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Seminars in Oncology Nursing, Vol 26, No 2 (May), 2010: pp 102-112

INSERTION AND PLACEMENT OF CENTRAL CATHETERS IN THE ONCOLOGY PATIENT
MARGY GALLOWAY
OBJECTIVES: To review the current up-to-date recommendations for insertion
and placement of central venous access devices and discuss the prevention of complications during and post-placement of central catheters.

DATA SOURCES: Journal articles, electronic articles, organizational position papers, personal experience. CONCLUSION: There are numerous types of vascular access catheters that
play an important role in the management of complex treatments for the oncology patient. Cancer patients with a catheter have a higher rate of thrombosis and infection as part of their disease process and treatment; hence, nursing care can eliminate or minimize complications.

IMPLICATIONS

FOR

NURSING PRACTICE: Nurses must be educated on the

correct procedures and rationale for insertion and placement as well as for the care and maintenance of each speci?c device.

KEY WORDS: Vascular access devices, insertion, infection, bundle, ultrasound.

T

HERE HAVE been many scienti?c advances in technology, techniques, and management of central lines that have signi?cantly changed vascular

Margy Galloway, RN, BSN, OCN?, CRNI: Vascular Access Nurse/PICC Team Clinical Educator, St. Luke’s Hospital, Kansas City, MO. Address correspondence to Margy Galloway, RN, BSN, OCN?, CRNI, St. Luke’s Hospital, 4401 Wornal Road, Kansas City, MO 64111 e-mail: margy501@ swbell.net ? 2010 Elsevier Inc. All rights reserved. 0749-2081/10/2602-$32.00/0. doi:10.1016/j.soncn.2010.02.004

access devices (VADs) and their management over the past 50 years.1 In the past, the peripheral intravenous cannula was the only device available for the delivery of intravenous medications.1 Today, the use of short-, intermediate-, or longterm central vascular access devices (CVADs; also called central venous catheters or CVCs) play an important part in the management of complex treatments for the oncology patient with the intended outcome of increasing the patient’s survival. The availability of venous access has become a priority in the management of patients with cancer because intravenous therapy makes up a major component of patient care. Oncology patients have a greater need for central venous

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access because their treatment involves the administration of repeated cycles of chemotherapy or other forms of systemic therapy, obtaining blood specimens to monitor the effects of treatment or for research, and the administration of supportive blood products, antiemetics, antibiotics, nutrition, and analgesics. Central lines may also be used for plasmapheresis, apheresis, and hemodynamic monitoring. Central lines are also placed when patients have poor peripheral venous access because of genetics, previous frequent healthcare treatments,2 or illicit drug use. The central approach spares the patient the physical and psychological trauma of repeated peripheral venipuncture. Treatment administered in the outpatient or home setting decreases the overall cost and helps the patient to maintain their independence. It is not possible to estimate how many VADs are used for cancer patients, but in 2005 over 7 million central lines were placed.3 The healthcare professional is challenged to maintain up-todate knowledge of the differences between the devices, the choice of device for individual patients, insertion procedures, and device maintenance protocols. It is documented that early device selection in the beginning of therapy can impact both clinical and ?nancial outcomes.2,4 Unfortunately, very few oncology patients are assessed for the appropriate VAD at the time of diagnosis and at regular intervals, as recommended.5,6 The obese patient and the severely thrombocytopenic patient, as well as the patient who does not tolerate repeated punctures through the skin, would do well with early planning. Planning in advance of long-term needs will enable early placement and decrease complications from intravenous therapy administration because of impaired peripheral veins.2,4,5 It will also set the precedent for an environment of shared decision-making between the patient and healthcare providers. As the patient’s treatment plan changes so does their vascular access needs. Assessment is an ongoing process. The continuous updating of VAD care guidelines has shown to be effective in reducing catheterrelated bloodstream infections (CR-BSI), as well as non-infectious complications.6-8 Several technology advancements, such as the use of ultrasound (US) guidance, catheter coatings, or impregnation with materials to reduce possible

infections and thrombosis, have contributed to the further reduction of catheter complications.8 To further reduce catheter complications, more patients need to be involved in the selection of their device.9 See Table 1 for a description and considerations of the various types of devices. Also, the development of up-to-date guidelines from new randomized controlled studies regarding the selection of the most appropriate device for each patient,9 along with further emphasis on education of all healthcare workers, is needed.

