Central Lines Primer by mikesanye

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									            Central Lines:
              A Primer
• Tamara Simon, M.D.
• July 2004, updated August 2005
                  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
   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
   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
            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
              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
            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
                        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
                        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
                      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
          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%
        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
      Complications: Infection
• Microbiology
  –Coagulase negative staph*           38%
  –Gram negative rods                  25%
  –Enterococcus                        10%
  –Candida*                            9%
  –Staph aureus
  –* lipids increase risk, especially of slime
   producers
  MMWR 2002, 51:12
      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
       Complications: Infection
• Types of infection:
  –   Tunnel or pocket infection
  –   Exit site infection
  –   Catheter-related bacteremia
  –   Phlebitis
     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
             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
             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
             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
                Phlebitis
• Inflamed, palpable, thromobosed vein
• Often due to physiochemical factors rather
  than infection
• Increases the risk of infection, observed
  with insertion-site infections
            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
    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)
    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
           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
              Catheter Declotting
Infusion          Deposit       Un-occluder
Lipid             waxy          70% ethanol
                                1 hour, 1x
Basic drug        high pH ppt   7.5 % NaBicarb
                  (phenytoin)   1 hr, 1-2 x

Acidic drug       low pH ppt    0.1 N HCl
                  (Ca, PO4)     20 min, 3x/2 hrs

None              blood clot    fibrinolytic
                                2 hrs, 1x/24 hrs
    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
      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
    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)
   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
    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
       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
          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
                 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.

								
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