or without microorganism isolation With or without concommitant blood infection Infection at the port siteInflammatory signs in the skin that cover the port or purulent exudate in subcutaneous pocket With or without concomitant blood infection Infection of the tunnelInflammatory signs in the skin that cover the catheter tip more than 2 cm from the insertion point With or without concomitant blood infection National Consensus about Central Vascular Access Device Associated Infections, 2003

18. SiteCharacteristics BacteremiaCompromise of general state, fever, chills, hypotension with no other apparent source of infection of the bloodstream National Consensus about Central Vascular Access Device Associated Infections, 2003

19. Treatment Follow recommendations of experts, clinical guidelines (Type III), etc. Attempt to rescue line with antibiotics associated or not with systemic "antibiotic-lock" (The rate of eradication with the therapy for both ways is 80% (BIII)) Antibiotic-lock: Introduce a solution with a high concentration of antibiotics into the lumen of the catheter for a period of 12 hours a day, usually at night.

20. Cefazolin: cefazolin 1ml + heparin 0.5 ml + NS 0.2ml Cefazolin + Gentamicin : gentamicin 0.5ml + cefazolin 1ml + heparin 0.5ml Gentamicin: gentamicin 0.5ml + heparin 0.5ml + NS 1ml Vancomycin: vancomycin 1ml+ heparin 0.5ml + NS 0.5ml Vancomycin + Gentamicin: vancomycin 1ml + gentamicin 0.5ml + heparin 0.5ml Antibiotics concentrations: Vancomycin 5mg/ml, gentamicin 4mg/ml, Cefazolin 10mg/ml Rev Chil Infect (2003); 20 (1): 71 Solutions frequently used with the “antibiotic – lock” system

21. Recommendation for Central Venous Catheter Removal Infection of the tunnel or at the site of departure Hemodynamic or respiratory compromise Local infection at the port site Systemic infections Infections caused by:  Candida sp  Burkholderia sp  Bacillus sp  Corynebacterium sp  Mycobacterium sp  Pseudomonas sp no aeruginosa Rev Chil Infect (2003); 20 (1): 72

22. Other Complications OCCLUSION  Mechanical  Chemical  Cluster

23. Mechanical supine position, raised arms, push – pull technique Cluster Use a thrombolitic agent Chemical occlusion Bicarbonate 8.4% Lipids occlusion Ethanol 70% Nursing Management

24. Other Complications AIR EMBOLISM

25. Symptoms: Signs of respiratory distress Tachycardia Anxiety Neurological compromise Management : Clamp the catheter Trendelenburg position Oxygen Management of the symptoms

26. Other Complications MIGRATION OF THE CATHETER TIP

27. Thank you very much!