A review of 560 Hickman catheter insertions

Efficacy of same venous route Hickman catheter replacement in patients with intestinal failure

BACKGROUND/PURPOSE

Periodical replacement of venous Hickman catheters is required for the nutritional care of patients with intestinal failure. The conventional de novo operation (DN-OP) involves inserting the catheter into a new venous tract in each replacement; however, this could result in fast consumption of functional central vessels in patients with intestinal failure. Recently, same-route operation (SR-OP) has been adopted as an alternative approach for retaining venous access.

METHODS

We conducted a retrospective study to compare the efficacy of Hickman catheters and the survival of venous vessels using two different operative strategies.

RESULTS

Overall, 181 catheters were inserted, 109 using DN-OP and 72 using SR-OP. The mean catheter duration was 11.9 ± 8.8 months in the DN-OP group and 10.5 ± 5.6 months in the SR-OP group; the infection rate was 0.74 in the DN-OP group and 0.44 in the SR-OP group. The vein accesses used in these insertions (n = 113) were classified: the DN-vein group for veins accessed only by DN-OP (n = 75) and the SR-vein group for veins accessed by an initial DN-OP and subsequent SR-OPs (n = 38). Mean working duration per vein access was 12.3 ± 10.1 months in the DN-vein group and 28.2 ± 14.8 months in the SR-vein group (p < 0.001); mean infection-free duration was 11.4 ± 10.1 months in the DN-vein group and 27.7 ± 15.3 months in the SR-vein group (p < 0.001).

CONCLUSION

Application of SR-OP in Hickman catheter replacement significantly extended the working duration of venous access by re-using the same venous route without compromising catheter efficacy in patients with IF having poor venous access.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BACKGROUND

To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.

METHODS

A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.

RESULTS

As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.

CONCLUSIONS

The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Right or left? Side selection for a totally implantable vascular access device: a randomised observational study

BACKGROUND

Totally implantable vascular access device (TIVAD)-related complications interfere in the anticancer treatment and increase medical expenses. We examined whether the implantation side of central line TIVADs is associated with the occurrence of thrombotic or occlusion events.

METHODS

We enrolled patients with cancer who required central line TIVADs and randomised them to receive the TIVAD implantation on either the left or right side. The primary endpoint was the occurrence of catheter-related thrombotic or occlusion events.

RESULTS

We randomised 240 patients, of which 235 received TIVAD implantation according to the protocol. In the per-protocol cohort, 117 and 118 patients received implantation on the left and right sides, respectively. Catheter-related thrombotic or occlusion events occurred in 9 (4%) patients, accounting for 0.065 events per 1000 catheter-days. Between the patients with left- and right-sided implantations, the occurrence rates (P=0.333) and the time from catheter implantation to the occurrence of thrombotic or occlusion events (P=0.328) were both similar. In the multivariate analysis, the side of implantation remained unassociated with the occurrence of thrombotic or occlusion events.

CONCLUSIONS

The side of central line TIVAD implantation was not associated with the occurrence of catheter-related thrombotic or occlusion events in patients with cancer.

Intravenous treprostinil infusion via a fully implantable pump for pulmonary arterial hypertension

OBJECTIVES

Parenteral prostanoids infused via external pumps are well-established pulmonary arterial hypertension (PAH) treatments. However, local side-effects and systemic infections restrict their use. The purpose of this study was to investigate the safety of a fully implantable treprostinil infusion pump (LENUS Pro^®) in patients with PAH.

METHODS

Thirty patients with PAH undergoing pump implantation (with stable PAH therapy for ≥3 weeks pre-implantation) were included in this prospective, multicenter, observational study (NCT01979822). Primary endpoints were predefined adverse events (AEs) during implantation, in-hospital and/or during 6-month follow-up. Refill-related AEs were a secondary endpoint.

