Thrombosis and infection caused by thoracic venous catheters: pathogenesis and imaging findings

Chest X-ray in intensive care unit patients: what there is to know about thoracic devices

Critically ill patients admitted to the intensive care unit require continuous monitoring of vital functions as well as mechanical and pharmacological support, provided through different devices. Chest radiographs play a fundamental role in monitoring the conditions of these patients and assessing the intensive-care devices after their insertion; therefore, the radiologist needs to know their normal appearance and their correct position and should be aware of the possible complications that may occur after their placement. This pictorial review illustrates the radiographic appearance of non-cardiological devices commonly used in clinical practice (central venous catheters, tunneled catheters, Swan-Ganz catheters, chest tubes, endotracheal tubes, and nasogastric tubes), their correct position and the most common complications that may occur after their placement.

The incidence and management of complications of venous access in home parenteral nutrition (HPN): A 19 year longitudinal cohort series

BACKGROUNDS AND AIMS

Long term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI). This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access.

METHODS

HPN data were analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days' distributions. Data were not normally distributed and so non-parametric tests were used. Spearman's Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used two sample t-tests to compare the groups.

RESULTS

From 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n = 16) was associated with total time on HPN (r² = 0.187, P < 0.05) and the number of infections (r² = 0.207, P < 0.05). Damage was strongly associated with increasing time on HPN with (r² of 0.494 and P < 0.005). Blockage was not associated with any patient or catheter factors. Overall catheter salvage rate for CRBSI by antibiotic treatment was 61.87%. Success varied according to organism cultured. Catheter salvage was less successful in other complications and overall catheter salvage rate was 41,115 catheters were salvaged from 282 complications.

CONCLUSIONS

This study has provided a baseline for rates of less common venous access complications in HPN and their management. Catheter salvage is possible after at least 41% of complications. It is likely that experience is helpful whether that of individual patient, the team or a clinical network. Our results support the use of smaller central venous catheters, in upper body veins, and the use of Taurolock-Hep100 in patients who have recurrent infections.

Twenty-five Years of Advances in Vascular Access: Bridging Research to Clinical Practice

Vascular access has become a key component for a multitude of IV therapies, including parenteral nutrition. Access of the central venous system has been long recognized for its associated complications of infection, thrombosis, and occlusion. Over the past 25 years, clinical practice based on research and innovation has attempted to decrease complication rates and therefore improve the safety of vascular access. This article highlights the research and its influence on catheter care procedures, technology, and education that has led to advances in vascular access. An improved understanding of the pathophysiology associated with catheter-related complications and an ongoing evaluation of new treatment modalities has provided clinicians today with new options for improved patient care and the ability to preserve vascular access options for patients.

Surface modification of a polyethylene film for anticoagulant and anti-microbial catheter

A functional anticoagulant and anti-bacterial coating for polyethylene (PE) films is described. The stepwise preparation of this nanocomposite surface coating involves O2 plasma etching of PE film, carbodiimide coupling of cysteamine to the etched PE film, binding of Ag to sulfhydryl groups of cysteamine, and assembly of heparin capped AgNPs on the PE film. The nanocomposite film and its components were characterized by 1H-nuclear magnetic resonance spectroscopy, attenuated total reflectance-Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, and field emission-scanning electron microscopy. The resulting PE films demonstrate anticoagulant activity using a hemoglobin whole blood clotting assay, and anti-bacterial activity against Bacillus cereus 3551 (Gram-positive) and Escherichia coli BL21 (Gram-negative) bacteria. The hydrophilicity of the heparin coated PE was determined by contact angle measurements; and the stability of the nanocomposite film, with respect to Ag leaching, was assessed by atomic absorption spectroscopy.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Review article: the management of long-term parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

AIM

To summarise the major issues in delivering long-term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.

METHODS

A literature search using PubMed and MEDLINE databases was performed.

RESULTS

Safe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter-associated blood stream infection (reported incidence 0.14-0.83 episodes/patient-year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient-year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19-75%) and advanced liver disease (0-50%). Five-year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long-term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.

