Central Venous Access.pptx

central venous access, non-tunneled and tunneled

1. Central Venous Access Mohamed M.A. Zaitoun, MD Associate Professor of Interventional Radiology Faculty of Medicine, Zagazig University, Egypt FINR-Switzerland Interventional Radiology Unit, Zagazig University Hospitals, Egypt www.zaitounclinic.com [email protected]

2. Knowing as much as possible about your enemy precedes successful battle and learning about the disease process precedes successful management.

3. Central Venous Access-Nontunneled -Introduction -Indications -Contraindications -Preprocedure Preparation -Procedure -Postprocedure Management -Results -Complications -Management of Complications

4. Introduction -Central venous (CV) access devices can be placed faster, more safely, and with fewer complications when imaging guidance is utilized than when placed with reliance on external anatomic landmarks. -The placement of a nontunneled CV catheter has certain advantages over the placement of a tunneled CV catheter or implantable subcutaneous chest port.

5. -Nontunneled CV catheters are commonly placed using local anesthesia only, often at the bedside in an intensive care unit (ICU) setting when patients are too ill to be transported. - As these temporary catheters are placed without subcutaneous tunneling, less stringent adherence to coagulation parameters can be observed. - When the indication for these CV catheters no longer exists, these devices can be easily removed at the bedside.

6. Indications a) Therapeutic indications: 1-Administration of chemotherapy, total parenteral nutrition (TPN), blood products, intravenous medications, and fluids. 2-Performance of hemodialysis and plasmapheresis

7. b) Diagnostic indications: 1-To confirm a diagnosis or establish a prognosis. 2-To monitor response to treatment. 3-For repeated blood sampling.

8. Contraindications a) Absolute: 1- Cellulitis at insertion site 2- Allergy to catheter material

9. b) Relative: 1- Uncorrectable coagulopathy 2- CV occlusion 3- Peripherally inserted central catheters (PICCs) are contraindicated in patients who are at risk for chronic renal failure or who have chronic kidney disease due to concern for damage to potential future dialysis fistula sites

10. Preprocedure Preparation -The preprocedure preparation is similar irrespective of the access device that is chosen . 1- Review of medical history to : a) Establish an indication b) Obtain a history of concurrent or prior CV access devices and history of related complications, such as extremity or facial swelling c) Identify pertinent allergies

11. 2-Review of prior imaging studies to assess for anatomic variants and vessel patency, a quick ultrasound survey is recommended . 3- Physical examination of extremities, including pulses 4- Informed consent 5-Nil per os (NPO) status is not needed as the procedure is typically performed with local anesthesia only . 6-Prophylactic antibiotics are not given before nontunneled CV catheter placement.

12. 7-Guidelines for coagulation parameters should be followed, PICCs and nontunneled CV access are considered to be low risk for bleeding, which is easily detected and controllable: a) International normalized ratio (INR) should be checked in patients on warfarin, INR goal is less than 2.0. b) Partial thromboplastin time (PTT) is recommended in patients receiving intravenous unfractionated heparin, PTT should be less than 1.5 times control .

13. Prothrombin Time (PT ) : This test is done to evaluate the blood for its ability to clot. Partial Thromboplastin Time (PTT) : This test is performed primarily to determine if heparin (blood thinning) therapy is effective, It does not show the effects of low molecular weight heparin. International Normalized Ratio (INR) : The INR is used to make sure the results from a PT test is the same at one lab as it is at another lab. INR = Patient PT ÷ Control PT

14. c) Platelet count not routinely recommended, but transfusion is recommended for counts less than 50,000 per μL, others utilize a platelet count ≥25,000 per μL. d) Plavix and aspirin do not need to be withheld . e) Low-molecular-weight heparin (therapeutic dose) should be withheld for one dose before procedure.

15. Procedure 1- General considerations 2- PICC placement 3- Central venous catheter placement 4- Device removal

16. 1-General considerations : a) Nontunneled CV catheters and PICCs are placed in the interventional radiology (IR) suite or at the bedside (with or without fluoroscopic guidance) depending on operator preference and the clinical status of the patient . b) The skin is sterilized with a 2% chlorhexidine-based preparation, standard surgical scrub protocol for the operator includes hand scrubbing, gloves, mask, cap, and gown.

17. c) Local anesthesia with 1% lidocaine is utilized for all line placements . d) Choice of line: 1-CV catheters differ in composition, length, number of lumens, and size. -A large internal lumen is optimal for infusions of viscous liquids, whereas multiple lumens facilitate infusion of incompatible infusates.

18. -Generally speaking, increasing the number of lumens in the catheter will increase the size of the catheter. -For multilumen catheters, if one lumen increases in size, the other lumens may have to decrease in size to maintain a reasonable catheter outer diameter. -The choice of catheter size and number of lumens is significant, as the risk of vessel thrombosis and infection increases as the size of the catheter and number of lumens increase.

19. 2-Power injectable PICCs and nontunneled CV catheters are available and can be identified by the catheter tubing which indicate the injection rate parameters. - The Bard Power PICC (Bard Access Systems , Salt Lake City, UT) has a maximum injection rate of 5 mL per second at 300 psi.

20. e) Guidance technique: 1- Ultrasound (US) guidance is always recommended for venipunctures to avoid inadvertent arterial puncture. 2- When the patient can medically tolerate movement to an angiographic suite, fluoroscopic guidance is used for visualization of guidewires, catheters, and venography. A spot fluoroscopic image at the conclusion is used to document the catheter tip .

21. 3-When bedside CV lines are placed, only US guidance is used . -Thus, a follow-up radiograph is obtained to verify catheter tip position.

22. f) Catheter tip position: 1-Superior vena cava-right atrial junction is ideal .

23.  Anatomic landmarks for positioning of an upper extremity–placed  CVC, the junction of the SVC and right atrium lies about 4 cm below the level of the carina.

24. -Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. - Ideally the distal end of a CVC should be orientated vertically within the SVC.

25. -CVCs placed for the purpose of long term chemotherapy may be placed more inferiorly at the cavo -atrial junction - the junction of the SVC and right atrium (RA ). - Catheters used for hemodialysis may be placed at the cavo-atrial junction or even in the RA itself. - Positioning the catheter tip too proximally, for example in the right or left brachiocephalic veins, is associated with increased risk of line infection and thrombosis.

26. Normal position of the SVC at radiography, frontal chest radiograph in a 41-year-old man shows the normal SVC interface (arrowheads) and the terminal portion of the azygos vein (arrow).

27. *Value of carina: -The lower part of the SVC is surrounded by the pericardial reflection; this is where the upper pericardium folds back on itself to form a sac. - Positioning a CVC tip within the SVC and below the level of the pericardial reflection is associated with a small risk of pericardial tamponade.

