Thrombosis: The Other Central Venous Catheter Complication

Transcription

1 Thrombosis: The Other Central Venous Catheter Complication The Thrombosis-Infection Relationship Cheryl Kelley RN BSN, VA-BC Sr. Vascular Access Clinical Specialist Disclosure Employed by Teleflex Medical Sr. Vascular Access Clinical Specialist; Marketing 2 Objectives Describe biological/clinical connection between catheter related bloodstream infection (CRBSI) and catheter related thrombosis (CRT) Identify three risk factors for CRT Discuss two-evidence based clinical papers which support the relationship between CRT and infection 3 1

2 Introduction Two most common complications of central venous catheters (CVC) 8 Infection Thrombosis Large focus on CRBSI In the forefront of news Educated consumers Unacceptable risk Limited focus on CRT Avoidable risk? Limited consequences? 4 Reduction of Bloodstream Infections 15 Have you tried these CDC Recommendations? 1 1. Surveillance (1B) and continuing education (1A) 2. Site of catheter insertion (1A) 3. Hand hygiene (1A) and aseptic technique (1A) 4. Skin antisepsis (1A) 5. Catheter site dressing regimens (1A) 6. Replacement of administration sets, fluids, needleless systems (1A and 1B) 7. Clean injection port with alcohol or iodophor (1A) 8. Minimal number of lumens (1B) 9. Antimicrobial or antiseptic catheter, dwell > 5 d (1A) 5 Rates of CRI and CRT CRT more common than CRI in all anatomical sites Especially in smaller upper extremity veins Unlike CRI, few guidelines developed to reduce complications 6 2

3 Incidence of Catheter Related Infection (CRI) Centrally Inserted Central Venous Catheter 1.2 to 14.7 per 1000 catheter days 1 Peripherally Inserted Central Venous Catheter (PICC) 0 to 2.5 per 1000 catheter days 1-3 Varies with in patient vs. outpatient use 13 7 As per Maki 13 8 Four Sources of CRI INTRALUMINAL Access sites EXTRALUMINAL Insertion site INFUSATE Rare HEMATOGEOUS SEEDING Distant site 9 3

4 Incidence of Catheter Related Thrombosis (CRT) Upper extremity deep vein thrombosis (UEDVT) accounts for 5% of all DVT 5 Centrally Inserted CVC Symptomatic rates: 2%-26% 3 Asymptomatic CRT: 33% 4 but reported as high as 66% 6 Peripherally Inserted CVC Symptomatic reported rate: 3.4% 1 Asymptomatic rates: up to 58% 3 10 Asymptomatic Thrombosis Thrombosis can be asymptomatic due to: 9 Extensive venous collaterals in upper extremity minimize hemodynamic effects of thrombosis Subclavian axillary pathway has few valves 11 Causes of CRT Virchow s Triad Hypercoagulability Acquired or inherited conditions Venous Stasis Issues with blood flow Endothelial abnormalities Vascular injury 12 4

5 Risk Factors for CRT Hypercoagulability Abnormalities is clotting factors Previous DVT Ethnicity; Age Malignancy Trauma Inflammatory process Pregnancy, hormone replacement Venous Stasis Dehydration, leukocytosis Multi-lumen catheters Immobility of blood flow Inappropriate catheter vessel ratio Vessel compression (tumor) 13 Small vein size Endothelial Damage Solutions with high or low ph or high osmolality Traumatic vessel cannulation Multiple insertion attempts Large bore introducer Repetitive passes thru subclavian Placement in area of friction Large catheter size (dialysis, PICC) Left sided insertion site Previous central venous catheter Location site (femoral, IJ, subclavian) Suboptimal tip location Length of dwell Does the relationship really exist? Relationship between infection and thrombosis: Not a new concept; why has it not been addressed? 30+ years ago was documented as per Stillman 7 Central venous catheters (CVC) critical to deliver required medications and therapies Special populations may be more affected by thrombosis: Hematological and oncological diseases Increased risk factors: Right sided heart failure 9 Critical care population, neutropenia What we know... Common biomaterials (in prosthetic devices) are an attractive surface for: 12 Fibrin attachment and/or thrombosis Bacterial adhesion and colonization This is due to multitude of factors, including: 12 Flow conditions around device Recirculation of blood around device Venous stasis Composition and texture of implanted material Thrombogenic materials 16 5