CONCLUSIONS

Home parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter-related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients

Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.

Malfunctioning central venous catheters in children: a diagnostic approach

Central venous access is increasingly becoming the domain of the radiologist, both in terms of the insertion of central venous catheters (CVCs) and in the subsequent management of these lines. This article seeks to provide an overview of the CVC types available for paediatric patients and a more detailed explanation of the spectrum of complications that may lead to catheter malfunction. A standard catheter contrast study or 'linogram' technique is described. The normal appearances of such a study and a detailed pictorial review of abnormal catheter studies are provided, together with a brief overview of how information from catheter investigations can guide the management of catheter complications.

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

BACKGROUND

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

METHODS

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

RESULTS

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11-45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

INTERPRETATION

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%-50%).

Venous thromboembolism associated with long-term use of central venous catheters in cancer patients

Long-term central venous catheters (CVCs) have considerably improved the management of cancer patients because they facilitate chemotherapy, transfusions, parenteral nutrition, and blood sampling. However, the use of long-term CVCs, especially for chemotherapy, has been associated with the occurrence of upper-limb deep venous thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to CVCs has been reported to vary between 0.3% and 28.3%. The incidence of CVC-related UL-DVT screened by venography reportedly varies between 27% and 66%. The incidence of clinically overt pulmonary embolism (PE) in patients with CVC-related UL-DVT ranges from 15% to 25%, but an autopsy-proven PE rate of up to 50% has been reported. Vessel injury caused by the procedure of CVC insertion, venous stasis caused by the indwelling CVC, and cancer-related hypercoagulability are the main pathogenetic factors for CVC-related venous thromboembolism (VTE). Several studies have assessed the benefit of the prophylaxis of UL-DVT after CVC insertion in cancer patients. According to the results of these studies, prophylaxis with low molecular weight heparin or a low fixed dose of warfarin has been recently proposed. However, the limitations of the experimental design of the prophylactic studies do not allow definitive recommendations. The recommended therapy for UL-DVT associated with CVC is based on anticoagulant therapy with or without catheter removal. This review focuses on the epidemiology, pathogenesis, diagnosis, prevention, and treatment of VTE in cancer patients with long-term CVC.

Analysis of early failure of tunneled hemodialysis catheters

OBJECTIVE

Tunneled hemodialysis catheters are often placed by the interventional radiology service using sonographic guidance and fluoroscopy for safe and optimal placement. The aim of this study was to determine the causes of early failure (<or=7 days) of these catheters in our practice.

SUBJECTS AND METHODS

Data were prospectively collected for 639 radiologically placed tunneled hemodialysis catheters. The reason for catheter removal was recorded in each case. Tips of removed catheters were routinely sent for microbial culture.

RESULTS

Fifty-two (8.1%) of 639 catheters were removed within 7 days of insertion. Six (0.9%) of these had completed their purpose and had not failed; these were not included in the study. Of the 46 catheters having early failure, six (0.9%) were clotted and 12 (1.9%) were suspected of being infected, only three of which had a proven catheter-related infection. Twenty-eight catheters (4.4%) were removed for other reasons. In this group, the most common reasons were poor tip position (n = 9) and catheter replacement over a guidewire into a preexisting fibrin sheath (n = 8). Only two failed because of poor tip orientation. Other reasons for failure were kinked or pinched catheters (n = 4) and bleeding (n = 3), including one exsanguination, and two unknown reasons.

CONCLUSION

By paying careful attention to catheter tip position, searching diligently for the presence of a fibrin sheath when catheter exchanges are made over a wire, and better investigating presumed catheter infection, we could reduce the early failure rate by more than half, from 46 cases to 20 cases (nine cases of suspected infection were in fact not infected).

Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: a prospective comparison of silver-coated and uncoated catheters

BACKGROUND

Catheter-related venous thrombosis is one of the most frequent complications of central venous catheters (CVCs). This complication occurs in 4- 40% of patients with hematologic malignancies receiving conventional chemotherapy after placement of CVCs.

