This is about different types of CVCs and especially about Hickman catheter, insertion, care and maintenance, complications and removal techniques.

1. Dr. Pritish Chandra Patra
Associate Professor
Dept. of Clinical Hematology
IMS & SUM Hospital

2. History
Werner Forssmann
Davies MK, Hollman A. Werner Forssmann. Heart. 2002 May;87(5):409. PMCID: PMC1767093

3. Landmarks
1
1929
1956
1950
“Forssmann” described the advance of a
ureteral catheter to the heart by puncturing his
own arm vein
“Aubaniac” reported about the puncture of the
subclavian vein
Got Nobel prize
This puncture technique helped to broaden the
use of this technically demanding procedure

4. Introduction
 Central venous access is a commonly performed
procedure with approximately 8% of hospitalised
patients during their hospital stay.

5. Indications
 Quick administration of large volume of fluids or drugs
 Administration of i.v. fluids or drugs in the event of the
collapse of peripheral vessels (shock)
 Administration of irritant or toxic drugs
 Administration of high-osmolarity solutions, e.g. TPN
 Longer therapies- lasting several days or weeks which
require a venous access
 Dialysis
 Measurement of CVP

6. Types
Non-Tunneled CVC
Tunneled CVC
Implanted Port
PICC

7. Non-tunneled CVC
 Placed percutaneously
 Catheter exits the skin in the vicinity of
the venous cannulation site
 Most commonly used for temporary
access to the central circulation
 Lengths
 15- 30 cm
 Materials
 polyurethane, silicone
 Valved catheters
 limit backflow of blood
 prevent infection & catheter thrombosis

8. Non-tunneled CVC
 Lumen- 1/2/3/4/…
 The distal hole is more reliable for
drawing blood - doesn’t get
suctioned against the wall of the vein
during aspiration.
 ↑ number of lumen >>
↑ overall diameter of the catheter >>
↓ diameter of the individual lumen
 ↑ no of lumens >>
↓ maximum infusion rate >>
↑ rate of catheter thrombosis

9. Tunneled CVC
 Robert O. Hickman
 A pediatric nephrologist and inventor of a catheter that
revolutionized care for patients with cancer, died on
April 4, 2019. He was 92.
 In 1970, he was a founding member of the transplant
team at Fred Hutchinson Cancer Research Center (Fred
Hutch), Seattle that pioneered the BMT procedure.

10. Tunneled CVC- Hickman
 Traverses a subcutaneous tunnel
between the catheterized vein and
the skin exit site.
Internal
Jugular Vein

11. Tunneled CVC
Hickman
 Round
 Material: Silicone
 Tip: soft and atraumatic
 Lumen- 1/2/3
 Sizes- 4.2 to 12 F (Hickman, Broviac,
Leonard)
 A cuff (Velour, Dacron) in the
subcutaneous tissue adjacent the exit
site
 Inflammatory response
 Allows fibroblastic ingrowth
 Prevents ascending infection
 Fixation- 3-4 weeks
 Rates of infection - lower than those
of non-tunneled CVCs
cuff

12. Tunneled CVC
 C-arm-
 for guidance and
 to confirm the tip position
 Anesthesia
 Adult- LA
 Children- GA
 Suture temporary  Dacron cuff seals it later
 Loop catheter under sterile dressing-
 tension reliving loop

16. Tunneled CVC- advantages
LONGER STAY LESSER
MAINTENANCE
LESSER
INFECTIONS

17. Contra-indications
 Patient is allergic to the CVC material
 Past irradiation to the insertion site
 Previous episode of venous thrombosis at the site
 Previous history of vascular surgery at the site
 Avoid placement
 under the arm
 in the breast
 In soft tissue of the abdomen

18. Other CVCs- Implanted Ports

19. Other CVCs- PICC lines

20. Antibiotic prophylaxis
 CDC, USA (O’Grady et al., 2002)-
 use of antimicrobial prophylaxis routinely before
insertion or during use of an intravascular catheter does
not prevent catheter colonization or BSI

21. Catheter insertion
 Only experienced personnel should insert central
venous catheters
 to minimize infection and other complications
 particularly in the presence of low platelets
 deranged clotting profile
 in critically ill patients

22. Catheter insertion
 Procedure should be performed in a clean area designated
for CVC insertion such as OT or a procedure suite where
high standard of asepsis is practiced.
 Risk of infection depends mainly on the presence of
bacteria on the skin.
 Skin cleansing is the most important part of care
before catheter insertion.

