1. Central Lines: A Primer Tamara Simon, M.D. July 2004, updated August 2005

2. Types of Lines Non-tunneled (jugular, femoral, subclavian) External Tunneled Catheters –Broviac- Leonard –Quinton (dialysis) - Corcath –Hickman –Cook –Groshong Internal (Totally Implantable) Catheters –Mediport –Infus-a-port –Port-a-cath –Pas-port Peripherally Inserted Central Catheters

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 –No swimming in oceans, lakes, and rivers

9. 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

10. 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

11. 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%

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

13. Complications: Infection Microbiology –Coagulase negative staph* 38% –Gram negative rods25% –Enterococcus10% –Candida*9% –Staph aureus –* lipids increase risk, especially of slime producers MMWR 2002, 51:12

14. 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

15. Complications: Infection Types of infection: –Tunnel or pocket infection –Exit site infection –Catheter-related bacteremia –Phlebitis

16. 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

17. 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

18. 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

19. 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

20. Phlebitis Inflamed, palpable, thromobosed vein Often due to physiochemical factors rather than infection Increases the risk of infection, observed with insertion-site infections

21. 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

22. 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)

23. 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

24. 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

25. Catheter Declotting InfusionDepositUn-occluder Lipidwaxy70% ethanol 1 hour, 1x Basic drughigh pH ppt7.5 % NaBicarb (phenytoin)1 hr, 1-2 x Acidic druglow pH ppt0.1 N HCl (Ca, PO4)20 min, 3x/2 hrs Noneblood clotfibrinolytic 2 hrs, 1x/24 hrs

26. 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

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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.