28. -Neither the SVC nor the pericardial reflection are visible on a chest X-ray. - As the carina is a visible structure, which is located above the level of the pericardial reflection, it can be used as an anatomical landmark to help determine the level of a CVC tip within the SVC and above the pericardial reflection. -In most individuals the carina is located between the levels of the 5th and 7th thoracic vertebral bodies .

29. -Diagram shows the major thoracic veins. -The internal jugular veins and subclavian veins join on each side to form the right and left brachiocephalic veins ( Rt BCV, Lt BCV ), which join to form the  SVC. - The azygos vein enters posterolaterally into the distal  SVC. - Some of the tributaries of the brachiocephalic veins are also shown: the right and left internal mammary veins ( Rt IMV, Lt IMV ), pericardiophrenic veins ( PCPVs ), right and left superior intercostal veins ( Rt SIV, Lt SIV ), and inferior thyroid vein ( ITV )

30. -The pericardial reflection is located below the level of the carina - The cavo-atrial junction is located approximately the height of two vertebral bodies below the level of the carina

31. 2-Catheter tips can migrate with respirations, retraction due to pendulous breast tissue, and with movement from the supine to upright position. 3-Preexisting CV stenoses or fibrin sheaths may necessitate placement either higher in the superior vena cava (SVC) or deeper in the right atrium.

32. The mechanism of the catheter retraction . ( a) In the supine position , the catheter tip was located in the superior vena cava, and the reservoir was implanted 3 cm above the left nipple in the midclavicular line. ( b) When the patient rose to an upright position, the natural downward and outward traction of the breast caused migration of the catheter . (c) When the patient returned to a supine position , the traction disappeared, because the catheter was fixed between the clavicle and the first rib, the tip of the catheter remained in the migrated position (the innominate vein) and the body of the catheter was coiled in the subcutaneous tissue around the reservoir. (d) These phenomena were repeated, the catheter retracted into the subclavian and the body of the catheter was coiled around the catheter .

33. A. Central venous port was inserted via RT IJV in 68 year-old woman with its tip just below carina at T5 level. B . Chest radiograph in erect position showed that catheter is retracted and tip is located somewhere in brachiocephalic or internal jugular vein, patient is obese with pendulous breasts. C . On fluoroscopy in supine position, catheter tip is further migrated cephalad into right internal jugular vein, patient complained of neck pain on infusion. D . After removal of port, another port was implanted via left internal jugular vein, and tip was placed deeper in upper portion of right atrium. E . Chest radiograph in erect position revealed that catheter was once again retracted with its tip probably located in left brachiocephalic vein .

34. -Because the catheter is inserted by percutaneous insertion technique, it is not fixed to the subcutaneous tissues but only to the reservoir. - In the obese patient, rising to an upright position results in a downward and outward displacement of the breast, pulling on the unfixed subcutaneous portion of the catheter and drawing it out of the vein. -Because of the compression between the first rib and clavicle, the catheter cannot return into the vein when tension is removed, which results in a gradual withdrawal of the catheter and coiling around the reservoir.

35. -To avoid catheter retraction in an obese patient with large breasts, the positional changes of the breast in the supine and upright positions should be assessed and the reservoir should be implanted in an area of least motion, usually medial along the sternum. -Also, fixation of the ipsilateral breast with adhesive non-woven fabric could be performed when the patient is sitting to decrease movement due to large pendulous breast, a gauze is applied on the nipple to decrease discomfort.

36. Breast fixation of ipsilateral breast on abdominal wall is performed when the patient is sitting using an adhesive nonwoven fabric

37. 2-PICC placement a) Choice of vein: 1-Either arm can be used, but the non-dominant arm is preferred. 2-Some operators will choose the largest vein in the upper arm above the elbow as their access vein, whereas others will routinely select the basilic vein, as it is not adjacent to the brachial artery and nerve. -The cephalic vein may be used but is prone to spasm and thrombosis. -The brachial veins travel alongside the brachial artery increasing the risk of arterial puncture.

38. Dorsal venous network of the hand Basilic vein  Medial aspect Cephalic vein  Lateral aspect Joins the brachial V  To form the axillary V empties into axillary V The cephalic V and basilic V are connected at the elbow by the median cubital vein.

39. b) A tourniquet is placed in the upper arm to distend the veins . c) US guidance and a micropuncture needle (typically 21 gauge) are used for venous access, the access vein can also be punctured using fluoroscopic guidance after injection of contrast medium . d) A 0.018-in., 60 cm mandril guidewire is advanced centrally under fluoroscopic guidance or until resistance is felt, if fluoroscopy is not available.

40. e) A skin nick is made, and an appropriately sized peel-away sheath is placed . f) Using fluoroscopy , the required catheter length is measured using the guidewire, and the PICC line is cut to length, if the procedure is performed at bedside, catheter length is estimated . g) The PICC is advanced using a stiffening stylet or a guidewire to the desired position.

41. h) PICC function is checked by injection of saline, and the peel-away sheath is removed . i) A catheter is anchored to the skin with an adhesive catheter lock or nonabsorbable suture . j) Dilute heparinized saline is instilled in the lumens, and catheter caps are placed . k) A sterile dressing is applied.

42. l) Completion spot fluoroscopic image (or chest radiograph) is obtained to document catheter tip position for future reference . m) Tips for puncturing veins: 1- For inadvertent arterial puncture with a skinny needle, simply remove the needle and apply manual compression to achieve hemostasis.

43. 2- If the wire does not advance easily through the needle, the needle tip is either against the wall or a double-wall puncture may have occurred, pull the wire back into the needle. Withdraw the needle into the lumen, and gently advance the wire with fluoroscopic guidance until the wire advances easily. 3- If the wire tip becomes significantly deformed, consider removing the wire and needle together ( as a unit ) in order to prevent shearing of the wire.

44. 4- If it is difficult to advance the wire further along the course of the vein, vasospasm may be present, this can be confirmed with a gentle flush of contrast. -Wait a few minutes for vasospasm to resolve spontaneously or consider administering nitroglycerin locally (100 to 200 μg), alternatively , choose a new vein . 5- Stenosis/occlusion: A tortuous vein or an anatomic variant may be present, venography will define anatomy, a digital road map and a properly selected wire and catheter will help in navigating past the problem.

45. 3-Central venous catheter placement a) Choice of vein: 1-The internal jugular vein (IJV) is the preferred site, access into this vein has the lowest risk of complications , including pneumothorax and thrombosis. It has a straight course toward the right atrium simplifying catheter placement.

