Browser Not Supported

It looks like you're using an outdated browser. To view this site properly, please switch to a more modern browser such as Chrome,Firefox, or Edge.

Central venous access in patients with intestinal failure

Date last published:

Patients with intestinal failure require long-term CVAD for intravenous nutrition (IVN/PN) and hydration

This document is only valid for the day on which it is accessed. Please read our .
NZ NIFRS guidance

This guideline should be used in conjunction with your district health board policy and guideline documents associated with the management of CVAD

Practice points for patients of all ages with intestinal failure
Patients with intestinal failure (IF) require long-term CVAD for intravenous nutrition (IVN/PN) and hydration
Device selection should factor in anticipated duration of IVN/PN treatment
NZ NIFRS recommend that the choice of CVAD and location of exit site be made by an experienced specialist together with the patient.  Right sided access is recommended to reduce the risk of thrombosis
Complications related to CVAD include: septicaemia, dislodgement, thrombosis, tip migration due to growth and skin breakdown
Meticulous CVAD care education and management is critical to the long-term survival of a patient with IF
Patients with well-healed tunnelled CVAD site, are able to swim & shower, provided that a water-resistant dressing is applied covering the whole catheter prior and replaced immediately after
CVAD infections in this cohort occur either due to incorrect/unhygienic line handling, or translocation of gut bacteria
Recurrent CRBSIs/CLABSI will significantly impact on patient morbidity and mortality, targeted antibiotic management guided by microbial history and ID consult is indicated. A detailed CVAD history should be maintained for all patients with IF
Progressive loss of central venous access sites is an indication for discussion with NIFRS and an Intestinal transplant centre +/- transplant assessment.  Critical central access may result in transplantation or death
Practice points for children and young people under 15 years of age with intestinal failure
To minimise the risk of infection a CVAD with the fewest number of lumens should be placed.  Preference is for a single lumen tunnelled device
Practice variation exists as relates to the standardised use of Heparinised saline.  Expert opinion in the presence of low levels of evidence is that Heparinised saline may have ongoing utility in preventing CVAD occlusion in small diameter CVAD.  Results of a randomised multi-centre trial in progress are awaited
Due to potential side effects including contact dermatitis, skin antisepsis with chlorhexidine in infants younger than two months cannot be recommended
Sampling blood from the CVAD is to be minimised where possible, balanced against the need to protect venous access and minimise patient trauma associated with blood tests
In the setting of frequent CVAD contamination due to exposure to bodily fluids variance of CVAD cares should be discussed with the IV therapy clinical nurse specialist or NIFS
Annual surveillance venous doppler ultrasound of the central vessels is recommended to monitor for subclinical thrombosis as children with central vein thrombosis are often asymptomatic

 

The number of CVAD in the first two years of life and diagnosis of NEC or Gastroschisis have been identified as non-modifiable risk factors for venous occlusive disease

Practice points for adolescents over 15 years of age and adults with intestinal failure
Patients with CLABSI can develop pulmonary lesions compatible with septic pulmonary embolism (SPE). It is recommended to screen for secondary lung infections to guide targeted antibiotic therapy

Types of CVAD

  • Totally implantable venous access device (TIVAD)

  • Peripherally inserted central catheter (PICC) – Associated with an increased risk of thrombosis, may impact patient ‘self-care’ ability

  • Short term central venous catheter

  • Tunnelled central venous catheter

  • Arterio-venous fistula – should be considered in patients with on-going CVAD associated complications and reduction in vascular access. Consideration of formation of an AV fistula for IVN/PN infusion should be discussed with wider MDT including Vascular Surgeon. If this is considered, contact NZ NIFRS

  • Umbilical catheters -practice variation in the neonatal patient population

CVAD tip position (confirmed on imaging)

  • Routinely placed at the cavoatrial junction between the right atrium and superior vena cava (SVC)

  • “In small infants (body length 47 – 57cm) the catheter tip of a jugular or subclavian CVAD should lie at least 0.5cm above the carina (within the SVC) on a chest x-ray, while on older larger infants (body length 58-108cm) that distance should be at least 1cm”(Wouters et al., 2019)

  • The catheter tip of a femoral catheter should lie above the renal veins (first lumbar vertebra).

Suspected CLABSI

  • Every effort should be made to clear bacteraemia and preserve the patient’s CVAD, however there are some situations such as candidaemia or other fungal infections when a CVAD will need to be removed

  • Indications for line removal are severe sepsis with end organ dysfunction, persistent bacteraemia of over 48 hours with appropriate antibiotic coverage and/or fungal infections

  • On-going management including the need for CVAD removal will be based on clinical review and blood culture results

  • If a patient requires CVAD replacement, replacement versus guidewire exchange requires consideration, replacement is aligned with reduced risk of infection, while guidewire exchange is preferable in the setting of difficult venous access

  • Lock therapy either antibiotic or 70% ethanol may be considered in some situations – this will need to be discussed with the responsible consultant or Infectious Diseases Team

Indicators and management of sepsis

Call Code - If patient condition critical. The decision to continue or stop IVN/PN must be discussed with the clinical team, with a written treatment plan in place (including fluid management)

For all patients with intestinal failure:

‘Sepsis six and severe sepsis resuscitation bundle’ principles apply to all patients with intestinal failure – all patients on this pathway require a full septic screen.

