chemo vascular access

Vascular access for Chemotherapy

Maj Sankalp Singh

Introduction

Need for better vascular access

Complex & long-term chemo regimensTotal parenteral nutritionAnalgesics for pain control

Classification

External cathetersPercutaneous non-tunneled CVCTunneled external catheter

PICC lineImplanted vascular access devices

Vascular access portsImplanted infusion pumps

External CVCs

Most frequently usedSimplestSafeAll aspects of patient careE.g. - Central lines, Hickman’s, Groshong and Broviac

Central Venous Line16 gaugePositioned via IJV, subclavian or femoral into RA /SVCSingle / multi lumenSafely used for 7-14 days (Short –term)Not for OPD/long-term useHighest risk of migration / infection

Central Venous LineUses:-

Transfusion of large volume of fluidsDialysisTransfusion of a drug which may irritate peripheral v.

E.g. - Quinton’s Catheter

Central Venous Line

Tunneled central catheters

Various designs & sizes Inserted in OR or IR suite Placed in central veinTunneled under skin but opening to lumen remains outside Longer length s.c. tunnel

Better fixationInfection control

Tunneled central catheters

Single / double lumenDacron cuffAntibiotic / silver ion cuffSlit valve design – GroshongLong term (months to years)External site care & regular flushing needed

Tunneled central catheters

Hickman’s Groshong BroviacNeostar

Hickman’s catheter

Groshong slit valve

Prevents air embolism & passive reflux of blood into lumen – reducing frequent catheter infection & thrombosis

PICC linePeripherally insertedCatheter tip in a RA/ SVC/ central v.Easy technique - insertion, maintenance by nursing teamIntermediate - term (wks to mnths)Safe & durable for OPD patientsChemo/Antibiotics/TPN

PICC lineSingle / double lumenLow bleeding risk ed thrombophlebitis & venous thrombosis Thinner diameter – limited lumenProne to obstruction or damage

PICC line

PICC line

Implanted devices

Catheter placed in central veinConnected to a reservoir or ‘port’Titanium / Plastic 1-3 ml heparinized salineCompressed, self-sealing silicone diaphragm placed below skinAllows repeated puncture with non-coring Huber needle

Implanted devicesSingle / Double lumenSurgically placed in OR

Under LA/sedationFluoroscopic guidanceMinimal dissectionFixed to pectoralis fascia

Hub located on chest / upper armExpected lifespan > 1 year

Implanted devicesMore durableRoutine care not neededIf not in use, once a month flushingCompatible with CT/MRIInfection, thrombosis & loss of patency comparable to ext. cath.Portsite infection surgical removal

Implanted devicesPort-A-CathBardPortPassPortMedi-portInfusaport

Implanted devices

PORT-A-CATHLIFE PORT

Implanted devices

Implantable infusion pumps

IV or Intra-arterialTitanium98-173 gms16-60 ml0.3 – 4.0 ml/dayRefillablePt can receive chemo/ Rx at home

Implantable infusion pumps

Surgically implantedPlaced in s.c. tissue on ant. abd. wallPercutaneous access with non-coring needlesMain chamber – reservoir s/by chamber with gas phase fluorocarbon

Implantable infusion pumps

System completely containedBolus / continuous infusionBattery powered systems – drug delivery at variable, controllable rate Uses:-

i.v. insulinintrathecal/systemic narcoticsintra-arterial, intrahepatic chemotherapy

Implantable infusion pumps

Medtronic Johnson & Johnson / Codman pump

Implantable infusion pumps

Catheter ComparisonDevice Placemen

tLifespan Adv Disadv

1. Percutaneous CVC

OT/IR suite 7-14 days

Low routine care

Migration, infection, insertion risks

2. Tunneled central catheter

OT/IR suite Long term – months to years

Durable External site care, insertion risks

3. PICC line Nursing staff

Intermed - Weeks to months

Easy insertion

Thrombophlebitis, thrombosis, limited lumen, frequent obstruction

4. Implanted device / pump

OT/IR suite > 1 year Low insertion complications

High cost, infection requires Sx removal.

