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Hickman-Broviac catheters
Hickman-Broviac Catheters Indications and Results
James H. Thomas, MD, Kansas City, Kansas Richard I. MacArthur, MD, Kansas City, Kansas George E. Pierce, MD, Kansas City, Kansas Arlo S. Hermreck, MD, PhD, Kansas City, Kansas
Circulatory access for long-term intravenous therapy is increasingly important in the management of patients with chronic debilitating diseases. Indwelling peripheral catheters with patency maintained by periodic heparinization have been used for venous access but are cumbersome, limited in application and difficult to maintain for extended periods. Arteriovenous fistulas, successful in patients with chronic renal failure, have a high failure rate when used for vascular access in patients without renal disease. In 1973, Broviac developed a silicone rubber catheter for prolonged venous cannulation, and in 1975 Hickman modified the Broviac catheter by increasing its internal diameter, thus expanding its clinical use. The most extensive experience with these catheters is that reported by Broviac and Hickman. The application of Hickman and Broviac catheters in the management of patients with a variety of clinical problems is presented herein. Material
and Methods
The University of Kansas Medical Center records of 84 patients with Hickman or Broviac catheters or both were evaluated to determine (1) the indications for insertion, (2) surgical techniques, (3) catheter longevity, and (4) complications. Catheter-related sepsis was defined by the presence of positive cultures, the absence of other sources From the Department of Surgery, Section of General Surgery, University of Kansas College ofHealth Sciences and Hospital, Kansas City, Kansas. Requests for reprints should be addressed to James H. Thomas, MD. Department of Surgery, Section of General Surgery, University of Kansas College of Health Sciences and Hospital, 39th and Rainbow Boulevard, Kansas City, Kansas 66103. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs. Colorado, May 5-8, 1980.
Volume 140, December 1960
of sepsis and the resolutionof septic episodesafter catheter removal. Means and standard errors were calculated for the duration of catheterization, and differences between the means were analyzed using Student’s t test. Results
From January 1977 through December 1979,98 Hickman-Broviac catheters were inserted in 84 patients. Forty-six of the patients were male and 38 female. The patients’ ages ranged from 11 months to 81 years (mean 40.1 years). Seven patients were less than 6 years of age. Indications: Hickman-Broviac catheters were used only for patients requiring vascular access for greater than 1 month. The catheters were inserted in 20 patients (‘23 percent) for chemotherapy alone and in 18 patients (‘21percent) for combined parenteral nutrition and chemotherapy. Twenty-four patients (28 percent) received Hickman-Broviac catheters for parenteral nutrition alone. Other indications included long-term antibiotic therapy in 13 patients (15 percent), bone marrow transplantation in 4 patients (5 percent) and miscellaneous reasons in 5 patients (6 percent). The diagnoses in the 84 patients were as follows: abdominal wall defect, 1; aplastic anemia, 3; bronchogenic carcinoma, 10; Candida infection, 2; cervical or uterine carcinoma, 2; chronic renal failure, 3; Crohn’s disease, 3; cryptococcal meningitis, 1; discitis, 1; encephalopathy, 2; endocarditis, 4; esophageal perforation, 1; gastrointestinal carcinoma, 1; hepatoblastoma, 1; jejunocolic bypass, 15; leukemia, 10; lymphoma, 11; Munchausen syndrome, 1; osteomyelitis of the foot and clavicle, 3; pancreatitis, 791
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2; retinoblastoma, 1; sarcoma of the extremity, chest wall or retroperitoneum, 3; septic arthritis, 1; short bowel syndrome, 5; sickle cell disease, 1; small bowel fistula, 2; sporotrichosis, 1; squamous cell cancer of the head and neck, 3; and testicular carcinoma, 4. Forty-seven of the 84 patients (56 percent) were catheterized for the management of malignancies, the most common of which were bronchogenic carcinoma, leukemia and lymphoma. The majority of the patients with catheters placed for parenteral nutrition alone had gastrointestinal disorders. Three patients received parenteral nutrition for chronic renal failure. Long-term antibiotic therapy in 13 patients involved the administration of amphotericin-B, penicillin G, vancomycin and cephalothin. Antibiotics were given to four patients for endocarditis, to four patients for fungal infections and to five patients for osteomyelitis or septic arthritis. Techniques: All catheters were inserted according to the surgical techniques suggested by Heimbach and Ivey [I] and Riella and Scribner [2]. Both Hickman and Broviac catheters were inserted through any vein of the arm and neck that terminated in the superior vena cava. The axillary vein, tributaries of the axillary vein or external jugular vein were used. The internal jugular vein was not directly cannulated, although Heimbach and Ivey [I] reported its use without significant complications. Small branches of the axillary vein were readily cannulated after dilatation. Cautious advancement of the catheter allowed it to “float” into proper position. For placement of the catheter into the subcutaneous position, long biopsy forceps or the trocar from a large Hemovac apparatus was used. The Dacron@ felt cuff was positioned within the subcutaneous tunnel in an intercostal space, a minimum of 3 cm from the exit site of the catheter. The length of TABLE I
792
catheter necessary to reach the superior vena cavaright atria1 junction was estimated by placing the catheter on the anterior chest wall and noting the position of the second right intercostal space. The majority of the catheters, 74 (75 percent), were inserted under local anesthesia. General anesthesia was used in 24 procedures (25 percent). Ten of these 24 operations were performed in patients less than 16 years of age. Seventy-one catheters (73 percent) were placed on the patient’s right side and 27 (27 percent) on the left. The surgeon used a cephalic vein in 73 procedures (74 percent). Direct cannulation of the axillary vein, unnamed tributaries of the axillary vein or the external jugular vein was required in 25 instances (26 percent). The position of the catheter in the superior vena cava was confirmed either by fluoroscopy or by intraoperative chest roentgenogram obtained during instillation of radiopaque medium. Multiple attempts to obtain correct positioning of the catheters were required in only eight operations. Prophylatic antibiotics, principally cephalosporins, were administered for 2 to 3 days after catheter placement. All catheters were intermittently heparinized. Exit sites were dressed every 2 days as described by Ivey et al [3] and Riella and Scribner [2]. Catheter longevity: The longest duration of catheterization was 365 days. The average duration was 65 f 7 days. The total number of days of catheterization was 6,308. Sixty-seven patients (79 percent) had uninterrupted use of the Hickman-Broviac catheters until no longer required. Thirty-three patients (39 percent) died with the catheter in place with no related complications. Multiple insertions were necessary in 11 patients (13 percent). Ten patients had two catheters inserted and 1 had five catheters inserted. Table I lists the reasons for mul-
Multiple Insertions
Patient No.
