Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio

Transcription

1 Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio Timothy R. Spencer, DipAppSc, BHSc, ICCert, RN, APRN, VA-BC

2 Disclosures Director, Global Vascular Access, LLC Consultant/Lead Faculty for the following companies; Teleflex Inc. Johnson & Johnson (Ethicon) FUJIFILM Sonosite (USA) Presidential Advisor for Australian Vascular Access Society I have no other membership or affiliation conflicts I have no stock/shareholding conflicts to declare

3 Most Catheter-related DVT Are Clinically Silent! van Rooden CJ, et al. J Thromb Haemost 2005; 3: % Symptoms 60% Silent The pathogenesis of CRT is complex and multifactorial, with risk factors associated with the catheter, the vessel selected for insertion and the underlying patient co-morbidities and their treatments.

4 Thrombosis with CVAD use is a serious complication that causes morbidity 1 deep vein thrombosis (DVT) pulmonary embolism (PE) and postthrombotic Thrombosis of any catheterized vein is a potential complication. Catheter-related thrombosis (CRT) is more common than infectious complications in all anatomic sites, especially when smaller veins of the upper extremity are considered. 2 syndrome. 1

5 Cause of Thrombosis Earlier studies have reported risks of symptomatic CRT as high as 28%, but more recent studies suggest 5% or less. 1 Studies have suggested that catheter material, tip position, infection, previous catheterization, vessel trauma may influence the risk of CRT. 1 Medication may play role in thromboticphlebitic influence with divergent ph/osmolar values in vessel wall dynamics. 2 Patient Groups DVT Prevalence(%) Medical patients General surgery Major gynaecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, HFS Major trauma Spinal cord injury Critical care patients 10 80

6 Current Evidence New standard from INS supporting 45% or less Ongoing Assessment

7 Incidence Symptomatic CVC-related DVT in adult varied between 0.3% and 28.3% 1 Incidence of venography-assessed cases (asymptomatic) ranged from 27% to 66%. 1 Comparatively, PICC symptomatic thrombosis has been reported to be 3% 20%, and the rate of asymptomatic thrombosis has been reported to be 61.9%. 2 Pulmonary embolism has been reported in 15% to 25% of patient with CVC-related DVT. 2 Nonetheless, CVC thrombosis can result in clinical symptoms, decreased catheter function, higher rate of infection, post-phlebitic syndrome of the upper extremity, pulmonary embolus, and greater costs. 1

8 Virchow s Triad The Triad of Virchow - formulated in the 19th Century, still forms the basis for the current theory on thrombus formation. 1 This pathophysiological explanation describes the precursors around three core relationships of vascular thrombosis. 1. vessel wall damage or endothelial injury (vascular injury) 2. alterations in blood flow (hematological stasis), and 3. hypercoagulability (changes in the chemical composition of blood) deeming it significant effectors in prevention of vessel- and catheter-related complications 2 Image: Hull CM, Harris JA. (2013) Venous Thromboembolism and Marathon Athletes, Circulation, 128: e469-e471

9 Virchow and Catheters Central venous catheters can impact this triad through stasis and direct vascular injury. Additionally, the presence of the catheter itself provides a thrombogenic surface to further create an environment favouring thrombosis. Industry trying to decrease thrombogenicity of materials used in production. In many cases, patients fit all 3 core criteria for thrombosis add various disease states and comorbidities and the risks rise significantly.

10 Catheter-Related Factors 1. Left sided insertions 2. >1 insertion attempt 3. Proximal tip location to cavoatrial junction/distal SVC 4. Catheter material (polyethylene, polyvinylchloride > silicone, polyurethane 5. Number of lumens (triple lumen > double lumen > single lumen) = external catheter size 6. Prior catheterization at same puncture site(s) (trauma related) 7. Prolonged catheter dwell time (>2 weeks) 8. Catheter related infections/septicaemia 1 9. Reverse tapered catheters 2 Catheter Size Catheter Taper

11 Arm Circumference latent sign of thrombosis development

12 INS 2002 & statements on catheter vessel ratio In 2007, the Infusion Nursing Society (INS) standards recommended that a target vein for vascular access must be able to accommodate the catheter. 1 In 2011, the INS Standards of Practice (SOP) were subsequently updated, yet the standards only included that the vasculature shall accommodate the gauge and length of the catheter required for the prescribed therapy. 2 What is missing is the actual unit of measurement, but there is still inconsistency amongst clinicians on what expression of CVR is important.

