Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.     

A surgical procedure and tethering system for chronic blood sampling, infusion, and temperature monitoring in caged nonhuman primates

A jacket and tethering system was used to maintain chronic catheters in monkeys, which provided catheter access and manipulability without further restraint. Surgical placement of catheters and a temperature probe allowed for a common cutaneous exit and interface with the jacket and tether. Monkeys were fitted in a sterile leather or denim jacket which was attached to a sterilized flexible stainless steel cable. Through this conduit, an indwelling temperature probe, as well as catheters from the internal jugular and femoral veins, were attached to a swivel unit located on the upper portion of the cage. The internal jugular catheter was used for the continuous infusion of support solution. The catheter from the femoral vein was maintained with a heparin lock and used for serial blood sampling. Using this system, it was possible to obtain frequent blood samples and body temperature readings, and to administer a continuous intravenous infusion without chemical or excessive physical restraint. To date, 367 monkeys, 322 cynomolgus (Macaca fasicularis), 16 rhesus (Macaca mulatta), and 21 African green (Cercopithecus aethiops) have been studied using this procedure.     

Eliminating the "Pitfalls" of chronic indwelling central venous access device placement in cancer patients by utilizing a venous cutdown approach and by selectively and appropriately utilizing intraoperative venography

There are several very obvious and simple solutions for eliminating the "Pitfalls" and for minimizing the risk of occurrence of any perioperative complications associated with placement of chronic indwelling central venous access devices in cancer patients. The first is the utilization of a venous cutdown approach, such as the cephalic vein or the external jugular vein, which essentially eliminates potentially life-threatening perioperative complications, such as pneumothorax and injury to the great vessels (with or without associated hemothorax). The second is the selective and appropriate utilization of intraoperative venography for defining the central venous anatomy and for providing a venous roadmap in those particularly challenging cases in which difficulties are encountered during chronic indwelling central venous access device placement.     

Factors Influencing Intracavitary Electrocardiographic P-Wave Changes during Central Venous Catheter Placement

Amplitude changes in the P-wave of intracavitary electrocardiography have been used to assess the tip placement of central venous catheters. The research assessed the sensitivity and specificity of this sign in comparison with standard radiographic techniques for tip location, focusing on factors influencing its clinical utility. Both intracavitary electrocardiography guided tip location and X-ray positioning were used to verify catheter tip locations in patients undergoing central venous catheter insertion. Intracavitary electrocardiograms from 1119 patients (of a total 1160 subjects) showed specific amplitude changes in the P-wave. As the results show, compared with X-ray positioning, the sensitivity of electrocardiography-guided tip location was 97.3%, with false negative rate of 2.7%; the specificity was 1, with false positive rate of zero. Univariate analyses indicated that features including age, gender, height, body weight, and heart rate have no statistically significant influence on P-wave amplitude changes (P>0.05). Multivariate logistic regression revealed that catheter insertion routes (OR = 2.280, P = 0.003) and basal P-wave amplitude (OR = 0.553, P = 0.003) have statistically significant impacts on P-wave amplitude changes. As a reliable indicator of tip location, amplitude change in the P-wave has proved of good sensitivity and excellent specificity, and the minor, zero, false positive rate supports the clinical utility of this technique in early recognition of malpositioned tips. A better sensitivity was achieved in placement of centrally inserted central catheters (CICCs) than that of peripherally inserted central catheters (PICCs). In clinical practice, a combination of intracavitary electrocardiography, ultrasonic inspection and the anthropometric measurement method would further improve the accuracy.     

Ablation of Post Transplant Atrial Flutter and Pseudo-fibrillation Using Magnetic Navigation via a Superior Approach

Ablation of cavotricuspid isthmus flutter and atrial tachycardia in a complex substrate has never been reported using remote navigation via superior approach. Venous access was obtained via right internal jugular for ablation and left subclavian for duodecapolar catheter placement into the coronary sinus. In a posttransplant patient presenting with both regular and irregular tachycardia, both cavotricuspid isthmus flutter in the donor and atrial tachycardia in the recipient was mapped using a two catheter approach. Successful ablation of typical atrial flutter and anastomotic block was achieved. This is the first report of successful ablation of cavotricuspid isthmus flutter and posttransplant atrial tachycardia using magnetic navigation via superior approach. Using only two catheters, this approach is logical and feasible in complex substrates with interrupted inferior venous access.     