METHODS

The objective of this prospective study was to assess whether a silver-coated CVC poses an additional risk in the development of catheter-related thrombosis in hematologic-oncologic patients. Patients were randomized to receive either silver-coated polyurethane catheters (BactiGuard; Metacot, Stockholm, Sweden) or uncoated standard polyurethane catheters (Cavatheter, Fresenius AG, Bad Homburg, Germany) for central venous access. Silver-coated catheters (n = 120) and standard catheters (n = 113) were inserted into the jugular vein in 233 consecutive patients. Variables that may be significant for the development of thrombosis were comparable in the two groups. After removal of the CVC, the patency of both jugularian veins internal as well as external was assessed with real-time ultrasound (Sonolayer-SAL-35A; Toshiba, Tokyo, Japan).

RESULTS

Four of 233 patients (1.5%) were found to have venous thrombosis. Incomplete occlusion of the internal jugular vein occurred in 2 patients (0.75%, parietal thrombosis), and complete thrombosis, although clinically silent, was found in 2 patients (0.75%). There was no difference between patients with silver-coated and uncoated CVCs.

CONCLUSIONS

The authors concluded that this novel silver-coated CVC does not cause a higher rate of central venous thrombosis compared with standard CVCs. The low overall incidence of central venous thrombosis might be attributed to the routine application of low-dose heparin in our patients during chemotherapeutic treatment.

Complicações dos catéteres venosos centrais de longa permanência: análise de 500 implantes consecutivos

Neste trabalho, são analisadas retrospectivamente as complicações locais e sistêmicas associadas ao implante e uso de catéteres venosos centrais (CVC) de longa permanência. Num período de oito anos, foram implantados 500 CVC para quimioterapia de doenças malignas ou para suporte em transplantes de medula óssea. Dois tipos de CVC foram usados: 322 CVC totalmente implantáveis (com reservatório subcutâneo) e 178 CVC semi-implantáveis (com segmento externo). Os implantes foram feitos por via percutânea ou por dissecção venosa cirúrgica. As veias de acesso foram: jugular interna, subclávia, cefálica, e safena magna. OS CVC foram usados de três dias a 75 meses (média de 4,8 meses). Foram analisadas as complicações que necessitaram de tratamento, prolongaram a estadia hospitalar ou levaram à retirada do catéter. Complicações menores foram excluídas deste estudo. Os tipos e os números de complicações observadas foram: Anestésicas: broncoespasmo grave (um); enfisema do pescoço por perfuração traqueal (um). Cirúrgicas: deiscência da incisão (duas); hematoma do pescoço (três); infecção aguda no local de implante (duas); lesão temporária do nervo vago (três}; linfocele (uma); fístula do ducto torácico (uma). Venosas: trombose aguda da jugular (três) e da veia subclávia (cinco); síndrome da cava superior (três). Do próprio catéter: bacteremia tardia (39); trombose do catéter (48); erosão da pele sobre o catéter/reservatório(três); torção do reservatório (duas); fratura do catéter (duas). No total, ocorreram 119 complicações, para uma taxa cumulativa de 23,8%. Nenhuma complicação foi fatal. O implante e uso dos CVC de longa permanência estão associados a complicações freqüentes, que podem ser graves. Mas os benefícios trazidos por estes CVC nos pacientes que necessitam de acesso venoso confiável por tempo prolongado são certamente muito maiores do que os riscos das complicações.

CT demonstration of infected SVC thrombus

We report a case in which computed tomography (CT) demonstrated gas within a thrombus in the superior vena cava in a patient with fever of unknown origin (FUO), indicating that the thrombus was infected. This CT finding is important to recognize, as it affects subsequent therapy.

Upper extremity DVT. Correlation of MR and nuclear medicine flow imaging

The purpose of this study is to determine correlation between MR and nuclear medicine flow studies in the evaluation of upper extremity deep venous thrombosis. We retrospectively reviewed MR and radionuclide venography images obtained in 10 patients with suspected upper extremity venous thrombosis. In nine cases there was complete agreement in the identification of thrombus. In one case, MR images failed to identify a thrombus in the axillary vein adjacent to a port-a-cath. Good correlation between MR and radionuclide venography images in evaluation of upper extremity DVT is present in the majority of cases.

