An audit of Hickman catheter use in patients with solid tumours

An audit of ultrasound-assisted catheter insertion in patients receiving chemotherapy

BACKGROUND AND AIMS

Hickman catheters have been shown to provide safe long-term venous access for patients with malignant diseases. In many centres, catheters are placed using fluoroscopic guidance. We hypothesised that ultrasound-assisted catheter placement by surgeons in the operating theatre would be a simple, safe and effective alternative technique with reduced infective complication rates.

METHODS

Hickman catheter insertions between May 1998 and March 2002 were studied. The data were collected from the Hospital Inpatient Enquiry database and the case notes of all patients were reviewed. Percutaneous catheter placement with tunnelling was performed in the operating theatre after scanning the internal jugular vein (IJV) for position, size and patency, using a Pie 100LC Scanner (Pie Medical, Maastricht). A standard chest radiograph confirmed catheter position at the end of the procedure.

RESULTS

Fifty-eight patients (30 males and 28 females) had 65 Hickman catheters inserted. The median age was 60 years (range 32-82 years). Catheter placement was achieved in all patients, 59 in the right IJV and six in the left. Ultrasound scanning demonstrated that the right IJV was thrombosed in six patients (10%), thus avoiding unnecessary attempts at cannulation. The Hickman catheters remained in situ for a combined total of 5857 days (median, 89 days, range 4-485 days). Immediate complications occurred in two patients (pneumothorax in both). One patient required a chest drain. The overall sepsis rate was 3.92 per 1000 catheter days. Systemic sepsis was slightly higher (2.21 per 1000 catheter days) than superficial sepsis (1.71 per 1000 catheter days). In all the patients who developed systemic sepsis the catheter had to be removed (n = 13). All the superficial infections were treated successfully with antibiotics (n = 10 patients). Two catheters developed thrombosis.

CONCLUSION

We conclude that ultrasound-assisted percutaneous placement of Hickman catheters in the operating suite is a simple, safe and effective technique and may help to reduce infective complications.

Infusional 5-fluorouracil can be a pain in the neck: A case for repositioning displaced Hickman lines

Increasing numbers of patients receive infusional chemotherapy or total parenteral nutrition via Hickman or Grochong lines. Although the insertion of these indwelling catheters is generally performed under radiological guidance and their positions verified by chest radiography, it is still feasible for them to become displaced at a later date. This possibility should be excluded in patients who develop unusual symptoms during the course of their infusional therapy. We review the reported complications associated with Hickman lines, and present a case history demonstrating that interventional radiology has a valuable role in displaced line repositioning, after the exclusion of thrombosis and infection.

A retrospective analysis of Hickman line-associated complications in patients with solid tumours undergoing infusional chemotherapy

We present a retrospective analysis of Hickman line use and associated complications in patients with solid tumours undergoing treatment with infusional chemotherapy. One hundred and ten lines were inserted in 94 patients (55 females and 39 males, median age 51), of whom 107 were placed under radiological screening, the remainder by a surgical approach. Catheters were in situ for a total of 9670 days (median 101 days, range 1-278). Fifty-five complications occurred during the lifespan of 39 catheters (35.5%), giving an overall complication rate of 4.03/1000 catheter days. Early complications included pneumothorax (4%), arterial puncture (1%) and failure of placement (1%). Late complications included sepsis (superficial and systemic) (24.5%), venous thrombosis (9%), line displacement (10%) and catheter blockage (1%). Fifteen episodes of systemic sepsis occurred in 12 patients, giving an overall sepsis rate of 1.55/1000 catheter days, while complications requiring catheter removal occurred in 20 cases (18% of insertions, 2.07/1000 catheter days). We conclude that the use of Hickman catheters as a means of long-term venous access in infusional chemotherapy patients is generally safe, but is associated with significant morbidity.

Hickman catheter-related infections in neutropenic patients: insertion in the operating theater versus insertion in the radiology suite

PURPOSE

To determine the influence of microbial air quality during Hickman catheter insertion in the operating theater versus insertion in the radiology suite on the incidence of catheter-related infections (CRIs).

PATIENTS AND METHODS

Hemato-oncologic patients with prolonged neutropenia on antimicrobial prophylaxis were entered onto the study. Catheters were inserted by experienced radiologists under sonographic and fluoroscopic guidance.

