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Central Venous Catheter Care for the Patient With Cancer: American Society of Clinical Oncology Clinical Practice Guideline

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Abstract

Purpose: To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and management of both catheter-related infection and thrombosis. Methods: A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant articles published in English. Results: The overall quality of the randomized controlled trial evidence was rated as good. There is consistency among meta-analyses and guidelines compiled by other groups as well. Recommendations: There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recommended before insertion. Data are not sufficient to recommend for or against routine use of antibiotic flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained. Some life-threatening infections require immediate catheter removal, but most can be treated with antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended. Prophylactic use of warfarin or low-molecular weight heparin is not recommended, although a tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters. CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that worsens despite anticoagulation therapy.
Central Venous Catheter Care for the Patient With Cancer:
American Society of Clinical Oncology Clinical Practice
Guideline
Charles A. Schiffer, Pamela B. Mangu, James C. Wade, Dawn Camp-Sorrell, Diane G. Cope, Bassel F. El-Rayes,
Mark Gorman, Jennifer Ligibel, Paul Mansfield, and Mark Levine
See accompanying article in J Oncol Pract doi:10.1200/JOP.2012.000780
Charles A. Schiffer, Karmanos Cancer
Institute, Wayne State University
School of Medicine, Detroit, MI;
Pamela B. Mangu, American Society of
Clinical Oncology, Alexandria, VA;
James C. Wade, Geisinger Cancer Insti-
tute, Danville, PA; Dawn Camp-Sorrell,
University of Alabama, Birmingham, AL;
Diane G. Cope, Florida Cancer Special-
ists and Research Institute, Fort Myers,
FL; Bassel F. El-Rayes, Emory Univer-
sity, Atlanta, GA; Mark Gorman, Patient
Representative, Silver Spring, MD;
Jennifer Ligibel, Dana-Farber Cancer
Institute, Boston, MA; Paul Mansfield,
University of Texas MD Anderson Cancer
Center, Houston, TX; and Mark Levine,
Henderson Hospital, Hamilton, Ontario,
Canada.
Published online ahead of print at
www.jco.org on March 4, 2013.
Clinical Practice Guideline Committee
Approved: September 5, 2012.
Editor’s note: This is a summary of the
literature that was used to inform the
American Society of Clinical Oncology
Clinical Practice Guideline for Central
Venous Catheter Care for the Patient
With Cancer and provides recommen-
dations with brief discussions of the
relevant literature for each. Evidence
tables with details about the studies
and meta-analyses cited are provided in
Data Supplements 1 and 2 at www.as-
co.org/guidelines/cvc.
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: American Soci-
ety of Clinical Oncology, 2318 Mill Rd,
Suite 800, Alexandria, VA 22314;
e-mail: guidelines@asco.org.
© 2013 by American Society of Clinical
Oncology
0732-183X/13/3110-1357/$20.00
DOI: 10.1200/JCO.2012.45.5733
ABSTRACT
Purpose
To develop an evidence-based guideline on central venous catheter (CVC) care for patients with
cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and
management of both catheter-related infection and thrombosis.
Methods
A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant
articles published in English.
Results
The overall quality of the randomized controlled trial evidence was rated as good. There is
consistency among meta-analyses and guidelines compiled by other groups as well.
Recommendations
There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should
be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is
recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is
recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in
high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recom-
mended before insertion. Data are not sufficient to recommend for or against routine use of antibiotic
flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained.
Some life-threatening infections require immediate catheter removal, but most can be treated with
antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended.
Prophylactic use of warfarin or low–molecular weight heparin is not recommended, although a
tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters.
CVC removal is recommended when the catheter is no longer needed or if there is a
radiologically confirmed thrombosis that worsens despite anticoagulation therapy.
J Clin Oncol 31:1357-1370. © 2013 by American Society of Clinical Oncology
INTRODUCTION
The management of the patient with cancer de-
mands stable venous access that is used for a wide
range of indications including chemotherapy, blood
product and antibiotic administration, fluid resusci-
tation, and access to the bloodstream for clinical
monitoring and microbial culturing. The use of
long-term central venous catheters (CVCs) can also
decrease patient anxiety associated with repeated ve-
nipunctures. The number and variety of CVCs used
in oncology practices during the past 30 years have
greatly increased, but the most commonly used
long-term devices include: surgically implanted
cuffed tunneled central venous catheters, subcuta-
neous implanted ports, peripherally inserted CVCs
(PICCs), and percutaneous noncuffed or tunneled
catheters. During the past decade, the composition
of these devices has changed, the catheter size and
lumen number have increased, and CVCs impreg-
nated with anti-infective material or antibiotics and
heparin have become available. A CVC care clinical
bundle
1,2
is now the standard of care. The insertion
and care of a CVC require a multidisciplinary ap-
proach, involving medical oncologists/hematolo-
gists, nurses, interventional radiologists, surgeons,
infectious disease specialists, and often a specialized
CVC care team.
3
CVCs have a considerable potential for serious
complications, which are often underappreciated.
JOURNAL OF CLINICAL ONCOLOGY
ASCO SPECIAL ARTICLE
VOLUME 31 NUMBER 10 APRIL 1 2013
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Early complications related to CVC placement include bleeding,
cardiac arrhythmia, malposition, air embolism, and pneumothorax
and, rarely, injury to vessels or nerves. Late complications include
infection, thrombosis, and catheter malfunction. Patients with cancer
with implantable port systems were found to experience a median of
0.2 infections per 1,000 catheter-days (range, 0 to 2.7 per 1,000
catheter-days)
4
versus a risk that ranges from 1.4 to 2.2 infections per
1,000 catheter-days for subcutaneous tunneled CVCs.
5,6
Some infec-
tions can be life threatening and require immediate catheter removal,
whereas others can be treated while the catheter remains in place. The
incidence of CVC-associated thrombi in patients with cancer varies in
different series, from 27% to 66%, when routine screening with
venography is performed. Most patients with CVC thrombi are
asymptomatic.
7
Reported rates of symptomatic thrombi also vary
widely, from 0.3% to 28%.
7-10
Infection or thrombosis of a CVC can
be an indication for removal, which can result in prolonged and costly
hospitalizations and significant delays in treatment. The purpose of
this guideline is to assist in care and decision making for patients with
cancer who often have long-term CVCs and to identify areas of con-
troversy, promoting future research and clinical trials. This is a new
American Society of Clinical Oncology (ASCO) guideline focused on
CVC care for patients with cancer.
GUIDELINE QUESTIONS
Clinical Question 1
In patients with cancer, does catheter type, insertion site, or
placement technique affect complication rates?
THE BOTTOM LINE
American Society of Clinical Oncology Clinical Practice Guideline for Central Venous Catheter Care for the
Patient With Cancer
Intervention
Placement of a central venous catheter (CVC) in adult and pediatric patients with cancer and the subsequent prevention and man-
agement of catheter-related infections and thromboses
Target Audience
Medical oncologists/hematologists, nurses, interventional radiologists, surgeons, infectious disease specialists, and specialized
CVC care teams
Key Recommendations
There is insufficient evidence to recommend a specific type of CVC or insertion site, but femoral vein insertion should be avoided,
except in certain emergency situations
CVCs should be placed by well-trained health care providers
Use of a CVC clinical care bundle is recommended
Use of antimicrobial/antiseptic-coated CVCs and/or heparin-impregnated CVCs has been shown to be beneficial, but the benefits
and costs must be carefully considered before they can be routinely used
Prophylactic use of systemic antibiotics is not recommended before CVC insertion
Cultures of blood from the CVC and/or tissue at the entrance-exit sites should be obtained before initiation of antibiotic therapy;
most clinically apparent exit- or entrance-site infections as well as bloodstream infections can be managed with appropriate mi-
crobial therapy, so CVC removal may not be necessary; antimicrobial agents should be optimized once the pathogens are identi-
fied; catheter removal should be considered if the infection is caused by an apparent tunnel or port-site infection, fungi, or
nontuberculous mycobacteria or if there is persistent bacteremia after 48 to 72 hours of appropriate antimicrobial treatment
Routine flushing with saline is recommended
Prophylactic warfarin and low–molecular weight heparin have not been shown to decrease CVC-related thrombosis, so routine
use is not recommended
Tissue plasminogen activator (t-PA) is recommended to restore patency in a nonfunctioning CVC; CVC removal is recommended
when the catheter is no longer needed, if there is a radiologically confirmed thrombosis that does not respond to anticoagulation
therapy, or if fibrinolytic or anticoagulation therapy is contraindicated
Methods
Systematic review and analysis of the medical literature on CVC care for patients with cancer by ASCO CVC Care Expert Panel
Additional Information
Data Supplements, including evidence tables, and clinical tools and resources can be found at http://www.asco.org/guidelines/cvc
Schiffer et al
1358
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Clinical Question 2
What is effective prophylaxis for the prevention of catheter-
related infections?
Clinical Question 3
What are effective treatments for the management of catheter-
related infections?
Clinical Question 4
What is effective prophylaxis for the prevention of catheter-
related thrombosis?
Clinical Question 5
What are effective treatments for the management of catheter-
related occlusions?
CLINICAL PRACTICE GUIDELINES
Practice guidelines are systematically developed statements that assist
practitioners and patients in making decisions about care. Attributes of
good guidelines include validity, reliability, reproducibility, clinical appli-
cability, flexibility, clarity, multidisciplinary process, review of evidence,
and documentation. Guidelines may be useful in producing better care
and decreasing cost. Specifically, use of clinical guidelines may provide:
1. Improvements in outcomes
2. Improvements in medical practice
3. A means for minimizing inappropriate practice variation
4. Decision support tools for practitioners
5. Points of reference for medical orientation and education
6. Criteria for self-evaluation
7. Indicators and criteria for external quality review
8. Assistance with reimbursement and coverage decisions
9. Criteria for use in credentialing decisions
10. Identification of areas where future research is needed
METHODS
Panel Composition
The ASCO Clinical Practice Guidelines Committee convened an Expert
Panel consisting of experts in clinical medicine and research relevant to CVC
care in patients with cancer, including medical and surgical oncologists and
oncology nurses. Academic and community practitioners and a patient repre-
sentative were also part of the Panel. The Panel members are listed in Appendix
Table A1 (online only).
