Leeds General Infirmary, Leeds, UK
*Corresponding author. Department of Anaesthesia, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. E-mail: andy.bodenham{at}leedsth.nhs.uk
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Abstract |
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Keywords: complications, central venous catheterization; equipment, venous access device
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Introduction |
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Anaesthetists will encounter long-term venous access devices already in situ in day-to-day practice. In addition, there is an increasing practice whereby anaesthetists are directly involved in the insertion and removal of such devices. Despite the apparent similarity between short- and long-term access devices, there are important differences in design, usage and patterns of complication that are relatively specific to longer-term venous access. This review will assume a working knowledge of short-term catheterization and highlight these differences.
We will confine the review to venous access devices and not comment on surgically created arteriovenous fistulae and other implanted devices, e.g. for access to the portal vein, CSF, epidural space, pleural or peritoneal cavity. This review relates mainly to adult practice, but much of it applies to patients of all ages, including the smaller child.
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Definition |
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Indications
The indications for long-term venous access are widening and are summarized in Table 1. The aim is to use a biocompatible catheter in a large vein, which allows adequate dilution of infused products; reduced pain on injection; delay in the development of thrombosis; and free aspiration of blood.
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Types of catheter |
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Broviac catheters
This was the original design from which the Hickman catheter was a modification.16 The major difference between the two is the internal (lumen) diameter. This was 1.6 mm for the original Hickman catheter (as opposed to 1.0 mm for a Broviac catheter)13 in order to facilitate repeated blood sampling. The main features are covered in the discussion of Hickman catheters.
Groshong catheters
These are made of PVC and are available in different, fixed lengths. The tip of Hickman and Broviac catheters are open ended; catheters are cut to the desired length. In contrast, Groshong catheters have a formed blunt end with a slit-like orifice just proximal to the distal end (Fig. 1). This acts as a valve with the following functions: it stops back-bleeding; it prevents air entry and embolism from negative intrathoracic pressure; and it obviates the need for a heparin lock as saline can be used instead. External clamping of the catheter is not required, which will reduce long-term catheter damage. A pressure difference must be generated by either suction or positive pressure to open the distal valvular slit. The valve function is able to withstand intravascular pressures between 7 and +80 mm Hg. This valve requires pressurized infusion systems, which may prove an inconvenience when using blood products. Another disadvantage of these devices is their increased cost, but this may be balanced by the decreased cost of saline flushes compared with heparin. This valve technology is now also available in the hub of catheters, on implantable ports, peripherally inserted catheters and short-term catheters.47
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Dialysis catheters
There are a number of long-term dual-lumen dialysis catheters with or without anchoring cuffs. These are typically inserted via the right internal jugular vein. The subclavian vein is generally avoided to prevent subclavian vein thrombosis or narrowing, which interferes with subsequent arteriovenous fistula formation in that arm. In addition, there are developments in dual-lumen port- type devices for accessing central veins for intermittent haemodialysis. These require passage of large-bore dialysis needles and have not entered mainstream practice in the UK, but have been tested and found to have adequate flow rates.59
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How long can catheters and ports function? |
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Materials |
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Chemical composition has an impact on thrombogenicity. Older materials such as polyethylene are more thrombogenic than newer polymers like polyurethane. Attempts to reduce thrombogenicity with anticoagulant coatings have been largely unsuccessful. However, coating catheters with Hydromer (polyvinylpyrrolidone a hydrophilic substance), forms a barrier between the catheter material and the blood, to inhibit coagulation.
