Transcript Tunneled Cuffed Catheters

Tunneled Cuffed
Catheters
Hemodialysis access
The number of patients with end-stage
renal disease (ESRD) has increased
steadily
The creation and maintenance of
functioning vascular access, along with the
associated complications, constitute the
most common cause of morbidity,
hospitalization, and cost in patients with
end-stage renal disease.
Vascular Access via Percutaneous
Catheters
useful method of
gaining immediate
access to the
circulation.
associated with
higher risks.
the use-life of this
type of access is
shorter than that of
AVFs.
Noncuffed catheters
Short term: <3 weeks
Vascular Access via Percutaneous
Catheters: cuffed catheters
Cuffed catheters
Patients who will require
long-term access should
have a tunneled catheter
placed.
allow so-called no-needle
dialysis with high flow
rates
eliminate the problem of
vascular steal
placed in a subcutaneous
tunnel under fluoroscopic
guidance
Vascular Access via Percutaneous
Catheters: cuffed catheters
The Dacron cuff allows tissue
ingrowth that helps reduce the risk
of infection when compared with
noncuffed catheters.
Hemodialysis access: complications
A chest radiograph must be taken after catheter
placement to rule out pneumothorax and injury to the
great vessels and to check for position of the catheter.
The incidence of pneumothorax is 1% to 4%,the
incidence of injury to the great vessels is less than 1%.
Thrombotic complications occur in 4% to 10% of patients
Infection may occur soon after placement (3 to 5 days)
or late in the life of the catheter and may be at the exit
site or the cause of catheter-related sepsis.
Rate of infection between 0.5 and 3.9 episodes per 1000
catheter-days.
Catheter thrombosis increases the incidence of catheter
sepsis.
PRESERVING CATHETER FUNCTION
CATHETER
ACCESS
TREATMENT
PLACEMENT
CARE
POSITIONING
Types of central lines
Open-ended tunneled catheters
Tunneled valved catheters
Implanted ports
Nontunneled central venous catheters
(CVCs)
Peripherally inserted central catheters
(PICCs)
Central Line Complications
Infections
Air embolus
Dislodgement of catheter
Catheter occlusion
Central Line Flow Control
Volume in ML x Drop factor DEVIDED
BY no. of hours to be infused x 60
Drop factors are 15 drops / cc OR 60
drops / cc
ADVANTAGES OF
CENTRAL VENOUS ACCESS
1. Immediate access
2. High flow and dilution of hyper tonic
solutions
3. Easy access
4. Permits outpatient care
DISADVANTAGES OF CENTRAL
VENOUS ACCESS
More invasive - potentially more
complications and pain
Acute
Chronic
CENTRAL VENOUS ACCESS:
INDICATIONS
1. Long term IV therapy:
Chemo
Antibiotics
TPN
Blood products
2. Recurrent blood draws
3. Dialysis/Pharesis
CONTRAINDICATIONS
1. Sepsis
2. Coagulopathy
TYPES OF
CENTRAL VENOUS ACCESS
1. Non tunneled external catheters
a. Central line
b. PICC line
2. Tunneled catheters
3. Subcutaneous Ports
a. chest
b. arm
CHOOSING THE ACCESS DEVICE
Patients disease and status
Number and type of solutions,
osmolality
Flow required
Frequency accessed
Duration of use- days vs months
Preferences - Dr. / Patient
NUMBER AND
COMPATIBILITY OF
INFUSATES
Determine true number of lumens
that are required based on the
number of infusates when they are
given and if they are compatible
FLOW
Internal Diameter (ID) vs Outer Diameter (OD)
The outer diameter is not always directly
proportional to flow. Some catheters are just thick
walled and although large yield slow flow. For
high flow - check the ID. Remember, larger
catheters cause more irritation potentiating
stenosis and thrombosis.
DURATION
> 7 days - PICC Line
1- 12 Weeks - PICC line / tunneled catheter
12 weeks - 6 months or greater - tunneled
catheter
> 6 months - Port
FREQUENCY
OF
ACCESS
Frequent access and infusion - tunneled
catheter
Infrequent access (every week or month)-port
MATERIAL
Silastic
thicker, softer, larger for same flow, more
friction over a wire
Polyurethane
stiffer, thinner wall, smaller for same flow, less
friction
PREFERENCES
Patient:
Some patients may prefer a port for
aesthetics, no restrictions on activities
Operator:
If the operator can’t place a port
choose an alternative!!!!!!!
