There is “major variation” in nearly all aspects of central venous access device (CVAD) management across Australian haematology centres, a survey has found.
Researchers, led by Monash Haematology and Monash University in Melbourne, conducted an anonymous cross-sectional survey of current CVAD practices in haematology and oncology centres in Australia and New Zealand between March and April 2021.
They focused on three CVADs – peripherally-inserted central catheters (PICCs), totally implanted venous devices (TIVDs) and Hickman-type tunnelled, cuffed catheters – asking each participant to indicate their preferred device for a number of different cancer treatment scenarios. The scenarios included autograft, allograft, induction therapy for ALL and AML, single- and multi-day chemotherapy and transfusion support/phlebotomy.
The survey received 40 responses from doctor and nurse members of the Australasian Leukaemia and Lymphoma Group (ALLG), most of whom were working in metropolitan cities (73%) and in the public health system (55%). All Australian states and territories were represented except SA and NT.
Results indicated considerable variability in CVAD selection, insertion, management and removal, “reflecting the need for further research and clinical guidance in this area”, the researchers said [link here].
Notably, few respondents reported use of TIVDs, which were primarily employed for transfusion support/phlebotomy (19%).
Responses for locking CVADs were similar across all three devices.
Normal saline was most frequently reported as a locking solution for PICCs (61%), whereas respondents reported similar use of normal saline and heparin alone for TIVDs or tunnelled catheters (37% and 40% respectively).
This variability in locking solutions highlighted a research gap, the researchers said.
“If normal saline were found to be non-inferior to heparin as a locking solution, avoidance of heparin could obviate associated risks of allergy, bleeding and heparin-induced thrombocytopenia,” the authors wrote in Internal Medicine Journal.
The most commonly reported indications for device removal included positive blood cultures with specific organisms, such as Staphylococci; infection with clinical deterioration despite broad-spectrum antibiotics; blockage of all CVAD lumens and device-related deep vein thrombosis irrespective of line function.
Less than half of respondents reported CVAD salvage in the event of a CAVD-related infection (29%, 42% and 42% for PICCs, TIVDs and tunnelled lines respectively).
Most said they thought line removal was indicated for a complication of deep vein thrombosis despite the CVAD retaining function.
The team pointed out the practice was contrary to recommendations, not specific to haematology, made by the American College of Chest Physicians Guidelines in 2008 based on weak and low-grade evidence.
“The enthusiasm of respondents to remove CVADs in the event of catheter-related thrombosis might reflect the high rate of severe thrombocytopenia among some haemato-oncology patients, which could prohibit adequate anticoagulation,” they commented.
They called for further research and guidance to inform the optimal and safe use of CVADs in haematology.