CVC Placement and Exchange

Adult CVC Placement and Exchange Page 1 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. Note: This algorithm is used by Acute Care Procedures Team ● Discuss with primary team and on-call Vascular Surgery History of arrhythmias ● Consider deferring procedure especially if new-onset or unstable or (i.e., atrial fibrillation) ● Refer to Vascular Surgery, if needed

● See Implanted Cardiac Pacemaker and Defibrillator Management algorithm Assess History of pacemaker ● Line must be placed contralateral to pacemaker. Consult Cardiac Catheterization patient Lab, Vascular Surgery or IR if only ipsilateral side of pacemaker available. history Current anticoagulation See Peri-Procedure Management of Anticoagulants algorithm prior to procedure medication use Page thoracic fellow/Vascular Surgery to discuss the following: ● Safety of treatment No History of blood clots to upper Patient pending extremity central veins (axillary, ● Obtaining further imaging [venous ultrasound duplex study, CT chest CVC placement IJ, subclavian, SVC) obtained within 30 days (contact radiology for vasculature review)] Are ● If contralateral site is free of thrombus, then APP may attempt [internal jugular (IJ), vital signs subclavian or femoral]. unstable1? History of radiation, surgery, ● Referring case to Vascular Surgery, if needed All requests placed to trauma or lesion/mass/wound Infusion Therapy. to neck, chest or access site, or Consider contralateral site. If no other site available, consider utilizing alternate any visible anatomical variants site for access after discussion with on-call Vascular Surgery and primary team. that may obscure landmarks Coagulopathy Threshold 2 Minimum Threshold to ● Patient with renal disease , with ● Consider IJ placement Procedure platelet infuse platelets INR Yes or without dialysis and/or ● Consult Vascular Surgery if platelets < 10 K/microliter threshold during procedure ● Platelets < 20 K/microliter IJ 20 K/microliter 10-20 K/microliter 2 Patient has no pertinent history or Proceed to Patient Evaluation on Page 2. Also, find information Subclavian 30 K/microliter 20-30 K/microliter 2 contraindications to procedure for patients needing simultaneous port removal on Page 3.

Femoral 20 K/microliter 10-20 K/microliter 2 1 Hemodynamically unstable / ● Inform primary team new onset symptoms ● Send to ACCC for evaluation with nursing escort APP = Advanced Practice Provider IR = Interventional Radiology ACCC = Acute Cancer Care Center SVC = superior vena cava Symptoms of severe cough, ● Contact primary team. If procedure cleared by primary team, 1 Heart rate >110 bpm or < 60 bpm, oxygen saturation < 92% and chest pain, shortness of breath, discuss with Vascular Surgery. systolic blood pressure < 95 mmHg or > 170 mmHg fever, vomiting, diarrhea, etc. ● Consider having patient evaluated by ACCC or primary team 2 Stage 3B or higher with glomerular filtration rate < 45 mL/minute Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult CVC Placement and Exchange Page 2 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. Note: This algorithm is used by Acute Care Procedures Team ● Discuss with B Continue with the following procedures: A primary team and ● If vein is completely flat after venous access attempt, abort procedure. Do not re- schedule procedure attempt4. If other side is appropriate for placement, have patient return next day after to be done under obtaining a bilateral duplex venous ultrasound. conscious sedation Vein can be ● If venous access successful but unable to thread wire after 4 attempts, attempt second if patient has assessed, venous access4. If unable to advance wire after third attempt, have patient return next Yes anxiety or is vein depth day after obtaining a bilateral duplex venous ultrasound if contralateral vein is patent. unable to assume 2-5 cm ● If wire migrates to neck, have patient turn head to ipsilateral side of catheter placement Does patient position for procedure and attempt to pass. Repass no more than 4 times. May repeat venous access for exhibit any of the 2 attempts, and repass wire4. If other side is appropriate for placement, have patient following: anxiety, ● Strongly consider uncooperative behavior, or IJ placement return next day after obtaining a bilateral duplex venous ultrasound. 2 language barrier ? ● If subclavian ● If unable to pull out wire after inserting, do not pull forcefully. Attempt rotation or placement still consult a more experienced provider. indicated, limit ● If arterial puncture or severe venous bleeding occurs post-dilation and/or catheter attempts to 1 only insertion, do not remove dilator or catheter; leave in place for tamponade/hemostasis by privileged APP. and consult Vascular Surgery immediately. If attempt Patient Yes unsuccessful, refer Post procedure: evaluation Is to Vascular Surgery. No ● Patient must await final chest x-ray No ● Refer back to Box A for CVC patient read from radiology before being alert and ● If patient appears placement discharged from clinic oriented? 3 dehydrated, give Is vein or Ultrasound Vein flat 250 mL-500 mL bolus still flat? ● Procedure performed under conscious exchange1 assessment No of normal saline for sedation should have portable chest 1 dose and re-assess x-ray performed to rule out malposition Patient Yes prior to patient being woken up for Assess ability for patient to able to follow Yes reposition to occur immediately. In follow commands and stay commands and Vein depth < 2 cm Refer back to Box A outpatient clinic areas, perform stable for placement stay stable? ultrasound of neck to rule out neck No Request for IJ placement or malposition for subclavian approach. Vein depth > 5 cm 1 For CVC exchanges only, refer to information on wire placement within Box B refer to Vascular Surgery 2 If language assistance is needed, an interpreter is required at bedside for duration of If post-procedure pneumothorax entire procedure 3 For pre-assessment and procedure, only use high level disinfected ultrasound probe ● Defer to IJ placement or Vascular Surgery and primary team on chest x-ray, see Post Central that is covered with a sterile cover and sterile individual gel packs ● Discuss with primary team and schedule procedure to be done under Line Placement Pneumothorax 4 Consider IJ placement or refer to Vascular Surgery for placement as needed conscious sedation if patient has anxiety or is unable to assume Management on Page 4 position for procedure Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult CVC Placement and Exchange Page 3 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. Note: This algorithm is used by Acute Care Procedures Team