Diagnosis
16 20 22 23 24 27
Gastric carcinoma Crohn’s disease Short bowel syndrome Leukemia Leukemia Sickle Cell anemia
32 34 39 40 75
Leukemia Lymphoma Discitis Crohn’s disease Short bowel syndrome
Reason for Failure of Catheter
No. of Catheters Inserted
Catheter sepsis Dislodgment Rule out catheter sepsis Thrombosis Thrombosis Thrombosis (2). dislodgmeqt (i), catheter sepsis (2) Dislodgment Catheter sepsis Thrombosis Rule out catheter sepsis Rule out catheter sepsis
2 2 2 2 2 5
2 2 2 2 2
The American Journal of Surgery
Hickman-Broviac
tiple catheterizations. No additional technical difficulty was encountered during replacement of these catheters. In all cases the contralateral axillary vein was cannulated through the usual access vessels. The average duration of catheterization was 62.4 f 11 days in patients with benign disease and 68.7 f 4 days in those with malignant disease. The average duration of catheterization was 38.9 f 9.2 days in the 13 patients receiving antibiotics, compared with 73.3 f 13.3 days in the 20 patients receiving chemotherapy, 73.3 f 19.6 days in the 24 patients receiving parenteral nutrition and 69.6 f 17.7 days in the 18 patients receiving both parenteral .nutrition and chemotherapy. There was no significant difference in the mean duration of catheterization in any two groups. Complications: Twenty-two catheter-related complications occurred in 17 patients (Table II). Multiple complications occurred in two patients. The complications included thrombotic catheter occlusion, catheter sepsis, exit site infection, dislodgment and axillary vein thrombosis. One catheter-related
TABLE II
Patient No. 14 16 18 20 23 24 25 27 27 27 27 27 32 32 34 39 42 48 54 57 62 76
Catheters
complication occurred in the 13 patients receiving antibiotics, compared with eight complications in the 20 patients receiving chemotherapy, four in the 24 patients receiving parenteral nutrition and 4 in the 18 patients receiving both parenteral nutrition and chemotherapy. The number of complications was significantly less in the patients receiving antibiotics than in any of the other groups (p <0.02). The average duration of catheterization in patients with complications was 84.8 f 17 days. Thrombotic occlusion of the catheters occurred eight times in seven patients. Only one of these patients had benign disease. The average duration of catheterization before thrombosis was 77.8 f 23 days. No thrombosis occurred within the first 2 weeks after catheter placement. The catheter was reinserted in all seven patients and only one had recurrent thrombosis. Eight episodes of catheter-related sepsis and one exit site infection occurred in eight patients. The clinical status of these eight patients is summarized in Table III. Four patients had benign disease and four had malignancy. Three of these eight
Catheter-Related Complications Indications for Insertion of Catheter Chemotherapy and parenteral nutrition Chemotherapy and parenteral nutrition Chemotherapy Parenteral nutrition Chemotherapy Chemotherapy Chemotherapy Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Chemotherapy Chemotherapy Chemotherapy Antibiotic therapy Parenteral nutrition Chemotherapy and parenteral nutrition Chemotherapy and parenteral nutrition Parenteral nutrition Chemotherapy Parenteral nutrition
Volume 140, December 1980
Diagnosis
Duration of Catheterization (days)
Bronchogenic carcinoma
63
Gastric carcinoma
52
Testicular cancer Crohn’s disease Leukemia Leukemia Lymphoma Sickle cell anemia
215 5 38 32 150 198
Sickle cell anemia
28
Sickle cell anemia
2
Sickle cell anemia
25
Sickle cell anemia
22
Leukemia Leukemia Lymphoma Discitis Small bowel fistula Cervical carcinoma
100 227 20 16 14 90
Dislodgment Sepsis Exit site infection Thrombosis Sepsis Axillary vein thrombosis
Leukemia
100
Thrombosis
Short bowel syndrome Hepatoblastoma Munchausen syndrome
104 64 300
Sepsis Sepsis Sepsis
Complication Thrombosis
Axillary vein thrombosis Dislodgment Thrombosis Thrombosis Thrombosis Thrombosis Sepsis Dislodgment
Sepsis
793
Thomas et al TABLE III
Patient No. 16 27 27 32 34 36 42 57 62
Catheter-Related
Sepsis
Diagnosis
Duration of Catheterization (days)
Organism
Source