6 What we know... Fibrin / thrombus formation provides fertile ground for development of infection Insertion process causes trauma to endothelium Fibrin platelet patch adheres to area of injury Fibrin sheath formation: encapsulation of CVC with thrombotic material Fibrin sheaths not only impair catheter function, but also are colonized by cocci 8 Fibrin sheath that engulfs the catheter promotes adherence of staphylococci and Candida species How do we know this? It is suggested in literature that: 4,7,8,10,14 Thrombosis may lead to enhanced risk of infection Adherent bacteria may enhance risk of thrombosis Mohammad 12 Design: An in vitro study looking at risk of infection in the presence of a device associated thrombi To investigate this, he assessed adherence of pathogens in the presence and absence of various components found in blood (fibrin, platelets, proteins, etc.) 18 Mechanism of Mohammad 12 study Inoculated bovine blood with bacteria (S. epidermidis) and thrombosis-promoting proteins and platelets Injected this treated blood into vitro coronary stent recirculating loop model Created environment for thrombosis formation on stents. Anticoagulants, anti-platelets agents, antibiotics to influence the bacteria, platelets and thrombosis 19 6

7 20 Results of Mohammad 12 study Bacteria adhered to stent in greater numbers when thrombosis was present on stent Presence of rifampin in blood caused only slight reduction in interaction of antibiotic with thrombus Thus, S. epidermidis was not just trapped in the fibrin network (fishnet) but rather adhered to the fibrin strands Bacteria adherence occurred: As thrombus forms Also on previously developed thrombi In the absence of thrombi, noted that bacteria had no structure to adhere to Staph Epi attachment to fibrin S. epidermidis adhered to thrombus even in presence of rifampin Conclusions of Mohammad 12 study Bacteria interact with old and new thrombi Adhesion of microorganisms to thrombi exists Need to focus on how and why bacteria adhere to thrombi This may shed light on adhesion to biomaterials (such as catheters?) Need to develop appropriate strategies to prevent and eliminate stubborn infections Prevention of thrombosis is one such approach! 21 Longitudinal view of thrombosed vessel with catheter 22 7

8 So... moving on Biological confirmation that bacteria and thrombi are attracted to each other Let s look towards literature: Is there evidence to support that catheter related thrombosis with central venous catheters and PICC s increase the risk for CRBSI? YES! 23 Literature Addressing Thrombosis Infection Relationship Crowley, L et al. Venous thrombosis in patients with short- and long-term central venous catheter associated Staphylococcus aureus bacteremia. Crit Care Med 2008; 36: Mehall, JR et al. Fibrin sheath enhances fibrin sheath formation. Crit Care Med 2002; 30: Van Rooden, CJ et al. Infectious complications of central venous catheters increase the risk of catheter-related thrombosis in hematology patients: a prospective study. J Clin Oncol 2005; 23: Thornburg CD, et al. Association between thrombosis and bloodstream infection in neonates with peripherally inserted catheters, Thromb Res 2007, doi: /j.thromres Timsit, JF et al. Central vein catheter-related thrombosis in intensive care patients. Incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998; 114(1): Review Articles for This Discussion Raad : The relationship between the thrombotic and infectious complications of central venous catheters Lordick : Ultrasound screening for internal jugular vein thrombosis aids the detection of central venous catheter-related infections in patients with haematooncological diseases: a prospective observational study 25 8

9 Raad Study Objectives Study Goal: Frequency of mural thrombosis of catheterized veins in comparison with un-catheterized veins What is the relationship of thrombosis to catheter related septicemia? Why? Generally understood that fibrin sleeve thrombosis is universal but clinically silent condition; S aureus, Candidia albicans adhere well to fibrin and produce coagulase enzyme that promotes adherence to the central venous catheter even further 26 Raad 11 : Procedure for catheter and vessel analysis Study Design Post-mortem examination of 72 cancer patients Majority was non-tunneled with 60% subclavian placed Median dwell was 19 days Within 24 hours after death, both subclavian veins and SVC opened lengthwise until atrium exposed Entire segment of catheterized vessel including atrium, valves, ventricles Segment of contralateral segment of un-catheterized vessel Cultures obtained from: catheter catheterized vessel 27 contralateral subclavian vein Raad 11 : Results Thrombosis: Fibrin layer noted on ALL catheter segments Mural thrombosis in 27 vessels (38%) of catheterized veins Mural thrombosis in 1 (1.4%) contralateral un-catheterized veins This contralateral vein had CVC within previous 2 months Infection: Four instances of thrombotic endocarditis CR sepsis in 7 patients Of the total 31 patients with mural thrombosis of vein, atrium: 7 (23%) developed sepsis None of the 41 remaining patients with normal vessels had sepsis 28 9

