Hickman-Broviac catheters: Indications and results

The records of 84 patients in whom 98 Hickman-Broviac catheters were inserted were reviewed. The most common indication for catheter insertion was for administration of parenteral nutrition. Forty-four patients (52 percent) had catheters inserted for chemotherapy or combined chemotherapy and parenteral nutrition. Thirteen patients had Hickman-Broviac catheters inserted for the administration of antibiotics. The majority of the patients (56 percent) had malignant disease.The insertion of Hickman-Broviac catheters was uncomplicated, especially through the external jugular vein. Catheter-related complications occurred in 20 percent of the patients, but none were fatal. The most common complications were thrombotic catheter occlusion and catheter-related sepsis. The catheter-related sepsis rate was catheter-days. These rates compare favorably with those reported by other investigators. Any patient with potential vascular access difficulty or obliterated or thrombosed veins who requires parenteral medication should be considered a candidate for insertion of a Hickman or Broviac catheter.     

Central venous catheters in surgical neonates

Central venous catheters (CVCs) are widely used in neonates, but have significant complication rates. Over a 4-year period, 65 lines were inserted in 55 surgical neonates with a total of 877 catheter days. The mean length of insertion was 13.5 days, with a range of 1 to 35 days. Eighty percent of the surgical diagnoses were of necrotising enterocolitis, diaphragmatic hernia, or gastroschisis. Insertion was almost exclusively via the internal jugular vein. Only two Broviac catheters were used, the other catheters were noncuffed. Fourteen (22%) were inserted in the neonatal unit, with a similar complication rate to those inserted in the surgical theater. Overall, complications occurred with 22 lines (34%), seven of which (11%) were primary catheter sepsis (infection incidence, 1:125 days). One patient died as a result of catheter sepsis. Although the complication rate was similar, the complication incidence per day of catheter usage was higher than comparable reports. It is not clear if this was due to the pathological conditions of the surgical neonate, surgical or nursing technique, or the type of catheter used.     

Complications of superior versus inferior vena cava occlusion in infants receiving central total parenteral nutrition

During a 9-year period, 204 infants younger than 12 months of age had 294 Broviac central venous hyperalimentation catheters inserted. Fifty-nine adult-size and 235 infant-size Broviac catheters were used. Catheter insertion was via the saphenous vein (267), external jugular (7), internal jugular (16), cephalic (2), and transthoracic right atrial veins (2). General anesthesia was used for all internal jugular, but for only 11 saphenous catheters. Catheter function ranged from 6 to 925 days (mean, 112 days). Forty-four infants had malabsorption syndromes, 36 had short bowel syndrome, 38 had intractable diarrhea, and 86 required nutritional support for a variety of other conditions. Fifteen of the 204 infants developed inferior (10) or superior vena caval thrombosis (2), or both (3). Thrombosis occurred in 13 of the 267 infants with saphenous catheters (4.9%), and five of the 25 with jugular or cephalic venous catheters (20.0%). Obstruction to normal catheter infusion was the first sign of caval occlusion. Transient mild leg edema (4) and prominent venous pattern over the legs (3) were present with inferior vena caval (IVC) occlusion, but no patient had renal vein obstruction or died as a direct result of this condition. Each of the two patients with superior vena caval (SVC) occlusion experienced mild to moderate edema and venous suffusion of the head and upper extremities, and one developed a pleural effusion. Each of the three infants with combined superior and inferior vena caval thrombosis died from pulmonary insufficiency within six months after SVC occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical evaluation of percutaneous insertion and long-term usage of a new cuffed polyurethane catheter for central venous access.

