Lines and Tubes in Critically Sick Patients“IR Perspective”

Ram Gurajala, MD

MRCSEd, FRCR, DABR

Interventional Radiology

Objectives

Lines and Tubes:Types:

Lines: Venous and Arterial

Tubes: Various

Indications

Contraindications

Complications

Indications for Central Venous Access

Short Term (Single hospital admission) Emergency fluid resuscitation

Vasopressors, Transfusions, Short Term Tx

Long term intermittent therapy Chemotherapy

Antibiotic

Long term continuous therapy Continuous TPN (Short Gut, Pancreatitis, Malnutrition)

Continuous Inotropes, Vasodilators, etc.

Dialysis Access

Questions to consider

Length of therapy?

Type of therapy acquired? (High vs Low Flow?)

Other concomitant therapies?

Dialysis or Potential Hemodialysis patient?

Temporary v. Tunneled: What duration is IV access needed?

Long term access is more appropriately tunneled

Is the patient bacteremic? No tunneled lines

How urgent is the placement?

SBCC*PICCs

Ports

Hickman Leonard

TDC

Terminology

High flow Dialysis (400 – 600 cc/min)Pheresis (150 – 250 cc/min)

Low flow Antibiotics;Chemotherapy;

TPN;Medications;

Hydration

Power injectable Arterial phase contrast injection;Allows for flow of 5cc/s;Pressures up to 600 psi

Power injectable catheters:

*SBCC : Small Bore Central Catheter

*Principle Considerations*

Request the minimum number of lumens needed More lumens = more thrombosis & more infection

Increased risk of thrombosis and infection (20% with 3L PICC)*

Have an indication for each lumen

Use the smallest diameter catheter to achieve the needed therapy

Keep dialysis access separate from IV access

*Trerotola et al. Triple-Lumen Peripherally Inserted Central Catheter in Patients in the Critical Care Unit: Prospective Evaluation n Radiology: Volume 256: Number 1—July 2010

Common Catheter Types

Peripherally Inserted Catheters (PICC)

Central Venous Catheters

Dialysis Catheters (TDC)

Port Catheters

Peripherally Inserted Catheters

•Type PICC Midline

Insertion Peripherally inserted Peripherally inserted

Central venous Yes No

Preferred Veins* Brachial and basilic Brachial and basilic

* Cephalic vein has an increased risk of thrombophlebitis and catheter occlusion

Central venous catheters

HohnHickmanBroviac

Small Bore CVCs Large Bore CVCs

Temporary Longer term

Names Hohn Broviac Hickman

Length of therapy >6 days – 4 mo* >4mo Long term access

Preferred Veins IJV, EJV, **Collateral IJV, EJV, **Collateral IJV, EJV, **Collateral

Less preferred SCV, Femoral SCV, Femoral SCV, Femoral

*Short term access: Acute resuscitation; Vasopressors; CVP monitoring; Short term admission with multiple meds; Chemotherapy, etc.

** Occluded central veins with collaterals

Dialysis Catheters

Trialysis CatheterTunneled Dialysis Catheters

Temporary Long term

Names Non-tunneled (Quinton, Trialysis) Tunneled

Length of therapy < 10 – 14 days Beyond 14 days

Uses Dialysis, Plasmapheresis Dialysis, Plasmapheresis

Preferred Veins IJV, EJV, CFV, **Collateral IJV, EJV, **Collateral

Less preferred SCV SCV

Quinton Catheter

** Occluded central veins with collaterals

Port CathetersPortcath Central venous access with attached

subcutaneous port

Types Single or Double lumenGroshong Vs Non- groshong

Length of therapy Long term, intermittent access(~monthly to ~weekly)

Uses Chemotherapy, Infusions, * TPN

Preferred Veins IJV, EJV, **Collateral

Less preferred SCV

Decision AlgorithmCentral venous access

Small bore Acute resuscitation; Vasopressors; CVP monitoring; Short term admission with multiple meds; Chemotherapy

Large bore TPN; Long term access

High flow Hemodialysis; Plasmapheresis

Indications Short term Long term

Poor/Difficult peripheral IV access

Temp CVC; Midline PICC; Tunneled

ICU needs* Temp CVC; Midline PICC; Tunneled

Chemotherapy Temp CVC PICC; Tunneled CVC; Portcath

TPN PICC** Tunneled Large Bore CVC (Hickman, Leonard)

Hemodialysis Quinton; Trialysis *** Tunneled #

Plasmapheresis Quinton Tunneled

*ICU gtts (vasopressors); Acute Resuscitation; CVP Monitoring; Short term, multiple meds; **No PICC, If Renal Tx or Potential?; GFR <45 & DM; ***ARF expected to

recover; Unstable; Suspected infection; # ARF unknown Px; ARF expected to progress to ESRD; Initiating HD for ESRD

