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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonyms: skin-tunnelled central venous catheter
These devices allow venous access for a period of months or even years, allowing infusions and withdrawal of venous samples. They are usually inserted into major veins with a section tunnelled under the skin. Such devices are often inserted with the aid of radiological guidance. Peripheral devices are also used which gain access to the major veins from a distal insertion point, usually in the antecubital fossa. Catheters may be made of polyurethane or silicone and can have 1, 2 or 3 lumens.
Types of long-term venous access devices
- The catheter is placed such that its tip lies within the right atrium, the superior vena cava (SVC) or at the junction between them.
- It is most often placed via the subclavian vein, as it is nearest to the SVC; however, the right internal jugular vein is a straighter route with less risk of damage to the carotid artery and vagus nerve.
- The cephalic or external jugular veins may also be used.
- The line has a section tunnelled subcutaneously to separate the venous entry site from the external environment and potential infecting micro-organisms.
- A cuff helps to anchor the line in situ and subcutaneous tissue grows around it to help make the line less prone to displacement.
- A Hickman® catheter cuff should be placed not less than 5 cm from the point of entry on the skin but other types of catheter are widely used, some with cuffs much further from the exit.
- Such lines usually need a cut-down procedure to remove them, usually under general anaesthesia, because of the need to use traction/surgical techniques to dissect out the embedded cuff.
- These lines may be used centrally as for a Hickman® catheter but can be inserted peripherally.
- They have a valve which closes off the lumen of the line from the blood.
- Infusion or aspiration of the line will open the pressure-sensitive valve.
Implantable venous access port (Portacath®, totally implantable venous access system (TIVAS) - subcutaneous port)
- This device is usually attached to a tunnelled central line and completely hidden under the skin.
- A thin rubber self-sealing disc with an underlying cavity allows a needle to be inserted through the skin and infusions to be given/blood samples to be withdrawn.
Peripherally inserted central catheter (PICC)
- These lines are inserted into a peripheral vein, usually the cephalic vein in the antecubital fossa and 'unwound' upwards into the subclavian vein/SVC.
- They are firmly secured with tape or sutures.
- They tend to be used for relatively short-term venous access (eg, a prolonged course of antibiotics) but can be used for periods of up to several months.
- Use of the Sherlock 3CG® tip confirmation system avoids the need for CXR to view placement and has been recommended by the National Institute for Health and Care Excellence (NICE).
Common indications for insertion
- Adminstration of a course of chemotherapy.
- Administration of long-term intravenous medications - eg, antibiotics.
- Administration of parenteral nutrition.
- Recurrent transfusion of blood products.
- Temporary venous access for haemodialysis before construction of surgical anatomical access.
- Drawing of multiple blood samples for disease/treatment monitoring.
Care of long-term indwelling venous catheters
- Patients may manage their lines themselves or with the help of carers/nursing staff.
- Patients with lines in situ should receive instructions on how to care for their lines and advice on complications and what to do if they experience problems.
- When assessing a patient with a line in situ, it's a good idea to ask to see any literature they have regarding it, to confirm initial indication and see if any support is available to manage complications, or appropriate place of referral to deal with problems.
- To prevent occlusion and thrombosis, such devices require regular flushing, usually with a heparinised saline solution.
- This is usually done on a daily- to alternate-day/twice-weekly basis.
- Patients (and healthcare professionals) should be aware that they shouldn't use force to flush an occluded catheter.
- Groshong® catheters require less frequent flushing (approximately weekly) and are purported to be cheaper to maintain and to occlude less frequently.
- However, comparative studies of use of Hickman® and Groshong® catheters in real-life clinical scenarios have shown little difference in occlusion or thrombosis rates or cost of maintenance.
- The venous access port and entry site should be kept scrupulously clean and the latter regularly checked for any signs of infection.
- Alcohol-impregnated wipes may be used to clean the exterior surfaces of the devices.
- When bathing and showering, the access ports are usually kept dry in plastic coverings.
Prevention of air entry into line
Non-valved lines must be kept clamped closed when not in use and care should be taken not to unclamp them until the port entry is sealed.