Management of total parenteral nutrition-related superior vena cava obstruction with expandable metal stents

Catheter-related thrombotic and stenotic obstructions are the second most common serious complication of long-term total parenteral nutrition. Subsequent venous access problems have profound implications because of immediate and long-term requirements of nutrition support. Although improved understanding of pathogenesis has led to improved prophylaxis and treatment of thrombosis, some patients will have refractory obstructions that threaten venous access and lead to severe clinical sequelae, including superior vena cava (SVC) syndrome. We describe two cases of patients with SVC syndrome refractory to anticoagulant, thrombolytic, and balloon angioplasty therapy, managed successfully with percutaneous placement of expandable metal stents. A discussion of the current understanding of prophylaxis and treatment of catheter-related thrombosis and the role for interventional measures to restore venous patency and avoid permanent venous access problems accompanies the case descriptions.

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 thrombosis in clinically asymptomatic oncologic patients: a phlebographic study

Fifty-seven oncologic patients with short- or long-term central venous catheters (CVCs) and without clinical signs of axillary-subclavian thrombosis were evaluated phlebographically. Different degrees of incomplete thrombosis were found in 26 patients (45.5%) and complete thrombosis, clinically silent, was found in six patients (10.5%). A fibrin sleeve around the CVC was radiologically demonstrated in 45 (78%) patients, 21 of them (46%) with negative standard venogram. Only in four patients there was no evidence of fibrin sleeve or parietal thrombosis. There were no significant differences between patients with long-term and short-term CVCs. We conclude that parietal thrombosis of the axillary-subclavian veins is a frequent event, even if there is no clinical evidence of flow obstruction and we confirm in vivo that a fibrin coating of the CVCs is present in the majority of the cases.

Transhepatic central venous access for cardiac catheterization and radiologic intervention

We describe a technique of direct puncture and catheterization of the hepatic veins for cardiac catheterization and radiologic intervention in children who lack conventional access routes. Four patients underwent eight direct hepatic vein punctures to allow cardiac catheterization (3 patients) and 5-12 F sheath insertions for balloon dilatation of hepatic vein stenoses (1 liver transplant patient). Gelfoam was injected in the sheath tract for hemostasis. All procedures were successful, including five hepatic vein dilatations and right heart access for three cardiac catheterizations. There were no complications. When conventional venous access is precluded, direct percutaneous catheterization of hepatic veins is easy, effective, and probably low risk.

Catheter malfunction and thrombus formation on double-lumen hemodialysis catheters: an intravascular ultrasonographic study

Intravascular ultrasound imaging (IVUS) is a new method that permits in vivo visualization of central venous catheters with hitherto unknown image resolution. It provides information not only about thrombus formation, but also about catheter movement, catheter malposition, and vessel wall injuries. In the present investigation the method was applied to evaluate the frequency of thrombus formation on double-lumen hemodialysis catheters and its significance for catheter malfunction. In 14 patients who had a double-lumen hemodialysis catheter for temporary or long-term vascular access, IVUS of the catheter and the mediastinal vein stems was performed. Mean indwelling duration at the time of the ultrasound investigation was 101 days (range. 3 to 730 days; median, 58 days). Four patients had catheter-related thrombotic complications: IVUS failed to detect an intracatheter thrombus in one case; a catheter thrombus and superior vena cava stenosis were found in a catheter with normal function in one case; in one case with catheter malfunction, a combined catheter-mural thrombus was found; and in the remaining case, a catheter thrombus and a mural superior vena cava thrombus were found in a patient with normal catheter function and pulmonary emboli. Thus, two of 12 patients with well-functioning catheters (16%) had thrombotic complications demonstrated by IVUS, and one of two patients with catheter malfunction had thrombus identified by IVUS. It is concluded that thrombus formation is less likely in patients without signs of catheter malfunction.(ABSTRACT TRUNCATED AT 250 WORDS)