Literature Review and Analysis
Literature search strategy. MEDLINE (Pubmed) and the Cochrane
Collaboration Library were searched with the date parameters of January 1980
through January 2012. Reference lists of related reports and review articles
were scanned for additional citations. Details about the literature search and
results are provided in Data Supplements 3 and 4 at www.asco.org/guidelines/cvc.
Inclusion and exclusion criteria. The systematic review conducted for
this guideline included 108 randomized controlled trials (RCTs) in which
adult or pediatric patients with cancer were randomly assigned to an appro-
priate control group or to an intervention of interest, including CVC type,
placement site, or strategies to prevent or manage infection or thrombosis.
Studies were included only if they had catheter type, placement site, infection,
or thrombosis as a priori planned primary or secondary outcome and de-
scribed a method of regular patient follow-up to ensure a consistent and
identical identification of the outcomes in both study arms. Infection and/or
thrombosis had to be confirmed either through objective tests (blood or
imaging) and/or clinical observation. Results of meta-analyses are also re-
ported in the Literature Review and Analysis sections pertaining to each rec-
ommendation; other guidelines, particularly those by the Centers for Disease
Control and Prevention (CDC), originally published by the CDC in August
2002 and updated in 2011, and the Infectious Disease Society of America
(IDSA), informed the decisions of the Panel.
Trials were excluded if they were nonrandomized reports or posthoc
subgroup analyses or if only a minority of the patients studied had cancer.
RCTs were also excluded if patients with CVCs were compared with patients
with peripheral catheters.
Data extraction. Two reviewers independently extracted the data on
basic study design, patient characteristics, interventions, study outcomes,
follow-up, and measures of study quality. Any discrepancies between review-
ers were resolved by consensus.
Study quality. Overall study quality was evaluated by the Jadad method.
The evidence tables in Data Supplements 1 and 2 at www.asco.org/guidelines/
cvc include information on randomization, blinding, allocation concealment,
withdrawals, and intention-to-treat analyses. Meta-analyses were evaluated
using the Oxman-Guyatt Index, in which questions must be clearly specified,
target populations identified and accessed, and appropriate information ob-
tained in an unbiased fashion.
Evidence-Based Guideline Development Process
The entire Panel met one time in person and a writing group met
subsequently; additional work on the guideline was completed through a
steering group and e-mail. The Panel and writing group drafted guideline
recommendations and distributed writing assignments. All members of the
Panel participated in the preparation of the draft guideline document, which
was then disseminated for review and approval by the entire Panel. The
guideline was submitted to Journal of Clinical Oncology for peer review. Feed-
back from additional external reviewers was also solicited. The content of the
guideline and the manuscript was reviewed and approved by the ASCO Clin-
ical Practice Guideline Committee before publication.
Guideline Policy
The practice guideline is not intended to substitute for the independent
professional judgment of the treating physician. Practice guidelines do not
account for individual variation among patients and may not reflect the most
recent evidence. This guideline does not recommend any particular product or
course of medical treatment. Use of the practice guideline is voluntary. The
guideline, evidence tables, and data supplements are available at http://www.
asco.org/guidelines/cvc.
Guideline and Conflicts of Interest
The Expert Panel was assembled in accordance with the ASCO Conflicts
of Interest Management Procedures for Clinical Practice Guidelines (summa-
rized at www.asco.org/guidelinescoi).
Revision Dates
At annual intervals, the Panel co-chairs will determine the need for revisions
to the guideline based on an examination of current literature. If necessary, the
entire Panel or an update committee will be reconvened to discuss poten-
tial changes. When appropriate, the Panel will recommend revised recom-
mendations to the Clinical Practice Guideline Committee for approval.
RESULTS
Literature Review Results and Limitations of
the Literature
A total of 108 RCTs with results specific to patients with cancer (Data
Supplement 1 at www.asco.org/guidelines/cvc), 25 meta-analyses or
systematic reviews (Data Supplement 2 at www.asco.org/guidelines/
cvc), and several existing guidelines
11-16
were identified in the search
of the literature. RCTs were considered eligible for data extraction if
the majority of patients had cancer. It should be noted that many of the
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trials had small numbers of patients, and there was considerable het-
erogeneity in trial design, types of catheters used, placement tech-
niques, and methods of evaluating end points, even among trials
addressing the same question. In addition, clinical practices have
changed over the years, and the Panel focused on more-recent trials
whenever possible. Nonetheless, the overall quality of the evidence was
rated as good, as evidenced in part by the consistency among meta-
analyses and guidelines compiled by other groups.
GUIDELINE RECOMMENDATIONS
On the basis of the evidence and the expert opinion of the CVC Care
Panel, the following recommendations are offered in Table 1.
Catheter Type, Insertion Site, and Placement
A CVC can be designated by its pathway to the vessel (eg, tun-
neled v nontunneled or implanted); its site of insertion (eg, subclavian,
femoral, internal jugular, or PICC); or its composition, length, or
special characteristic (eg, presence or absence of a cuff; impregnation
with heparin, antibiotics, or antiseptics; single or multiple lumens).
When selecting the proper CVC, factors to consider are the purpose,
the expected duration of the catheter, who will maintain the device,
and patient preference. The use of a CVC should be considered for
patients with cancer (adults and children) with limited peripheral
venous access, for those receiving regimens that require prolonged or
continuous intravenous (IV) infusions of multiple chemotherapeutic
or supportive care agents, for those requiring repeated blood sampling
or clinical monitoring, and for those expected to receive a vesicant as
Table 1. ASCO Recommendations for CVC Care
Clinical Question Recommendation
1. In patients with cancer, does
catheter type, insertion site, or
placement affect complication
rates?
1.1. There is insufficient evidence to recommend one type of CVC routinely for all patients with cancer; the choice
of catheter should be influenced by the expected duration of use, chemotherapy regimens, and patient ability to
provide care; the minimum number of lumens essential for the management of the patient is recommended;
these issues should be discussed with the patient
1.2. There is insufficient evidence to recommend one insertion site or approach (left sided or right sided) for
tunneled CVCs for patients with cancer; individual risks and benefits (comfort, security, maintenance of asepsis)
of the catheter site should be considered; the Panel recommends that CVC insertion into the femoral vein be
avoided because of increased infection risks and concerns about thrombosis, except in certain emergency
situations
1.3. Most CVC placement in patients with cancer is performed as an elective procedure; although image-guided
insertion (eg, ultrasound guided, fluoroscopy) of CVCs is recommended, well-trained providers who use the
landmark method regularly (eg, for subclavian or internal jugular) may have high rate of success and low
incidence of acute and/or chronic complications
2. What is effective prophylaxis for
the prevention of catheter-
related infections?
2.1. CVC care clinical bundle (including hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis
during catheter insertion, optimal catheter site selection, and assessment of CVC necessity) is recommended
for placement and maintenance of all CVCs to prevent infections; there is no evidence that particular dressing
types or more frequent IV set and/or dressing changes decrease risk of infection; use of topical antibiotic
ointment or cream on insertion sites is not recommended because of potential to promote fungal infections and
resistance to antimicrobials; scheduled guidewire exchange of CVC may be associated with greater risk of
infection versus catheter replacement at new vascular site; thus, guidewire exchange is not routinely
recommended, unless access options are limited
2.2. Use of antimicrobial/antiseptic-impregnated or -coated CVCs (CH-SS or minocycline/rifampin) and/or heparin-
impregnated catheters is recommended to decrease risk of catheter-related infections for short-term CVCs,
particularly in high-risk groups such as bone marrow transplantation recipients or patients with leukemia;
however, relative benefit and increased cost must be carefully considered before they are routinely used
2.3. Prophylactic use of systemic antibiotics (IV or oral) before insertion of long-term CVCs is not recommended
2.4. There are conflicting data about the relative value of prophylactic heparin with saline flushes to prevent
catheter-associated bloodstream infections or thrombosis; data are not sufficient to recommend for or against
routine use of antibiotic-flush/antibiotic-lock therapy
3. What are effective treatments for
the management of catheter-
related infections?
3.1. Cultures of blood from the catheter and when appropriate of soft tissues at entrance-exit sites or tunnel
should be obtained before initiation of antibiotic therapy; most exit- or entrance-site infections can be treated
successfully with appropriate antimicrobial therapy without the need for catheter removal, although removal is
usually needed for clinically apparent tunnel or port-site infections; antimicrobial agents should be optimized
once pathogens are identified and antibiotic susceptibilities defined
4. What is effective prophylaxis for
the prevention of catheter-
related thrombosis?
4.1. Use of systemic anticoagulation (warfarin, LMWH, UFH) has not been shown to decrease incidence of
catheter-associated thrombosis; therefore, routine prophylaxis with anticoagulants is not recommended for
patients with cancer with CVCs; routine flushing with saline of the CVC to prevent fibrin buildup is
recommended
4.2. Data are insufficient to recommend routine use of urokinase (not available in the United States) and/or other
thrombolytics to prevent catheter occlusion
5. What are effective treatments for
the management of occluded
catheters?
