Prophylaxis of port system-associated thromboses in advanced oncology patients using heparin flushing

Heparin versus 0.9% saline solution to maintain patency of totally implanted venous access ports in cancer patients: A systematic review and meta-analysis

AIM

The use of heparin and 0.9% saline solution is always controversial for central venous catheters. However, there is no systematic review or guideline about whether saline solution can replace heparin solution in adult cancer patients with totally implantable venous access ports (TIVAPs). The purpose of this review is to evaluate whether saline solution can replace heparin saline to lock TIVAPs.

METHODS

The following databases were searched: PubMed, the Cochrane Library, Web of Science, Embase, CINAHL and Ovid (January 1, 1982, and February 21, 2020). All statistical analyses of the meta-analysis were completed using the Review Manager 5.3.

RESULTS

A total of 201 studies were identified from these databases after initial review, and four studies met inclusion criteria, including 2652 cases. There was little heterogeneity among the included studies (I² < 30%), and all analyses were conducted by the fixed-effects model. The total complications, catheter occlusions, catheter-related bloodstream infections and other complication rates in the heparin solution group were higher than in the saline solution group. In the subgroup analysis of heparin concentration, total complication rates in the saline solution group were higher than with 50 U of heparin and lower than with 100 U of heparin. However, the differences in these complications were small, and no significant difference was observed (all P > 0.05).

CONCLUSIONS

Based on existing clinical studies, we recommend that saline solution can replace 50 or 100 U/ml of heparin as a safe and effective flush solution for TIVAPs.

Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections

OBJECTIVES

A catheter thrombosis and the presence of a catheter-associated bloodstream infection (CBSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CBSIs. To date, there has been limited human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. The use of alteplase for malfunctioning central venous catheter may indicate the formation of intraluminal thrombus or fibrin sheath. A catheter that requires alteplase is at higher risk of a CBSI.

DESIGN

A retrospective chart review from July 2008 to December 2010.

SETTING

PICU.

PATIENTS

All patients with central catheters admitted to the PICU.

INTERVENTIONS

No interventions performed with the retrospective study.

MEASUREMENTS

Number of total central venous catheters, number of central venous catheters that received treatment with alteplase, and number of CBSIs.

MAIN RESULTS

Preliminary data during the study period identified 3,289 central venous catheters. Twelve percent of these catheters required at least one dose of alteplase. There were 40 CBSIs during this same time period of which 28% received alteplase during the 5 days preceding the positive blood culture. The odds ratio for getting a CBSI when alteplase is administered is 2.87 (confidence interval 1.42-5.80; p = 0.002). The average age of the central venous catheters at time of infection was not statistically different, 16.1 days in the alteplase catheters compared with 25.6 days for the catheters that did not receive alteplase (p = 0.6).

CONCLUSIONS

There is a positive correlation between the use of alteplase for malfunctioning central venous catheters and the development of a CASBI. This is likely associated with the presence of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CBSI.

[How should urologists perform implantation of subcutaneous central venous port systems? A single center experience of 347 cases]

BACKGROUND

Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG.

METHODS

Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed.

RESULTS

The median follow-up was 491.6 days (2-2568), and 163.254 catheter days (mean 239 days, range 2-2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14-85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30 days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur.

CONCLUSIONS

Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.

Tissue plasminogen activator to prevent central venous access device infections: a systematic review of central venous access catheter thrombosis, infection and thromboprophylaxis

The recent unequivocal demonstration that prophylaxis, three to four weekly factor infusions, is effective in preventing joint disease in children with haemophilia, has provided impetus to initiate prophylaxis early in such children. Yet, nearly a quarter (22%) of the 83% who required central venous access devices for factor infusion developed central venous access catheter (CVAD)-related infection. This limitation of CVAD use prevents many families from initiating prophylaxis. The frequent occurrence of local thrombosis accompanying CVAD-related infection in surgical patients and autopsy cases, the thrombogenic plastic CVAD surfaces, and local clot formation at the insertion site, suggest the potential role of thrombolytic agents in preventing these infections. Yet, correlation between CVAD-related infection and local thrombosis in children with haemophilia are lacking, and thromboprophylaxis to prevent CVAD-related infection is controversial. Tissue plasminogen activator (t-PA), a recombinant serine protease glycoprotein that lyses plasmin-bound fibrin and is safe and effective in the treatment of occluded catheters, has not been evaluated in the prevention of these infections. We performed a literature review of CVAD-related infection, CVAD-related thrombosis, and thromboprophylaxis studies to evaluate the role of t-PA in the prevention of these infections in children with haemophilia. Metanalysis of published thromboprophylaxis trials demonstrate current prophylaxis regimens do not prevent CVAD infection, and further, that thrombosis and infection do not necessarily occur simultaneously. Pilot data demonstrate CVAD infection reduction in haemophilic children by monthly t-PA in 18 haemophilic children, suggesting the potential role of t-PA in CVAD infection prevention. Clinical trials to evaluate t-PA in CVAD infection prevention are justified.

