Indwelling Access Devices

Published on 04/03/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 22/04/2025

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Chapter 41 Indwelling Access Devices

Franklin W. Huang, Janet L. Abrahm

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Figure 41-1 Schematic diagram of an indwelling central venous catheter in place. Insertion site refers to the insertion of the proximal end of the catheter into the chest wall. Clamp attached to the catheter is shown next to the Luer-Lok cap at the distal end.

(Modified from Hickman Subcutaneous Port, Use, and Maintenance and How to Care for Your Hickman or Broviac Catheter. Cranston, RI, Davol Inc.)

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Figure 41-2 Totally implanted Hickman subcutaneous (central venous access) port with a noncoring needle in place.

(Modified from Hickman Subcutaneous Port, Use, and Maintenance and How to Care for Your Hickman or Broviac Catheter. Cranston, RI, Davol Inc.)

Table 41-1 Choices of Indwelling Venous Access Devices

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Choice of Device

We recommend indwelling venous access devices based on patient characteristics and preference, anticipated duration of use, purpose(s) for which the device is required, and relative complication rates among catheters and ports.

PICCs can be selected when duration of use will be 3 months or less. They are an appropriate choice when patients have chest wall problems, require outpatient-based treatments, and/or have thrombocytopenia. PICCs allow for vesicant infusions, antifungal and antibiotic therapies, and hyperalimentation.

Peripheral ports may be used longer than PICCs, but not longer than 6 months, and they may be chosen for patients with chest wall problems receiving outpatient-based treatments.

Tunneled catheters may be chosen for patients with thrombocytopenia who require frequent access, rapid infusion, or administration of vesicants. Valved catheters that do not require heparin are useful for patients who should not receive heparin. Like peripheral ports, they may be used for up to 6 months.

Of the various devices, central ports allow for the longest duration of use (more than 6 months). They are appropriate for outpatients, particularly children or adolescents, but they may be problematic in patients who are obese, especially if they are thrombocytopenic. They are used for rapid infusions and administration of vesicants and, if they have more than one lumen, for hyperalimentation.

Infection

Definitions

The Centers for Disease Control and Prevention (CDC) has established the following definitions for catheter- and port-associated infections.8

Localized catheter colonization: Significant growth of a microorganism (greater than 15 CFU) from the catheter tip, subcutaneous segment of the catheter, or catheter hub.

Exit-site infection: Erythema, or induration within 2 cm of the catheter exit site, in the absence of concomitant bloodstream infection (BSI) and without concomitant purulence.

Clinical exit-site infection (or tunnel infection): Tenderness, erythema, or site induration of more than 2 cm from the catheter exit site along the subcutaneous tract of a tunneled catheter (i.e., Hickman or Broviac) in the absence of concomitant BSI.

Pocket infection: Purulent fluid in the pocket of a totally implanted intravascular catheter that may or may not be associated with spontaneous rupture and drainage or necrosis of the overlaying skin in the absence of concomitant BSI.

Infusate-related bloodstream infection: Concordant growth of the same organism from the infusate and blood cultures (preferably percutaneously drawn) with no other identifiable source of infection.

Catheter-related bloodstream infection: Bacteremia or fungemia in a patient with an intravascular catheter with at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (e.g., fever, chills, or hypotension) and no apparent source for the BSI except the catheter. One of the following should be present: a positive semiquantitative (greater than 15 CFU/catheter segment) or quantitative (greater than 102 CFU/catheter segment) culture whereby the same organism (species and antibiogram) is isolated from the catheter segment and peripheral blood; simultaneous quantitative blood cultures with a 3 : 1 ratio for CVC versus peripheral; or differential period of CVC culture versus peripheral blood culture positivity of more than 2 hours.

Infectious Indications for Device Removal

Venous Access Devices

Tunnel infection or port pocket abscess

Catheter-related bacteremia caused by Staphylococcus aureus, Xanthomonas, Pseudomonas spp, mycobacteria, Bacillus and Corynebacterium species

Catheter-related fungemia

Septic thrombosis

Endocarditis

Osteomyelitis

Sepsis with signs of shock/persistent end-organ dysfunction

Central venous thrombosis

Central Nervous System Access Devices

Deep catheter track or epidural space infection

From Mermel LA, Farr BM, Sheretz R, et al: Guidelines for the management of intravascular catheter-related infections. J Intraven Nurs 24:180, 2001; and

Simon A, Bode U, Beutel K: Diagnosis and treatment of catheter-related infections in paediatric oncology: An update. Clin Microbiol Infect 12:606, 2006.

Treatment of Vesicant Drug Extravasation

Treatment protocols for vesicant drug extravasation, including those recommended by the Oncology Nursing Society, are outlined in Table 41-2. When these protocols were used, 89% of vesicant extravasations were reported to resolve without additional therapy. However, 30% of anthracycline extravasations progressed to ulceration.

At many centers, it is recommended that an extravasation kit be kept in units in which vesicant drugs are given. The kit includes the appropriate medications, as well as order sheets preprinted for immediate use. For most vesicant drugs there is no proved antidote or local care measures. In general, whether an antidote is to be administered through the device or not, as much of the residual drug as possible should be aspirated from the needle, tubing, and tissues. Any antidote may then be administered. If swelling or pain persists for 72 to 96 hours after drug administration, a plastic surgeon should be consulted.

Table 41-2 Management of Vesicant Drug Extravasation

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From Schulmeister L: Extravasation management: Clinical update, Semin Oncol Nurs 27:82, 2011.

Table 41-3 Important Pathogens in Central Venous Access Device–Related Infections

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