Central venous catheters for chemotherapy of solid tumors--our results in the last 5 years

Central venous catheters provide an easy access for intravenous medications. Having a central line in place will relieve a child from the discomfort and danger of multiple regular intravenous lines for chemotherapy. The use of indwelling central venous catheters has become commonplace in the management of children undergoing oncological treatment. There are two types of central lines commonly used. There are Broviac catheters and Port-A-Cath (PAC) catheters. In the last 5 years we inserted 194 catheters in 175 children. We inserted 121 Broviac catheters and 73 PAC catheters. During the follow up of 39382 catheter days 44 complications were observed. In Broviac group the median follow up was 155 days and in PAC group was 230 days. We observed differences in the incidence between two devices. In Broviac group infections were more frequent and in PAC group other complications were more frequent than infections.     

Ultrasonic locating devices for central venous cannulation: meta-analysis

Objectives To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation.Data sources 15 electronic bibliographic databases, covering biomedical, science, social science, health economics, and grey literature.Design Systematic review and meta-analysis of randomised controlled trials.Populations Patients scheduled for central venous access.Intervention reviewed Guidance using real time two dimensional ultrasonography or Doppler needles and probes compared with the anatomical landmark method of cannulation.Data extraction Risk of failed catheter placement (primary outcome), risk of complications from placement, risk of failure on first attempt at placement, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation.Data synthesis 18 trials (1646 participants) were identified. Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants confirmed a higher success rate with two dimensional ultrasonography for internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided cannulation of the internal jugular vein in adults was more successful than the landmark method (0.39, 0.17 to 0.92), but the landmark method was more successful for subclavian vein procedures (1.48, 1.03 to 2.14). No significant difference was found between these techniques for cannulation of the internal jugular vein in infants. An indirect comparison of relative risks suggested that two dimensional ultrasonography would be more successful than Doppler guidance for subclavian vein procedures in adults (0.09, 0.02 to 0.38).Conclusions Evidence supports the use of two dimensional ultrasonography for central venous cannulation.     

Chronic silastic central venous catheterization for induction, maintenance and support of persistent granulocytopenia in rabbits

In order to investigate new approaches in diagnosis, prevention and treatment of infectious complicating chemotherapy-induced granulocytopenia, we developed and prospectively evaluated a method of chronic central venous catheterization for the induction, maintenance and support of persistent granulocytopenia in rabbits. The method entails a central venous silastic catheter with a subcutaneous tunnel and a heparin lock device for repeated non-traumatic sampling of blood and administration of medications. During the course of 10 months, 226 rabbits were studied. Mean duration of catheter placement was 27 days, 17 of which were spent in granulocytopenia. Two-way flow was sustained throughout the duration of placement in 205 rabbits (91%) and for 5,845 (95%) of a total 6,163 catheter-days. All but two catheters could be flushed throughout the duration of their placement. Postoperative infectious complications related to catheter insertion developed in less than 1% of the rabbits. This method of chronic catheterization safely provides long-term venous access for studies requiring frequent venous access, including the painless induction, maintenance, and support of chronic granulocytopenia in rabbits.     

Femoral Arterial and Venous Catheterization for Blood Sampling,Drug Administration and Conscious Blood Pressure and Heart Rate Measurements

In multiple fields of study, access to the circulatory system in laboratory studies is necessary. Pharmacological studies in rats using chronically implanted catheters permit a researcher to effectively and humanely administer substances, perform repeated blood sampling and assists in conscious direct measurements of blood pressure and heart rate. Once the catheter is implanted long-term sampling is possible. Patency and catheter life depends on multiple factors including the lock solution used, flushing regimen and catheter material. This video will demonstrate the methodology of femoral artery and venous catheterization of the rat. In addition the video will demonstrate the use of the femoral venous and arterial catheters for blood sampling, drug administration and use of the arterial catheter in taking measurements of blood pressure and heart rate in a conscious freely-moving rat. A tether and harness attached to a swivel system will allow the animal to be housed and have samples taken by the researcher with minimal disruption to the animal. To maintain patency of the catheter, careful daily maintenance of the catheter is required using lock solution (100 U/ml heparinized saline), machine-ground blunt tip syringe needles and the use of syringe filters to minimize potential contamination. With careful aseptic surgical techniques, proper catheter materials and careful catheter maintenance techniques, it is possible to sustain patent catheters and healthy animals for long periods of time (several weeks).     