Avoidance of damage
Care must be taken not to cut lines with scissors, etc, whilst adjusting dressings, or to allow chemicals that may damage the line to come into contact with it.
Early complications (associated with insertion or immediate aftermath)
- There is a complication rate of around 4% of all procedures, with bruising and pain affecting about 8%.
- The rate of complications of insertion is significantly decreased by the use of radiological guidance.
- Potential early complications include:
- Arterial puncture
- Venous thrombosis
- Air embolism
- Catheter transection
- Catheter migration
- Guidewire entrapment
- Catheter occlusion may occur due to:
- Intraluminal thrombus.
- Fibrin sheath formation at the catheter tip.
- Malpositioning of the tip against a vessel wall.
- 'Pinch-off' of catheter between clavicle and first rib.
- Thrombosis within the vessel in which the line is located.
- Thrombosis rate is approximately 3%.However, asymptomatic thrombosis rate is probably significantly higher. Thrombolytic agents may be used to remove clots.
- Infection occurs in about 4 %.This should be treated with systemic antibiotics and/or removal of the device, according to clinical condition and local procedures/guidelines. Efforts have been made to try to distinguish the risk of infection with the various different types of catheters.[7, 8]Having dedicated line management teams for inpatients may be helpful.
- The following may be used to treat colonisation/infection of long-term indwelling central venous catheters:
- Intraluminal antibiotic solutions.
- Antifungal agents.
- Ethanol/water mixtures (currently an experimental treatment).
- Chemotherapy patients are obviously at increased risk of infection and any suspicion of sepsis should prompt referral to secondary care for assessment.
- The device may fail in about 1% of cases.
- Air embolus appears to be rare if lines are correctly cared for.
- Catheters may break and be dislodged, especially if 'pinch-off' occurs repeatedly.
- Hickman® is a registered trademark of CR Bard Inc, as applied to a central venous catheter.
- Groshong® is a registered trademark of CR Bard Inc, as applied to a central venous catheter.
Further reading and references
Central lines; Macmillan Cancer Support
Implantable ports; Macmillan Cancer Support
PICC lines (peripherally inserted central catheters); Macmillan Cancer Support
Bamberger DM, Boyd SE; Management of Staphylococcus aureus infections. Am Fam Physician. 2005 Dec 1572(12):2474-81.
Galloway S, Bodenham A; Safe removal of long-term cuffed Hickman®-type catheters. Hosp Med. 2003 Jan64(1):20-3.
The Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters; NICE Medical Technology Guidance, March 2015
Guidelines for insertion and maintenance of central venous access devices in children and young people; Guidelines and Audit Implementation Network (GAIN) (Jan 2014)
Haire WD, Lieberman RP, Lund GB, et al; Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman® and Groshong® catheters. Bone Marrow Transplant. 1991 Jan7(1):57-9.
Vardy J, Engelhardt K, Cox K, et al; Long-term outcome of radiological-guided insertion of implanted central venous access port devices (CVAPD) for the delivery of chemotherapy in cancer patients: institutional experience and review of the literature. Br J Cancer. 2004 Sep 1391(6):1045-9.
Maki DG, Kluger DM, Crnich CJ; The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006 Sep81(9):1159-71.
Safdar N, Maki DG; Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005 Aug128(2):489-95.
Zhang L, Marsh N, McGrail MR, et al; Assessing microbial colonization of peripheral intravascular devices. J Infect. 2013 Oct67(4):353-5. doi: 10.1016/j.jinf.2013.06.001. Epub 2013 Jun 14.
Carratala J; The antibiotic-lock technique for therapy of 'highly needed' infected catheters. Clin Microbiol Infect. 2002 May8(5):282-9.
Angel-Moreno A, Boronat M, Bolanos M, et al; Candida glabrata fungemia cured by antibiotic-lock therapy: case report and short review. J Infect. 2005 Oct51(3):e85-7.
Chambers ST, Pithie A, Gallagher K, et al; Treatment of Staphylococcus epidermidis central vascular catheter infection with 70% ethanol locks: efficacy in a sheep model. J Antimicrob Chemother. 2007 Feb 5.