Central venous access device definition: Central Venous Access Devices (CVADs) and Peripherally Inserted Central Catheters (PICCs) for Adult and Pediatric Patients: A Review of Clinical Effectiveness and Safety

04.08.202315.06.2023 by alexxlab

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Central Venous Access Devices (CVADs) and Peripherally Inserted Central Catheters (PICCs) for Adult and Pediatric Patients: A Review of Clinical Effectiveness and Safety

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Rapid Response Report: Summary with Critical Appraisal

Chuong Ho and Carolyn Spry.

Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Apr 27.

Search term

Central venous access devices (CVADs) or central venous catheters (CVCs) are devices that are inserted into the body through a vein to enable the administration of fluids, blood products, medication and other therapies to the bloodstream. CVADs can be inserted into the subclavian or jugular vein (implanted ports, tunneled catheters), or can be inserted into one of the peripheral veins of the upper extremities, called peripherally inserted central catheters (PICCs). ¹

While generally safe, CVADs can be associated with complications such as catheter occlusion or rupture, venous thrombosis, and bloodstream infection.¹ A number of strategies have been used to minimize the occurrence of CVAD- and PICC-associated complications such as antimicrobial-impregnated lines for prevention of infection, or addition of a valve (valved catheters) to prevent occlusion by preventing reflux of blood into the catheter.² Flushing the catheters with saline or heparin – an agent with anticoagulant activity – have been used to reduce clot formation and occlusion of the catheters.

This Rapid Response report is an update of the previous CADTH reports which found no difference in terms of frequency of occlusion in patients who had a valved versus a non-valved PICCs, and similar patency between heparin and saline use for CVCs.^3,4 This report aims to review the evidence on the clinical effectiveness of valved versus non-valved PICCs, and saline versus heparin flushing in the maintenance of CVADs patency and reduction of complications.

Context and Policy Issues
Research Questions
Key Findings
Methods
- Literature Search Methods
- Selection Criteria and Methods
- Exclusion Criteria
- Critical Appraisal of Individual Studies
Summary of Evidence
- Quantity of Research Available
- Summary of Study Characteristics
- Summary of Critical Appraisal
- Summary of Findings
- Limitations
Conclusions and Implications for Decision or Policy Making
References
Appendix 1. Selection of Included Studies
Appendix 2. Characteristics of Included Publications
Appendix 3. Critical Appraisal of Included Publications
Appendix 4. Main Study Findings and Author’s Conclusions

About the Series

Rapid Response Report: Summary with Critical Appraisal

ISSN: 1922-8147

The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.

While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH.

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Bookshelf ID: NBK470804PMID: 29293304

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Central Line (Central Venous Access Device)

You need a central line as part of
your treatment. It’s also called a central venous access device (CVAD) or central
venous
catheter (CVC). A small, soft tube called a catheter is put in a vein that leads to
your
heart. When you no longer need the central line, it will be taken out. Your skin will
then
heal. This sheet describes types of central lines. It also explains how the central
line is
placed in your body.

What a central line does

A central line is often used
instead of a standard IV (intravenous) line when you need treatment for longer than
a
week or so. The line can deliver medicine, fluids, or nutrition right into your
bloodstream. It can also be used to measure blood flow (hemodynamic monitoring), to
draw
blood, or for other reasons. Ask your healthcare provider why you need the central
line
and which type you’ll get.

Types of central lines

The central line will be placed
into one of the veins as described below. Which vein is used depends on your needs
and
overall health. The catheter is threaded through the vein. It is passed along until
the
tip sits in the large vein near the heart (vena cava). Types of central lines
include:

Peripherally inserted central catheter (PICC). This line is placed in a
large vein in the upper arm, or near the bend of the elbow.
Subclavian line. This line is placed into the vein that runs behind the
collarbone.
Internal jugular line. This line is placed into a large vein in the
neck.
Femoral line. This line is placed in a large vein in the groin.

Placing the central line

The central line is placed in your
body during a short procedure. This may be done in your hospital room, the emergency
department, or an operating room. Your healthcare team can tell you what to expect.
During central line placement:

You’re fully covered with a
large sterile sheet. Only the spot where the line will be placed is exposed. The
skin is cleaned with antiseptic solution. These steps lower the risk for
infection.
Medicine (local anesthetic)
is injected near the vein. This numbs the skin so you don’t feel pain during the
procedure.
After the pain medicine
starts to work, the catheter is gently passed into the vein. It’s moved forward
until the tip of the catheter is in the vena cava, close to the heart. This is
usually done with the help of an ultrasound machine. The ultrasound machine helps
see below the skin. It helps the provider guide the catheter into the vein without
hurting other tissues or organs.
The other end of the catheter
extends a few inches out from your skin. It may be loosely attached to the skin
with stitches to hold it in place.
The healthcare provider
flushes the catheter with saline solution to clear it. The solution may include
heparin. This prevents blood clots.
An X-ray or other imaging
test is done. This allows the provider to confirm the catheter’s position and
check for problems.

Risks and possible complications

As with any procedure, having a
central line placed has certain risks. These include:

Infection
Bleeding problems
An irregular heartbeat
Injury to the vein or to
lymph ducts near the vein
Inflammation of the vein
(phlebitis)
Air bubble in the blood (air
embolism). An air embolism can travel through the blood vessels and block blood
flow to the heart, lungs, brain, or other organs.
Blood clot (thrombus) that
can block the flow of blood. A blood clot can also travel through the blood
vessels. It can block blood flow to the heart, lungs (pulmonary embolism), brain,
or other organs.
Collapsed lung (pneumothorax)
or blood buildup between the lungs and the chest wall (hemothorax)
Nerve injury
Accidental insertion into an
artery instead of a vein
Catheter not positioned
correctly

If you have any problems with your
central line, talk with your healthcare provider.

