lines and tubes in critically sick patients “ir perspective”
TRANSCRIPT
Lines and Tubes in Critically Sick Patients“IR Perspective”
Ram Gurajala, MD
MRCSEd, FRCR, DABR
Interventional Radiology
Objectives
Lines and Tubes:Types:
Lines: Venous and Arterial
Tubes: Various
Indications
Contraindications
Complications
Indications for Central Venous Access
Short Term (Single hospital admission) Emergency fluid resuscitation
Vasopressors, Transfusions, Short Term Tx
Long term intermittent therapy Chemotherapy
Antibiotic
Long term continuous therapy Continuous TPN (Short Gut, Pancreatitis, Malnutrition)
Continuous Inotropes, Vasodilators, etc.
Dialysis Access
Questions to consider
Length of therapy?
Type of therapy acquired? (High vs Low Flow?)
Other concomitant therapies?
Dialysis or Potential Hemodialysis patient?
Temporary v. Tunneled: What duration is IV access needed?
Long term access is more appropriately tunneled
Is the patient bacteremic? No tunneled lines
How urgent is the placement?
SBCC*PICCs
Ports
Hickman Leonard
TDC
Terminology
High flow Dialysis (400 – 600 cc/min)Pheresis (150 – 250 cc/min)
Low flow Antibiotics;Chemotherapy;
TPN;Medications;
Hydration
Power injectable Arterial phase contrast injection;Allows for flow of 5cc/s;Pressures up to 600 psi
Power injectable catheters:
*SBCC : Small Bore Central Catheter
*Principle Considerations*
Request the minimum number of lumens needed More lumens = more thrombosis & more infection
Increased risk of thrombosis and infection (20% with 3L PICC)*
Have an indication for each lumen
Use the smallest diameter catheter to achieve the needed therapy
Keep dialysis access separate from IV access
*Trerotola et al. Triple-Lumen Peripherally Inserted Central Catheter in Patients in the Critical Care Unit: Prospective Evaluation n Radiology: Volume 256: Number 1—July 2010
Common Catheter Types
Peripherally Inserted Catheters (PICC)
Central Venous Catheters
Dialysis Catheters (TDC)
Port Catheters
Peripherally Inserted Catheters
•Type PICC Midline
Insertion Peripherally inserted Peripherally inserted
Central venous Yes No
Preferred Veins* Brachial and basilic Brachial and basilic
* Cephalic vein has an increased risk of thrombophlebitis and catheter occlusion
Central venous catheters
HohnHickmanBroviac
Small Bore CVCs Large Bore CVCs
Temporary Longer term
Names Hohn Broviac Hickman
Length of therapy >6 days – 4 mo* >4mo Long term access
Preferred Veins IJV, EJV, **Collateral IJV, EJV, **Collateral IJV, EJV, **Collateral
Less preferred SCV, Femoral SCV, Femoral SCV, Femoral
*Short term access: Acute resuscitation; Vasopressors; CVP monitoring; Short term admission with multiple meds; Chemotherapy, etc.
** Occluded central veins with collaterals
Dialysis Catheters
Trialysis CatheterTunneled Dialysis Catheters
Temporary Long term
Names Non-tunneled (Quinton, Trialysis) Tunneled
Length of therapy < 10 – 14 days Beyond 14 days
Uses Dialysis, Plasmapheresis Dialysis, Plasmapheresis
Preferred Veins IJV, EJV, CFV, **Collateral IJV, EJV, **Collateral
Less preferred SCV SCV
Quinton Catheter
** Occluded central veins with collaterals
Port CathetersPortcath Central venous access with attached
subcutaneous port
Types Single or Double lumenGroshong Vs Non- groshong
Length of therapy Long term, intermittent access(~monthly to ~weekly)
Uses Chemotherapy, Infusions, * TPN
Preferred Veins IJV, EJV, **Collateral
Less preferred SCV
Decision AlgorithmCentral venous access
Small bore Acute resuscitation; Vasopressors; CVP monitoring; Short term admission with multiple meds; Chemotherapy
Large bore TPN; Long term access
High flow Hemodialysis; Plasmapheresis
Indications Short term Long term
Poor/Difficult peripheral IV access
Temp CVC; Midline PICC; Tunneled
ICU needs* Temp CVC; Midline PICC; Tunneled
Chemotherapy Temp CVC PICC; Tunneled CVC; Portcath
TPN PICC** Tunneled Large Bore CVC (Hickman, Leonard)
Hemodialysis Quinton; Trialysis *** Tunneled #
Plasmapheresis Quinton Tunneled
