This document discusses complications of central venous catheters including infection, occlusion, and thrombosis. It provides details on definitions, risk factors, treatments, and outcomes for each complication. Central line-associated bloodstream infection is the most common complication, occurring in 1.3-1.5 per 1000 catheter days. Occlusion can often be treated by restoring patency with thrombolytics or other methods in over 70% of cases without needing catheter replacement. Venous thrombosis is another significant complication that requires proactive treatment to preserve central vein access long term.

1. Complications of central venous catheters: current
perspectives
Dr Simon Gabe
Consultant Gastroenterologist
St Mark’s Hospital
Sue Larsen
Clinical Nurse Specialist
Aukland

2. Management of complications
CVC infection CVC occlusion CV thrombosis
CVC tunnel
infection
CVC pocket
infection
CVC cuff extrusion
CVC fracture

3. Management of complications
CVC infection CVC occlusion CV thrombosis
CVC tunnel
infection
CVC pocket
infection
CVC cuff extrusion
CVC fracture

4. How common?
Complication
Frequency
(per 1000 cath days)
Source
CRBSI
1.31 (0.38-4.85) Dreesen et al, Clin Nutr 2012
1.3-1.5 St Mark’s HPN inpatients
0.8-1.2 St Mark’s HPN outpatients
CVC occlusion 0.3 St Mark’s data
CV thrombosis
0.16 Lloyd et al, AP&T 2006
0.07 Health Technology Assessment 1997
CVC comp rate
HPN patients
(NZ & Australia)
3.6/1000 cath days Gillanders et al, Clin Nutr 2012
CVC comp rate
(NZ inpatients)
25%
IPNA study, personal communication
from S Larsen

5. Catheter-related infection (CRI)
 Exit site infection
 Tunnel infection
 Port pocket infection
 Infusate related
 Catheter associated
 Catheter related
Localised Systemic
A tunnel infection is rarely associated with
a systemic infection
A systemic CVC infection often occurs with
a normal CVC exit site
The CVC exit site is a poor judge of the
presence of a systemic CVC infection

6. CRI definitions
• Erythema or induration within 2cm of exit site in absence of
bloodstream infectionExit site
• Erythema or induration >2cm from exit site along
subcutaneous tract of tunnelled catheterTunnel infection
• Purulent fluid in skin pocket of totally implanted devicePocket infection
• Growth of same organism from infusate and peripherally
drawn cultures with no other identifiable source of infection
Infusate-related blood
stream infection
O’Grady et al (2011)

7. CRI definitions
CRBSI
Systemic infection plus evidence implicating
the CVC as its source
A positive central and peripheral
blood culture with isolation of the
same organism with a 5:1 ratio
CVC vs peripheral
Differential period of CVC culture
vs peripheral blood culture
positivity of >2 hours
Isolation of the same micro-
organism from at least one blood
sample (preferably peripheral),
and the CVC tip, with no other
identifiable source of infection
O’Grady et al (2011)

8. Catheter related bloodstream
infections (CRBSI)
 Spiking fever (>38C)
 Malaise with chills /
rigors
 Occurs when IVN running
 Stops when IVN stopped
 Positive blood cultures
 CVC > peripheral

9. Risk factors
 Implanted port
 Multi lumen catheter
 Daily Infusion
 Increased frequency of lipid infusion
 Increased catheter dwell time
 Compliance
 CVC for medication or blood drawing
 Opiate use
 Smoking
Richards et al (1997), Pironi et al (2012), Buchman et al (2013)

10. Treating CRBSI
Catheter removal
 Cardiovascular compromise
(inotropes)
 Staphylococcus aureus
infection
 Candidaemia
Attempted salvage
 Not septicaemic with
cardiovascular compromise
(inotropes)
 1st or 2nd infection in the
CVC
No published RCTs or other papers on treatments for CRBSI

12. CRBSI eradication rate
CVC not flushed after antibiotic given
No significant difference between 7 & 10 days antibiotic treatment
CRBSI eradication dependent on the organism type

13. Antimicrobial prophylaxis (lock)
 First described by (Messing et al 1988)
 High concentrations needed to penetrate biofilm
(Mermel et al, 2001)
 Antimicrobial solutions
 Taurolidine (Liu et al, 2013)(Taurolodine™, Taurolock™, Taurosept™)
 Trisodium citrate (Ko et al, 2009)(Citra-Lock™, DuraLock-C™)
 70% Ethanol (Tan et al, 2014)

14. Taurolock
 31 patients included after a CRBSI
 RCT: heparin (14) or taurolidine (16) as catheter lock
Bisseling et al, Clin Nutr 2010:29;464-468
Heparin (5ml, 150 U/ml)
Taurolidine (5ml, 2%)

