Long-term central venous catheters: issues for care

Blood collection in unstressed, conscious, and freely moving mice through implantation of catheters in the jugular vein: a new simplified protocol

The mouse has become the most common mammalian animal model used in biomedical research. However, laboratory techniques used previously in rats and other larger animals to sample blood had to be adapted in mice due to their lower mouse plasma volume. Sampling is further confounded by the variability in plasma hormone and metabolite concentrations that can occur from the stress or the anesthesia that accompanies the collection. In this article, we describe in detail a protocol we developed for blood sampling in conscious, unrestrained mice. Our protocol implements the use of chronic indwelling catheters in the right external jugular vein, allowing the mice to recover fully in their home cages, untethered until the time of blood sampling. This protocol employs catheters that remain patent for days and does not require the purchase of expensive equipment. We validated this protocol by measuring the time course of plasma norepinephrine (NE) concentration during and after the relief of acute immobilization stress in wild type (WT) and pendrin knockout (KO) mice and compared these results with our previously published values. We found that following relief from immobilization stress, it takes longer for plasma NE concentration to return to basal levels in the pendrin KO than in the wild type mice. These results highlight the potential utility of this protocol and the potential role of pendrin in the neuroendocrine response to acute stress.

Percutaneous Placement of an Implantable Arm Port through an Internal Mammary Venous Pathway: Case Report

Current chemotherapeutic regimens often require long-term central venous access for their administration. Obtaining a durable form of vascular access in patients with recurrent cancer can be a challenge due to direct tumor involvement and prior surgical, chemotherapeutic or radiation therapy. We describe a case of a peripherally inserted access port in a patient with recurrent head and neck cancer, in whom radiation therapy planned for metastatic mediastinal disease prevented placement of a chest port. At the time of port implantation, venography revealed central venous occlusion. Using mediastinal venography, a collateral pathway to the superior vena cava was identified between the left and right internal mammary veins. By employing this technique, an arm port system was successfully navigated through the collateral pathway percutaneously with the tip of the port tubing placed at the cavoatrial junction. This case illustrates technical nuances and emphasizes the importance of thorough venography when attempting to achieve difficult vascular access.

Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg

PURPOSE

To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children.

MATERIALS AND METHODS

Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis.

RESULTS

PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001).

CONCLUSIONS

Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.

The effect of low-dose heparin on maintaining peripherally inserted percutaneous central venous catheters in neonates

OBJECTIVE

To evaluate the effect of low-dose heparin on duration of peripherally inserted percutaneous central venous catheter (PCVC) patency and catheter occlusion.

STUDY DESIGN

Our research was a prospective, randomized, controlled, double-blind clinical study including 246 eligible neonates with PCVCs. It was conducted at the neonatal intensive care unit (NICU) of Diyarbakir Children's Hospital between 1 February 2007 and 31 October 2008. In the heparin group (n=118), the total parenteral nutrition (TPN) solutions contained heparin, which was infused at a rate of 0.5 IU kg⁻¹ h⁻¹ . The no-heparin group (n=121) received TPN fluids without heparin.

RESULT

In the heparin group, the duration of catheter patency was longer than that of the no-heparin group reaching a statistically significant difference (12.4 ± 4.5 vs 9.7 ± 4.0, P<0.0001). In the heparin group, the proportion of patients completing the TPN therapy successfully was higher than in the no-heparin group (P=0.0001; relative risk (RR): 3.32 (95% confidence interval (CI): 1.92 to 5.73)) also demonstrating a statistically significant difference. The rate of catheter occlusion among infants in the heparin group was smaller (P=0.0001; RR: 3.44 (95% CI: 1.92 to 6.44)). There were no statistically significant differences between the two groups in the incidence of other catheter-related problems. The length of the occluded catheter outside the skin, TPN infusion rate and catheter duration time were found to be the factors associated with catheter occlusion. Heparin prevented catheter occlusion with a mechanism unrelated to these factors.

CONCLUSION

In neonates with PCVCs, low-dose continuous infusion of heparin (0.5 IU kg ⁻¹h⁻¹ within TPN fluids is an effective measure in terms of reducing catheter occlusion, allowing successful completion of the therapy, without increasing adverse effects. Furthermore, this effect of heparin may occur independently via occlusion-related factors that we evaluated in the study.

Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer

The long-term use of subcutaneous implanted ports for chemotherapy in cancer patients has been associated with the occurrence of thrombosis and infection. In this study, we compared the safety and efficacy of administration of 1000 U of heparin flushes in prolonged interval (every 6 weeks) with standard dose and schedule (500 U every 4 weeks) for port-related infections and thrombosis during periods of non-use. Data were collected retrospectively from patients treated for various cancer types (matched as 2:1 for age, gender, stage of the disease). Patients who had diseases that could cause thrombosis or bleeding in their past medical history, or were taking oral anticoagulants, or had contraindications for heparin usage were excluded. After completing their chemotherapy, 59 patients received prolonged interval, while 30 patients received standard schedule. All patients were followed for at least 1 year. No clinically documented port-related infection or thrombosis has been found in both groups. Also, none of the devices was removed during this time. Prophylactic flushing of central venous ports with 1000 U of heparin in every 6 weeks might be a safe, easy, cheaper, comfortable and effective alternative to standard dose and schedule for preventing thrombosis and infections.

Prospective, randomized trial of two different modalities of flushing central venous catheters in pediatric patients with cancer

PURPOSE

There are limited prospective data on whether the method of flushing affects the complication rate of tunnelled central venous catheters (CVCs).

PATIENTS AND METHODS

During a 25-month period, 203 pediatric patients who had newly placed Broviac-Hickman CVCs were randomly assigned to standard flushing with heparin solution or to experimental flushing with normal saline via a positive-pressure cap.

RESULTS

Two hundred twenty-one complications were recorded among 75,249 CVC-days (2.94 per 1,000 CVC-days). A higher incidence of CVC occlusion (83 v 41 episodes; P = .0002) and bacteremia (24 v 9; P = .01) were found in the experimental arm. The cumulative probability of developing at least one CVC complication was higher in the experimental arm than in the standard arm (65.1% [95% CI, 55% to 75%] v 43.8% [95% CI, 34% to 54%], respectively; P = .01). No difference was found in either the cause or the frequency of premature removal of CVCs between the two study arms. After a median follow-up of 360 days (range, 4 to 1,073), CVC survival was similar: 77% (95% CI, 66% to 84%) for the experimental arm and 69% (95% CI, 53% to 80%) for the standard arm (P = .7). The factors associated with the occurrence of CVC complication were a diagnosis of leukemia/lymphoma, double-lumen CVC, and experimental flushing. The only factor significantly associated with premature removal of a CVC was a diagnosis of leukemia/lymphoma (hazard rate, 2.3; 95% CI, 1.1 to 4.7).

CONCLUSION

An increased complication rate was found with normal saline flushing, but additional investigation is warranted to clarify whether it is related to saline use or to once-a-week flushing.

Complications of Hickman-Broviac catheters in children with malignancies

The aim of this study was to explore the complications related to Hickman-Broviac central venous catheters (Hickman-Broviac CVCs) in children with cancer, their incidence, and possible associations of complications and premature removal of CVCs with a number of risk factors. During the study period (1 Jan 2000-31 Dec 2003), 223 CVCs were inserted in 198 children (117 boys, 81 girls) at a mean age of 5.73 years (95% CI 5.19-6.27, SE 0.275). In total, 76 (38.4%) children suffered from solid tumors and 122 (61.6%) from leukemia. The mean follow-up after CVC insertion was 232.5 days (95% CI 214.9-250.2, SE 8.94) for a total of 51,839 catheter-days. A complication occurred in 20.8% of them and in 9.6% the complication led to the removal of the catheter. The most frequent complications were infection (63.9%), obstruction (26.2%), accidental failure (8.2%), and rupture (1.6%). An overall incidence of 1.17 (0.38 and 0.79 for mechanical complication and infection, respectively) per 1000 catheter days for the development of a complication was recorded. Additionally, the study revealed more nonelective removals in cases of leukemia compared to those of solid tumors. Systemic use of CVC does not appear to increase significantly the number of complications, and thus CVC remains an effective and safe tool for the management of childhood malignancies.

The Use of Low-Dose Warfarin as Prophylaxis for Central Venous Catheter Thrombosis in Patients With Cancer: A Meta-Analysis

PURPOSE/OBJECTIVES

To determine whether the use of low-dose warfarin could reduce the incidence of thrombosis in patients with cancer who have a central venous catheter (CVC).

DATA SOURCES

MEDLINE, CINAHL, CANCERLIT, EMBASE, and the Cochrane Library.

DATA SYNTHESIS

Meta-analysis of four studies (N = 1,236 patients) revealed that 6.4% of warfarin-treated patients experienced a thrombotic event compared with 7.5% in the control (no treatment) group. The risk difference for thrombus formation was not significant (2.0%, confidence interval = -9.0% to 5.0%).

CONCLUSIONS

The administration of warfarin did not reduce the incidence of symptomatic or asymptomatic CVC-associated thrombosis in patients with cancer.

IMPLICATIONS FOR NURSING

Using research findings to inform clinical nursing practice is important in caring for patients and providing optimal and improved patient outcomes. Prophylactic use of low-dose warfarin may not prevent thrombus formation and is associated with potentially adverse patient outcomes.