GUIDELINES FOR PREVENTION OF INFECTION
Effective treatment of the cancer patient requires access to the venous system. Each time the venous system is accessed the oncology patient is at increased risk for an infection because of their compromised immune system and subsequent chronic illnesses. The most common pathogens found are coagulase-negative staphylococci epidermidis, Staphylococcus aureus, aerobic gram-negative bacilli (eg, Escherichia coli), and Candida albicans.8 Whereas oncology patients are more susceptible to infection because of their compromised immune system they should be protected from this potential complication. The literature states that infections from central lines can occur by two mechanisms.6-10 The ?rst mechanism for infection can be at the exit site, when a pathogen migrates down the external catheter surface (extraluminal pathway). The second is contamination of the catheter hub that leads to colonization on the inside of the catheter (intraluminal ?uid pathway). This second mechanism allows for the pathogen to enter the circulation and seed itself. The problem of central line-associated bloodstream infections has led to the development of several guidelines for infection prevention. One guideline ‘‘Guidelines for the Prevention of Intravascular Catheter-Related Infections’’ was developed in 2002 by the Centers for Disease Control (CDC).8 This guideline was written by healthcare professionals who were experts in the ?eld of vascular access and was designed to apply to the home healthcare setting, the acute care setting, and the outpatient arena. Organized programs were developed that allowed specialized education of healthcare professionals to provide infection

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TABLE 1.
Description and consideration of various types of devices. Type of Device Peripheral IV catheter Description Less than 3 inches in length. Tip of catheter resides in peripheral vein Advantages Ease of insertion Low cost Low complication rate Disadvantages Use is limited to certain infusates Easily occluded Potential for tissue damage at site Potential for occlusion

Peripherally inserted central catheter (PICC)

Nontunneled central catheter (acute care catheter, triple lumen)

Tunneled central catheter

Implanted port

Tip of catheter resides at the most distal superior vena cava or cava-atrial junction Can be single or multi lumen Tip of catheter resides at the most distal superior vena cava or cava-atrial junction. If inserted in femoral vein, tip should reside in the inferior vena cava Can be inserted in jugular, subclavian or femoral vein Can be single or multi lumen Tip of catheter resides at the most distal superior vena cava or cava-atrial junction. If inserted in femoral vein, tip should reside in the inferior vena cava Can be inserted in jugular, subclavian or femoral vein Can be single or multi lumen Tip of catheter resides at the most distal superior vena cava or cava-atrial junction. If inserted through femoral vein, tip should reside in the inferior vena cava

Can be inserted at bedside Can be used with all infusates Inexpensive Low complication rate Can be inserted at bedside, procedure room, or surgery suite Can be used with all infusates Percutaneous insertion

Risk of infection and/or thrombosis

Lower infection rate Can be used with all infusates May dwell as long as needed if remain without complications

Requires insertion in interventional radiology, procedure room, or surgery suite Increased cost

Lowest rate of infection Minimum body image distortion Can be used with all infusates May dwell as long as needed if remains without complications

Increased cost Requires insertion in interventional radiology, procedure room, or surgery suite

prevention strategies, to monitor those strategies, and to evaluate their outcomes. The guidelines discuss catheter insertion, type of catheter material, hand hygiene, aseptic technique, skin antisepsis, dressing protocols, securement devices, and in-line ?lters. These guidelines were categorized on the basis of existing scienti?c data, theoretical rationale, applicability, and economic impact.8

In 2004, the ‘‘100,000 lives initiative’’ was developed and implemented by the Institute for Healthcare Improvement (IHI) to reduce the morbidity and mortality in healthcare by introducing six different healthcare areas of evidence-based practices to reduce harm and improve care for patients.10 The grouping together of best practices helps individually improve patient care but results in substantially greater improvement when used

