Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients.A Hickman catheter is a device used for long-term intravenous access, most commonly for chemotherapy double lumen hickman total parenteral nutrition. Radiology Secrets Plus Third Edition For external catheters Hickman, Broviacan exit site infection, manifested as inflammation and occasionally exudate limited to where the catheter emerges through the skin, can usually be managed with a combination of dx code for steroid induced diabetes care and systemic antibiotics. Patients with indwelling catheters are at increased risk for blood infections. Many bacterial blood infections associated with central lines can be cleared with intravenous antibiotics administered through the central catheter, rotating lumens for multiline catheters. The potentially most serious bacterial infection is a double lumen hickman infection, manifested by inflammation and tenderness along the entire subcutaneous tract of the catheter.
The double-lumen Hickman catheter. - PubMed - NCBI
A Hickman catheter is a device used for long-term intravenous access, most commonly for chemotherapy or total parenteral nutrition. Radiology Secrets Plus Third Edition , For external catheters Hickman, Broviac , an exit site infection, manifested as inflammation and occasionally exudate limited to where the catheter emerges through the skin, can usually be managed with a combination of local care and systemic antibiotics.
Patients with indwelling catheters are at increased risk for blood infections. Many bacterial blood infections associated with central lines can be cleared with intravenous antibiotics administered through the central catheter, rotating lumens for multiline catheters. The potentially most serious bacterial infection is a tunnel infection, manifested by inflammation and tenderness along the entire subcutaneous tract of the catheter. These infections mandate prompt removal of the catheter and administration of intravenous antibiotics.
This can pose formidable challenges to management with long-term, surgically implanted IVDs such as Hickman and Broviac catheters, cuffed and tunneled hemodialysis catheters, and subcutaneous central venous ports. If a laboratory has available an automated quantitative system for culturing blood e.
IVD-drawn cultures demonstrating 5- to fold higher concentrations of microorganisms per milliliter, as compared with counts of the same microorganism obtained in a culture drawn from a peripheral vein, confirm the presence of IVD-related BSI.
The differential-time-to-positivity DTP of paired blood cultures, one drawn through the IVD and the second, concomitantly from a peripheral vein, has also been shown to reliably identify IVD-related BSI of long-term IVDs if the blood culture drawn from the IVD turns positive 2 or more hours before the culture drawn peripherally. James Valentine, Mitchell M. Plummer, in Vascular Medicine: Suppurative thrombophlebitis often follows prolonged intravenous therapy in immunocompromised patients.
The condition is most common in patients receiving total parenteral nutrition, in critically ill patients receiving intravenous therapy through central venous catheters, and in those with long-term cannulation devices such as Hickman or Broviac catheters.
Central suppurative thrombophlebitis may also be the consequence of intravenous drug abuse see earlier discussion. Catheter infections are usually due to microorganisms that migrate from the skin entry site, but hematogenous seeding and contaminated fluids have also been implicated.
The thrombus becomes attached to the central vein wall and causes localized inflammation. Central suppurative thrombophlebitis should be suspected in any patient who fails to improve after removal of an infected central venous catheter. Systemic signs of infection are more common than venous obstructive symptoms such as arm edema. Diagnosis can be made by demonstrating a deep vein thrombosis DVT by duplex ultrasonography, venography, or MRI in a septic patient with positive blood cultures who does not have other sources of primary infection.
Treatment of central suppurative thrombophlebitis involves removal of central catheters, use of broad-spectrum antibiotics, and anticoagulation with heparin. In some cases, fibrinolytic therapy or surgical thrombectomy may be required. Long-term anticoagulation with warfarin is recommended to reduce the risk of embolization and recurrent thrombosis.
A 2- to 3-week course of culture-directed antibiotics is usually appropriate. External tunneled catheters that lead to tubing that exits the skin. They can be single, double and occasionally triple lumen.
The most frequently used types are the Broviac catheter and the Hickman catheter. Such devices are more cosmetically satisfactory to older children and adolescents and have a lower infection rate than external tunneled catheters.
Catheters are inserted via the subclavian, internal, or external jugular vein with a subcutaneous tunnel to the anterior or lateral chest wall. Alternatively, catheters can be placed via the femoral vein to the inferior vena cava with a tunnel to the abdominal wall. These devices are the most common type of long-term venous access device in current use for stem cell transplantation cases.
They consist of a soft, pliable catheter which is inserted into one of the central veins and then tunneled under the skin to an exit site distant to the venepuncture site. A Dacron cuff attached to the line lies in the tunnel and produces a local fibrotic reaction which anchors the cuff and catheter to the tissues. Since their introduction by Broviac in , 7 a number of similar devices with a range of features has been used.
Tunneled lines can stay in the circulation with minimal complications for many months or even years. Hickman lines are essentially the same as Broviac lines, but with a larger internal lumen. They are the most common type of long-term device in use today. Derivatives of these are common, and double- and triple-lumen lines have increased their range of application.
Large-bore implantable devices are available such as Tesio lines which consist of two large-bore parallel tunneled catheters. They are usually used for renal replacement therapy, with one limb being used as the arterial side and one as the venous, but are equally suitable for apheresis. Valved catheters have a valve at their distal tip Groschong , or proximally which requires either a negative or positive pressure up to 80 mmHg to open and pressurized systems to infuse.
They cannot be used to measure central venous pressure. This valve prevents backflow of blood into the line, and hence reduces the need for heparin locks. It can also prevent air embolism.
Double-lumen versions are available. Implantable ports consist of a tunneled venous line connected to an access device which is inserted subcutaneously, often on the chest wall. A special non-coring needle is required to access the thick port membrane.