23. Cleansing
 Povidone iodine
 2% aqueous chlorhexidine
 2% chlorhexidine in alcohol

24. Long term care- Flushing
 Heparin Vs Normal Saline
 Exposure to heparin should be minimized
 to prevent HIT
 to avoid bleeding complications
 Prevent rupture
 smaller syringes create greater pressure
 Use 10ml syringes ONLY
 Prevent back flow
 pulsatile flush method– push–pause-push–pause
 maintain +ve pressure while removing the syringe
Passannante & Macik, 1998
Pellowe et al. 2004
Conn, 1993; Primhak, 1998
Goodwin & Carlson, 1993; Dougherty, 2004

25. Long term care
 Patient education
 Hand washing
 Chlorhexidine gluconate
 Sterile gloves or clean gloves

26. Complications
 The main complications are-
 catheter-related infection
 catheter malfunction
 catheter-related thrombosis

27. Catheter-related infections
 Infection rates vary from 0.08 per 1000 days in
oncology outpatients to 19/1000 catheter days in the
critically ill.
 Hemato-oncology infection rates probably lie
somewhere within this range.
 CRBSI can be severe and life-threatening depending
on the micro-organism involved.
Fletcher, 2005

28. Catheter-related infections
CRBSI
(catheter-related
blood stream
infection)
≥2 blood cultures +ve
with the same organism
from ≥2 separate sites
at different times,
in association with e/o
colonization with the same
organism
Exit site
infection
Erythema
Tenderness
Discharge
Tunnel
infection
Pain
Induration
along the track of
the catheter

29. Category Non-neutropenic patient Neutropenic patient
Exit site infection
•Remove catheter if no longer needed
•Treat empirically with *flucloxacillin
•Remove catheter if no longer needed
•Initial empirical therapy including glycopeptide
•Treat for 10–14 days or longer until infection resolved
•Modify according to isolates
•Remove catheter
•if evidence of progression or
•if blood cultures are positive for Staph. aureus,
Pseudomonas spp., Mycobacterium spp., or fungi
Tunnel infection
•Remove catheter if no longer needed
•Treat empirically with *flucloxacillin
•Remove catheter if no longer needed
•Initial empirical therapy including glycopeptide
•Treat for 10–14 days or longer until resolution of
soft tissue infection. Modify according to isolates
•If tracking continues to spread remove catheter
Presumed CRBSI
•Remove catheter if no longer needed
•Treat empirically with antibiotics
targeted against isolates
•Remove catheter if no longer needed
•Initial empirical antibiotic therapy. Modify
according to isolates.
•Treat for at least 10–14 days
•Remove catheter
•if cultures remain positive after 48 h of
therapy or
•if proven catheter-related infection with
Staph. Aureus, Pseudomonas spp.,
Mycobacterium spp., or fungi
*Unless known to be colonized with MRSA, when a glycopeptide should be used

30. ‘Antibiotic lock’ technique
 May be effective in reducing catheter-related
bacteremia
 A technique by which
 an antimicrobial solution is used to fill a catheter lumen
 allowed to dwell for a period of time while the catheter is
idle

31.  Antibiotics- vancomycin, gentamicin, ciprofloxacin,
minocycline, amikacin, cefazolin, cefotaxime, and
ceftazidime
 Antiseptics- taurolidine, trisodium citrate
 Anticoagulant- heparin or EDTA
 Designed to render the internal flow passages
resistant to clot formation and hostile to bacterial
and fungal growth.
 There are no FDA approved formulations.
‘Antibiotic lock’ technique

32. Catheter removal
Indications
 catheter related infection
 Staph. aureus, Pseudomonas spp., Mycobacterium spp., or fungi
 persistent catheter occlusion
 catheter-related thrombus
 damaged catheter
 end of treatment

33. Removing the Hickman catheter
 Removed by surgeon
 Pinch off
 Catheter breakage
 Catheter embolism

34. Catheter removal
 Local anesthetic and minor surgical cut-down to remove the cuff
 Remove the catheter in the direction of the tunnel
 Catheter should be inspected carefully after removal to ensure that it
is complete
 If infection is suspected, send tip for culture
 The cutdown site should be sutured with a fine 3/0 or 4/0
monofilament suture
 After removal, apply pressure to the exit point, tunnel and an
occlusive dressing placed over the exit site to avoid air embolism.