A new, long-term venous access catheter was evaluated in clinical practice and the insertion time, complication rate and prospective follow-up recorded. Fifty novel polyurethane catheters (Cuff-Cath) were inserted in 48 patients, for cytotoxic chemotherapy in 36, long-term total parenteral nutrition in five and miscellaneous indications in seven. All catheters were inserted by a percutaneous technique under local anaesthesia. The mean insertion time was 18 min. There were three insertion complications; failure to cannulate, pneumothorax and malposition. Seven catheters required removal (sepsis in five, subclavian vein thrombosis in two) and one catheter fell out. Total catheter days to date has been 6607 (mean 132, range 18-831 days). Eleven catheters are still in use a mean of 154 days (range 38-490 days) after insertion. Furthermore, a new technique has been described which prevents inadvertent displacement. This new catheter combines the mechanical advantages of polyurethane, together with those of a Dacron cuff. Early results suggest that this catheter may be a useful alternative to silicone catheters of the Hickman/Broviac type for long-term central venous access.     

Catheter-related infections following axillary vein catheterization

Background : The aim of this study was to determine the rate of infectious complications following axillary vein cannulation and a compare to that observed after internal jugular vein cathterization.
Methods : A prospective comparative open study was carried out to determine the rate of infectious complications related to the use of catheters inserted via the axillary vein or the internal jugular vein. During the study period all patients submitted to central venous catheterization were evaluated. A total of 141 patients entered and completed the study. Catheter insertion sites were either the axillary vein punctured in the axilla, or the internal jugular vein punctured using an anterior approach. Catheter tips were cultured using a quantitative technique. Clinical information pertaining to the analysis was prospectively collected.
Results : A total of 141 catheters from 141 patients entered was studied. Clinical characteristics and risk factors for catheter infection were similar in both groups. The incidence of catheter-related infection (including catheter-related sepsis, and bacteremia) was not different between the two groups (axillary vein: 8.1%; internal jugular vein: 7.6%). Catheter-related bacteremia were seen at a rate of 3.7% in the internal jugular vein group and a rate of 1.6% in the axillary vein group (NS). The incidence of catheter colonization was similar in both groups (axillary vein: 14.5%; internal jugular vein: 11.4%).
Conclusion : Catheter-related infection after axillary vein catheterization was similar to that observed after internal jugular vein catheterization. The chance of developing catheter-related sepsis was less than 10% with either route when catheters were used for the treatment of severely ill patients.     

Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study

BACKGROUND: The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined. METHODS: This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss. RESULTS: 100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes ofnon-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation. CONCLUSIONS: Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anticoagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.     

Radiological placement of the AshSplit haemodialysis catheter: a prospective analysis of outcome and complications.

BACKGROUND: The AshSplit catheter has recently been introduced as an alternative permanent tunnelled haemodialysis catheter, combining ease of insertion with good long-term patency and flow rates. METHODS: Data were collected prospectively on all the long-term tunnelled haemodialysis (AshSplit) catheters inserted radiologically between January 1998 and March 1999. Information was obtained regarding the initial insertion, ongoing catheter function and re-intervention up to September 1999. RESULTS: A total of 118 catheters were inserted in 88 patients (50 male), median (range) age 64 (20-86) years. Ultrasound guidance was used routinely and the right internal jugular vein was used in 80 (68%) cases. Initial complications occurred in 14 (11.9%) cases, which included local haemorrhage, carotid artery puncture, and air embolism. Infection occurred in 34% of catheters (2.4/1000 catheter days). Line thrombosis was documented in 20% (1.2/1000 catheter days). Satisfactory mean urea reduction ratio (URR) of 63 was obtained for all catheters. There were 47 re-interventions, mainly for fibrin sheath stripping (34) and/or thrombectomy (25). Total catheter duration was 21600 days with a 1 month cumulative survival of 87% (Kaplan-Meier probability 85%). At the end of the study, 20 (17%) catheters were still functioning, 39 (33%) had been removed electively, and 22 (18%) patients had died with a functioning catheter in situ. Catheter infection was implicated in four deaths. CONCLUSIONS: Radiological insertion of the AshSplit catheter is well tolerated, providing reliable short- and long-term dialysis access. Radiology also has a role in maintaining patency. As with all tunnelled catheters, infection remains a problem.     

