Tunneled Cuffed Tunneled Cuffed CathetersCatheters

Hemodialysis accessHemodialysis access

The number of patients with end-stage The number of patients with end-stage renal disease (ESRD) has increased renal disease (ESRD) has increased steadilysteadilyThe creation and maintenance of The creation and maintenance of functioning vascular access, along with the functioning vascular access, along with the associated complications, constitute the associated complications, constitute the most common cause of morbidity, most common cause of morbidity, hospitalization, and cost in patients with hospitalization, and cost in patients with end-stage renal disease. end-stage renal disease.

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters Catheters

useful method of useful method of gaining immediate gaining immediate access to the access to the circulation.circulation.associated with associated with higher risks. higher risks. the use-life of this the use-life of this type of access is type of access is shorter than that of shorter than that of AVFs. AVFs.

Noncuffed cathetersNoncuffed cathetersShort term: <3 weeksShort term: <3 weeks

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters: cuffed catheters Catheters: cuffed catheters

Cuffed cathetersCuffed catheters

Patients who will require Patients who will require long-term access should long-term access should have a tunneled catheter have a tunneled catheter placed. placed.

allow so-called no-needle allow so-called no-needle dialysis with high flow dialysis with high flow ratesrates

eliminate the problem of eliminate the problem of vascular steal vascular steal

placed in a subcutaneous placed in a subcutaneous tunnel under fluoroscopic tunnel under fluoroscopic guidanceguidance

Vascular Access via Percutaneous Vascular Access via Percutaneous Catheters: cuffed cathetersCatheters: cuffed catheters

The Dacron cuff allows tissue The Dacron cuff allows tissue ingrowth that helps reduce the risk ingrowth that helps reduce the risk of infection when compared with of infection when compared with noncuffed catheters. noncuffed catheters.

Hemodialysis access: complicationsHemodialysis access: complications

A chest radiograph must be taken after catheter A chest radiograph must be taken after catheter placement to rule out pneumothorax and injury to the placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter. great vessels and to check for position of the catheter. The incidence of pneumothorax is 1% to 4%,the The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%.incidence of injury to the great vessels is less than 1%.Thrombotic complications occur in 4% to 10% of patients Thrombotic complications occur in 4% to 10% of patients Infection may occur soon after placement (3 to 5 days) Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis. site or the cause of catheter-related sepsis. Rate of infection between 0.5 and 3.9 episodes per 1000 Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days.catheter-days.Catheter thrombosis increases the incidence of catheter Catheter thrombosis increases the incidence of catheter sepsis.sepsis.

PRESERVING CATHETER FUNCTIONPRESERVING CATHETER FUNCTION

CATHETER

CARE

PLACEMENT

TREATMENT ACCESS

POSITIONING

Types of central linesTypes of central linesOpen-ended tunneled cathetersOpen-ended tunneled cathetersTunneled valved cathetersTunneled valved cathetersImplanted portsImplanted portsNontunneled central venous catheters Nontunneled central venous catheters (CVCs)(CVCs)Peripherally inserted central catheters Peripherally inserted central catheters (PICCs)(PICCs)

Central Line ComplicationsCentral Line ComplicationsInfectionsInfectionsAir embolusAir embolusDislodgement of catheterDislodgement of catheterCatheter occlusionCatheter occlusion

Central Line Flow ControlCentral Line Flow ControlVolume in ML x Drop factor Volume in ML x Drop factor DEVIDED BY no. of hours to be DEVIDED BY no. of hours to be infused x 60infused x 60Drop factors are 15 drops / cc OR 60 Drop factors are 15 drops / cc OR 60 drops / ccdrops / cc

ADVANTAGES OF ADVANTAGES OF CENTRAL VENOUS ACCESSCENTRAL VENOUS ACCESS

1. Immediate access1. Immediate access

2. High flow and dilution of hyper tonic 2. High flow and dilution of hyper tonic solutionssolutions

3. Easy access3. Easy access

4. Permits outpatient care4. Permits outpatient care

DISADVANTAGES OF CENTRAL DISADVANTAGES OF CENTRAL VENOUS ACCESSVENOUS ACCESS

More invasive - potentially more More invasive - potentially more complications and paincomplications and pain

