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Chapter 073. Enteral and Parenteral Nutrition (Part 9)

Complications Mechanical The insertion of a central venous catheter should be performed by trained and experienced personnel using aseptic techniques to limit the major common complications of pneumothorax and inadvertent arterial puncture or injury. Catheter position should be radiographically confirmed to be in the superior vena cava distal to the junction with the jugular or subclavian vein and not directly against the vessel wall. Thrombosis related to the catheter may occur at the site of entry into the vein and extend to encase the catheter. Catheter infection predisposes to thrombosis, as does the systemic inflammatory response. . | Chapter 073. Enteral and Parenteral Nutrition Part 9 Complications Mechanical The insertion of a central venous catheter should be performed by trained and experienced personnel using aseptic techniques to limit the major common complications of pneumothorax and inadvertent arterial puncture or injury. Catheter position should be radiographically confirmed to be in the superior vena cava distal to the junction with the jugular or subclavian vein and not directly against the vessel wall. Thrombosis related to the catheter may occur at the site of entry into the vein and extend to encase the catheter. Catheter infection predisposes to thrombosis as does the systemic inflammatory response. The addition of 6000 U of heparin in the daily parenteral formula in hospitalized patients with temporary catheters reduces the risk of fibrin sheath formation and catheter infection. Temporary catheters that develop a thrombus should be removed and based on clinical findings treated with anticoagulants. Thrombolytic therapy can be considered for patients with permanent catheters depending on the ease of replacement and presence of alternate reasonably acceptable venous access sites. Low-dose warfarin therapy of 1 mg d reduces the risk of thrombosis in permanent catheters used for home PN but full anticoagulation may be required in patients who have recurrent thrombosis related to permanent catheters. A recent U.S. Food and Drug Administration mandate to reformulate parenteral multivitamins to include vitamin K at a dose of 150 iig daily may affect the efficacy of low-dose warfarin therapy. There is a no vitamin K version available for patients receiving this therapy. Catheters can become mechanically occluded and may also become occluded by fibrin at the tip or by fat minerals or drugs intraluminally. These occlusions can be managed with low-dose alteplase for fibrin with indwelling 70 alcohol for fat with 0.1 N hydrochloric acid for mineral precipitates and with either 0.1 N .