*ICU gtts (vasopressors); Acute Resuscitation; CVP Monitoring; Short term, multiple meds; **No PICC, If Renal Tx or Potential?; GFR <45 & DM; ***ARF expected to
recover; Unstable; Suspected infection; # ARF unknown Px; ARF expected to progress to ESRD; Initiating HD for ESRD
Pre-Procedure Preparation & Assessment
Antibiotics: Needed? Infection rate is 0.04/100 catheter days1
Infection rate was 0.14/100 catheter days2
Minocycline & rifampin impregnated central lines available - ? Risk of emerging resistance3
Coagulopathy4,5
INR: Correct to ≤ 2.0
Platelets: ≤ 50,000/µL recommend transfusion
aPTT: No consensus
Vein Preservation in CKD patients
1. Trerotola SO, Johnson MS, Harris VJ, et al. Outcome of tunneled right internal jugular hemodialysis catheters placed via the right internal jugular vein by interventional radiologists. Radiology 1997; 203:489-495. 2. Lund GB, Trenotola SO, Scheel PF Jn, et al. Outcome of tunneled hemodialysis catheters placed by radiologists. Radiology 1996; 198:467-472. 3. Ramos et. al Crit Care Med 2011 Vol. 39, No. 2. 4. Patel IJ et al. “Addendum of Newer Anticoagulants to the SIR Consensus Guidelines. JVIR. 2013 5. Hass et. Al J Vasc Interv Radiol 2010; 21:212–217
*Upper extremity vein preservation is paramount in patients who at risk for ESRD*PICC
Midline
Risks
Contraindications (Relative) Bleeding disorders; Anticoagulation therapy
Combative patients; Distorted anatomy; Cellulitis; burns at site
Procedural complications Immediate Bleeding
Pneumothorax
Air embolus
Delayed Infection
Thrombosis
Fibrin Sheath
Malfunction
Fracture
Air embolism Fractured Portcath
Pinch off syndromeMalposition
Twisted
Twisted MalpositionTip in pleura
CO2 Venogram
Pneumothorax
Tip in subclavian artery
Tip in Vertebral/subclavian artery
Femoral vein: Less preferred
Favorable Not favorable
Easy to find vein Highest risk of infection
No risk of pneumothorax Risk of DVT
Preferred site for emergencies Not good for ambulatory patients
Fewer bad complications
Subclavian vein: Less preferred?
Risks
Mechanical Pneumothorax
Arterial Injury
Malposition
“Pinch off syndrome”
Renal Failure Fistula creation
Thrombosis
Swollen extremity Lymphedema
PCM insertion
Thoracic outlet syndrome
Infection?
Complications in the Three-Choice Comparison, According to Insertion-Site Group.
Parienti J et al. N Engl J Med 2015;373:1220-1229
Technical
High access
Hair
Low access
Extreme cases
• Trans lumbar
• Trans renal
• Trans hepatic
• Recanalization
• ? Collaterals - temporary
Trans lumbar
Trans splenic
Recanalization
Direct intra-atrial
Direct Intra-atrial
BEWARE, When the access crosses MIDLINE
Arterial
Indications Monitoring blood pressure
Frequent blood gas analysis
Sites Radial, Femoral
Axillary, Brachial
Troubleshoot – Bad waveforms Repositioning/splint
Replacement/Guidewire exchange
Complications
Pseudoaneurysm
Extravasation
TubesTypes Indications
Chest Chest tube: Non tunneled Effusions; Empyema; Hemo/Pneumothorax; Post surgery
Chest tube: Tunneled Malignant; Recurrent
Pericardial drain Effusion*
Abdomen and Pelvis Enteric Feeding; Ventilation
Ascitic: Non tunneled Diagnostic; Therapeutic
Ascitic: Tunneled Malignant; Recurrent
Drainage Abscess; Fluid; Cholecystostomy; PTHC
Nephrostomy Hydronephrosis; Pyonephrosis; Obstruction
Suprapubic Obstruction
Chest Tube: Non Tunneled
Beware!!
Spleen
Chest Tube: Tunneled (Pleurex) catheter
Pericardial Drainage
Case 1 Case 2
Gastrostomy
Cholecystostomy
Cystic duct rupture
Suprapubic drainage
Nephrostomy
Ureteric stent
Nephro ureteral catheter
Ascitic : Non Tunneled Tunneled
Drainages
Abscess Fluid drainage Abscess
Risks
Contraindications (Relative) Bleeding disorders; Anticoagulation therapy
Procedural complications Immediate Bleeding
Pneumo/Hemothorax
Death*
Delayed Infection
Occlusion
Dislodgement/migration
*Complex cases
Conclusion
This is just a brief summary of various procedures
Lines and Tubes: A systematic approach, knowledge and defined algorithms needed
IR: Minimal invasive and safe approaches
We play a great role in patients CARE.