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Caring Central Venous Access Device in Hematology
1) Central venous access devices are used for long-term vascular access in hematology patients. There are different types including non-tunneled CVCs, tunneled CVCs, implanted ports, and PICCs. 2) Proper care and maintenance is required to prevent complications such as infection, malfunction, and thrombosis. Dressings should be changed regularly and catheters flushed according to protocol. 3) Infections are a major complication and can be life-threatening, so strict sterile technique is important. Other complications include malfunctions from blockages or kinks, and thrombus formation which may require fibrinolytic treatment or catheter removal.
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Caring Central Venous Access Device in Hematology
- 1. Caring Central Venous AccessDevices in Hematology Dr Pritish Chandra Patra Department of Clinical Hematology IMS & SUM Hospital Bhubaneswar
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- 3. Landmarks 1 1929 1956 1950 “Forssmann” described theadvance 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 TunneledCVC Implanted Port PICC
- 5. Non-tunneled CVC • Fortemporary 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 dueto 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
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- 10. Secure & reliableAlways 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 syringescreate 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 ofthe 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
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- 17. Catheter-related infections • Infectionrates: • 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- relatedblood stream infection) Exit site infection Erythema Tenderness Discharge Tunnel infection Pain Induration along the track of the catheter
- 19. Blood cultures • Microbiologiccultures (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 beeffective 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 • Partialand 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 (heparinsodium 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 removalif thrombosis is confirmed • May be prevented by adhering to appropriate flushing protocols
- 26. • If thepatient 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 • catheterrelated infection • persistent catheter occlusion • catheter-related thrombus • damaged catheter • end of treatment
- 28. Catheter removal • Itis 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.
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Editor's Notes
- #13 heparin (10 U/ml)