RESULTS

Twenty-nine patients completed 6-month follow-up (one underwent lung transplantation). During implantation, one pneumothorax (not requiring drainage) occurred. Four patients had an in-hospital AE (including one catheter revision). During 6-month follow-up, AEs were most frequent at the first refill (10); the most common AE was seroma around the pump. No infections occurred. One pump required replacement because of a defective septum caused by use of a non-approved refill needle (associated with extravasation). Apart from the extravasation, no refill-related AEs were recorded. Post hoc efficacy analyses showed significant improvements in functional class [number in functional class I/II/III/IV: 0/5/21/2 (baseline) versus 3/8/17/0 (6 months); p = 0.012] and 6-min walk distance (mean ± standard deviation: 407 ± 122 m versus 445 ± 127 m; n = 17; p = 0.014).

CONCLUSIONS

This study supports use of a fully implantable treprostinil infusion pump in patients with PAH requiring parenteral prostanoids. Refills should be performed by specialized healthcare professionals at patients' homes or at experienced centers using approved equipment.

Motivo de retirada do cateter de Hickman em pacientes submetidos ao transplante de células-tronco hematopoéticas

OBJETIVO: Identificar os motivos da retirada do primeiro cateter de Hickman implantado em pacientes submetidos ao transplante de células-tronco hematopoéticas alogênico, os micro-organismos envolvidos na ocorrência de infecção e o tempo de permanência do cateter in situ. MÉTODOS: Estudo transversal retrospectivo. A amostra foi constituída por 57 prontuários de pacientes transplantados. Para a obtenção dos dados, elaborou-se um instrumento contendo variáveis relativas à identificação do paciente, tempo de permanência do cateter, motivo de retirada e micro-organismo isolado. RESULTADOS: Dentre os motivos de retirada do cateter, destacou-se como o mais frequente a infecção (49%). O Stenotrophomonas maltophilia (25%) foi o micro-organismo identificado com maior frequência. CONCLUSÕES: Diante da elevada incidência de complicações infecciosas que levam à retirada do cateter de Hickman, faz-se necessária uma padronização de cuidados relacionados a esse cateter, tanto para a equipe de saúde como ao paciente e seu cuidador.

Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

AIM

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

METHODS

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

RESULTS

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

DISCUSSION

1. The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis. 2. Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology. 3. A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

Pharmacokinetics of intraperitoneally instilled aminophylline, terbutaline and tobramycin in pigs

INTRODUCTION

Venous catheters are sometimes difficult or even impossible to insert and may also be associated with serious complications. This study was carried out to investigate whether intraperitoneal administration of drugs may be an alternative to the intravenous route in patients with limited vascular access.

MATERIALS AND METHODS

Three drugs commonly in use in clinical practise, aminophylline, terbutaline and tobramycin, were administered to pigs intravenously and intraperitoneally in small volumes. Serum concentrations were analysed over a period of 6 h and pharmacokinetic key variables for each drug were calculated.

RESULTS

Aminophylline (theophylline), terbutaline and tobramycin were absorbed from the peritoneal space and into systemic circulation. For theophylline, the concentration/time profiles after intraperitoneal and after intravenous administration were almost identical, and the intraperitoneal bioavailability was calculated to 0.94. For terbutaline and tobramycin, the intraperitoneal absorption was delayed without any initial peak. Moreover, the intraperitoneal bioavailability was lower than for theophylline (0.71 and 0.65, respectively).

CONCLUSION

The pharmacokinetic properties after intraperitoneal administration differed among the three drugs, but the results are encouraging and provide a basis for further investigation in humans.

