Use of Tunneled-Cuffed Central Catheters in Patients with Cancer: A Single-Center Experience

Background

Effective and reliable venous access is among the cornerstones of modern medical therapy in oncology.

A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters.

BACKGROUND. The incidence of infection increases with the prolonged use of central vascular catheters, but it is unclear whether changing catheters every three days, as some recommend, will reduce the rate of infection, It is also unclear whether it is safer to change a catheter over a guide wire or insert it at a new site. METHODS. We conducted a controlled trial in adult patients in intensive care units who required central venous or pulmonary-artery catheters for more than three days. Patients were assigned randomly to undergo one of four methods of catheter exchange: replacement every three days either by insertion at a new site (group 1) or by exchange over a guide wire (group 2), or replacement when clinically indicated either by insertion at a new site (group 3) or by exchange over a guide wire (group 4). RESULTS. Of the 160 patients, 5 percent had catheter-related bloodstream infections, 16 percent had catheters that became colonized, and 9 percent had major mechanical complications. The incidence rates (per 1000 days of catheter use) of bloodstream infection were 3 in group 1, 6 in group 2, 2 in group 3, and 3 in group 4; the incidence rates of mechanical complications were 14, 4, 8, and 3, respectively. Patients randomly assigned to guide-wire-assisted exchange were more likely to have bloodstream infection after the first three days of catheterization (6 percent vs. 0, P = 0.06). Insertions at new sites were associated with more mechanical complications (5 percent vs. 1 percent, P = 0.005). CONCLUSIONS. Routine replacement of central vascular catheters every three days does not prevent infection. Exchanging catheters with the use of a guide wire increases the risk of bloodstream infection, but replacement involving insertion of catheters at new sites increases the risk of mechanical complications.     

Temporary vascular catheters for hemodialysis: a 3-year prospective study

BACKGROUND: Temporary hemodialysis catheters are necessary in patients with uremia, but complications associated with these catheters represent one of the most important sources of morbidity among ESRD patients. There is no general agreement about the optimal venous access for insertion of a central venous catheter, while risk factors of catheter related complications have not been entirely elucidated. METHODS: One hundred and seven consecutive patients who required a temporary hemodialysis catheter were prospectively examined. RESULTS: Catheters were placed in 107 consecutive patients (66 right jugular (JC), 41 right femoral (FC)) and maintained in situ for a cumulative total of 2101 days. Early complications (puncture site hemorrhage, hematoma formation, artery puncture) were infrequent, without clinical sequelae. The main late complication was catheter related bacteremia (CRB). There were 16 episodes of CRB (JC-10; FC-6) and Staphylococcus aureus was the most frequently isolated cause of CRB. The mean catheter duration before the onset of CRB was 19.9 and 18.2 days for JC and FC, respectively. Duration of catheter use, and the number of hemodialyses significantly increased the risk for CRB. Actuarial survival for FC was significantly worse than for JC, while Cox proportional hazard models revealed that the femoral site, chronic renal failure and kidney transplantation increased the risk of catheter failure significantly. CONCLUSION: CRB was the most common late complication. Its frequency was similar in JC and FC. The main risk factors for development of CRB were duration of catheter use and the number of performed dialyses. Cumulative hazard of CRB was significantly magnified 3 weeks after insertion for both JC and FC, but actuarial survival with JC was significantly longer.     

126例中心静脉导管在血液净化中的临床应用

目的通过观察中心静脉留置导管在血液透析中使用状况,探讨中心静脉导管相关并发症及处理方法,改善血液透析患者预后。方法回顾性分析126例使用中心静脉置管维持性血液透析患者的临床资料。其中25例为长期双腔导管,101例为临时双腔导管,分析中心静脉导管的相关并发症与处理效果。结果置管过程中的常见并发症有：误穿动脉11例（8.73%）、皮下血肿6例（4.76%）。导管留置并发症有：血流量不足24例（19.04%）,导管相关感染23例（18.25%）,穿刺部位渗血15例（11.90%）,导管意外脱落3例（2.38%）。以上并发症均在给予相应的处理后痊愈,未留下相关后遗症。结论中心静脉导管相关并发症值得临床重视,提高置管技术,加强导管护理,及时处理是防范导管失功能的关键。     

Right atrial thrombi complicating use of central venous catheters in hemodialysis