13 Catheter to Vessel Ratio The term CVR (Catheter to Vessel Ratio) has not been defined by the Infusion Nurses Society (INS) giving it only a numerical value (<45%). In the current 2016 INS Standards of Practice, there are only two mentions of CVR with a relationship of using <45% (S55, S112). 1 INS however did include more recent evidence to say that a catheter vessel ratio of 45% was a satisfactory risk prevention strategy. A supporting publication showed that there was statistical significance with catheter vessel ratios 45%, with a 13-fold increase in CRT risk. 2

14 2016 INS Standards of Practice addresses CVR 1 S55 S112

15 Catheter to Vessel Ratio CVAD diameter has been found to be a predictive factor for thrombosis in several studies. 1,2 Authors have recommended use of the smallest diameter to reduce the rates of thrombosis 1,2,3,4 Conversely, smaller devices occupy less cross-sectional venous area allowing greater blood flow around catheter, substantially reducing this risk. 2,3,4 Larger diameter CVADs are associated with higher thrombosis rates, and a taper near the hub also potentially results in an increased thrombosis rate, specially at the insertion site of vessel. 2,3,4

16 Catheter to Vessel Ratio # of lumens There is now established clinical evidence that shows CRT is related to the catheter size within the intraluminal space 1,2,3,4 An increase in the number of PICC lumens also results in greater French/gauge, a factor independently associated with risk of DVT 5 While PICC use has significantly increased over several years, as too has upper extremity DVT. Reported PICC-associated DVT rates have ranged from 0 to 20% and are a greater common complication than infection 6

17 Flow & Catheter to Vessel 1 Ratio

18 Converting French size to mm Catheter Fr. x 0.33 = catheter outer diameter (OD) in mm Vessel measurement is currently expressed in mm (or cm) on ultrasound. Why is this important?

19 Catheter to Vessel Ratio currently 1 Current guidelines say the catheter should never take up more than 1/3 of the internal vessel diameter. Just increasing from 33% to 45% is a 26.7% increase in overall external catheter size

20 Catheter to Vessel Ratio new concept No real clinical definition. until Spencer & Mahoney (2017) defined the Catheter to Vessel Ratio (CVR) as the indwelling space or area consumed or occupied by an intravascular device inserted and positioned within a venous or arterial blood vessel. 1

21 2017 PIVC study recommends cross-sectional area measurement 1 International Journal of Vascular Medicine (2017) Recommended cross-sectional area for vessel measurement Impacts on peripheral device functionality (aspiration) Did not address catheter-related thrombosis

22 Catheter to Vessel Ratio make it easy to measure Spencer & Mahoney (2017) compared the traditional rule of thumb (33% rule), and the recent 45% rule of CVR 1 However, these general rules are traditionally based on a single, linear measurement, not focusing on the AREA the catheter consumes within the vessel There is a need to consider the vessel a three-dimensional object, meaning it has height, width, depth and volume - much more beyond the two-dimensional view seen on the ultrasound. Moving to a CVR that compares the two-dimensional area consumed by the catheter within the cross sectional area of the vessel measured, we are driving our data pool dimensions ahead potentially reducing CRT

23 Catheter to Vessel Ratio make it easy to calculate The aim was for simplicity and effectiveness of this tool for a quick and accurate review with a simple colour scheme to highlight the areas (or zones) of CVR safety, which have been colour-coded accordingly: RED ZONE - 45% or greater high risk zone YELLOW ZONE % cautionary zone GREEN ZONE - 33% or less safe zone

24 Behind the scenes Based purely upon mathematical calculations. Very small changes in vessel size have significant impact on CVR when focusing on an AREA calculation

25 Living Example.. Catheter Size: 5Fr Vessel Size: 4.2mm Linear-based calculations Fr mm = 5 x 0.33 = 1.65mm 1.65mm/4.2mm = Linear CVR = 39.3%

26 Simplify the process.. And a tool is created

27 Coming soon.. the CVR App

28 Summary We need look at ways to minimize thrombotic risks to all patients Catheter size, vessel size, frequent & accurate patient assessment CVR relationship is important for ALL devices PIV to HD catheters Thrombosis is a long-term problematic issue and deep vein thromboses of the upper extremity are often asymptomatic, but lower risk than lower extremity DVT 1 Ultrasound is still diagnostic gold standard use it to patients advantage & monitor frequently

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