Safe techniques for inserting the hickman catheter in pediatric patients

The placement of the Hickman catheter in the central veins is thought to be an effective method for providing venous access in various clinical situations in children. The catheter is usually inserted by the percutaneous approach, but in some cases various troublesome complications can occur, such as sheath introducer kinking or damage, in addition to other major ones. Therefore, some modified techniques, using vascular dilators, both to dilate the route and to avoid such complications, have been developed and investigated to obtain a smooth and safe percutaneous insertion of the Hickman catheter in children. A total of 41 Hickman catheters were inserted by the percutaneous method in 41 pediatric patients from 1996 to 2004 in our department. Sixteen catheters were inserted by means of a standard method, using the manufacturer's insertion kit, and 25 catheters were inserted by means of a modified method, namely, using various sized vascular dilators. The length of time for the procedure, the complication rate, and the changes in the serum C-reactive reaction (CRP) levels were then compared between the standard and the modified methods. Those parameters were also compared between a right-side and left-side approach using both methods, to clarify which side was better for the insertion of this catheter. The length of time for the catheter replacement procedure in the standard group was significantly longer than that in modified one. The occurrence rate for both the kinking and small damage to the sheath introducer in the standard group was higher than that in the modified one. The peak of serum CRP in the modified group was significantly lower than that in the standard one. When comparing a right-side and left-side approach, 7 catheters out of 16 were inserted by the right-side approach in the standard group, while 10 catheters out of 25 were done by the right-side approach in the modified group. The length of time for the procedure for the left-side approach was significantly shorter than that for the right-side one in both groups. No difference in technical complications was observed between the two different approaches in the modified group, while complications when using the right-side approach often occurred in the standard group. The peak of serum CRP in the left-side approach was lower than that in the right-side one in both groups. The use of the modified percutaneous method, using various sized vascular dilators and the left-side approach, was therefore found to be useful for the safe and smooth placement of the Hickman catheter in children.

Nurse-led central venous catheter service: Christie experience

The aim of this study was to evaluate the success and complication rate of Nurse-led subclavian central venous catheter (CVC) insertion using the landmark technique. A prospective study was performed on all subclavian CVC insertion between 13/01/03 to 01/07/03. Data recorded included indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction. A total of 348 subclavian cuffed tunnelled catheters were inserted over the study period. The age group ranged from 31 years to 84 years with a mean age of 53 years. This included 192 women and 156 men. The majority of CVC insertions were through the right subclavian (79%) and were single lumen (76%). In total, complications were encountered in 48 patients (14%). These included misplaced tip in 29 (8%), arterial puncture in 16 (4%), pneumothorax in 3 (1%) and the procedure failed in 3 (1%). Of these multiple complications were seen in 3 (1%). No interventions were required for the pneumothoraces or for the arterial punctures. In conclusion, nurse-led subclavian CVC placements using the landmark technique are both safe and effective.

Subclavian venipuncture following ipsilateral extrapleural dissection is hazardous

Subclavian artery puncture is an infrequent complication of subclavian vein cannulation. In spite of the limited ability to apply direct pressure to the bleeding vessel, significant hematoma or exsanguinating bleeding rarely occurs. This study was a retrospective chart review of a neonate who underwent extrapleural repair of a tracheo-esophageal fistula and sustained significant blood loss following an accidental ipsilateral subclavian artery puncture. This case highlights the importance of an intact apical pleura in controlling bleeding from the subclavian vessels. Thus, ipsilateral percutaneous subclavian venipuncture should be avoided in patients in whom the apical pleura is not intact.

Intraperitoneal fluid therapy: an alternative to intravenous treatment in a patient with limited vascular access

We describe a 58-year-old female with Crohn's disease and short bowel syndrome after repeated intestinal resections, with only 90 cm of small intestine left. She had been dependent on vascular access for total parenteral nutrition for 16 years. Due to intravascular complications after numerous long-term central venous catheters, her vascular accessibility became limited. During the course of a year she was fed enterally through a gastrostomy, but required supplementary fluid therapy through peripheral venous route. Because of extremely limited venous access, we decided to implant an intraperitoneal catheter for administration of crystalloid fluid. The first intraperitoneal catheter had to be removed because of a postoperative infection, but after antibiotic treatment, a second intraperitoneal catheter was implanted without complications, through which the patient is now fully provided with crystalloid fluid (Ringer's acetate). Abdominal ultrasound examination shows good absorption of the fluid, and for the first time in 16 years the patient does not need intravascular access. We suggest that intraperitoneal administration of fluid may be an alternative for patients with limited vascular access.