  1. Early recognition

  2. Rapid vascular access

  3. Empiric antibiotic therapy

  4. Rapid, judicious, fluid resuscitation

  5. Early initiation of inotropes

  6. Source control (if possible)

Adult patient assessment framework:

  • Systemic Inflammatory Response Signs (SIRS) criteria

  • Temp >38°C or < 36°C

  • Heart rate > 90

  • Respiratory rate > 20

  • White cell count >12 or < 4

>2 SIRS criteria + hypotension (despite adequate fluid resuscitation) is indicative of Septic Shock.

Paediatric patients may present with tachycardia, increased irritability, drowsiness +/- fluctuating low grade pyrexia. Assessment should include a blood glucose level

Figure 1: Management of suspected CVAD sepsis

Click on the image below to open a full sized pdf

CVAD selection

For all patients with intestinal failure:

  • IVN/PN should be infused via a dedicated lumen of a CVAD

  • In the acute setting patients may require ≥ 1 lumen of a CVAD for management of multiple modalities eg: IVN/PN, analgesia, IV therapies, blood sampling. It should be noted that the CLABSI rates are observed to increase for each additional CVAD lumen

  • If a multi-lumen CVAD is placed, please ensure a lumen is dedicated and labelled for IVN/PN

  • IVN/PN solution osmolality informs venous access device selection

For young people over 15 years of age and adults with intestinal failure:

  • If recurrent CVAD infections/CLABSI in patients receiving IVN/PN over 31 days. AV fistula for IVN/PN should be considered. This requires discussion with your vascular team

Figure 2: Considerations for CVAD selection for IVN/PN infusion

Click on the image below to open a full sized pdf

 

Lock therapy

The decision to initiate taurolidine or ethanol lock therapy is a collaborative decision by the primary team, the infectious diseases service and the pharmacist. The infectious diseases team in collaboration with the pharmacist will determine the appropriate solution, dwell time and duration of therapy – reviewed minimum three monthly

70% ethanol lock – silicone CVAD only

  • An ethanol lock is used to prevent CLABSI and to protect long term vascular access in patients with IF. Ethanol may have a negative impact on CVAD integrity e.g. CVAD fracture and increasing resistance.

  • After a child's first CLABSI event please commence 70% ethanol locks as per the protocol below. On days that 70% ethanol is not used, heparin locks are recommended.

Contraindications for Ethanol lock

  • Anaphylaxis to ethanol

  • Access device; non silicone catheters and subcutaneous vascular access device (port)

  • Abnormal liver function test

  • Heparin administration

Ethanol lock frequency and dwell time

The frequency and dwell time for ethanol locks vary, from daily in the setting of recurrent bacteraemia; to three times per week (standard) or once weekly prophylaxis. Minimum dwell time is 2 - 4 hours to achieve meaningful elimination of biofilm. Maximum dwell time 12 hours.

Taurolidine locks

There is evidence to support the use of taurolidine citrate line locks in the prevention and management of CLABSI. It is currently available in New Zealand via the Named Patient Pharmaceutical Application (NPPA) process. Supporting evidence including history of recurrent CLABSI will be required in the NPPA application.

CVAD line pressure monitoring (preventing occlusion)

  • Average CVAD line pressure while infusing IVN/PN is 0.2-0.3 Bar

  • Early intervention is indicated to prevent catheter occlusion. Increased resistance when flushing the CVAD, episodes of downstream occlusion or persisting increased pressure readings 0.45 and above would indicate a need for pre-emptive fibrinolytic treatment

CVAD repair

  • “CVAD’s are subject to mechanical degradation and potential failure over time. Often the source of mechanical failure of tunnelled CVAD is in the external portion of the catheter. Common examples of mechanical failure include ballooning, fracturing, and cracking of the hub. These issues may be due to excessive pressure with flushing, catheter manipulation or natural wear.” 7

Repair of CVAD should be carried out by appropriately trained clinical staff in the hospital setting. Timing and planning are critical and considerations should include

  • Suitability for repair - assess the integrity of the lumen and length of the remaining catheter

  • Clinical status - line repairs should only be completed in the absence of CLABSI and sepsis

  • If there is a risk of a septic shower post repair please consider short term antibiotic cover as there is a low infection risk with CVAD repair in some Home IVN/PN patients 7, 8

  • Fragility of the repaired CVAD - multiple repair sites should be avoided if possible
    Please secure all administration tubing and CVAD carefully to prevent further breakage

Post repair – plan and documentation must include

  • The remaining length of CVAD

  • Number of repair sites

  • Confirmation of when the CVAD can be used i.e. time and date

  • Fluid management if the patient’s routine IVN/PN has been disrupted

For patients receiving Home IVN/PN it is recommended that their local hospital has a replacement CVAD and repair kit in stock.

Critical central access

Salvaging veins where possible is the preferred approach. NZ NIFRS recommends early discussion with Interventional Radiology, the patient’s surgeon and the NZ NIFRS to salvage veins rather than moving to a new vein in situations of occlusion or thrombosis.

  • The use of invasive transcatheter techniques to recanalize and rehabilitate chronically occluded central veins are emerging as an alternative strategy, when anticoagulation is unsuccessful. Hybrid endovascular/open surgical procedures can be successfully applied for restoring or maintaining permanent central venous catheters in patients with intestinal failure and end-stage venous access

  • Intestinal transplant listing criteria

  • Infants; loss of two of the four standard available sites at the left and right subclavian and internal jugular veins

  • Older patients; loss of three of the six standard available sites at left and right subclavian, internal jugular and femoral veins 

 

Tools