Catheter Tip & PIVC Position

What is the optimal catheter tip position for central venous access cevices (CVADs), and the optimal site of peripheral intravenous cannulas (PIVC) for paediatric and adult patients with cancer?

TERMINOLOGY

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSAeviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

INTRODUCTION

The catheter tip of a Central Venous Access Device (CVAD) is the internal or distal end of the catheter. There is much discussion in the literature about the optimal position of the CVAD catheter tip and the relationship between catheter tip position and functional complications such as occlusion (1). This question will discuss current evidence for the optimal catheter tip location, the methods of determining the catheter tip location and complications associated with tip malposition.

The majority of studies noting catheter tip position were observational or incidental findings in retrospective studies which primarily documented incidence rates of CVAD complications. It is unlikely that high quality studies, for example randomised controlled trials comparing the recommended or ideal catheter tip position versus suboptimal position will be undertaken because it would be unethical with documented detimental effects of catheter tip malposition. Hence, recommendations included in this answer will be supported by other literature, for example international recommendations and standards of practice.

Literature that discussed the optimal insertion site of Peripheral Intravenous Cannulas (PIVCs) to reduce the risk of complications, identified in this review of the cancer patient cohort, was expert opinion. Therefore, literature for all patient cohorts was used to support the practice recommendations.

SUMMARY OF RECOMMENDATIONS

CENTRAL VENOUS ACCESS DEVICES:

CNSA recommends for adult and paediatric patients with cancer:

  1. Optimal catheter tip position of Central Venous Access Devices is at the cavoatrial junction (1-11), and in acceptable position of the lower third of the superior vena cava (3,12-21) and the upper right atrium (3,14,22-24).

  2. Technique of identifying the catheter tip location: can be determined by

    • use of intracavity electrocardiographic (ECG) guidance during the insertion procedure (1,15,25,26)

    • radiological examination including:

      • chest x-ray immediately post procedure and prior to first use (2,6,10,13,20,21,23,27-31) and investigation of complications e.g. malposition, catheter migration, kinking, pinch-off syndrome (32) and with arms beside the body (33)

      • avoid fluoroscopy due to patient exposure to ionizing radiation (34)

PERIPHERAL INTRAVENOUS CANNULA (PIVC)

CNSA recommends the optimal peripheral intravenous cannula insertion site to reduce the risk of all complications for adults are the veins in the forearm including the metacarpal, cephalic, basilic, and median veins, and the veins in the hand, forearm, and foot if not walking for paediatrics (35) and:

Adult patients:

  • Avoid areas of flexion (including antecubital fossa and wrist), pain, impaired skin, infection (in same limb), lower limbs, and superficial veins on the torso

  • Consider veins on hand for short-term use e.g less than 24 hours

  • Avoid insertion sites distal to recent venepuncture or insertion sites to reduce the risk of extravasation (32)

Paediatric patients:

  • Avoid antecubital fossa

SECTION A: CENTRAL VENOUS ACCESS DEVICES

1. OPTIMAL CATHETER TIP - CVAD

1.1 Summary of Evidence

Numerous adult and paediatric studies state the optimal position for the CVAD catheter tip is within a defined range between the lower third of the superior vena cava, cavoatrial junction to the upper right atrium (14,21,22,30,36). A small number of adult and paediatric studies state the superior vena cava is acceptable (29,31,37,38). However, a larger number of studies specify the optimal catheter tip position is the lower third of the superior vena cava (3,12-22). Optimal catheter tip at the cavoatrial junction (CAJ) is supported by numerous adult and paediatric studies (1-11,15). The cavoatrial junction (CAJ) is where the right lateral border of the superior vena cava (SVC) meets the superior border of the right atrium (39). A smaller number of studies identify the upper right atrium is also an acceptable catheter tip position (3,14,22-24). The optimal catheter tip position is an observational finding in these retrospective studies which primarily documented incidence rates of CVAD complications.

One study of femorally inserted central catheters (FICCs) stated a catheter tip position in the inferior vena cava between the third and fourth lumbar vertebra on imaging was acceptable (40).

1.2 Practice Recommendation

CNSA recommends the optimal catheter tip position of Central Venous Access Devices for adult and paediatric patients with cancer is at the cavoatrial junction (1-11), and in acceptable position of the lower third of the superior vena cava (3,12-21) and the upper right atrium (3,14,22-24).

