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 This is an original JCO publication from 2013. Please visit the JCO website to access the full article.


Central Venous Catheter Care for the Patient With Cancer


 

 Authors

Charles A. Schiffer, Pamela B. Mangu, James C. Wade, Dawn Camp-Sorrell, Diane G. Cope,Bassel F. El-Rayes, Mark Gorman, Jennifer Ligibel, Paul Mansfield, and Mark Levine

 

BOTTOM LINE

 

Intervention

  • Placement of a central venous catheter (CVC) in adult and pediatric patients with cancer and the subsequent prevention and management of catheter-related infections and thromboses.


Target Audience

  • Medical oncologists/hematologists, nurses, interventional radiologists, surgeons, infectious disease specialists, and specialized CVC Care Teams

 

Key Recommendations

  • There is insufficient evidence to recommend a specific type of CVC or insertion site, but femoral vein insertion should be avoided unless in a clinically emergent situation.
  • A CVC should be placed by well-trained health care providers.
  • Use of a CVC Clinical Care Bundle is recommended.
  • The use of antimicrobial/antiseptic coated CVC and/or heparin-impregnated CVC has been shown to be beneficial but the benefits and costs must be carefully considered before they can be routinely utilized.
  • The prophylactic use of systemic antibiotics is not recommended before CVC insertion.
  • Cultures of blood from the CVC and/or tissue at the entrance-exit site should be obtained prior to initiation of antibiotic therapy. Most clinically apparent exit or entrance site infections as well as bloodstream infections can be managed with appropriate microbial therapy so CVC removal may not be necessary. Antimicrobial agents should be optimized once the pathogens are identified. Catheter removal should be considered if the infection is caused by an apparent tunnel or port site infection, fungi, non-tuberculous mycobacteria, or if there is persistent bacteremia after 48-72 hours of appropriate antimicrobial treatment.
  • Routine flushing with saline is recommended.
  • Prophylactic warfarin or low molecular weight heparin have not been shown to decrease CVC related thrombosis, so routine use is not recommended.
  • T-PA is recommended to restore patency in a non-functioning CVC. CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that does not respond to anticoagulation therapy or if fibrinolytic or anticoagulation therapy is contraindicated. 

 

Methods

  • Systematic review and analysis of the medical literature on CVC care for cancer patients by ASCO CVC Care Expert Panel.



SUMMARY OF RECOMMENDATIONS

 

 

QuestionRecommendation

Clinical Question#1: In cancer patients, does catheter type, insertion site, or placement affect complication rates?

[Catheter Type, Insertion site, and Placement]

Recommendation #1.1:  There is insufficient evidence to recommend one type of central venous catheter routinely for all cancer patients. The choice of catheter should be influenced by the expected duration of use, the chemotherapy regimen(s), and the patient’s ability to provide care. The minimum number of lumens essential for the management of the patient is recommended. These issues should be discussed with the patient.

Recommendation #1.2: There is insufficient evidence to recommend one insertion site or approach (left-sided or right sided) for tunneled CVC for cancer patients. Individual risks and benefits (comfort, security, and maintenance of asepsis) of the catheter site should be considered. The Panel recommends that CVC insertion into the femoral vein be avoided because of increased infection risks and concerns about thrombosis, except in certain emergency situations.

Recommendation #1.3: Most CVC placement in patients with cancer is done as an elective procedure. While image-guided insertion (e.g. ultrasound-guided, fluoroscopy) of CVC is recommended, well-trained providers who use the landmark method regularly (e.g. for subclavian or internal jugular) may have a high rate of success and a low incidence of acute and/or chronic complications.

Clinical Question #2: What is effective prophylaxis for the prevention of catheter-related infections?

[Infection Prophylaxis]

Recommendation #2.1: A CVC care clinical bundle (including hand hygiene; maximal barrier precautions; chlorhexidine skin antisepsis during catheter insertion; optimal catheter site selection; and assessment of CVC necessity) is recommended for the placement and maintenance of all CVC in order to prevent infections.  There is no evidence that particular dressing types or more frequent IV set and/or dressing changes decrease the risk of infection. The use of topical antibiotic ointment or creams on insertion sites is not recommended because of the potential to promote fungal infections and resistance to antimicrobials.

A scheduled “guidewire exchange” of CVC may be associated with a greater risk of infection than catheter replacement at a new vascular site and thus “guidewire exchange” is not routinely recommended, unless access options are limited.

 

Recommendation #2.2: The use of antimicrobial/antiseptic impregnated or coated central venous catheters (chlorhexidine and silver sulfadiazine [CH-SS] or minolcycline/rifampin) and/or heparin impregnated catheters are recommended to decrease the risk of catheter-related infections for short term CVC, particularly in high-risk groups such as bone marrow transplant (BMT) or leukemia patients. But, the relative benefit and increased cost must be carefully considered before they are routinely utilized.

Recommendation #2.3:  The prophylactic use of systemic antibiotics (IV or oral) before insertion of a long-term CVC is not recommended. 

Recommendation #2.4:  There are conflicting data about the relative value of prophylactic heparin with saline flushes to prevent catheter- associated blood stream infections or thrombosis.  Data are not sufficient to recommend for or against the routine use of antibiotic flush/antibiotic lock therapy.

Clinical Question #3:  What are effective treatments for the management of catheter-related infections?

 

[Management of Infection]

Recommendation #3.1: Cultures of blood from the catheter and, when appropriate, of soft tissues at the entrance/exit sites or tunnel should be obtained prior to the initiation of antibiotic therapy.  Most exit or entrance site infections can be treated successfully with appropriate antimicrobial therapy without the need for catheter removal, although removal is usually needed for clinically apparent tunnel or port site infections. Antimicrobial agents should be optimized once the pathogens are identified and antibiotic susceptibilities defined.

Clinical Question #4:  What is effective prophylaxis for the prevention of catheter-related thrombosis?

[Prophylaxis of Thrombosis]

Recommendation #4.1: The use of systemic anticoagulation (warfarin or low molecular-weight heparin [LMWH], UFH) has not been shown to decrease the incidence of catheter- associated thromboses and therefore routine prophylaxis with anticoagulants is not recommended for cancer patients with a CVC. Routine flushing with saline of the CVC to prevent fibrin buildup is recommended.

Recommendation #4.2:  Data are insufficient to recommend routine use of urokinase (not available in the United States) and/or other thrombolytics to prevent catheter occlusion.

Clinical Question #5: What are effective treatments for the management of occluded catheters?

[Management of Occlusion]

Recommendation #5.1: The instillation of 2 mg t-PA (tissue plasminogen activator) is recommended to restore patency and preserve catheter function.

Recommendation #5.2:  While it is appropriate to try to clear a thrombosis with the CVC in place, if there is radiologically confirmed thrombosis that does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated, catheter removal is recommended.  Prolonged retention of an unneeded CVC can lead to significant problems associated with thrombosis and fibrosis. Three to six months of anticoagulant therapy with LMWH or LMWH followed by warfarin (INR 2.0 to 3.0) is recommended for the treatment of symptomatic CVC thrombosis, the duration depending on clinical issues in individual patients.

 

 

 

 

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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