Acute Chronic

1. Long term IV therapy:1. Long term IV therapy:

ChemoChemo

AntibioticsAntibiotics

TPNTPN

Blood productsBlood products

2. Recurrent blood draws2. Recurrent blood draws

3. Dialysis/Pharesis3. Dialysis/Pharesis

CENTRAL VENOUS ACCESS:CENTRAL VENOUS ACCESS:INDICATIONSINDICATIONS

CONTRAINDICATIONSCONTRAINDICATIONS

1. Sepsis1. Sepsis

2. Coagulopathy2. Coagulopathy

TYPES OF TYPES OF CENTRAL VENOUS ACCESSCENTRAL VENOUS ACCESS

1. Non tunneled external catheters1. Non tunneled external catheters

a. Central linea. Central line

b. PICC line b. PICC line

2. 2. Tunneled cathetersTunneled catheters

3. Subcutaneous Ports3. Subcutaneous Ports

a. chesta. chest

b. armb. arm

CHOOSING THE ACCESS DEVICECHOOSING THE ACCESS DEVICE

Patients disease and statusPatients disease and status

Number and type of solutions, Number and type of solutions,

osmolalityosmolality

Flow requiredFlow required

Frequency accessedFrequency accessed

Duration of use- days vs monthsDuration of use- days vs months

Preferences - Dr. / PatientPreferences - Dr. / Patient

NUMBER AND NUMBER AND COMPATIBILITY OF COMPATIBILITY OF

INFUSATESINFUSATES

Determine true number of lumens Determine true number of lumens that are required based on the that are required based on the number of infusates when they are number of infusates when they are given and if they are compatiblegiven and if they are compatible

FLOWFLOW

Internal Diameter (ID) vs Outer Diameter (OD)Internal Diameter (ID) vs Outer Diameter (OD)

The outer diameter is not always directly The outer diameter is not always directly proportional to flow. Some catheters are just thick proportional to flow. Some catheters are just thick walled and although large yield slow flow. For walled and although large yield slow flow. For high flow - check the ID. Remember, larger high flow - check the ID. Remember, larger catheters cause more irritation potentiating catheters cause more irritation potentiating stenosis and thrombosis.stenosis and thrombosis.

DURATIONDURATION

> 7 days - PICC Line> 7 days - PICC Line

1- 12 Weeks - PICC line / tunneled catheter1- 12 Weeks - PICC line / tunneled catheter

12 weeks - 6 months or greater - tunneled 12 weeks - 6 months or greater - tunneled

cathetercatheter

> 6 months - Port> 6 months - Port

FREQUENCYFREQUENCY OF OF

ACCESSACCESS

Frequent access and infusion - tunneled Frequent access and infusion - tunneled cathetercatheter

Infrequent access (every week or month)-portInfrequent access (every week or month)-port

MATERIALMATERIAL

Silastic Silastic thicker, softer, larger for same flow, more thicker, softer, larger for same flow, more

friction over a wirefriction over a wire

PolyurethanePolyurethanestiffer, thinner wall, smaller for same flow, less stiffer, thinner wall, smaller for same flow, less

frictionfriction

PREFERENCESPREFERENCES

Patient: Patient:

Some patients may prefer a port for Some patients may prefer a port for aesthetics, no restrictions on activitiesaesthetics, no restrictions on activities

Operator:Operator:If the operator can’t place a port If the operator can’t place a port

choose an alternative!!!!!!!choose an alternative!!!!!!!

NON-TUNNELED EXTERNAL CATHETERSNON-TUNNELED EXTERNAL CATHETERS

TUNNELED CATHETERSTUNNELED CATHETERS

1. Single or multiple lumens1. Single or multiple lumens

2. Flow - variable2. Flow - variable

3. Long term3. Long term

4. Easy access (no skin puncture)4. Easy access (no skin puncture)

5. Cuff - Dacron, vita5. Cuff - Dacron, vita

Tunneled catheter with cuffs

Tunneled catheter with cuff

Tunneled catheter

SITES OF ACCESSSITES OF ACCESSSITES OF ACCESSSITES OF ACCESS11. . Upper extremity Upper extremity

2. Subclavian and Internal Jugular Vein2. Subclavian and Internal Jugular Vein

3. Collaterals and Thrombosed veins3. Collaterals and Thrombosed veins

4. IVC – trans hepatic, trans lumbar4. IVC – trans hepatic, trans lumbar

5. Hepatic vein5. Hepatic vein

6. Intercostal veins6. Intercostal veins

11. . Upper extremity Upper extremity

2. Subclavian and Internal Jugular Vein2. Subclavian and Internal Jugular Vein

3. Collaterals and Thrombosed veins3. Collaterals and Thrombosed veins

4. IVC – trans hepatic, trans lumbar4. IVC – trans hepatic, trans lumbar

5. Hepatic vein5. Hepatic vein

6. Intercostal veins6. Intercostal veins

LOWER EXTREMITYLOWER EXTREMITY

Most commonly femoral veinMost commonly femoral vein

Easily contaminated from proximity to Easily contaminated from proximity to groingroin

Complication of DVT less tolerated Complication of DVT less tolerated

than upper extremitythan upper extremity

SUBCLAVIAN VEINSUBCLAVIAN VEIN

ACUTEACUTE

Senagore - 10% incidence of art. PunctureSenagore - 10% incidence of art. Puncture

