1. Tunneled Cuffed Catheters

2. 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.

3. 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

4. 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

5. 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.

6. 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.

7. PRESERVING CATHETER FUNCTION CATHETER CARE PLACEMENT TREATMENT ACCESS POSITIONING

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

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

10. 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

11. 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

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

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

14. CONTRAINDICATIONS 1. Sepsis 2. Coagulopathy

15. 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

16. 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

17. 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

18. 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.

19. DURATION > 7 days - PICC Line 1- 12 Weeks - PICC line / tunneled catheter 12 weeks - 6 months or greater - tunneled catheter > 6 months - Port

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

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

22. 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!!!!!!!

23. NON-TUNNELED EXTERNAL CATHETERS NON-TUNNELED EXTERNAL CATHETERS

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

25. Tunneled catheter with cuffs

26. Tunneled catheter with cuff

27. Tunneled catheter

28. 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

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

30. SUBCLAVIAN VEIN ACUTE ACUTE Senagore - 10% incidence of art. Puncture Senagore - 10% incidence of art. Puncture Mansfield - 12.2% unsuccessful access Mansfield - 12.2% 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 - 10-30% thrombosis, 10-40% Uldall - 10-30% thrombosis, 10-40% stenosis stenosis ACUTE ACUTE Senagore - 10% incidence of art. Puncture Senagore - 10% incidence of art. Puncture Mansfield - 12.2% unsuccessful access Mansfield - 12.2% 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 - 10-30% thrombosis, 10-40% Uldall - 10-30% thrombosis, 10-40% stenosis stenosis

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

32. 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

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

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

35. PREP Maximum Sterile Barrier - Surgical hats, gowns, masks & gloves 3 - 5 min. surgical scrub Antibiotics (controversial) 30-60 min. prior Cefazolin (Kefzol, Ancef) 1 gm IV or Gentamycin 80 mg IV

36. 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

37. 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

39. 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

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

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

42. 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

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

44. 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

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

46. 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

47. 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

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

49. INFECTION: CATHETER REMOVAL 1. Exit site - 15.4% 2. Tunnel - 69% 3. Septic thrombophlebitis - 100%

50. INFECTION 1. Septic thrombophlebitis - remove catheter 2. Cutaneous - local treatment 3. Bacteremia - 1. IV antibiotics 48 -72 hours if improved - keep catheter if no change, worse or recurs remove catheter or 2. Exchange catheter over wire, 85% cure with treatment

51. Continue to treat infection for 10 - 14 days If ineffective - try locking with thrombolytics between antibiotic doses and administer antibiotics through catheters INFECTION

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

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

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

55. CORRECTING MALPOSITION 1. Imaging guidance 2. Redirecting catheters

56. THANK YOU !