Infusion central venous catheters

Amphotericin B is the mainstay of treatment of patients with severe endemic fungal infections. The conventional deoxycholate formulation of the drug can be associated with substantial infusion-related adverse effects (e.g., chills, fever, nausea, rigors, and in rare cases hypotension, flushing, respiratory difficulty, and arrhythmias). Pre-medication with low doses of hydrocortisone, acetaminophen, nonsteroidal anti-inflammatory agents, and meperidine is common to reduce acute infusion-related reactions. Venous irritation associated with the drug can also lead to thrombophlebitis, hence central venous catheters are the preferred route of administration in patients receiving more than a week of therapy. 

Because of the need for repeated venous access, a central venous catheter or infusion port is placed prior to starting treatment. These devices are useful not only for delivery of chemotherapy but also to support patients during periods of myelosuppression. Infection and bleeding complications are the primary cause of mortality in patients with leukemia. 

Central PN refers to the administration of PN via a large central vein, and the catheter tip must be positioned in the vena cava. Central PN allows the infusion of a highly concentrated, hypertonic nutrient admixture. The typical osmolarity of a central PN admixture is about 1500 to 2000 mOsm/L. Central veins have much higher blood flow, and the PN admixture is diluted rapidly on infusion, so phlebitis is usually not a concern. Patients who require PN administration for longer periods of time (greater than 7 days) should receive central PN. One limitation of central PN is the need for placement of a central venous catheter and an x-ray to confirm placement of the catheter tip. Central venous catheter placement may be associated with complications, including pneumothorax, arterial injury, air embolus, venous thrombosis, infection, chylothorax, and brachial plexus injury.1,20... 

Mechanical complications of PN are related to catheter placement and the system and equipment used to administer PN. A central venous catheter must be placed by a trained professional, and risks associated with placement include pneumothorax, arterial puncture, bleeding, hematoma formation, venous thrombosis, and air embolism.1,20 Over time, the catheter may require replacement. Problems with the equipment include malfunctions of the infusion pump, intravenous tubing sets, and filters. 

Amiodarone IV concentrations greater than 3 mg/mL in D5Whave been associated with a high incidence of peripheral vein phlebitis however, concentrations of 2.5 mg/mL or less appear to be less irritating. Therefore, for infusions more than 1 hour, amiodarone IV concentrations should not exceed 2 mg/mL unless a central venous catheter is used. Use an in-line filter during administration. 

Oral formulations of 5-FU would allow a protracted exposure without the need for a central venous catheter or costly infusion pump. However oral 5-FU is unreliably absorbed from the gastrointestinal tract, leading to incomplete and erratic bioavailability. This has led to the development of oral prodrugs of 5-FU such as capecitabine (Hoff, 2003) and uracil/tegafur (UFT). 

Amikacin has been tested for compatibility with a chlorhexidine-bearing central venous catheter, the ARROWg+ard Blue Plus, and did not cause a substantial increase in chlorhexidine delivery (15). The amount of amikacin sulfate that was delivered was slightly less than the amount in the infusion solution (92%), but this was considered acceptable. 

After rapid intravenous administration hypotension, shock, and atrioventricular block can occur and can be fatal (2). The rate of infusion should not exceed 5 mg/minute. Qther adverse effects reported during intravenous infusion include sinus bradycardia (236), facial flushing, and thrombophlebitis (236-239). The risk of this last complication can be reduced by infusing the drug into as large a vein as possible and preferably via a central venous catheter, or perhaps by using a very dilute solution of the drug (240). 

When blood is collected from a central venous catheter or arterial line, it is necessary to ensure that the composition of the specimen is not affected by the fluid that is infused into the patient. The fluid is shut off using the stopcock on the catheter, and lOmL of blood is aspirated through the stopcock and discarded before the specimen for analysis is withdrawn. Blood properly collected from a central venous catheter and compared with blood drawn from a peripheral vein at the same time shows notable differences in composition. A comparison of arterial blood with central and peripheral venous blood is illustrated in Table 2-5. 

Catheter device selection is based on a number of factors, including the plarmed application and placement site, duration of implantation, composition of fluids infused, and frequency of access (Namyslowski and Patel, 1999). Vascular catheters can be divided into two genei groups shortterm, temporary catheters that are placed percutaneously, and long-term, indwelling vascular catheters that usually require a surgical insertion. Temporary catheters include short peripheral venous and arterial catheters, nontunneled central venous and arterial catheters, and peripherally inserted central catheters (Pearson, 1996). Tunneled central venous catheters and totally implantable intra-... 

Nimodipine is poorly soluble in water <0.1 mg/mL. The licensed pharmaceutical product Nimotop infusion solution contains 0.2 mg/mL nimodipine and 170 mg/mL macrogol 400. This high concentration of macrogol is needed to dissolve the active substance but causes phlebitis when Nimotop is administered via a peripheral vein. Therefore in the product information it is recommended to administer Nimotop via a central venous catheter. 