46. 2- The left IJV is a more challenging access site because it drains into the brachiocephalic vein, which may be tortuous and enter the SVC at a right angle, necessitating additional manipulation for central access. -The wire has a natural tendency to enter the azygous arch or the right ventricle when directed from the left side. - In such situations, curved catheters (e.g., MPA, Boston Scientific , Natick, MA) and floppy-tip wires (e.g., J-wire or a hydrophilic glidewire) are helpful to access the IVC.

47. 3- If internal jugular access cannot be achieved, the external jugular veins are acceptable targets. 4-Subclavian veins are often targeted by non-radiologists as they can be catheterized using external landmarks, however , subclavian vein access is associated with a higher risk of CV thrombosis and pneumothorax. Given the risk of thrombosis and stenosis, subclavian vein access is contraindicated in patients who are at risk for chronic renal failure, who have chronic kidney disease , or who are on dialysis.

48. Right-sided catheters -CVCs are most commonly inserted via the right internal jugular vein. -Right internal jugular catheters are positioned on the right side of the neck, and pass vertically from a position above the clavicle. Left-sided catheters -Left-sided catheters approach the SVC at a shallow angle such that they may abut the right lateral wall of the SVC . - They may need to be inserted further so the distal end obtains a vertical orientation. -This may mean locating the tip below the level of the carina. - In this position the risk of vessel wall erosion is reduced, but with a small increased risk of pericardial tamponade.

49. Right internal jugular vein catheter -The catheter is orientated vertically - The tip is projected over the anatomical location of the SVC, approximately 1.5 cm above the level of the carina - This is an ideal position for right-sided catheters for fluid administration and venous pressure monitoring, but not for long-term chemotherapy or dialysis

50. Right subclavian vein catheter -The catheter passes below the level of the clavicle -The distal catheter is orientated vertically -The tip is located 1 cm above the level of the carina

51. Left subclavian vein catheter - This left subclavian catheter is located with its tip below the level of the carina. - Positioning the tube vertically avoids abutment of the tip against the right lateral wall of the SVC

52. Long term catheter - PICC line - This peripherally inserted central catheter ( PICC ) is correctly located with its tip at the level of the cavo-atrial junction, approximately the height of two vertebral bodies below the level of the carina. - This is often considered a preferable location for long-term catheters.

53. 5- The femoral veins are often catheterized in patients who are uncooperative or coagulopathic, or when access is obtained in emergency situation as these veins can be easier to cannulate. -The groin is more tolerant of complications such as bleeding when compared to the neck. - Femoral veins are less optimal sites of venous access as there is an increased risk of infection and worse patency.

54. 6-After a medical course necessitating multiple catheters, patients are predisposed to developing CV occlusions. - When conventional veins have been exhausted, unconventional venous access should be attempted. - Unconventional routes to the central veins include recanalization of collateral neck or chest veins, translumbar access into the IVC, transhepatic venous access, or a surgically placed direct right atrial venous access.

55. b) Access: - Using US guidance and a micropuncture needle, the vein is accessed c) The microwire (0.018 in .): -Is advanced centrally under fluoroscopic guidance or until resistance is felt, if fluoroscopy is not available, a transitional dilator is placed (typically 5 Fr .). d) A working guidewire (typically 0.035 in .): -Is advanced into the inferior vena cava (IVC)

56. (a) IJV (arrow), ICA (star), (b) compression of the IJV (arrow), (c) echogenic needle tip in the center of the IJV

57. e) Serial dilators: -Are advanced over the wire. f) An appropriate length catheter: -Is advanced over the wire. - A 15-cm long catheter is commonly used when accessing the right IJV, and a 19-cm long catheter is used when accessing the left IJV. - The wire is then removed.

58. Placement of temporary catheter through the IJV, (a) guidewire is placed into IVC, (b) after serial dilators are advanced over the wire, a non-tunneled catheter is advanced over the guidewire, (c) the guidewire is removed and the catheter function verified, catheter tip is at the SVC/RT atrium junction

59. g) Catheter tip position: -Is assessed when possible, and function is verified h) Catheter is sutured to the skin. i) Catheter flushing and dressings are placed per hospital protocol.

60. 4-Device removal: a) Nontunneled central lines and PICCs can be removed at bedside or in the recovery room using local anesthesia and manual traction. b) If the device is removed for suspected catheter infection, the catheter tip is sent for culture.

61. Postprocedure Management 1- With the use of imaging guidance, catheter malposition is rare. If the catheter was not placed under fluoroscopic guidance, a chest x-ray is obtained following the procedure to document position. 2- Patients are given written instructions that describe proper care of the catheter and catheter exit sites. Signs and symptoms of complications are discussed, and contact information is provided. 3- The care of CV catheters is dictated by hospital protocol and includes instructions for line-flushing and dressing changes.

62. Results -Successful placement of a CV access device requires a catheter placed into the venous system with the tip in the desired location. - The catheter must also function appropriately for its intended use (i.e., medication administration vs. dialysis ). - The reported placement success rates are between 95% and 96 %. - The threshold for successful placement in the IJV is 95% and in the subclavian or peripheral route is 90 %.

63. Complications -Complications are defined as early (within 30 days of placement) or late (occurring after 30 days ). - Early complications are subdivided into those within 24 hours (procedurally related) and those that occur beyond that time window. - Image-guided insertions are associated with lower complication rates when compared to placement using external landmarks.

64. -The overall complication rate is 7 %. - The overall procedure threshold for major complications is 3 %. - Imaging-guided placement results in fewer early complications (5 % to 10%), lower infection rates (9.7 vs. 14 per 1,000 catheter-days), and fewer late complications (20% vs. 30 %) when compared to surgical placement.

65. -Complications: 1-Malposition 2-Pneumothorax 3- Air embolus 4- Great vessel or cardiac perforation 5- Late complications

66. 1-Malposition: -Catheter malposition immediately after placement is rare with the use of image guidance (IG ). - Tip malposition occurs in 3% to 32% without image guidance, versus 0% to 4% with image guidance. -Fluoroscopic guidance is used to confirm the proper positioning of the catheter, and immediate adjustments can be made at the time of placement. - If the catheter position is uncertain, venography can also be performed.

67. -Routine chest radiographs are not needed after image-guided catheter placement. -If a PICC line is inserted at the bedside, a follow-up chest radiograph is obtained to verify catheter tip position . -Catheter tips may lodge in a variety of locations due to anatomic variants including a left SVC, duplicated SVC, anomalous pulmonary vein, a collateral vein, or retrograde within a vein.