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together as a ‘bundle.’10 One area focused on the prevention of central line infection. The IHI campaign encouraged hospitals to join together to use speci?c steps for the prevention of central line infections by implementing a series of interdependent, scienti?cally grounded steps called the ‘‘Central Line Bundle.’’10 Key parts of the Central Line Bundle includes hand hygiene, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection while avoiding the femoral vein, and the daily review of the necessity of the central line.10 Each of the key parts was further de?ned for all patients. The IHI recommended the use of the CDC guidelines on the appropriate times for the healthcare worker to wash their hands or use the alcoholbased waterless hand cleaner as support for their hand hygiene recommendation.8,10 Because there is an increase in catheter-related infections when maximal sterile barrier was not used, a recommendation was made for the healthcare worker inserting the catheter and any one assisting in the procedure to use maximum sterile barrier precautions.10 The precautions included strict healthcare personnel compliance with hand washing, wearing a cap that would cover all of the inserter’s hair, a mask that would cover the nose and mouth tightly, sterile gown, sterile gloves, and a large patient drape. The large drape was further de?ned as covering the patient from head to toe, with a small opening for inserting the catheter.10 The campaign encouraged facilities to adopt a central line checklist (see Fig. 1) to make sure all the important steps were taken before, during, and after a central line was inserted, as well as the use of a cart to keep all needed supplies in one location. The IHI partnered with the American Hospital Association, the American Medical Association (AMA), the Joint Commission, the Centers for Medicare and Medicaid Services, and other in?uential medical organizations, to make sure the initiative ?t together with the work already in progress to meet requirements and regulations.10 It was estimated that over 122,000 lives were saved as a result of this initiative. Several examples of institutions that implemented these recommendations are discussed below. The PICC (Peripherally Inserted Central Catheters) team at Sutter Roseville Medical Center, Roseville, CA, a not-for-pro?t community-based teaching acute care facility, was able to reduce their central CR-BSI to zero by developing

a central line bundle. The CR-BSI rate remains at zero 4-years later. The bundle was aimed at improving outcomes by updating current policies and procedures for all central lines after review of the most current literature available. By using evidence-based practices directed toward an early assessment program and minimizing the risk of infection, at the extraluminal catheter tract and the intraluminal ?uid pathway, their central line infection rate was reduced.11 Infections in the intensive care unit of New York Methodist Hospital, Brooklyn, NY, were reduced from 5.0 to 0.90 per 1,000 central lines days by adopting a central line bundle. A multidisciplinary team implemented the bundle to ensure that every central line placement was performed using the latest evidence-based techniques. At the onset, physicians, residents, and nurses were educated on infection control practices. This bundle included the use of a central line cart, maximal sterile barrier precautions, hand hygiene, use of ChloraPrep (CareFusion; Leawood, KS) for skin antisepsis, and avoiding the use of the femoral vein. A checklist was completed each time a central line was placed, and the need for the catheter was documented every day. There were 1,395 catheters placed with a total of 9,938 catheter days included in this study.12 In 2005, the CDC published the outcomes of the Pittsburgh Regional Healthcare Initiative which was to eliminate central line-associated bloodstream infections in intensive care units.13 They looked at ?ve components: 1) promotion of evidence-based catheter insertion practices (ie, use of chlorhexidine for skin antisepsis, avoiding use of femoral site for catheter insertion, use of maximum sterile barrier precautions, removal of catheter when no longer needed, and the recommended insertion-site dressing care practices); 2) use of an educational module for education about central line-associated bloodstream infection (CLABSI) and strategies for prevention; 3) the use of a standardized tool to document adherence to the recommended catheter insertion practices; 4) the use of a standardized list of contents for all central line insertion kits to promote adherence to recommended insertion practices; and 5) collection of CLABSI rates to be distributed to the participating hospitals, allowing comparison of rates.13 The results showed a 68% reduction in bloodstream infection rates with the use of those ?ve components.13 The addition of interventions to protect the

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M. GALLOWAY

Directions for use: Monitor assisting clinician must complete this checklist Date:_________ Location of patient______________ ____IJ

1. Type of CVC: ____Acute care catheter _____Swan Ganz ____PICC

____ Temp dialysis catheter _____ Femoral ____Other 2. Is the procedure _______elective or _______ emergent

3. Clinician performing insertion _______________________________ 4. Before the procedure did the inserter perform Hand Hygiene? (using either soap and water or alcohol based product) Yes No Don’t know

Was the Equipment Listed below Available? _________________________________________ 5. Maximum Sterile Barrier Precautions Used by Inserter: Mask yes no Sterile Gown yes no Lg. Sterile Drape yes no Sterile gloves yes no Cap yes no CHG scrub (2%) for 30 sec. Povidone iodine (10%) allowed to dry 2 minutes Alcohol (70%) with friction for 10 sec. yes yes yes yes yes no no no no no

