Audit Article

An audit of ultrasoundassisted catheter insertion in

patients receiving chemotherapy

J. Shabbir S. G. Kallimutthu J. B. O’Sullivan A. Nisar E. G. Kavanagh P. E. Burke P. A. Grace
Department of Vascular Surgery, Midwestern Regional Hospital, Limerick

Correspondence to: P. A. Grace, Midwestern Regional Hospital, Limerick Email: pagrace@eircom.net

Introduction Methods Surgical Technique Catheter Care Removal Complications Results Discussion Conclusion References

Background and Aims: Hickman catheters have been shown to provide safe long-term venous access for patients with malignant diseases. In many centres, catheters are placed using fluoroscopic guidance. We hypothesised that ultrasound-assisted catheter placement by surgeons in the operating theatre would be a simple, safe and effective alternative technique with reduced infective complication rates. Methods: Hickman catheter insertions between May 1998 and March 2002 were studied. The data were collected from the Hospital Inpatient Enquiry database and the case notes of all patients were reviewed. Percutaneous catheter placement with tunnelling was performed in the operating theatre after scanning the internal jugular vein (IJV) for position, size and patency, using a Pie 100LC Scanner (Pie Medical, Maastricht). A standard chest radiograph confirmed catheter position at the end of the procedure. Results: Fifty-eight patients (30males and 28 females) had 65 Hickman catheters inserted. The median age was 60 years (range 32-82 years). Catheter placement was achieved in all patients, 59 in the right IJV and six in the left. Ultrasound scanning demonstrated that the right IJV was thrombosed in six patients (10%), thus avoiding unnecessary attempts at cannulation. The Hickman catheters remained in situ for a combined total of 5857 days (median, 89 days, range 4-485 days). Immediate complications occurred in two patients (pneumothorax in both). One patient required a chest drain. The overall sepsis rate was 3.92 per 1000 catheter days. Systemic sepsis was slightly higher (2.21per 1000 catheter days) than superficial sepsis (1.71 per 1000 catheter days). In all the patients who developed systemic sepsis the catheter had to be removed (n=13). All the superficial infections were treated successfully with antibiotics (n= 10 patients). Two catheters developed thrombosis. Conclusion: We conclude that ultrasound-assisted percutaneous placement of Hickman catheters in the operating suite is a simple, safe and effective technique and may help to reduce infective complications

Keywords: Indwelling catheters, chemotherapy, USG, parenteral Surgeon, 1 February 2005, 32-35

INTRODUCTION

The current chemotherapeutic management of a number of malignancies depends upon repeated access to the venous system for the delivery of drugs, fluids and blood products. Such venous access is also important to monitor the effect of treatment upon cell counts and serum analyses. It can be very difficult to maintain constant venous access in patients with malignant disease because of the extended duration of therapy required and the sclerosant effect of some of the agents used. This is especially true if peripheral intravenous catheters are changed every three days, as is currently recommended.¹ Hickman catheters are the most commonly used catheters for providing long-term venous access in this patient population. Since these patients often have decreased immunocompetence or thrombocytopenia, the risk of infection and operative complications are increased. There are various techniques used for insertion of Hickman catheters ranging from surgical cutdown to percutaneous placement with or without fluoroscopy, performed either by surgeons or radiologists. The commonly used approaches are via the internal jugular or subclavian veins. Radiologists insert these lines under fluoroscopy in the radiology department. In our unit, all the Hickman catheters were placed percutaneously by the vascular team in the operating room using ultrasonography. As most of these patients are immunocompromised we hypothesised that the sterile environment of the operation theatre could reduce the rate of infective complications. The purpose of this study was to analyse the success rate, peroperative complications and infection rate in ultrasound-assisted percutaneously placed Hickman catheters.

METHODS

This was a retrospective study of all patients who had a Hickman line inserted between May 1998 and March 2002. All the data were collected from the Hospital Inpatients Enquiry System and confirmed from theatre logbooks. Data on the incidence of acute and late complications were obtained retrospectively from the medical case notes, which were available for all the patients.

SURGICAL TECHNIQUE

The site of choice for catheter insertion was the internal jugular vein (IJV) on the right side. A combination of local anaesthesia (0.5% lignocaine with adrenaline) with sedation (midazolam and fentanyl) was used in all patients. All patients received a pre-operative dose of teicoplanin 200mg IV.

Using a Pie 100LC Scanner (Pie Medical, Maastricht) the internal jugular vein (IJV) was scanned in all patients by the surgical team in theatre just prior to catheter insertion. The IJV was assessed for position, size and patency and was cannulated under ultrasound guidance.