35. Indian experience of CVCs

36. A total of 213 CVCs were inserted in patients with hematological (62%) and solid organ
malignancies (38%). Ninety-eight patients (46%) had peripheral inserted central catheter
(PICC), 90 (42%) patients had Hickman catheters and 25 (12%) had a port. The median
duration of retention of Hickman catheters was 104 days (3-365 days), for the peripherally
inserted central catheters was 59 days (3-100 days) and for the port it was 280 days (45-365
days). Non-infective complications were more than infective (12% vs. 7%). The most
common complication was non-infective occlusion and thrombophlebitis. In one patient
with PICC thrombosis occurred in the cephalic, radial and ulnar vein and in one patient with
port thrombosis occurred in the superior vena cava. Organisms were isolated in 60% (12 out
of 20) of cultures. Common organisms isolated were Pseudomonas aeruginosa in 5
(42%), Staphylococcus aureus in 2 (16%), Escherichia coli in 2 (16%) and Aspergillus in 3
(25%) patients. 7 out of 12 infected patients had negative blood cultures within 7 days of
antibiotic treatment, 5 patients remained positive for more than 7 days with antibiotics. In 155
patients (73%), the desired treatment protocol was completed and at present there are still 28
patients (13%) with catheters. 5 patients (2.3%) died of febrile neutropenia and septicemia with
multi-organ failure. In 5 patients (2.3%), the catheters (1 Port, 1 Hickman and 3 PICC)
were prematurely removed because of thrombosis.

37. A total of 111 catheters were used in 110 patients. Two catheters were used in one patient due to loss of
first catheter due to rupture. Duration of catheter indwelling period ranged from 7 to 365 days with a
median of 120 days. In 99 out of 111 (90%) cases catheter tip was located either in superior vena cava or
in right atrium.
Total catheter related complications occurred in 37 (34.5%) patients
and total catheter loss due to complications were documented in 17
(15.4%) patients. A total of 8 catheters (7.27%) were lost due to
infective complications. Two-thirds of these cases had infection
during the granulocytopenic phase of chemotherapy (TLC <
1000/dl). Exit site infection, catheter blood culture proven
bacteraemia and PUO were seen in 3, 6, and 10 patients respectively.
All 3 exit site infections were treated with local dressing and
antibiotics. Seven out of 10 PUO and 1 out of 6 systemic
bacteraemias were managed by giving systemic antibiotics. Five
patients with blood culture proven bacteraemia and 3 patients with
PUO did not respond to systemic antibiotics necessiating catheter
removal. Staphylococcus aureus was found in 4 and candida albicans in 2 patients in blood culture
proven bacteraemia cases while Staphylococcus aureus was found in 3 patients of PUO.
A total of 9 catheters were lost due to non-infective complication. Seven (6.36%) catheters were lost
due to blockage and, 1 catheter was lost due to extrusion and one due to rupture during infusion.
Blockage of catheter occurred in 16 patients out of which 9 could be salvaged by flushing with heparin
saline. One patient had supraventricular tachycardia during the insertion of the catheter which
returned to normal sinus rhythm promptly on withdrawing the catheter. We did not encounter any
haemorrhagic complications.

38. Summary
 In high-risk cancer patients it may not be possible to
prevent nosocomial infections.
 However, with appropriate use of CVAD devices and
careful infection control measures, these devices may
help to facilitate care without added risk of infection.

39. References
 Guidelines on the insertion and management of central venous access devices
in adults L. BISHOP*, L. DOUGHERTY†, A. BODENHAM‡, J. MANSI*, P.
ROWE§, C. KIBBLER–, M. SHANNON**, J. RELEAVEN†:6 February 2007
 CDC Guidelines for the Prevention of Intravascular Catheter-Related
Infections, 2011
 Experience with Venous Access Devices in Pediatric Cancer Patients, Tulika
seth, INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 25 No. 2, 2004
 A retrospective study of central venous catheters GCRI experience Sachin A.
Jain etal, Indian J Med Paediatr Oncol. 2013 Oct-Dec; 34(4): 238–241.
 An analysis of long-term venous access catheters in cancer patients:experience
from a tertiary care centre in India. NK Shukla, DK Das, SV Deo, V Raina

40. Thank You