Central venous catheters for children with cancer

Cancer treatment usually includes various injections, blood draws, and intravenous drugs and fluids. To facilitate the process, many children with cancer have a catheter (a thin, flexible plastic tube) placed under the skin to access a vein.

During the first few days of treatment, a peripheral IV catheter may be placed for temporary use. A peripheral IV catheter is a small, short catheter that is usually inserted into a vein in the hand or inside of the arm near the elbow. These catheters are intended for short-term use and should be replaced within a few days. In addition, due to the small size of the vein, some drugs cannot be administered through a peripheral intravenous catheter.

PVCC
Tunneled central catheter
Subcutaneous Port System

The central venous catheter can be used for blood sampling, chemotherapy, administration of fluids and electrolytes, parenteral nutrition, antibiotics and other drugs. The figure shows a subcutaneous port system as an example.

During cancer treatment, an intravenous catheter may be inserted into a large vein leading to the heart. This type of catheter is called a central venous catheter (also called a CVC). A central venous catheter can be used to administer drugs, fluids, blood products, and nutrients. Some blood samples may also be taken through a central venous catheter. The catheter reduces the number of needle sticks that can cause discomfort and anxiety for patients and their families. Often the central venous catheter remains in the vein throughout the entire treatment period (several months or years). If an infection or other complications occurs, it is removed and replaced with a new one.

Central venous catheter use:

Blood sampling
Administration of chemotherapy
Introduction of fluids and electrolytes
Providing parenteral nutrition
Administration of antibiotics and other drugs

Types of central venous catheters

There are 3 main types of central venous catheters that are used in the treatment of children with cancer.

Peripherally inserted central catheter (PICC)
Tunneled central catheter
Subcutaneous Port System

The subcutaneous port system is a central venous catheter placed completely under the skin. The drug is injected through the port system using a Huber needle.

Catheters vary in location and method of use. The choice of the most suitable catheter for the patient is determined by several factors. These include:

Type and amount of drugs and other treatments
Duration of treatment
Frequency of use
Therapy intensity
Age, body size and health of the child
Child activity level
Catheter Care Features
Risk of infection and other complications

The doctor will talk about the procedure and the possible risks and benefits. One of the biggest risks when using a central venous catheter is the risk of infection. It is important to follow all instructions for caring for your catheter to reduce the risk of infection and ensure it is working properly.

–
Modified June 2018

How often should central venous access devices (CVDs) be changed to reduce the risk of catheter-associated infection?

Relevance

A central venous access device (CVD, also known as a central venous catheter) is a hollow tube placed in a large vein, with the end near the heart. CVDs allow drugs, fluids, and blood products to be injected directly into the bloodstream, and allow blood samples to be taken for analysis. One of the negative consequences of the use of UCVD can be an infection of the bloodstream, which is called a catheter-associated infection of the bloodstream or CAIC. These infections can be serious and even life-threatening. Some UCVDs may remain in place for weeks, months, or years. Most patients admitted to the intensive care unit will have a CVD installed. UCVD may also be needed for patients with “bad” veins or who require long-term treatment. To protect the skin surrounding the catheter entry site, dressings are used that are placed over the catheter entry site into the vein; usually on the chest, neck, or arm. The dressings help prevent infections and they allow the UCVD to be secured so that it does not move. Dressings are changed when they get dirty or when they start to fall off. Frequent dressing changes can cause damage to the surrounding skin, so patients may experience pain or skin damage during dressing changes. Frequent dressing changes are also costly.

We wanted to know if there were any advantages or disadvantages to longer or shorter dressing intervals on the CVD. Some hospitals or health care facilities recommend changing dressings every few days, while others keep dressings in place for much longer.

Review

We reviewed the available evidence on the effects of different UCVD dressing intervals and whether they affect the risk of CAD and other complications. We found five studies that provided information for our review.

Research Characteristics

The five studies included in this review were published between 1995 and 2009 and included a total of 2277 participants. The studies were conducted in four countries (two studies in France and one study each in Italy, Sweden and the Czech Republic). One study included children, while the remaining four studies included only adults. Four studies included cancer patients and one study included intensive care unit patients.

We classified dressing change intervals as short (2–5 days) in the higher dressing frequency group and long (5–15 days) in the lower dressing change group. All studies used transparent dressings made from synthetic materials, and two studies used gauze (a dressing that does not stick to the skin) attached with tape in cases where the skin was broken. CVD dressings were monitored daily in all studies, and patients were observed at least until CVD removal or until discharge. In one study, the manufacturer provided one of the medical products but had no influence on the design or on the analysis and presentation of the results.

Main results

Existing evidence leaves it uncertain whether the frequency of dressing changes on the CVP affects the risk of CVCC or death. Of particular interest to patients are problems that may be associated with self-dressing changes, such as pain on removal of the dressing and skin damage that may be caused by the dressing. We found that there was no clear evidence that the frequency of dressing changes affected pain (which was assessed daily).

Quality of evidence:

Overall, the quality of the evidence was very low to low. We lowered the quality of the evidence due to the fact that the studies were small and small, due to poor study design, and due to differences in results between these studies. Better-designed studies are needed to show whether longer or shorter dressing change intervals are more effective in preventing catheter-associated infections, mortality, skin damage, pain on dressing removal, and in terms of quality of life and cost.