Gastric carcinoma Sickle cell anemia Sickle cell anemia Leukemia Lymphoma Munchausen syndrome Small bowel fistula Short bowel syndrome Hepatoblastoma
52 28 22 227 20 300 14 104 64
Staphylococcus aureus Enterococcus Staphylococcus epidermidis Staphylococcus epidermidis Pseudomonas aeruginosa Candida albicans Enterococcus Staphylococcus epidermidis Staphylococcus epidermidis
Exogenous Endogenous (pulmonary) Exogenous Exogenous Endogenous (pulmonary) Exogenous Endogenous (wound) Exogenous Exogenous
patients were receiving chemotherapy alone. Three were receiving parenteral nutrition only and one a combination of parenteral nutrition and chemotherapy. One patient’s catheter was used solely for the administration of analgesic agents. Three patients apparently developed catheter sepsis from an endogenous source. The infecting organisms were found in the wound or the sputum in these three patients. The average duration of catheterization was 92.3 f 3.4 days in the eight patients developing catheter-related sepsis, compared with 62.9 f 7.2 days in the 76 patients without sepsis (difference not significant). No patient receiving antibiotic therapy through a catheter for treatment of a known infection developed catheter-related sepsis. All infected catheters were removed and appropriate antibiotics administered. Catheters were reinserted in three patients within 7 to 10 days, but only one of them developed recurrent catheter-related sepsis. No patient died as a result of catheterrelated infection. Three dislodgments occurred without serious complications. Axillary vein thrombosis occurred in two patients, but in neither was the catheter removed. One patient underwent anticoagulation with heparin. Both thromboses resolved without complication. No extravasation or air emboli occurred. Comments The introduction by Broviac of a specially constructed Silastic@ catheter with a Dacron@ cuff for chronic cannulation of the venous system has contributed to the management of patients whose peripheral veins have been thrombosed or obliterated during the course of prolonged illness. The Hickman catheter, which has a larger diameter than the Broviac catheter (1.6 versus 1.0 mm internal diameter), provides a route that can be used for venous sampling in addition to the administration of blood products,
794
parenteral nutrients and intravenous medication. Information on the function of Hickman-Broviac catheters is available only in patients in whom these catheters were inserted for parenteral nutrition [I--71 or bone marrow transplantation [8]. In this study Hickman-Broviac catheters were inserted in 38 patients (45 percent) for reasons other than parenteral nutrition or bone marrow transplantation. The most frequent indications in these 38 patients were antibiotic therapy and chemotherapy. The absence of septic complications in the 13 patients receiving antibiotic therapy suggests that with the appropriate selection and dosage of antibiotics for treatment of specific organisms, HickmanBroviac catheters carry minimal increased risk for endogenous catheter-related sepsis. Riella [9] suggested use of the Hickman-Broviac catheter for administering chemotherapy. Nineteen patients in this series had 20 catheters inserted solely for this purpose. There were only two episodes (10 percent) of catheter-related sepsis in this group, which is comparable to the 3 to 10 percent infection rate reported by Ivey et al [3] in oncologic patients with compromised immune responses. The techniques for the insertion of HickmanBroviac catheters are well standardized. Any patient with a history suggestive of axillary vein thrombosis should undergo venography to determine the patency of arm veins before attempted insertion of a Hickman-Broviac catheter. Although cephalic veins were the first choice for access to the,superior vena cava, the use of alternate routes was required in 25 percent of the operative procedures in this group of patients. Placement of the cannulas through the external jugular was uncomplicated and easily accomplished. This route may be preferable to or at least the first alternative to the cephalic vein. The major theoretical disadvantage of using the external jugular vein is its proximity to the skin surface. However, no wound complications occurred at this site.
