1. Central venous catheters February 2010 Anne Aspin

2. Central venous catheter Central venous access is the placement of a venous catheter in a vein that leads directly to the heart. Central venous access is the placement of a venous catheter in a vein that leads directly to the heart.

3. Site Basillic or long saphenous vein preferred. Basillic or long saphenous vein preferred. NB. Blood or blood products should not be infused. Catheter may rupture or block. NB. Blood or blood products should not be infused. Catheter may rupture or block. Catheter should always be flushed with Catheter should always be flushed with 10 ml syringe 10 ml syringe

4. Which vein to cannulate Veins commonly lie close to arteries and nerves Veins commonly lie close to arteries and nerves Subclavian vein lies close to dome of pleura, damage lead to pneumothorax Subclavian vein lies close to dome of pleura, damage lead to pneumothorax

5. Types used Percutaneous long lines Percutaneous long lines Percutaneous multi lumen lines Percutaneous multi lumen lines Peripheral inserted central catheter (PICC) Peripheral inserted central catheter (PICC) Broviac and Hickman lines Broviac and Hickman lines Portacath Portacath

6. Length of time to use Percutaneous line. Percutaneous line. 10 – 12 weeks 10 – 12 weeks Percutaneous multi lumen line Percutaneous multi lumen line 5 – 10 days post operation 5 – 10 days post operation

7. PICC line PICC line 10 / 12 weeks 10 / 12 weeks Broviac / Hickman line / Portacath Broviac / Hickman line / Portacath For long term use For long term use

8. Percutaneous long line TPN TPN Clear fluids Clear fluids Medications - infuse slowly Medications - infuse slowly

9. PICC TPN TPN Clear fluids Clear fluids Blood transfusion Blood transfusion Medications Medications Flush off Flush off

10. Broviac / Hickman / Portacath TPN TPN Clear fluids Clear fluids Blood transfusion Blood transfusion Medications Medications

11. Percutaneous Multi lumen line TPN TPN Clear fluids Clear fluids Blood transfusion Blood transfusion Medications Medications Caution, ports 1, 2, 3 Caution, ports 1, 2, 3

12. Complications Sepsis Sepsis Embolus Embolus Malposition Malposition Occlusion Occlusion Fibrin sheath formation Fibrin sheath formation Dislodge Dislodge rupture rupture Thrombus Thrombus Pneumothorax Pneumothorax Perforation of vessel Perforation of vessel Cardiac tamponade Cardiac tamponade Endocarditis Endocarditis Vent arrythmia Vent arrythmia Phlebitis Phlebitis Cuff erosion Cuff erosion

13. Sepsis Pyrexia, >38c Pyrexia, >38c Labile temperature Labile temperature Labile sugars Labile sugars Shock, pallor Shock, pallor Apnoea Apnoea tachycardia tachycardia Bradycardia Bradycardia Capillary venous return > 4 secs Capillary venous return > 4 secs Grey Grey Quiet Quiet thrombocytopenia thrombocytopenia

14. Infection Life threatening where neutriphil counts <500 cells/mm. Life threatening where neutriphil counts <500 cells/mm. Local infection – exit site, port pocket and tunnel infection. Local infection – exit site, port pocket and tunnel infection. Systemic infection, colonised thrombi or fibrin sleeves Systemic infection, colonised thrombi or fibrin sleeves Intraluminal or extraluminal colonisation Intraluminal or extraluminal colonisation

15. Infection Gram –ve aerobes from gastro intestinal tract Gram –ve aerobes from gastro intestinal tract E. coli, klebsiella, pseudomonas 25-33pc E. coli, klebsiella, pseudomonas 25-33pc Gram pos aerobes, Staph aureus,staph epidermis, strep 50pc Gram pos aerobes, Staph aureus,staph epidermis, strep 50pc Candida 5-7pc Candida 5-7pc

16. Greater risk infection with multi lumen catheter Greater risk infection with multi lumen catheter In one study removed 139 days earlier. In one study removed 139 days earlier. Implanted port less infections Implanted port less infections Extraluminal clot at catheter tip –related to cath related sepsis. Extraluminal clot at catheter tip –related to cath related sepsis.

17. Pseudomonas difficult to eradicate Pseudomonas difficult to eradicate Antibiotics down the line Antibiotics down the line Locking catheter for two hours could eradicate pseudomonas, not confirmed in human studies. Locking catheter for two hours could eradicate pseudomonas, not confirmed in human studies. ?Trial, Benefit / risk antibiotic resistance. ?Trial, Benefit / risk antibiotic resistance.

18. Catheter occlusion Cannot draw back nor solutions infuse Cannot draw back nor solutions infuse Usually clotted blood, precipitate Usually clotted blood, precipitate Flush well after sampling Flush well after sampling Streptokinase, Urokinase – fibrinolytic agents. 5000 units per 1 cc Streptokinase, Urokinase – fibrinolytic agents. 5000 units per 1 cc 1ml each lumen, 4 hours. Check pharmacy. 1ml each lumen, 4 hours. Check pharmacy. Takes 27 minutes, leave 60 mins. Takes 27 minutes, leave 60 mins.

19. Extravasation Leakage from vein into subcutaneous space Leakage from vein into subcutaneous space Pain, irritation in chest, swelling, necrosis Pain, irritation in chest, swelling, necrosis Crying, fussy, distressed. Crying, fussy, distressed.

