about caring central venous access device in hematology/critical care setup

1. Caring
Central Venous Access Devices
in Hematology
Dr Pritish Chandra Patra
Department of Clinical Hematology
IMS & SUM Hospital
Bhubaneswar

2. History
Werner Forssmann

3. Landmarks
1
1929
1956
1950
“Forssmann” described the advance of a plastic
tube to the heart by puncturing his own arm vein
“Aubaniac” reported about the puncture of the
subclavian vein
Got Nobel prize
This puncture technique helped to broaden the use
of this technically demanding procedure

4. Types
Non Tunneled CVC
Tunneled CVC
Implanted Port
PICC

5. Non-tunneled CVC
• For temporary access to the central
circulation
• Lengths (15- 30 cm)
• Materials (polyurethane, silicone)
• Valved catheters (limit backflow of
blood)

6. Non-tunneled CVC
• Single, double, triple or quadruple
lumen.
• The distal hole is more reliable for
drawing blood - doesn’t get suctioned
against the wall of the vein during
aspiration.
• As the number of lumens increase, the
overall diameter of the catheter
increases, and the diameter of the
individual luminal channels generally
decreases.
• The use of multi-lumen catheters
reduces the maximum infusion rate of
the catheter and increases the rate of
catheter thrombosis.

7. PICC
• Popular due to the
• Ease of insertion into
the upper arm veins
(cephalic/basilic veins)
• Good patient tolerance
• Available as
• Single lumen
• Double lumen

8. PICC
• Made of - silicon rubber / polyurethane
• Silicon is associated with a lower risk of thrombosis
• Polyurethane PICC are recommended
• Tougher material
• enabling thinner lumen walls
• larger internal diameters of the lumens
• This significantly increases flow rates
• Reduces the potential for breakage and rupture of
catheter
• This is an advantage because of the volume of blood
and platelet infusions required by hematology patients

9. Dressing

10. Secure & reliable Always visible
Bath & shower Stays long > gauze/tape
Dressing
A transparent semi-occlusive
dressing is recommended

11. Changing of dressing
• The dressing should be
changed
• after the procedure- if
bleeding has occurred
• otherwise not until 24 hr
postoperatively
• It should then be changed
weekly if there are no signs
of bleeding and/or infection
• If blood is oozing from the
catheter insertion site, gauze
dressing might be preferred

12. Long term care- Flushing
Heparin
vs
NS
Correct
solution?
Thrombi &
fibrin  nidus
for infection
Larger bore
catheter 
quicker
backflow
HIT
Bleeding risk
When
Infrequently
accessed
Still unproven

13. Flushing
• Smaller syringes create greater pressure and may
contribute to catheter rupture if excessive pressure
is exerted
• Pulsatile flush method
• Maintaining positive pressure while removing the
syringe at the end of flushing in order to avoid
reflux of blood

14. Long term care
• Patients should be educated in the care of their
catheters
• Infections can be minimized by careful hand
washing and catheter site care
• The external surfaces of the access port should be
disinfected with a chlorhexidine gluconate solution
• Sterile (sterile gloves) or (hand care) must be
utilized when accessing any CVC lumen

15. Sampling
• Removal of the heparinized dead space
(approximately 5 ml) prior to sampling, to avoid
erroneous results
• The volume to be removed before coagulation
studies are performed is uncertain with central
venous catheters
• Peripheral vein- for coagulation studies

16. Complications
ComplicationsInfection
Malfunction Thrombosis

17. Catheter-related infections
• Infection rates:
• 0.08 per 1000 catheter days in oncology outpatients
• 19 per 1000 catheter days in the critically ill
• CRBSI can be severe and life-threatening depending
on the micro-organism involved
0.08/1000 days 19/1000 days
Haemato-oncology
infection

18. Catheter-related infections
CRBSI (catheter-
related blood stream
infection)
Exit site infection
Erythema
Tenderness
Discharge
Tunnel infection
Pain
Induration
along the track of the
catheter

19. Blood cultures
• Microbiologic cultures (including blood)-
• before starting antimicrobial therapy
• shouldn’t delay starting of antimicrobials
19
Kaasch AJ et al, Differential time to positivity is not predictive for central line related Staph. aureus blood stream infection in routine clinical care. J Infect (2014), 68(1):58–61
Timing
Within 45 mins
Set of 2
aerobic anaerobic
• Cultures can become sterile shortly after Abx initiation
• CVAD for >48hrs- site of infection not proven- paired
samples for c/s
• DTP- ?
2 sets of
blood cultures
aerobic
anaerobic

20. • May be effective in reducing catheter-related
bacteraemia
• A technique by which
• an antimicrobial solution is used to fill a catheter lumen
• allowed to dwell for a period of time while the catheter
is idle
‘Antibiotic lock’ technique

21. • Antibiotics- vancomycin, gentamicin, ciprofloxacin,
minocycline, amikacin, cefazolin, cefotaxime, and
ceftazidime
• Antiseptics- taurolidine, trisodium citrate
• Anticoagulant- heparin or EDTA
• Designed to render the internal flow passages
resistant to clot formation and hostile to bacterial
and fungal growth.
• There are no FDA approved formulations
‘Antibiotic lock’ technique

22. ‘Antibiotic lock’ technique
• Potential side effects:
• Toxicity
• Allergic reactions
• Emergence of resistance

23. Catheter malfunction
• Partial and complete catheter blockage
• Difficulty in aspirating blood or infusing fluid
• Forcible manipulation  catheter rupture
• Causes
• kinking of the catheter
• pinch off syndrome
• occlusion of the catheter tip on the vessel wall
• fibrin sheath or fibrin flap
• luminal thrombus
• migration of the tip into a smaller vessel
• Plain X-ray may be helpful in confirming the diagnosis

24. Thrombus
• Heparin (heparin sodium 10 U/ml) may be effective
OR
• Urokinase
• 10,000 U/ml
• reconstituted in 4 ml normal saline
• using 2 ml of solution into each catheter lumen
(ensuring that intra-luminal volumes only are instilled)
• The solution should be injected gently into the catheter with a
push-pull action to maximize mixing within the lumen
• The lumen should then be clamped and left for at least 2–3 h
• The catheter should then be unclamped and the solution
containing disaggregated clot aspirated

25. Thrombosis
• Catheter removal if thrombosis is confirmed
• May be prevented by adhering to appropriate flushing
protocols

26. • If the patient has a PICC, any swelling of the arm
should be monitored
• Swelling alone does not confirm thrombosis
• Must be confirmed radiologically
• If confirmed, the PICC should be removed and
anticoagulants commenced as described previously

27. Catheter removal
Indications
• catheter related infection
• persistent catheter occlusion
• catheter-related thrombus
• damaged catheter
• end of treatment

28. Catheter removal
• It is important to remove the catheter in the
direction of the tunnel
• The catheter should be inspected carefully after
removal to ensure that it is complete
• If infection is suspected, the tip should be sent to
the microbiology department for culture
• After removal, pressure should be applied to the
exit point, tunnel and an occlusive dressing placed
over the exit site to avoid air embolism.

29. Thank you