Real-time ultrasound and endocavitary electrocardiography for venous catheter placement

The authors report on their experience with internal jugular vein catheterization with temporary and tunnelled cuffed hemodialysis catheters in 527 patients from 1991 to 2001, using ultrasound guidance and monitoring of catheter placement by endocavitary electrocardiography. The incidence of successful puncture and cannulation using ultrasound was 99.62%. The majority of patients had catheters inserted on the first pass (93%) and fewer attempts were required (range, 2 to 5). In the first year of the procedure in 1991, we observed two cases of accidental puncture of the carotid artery because of an error in ultrasound localization of the neck vessel. Arrhythmias were not observed during this procedure. Right atrial electrocardiography was successful on 504 occasions (96.83%), and correct catheter placement was confirmed by plain chest-X-ray in the first 100 patients. The results confirm that real-time ultrasound guidance for catheter insertion is superior to tradi-tional techniques relying on anatomic landmarks and should be adopted as the standard of care. Ultrasound guidance and EC-ECG improves both the success and the safety of internal jugular catheter insertion. The authors propose that EC-ECG be validated as a technique in compliance with recent Food and Drug Ad-ministration guidelines regarding the location of central venous catheter tips.     

Multiple purpose central venous access in infants less than 1,000 grams

The use of central venous catheters in low birthweight infants has been associated with a high rate of infectious and mechanical-related complications. We reviewed our experience with multipurpose central venous catheters in infants less than 1,000 g to determine the rate of catheter-related sepsis and mechanical catheter malfunction. From October 1981 to August 1984, 20 infants (average weight 778 g) underwent placement of 22 central venous Broviac catheters. In addition to parenteral nutrition, antibiotics, aminophylline, and replacement fluids were infused. Total catheter days were 961, with an average of 44 days per catheter. Primary catheter sepsis occurred with two catheters (9%). Mechanical complications occurred with six catheters (exposed cuff, 1; catheter break, 2; catheter reposition, 1; catheter thrombosis, 1; dehiscence of cutdown site, 1). The incidence of catheter-related sepsis was acceptably low. The high incidence of mechanical catheter malfunction (6/22, 27%) resulted in minimal morbidity to the infant and could have been avoided by better operative technique, proper positioning intraoperatively, and meticulous care of the catheter post-operatively. We conclude that multipurpose long-term central venous access can be safely utilized with the Broviac catheter in infants less than 1,000 g.     

Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial

BACKGROUND: Chlorhexidine is better than povidone iodine for skin preparation before intravascular device insertion or blood culture collection, but it is not known whether chlorhexidine is superior in reducing colonization of continuous epidural catheters. METHODS: Children requiring an epidural catheter for postoperative analgesia longer than 24 h were randomly assigned to receive skin preparation with an alcoholic solution of 0.5% chlorhexidine or an aqueous solution of 10% povidone iodine before catheter insertion. Using surgical aseptic techniques, catheters were inserted into either the lumbar or the thoracic epidural space based on the preferences of the anesthesia team, on clinical indication, or both. Immediately before epidural catheter removal, their insertion site and hub were qualitatively cultures. After their removal, the catheter tips were quantitatively cultured. Catheters were classified as colonized when their tips yielded 1,000 or more colony-forming units/ml in cultures. RESULTS: Of 100 randomly assigned patients, 96 were evaluable. The clinical characteristics of the patients and the risk factors for infection were similar in the two groups. Catheters were kept in place for a median (range) duration of 50 (range, 21-100) h. Catheters inserted after skin preparation with chlorhexidine were one sixth as likely and less quickly to be colonized as catheters inserted after skin preparation with povidone iodine (1 of 52 catheters [0.9 per 100 catheter days] vs. 5 of 44 catheters [5.6 per 100 catheter days]; relative risk, 0.2 [95% confidence interval, 0.1-1.0]; P = 0.02). Coagulase-negative staphylococci were the only colonizing microorganisms recovered, and the skin surrounding the catheter insertion site was the origin of all the colonizing microorganisms. CONCLUSIONS: Compared with aqueous povidone iodine, the use of alcoholic chlorhexidine for cutaneous antisepsis before epidural catheter insertion reduces the risk of catheter colonization in children.     