5.1. Instillation of 2-mg t-PA is recommended to restore patency and preserve catheter function
5.2. Although it is appropriate to try to clear thrombosis with the CVC in place, if there is radiologically confirmed
thrombosis that does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is
contraindicated, catheter removal is recommended; prolonged retention of unneeded CVCs can lead to
significant problems associated with thrombosis and fibrosis; 3 to 6 months of anticoagulant therapy with
LMWH or LMWH followed by warfarin (INR, 2.0 to 3.0) is recommended for treatment of symptomatic CVC
thrombosis, with duration depending on clinical issues in individual patients
Abbreviations: ASCO, American Society of Clinical Oncology; CH-SS, chlorhexidine and silver sulfadiazine; CVC, central venous catheter; INR, international
normalized ratio; IV, intravenous; LMWH, low–molecular weight heparin; t-PA, tissue plasminogen activator; UFH, unfractionated heparin.
Schiffer et al
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part of their treatment regimen. It should be noted, however, that
many regimens containing vesicants can be administered safely to
patients with good peripheral venous access by skilled infusion nurses.
Patient education about types of CVCs facilitates an informed deci-
sion before catheter placement, because the decision about the type of
catheter should involve both the health care provider and the patient
(see Patient and Clinician Communication section). A table of CVC
types and risks of infection is provided in Data Supplement 5
at www.asco.org/guidelines/cvc.
Clinical Question 1
In patients with cancer, does catheter type, insertion site, or
placement affect complication rates?
Recommendation 1.1. There is insufficient evidence to recom-
mend one type of CVC routinely for all patients with cancer. The
choice of catheter should be influenced by the expected duration of
use, the chemotherapy regimen, and the patient’s ability to provide
care. The minimum number of lumens essential for the management
of the patient is recommended. These issues should be discussed with
the patient.
Literature review and analysis. Ten RCTs
17-26
and three meta-
analyses
6,27,28
addressed these issues. They supported the conclusions
that single- or double-lumen (v triple) CVCs should be used whenever
feasible; and that, for a patient who requires more intensive therapy
(ie, hematopoietic cell transplantation recipient, patient with acute
leukemia), a subcutaneous port is often not adequate to meet all the
patient’s clinical needs. In one meta-analysis,
6
the authors reviewed
200 prospective studies in adult patients. Catheter types were com-
pared using the mean rates of intravascular device (IVD) –related
bloodstream infections (BSIs) per 100 IVDs (%) and per 1,000 IVD-
days. Point incidence rates of IVD-associated BSIs were lowest for
peripheral IV catheters (0.5 per 1,000 IVD-days) and were
much higher for short-term, noncuffed, and non–antimicrobial-
impregnated CVCs (2.7 per 1,000 IVD-days). Surgically implanted
long-term cuffed and tunneled central venous devices resulted in an
intermediate infection risk (1.6 per 1,000 IVD-days). PICCs for pa-
tients who were hospitalized seemed to pose a substantial risk of
infection (2.4%; 2.1 per 1,000 IVD-days), but when assessed just for
patients who received both inpatient and outpatient care, the risk of
infection was much lower (1.1 per 1,000 IVD-days). The published
data do not provide a specific recommendation that could apply to all
patients with cancer because of the heterogeneity of the patient popu-
lations, variability of the severity of patient illness, different protocols
for insertion and site care, and multiple different devices that were
tested. Thus, it is critical to carefully consider the patient’s present and
future needs in making the decision about catheter type.
Recommendation 1.2. There is insufficient evidence to recom-
mend one insertion site or approach (left sided or right sided) for
tunneled CVCs for patients with cancer. Individual risks and benefits
(comfort, security, and maintenance of asepsis) of the catheter site
should be considered. The Panel recommends that CVC insertion into
the femoral vein be avoided because of increased infection risks and
concerns about thrombosis, except in certain emergency situations.
Literature review and analysis. Evidence from six RCTs
21,29-33
and one meta-analysis
34
indicated that there was no compelling evi-
dence for one insertion site or approach (left sided or right sided). No
differences were found for early complication rate among three
groups (internal jugular, 0%; 95% CI, 0.0% to 2.7%; subclavian, 0%;
95% CI, 0.0% to 2.7%; cephalic, 1.5%; 95% CI, 0.1% to 5.3%).
29
Four
of the RCTs
21,31-33
evaluated subcutaneous tunneled CVCs for pa-
tients with malignancies, and taken together, the results of the studies
show that subcutaneous tunneling decreases the rate of short- and
long-term complications. The CDC guideline
14
and one RCT
35
pres-
ent data that femoral vein CVCs have relatively high bacterial coloni-
zation rates when used in adults and an equivalent infection rate in
children, and another meta-analysis provides data that a femoral
placement can increase thrombosis
36
; thus, femoral vein insertion
should be avoided when other sites are available.
Recommendation 1.3. Most CVC placement in patients with
cancer is performed as an elective procedure. Although image-guided
insertion (eg, ultrasound guided, fluoroscopy) of CVCs is recom-
mended, well-trained providers who use the landmark method regu-
larly (eg, for subclavian or internal jugular) may have a high rate of
success and a low incidence of acute and/or chronic complications.
Literature review and analysis. Four RCTs
37-40
and three meta-
analyses
41-43
specifically addressed the effectiveness of teams who used
image-guided versus landmark-guided CVC placement (eg, subcla-
vian or internal jugular). Using two-dimensional or Doppler ultra-
sound may achieve lower complication rates.
37
In one RCT, although
there were no significant differences, in secondary measures (such as
pneumothorax, arterial puncture, hematoma), there was 14% mis-
placement in the blind arm versus only 1% misplacement in the
image-guided arm (P .001). However, another RCT
38
found that
real-time Doppler guidance of subclavian vein catheterization is
highly operator dependent and did not increase the success rate or
decrease the complication rate of subclavian vein catheterization when
compared with the standard technique in high-risk patients, nor was it
more useful than the standard technique as a salvage technique after a
previous failure of catheterization. Another small RCT
39
found that
ultrasound techniques did not influence the rate of complication or
failure of subclavian vein catheterizations. The authors reported a
12% failure rate (n 51) in the ultrasound group and 12% failure
rate (n 49) in the control group. A final RCT
40
concluded that
the surface landmark technique was not as reliable as IV
electrocardiography-guided catheter tip placement (satisfactory
placement for 16 of 30 patients v 30 of 30 patients, respectively).
In meta-analyses,
41-43
it was concluded that two-dimensional
ultrasound is significantly better than the landmark method. Not all
the patients in these meta-analyses had cancer, and thus, there was
significant heterogeneity of study results. However, in another meta-
analysis,
41
a subgroup analysis suggested improved outcomes for pa-
tients with cancer with image-guided CVC insertion.
Infection
The CDC Guidelines for the Prevention of Intravascular Catheter-
Related Infections
14
and the IDSA 2009 Update of the Clinical Practice
Guidelines for the Diagnosis and Management of Intravascular Catheter-
Related Infection
44
conclude that experienced, educated health care
workers or dedicated CVC teams are critical for infection prophylaxis for
CVCs in patients with cancer. The CDC and IDSA guidelines were written
for all patients but provide specific recommendations regarding diagnosis
and management of infection for patients with cancer as well. Two RCTs
focusing on patients with cancers
45,46
reported that catheter-related infec-
tions are largely preventable and that education for all providers and
systematic individualized, supervised patient and caregiver education are
effective and affordable and decrease infection rates.
Central Venous Catheter Care for the Patient With Cancer
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Catheter-related infections can be grouped into one of three
categories: one, localized entrance- or exit-site infections; two, tunnel
and/or port-pocket infections; and three, catheter-associated BSIs
(catheter-related BSIs). The pathogens that cause catheter-associated
infections have changed during the past decades, influenced by chang-
ing catheter materials, antimicrobial impregnation of the catheters,
sites of catheter placement, and the antimicrobial selection that occurs
as a result of changing antibiotic prescribing habits. More detailed
information is available at Definitions of Infections Associated With
CVCs and Treatment, provided in Data Supplement 6 at www.asco-
.org/guidelines/cvc. In general, entrance- or exit-site infections are
associated with a low incidence of BSIs. However, tunnel or port-site
catheter BSIs are not uncommon and can be a significant cause of
morbidity. The consequences of catheter-related infections depend on
several factors such as the type of CVC, the catheter placement loca-
tion, and the patient’s performance status, including associated my-
elo/immunosuppression. Patients with cancer with implantable port
systems were found to experience a median of 0.2 infections per 1,000
catheter-days (range, 0 to 2.7 per 1,000 catheter-days)
4
versus a risk
that ranges from 1.4 to 2.2 infections per 1,000 catheter-days for
subcutaneous tunneled CVCs.
5,6
However, this difference may be
artifactual, because patients who receive implantable subcutaneous
ports usually receive much less intensive cancer therapy. The duration
of antimicrobial therapy for the treatment of catheter-associated in-
fections ranges from 7 to 21 days, and success rates have ranged from
60% to 91%.
47
It is important to note that both duration of treatment
and treatment success are highly dependent on the organism(s) re-
sponsible for the infection, the need for catheter or subcutaneous port
removal, and the patient’s underlying neutrophil count. Early catheter
removal is critical for some infections, whereas premature or unnec-
essary catheter removal may interrupt treatment and increase patient
discomfort, anxiety, and cost because of the need for placement of
another catheter.
Clinical Question 2
What is effective prophylaxis for the prevention of catheter-
related infections?
Recommendation 2.1. A CVC care clinical bundle (including
hand hygiene, maximal barrier precautions, chlorhexidine skin anti-
sepsis during catheter insertion, optimal catheter site selection, and
assessment of CVC necessity) is recommended for the placement and
maintenance of all CVCs to prevent infections (Table 2). There is no
evidence that particular dressing types or more frequent IV set and/or
dressing changes decrease the risk of infection. The use of topical
antibiotic ointment or cream on insertion sites is not recommended
because of the potential to promote fungal infections and resistance to
antimicrobials. A scheduled guidewire exchange of CVCs may be
associated with a greater risk of infection compared with catheter
replacement at a new vascular site, and thus, guidewire exchange is not
routinely recommended unless access options are limited.
