So it's all about assessment. He says, "First of all, Mr. Hawkins, let's put the gun down. "I would guess it's an itchy trigger finger,
"but I want to take a closer look." So when I assess a patient, I basically separate out the things that I need to think about into these categories. Starting with the history, comorbid conditions you can fold right into that.
Are there any issues from a physical exam perspective? What does the patient need, how long do they need it? What are the options? And one of the things that people forget about all the time, whoops, just looking for the laser pointer, is patient preference.
So too often we walk into the room and say to the patient, "Oh, you have osteomyelitis. "You need six weeks of antibiotics. "Your doctor wants you to have a PICC. "Let me tell you about a PICC." And da-da-da-da-da-da-da.
We totally blew past what some other options might be. Now, maybe a PICC is the right choice for that patient in that situation, but maybe it's not. So I sort of get a little bit of a soapbox about patient decision-making. So when I see a patient,
here are the things that I want to know. Have you had a line before? If so, where was it? How long did it last, why did it come out? And then there's the political question, like who put it in? And a little dirty secret in healthcare
is if the patient says to me, "A surgeon put it in via my subclavian vein "and it worked some of the time and didn't work. "And I had to lay back and rotate my arm," and da-da-da-da-da, then I'm gonna know that that's pinch-off syndrome from an approach
that was too medial into the subclavian vein. So those all give me hints about, how worried should I be? If this patient comes in and tells me, "I've had 15 lines and I've lost "most of them for infection," then it's time for a giant step backwards and figure out
what in the heck is going on that maybe is device-related, but maybe is related to care and maintenance. Maybe it's related to diversion of that line for other purposes. You name it, put everything on the table. Oops, sorry.
What am I doing, I'm getting crazy here with the, I'm gonna put that puppy down. I say to the patient, look, did they have any trouble getting the line in? Some patients will say, "Oh my gosh, "they had to stick me over and over and over again."
Well, who was that person that was sticking you over and over again? Maybe it was somebody that didn't have ultrasound. Maybe it was a med student. I don't know about you, but we still have a lot of institutions in the United States
where we're sending the med students or the first-year resident up there with an 18-gauge needle into the ICU to put a line in using a landmark approach. Should not happen like that, should not. And if we're honest with each other, we'll say, "You know what, we wouldn't allow that
"to happen to our family member, "so why are we letting it happen to anybody else?" So those are all the things. What did you have, how long did you have it? How did it work, did you have any problems with it? That kind of thing.
In terms of a more targeted history for non-device-related things, IVC filters. Patients don't remember to tell you that. It's sort of like having a filling in their tooth. They totally forget about it, but it has implications for us
in putting vascular access devices in if we're gonna send that wire through the heart and down into the IVC and you don't want to grab a filter by mistake with a J-tip wire. So you want to know that. Sometimes you can glean that from the record,
but we have patients who go from one hospital to another, have moved or whatever, and don't necessarily report accurately. If that patient's had a CT of the abdomen or a plain film of the abdomen, another place to look. And if you're really worried, pan down
and look at the abdomen as you're putting the line in. Now, all bets are off if you're placing at the bedside. And I don't know if your teams do that or not, but a lot of teams do, especially if you've got the 500-pounder in the ICU on a vent, platelet count of 10, whatever.
You go up and you do it. So I personally never use J-tip wires. And if I'm at the bedside, I'm not going very far with that 035 wire. Look for permanent dialysis access. Look for vein harvest, maybe before a CABG.
Does the patient have breast implants? And so maybe you don't have a lot of real estate between the clavicle and the breast implant to put a device. All these other kinds of things.