Do AshSplit haemodialysis catheters provide better flow rates in the long term?

BACKGROUND: Recently, interventional radiologists have adopted an increasingly prominent role in the placement and management of hemodialysis catheters, as well as in the research and development of new and better catheters. The purpose of this study was to evaluate the viability and hemodialysis efficiency of the AshSplit catheter and the Permcath catheter. METHODS: 204 consecutive patients requiring radiological insertion of hemodialysis catheters were followed, retrospectively, over a 42-month period. Both hemodialysis catheters were placed using a combination of ultrasonic and fluoroscopic guidance and tunneled appropriately. Information collected included catheter insertion sites, insertion complications, catheter duration, and final outcome. RESULTS: Over the study period of two years, 269 catheters were placed into 204 patients with end stage renal failure. Patients received either an AshSplit (101 patients, 127 catheters) or a Permcath (103 patients, 142 catheters). Vascular access route of choice was the right internal jugular vein (67% AshSplit, 71% Permcath). Insertion complications occurred in 18 patients overall (6.6%), with only 1 requiring further intervention (hemopneumothorax). Flow rates averaged 259 mls/min for AshSplits and 248 mls/min for Permcaths (p < 0.001). Follow-up of catheter viability for 42 months yielded a mean AshSplit catheter duration of 246 days (range 6-932) and 239 days (range 1-1,278) for Permcath (p = 0.46). Reasons for catheter failure and elective catheter removal were similar in both groups; however, Permcaths required significantly more thrombolysis than AshSplits, p < 0.001. CONCLUSION: The AshSplit provides significantly better flow rates and less thrombolysis compared to the Permcath, with similar catheter dwell times.     

Chlorhexidine versus Povidone Iodine in Preventing Colonization of Continuous Epidural Catheters in Children: A Randomized, Controlled Trial

Background: Chlorhexidine is better than povidone iodine for skin preparation before intravascular device insertion or blood culture collection, but it is not known whether chlorhexidine is superior in reducing colonization of continuous epidural catheters.

Methods: Children requiring an epidural catheter for postoperative analgesia longer than 24 h were randomly assigned to receive skin preparation with an alcoholic solution of 0.5% chlorhexidine or an aqueous solution of 10% povidone iodine before catheter insertion. Using surgical aseptic techniques, catheters were inserted into either the lumbar or the thoracic epidural space based on the preferences of the anesthesia team, on clinical indication, or both. Immediately before epidural catheter removal, their insertion site and hub were qualitatively cultures. After their removal, the catheter tips were quantitatively cultured. Catheters were classified as colonized when their tips yielded 1,000 or more colony-forming units/ml in cultures.

Results: Of 100 randomly assigned patients, 96 were evaluable. The clinical characteristics of the patients and the risk factors for infection were similar in the two groups. Catheters were kept in place for a median (range) duration of 50 (range, 21-100) h. Catheters inserted after skin preparation with chlorhexidine were one sixth as likely and less quickly to be colonized as catheters inserted after skin preparation with povidone iodine (1 of 52 catheters [0.9 per 100 catheter days]vs. 5 of 44 catheters [5.6 per 100 catheter days]; relative risk, 0.2 [95% confidence interval, 0.1-1.0];P = 0.02). Coagulase-negative staphylococci were the only colonizing microorganisms recovered, and the skin surrounding the catheter insertion site was the origin of all the colonizing microorganisms.     