Mansfield - 12.2% unsuccessful accessMansfield - 12.2% unsuccessful access

CHRONICCHRONIC

Cimchowski - 50% stenosis SCV, 10% IJVCimchowski - 50% stenosis SCV, 10% IJV

Shillinger - 42% stenosis SCV, 10% IJVShillinger - 42% stenosis SCV, 10% IJV

Uldall - 10-30% thrombosis, 10-40% Uldall - 10-30% thrombosis, 10-40%

stenosisstenosis

ACUTEACUTE

Senagore - 10% incidence of art. PunctureSenagore - 10% incidence of art. Puncture

Mansfield - 12.2% unsuccessful accessMansfield - 12.2% unsuccessful access

CHRONICCHRONIC

Cimchowski - 50% stenosis SCV, 10% IJVCimchowski - 50% stenosis SCV, 10% IJV

Shillinger - 42% stenosis SCV, 10% IJVShillinger - 42% stenosis SCV, 10% IJV

Uldall - 10-30% thrombosis, 10-40% Uldall - 10-30% thrombosis, 10-40%

stenosisstenosis

SUBCLAVIAN VEIN SUBCLAVIAN VEIN COMPLICATIONSCOMPLICATIONS

Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)

PINCH-OFFSYNDROME

THROMBOSIS STENOSIS

ADVANTAGES OF THE ADVANTAGES OF THE RIGHT IJRIGHT IJ

1. Larger1. Larger

2. More superficial2. More superficial

3. Further from the lung3. Further from the lung

4. More direct route to the heart4. More direct route to the heart

5. Acute and chronic complications are 5. Acute and chronic complications are reducedreduced

CENTRAL VENOUS CENTRAL VENOUS CATHETER PLACEMENTCATHETER PLACEMENT

1. Prep1. Prep

2. Access2. Access

3. +/- Tunnel3. +/- Tunnel

4. Secure4. Secure

Alcohol scrub to remove surface oilsAlcohol scrub to remove surface oils

Chlorhexidine scrubChlorhexidine scrub

Betadine prep (allow to dry)Betadine prep (allow to dry)

Ioban dressing and drapesIoban dressing and drapes

PREPPREP

PREPPREP

Maximum Sterile Barrier - Maximum Sterile Barrier - Surgical hats, gowns, masks & glovesSurgical hats, gowns, masks & gloves

3 - 5 min. surgical scrub3 - 5 min. surgical scrub

Antibiotics (controversial) 30-60 min. priorAntibiotics (controversial) 30-60 min. priorCefazolin (Kefzol, Ancef) 1 gm IV orCefazolin (Kefzol, Ancef) 1 gm IV or

Gentamycin 80 mg IVGentamycin 80 mg IV

ACCESSACCESS

Ultrasound (US) or venography to localize Ultrasound (US) or venography to localize veinvein

Micropuncture technique Micropuncture technique 21 ga needle21 ga needle.018” wire.018” wire

Dilate to appropriate size for peel Dilate to appropriate size for peel away sheathaway sheath

TUNNELTUNNEL

Some evidence suggests it should exceed Some evidence suggests it should exceed

6 cm for best results6 cm for best results

Tunnel using sharp or blunt deviceTunnel using sharp or blunt device

Avoid bleeding !!!!!!Avoid bleeding !!!!!!

Position and place through peel awayPosition and place through peel away

SECURESECURE

A small exit site should retain cuffA small exit site should retain cuff

If using suture, place 2-3cm away from If using suture, place 2-3cm away from exit site to reduce potential for infectionexit site to reduce potential for infection

DO NOT secure suture too tightly around DO NOT secure suture too tightly around cathetercatheter