The American Journal of Surgery
Hickman-Broviac Catheters
General anesthesia for catheter placement is appropriate in many pediatric patients and any patient who has had multiple previous procedures or who, for any reason, has a low pain threshold. In most patients, however, the procedures can be readily performed under local anesthesia. In the present series 17 patients (20 percent) developed 22 catheter-related complications. Riella and Scribner [2] reported catheter-related complications, including obstruction, infection, leakage and malposition, in 38 of 43 patients (88 percent) receiving parenteral nutrition at home. Strobe1 et al [IO] reported 22 catheter-related complications in 15 of 34 patients (44 percent) with Broviac catheters for parenteral nutrition, and Heimbach and Ivey [I] reported catheter-related complications in 30 of 66 catheters (46 percent) in 37 patients receiving parenteral nutrition. In the present series both the percentage of patients with catheter complications (20 percent) and the percentage of affected catheters (22 percent) are better than the rates in the reports just cited. The catheter-related sepsis rate of 816,308 catheter-days is comparable to the rates reported by Broviac et al [4] (2/2,599 catheter-days) and Bryne et al [7] (2/1,139 catheter-days). There was no relation between the incidence or type of complication and the diagnosis, the indication for catheterization or the duration of catheterization. However, the occurrence of seven of the nine septic complications in patients either malnourished or receiving chemotherapy suggests that such patients are at increased risk for the development of catheter-related sepsis. It is difficult to assess the contribution of a patient-based catheter care system to the incidence of catheter-related sepsis. Thus it is important that all patients with Hickman-Broviac catheters be carefully trained in the care and management of these catheters. The application of Hickman-Broviac catheters to a variety of clinical problems is an extension of the initial suggestion by Broviac that these catheters serve as a basis for the artificial gut system. The experience reported herein suggests that both catheters may be used effectively in patients requiring the administration of sclerotic medications such as chemotherapeutic agents and certain antibiotics. Summary The records of 84 patients in whom 98 HickmanBroviac catheters were inserted were reviewed. The most common indication for catheter insertion was for administration of parenteral nutrition. Forty-four patients (52 percent) had catheters inserted for
Volume 140, Deoember 1980
chemotherapy or combined chemotherapy and parenteral nutrition. Thirteen patients had HickmanBroviac catheters inserted for the administration of antibiotics. The majority of the patients (56 percent) had malignant disease. The insertion of Hickman-Broviac catheters was uncomplicated, especially through the external jugular vein. Catheter-related complications occurred in 20 percent of the patients, but none were fatal. The most common complications were thrombotic catheter occlusion and catheter-related sepsis. The catheter-related sepsis rate was 816,308 catheterdays. These rates compare favorably with those reported by other investigators. Any patient with potential vascular access difficulty or obliterated or thrombosed veins who requires parenteral medication should be considered a candidate for insertion of a Hickman or Broviac catheter. References 1. HeimbachDM, lveyTD. Techniquefor placement of a permanent home hyperalimentation catheter. Surg Gynecol Obstet 1976;143:635. 2. Riella MC, Scribner BH. Five years’ experience with a right atrial catheter for prolonged parenteral nutrition at home. Surg Gynecol Obstet 1976;143:205. 3. lvey MF. Adam SM, Hickman RO, Gibson DL. Right atrial indwelling catheter for patient requiring long-term intravenous therapy. Am J Hosp Pharm 1976;35: 1525. 4. Broviac JW. Cole BS, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;136:602. 5. Broviac JW, Scribner BH. Prolonged parenteral nutrition in the home. Surg Gynecol Obstet 1974;139:24. 6. Shils ME. A program for total parenteral nutrition at home. Am J Clin Nutr 1975;28:1429. 7. Byrne WJ, Halpin TC, Asch MJ, Fonkalsrud EW, Ament ME. Home total parenteral nutrition: an alternative approach to the management of children with severe chronic small bowel disease. J Pediatr Surg 1977;12:359. 8. Hickman RO, Buckner CD, Clift RA, Sander JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871. 9. Riella MC. Atrial catheter for prolonged chemotherapy. Lancet 1977;8012:658. 10. Strobe1 CT, Byrne WJ, Fonkalsrud EW, Ament ME. Home parenteral nutrition: results in 34 pediatric patients. Ann Surg 1978:188:394.
Discussion Kent C. Westbrook (Little Rock, AR): Recently, more patients are needing chronic vascular access for parenteral nutrition, chemotherapy or long-term blood or antibiotic administration. There are two basic approaches to this problem. One technique utilizes internal arteriovenous fistulas and the second uses external catheters. Two years ago at this meeting, Dr. Buckley reported the construction of internal fistulas from the axillary artery to the axillary or internal jugular vein, primarily for chronic
795
Thomas et al
chemotherapy. Since then, Dr. Raff has reported from M.D. Anderson on construction of chronic fistulas in the arm or groin for chronic vascular access for chemotherapy. I would like for Dr. Thomas to compare the technique of an external catheter to that of an internal fistula with regard to the difficulty of construction, the longevity of function and patient acceptance. Charles W. Van Way, III (Denver, CO): What do you tell patients who use these catheters at home? How do they care for them? What is your heparin regimen? What is the regimen for dressing the exit site? Do you have any problems removing them? Do you have any problem getting the Teflon@ cuff out from under the skin incision? James A. Carson (Oklahoma City, OK): When you have patients who are simultaneously receiving total parenteral alimentation along with either antibiotics or antineoplastic drugs, do you infuse them simultaneously through Y connectors, or interrupt the infusion of one to infuse the other, or push the drugs? James H. Thomas (closing): With reference to the use of other methods of vascular access in patients who require
796
chemotherapy or antibiotics, we have not used those particular methods. The one probelm that I recognize when using an internal fistula, such as the classic radial artery to cephalic vein fistula, is that it takes approximately 6 weeks for this fistula to develop to the point where it can be readily used. In general, the catheter is dressed daily and, depending on how often it’s used, it is heparinized. There is a cap that can be applied to the end of the catheter. The catheter can be placed very easily under a small dressing or can even be carried in a woman’s brassiere. The catheters are easily removed, usually on an outpatient basis. Occasionally I have had to use a local anesthetic. The attachment of the cuff tends to vary, so that sometimes it slides out very nicely and other times I have had to make an incision over the cuff to remove the catheter. Most of our patients on home parenteral nutrition receive 3,000 ml within a short period, most often about 10 hours, so that this does not present a problem. You must check with the pharmacy, however, if you are going to give two different drugs, to make sure they are compatible with hyperalimentation solution to avoid difficulty with any sediment being administered into the central venous system.