68. Malposition , CVC in left brachiocephalic vein, the tip of this catheter is projected over the left brachiocephalic vein rather than the SVC (superior vena cava), a nasogastric tube is also in situ (not fully imaged)

69. Malposition , catheter in right atrium, this peripherally inserted central catheter (PICC) was aimed to be inserted with its tip at the level of the cavo-atrial junction (the height of two vertebral bodies below the carina), the PICC has been inserted too far with its tip in the right atrium (RA ). Note : Some large hemodialysis catheters are designed to be placed with their tip in the RA

70. Malposition , horizontal positioning in SVC, catheters placed via a left-sided approach are prone to being positioned nearly horizontally rather than vertically within the SVC, catheters which contact the lateral wall of the SVC in this way may cause vessel erosion if positioned long term, and should therefore be placed so the tip is orientated vertically, a nasogastric tube is also in situ (not fully imaged)

71. Malposition , IJV catheter , CV catheters may take an incorrect course and end with their tip in completely the wrong place, this left internal jugular catheter has entered the left subclavian vein, the catheter needs to be repositioned, note also the ET tube, the external cardiac monitoring wire, and the lung shadowing - due to pulmonary edema in this case

72. Persistent left superior vena cava

73. Persistent left SVC at radiography, frontal chest radiograph in a 35-year-old man after placement of a right PICC shows the catheter (arrow) crossing the midline and traversing the left mediastinum in a persistent left SVC.

74. Persistent left superior vena cava

75. Persistent Left SVC

76. Duplicated SVC

77. Duplicated SVC

78. Duplicated SVC

79. Anomalous pulmonary vein , incidental cannulation of the anomalous pulmonary vein during central catheter placement should be considered when backflow appears arterial and the catheter tip projects laterally .

80. Anomalous pulmonary vein, CXR depicting abnormal position left internal jugular catheter.

81. ( A) A CVC inserted via the left IJ is noted to have taken an abnormal course on CXR tracking to the left side. Non-pulsatile low-pressure bright red blood was aspirated. It was not clear where the catheter tip lay, so it was left in situ and a contrast study was requested . ( B) Contrast injected through the catheter reveals a pulmonary venogram with contrast draining to the left brachiocephalic vein, therefore , the catheter tip lies in an anomalous pulmonary vein, the catheter was then safely withdrawn a small distance and repositioned in a central vein. Airway filter and related tubing are also seen on this image.

82. Anomalous pulmonary vein , CXR demonstrating two CVCs, Vascath (A) inserted via the right subclavian vein appropriately positioned and multilumen catheter (B) inserted via the left internal jugular vein positioned in an anomalous pulmonary vein.

83. 2-Pneumothorax: - The incidence of pneumothorax (PTX) and accidental arterial puncture is low when US guidance is used for IJV access (1% to 2 %). - The risk of PTX is higher when only external anatomic landmarks are used for direct subclavian vein access. - The risk is 0% for PICC placements.

84. -Most PTX remain asymptomatic, especially if the visceral pleura is displaced less than 2 to 3 cm from the parietal pleura. -PTX is usually apparent immediately on postprocedure imaging. - Rarely , a delayed PTX can develop several days later.

85. Iatrogenic pneumothorax , this right subclavian catheter is adequately positioned with its tip in the superior vena cava, positioning was complicated by pneumothorax due to pleural injury

86. 3-Air embolus: - Air embolus is a rare complication that occurs, if intrathoracic pressure drops, during catheter insertion into the vein through a peel-away sheath (1 %). - Air entry can be minimized by having the patient maintain a positive intrathoracic pressure by continuously humming and by manually crimping the external portion of the sheath immediately after removing the dilator and guidewire.

87. -The sheath should remain crimped until the catheter is advanced into it. - Tiny air emboli declare themselves less frequently as patients remain asymptomatic. - Large air emboli can be symptomatic, with cough and respiratory distress, or can even be fatal. - In these cases, air lucency in the right atrium or pulmonary outflow can be seen on fluoroscopy. A peel-away sheath with a valve can help minimize this risk.

88. 4-Great vessel or cardiac perforation: -Perforation is a rare complication (<1%) that may occur if dilator is advanced over a kinked guidewire or if the wire is not in the IVC. - Catheters placed in the right subclavian vein are more prone to this as the vessel enters perpendicular to the SVC. - Signs of hemodynamic instability, hemothorax, mediastinal hematoma, or cardiac tamponade may be present.

89. 5-Late complications: -Such as infection, fibrin sheath formation, venous thrombosis, and catheter fracture. - These are more often the consequence of longterm access .

90. Management of Complications 1-Malposition: a) A malpositioned catheter at the time of placement can be adjusted using fluoroscopic guidance and a guidewire. b) If a catheter tip has migrated after the initial placement, many corrective options exist. - For instance, if a catheter tip has migrated into the azygous arch, the catheter can be repositioned into the SVC using a pigtail catheter or an endovascular snare from a femoral approach.

91. -If the catheter is too short, a catheter exchange may be indicated. - If the catheter is too long, catheter can be pulled back . c) Poor aspiration of a PICC may indicate that the catheter may be kinked, this can be corrected using a guidewire to straighten out the catheter. - If any catheter will not aspirate when the tip is central, the tip may be against the wall of the RA. - The catheter can slowly be withdrawn until free flow is achieved.

92. d) If a small-bore catheter is accidentally placed in the arterial system, catheter removal with manual compression can be attempted. - If a large-diameter catheter is placed in the arterial system, removal may need to be performed in the operating room with a cut down. - Other options upon removal of an arterial catheter include balloon tamponade or deployment of a covered-stent or closure device.

93. 2-Pneumothorax: a) Small PTXs are managed conservatively . b) A large or symptomatic PTX can be treated with a small-bore chest tube attached to a Heimlich valve (Becton Dickinson, Franklin Lakes, NJ ). c) If a Heimlich valve is insufficient, the catheter can be attached to a Pleur-evac (Teleflex, Inc, Morrisville , NC) system or wall suction . d) Rarely would a conventional surgical large-bore chest tube need to be placed.

94. 3-Air embolus: a) Not treated if emboli are small or patient is asymptomatic. b) If symptomatic, place patient in the left lateral decubitus position (left side down) and administer 100 % oxygen.

95. 4-Great vessel or cardiac perforation: a) Catheter removal in the operating room, as needed. b) Catheter can be removed in the angiography suite, however , the equipment for balloon tamponade or stenting should be readily available. - A surgical team may need to stand by for high-risk cases.

96. A) A left-sided dialysis catheter has perforated through the right wall of the SVC and the tip has entered the right hilum and pleural space, with tear to the pleura and pulmonary vessels. The patient collapsed and blood and fluids infused through the catheter entered the right pleural space to produce a hemothorax. The catheter was left in situ and referral to radiology for successful stenting procedure (B).