Literature review and analysis. CVC clinical care bundles
have been validated as a highly effective approach to decrease
catheter-related BSIs.
1,2,16,48,49
As has been shown in many RCTs,
including three performed in patients with cancer, and in meta-
analyses, antiseptic chlorhexidine-based preparations used at the time
of insertion decrease the incidence of CVC-related infections by 40%
to 50% compared with povidone-iodine solutions.
50-53
Of note, one
meta-analysis conducted in 2006
53
also assessed the effect of an
antiseptic chlorhexidine-impregnated dressing on the risk of vas-
cular and epidural catheter bacterial colonization and infection.
The chlorhexidine-impregnated dressing substantially reduced the
risk of intravascular catheter or exit-site bacterial colonization (14.8%
v 26.9%; odds ratio [OR], 0.47; P .001). In contrast, in eight
RCTs,
54-61
patients with entrance- or exit-site dressings, combined
with antibiotic ointments applied at the insertion site, experienced a
higher incidence of catheter-related infections than those patients for
whom no antibiotic ointment or cream was used.
Several RCTs, systematic reviews, and meta-analyses conducted
among patients with cancer have addressed the frequency of catheter
dressing changes, replacement of administration sets, and replace-
ment of catheters using a vascular guidewire.
14,61-65
Scheduled guide-
wire exchanges of CVCs failed to reduce infection rates compared with
replacement at a new site, and indeed, the routine replacement of
catheters that are functioning well and do not seem to be infected is
not recommended.
64
Recommendation 2.2. The use of antimicrobial/antiseptic-
impregnated or -coated CVCs (chlorhexidine and silver sulfadiazine
[CH-SS] or minocycline/rifampin) and/or heparin-impregnated
catheters is recommended to decrease the risk of catheter-related
infections for short-term CVCs, particularly in high-risk groups such
as bone marrow transplantation recipients or patients with leukemia.
However, the relative benefit and increased cost must be carefully
considered before they are routinely used.
Literature review and analysis. Regarding CVCs impregnated
with CH-SS, although the data are mixed, evidence from five
RCTs
66-70
and two meta-analyses
71,72
indicates that antimicrobial/
Table 2. CVC Clinical Care Management Bundle
Component Criteria
Hand hygiene Every person entering the room during the insertion procedure should perform hand hygiene
Maximal barrier precautions upon insertion Sterile drape extends from head to toe; all health care providers participating in the procedure employ mask,
cap, sterile gown, and sterile gloves
Chlorhexidine skin antisepsis Skin at the insertion site should be scrubbed with 2% chlorhexidine for 30 seconds and allowed to dry for at
least 30 seconds
Optimal catheter site selection Subclavian vein is the preferred site for nontunneled catheters; avoid femoral site if possible
Assessment of CVC necessity Prompt removal of CVC line after completion of therapy unless clinical circumstances suggest that further
infusional therapy is likely to be necessary in the future
NOTE. Content adapted.
1,14,48
Abbreviation: CVC, central venous catheter.
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antiseptic-impregnated catheters and cuffs that are coated externally
with CH-SS reduce catheter-related BSIs and catheter-related coloni-
zation, although there is some evidence to the contrary; one meta-
analysis
72
included studies with methodologic flaws, whereas the
nonsignificant findings in three RCTs may have resulted from the
development of newer generations of coated catheters.
Regarding CVCs impregnated with minocycline/rifampin, in
one large RCT,
73
patients with cancer randomly assigned to long-
term, nontunneled silicone CVCs impregnated with minocycline and
rifampin had lower rates of catheter-related BSIs versus those ran-
domly assigned to nonimpregnated catheters (0.25 v 1.28 infections
per 1,000 catheter-days, respectively; P .003). In another RCT,
74
BSIs were four times less likely to originate from impregnated silicone
catheters. In a meta-analysis
75
of trials not restricted to patients with
cancer, rifampicin/minocycline-impregnated CVCs were associated
with fewer catheter-related BSIs compared with catheters not im-
pregnated with rifampicin/minocycline.
With regard to CVCs impregnated with heparin, intraluminal
fibrin deposition may contribute to the development of infection, and
hence, a CVC-impregnated with heparin has the potential to reduce
catheter-related infections.
76
In one RCT of patients with cancer,
catheter-related BSIs occurred in 2.5% of patients (three of 120 cath-
eters) with heparin-coated catheters with saline infusion (0.9 events
per 1,000 days) versus 9.1% of patients (11 of 120 catheters) with
noncoated catheters flushed with unfractionated heparin in the con-
trol group (3.5 events per 1,000 days; P .027).
76
The use of antimicrobial-impregnated CVCs remains somewhat
controversial because of cost. Catheters impregnated with CH-SS or
minocycline/rifampin (and heparin) are more expensive than stan-
dard catheters, although it has been suggested that such catheters
could be cost effective in higher-risk patients. It should be noted that a
majority of these studies were conducted in patients with short-
term CVCs.
Recommendation 2.3. The prophylactic use of systemic
antibiotics (IV or oral) before insertion of a long-term CVC is
not recommended.
Literature review and analysis. The routine use of systemic anti-
biotics (IV or oral) before the insertion of a CVC to prevent infection
is not recommended.
44
This recommendation is supported specifi-
cally for patients with cancer in one RCT
77
when the CVC care bundle
was used and in four RCTs
78-81
where prophylactic systemic antibiot-
ics, including vancomycin, did not significantly reduce catheter-
related sepsis in patients with cancer. Two small RCTs,
82,83
with
methodologic issues, were inconclusive.
In a Cochrane review of nine RCTs,
84
CVC tunnel infections
were not reduced by the use of prophylactic IV antibiotics before
catheter insertion (OR, 0.42; 95% CI, 0.13 to 1.31), although flushing
the CVC lumens with antibiotics and heparin seemed to decrease the
incidence of Gram-positive infections (OR, 0.43; 95% CI, 0.21 to
0.87). This seemingly positive meta-analysis should be considered
carefully before it is translated to most patients with cancer because of
the small number of studies and patients.
Recommendation 2.4. There are conflicting data about the rela-
tive value of prophylactic heparin with saline flushes to prevent
catheter-associated BSIs or thrombosis. Data are not sufficient to
recommend for or against the routine use of antibiotic-flush/antibiotic-
lock therapy.
Literature review and analysis. Numerous flushing protocols
exist, often determined by the manufacturer, which use different vol-
umes and concentrations of heparin, saline, or tissue plasminogen
activator (t-PA; or other similar agents) and different frequencies for
catheter flushing. Antimicrobial/antiseptic-coated CVCs or heparin-
impregnated CVCs are recommended, but conflicting data from one
RCT and a meta-analysis
85,86
suggest that the evidence supporting the
use of prophylactic heparin with saline flushes is inconclusive, and
definitive randomized comparisons have not been performed. A ran-
domized trial
87
in the intensive care unit setting evaluating short-term
catheter placement did not show a difference between heparin or
saline flushes in the rate of catheter thrombosis or catheter-related
BSIs. There is a theoretic concern about the clinical syndrome of
heparin-associated thrombocytopenia with heparin flushes, although
the incidence of this complication has not been determined and seems
to be low. The issue of antibiotic flushing and/or antibiotic lock tech-
niques continues to be controversial. The CDC guideline
14
is in favor
of these techniques only if the patient is at risk because of a history of
previous infections. This is supported by seven RCTs, which reported
a significant decrease in catheter-related BSIs or an increase in the time
to first episode of catheter-related BSI when antibiotic flush or bacte-
riostatic saline flushes were used.
85,88-93
In addition, two other older
small RCTs
94,95
concluded that vancomycin locks or catheter flushes
may prevent bacteremia by vancomycin-susceptible organisms in
non-neutropenic pediatric patients. This practice must be weighed
against the risk that routine use of vancomycin may result in the
selection of resistant bacteria. Alternately, two other RCTs
78,96
re-
ported that the addition of vancomycin to heparin CVC flush solution
did not reduce bacteremia with vancomycin-susceptible organisms.
Another meta-analysis
5
of seven prospective, randomized trials
(n 463) compared a vancomycin-heparin lock or flush solution
with heparin alone for prevention of BSI. Five of these seven studies
were conducted among patients with cancer. The summary risk ratio
supporting the use of vancomycin-heparin lock solutions for the
prevention of IVD-associated BSIs was 0.49 (95% CI, 0.26 to 0.95;
P 03). When vancomycin was instilled in the catheter for a
defined period, rather than simply flushing it directly through the
catheter, the benefit was greater, with a risk ratio of 0.34 (95% CI,
0.12 to 0.98; P .04). The results of the test for heterogeneity were
statistically significant, although heterogeneity was no longer pres-
ent when one of the studies was removed. Thus, clinicians must be
cautious in the interpretation of these data.
Two RCTs addressed the use of urokinase flushes/locks or
urokinase-heparin flushes/locks in patients with cancer.
97,98
Because
urokinase is no longer available in the United States, this intervention
is no longer applicable in the United States.
Management of Clinically Established Catheter-
Related Infection
Determining the source of BSI is often challenging in patients
with long-term indwelling CVCs. A helpful diagnostic tool for at-
tempting to diagnose a catheter-related BSI is the differential time to
positivity of blood cultures drawn simultaneously through the cathe-
ter and a peripheral vein. A blood culture drawn from the CVC that
becomes positive at least 120 minutes earlier than simultaneously
drawn peripheral vein blood indicates that the catheter is the likely
source of infection.