Saphenous vein eversion: a novel technique for Hickman catheter insertion

Saphenous eversion Hickman catheter insertion can provide an alternative technique for venous access in patients in whom upper body access is not feasible. The technique is simple and obviates many of the complications of upper body permanent venous access catheter insertion. Further experience is required to assess whether this technique can become one of the standard Hickman insertion techniques.

Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebo-controlled phase III trial

BACKGROUND

Cancer patients receiving chemotherapy experience thromboembolic complications associated with the use of long-term indwelling central venous catheters (CVCs). This prospective, double-blind, placebo-controlled, multicenter study evaluated whether prophylactic treatment with a low molecular weight heparin could prevent clinically relevant catheter-related thrombosis.

PATIENTS AND METHODS

Patients with cancer undergoing chemotherapy for at least 12 weeks (n=439) were randomly assigned, in a 2:1 ratio, to receive either dalteparin (5000 IU) or placebo, by subcutaneous injection, once daily for 16 weeks. Patients underwent upper extremity evaluation with either venography or ultrasound at the time of a suspected catheter-related complication (CRC) or upon completion of study medication. The primary end point, as determined by a blinded adjudication committee, was the occurrence of a CRC, defined as the first occurrence of any one of the following: clinically relevant catheter-related thrombosis that was symptomatic or that required anticoagulant or fibrinolytic therapy; catheter-related clinically relevant pulmonary embolism; or catheter obstruction requiring catheter removal.

RESULTS

There was no significant difference in the frequency of CRCs between the dalteparin arm (3.7%) and the placebo arm (3.4%; P=0.88), corresponding to a relative risk of 1.0883 (95% confidence interval 0.37-3.19). No difference in the time to CRC was observed between the two arms (P=0.83). There was no significant difference between the dalteparin and placebo groups in terms of major bleeding (1 versus 0) or overall safety.

CONCLUSIONS

Dalteparin prophylaxis did not reduce the frequency of thromboembolic complications after CVC implantation in cancer patients. Dalteparin was demonstrated to be safe over 16 weeks of treatment in these patients.

O cuidado de enfermagem e o cateter de Hickman: a busca de evidências

INTRODUÇÃO: Os pacientes submetidos ao transplante de medula óssea (TMO) necessitam de um acesso venoso seguro para a infusão da medula óssea. A implantação de um cateter venoso central é parte da terapêutica, sendo o de Hickman o mais utilizado atualmente; entretanto, sua presença impõe riscos, sendo a infecção, o mais preocupante. OBJETIVO: Revisão integrativa da literatura, que teve como objetivo buscar e avaliar as evidências sobre os cuidados de enfermagem relacionados ao cateter de Hickman. MÉTODO: Para a seleção dos artigos utilizamos as bases de dados Lilacs, Medline, Cinahl e o periódico Bone Marrow Transplantation, e a amostra constituiu-se de 18 artigos. RESULTADOS: O curativo recomendado é o de poliuretano trocado a cada 7 dias. O método de coleta de sangue observado foi o de descarte, sendo que a dosagem de ciclosporina não deve ser coletada da mesma via onde foi infundida. A redução do número de manipulações do cateter é considerada uma medida eficaz na prevenção e no controle de infecção. CONSIDERAÇÕES FINAIS: As evidências extraídas dos estudos analisados podem auxiliar a implementação de cuidados de enfermagem eficazes relacionados ao cateter de Hickman.

A review of an anaesthetic led vascular access list

The demand for insertion of long-term central venous (Hickman type) catheters is thought to be increasing. Organisation is required to meet this demand in a safe and efficient manner. This report reviews the results from a dedicated, anaesthetic led vascular access list over the initial 61-month period. One thousand procedures were performed. Nine hundred and twenty catheters were inserted under local anaesthesia, with or without intravenous sedation and analgesia. Eighty catheters were removed. All procedures were performed during a dedicated once weekly, morning list. A total of 53% of all procedures were performed on a day-case basis, 43% on in-patients. Only 1.5% of patients required an unexpected overnight stay (usually medically unfit patients). There were 81 (9%) cancellations on the day of procedure due to neutropaenia, pneumonia or urinary tract infections. Ultrasound guidance was used initially selectively in 14%, latterly in 100% of procedures and fluoroscopy in all insertions to confirm or adjust catheter position. This service has been well received by patients and oncology services. In addition it provides an interesting area of practice for anaesthetists and an ideal environment for teaching more advanced aspects of central venous access. It may provide a template of service for other centres.