15. Continuous passive disinfection
 Variability in practice
 May not destroy all micro-organisms
 Does not provide any protection when
CVC not in use
Passive disinfection
Works by continual contact
Active disinfection
Works by intermittent contact
with friction
 Active disinfection
 Passive disinfection
 Provides continuous disinfection, plus a
physical barrier to cross contamination
 Eliminates variability in disinfection
 Increased compliance with guidelines
Marschall et al (2014)

16. Effect of port protection on CRBSI
p=0.07
0
10
20
30
40
50
60
70
Pre Curos Post Curos
1.21-2.12/1000 catheter days
0.23-1.18/1000 catheter days
p0.001
Small (2014) Abstract

17. Management of complications
CVC infection CVC occlusion CV thrombosis
CVC tunnel
infection
CVC pocket
infection
CVC cuff extrusion
CVC fracture

18. Catheter occlusion
 Thought to affect 30% CVC (Ernst 2014)
 Thrombotic or non thrombotic
 Partial, complete, or withdrawal
 Mechanical compression
 Pinch off
 Kink memory from clamp
 Lipid, or drug/mineral precipitate
 Blood reflux

19. Restoring Patency
 Fibrin deposits
 t-PA 2mg, Urokinase 10,000 units (Atkinson
et al 1990, Haire & Herbst 2000)
 Lipid deposits
 Ethanol 70% (Pennington & Pithie 1987)
 Fibrin + lipid
 Sodium hydroxide 0.1M (Borg et al 1993,
Bader et al 2007)
 Drug/mineral precipitate
 Hydrochloric acid 0.1M (Werlin et al 1995)
Due to the risk of CVC rupture, restoration of patency should only be
attempted by suitably qualified/experienced healthcare staff

20. St Mark’s Experience
 38 occlusions 2010 -2011
 11% CVC, 0.26 per 1000 CVC days
 11 partial
 27 complete
 Partial
 Success rate 10/11 (91%)
 Alcohol 18%
 Urokinase 9%
 Complete
 Success rate 22/27 (81%)
 Alcohol 11%
 Urokinase 25%
Major et al (2012) Abstract

21. POP technique
39 catheter occlusions on IF database at St Mark’s
Outcome Number (%)
Patency restored 29 (74%)
Partial improvement 3 (8%)
ineffective 3 (8%)
Not recorded 4 (10%)
Have to be patient …
can take 30-60 minutes!

22. Management of complications
CVC infection CVC occlusion CV thrombosis
CVC tunnel
infection
CVC pocket
infection
CVC cuff extrusion
CVC fracture

23. CVC related thrombosis
 Affect 35-65% long term devices
 Often asymptomatic
 Strategies which may influence
incidence
 Avoid dehydration
 Use the smallest size CVC possible
 Minimise insertion site trauma
 Cyclical vs continuous infusion
 Tip position
 Tip integrity
Ghosh & Griffiths (2000), Pratt et al (2007), O;Grady et al (2011)
Endothelial trauma
StasisPlatelet
adhesion

24. Reducing thrombosis
Catheter tip Thrombosis
%
Odds
Ratio
Proximal 42 27
Intermediate 5 2
Distal 3 1
Cadman et al (2004)
48% CVC on transfer
tip position too high
The risk of thrombosis is significantly increased with proximal
SVC tip position

25. Central venous thrombosis
CV Thrombosis
Acute
Thrombolysis
Venoplasty
Venous stent
Chronic
Venoplasty
Venous stent
Venous
recanalisation
Venoplasty
Venous stent
=
=

26. Sharp venous recanalisation
 51 year old lady
 Visceral myopathy and jejunostomy at 50cm
 SVC inaccessible since 2001
 IVC only accessible by direct puncture since 2004

28. Measuring infusion pressures
www.micrelmed.com
Unique system to assess infusion pressures
Pressures can be viewed and analysed using MicrelcareTM

29. Infusion pressure per infusion
Upper Confidence
Interval
0.58 bar
Mean 0.29 ± 0.1
(0.01-0.85) bar
Infusion days
Pressure(bar)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
0 50 100 150 200 250 300 350 400
, n=5910

30. 0.00
0.20
0.40
0.60
0.80
1.00
1.20
30 50 70 90 110 130
Infusionpressure(bar)
Day
Avg pressure per infusion
Max pressure per infusion
Max presure diff during infusion
Gabe et al (2013) Abstract

31. Management of complications
CVC infection CVC occlusion CV thrombosis
CVC tunnel
infection
CVC pocket
infection
CVC cuff extrusion
CVC fracture

32. Conclusion
 CRBSI most common complication
 Need to develop common policies and optimal treatment
 Catheter occlusion
 Usually can be treated without replacement
 Venous thrombosis
 Proactive treatment essential
 Loss of >3 central veins: transplant indication