99
Many approaches to quantify the number of
organisms cultured from each site have been proposed. Although not
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specific to patients with cancer, there are recommendations for cul-
turing and treatment in the IDSA 2009 Update of the Clinical Practice
Guidelines for the Diagnosis and Management of Intravascular
Catheter-Related Infection
44
(pocket card can be found at http://
www.idsociety.org/IDSA_Practice_Guidelines/including). The use of
antimicrobial agents in patients with cancer and/or neutropenia are
also clearly addressed in the IDSA 2010 Update of the Clinical Practice
Guideline for the use of Antimicrobial Agents in Neutropenic Patients
with Cancer.
100
Information on the management of febrile neutrope-
nia in the outpatient setting can be found at www.asco.org/guidelines/
outpatientfn.
Specific therapy with standard antimicrobial agents should be
initiated as soon as possible. Catheter-related BSIs are most com-
monly caused by coagulase-negative staphylococci, Staphylococcus au-
reus, and Candida species and less commonly with Bacillus species,
Corynebacterium jeikeium, enterococci (including vancomycin resis-
tant), rapidly growing mycobacteria, and nonlactose fermenting
Gram-negative bacilli.
44
Many of these pathogens are organisms that
frequently colonize the skin.
Most BSIs that occur in patients with cancer can be treated
effectively without catheter removal. Clinical experience suggests that
most bloodstream infections that occur among patients with cancer
may not actually originate from or involve the catheter. That said,
fungemias or bacteremias with Bacillus species, C jeikeium, S aureus, P
aeruginosa,orStenotrophomonas maltophilia and nontuburculous
mycobacteria (eg, Mycobacterium chelonei, M fortuitum, M mucogeni-
cum, M abscessus) often persist despite appropriate antibiotics and
then require catheter removal. Catheter removal should also be con-
sidered when blood cultures remain positive after 48 hours of antibi-
otic treatment if no other site of infection has been identified or if
bacteremia recurs shortly after completion of a course of antibiotics.
In some patients, catheter removal is not advisable because of
platelet transfusion refractory thrombocytopenia and hemorrhagic
hazards associated with reimplantation or the absence of other vascu-
lar access sites. In these complex cases where the catheter is to be
retained, the clinician may find it prudent to prolong the duration of
IV antimicrobial therapy.
Clinical Question 3
What are effective treatments for the management of catheter-
related infections?
Recommendation 3.1. Cultures of blood from the catheter and
when appropriate of soft tissues at the entrance-exit sites or tunnel
should be obtained before the initiation of antibiotic therapy. Most
exit- or entrance-site infections can be treated successfully with appro-
priate antimicrobial therapy without the need for catheter removal,
although removal is usually needed for clinically apparent tunnel or
port-site infections. Antimicrobial agents should be optimized once
the pathogens are identified and antibiotic susceptibilities defined.
Immediate catheter removal is recommended for BSIs caused by
fungi and nontuburculous mycobacteria (eg, M chelonei, M fortuitum,
M mucogenicum, M abscessus). BSIs caused by Bacillus species, C
jeikeium, S aureus, P aeruginosa, S maltophilis, and vancomycin-
resistant enterocci may be difficult to eradicate with antimicrobial
therapy alone, and early catheter removal should be considered. Cath-
eter removal is also recommended for patients with an apparent tun-
nel or port-site infection, persistent bacteremia after 48 to 72 hours of
appropriate antimicrobial treatment in the absence of other obvious
sites or sources of infection, infective endocarditis or peripheral em-
bolization, presence of local catheter-associated complications not
responsive to treatment, or relapse of infection with the same patho-
gen after the completion of an appropriate course of antibiotics.
Literature review and analysis. There are five RCTs
95,101-104
spe-
cifically focused on treatment options for patients with cancer with
catheter-related infections. Once the diagnosis of a catheter-related
BSI is established or suspected (more information about culturing is
available in Data Supplement 7 at www.asco.org/guidelines/cvc), de-
cisions about the duration and type of antimicrobial therapy and
catheter removal should be made depending on the patient’s disease
status, presence of myelosuppression, previous antibiotic exposure,
the isolated pathogen, and the type of catheter. In hemodynamically
stable patients, depending on the pathogen and in the absence of signs
of metastatic infection and/or tunnel or port-site infection, many
catheter-related BSIs can be effectively treated without catheter re-
moval, assuming the patient clinically improves, and blood cultures
become negative within 48 to 72 hours after antibiotic initiation. Most
catheter-related BSIs caused by coagulase-negative Staphylococcus can
be successfully managed with the catheter in place. These recommen-
dations are consistent with guidelines from other groups, including
the IDSA. In contrast, tunnel and port-pocket infections generally
require prompt catheter removal coupled with modification of em-
piric antibiotics based on cultures and the antibiotic susceptibilities of
the recovered pathogens.
The duration of systemic antimicrobial therapy after a catheter-
related BSI is documented depends on several factors including: cath-
eter removal or retention, response to antimicrobial therapy within
the first 48 to 72 hours (resolution of fever and bacteremia), and the
development of other complications (embolic tissue infection, septic
thrombosis, or endocarditis). In general, for organisms other than
coagulase-negative Staphylococci, a 14-day course of systemic antimi-
crobial therapy is adequate, assuming a response to antimicrobial
therapy within 48 to 72 hours and the absence of a deep-tissue infec-
tion, even in a patient with neutropenia. However, a recent study
suggested that catheter-related BSIs resulting from S aureus in patients
with cancer (including neutropenic patients) may improve with du-
rations of therapy that are longer than 2 weeks because of the increased
risk of complications with shorter treatment courses.
105
Catheter-
related BSIs resulting from any pathogen that are complicated by
disseminated or deep infection require at least 4 to 6 weeks of antimi-
crobial therapy.
44,100
Thrombosis
In 2007, ASCO published a guideline addressing the many issues
related to venous thromboembolism in patients with cancer: Clinical
Practice Guideline Recommendations for Venous Thromboembo-
lism Prophylaxis and Treatment in Patients With Cancer.
106
CVC-
associated thrombosis was not considered in that guideline. This
guideline is currently being updated. Thrombosis associated with a
CVC can involve the catheter tip, the length of the catheter, or the
catheterized vessel in the upper limb, with or without involvement of
the central vasculature of the neck or mediastinum.
The incidence of catheter-related thrombosis (symptomatic and
asymptomatic) in patients with cancer varies considerably, ranging as
high as 27% to 66% in adults
7
and 50% in children.
107
The variation is
in part related to the different techniques (eg, venography, ultrason-
agraphy) used to assess catheter-associated clots, differing definitions
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of thrombosis, and varying study designs. In one systematic review,
the rates of symptomatic thrombosis were between 0.3% and 28.6%,
7
whereas another review found that on average, 12% of CVC throm-
bosis events were symptomatic.
8
In more recent years, however, lower
rates of symptomatic CVC-related venous thrombosis in the range of
4% to 8% have been reported.
10,108,109
The reasons for this decrease
are unclear, but it has been suggested that improvement in catheter
materials, better insertion practices, and better catheter maintenance
are contributory. Malpositioning of the catheter tip can cause difficul-
ties with blood withdrawal and contribute to catheter occlusion. A
catheter that is too short increases the risk of thrombosis; therefore,
proper insertion technique and confirmation of catheter tip place-
ment are important. Clinical symptoms of CVC-related thrombosis
include edema, pain, and erythema of the affected limb, which can
develop acutely or over a more prolonged period of time. With upper-
extremity catheters, there may be swelling of the neck, supraclavicular
area, or face. Often, problems with catheter function can lead to
ultrasound or radiographic evaluations, which identify catheter-asso-
ciated clots.
Clinical Question 4
What is effective prophylaxis for the prevention of catheter-
related thrombosis?
Recommendation 4.1. The use of systemic anticoagulation (war-
farin, low –molecular weight heparin [LMWH], or unfractionated
heparin) has not been shown to decrease the incidence of catheter-
associated thrombosis, and therefore, routine prophylaxis with anti-
coagulants is not recommended for patients with cancer with CVCs.
Routine flushing with saline of the CVC to prevent fibrin buildup
is recommended.
Literature review and analysis. Older studies produced conflict-
ing conclusions regarding the efficacy of routine primary throm-
boprophylaxis in patients with cancer. Two small RCTs
110,111
evaluated the use of low-dose warfarin and LMWH to prevent
catheter-related thrombosis. Although in retrospect, there were many
methodologic issues with the first study,
110
the use of low-dose warfa-
rin became common in some clinical practices. It was noted subse-
quently that the prothrombin time could be prolonged excessively in
some patients because of interactions with chemotherapy drugs.
112
More recently, 10 randomized trials, three systematic reviews,
and one meta-analsyis have addressed the routine use of thrombopro-
phylaxis using a variety of different anticoagulants in a variety of
different populations of patients with cancer.
113-126
Details of these
articles are provided in the evidence tables in Data Supplements 1 and
2 at www.asco.org/guidelines/cvc. The use of anticoagulants did not
increase the risk of bleeding, although bleeding certainly remains a
concern in patients receiving intensely myelosuppressive therapy.
More importantly, the systematic reviews and meta-analysis did not
show a decrease in the incidence of symptomatic CVC-related throm-
bosis, and hence, the systemic administration of anticoagulants to
prevent CVC-associated thromboses is not recommended.
There are a number of reasons that may explain the differences in
event rates of contemporary compared with earlier studies. First, ear-
lier trials were not double blinded and may have overestimated the
treatment effects because of possible biases in diagnosis. Second, im-
provements in biocompatibility, insertion, and maintenance tech-
niques for CVCs have helped to lower thrombosis rate in recent years,
necessitating large trials to detect differences. Third, the patient pop-
ulations may have been different in the earlier trials. A number of new
antithrombotic agents are undergoing clinical investigation or are in
the pipeline, but more highly powered RCTs of better design are
needed to define whether specific subgroups of patients with cancer
might benefit from receiving thromboprophylaxis.
