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WORKSHOP CENTRAL LINE CARE HUSNI ROUSAN KING ABDULLAH UNIVERSITY HOSPITAL
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OBJECTIVES 1. Identify Various Central Devices 2. Determine critical elements of care and maintenance of central venous lines 3. Identify potential complications related to central lines 4. Demonstrate ideal dressing for central lines
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Out line Introduction Objectives Types of central lines Central line complications Central line flow control Flushes for central lines Dressing changes for central lines Blood withdrawal from central lines Changing access/injection caps Care of the hickman site
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PRESERVING CATHETER FUNCTION CATHETER CARE PLACEMENT TREATMENT ACCESS POSITIONING
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Types of central lines Open-ended tunneled catheters Tunneled valved catheters Implanted ports Nontunneled central venous catheters (CVCs) Peripherally inserted central catheters (PICCs)
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Central Line Complications Central Line Complications Infections Air embolus Dislodgement of catheter Catheter occlusion
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Central Line Flow Control Central Line Flow Control Volume in ML x Drop factor DEVIDED BY # of hours to be infused x 60 Drop factors are 15 drops / cc OR 60 drops / cc
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WHY INTERVENTIONAL RADIOLOGY ?? Patient convenience Fewer complications Expediency Accuracy Lower cost
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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
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DISADVANTAGES OF CENTRAL VENOUS ACCESS More invasive - potentially more complications and pain Acute Chronic
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1. Long term IV therapy: Chemo Antibiotics TPN Blood products 2. Recurrent blood draws 3. Dialysis/Pharesis CENTRAL VENOUS ACCESS: INDICATIONS
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CONTRAINDICATIONS 1. Sepsis 2. Coagulopathy
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TYPES OF CENTRAL VENOUS ACCESS 1. Non tunneled external catheters a. Central line b. PICC line 2. Tunneled catheters 3. Subcutaneous Ports a. chest b. arm
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CHOOSING THE ACCESS DEVICE Patients disease and status Number and type of solutions, osmolality Flow required Frequency accessed Duration of use- days vs months Preferences - Dr. / Patient
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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
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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.
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DURATION > 7 days - PICC Line 1- 12 Weeks - PICC line / tunneled catheter 12 weeks - 6 months or greater - tunneled catheter > 6 months - Port
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FREQUENCY OF ACCESS Frequent access and infusion - tunneled catheter Infrequent access (every week or month)-port
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MATERIAL Silastic thicker, softer, larger for same flow, more friction over a wire Polyurethane stiffer, thinner wall, smaller for same flow, less friction
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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!!!!!!!
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NON-TUNNELED EXTERNAL CATHETERS 1. Polyurethane 2. Single or multiple lumens 3. Flow varies depending on size and ID 4. Temporary - requires frequent exchanges 5. Easier placement, removal and replacement
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PICC LINES 1. Silastic or polyurethane 2. Single or double lumen 3. Low flow 4. Short - long term 5. Easy access
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TUNNELED CATHETERS 1. Single or multiple lumens 2. Flow - variable 3. Long term 4. Easy access (no skin puncture) 5. Cuff - Dacron, vita
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Tunneled catheter with cuffs
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Tunneled catheter with cuff
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Tunneled catheter
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SUBCUTANEOUS PORTS 1. Single or double lumen 2. Flow - most commonly slow 3. Long term 4. Access requires needle puncture
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Port
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5. Less maintenance 6. Activity is unlimited after site heals 7. Cosmetically more appealing 8. Concealed pocket retards infection (?) SUBCUTANEOUS PORTS
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Dual Port
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Residual debris in explanted ports
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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
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LOWER EXTREMITY Most commonly femoral vein Easily contaminated from proximity to groin Complication of DVT less tolerated than upper extremity
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SUBCLAVIAN VEIN ACUTE Senagore - 10% incidence of art. Puncture Mansfield - 12.2% unsuccessful access CHRONIC Cimchowski - 50% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Uldall - 10-30% thrombosis, 10-40% stenosis ACUTE Senagore - 10% incidence of art. Puncture Mansfield - 12.2% unsuccessful access CHRONIC Cimchowski - 50% stenosis SCV, 10% IJV Shillinger - 42% stenosis SCV, 10% IJV Uldall - 10-30% thrombosis, 10-40% stenosis
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SUBCLAVIAN VEIN COMPLICATIONS STENOSISTHROMBOSIPINCH OFF SYNDROME Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)
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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
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CENTRAL VENOUS CATHETER PLACEMENT 1. Prep 2. Access 3. +/- Tunnel 4. Secure
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Alcohol scrub to remove surface oils Chlorhexidine scrub Betadine prep (allow to dry) Ioban dressing and drapes PREP
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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
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ACCESS Ultrasound (US) or venography to localize vein Micropuncture technique 21 ga needle.018” wire Dilate to appropriate size for peel away sheath
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TUNNEL Some evidence suggests it should exceed 6 cm for best results Tunnel using sharp or blunt device Avoid bleeding !!!!!! Position and place through peel away
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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
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PORT POCKET Choose convenient comfortable site Use 1% lidocaine with epi Make a 3 cm incision with a # 15 blade Create pocket with blunt dissection - hemostat and finger
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4 X 4’s or portable bovie to abate bleeding Prevent bleeding to avoid infection Secure port with non-absorbable sutures Close wound with subcuticular or interrupted sutures PORT POCKET
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COMPLICATIONS 1. Acute Procedural 2. Sub-acute Infection 3. Chronic Infection Catheter fragmentation Non-function
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COMPLICATIONS: ACUTE 1. Spasm 4. Pneumothorax 2. Access failure 5. Malposition 3. Arterial puncture 6. Air embolus
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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
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AIR EMBOLUS: SYMPTOMS 1. Respiratory distress 2. Increased heart rate 3. Cyanosis 4. Poor pulse 5. Change in the level of consciousness
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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% 30% with conventional treatment
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COMPLICATIONS: CHRONIC 1. Infection 2. Catheter fragmentation 3. Non-function
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PREVENTING INFECTION 1. Sterile environment 2. Periprocedural antibiotics 3. Number of lumens incidence of infection 4. Prep 5. Skin fixation 6. Dry dressing vs. Occlusive dressing 7. Ointments - Iodophor vs antibiotic 8. Special instructions
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TYPES OF INFECTION EXIT SITE, TUNNEL/POCKET or CATHETER 1. Cutaneous - pain, erythema, swelling, +/- exudate 2. Bacteremia - fever, leukocytosis and positive blood cultures 3. Septic thrombophlebitis - bacteremia, thrombosis and purulent discharge
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INFECTION CAUSATIVE ORGANISMS Staph epidermidis 25-50% Staph aureus25% Candida 5-10%
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INFECTION: CATHETER REMOVAL 1. Exit site - 15.4% 2. Tunnel - 69% 3. Septic thrombophlebitis - 100%
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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
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Continue to treat infection for 10 - 14 days If ineffective - try locking with thrombolytics between antibiotic doses and administer antibiotics through catheters INFECTION
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INFECTION: CATHETER REPLACEMENT 1. Afebrile 2. Negative blood culture
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CATHETER FRAGMENTATION 1. Power injection - > 2 cc/sec 2. Port injection - 10 cc syringe or greater 3. Catheter withdrawal 4. Pinch Off Syndrome
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NON - FUNCTION: CATHETER MALPOSITION 1.Intravascular vs. Extravascular 2. Infuses but doesn’t aspirate 3. Check the CXR
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CORRECTING MALPOSITION 1. Imaging guidance 2. Redirecting catheters
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