20. Catheter malposition Painful phlebitis Painful phlebitis Thrombosis Thrombosis Backtracking Backtracking Pericardial effusion Pericardial effusion Cardiac tamponade chest pain, shortness of breath. Cardiac tamponade chest pain, shortness of breath.

21. Cochrane review 2004 Perc CVC versus peripheral cannula Perc CVC versus peripheral cannula RCTs RCTs 3 trials for inclusion 3 trials for inclusion CVC does improve nutrient input CVC does improve nutrient input No evidence of CVC increased risk of adverse events, ie infection. No evidence of CVC increased risk of adverse events, ie infection.

22. Percutaneous CVC infants <1000g 28g single lumen, 20cm long maximum flow 38mls / hr. infants <1000g 28g single lumen, 20cm long maximum flow 38mls / hr. Premicath 27g, markings every 5cm, max flow rate 30ml / hr Premicath 27g, markings every 5cm, max flow rate 30ml / hr

23. Percutaneous CVC Infants > 1000g, 24g, 30cms long, max flow 50 ml/hr Infants > 1000g, 24g, 30cms long, max flow 50 ml/hr PICC, 20g, silicone, 50cm long PICC, 20g, silicone, 50cm long Epicutaneo Neocath, silicone, 30cm and 50cm length. Max flow 100ml/hr. Epicutaneo Neocath, silicone, 30cm and 50cm length. Max flow 100ml/hr.

24. Perc CVC removal Use no longer justified Use no longer justified Bacteraemia beyond 48-72 hrs despite appropriate antibiotics Bacteraemia beyond 48-72 hrs despite appropriate antibiotics Septicaemia due to fungal infection Septicaemia due to fungal infection Evidence of septic emboli or endocarditis Evidence of septic emboli or endocarditis

25. Broviac / Hickman line Soft silicone Soft silicone Tunneled Tunneled Buried under skin Buried under skin Tissue grows around cuff to secure in place. Tissue grows around cuff to secure in place. Cuff acts as barrier to infection Cuff acts as barrier to infection Can be flushed off. Can be flushed off.

26. Dressings Evidence. Evidence. Transparent / gauze / no dressing Transparent / gauze / no dressing Change dressing daily until dry then change twice weekly. Change dressing daily until dry then change twice weekly. Chlorhexidine 1:200, 70% alcohol Chlorhexidine 1:200, 70% alcohol

27. Portacath Chemotherapy Chemotherapy Medications Medications For cancer or leukaemia For cancer or leukaemia Soft plastic tube, disc between 2.5-4cm. Soft plastic tube, disc between 2.5-4cm. Catheter tunneled Catheter tunneled Years. Discreet Years. Discreet

28. Ultrasound devices Systematic review 2003 Systematic review 2003 Objective. To investigate clinical and cost- effectiveness of ultrasonic locating devices. Objective. To investigate clinical and cost- effectiveness of ultrasonic locating devices. Ultrasound – two dimensional image Ultrasound – two dimensional image Dopplers – audible sound from venous blood flow Dopplers – audible sound from venous blood flow

29. Result Twenty RCTs Twenty RCTs Sample size small Sample size small < ten pounds per procedure < ten pounds per procedure For every 1000 procedures, ?save 2000 For every 1000 procedures, ?save 2000 Improved failure and complication rate. Improved failure and complication rate.

30. References Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J, Levy I (2005). Infectious complications for implantable parts and Hickman catheters in paediatric haematology oncology patients. Journal of Hospital Infection. 62 : 358 - 365 Adler A, Yaniv I, Steinberg R, Solter E, Samra Z, Stein J, Levy I (2005). Infectious complications for implantable parts and Hickman catheters in paediatric haematology oncology patients. Journal of Hospital Infection. 62 : 358 - 365 Alexander N (2010). Question 3. Do Portocaths or Hickman lines have a higher risk of catheter-related bloodstream infections in children with leukaemia. Archives of Disease in Childhood. 95 : 239 - 241. Alexander N (2010). Question 3. Do Portocaths or Hickman lines have a higher risk of catheter-related bloodstream infections in children with leukaemia. Archives of Disease in Childhood. 95 : 239 - 241. doi:10.1136/adc2009.176545 doi:10.1136/adc2009.176545 Larson S, Hebra A, Raju R, Lee S (2010). Vascular Access, Surgical treatment. http://emedicine.medscape.com/article/1018395- overview Larson S, Hebra A, Raju R, Lee S (2010). Vascular Access, Surgical treatment. http://emedicine.medscape.com/article/1018395- overviewhttp://emedicine.medscape.com/article/1018395- overviewhttp://emedicine.medscape.com/article/1018395- overview McIntosh W (2003). Central venous catheters : reasons for insertion and removal. Paediatric Nursing. Vol 15, No 1 McIntosh W (2003). Central venous catheters : reasons for insertion and removal. Paediatric Nursing. Vol 15, No 1 Simon A, Ammann R, Wiszniewsky G, Bude U, Fleischhack G, Besuden M (2008). Taurolidine-citrate lock solution (Taurolock) significantly reduces CVAD - associated grampositive infections in paediatric cancer patients. BMC Infectious Diseases. 8 : 102 Simon A, Ammann R, Wiszniewsky G, Bude U, Fleischhack G, Besuden M (2008). Taurolidine-citrate lock solution (Taurolock) significantly reduces CVAD - associated grampositive infections in paediatric cancer patients. BMC Infectious Diseases. 8 : 102