A special note is warranted for Factor V Leiden. A meta- analy-
sis
127
of 10 studies was published on 1,000 patients with cancer with
Factor V Leiden and the G20210A prothrombin mutation (PTM).
The pooled OR for CVC-related thrombosis was 4.6 (95% CI, 2.6 to
8.1) in patients with Factor V Leiden compared with those without.
The pooled OR for CVC-related thrombosis was 4.9 (95% CI, 1.7 to
14.3) in patients with PTM. The estimated attributable risk of CVC-
related thrombosis was 13.1% for Factor V Leiden. They concluded
that the presence of Factor V Leiden and PTM is associated with
CVC-related thrombosis. However, Factor V Leiden and the pro-
thrombin gene mutation were not associated with an increased risk of
catheter-associated thrombosis in another study.
128
The study also
described an increased risk of catheter-associated thrombosis with
elevated homocysteine levels. Overall, there is no clear consensus at
this time regarding the role of either inherited or acquired thrombo-
philic states in the pathogenesis of catheter-associated thrombosis, nor
is there a clear recommendation on the use of prophylactic measures
in this population.
Recommendation 4.2. Data are insufficient to recommend rou-
tine use of urokinase (not currently available in the United States)
and/or other thrombolytics to prevent catheter occlusion.
Literature review and analysis. Three RCTs have evaluated
methods to decrease the risk of CVC occlusion by flushing with uroki-
nase in a variety of patient populations, and the conclusions are mixed.
In two of the three studies,
129,130
patients receiving urokinase had
fewer occlusive events (23% v 31%; P .02 and 4% v 16%; P .05).
In contrast, another study
131
did not report any benefit of prophylactic
urokinase in a trial of 100 patients undergoing bone marrow trans-
plantation (including a large number of patients undergoing autolo-
gous transplantation for breast cancer) or receiving high-dose
chemotherapy for hematologic malignancies. The incidence of
catheter-related thrombosis was also similar in both groups, with 16%
of the heparin group and 19% of the urokinase group developing a
symptomatic upper-extremity deep venous thrombosis. One of the
studies was closed early because of withdrawal of urokinase in the
United States; nonetheless, it was determined that there were no sig-
nificant differences in occlusive events with urokinase versus hepa-
rin instillation.
129
It is not clear why the incidence of catheter occlusion was differ-
ent among the three RCTs, although the patient populations varied,
and the definition and diagnosis of catheter occlusion differed. On the
basis of both the lack of solid evidence and the unavailability of the
agent in the United States, it is not possible for the Panel to recom-
mend urokinase prophylaxis to prevent catheter occlusion.
Two other RCTs examined alternative interventions to pre-
vent thrombotic events. One study
132
found that ionic implanta-
tion of silicone chronic venous access devices did not alter
thrombotic complications in a double-blinded, randomized clini-
cal trial, whereas another small, and probably underpowered,
study
133
suggested that a novel silver-coated CVC did not affect the
rate of CVC-related thrombosis.
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Management of Catheter-Related Occlusion
Clinical Question 5
What are effective treatments for the management of catheter-
related occlusions?
Recommendation 5.1. The instillation of 2-mg t-PA is recom-
mended to restore patency and preserve catheter function.
Literature review and analysis. Four RCTs
134-137
have evaluated
methods of restoring line patency using fibrinolytic therapy (alteplase
[t-PA], reteplase, or tenecteplace), urokinase with t-PA, or urokinase with
heparin (urokinase unavailable in the United States) for catheter occlu-
sions. Most cancer centers have standard policies and procedures to treat
asymptomatic CVC occlusions
138
with thrombolytic drugs. Although
more studies are needed to establish a consensus for treatment of asymp-
tomatic CVC-related thrombosis,
139
most are often diagnosed inciden-
tally by cancer staging studies. Current data suggest that the treatment of
incidental thrombi should be the same as treatment of symptomatic
thrombi. These issues will be addressed in more detail in the forthcoming
update (manuscript submitted, Lyman et al: Venous Thromboembolism
Prophylaxis and Treatment in Patients with Cancer: American Society of
Clinical Oncology Clinical Practice Guideline Update).
Recommendation 5.2. Although it is appropriate to try to clear a
thrombosis with the CVC in place, if there is radiologically confirmed
thrombosis that does not respond to fibrinolytic therapy or if fibrino-
lytic or anticoagulation therapy is contraindicated, catheter removal is
recommended. Prolonged retention of an unneeded CVC can lead to
significant problems associated with thrombosis and fibrosis. Three to
6 months of anticoagulant therapy with LMWH or LMWH followed
by warfarin (international normalized ratio, 2.0 to 3.0) is recom-
mended for the treatment of symptomatic CVC thrombosis, with the
duration depending on clinical issues in individual patients.
Literature review and analysis. There are no randomized trials of
anticoagulant therapy in patients with acute symptomatic CVC
thrombosis. The natural history of acute CVC thrombosis is unclear.
Although pulmonary embolism can occur,
140
the incidence is less
frequent than that of proximal deep vein thrombosis of the leg. Treat-
ment of this condition is based on extrapolation of the results of acute
deep leg vein thrombosis. The duration of anticoagulation therapy is
unclear, but 3 to 6 months seems reasonable. It is possible (even likely)
that the duration of anticoagulation can be shorter if the catheter has
been removed. Additional clinical issues, such as the planned admin-
istration of intensive chemotherapy that will produce thrombocyto-
penia, should be considered in individual patients.
The timing of the removal of a CVC because of a CVC-related
thrombosis is unclear. It is the expert opinion of the CVC Care Panel
that it may not always be necessary to remove the catheter in patients
with CVC-associated thrombosis. One alternative is to keep the CVC
in place and to add systemic anticoagulants, but there are no RCTs
addressing this issue. For patients with deep vein thrombi for whom
there are contraindications for anticoagulation, such as those with
active bleeding, platelet count 50,000/
L, or recent CNS bleeding or
surgery, catheter removal is recommended, and anticoagulation ther-
apy should be initiated if and/or when it becomes possible. Patients
with cancer who have had their CVCs removed and then replaced
without anticoagulation often experience recurrent thrombosis, but
this has not been sufficiently studied. An important issue that needs to
be studied is where to put the next CVC. Future research questions
should include analyses of the development of postphlebitic syn-
drome, the importance and value of testing for thombophilia and
inherited disorders such as Factor V Leiden in patients who experience
thromboses, and the management of small pericatheter clots detected
by imaging studies in otherwise asymptomatic patients. Other ideas
for future research on CVC care for patients with cancer are available
in Data Supplement 8 at www.asco.org/guidelines.cvc.
PATIENT AND CLINICIAN COMMUNICATION
Adequate vascular access is critical for the patient with cancer and
should be included in the patient assessment when making treatment
decisions. Many CVCs are available; however, there is no evidence-
based guideline for the selection of a particular CVC for each patient
situation. Therefore, it is important for the oncologist to discuss CVC
options, including risks and benefits, with the patient. It is important
to explain to the patient that a central line may be inserted for one or
more of the following reasons:
Some chemotherapy drugs are not suitable to be adminis-
tered into small veins in the hand or arm and must be
administered in a larger vein for adequate dilution
To allow some chemotherapy treatments, such as those ad-
ministered by continuous infusion, to be administered at
home and not require a lengthy hospital stay
When extended chemotherapy treatments and frequent nee-
dle sticks to obtain blood samples are anticipated
When a patient is felt to have poor venous access in the hands
and arms not suitable for treatment infusions
When a patient verbalizes or displays anxiety regarding
needle sticks
When the oncologist and other practitioners determine that a
CVC is required, it should be explained that a central line is a long
narrow hollow tube made of soft plastic, which provides access to a
large vein in the chest. The entrance location of the catheter is depen-
dent on the type of central line, including tunneled, implanted, and
PICC. Long-term CVCs can be used for medication administration,
blood products, total parenteral nutrition, and blood drawing. Pa-
tients and caregivers of outpatients should be instructed about how to
monitor for infection at the entrance-exit sites and to report other
signs of infection or thrombosis such as fever or pain. The patient
should be informed about his or her catheter, as follows:
Types of Catheters
Nontunneled catheters. When these catheters are used, they are
most commonly placed into the subclavian vein (under the collar
bone) or internal jugular vein in the neck. With proper care from a
dedicated team, these catheters can facilitate the administration of
fluids and chemotherapy as well as the drawing of blood samples,
often for the entire duration of therapy. These will require sutures at
the site where the catheter exits the skin. These catheters do not require
that a patient go to the operating room or have general anesthesia, and
they can be removed easily when no longer needed. In urgent situa-
tions for short-term use, these catheters can be placed into the large
veins of the neck or groin but should be removed as quickly as possible
because they carry a higher risk of complications.
Tunneled catheters. Tunneled catheters, sometimes referred to
as Hickman catheters, are inserted by puncturing the vein below the
collar bone or lower neck (the insertion site) and secured by threading
Schiffer et al
1366
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the line under the skin, exiting above the nipple on the chest wall (the exit
site). The line may have a small Dacron cuff around it that imbeds into the
tissue in the skin tunnel to prevent it from falling out. A small cut is made
at both the insertion and exit sites, requiring one or two stitches in each.
The stitches are removed in approximately 3 weeks when the cuff is secure,
and the skin has healed. No needle sticks are needed with this type of
catheter. Complications may include infection or bleeding at the
entrance-exit site or in the subcutaneous tunnel, blood clots in or around
the catheter, lung collapse during insertion, and catheter occlusion.
