Catheter-Related Thrombosis A Catalyst of Complications

Catheter-Related Thrombosis A Catalyst of Complications

Catheter-Related Occlusions 1,2 Most common non-infectious complication in the long-term use of CVCs, and in particular PICCs Approximately 1 in 4 CVCs may become occluded 3 types of Occlusions: Biological Mechanical Physical 2

Economics of Thrombotic Occlusions 3,4 Cost of ER visit or readmit Cost of Catheter Exchange RN $35-50/hour TPA $120/dose What is the cost of inefficient delivery of IV therapy? * Based on anecdotal reports Fall 2014 3

Tissue Plasminogen Activator (TPA) 5,6 3,723 patients with PICCs 40% received TPA The adjusted odds of developing CLA-BSI 3.59 times greater in those patients that received TPA compared with those who did not There is a positive correlation between the use of alteplase for malfunctioning catheters and the development of CLABSI 6 4

VTE, DVT, UEDVT 7 VTE = Venous ThromboEmbolism A condition that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT = Deep Vein Thrombosis The formation of a blood clot in a deep vessel. The deep veins follow the course of the arteries. They are generally arranged in pairs, and are situated on either side of the artery, and connected at intervals by short transverse branches UEDVT = Upper Extremity Deep Vein Thrombosis Deep vein thrombosis occurring in the upper extremities 5

Incidence Rates 8,9-15 Symptomatic PICC related DVTs = 3-20% incidence 72% Rate of Asymptomatic PICC Related DVTs and thrombosis Asymptomatic + symptomatic PICC related DVTs = 60-72 % incidence Median time to thrombus: 8 to 12 days Financial impact of one DVT = Avg. $10,000- $15,000 3-20% Rate of Symptomatic PICC Related DVTs 6

UEDVT Risk Factors 16 History of DVT History of venous thrombosis was the strongest risk factor for developing a PICCrelated thrombosis Catheter tip placement Correct positioning significantly lowered the risk of catheter-related thrombosis Non-central PICC tip location was associated with a 2.34-fold higher risk of thrombosis development Infection Catheter-related thrombosis and infection are significantly correlated in multiple studies Cancer The presence of cancer and a CVC increase the risk of UEDVT 18-fold Hypertension (HTN) 70% of patients who developed UEDVT had a history of HTN 7

UE-DVT Risk Factors 16 Infection Cancer Osteomyelitis Obesity HTN Diabetes History of DVT Use of anticoagulants Insertion attempts Catheter tip location Size of the catheter Vein selection Solution infused Provider who places the PICC Major surgery Pregnancy Contraception Hormone replacement therapy Age Gender Smoking Immobility 8

The 3 P s of CRT 16,17 Patient Cancer Previous DVT Hypertension Provider Tip termination location Catheter: Vein ratio Determination of necessity PICC Diameter # of lumens Anti-thrombogenic technology 9

Link Between Infection & Thrombosis 18 Infection is linked to thrombosis Post-mortem evaluation of 72 cancer patients with CVCs showed a strong correlation between CR-sepsis and CVC thrombosis Fibrin layer present on ALL catheters CR-Thrombosis present in 38% of cases** 23% of these had sepsis** All patients with sepsis had thrombosis 10

Patients With Cancer 19 Patients with cancer are at high risk for developing venous thromboembolism (VTE) due to disease state & treatment factors The presence of a central venous catheter (CVC) further increases this risk Thrombosis and Infection are serious complications and more common in patients with cancer There is a 47-fold increase in the risk of mortality from VTE in cancer patients with a CVC 11

Deep Vein Thrombosis Awareness 20-22 Each year as many as 1.2 Million Americans suffer from Venous Thromboembolism (VTE), which includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) (CDC) At least 120,000 deaths per year are directly related to VTE It is among the top 5 causes of death in the US VTE is the leading cause of preventable, in-hospital deaths affecting more people annually than highway fatalities, breast cancer and AIDS combined 74% of people surveyed have little or no awareness of DVT symptoms Cost to treat (mean) $9,247/patient/year 12

Impact of PICC-Related DVT 22 Interrupts treatment Increased LOS Increases cost Morbidity Risk of Mortality 13

Healthy People 2020 21 Surgeon General s Call to Action About 10 percent of people with DVT die from pulmonary embolism making DVT the most common preventable cause of death in hospitals. 54.3 persons per 10,000 population aged 18 and older developed VTE in 2007 TARGET: 48.9 per 10,000 10% www.healthypeople.gov 14

