64 / 176
708
•
Cancer chemotherapy
•
IV nutrition
•
Repeated blood transfusions Fluid administration
requirement Antibiotics
•
Dialysis
•
Venesection
TABLE 5.
2.
Perforation by catheters via the lower SVC or RA, allowing
pressurized infusion into pericardium (30). Series suggest
this is more common than bleeding.
Tamponade is often a post-mortem finding. Suspicion is
necessary to prompt, and confirm diagnosis by echocar-
diogram. Aspiration of fluid through the catheter may be
successful. Urgent pericardiocentesis, stenting, or surgery
repair are needed.
Removal of catheters
Most catheters can be pulled out easily. The negative pres-
sure in central veins can entrain air via an open/damaged
catheter or insertion tract. This is a higher risk with large-
bore devices, and established short tracts (e.g. jugular
dialysis catheter), and is a rare cause of collapse and death.
Position the patient head-down, with applied pressure, and
an occlusive dressing to entry site.
There are other potential complications (Table 4.).
Occasional long-term devices cannot be removed due to tight
constriction of a fibrin sleeve, or organized clot anchoring
catheter centrally. Do not persist to catheter breakage or
vessel damage, seek specialist advice. Some are cut off and
left
in situ
.
Short versus long-term venous access
Peripheral vein cannulae last only a few days. Long term
devices last months/years, and are increasingly used in and
out of hospital for predicted use longer than 6 weeks. Basic
knowledge of function (Table 5) is valuable as devices are used
for routine and emergency use. Some devices (e.g. Groshong)
have a valve in tip or proximal hub.
Ports are accessed with non-coring Huber tip needles,
although acutely any small bore needle can be used. Needles
need a firm push through the thick rubber membrane to then
hit the back wall.
Many long term devices are inserted by anaesthetists and
other non-surgical specialists as standalone procedures.
Points to consider re devices include: Indications and dura-
tion of treatment, location for therapy (hospital/community),
clinical status (e.g. coagulation, sepsis), self- administration
of infusions. Early use of devices is used to save peripheral
veins, prevent pain and discomfort, and complications from
repeated attempts at peripheral cannulation (32).
REMOVING A CUFFED TUNNELED CATHETERS AND
IMPLANTED PORTS
Cuffed catheters can be pulled out if less than 3-4 weeks old,
before adhesions form, or if infection has broken down adhesions.
Anchored catheters need a cut-down to release the cuff (31).
The cuff can be found with palpation or ultrasound. Perform
a cut down (1cm length) on venous side of cuff under LA, and
with blunt dissection free and remove the venous section first
to avoid catheter embolism. A thin fibrin sheath will need to
be incised. Then sharp dissect around the cuff to free adhe-
sions and remove it. Similar principles apply to ports encased
in a fibrous capsule with sutures.
[REV. MED. CLIN. CONDES - 2017; 28(5) 701-712]
•
Haemorrhage
•
Air embolism
•
Catheter fracture and embolism
-Dislodgement or thrombus or fibrin sheath
-Occult arterial complications—bleeding
•
Infection—local/systemic
•
Catheter trapped in vein/tissues.
TABLE 4. COMPLICATIONS FROM CVC REMOVAL
Site of access
Some studies suggest right-sided catheters have lower
risks of thrombosis, because of straighter route to SVC,
with easier tip positioning. Site choice takes in patient
factors, previous vein access, and clinician experience,
evidence of vein thrombosis, previous scars, or venous
collaterals. Central vein imaging (venogram, CT, MRI) is
helpful in difficult cases.
Tips for insertion of long-term devices
Central passage of guidewire/catheter is aided by
requesting awake patients to inspire during insertion.
Measurements catheter length can be made from a guide-
wire or uncut catheter (with fluoroscopy), or measure
predicted length externally on chest wall.
Stiff sheaths/dilators risk vein damage, and are typically
longer than required and don’t need to be inserted fully.