Implanted catheters. The implantable catheter or port consists of a
catheter attached to a reservoir that is implanted into a surgically created
pocket on the chest wall or upper arm. A needle is inserted through the
skin to the septum of the port to access the reservoir. Advantages of this
type of catheter are reduced risk of infection, less frequent flushing, and
less interference with daily activities. Complications may include infection
of the port site or catheter, blood clots in or around the catheter, lung
collapse during insertion, and catheter occlusion.
Peripherally Inserted Central Catheters. The PICC line is inserted
into the upper arm veins and threaded into the larger veins in the
chest. This catheter is intended for patients requiring up to 12 months
of IV therapy. An advantage of this type of catheter is the lack of needle
sticks and placement at the bedside. Disadvantages include more
frequent flushing and dressing changes. Complications may include
infection at the exit site, blood clots in or around the catheter, and
catheter occlusion. Placement of these types of catheters above the
antecubital fossa diminishes the likelihood of thrombophlebitis.
Reliable venous access is critical for the patient with cancer
to prevent delays in treatment. Effective communication among
the oncologist, the individuals placing the venous access device,
and most importantly the patient during the treatment-
planning phase will promote improved patient outcomes. More
patient information about CVCs in cancer treatment, including
information about monitoring and caring for catheters at
home, can be found at www.cancer.net, specifically www.cancer.
net/patient/AllAboutCancer/Cancer.NetFeatureArticles/
Treatments%2CTests%2CandProcedures/Cathetersand
PortsinCancerTreatment.
HEALTH DISPARITIES
Although ASCO clinical practice guidelines represent expert rec-
ommendations on the best practices in disease management to
provide the highest level of cancer care, it is important to note that
many patients have limited access to medical care. Racial and
ethnic disparities in health care contribute significantly to this
problem in the United States. Racial/ethnic minority patients with
cancer suffer disproportionately from comorbidities, can experi-
ence substantial obstacles to receiving care, are more likely to be
uninsured, and are at greater risk of receiving poorer quality care
than other Americans.
141-144
Many other patients lack access to care
because they live at a distance from appropriate treatment facilities.
Awareness of these disparities in access to care should be
considered in the context of this clinical practice guideline, and
health care providers should strive to deliver the highest level of
cancer care to these vulnerable populations. In particular, the
availability of adequate home care for catheter maintenance
might vary widely among different patient populations and
could influence the choice of CVC. The role of the oncologist/
hematologist in guiding patient decisions should not be mini-
mized. Furthermore, although in the overall scheme of a
patient’s care, the placement of a venous access device may seem
minor, it can present difficulties that can dramatically affect a
patient’s ability to receive appropriate treatment.
ADDITIONAL RESOURCES
Data supplements, including evidence tables, and clinical tools and
resources can be found at www.asco.org/guidelines/cvc. Patient infor-
mation is available at www.cancer.net.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF
INTEREST
The author(s) indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Administrative support: Pamela B. Mangu
Manuscript writing: All authors
Final approval of manuscript: All authors
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Article
Central venous catheters (CVCs) are essential devices in the treatment of pediatric patients with hematological and oncological disorders; however, the most suitable type of CVC for these patients remains unclear. We retrospectively compared risk factors for unplanned removal of two commonly used CVCs, peripherally inserted central catheters (PICCs) and tunneled CVCs, to propose which is the better device. We followed 89 patients fitted with a tunneled CVC (total 21,395 catheter-days) and 84 fitted with a PICC (total 9177 catheter-days) between January 1, 2013 and December 31, 2015, until catheter removal. Patients with a PICC had a significantly higher 3-month cumulative incidence of catheter occlusion (5.2% vs. 0%, p = 4.08 × 10−3) and total unplanned removals (29.0% vs. 6.9%, p = 0.0316) than those with tunneled CVCs. However, the cumulative incidence of central line-associated bloodstream infection did not differ significantly by CVC type. Multivariable analysis identified younger age (< 2 years) [sub-distribution hazard ratio (SHR) 2.29; 95% confidence interval (CI) 1.27–4.14] and PICC (SHR 2.73; 95% CI 1.48–5.02) as independent risk factors for unplanned removal. Thus, our results suggest that tunneled CVCs are preferable in pediatric patients with hematological and oncological disorders requiring long-term, intensive treatment.
Article
Central venous catheters (CVCs) are important for maintenance of childhood leukemia treatment but CVCs may develop complications. The aim of this study was to retrospectively evaluate the CVC-related complication rate, complication types, and outcome in children with acute leukemia. Complications developing in 310 CVCs (ports n=250, Hickman catheters n=60) inserted in 262 patients were evaluated. A total of 225,296 catheter days were screened. Median (range) CVC in-dwelling time was 661.5 (1 to 2636) days. In total, 157 complications developed of which 91 (58%) were infectious complications, 35 (22.3%) were vascular, 19 (12.1%) were surgical, and 12 (7.6%) were mechanical. Hickman catheters had a higher complication rate and were more prone to mechanical complications (P<0.01) but there was no difference for other complications. A lower absolute neutrophil count at insertion was observed in children with infectious complications (P<0.01). Seventy-eight of 136 catheters (57.3%) had to be removed prematurely. The overall complication rate was 0.65 per 1000 catheter days. In multivariate analysis, relapse leukemia, Hickman catheter and low absolute neutrophil count increased complication risk by 4.00, 1.97, and 1.92 times, respectively. Five (1.9%) deaths occurred because of catheter complications. Safe use of CVCs can be improved by early detection of complications and an experienced catheter care team.
Article
Venous access devices are used in health care. To prevent occlusions the evidence confirmed the need for routine catheter flushing before and after infusion as well as at the end of use. To date, the efficacy of heparin has not been demonstrated. The aim of this study was to evaluate the effectiveness of the locking of central venous catheters with heparin versus normal saline in adults to prevent occlusion, catheter-related infections and thrombosis in adults. A literature search using Medline, Embase, Cochrane Library and Cinahl was performed to identify all meta-analyses addressing the effectiveness of heparin versus normal saline in locking central venous catheters in adults. Four reviewers independently selected publications assessed quality and extracted data. Parameter estimates regarding occlusion, catheter- related infections and thrombosis were pooled using an umbrella review. We identified 6356 references. Seven systematic reviews were included in the study. Most of the studies included in the systematic reviews were conducted in oncohaematology departments, intensive care and cardiac surgery units among patients with multiple diseases and chronicity. Most studies report a heparin concentration of 10 to 5000 IU/ml versus normal saline and other solutions. There was no evidence that heparin was more effective than normal saline in reducing complications such as occlusion, catheter-related infections and thrombosis. No statistically significant difference was found between heparin and normal saline in reducing catheter occlusion. Heparin is not superior compared to normal saline.
Article
PURPOSE Totally implantable ports require regular maintenance to prevent port-related complications. Manufacturers recommend monthly maintenance port flushes for patients for the life of the port. Previous studies show that extending intervals between maintenance port flushes up to 16 weeks does not increase incidence of port-related complications. To date, no prospective study has been conducted to evaluate the medical safety of extending flush intervals from monthly to every 12 weeks within a heterogeneous disease cohort. Research Question: Is it feasible and medically safe to extend intervals between maintenance port flushes to every 12 weeks in patients with cancer not on active treatment? PATIENTS AND METHODS This study enrolled oncology and hematology patients who had retained their port following completion of anticancer treatment. Clinical data were extracted for 1,059 participants. The primary end points of this study were the overall number of ports removed and incidence of port-related complications reported between cohorts 1 and 2 (flushes every 4-8 weeks), and cohort 3 (flushes every 12 weeks). RESULTS Data were allocated into three study cohorts on the basis of year and duration between port flushes. No difference was observed in the overall percentage of ports removed because of physician-reported complications across all cohorts (25%-30%). No change in the incidence of port-related complications including suspected infection and malfunction was observed between cohorts 1 and 2 (8%), or cohort 3 (5%). CONCLUSION Our findings show that extending maintenance port flush intervals to 12 weeks does not increase the incidence of port-related adverse events and is medically safe.
Chapter
Insertion and management of vascular access are critical concerns for children affected by malignancies. Prolonged course of disease, complexity, and variety of treatment protocols require long-lasting vascular access to provide an adequate avenue for administration of intravenous therapies as well as to allow routine blood sampling without repeated and painful venipuncture. For those reasons, central venous catheters are nowadays an important component in the care of this patient population, with a direct influence on outcome. In this respect, there are peculiar issues (techniques of insertion, management, complications etc.) which must be known to improve both quality of life over the course of the disease and outcome of children with cancer.
Article
Background: Children and adolescents with cancer often undergo aggressive treatment and receive supportive care requiring a long-term tunneled central venous catheter (TCVC). Regular flushing promotes TCVC patency when not in use (i.e., noninfusing). However, TCVC flushing guidelines and the current practice of daily flushing are not based on high-quality evidence. Few studies have compared the effect of less frequent flushing on TCVC patency. The purpose of this study was to evaluate the feasibility of a three times weekly heparin flushing intervention, as compared to daily heparin flushing, in children and adolescents and young adults (AYAs) with noninfusing TCVCs. Methods: Twenty children and AYAs were randomized to one of two groups, standard of care (SOC) (i.e., daily heparin flushing) or intervention (three times weekly heparin flushing) for 8 weeks. Feasibility data (recruitment, retention, acceptability, TCVC patency, and complications) were analyzed descriptively. Results: Twenty of 22 eligible patients were enrolled in the study (90% recruitment rate). Four participants discontinued the study early due to TCVC removal (20% attrition rate). One participant in each group had their TCVC removed due to a central line-associated bloodstream infection, one SOC group participant had their TCVC removed due to damage, and one intervention group participant had their TCVC removed due to discontinuation of treatment. No participants were withdrawn for safety concerns or because they did not find the protocol acceptable. Conclusions: It is feasible to conduct a large-scale randomized controlled trial to investigate a three times weekly heparin flushing intervention in children and AYAs with TCVCs.