Do they have swelling in their arm, and is that because of lymph edema
from a previous lymph node dissection? Have they had a DVT before, is it just dependent? So sort that out. Here are some comorbid conditions that really impact on our ability to place a line. So not necessarily your technical ability,
but your decision-making. So you get a call from the nephrologist and they say, "45-year old guy, acute kidney injury. "Potassium is six and he needs urgent dialysis. "Oh, by the way, the platelet count is 10." But meanwhile the patient's been hypertensive
and diabetic for a long, long time. And you have to make a decision, is this a patient who needs temporary access or this a patient who needs long-term access? I gotta tell you, I hate when a patient gets a temporary catheter and then four or five days later,
the patient gets referred for a tunneled catheter. And it's like, okay, the patient just went through two procedures when they could've had one. And there was an interesting study that came out that Scott Trerotola and his team did out of Penn. And they looked at, could you predict in those patients
who came into the hospital in acute renal failure, who was gonna need a temporary or short-term catheter and who was gonna need a long-term? And you know what the answer was? They couldn't figure it out. And so what they advocate for, and I do as well,
is unless this is clearly a very short-term, like drug overdose kind of situation, something like that, put the tunneled catheter in. If you take it out in three weeks, no harm, no foul. But the patient doesn't have to go through a couple procedures.
There will be times when you have to put that non-tunneled catheter in because, say, the patient is in blast crisis. They need pheresis and they have 5000 platelets. And you can transfuse them 'til the cows come home and they're not gonna get a bump.
But just think about that, and whether you can correct it. And we'll talk more about coagulopathy in a little bit. There's factors that influence placement. Can you position the patient? Are they 500 pounds and have a trach and sort of no neck? Can you get those trach ties out of the way,
or did that trach just get put in yesterday, and so you're in a little bit of trouble there? Other comorbid kind of issues. Does the patient have a current bacteraemia? And ideally you don't have a catheter in those patients. But some of those patients are septic.
They need pressors and you have to say as a team, you say, "Look, this is a suboptimal situation. "We've got a positive blood culture. "We're gonna put a line in and we're worried "that that bacteria will seed the line, "but this patient needs seven things at the same time,
"and that's what we've gotta do, "and then get that line out of there as soon as you can." Patients with hypercoagulable states and a history of DVT scare me, in terms of putting a new line in and risk of DVT. I took care of a patient last week
who was about 35 years old, had a right upper extremity DVT from a PICC, and really life-altering complication. Had been on Xarelto for a month following diagnosis of the DVT and removal of the PICC, and still had a swollen arm, couldn't do a full hand grip, that kind of thing.
And we looked at her for lysis, but the interesting thing was when she was in the inpatient and was diagnosed with the DVT in her right upper extremity,
they pulled the right upper extremity PICC out and immediately put a left upper extremity PICC in. Not good.
Okay, so let's talk a little bit about bleeding. I just want to divert, just a little bit, and talk about bleeding with central line placement. 'Cause this is something we deal with in IR a lot. A lot of the infection problems, even though they're significant,
aren't related to insertion or are diagnosed later. But bleeding is something that we deal with all the time. We get called and say, "Look, the dressing is soaked with blood. "Can somebody come up," that kind of thing. So patients who bleed include patients
who have inherited disorders of hemostasis as well as those who have acquired disorders, like your TTP patient, end-stage liver disease patients. CKD patients are interesting because they have normal platelet counts. So you get the patient, they come in 150,000 platelets.
But they have dysfunctional platelets, particularly if they're uremic at the time of placement.
So those are the patients in IR that I always consider on the banana peel. Like they're chronic, you've dealt with them a million times,
but it doesn't take much to push them over the edge. So what are the kind of tests that we want to look at before we place a line? And I think a lot of us experienced in clinical practice would say this is of questionable value. But the normal things we look at
are PT/INR, PTT, and platelet count. I apologize, one of those got moved over. So the biggest predictor, in terms of lab tests that predicts bleeding risk, is your platelet count. When you're below 50,000, that's when you start to get in trouble.
I worry more about a platelet count, honestly, when I take a line out than when I put a line in, 'cause I figure I'm plugging the hole when I put the line in, a temporary catheter. But I put lines in when patients have hardly any platelets and I take them out as well, and usually you're okay.
So it's all relative to the overall situation. The other issues you want to think about are, is the patient on anticoagulation? Are they on a heparin drip? Are they on Coumadin, Xarelto, ELIQUIS, any of those drugs? And how long, if at all, do you need to hold them?
And there's a lot of variability around the country about that. On these targeted lab values, it depends upon the line that you're gonna put in, whether you even care. So for example, for a PICC I do not care if the INR is six. I don't care if the platelet count is five.