Catheter-Related Thrombosis in Cancer Patients: Pathophysiology, Diagnosis, and Management

Central venous catheters (CVCs) are commonly used in oncology patients. Up to 50% of CVCs are complicated by thrombosis within the catheter or the blood vessel. These thrombi are the result of local tissue damage, the catheter itself, and the thrombophilia of cancer. Frequent flushes with saline or heparin may reduce the frequency of catheter dysfunction but do not reduce the rate of deep venous thrombosis (DVT) in the catheterized blood vessel. Efforts to use prophylactic heparin or warfarin to reduce catheter-related DVT have not been rewarding.

BisEDT and RIP act in synergy to prevent graft infections by resistant staphylococci

Staphylococci are a major cause of infections associated with indwelling medical devices. Biofilm formation on these devices adds to the antibiotic resistance seen among clinical isolates. RNAIII-inhibiting peptide (RIP) is a heptapeptide that inhibits staphylococcal pathogenesis, including biofilm formation, by obstructing quorum sensing mechanisms. Bismuth ethanedithiol (BisEDT) also prevents biofilm formation at subinhibitory concentrations. RIP and BisEDT were combined to prevent infections in a rat graft model, using antibiotic sensitive and resistant strains of Staphylococcus aureus and Staphylococcus epidermidis. BisEDT, RIP, or rifampin, or their combinations reduced the graft associated bacterial load over seven days. BisEDT-RIP was the best combination, reducing bacterial load to undetectable levels. BisEDT-RIP may prove useful for coating medical devices to prevent staphylococcal infections.

Provision of long-term venous access procedures by UK anaesthetists: A postal survey

Long-term venous access is widely used in hospital and in the community for cancer chemotherapy, total parenteral nutrition and long-term administration of antibiotics. There is a large variety of catheters, ports and other devices designed to facilitate these treatments. A postal survey of anaesthetic departments in England, Wales, Scotland and Northern Ireland was undertaken to assess the role of anaesthetists in this area of clinical practice. Two hundred and fifteen out of 276 (78%) anaesthetic departments responded. Forty-three percent of departments (92 out of 215) provided some form of long-term vascular access service. Twenty-two percent of departments which provided this service (20 out of 92) had anaesthetists with sessional allocation for such procedures. Such work represents a significant workload for anaesthetic departments which is likely to increase over time.

To clot or not to clot? That is the question in central venous catheters

AIM

To establish the relationship between the tip position of tunnelled central venous catheters (CVC) and the incidence of venous thrombosis.

MATERIALS AND METHODS

A randomly sampled, retrospective review of 428 CVC inserted into 334 patients was performed. The chest radiograph obtained post-catheter insertion, as well as follow-up radiographs, linograms, venograms and Doppler ultrasounds (US), were reviewed.

RESULTS

The median follow-up was 72 days (range 1-720 days), with a total follow-up of 23,040 line days. Venous thrombosis occurred in five out of 191 (2.6%) CVC in a distal position (distal third of the superior vena cava (SVC) or right atrium (RA)), five of 95 (5.3%) in an intermediate position (middle third of the SVC) and 20 of 48 (41.7%) in a proximal position (proximal third SVC or thoracic inlet veins). There was a significant difference in thrombosis rate between lines sited with the tip in a distal compared with a proximal position (p<0.0005). CVC with tips in a proximal position were 16 times more likely to thrombose than those in a distal position. None of the 58 CVC with the tip located in the RA thrombosed or caused complications.

CONCLUSION

Distal placement of tunnelled CVC, either in the distal third of the SVC or proximal RA is optimal.