97. (A) A large-bore dialysis catheter inserted via attempted left IJ puncture is seen to take an abnormal course projected over the left mediastinum. Pulsatile blood was evident and the catheter was recognized to be intra-arterial. -It was left in situ and management discussed with vascular surgery and interventional radiology. B ) Further imaging with and contrast injection via a pigtail catheter in the aorta and CT shows the catheter entering the arterial tree via the left subclavian artery passing into the descending aorta. -The hole in the artery was successfully repaired with a stent graft placed over the defect.

98. 5-Late complications: -See later.

99. Central Venous Access-Tunneled -Introduction -Indications -Contraindications -Preprocedure Preparation -Procedure -Postprocedure Management -Results -Complications -Management of Complications

100. Introduction -Long-term central venous (CV) access devices are composed of tunneled catheters and subcutaneous chest ports. -Tunneled catheters are used for weeks to months (or even years) and are most commonly placed for chemotherapy , total parenteral nutrition (TPN), plasmapheresis, and hemodialysis.

101. -Implantable subcutaneous ports are used for access if the indication remains for months to years. - Most commonly, ports are placed for chemotherapy. - Generally speaking, tunneled catheters are easier/quicker to place and exchange but have a higher risk of infection and are more lifestyle-limiting (overall cosmetic appearance and ease of hygiene) when compared to subcutaneous ports. - All of these devices can be removed when they are no longer needed.

102. Indications 1-Administration of chemotherapy, TPN, blood products, intravenous medications, and fluids. 2- Performance of hemodialysis and plasmapheresis.

103. Contraindications a) Absolute: 1-Bacteremia or sepsis 2-Cellulitis at insertion site 3-Allergy to catheter material

104. b) Relative: 1- Uncorrectable coagulopathy 2- CV occlusion

105. Preprocedure Preparation - Preprocedure preparation is similar to the placement of temporary CV access catheters described before, notable differences are: 1- In addition to local anesthesia, patients often require conscious sedation, patients must remain nil per os (NPO ) for 6 hours, or per institutional protocol . 2-Guidelines to coagulation parameters should be followed to prevent bleeding complications , tunneled CV access and subcutaneous ports are considered to be procedures with moderate risk of bleeding.

106. a) Routine international normalized ratio (INR) should be obtained in all patients, INR goal is less than 1.5. b) Partial thromboplastin time (PTT) is recommended in patients receiving intravenous unfractionated heparin, normal range is 25 to 35 seconds, PTT should be less than 1.5 times control.

107. c) Platelet count not routinely recommended, but transfusion is recommended for counts less than 50,000 per μL, others utilize a platelet count ≥25,000 per μL. d) Plavix is withheld for 5 days before procedure. Aspirin not withheld . e) Low-molecular-weight heparin (therapeutic dose) should be withheld for one dose before procedure.

108. 3-Prophylactic antibiotics before central line placement is controversial because several studies support and refute their utility. - If prophylaxis is desired for tunneled catheter or port placement, 1 g cephazolin or 600 mg clindamycin can be administered within 45 minutes of skin incision.

109. Procedure 1-General considerations 2-Tunneled central venous catheters 3-Chest port 4-Device removal 5-Exchanging a nonfunctioning tunneled catheter

110. 1-General considerations: a) All tunneled catheters and ports are placed in a fluoroscopy suite . b) The skin is sterilized with a 2% chlorhexidine-based preparation, standard surgical scrub protocol for the operator includes hand scrubbing, gloves, mask, cap, and gown . c) Local anesthesia with 1% lidocaine is used for all line placements.

111. d) Conscious sedation with fentanyl citrate and midazolam hydrochloride is routinely administered, the nurse must continuously monitor vital signs . e) Choice of device: -As with temporary catheters, the smallest catheter size and minimum number of lumens to satisfy the indication for the access is important to decrease thrombotic complications. - Power injectable devices permit their use for contrast injection during computed tomography ( CT) examination .

112. f) Guidance technique: - Ultrasound (US) guidance is always recommended for venipunctures . - Fluoroscopic guidance is used for visualization of guidewires, catheters, and venography . g) Choice of vein: -The jugular veins are the preferred access site for tunneled catheters and subcutaneous ports. - Subcutaneous ports can be placed through an arm vein, similar to a peripherally inserted central catheter (PICC); however, arm ports are associated with higher risk of complications such as thrombosis.

113. -Femoral veins are less optimal sites of venous access because there is an increased risk of infection and worse patency. - When conventional veins are exhausted, nonconventional access is considered.

114. 2-Tunneled central venous catheters: a) For women with large breasts, the breast should be taped inferiorly to prevent excessive retraction (with cephalad catheter-tip movement) when the patient resumes an upright posture . b) The placement of tunneled catheters using conventional veins is essentially the same for all indications, access to the jugular vein is made similarly to nontunneled access. c) A working guidewire is placed from access site to the IVC.

115. d) The intended subcutaneous path of the tunnel is anesthetized with lidocaine using a long needle and preferably a single skin entry . e) A skin nick is made in the chest wall at the desired catheter entry site so as to create a subcutaneous tunnel of 8 to 10 cm in length, and a tunneling device is advanced through this nick toward the neck venotomy site making a gentle curve in the tract, some devices have a preformed curve.

116. f) An appropriately sized peel-away sheath is placed through the jugular access over the existing stiff 0.035-in . wire . g) The tunneled catheter is pulled through the tunnel so that the proximal retention cuff is at least 2 cm within the entry to the tunnel. h) Then the catheter is briskly advanced through the jugular peel-away sheath positioning the tip at the superior vena cava/right atrium (SVC/RA) junction, Avoid air embolism.

117. i) The neck venotomy site is closed with skin glue (Dermabond, Ethicon, Mokena, IL) or a suture . j) The tunneled catheter is anchored to the skin with a nonabsorbable suture . k) Function is verified by aspiration and flushing of ports with saline . l) Heparin is instilled in the lumens and caps are placed according to hospital policy . m) A sterile dressing is applied . n) A completion spot fluoroscopic image is saved to document tip position.

118. 3-Chest port: a) After gaining access to the jugular vein, a working guidewire is placed from access site to the IVC. b) The intended port placement site and the tunnel tract are generously anesthetized with lidocaine with a minimal number of skin entries.

119. c) Using a no. 15 scalpel, a single 3-cm long skin incision is made in the chest wall parallel to the sensory dermatomes. - A subcutaneous pocket is made using blunt dissection. - The pocket should be large enough to contain the port without excessive skin tension. - If the port is placed too deeply, access with the Huber needle (B. Braun Medical, Inc, Bethlehem, PA) can be difficult. - If the pocket is too superficial , skin erosion and breakdown can occur. - If the pocket is too capacious, the port can flip over. - If pocket is too small, excessive tension may lead to dehiscence of the wound.