Central line placement Proceed with central contralateral to line placement first port removal side Proceed with port removal (refer to Implanted and Tunneled Port and Catheter Removal algorithm)

Yes

Is Patient pending central line simultaneous placement successful? CVC placement and port removal No Do not remove If patient has history of port-a-cath; consult ● For ipsilateral attempt, consider obtaining multiple attempts on each side Vascular Surgery bilateral venous duplex ultrasound prior (PICC line or port or catheter), for central line to placement to rule out obstruction obtain ultrasound prior to placement and port ● If attempting subclavian catheter referral to Vascular Surgery Central line placement placement on same side as IJ port, do not removal ipsilateral to remove port first. Proceed with placing port removal side subclavian catheter first before port removal. ● Do not attempt ipsilateral subclavian CVC placement with subclavian port as well as IJ CVC placement with IJ port

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult CVC Placement and Exchange Page 4 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. Note: This algorithm is used by Acute Care Procedures Team Post Central Line Placement Pneumothorax Management On-call surgical attending must determine Pneumothorax found whether to admit to: ● APP proceduralist and Vascular ● Vascular Surgery service on post-line insertion Proceduralist APP should round on Access Team (VAT) nurse to ● Primary team’s service chest x-ray inpatient until discharged home or perform STAT IR consult for pigtail ● General Internal Medicine (per the delegate to scheduled ITT catheter placement determination of the Admitting Service Yes proceduralist on the subsequent day ● Admit patient Workflow (#ATT1942) within the Clinician Scope of Services and Responsibilities ● Contact via page: Policy [#CLN0598]) ○ On-call surgery fellow to evaluate patient and staff Is patient with on-call symptomatic and/or Discuss with surgery attending Normal hemodynamically surgical ○ Primary team chest x-ray unstable1? fellow for ● Contact via email: result clearance ○ APP supervisor Patient scheduled and proceduralist through CDU for medical director repeat chest x-ray the subsequent Is Yes No morning Place patient in Perform chest x-ray at pneumothorax Abnormal Refer to Clinical Decision Unit 1 hour and 3 hour 20% or less chest x-ray Box C (CDU) for monitoring intervals after diagnosis and/or 2 cm result below or less? No C Consult IR for Schedule repeat chest x-ray pigtail catheter the subsequent morning placement with ongoing evaluation

1 Heart rate > 110 bpm or < 60 bpm, oxygen saturation < 92% and systolic blood pressure < 95 mmHg or > 170 mmHg

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult CVC Placement and Exchange Page 5 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.