What is the patient's alternative? If you get a patient in blast crisis that comes into your emergency room with those numbers, what's the alternative to you putting a PICC in? They're gonna get probably two peripheral IVs and then they're gonna get stuck every six hours for labs.
It's a bad alternative. And you can achieve hemostasis if you need to with topical methods, lots of different strategies. And you can compress the site. Of course you wouldn't put a port in that patient at those numbers.
The ones I worry about the most are ports, and people oozing into their pocket. So I definitely want a platelet count above 50 and an INR below 1.5. I tend to be pretty hard and fast about that rule, and that those numbers need to be sustained.
If you're in a situation where the patient's got a platelet count of 15 and you transfuse them up so that you can put a port in, you'd better be sure you can keep that platelet count up for a couple days. Because it's not enough to just get
that nice peak in your platelet count for four hours and then the next day they drop because they're consuming again. So you really want to think of management outside of the suite. So here's a study that looked at the effect
of INR on bleeding outcomes with PICCs. And you can see, even patients with an INR greater than three, some of them had what's called moderate bleeding, but moderate bleeding that was managed with site care. It wasn't like they got compartment syndrome,
bled into their arm, anything like that. And yes, it's a resource issue, in terms of nursing time or RT time that's taken to manage the site. But still not bad, especially as far as PICCs go. So here's a study that looked at, well, does it even matter if we look at these things?
And what they did is they reviewed over 1700 cases and looked at in the patients who had these lines put in, what was their coagulation status? Did the patient get transfused? What kind of catheters did the patients have put it? And what kinds of problems did they have?
And so you can see, 16 patients, which was less than 1%, needed a little prolonged compression at the site. To me, that's no big deal. And when this study was done, most of us didn't have things like StatSeal and other, all the best hemostatic devices on our shelf.
Interestingly, the number of needle passes into the site did not predict risk. I always think that that does, but in this study it didn't. But interestingly, it was the insertion of a hemodialysis catheter that was an independent risk factor for bleeding in these patients.
And why do you think that was? 'Cause they have platelet dysfunction, that's it.
I explain it to patients, those are like, you have enough students in your high school but the students you have are the juvenile delinquents. They're not doing their job.
So general principles about reversal, and I have tables on all this, in terms of when do you need to hold and all that kind of thing. If any of you are interested for you practice, I would be happy to forward, we have a spreadsheet that we use
about what do you hold, when, what lab tests do you need, and for procedures that include everything that we do, not just vascular access. So you want to think about, is this procedure urgent, do I really need to do it, and if so, how long do I need to hold?
And it's gonna depend upon what the anticoagulant is, how long you need to hold. So something with a short half-life like heparin is much easier to deal with than something like Warfarin, which is much longer. Don't forget to use different strategies in combination.
So maybe this patient really needs a long-term line, like a tunneled, cuffed line, but for now we're gonna have to put a PICC in because we can't correct this blood dyscrasia. And then we're gonna put a StatSeal on it. Is anybody using glue?
Skin glue like Dermabond? You're using it on your lines? If you're not, use it on your lines, I am telling you. I do it on every single line that I put in, whether it's a PICC or a dialysis catheter or anything. And I do it for two reasons.
One is to control any oozing or bleeding at the site. I just zip it up. And I also am thinking, though not proven, that it may have a role in reduction of infection risk. And so there's a lot of work being done in Spain and Italy right now that's looking at that.
And they have some preliminary data that, yes, it reduces CLABSI risk from PICCs. So what's it cost you, $5?
Just zip it up at all your exit sites. You know how sometimes patients ooze from the sutures and not the line?
Just zip it up with some glue, every line you put in. Okay, physical examination. So here's one of our long-term patients. And you can see all the collaterals that he's got on his chest. And when you see that, you would think,
"Okay, this guy's got some central vein occlusion, "because he's got all these prominent collaterals." Which are not new veins, right? It's not a neovascularization process like you would get in a tumor. They're just enlarged veins that are taking over the flow
in the setting of a neighboring obstruction. So that's pretty specific to some kind of central venous stenosis or occlusion. But other elements of the physical exam are not. For example, the swollen arm. Maybe it's lymph edema, maybe it's a DVT, you don't know.