6. Skin Preparation:

yes yes yes

no no no

7. Did personnel involved in setting up the sterile site or assisting in the procedure wear a mask ? 8. Post-procedure was a CHG dressing placed? 9. After procedure was dressing dated? 10. Pt. Education information given to pt/family

yes yes yes yes

no no no no

yes yes

no no

NA

NA ___ pt comatose ___ no family

Form completed by ___________________________________

FIG 1. Central venous catheter (CVC) insertion checklist. Abbreviations: IJ, internal jugular; PICC, peripherally inserted
central catheter.

intraluminal pathway might decrease the infection rate further. In May of 2008 the Institute for Healthcare Improvement introduced the ‘‘protecting 5 million lives from harm’’ campaign. The new campaign built on the original six interventions and added six new interventions to prevent harm to patients.14 The goal is the continued use of the central line bundle to reduce catheter-related infections with the use of a checklist so that healthcare professionals are forced to think about

the critical issues every time they place a central line.14

TECHNIQUES FOR PLACING CENTRAL CATHETERS
All central catheters used for oncology treatments require access to the central circulation through venous branches for correct tip placement in the distal third of the superior vena cava.15-20 The major risk of leaving the catheter tip above the mid

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superior vena cava is thrombosis.21 Risks associated with catheter tips in the right atrium include thrombosis, cardiac arrhythmias, cardiac perforation, and tamponade.16 In the United States, catheter tip con?rmation is done by x-ray.15,19 Europeans have incorporated electrocardiogram interpretation for tip con?rmation with and without a chest x-ray.8 The most popular technique for obtaining central access is through the skin (percutaneous). An alternate placement technique is by the cutdown method. According to the CDC, percutaneous insertions have a lower infection rate than the cut-down approach.5 In 1953, the Seldinger technique was introduced by Dr. Seldinger and has allowed us to move away from the cut-down approach. The Seldinger technique is described as accessing a vein or artery with a small needle, introducing a ?exible guidewire, removing the needle, and advancing a catheter over the wire and into the vein or artery.1 As newer catheters have become softer, the Seldinger technique has been modi?ed to include the insertion of a dilator/introducer over the wire to help dilate the tissue to allow for the larger size of the catheter. The wire/dilator is then removed as one unit leaving behind the introducer. The newer softer catheters could then be inserted through the introducer. The percutaneous approach using the Seldinger technique has allowed healthcare professionals to take the procedure from the surgery suite to the bedside and even the outpatient setting for oncology patients.22 Central catheters can be inserted in the interventional radiology suite, outpatient surgery suite, surgery suite, or at the patient’s bedside. The healthcare professional inserting a percutaneous central catheter must use strict sterile procedure to isolate a large central vein for use. If placing a tunneled line, the inserter would create a subcutaneous tunnel from the entrance site of the vessel to the exit site on the chest area by separating the skin from the subcutaneous tissue with a tunneling device or blunt forceps. These catheters have a Dacron cuff that allows ?brous subcutaneous tissue to grow into the cuff, providing a barrier against any skin bacteria from migration along the catheter tract. The cuff also provides an anchor for the device after engraftment has taken place, approximately 30 to 45 days later. Totally implanted subcutaneous access devices (Port-a-Cath) are placed similarly except that

a reservoir/port is attached to the catheter and inserted under the skin in a subcutaneous pocket. Ports usually require the least maintenance but are the most costly and most time-consuming to implant as well as remove.5,9 PICCs are inserted in the mid portion of the upper arm using US and the tip advanced to the distal superior vena cava. They can be inserted in the home if needed using strict sterile procedure and a mobile x-ray for tip con?rmation. Advantages to the use of a PICC are decreased cost and fewer potential complications associated with the insertion procedure.2,5,9 Complications are usually less severe than with conventionally placed central lines.2,5,9 Con?rmation chest x-ray should be used after each placement procedure to con?rm catheter tip position and rule out possible complications.22 Most catheters can be used as soon as proper tip placement is con?rmed. A routine follow-up chest x-ray is not a standard procedure but should be considered when any signs or symptoms of catheter tip malposition (eg, ringing in ear) or other complications (eg, arm swelling on side of catheter placement) are suspected.22 The Oregon Health & Science University Hospital (OHSU) has a highly skilled nursedriven vascular access specialty team (PICC team) that uses the most up-to-date standard of practice when inserting PICCs.23 The standard of practice includes the use of upper arm veins for placement of PICCs using modi?ed Seldinger technique and US guidance. PICCs used in critical care at OHSU increased from 11% in 1999 to 29% in 2007. Their concern about infection rates of PICCs versus CVC in the intensive care unit led to a retrospective review of 1,800 patients who had PICCs placed over a 9-month period. Eighty lines had been removed for suspected infection; 74 of the 80 lines had blood cultures, with 0.4% (7 catheters) testing positive.23 A study by Patel et al24 that compared the use of PICCs and ‘‘non-PICC’’ catheters over 3 years looked at dwell time and catheter-related blood stream infection. They found a decrease in infection and antibiotic usage with PICCs, but suggested further studies to evaluate PICC utilization as part of an infection prevention initiative for central lines. It is inconclusive at this time as to the incidence of bloodstream infections of PICCs versus other CVCs in hospitalized patients. There is a need for randomized, controlled clinical trials,