Article
Background Catheter-related thrombosis (CRT) is a common complication in cancer patients, that may lead to chemotherapy deferral, elevated risk for systemic infections and pulmonary embolism. This study aimed to assess CRT incidence and risk factors in newly-diagnosed acute myeloid leukemia (AML) patients and create predictive models potentially allowing to decrease CRT occurrence in this population. Methods This retrospective single-center analysis included all AML patients treated at the Rambam Health Care Campus between 2006 and 2019. Patient clinical and laboratory data were collected to evaluate thrombosis occurrence and time from AML diagnosis to CRT development. Multivariate classification models were created using logistic regression (LR) and competing risk analyzes. Results The final analysis included 632 newly-diagnosed AML patients (mean age 54 ± 15 years). CRT incidence was 10.1% [confidence interval (CI) 7.7–12.9%], median time from AML diagnosis to CRT was 12.5 days [interquartile range 6–30]. In an LR multivariate model, prior history of venous thromboembolism [adjusted odds ratio (AOR) 12.046, p < 0.0001], acute promyelocytic leukemia (APL) (AOR 2.824, p = 0.015), a high body mass index and initial platelet counts <100 × 10E9/L (AOR 1.059 and 0.546; p = 0.011 and 0.040, respectively) were significantly associated with high CRT risk. Analysis of 587 non-APL patients demonstrated comparable results, with CRT incidence of 9.3% (CI 7.0%-12.1%) and emergence of chronic obstructive pulmonary disease (COPD) as a novel significant co-factor (AOR 34.491, p = 0.004). In both models, the area under curve (AUC) was ≥70%. Conclusions Significant CRT risk factors defined using the created model could be used for identification of high-risk newly-diagnosed AML patients requiring CRT prophylaxis.
Article
Central vascular access devices (CVADs) are often essential to the care of patients undergoing long-term cancer treatment. CVAD maintenance is an essential oncology nurse competency. Evidence-based practice (EBP) in flushing and locking help to prevent intraluminal occlusion, a common complication. Heparinized saline (HS) has been the standard locking solution for CVADs. However, research indicates no superiority of HS over normal saline (NS). The objectives of this EBP project were 1) to evaluate whether a significant difference in intraluminal occlusion was associated with the change from HS to NS use for locking CVADs in ambulatory oncology care, and 2) to evaluate the effects of peer nurse mentoring on nurses’ and patients’ perspectives about the practice change. Analysis of data revealed decreases in alteplase usage after transitioning to NS locking. Patient and nurse surveys indicated that peer nurse mentoring increased nurse and patient confidence and competence in making the practice transition.
Article
Les patients recevant un traitement à long terme contre le cancer doivent très souvent se faire poser un cathéter veineux central (CVC). L’entretien du CVC est donc une compétence fondamentale des infirmières en oncologie. Les pratiques d’irrigation et de fermeture du CVC fondées sur la recherche aident à prévenir l’occlusion intraluminale, une complication fréquente. Les normes recommandent l’utilisation d’un soluté physiologique hépariné pour fermer le CVC; toutefois, selon la recherche, le soluté hépariné n’est pas plus efficace que le seul sérum physiologique. Les objectifs du présent projet de pratique fondée sur la recherche étaient : 1) d’évaluer si la fermeture au sérum physiologique plutôt qu’au soluté hépariné était liée à une différence significative du nombre de cas d’occlusion intraluminale chez les patients suivis en clinique d’oncologie externe; et 2) d’évaluer les effets du mentorat entre pairs sur le point de vue des infirmières et des patients quant au changement de pratique. L’analyse des données a révélé une diminution de l’utilisation d’altéplase après l’adoption du sérum physiologique pour fermer les CVC. Les sondages réalisés auprès des patients et des infirmières montrent que le mentorat entre pairs accroît la confiance des infirmières et des patients, ainsi que l’habileté à procéder au changement de pratique.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the effectiveness and safety of anticoagulant thromboprophylaxis in reducing VTE events in cancer patients with CVL. We will assess all anticoagulants approved for clinical use. There are currently five anticoagulants available: unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), fondaparinux and ximelagatran.
Article
Forty-five children with oncologic or hematologic disorders requiring tunneled central venous catheters (TCVC) for the administration of immunosuppressive therapy were randomized to receive either 10 U/mL heparin (H) (24 patients) or a solution of 10 U/mL H and 25 μg/mL vancomycin (H-V) (21 patients) for all catheter flushes. Episodes of fever or suspected sepsis were evaluated to determine whether the addition of vancomycin to the flush solution would alter the incidence of symptomatic bacteremia attributed to luminal colonization of TCVC with vancomycin-susceptible bacteria. Patients were enrolled for 247 ± 150 days, accounting for a total of 11,095 days of catheter use. Bacteremia attributed to luminal colonization with vancomycin-susceptible organisms occurred in five patients (six infections) receiving H alone compared with zero patients receiving H-V (P = .035). The time to the first episode of bacteremia with vancomycin-susceptible organisms, analyzed by Kaplan-Meier survival curves, was significantly longer in patients receiving H-V (P = .04). There were no differences in the incidence of other infections including bactermia attributed to luminal colonization with vancomycin-resistant organisms, other bacteremias (including those arising from the catheter exit site), exit-site cellulitis, or fungal infections. No organisms resistant to vancomycin were identified. Vancomycin could not be detected in the peripheral blood of patients receiving vancomycin in the flush solution. No vancomycin-related toxicities were noted. We conclude that the use of an H-V flush solution in immunocompromised patients with TCVC can decrease the frequency of bacteremia attributed to luminal colonization with vancomycin-susceptible bacteria.
Article
Objective To examine the rate of success and complications of Doppler-guided subclavian vein catheter insertion compared with standard insertion in patients considered at high risk for failure.Design Prospective, randomized, crossover trial.Setting University-affiliated tertiary care medical center.Patients Two hundred forty patients were enrolled in the study. Patients were stratified for 3 known risk factors: (1) prior surgery in the subclavian vein region, (2) prior radiotherapy at the attempted catheterization site, and (3) an abnormal weight-height ratio.Interventions Subclavian vein catheterization was performed either in standard or Doppler-guided fashion using the Smart Needle (Peripheral Systems Group, Mountain View, Calif), which is a Doppler probe at the tip of a cannulating needle. If subclavian vein catheterization was unsuccessful after 2 attempts, patients were crossed over to the other technique.Main Outcome Measure Successful cannulation of the subclavian vein.Results The success rate, either as an initial technique or as a salvage technique, and complication rate were not significantly different with use of the Smart Needle. A subgroup of physicians had a significantly lower success rate using the Smart Needle.Conclusions Doppler guidance did not increase the success rate or decrease the complication rate of subclavian vein catheterization when compared with the standard technique in high-risk patients. Doppler guidance was not more useful than the standard technique as a salvage technique following a previous failure of catheterization. Furthermore, real-time Doppler guidance of subclavian vein catheterization is a technique that is highly operator dependent.
Article
Objective: To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients. Data Sources: We searched for published and unpublished research by means of MEDLINE and Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, review of personal files, and contact with primary investigators. Study Selection: From a pool of 151 randomized, controlled trials on central venous catheter management, we identified 12 relevant randomized trials of catheter replacement over a guidewire or at a new site. Data Extraction: In duplicate and independently, we abstracted data on the population, intervention, outcome, and methodologic quality. Data Synthesis: As compared with new-site replacement, guidewire exchange is associated with a trend toward a higher rate of catheter colonization (relative risk 1.26, 95% confidence interval 0.87 to 1.84), regardless of whether patients had a suspected infection. Guidewire exchange is also associated with trends toward a higher rate of catheter exit-site infection (relative risk 1.52, 95% confidence interval 0.34 to 6.73) and catheter-related bacteremia (relative risk 1.72, 95% confidence interval 0.89 to 3.33). However, guidewire exchange is associated with fewer mechanical complications (relative risk 0.48, 95% confidence interval 0.12 to 1.91) relative to new-site replacement. Exchanging catheters over guidewires or at new sites every 3 days is not beneficial in reducing infections, compared with catheter replacement on an as-needed basis. Conclusions: Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement. More studies on scheduled vs. as-needed replacement strategies using both techniques are warranted. If guidewire exchange is used, meticulous aseptic technique is necessary. (Crit Care Med 1997; 25:1417-1424)
Article
Objective To evaluate the effect of heparin on thrombus formation and infection associated with use of central venous and pulmonary artery catheters. Data sources We used MEDLINE, EMBASE, citation review of relevant primary and review articles, personal files, and contact with expert informants. Study selection Fourteen randomized controlled trials evaluating prophylactic doses of heparin or heparin bonding were included. Data extraction In duplicate, independently, we abstracted data on the population, intervention, outcome, and methodologic quality. Data synthesis Prophylactic heparin decreases catheter-related venous thrombosis (relative risk [RR], 0.43; 95% confidence interval [CI], 0.23, 0.78) and bacterial colonization (RR, 0.18; 95% CI, 0.06, 0.60) of central venous catheters and may decrease catheter-related bacteremia (RR, 0.26; 95% CI, 0.07, 1.03). Heparin bonding decreases the risk of pulmonary artery catheter clot formation within 24 h (RR, 0.08; 95% CI, 0.02, 0.37). Conclusions Heparin administration effectively reduces thrombus formation and may reduce catheter-related infections in patients who have central venous and pulmonary artery catheters in place. Cost-effectiveness comparisons of unfractionated heparin, low molecular weight heparin, and warfarin are needed.