BACKGROUND: There has been an increase in the use of central venous catheters for temporary hemodialysis access. In this report, we describe a case series of 12 patients on hemodialysis who developed intracardiac clots associated with the use of central venous catheters, their outcomes and review the literature on this syndrome. METHODS: Retrospective, single-center case series of 12 patients with right atrial thrombi associated with central venous catheter use for dialysis vascular access. These patients were treated between June 1, 2001 and June 30th 2002 at the three University of Rochester affiliated dialysis clinics. The medical records of these patients were reviewed to obtain information concerning demographics, dialysis history, dates of catheter insertion, catheter complications, identification and dimensions of intracardiac thrombi, echocardiographic data, and outcome of anticoagulant therapy. RESULTS: Right heart thrombi were identified in 12 patients in our hemodialysis population over the study interval. Anticoagulation for 6 months led to clot resolution in more than 50% of our patients. Bacteremia recurred in 6 patients (50%), in spite of catheter replacement. There was zero mortality related to presence of clots in the short term. One patient with non-bacteremic right atrial thrombus suffered sudden cardiac arrest, but was successfully resuscitated. CONCLUSION: Right atrial thrombi may occur in hemodialysis patients who use central venous catheters for dialysis access. These clots are frequently found in the right atrium or right atrial-superior vena caval junction. Ten of 12 patients (83%), had catheter-associated bacteremia, but the precise relationship between bacteremia and intracardiac clots is unclear. Chronic anticoagulation for 6 months lead to resolution of these clots in more than 50% of patients in our series.     

The Risk of Central Venous Catheter Placement Ipsilateral to the Permanent Pacemaker

PurposeThe use of a central venous catheter is essential in the delivery of chemotherapy and other necessary intravenous treatments for oncology patients. This paper reviews the published reports of venous complications associated with an implanted cardiac pacemaker, and suggests some important considerations when planning to insert a central venous catheter through a peripheral approach.Review of LiteratureThe subclavian venous system in the chest is the most common site for implanting pacemaker leads in patients with underlying heart problems. Venous complications after pacemaker implantation, such as stenosis, hematoma, thrombophlebitis, and thrombosis, can occur with or without the known associated local symptoms.DiscussionNo published case reports were found describing pacemaker leads displacement after insertion of central venous catheters, including peripherally inserted central catheters.Implications for Clinical PracticePrior to inserting a central venous catheter, a thorough assessment should include the patient's history of any implanted medical device, in the context of understanding the clinical manifestations associated with the signs and symptoms of venous obstruction.     

Risk factors for central venous catheter-related infections in general surgery.

BACKGROUND AND PURPOSE: Central venous catheter (CVC) infection is a common problem during hospitalization and nosocomial bloodstream infection in these patients is associated with increased morbidity, mortality, and health care cost. This prospective study examined the risk factors of CVC-related infections. METHODS: During a 6-month period, a total of 281 patients who underwent central venous catheterization after general surgery were enrolled. RESULTS: The mean duration from CVC insertion to the development of infection was 7.12 days. The rate of bloodstream infection without isolation of the same organism from the catheter was 1.4% (4/281). The rate of catheter-related bloodstream infection was 6.0% (17/281). The rate of catheter bacteremia, defined as positive culture from a catheter blood sample in a patient without signs of infection, was 8.5% (24/281). The incidence of catheter-related bloodstream infection was 7.5/1000 catheter-days. Risk factors for catheter-related infection on univariate analysis included place of insertion (operating room or surgical ward), total parenteral nutrition (TPN), more than 3 tubings, and duration of catheterization. TPN was a significant risk factor in the logistic regression analysis. CONCLUSIONS: Established infection control guidelines should be rigorously observed with regard to catheter use and various risk factors controlled to prevent the occurrence of CVC-related infection, especially in patients receiving TPN.     

Prevention of catheter related bloodstream infection by silver iontophoretic central venous catheters: a randomised controlled trial

AIM: To evaluate the efficacy of silver iontophoretic central venous catheters in preventing catheter related colonisation and bloodstream infection among high risk patients in a tertiary hospital. METHODS: Patients requiring central venous access for a period greater than seven days were stratified into two groups according to systemic inflammatory response syndrome criteria before being randomly assigned to receive either silver iontophoretic or control catheters. The incidence of catheter colonisation and catheter related bloodstream infection (CRBSI) was recorded. RESULTS: Three hundred and four single lumen study catheters were inserted into 268 patients. Total duration of catheterisation was 5449 days (median, 12 days/catheter). Complete data could be evaluated in 270 catheters: 128 silver iontophoretic catheters and 140 untreated catheters. Forty seven silver iontophoretic catheters (36.7%) were colonised compared with 48 control catheters (33.8%). Seven cases (5.5%) of CRBSI occurred in patients who received silver iontophoretic catheters, compared with 11 cases (7.7%) in patients receiving control catheters. There was no significant difference in the incidence of catheter colonisation or CRBSI between silver iontophoretic and control catheters. When the duration of catheter placement was taken into consideration, Kaplan-Meier analysis showed no significant difference in the risk of CRBSI between the silver iontophoretic catheters and the untreated catheters (p = 0.77). CONCLUSION: There was no significant difference in the incidence of catheter colonisation or CRBSI among high risk patients between silver iontophoretic catheters and control catheters. Future prospective, randomised studies with a larger number of catheters are encouraged to confirm or refute these results.     

