1. Karen Williford RN, CRNI Beebe Medical Center Tunnell Cancer Center Lewes, Delaware Catheter Related Thrombus Management

2. Objectives •Discuss the pathophysiology of catheter related thrombosis •Discuss thrombosis prevention strategies related to vascular access device assessment and insertion •Discuss current research findings as they relate to vascular access device thrombosis

3. Upper Extremity Deep Vein Thrombosis (UEDVT) Increasing prevalence with potential for considerable morbidity Increased use of CVC/PICC Chemotherapy Bone Marrow Transplant Parenteral Nutrition Dialysis

4. Types of Thrombus

5. Assessment History of a previous device Fluid Status Sepsis Duration of Catheter Cancer Hypercoaguability Improper Maintenance

6. Hypercoagulability Blood viscosity can be affected by: Hematocrit Temperature Low flow Diabetes Pregnancy Cancer

7. Risk Factors

8. Risk Factors Administration of incompatible solutions and medications Administration of solutions or medications with high pH or tonicity Ineffective filtration Thrombogenic catheter materials Malpositioned catheter

9. Virchow’s Triad

10. Anatomy

11. Physiology of Clotting

12. Physiology

13. Endothelial Injury Larger stiffer catheters pose a higher risk of endothelial injury on insertion Infusion of irritants or vesicants Sub Optimal Catheter Tip Locations carry larger risk of endothelial injury

14. Does Size Matter??

15. King et al. (2006)

16. Blood Flow Dynamics

17. Laminar Flow Characteristics

18. Poiseuille’s Law

19. Flow Dynamics

20. Evans et al (2010) Previous DVT history increases risk Large sample size-2014 PICC’s Single double and triple lumen catheters 60 of 2014 patients developed DVT 0.6% Single lumen DVT rate 2.9% Double lumen DVT rate 8.8% Triple lumen DVT rate

21. Factors leading to Thrombus Formation

22. Seeley et al. (2007)

23. Catheter Thrombosis Swelling of extremity Pain with infusions Fluid leaking at insertion site Ultrasound of extremity Anticoagulation Possible catheter removal

24. Burns 2009 CVC thrombosis results in: Vascular and catheter occlusion Infection Pulmonary embolus Right heart thrombo-emboli Incidence underestimated Synergy of events

25. Fibrin Sheath Courtesy of :http://www.konez.com/CentralCatheter_fibrin%20sheath_dialysis.JPG

26. Does Tip Location Matter?

27. Standards

28. Define Central

29. Luciani et al. (2001) Prospective US study 3/62 (5%) with tips at CAJ developed thrombosis 5/7 (71%) at SCV/BCV junction developed thrombosis

30. Lobo et al. (2009)

31. Cadman, Lawrance, Fitzsimons,Spencer-Shaw, Swindell (2004) Relationship between tip position andvenous thrombosis 428 tunneled catheters 72 days 5/91 in lower 1/3 (2.6%) 5/95 in middle 1/3 (5.3%) 20/48 in upper 1/3 (41.7%)

32. Verhey, Gosselin, Primack,Blackburn, Kraemer (2008)

33. Trerotola et al 2010

34. Tretola Study 2010 Stopped at 50 of 167 planned patients Scheduled interim US showed an DVT rate of 20% (10 of 50) Venous Thrombosis (symptomatic or asymptomatic) 58% 0% CRBSI Colonization 10% Malfunction & Dislodgement in 1 patient

35. Duke University 2011 Purpose: Evaluate the effectiveness of practice changes to reduce PICC thrombus risk Retrospective analysis of adult patients 1307 charts reviewed January 2008, October 2008, and August 2010. Clinical Practice change to include US & tip in SVC

36. Duke University 2011 PICC related DVT rates decreased from 4.8% to 2.9% (January 2008-October 2008) October 2008-August 2010 practice change to measure & document native vein diameters prior to PICC insertion -2X outer cath diameter PICC related DVT decreased from 2.9% to 1.4%

37. INS National Standards Medications with a pH <5 or >9 OR Osmolarity greater than 600mOsm/L can cause vein irritation, phlebitis, infiltration or extravasation.

38. Extreme pH IV MedicationspH <5 or >9 pH <5 Ciprofloxin 3.3-4.6 Dopamine 2.5-5.0 Doxycycline 1.8-3.3 Dopamine 2.5-5.0 Morphine 2.5 Pentamidine 4.1-5.4 Phenergan 4.0 Potassium 4.0 Taxol 4.4-5.6 Vancomycin 2.4 Zofran 3.0-4.0 pH >9 Acyclovir 10.5-11.6 Ampicillin 8.0-10 Bacterium 10 Cerebyx 8.6-9.0 5FU 9.2 Ganciclovir 9-11 Phenytoin 12 Protonix 9-10.5

39. Vesicants Acyclovir Amiordarone Ampho B Ampicillin Bactrim Calcium chloride Calcium Gluconate 10% Ciprofloxacin Cerebyx Contrast media Aramine Daptinomycin Dextrose >10% Digitoxin Dobutamine Dopamine Doxapram Doxycycline Epinephrine Erythromycin Ganciclovir Gentamycin

40. Vesicants Levophed Lorazepram Magnesium sulfate Mannitol 10% and 20% Morphine Nafcillin Norepinephrine Phenergan Phenytoin Phenylephrine Pentamadine Levophed Lorazepram Magnesium sulfate Mannitol 10% and 20% Morphine Nafcillin Norepinephrine Phenergan Phenytoin Phenylephrine Pentamadine

41. Hypertonic Hypertonic solution has an osmolality of 350 mOSM/liter and above. The osmolality of PPN is about 750 mOSM/liter and above. Hypertonic solutions cause phlebitis peripherally in less than 24 hours

42. Examples D25W (1330mOSM/liter). D40W (2020mOSM/liter). D50W (2525mOSM/liter). Literature states hypertonic drugs withan osmolality over 600mOSM/liter resultin phlebitis in 24 hours with shortperipheral catheters. Consider central venous administration

43. Assessment is the Key!

44. Take this Home!! History and Physical/Physician Collaboration Limit Catheter Manipulation*Catheter Exchange can increase thrombosis and infection risk Prevent catheter related infections Get the tip in the right place!