彩色超声与盲探穿刺右颈内静脉并发症比较

目的比较彩色超声引导与盲探穿刺右侧颈内静脉置管术的并发症情况。方法将我院拟择期(在腹腔镜下)行结直肠肿瘤切除术的患者100例,ASA分级Ⅰ~Ⅲ级,年龄23~81岁,体重32~81kg。采用抛硬币法将患者随机分为彩色超声组(C)和盲探穿刺组(M)各50例。记录两组病人黑色细针试穿中静脉时次数、薄壁蓝空针穿刺中静脉时次数、穿刺点的数目、导管置入失败的次数,并记录病人由于穿刺引起的机械并发症及术后留置导管并发症情况。结果两组患者均未见明显机械并发症,且两组比较无统计学意义;两组无误穿动脉、血气胸及心律失常或心脏损伤的情况。结论彩色超声引导下行右颈内静脉穿刺成功率较盲探穿刺高,盲探穿刺刺破颈内静脉后壁概率较彩色多普勒超声引导下穿刺组高,其余机械并发症及留置中心静脉导管并发症比较无统计学意义。     

The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or subclavian veins is performed with a micro-convex ultrasound probe, using a neonatal abdominal preset with a probe frequency of 10 Mhz at a depth of 10-12 cm. Following insertion of the guidewire into the vein, the probe is shifted to the right supraclavicular fossa to obtain a view of the superior vena cava (SVC), right pulmonary artery and ascending aorta. Under real-time ultrasound view, the guidewire and its J-tip is visualized and pushed forward to the lower SVC. Insertion depth is read from guidewire marks using central venous catheter. CVC is then inserted following skin and venous dilation. The supraclavicular fossa view is most suitable for right IJV CVC insertion. If other insertion sites are chosen the right supraclavicular fossa should be within the sterile field. Scanning of the IJVs, brachiocephalic veins and SVC can reveal significant thrombosis before venipuncture. Misplaced CVCs can be corrected with a change over guidewire technique under real-time ultrasound guidance. In conjunction with a diagnostic lung ultrasound scan, this technique has a potential to replace chest radiograph for confirmation of CVC tip position and exclusion of pneumothorax. Moreover, this view is of advantage in patients with a non-p-wave cardiac rhythm were an intra-cardiac electrocardiography (ECG) is not feasible for CVC tip position confirmation. Limitations of the method are lack of availability of a micro-convex probe and the need for training.     

A Retrospective Study of Preferable Alternative Route to Right Internal Jugular Vein for Placing Tunneled Dialysis Catheters: Right External Jugular Vein versus Left Internal Jugular Vein

Background

Right internal jugular vein (IJV) is a preferred access route for tunneled (cuffed) dialysis catheters (TDCs), and both right external jugular vein (EJV) and left IJV are alternative routes for patients in case the right IJV isn’t available for TDC placement. This retrospective study aimed to determine if a disparity exists between the two alternative routes in hemodialysis patients in terms of outcomes of TDCs.

Methods

49 hemodialysis patients who required TDCs through right EJV (n = 21) or left IJV (n = 28) as long-term vascular access were included in this study. The primary end point was cumulative catheter patency. Secondary end points include primary catheter patency, proportion of patients that never required urokinase and incidence of catheter-related bloodstream infections (CRBSI).

Results

A total of 20,870 catheter-days were evaluated and the median was 384 (interquartile range, 262–605) catheter-days. Fewer catheters were removed in the right EJV group than in the left IJV group (P = 0.007). Mean cumulative catheter patency was higher in the right EJV group compared with the left IJV group (P = 0.031). There was no significant difference between the two groups in the incidence of CRBSI, primary catheter patency or proportion of patients that never required urokinase use. Total indwell time of antecedent catheters was identified as an independent risk factor for cumulative catheter patency by Cox regression hazards test with an HR of 2.212 (95% CI, 1.363–3.588; p = 0.001).

Conclusions

Right EJV might be superior to left IJV as an alternative insertion route for TDC placement in hemodialysis patients whose right IJVs are unavailable.     