120. d) The tunneling device is then advanced from the pocket to the neck venotomy site making a gentle curve in the tract, the catheter is pulled through the subcutaneous tunnel. e) An appropriate peel-away sheath is placed over the wire at the internal jugular vein (IJV) entry site . f) The catheter tubing is advanced through the peel-away sheath and positioned at the SVC/RA junction, the end hole of the catheter tubing outside of the patient must be clamped in order to prevent air embolism and bleeding.

121. g) The catheter tubing is cut at the level of the port pocket and is then attached to the port reservoir and secured by the hub (done in nonattached systems only ). - Care is required in allowing for enough catheter length within the pocket to attach it to the port but not so much that it kinks. - The port is lowered into the pocket.

122. h) The pocket is closed with a two-layer closure. - The deep layer is closed with 3-0 absorbable sutures (Ethicon , Mokena, IL ). - A recent report suggests that barbed absorbable suture can be used for the deep layer closure with good success and potentially better outcomes than traditional absorbable suture. -The cutaneous layer is closed with skin glue or a running subcuticular 4-0 absorbable suture.

123. i) The port is accessed with noncoring needle, aspirated, flushed with saline to check for leaks, and instilled with heparin volume as specified . j) The venotomy site is closed with skin glue or 4-0 absorbable suture . k) A sterile dressing is applied . l) Follow-up spot fluoroscopic image is obtained to document catheter-tip position . m) If needed, the Huber needles are placed and secured for the clinical service.

124. 4-Device removal: a) Tunneled central lines can be removed at bedside or in the recovery room using local anesthesia and manual traction. -The retention cuff is freed from the subcutaneous tissues by using blunt and/or sharp dissection. - Tunneled catheters can break during removal. - The catheters will typically break at the junction of the catheter tubing and the cuff.

125. -If possible, the catheter is clamped to prevent air embolus and bleeding. -If this is not possible, extrinsic compression on the catheter over the clavicle is performed to prevent bleeding and air embolus. - An incision is made central to the cuff and the catheter is removed using blunt dissection.

126.   ( A)  Catheter exit site prepped and draped.  (B, C)  Exit site and tunnel infiltrated with lidocaine with 1% epinephrine.  (D)  The stitch holding the catheter is removed.

127. ( E)  Blunt dissection of the tunnel with a Kelly clamp.  (F)  The catheter is withdrawn from the tunnel.  (G)  Hemostasis is obtained.  (H)  Dressing is applied

128. b) Port removal is performed in the procedure room using sterile conditions. - Most port removals are performed with local anesthesia only . 1- An incision is made and the port is removed using blunt dissection. - The port, hub, and catheter are removed. -If the pocket is clean, the pocket is closed with absorbable sutures and skin glue .

129. 2- If the pocket is infected, copious irrigation is performed. - The pocket is packed with iodoform packing strips and allowed to close secondarily . 3- If the device is removed for suspected catheter infection, the catheter tip is sent for culture.

130. 5-Exchanging a nonfunctioning tunneled catheter: a) A tunneled catheter may not be functioning due to malposition of the catheter tip, fibrin sheath formation , or clotting of the catheter. -Exchange of a tunneled catheter can be done using the same tract. - Preprocedure protocol detailed before is followed.

131. b) A stiff hydrophilic wire is advanced into each lumen of the old tunneled catheter and into the IVC using fluoroscopic guidance. - The old catheter is removed after dissecting the cuff out of the subcutaneous tissues and the old catheter is removed over the wires . c) If a pericatheter fibrin sheath is suspected, angioplasty can be performed using an 8- to 12-mm balloon to disrupt it.

132. d) A new catheter is advanced over the wires . e) The catheter is secured and function is verified . f) Spot fluoroscopic image and sterile dressing are placed . g) Occasionally, the new catheter may be difficult to advance through the tract, which can be due to an immature tract or sharp angulation at the venotomy entry site. - The tract and venotomy site can be stretched with dilators or angioplasty balloons.

133. -The catheter can be advanced through a peel-away sheath placed in the tract to provide stiffness and support while manual compression is placed over the venotomy site to help direct the catheter inferiorly. - Many catheters have either tapered distal ends or have guidewire stylets which can help facilitate catheter exchanges.

134. Postprocedure Management 1- With the use of imaging guidance, catheter malposition is rare. - A spot radiograph is obtained to document tip position . 2- Patients are given written instructions that describe proper care of the catheter and wound. - Signs and symptoms of complications are discussed and contact information provided.

135. 3- The care of tunneled catheters and subcutaneous ports is dictated by hospital protocol and includes instruction for line flushing and dressing changes . 4- Power injectable catheters: a) Power injectable tunneled catheters have external identifying labels on the catheter which indicate maximum injection rates.

136. b) Power injectable ports have multiple safety identifiers. - Certain devices can be identified by shape or palpation points on the septum. - Identifiers are also present on scout CT or plain radiographs. - A special power injectable Huber needle must be used during power injections . c) Patients should be given written information to document the type of device that has been placed.

137. Results -As with temporary access, successful fluoroscopic placement of a CV access device into the venous system with the tip in the desired location and with appropriate function for its intended use is accomplished in nearly all cases (95%).

138. Complications -Early complications of CV access were described before and are directly applicable to longterm CV access. - Unique late complications do arise with long-term CV catheters because their implantation time is longer than temporary catheters . 1-Infection 2- Fibrin sheath formation 3- Catheter-related CV thrombosis 4- Catheter pinch-off

139. 1-Infection: -Most common complication. -Coagulase-negative Staphylococcus species, Staphylococcus aureus, aerobic gram-negative bacilli, and Candida albicans are the most common pathogens. -In general, ports have the lowest infection rate, followed by tunneled catheters, and then nontunneled catheters. - The infection rate of ports has been reported at 0.21 per 1,000 catheter days, whereas for tunneled lines it has been reported at 2.77 per 1,000 catheter days.

140. -Rate of catheter exit site infection is 0.26 per 1,000 catheter days, rate of bloodstream infections is 0.19 per 1,000 catheter days. - In cases of suspected line infection, patients are treated with broad-spectrum antibiotics to cover the most common pathogens, t he antibiotic choice is tailored based on results of blood cultures, wound cultures, or catheter-tip cultures.