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acceptable prospective studies, and retrospective reviews that evaluate the incidence of infection.

MULTIPLE LUMEN VERSUS SINGLE LUMEN CATHETERS
The 2002 CDC guidelines for prevention of intravascular catheter-related infections include a recommendation to use the minimum number of catheter lumens that is necessary for care of the patient.8 This information is not found in the draft version of the 2009 CDC guidelines, which is available for public comment at this time.25 The ‘‘Oncology Nursing Society Access Device Guidelines’’ state that when choosing patients that would bene?t from nontunneled central venous lines ‘‘consider that infection rates rise exponentially with the addition of each subsequent lumen,’’ but the guidelines do not discuss the risk of infection with multiple lumens in any other type of VAD.15 Multiple lumen catheters are bene?cial in oncology patients who may be receiving a number of different chemotherapy agents with or without blood transfusions or the patient who is receiving a bone marrow transplant. A meta-analysis of the rates of infection for singlelumen versus multilumen CVCs showed that multilumen catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters.26 However, when evaluating studies that had controlled for patient differences, the slight risk diminished.26 Thus, the risk and bene?ts of using multilumen catheters should be considered for each patient until other randomized control studies have been completed.

or visible structures with known relationships to the desired vein.7,9,27,28 For example, the approach to the internal jugular vein requires knowledge of the vein’s pathway in relation to the carotid artery and sternocleidomastoid muscle where the approach to the subclavian vein requires more factors. Those factors include being able to ?nd the correct locations of the clavicle site, suprasternal notch, and sternocleidomastoid-clavicular triangle landmarks. Data shows that experienced inserters have good success rates and lower complication rates.7,27 McGee and Gould7 recommended that if two or more needle passes are needed to access the vein for catheter insertion, the professional should ask for assistance from a more experienced professional or obtain US guidance. Using a multidisciplinary approach to select the correct CVC can help reduce complications and poor outcomes.29 A thorough assessment should be implemented before device selection. The decision should be based on the patient’s history, physical exam, anatomy, risk factors, access needs, prescribed therapy, expected duration of therapy, patient’s vascular integrity, types of central lines available, and the inserter’s experience.5,7,9,29 It is a complex decision to select the most appropriate site for central venous cannulation. There are multiple approaches for venous catheterization; such as upper arm veins (basilic, brachial, cephalic), external or internal jugular vein, and subclavian and femoral veins, each having their own advantages and disadvantages (see Table 2).7,9,27

CHOOSING AND PLACING THE CATHETER
It is important that well-educated and experienced healthcare professionals place CVCs to reduce the risk of infection. When performing the procedure the highest possible standard for asepsis should be used, including the use of maximal sterile barrier. There is a learning curve for either the cut-down approach or the percutaneous technique. To use the percutaneous cannulation of the central veins, the inserter must have knowledge of 3-dimensional anatomy relating to the access approach.7 Percutaneous insertions of CVCs are usually performed by ‘‘blind’’ techniques that rely on anatomic landmarks that can be either palpable

USE OF ULTRASOUND TO REDUCE POSSIBLE INSERTION COMPLICATIONS
Sometimes the inserter may be forced to use an alternate to the originally selected site because of abnormalities of the patient’s anatomy, diseaserelated alterations of the body, or lack of experience by the inserter.9 This may increase the risk of complications during the insertion procedure. There are many studies reporting complication rates, which vary between 5% to as high as 40% when using up to three attempts to insert a central catheter in the subclavian or internal jugular vein.7,9,27,28 Ultrasound has been found to signi?cantly reduce insertion-related complications and increase ?rst-pass success rate if used