Internal Jugular/Subclavian Venous Access In Electrophysiology Study And Ablation

Multiple venous accesses are required for catheter placement during electrophysiology study and ablation. Internal jugular/subclavian venous access, though restricted nowadays, can be important in difficult situations.     

Ethanol Causes Protein Precipitation—New Safety Issues for Catheter Locking Techniques

Objective

The ethanol lock technique has shown great potential to eradicate organisms in biofilms and to treat or prevent central venous catheter related infections. Following instillation of ethanol lock solution, however, the inherent density gradient between blood and ethanol causes gravity induced seepage of ethanol out of the catheter and blood influx into the catheter. Plasma proteins so are exposed to highly concentrated ethanol, which is a classic agent for protein precipitation. We aimed to investigate the precipitating effect of ethanol locks on plasma proteins as a possible cause for reported catheter occlusions.

Methods

Plasma samples were exposed in-vitro to ethanol (concentrations ranging from 7 to 70 v/v%) and heparin lock solutions. In catheter studies designed to mimic different in-vivo situations, the catheter tip was placed in a plasma reservoir and the material contained within the catheter was analyzed after ethanol lock instillation. The samples underwent standardized investigation for protein precipitation.

Results

Protein precipitation was observed in plasma samples containing ethanol solutions above a concentration of 28%, as well as in material retrieved from vertically positioned femoral catheters and jugular (subclavian) catheters simulating recumbent or head down tilt body positions. Precipitates could not be re-dissolved by dilution with plasma, urokinase or alteplase. Plasma samples containing heparin lock solutions showed no signs of precipitation.

Conclusions

Our in-vitro results demonstrate that ethanol locks may be associated with plasma protein precipitation in central venous catheters. This phenomenon could be related to occlusion of vascular access devices locked with ethanol, as has been reported. Concerns should be raised regarding possible complications upon injection or spontaneous gravity induced leakage of such irreversibly precipitated protein particles into the systemic circulation. We suggest limiting the maximum advisable concentration of ethanol to 28 v/v% in catheter lock solutions.     

Rhodococcus bacteremia in cancer patients is mostly catheter related and associated with biofilm formation

Rhodococcus is an emerging cause of opportunistic infection in immunocompromised patients, most commonly causing cavitary pneumonia. It has rarely been reported as a cause of isolated bacteremia. However, the relationship between bacteremia and central venous catheter is unknown. Between 2002 and 2010, the characteristics and outcomes of seventeen cancer patients with Rhodococcus bacteremia and indwelling central venous catheters were evaluated. Rhodococcus bacteremias were for the most part (94%) central line-associated bloodstream infection (CLABSI). Most of the bacteremia isolates were Rhodococcus equi (82%). Rhodococcus isolates formed heavy microbial biofilm on the surface of polyurethane catheters, which was reduced completely or partially by antimicrobial lock solution. All CLABSI patients had successful response to catheter removal and antimicrobial therapy. Rhodococcus species should be added to the list of biofilm forming organisms in immunocompromised hosts and most of the Rhodococcus bacteremias in cancer patients are central line associated.     

Simultaneous sampling of portal, hepatic and systemic blood during intragastric loading and tracer infusion in conscious pigs

A surgical model for catheterization at multiple sites has been developed for use in long-term metabolic studies. For blood sampling, catheters were inserted into the portal and hepatic veins and the common carotid artery. The hepatic vein catheter was inserted from the margin of a liver lobe and led through the venous system, until the tip was close to the bifurcation with the inferior vena cava. A new technique was developed to ensure correct placement of the hepatic vein catheter using the specific extraction of indocyanin-green over the liver during surgery. Gastrostomy was performed using a Pezzer catheter. Catheters in the artery and hepatic and portal veins were patent for blood withdrawal for up to 4 weeks, and thus allowed repeated metabolic studies. Studies were performed in conscious animals familiar with the experimental situation.     