Pre-Procedure Preparation & Assessment

Antibiotics: Needed? Infection rate is 0.04/100 catheter days1

Infection rate was 0.14/100 catheter days2

Minocycline & rifampin impregnated central lines available - ? Risk of emerging resistance3

Coagulopathy4,5

INR: Correct to ≤ 2.0

Platelets: ≤ 50,000/µL recommend transfusion

aPTT: No consensus

Vein Preservation in CKD patients

1. Trerotola SO, Johnson MS, Harris VJ, et al. Outcome of tunneled right internal jugular hemodialysis catheters placed via the right internal jugular vein by interventional radiologists. Radiology 1997; 203:489-495. 2. Lund GB, Trenotola SO, Scheel PF Jn, et al. Outcome of tunneled hemodialysis catheters placed by radiologists. Radiology 1996; 198:467-472. 3. Ramos et. al Crit Care Med 2011 Vol. 39, No. 2. 4. Patel IJ et al. “Addendum of Newer Anticoagulants to the SIR Consensus Guidelines. JVIR. 2013 5. Hass et. Al J Vasc Interv Radiol 2010; 21:212–217

*Upper extremity vein preservation is paramount in patients who at risk for ESRD*PICC

Midline

Risks

Contraindications (Relative) Bleeding disorders; Anticoagulation therapy

Combative patients; Distorted anatomy; Cellulitis; burns at site

Procedural complications Immediate Bleeding

Pneumothorax

Air embolus

Delayed Infection

Thrombosis

Fibrin Sheath

Malfunction

Fracture

Air embolism Fractured Portcath

Pinch off syndromeMalposition

Twisted

Twisted MalpositionTip in pleura

CO2 Venogram

Pneumothorax

Tip in subclavian artery

Tip in Vertebral/subclavian artery

Femoral vein: Less preferred

Favorable Not favorable

Easy to find vein Highest risk of infection

No risk of pneumothorax Risk of DVT

Preferred site for emergencies Not good for ambulatory patients

Fewer bad complications

Subclavian vein: Less preferred?

Risks

Mechanical Pneumothorax

Arterial Injury

Malposition

“Pinch off syndrome”

Renal Failure Fistula creation

Thrombosis

Swollen extremity Lymphedema

PCM insertion

Thoracic outlet syndrome

Infection?

Complications in the Three-Choice Comparison, According to Insertion-Site Group.

Parienti J et al. N Engl J Med 2015;373:1220-1229

Technical

High access

Hair

Low access

Extreme cases

• Trans lumbar

• Trans renal

• Trans hepatic

• Recanalization

• ? Collaterals - temporary

Trans lumbar

Trans splenic

Recanalization

Direct intra-atrial

Direct Intra-atrial

BEWARE, When the access crosses MIDLINE

Arterial

Indications Monitoring blood pressure

Frequent blood gas analysis

Sites Radial, Femoral

Axillary, Brachial

Troubleshoot – Bad waveforms Repositioning/splint

Replacement/Guidewire exchange

Complications

Pseudoaneurysm

Extravasation

TubesTypes Indications

Chest Chest tube: Non tunneled Effusions; Empyema; Hemo/Pneumothorax; Post surgery

Chest tube: Tunneled Malignant; Recurrent

Pericardial drain Effusion*

Abdomen and Pelvis Enteric Feeding; Ventilation

Ascitic: Non tunneled Diagnostic; Therapeutic

Ascitic: Tunneled Malignant; Recurrent

Drainage Abscess; Fluid; Cholecystostomy; PTHC

Nephrostomy Hydronephrosis; Pyonephrosis; Obstruction

Suprapubic Obstruction

Chest Tube: Non Tunneled

Beware!!

Spleen

Chest Tube: Tunneled (Pleurex) catheter

Pericardial Drainage

Case 1 Case 2

Gastrostomy

Cholecystostomy

Cystic duct rupture

Suprapubic drainage

Nephrostomy

Ureteric stent

Nephro ureteral catheter

Ascitic : Non Tunneled Tunneled

Drainages

Abscess Fluid drainage Abscess

Risks

Contraindications (Relative) Bleeding disorders; Anticoagulation therapy

Procedural complications Immediate Bleeding

Pneumo/Hemothorax

Death*

Delayed Infection

Occlusion

Dislodgement/migration

*Complex cases

Conclusion

This is just a brief summary of various procedures

Lines and Tubes: A systematic approach, knowledge and defined algorithms needed

IR: Minimal invasive and safe approaches

We play a great role in patients CARE.