Long-term use of central venous catheters in paediatric oncology treatment

During a 26-month period, 158 central venous catheters were inserted in 114 children (median age: 4.5 years) with malignant diseases. Polyurethane catheters were used, inserted either using a cut-down procedure or percutaneously in the external or internal jugular vein. All catheters were tunnelled from the point of insertion to the midpoint of the manubrium or upper sternum. The catheter tip reached the superior caval vein or the right atrium in 94% of the cases. The catheters were used for all infusions, including total parenteral nutrition, and for blood sampling. The median catheter duration was 104 days (range 5-835 days). Sixty-eight (43%) of the catheters were removed as they were no longer needed, and 31 (20%) were removed due to local infection or septicaemia. During a total of 23,486 catheter days (64.4 years), 110 episodes of septicaemia occurred. This represents one episode per 214 catheter days. In 43 of the 110 episodes of septicaemia, blood cultures showed growth of bacteria of the kind usually found in the gastrointestinal and respiratory tracts. All septicaemias were treated with intravenous broad-spectrum antibiotics and in 21 cases the catheters were removed due to septicaemia. Thirty-four (22%) catheters were removed accidentally. There were two cases of subclavian vein thrombosis.     

Home parenteral nutrition: results in 34 pediatric patients.

Although home parenteral nutrition (HPN) has been used successfully for adult patients, no extensive experience with children has been reported. During the past three years, we have managed 34 patients, ages 1 1/2 months to 20 1/2 years, on a HPN program for periods ranging from 23 to 786 days. Silastic Broviac catheters were inserted into the superior vena cava through the jugular or cephalic veins or into the inferior vena cava through the saphenous vein. The catheters were brought out onto the chest or lower abdominal wall through a subcutaneous tunnel. Solutions were infused over a 10--14-hour period each day, using a volumetric pump system. All patients improved their nutritional status. Twenty-three of 29 on the program for more than two months showed an increase in height. All patients evidenced a significant decrease in symptomatology. All resumed per group activities while on HPN and were able to continue their education or work. At present 24 patients including 15 with Crohn's disease no longer receive HPN. Administration of HPN through a Broviac catheter is a safe, successful technique for maintaining an optimal nutritional status in children with severe digestive disorders, and permits resumption of a more normal daily lifestyle. Following HPN, bowel adaptation and initiation of full oral alimentation become possible in many patients.     

New tunneled hemodialysis catheter placement through the old exit site

Accidental loss of tunneled hemodialysis catheters has been observed in chronic hemodialysis patients. Although a new catheter could be inserted using a fresh site, catheter insertion can also be accomplished by utilizing the existing exit site. In this analysis, we report 10 cases of an extruded tunneled hemodialysis catheter. The catheters had been in place for 2-6 months. The time elapsed after catheter extrusion ranged from 6 to 72 hours. None of the patients demonstrated any evidence of exit site or tunnel infection. Patient age ranged from 45 to 77 years. Diabetes mellitus was the cause of renal failure in 40% of the cases. Catheter insertion was accomplished by inserting a guidewire into the exit site and navigating it through the tunnel to the central venous system and into the right atrium. A diagnostic catheter was then navigated over the wire and contrast study performed to confirm the position. The wire was reinserted and a new tunneled hemodialysis catheter fed over the wire and into the atrium. Nine catheters were successfully placed using this technique. One patient had nausea and hiccups upon wire insertion into the atrium. There were no hemodynamic consequences. The wire was removed and a new catheter inserted on the other side using the left internal jugular vein. All of the catheters inserted using this technique functioned appropriately. There were no exit site or tunnel infections for up to 4 weeks' follow-up. We conclude that patients with catheter extrusion can receive a new catheter through the existing exit site, tunnel, and venotomy.     

A standardised approach to the insertion of Hickman catheters.