According to some recommendations [36] if osmolarity of the infusion is higher than 500 mOsmol/1, administration should occur via a central venous catheter that is inserted in a vessel with high blood flow such as the vena subclavia, proximal axillary vein or superior vena cava. 

Osmolarity of the nutrient admixtures and thereby the infusion route is determined by the type and amount of the components mixed. In general the admixtures are hyperosmolar and to be administered via a central venous catheter in a big vein (vena cava superior or vena subclavia). Only admixtures with a maximum osmolarity of900 mOsm/ L can be administered via a peripheral vein and only for a limited period of time [69]. Lmig term parenteral nutrition can be also administered via a port (see Sect. 13.10.3) especially when patients are treated at home. Because of the high probability of incompatibilities nutrition admixtures should always be administered via a separate line and Y-site infusion should be avoided. 

MidUne catheters and peripherally inserted central catheters (PlCC) are inserted in a peripheral vein but the tip rests in a larger vein. The infusion fluid flows directly in the larger vein which diminishes the chance of phlebitis. Both types of catheters are typically inserted in a vein in the upper arm. The midline catheter ends at armpit height the tip of the PICC rests in the vena cava superior. The PlCC may have single or multiple lumens. The PlCC line can be used as a central venous catheter for infusion which needs fast dilution or distribution or both such as antibiotics, pain medicine, chemotherapy, nutrition, etc. 

Shah, P.S., Shah, V.S., 2008. Continuous Heparin Infusion to Prevent Thrombosis and Catheter Occlusion in Neonates with Peripherally Placed Percutaneous Central Venous Catheters. The Cochrane Library. 

In nine patients a central venous catheter had been placed for indications other than intravenous feeding. These central venous lines were then used for parenteral alimentation. As soon as the catheters were no longer considered essential for their care, supplementary nutrition was given through a peripheral vein in two of these children. In three additional patients the latter route was used entirely. Infusate for the central venous catheters was a hypertonic glucose solution containing 5% protein hydrolysate and 900 calories per liter ("MGH 900", see chapter by Dr. Fischer). 

In patients with CKD, preservation of the integrity of peripheral and central veins is of vital importance for future hemodialysis access. Avoid i.v. infusion or vein puncture in the forearm and upper arm veins at both arms whenever possible. Insertion of venous access devices carries the risk to injure the veins and thereby incite phlebitis, sclerosis, stenosis or thrombosis and has to be avoided. Whenever a central venous catheter is needed, catheterization of the internal jugular or femoral vein is always preferred. Use of subclavian vein should be... 

PN can be administered via a smaller peripheral vein (e.g., cephalic or basilic vein) or via a larger central vein (e.g., superior vena cava). Peripheral PN (PPN) is infused via a peripheral vein and generally is reserved for short-term administration (up to 7 days) when central venous access is not available. PN formulations are hypertonic, and infusion via a peripheral vein can cause thrombophlebitis. Factors that increase the risk of phlebitis include high solution osmolarity, extreme pH, rapid infusion rate, vein properties, catheter material, and infusion time via the same vein.20 The osmolarity of PPN admixtures should be limited to 900 mOsm/L or less to minimize the risk of phlebitis. The approximate osmolarity of a PN admixture can be calculated from the osmolarities of individual components ... 

The infusion site should be examined daily and changed regularly to prevent opportunistic infection, which is usually with coagulase-negative staphylococci or fungi. Alternatively, use may be made of a central subclavian venous catheter sited with meticulous attention to aseptic technique. 

Gray, R. J., Levitin, A., Buck, D., Brown, L. C., Sparling, Y. H., Jablonski, K. A., Fessahaye, A., and Gupta, A. K., Percutaneous fibrin sheath stripping versus transcatheter urokinase infusion for malfunctioning well-positioned tunneled central venous dialysis catheters A prospective, randomized triaL /- Vase. Interv. Radiol., 2000 11(9) 1121-1129. 

The incidence and duration of phlebitis seems to be dependent on a variety of factors. Physical-chemical factors such as low pH, hypertonicity, particles and precipitation play a role in the cause. Active substances that are poorly soluble in water may precipitate and can cause acute phlebitis. Active substances with adequate aqueous solubility may tend to cause phlebitis only because of prolonged or chronic administration. Clinical factors involving injection technique (infiltration, extravasation, type of needle, duration of infusion) but also irritating characteristics of the active substance can contribute to the occurrence of phlebitis [9, 10]. Sometimes (septic) phlebitis is caused by bacterial infection (e.g. cause of inappropriate aseptic technique during catheter insertion) and is characterised by inflammation with suppuration of the vein wall. Local responses to the parenteral challenges can be diminished by dilution of the medicine or by central venous instead of peripheral venous administration (see Sect. 13.10.3). 

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