Using a Seldinger technique and a peel away polytetrafluoroethylene sheath over a rigid 11F vein introducer, a double-lumen Hickman catheter (Vygon) was placed into the IJV. All catheters were tunnelled to the anterior chest wall and all had a dacron cuff which was positioned just inside the tunnel exit on the anterior chest wall. The catheter lumen was filled with heparinised saline and the catheter’s capacity for withdrawal and infusion was tested before it was flushed and secured in place. A standard chest radiograph was used to confirm the position of the catheter tip and the absence of pneumothorax at the end of the procedure.

CATHETER CARE

During hospitalisation the catheter dressing was changed daily by an oncology or haematology nurse. Each lumen not in use was flushed with 10mls saline followed by 2ml of heparinised saline (500u/ml). All the patients were given a printed booklet about catheter care, on discharge from hospital. The dressings were changed twice weekly at home and the catheter was flushed with heparin once a week at home when not in use.

REMOVAL

All the catheters were removed under local anaesthetic. A small incision was made over the dacron cuff. The cuff was separated from the subcutaneous tissue by blunt dissection and grasped with the dissecting clamp. Once the cuff was free, the catheter could be removed easily.

COMPLICATIONS

We defined systemic sepsis as the presence of symptoms and signs of systemic infection, with or without positive blood or catheter tip cultures.^2,3 Episodes of systemic infection required a course of intravenous antibiotics and hospital stay which facilitated the collection of information on this complication. Superficial sepsis was defined as the presence of symptoms and signs of infection, with or without positive swab culture, at the exit site or along the subcutaneous tunnel.^2,3 This complication was managed as an outpatient with oral antibiotics.

A criticism of reporting catheter infections as a percentage of catheters that become infected is that it ignores the duration of catheter use. Therefore, many institutions now report catheter infection rates based on the number of infective episodes per 1000 patients days of catheter use.⁴

RESULTS

Fifty-eight patients (30 males and 28 females) had 65 Hickman catheters inserted. The median age of the patients was 60 years (range 32-82). The various diagnoses in these patients are shown in Table 1. All catheters were placed in the IJV, 59 on the right-side and six on the left.

The catheters remained in situ for a combined total of 5857 days, median 89 days (range 4-485 days). Immediate complications occurred in two patients, pneumothorax in both. One patient required a chest drain. The overall catheter sepsis rate was 3.92 per 1000 catheter days. The systemic sepsis rate was slightly higher at 2.21 per 1000 catheter days compared with superficial sepsis which was 1.71 per 1000 catheter days. Two patients developed catheter thrombosis. In all the patients who developed systemic sepsis (n=13) the catheter had to be removed. However, all the superficial infections (n=10) were treated successfully with oral antibiotics.

Line removal was required to achieve cure in all the cases of systemic sepsis, despite the use of antibiotics. In eight patients gram-positive cocci were isolated on blood and/or tip culture (coagulase negative staphylococcus = 5, staph aureus = 3). Gram-negative cocci were cultured from two patients. Grampositive bacilli were grown from tip culturesin one patient. No bacteria were grown from cultures in two patients.

In patients who developed superficial sepsis (n=10), seven had positive culture swabs. In six patients, gram positive cocci (staph aureus = 3, staph epidermis = 2, staph albus = 1) were grown in culture and candida was obtained from another patient’s culture.

Two patients developed catheter thrombosis. A streptokinase infusion was tried in one patient to salvage the catheter but it proved unsuccessful. Both the catheters had to be removed. In all, 15 catheters were removed because of complications, (systemic sepsis = 13, thrombosis = 2). One patient pulled out his catheter accidentally. Six patients died with catheters in situ, 27 were removed electively and 16 patients still have their catheters.

DISCUSSION

Successful treatment of patients with malignant diseases requires reliable access to the venous system for the administration of chemotherapeutic agents, antibiotics, blood components and for periodic sampling of blood indices and serum chemistry. The large bore Hickman catheter has been shown to be an effective method for providing venous access and its superiority to AV fistulae, as a means of repeated access to the vascular system in cancer patients has been amply demonstrated.⁵

The two most commonly used techniques for catheter insertion are surgical ‘cut down’ and percutaneous insertion with fluoroscopy. The cutdown technique remains a safe method, but it is very invasive and commonly requires general anaesthesia. The fluoroscopic guided percutaneous technique is technically easier and faster but has a higher complication rate compared with the cutdown method as most of these are performed in the radiology suites where the environment is not as clean as in operating theatres.³ In our series, we performed a pre-operative on-table ultra sonogram to check the position, patency and size of the IJV prior to catheter placement. The internal jugular vein was found to be thrombosed in six patients (10%) thus avoiding unnecessary attempts at cannulation in these patients. The use of an ultrasound scanner is much quicker than fluoroscopy; also, there is no risk of radiation exposure or need for radiography. In addition, the clean theatre environment is likely to reduce the risk of infective complications.