Correction of CAPD catheter displacement using gastric biopsy forceps: the push-pull method.

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the "push-pull method". A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5-10 minutes and there were no complications.     

The Effects of 3 Peripherally Inserted Central Catheter Insertion Techniques in Chinese Patients With Different Vascular Status

ObjectiveTo provide evidence for selecting an appropriate peripherally inserted central catheter (PICC) insertion technique by comparing the insertion success rate and the incidence of complications with 3 PICC insertion techniques.MethodsWe assigned enrolled patients to 3 groups according to the insertion technique selected by the individual patient: Group A, usual insertion technique (traditional, blind insertion); Group B, Modified Seldinger Technique (MST) insertion without ultrasound guidance; and group C, ultrasound-guided MST insertion. We compared the insertion success rate and the incidence of complications among these groups.ResultsWhen comparing these 3 PICC insertion techniques, no significant difference was seen with respect to the insertion success rate and the incidence of catheter malposition (P > 0.05), although a significant difference existed in the incidence of bleeding at the insertion site after the PICC procedure (P < 0.05), with the ultrasound-guided MST insertion technique superior to the other 2 techniques; the incidence of mechanical phlebitis and catheter occlusion during the use of PICC had no significant difference among the 3 groups (P > 0.05); but a significant difference was seen in the incidence of thrombosis and catheter-related infections (P < 0.05), with a lower incidence in the ultrasound-guided MST insertion group than that in the other 2 groups.ConclusionsUltrasound-guided MST insertion technique may address the problems occurring in patients with poor vascular access during the PICC procedure, whereas the usual insertion technique is the best choice for patients with good vascular access and poor economic status. Therefore, the selection of an appropriate insertion technique should be based on the economic and vascular status of the individual patient in clinical practice.     

Central venous catheter - related infections

Central venous catheters are essential in complex medical and surgical interventions. It is estimated that 200,000 nosocomial bloodstream infections occur each year; 90% of these infections are related to the use of central venous catheters with increased morbidity and mortality, prolonged hospitalization and intensive unit stay, and greater hospital cost. The cause of the increased incidence of bacteremia and intravascular catheter infections is multifactorial and a source of ongoing debate. The skin, parenteral nutritional mixtures or hematogenous seeding accounted for 70% of the catheter-related bloodstream infections (CBI); the remaining 30% were traced to the hub. The three most common types of organisms causing CBI are coagulase negative staphylococci (usually S. epidermidis), S. aureus, and Candida spp. More rarely, gram-negative bacilli (Pseudomonas spp, Acinetobacter spp), enteric organisms and enterococci are implicated. Treatment includes catheter withdrawal and appropriate antibiotic coverage. For patients requiring only short-term access, the most effective approach is catheter removal, administration of parenteral antibiotics and replacement of the catheter at a different site. However, critically ill patients in hemodynamic monitoring or in TPN or chemotherapy require continuous central venous access, and the approach is to change the potentially infected line over guidewire, intravenous antibiotics and "catheter antibiotic lock" for 24 hours. If a patient's clinical course fails to improve after 28-48 hours of antimicrobial therapy, the catheter should be removed and replaced at a new site.     

218例儿科经外周静脉置入中心静脉导管置管相关并发症分析及预防处理对策

目的：探讨经外周静脉置入中心静脉导管(peripherally inserted central catheter,PICC)在儿科患者应用中出现的常见并发症及预防处理对策对策,以期减少并发症的发生。方法：对我院儿科218例行PICC患者进行调查,分析其相关并发症,同时总结预防处理对策。结果：218例患儿均置管成功,置管后39例出现了置管相关并发症(12例导管出现2种以上并发症),其发生率为23.4%(51/218),其中静脉炎发生率最高,发生率为18(8.3%);非计划性拔管、导管堵塞、导管异位及导管相关血流感染发生率分别为12(5.5%)、7(3.2%)、6(2.8%)、5(2.3%)。结论：加强小儿PICC的围手术期护理和有效干预,对并发症进行积极有效的处理,可延长置管时间,减少并发症的出现。     

Complications of peritoneal dialysis catheters: early and late

The complications of peritoneal dialysis catheters are often due to errors made during the initial catheter insertion procedure. Other complications relate to the improper selection of the catheter type or size. Thus, many complications are preventable. This review summarizes the complications resulting from the insertion or presence of a PD catheter and classifies them as either early or late events. A short comment on early diagnosis and appropriate management is also provided.     

Evaluation of length of central venous catheter inserted via cubital route in Indian patients

Aim:

Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning.

Materials and Methods:

A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR.

Results:

200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated.

Conclusions:

Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.     

