catheter related thrombus management (enhanced by visualbee)
TRANSCRIPT
Catheter Related Thrombus Management
Karen Williford RN, CRNIBeebe Medical CenterTunnell Cancer CenterLewes, Delaware
Objectives
•Discuss the pathophysiology of catheter related thrombosis
•Discuss thrombosis prevention strategies related to vascular access device assessment and insertion
•Discuss current research findings as they relate to vascular access device thrombosis
Upper Extremity Deep Vein Thrombosis (UEDVT)
• Increasing prevalence with potential for considerable morbidity
• Increased use of CVC/PICC• Chemotherap
y
• Bone Marrow Transplant
• Parenteral Nutrition
• Dialysis
Types of Thrombus
Intra-
luminal
•Within the lumen of the catheter
•Accounts for 60% of occlusions
Extra-
luminal
•On the outside of the Catheter
•Usually a Fibrin Sheath
Venous Thrombus
•Within the vein
•Concern for systemic complications
Assessment
• History of a previous device
• Fluid Status
• Sepsis
• Duration of Catheter
• Cancer
• Hypercoaguability
• Improper Maintenance
Blood viscosity can be affected by:
• Hematocrit
• Temperature
• Low flow
• Diabetes
• Pregnancy
• Cancer
Hypercoagulability
Risk Factors
Venipuncture by unskilled professional
Multiple Venipuncture attempts
Use of a catheter that is larger than the vein lumen
Poor circulation with venous stasis
Risk Factors
• Administration of incompatible solutions and medications
• Administration of solutions or medications with high pH or tonicity
• Ineffective filtration
• Thrombogenic catheter materials
• Malpositioned catheter
Virchow’s Triad
Anatomy
Physiology of Clotting
Thrombus
Conversion of Thrombin to Fibrin
Creation of Factor X
Intrinsic Pathway
Extrinsic Pathway
Physiology
Endothelial Injury
• Larger stiffer catheters pose a higher risk of endothelial injury on insertion
• Infusion of irritants or vesicants
• Sub Optimal Catheter Tip Locations carry larger risk of endothelial injury
Does Size Matter??
King et al. (2006)
Increased incidence in oncology population
Overall 2% incidence of thrombosis
Increased incidence with larger diameter catheters
No decrease in incidence with prophylactic anticoagulation
Increased incidence in polyurethane vs. silicone catheters
Blood Flow Dynamics
Pouissille’s Equation
• This law describes the relationship between pressure, flow and resistance through a cylindrical tube (blood vessel)
• The amount of blood that flows is in terms of the difference in pressure between the arteries and the veins X the quantity known as the total peripheral resistance.
Laminar Flow Characteristics
Blood flows in concentric sheets
There is no overlap or mixing
The flow is steady through the vessel
Poiseuille’s Law
Flow Dynamics
Introduction of a catheter into the blood vessel will slow the flow in
the vessel at least 50%
The larger the catheter the greater the
amount of stasis
Optimally vein to catheter ratio
should be at least 3:1 (2:1
minimum)
Evans et al (2010)
• Previous DVT history increases risk
• Large sample size-2014 PICC’s
• Single double and triple lumen catheters
• 60 of 2014 patients developed DVT
• 0.6% Single lumen DVT rate
• 2.9% Double lumen DVT rate
• 8.8% Triple lumen DVT rate
Factors leading to Thrombus Formation
Endothelial Injury
Vasoconstriction, Platelet Adherence &
Aggregation, Coagulation activation
Thrombus FormationFibrinolysis
Reperfusion & Vascular Healing
Seeley et al. (2007)
Multiple venipunctures associated with 38%
thrombosis rates
Patients with DVT history are at higher risk of new
thrombosis
High levels of factor II, factor VIII, factor IX and XI are
associated with increased risk
Stiffer catheter materials produce more intimal damage
that leads to thrombus formation
• Swelling of extremity
• Pain with infusions
• Fluid leaking at insertion site
• Ultrasound of extremity
• Anticoagulation
• Possible catheter removal
Catheter Thrombosis
Burns 2009
• CVC thrombosis results in:
• Vascular and catheter occlusion
• Infection
• Pulmonary embolus
• Right heart thrombo-emboli
• Incidence underestimated
• Synergy of events
Fibrin Sheath
Courtesy of :http://www.konez.com/CentralCatheter_fibrin%20sheath_dialysis.JPG
Does Tip Location Matter?
Standard Infusion Nurses Society 2011 Standard of Practice
Lower 1/3 of SVC to the junction of the RA
Guideline 2011 ONS Access Device Guideline
Distal third of the SVC
Guideline NKF KDOQI Guideline Long Term:RAShort Term: SVC(dialysis access)
Guideline SIR 2003 Quality Improvement Guidelines for CVC
Cava Atrial Region
Guideline AVA 2006 Position Statement
Distal SVC close to the RA
Statement FDA/CVC Working Group 1989, 1994
Lower 1/3 of the SVC
Standards
Central vascular access devices with tiplocations other than the vena cava should beaddressed in collaboration with members ofthe healthcare them. Standard 42, 49.