The reported risk of pneumothorax following fluoroscopicassisted catheter insertion ranges from 2.3% to 14%.^3,4 In the current study the incidence of pneumothorax was 3.2% (2/63). However, of these two patients, only one required the insertion of a chest drain.

Twenty three patients (36.5%) developed an infective complication in our study, 10 patients (16%) had superficial infection while 13 patients (21%) had systemic infection. The overall incidence of superficial sepsis was 1.71 per 1000 catheter days, which is similar to that reported in other studies for superficial sepsis (Table 4). All of these infections cleared with oral antibiotics and line removal was not required in any patient. The incidence of systemic sepsis was 2.2 per 1000 catheter days in our study which is comparable to other published data (Table 4). The commonest organism isolated was coagulase negative staphylococcus (n=5), which has been reported in other studies.²

There is considerable variation in reporting infective complication rates following catheter insertion. Press et al (1984) reported a systemic sepsis rate of 0.18 per 1000 catheter days, a figure that is lower than that reported in any other study.⁶ This low rate is due to exclusion of 23 episodes of septicaemia, 11 of which had positive blood cultures for staphylococcus epidermis. These authors also included patients with positive blood and tip cultures in the superficial infection group. The incidence of systemic sepsis of 2.2 per 1000 catheter days in our study is comparable to the incidence of 0.18 to 4.9 per 1000 catheter days reported by others.^7,8,9

Two patients in our study developed catheter thrombosis after 20 and 65 days respectively. We attempted, unsuccessfully, catheter lysis with streptokinase in one patient. Both of these catheters were removed. However, a previous study reported successful lysis of 25 of 30 clots in patients treated with 500 to 2000 U/kg/hr of urokinase infused directly into the thrombus.¹⁰ It appears that a trial of fibrinolytic therapy in cases of documented thrombosis is warranted before catheter removal is undertaken.

CONCLUSION

Although Hickman catheters have improved the care of patients requiring long-term venous access for infusion chemotherapy they are associated with significant morbidity. We conclude that ultrasound assisted percutaneous insertion of Hickman catheters by surgeons is a safe and effective technique. As in our study, by performing this procedure in the aseptic environment of the operating room the risk of infective complications in this group of immunocompromised patients requiring chemotherapy may be reduced.

Copyright 18 December 2004

REFERENCES

1. Maki DG, Botticelli JT, Leroy ML, Thielke TS. Prospective study of replacing administration sets for intravenous therapy at 48 vs. 72-hours is safe and cost effective. JAMA 1987; 258: 1771-81.

2. Harrington KJ, Kelly SA, Pandha HS, Jackson JE, Hollyer JS, McKenzie CG. An audit of Hickman catheters use in patients with solid tumours. Clin Oncol 1994; 6:288-93.

3. Pessa ME, Howard RJ. Complications of Hickman-Broviac catheters. Surg Gynecol Obstet 1985; 161:257-60.

4. Clarke DE, Raffin TA. Infectious complications of indwelling long-term central venous catheters. Chest 1990; 97:966-72.

5. Wade JC, Newman KA, Schimpff SC Vanecho DA, Gelber RA, Reed WP et al. Two methods for improved venous access in acute leukaemia patients. JAMA 1981; 246:140-44.

6. Press OW, Ramsey PG, Larson EB Fefer A, Hickman RD. Hickman catheter infections in patients with malignancies. Medicine 1984; 63:189-200.

7. Larson EB, Wooding M, Hickman RO. Infectious complications of right atrial catheters used for venous access in patients receiving intensive chemotherapy. Surg Gynecol Obstet 1981; 153:369-73.

8. Reed WP, Newman KA, DeJongh C, Wade JC, Schimpff SC, Wiernik PH et al. Prolonged venous access for chemotherapy by means of the Hickman catheter. Cancer 1983; 52:185-92.

9. Cockburn JF, Eynon CA, Virji N, Jackson JE. Insertion of Hickman central venous catheters by using angiographic techniques in patients with haematological disorders. AJR 1992; 159:121-24.

10. Fraschini G, Jadeja J, Lawsom M, Holmes FA, Carrasco HC, Wallace S. Local infusion of urokinase for the lysis of thrombosis associated with permanent central venous catheters in cancer patients. J Clin Oncol 1987; 5:672-78.