Assessing the Quality of Central Venous Catheter and Peripherally Inserted Central Catheter Videos on the YouTube Video-Sharing Web site

BackgroundVideo sharing networks such as YouTube have revolutionized communication. Whilst access is freely available uploaded videos can contain non peer-reviewed information. This has consequences for the scientific and health care community, when the challenge in teaching is to present clinical procedures that follow empirical methods.ObjectiveTo review 50 central venous catheter and peripherally inserted central catheter videos posted on YouTube. The aim was to appraise these videos using current evidenced-based guidelines.MethodsWe searched YouTube using the key words central venous cannulation and peripherally inserted central catheter insertion on September 21, 2012. We consecutively reviewed 50 videos for both procedures.ResultsThere was poor adherence to evidence-based guidelines in the critiqued videos. There was a difference in adherence with the use of appropriate skin antisepsis in the 2 groups (18% for central venous catheters vs 52% for peripherally inserted central catheters; p=0.009). And a large proportion in both groups compromised aseptic technique (37% for central venous catheters vs 38% for peripherally inserted central catheter; p=0.940). The use of ultrasound guidance during procedures was also different between the 2 groups (33% for central venous catheters vs 85% for peripherally inserted central catheters; p=0.017).ConclusionsThis critique of instructional videos related to the insertion of central venous catheters and peripherally inserted central catheters uploaded to YouTube has highlighted poor adherence to current evidence-based guidelines. This lack of adherence to empirical guidelines can pose risks to clinical learning and ultimately to patient safety.     

Use and Performance of Midline Catheters in a Geriatric Population

Elderly patients present unique challenges to the infusion therapist. Normal physiologic changes make venous access and catheter retention difficult. The performance of midline catheters was assessed in 138 patients 60 years of age and older. The data were analyzed separately for old patients (defined as those 60–79 years of age) and older patients (defined as those 80 years of age and older). Midline catheters were placed in patients primarily for infection, fluid maintenance, cancer chemotherapy, and pain management by nurses at Advanced Infusion Systems. Patients in the older group were more difficult to access on the first attempt and also were more likely to pull their catheters out prior to end of therapy. The catheters remained indwelling up to 45 days in both groups, with a median time to a catheter-related complication of 20 days in old patients and 24 days in older patients. Inflammation rates were similar in the two age groups. The older group developed inflammation earlier in therapy than the old group. The midline catheter offered reliable venous access for patients age 60 and older.     

Central venous catheter-related sepsis in a cohort of 366 hospitalised patients

Five hundred two central venous catheters inserted in 366 patients were evaluated prospectively over a one-year period to determine the frequency and risk factors associated with catheter-related sepsis. For study purposes, in cases in which catheter infection was suspected but the initial blood cultures were negative, the catheters were replaced by guidewire technique; otherwise, the catheters were routinely changed after 21 days by guidewire technique. A catheter-related infection was suspected in 190 cases (190/502, 38%). A diagnosis of catheter-related sepsis was established in 50 patients, which represents 10% of the total number of lines (502). Over a total of 6428 days of catheter use, the infection rate was 0.8 cases of sepsis per 100 catheter-days.Staphylococcus epidermidis, Staphylococcus aureus, andCandida spp. were the most frequently isolated aetiological agents of sepsis. On univariate analysis, six variables affecting the rate of catheter-related sepsis were identified: neutropenia for more than eight days (p<0.001); AIDS (p<0.001); haematological malignancy (p<0.001); administration of total parenteral nutrition (p=0.001); duration of site use (p=0.04); and high APACHE II score (p=0.04). The logistic regression analysis revealed that AIDS and haematological malignancies were independent risk factors of catheter-related sepsis. Catheter replacement over a guidewire was no more likely to be associated with sepsis than was percutaneous catheter insertion. In conclusion, although the incidence of established catheter infection is much lower than the incidence of suspected infection, in most cases of suspected infection it is wise to change the catheter with the guidewire technique and wait for culture of the tip, rather than to remove the catheter immediately. Such a policy may help reduce the number of unnecessary catheter removals.     

Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai

Blood stream infections related to central venous catheterization are one of the major device-associated infections reported. Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI). The CRBSI rate was 9.26 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27.02/1000 days). Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate. Coagulase-negative Staphylococci were the predominant cause. Mortality of 33% was observed in patients with CRBSI. Since central venous catheters are increasingly being used in the critical care, regular surveillance for infection associated them are essential.     

Chronic venous access in the elderly

The use of chronic venous catheters has become routine in the management of neoplastic disease. If an anticipated result of diagnosis related grouping (DRG) reimbursement to hospitals is earlier patient discharge and reliance on more intensive outpatient management, concern about the safety and maintenance of such catheters in the outpatient elderly will become a more common issue. With careful patient selection and emphasis on catheter care, insertion of these catheters in the elderly is safe and reliable.