RESULTS

Forty-eight Hickman catheters in 39 patients were inserted (23 in the operating theater, 25 in the radiology suite). CRIs were seen in 16 catheters (33%; six per 1,000 catheter days; eight in each group). Local infections were found in nine catheters (22%; six in the operating theater v three in the radiology suite; not significant [NS]), catheter-related bacteremia was found in 10 (29%; three in the operating theater v seven in the radiology suite; NS). Coagulase-negative staphylococci (CoNS) caused all CRIs. Despite early vancomycin therapy, 11 (69%; four in the operating room group v seven in the radiology suite group; NS) of the catheters with CRIs had to be removed prematurely. At 90 days after insertion, catheter survival was 78% and 60% (NS) for the operating room and radiology suite, respectively. Multivariate analysis showed that neutropenia increased the CRI risk 20-fold (P =.004) and was strongly related to premature catheter removal owing to infection (relative risk = 11.9; P =.009). Neutropenia on the day of insertion was also significantly correlated with CRI (P =.04) and premature catheter removal owing to infection (P =.03). Serial cultures of blood, exit site, and catheter hub did not predict the development of CRI.

CONCLUSION

The high incidence of Hickman CRI caused by CoNS was not associated with insertion location (operating theater v radiology suite). Neutropenia, including neutropenia on the day of insertion, was a significant risk factor for CRI and infection-related catheter removal.

Cancer-related thromboembolic disease in patients with solid tumours: a retrospective analysis

BACKGROUND

Cancer patients frequently suffer thromboembolic events. This study assessed the incidence and resource implications of cancer-related thromboembolic disease (CTD) in a single, large cancer centre.

PATIENTS AND METHODS

A retrospective analysis of patients admitted with CTD and/or the complications of treatment of CTD over a two-year period has been conducted. Forty-eight patients (23 male, 25 female, median age 60 years) with a variety of solid tumours were identified.

RESULTS

The initial presentations were venous thromboses (28 patients) and pulmonary embolism (20 patients). The median interval from cancer diagnosis to the initial episode of CTD was eight (range 0-112) months. Twenty-two patients suffered additional thromboses, despite maintenance warfarin anticoagulation in 18 patients. Six patients experienced anticoagulation-induced haemorrhage. Forty-one (85.4%) patients have died. The median survival from the first thromboembolic event was 8.5 months. The median inpatient stay for management of the first event was 10 (range 4-75) days, accounting for 729 inpatient days during the study period. Recurrent episodes of CTD or complications of anticoagulation resulted in 28 readmissions, accounting for 295 inpatient days. During the two-year period 1024 inpatient days were directly caused by CTD and its complications, representing 6.1% bed occupancy on our unit.

CONCLUSION

This study demonstrates that CTD represents a significant cause of morbidity in cancer patients with considerable resource implications for cancer centres. Improvements in prevention and management of CTD would reduce morbidity and lead to considerable cost savings.

Risk factors for pneumothorax during percutaneous Hickman line insertion in patients with solid and haematological tumours

The purpose of this study was to identify risk factors for pneumothorax during percutaneous subclavian Hickman line insertion in patients with haematological (HT) or solid tumours (ST). One hundred and twelve patients (55 HT, 57 ST) had 132 subclavian Hickman lines inserted under fluoroscopic control. Lines were inserted on the left on 116 occasions and the right in 16. Thirty-five single, 29 double and 68 triple lumen catheters were inserted. Variables included in the analysis were age, sex, side of insertion, catheter gauge and nutritional status as indicated by the body mass index (BMI kg/m2). Both univariate and logistic regression analyses were performed. There were ten pneumothoraces, all occurring in patients with STs. Univariate analysis revealed that patients with STs were older (median age 59 versus 36 years; P = 0.0001) and more cachectic (median BMI 21.9 versus 24.2 kg/m2; P = 0.03) than those with HTs, and the patients experiencing pneumothorax were older (median age 57 versus 44 years; P < 0.01) and more cachectic (median BMI 19.6 versus 24.0 kg/m2; P = 0.004) than those undergoing uncomplicated procedures. For patients with a BMI < 19 kg/m2 versus those with a BMI > 19 kg/m2, the pneumothorax rate was 5/8 versus 5/124 (P < 0.00001). Logistic regression analysis confirmed the significantly older age of the patients with STs (P < 0.001) and of those experiencing pneumothorax (P = 0.02). This analysis also confirmed the lower BMI of patients experiencing pneumothorax (P = 0.002). The patients' sex, the side of line insertion and the catheter gauge were not associated with pneumothorax on either the univariate or logistic regression analyses. From these data we conclude that pneumothorax complicating a subclavian Hickman line is significantly more likely in elderly patients with a low BMI. Such patients are more likely to have STs than HTs. In patients with a BMI < 19 kg/m2, the subclavian route should be used with caution.