The American Journal of Surgery
James H. Thomas, MD, Kansas City, Kansas Richard I. MacArthur, MD, Kansas City, Kansas George E. Pierce, MD, Kansas City, Kansas Arlo S. Hermreck, MD, PhD, Kansas City, Kansas
Circulatory access for long-term intravenous therapy is increasingly important in the management of patients with chronic debilitating diseases. Indwelling peripheral catheters with patency maintained by periodic heparinization have been used for venous access but are cumbersome, limited in application and difficult to maintain for extended periods. Arteriovenous fistulas, successful in patients with chronic renal failure, have a high failure rate when used for vascular access in patients without renal disease. In 1973, Broviac developed a silicone rubber catheter for prolonged venous cannulation, and in 1975 Hickman modified the Broviac catheter by increasing its internal diameter, thus expanding its clinical use. The most extensive experience with these catheters is that reported by Broviac and Hickman. The application of Hickman and Broviac catheters in the management of patients with a variety of clinical problems is presented herein. Material
and Methods
The University of Kansas Medical Center records of 84 patients with Hickman or Broviac catheters or both were evaluated to determine (1) the indications for insertion, (2) surgical techniques, (3) catheter longevity, and (4) complications. Catheter-related sepsis was defined by the presence of positive cultures, the absence of other sources From the Department of Surgery, Section of General Surgery, University of Kansas College ofHealth Sciences and Hospital, Kansas City, Kansas. Requests for reprints should be addressed to James H. Thomas, MD. Department of Surgery, Section of General Surgery, University of Kansas College of Health Sciences and Hospital, 39th and Rainbow Boulevard, Kansas City, Kansas 66103. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs. Colorado, May 5-8, 1980.
Volume 140, December 1960
of sepsis and the resolutionof septic episodesafter catheter removal. Means and standard errors were calculated for the duration of catheterization, and differences between the means were analyzed using Student’s t test. Results
From January 1977 through December 1979,98 Hickman-Broviac catheters were inserted in 84 patients. Forty-six of the patients were male and 38 female. The patients’ ages ranged from 11 months to 81 years (mean 40.1 years). Seven patients were less than 6 years of age. Indications: Hickman-Broviac catheters were used only for patients requiring vascular access for greater than 1 month. The catheters were inserted in 20 patients (‘23 percent) for chemotherapy alone and in 18 patients (‘21percent) for combined parenteral nutrition and chemotherapy. Twenty-four patients (28 percent) received Hickman-Broviac catheters for parenteral nutrition alone. Other indications included long-term antibiotic therapy in 13 patients (15 percent), bone marrow transplantation in 4 patients (5 percent) and miscellaneous reasons in 5 patients (6 percent). The diagnoses in the 84 patients were as follows: abdominal wall defect, 1; aplastic anemia, 3; bronchogenic carcinoma, 10; Candida infection, 2; cervical or uterine carcinoma, 2; chronic renal failure, 3; Crohn’s disease, 3; cryptococcal meningitis, 1; discitis, 1; encephalopathy, 2; endocarditis, 4; esophageal perforation, 1; gastrointestinal carcinoma, 1; hepatoblastoma, 1; jejunocolic bypass, 15; leukemia, 10; lymphoma, 11; Munchausen syndrome, 1; osteomyelitis of the foot and clavicle, 3; pancreatitis, 791
Thomas et al
2; retinoblastoma, 1; sarcoma of the extremity, chest wall or retroperitoneum, 3; septic arthritis, 1; short bowel syndrome, 5; sickle cell disease, 1; small bowel fistula, 2; sporotrichosis, 1; squamous cell cancer of the head and neck, 3; and testicular carcinoma, 4. Forty-seven of the 84 patients (56 percent) were catheterized for the management of malignancies, the most common of which were bronchogenic carcinoma, leukemia and lymphoma. The majority of the patients with catheters placed for parenteral nutrition alone had gastrointestinal disorders. Three patients received parenteral nutrition for chronic renal failure. Long-term antibiotic therapy in 13 patients involved the administration of amphotericin-B, penicillin G, vancomycin and cephalothin. Antibiotics were given to four patients for endocarditis, to four patients for fungal infections and to five patients for osteomyelitis or septic arthritis. Techniques: All catheters were inserted according to the surgical techniques suggested by Heimbach and Ivey [I] and Riella and Scribner [2]. Both Hickman and Broviac catheters were inserted through any vein of the arm and neck that terminated in the superior vena cava. The axillary vein, tributaries of the axillary vein or external jugular vein were used. The internal jugular vein was not directly cannulated, although Heimbach and Ivey [I] reported its use without significant complications. Small branches of the axillary vein were readily cannulated after dilatation. Cautious advancement of the catheter allowed it to “float” into proper position. For placement of the catheter into the subcutaneous position, long biopsy forceps or the trocar from a large Hemovac apparatus was used. The Dacron@ felt cuff was positioned within the subcutaneous tunnel in an intercostal space, a minimum of 3 cm from the exit site of the catheter. The length of TABLE I
792
catheter necessary to reach the superior vena cavaright atria1 junction was estimated by placing the catheter on the anterior chest wall and noting the position of the second right intercostal space. The majority of the catheters, 74 (75 percent), were inserted under local anesthesia. General anesthesia was used in 24 procedures (25 percent). Ten of these 24 operations were performed in patients less than 16 years of age. Seventy-one catheters (73 percent) were placed on the patient’s right side and 27 (27 percent) on the left. The surgeon used a cephalic vein in 73 procedures (74 percent). Direct cannulation of the axillary vein, unnamed tributaries of the axillary vein or the external jugular vein was required in 25 instances (26 percent). The position of the catheter in the superior vena cava was confirmed either by fluoroscopy or by intraoperative chest roentgenogram obtained during instillation of radiopaque medium. Multiple attempts to obtain correct positioning of the catheters were required in only eight operations. Prophylatic antibiotics, principally cephalosporins, were administered for 2 to 3 days after catheter placement. All catheters were intermittently heparinized. Exit sites were dressed every 2 days as described by Ivey et al [3] and Riella and Scribner [2]. Catheter longevity: The longest duration of catheterization was 365 days. The average duration was 65 f 7 days. The total number of days of catheterization was 6,308. Sixty-seven patients (79 percent) had uninterrupted use of the Hickman-Broviac catheters until no longer required. Thirty-three patients (39 percent) died with the catheter in place with no related complications. Multiple insertions were necessary in 11 patients (13 percent). Ten patients had two catheters inserted and 1 had five catheters inserted. Table I lists the reasons for mul-
Multiple Insertions
Patient No.