So although it's helpful, there are many components of the physical exam that aren't specific enough to give you much information. However, if you've got other imaging, venogram, ultrasound, MRV, whatever, even some CT imaging with contrast, that can guide you.
It's not that you need to do that in most patients, but of course that's why the nephrologists want their patients mapped, so they know where to put the fistula and the graft in. Of course there's the ultrasound. And here's a completely occluded
right internal jugular vein, occluded with thrombus. You can see how it's all gray and you don't see any flow through it.
And it's a sensitive test and it takes you two seconds. You can do this before you put the patient in the room so you're gonna know whether you're gonna go right or left.
Make some decisions ahead of time. So what about the patient's infusions? This is a real patient, not too long ago in my hospital, who had all these infusions. And you say to the nurse, "How many lumens do you need?" And he or she laughs and looks at you
and they're like, "You can't give me enough. "You can't give me enough for this patient." But you need to know some of this, or your operator needs to know some of this. What are the infusions and how do they interact with one another?
Can you piggyback one into the other? You can't if you've got things like pressors and Propofol and things like that going. You can't piggyback into that, because that'll change your infusion rate every time you add something into that.
And then you end up bolusing the patient with that drug. Something like Propofol is not compatible with just about anything else. So if the patient's on Propofol, boom, one lumen gone. What if the patient's on TPN? Boom, lumen number two gone.
So if you gotta triple-lumen, that leaves that nurse one lumen to do all the electrolyte replacement, all the sampling. So three lumens sounds like a lot until you figure out you have to do this. And don't forget to think about that for patients at home.
Patients need to figure out. All right, if I send a patient home with osteomyelitis on Vanco, I know they're gonna need Vanco levels. So do I send that patient home with a dual lumen or do I send them home with a single lumen?
I send them home with a single lumen most of the time, unless they've got really horrible veins elsewhere. Because the Vanco levels are not drawn that often that it warrants adding that second lumen, just to use it once a week. But you want to think through all those kinds of things.
You don't want to give something like, what's the seizure drug? There's a seizure drug that, I just heard somebody say it. - [Audience Member] Dilan. - Dilan, yeah, like Phenytoin, that precipitates in lines.
So you'd want to avoid giving that
through any line no matter what, anyway. It doesn't matter if you dilute it, it still precipitates in your line. Okay, so what about patient preference? You got one basilic vein, right? Each of us in each arm, that's it.
We take that out, it's gone. You're not getting it back, that's it. We have to think long-term and think about, oh, sorry. The patient and what their preference is. So when I see a patient in consultation, I sit down and I say, here are the choices
and here are the pros and cons of the choices. Talk to me about your lifestyle. Do you do sports, are you at work during the day? Does it matter to you if you can swim? Does it matter to you if people know the line is there and can see it at all?
Those kinds of things. And talk to me about what you're willing to do. Are you willing to have a dressing on your chest or your arm all the time? Who do you have as a caregiver? Can you see well enough to be able to do that?
So if I have a patient that I put a port in, I make sure I put it low enough that the patient can see what they're doing if they're gonna self-access. 'Cause if it's up here, they can't see it. And then they're trying to look in a mirror and do it and everything's reversed.
So what's the answer to that? Mark the exit site. We don't put an ostomy in a patient before we mark the site and figure out, all right, is this a comfortable spot for you? Where does your belt go, where do your pants typically fit?
For a woman, where do your bra straps typically fit? What kind of shirts do you like to wear? I'm gonna get rid of that. You know, where does it work for you? So just mark it, use a surgical marker and mark it. So these are all the things that I ask people.
And people might say, "You know what, I'm on TPN. "I infuse 12 hours every night and I want to go to work "and I want to swim in the morning before I go to work. "And so I want a port." And you might say, "You know what, are you kidding me? "If you're gonna needle in and out seven days a week,
"a port is not the right device for you." But the patient may say, "But that's the device "that works for my lifestyle." And I've had several long-term TPN patients say that to me. And I think, oh man, I don't think this is the right thing to do.
But as long as they're informed on the risks and benefits, then that's what they do. And I had one patient who was an attorney who had a port for probably 15 years. Not the same port, she probably had three or four ports in that 15 years.