The catheter has a relatively low internal diameter which limits maximum flow rates. These devices are sometimes more acceptable to patients as they are completely subcutaneous when not being used and hence are more cosmetically pleasing. They also allow the patient to swim or bathe and have the lowest rates of infection for long-term access devices. These advantages progressively disappear as the need for access moves from intermittent injection to continuous infusions over days and weeks.
The continued presence of the access needle breaches protective skin barriers and makes the device more like a Hickman-type catheter with the disadvantage of lower flow rates and the inconvenience of a stiff needle protruding from the device, with risks of dislodgment and extravasation.
Although MTX potentially may increase the risk for common bacterial infections, herpes zoster, and opportunistic infections, these complications are infrequently reported in treated patients.
One study of 62 children with JRA treated for a mean of weeks reported only two cases of recurrent cellulitis, one of osteomyelitis, and one of an infected Hickman catheter site; there were eight viral infections, including one case of herpes zoster, one case of mononucleosis, and six cases of primary varicella.
Many of the patients with varicella infection were also concurrently receiving glucocorticoids. Although the overall risk of infection seems to be low, it has not been precisely quantitated in adults or in children. The development of hypogammaglobulinemia in patients treated with MTX may predispose to infection. Active varicella immunization of susceptible children and family members may need to be considered before initiation of MTX therapy.
Chlorhexidine preparations have been shown to be superior to povidone—iodine for skin decontamination prior to device insertion and are also now recommended for decontamination of hubs and connections. Trial data suggest that chlorhexidine-impregnated sponge dressings reduce the risk of vascular access device-associated bloodstream infection in patients with short-term central venous catheters. A number of antimicrobial impregnated venous catheters have been marketed over the last 10 years.
The antimicrobials that have been incorporated have included silver sulfadiazine with chlorhexidine, , minocycline—rifampicin, 98 microdispersed silver , and silver—platinum. It is not clear that prophylactic use of systemic antibiotics at the time of vascular access device implantation reduces the risk of device-associated infection. A number of randomized controlled trials have shown that rates of bloodstream infection can be greatly reduced by using antimicrobial lock solutions.
Recent meta-analyses support the use of antimicrobial locks to prevent infection in patients with long-term devices. The benefits of use of antimicrobial locks is increasingly recognized within best practice guidelines. Nussenblatt, in Uveitis Fourth Edition , Ganciclovir is similar to aciclovir but is a much more effective substrate for cytomegalovirus CMV.
It has been shown to be effective in the treatment of CMV retinitis. In the past patients were wedded to this therapy once it had begun, and an indwelling catheter i. The administration time has an impact on the patient's quality of life. Ganciclovir is not frequently nephrotoxic, but like aciclovir is excreted by the kidneys, and the dose should be adjusted for renal function. Bone marrow depression is problematic if patients are taking antiretroviral agents, such as azidothymidine AZT , with similar toxicity.
Ganciclovir may have significant testicular toxicity. Intravitreal injections of ganciclovir are effective in delaying the progression of CMV retinitis.
There is an associated risk of endophthalmitis, retinal detachment, and vitreous hemorrhage. In that study the median time to progression of CMV retinitis in eyes with the device was days; 12 implants were exchanged for new devices.
Of note was the fact that in the patient group studied, seven late retinal detachments and one retinal tear without detachment occurred. Future studies will certainly deal with the retinal detachment risk and the use of the device in conjunction with oral systemic medications for the prophylactic treatment of patients with CMV infection, either viscerally or in the contralateral eye.
The use of local therapy clearly benefits the patient's quality of life, because the hours of intravenous infusion previously needed are avoided.
However, the lack of systemic coverage and HAART therapy have to be considered in the treatment strategy. An oral form of ganciclovir has been developed and has been shown to impede the development of CMV retinitis. Valganciclovir is a monovalyl ester prodrug that is rapidly hydrolyzed to the active form — ganciclovir. Several studies have looked at various combination of the oral formulation compared with the intravenous preparation in the treatment of CMV retinitis.
Earlier work looked at the use of an oral formulation combined with a ganciclovir implant. Orally administered valganciclovir appeared to be as effective as intravenous ganciclovir for induction treatment, and was a convenient and effective maintenance regimen as well.
Cookies are used by this site. For more information, visit the cookies page. Hickman line A Hickman catheter is a device used for long-term intravenous access, most commonly for chemotherapy or total parenteral nutrition. Adamson MD, in Pediatric Secrets Fifth Edition , 29 Describe three different types of infection that are associated with central venous catheters, and how the treatment approaches to these infections differ For external catheters Hickman, Broviac , an exit site infection, manifested as inflammation and occasionally exudate limited to where the catheter emerges through the skin, can usually be managed with a combination of local care and systemic antibiotics.
A Companion to Braunwald's Heart Disease Second Edition , Central suppurative thrombophlebitis following intravenous line sepsis Suppurative thrombophlebitis often follows prolonged intravenous therapy in immunocompromised patients. Vascular access John Oram, Andrew Bodenham, in Hematopoietic Stem Cell Transplantation in Clinical Practice , Tunneled central venous lines These devices are the most common type of long-term venous access device in current use for stem cell transplantation cases.
Laxer, in Textbook of Pediatric Rheumatology Sixth Edition , Infection Although MTX potentially may increase the risk for common bacterial infections, herpes zoster, and opportunistic infections, these complications are infrequently reported in treated patients. Nussenblatt, in Uveitis Fourth Edition , Ganciclovir Ganciclovir is similar to aciclovir but is a much more effective substrate for cytomegalovirus CMV.
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