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
Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India. , India
BACKGROUND: Venous access is crucial for cancer management for administration of drugs blood products, antibiotics and periodic sampling. AIMS: To review our experience of long-term venous access devices used over a ten-year period and to analyse the outcome in cancer patients in Indian setting. Setting and Design: A retrospective analysis of data in a tertiary care Regional cancer centre. PATIENTS AND METHODS: A total of 110 patients with various malignancies requiring long-term venous access were included in the study. A uniform open cut down procedure under local anaesthesia was used and silastic Hickman catheters were inserted in the cephalic or external jugular or internal jugular veins. A record of all complications and catheter loss and final out come were analysed. RESULTS: A total of 111 catheters were used in 110 patients. Sixty-nine catheters were placed in cephalic, 40 in external jugular, and 2 in internal jugular vein. Duration of catheter indwelling period ranged from 7 to 365 days with a median of 120 days. In 90% of the cases the catheter tip was located either in superior vena cava or in right atrium. Total catheter related complications were observed in 37 (34.54%) patients and catheter loss rate due to complications was 15.4% (17/111). CONCLUSIONS: Long-term venous access using Hickman catheter insertion by open cut down method is a simple, safe and reliable method for administration of chemotherapeutic agents, antibiotics and blood products. The incidence of various complications and catheter loss was acceptable and overall patient satisfaction was good.
Keywords: Adult, Catheterization, Central Venous, adverse effects,instrumentation,statistics &numerical data,Catheters, Indwelling, Child, Equipment Contamination, Equipment Failure, Female, Human, India, Male, Neoplasms, therapy,Retrospective Studies,
Modern chemotherapeutic management of cancer patients depends upon repeated and prolonged access to venous system for safe and easy administration of various chemotherapeutic agents, antibiotics, intravenous fluids, blood
components and blood sampling. Repeated venepunctures has various disadvantages and to overcome this problem
arteriovenous fistulae, peripherally inserted silastic catheters and implantable venous ports have been tried with varying success., Silastic catheters described by Hickman and Broviac are most commonly used due to advantages like simple insertion technique, reliable patency and low complication rate., Venous access devices have been used widely in the western countries. However they are not commonly used in developing countries like India due to various reasons. We report our experience of 111 silastic Hickman catheter insertions in 110 cancer patients.
One hundred and ten cancer patients attending Institute Rotary Cancer Hospital (IRCH) of All India Institute of Medical Sciences (AIIMS), New Delhi during the period between January 1991 and December 2000 requiring prolonged venous access were taken up for Hickman catheter insertion. Routine pre-operative haemogram was done in all the patients to ensure minimum of 9 gm/dl haemoglobin and 100,000 per cubic mm of platelet count. [Table:I] shows the patient characteristics.
Technique of Hickman catheter Insertion
Uniform open cut down technique was used in all patients under strict aseptic precautions in the operation theatre. Right sided veins were mostly used in view of its direct course in to the right atrium. Left cephalic or jugular vein were only used when right cephalic or external jugular vein could not be accessed. 1% Lignocaine was used at the proposed site of venepuncture and along the subcutaneous plane on the chest wall for tunnelling the catheter 2 cms medial to anterior axillary line till the exit site 2 cms below the nipple. After localisation of the cephalic vein in the deltopectoral groove vein was looped using two separate 2-0 silk ligatures. Tunnelling was completed using a metallic tunneller designed by our team and the catheter was threaded with the help of tunneller in to the venotomy wound. The dacron cuff at the proximal end of the catheter was positioned in the subcutaneous tissue 2 cm proximal to the exit site and the catheter was anchored to the skin with a 2-0 silk suture. Required length of the catheter was determined by measuring the length of distance from venotomy site to sternal angle along the course of cephalic, subclavian and superior vena cava axis. Subsequently the distal suture was ligated securely over the cephalic vein and a venotomy was performed using venotomy scissors proximal to the distal ligature. After dilatation of the vein lumen by a vein dilator the catheter tip was threaded through venotomy and pushed inside to the desired length. During the catheter advancement manual pressure was applied over the internal jugular vein to prevent malposition of the catheter tip in internal jugular vein. Once the position of the catheter was secured and free flow of blood established, the proximal end of the vein was ligated over the catheter. After securing haemostasis, the wound was closed using 3-0 nylon. The catheter was flushed with heparinised saline 100 IU / ml and 1 gm of Cefotaxime was injected through the catheter at the end of the procedure. Whenever cephalic cutdown has failed external jugular vein was accessed through a separate incision. In patients with failed cephalic and external jugular vein cutdowns Internal jugular vein was accessed under general anaesthesia. Catheter was secured in Internal jugular vein using a 5-0 prolene purse string suture. A record of all complications and fate of the catheter was maintained. Catheter related sepsis was defined as I) Exit site infection – infection at catheter exit site II) Catheter blood culture proven bacteraemia in the absence of any other focus of infection III) Catheter tunnel infection- Signs of inflammation along the course of the tunnel IV) PUO-Pyrexia of unknown origin. The data was analysed using Fox Pro Windows version 2.5 (Microsoft Corporation, USA).
