Article

Cathéters à chambre implantable : épidémiologie des complications et étude microbiologique des dispositifs après ablation

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Abstract

Totally implantable venous access ports (TIVAP) are valuable medical devices for long-term intravenous treatment such as parenteral nutrition, cancer chemotherapy or antiviral therapy. Implantation and use of these devices are each associated with infectious or mechanical complications. To determine the frequency of complications and to analyze bacterial contamination of different parts of TIVAP (tip, septum, internal lumen of the port). Clinical charts of patients, which TIVAP was removed between April 20th to December 31st 2003, were retrospectively reviewed. Infectious complications (local and septicemic) and non-infectious complications (i.e. obstruction, thrombosis, drug extravasation...) were defined using clinical and/or microbiological criteria. Quantitative culture from different parts of the TIVAP was performed. One hundred and ten patients (age 57 +/- 14-years-old, 94.3% cancers) were included, corresponding to 57,018 catheter-days: 39.1% had one or more non-infectious complications (density incidence: 0.86 for 1000 catheter-days). Among the 49 complications, obstruction, thrombosis, extravasations and malposition accounted for 30.6%, 30.6% 4.1% and 6% of cases. Twenty-one patients (19.1%) had an infectious complication: 11 were local and 14 were systemic (density incidence 0.43 for 1000 catheter-days). Bacteria responsible for TIVAP-associated bacteraemia were coagulase negative staphylococci (N = 2), Staphylococcus aureus susceptible to methicilline (N = 3), micrococci (N = 1), corynebacteria (N = 1) or Gram-negative bacilli (N = 8). Comparison of quantitative culture of the different parts of TIVAP with a threshold at 10(3) CFU/ml showed that culture of tip, septum and port has a sensitivity of 47.6% 57.1% and 61.9 %, respectively and a specificity of 100% 92.1% and 92.1%, respectively for the diagnosis of TIVAP infection. Complications associated to TIVAP are frequent but incidence that we have reported is comparable with previous studies. Analysis of internal lumen of the port is the most sensitive method for the diagnosis of TIVAP-associated infections.

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... Maki DG et al montrent, dans une revue de la littérature, que l'incidence moyenne des bactériémies associées aux CCI est de 0,10 pour 1000 jourscathéters (59). Elles restent, cependant, plus faibles que celles des cathéters centraux (44,50,54). Ces données sont présentées dans le tableau 5. Karnofski, un index élevé de co-morbidité de Charlson, la présence de métastases et un taux de protéine C-réactive (CRP) élevé (70). ...
... Les CCI, apparues dans les années 80, sont largement utilisées dans les établissements de santé et en ambulatoire (6). Bien que ces dispositifs soient associés à un moindre risque infectieux par rapport aux CVC (44,50,54), la pose, la manipulation et l'entretien de la CCI peuvent s'accompagner de complications infectieuses. La production de recommandations pour la prévention de ces complications est essentielle. ...
... Localisation veineuse des chambres à cathéter implantables(47) Plus rarement, les cathéters peuvent être situés au niveau des veines céphaliques, jugulaires externes, brachiales ou fémorales(48,49).Le motif de pose d'une CCI est la nécessité d'utiliser, de façon prolongée et répétée dans le temps, le système veineux central. Les principales indications sont (41,47) : -Les chimiothérapies anticancéreuses qui représentent l'indication la plus fréquente : l'administration des produits anticancéreux dans des veines de faible calibre provoque des lésions vasculaires -L'antibiothérapie prolongée ou récurrente dans certaines indications -La nutrition parentérale -La transfusion répétée de produits sanguins labiles La présence d'un cathéter intravasculaire expose à quatre complications principales : -les complications infectieuses -la thrombose -la rupture du cathéter -l'extravasion du soluté autour du réservoir Le délai de survenue de ces complications permet de les classer en trois catégories (44) : -Les complications immédiates qui apparaissent dès les premières heures suivant la pose -Les complications précoces qui apparaissent dans le premier mois d'utilisation, et qui sont souvent liées à l'acte chirurgical -Les complications tardives qui apparaissent après plusieurs mois, voire davantage, et sont liées à l'utilisation de la CCI D'après les données de la littérature, la majorité des complications liées aux CCI apparaissent précocement(44,(50)(51)(52). ...
