1. WORKSHOP CENTRAL LINE CARE HUSNI ROUSAN KING ABDULLAH UNIVERSITY HOSPITAL

2. 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

3. 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

4. PRESERVING CATHETER FUNCTION CATHETER CARE PLACEMENT TREATMENT ACCESS POSITIONING

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

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

7. 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

8. WHY INTERVENTIONAL RADIOLOGY ?? Patient convenience Fewer complications Expediency Accuracy Lower cost

9. 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

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

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

12. CONTRAINDICATIONS 1. Sepsis 2. Coagulopathy

13. 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

14. 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

15. 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

16. 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.

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

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

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

20. 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!!!!!!!

21. 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

23. PICC LINES 1. Silastic or polyurethane 2. Single or double lumen 3. Low flow 4. Short - long term 5. Easy access

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

26. Tunneled catheter with cuffs

27. Tunneled catheter with cuff

28. Tunneled catheter

29. SUBCUTANEOUS PORTS 1. Single or double lumen 2. Flow - most commonly slow 3. Long term 4. Access requires needle puncture

30. Port

31. 5. Less maintenance 6. Activity is unlimited after site heals 7. Cosmetically more appealing 8. Concealed pocket retards infection (?) SUBCUTANEOUS PORTS

32. Dual Port

33. Residual debris in explanted ports

34. 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

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

36. 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

37. SUBCLAVIAN VEIN COMPLICATIONS STENOSISTHROMBOSIPINCH OFF SYNDROME Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)

38. 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

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

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

41. 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

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

43. 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

45. 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

46. 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

47. 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

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

49. COMPLICATIONS: ACUTE 1. Spasm 4. Pneumothorax 2. Access failure 5. Malposition 3. Arterial puncture 6. Air embolus

50. 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

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

52. 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

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

54. 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

55. 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

56. INFECTION CAUSATIVE ORGANISMS Staph epidermidis 25-50% Staph aureus25% Candida 5-10%

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

58. 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

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

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

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

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

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