NEW YORK (Reuters Health) – In cancer patients with a central venous catheter (CVC), the occurrence of a related infection or thrombosis can often be resolved while the catheter is left in place, according to a newly published guideline. As the authors point out, removal of a CVC in this setting “can result in prolonged and costly hospitalizations and significant delays in treatment.”
Dr. Charles A. Schiffer, at Wayne State University School of Medicine in Detroit, Michigan, and fellow panelists synthesized the findings of 108 randomized controlled trials, 25 meta-analyses and 6 existing guidelines to compile a guideline on central venous catheter care for patients with cancer, for the American Society of Clinical Oncology.
As reported in the Journal of Clinical Oncology online March 4, the team found that the overall quality of the trials was good, and there was consistency among the meta-analyses and other groups’ guidelines.
Regarding the type of catheter and placement, the authors found insufficient evidence to make a universal recommendation. Rather, they advise, the choice should be based on clinical and patient factors. However, they do recommend avoiding CVC insertion in the femoral artery except in emergency situations.
The guideline opposes the use pre-insertion systemic antibiotics or application of topical antibiotics at insertion sites to prevent catheter-related infections, because of the potential to promote fungal infections and antimicrobial resistance. On the other hand, it endorses the use of antimicrobial-coated and heparin-impregnated catheters.
Certain practices aimed at preventing catheter-related thrombosis in cancer patients are also discouraged, including routine systemic anticoagulation. However, regular flushing with saline to prevent fibrin accumulation is recommended.
If a catheter-related infection does occur, blood from the catheter, as well as tissue from entrance/exit sites if appropriate, should be obtained for culture before beginning antibiotic therapy. “Most clinically apparent exit- or entrance-site infections as well as bloodstream infections can be managed with appropriate microbial therapy, so CVC removal may not be necessary;” the guideline states.
However, “catheter removal should be considered if the infection is caused by an apparent tunnel or port-site infection, fungi, or nontuberculous mycobacteria or if there is persistent bacteremia after 48 to 72 hours of appropriate antimicrobial treatment.”
It is appropriate to try to clear any thrombosis with the CVC in place, the guideline advises, and instillation of t-PA is recommended to restore catheter function. If fibrinolytic therapy is not effective, removal of the catheter is indicated.
The authors of the guideline stress the importance of discussing CVC options, including risks and benefits, with the patient, and they outline several information points. “Effective communication among the oncologist, the individuals placing the venous access device, and most importantly the patient during the treatment planning phase will promote improved patient outcomes,” Dr. Schiffer and colleagues conclude.
SOURCE: Central Venous Catheter Care for the Patient With Cancer: American Society of Clinical Oncology Clinical Practice Guideline
J Clin Oncol 2013;31.