But that was important enough for her, from a quality of life perspective, that that's the device she wanted, even though I might say,
why wouldn't you have a tunneled, cuffed catheter? What advantage do you gain? But she gained that 14-hour window
where she could go to the pool and then go to work and not have anything there. Let's talk about the device options, the lumens, the configurations, that kind of thing. These haven't changed that much. So we've got our non-tunneled, non-cuffed catheters.
Unfortunately, we don't have a standard nomenclature in vascular access right now. We still call, it's like Xerox for photocopy. We say, "Oh, they need a Hickman." And that's our word for a tunneled, cuffed catheter. We say a Quinton for a non-tunneled dialysis catheter.
We need to standardize this language, particularly for our referral sources who don't know what to ask for. 'Cause they don't get this information in med school or residency. It's just all very casual transmission of knowledge.
Easy in, easy out, short dwell time, fairly atraumatic in a patient who's got target vessels. You can go up to four lumens, I think there might be a five. Does anybody have a five? No, okay, in ICU. Obviously require external maintenance all the time.
Clearly visible, good flow rates, but not long-term.
You've all seen those. Those are your typical critical care catheters. I would include PICCs in this category. I don't think PICCs are a separate category to me. They're still non-tunneled, non-cuffed lines.
Then you've got your tunneled lines. So the Hickmans, TDC for tunneled dialysis catheter. You'll also see hear people say, "Oh, femoral line." And you're like, "Femoral line, what's femoral line mean? "Is that a triple lumen, is that cuffed, is that tunneled?" You don't know, so we need to clean up our language.
So these last a long time. The longest I've ever had a patient with one tunneled, cuffed line was 18 years. And you know what his secret was? He was never in the hospital. 'Cause he took really meticulous care of his line.
TPN patient at home. Up to three lumens, very comfortable. On the downside, always something hanging out. Always something to keep clean and dry.
Different opinions from clinicians on whether you can swim and shower and get that site wet.
But relatively easy to take out, although you have to dissect the cuff. And then implanted ports. People call them PortaCath, whatever. Last a really long time. The longest I've known anybody who's had a port is 25 years.
Hardly ever flushed it. Guy with cystic fibrosis. He's like, "Yeah, once or twice a year." And that's okay, because all this, there's some voodoo in vascular access. We say, "Oh, you gotta flush it every month."
Why do you have to flush it every month? Why do you have to flush a PICC once a day if you're not using it, but a port if you're not using it, you have to flush it once a month? And there is no data.
Ports came out in 1969. No studies on how often you need to flush a port or what you should flush it with. So don't, I think the moral of the story there is I tell my patients, don't get upset. If you're going on vacation
and your port doesn't get flushed for five weeks or six weeks, don't worry about it. The longest I've ever had a patient not flush a port, 11 years, 11 years. And I'm like, man, everybody forgot that that was there.
That's sort of funny, right?
And so the nurses call me, they're like, "What should I do?" And I said, well, fire it up and see what happens. Do you know, it had a beautiful blood return and flushed beautifully? So go figure. Ports are now available in pheresis ports.
So if you want to use that, you can. But you still can't dialyze through a port. So here's how I choose when I look at a device. I look at catheter material. I'm gonna talk about that in a few minutes. Whether the patient needs power injection or not.
Whether the patient can care for it themselves,
whether they want to. How long is the therapy, the infusates, all the other things we talked about. Cost, I will tell you I don't care. I know I should care, but I don't care.
Let me talk to you a little bit about ethanol lock, because this is something that you're probably not hearing about. And I don't know about you, but I was one of those people that about five years ago when we still had silicone catheters on our shelves,
the old Leonards and Hickmans and Broviacs, I'm like, now we have power injectable tunneled lines. Why are we even keeping these in inventory? Why don't we just get rid of these? But you need a silicone catheter if you're gonna ethanol lock.
And the patients that you want to ethanol lock on are long-term home TPN patients, 'cause there's excellent data that ethanol lock reduces your risk of catheter-related bloodstream infection. So you really want to pay attention to this in that subset of patients.
Now, it may turn out we'll get data that says, you know what, in all patients. If you have a leukemic patient who has a tunneled line, that we should also ethanol lock in them. But the data exists right now in long-term TPN patients. So it's bactericidal, it's fungicidal.