The material of choice for long-term venous access is silicone elastomer,48 despite the possible difficulty of insertion. The alternative material of choice would be Hydromer-coated polyurethane. Different materials have a different risk of catheter-related sepsis. Teflon, silicone elastomer and polyurethane have much lower risk than more traditional polyvinyl-type catheters,93 and of these, silicone has been shown to have the lowest rate of infection when inserted peripherally.61 Theoretical work suggests that materials differ in their susceptibility to microbial adherence and colonization, but there is little evidence of this in vivo and no evidence of an effect on long-term catheter-related sepsis.96
Attempts to reduce the risk of catheter-related sepsis have included addition of antiseptic or antibiotic compounds. Chlorhexidine or silver sulphadiazine coatings have been studied repeatedly and often shown to reduce the risk of catheter colonization by between 1.5 and eight times.65 78 97 However, only one study has shown a clinically relevant decrease in catheter-related sepsis, from 4.6 to 1.4%,65 although most authors suggest that the effect on catheter-related bacteraemia and mortality is negligible.45 78 There have been reports of anaphylaxis to the chlorhexidine coating.95
Studies of minocycline and rifampicin coatings have shown lower rates of infection than for antiseptic impregnated catheters.23 85 The rate of colonization decreased from 22.826 to 7.98%. More importantly, the rate of catheter-related sepsis fell from 3.45 to 00.3%. It must be stated that none of these catheters was in place for longer than 14 days, and there is no evidence of any long-term effects. The disadvantage of these catheters, in addition to the two- or three-fold increase in price, is the potential risk of increased antibiotic resistance. This has not been systematically studied,78 and there is a lack of evidence. Further surveillance will be required in the event that use of such catheters becomes more widespread. Developments in technology have allowed impregnation of catheter materials themselves rather than surface coating, which tends to leach away.78 The cost of treating catheter-related sepsis is such that the saving made by the introduction of antibiotic-coated catheters would be of the order of $100 million in the USA, with 700012 000 deaths prevented.78 However, to date no long-term devices have been marketed with such coatings or impregnation.
Silver-impregnated exit site cuffs have been shown to reduce colonization in short-term non-tunnelled catheters64 but not in longer-term catheterization (>20 days).41
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Insertion techniques |
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Patients requiring long-term venous access may well be challenging because of several previously successful or failed venous access procedures, underlying medical problems, and anticoagulation. Specialized imaging and radiological intervention may be required (Figs 3 and 4). The usefulness of ultrasound-guided vein access in this setting has been highlighted.44 Recent NICE (www.nice.org.uk) guidelines on this topic support the routine use of this technology for the internal jugular route, but there is insufficient evidence to make recommendations on other sites of access. However, there is no reason why ultrasound should not give similar advantages in infraclavicular axillary38 or femoral access. Nevertheless, there has been considerable criticism of the NICE guidelines.72 94
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Most studies have been on uncomplicated patients, often under general anaesthesia.
Patients requiring long-term venous access are likely to have increased frequency of vein blockage or thrombosis and anticoagulation, making ultrasound guidance advantageous in this group. Observational studies with ultrasound have shown significant numbers of underlying vascular abnormalities in such patients, with obvious relevance to subsequent venous access. An alternative site is often required.34 44
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A typical insertion sequence |
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A splitting sheath is passed over an introducing dilator into a central vein. The dilators and sheath are stiff and generally longer than required.76 There is a risk of vessel perforation; however, there is no need to insert the dilator or sheath to its full length. The length of needle that is required to puncture the vein gives a guide to the amount of dilator (and splitting sheath) that should be inserted. The dilator and sheath entering the vein is accompanied by a sudden give.
The catheter is then passed through the splitting sheath, which is withdrawn and peeled apart. Such sheaths often kink if passed around an angle in the vein and need to be withdrawn to allow the catheter to pass. The correct position of the intravascular catheter tip is adjusted under X-ray control. The internal segment of cuffed devices can be adjusted by pulling the cuff inwards or outwards along the tract.
Misplaced catheters or guidewires may enter or coil in the internal jugular vein, the innominate vein, the azygos vein or the internal mammary vein. Positioning can be facilitated by asking the patient to breathe in deeply, which straightens the great vessels as the heart and diaphragm descend on inspiration. Soft catheters can be stiffened by the use of a long (70 cm) guidewire of the type used by interventional radiologists, passed through the catheter, if the standard wire in the kits is too short (50 cm). In more difficult cases, the vascular anatomy and catheter position can be determined by injecting X-ray contrast through the catheter.