DATA Collect It Understand It Use It to improve your practice! Use it to improve your outcomes! 15

References 1. Bartock, L. (July 2010) Evidence-based Systematic Review of Literature for the Reduction of PICC Line Occlusions. Journal of the Association for Vascular Access. 15(2).58-63 2. Hadaway, L. (2005) Reopen the Pipeline. Nursing. pp. 54-61. 3. Haire WD & Herbst SF. (Summer 2000). Consensus conference on the use of alteplase (TPA) for the management of thrombotic catheter dysfunction. Journal of Vascular Devices. 4. Palatnik, A. (2001). Cathflo Activase (alteplase) FDA-approved fibrinolytic indicated in the treatment of CVAD occlusions. Retrieved November 10, 2014 at http://nursing.advanceweb.com/article/cathflo-activase-alteplase-fda-approved-fibrinolytic-indicated-in-the-treatment-of-cvad-occlusions-1.aspx 5. Thakarr, K., Collins, M., Kwong, L., Sulis, C., Korn, C., Bhadelia, N. (2014) The role of tissue plasminogen activator use and systemic hypercoaguablity in central line associated blood stream infections. American Journal of Infection Control. 42:417-20 6. Rowan et al. (2013). Alteplase use for malfunctioning central venous catheters correlates with catheter assoicated blood stream infections. Pediatric Critical Care Medicine. 7. John Hopkins Medicine. (2014). Deep vein thrombosis. www.hopkinsmedicine.org/healthlibrary/conditions/adult/cardiovascular_diseases/deep_vein_thrombosis_dvt_thrombophlebitis_85,p08252/ accessed September 2014 8. Journeycake, J. & Buchanan, G. (2003). Thrombotic complications of CVC in Children. Current Opinion in Hematology. 10:369-374. 9. Itkin, M., Mondshein, J., Stavropoulos, W., Shlanski-Goldberg, R., Sallen, M., Trerobla, S. (2013). Peripherally inserted central catheter thrombosis reverse taper vs. nontapered catheters: A randomized controlled study. Journal of Vascular Interventional Radiology. Doi: org/10.1016/j.jvir.2013.10.009 10. Evans, RS, Sharp, JH, Linford, LH, et al. (2010). Risk of symptomatic DVT associated with peripherally inserted central catheters. CHEST. 138:803-810. 11. Tran, H, Arellano, M., Chamsuddin, A, et al. (2010). Deep vein thrombosis in patients with hematological malignancies after peripherally inserted central venous catheters. Leuk Lymph. 51:1473-1477. 12. Trerotola SO, Stavropoulos SW, Mondschein JI, et al. (2010). Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology. 256: 312-320. 13. Lobo, BL, Vaidean, G., Broyles, J., Reaves, AB, Shorr, RI. (2009). Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 4:417-422. 14. Nash, EF, Helm, EJ, Stephenson, A, Tullis, E. (2009). Incidence of deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis. J Vasc Interv Radiol. 20:347-351 15. Paauw, JD, Border, H., Ingalls, N. et al. (2008). The incidence of deep vein thrombosis associated with peripherally inserted central catheters in thrombosis with and without the use of prophylactice anti-coagulants. JPEN. 32:443-447 16. Clemence, B. & Maneval, R. (2014). Risk factors associated with catheter-related upper extremity deep vein thrombosis in patients with peripherally inserted central catheters: Literature Review: Part 1. Journal of Infusion Nurses Society. 37(3):187-196 16

References (con t) 17. Trerotola, S., & V. Chopra, (September, 2014). Venous thrombosis: The elephant in the room for PICCs. Presented at the Association for Vascular Access National Scientific Meeting, National Harbor, MD. Slide 26 18. Raad, I., Luna, M., Kahil, S., Costerton, J., Lam., C., Bodey, G. (1994). The relationship between the thrombotic and infectious complications of CVC. JAMA. 271(13). 19. Khorana, AA, et al (2007). Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. Journal Thromb Haemost. 20. Kutcher, N. (2011). Deep vein thrombosis of the upper extremities. The New England Journal of Medicine. 364(9):861-869 21. Healthy People 2020. Blood disorders and blood safety. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=4 Accessed September 2014 22. Khorana et al., (2013). Health care costs associated with venous thromboembolism in selected high-risk ambulatory patients with solid tumors undergoing chemotherapy in the United States.Clin Econ Outcomes Res.5:101-108 17