Thrombotic Complications of Central Venous Catheters in Cancer Patients

Central venous catheters (CVCs), such as the tunneled catheters and the totally implanted ports, play a major role in general medicine and oncology. Aside from the complications (pneumothorax, hemorrhage) associated with their initial insertion, all of these CVCs are associated with the long-term risks of infection and thrombosis. Despite routine flushing with heparin or saline, 41% of CVCs result in thrombosis of the blood vessel, and this markedly increases the risk of infection. Only one-third of these clots are symptomatic. Within days of insertion, almost all CVCs are coated with a fibrin sheath, and within 30 days, most CVC-related thrombi arise. Aside from reducing the function of the catheter, these CVC-related thrombi can cause postphlebitic syndrome in 15%-30% of cases and pulmonary embolism in 11% (only half of which are symptomatic). Risk factors for CVC thrombosis include the type of malignancy, type of chemotherapy, type of CVC, and locations of insertion site and catheter tip, but not inherited thrombophilic risk factors. Efforts to reduce CVC thrombosis with systemic prophylactic anticoagulation with low-molecular-weight heparin have failed. Low-dose warfarin prophylaxis remains controversial; all studies are flawed, with older studies, but not newer ones, showing benefit. Currently, less than 10% of patients with CVCs receive any systemic prophylaxis. Although its general use cannot be recommended, low-dose warfarin may be a low-risk treatment in patients with good nutrition and adequate hepatic function. Clearly, additional studies are required to substantiate the prophylactic use of low-dose warfarin. Newer anticoagulant treatments, such as pentasaccharide and direct thrombin inhibitors, need to be explored to address this major medical problem.

Endovascular techniques for placement of long-term chemotherapy catheters

PURPOSE

To analyze the results from using endovascular techniques to place long-term chemotherapy catheters when advancing the catheter using the external jugular vein is difficult due to obstructions or kinking.

METHODS

Between July 1997 and August 2000, 320 long-term chemotherapy catheters were placed, and in 220 cases the external jugular vein was used as the primary venous approach. In 18 of these patients, correct positioning was not achieved and several endovascular techniques were then utilized to overcome these obstacles, including manipulation of a J-wire with a moveable core, venography, and the exchange wire technique.

RESULTS

In 94.5% of the patients with difficulties in obtaining the correct positioning, we were able to advance the long-term catheter to the desired position with the assistance of endovascular techniques.

CONCLUSIONS

Venography and endovascular guidance techniques are useful for the placement of long-term catheters in the external jugular vein.

Twelve weeks of protracted venous infusion of fluorouracil (5-FU) is as effective as 6 months of bolus 5-FU and folinic acid as adjuvant treatment in colorectal cancer

We performed a multicentre randomised trial to compare the efficacy and toxicity of 12 weeks of 5-fluorouracil (5-FU) delivered by protracted intravenous infusion (PVI 5-FU) against the standard bolus regimen of 5-FU and folinic acid (5-FU/FA) given for 6 months as adjuvant treatment in colorectal cancer. A total of 716 patients with curatively resected Dukes' B or C colorectal cancer were randomised to 5-FU/FA (5-FU 425 mg m(-2) i.v. and FA 20 mg m(-2) i.v. bolus days 1-5 every 28 days for 6 months) or to PVI 5-FU alone (300 mg m(-2) day for 12 weeks). With a median follow-up of 19.8 months, 133 relapses and 77 deaths have been observed. Overall survival did not differ significantly (log rank P=0.764) between patients receiving 5-FU/FA and PVI 5-FU (3-year survival 83.2 vs 87.9%, respectively). Patients in the 5-FU/FA group had significantly worse relapse-free survival (RFS, log rank P=0.023) compared to those receiving PVI 5-FU (3-year RFS, 68.6 vs 80%, respectively). Grades 3-4 neutropenia, diarrhoea, stomatitis and severe alopecia were significantly less (P<0.0001) and global quality of life scores significantly better (P&<0.001) for patients in the PVI 5-FU treatment arm. In conclusion, infused 5-FU given over 12 weeks resulted in similar survival to bolus 5-FU and FA over a 6 month period, but with significantly less toxicity.