Catheter selectionType of agentNumber of agentDuration of treatmentFrequency of treatmentBolus vs Continuous-infusionBlood withdrawl / administration frequency

Selection of catheterAge & size of patientPrevious h/o catheterPatient’s immune statusPatient’s vascular anatomyFinancial factorsPatient / Physician preference

Vascular access team

Responsible for catheterSelectionInsertionLong time care

Standardization of techniqueAccurate assessment of complicationsImproved efficiency

Prolongation of catheter lifeDecreased infection rate

Insertion Technique

OR / IVR suiteSterilityAnalgesia LA + sedationFluoroscopyLandmark guidance / USG guidance

PositioningTrendelenburg position

Head turned to opp. side

Roll placed between shoulders

PreparationClean with 2% chlorhexidine

Expose adequate area

Sterile draping

Seldinger techniquePuncture–aspiration of IJV with saline syringe & 20-22 ga needlebetween sternal & clavicular heads of

SCM

Needle at 45º to skin surface & towards I/L nippleAspiration of blood confirms placement

Guidewire passageGuidewire passed through needle

Tip placed in IVC

Watch out for ectopics

Dilator peel-off sheath threaded over guidewire

Remove needle & introduce dilator sheath

Remove dilator sheath & introduce peel off sheath

Remove guidewire & aspirate blood

Line tunneled in5mm incision at midpt bet. humeral head & nipple

Tunnel up to the neck puncture

Pull central line tip from incision upto neck puncture

Determine correct length of line required

Line length adjustedLine cuff placed 2-3 cm from incision

Length of Line approximated to length of peel off sheath, using II

No touch technique

Line insertion into peel off sheath

Assistant pulls out trochar of peel off sheath

Central line is inserted & advanced gradually as sheath is peeled off simultaneously

Radiographic confirmation

Final position in high RA or junction of SVC with RA

Looping of line in neck should be smooth

Line fixing with suturesNon-absorbable sutures to affix line to skin

Dresssing for 3 weeks

Semi-permeable dressing

Leave undisturbed for 3 weeks

Complications – (Intra-op)

Arterial injury / catheterizationAir embolism Hemorrhage / hematomaPneumothorax / hemothoraxArrhythmiasCardiac injury / tamponade

Complications(Post-op)

Venous thrombosisInfectionsPhlebitisInfiltration / ExtravasationPainBleedingPinch-off syndromeCatheter block

Venous ThrombosisMost common complication 30-70%Only 5-10% symptomaticDevelop early in catheter lifeChronic irritation at catheter-endothelium contact siteSource of :-

InfectionPulmonary emboliPermanent venous obstruction (10-15% in upper limb)

Venous Thrombosis Mangement

Catheter preservation & prevention of 2ndary complicationsElevation of affected limbClinically significant thrombus same as other DVTsTherapeutic anticoagulation

Heparinization (LMWH) f/b Oral Warfarin (long-term)

Thrombolytic therapy –rTPA for salvage of vital vein

InfectionsGreatest cause of catheter lossRisk factors

Type of catheter- (percutaneous short-term) Lack of skilled catheter nursing careLength & frequency of useLack of antibiotic coated cathetersSite (Femoral> IJV > Subclavian)Long term -Tunneled (40%)> Implanted devices (5-10%)

Infectious complications with time

InfectionsSkin flora – commonest contaminantInfection sites – exit/ access site, s.c. tunnel, bacteremia.Cellulitis / erythema / localized purulent discharge – S. epidermis Catheter preservation + Local/ systemic antibioticsAbscess / blood culture positive / Pseudomonas / Atypical mycobacterium Catheter removal + IV antibiotics

InfectionsCatheter related bacteremia - Coagulase -ve staph VancomycinLow dose rTPA – destruction of thrombus assoc. with infectionIndications for removal

Inability to clear infection after full course.Continued signs/symptoms of bacteremiaRecurrent infection after completion of full course.

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