10 Lordick Study Goals: To define the rates of catheter-related thrombosis (CRT) and catheter-related infection (CRI) To prove the correlation of both in cancer patients. Rationale for study: Hem/Onc population (neutropenic) has altered host defense which increases their morbidity morality risks if CRBSI develops Any means for early detection or avoid CRI is critical 30 Lordick 9 : Study Design and Demographics Prospective observational small study, 43 patients 30 patients received low does heparin prophylaxis 31 patients received prophylactic oral antibiotic Internal jugular ultrasound placed CVC with a dwell of at least 5 days with mean dwell of 15.4 days CVC assessment Site assessment preformed daily Ultrasound assessment every 4 days Thrombi criteria: >5mm were regarded as detectable If < 5mm, US assessment changed to every other day Blood cultures and catheter tip cultures 31 Lordick 9 : Results CVC infection data: 14 of 43 (33%) Defined as either CRBSI, colonized catheter or exit site infection 9 of 14 patients had at least one clinical symptom Erythema 5mm, tenderness, swelling, warmth In the remaining 4 patients with CRBSI, none had clinical symptoms of infection CVC thrombosis data: Partial thrombosis in 13 of 43 (30%) and 5 were asymptomatic Neutropenic episodes while CVC was present created a higher probability of CRT 32 10

11 Lordick 9 : Discussion Clinical symptom assessment: (CDC 2011 Category II) Weak in determining presence of CRI 4 patients with CRBSI had NO clinical signs observed at catheter site Ultrasound assessment Thrombosis development preceded clinical symptom development in 36% of patients Thus, this study strongly favors the use of ultrasound based monitoring of IJ vein catheters in cancer patients 33 Lordick 9 : Conclusion A highly significant correlation between CRI and CRT was observed Sensitivity of US assessment exceeds that of clinical assessment of the site Removal of the catheter in the presence of thrombosis may prevent patients from sustaining life altering CR infectious complications. 34 Methods to Reduce CR Thrombosis PLACING SMALLEST FRENCH SIZE PROTECT ENDOTHELIUM CRT REDUCTION TIP DEEP IN THE SVC CHOOSING THE RIGHT LINE ADEQUATE CATHETER VESEL RATIO 41 11

12 EXTRA Pieces of the CRBSI Puzzle Worth Consideration APPROPRIATE END CAP TECHNOLOGY CLEAR OCCLUSIONS PROMPTLY GETTING TO ZERO DEDICATED VA TEAM ANTIMICROBIAL CATHETERS CVC & PICC THROMBOSIS REDUCTION 42 Conclusion Catheter related thrombosis is a serious consequence: Associated with acute consequences Infection, pulmonary embolus, need for anticoagulation etc. Associated with long term consequences Post thrombotic syndrome, loss of future access, etc. By reducing the risk of thrombosis, the risk of deviceassociated infection may also be reduced 12 After all, the new goal for CRBSI is ZERO. 43 How can we get there? 44 Bibliography 1. Turcotte, S, Dube, S, Beauchamp, G. Peripherally inserted central venous catheters are not superior to CVCs in the acute care of surgical patients on the ward. World Journal of Surgery 2006; 30: Raiy, B. Infectious complications of PICCs in the hospital setting. American Journal of Infection Control 2005;36(10):S176, Abstract 3. Trerotola, S, Stavropoulos, S, Mondschein, J, et al. Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology 2010;256(1): Timsit, JF, Farkas, JC, Boyer, JM, Martin, JB et al. Central vein catheter-related thrombosis in intensive care patients. Incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998; 114(1): Lechner D, Wiener C, Weltermann A, Eischer L, Eichinger S, Kyrle PA. Comparison between idiopathic deep vein thrombosis of the upper and lower extremity regarding risk factors and recurrence. J Thromb Haemost 2008; 6: Chastre J, Cornud F, Bouchama A, et al. Thrombosis as a complication of pulmonary artery catheterization via the internal jugular vein: prospective evaluation by phlebography. N Engl J Med 1982; 306: Stillman RM, Soliman F, Garcia L, Sawyer P. Etiology of catheter-associated sepsis. Arch Surg. 1977;112:

13 Bibliography 8. Raad I, Luna M, Khali S, Costerton J, et al. The relationship between the thrombotic and infectious complications of central venous catheters. JAMA. 1994;271: Wechsler R, Spim P, Conant E, Sterner R, Needleman L. Thrombosis and infection caused by thoracic venous catheters: pathogenesis and imagine findings. American Journal of Radiology. 1993;160: Lordick F, Hentrich M, Decker T, Henning M, Pohlmann H, et al. Ultrasound screening for internal jugular vein thrombosis aids the detection of central venous catheter-related infections in patients with haemato-oncological diseases: a prospective observational study. British Journal of Haematology. 2003; Peters WR, Bush WH, McIntyre RD, Hill LD. The development of fibrin sheath on indwelling venous catheters. Surg Gynecol Obstet. 1973;137: Mohammad S. Enhanced risk of infection with device-associated thrombi. ASAIO Journal 2000; 46:S63 S Maki D, Kluger D, Crnich C. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9): Bibliography 14. Thornburg CD, et al. Association between thrombosis and bloodstream infection in neonates with peripherally inserted catheters, Thromb Res (2007), doi: /j.thromres Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002;51(No.RR-10). 16. Keene A. Thrombosis in central catheter-associated Staphylococcus aureus bacteremia: always scan the site? Crit Care Med. 2008;36(2):