Chemo Vascular Access
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Transcript of Chemo Vascular Access
Vascular access for Chemotherapy
Maj Sankalp Singh
Introduction
Need for better vascular access
Complex & long-term chemo regimensTotal parenteral nutritionAnalgesics for pain control
Classification
External cathetersPercutaneous non-tunneled CVCTunneled external catheter
PICC lineImplanted vascular access devices
Vascular access portsImplanted infusion pumps
External CVCs
Most frequently usedSimplestSafeAll aspects of patient careE.g. - Central lines, Hickman’s, Groshong and Broviac
Central Venous Line16 gaugePositioned via IJV, subclavian or femoral into RA /SVCSingle / multi lumenSafely used for 7-14 days (Short –term)Not for OPD/long-term useHighest risk of migration / infection
Central Venous LineUses:-
Transfusion of large volume of fluidsDialysisTransfusion of a drug which may irritate peripheral v.
E.g. - Quinton’s Catheter
Central Venous Line
Tunneled central catheters
Various designs & sizes Inserted in OR or IR suite Placed in central veinTunneled under skin but opening to lumen remains outside Longer length s.c. tunnel
Better fixationInfection control
Tunneled central catheters
Single / double lumenDacron cuffAntibiotic / silver ion cuffSlit valve design – GroshongLong term (months to years)External site care & regular flushing needed
Tunneled central catheters
Hickman’s Groshong BroviacNeostar
Hickman’s catheter
Groshong slit valve
Prevents air embolism & passive reflux of blood into lumen – reducing frequent catheter infection & thrombosis
PICC linePeripherally insertedCatheter tip in a RA/ SVC/ central v.Easy technique - insertion, maintenance by nursing teamIntermediate - term (wks to mnths)Safe & durable for OPD patientsChemo/Antibiotics/TPN
PICC lineSingle / double lumenLow bleeding risk ed thrombophlebitis & venous thrombosis Thinner diameter – limited lumenProne to obstruction or damage
PICC line
PICC line
Implanted devices
Catheter placed in central veinConnected to a reservoir or ‘port’Titanium / Plastic 1-3 ml heparinized salineCompressed, self-sealing silicone diaphragm placed below skinAllows repeated puncture with non-coring Huber needle
Implanted devicesSingle / Double lumenSurgically placed in OR
Under LA/sedationFluoroscopic guidanceMinimal dissectionFixed to pectoralis fascia
Hub located on chest / upper armExpected lifespan > 1 year
Implanted devicesMore durableRoutine care not neededIf not in use, once a month flushingCompatible with CT/MRIInfection, thrombosis & loss of patency comparable to ext. cath.Portsite infection surgical removal
Implanted devicesPort-A-CathBardPortPassPortMedi-portInfusaport
Implanted devices
PORT-A-CATHLIFE PORT
Implanted devices
Implantable infusion pumps
IV or Intra-arterialTitanium98-173 gms16-60 ml0.3 – 4.0 ml/dayRefillablePt can receive chemo/ Rx at home
Implantable infusion pumps
Surgically implantedPlaced in s.c. tissue on ant. abd. wallPercutaneous access with non-coring needlesMain chamber – reservoir s/by chamber with gas phase fluorocarbon
Implantable infusion pumps
System completely containedBolus / continuous infusionBattery powered systems – drug delivery at variable, controllable rate Uses:-
i.v. insulinintrathecal/systemic narcoticsintra-arterial, intrahepatic chemotherapy
Implantable infusion pumps
Medtronic Johnson & Johnson / Codman pump
Implantable infusion pumps
Catheter ComparisonDevice Placemen
tLifespan Adv Disadv
1. Percutaneous CVC
OT/IR suite 7-14 days
Low routine care
Migration, infection, insertion risks
2. Tunneled central catheter
OT/IR suite Long term – months to years
Durable External site care, insertion risks
3. PICC line Nursing staff
Intermed - Weeks to months
Easy insertion
Thrombophlebitis, thrombosis, limited lumen, frequent obstruction
4. Implanted device / pump
OT/IR suite > 1 year Low insertion complications
High cost, infection requires Sx removal.