Vesicant extravasation part II: Evidence-based management and continuing controversies

PURPOSE/OBJECTIVES

To review the literature, synthesize current recommendations, and discuss remaining controversies regarding vesicant extravasation management.

DATA SOURCES

Published evidence-based reports, clinical articles, and anecdotal case reports about antineoplastic and nonantineoplastic vesicant agent management.

DATA SYNTHESIS

Prevention of vesicant extravasation sequelae requires knowledge about vesicant extravasation manifestations and differentiation of vesicant extravasation from other local IV site reactions. When evidence is weak or missing, logical application of data-based or empirical management strategies is critical. Actions may include timely administration of subcutaneous or topical antidotes, comfort measures, and surgical interventions to minimize the extent of tissue damage and morbidity should extravasation occur.

CONCLUSIONS

Vesicant extravasation and sequelae constitute a complex patient problem. Clinicians should strive to prevent extravasation or seek to minimize injury should it occur. To this end, clinicians must demonstrate awareness of its risks and use specialized knowledge when administering vesicant agents.

IMPLICATIONS FOR NURSING

Nurses who administer vesicant agents should understand the nursing and collaborative actions that should be taken to minimize patient morbidity, pain, and disability.

A Theory-based Intervention to Improve Nursesʼ Knowledge, Self-efficacy, and Skills to Reduce PICC Occlusion

The peripherally inserted central catheter (PICC) is an effective intermediate and long-term central vascular access device. Its functions are comparable with those of other percutaneously placed central venous catheters. However, its high occlusion rate and the consequent infection risk may disrupt therapy for patients. The primary investigator in this study developed an educational intervention based on Albert Bandura's social learning theory, and hypothesized that increasing nurses' knowledge and self-efficacy related to PICCs would have a positive impact on patient outcomes related to occlusion and infection rates. The study outcome showed an overall increase in nurses' knowledge and self-efficacy related to PICC care, and a significant reduction in the catheter occlusion rate, from 29% to 8.5%, over a 6-month period.

Central venous catheters: choosing the most appropriate access route

Intravenous therapy and care is a complex and intricate area of practice, which is being subsumed into the core role of registered nurses. As more patients become recipients of a vascular access device (VAD), particularly those requiring intermediate to long-term central venous access, it is important to ensure that not only the device but also the most appropriate vein meets their clinical physiological and psychological needs. There is much research and literature on the insertion and care of central venous catheters (CVCs) as well as the detection and treatment of complications. However, apart from a few small studies comparing the performance of devices placed either in the subclavian or jugular veins, there is little to guide doctors or nurses as to which vein is preferable, if secondary complications are to be avoided. This article will describe a number of primary and secondary complications associated with both the subclavian and internal jugular veins and how these can be minimized by selecting the most appropriate vessel. The article concludes with the author's suggestions for correct patient assessment in order that the correct vein is utilized.

The Impact of Safety Product Use on Catheter-related Infections

This article provides an overview of the issues that affect the use and proliferation of safety infusion products. In particular, the associated risks and benefits of needleless infusion systems are discussed. Recent legislation and regulations address healthcare worker exposure to bloodborne pathogens and mandate the use of these devices to mitigate the risk of healthcare worker exposure to bloodborne pathogens. This article examines whether safety devices increase the risk for catheter-related infections among patients, and evaluates the implications for clinical practice and compliance. Clinician education and standards of care also are discussed as methods to ensure the optimal safety of both healthcare workers and the patients for whom they are responsible.

Complications associated with implantable vascular access devices in the patient with cancer

Implantable vascular access devices (IVADs), or implantable ports, have been used for patients with cancer for more than 20 years. Although these devices have greatly improved infusion access for this population of patients, complications may still occur. Nurses working with oncology patients who have IVADs must be aware of possible problems for these patients, as well as the importance of early assessment and intervention. The diagnosis of cancer and potential treatments for this disease may make these patients at higher risk for complications associated with the use of IVADS.

Totally implantable venous-access ports: local problems and extravasation injury

Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.