141. 2-Fibrin sheath formation: -Most common cause of catheter dysfunction. - The classic complaint is that the catheter can infuse but will not aspirate . - A fibrin sheath is a proteinaceous coat of eosinophilic material and scattered inflammatory cells that envelops the catheter tubing and tip that can be identified on venography by contrast puddling at the tip or traveling in a retrograde direction along catheter tubing rather than flowing directly into the central veins.

142. -Fibrin sheaths form around nearly every CV catheter, catheter dysfunction secondary to fibrin sheath can be seen in 13% to 57% of all dialysis catheters (which can be detected early due to low flow rates), catheter dysfunction due to fibrin sheath is likely seen less commonly in ports and non-dialysis tunneled lines because these catheters can function despite having low flow rates.

143. -Catheter dysfunction caused by a thrombus near the tip of the catheter can mimic the symptoms of a fibrin sheath because both can cause a one-way valve disrupting proper function.

144. Catheterogram in an 18-year-old female shows narrowing of the contrast jet (thick arrow) as it exits the catheter tip (dashed arrow) and tracking in a retrograde manner along the catheter confined by the fibrin sheath (thick arrow)

145. Port was accessed in a sterile technique and contrast injected with mild resistance, line tip is in the SVC with no kink of discontinuation. On injection there is loss of normal jet from the tip with retrograde flow superiorly close to the catheter. 

146. The fibrin sheath is indirectly seen in these images before and after contrast injection, as the contrast collects around the catheter.

147. Calcified fibrin sheath at radiography, frontal radiograph in a 57-year-old woman with end-stage renal disease and a long history of multiple CVC placements shows interrupted linear calcifications (arrowheads) along the right internal jugular vein and SVC, findings consistent with a calcified retained fibrin sheath, note the left subclavian CVC (arrow) with its tip in the mid SVC.

148. 3-Catheter-related CV thrombosis: -Manifestations of SVC syndrome such as arm swelling and face swelling can develop due to catheter related CV thrombosis. - Often there is a preexisting stenosis which is exacerbated by superimposed acute clot. - Catheter tip malposition increases the risk of thrombosis. -Incidence is ~4 %.

149. Postulated mechanisms by which the presence of a CVC may contribute to the development of thrombosis.

150. 4-Catheter pinch-off: - Complications related to catheters passing through the subclavian vein do not occur with IJV access . -Catheters that are placed too medially are chronically compressed by the right rib and clavicle by the costoclavicular ligament and subclavius muscle. - Repetitive compression can lead to fatigue and fracture. - The catheter fragment may then embolize to the heart or pulmonary artery (~1%)

151. -Clinically , pinch-off may present as postural-related difficulty in injection (injection is easier with the patient supine with arm and shoulder raised), or the patient may complain of infraclavicular discomfort and swelling due to extravasation of infused fluids. -The condition needs to be recognized, and there are characteristic X-ray appearances showing scalloping of the catheter on plain CXR.

152. -The condition can be avoided by choosing a more lateral puncture site of the vein during subclavian catheterization or using alternative sites of vein access. - If a subclavian access site is felt to be very tight when dilators are passed, consideration should be given to siting the catheter elsewhere .

153. Diagram to explain proposed mechanism of `pinch-off '. At the time of catheter insertion the angle between the clavicle and the first rib is wide (a ), in the upright position, the angle narrows and pinches the catheter (b).

154. Catheter fracture due to pinch-off syndrome, (A ) The catheter was entrapped at the point where the catheter crosses between the clavicle and the first rib (arrow ), ( B) Distal portion of the catheter was fractured and embolized to the right pulmonary artery (arrows).

155. (A) Chest X-ray showed deviated central venous catheter between clavicle and first rib representing pinch-off sign grade 1, (B ) Close up view.

156. Close-up view of left upper portion of chest X-ray, a single-lumen Hickman catheter has been inserted via the left subclavian route, the section of catheter lying under the first rib and clavicle (arrow) shows characteristic compression (scalloping) suggestive of pinch-off.

157. Management of Complications 1-Infections: - Not every catheter suspected of being infected should be removed immediately. - Consider catheter salvage if a patient is stable and/or lacks other sites for potential venous access . -Exit site or wound infections are initially treated with antibiotics.

158. -Tunnel infections or port pocket infections require catheter removal and antibiotics . - If bacteremia is present, antibiotics are given. -If blood cultures are negative for 48 hours, catheter exchange over a guidewire can be performed for tunneled PICCs or tunneled central lines . - If patient is septic, emergent catheter removal is indicated.

159. - Infected tunneled lines are removed by manual traction after dissection of the cuff. - The catheter exit site closes by secondary intention. - The catheter tip is sent for culture and sensitivity . - Infected ports are excised and pocket irrigated. If the pocket is clean, it can be closed primarily. - If the port pocket is purulent, the pocket is packed with iodoform packing gauze until the pocket is clean and closes by secondary intention. - Catheter tips are sent for culture and sensitivity. - Extensive port pocket infections may require plastic surgery consultation.

160. 2-Fibrin sheath formation: a) First-line treatment is administering tissue plasminogen activator (tPA) into the lumens, success rate is 87% to 93% for catheter clearance. -Alteplase ( Cathflo , Genentech, San Francisco, CA) is reconstituted by injecting 2.2 mL of sterile water into the alteplase powder.

161. -Administer the appropriate amount of alteplase based on the specified volume of the catheter . - Allow 30 minutes of dwell time and reassess for patency . - If still occluded, allow an additional 90 minutes of dwell time (120 minutes total) and recheck for patency. - If still occluded, re-administer a repeat dose of alteplase and repeat dwell times.

162. -An alternative protocol for pharmaceutical fibrin sheath disintegration involves administering an alteplase drip. - A sample infusion protocol is to administer 2 to 4 mg alteplase mixed with 50 mL saline and infused over 3 to 4 hours. b) If thrombolytics fail, exchange of catheter over a guidewire, with or without balloon angioplasty, can be performed.

163. c) Exchange of a port is more involved compared to exchange of a tunneled catheter. - Therefore , fibrin sheath stripping using a loop snare is recommended. -If fibrin sheath stripping fails, the port and catheter should be exchanged.

164. Digital subtraction angiography of clinically dysfunctional venous port system correctly placed into the cavoatrial junction. Note : A 7 cm long fibrin sheath around the tip of the port catheter (arrows) causes an irregular and retrograde opacification along the catheter tube. Effective local thrombolysis resulted in complete dissolution of the fibrin sheath. Note : After contrast injection, there was a regular, jetlike efflux out of the catheter orifice.

