Prevention, diagnosis and treatment of non-infectious complications
Should the catheter be routinely flushed and if so which solution should be used and how often?
Most central venous access devices for PN can be safely flushed and lock with standard saline solution when not in use. Also, since heparin may facilitate the precipitation of lipids, saline flushing is mandatory during PN with lipids before any flushing with heparin.
Heparinised solutions should be used as a lock (after proper flushing with saline), when recommended by the manufacturer, in the case of implanted ports or opened-ended catheter lumens which are scheduled to remain closed for more than 8 hours.
What measures are recommended to prevent catheter-related central venous thrombosis?
Prevention of catheter-related central venous thrombosis should include
- US guided catheter insertion to minimise damage to the vein.
- Use of lowest calibre catheter
- Appropriate position of the tip of the catheter in proximity of the atrio-caval junction and
- Prophylaxis with a daily single dose of LMWH 100 IU/kg, exclusively in patients at high risk for thrombosis (family history or previously h/o idiopathic venous thrombotic events)
How do you treat catheter-related central venous thrombosis?
- Remove catheter only if infected or malpositioned or obstructed. There is a risk of embolization during or immediately after catheter removal; nonetheless, catheter should be removed if infected, obstructed or malpositioned.
- Thrombolytic drugs should be used only in acute symptomatic cases (diagnosis <24 hours after the first symptoms). Efficacy of systemic versus local thrombolysis is still matter of debate, especially for large thrombi.
- Chronic symptomatic cases should be treated with a combination of LMWH and then oral anticoagulants, or LMWH long term alone, depending on the clinical setting.
How do you manage blocked catheter?
- The most appropriate action is exchange over guidewire or removal in case of nontunneled CVC).
- Pharmacological disobstruction in case of PICCs or long term venous access devices. Disobstruction can be done using 10 ml syringe (or bigger), so to avoid inappropriate high pressure which may damage the catheter, and using the solution most adequate for the presumed type of obstruction (ethanol for lipid aggregates; urokinase or rTPA for clots; NaOH or HCl for drugs; Na Bicarbonate for contrast medium).
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