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

Background

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

Methods

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

Results

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11–45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

Interpretation

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%–50%).Most data available in the adult and pediatric literature on the incidence of deep vein thrombosis concern centrally inserted venous catheters, which are inserted directly in a central vein (jugular, subclavian or femoral). Typical symptoms of deep vein thrombosis are frequently absent in children and adolescents. Although the diagnosis of deep vein thrombosis is more reliable when based on Doppler ultrasonography or venous angiography,^1–10 in most studies these diagnostic tests were performed only when patients presented clinical symptoms of deep vein thrombosis or catheter dysfunction. In studies focused on the pediatric population, the frequency of deep vein thrombosis related to centrally inserted venous catheters has varied from 11% to 50%.^1,5,6,8,11In the past 10 years, peripherally inserted central catheters (PICC) have been used with increasing frequency in children and adolescents. The catheter is inserted percutaneously via a peripheral vein, with its tip residing in the superior vena cava. The main indications for this type of catheter insertion are difficult venous access, home intravenous antibiotic therapy, administration of chemotherapy or other hyperosmolar solution and long-term parenteral nutrition. The risk of deep vein thrombosis related to peripherally inserted central catheters could be greater among children and adolescents than among adults, given the size of the veins. Several studies have published complications related to peripherally inserted central catheters,^12–20 but few focused on the pediatric population.^13–21 Furthermore, in all of these studies, screening for deep vein thrombosis was not systematic. The real incidence of deep vein thrombosis related to peripherally inserted central catheters and their complications in the pediatric population are therefore unknown. We conducted this study to determine the incidence and characterize the risk factors of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents in our institution.     

The analysis of glucose kinetics using a single jugular catheter in awake rats

The rates of glucose production and utilization can be estimated by a primed-constant infusion technique using separate catheters for the infusion of radiolabelled glucose and periodic blood withdrawal. In rats, a carotid artery catheter is most often combined with a jugular or femoral venous catheter in such studies. We presently describe a method which utilizes a single jugular catheter for both infusion and sampling in the awake rat. This method is directly compared with simultaneous carotid artery sampling during both the dynamic steady state and a nonsteady state induced by a constant infusion of insulin. Our results demonstrate the validity of a single vein design for the analysis of glucose kinetics in either state. Rapid sampling and complete flushing prevent disruption of infusate equilibrium and sample contamination respectively. This single catheter method requires less technical skill for placement, reduces surgical intervention and enhances the comfort of the awake rat.     

In vivo quantitative assessment of catheter patency in rats

Formation of fibrin sleeves around catheter tips is a central factor in catheter failure during chronic implantation, and such tissue growth can occur despite administration of anticoagulants. We developed a novel method for monitoring catheter patency. This method recognizes the progressive nature of catheter occlusion, and tracks this process over time through measurement of changes in catheter resistance to a standardized 1 mL bolus infusion from a pressurized reservoir. Two indirect measures of catheter patency were used: (a) reservoir residual pressure and (b) reservoir discharge time. This method was applied to the study of catheter patency in rats comparing the effect of catheter material (silastic, polyurethane, Microrenathanetrade mark), lock solution (heparin, heparin/dexamethasone) and two different cannulation sites (superior vena cava via the external jugular vein, inferior vena cava via the femoral vein). Our findings reveal that application of flexible smaller-size silastic catheters and a dexamethasone lock solution resulted in prolonged catheter patency. Patency could be maintained over nine weeks with the femoral vein catheters, compared with five weeks with the external jugular vein catheters. The current method for measuring catheter patency provides a useful index for the assessment of tissue growth around the catheter tip. The method also provides an objective and quantitative way of comparing changes in catheter patency for different surgical methods and catheter types. Our method improves on the conventional method of assessing catheter occlusion by judging the ability to aspirate from the catheter.     

Mini-review: Antimicrobial central venous catheters--recent advances and strategies

Central venous catheters (CVCs) nowadays constitute critical devices used in medical care, namely in intensive care units. However, CVCs also represent one of the indwelling medical devices with enhanced risk of nosocomial device-related infection. Catheter-related infections (CRIs) are a major cause of patient morbidity and mortality, often justifying premature catheter removal and an increase in costs and use of resources. Adhesion and subsequent biofilm formation on the surfaces of indwelling catheters is elemental to the onset of pathogenesis. Seeking the prevention of CVC colonisation and CRI, a variety of approaches have been studied, tested and, in some cases, already applied in clinical practice. This review looks at the current preventive strategies often used to decrease the risk of CRIs due to colonization and biofilm formation on catheter surfaces, as well as at the more recent approaches under investigation.