Last updated December 18, 2021

Central Venous Catheter Care for the Patient With Cancer

Recommendations

There is insufficient evidence to recommend one type of CVC routinely for all patients with cancer; the choice of catheter should be influenced by the expected duration of use, chemotherapy regimens, and patient ability to provide care; the minimum number of lumens essential for the management of the patient is recommended; these issues should be discussed with the patient.
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There is insufficient evidence to recommend one insertion site or approach (left sided or right sided) for tunneled CVCs for patients with cancer; individual risks and benefits (comfort, security, maintenance of asepsis) of the catheter site should be considered; the Panel recommends that CVC insertion into the femoral vein be avoided because of increased infection risks and concerns about thrombosis, except in certain emergency situations.
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Most CVC placement in patients with cancer is performed as an elective procedure; although image-guided insertion (eg, ultrasound guided, fluoroscopy) of CVCs is recommended, well-trained providers who use the landmark method regularly (eg, for subclavian or internal jugular) may have high rate of success and low incidence of acute and/or chronic complications.
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CVC care clinical bundle (including hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis during catheter insertion, optimal catheter site selection, and assessment of CVC necessity) is recommended for placement and maintenance of all CVCs to prevent infections; there is no evidence that particular dressing types or more frequent IV set and/or dressing changes decrease risk of infection; use of topical antibiotic ointment or cream on insertion sites is not recommended because of potential to promote fungal infections and resistance to antimicrobials; scheduled guidewire exchange of CVC may be associated with greater risk of infection versus catheter replacement at new vascular site; thus, guidewire exchange is not routinely recommended, unless access options are limited.
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Use of antimicrobial/antiseptic-impregnated or -coated CVCs (CH-SS or minocycline/rifampin) and/or heparin-impregnated catheters is recommended to decrease risk of catheter-related infections for short-term CVCs, particularly in high-risk groups such as bone marrow transplantation recipients or patients with leukemia; however, relative benefit and increased cost must be carefully considered before they are routinely used.
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 Prophylactic use of systemic antibiotics (IV or oral) before insertion of long-term CVCs is not recommended.
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There are conflicting data about the relative value of prophylactic heparin with saline flushes to prevent catheter-associated bloodstream infections or thrombosis; data are not sufficient to recommend for or against routine use of antibiotic-flush/antibiotic-lock therapy.
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Cultures of blood from the catheter and when appropriate of soft tissues at entrance-exit sites or tunnel should be obtained before initiation of antibiotic therapy; most exit- or entrance-site infections can be treated successfully with appropriate antimicrobial therapy without the need for catheter removal, although removal is usually needed for clinically apparent tunnel or port-site infections; antimicrobial agents should be optimized once pathogens are identified and antibiotic susceptibilities defined.
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Use of systemic anticoagulation (warfarin, LMWH, UFH) has not been shown to decrease incidence of catheter-associated thrombosis; therefore, routine prophylaxis with anticoagulants is not recommended for patients with cancer with CVCs; routine flushing with saline of the CVC to prevent fibrin buildup is recommended.
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Data are insufficient to recommend routine use of urokinase (not available in the United States) and/or other thrombolytics to prevent catheter occlusion.
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Instillation of 2-mg t-PA is recommended to restore patency and preserve catheter function.
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Although it is appropriate to try to clear thrombosis with the CVC in place, if there is radiologically confirmed thrombosis that does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated, catheter removal is recommended; prolonged retention of unneeded CVCs can lead to significant problems associated with thrombosis and fibrosis; 3 to 6 months of anticoagulant therapy with LMWH or LMWH followed by warfarin (INR, 2.0 to 3.0) is recommended for treatment of symptomatic CVC thrombosis, with duration depending on clinical issues in individual patients.
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Recommendation Grading

Overview

Title

Central Venous Catheter Care for the Patient With Cancer

Authoring Organization

Publication Month/Year

March 4, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Patient Population

Adult and pediatric patients with cancer

Target Provider Population

Medical oncologists/hematologists, nurses, interventional radiologists, surgeons, infectious disease specialists

Inclusion Criteria

Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital

Intended Users

Physician assistant, physician, nurse practitioner, nurse, epidemiology infection prevention

Scope

Prevention, Management

Keywords

cancer, Central Venous Catheter, Catheter-related thrombosis, Catheter-related infection

Source Citation

DOI: 10.1200/JCO.2012.45.5733 Journal of Clinical Oncology 31, no. 10 (April 01, 2013) 1357-1370.