Thesis
La sécurité des soins est une préoccupation internationale et s'intègre dans un dispositif national deplus en plus exigeant. Le signalement des infections associées aux soins (IAS) est obligatoire suivid'une recherche des causes. Des déposes de chambres à cathéter implantables (CCI) ont été signaléesau service d'Hygiène Hospitalière, pour suspicion de complications infectieuses.L'objectif de ce travail était de réaliser une évaluation des pratiques professionnelles liées à la prise encharge diagnostique et thérapeutique des complications infectieuses sur CCI afin d'améliorer leur priseen charge.Deux services ont participé à l'audit clinique. Les patients inclus étaient des patients présentant unesuspicion de complications infectieuses sur CCI entre octobre 2012 et juin 2013 pour le premier tour etentre janvier et avril 2014 pour le second tour. Un référentiel comprenant quatre critères de jugement aété défini grâce aux recommandations nationales et internationales.Cette étude a mis en évidence des écarts de pratiques. Lors du premier tour, trente-cinq dossiers ontété jugés non conformes sur quarante-sept étudiés. Cinquante non-conformités ont été répertoriéesconcernant la prise en charge thérapeutique. Les plus fréquentes étaient : absence de réévaluation del'antibiothérapie (10/50), absence de désescalade de l'antibiothérapie (10/50), absence de la réalisationd'un verrou antibiotique (8/50) et ablation de la CCI jugée comme « réalisée à tort » (6/50). L'absencede recherche de complications était la non-conformité la plus fréquente concernant la prise en chargediagnostique. Une sensibilisation auprès des équipes médicales a été faite en proposant cinq mesurescorrectives. La comparaison des résultats des deux tours n'a pas mis en évidence une améliorationsignificative des pratiques. Sur les vingt dossiers étudiés, cinq présentaient une prise en charge globaleconforme. Vingt non-conformités ont été répertoriées. Les mêmes types de non-conformités ont étéretrouvés.La prise en charge diagnostique et thérapeutique des complications infectieuses reste difficile. Ils'avère nécessaire de mettre en place un protocole validé reprenant la démarche à suivre lors de laprise en charge d'un patient porteur de CCI présentant une suspicion de complication infectieuse.
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From 2010 to 2015, a study analysed the infections of implantable ports in haematology patients. Communication, collaboration and diligence were some of the main issues raised. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
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To evaluate the quality of care during the insertion and the maintenance of the implanted subcutaneous ports, an epidemiological surveillance has been set up in all wards of a university hospital. The methodology of surveillance is based on two database files : the nosocomial bacteriemia file and the file of surgical operations consisting in the implantation of subcutaneous ports. 140 ports were inserted (13110 port days) and the frequency of the infection was 4.3 %, namely 0.46 case for 1000 port days. The proposed methodology seemed reliable, but heavy in cost of work. The denominator constituted by the number of ports implanted is easy to obtain but in a routine maintenance, it is difficult to get the number of port days. The severity of these infections and the importance of the quality of care for taking charge of these devices incite to carry on a minimum epidemiological surveillance and to spread information about the good practices to comply with.
Article
Introduction. By offering a rapid and convenient vascular access option for hemodialysis, permanent catheters are increasingly used in ESRD patients. Indeed, permanent catheters are associated with an increased risk for complications. Moreover, catheter bearing spoils the self body image and may alter the quality of life of dialysis patients. Implantable port catheter device, recently introduce in dialysis, may offer an attractive option, able to reduce most of infectious risk and inconveniences of the permanent catheters. Patient and material. The Dialock (Biolink®) device was evaluated in a multicenter French trial. Twelve dialysis facilities enrolling 51 ESRD patients (male 28, female 23, age 56 ± 2 years) participated in this trial. Dialock devices were inserted in patients for whom a permanent venous catheter was indicated. The cumulative experience was 56,8 years-patient. The technical survival (intent to treat) of Dialock devices was 85% at two years. Blood flow were 299 ± 7 ml/min. Dialysis adequacy was achieved in all patients without altering dialysis schedule (3 sessions per week, 240 ± 30 min each). Dialysis dose (K(Ndp) delivered was 1,3 ± 0,2. Satisfaction of patients and nursing staff was achieved in 75% of cases. Normalized incidence of complications (events for 1000 patient-days) in the evaluation phase (II) were as follows: hematoma and/or small bleeding (2,1), bacteremia (1,1), device infection (0,2), skin necrosis (0,1). A significant reduction of the infection and hematoma incidence rate was noticed when heparin lock was substituted for an non hemorragic antithrombotic locking solution (fragmented heparin or sodium citrate). This observation tend to accreditate the hypothesis that port catheter infection occurs via a transluminal bacteria passage. Conclusion. The Dialock device, offers a new and comfortable hemodialysis vascular access for ESRD patients. Performances are in agreement with those needed to achieve adequate dialysis. The regular use of dual antithrombotic-antiseptic catheter locking solution seems to be necessary to prevent any bacterial contamination.