Prevention of central venous catheter-associated thrombosis: a meta-analysis

PURPOSE

Anticoagulant prophylaxis in patients with central venous catheters is controversial. We performed a meta-analysis of randomized controlled trials of anticoagulant prophylaxis in patients with central venous catheters.

METHODS

MEDLINE and EMBASE were searched up to May 2006, supplemented by manual searches of conference proceedings and bibliographies.

RESULTS

Fifteen trials were included. Unfractionated heparin infusion, oral fixed low-dose vitamin K antagonist, and subcutaneous low-molecular-weight heparin were evaluated. For all catheter-associated deep vein thrombosis (symptomatic and asymptomatic combined), the summary relative risks ranged from 0.31 to 0.73 (all achieved statistical significance). For symptomatic deep vein thrombosis, the summary relative risks ranged from 0.28 to 0.72, but did not achieve statistical significance for any individual regimen.

CONCLUSION

Anticoagulant prophylaxis is effective for preventing all catheter-associated deep vein thrombosis in patients with central venous catheters. The effectiveness for preventing symptomatic venous thromboembolism, including pulmonary embolism, remains uncertain.

Subklaviathrombose nach Portanlage bei metastasiertem Melanom

The use of implanted central venous catheters with ports has become almost irreplaceable in clinical treatment of cancer patients with advanced disease. It improves the patient's quality of life and simplifies medical treatment. For safe use during outpatient follow-up treatment, possible complications such as wound infections, thrombosis or even pulmonary embolism have to be considered. The incidence of catheter-associated thrombosis in cancer patients has been estimated as 25-66% in screening evaluations. Clinical symptoms were present in only in 6-28% of all patients with diagnosed thromboses. We report on a patient with metastatic malignant melanoma, who developed a deep arm vein thrombosis two weeks after port implantation. The prognosis of deep arm vein thrombosis is determined by the development of pulmonary embolism (8-36%). In such cases, early diagnosis and treatment are essential for the patient's survival.

Heparin Locking for Central Venous Catheters

Traditionally, heparin-lock solution has been used with all central venous catheters. The introduction of new technology calling for the elimination of heparin and the growing concerns about the use of heparin have caused many health care professionals to question its continued use for this purpose. This literature review attempts to answer the most common questions using available research; however, there continues to be more questions than answers. At present, it appears that some farm of anticoagulant will produce more patent catheters, and heparin-lock solution is the only product commercially available. This situation drives the need for a careful assessment of patients' needs prior to abandoning the use of heparin.

Central venous line-related thrombosis in children

Central venous lines are used in critically ill children and in children with chronic conditions for the administration of intravenous therapy, such as fluids, medications, total parenteral nutrition and blood products. Although the use of central venous lines has greatly improved the quality of care in these children, these catheters may cause serious mechanical, infectious and thrombotic complications. The reported frequency of catheter thrombosis in children is low as 5% in studies including only symptomatic cases and high as 50% in studies where patients are systematically screened for catheter-related thrombosis. The risk factors for catheter-related thrombosis in children are associated with the methods used for catheter insertion and with individual patient characteristics, underlying diagnosis and treatment. The management of catheter-related thrombosis is largely dependent on the requirement of the catheter. If no longer required or nonfunctioning the catheter should be removed. If access is still required and the catheter is functioning, treatment with anticoagulation is recommended in the absence of contraindications. The management of radiographically detected asymptomatic thrombosis in children is less clear. Clinical studies of prophylaxis for catheter-related thrombosis are inconclusive and no definitive recommendations for prophylaxis in adults or in children with central venous thrombosis can be made. Properly designed studies are needed to assess the role of prophylactic anticoagulation for preventing catheter-related thrombosis.