In hospital catheter care including aseptic precautions and periodic flushing of catheter before and after use was performed by a dedicated team of doctors and nurses. During this period the patient or a responsible attendant was also trained in catheter care and was also explained regarding the potential complications that can occur at home. When catheter was not used for long periods a weekly catheter flush using Heparin saline ( 100 IU/ml) was advised.
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. [Table - 2] shows the site of catheter insertion and position of catheter tip.
Total catheter related complications occurred in 37 (34.5%) patients and total catheter loss due to complications were documented in 17 (15.4%) patients. [Table - 3] shows various catheter related complications. 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.
The most disturbing aspect of treatment of a cancer patient is multiple painful venepunctures made for administration of cytotoxic agents, antibiotics, blood products and nutritional supplements. To overcome this problem arteriovenous fistulae, peripherally inserted silicone catheters, implantable ports have been tried with varying success., A number of clinical trials have favoured silastic Hickman catheters because of its simple insertion technique, reliable patency and short maturation time in comparison to other means of long term venous access., Two methods of Hickman catheter insertion have been described – 1) Open phlebotomy and 2) Closed percutaneous puncture technique. Open phlebotomy is much simpler and safer in comparison to closed technique which requires technical expertise and carries a higher complication rate like pneumothorax, haemo-pneumothorax and injury to great vessels. Post et al described ultrasound and fluoroscopy guided procedure of subclavian vein catheterisation with a very low complication rate but experience with this technique is limited. Fluoroscopy helps in proper placement of Hickman catheter tip even in open phlebotomy methods but its use is not mandatory. Despite not using routine fluoroscopy control we could achieve 90% success rate in positioning the catheter tip in large central veins. Only 11 catheters out of 111 could not be positioned in central veins. Satisfactory placement of catheter tip can be verified by a post operative chest x-ray. Cephalic cut down was performed in 63 % (69/111) patients in our series and our success rate of cephalic vein cannulation was comparable to the success rate quoted in literature., Torramed et al reported a success rate of 70% with cephalic cutdown and Wade et al reported 38 % successful cephalic cumulation rate. Failed cephalic cut down is mostly due to either small vein size or absence of the proper cephalic vein itself.
Two-thirds of bacteraemias occurred in severely immune compromised infection prone patients in our series.
Catheter related sepsis (17.27%) and catheter loss due to infective complications (7.27%) in our series was comparable to the results quoted by other series.,,, Rao et al in an Indian experience of long term venous access using cavafix central venous lines reported a infection rate of 19% with subclavian lines and 32% with cubital lines.
Antibiotic prophylaxis is often recommended, as some studies showed low incidence of septic complications by
using prophylactic antibiotics.,, Raad et al using a non tunnel technique reported low complication rate and increased durability of catheters but the experience with this method is limited. The catheter blockage rate in the current study is 14.5% in comparison to 13% reported by Rao, et al. Only flushing of blocked catheter using 20 ml of heparin saline (100 iu/ml ) solution was attempted to clear the block in the current study and 9 out of 16 catheters could saved. No thrombolytic agents like urokinase or streptokinase were used to clear the blocks due to cost factors.
Absence of haemorrhagic complications in our study can be attributed to strict adherence to a minimum platelet count of 100,000 per cubic mm. There was no catheter related mortality in our series and overall patients satisfaction was excellent.
In conclusion, long term venous access using Hickman catheter is a safe and reliable method for administration of chemotherapeutic agents and other intravenous components in the management of various malignancies. Results of our study prove that open cut down method for Hickman catheter insertion is safe with a low complication and high success rate and they can be maintained safely at home. Routine insertion of such devices can save valuable time of medical and para medical staff. Based on our experience, we feel that these catheters can be widely used in country like India as a means of prolonged venous access in the management of various malignancies.
[Table - 1], [Table - 2], [Table - 3]