Article
To evaluate infectious morbidity associated with long-term use of venous access devices. Prospective, observational study. Comprehensive cancer center at a university hospital. 1431 consecutive patients with cancer requiring 1630 venous access devices for long-term use inserted between 1 June 1987 and 31 May 1989. Quantitative microbiologic tests to identify device-related bacteremia and fungemia, catheter tunnel infection, pocket infection in implantable port devices, and site infections; number of days the device remained in situ and time until infectious morbidity; vessel or device thrombosis and device breakage. At least one device-related infection occurred with 341 of 788 (43% [95% CI, 39% to 47%]) catheters compared with 57 of 680 (8% [CI, 6% to 10%]) completely implanted ports (P
Article
To evaluate the quality of care during the insertion and the maintenance of the implanted subcutaneous ports, an epidemiological surveillance has been set up in all wards of a university hospital. The methodology of surveillance is based on two database files : the nosocomial bacteriemia file and the file of surgical operations consisting in the implantation of subcutaneous ports. 140 ports were inserted (13110 port days) and the frequency of the infection was 4.3 %, namely 0.46 case for 1000 port days. The proposed methodology seemed reliable, but heavy in cost of work. The denominator constituted by the number of ports implanted is easy to obtain but in a routine maintenance, it is difficult to get the number of port days. The severity of these infections and the importance of the quality of care for taking charge of these devices incite to carry on a minimum epidemiological surveillance and to spread information about the good practices to comply with.
Article
The results of a simplified quantitative broth dilution quantitative tip culture (QTC) of 331 central venous catheters were compared with clinical data prospectively recorded in critically III patients to diagnose bacteremic or nonbacteremic catheter-related sepsis (CRS) (36 catheters), as opposed to contamination (42 catheters) or simple colonization from a distant septic focus (seven catheters). Thirty-five of 36 catheters associated with CRS yielded 10(3) colony-forming units per milliliter (CFU/mL) or more, and 3.8 X 10(2) Candida organisms grew from one. In contrast, 5 X 10(2) CFU/mL or less grew from 37 of 42 contaminated catheters. A QTC of 10(3) CFU/mL or more was 97.5% sensitive and 88% specific for the diagnosis of CRS. The QTC appeared especially useful for the diagnosis of CRS secondary to blood-borne seeding of catheters, or associated with coagulase-negative staphylococci.
Article
Implanted venous access port infection can be difficult to diagnose and treat. If device removal is necessary, confirming port infection is problematic. Culture specimens from three sites, catheter tip (Tip), port pocket, and the material within the reservoir (Inside), were sent from ports removed for potential infection. The results of these cultures were compared to preremoval peripheral and central blood cultures. Forty-five ports were removed for suspected infection. Confirmed port infection was defined as positive culture(s) from one or more experimental specimen(s). In 29 evaluable cases, the Inside specimens were completely predictive. Tip specimens were less accurate, even with a lower diagnostic threshold. In 7 of 19 confirmed infections, only the Inside culture was diagnostic. The most predictive culture specimen in a potentially infected port is the thrombotic material inside the reservoir.
Article
To evaluate infectious morbidity associated with long-term use of venous access devices. Prospective, observational study. Comprehensive cancer center at a university hospital. 1431 consecutive patients with cancer requiring 1630 venous access devices for long-term use inserted between 1 June 1987 and 31 May 1989. Quantitative microbiologic tests to identify device-related bacteremia and fungemia, catheter tunnel infection, pocket infection in implantable port devices, and site infections; number of days the device remained in situ and time until infectious morbidity; vessel or device thrombosis and device breakage. At least one device-related infection occurred with 341 of 788 (43% [95% CI, 39% to 47%]) catheters compared with 57 of 680 (8% [CI, 6% to 10%]) completely implanted ports (P < or = 0.001). Device-related bacteremia or fungemia is the predominant infection occurring with catheters, whereas ports have a more equal distribution of pocket, site, and device-related bacteremia. The predominant organisms isolated in catheter-related bacteremia were gram-negative bacilli (55%) compared with gram-positive cocci (65.5%) in port-related bacteremia. The number of infections per 1000 device days was 2.77 (95% CI, 2.48 to 3.06) for catheters compared with 0.21 (CI, 0.16 to 0.27) for ports (P < or = 0.001). Based on a parametric model of time to first infection, devices lasted longer in patients with solid tumors than in those with hematopoietic tumors. Ports lasted longer than catheters across all patient groups. The incidence of infections per device-day was 12 times greater with catheters than with ports. Patients with solid tumors were the least likely to have device-related infectious morbidity compared with those with hematologic cancers. The reasons for the difference in infectious complications is uncertain but may be attributable to type of disease, intensity of therapy, frequency with which devices are accessed, or duration of neutropenia.