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TABLE 2.
Advantages and Disadvantages for Each Central Catheter Insertion Site Approach Femoral Advantages Easy, fast High success rate No risk of pneumothorax Does not interfere with intubation Does not interfere with CPR Better access when airway control is being established More comfortable for patient Easy to maintain dressing Landmarks easier to determine when patient is obese Vein less collapsible with shock or hypovolemia Easier for large volume Resuscitation High success rate Can control bleeding easier Pneumothorax uncommon Right-sided IJ has straighter path to superior vena cava (straight shot, less malposition) Lower failure rate with inexperienced operator Disadvantages Dif?cult to keep sterile Prevents patient’s mobility

Subclavian

Increased risk of pneumothorax Low success rate with inexperienced inserters Catheter malposition is common Compression to bleeding site dif?cult May interfere with chest compressions

Internal jugular (IJ)

External jugular

Low pneumothorax rate Prominent in elderly patients Comfortable for patient Easy to maintain dressing No risk of pneumothorax Can control bleeding with pressure

Upper arm veins (basilica, brachial, cephalic)

Can be uncomfortable Dressing can be dif?cult to maintain in obese/edematous patient Landmarks obscure Dif?cult access during emergencies when airway control is being established With hypovolemia, vein may collapse Frequent carotid artery puncture reported Thoracic duct injury possible on left Can be dif?cult to access with tracheostomies High failure rate Can be uncomfortable High malposition rate Needs ultrasound skills to access Rubs against patient’s side when using arm Thrombosis common

when placing central lines.9,30,31 The recommendation to use US guidance when inserting a central catheter, was initiated by the Agency for Healthcare Research and Quality (AHRQ) in 2001.30 The complications of arterial puncture (chylothorax, pneumothorax, hematoma, hemothorax, brachial plexus injury, arrhythmias, air embolus, and catheter malposition) occur with attempted CVC insertion, no matter whether insertion is successful or not.27 US imaging improves the ability to locate a vessel7,9,30 and uses high-frequency sound waves to produce a 2-dimensional, real-time, grayscale image of tissue.30-33 Real-time US guidance of a CVC insertion shows the inserter the desired vein and the surrounding anatomic structures prior to and during insertion of the needle, guidewire, and catheter.7,9,30-33 Different views of the

structures directly below the beam can be seen, depending on the angle at which the beam passes through the vessels. The literature describes two types of real-time US guidance: 1) the Doppler US guidance method (audio-guided Doppler, ?ngertip pulsed Doppler, and probe-in-the-needle); and 2) the nonDoppler US guidance method (referred to as US guidance).9 According to the literature, patients bene?t more with US placement when the inserter is experienced, the patient has multiple risk factors, and in intensive care unit or other highrisk settings.7,9,28,30,31 A meta-analysis by Randolph et al33 showed that US used for CVC insertion reduced placement failures over the landmark technique, reduced the number of needed venipunctures for successful CVC insertion by 40%, and there was an estimated

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78% reduction in complications during CVC placement. Orsi et al34 evaluated 427 Port-a-Cath placements using US placement and compared it with the blind technique over a 40-month period. The subclavian vein was used for all placements. They reported that the use of US reduced the procedure time, and insertion was easier for the inserter and safer for the patient than the blind technique. They reported a reduction in early complications and costs. A retrospective study of cancer patients with coagulation disorders from Milan, Italy showed that using US guidance was safe and that correction of any abnormal coagulopathy is unnecessary. All central lines, which included 233 subclavian vein sticks and six internal jugular vein sticks, were accomplished with the ?rst stick when using US guidance. Forty-?ve of the patients were at high risk for bleeding, a platelet count of less than 50,000/mm3 and/or partial thromboplastin time, or prothrombin time of greater than 2.2 times normal, and no bleeding events occurred. Because there were no complications from any central line insertions the authors noted that the skill level of the inserter affects the rate of complications for central line placement.35 With US guidance there is the potential for harm, which is identi?ed as a possible increase in the length of time required to place a CVC. This increase in time in an emergency situation may be unacceptable.31 Another disadvantage is the need to train the inserters to use US guidance and then the possible dependence on US guidance.28 In 2002, the National Institute for Clinical Excellence-United Kingdom established guidelines with the following recommendations9,32: 1. Two-dimensional imaging US guidance should be the preferred method when placing a CVC into the internal jugular vein of adults and children in ‘‘elective situations.’’ 2. Two-dimensional imaging US guidance should be considered in most clinical situations (elective or emergency procedure) where CVC insertions are necessary. 3. Everyone using 2-dimensional guidance to insert CVCs should be appropriately trained so the technique could be used competently. These guidelines resulted in a signi?cant reduction in complication rates associated with CVC insertions.9