165. Balloon angioplasty for fibrin sheath management in a 54-year-old man with malfunction of a tunneled dialysis catheter in the right internal jugular vein . (a) Digitally subtracted venogram obtained with contrast agent injected through a partially retracted dialysis catheter shows a linear contrast agent–filled track (arrow) extending distally beyond the catheter tip (arrowheads), a finding consistent with retained fibrin sheath . ( b) Fluoroscopic image shows treatment of the lesion with balloon venoplasty (arrowheads ). ( c) Digitally subtracted SVC cavogram obtained after angioplasty shows disruption of the fibrin sheath and restored SVC patency.

166. 3-Catheter-related CV thrombosis: -Anticoagulation is the initial treatment . - If the catheter is no longer needed, removal is indicated . - If the catheter is needed, anticoagulation is continued, if anticoagulation is insufficient, thrombolytic therapy may be instituted . -If a patient has an underlying SVC stenosis, angioplasty and/or stenting is needed to relieve symptoms. -A small amount of thrombus is often seen around catheter tips by CT. -If asymptomatic and a small clot burden , manage conservatively, if thrombus is large, consider anticoagulation.

167. The right internal jugular vein (IJV) shows normal flow distal to the central line, there is an inhomogeneous thrombus adhering to the central line partially occluding the IJV. 

168. 4-Catheter pinch-off: -A compressed, unfractured, subclavian catheter is followed with serial radiographs. - If the catheter is partially fractured or has embolized, removal of the device is indicated, the embolized fragment can be retrieved using a loop snare . - Fragments can get chronically “endothelialized” into the right heart wall, which would preclude removal .

169. Catheter pinch-off with foreign body retrieval . ( A,B ) Scout view shows fractured catheter with fragment in the expected region of the left pulmonary artery . ( C ) Fluoroscopic image shows loop snare adjacent to catheter fragment . ( D ) Fluoroscopic image demonstrates fragment captured by snare . ( E ) Fluoroscopic image shows catheter being retracted to the common femoral vein via the inferior vena cava . ( F ) Final fluoroscopic image after removal of fragment and chest port.

170. Central Venous Access Management -Introduction -Flushing -Access and Administration Sets -Site Care

171. Introduction -Maintaining lumen patency and preventing catheter-related bloodstream infections (CR-BSIs) or central line associated bloodstream infection (CLABSIs) are the goals of proper line care for both peripherally inserted central catheters (PICC) and central venous catheters (CVCs ). - Vascular access devices are cited as the main cause of health care-associated bloodstream infections. - Rates of infection vary by line type, insertion location, number of lumens, and tunneling.

172. - Estimates of associated mortality range from 0% to 35% if the study is controlled for illness severity. - In addition to the ICU setting, central venous access is also frequently used in the outpatient oncology setting , where patients are immunosuppressed secondary to chemotherapy treatment and have a higher likelihood of developing a central line infection. - Infections of all types are a significant cause of morbidity and mortality in oncology patients, One of the major risk factors determined from multivariate analysis is inflammation at CVC insertion site.

173. Flushing -Anticoagulants such as heparin are used to maintain the patency of catheters by preventing intraluminal thrombosis. - There is a lack of clinical evidence for or against using heparin flushes in central lines, which is noted by many of the evidence-based guidelines for catheter care.

174. -A systematic review showed weak evidence for the use of heparin flushes in reducing the incidence of catheter occlusion. - Risks of using heparin flushes include heparin-induced thrombocytopenia (HIT), allergic reactions to heparin, and chemical contaminants. - No current studies have been done that are sufficiently powered to assess the risk of HIT from routine central venous catheter flushing.

175. -One randomized trial comparing normal saline versus heparin flushes in short-term, nontunneled, CVCs demonstrated no difference in catheter patency and suggests that frequency of flushes and proper flushing technique are critical in maintaining catheter patency. - The CDC recommends against the use of anticoagulant therapy, but the focus of their guidelines is prevention of infection and not on maintaining catheter patency.

176. Access and Administration Sets -There is limited Category I evidence on the care of needleless access ports for CVCs. - The use of needleless access is mandated to help prevent needlestick injuries. - There are multiple types of stopcocks, needleless system connectors, and Luer -activated devices currently on the market . -The CDC recommends accessing these ports with sterile devices after disinfecting the port with chlorhexidine, povidone iodine, and iodophor , or 70% alcohol (Category IA ).

177. -There is growing evidence in the literature suggesting that universal disinfectant caps placed on the end of the needleless connectors reduce CLABSI rates, and guidelines published by the Society for Healthcare Epidemiology of America recommend use of disinfectant caps as Category I. -Tubing used to administer fluids should be replaced routinely depending on the infusate.

178. -Propofol tubing should be replaced every 6 to 12 hours. -Tubing for blood, blood products, or fat emulsions should be replaced within 24 hours of starting the infusion. -All other administration sets should be replaced between 4 days and 7 days of first use.

179. Site Care a) Insertion b) Dressing c) Infection Prevention

180. a) Insertion: - For catheter insertion as well as dressing changes, the skin should be cleaned with >0.5% chlorhexidine. - If the patient has an allergy, tincture of iodine or 70% alcohol can also be used (Category IA ). - When placing or replacing PICCs or CVCs, maximum sterile barriers including hat, mask, sterile gown, sterile gloves, and full body drape should be used

181. b) Dressing: - The CDC recommends using sutureless securing devices to help prevent infection (Category II ). - Either sterile transparent polyurethane dressings or sterile gauze and tape are appropriate dressings for central lines (Category IA ). - There is no evidence demonstrating one dressing is superior to another in preventing infection. -Gauze is most appropriate if the catheter site is bleeding or if the patient is diaphoretic (Category II).

182. -The dressing , regardless of what type, should be changed if it is soiled or starting to become detached from the skin (Category IB ). - Depending on patient preference, transparent dressings can be changed on a weekly basis (Category II ). - Gauze dressings should be changed every 2 days. -Patients may be permitted to shower with the dressing in place 48 hours after placement as long as catheter is covered with an impermeable cover ( Category II ).

183. -Tunneled catheters that are well-healed may go without a dressing except in the case of immunocompromised patients; no recommendations have been made on dressings for these catheters. - A chlorhexidine impregnated sponge dressing should be used on short-term catheters in patients older than 2 months if the infection rate is not decreasing (Category IB).

184. c) Infection Prevention: -Additional infection prevention strategies include the use of povidone -iodine antiseptic ointment at the hemodialysis catheter exit site after insertion and at the end of each dialysis session as long as ointment will not interact with catheter material (Category IB ). -Bacitracin/gramicidin/ polymyxin B ointment may be used if it is available.

185. -If CLABSI rates are not decreasing, the CDC recommends using chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVCs in patients who need access for 5 days or longer (Category IA ). - An antibiotic lock prophylaxis is recommended in patients with long-term catheters who have had multiple line infections (Category II ).