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

March 2013
Journal of Clinical Oncology 31(10)

DOI:10.1200/JCO.2012.45.5733

Source
PubMed

Authors:

Pamela Mangu

American Society of Clinical Oncology

Dawn Camp-Sorrell

Children's Hospital of Alabama

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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.

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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.

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.

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.

CVCs have a considerable potential for serious

complications, which are often underappreciated.

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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)

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.

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

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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

Central Venous Catheter Care for the Patient With Cancer

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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,

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

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%).

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

and one RCT

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

; 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.

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

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

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

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,

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

and the IDSA 2009 Update of the Clinical Practice

Guidelines for the Diagnosis and Management of Intravascular Catheter-

Related Infection

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.

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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)

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%.

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

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.

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

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,

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,

BSIs were four times less likely to originate from impregnated silicone

catheters. In a meta-analysis

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.

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).

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.

This recommendation is supported speciﬁ-

cally for patients with cancer in one RCT

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,

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

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

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

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.

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

(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.

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

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%,

whereas another review found that on average, 12% of CVC throm-

bosis events were symptomatic.

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/All⫹About⫹Cancer/Cancer.Net⫹Feature⫹Articles/

Treatments%2C⫹Tests%2C⫹and⫹Procedures/Catheters⫹and⫹

Ports⫹in⫹Cancer⫹Treatment.

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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Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

Article

Jul 2023

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review. Fullsize Image

Peripherally inserted central venous catheter in Autologous Hematopoietic Stem Cell Transplantation: Feasibility and Outcome

Article

Full-text available

Jun 2023

Objectives: This study describes our experience using PICC in patients submitted to autologous stem cell transplant (ASCT) regarding the time of use, withdrawal reasons, and complications. Methods: A retrospective cohort of 143 patients from 2017 and 2019, with a PICC inserted before the ASCT. Results: Regarding baseline disease, 104 (73%) of patients had multiple myeloma. The median days of use was 15 (1 – 37) per catheter. More than 80% of PICC remained in place after D+15, and 112 (78%) patients had the PICC removed at discharge. Only 13 (9%) patients had replacement of the PICC. The rates of central line associate bloodstream infection and thrombosis were 1.36 and 1.36 events per 1,000 PICC days, respectively. Conclusions: PICCs were successfully remained until discharge, with manageable rates of complications. All procedures were executed by nurses at the bedside. We concluded that PICC is a safe and feasible alternative to CVC for ASCT.

A Survey on Handling and Administration of Therapeutic Protein Products in German and Swiss Hospitals

Article

Sep 2023
J PHARM SCI-US

A GAVeCeLT bundle for PICC-port insertion: The SIP-Port protocol

Article

Full-text available

Nov 2023
J Vasc Access

In the last decade, a new type of brachial port has been introduced in clinical practice, the so-called “PICC-port.” This is a brachial port, but inserted according to the methodologies and technologies currently adopted for the insertion of peripherally inserted central catheters (PICCs). Several studies have shown that PICC-port insertion is safe, not associated with any relevant immediate or early complication, and that the expected incidence of late complications is significantly lower if compared to “traditional” brachial ports (i.e. inserted without ultrasound guidance). Furthermore, PICC-ports yield excellent esthetic results and are associated with optimal patient compliance. This paper describes an insertion bundle—developed by GAVeCeLT, the Italian Group of Long Term Venous Access Devices, and nicknamed “SIP-Port” (Safe Insertion of PICC-Ports)—which consists of few evidence-based strategies aiming to further minimize all immediate, early, or late complications potentially associated with PICC-port insertion. Also, this insertion bundle has been developed for the purpose of defining more closely the differences between a traditional brachial port and a PICC-port. The SIP-Port bundle is currently adopted by all training courses on PICC-port insertion held by GAVeCeLT. It includes eight steps: (1) preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; (2) appropriate skin antiseptic technique and maximal barrier precautions; (3) choice of appropriate vein, in terms of caliber and site; (4) clear identification of the median nerve and of the brachial artery during the venipuncture; (5) ultrasound-guided puncture and cannulation of the vein; (6) ultrasound-guided tip navigation; (7) intra-procedural assessment of tip location by intracavitary ECG or by trans-thoracic echocardiography; (8) appropriate creation and closure of the subcutaneous pocket.

