Catheter Related Thrombus Management (enhanced by VisualBee)

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Catheter Related Thrombus Management (enhanced by VisualBee)

  1. 1. Karen Williford RN, CRNI<br />Beebe Medical Center<br />Tunnell Cancer Center<br />Lewes, Delaware<br />Catheter Related Thrombus Management<br />
  2. 2. Objectives<br />•Discuss the pathophysiology of catheter related thrombosis<br />•Discuss thrombosis prevention strategies related to vascular access device assessment and insertion<br />•Discuss current research findings as they relate to vascular access device thrombosis<br />
  3. 3. Upper Extremity Deep Vein Thrombosis (UEDVT)<br />Increasing prevalence with potential for considerable morbidity<br />Increased use of CVC/PICC<br />Chemotherapy<br />Bone Marrow Transplant<br />Parenteral Nutrition<br />Dialysis<br />
  4. 4. Types of Thrombus<br />
  5. 5. Assessment<br />History of a previous device<br />Fluid Status<br />Sepsis<br />Duration of Catheter<br />Cancer<br />Hypercoaguability<br />Improper Maintenance<br />
  6. 6. Hypercoagulability<br />Blood viscosity can be affected by:<br />Hematocrit<br />Temperature<br />Low flow<br />Diabetes<br />Pregnancy<br />Cancer<br />
  7. 7. Risk Factors<br />
  8. 8. Risk Factors<br />Administration of incompatible solutions and medications<br />Administration of solutions or medications with high pH or tonicity<br />Ineffective filtration<br />Thrombogenic catheter materials<br />Malpositioned catheter<br />
  9. 9. Virchow’s Triad<br />
  10. 10. Anatomy<br />
  11. 11. Physiology of Clotting<br />
  12. 12. Physiology<br />
  13. 13. Endothelial Injury<br />Larger stiffer catheters pose a higher risk of endothelial injury on insertion<br />Infusion of irritants or vesicants<br />Sub Optimal Catheter Tip Locations carry larger risk of endothelial injury<br />
  14. 14. Does Size Matter??<br />
  15. 15. King et al. (2006)<br />
  16. 16. Blood Flow Dynamics<br />
  17. 17. Laminar Flow Characteristics<br />
  18. 18. Poiseuille’s Law<br />
  19. 19. Flow Dynamics<br />
  20. 20. Evans et al (2010)<br />Previous DVT history increases risk<br />Large sample size-2014 PICC’s<br />Single double and triple lumen catheters<br />60 of 2014 patients developed DVT<br />0.6% Single lumen DVT rate<br />2.9% Double lumen DVT rate<br />8.8% Triple lumen DVT rate<br />
  21. 21. Factors leading to Thrombus Formation<br />
  22. 22. Seeley et al. (2007)<br />
  23. 23. Catheter Thrombosis<br />Swelling of extremity<br />Pain with infusions<br />Fluid leaking at insertion site<br />Ultrasound of extremity<br />Anticoagulation<br />Possible catheter removal<br />
  24. 24. Burns 2009<br />CVC thrombosis results in:<br />Vascular and catheter occlusion<br />Infection<br />Pulmonary embolus<br />Right heart thrombo-emboli<br />Incidence underestimated<br />Synergy of events<br />
  25. 25. Fibrin Sheath<br />Courtesy of :http://www.konez.com/CentralCatheter_fibrin%20sheath_dialysis.JPG<br />
  26. 26. Does Tip Location Matter?<br />
  27. 27. Standards<br />
  28. 28. Define Central<br />
  29. 29. Luciani et al. (2001)<br />Prospective US study<br />3/62 (5%) with tips at CAJ developed thrombosis<br />5/7 (71%) at SCV/BCV junction developed thrombosis<br />
  30. 30. Lobo et al. (2009)<br />
  31. 31. Cadman, Lawrance, Fitzsimons,Spencer-Shaw, Swindell (2004)<br />Relationship between tip position andvenous thrombosis<br />428 tunneled catheters<br />72 days<br />5/91 in lower 1/3 (2.6%)<br />5/95 in middle 1/3 (5.3%)<br />20/48 in upper 1/3 (41.7%)<br />