If the CVC tip is located outside the venacava, the catheter is no longer consideredcentrally located and should be removed.Standard 49.
Removal of PICC determined by…catheter
malposition. Standard 49.
Define Central
Anything in the Chest
Mid Chest vs. Midline
Superior Vena Cava
Cava Atrial Junction
Right Atrium
Luciani et al. (2001)
• Prospective US study
• 3/62 (5%) with tips at CAJ developed thrombosis
• 5/7 (71%) at SCV/BCV junction developed thrombosis
Lobo et al. (2009)
38 of 777 adult patients studied developed DVT
4.89% symptomatic DVT rate
Incidence increased 2.6 times when tip located outside the
SVC
Incidence increased 10 times for previous
DVT history
Cadman, Lawrance, Fitzsimons,Spencer-Shaw, Swindell (2004)
• Relationship between tip position andvenous thrombosis
• 428 tunneled catheters
• 72 days
• 5/91 in lower 1/3 (2.6%)
• 5/95 in middle 1/3 (5.3%)
• 20/48 in upper 1/3 (41.7%)
Verhey, Gosselin, Primack,Blackburn, Kraemer (2008)
SVC 7.6 cm (5-10.5cm)
Most superior right cardiac border is Right Atrial Appendage (RAA)
Distance from RAA to CAJ: 1.8cm(1-3cm)
Distance from carina to CAJ: 4.7cm(2.5-7.2cm)
Trerotola et al 2010
Prospective study to evaluate outcomes Triple Lumen PICCs in the ICU
6F TL PICCs placed at bedside by Nursing Team with IR back-up
Placement & longterm complications were recorded
On removal US done to detect DVT
Catheters were cultured for colonization
Tretola Study 2010
• Stopped at 50 of 167 planned patients
• Scheduled interim US showed an DVT rate of 20% (10 of 50)
• Venous Thrombosis (symptomatic or asymptomatic) 58%
• 0% CRBSI
• Colonization 10%
• Malfunction & Dislodgement in 1 patient
Duke University 2011
Purpose: Evaluate the effectiveness of practice changes to reduce PICC thrombus risk
Retrospective analysis of adult patients
1307 charts reviewed January 2008, October 2008, and August 2010. Clinical Practice change to include US & tip in SVC
Duke University 2011
PICC related DVT rates decreased from
4.8% to 2.9% (January 2008-October 2008)
October 2008-August 2010 practice change to
measure & document native vein diameters prior to PICC insertion -2X outer cath diameter
PICC related DVT decreased from 2.9% to 1.4%
INS National Standards
Medications with a pH <5 or >9
OROsmolarity
greater than 600mOsm/L
can cause vein irritation,
phlebitis, infiltration or extravasation.
pH <5Ciprofloxin 3.3-4.6Dopamine 2.5-5.0Doxycycline 1.8-3.3Dopamine 2.5-5.0Morphine 2.5Pentamidine 4.1-5.4Phenergan 4.0Potassium 4.0Taxol 4.4-5.6Vancomycin 2.4Zofran 3.0-4.0
pH >9Acyclovir 10.5-11.6Ampicillin 8.0-10Bacterium 10Cerebyx 8.6-9.05FU 9.2Ganciclovir 9-11Phenytoin 12Protonix 9-10.5
Extreme pH IV MedicationspH <5 or >9
AcyclovirAmiordaroneAmpho BAmpicillinBactrimCalcium chlorideCalcium Gluconate 10%CiprofloxacinCerebyxContrast mediaAramine
DaptinomycinDextrose >10%DigitoxinDobutamineDopamineDoxapramDoxycyclineEpinephrineErythromycinGanciclovirGentamycin
Vesicants
LevophedLorazepramMagnesium sulfateMannitol 10% and 20%MorphineNafcillinNorepinephrinePhenerganPhenytoinPhenylephrinePentamadine
LevophedLorazepramMagnesium sulfateMannitol 10% and 20%MorphineNafcillinNorepinephrinePhenerganPhenytoinPhenylephrinePentamadine
Vesicants
Hypertonic
Hypertonic solution has an osmolality of
350 mOSM/liter and above.
The osmolality of PPN is about 750
mOSM/liter and above.
Hypertonic solutions cause phlebitis
peripherally in less than 24 hours
Examples
• D25W (1330mOSM/liter).
• D40W (2020mOSM/liter).
• D50W (2525mOSM/liter).
• Literature states hypertonic drugs withan osmolality over 600mOSM/liter resultin phlebitis in 24 hours with shortperipheral catheters.
• Consider central venous administration
Assessment is the Key!
Through ultrasound assessment
Correct vein to catheter ratio (Bigger veins are better!)
Advocate for single lumen catheters if possible
Consider softer catheters for long term therapies
Consider baseline sedimentation rate
Take this Home!!
• History and Physical/Physician Collaboration
• Limit Catheter Manipulation*Catheter Exchange can increase thrombosis and infection risk
• Prevent catheter related infections
• Get the tip in the right place!