In 2008, the Association for Vascular Access (AVA) published their position statement recommending all health professionals inserting CVADs use real-time imaging guidance for inserting all non-emergent CVADs.36 The position statement recommends that all facilities establish a competency that shows each inserter has shown ‘‘mastery of their psychomotor skills,’’ as well as have training and ongoing education related to the use of US.36 Even with the recommendations for the use of US guidance, a questionnaire-based study of 2005 showed that less than 15% of those who responded (emergency medicine, internal medicine, family medicine house staff, surgery, and anesthesia) used US guidance more than 60% of the time. Those responders who more frequently performed central line procedures reported lower use of US. Multiple knowledge and attitudinal barriers to the use of US guidance exist and a standardized approach to education of US must be adopted.37 The AMA and AVA, as well as other professional organizations, have statements recommending that US users participate in a didactic and clinical training. A return demonstration of the cognitive and psychomotor skills is encouraged.30,36 Quality improvement data must be measured, as well as continued credentialing.30 US machines are becoming smaller and more portable, allowing central lines to be placed at the bedside, limiting the number of times the patient has to be transported to another area. Studies have shown that US has decreased complications at the time of insertion and increased the ?rst-time pass success rate.34,36 It is vital that the oncology ?eld advocates for the use of US for their patients.

THROMBOSIS OF CENTRAL LINES IN THE CANCER PATIENT
Catheter-related thrombosis is a major complication of CVCs.9,38 A few of the risk factors associated with catheter-related thrombosis include the location used for placement of the catheter, catheter tip placement, number of lumens in the catheter, patient’s underlying disease, the treatment of the disease, the time it was placed, malposition of the catheter, and the type of infusate.39-41 All of these factors have a direct affect on the blood ?ow and the vein adjacent to the catheter. Documentation shows

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catheter-related thromboses can increase the patient’s risk of catheter infections, pulmonary embolism, post-thrombotic syndrome, and persistent vascular compromise, which increases the cancer patient’s morbidity and mortality.39,40 Mehall et al42 showed that proteins within a clot (?brinogen and ?bronectin) attract staphylococcal species and promote their adherence to the surface of the clot, thus promoting colonization and further catheter infections. Previous quantitative electron microscopy and quantitative microbiologic testing of ?brin showed it was always colonized by cocci, which puts the patient at higher risk for a blood stream infection.40 Cancer patients and patients with a CVC have a higher rate of thrombosis of the upper extremity than patients without the diagnosis of cancer or CVCs.43 When a venogram was performed on cancer patients with an indwelling CVC, the reported thromboses rate ranged from 27% to 66%. The majority of the patients were asymptomatic.41 The rate of symptomatic venous thromboembolism was between 0.3% and 28.3%.38,41 Streiff43 noted that, on average, 15% of cancer patients will develop a deep vein thrombosis or pulmonary embolism during the course of their cancer treatment. A long-term complication from the diagnosis of deep-vein thrombosis can be post-thrombotic syndrome.41,43 Presenting symptoms are edema, pain, and skin hyperpigmentation, which is caused by the blood pooling around the original

clot with further venous destruction. These symptoms might not develop for several years after the original thrombosis. Catheter-related thrombosis is a serious complication that must be diagnosed and appropriately treated. Effective prophylactic measures have not been established. Future research should examine the best strategies for prevention of catheter-related thrombosis and its treatment.38-40

CONCLUSION
The development of new VADs and their safe use requires the oncology health professional to review and analyze the current literature to either utilize current bundles or develop complete institution-speci?c central line bundles for the prevention of infections. By collaborating with members of the healthcare team and the use of critical thinking skills, oncology nurses can reduce the chance of catheter related-blood stream infections and thrombosis. The use of CVCs will continue to increase; therefore, additional studies are needed to better de?ne optimal management. Other studies that would bene?t the patient include research on quality of life and patient satisfaction with a VAD. Publishing the outcomes from research studies associated with vascular access in the oncology patient will help improve outcomes.

REFERENCES
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