Article
Few reports have been made regarding the long term safety of implantable venous access devices used for the delivery of chemotherapeutic agents. The authors' goals were to determine the frequency of complications in patients receiving chemotherapy with these devices; to determine whether complications were associated with the mode of chemotherapy delivery (push/bolus or infusional regimens); and to evaluate the influence of other risk factors, including home-based versus hospital-based administration. A total of 152 oncology patients at the John L. McClellan Memorial Veterans Administration Medical Center in Little Rock, Arkansas (ages 26-81 years; mean age, 62 years), who underwent surgical placement of an Infus-a-Port (Strato, Inc., Beverly, MA) between May 1, 1992 and May 31, 1994, were evaluated retrospectively for postplacement device complications, such as infection, thrombosis, and mechanical failure. Twenty-seven patients experienced 1 complication each: 17 episodes of device-related sepsis, cellulitis, or fever of unknown origin; 8 episodes of thrombosis or catheter occlusion; 1 episode of drug extravasation; and 1 mechanical failure. Patient age, frequency of port accession, mode of chemotherapy delivery, tumor type, and neutropenia were evaluated as risk factors, but none was statistically significant. Complications were more frequent during the first 90 days after implantation, but they continued to occur throughout the observation period. Complications attributable to an implantable venous access device were infrequent in this patient population. No differences in complications for patients receiving home-based versus hospital-based chemotherapy administration were noted, opening the possibility of significant time and cost savings with home treatment.
Article
Experience of the Port-A-Cath implantable venous access system in 53 children with severe or moderate haemophilia A or B from seven centres in five countries is reviewed. The cumulative duration of follow-up was 1578 months (median 30 months, range 1-114). Of the devices implanted, 70% (37/53) were used without complications (median follow-up 32 months; range 1-114) and the remaining 30% (16/53) were associated with various types of complication: infection, bacteraemia or septicaemia in 56% (9/16) of cases, i.e. a rate of 0.07 per follow-up year or 0.19 per 1000 patient days, or various technical complications occurring after a median of 32 months (range 4-75) of uncomplicated use in the remaining 44% (7/16). Of the patients with inhibitors, 64% (7/11) manifested complications. Both doctors and parents considered that the Port-A-Cath device can be used with an acceptable frequency and severity of complications, and that it enables regular prophylactic or on-demand home treatment of children with haemophilia to be begun at an early age.
Article
Totally implantable central venous access devices (ports) have been available for over 10 years but have not achieved widespread use in paediatric oncology patients. We reviewed our experience with these devices over 9 years to assess their safety and acceptability. We conducted a retrospective review of insertion technique and reasons for removal of all ports placed in paediatric oncology patients in this hospital between 1989 and 1996, with follow-up until 1998. Acceptability of both ports and external catheters was assessed by a questionnaire in a subgroup of families attending the oncology clinic. One hundred forty-nine ports were inserted during the study period. The median catheter life was 399 days (4-1,406), with a total of 69,342 catheter days. Sixty-nine percent of ports were removed electively at the end of treatment; 8% required removal because of infection and 5% because of blockage. No ports were accidentally dislodged or damaged. Children experienced significantly less restriction of activity with a port compared to an external catheter and greatly preferred the cosmetic appearance. The need for needle insertion to access the port was not seen as a disadvantage by most families. Ports can provide satisfactory central venous access for the majority of paediatric oncology patients, with a low risk of line-related complications and a high degree of acceptability to children and their parents.
Article
Chronic indwelling central venous access devices (CICVAD) generally are placed by the percutaneous subclavian vein approach. The cephalic vein cutdown approach is used only infrequently. Although the technique has been well described, few prospective data are available on the cephalic vein cutdown approach. From September 9, 1998, to July 20, 1999, the cephalic vein cutdown approach was attempted in 100 consecutive cancer patients taken to the operating room with the intention of placing CICVAD. Median patient age was 54.5 years (range 18-88), with 46 men and 54 women. Twenty-five patients had gastrointestinal malignancies, 17 had breast cancer, 15 had lymphoma, 13 had lung cancer, 12 had leukemia, 5 had multiple myeloma, and 13 had other malignancies. Patients were followed prospectively for immediate and long-term outcome. CICVAD placement via the cephalic vein cutdown approach was successful in 82 patients; the remaining 18 patients required conversion to a percutaneous subclavian vein approach. The reasons for inability to place CICVAD via cephalic vein cutdown approach were a cephalic vein that was too small (10 patients), an absent cephalic vein (7 patients), and inability to traverse the angle of insertion of the cephalic vein into the subclavian vein (1 patient). There were 56 subcutaneous ports and 26 tunneled catheters. Median operating time was 44 minutes (range, 26-79 minutes). No postoperative pneumothorax occurred. Median catheter duration was 198 days (range, 0-513 days). Long-term complications included catheter-related bacteremia (6%), site infection (2%), deep venous thrombosis (5%), port pocket hematoma (1%), and superior vena cava stricture (1%). Thirty-seven percent of patients have died since CICVAD placement. Twenty-nine percent of the CICVADs have been removed. The cephalic vein cutdown approach was successful in 82% of patients. This approach is a safe and useful alternative to the percutaneous subclavian vein approach.