Diagnosis
16 20 22 23 24 27
Gastric carcinoma Crohn’s disease Short bowel syndrome Leukemia Leukemia Sickle Cell anemia
32 34 39 40 75
Leukemia Lymphoma Discitis Crohn’s disease Short bowel syndrome
Reason for Failure of Catheter
No. of Catheters Inserted
Catheter sepsis Dislodgment Rule out catheter sepsis Thrombosis Thrombosis Thrombosis (2). dislodgmeqt (i), catheter sepsis (2) Dislodgment Catheter sepsis Thrombosis Rule out catheter sepsis Rule out catheter sepsis
2 2 2 2 2 5
2 2 2 2 2
The American Journal of Surgery
Hickman-Broviac
tiple catheterizations. No additional technical difficulty was encountered during replacement of these catheters. In all cases the contralateral axillary vein was cannulated through the usual access vessels. The average duration of catheterization was 62.4 f 11 days in patients with benign disease and 68.7 f 4 days in those with malignant disease. The average duration of catheterization was 38.9 f 9.2 days in the 13 patients receiving antibiotics, compared with 73.3 f 13.3 days in the 20 patients receiving chemotherapy, 73.3 f 19.6 days in the 24 patients receiving parenteral nutrition and 69.6 f 17.7 days in the 18 patients receiving both parenteral .nutrition and chemotherapy. There was no significant difference in the mean duration of catheterization in any two groups. Complications: Twenty-two catheter-related complications occurred in 17 patients (Table II). Multiple complications occurred in two patients. The complications included thrombotic catheter occlusion, catheter sepsis, exit site infection, dislodgment and axillary vein thrombosis. One catheter-related
TABLE II
Patient No. 14 16 18 20 23 24 25 27 27 27 27 27 32 32 34 39 42 48 54 57 62 76
Catheters
complication occurred in the 13 patients receiving antibiotics, compared with eight complications in the 20 patients receiving chemotherapy, four in the 24 patients receiving parenteral nutrition and 4 in the 18 patients receiving both parenteral nutrition and chemotherapy. The number of complications was significantly less in the patients receiving antibiotics than in any of the other groups (p <0.02). The average duration of catheterization in patients with complications was 84.8 f 17 days. Thrombotic occlusion of the catheters occurred eight times in seven patients. Only one of these patients had benign disease. The average duration of catheterization before thrombosis was 77.8 f 23 days. No thrombosis occurred within the first 2 weeks after catheter placement. The catheter was reinserted in all seven patients and only one had recurrent thrombosis. Eight episodes of catheter-related sepsis and one exit site infection occurred in eight patients. The clinical status of these eight patients is summarized in Table III. Four patients had benign disease and four had malignancy. Three of these eight
Catheter-Related Complications Indications for Insertion of Catheter Chemotherapy and parenteral nutrition Chemotherapy and parenteral nutrition Chemotherapy Parenteral nutrition Chemotherapy Chemotherapy Chemotherapy Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Administration of analgesic medication Chemotherapy Chemotherapy Chemotherapy Antibiotic therapy Parenteral nutrition Chemotherapy and parenteral nutrition Chemotherapy and parenteral nutrition Parenteral nutrition Chemotherapy Parenteral nutrition
Volume 140, December 1980
Diagnosis
Duration of Catheterization (days)
Bronchogenic carcinoma
63
Gastric carcinoma
52
Testicular cancer Crohn’s disease Leukemia Leukemia Lymphoma Sickle cell anemia
215 5 38 32 150 198
Sickle cell anemia
28
Sickle cell anemia
2
Sickle cell anemia
25
Sickle cell anemia
22
Leukemia Leukemia Lymphoma Discitis Small bowel fistula Cervical carcinoma
100 227 20 16 14 90
Dislodgment Sepsis Exit site infection Thrombosis Sepsis Axillary vein thrombosis
Leukemia
100
Thrombosis
Short bowel syndrome Hepatoblastoma Munchausen syndrome
104 64 300
Sepsis Sepsis Sepsis
Complication Thrombosis
Axillary vein thrombosis Dislodgment Thrombosis Thrombosis Thrombosis Thrombosis Sepsis Dislodgment
Sepsis
793
Thomas et al TABLE III
Patient No. 16 27 27 32 34 36 42 57 62
Catheter-Related
Sepsis
Diagnosis
Duration of Catheterization (days)
Organism
Source