  32. 32. Verhey, Gosselin, Primack,Blackburn, Kraemer (2008)<br />
  33. 33. Trerotola et al 2010<br />
  34. 34. Tretola Study 2010<br />Stopped at 50 of 167 planned patients<br />Scheduled interim US showed an DVT rate of 20% (10 of 50)<br />Venous Thrombosis (symptomatic or asymptomatic) 58%<br />0% CRBSI<br />Colonization 10%<br />Malfunction & Dislodgement in 1 patient<br />
  35. 35. Duke University 2011<br />Purpose: Evaluate the effectiveness of practice changes to reduce PICC thrombus risk<br />Retrospective analysis of adult patients<br />1307 charts reviewed January 2008, October 2008, and August 2010. Clinical Practice change to include US & tip in SVC<br />
  36. 36. Duke University 2011<br />PICC related DVT rates decreased from<br />4.8% to 2.9% (January 2008-October 2008)<br />October 2008-August 2010 practice change to<br />measure & document native vein diameters prior to PICC insertion -2X outer cath diameter<br />PICC related DVT decreased from 2.9% to 1.4%<br />
  37. 37. INS National Standards<br />Medications with a pH <5 or >9<br />OR<br />Osmolarity greater than 600mOsm/L<br />can cause vein irritation,<br />phlebitis, infiltration or extravasation.<br />
  38. 38. Extreme pH IV MedicationspH <5 or >9<br />pH <5<br />Ciprofloxin 3.3-4.6<br />Dopamine 2.5-5.0<br />Doxycycline 1.8-3.3<br />Dopamine 2.5-5.0<br />Morphine 2.5<br />Pentamidine 4.1-5.4<br />Phenergan 4.0<br />Potassium 4.0<br />Taxol 4.4-5.6<br />Vancomycin 2.4<br />Zofran 3.0-4.0<br />pH >9<br />Acyclovir 10.5-11.6<br />Ampicillin 8.0-10<br />Bacterium 10<br />Cerebyx 8.6-9.0<br />5FU 9.2<br />Ganciclovir 9-11<br />Phenytoin 12<br />Protonix 9-10.5<br />
  39. 39. Vesicants<br />Acyclovir<br />Amiordarone<br />Ampho B<br />Ampicillin<br />Bactrim<br />Calcium chloride<br />Calcium Gluconate 10%<br />Ciprofloxacin<br />Cerebyx<br />Contrast media<br />Aramine<br />Daptinomycin<br />Dextrose >10%<br />Digitoxin<br />Dobutamine<br />Dopamine<br />Doxapram<br />Doxycycline<br />Epinephrine<br />Erythromycin<br />Ganciclovir<br />Gentamycin<br />
  40. 40. Vesicants<br />Levophed<br />Lorazepram<br />Magnesium sulfate<br />Mannitol 10% and 20%<br />Morphine<br />Nafcillin<br />Norepinephrine<br />Phenergan<br />Phenytoin<br />Phenylephrine<br />Pentamadine<br />Levophed<br />Lorazepram<br />Magnesium sulfate<br />Mannitol 10% and 20%<br />Morphine<br />Nafcillin<br />Norepinephrine<br />Phenergan<br />Phenytoin<br />Phenylephrine<br />Pentamadine<br />
  41. 41. Hypertonic<br />Hypertonic solution has an osmolality of<br />350 mOSM/liter and above.<br />The osmolality of PPN is about 750<br />mOSM/liter and above.<br />Hypertonic solutions cause phlebitis<br />peripherally in less than 24 hours<br />
  42. 42. Examples<br />D25W (1330mOSM/liter).<br />D40W (2020mOSM/liter).<br />D50W (2525mOSM/liter).<br />Literature states hypertonic drugs withan osmolality over 600mOSM/liter resultin phlebitis in 24 hours with shortperipheral catheters.<br />Consider central venous administration<br />
  43. 43. Assessment is the Key!<br />
  44. 44. Take this Home!!<br />History and Physical/Physician Collaboration<br />Limit Catheter Manipulation*Catheter Exchange can increase thrombosis and infection risk<br />Prevent catheter related infections<br />Get the tip in the right place!<br />

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