Catheter Complications

Complications with central venous catheters most frequently include obstructions, infections, and occasional leakage and perforation. Although PN can be temporarily provided through peripheral intravenous catheters, the high osmolarity of intravenous glucose-electrolyte solutions often causes phlebitis and loss of access. Therefore, long-term access requires placement of a central venous catheter placed via the internal or external jugular vein or a subclavian vein. There is also increased

Table 4 Suggested monitoring schedule for inpatients receiving parenteral nutrition

Parameter

Daily Weeklya

Periodicallya

Weight Fluid balance Vital signs Urine sugar Catheter site/function Laboratory (serum) Sodium Potassium Chloride Bicarbonate Glucose Urea nitrogen Creatinine Triglycerides Calcium Magnesium Phosphorus Albumin and/or prealbumin Transaminases Bilirubin Selenium Copper Zinc Iron aOr more often as necessitated by clinical course.

Adapted from Hendricks KM, Duggan C, and Walker WA (eds.)

(2000) Manual of Pediatric Nutrition, 3rd edn., London: BC Decker.

placement of peripherally inserted catheters by a team of specially trained staff and/or an interven-tional radiologist. Tip position in the superior vena cava or right atrial junction should be verified radiographically to reduce complications from venous thrombosis or rare perforations. Central placement allows rapid dilution of hypertonic solutions in a large-diameter vein to minimize obstruction or thrombosis. Catheters for central venous access have been made of polyvinyl chloride, polyurethane, and silastic, often with a Teflon cuff to anchor the catheter subcutaneously. However, formation of a fibrin sheath is still common, often with a biofilm that may harbor infectious organisms and prevent penetration of antibiotics. Central catheter obstructions can often be visualized by ultrasound or inserting radio-opaque dye in the catheter. A thrombus can often be lysed with installation of a small bolus of tissue plasminogen activator. Long-term anticoagulation with couma-din, low-dose coumadin, or low-molecular-weight heparin has been advocated by some to avoid repeated catheter obstruction, venous thrombosis, superior vena cava obstruction, and potential pulmonary emboli.

Obstructions caused by precipitation of calcium phosphate salts or medications may be susceptible to installation of a small amount of dilute acid, and those due to fatty material may be dissolved with dilute ethanol. For long-term home parenteral use, some patients prefer the use of implantable ports, which can be accessed through the skin daily with a special needle. Recently, peripherally inserted central catheters have been used for periods up to 1 month or longer without requiring a surgical procedure.

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