It's been used in children and adults, but only silicone catheters. Right now, most people are using 70%. But probably we can go down to 30%, but we're looking at that right now. And we're looking at a commercially-available
prepackaged flushed syringe to bring to the United States. It's not there now, it is available in Canada. You put in 110% the volume of your catheter. Okay, so that's the same thing you would do with Cathflo or TPA. You'd go a little past the lumen
to get any sort of gunk that's sitting there. And most of the time that's not really an issue. Even in kids, it's gonna be about an ml. And it works, it reduces catheter-related bloodstream infections by 81% and catheter replacements by 72% in this 2012 study.
And there's more studies going on now. So just remember that in your long-term TPN patients. If you have people coming into your practice who are repeatedly getting infected, you need to repeatedly place their lines. So above all, choose the device to get the job done.
And don't put a "just in case" lumen in. Every time you add a lumen, you add infection risk. Okay, just a few words about using standard devices in novel ways. Okay, we talked about tunneled catheters,
non-tunneled catheters, stuff like that.
Don't be afraid to get creative with these devices. And there's the turbocharged gazelles. And he goes, "Forget these guys. "I'm not going after them." Be the turbo gazelle. So here's a tunneled, cuffed line from the groin.
So on the right is the puncture site. You can see it's just a little teeny distal into the right common femoral vein. And then the exit site, which has come superior and is just below the ribs. And this is this guy that you saw earlier
that had all the collaterals. And he was centrally occluded, but his IVC was patent. And he was a farmer, liked to chop wood and all this kind of stuff. And so what we did is stick the right groin and then tunnel up and bring his exit site
just below the ribs. And that was a perfect spot for him, 'cause he could manipulate it. He had this line for seven years.
So everybody says groin lines are bad, femoral lines are bad.
All that data is from non-tunneled, non-cuffed catheters in hospitalized patients, not patients with chronic catheters who are at home. Here's a patient who had an occluded SVC. And we put a port into her azygous. So when you look at this, you're like,
"Man, who buggered that up?"
But it was a puncture into a collateral in her neck, then down, looped around, and then the catheter tip in a very enlarged azygous vein. Had this line for years and did well. Here is a catheter, again, from a femoral approach.
And you can see the filter on the bottom. Gonna drive the catheter right through the filter and up. So there are lots of ways you can be creative with your line placement. I would not park a dialysis catheter below or within the filter.
You start that thing up, and that's gonna be bad. But just drive through the filter and up. And I have driven dialysis catheters through filters too. Sometimes it's the right thing to do. This is that patient, going through the filter. So here's her port pocket in her leg.
And you can see the port pocket on the right. So you want to be remote from the groin with your exit site. If you're gonna go down the leg, whether it's dialysis, catheter, or port, then get a ways away from the groin. Don't be an inch or two away from the groin with your port.
Get it, that's probably eight inches at least, away from the groin. Has had it for years. Why not take a device and use it in a different way? So why not take a five French single-lumen tunneled, cuffed catheter and put it in a PICC?
So this patient's left arm, you've got your standard PICC stick with your peel-away introducer. And then just pick an exit site.
This is probably, what, four or five centimeters away, and put a tunneled, cuffed catheter in there instead of a PICC, if this is a long-term patient.
You've got the stability of the tunnel and the cuff. This is a lady who came in, really tiny lady, breast cancer. And I thought, I'll put a port in her arm. And then she came and she's so tiny. I'm like, I don't have enough real estate here to put a port in her.
And she had recurrent cutaneous disease along her chest, and tissue expanders. There was very little room below her clavicle. And this is one of these days where you get an idea and you're proud of yourself for the idea, but you also think,
"Why did it take me this long to think of this? "How come, years ago, I didn't figure this out?" And I said to her, do you mind if we go backwards? And she said no, so this is a week later. And we just stuck the left IJ and tunneled and put the port over her scapula.
And the oncology nurses loved it. Super stable site to stick. If you have any questions, I know we're limited on time. I'm trying to catch us up. Please feel free to give me a call, email me, whatever, if you want to talk about a case.
You ever want to come into a suite and see how maybe another group is doing it differently than yours, please feel to come visit us in the land of fruits and nuts in Northern California.
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