Assessment of parameters associated to the risk of PVC catheter reuse

The practice of single use devices (SUD) recycling raises public health concerns, primarily with regard to the potential risks of infection and device malfunction. These concerns have led to a Food and Drug Administration (FDA) revision of the present regulations. The purpose of our work is to identify different material parameters that could contribute to the health risks associated with the practice of reprocessing PVC catheters for use in other patients. Ethylene oxide hospital-reprocessed central venous catheter samples were obtained from the stock of a health-care institution. One device trademark was selected, and samples that had been used 8 and 24 times were compared with new ones. In order to determine the total percentage of extractables, supercritical fluid extraction (SFE) was used, and off-line gas-chromatography-flame-ionization detection (GC-FID) was employed for identification and quantitation of bis-(2-ethyl hexil)phthalate (DEHP). Storage modulus (E') and dissipation factor (tan delta curves were obtained by dynamic mechanical analysis (DMA). Successive catheter recycles produced increased plasticizer loss, increased glass transition temperature (T(g)) and E', widening of tan delta curve with a simultaneous shift to higher temperature, small decrease of weight average molecular weight (M(w)), increased surface roughness, and increased appearance of surface grooves (severe damage). The magnitude of biomaterial parameter changes measured suggests that reuse could alter the original device performance. Examples of possible adverse clinical events include leaching of toxic agents, device rigidization or breakage, increased catheter protein retention, or the promotion of bacterial adhesion by device topography modification.

Silicone venous access devices positioned with their tips high in the superior vena cava are more likely to malfunction

BACKGROUND

Silicone venous access devices (VADs) are commonly used for multiple intravenous infusions and blood sampling in chronically ill patients, particularly cancer patients. These devices are susceptible to malfunctions most commonly characterized by difficulty infusing fluids or withdrawing blood. We hypothesized that the incidence of such malfunctions is primarily related to the position of the catheter tip relative to the superior vena cava/right atrial junction.

METHODS

We reviewed medical records for 141 patients in whom silicone venous access devices were used. Chest radiographs obtained following catheter insertion were reviewed by a single radiologist to rule out pneumothorax and determine the position of the catheter tip. Other potential factors included in the analysis were catheter brand, the vein into which the catheter was inserted, and the side (right or left). A malfunction was defined as resistance to flushing or infusion of a substance, complete inability to infuse a substance, resistance to blood aspiration attempts, or absence of blood return with aspiration, occurring any time during which the catheter was in place. Multiple logistic regression was used to determine which factor(s) most strongly predicted catheter malfunction.

RESULTS

Catheter tip location was the only factor that was statistically predictive of malfunctions (coefficient 0.842, P < 0.001). A significant increase in malfunctions was observed in cases where the catheter tip was located greater than 4 cm superior to the junction of the right atrium and the superior vena cava (z-test of proportions, P = 0.003). Malfunctions were minimized in those cases where the catheter tip was located in the right atrium.

CONCLUSIONS

These results indicate that malfunctions can be minimized in silicone venous access catheters by locating the catheter tip as close to the superior vena cava/right atrial junction as possible, or slightly inside the right atrium. To ensure proper location of the catheter tip, placement should be performed under fluoroscopy, and a radiograph should be obtained immediately following placement, with the patient in the upright position.

Rare complications of vascular access devices

OBJECTIVE

To provide an overview of rare complications of vascular access devices in terms of etiology, assessment, management, and follow-up.

CONCLUSIONS

Rare complications of vascular access devices are serious and in some cases life-threatening. These complications include pinch-off and catheter fracture, catheter malposition and migration, cardiac perforation, extravasation, breakage, and defective devices. Knowledge and awareness of these complications can contribute to accurate identification and immediate management. Documentation and reporting of complications to the Food and Drug Administration helps to ensure the safety and efficacy of vascular access devices.

IMPLICATIONS FOR NURSING PRACTICE

Developing the expertise needed to manage these types of complications is a continual challenge to the oncology nurse. Although managing rare complications is usually performed by a physician, recognizing the clinical manifestations will alert the nurse to seek medical advice immediately, thus decreasing the risk of mortality. All health care professionals are responsible for continually monitoring vascular access devices, consistently documenting findings, and communicating recommendations for care.

Management of infection and occlusion associated with vascular access devices

OBJECTIVE

To provide an overview of the etiology, assessment, diagnosis, and management of infections and occlusions that occur with venous access devices (VADs).

CONCLUSIONS

The two major complications of VADs are infections and occlusions. Several strategies have been attempted to prevent and treat infections and occlusions; however, one specific method has yet to be determined. As a result, major controversies exist regarding the best method to manage these complications. Controlled randomized studies are needed to examine each type of VAD in relation to preventive and treatment strategies.

IMPLICATIONS FOR NURSING PRACTICE

Preservation of VADs demands the development of and adherence to specific guidelines for maintenance care as well as an awareness of the incidence, presentation, and management of complications. Clearly, prevention is the key to effective management of infection and occlusion associated with VADs. Nurses must be familiar with institutional policies and procedures for the care of VADs.

Central venous catheter-related infections: pathogenesis, predictors, and prevention

Central venous catheters are used widely for a variety of therapeutic purposes and have an increased incidence of infections related to their use. The purpose of this article is to address the issue of central venous catheter-related infections, including pathogenesis, predictors and diagnosis, and prevention.