A standardised technique for the insertion of Hickman catheters under local anaesthetic is described. The external jugular vein is to be preferred, but if this proves too small the catheter may be introduced via the internal jugular vein using a Seldinger technique. A total of 44 Hickman catheters were inserted into 44 patients using this approach without major complication.     

An audit of percutaneous central venous catheters in paediatric patients

A prospective audit of all central venous catheters placed percutaneously by anaesthetists was conducted at the Hospital for Sick Children over a three-month period in 1990. A total of 443 attempts at catheter insertion were made of which 394 catheters were successfully sited in 182 children. Patients ranged in weight from 1.5 kg to 83 kg and in age from 12 h to 17 years. 85.8% of catheters were inserted into the internal jugular, 10.1% into the femoral, and 3.5% into the subclavian veins. Complications of insertion occurred with 14.7% of attempts of which 11.0% resulted in failure at that site. Later complications were found with 17.2% of catheters. Failure to cannulate any central vein occurred in 5 patients (1.1% of all attempts).     

RIGHT ATRIAL CATHETERS: RELIABLE,IMMEDIATE AND DURABLE VASCULAR ACCESS FOR HAEMODIALYSIS AND PLASMA EXCHANGE

This paper prospectively evaluates 33 dual lumen, right atrial catheters inserted into either an external or internal jugular vein by open operation in 29 patients, of whom 15 required haemodialysis and 14 required temporary plasma exchange. The median (range) catheter survival in the haemnodialysis and plasma exchange groups was 108 days (7–334 days) and 61 days (10–116 days), respectively. Life table analysis demonstrated that overall catheter survival was 58% at 200 days. The main causes of catheter failure were infection (four cases), poor flow (three cases) and accidental removal (one case). Another nine catheters were removed electively because of maturation of alternative methods of vascular access (five cases). completion of plasma exchange treatment (three cases), or successful renal transplantation (one case). Long-term silastic catheters, inserted into the right atrium via a jugular vein. have distinct advantages over temporary subclavian vein catheters and external arteriovenous (AV) shunts; this form of access is the method of choice for hamodialysis and plasma exchange patients who require immediate and short- to medium-term vascular access.     

Prophylactic inferior vena cava filter insertion for trauma: intensive care unit versus operating room

The frequency of insertion of prophylactic inferior vena cava filters (IVCF) among traumatized patients has increased nationally. That has placed a substantial operational and economic burden upon trauma centers. The purpose of this study was to compare and contrast successful implantation, morbidity, and cost-effectiveness of prophylactic IVCF insertion in a surgical-trauma intensive care unit (STICU) versus an operating room (OR). A retrospective chart review was conducted of all trauma patients who received a prophylactic IVCF at an urban Level I trauma center between January 1999 and December 2003. Data were collected to identify patient demographics, indications, anatomical site of insertion, hospital location of insertion, hospital days before insertion, and complications associated with insertion. One hundred thirty-four patients underwent prophylactic IVCF during the study period: seventy-eight (58%) in the OR and fifty-six (42%) in the STICU. The average age of patients for the OR and STICU groups were 38.6 years and 39.6 years, respectively. The average number of days to IVCF insertion was 6.5 days and 7.0 days in the OR and STICU groups, respectively. Indications for IVCF among patients who had placement in the OR were orthopedic injury (60%), spinal cord injury (25%), and head injury (15%). Indications for IVCF among patients who had placement in the STICU were head injury (38%), orthopedic injuries (34%), and spinal cord injury (25%). Three (3.8%) patients in the OR group and two (3.6%) patients in the STICU group required a change of anatomic insertion site from the femoral to the internal jugular vein. There were two (2.6%) complications associated with IVCF insertion in the OR and two (3.5%) complications associated with IVCF insertion in the STICU (P > 0.05). Insertion of IVCF in the STICU decreased patient-cost by an average of dollar 1636 per patient. Prophylactic IVCF insertion in an STICU is cost-effective and can be performed with similar success and complication rates to IVCF insertion in an OR.