Article
Totally implantable venous access devices (TIVADs) are valuable instruments in case prolonged intravenous therapy is required, but implantation and use of these devices are associated with complications. The purpose of this study was to evaluate perioperative and long-term complications associated with TIVADs. In addition, we compared two different types of TIVADs with respect to implantation, care protocol and patients' comfort. In a retrospective study perioperative and long-term complications in a general oncology population were analysed. In a prospective randomized study comparison of two types of TIVADs was carried out. Perioperative complications occurred in 27 (21.4%) of 126 implanted TIVADs: catheter malposition (16.7%) in 21 patients, pneumothorax (0.8%) in one and haemorrhage (4.0%) in five. Long-term complications appeared in 31 (25.2%) out of 123 TIVADs: thrombosis in 9 (7.3%), especially associated with malposition of the tip of the catheter; infection in 10 (8.1%); extravasation in 2 (1.6%); migration of the catheter tip in 6 (4.8%); pain at reservoir in 3 (2.4%) and inaccessibility of the port in 1 (0.8%). No significant differences were found with respect to implantation, care accessibility and patients' comfort between the two TIVADs. The use of TIVADs is associated with some risk of serious perioperative and long-term complications. In case of thrombotic complications these systems can be saved with appropriate treatment. Correct positioning of the catheter tip is essential to prevent thrombotic complications. In case of TIVAD-related infectious complications, the possibility of saving the TIVAD depends on the causative microorganism and type of infection. Furthermore, to increase patients' satisfaction with TIVADs they should be well informed about the surgical procedure and possible disadvantages of these devices.
Article
Introduction: By offering a rapid and convenient vascular access option for hemodialysis, permanent catheters are increasingly used in ESRD patients. Indeed, permanent catheters are associated with an increased risk for complications. Moreover, catheter bearing spoils the self body image and may alter the quality of life of dialysis patients. Implantable port catheter device, recently introduce in dialysis, may offer an attractive option, able to reduce most of infectious risk and inconveniences of the permanent catheters. Patient and material: The Dialock (Biolink) device was evaluated in a multicenter French trial. Twelve dialysis facilities enrolling 51 ESRD patients (male 28, female 23, age 56 +/- 2 years) participated in this trial. Dialock devices were inserted in patients for whom a permanent venous catheter was indicated. The cumulative experience was 56.8 years-patient. The technical survival (intent to treat) of Dialock devices was 85% at two years. Blood flow were 299 +/- 7 ml/min. Dialysis adequacy was achieved in all patients without altering dialysis schedule (3 sessions per week, 240 +/- 30 min each). Dialysis dose (K(/Vdp) delivered was 1.3 +/- 0.2. Satisfaction of patients and nursing staff was achieved in 75% of cases. Normalized incidence of complications (events for 1000 patient-days) in the evaluation phase (II) were as follows: hematoma and/or small bleeding (2.1), bacteremia (1.1), device infection (0.2), skin necrosis (0.1). A significant reduction of the infection and hematoma incidence rate was noticed when heparin lock was substituted for an non hemorrhagic antithrombotic locking solution (fragmented heparin or sodium citrate). This observation tend to accreditate the hypothesis that port catheter infection occurs via a transluminal bacteria passage. Conclusion: The Dialock device, offers a new and comfortable hemodialysis vascular access for ESRD patients. Performances are in agreement with those needed to achieve adequate dialysis. The regular use of dual antithrombotic-antiseptic catheter locking solution seems to be necessary to prevent any bacterial contamination.
Article
Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.
Les dispositifs intraveineux implantables
  • Tesson
Tesson M. Les dispositifs intraveineux implantables. Soins 1997;619: 11–4.
Totally implantable central venous access ports for long-term chemiotherapy
  • Biffi
Mode of chemiotherapy does not affect complications with an implantable venous access device
  • Brown
Comparison of diagnostic specimens and methods to evaluate infected venous access ports
  • Witman