There is ongoing debate as to the optimum position for catheter tips, but most centres would leave the tip either in the lower superior vena cava or upper right atrium.32 There have been reports of cardiac tamponade resulting from atrial or ventricular perforation if the tip of the catheter lies within the pericardial sac. The pericardium may ascend along the medial wall of the superior vena cava up to a distance of 5 cm, giving a risk of cardiac perforation even if the catheter tip lies outside the atrium.91 The risk of this type of perforation is low and higher positioning leads to an increased risk of vein puncture, hydrothorax or mediastinal fluid,22 and thrombus formation.84
Catheter tips can change position on moving from lying to standing. Most insertions are done in a supine or head-down position. Subsequent X-rays show descent of the abdominal contents and diaphragm and a change in the catheter position relative to the mediastinal contents.74 This may lead to catheter malposition. It is revealing to screen the catheter tip position whilst the patient inspires deeply. Similarly, there is evidence that pendulous breast tissue may exert traction on the extra-thoracic portion of a tunnelled catheter, which will cause outward movement with the potential for extravasation.70
Catheters commonly fall out or migrate outwards unless adequately fixed in; we are even aware of one catheter accidentally pulled out by a patients dog. This fixation should include suturing of the external portion, using temporary wings, if they are included in the kit. At least 3 weeks is required for cuff fixation in healthy patients.
There is debate as to the value of a post-insertion chest X-ray after such an insertion sequence.39 This is very different from the standard for anaesthesia or intensive care, where post-procedural radiographs are usually mandatory. If the position of the catheter has been verified fluoroscopically, then the tip position is not in doubt and an additional X-ray will add little information.60 It must be remembered that there will be exceptions to this rule. For example, cases where excessive tip movement is expected because of pendulous breast tissue should be routinely X-rayed in the sitting position to ascertain final tip position. In our experience, the occurrence of a pneumothorax (which is rare in skilled hands) is often not detected on an early chest X-ray. Day-case patients go home to return with clinical signs later.
The intravascular portion of a port system is sited in the same fashion as other catheters, but the body of the port requires a percutaneous pocket to be created surgically. There are suture holes in the base of the port which are anchored to fascial layers with non-absorbable sutures. To avoid a large incision, these sutures should be placed first and the port slid down into the pocket. This technique, similar to that used by cardiac surgeons for the insertion of artificial valves, is known as the parachute technique (Fig. 2).
For safe, efficient practice, a sterile area such as the radiology suite or an operating theatre is required for insertions. Ready access to ultrasound and X-ray screening is required. We currently perform such procedures for oncology and other specialties both on an ad hoc basis in the emergency theatres, and also on a dedicated list. We can insert six Hickman catheters in a 3.5 h session as well as one or two removals. Almost all are performed under local anaesthesia and i.v. sedation, many as day cases. A service can be provided on an outpatient basis,1 with only a short period of observation. The organization of a service depends on the number of patients that are seen. A fully dedicated session would be likely to be impracticable for the throughput of a smaller district general hospital unless combined with other procedures.
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Sites of access |
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Removal techniques |
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Ports are removed by making an incision into the dense fibrous sac which forms round the port in the longer term. There are typically four small anchoring sutures attaching the port through holes to deeper tissues. These will need to be cut for removal. The same conditions regarding the risk of catheter damage and embolization apply as to other catheters.
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Training and accreditation |
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Many different specialties have experience in such techniques. Procedures are done by radiologists, anaesthetists, surgeons, renal physicians, cardiologists, oncologists and oncology nurses. There is no evidence to suggest one specialty is better than another in respect of complications. What is more important is to have appropriately trained, skilled operators who do adequate numbers of these procedures to develop and retain their skills. Ideally, one requires skills in local anaesthesia, i.v. sedation, central venous access, use of ultrasound for venous access, X-ray screening, and the management of complications such as bleeding, pneumothorax and arrhythmias.