Central venous catheter pinch-off and fracture: recognition, prevention and management

The so-called pinch-off syndrome is observed in up to 1% of all central venous catheters (CVCs), and is a valuable warning prior to fragmentation, which occurs in approximately 40% of the respective cases. As long-term indwelling CVCs are used with increasing frequency, this paper describes the necessity of pinch-off monitoring following the experiences of a case study and a review of the current literature on this specific topic in order to point out preventive practice guidelines. Besides easy preventive practices such as a high level of suspicion and adequate X-ray controls, findings give strong evidence that the most important specific factor might be the adequate approach. In our hands, the supraclavicular technique has provided the best results with regards to percutaneous introduction of large bore CVCs.

Safe removal of long-term cuffed Hickman-type catheters

The use of long-term venous access devices is increasing. Most devices are anchored by a cuff, usually made of Dacron. The disadvantage of such cuffs is that a cut-down procedure is required for their removal. This article presents a simple technique for removal of Hickman-type catheters, emphasizing avoidance of complications.

Penetration of rifampin through Staphylococcus epidermidis biofilms

Rifampin penetrated biofilms formed by Staphylococcus epidermidis but failed to effectively kill the bacteria. Penetration was demonstrated by a simple diffusion cell bioassay and by transmission electron microscopic observation of antibiotic-affected cells at the distal edge of the biofilm.

Expanding our interventional skills: placement of totally implantable injection ports by internists/intensivists

Totally implantable injection ports are usually placed by surgeons or radiologists using fluoroscopic guidance. In a prospective study we evaluated the efficacy of percutaneous insertion of these devices without the use of fluoroscopic control by internists/intensivists experienced in the placement of permanent cuffed catheters. The supraclavicular approach to the subclavian vein was chosen for first line puncture site because of its low rate of malpositions and complications. 101 ports were inserted in 101 consecutive patients, 96 from the supraclavicular approach. Difficulties in introducing the catheter through the peel-away sheath, misplacement into adjacent vessels, secondary migration, or fragmentation of a line were not observed. Function was excellent in all ports. Three pneumothoraces (3%) and three arterial punctures (3%), none of which required intervention, were recorded. Two ports (2%) had to be revised, one due to local hematoma and another because of inadequate catheter length. Catheter survival was 94% in a 30-month observation period. Placement of totally implantable port systems by internists/intensivists experienced in placing central venous lines is safe and efficient, thus the implantation can easily be performed with minimal technical expenditure in the setting of an intensive care unit. The supraclavicular approach is suitable for insertion of permanent infusion port systems without fluoroscopic control.

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.

Multi-purpose silastic dual-lumen central venous catheters for both collection and transplantation of hematopoietic progenitor cells

Autologous peripheral blood progenitor cell (PBPC) transplantation frequently requires sequential placement and use of two separate central venous catheters: (1) a short-term, large-bore, stiff device inserted for leukapheresis, and after removal of that device, (2) a long-term, multi-lumen, flexible, Silastic catheter for administration of high-dose chemotherapy, re-infusion of hematopoietic cells, and intensive supportive care. We reviewed our recent experience with two dual-lumen, large-bore, Silastic multi-purpose ('hybrid') catheters, each of which can be used as a single device for both leukapheresis and long-term supportive care throughout the transplant process. Quinton-Raaf PermCath and Bard-Hickman hemodialysis/apheresis dual-lumen catheters were used as the sole venous access device in 112 consecutive patients who underwent autologous PBPC collection and transplantation. The catheter exit site was monitored three times a week, and lumen patency was assessed using clinical and radiologic techniques. Catheters were removed prematurely for persistent thrombus, positive blood cultures despite appropriate antibiotics, or mechanical dysfunction. There were no intra-operative or immediate post-operative complications relating to insertion. Thirty-two patients experienced catheter occlusion necessitating urokinase instillation. Persistent occlusive problems were noted in 16 patients, and in 10 patients the catheter had to be removed. Two exit site infections and 17 bacteremias occurred. Catheters had to be removed for persistent infection in two subjects and for mechanical problems in five others. Cost analysis comparing the hybrid catheters alone vs conventional devices revealed a charge of $4230 in patients with hybrid catheters vs. $7530 in those requiring a temporary non-Silastic dialysis catheter in addition to a flexible, long-term Silastic catheter. Hybrid, Silastic, dual-lumen, large-bore central venous catheters are safe, cost-effective and convenient multi-purpose venous access devices that may be used in the setting of autologous PBPC collection and transplantation. The rate of thrombotic, infectious and mechanical complications appears comparable to other central venous access devices.

