Central Venous Catheters Clinical Considerations

Igor Voskresensky 8.15.09 CVCs…Necessary Evil

TLC

Cordis

MICU TRIC (triple lumen infusion catheter) Vascular Access Devices

I. Nontunneled (TLC, Cordis, MAC, VasCath) ‐ short‐term, drips/meds, HDM/resus, dialysis, plasmapheresis, TPN

II. Tunneled (Hickman, Broviac, Groshong) ‐ long‐term, OR, abx, chemo, TPN, pediatric, frequent lab work

III. Peripherally inserted (PICC) ‐ long‐term, abx, TPN

IV. Implanted ports (percutaneous, cutdown) ‐ long‐term, chemo, periodic transfusions

Preparation for Insertion –C5, Do20, Teach100

• KTCLT, live it… • Patient’s anatomy, site selection, ultrasound? • Turn off tube feeds and check labs (plts, ffp?) • Know the process • Get your own things (syringes, flushes, claves) • Set it up, same way every time • Head‐Down‐burg • Pain control • Complications Pearls

• Withdraw gently • Hand on the wire • Visualize needle tip with US • Shallow angle, hit the clavicle, arm tug • Poor form is unacceptable • No COW if the ports don’t draw/flush • No femoral access cardiology style • Secure your line with quality • Get a CXR (PTX, HTX, positioning) • If it don’t feel right, it probably ain’t right Complications

• Catheter‐related (type, mechanical and antibacterial properties, use)

• Patient‐related (anatomy, nature of disease, immunocompromise)

• Site‐related (IJ, SC, Fem)

• Catheter care (experience of medical and nursing staff, hygiene and care)

Inten Car Med 28:1–17 NEJM 348:1123‐1133 Ann Surg 173:184–190 Chest 113:165–171 J Vasc Surg 48: 918‐925 Catheter‐Associated Infections

• Colonization (semiquant vs. quant) ‐ 15 CFU agar vs. 1000 CFU broth

• Exit‐site infection ‐ erythema, induration tenderness, purulence

• CRBSI CRBSI • CVC colonization and peripheral blood cx • 10‐25 % associated mortality, $ • Sick pts, ETT/ICU/TPN, T‐T‐T‐T • SC/IJ vs. Fem organisms • G+ coverage, G– in neutropenic, IC pts • Catheter removal vs. exchange

Crit Car Med 37: 702‐712 NEJM 348:1123‐1133 Inten Car Med 28:18‐29

Conclusions

• CVCs ubiquitous • Complications can be avoided • Catheter care • CRBSI common, challenging

Clinical Anatomy 21:15–22 (2008)

Clinical Anatomy 20:602–611 (2007)