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Complications related to long-term access |
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Blockage of major veins may occur as a result of thrombosis or ongoing scarring of the vein. This may lead to local problems, e.g. swelling of the arm from axillary thrombosis. Central blockage of the superior vena cava (SVC) or inferior vena cava may lead to more serious problems. There are cases in the literature of acute airway obstruction secondary to SVC obstruction, as a result of subclavian Hickman catheter insertion.77 In the presence of long-term venous thrombosis and obstruction, venous collaterals open up to bypass such blockages. These may or may not be visible superficially (Fig. 3A); if they are then attending, staff should be aware of the likelihood of underlying major vessel obstruction (Fig. 3B), with obvious implications for venous access. Innocuous-looking scars from previous access may herald such problems. It is debatable whether it is a good idea to pass catheters through such a narrowing. Even if this is technically possible, the presence of yet another catheter may produce complete blockage. Such stenoses may be dilated by balloon angioplasty or stenting (Fig. 4A and B).
The issue of whether to remove the catheter in the presence of vessel thrombosis, if it still functions, has yet to be resolved. Although removal of the catheter seems intuitive, there are reports of successful treatment using anticoagulation or thrombolysis with the catheter left in situ.35 71
Heparin-bonded coatings have been tried to attempt to delay catheter thrombosis, but are not widely used for longer-term catheters and their effectiveness has never been established. Many centres administer low-dose warfarin. A typical regime is a 10 mg loading dose and 1 mg daily thereafter. This has been shown to reduce the incidence of venous thrombosis from 37.5 to 9.5%. However, these small doses of warfarin may produce significant anticoagulation in susceptible patients with complications.10 Low molecular weight heparin at a dose of 2500 IU per day has been shown to reduce the incidence of venous thrombosis from 62 to 6%, but with an incidence of significant haemorrhage of 6%.69 88 Unfractionated heparins have been used similarly, in doses of 5000 units twice or four times daily, or 3 U per ml of parenteral nutrition.88 99 There are few controlled trials to support such interventions and certainly not enough to distinguish which method should be recommended.
Catheter lumen blockage
Another aspect of catheter thrombosis is intraluminal thrombosis. This can usually be prevented by a heparin lock. Catheters are flushed with heparinized saline after use, or weekly. Various solutions and strategies have been used to aid unblocking of catheters. These include heparin, urokinase, streptokinase,49 streptodornase and recombinant tissue plasminogen activator (rTPA).7 Urokinase (a fibrinolytic drug) has been used with some success; typical doses would be 500010 000 U injected slowly,8 or a low-dose infusion.42 If the catheter is completely blocked, two techniques can be used to put the drug into the lumen. First, aspiration of air from the lumen using a small-volume syringe to create a vacuum, followed by connection to a syringe containing the fibrinolytic agent. Alternatively, simply connecting the syringe to the catheter and leaving for several hours will allow the enzyme to diffuse into the lumen and break down the thrombus. Trials with recombinant urokinase are currently under way, which look promising. These drugs should be used with caution, as they may lead to bleeding complications.
Catheter-related infection
The Department of Health, in its guidelines on catheter-related infection, suggests that tunnelled catheters should be used for patients likely to need vascular access for more than 30 days.6 27 Infection is a major problem with long-term venous access, with reported rates between 3 and 60%.40 43 92 These infections can be divided into three main groups, which may coexist: exit site infection; tunnel or pocket infection; and catheter sepsis or catheter-related bacteraemia. This is a complex area and readers are referred to other reviews for more information.27 31 48 82
Exit site infections
These are localized to the point at which a device exits through the skin. Most infections are due to Staphylococcus epidermidis.56 83 Frequently, these can be managed with local wound care and antibiotics without resorting to catheter removal. However, if there is evidence of bacteraemia or a more virulent pathogen such as Staphylococcus aureus, such treatment will not be adequate.
Tunnel or pocket infection
This represents a process of suppuration or induration related to the subcutaneous tunnel (or pocket in the case of ports). Because of the presence of suppuration and a foreign body, these infections usually require the removal of the catheter as well as the use of antibiotics.