Gastric carcinoma Sickle cell anemia Sickle cell anemia Leukemia Lymphoma Munchausen syndrome Small bowel fistula Short bowel syndrome Hepatoblastoma
52 28 22 227 20 300 14 104 64
Staphylococcus aureus Enterococcus Staphylococcus epidermidis Staphylococcus epidermidis Pseudomonas aeruginosa Candida albicans Enterococcus Staphylococcus epidermidis Staphylococcus epidermidis
Exogenous Endogenous (pulmonary) Exogenous Exogenous Endogenous (pulmonary) Exogenous Endogenous (wound) Exogenous Exogenous
patients were receiving chemotherapy alone. Three were receiving parenteral nutrition only and one a combination of parenteral nutrition and chemotherapy. One patient’s catheter was used solely for the administration of analgesic agents. Three patients apparently developed catheter sepsis from an endogenous source. The infecting organisms were found in the wound or the sputum in these three patients. The average duration of catheterization was 92.3 f 3.4 days in the eight patients developing catheter-related sepsis, compared with 62.9 f 7.2 days in the 76 patients without sepsis (difference not significant). No patient receiving antibiotic therapy through a catheter for treatment of a known infection developed catheter-related sepsis. All infected catheters were removed and appropriate antibiotics administered. Catheters were reinserted in three patients within 7 to 10 days, but only one of them developed recurrent catheter-related sepsis. No patient died as a result of catheterrelated infection. Three dislodgments occurred without serious complications. Axillary vein thrombosis occurred in two patients, but in neither was the catheter removed. One patient underwent anticoagulation with heparin. Both thromboses resolved without complication. No extravasation or air emboli occurred. Comments The introduction by Broviac of a specially constructed Silastic@ catheter with a Dacron@ cuff for chronic cannulation of the venous system has contributed to the management of patients whose peripheral veins have been thrombosed or obliterated during the course of prolonged illness. The Hickman catheter, which has a larger diameter than the Broviac catheter (1.6 versus 1.0 mm internal diameter), provides a route that can be used for venous sampling in addition to the administration of blood products,
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parenteral nutrients and intravenous medication. Information on the function of Hickman-Broviac catheters is available only in patients in whom these catheters were inserted for parenteral nutrition [I--71 or bone marrow transplantation [8]. In this study Hickman-Broviac catheters were inserted in 38 patients (45 percent) for reasons other than parenteral nutrition or bone marrow transplantation. The most frequent indications in these 38 patients were antibiotic therapy and chemotherapy. The absence of septic complications in the 13 patients receiving antibiotic therapy suggests that with the appropriate selection and dosage of antibiotics for treatment of specific organisms, HickmanBroviac catheters carry minimal increased risk for endogenous catheter-related sepsis. Riella [9] suggested use of the Hickman-Broviac catheter for administering chemotherapy. Nineteen patients in this series had 20 catheters inserted solely for this purpose. There were only two episodes (10 percent) of catheter-related sepsis in this group, which is comparable to the 3 to 10 percent infection rate reported by Ivey et al [3] in oncologic patients with compromised immune responses. The techniques for the insertion of HickmanBroviac catheters are well standardized. Any patient with a history suggestive of axillary vein thrombosis should undergo venography to determine the patency of arm veins before attempted insertion of a Hickman-Broviac catheter. Although cephalic veins were the first choice for access to the,superior vena cava, the use of alternate routes was required in 25 percent of the operative procedures in this group of patients. Placement of the cannulas through the external jugular was uncomplicated and easily accomplished. This route may be preferable to or at least the first alternative to the cephalic vein. The major theoretical disadvantage of using the external jugular vein is its proximity to the skin surface. However, no wound complications occurred at this site.
