Central Venous Catheter Complications, Prevention & Treatment

Outpatient central line infection prevention bundle

• Encouraging good hand hygiene.
• Scrubbing the central line hub for 15 seconds before each line access.
• Changing central line dressing once per week or more frequently if soiled, using aseptic technique.
• Change the central line end cap using clean technique.
• Chlorhexadine patch or impregnated central line dressing to cover exit site.
• Encourage peripheral venipuncture for labs.
• Limiting potential for central line access by standard outpatient lab monitoring every 1-2 months.
• Changing intravenous tubing daily.
• Use of alcohol-impregnated disinfection caps (Curos).
• Caregivers wearing a mask during central line dressing change.
• Preparing PN on a clean workspace.

Ethanol lock Prophylaxis (ELP)

• Ensure superb CVC and ELP teaching.
• Prescribe correct ELP dose.
• Quality assurance regarding ELP practices, preparation.
• Avoid heparin-ethanol interactions.
• Track adverse outcomes.

Inclusions:

• History ≧ 1 CLABSI
• Presence of a silicone central venous catheter (tunneled or peripherally inserted central catheter)
• Age ≧ 1 6 months
• Weight ≧ 5 kg

• Parent preference
• Polyurethane central venous catheter (ethanol can erode catheters made from polyurethane)
• Documented allergy to ethanol
• Social or religious objection to use of ethanol

• Before prescribing ELP, patient receives a test dose and is observed ≧ 1 hour for any adverse events.
• Caregivers receive written ELP educational sheets.
• Sterile, single-use 70% ethanol lock in syringes prepared by home infusion companies (needs refrigeration).  
• At the end of HPN cycle, flush with 3-5 ml of normal saline.
• Instill prescribed dose of 70% ethanol into both lumens simultaneously (if double-lumen CVC present).
• Dwell time ≧2 hours (max 12 hours).
• At start of next HPN cycle, caregivers withdraws exact dose of ELP using a 10-ml syringe.  Discards ELP (do not re-use).
• If unable to withdraw ELP, caregivers can flush entire volume with saline.
• Prior to infusing HPN, caregivers flush the CVC with normal saline 3 to 5 ml.
• Start HPN infusion (no heparin added to bag)

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• At least 2 negative blood cultures. Second blood culture is negative ≥48 hours.
• Otherwise medically stable for discharge.
• IV antibiotics have been narrowed based upon sensitivities, when able.
• Patient has tolerated a dose of IV antibiotics.
• Previously discharged on HPN with demonstration of reliability in case of emergencies.
• WARNING: Oral antibiotics are not a standard treatment of central line associated bloodstream infections.

Safety Checklist for discharge on IV antibiotics

1. Teaching with family on antibiotics at every discharge.
2. Antibiotic frequency (maximum 3 times per day)
3. Pre-medication (oral if possible)
4. PN and IV lipid compatibility with antibiotics
5. Administration device (syringe pump, ball)
6. Tubing (bifuse)
7. Laboratory coordination (electrolytes, repeat blood cultures)
8. Family counseled on antibiotic side-effects
9. Provider has experience with family being reliable as this is a high-risk discharge.  Assurance that family will administer full antibiotic course, call with issues and follow-up as outpatient.

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Test of cure blood culture

• Check aerobic blood cure from central venous catheter 48-72 hours following discontinuation of intravenous antibiotics.
• Draw culture in ambulatory setting, so provider can be personally accountable for following up results.
• Most important for staph aureus and enterococcus, because they are hard to clear.
• Least important if catheter is removed as part of treatment.
• WARNING: Avoid drawing blood cultures at home or in community setting where results may be not be reported directly to provider ordering test.  Anticipate any blood culture that is drawn is potentially positive, and as a provider you must be able to act on this result as soon as possible for the safety of your patient.

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Central venous access procedure complications

As HPN teams are often provide referrals for central line placement, it is important for team members to be familiar with the following common procedural complications: 

• Arterial puncture
• Pneumothorax
• Cardiac tamponade
• Nerve lesions
• Thrombosis
• Infection 

Vascular Catheter Location for Home Parenteral Nutrition Administration

• Ideal tip location = Junction of the superior vena cava & right atrium.
• Acceptable tip locations = superior vena cava including anywhere between the brachiocephalic and superior vena cava junction, as well as right atrium, or inferior vena cava. 
• All other vascular tip locations =  non-central.

The maximal osmolarity of parenteral nutrition for a non-central vascular catheter is 900 mosm/L.

Complications of infusing high osmolarity parenteral nutrition solution (>900 mosm/L) through non-central vascular catheter include:

• Phlebitis
• Thrombosis
• Thrombophlebitis
• Infiltration
• Extravasation

Other factors may contribute to risk of developing a complication:

• patient's vascular health status
• patient's receiving vessicant IV medications 

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Thrombosis work-up

• Careful past medical history and family history
• Consider hematology referral
• CBC
• Coags
• D-Dimer
• Fibrinogen
• CRP
• Thrombosis panel (Anti-thrombin III, Protein C&S
• Antigen/activity) BX3
• Factor VIII L324) B
• Anti-phospholipid antibody panel (send-out Quest 148908) B
• Homocysteine (L1097) J
• Lipoprotein A (L10212) J
• Require genetic consent:
• Factor V Leiden mutation (L62005)
• MTHFR mutation (THF)
• Prothrombin 20210 mutation

Thrombosis Prophylaxis

• There's no clear indication to prescribe prophylaxis for HPN patients without other risk factors for thrombosis and no history of thrombosis.  Small studies in children may show decreased rate of thrombosis and occlusion without increased rate of bleeding.  Larger adult studies showed reduced thrombosis, but also carries significant complication risks. 

• Low molecular weight heparin (LMWH)
• Warfarin
• Aspirin