GRADE: A/P

1.3 Visual Representation

The lower third of the superior vena cava, cavoatrial junction to the upper right atrium is highlighted in yellow in the diagram:

Figure 1: upper limb PICC tip placement

Figure 2: lower limb PICC tip placement

Illustrations: ©2020 Cincinnati Children's Medical Center, Concept: Neil D Johnson MD, Illustrations: Glenn Miñano http://stopivharm.org/


Chest x-ray:

Figure 3: Chest x-ray with catheter tip at cavoatrial junctio​​​​​​​n

Intracavity ECG

Use of new technology or catheter guidewire or column of sodium chloride connected to a ECG monitor to identify when the p wave is peaked which indicates when the catheter tip is at the cavoatrial junction:

2. TECHNIQUE OF IDENTIFYING THE CATHETER TIP LOCATION

2.1 Summary of Evidence

Location of the catheter tip can be performed during or after the insertion procedure.

During the procedure:

  • Intracavity electrocardiograph (IC-ECG) guidance utilizes the ECG wave form to establish the location of the cavoatrial junction (1,15,25 26)
  • Radiological examination: a number of studies describe using intraprocedure CXR or fluoroscopy (5,7), fluoroscopy (7,9,18,42,43), or fluoroscopy or ECG guidance (3,12). One study used angiographic examination after the injection of contrast media (36).

Post procedure:

  • Studies identified using chest x-ray (CXR) or fluoroscopy (11,16). The majority of studies described the use of CXRs performed after the procedure and prior to CVAD use for the first time (2,6,10,13,20,21,23,27-31,44).

2.2 Practice Recommendation

CNSA recommends the catheter tip position of Central Venous Access Devices for adult and paediatric patients with cancer can be determined by:

  • real-time use of intracavity electrocardiograph guidance during the insertion procedure (1,15,25,26)

  • or radiological examination including:

    • e.g., chest x-ray immediately post procedure and prior to first use (2,6,10,13,20,21,23,27-31) and investigation of complications e.g. malposition, catheter migration, kinking, pinch-off syndrome (32)

    • with arms beside the body (33)

    • avoid fluoroscopy due to patient exposure to ionizing radiation (34)

GRADE: V

3. IMPACT OF CATHETER TIP POSITION

Catheter tips not located at the cavoatrial junction are associated with a higher risk of complications including (1) functional complications (1) including occlusions (11,21,26) which are associated with (2) deep vein thrombosis (22,34,45).

1. Functional complications:

  • Catheter tip in the superior vena cava compared to right atrium had an increased risk of occlusion by 2.7 times in a paediatric, prospective data registry (42)
  • 80.6% of malfunctions were associated with tip malposition in a descriptive, retrospective study (15)
  • Irreversible complete occlusions were 22 times more likely to occur with catheter malposition, that is out of the lower third of the superior vena cava in an observational cohort study (13)
  • Suboptimal catheter tip position was identified to be a statistically significant risk factor for occlusion and premature TIVAD removal in a cohort study of 235 adult participants with TIVADs (21)
  • Higher risk of malfunction with catheter tip malposition in a consensus statement by international vascular access experts (36)
  • High risk profile for development of peripheral and central venous access device occlusions (19)

2. Thrombosis:

  • A significant risk of thrombosis with catheter tip malpositon was noted in a retrospective cohort study of 488 paediatric participants identified (46)
  • A reduced risk of thrombosis and fibrin sleeve formation at the catheter tip when in the correct position was noted in a questionnaire of adult and paediatric oncology centres (22).
  • Catheter tip malposition is a major risk of CVAD related DVTs in expert opinion article (17)

In contrast, 93% patients had no complications when the catheter tip was located in the recommended lower superior vena cava and at the cavoatrial junction in a prospective cohort study in 477 adult participants (30). Low numbers of thrombotic complications were related to accurate positioning of the catheter tip at the cavoatrial junction in a retrospective study of 1247 adults (5).

 

SECTION B: PERIPHERAL INTRAVENOUS CANNULA (PIVC)

4. OPTIMAL SITE

4.1 Summary of Evidence

There are three expert opinion articles that briefly discuss Peripheral Intravenous Cannulas. Therefore practice recommendations in the following section are supported by evidence not specific to patients with cancer therefore literature was sought from outside of cancer care.

4.2 Practice Recommendation

CNSA recommends the optimal peripheral intravenous cannula insertion site to reduce the risk of all complications for adults are the veins in the forearm including the metacarpal, cephalic, basilic, and median veins, and the veins in the hand, forearm, and foot if not walking for paediatrics (35) and:

Adult patients:

  • Avoid areas of flexion (including cubital fossa and wrist), pain, impaired skin, infection (in same limb), lower limbs, and superficial veins on the torso

  • Consider veins on hand for short-term use e.g less than 24 hours

  • Avoid insertion sites distal to recent venepuncture or insertion sites to reduce the risk of extravasation (32)

Paediatric patients:

  • Avoid antecubital fossa (35)

GRADE: Committee Consensus

 

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