Care for Central Venous Catheters and Their Removal: A Retrospective Study

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Introduction

Peripheral vein access is a common issue in surgical patients and critical care units, particularly in patients with cancer. This issue is made more difficult by the necessity of administering chemotherapy and medications that cause severe irritation to the peripheral veins over an extended period of time, the need for frequent blood draws, the short lifespan of catheters placed into peripheral veins, the frequent occurrence of superficial thrombophlebitis, which causes discomfort for the patient, the requirement for hyper alimentation, and the monitoring of central venous pressure to direct fluid resuscitation in surgical patients who are hypovolemic.

These issues have been significantly simplified by the advent of central venous catheterization, which has also made it easier to treat patients—particularly cancer patients—who have inadequate peripheral venous access. Problems could arise during or after the implantation of the catheter. They could have an infectious and thrombotic origin, or they could have anything to do with mechanical obstruction, accidental device damage, or malfunctioning devices [2]. Central venous catheters (CVC) are a ubiquitous tool in the critical care setting; however, their use does not come without risks. Potentially one of the most serious and preventable complications is catheter related bloodstream infection (CR-BSI). Current evidence suggests that CVCs should not be routinely changed to prevent CR-BSI, and that clinical diagnosis of CR-BSI prior to catheter removal has a very low specificity [1, 2, 3].

Aim The aim of this study was to examine the reasons why CVCs are removed and to see whether clinical suspicion of CR-BSI is reflected by microbiological results and improvement following line removal.

Material and Methods

We conducted a retrospective analysis of central venous catheter placement, management, and removal in ICU of Saraswathi institute of medical science, Hapur. Data was collected on insertion sites, duration of insertion, and reason for removal.

This was then matched to corresponding inflammatory markers including leukocyte count (WCC) and C-reactive protein (CRP), and microbiological culture results Study definitions Suspected CR-BSI: Clinical evidence of sepsis (SIRS criteria) and with no apparent source of septicemia except catheter tip colonization.

CR-BSI: Colonization of a catheter tip with the same micro-organism and sensitivity profile grown from a peripheral blood culture [4].

Routine change of CVC: CVC replacement without evidence of sepsis or problems with the functioning of the catheter. Increasing/decreasing inflammatory marker trend: ≥ 10% change in WCC or CRP

Results

A total of 87 CVCs were studied with an average duration of insertion of 5.5 days. (Table 1).

The most common reason for removal was absence of indication (28.7%).

17 out of 87 (19.5%) of CVCs were removed due to suspicion of CRBSI, and of these only 1 was confirmed (Table 2). There was no significant difference between the duration of insertion of colonized and uncolonized CVCs (table 3). We further examined the cultured catheters for evidence of biochemical improvement following removal (Table 4). Of those who experienced improvement of inflammatory markers (by ≥ 10%) following CVC removal, we found no difference in mean duration of insertion, and similarly they were no more likely to have colonized CVCs than patients who did not experience improvement of their inflammatory markers (25% vs 29%)

Table 1: Catheter characteristics In table 1- 87 total number of catheters were used for mean duration of 5.5 +-0.3 days, in which 45 were cultured and 13 were colonised. Table 2: Central venous catheters by reason for removal In table 2 – 25 catheters were removed as they were no longer needed, 17 were suspected to have CR-BSI, 17 were discharged from ITC, 14 were changed routinely and 11 had death.

Table 3: Comparison of cultured CVCs In Table 3- 13 were colonised CVCs and 35 were uncolonized CVCs.

Table 4: CVCs by trend of inflammatory markers post removal In Table4 – 9 showed increasing trend of inflammatory markers post removal, 12 showed decreasing trend and 25 had no change of inflammatory markers.

Fig 1: Central venous catheters by insertion site In Figure 1 – right IJV is the most common insertion site of CVCfollowed by left IJV, right femoral, left femoral, right SC and left SC.

Fig 2: Colonization of CVC tips by bacteria In figure 2 – most common colonization of CVCs tips by CONS bacteria then coliform followed by Klebsiella pneumonae, candida, pseudomonas and proteus.

Discussion

In our study, total of 87 CCs were studied for a duration of 5.5 days, among which 28.7% CVCs were removed without and indication and 19.5% CVCs were removed due to suspicion of CR-BSI. There was no significant difference between the duration of insertion of colonized and uncolonized CVCs, which is similar to the findings found in Lorente et a.l study (3).

Further there was no biochemical improvement after removal of catheter and there was no difference in mean duration of insertion and similarly they were no more likely to have colonized CVCs than patients who did not experience improvement of their inflammatory markers (25% vs 29%).

Conclusion

We observed a rate of CR-BSI of 2.09/1000 days. We found that 15.6% of central venous catheters were routinely changed after an average of 7.1 days without obvious indication other than to prevent catheter-related infection.

Furthermore, we did not find any biochemical benefit to removing colonized CVCs.

This is consistent with current literature which shows that routine replacement does not reduce rates of catheter-related bloodstream infection compared with changing them when clinically indicated [2, 5].

A more conservative approach to catheter removal is also likely to be beneficial even in those with suspected CR-BSI [3, 6].