NON-TUNNELED EXTERNAL CATHETERS
TUNNELED CATHETERS
1. Single or multiple lumens
2. Flow - variable
3. Long term
4. Easy access (no skin puncture)
5. Cuff - Dacron, vita
Tunneled catheter with cuffs
Tunneled catheter with cuff
Tunneled catheter
SITES OF ACCESS
1. Upper extremity
2. Subclavian and Internal Jugular Vein
3. Collaterals and Thrombosed veins
4. IVC – trans hepatic, trans lumbar
5. Hepatic vein
6. Intercostal veins
LOWER EXTREMITY
Most commonly femoral vein
Easily contaminated from proximity to
groin
Complication of DVT less tolerated
than upper extremity
SUBCLAVIAN VEIN
ACUTE
Senagore - 10% incidence of art. Puncture
Mansfield - 12.2% unsuccessful access
CHRONIC
Cimchowski - 50% stenosis SCV, 10% IJV
Shillinger - 42% stenosis SCV, 10% IJV
Uldall - 10-30% thrombosis, 10-40%
stenosis
SUBCLAVIAN VEIN
COMPLICATIONS
PINCH-OFF
SYNDROME
THROMBOSIS
STENOSIS
Subclavian vein (SCV) access is prone to more complications than
internal jugular vein (IJV)
ADVANTAGES OF THE
RIGHT IJ
1. Larger
2. More superficial
3. Further from the lung
4. More direct route to the heart
5. Acute and chronic complications are
reduced
CENTRAL VENOUS
CATHETER PLACEMENT
1. Prep
2. Access
3. +/- Tunnel
4. Secure
PREP
Alcohol scrub to remove surface oils
Chlorhexidine scrub
Betadine prep (allow to dry)
Ioban dressing and drapes
PREP
Maximum Sterile Barrier Surgical hats, gowns, masks & gloves
3 - 5 min. surgical scrub
Antibiotics (controversial) 30-60 min. prior
Cefazolin (Kefzol, Ancef) 1 gm IV or
Gentamycin 80 mg IV
ACCESS
Ultrasound (US) or venography to localize
vein
Micropuncture technique
21 ga needle
.018” wire
Dilate to appropriate size for peel
away sheath
TUNNEL
Some evidence suggests it should exceed
6 cm for best results
Tunnel using sharp or blunt device
Avoid bleeding !!!!!!
Position and place through peel away
SECURE
A small exit site should retain cuff
If using suture, place 2-3cm away from
exit site to reduce potential for infection
DO NOT secure suture too tightly around
catheter
COMPLICATIONS
1. Acute
Procedural
2. Sub-acute
Infection
3. Chronic
Infection
Catheter fragmentation
Non-function
COMPLICATIONS:
ACUTE
1. SPASM
4. PNEUMOTHORAX
2. ACCESS FAILURE
5. MALPOSITION
3. ARTERIAL PUNCTURE
6. AIR EMBOLUS
PREVENTING ACUTE
COMPLICATIONS
1. Micropuncture - 21ga needle, .018”wire
2. Imaging - US, Fluoro, Contrast, CO2
3. Right Internal Jugular vein approach
4. Tilting table, Valsalva, Pinch Sheath
AIR EMBOLUS: SYMPTOMS
1. Respiratory distress
2. Increased heart rate
3. Cyanosis
4. Poor pulse
5. Change in the level of
consciousness
AIR EMBOLUS: TREATMENT
1. Left lateral decubitus (Durant’s)
Position
2 100% O2
3. Vasopressin if necessary
4. Chest compression
5. Aspiration through catheter +/Mortality decreases from 90% to
30% with conventional treatment
COMPLICATIONS:
CHRONIC
1. Infection
2. Catheter
fragmentation
3. Non-function
PREVENTING INFECTION
1. Sterile environment
2. Periprocedural antibiotics
3. Number of lumen incidence of
infection
4. Prep
5. Skin fixation
6. Dry dressing vs. Occlusive dressing
7. Ointments - Iodophor vs antibiotic
8. Special instructions
TYPES OF INFECTION
EXIT SITE, TUNNEL/POCKET or
CATHETER
1. Cutaneous - pain, erythema, swelling,
+/- exudate
2. Bacteremia - fever, leukocytosis and
positive blood cultures
3. Septic thrombophlebitis - bacteremia,
thrombosis and purulent discharge
INFECTION
CAUSATIVE ORGANISMS
Staph epidermidis
25-50%
Staph aureus
25%
Candida
5-10%
INFECTION:
CATHETER REMOVAL
1. Exit site - 15.4%
2. Tunnel - 69%
3. Septic thrombophlebitis - 100%
INFECTION
1. Septic thrombophlebitis - remove catheter
2. Cutaneous - local treatment
3. Bacteremia 1. IV antibiotics 48 -72 hours
if improved - keep catheter
if no change, worse or recurs
remove catheter
or
2. Exchange catheter over wire,
85% cure with treatment
INFECTION
Continue to treat infection for 10 - 14
days
If ineffective - try locking with
thrombolytics between antibiotic
doses and administer antibiotics
through catheters
INFECTION:
CATHETER REPLACEMENT
1. Afebrile
2. Negative blood culture
CATHETER FRAGMENTATION
1. Power injection - > 2 cc/sec
2. Port injection - 10 cc syringe or greater
3. Catheter withdrawal
4. Pinch Off Syndrome
NON - FUNCTION:
CATHETER MALPOSITION
1.Intravascular vs. Extravascular
2. Infuses but doesn’t aspirate
3. Check the CXR
CORRECTING
MALPOSITION
1. Imaging guidance
2. Redirecting
catheters
THANK YOU !