The American Journal of Surgery
Hickman-Broviac Catheters
General anesthesia for catheter placement is appropriate in many pediatric patients and any patient who has had multiple previous procedures or who, for any reason, has a low pain threshold. In most patients, however, the procedures can be readily performed under local anesthesia. In the present series 17 patients (20 percent) developed 22 catheter-related complications. Riella and Scribner [2] reported catheter-related complications, including obstruction, infection, leakage and malposition, in 38 of 43 patients (88 percent) receiving parenteral nutrition at home. Strobe1 et al [IO] reported 22 catheter-related complications in 15 of 34 patients (44 percent) with Broviac catheters for parenteral nutrition, and Heimbach and Ivey [I] reported catheter-related complications in 30 of 66 catheters (46 percent) in 37 patients receiving parenteral nutrition. In the present series both the percentage of patients with catheter complications (20 percent) and the percentage of affected catheters (22 percent) are better than the rates in the reports just cited. The catheter-related sepsis rate of 816,308 catheter-days is comparable to the rates reported by Broviac et al [4] (2/2,599 catheter-days) and Bryne et al [7] (2/1,139 catheter-days). There was no relation between the incidence or type of complication and the diagnosis, the indication for catheterization or the duration of catheterization. However, the occurrence of seven of the nine septic complications in patients either malnourished or receiving chemotherapy suggests that such patients are at increased risk for the development of catheter-related sepsis. It is difficult to assess the contribution of a patient-based catheter care system to the incidence of catheter-related sepsis. Thus it is important that all patients with Hickman-Broviac catheters be carefully trained in the care and management of these catheters. The application of Hickman-Broviac catheters to a variety of clinical problems is an extension of the initial suggestion by Broviac that these catheters serve as a basis for the artificial gut system. The experience reported herein suggests that both catheters may be used effectively in patients requiring the administration of sclerotic medications such as chemotherapeutic agents and certain antibiotics. Summary The records of 84 patients in whom 98 HickmanBroviac catheters were inserted were reviewed. The most common indication for catheter insertion was for administration of parenteral nutrition. Forty-four patients (52 percent) had catheters inserted for
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chemotherapy or combined chemotherapy and parenteral nutrition. Thirteen patients had HickmanBroviac catheters inserted for the administration of antibiotics. The majority of the patients (56 percent) had malignant disease. The insertion of Hickman-Broviac catheters was uncomplicated, especially through the external jugular vein. Catheter-related complications occurred in 20 percent of the patients, but none were fatal. The most common complications were thrombotic catheter occlusion and catheter-related sepsis. The catheter-related sepsis rate was 816,308 catheterdays. These rates compare favorably with those reported by other investigators. Any patient with potential vascular access difficulty or obliterated or thrombosed veins who requires parenteral medication should be considered a candidate for insertion of a Hickman or Broviac catheter. References 1. HeimbachDM, lveyTD. Techniquefor placement of a permanent home hyperalimentation catheter. Surg Gynecol Obstet 1976;143:635. 2. Riella MC, Scribner BH. Five years’ experience with a right atrial catheter for prolonged parenteral nutrition at home. Surg Gynecol Obstet 1976;143:205. 3. lvey MF. Adam SM, Hickman RO, Gibson DL. Right atrial indwelling catheter for patient requiring long-term intravenous therapy. Am J Hosp Pharm 1976;35: 1525. 4. Broviac JW. Cole BS, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;136:602. 5. Broviac JW, Scribner BH. Prolonged parenteral nutrition in the home. Surg Gynecol Obstet 1974;139:24. 6. Shils ME. A program for total parenteral nutrition at home. Am J Clin Nutr 1975;28:1429. 7. Byrne WJ, Halpin TC, Asch MJ, Fonkalsrud EW, Ament ME. Home total parenteral nutrition: an alternative approach to the management of children with severe chronic small bowel disease. J Pediatr Surg 1977;12:359. 8. Hickman RO, Buckner CD, Clift RA, Sander JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871. 9. Riella MC. Atrial catheter for prolonged chemotherapy. Lancet 1977;8012:658. 10. Strobe1 CT, Byrne WJ, Fonkalsrud EW, Ament ME. Home parenteral nutrition: results in 34 pediatric patients. Ann Surg 1978:188:394.
Discussion Kent C. Westbrook (Little Rock, AR): Recently, more patients are needing chronic vascular access for parenteral nutrition, chemotherapy or long-term blood or antibiotic administration. There are two basic approaches to this problem. One technique utilizes internal arteriovenous fistulas and the second uses external catheters. Two years ago at this meeting, Dr. Buckley reported the construction of internal fistulas from the axillary artery to the axillary or internal jugular vein, primarily for chronic
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chemotherapy. Since then, Dr. Raff has reported from M.D. Anderson on construction of chronic fistulas in the arm or groin for chronic vascular access for chemotherapy. I would like for Dr. Thomas to compare the technique of an external catheter to that of an internal fistula with regard to the difficulty of construction, the longevity of function and patient acceptance. Charles W. Van Way, III (Denver, CO): What do you tell patients who use these catheters at home? How do they care for them? What is your heparin regimen? What is the regimen for dressing the exit site? Do you have any problems removing them? Do you have any problem getting the Teflon@ cuff out from under the skin incision? James A. Carson (Oklahoma City, OK): When you have patients who are simultaneously receiving total parenteral alimentation along with either antibiotics or antineoplastic drugs, do you infuse them simultaneously through Y connectors, or interrupt the infusion of one to infuse the other, or push the drugs? James H. Thomas (closing): With reference to the use of other methods of vascular access in patients who require
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chemotherapy or antibiotics, we have not used those particular methods. The one probelm that I recognize when using an internal fistula, such as the classic radial artery to cephalic vein fistula, is that it takes approximately 6 weeks for this fistula to develop to the point where it can be readily used. In general, the catheter is dressed daily and, depending on how often it’s used, it is heparinized. There is a cap that can be applied to the end of the catheter. The catheter can be placed very easily under a small dressing or can even be carried in a woman’s brassiere. The catheters are easily removed, usually on an outpatient basis. Occasionally I have had to use a local anesthetic. The attachment of the cuff tends to vary, so that sometimes it slides out very nicely and other times I have had to make an incision over the cuff to remove the catheter. Most of our patients on home parenteral nutrition receive 3,000 ml within a short period, most often about 10 hours, so that this does not present a problem. You must check with the pharmacy, however, if you are going to give two different drugs, to make sure they are compatible with hyperalimentation solution to avoid difficulty with any sediment being administered into the central venous system.
The American Journal of Surgery