Catheter selectionType of agentNumber of agentDuration of treatmentFrequency of treatmentBolus vs Continuous-infusionBlood withdrawl / administration frequency
Selection of catheterAge & size of patientPrevious h/o catheterPatient’s immune statusPatient’s vascular anatomyFinancial factorsPatient / Physician preference
Vascular access team
Responsible for catheterSelectionInsertionLong time care
Standardization of techniqueAccurate assessment of complicationsImproved efficiency
Prolongation of catheter lifeDecreased infection rate
Insertion Technique
OR / IVR suiteSterilityAnalgesia LA + sedationFluoroscopyLandmark guidance / USG guidance
PositioningTrendelenburg position
Head turned to opp. side
Roll placed between shoulders
PreparationClean with 2% chlorhexidine
Expose adequate area
Sterile draping
Seldinger techniquePuncture–aspiration of IJV with saline syringe & 20-22 ga needlebetween sternal & clavicular heads of
SCM
Needle at 45º to skin surface & towards I/L nippleAspiration of blood confirms placement
Guidewire passageGuidewire passed through needle
Tip placed in IVC
Watch out for ectopics
Dilator peel-off sheath threaded over guidewire
Remove needle & introduce dilator sheath
Remove dilator sheath & introduce peel off sheath
Remove guidewire & aspirate blood
Line tunneled in5mm incision at midpt bet. humeral head & nipple
Tunnel up to the neck puncture
Pull central line tip from incision upto neck puncture
Determine correct length of line required
Line length adjustedLine cuff placed 2-3 cm from incision
Length of Line approximated to length of peel off sheath, using II
No touch technique
Line insertion into peel off sheath
Assistant pulls out trochar of peel off sheath
Central line is inserted & advanced gradually as sheath is peeled off simultaneously
Radiographic confirmation
Final position in high RA or junction of SVC with RA
Looping of line in neck should be smooth
Line fixing with suturesNon-absorbable sutures to affix line to skin
Dresssing for 3 weeks
Semi-permeable dressing
Leave undisturbed for 3 weeks
Complications – (Intra-op)
Arterial injury / catheterizationAir embolism Hemorrhage / hematomaPneumothorax / hemothoraxArrhythmiasCardiac injury / tamponade
Complications(Post-op)
Venous thrombosisInfectionsPhlebitisInfiltration / ExtravasationPainBleedingPinch-off syndromeCatheter block
Venous ThrombosisMost common complication 30-70%Only 5-10% symptomaticDevelop early in catheter lifeChronic irritation at catheter-endothelium contact siteSource of :-
InfectionPulmonary emboliPermanent venous obstruction (10-15% in upper limb)
Venous Thrombosis Mangement
Catheter preservation & prevention of 2ndary complicationsElevation of affected limbClinically significant thrombus same as other DVTsTherapeutic anticoagulation
Heparinization (LMWH) f/b Oral Warfarin (long-term)
Thrombolytic therapy –rTPA for salvage of vital vein
InfectionsGreatest cause of catheter lossRisk factors
Type of catheter- (percutaneous short-term) Lack of skilled catheter nursing careLength & frequency of useLack of antibiotic coated cathetersSite (Femoral> IJV > Subclavian)Long term -Tunneled (40%)> Implanted devices (5-10%)
Infectious complications with time
InfectionsSkin flora – commonest contaminantInfection sites – exit/ access site, s.c. tunnel, bacteremia.Cellulitis / erythema / localized purulent discharge – S. epidermis Catheter preservation + Local/ systemic antibioticsAbscess / blood culture positive / Pseudomonas / Atypical mycobacterium Catheter removal + IV antibiotics
InfectionsCatheter related bacteremia - Coagulase -ve staph VancomycinLow dose rTPA – destruction of thrombus assoc. with infectionIndications for removal
Inability to clear infection after full course.Continued signs/symptoms of bacteremiaRecurrent infection after completion of full course.
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