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).