Published trends and research hotspots of central venous catheter-associated thrombosis from 1973 to 2022: A scientometric analysis

Article

Nov 2023
MEDICINE

This study aims to explore the intellectual landscape and research hotspots in the central venous catheter-related thrombosis (CVC-RT) research field. Studies discussing CVC-RT published from 1973 to 2022 in the Web of Science Core Collection database were retrieved on February 24th, 2022. Citespace was used to perform a scientometric analysis to identify the intellectual landscape and research hotspots in the research fields of CVC-RT. A total of 4358 studies were retrieved, with an ascending trend in publication numbers. The United States of America was the most influential country. The Journal of Vascular Access published the most studies, and McMaster University was the most prolific institution. The results showed that the focus population of CVC-RT research has changed from pediatric patients to cancer patients, the management of CVC-RT has become more formal and standardized, and the focused CVC type has shifted to port and peripherally inserted central catheters. In addition, seventeen active burst keywords were detected, such as patient safety, clinical practice guidelines, and postthrombotic syndrome. This study comprehensively reviewed publications related to CVC-RT. The research topics on patient safety, clinical practice guidelines, and postthrombotic syndrome related to CVC-RT may be future hotspots.

Peripherally inserted central venous catheter for pediatric acute leukemia: A retrospective 11-year single-center experience

Article

Jul 2023
J Vasc Access

Background: Peripherally inserted central catheters (PICCs) are successfully increasingly used in children in onco-hematologic setting. PICC insertion, especially in oncologic patients, can be associated with adverse events (thrombosis, mechanical complications, and infections). Data regarding the use of PICC, as long-term access in pediatric patients with severe hematologic diseases, are still limited. Methods: We retrospectively evaluated the safety and efficacy of 196 PICC, inserted in 129 pediatric patients with acute leukemia diagnosed and treated at Pediatric Hematology Unit, Sapienza University of Rome. Results: The 196 PICC analyzed were in situ for a median dwell time of 190 days (range 12-898). In 42 children, PICC was inserted twice and in 10, three times or more due to hematopoietic stem cell transplant, disease recurrence, or PICC-related complications. The overall complication rate was 34%: catheter-related bloodstream infections (CRBSI) occurred in 22% of cases after a median time of 97 days; a catheter-related thrombosis (CRT) in 3.5% and mechanical complications in 9% of cases. Premature removal for complications occurred in 30% of PICC. One death from CRBSI was observed. Conclusions: To our knowledge, this study represents the largest cohort of pediatric patients who have inserted the PICC for acute leukemia. In our experience, PICC was a cheap, safe, and reliable device for long-term intravenous access in children with acute leukemia. This has been possible with the help of dedicated PICC team.

Complications and Management Strategies of Totally Implantable Venous Access Devices

Article

Jan 2023

宸君郭

A multi-national survey of experience and attitudes towards managing catheter related blood stream infections for home parenteral nutrition

Article

Jun 2023

Management of Head and Neck Cancer Patients During the Epidemic of COVID-19 in Wuhan

Article

Jun 2020

Complication rates of peripherally inserted central catheters vs implanted ports in patients receiving systemic anticancer therapy: A retrospective cohort study

Article

May 2023
INT J CANCER

While implanted port catheters ("PORTs") have historically been the standard device for intravenous systemic anticancer therapy, the use of peripherally inserted central catheters (PICCs) has increased continuously and reliable catheter selection guidelines are lacking. We compare complication rates of PORTs and PICCs in cancer treatment in a retrospective study of 3365 patients with both solid organ (n = 2612) and hematologic (n = 753) malignancies, between 2001 and 2021. 26.4% (n = 890) of all patients were treated via PICCs and 73.6% (2475) via PORTs. 20.7% (578) experienced a major catheter-related complication with a higher rate in PICCs than in PORTs (23.5% vs 14.9%, P < .001). Among major complications, infections and mechanical complications were more common in PICCs than in PORTs (11.9% vs 6.4%, P = .001, 7.3% vs 4.2%, P = .002), whereas the rate of thrombosis was similar (3.4% vs 3.0%, P = .9). While PORTs had a higher rate of periprocedural complications (2.7% vs 1.1%, P < .05), PICCs overall complication rate exceeded PORTs within 3 days from implantation. Median follow-up was 49 (PICC) and 60 weeks (PORT). PORTs are safer and therefore should be preferred in this setting regardless of catheter dwell time.

Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection

Article

Oct 1989

Anticoagulation for thrombosis prophylaxis in cancer patients with central venous lines

Article

Apr 2007

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.

Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin-susceptible organisms

Article

Sep 1990

C. Schwartz

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.

Prospective, Randomized Trial of Doppler-Assisted Subclavian Vein Catheterization

Article

Oct 1998
ARCH SURG-CHICAGO

Richard J. Bold

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.

Central venous catheter replacement strategies

Article

Aug 1997
CRIT CARE MED

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)

Benefit of H

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

Abstract