Catheter-related bacteraemia
This is the most serious type of infection. This occurs with 733% of catheters.21 90 The larger value relates to patients receiving parenteral nutrition. The mortality is estimated at between 14 and 24%.80 The usual presentation is a bacteraemia with no other obvious source of sepsis. This may be secondary to chronic colonization of the intravascular portion of the catheter from the exit site or external portions of the catheter. There is a strong correlation between thrombus formation and infection. The thrombus probably serves as a culture medium for bacteria. It is likely that any additional vessel wall damage (associated with traumatic insertion, for example), will predispose to infection. It has been shown that flushing the catheter with heparin,88 use of oral anticoagulants10 and the use of low molecular weight heparin69 are associated with a reduction in rates of catheter-related infection. This only applies if the intervention is given before any thrombus has formed. Administration after thrombus formation may lead to septic emboli breaking off from the clot.
Correct diagnosis is important in order to avoid premature or unnecessary catheter removal. Successful treatment of catheter-related sepsis has been reported with the catheter left in situ.15 43 However, this is dependant on the pathogen. Staphylococcus aureus bacteraemia and candidaemia have not been amenable to treatment without catheter removal.24 29 30 This is because of the high rates of failure and also the risk of complications, including endocarditis. With the exception of these two situations, the decision regarding removal should be individualized and made according to the patients response to antibiotics. Other factors, such as the potential ease of reinsertion, the fitness to undergo another procedure and the immediacy of need, should be considered.
Diagnosis of infection
This has been performed in a number of ways. Clinically, it should be suspected in any patient with features of sepsis, no obvious cause and a central venous catheter in situ. Patients will often develop rigors and a pyrexia on flushing or using the catheter. The roll plate method66 has for many years been the standard diagnostic test, and involves rolling the tip of the catheter on a culture plate. This only cultures organisms from the outside of the catheter and requires removal of the catheter. An alternative technique is the semiquantitative Cleri technique, which involves flushing the lumen of a catheter with a nutrient broth. This liquid is then cultured and colony-forming units are counted after a few days.19 Sampling of blood through the catheter before it is removed can be used in the diagnostic process. Differences in time to positive blood cultures and colony counts collected through the catheter compared with similar-volume peripheral blood samples suggest likely catheter-related sepsis.14 33 Alternatively, a small brush can be used to sample endoluminal organisms, without removal of the catheter.55 There is, however, concern about bacterial embolization from this procedure, and results of this technique in an intensive care setting did not support its routine use.63
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When should such devices be used in anaesthesia and intensive care? |
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Provided adequate aseptic precautions are used when connecting such infusions, there should be minimal additional risk to the patient. The risk of any contamination of long-term access devices needs to be weighed against their suitability for the particular indication and the risk of difficulty in establishing alternative access. It should be noted that any patient who has had multiple long-term venous access devices may well have thrombosed central veins, with the potential to make further access difficult and dangerous (Figs 3 and 4). We have used such devices, often for prolonged periods, on the intensive care unit without serious sequelae.
Indwelling ports are probably less suited to use for a long period of anaesthesia or intensive care. This is because of the small diameter of the access needle limiting infusion rates and the risk that the needle may slip out. The technique for accessing the ports is simple. The area can be prepared in advance with anaesthetic cream or may have been denervated during surgical formation. When ready for access, the site is cleaned and the skin either side of the port is grasped firmly between two gloved fingers. The Huber needle is pushed through the skin and thick port membrane, which requires considerable force. There will be a palpable clunk as the needle hits the back wall of the device. Aspiration of blood confirms that the needle is in place and the port is working, and injection may then proceed.
Hickman and Broviac catheters simply require flushing before use. With Groshong catheters it is important to note that pressure is required to inject and aspirate through the catheter. Groshong lines cannot be used to monitor central venous pressure because of the valve function. It is also likely that, at low flow rates, the valve may produce intermittent boluses of fluid or drug, which may make these catheters inappropriate to use for inotropes or vasopressor infusions.
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Summary |
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References |
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