COMPLICATIONSCOMPLICATIONS

1. Acute 1. Acute Procedural Procedural

2. Sub-acute 2. Sub-acute InfectionInfection

3. Chronic3. Chronic

InfectionInfection

Catheter fragmentationCatheter fragmentation

Non-functionNon-function

COMPLICATIONS:COMPLICATIONS:ACUTEACUTE

1. SPASM1. SPASM

2. ACCESS FAILURE2. ACCESS FAILURE

3. ARTERIAL PUNCTURE3. ARTERIAL PUNCTURE

4. PNEUMOTHORAX4. PNEUMOTHORAX

5. MALPOSITION5. MALPOSITION

6. AIR EMBOLUS6. AIR EMBOLUS

PREVENTING ACUTE PREVENTING ACUTE COMPLICATIONSCOMPLICATIONS

1. Micropuncture - 21ga needle, .018”wire1. Micropuncture - 21ga needle, .018”wire

2. Imaging - US, Fluoro, Contrast, CO22. Imaging - US, Fluoro, Contrast, CO2

3. Right Internal Jugular vein approach3. Right Internal Jugular vein approach

4. Tilting table, Valsalva, Pinch Sheath4. Tilting table, Valsalva, Pinch Sheath

AIR EMBOLUS: SYMPTOMSAIR EMBOLUS: SYMPTOMS

1. Respiratory distress1. Respiratory distress

2. Increased heart rate2. Increased heart rate

3. Cyanosis3. Cyanosis

4. Poor pulse4. Poor pulse

5. Change in the level of 5. Change in the level of

consciousnessconsciousness

AIR EMBOLUS: TREATMENTAIR EMBOLUS: TREATMENT

1. Left lateral decubitus (Durant’s) 1. Left lateral decubitus (Durant’s) PositionPosition

2 100% O2 100% O22

3. Vasopressin if necessary3. Vasopressin if necessary

4. Chest compression4. Chest compression

5. Aspiration through catheter +/-5. Aspiration through catheter +/-

Mortality decreases from 90% to Mortality decreases from 90% to 30% with conventional treatment30% with conventional treatment

COMPLICATIONS:COMPLICATIONS:CHRONICCHRONIC

1. Infection1. Infection

2. Catheter 2. Catheter fragmentationfragmentation

3. Non-function3. Non-function

PREVENTING INFECTIONPREVENTING INFECTION1. Sterile environment1. Sterile environment

2. Periprocedural antibiotics 2. Periprocedural antibiotics

3. Number of lumen incidence of 3. Number of lumen incidence of infectioninfection

4. Prep4. Prep

5. Skin fixation5. Skin fixation

6. Dry dressing vs. Occlusive dressing 6. Dry dressing vs. Occlusive dressing

7. Ointments - Iodophor vs antibiotic7. Ointments - Iodophor vs antibiotic

8. Special instructions8. Special instructions

TYPES OF INFECTIONTYPES OF INFECTION

EXIT SITE, TUNNEL/POCKET or EXIT SITE, TUNNEL/POCKET or CATHETER CATHETER

1. Cutaneous - pain, erythema, swelling, 1. Cutaneous - pain, erythema, swelling, +/- exudate+/- exudate

2. Bacteremia - fever, leukocytosis and 2. Bacteremia - fever, leukocytosis and positive blood culturespositive blood cultures

3. Septic thrombophlebitis - bacteremia, 3. Septic thrombophlebitis - bacteremia, thrombosis and purulent dischargethrombosis and purulent discharge

INFECTION INFECTION CAUSATIVE ORGANISMSCAUSATIVE ORGANISMS

Staph epidermidis Staph epidermidis 25-50%25-50%

Staph aureusStaph aureus 25% 25%

Candida Candida 5-10%5-10%

INFECTION:INFECTION:CATHETER REMOVALCATHETER REMOVAL

1. Exit site - 15.4%1. Exit site - 15.4%

2. Tunnel - 69%2. Tunnel - 69%

3. Septic thrombophlebitis - 100%3. Septic thrombophlebitis - 100%

INFECTIONINFECTION

1. Septic thrombophlebitis - remove catheter1. Septic thrombophlebitis - remove catheter

2. Cutaneous - local treatment2. Cutaneous - local treatment3. Bacteremia - 3. Bacteremia -

1. IV antibiotics 48 -72 hours1. IV antibiotics 48 -72 hoursif improved - keep catheterif improved - keep catheterif no change, worse or recursif no change, worse or recursremove catheter remove catheter oror2. Exchange catheter over wire, 2. Exchange catheter over wire, 85% cure with treatment85% cure with treatment

Continue to treat infection for 10 - 14 Continue to treat infection for 10 - 14 daysdays

If ineffective - try locking with If ineffective - try locking with thrombolytics between antibiotic thrombolytics between antibiotic doses and administer antibiotics doses and administer antibiotics through cathetersthrough catheters

INFECTIONINFECTION

INFECTION:INFECTION:CATHETER REPLACEMENTCATHETER REPLACEMENT

1. Afebrile1. Afebrile

2. Negative blood culture2. Negative blood culture

CATHETER FRAGMENTATIONCATHETER FRAGMENTATION

1. Power injection - > 2 cc/sec1. Power injection - > 2 cc/sec

2. Port injection - 10 cc syringe or greater2. Port injection - 10 cc syringe or greater

3. Catheter withdrawal3. Catheter withdrawal

4. Pinch Off Syndrome4. Pinch Off Syndrome

NON - FUNCTION:NON - FUNCTION:CATHETER MALPOSITIONCATHETER MALPOSITION

1.Intravascular vs. Extravascular1.Intravascular vs. Extravascular

2. Infuses but doesn’t aspirate2. Infuses but doesn’t aspirate

3. Check the CXR 3. Check the CXR

CORRECTING CORRECTING MALPOSITIONMALPOSITION

1. Imaging guidance1. Imaging guidance

2. Redirecting 2. Redirecting catheterscatheters

THANK YOU ! THANK YOU !