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Tip Position of Long-Term Central Venous Access Devices Used for Parenteral Nutrition

Robert DeChicco, MS, RD, CNSD^*, Douglas L. Seidner, MD, FACG, CNSP^*,, Carlos Brun, MD, CNSP^*, Ezra Steiger, MD, FACS, CNSP^*,, Judy Stafford, RN^* and Rocio Lopez, MS, MPH

From the ^* Nutrition Support Team and Departments of Gastroenterology and Hepatology, General Surgery, and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio

Correspondence: Robert DeChicco, MS, RD, CNSD, Nutrition Support Team TT22, Cleveland Clinic, Cleveland, OH 44145. Electronic mail may be sent to dechicb{at}ccf.org.

Background: Venous thrombosis is a potential postplacement complication of a central venous access device (VAD). Improper catheter tip position is a predisposing factor, especially when the device is used to administer parenteral nutrition (PN). American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines recommend that a central VAD used for PN be placed with its tip in the superior vena cava (SVC) adjacent to the right atrium (RA). The purpose of this study is to determine the prevalence of improper central VAD tip position and factors associated with malpositioning. Methods: All adult patients with a longterm VAD (ie, tunneled central venous catheter, peripherally inserted central catheter [PICC], or implanted port) placed before the current admission who were scheduled to receive PN also received chest x-rays to evaluate position of the catheter tip. Position was determined by a staff radiologist. A catheter with its tip ranging from the middle third of the SVC to the RA was considered acceptable; a catheter with its tip in any other position was considered malpositioned. Subjects with multiple VADs or multiple evaluations for the same catheter had the first placement and last evaluation considered. A logistic regression analysis was used to study the univariable and multivariable associations of these factors with tip malposition. Results: Data were collected for catheters in 124 patients, including 74 tunneled catheters (71 Hickman, 2 Broviac, 1 Groshong), 38 PICCs, and implanted ports. Most of the catheters were placed for (81.9%) or chemotherapy (14.5%). Median catheter duration was 1.6 months at time of evaluation. Of 138 catheters ied, 15.9% (95% confidence interval, 10.2–23.1) were sitioned at time of evaluation. According to univariable ysis, factors associated with malpositioned catheters included shorter catheter duration (p = .001), greater ber of lumens (p = .029), venous entry site on the arm (p .001) and catheters placed at institutions other than Cleveland Clinic (p = .007). Additionally, PICCs were likely to be malpositioned at time of evaluation compared with other long-term VADs combined (34.2% vs 9.0%; p .001). Conclusions: A high percentage of long-term VADs improperly positioned for PN in the present study. were more likely to be malpositioned at time of evaluation compared with tunneled catheters and implanted These findings suggest the tip position of long-term should be confirmed before infusing PN.

Journal of Parenteral and Enteral Nutrition, Vol. 31, No. 5, 382-387 (2007)
DOI: 10.1177/0148607107031005382


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