Epirubicin, cisplatin and oral UFT with leucovorin ('ECU'): a phase I-II study in patients with advanced upper gastrointestinal tract cancer

BACKGROUND

ECF (epirubicin, cisplatin, protracted venous fluorouracil) is superior to FAMTX in gastroesophageal cancer, but protracted fluorouracil adds to its morbidity and cost. In this dose-escalation pilot study, fluorouracil was replaced by oral UFT and leucovorin.

PATIENTS AND METHODS

Thirty unpretreated patients with advanced upper gastrointestinal cancers received epirubicin 50 mg/m2 and cisplatin 60 mg/m2 i.v. on day 1, and leucovorin 45 mg p.o. on days 1, 8 and 15, of a 21-day cycle for up to 8 cycles. UFT was taken 12-hourly throughout, at escalating doses in four cohorts ranging from 150-325 mg/m2 per day.

RESULTS

The maximum tolerable dose of UFT, recommended for further study, was 200 mg/m2 per day. At higher doses, more than two-thirds patients required dose reductions, although mostly for persistent mild (CTC grade 2) nausea, diarrhoea or fatigue, rather than for severe acute toxicity. Myelotoxicity was mild. Twenty patients, including 15 with gastroesophageal cancer, had assessable disease. Among these there were nine WHO objective responses, all in gastroesophageal patients, including two radiological complete responses.

CONCLUSIONS

ECU is well tolerated at the defined dose, with activity comparable to ECF in gastroesophageal cancer. UFT and other oral 5FU dosing strategies make promising components of combination chemotherapy, deserving further, randomised evaluation.

Hickmans in unusual places

Radiologists now commonly insert long-term indwelling right atrial catheters. The insertion of these catheters in patients with limited venous access is a challenging clinical problem. Our experience in dealing with patients with limited venous access from a series of 500 Hickman catheter insertions is presented, as are the problems encountered during the insertion of catheters in patients with anomalies of the venous system.

Spontaneous fracture and embolization of a central venous catheter: prevention and early detection

Central venous catheters are used increasingly in oncology patients. Spontaneous fracture and embolization of a catheter is a rare complication. This report illustrates such a case, in which the fragment was retrieved percutaneously. Impending line fracture may be detected by the 'pinch-off sign' on a chest radiograph. Prevention may be possible by inserting the catheter more laterally.

Acute airway obstruction in a child with acute lymphoblastic leukaemia during central venous catheterization

We report the case of a seven-year-old girl with recently diagnosed acute lymphoblastic leukaemia (ALL) who suffered acute airway obstruction during insertion of a central venous catheter under general anaesthesia. The central airway obstruction was due to a mixture of leukaemic cells, blood clot and fibrin. There is discussion about airway obstruction both as a complication of central line insertion and secondary to ALL. The pulmonary complications of ALL, with particular reference to pulmonary haemorrhage, are detailed. The management of blood clot obstructing the central airway is discussed.

Assessment of patients requiring i.v. therapy via a central venous route

In the past, problems associated with the prolonged maintenance of a patient with a central venous catheter (CVC), inserted for the administration of antibiotics, chemotherapy, intravenous (i.v.) fluid replacement of i.v. alimentation, have limited the duration that such catheters can remain in situ. This article highlights the necessity for and increasing importance of accurate patient assessment before catheter insertion for the long-term care and maintenance of individual i.v. devices. CVCs that may once have had a limited lifespan as a result of thrombosis, infection and eventual lack of suitable venous access, are increasingly being maintained in a satisfactory functional condition for long periods, ranging from many months to years.