SUGGESTED READINGS - continued

Modeliar, S., Sevestre, M. A., de Cagny, B., & Slama, M. (2008). Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. Intensive Care Medicine, 34(2), 333-338. https://doi.org/10.1007/s00134-007-0875-9 O'grady, N., Alexander, M., Burns, L., Dellinger, E., Garland, J., Heard, S., . . . The Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52(9), 1087-1099. https://doi.org/10.1093/cid/cir138 Parienti, J. J., du Cheyron, D., Timsit, J. F., Traoré, O., Kalfon, P., Mimoz, O., & Mermel, L. (2012). Meta-analysis of subclavian insertion and nontunneled central venous catheter- associated infection risk reduction in critically ill adults. Critical Care Medicine, 40(5), 1627-1634. https://doi.org/10.1097/ccm.0b013e31823e99cb Parienti, J. J., Mongardon, N., Mégarbane, B., Mira, J. P., Kalfon, P., Gros, A., . . . Du Cheyron, D. (2015). Intravascular complications of central venous catheterization by insertion site. The New England Journal of Medicine, 373(13), 1220-1229. https://doi.org/10.1056/nejmoa1500964 Parienti, J. J., Thirion, M., Mégarbane, B., Souweine, B., Ouchikhe, A., Polito, A., . . . Charbonneau, P. (2008). Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: A randomized controlled trial. The Journal of the American Medical Association, 299(20), 2413-2422. https://doi.org/10.1001/jama.299.20.2413 Parry, G. (2004). Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Canadian Journal of Anesthesia, 51(4), 379-381. https://doi.org/10.1007/BF03018243 Pegues, D., Axelrod, P., McClarren, C., Eisenberg, B., Hoffman, J., Ottery, F., . . . Weese, J. (1992). Comparison of infections in Hickman and implanted port catheters in adult solid tumor patients. Journal of Surgical Oncology, 49(3), 156-162. https://doi.org/10.1002/jso.2930490306 Plumhans, C., Mahnken, A., Ocklenburg, C., Keil, S., Behrendt, F., Günther, R., & Schoth, F. (2011). Jugular versus subclavian totally implantable access ports: Catheter position, complications and intrainterventional pain perception. European Journal of Radiology, 79(3), 338-342. https://doi.org/10.1016/j.ejrad.2009.12.010 Ruesch, S., Walder, B., & Tramèr, M. (2002). Complications of central venous catheters: Internal jugular versus subclavian access—a systematic review. Critical Care Medicine, 30(2), 454- 460. https://doi.org/10.1097/00003246-200202000-00031 Sznajder, J., Zveibil, F., Bitterman, H., Weiner, P., & Bursztein, S. (1986). Central vein catheterization: Failure and complication rates by three percutaneous approaches. Archives of Internal Medicine, 146(2), 259-261. https://doi.org/10.1001/archinte.1986.00360140065007 Tanner, J., Moncaster, K., & Woodings, D. (2007). Preoperative hair removal: A systematic review. Journal of Perioperative Practice, 17(3), 118-132. https://doi.org/10.1177/175045890701700304 Timsit, J. F., Bouadma, L., Mimoz, O., Parienti, J. J., Garrouste-Orgeas, M., Alfandari, S., . . . Lucet, J. C. (2013). Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. American Journal of Respiratory and Critical Care Medicine, 188(10), 1232-1239. https://doi.org/10.1164/rccm.201303-0460OC Troianos, C., Hartman, G., Glas, K., Skubas, N., Eberhardt, R., Walker, J., & Reeves, S. (2012). Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesthesia & Analgesia, 114(1), 46-72. https://doi.org/10.1213/ANE.0b013e3182407cd8

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult CVC Placement and Exchange Page 8 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.

DEVELOPMENT CREDITS

This practice consensus statement is based on majority opinion of the Acute Care Services experts at the University of Texas MD Anderson Cancer Center for the patient population. These experts included:

Ivy Cocuzzi, PA-C (Acute Care Services)Ŧ Wendy Garcia, BS♦ Marina George, MD (Inpatient Medical Practice) Susanna Girocco, PA-C (Acute Care Services) Tam Huynh, MD (Thoracic & Cardiovascular Surgery) Christina Perez♦ Amy Pai, PharmD♦ Kimberly Tripp, MBA, BSN, RN (Acute Care Services Administration)

Ŧ Core Development Team ♦ Clinical Effectiveness Development Team

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020