What are the management and treatment options for post-catheterization (post-cath) complications?

Management of Post-Catheterization Complications

Remove the catheter immediately if there is erythema, purulence at the exit site, clinical signs of sepsis, or positive blood cultures, and initiate appropriate systemic antimicrobial therapy based on culture results. 1

Immediate Assessment and Monitoring

Post-catheterization complications require systematic surveillance and rapid intervention when detected:

• Check blood pressure, pulse, distal pulses, and access site status every 15-30 minutes for the first 2 hours, then hourly for several hours thereafter. 2
• A catheterization team member must examine the patient later the same day and subsequently as clinically indicated. 2
• Obtain paired blood cultures (one from the catheter and one peripherally) before starting antibiotics if infection is suspected. 1, 3

Catheter-Related Bloodstream Infection (CRBSI)

Non-Tunneled Central Venous Catheters

For non-tunneled CVCs, do not routinely remove the catheter in patients with fever and mild-to-moderate illness. 1 However, specific indications mandate immediate removal:

• Remove the catheter if erythema or purulence overlies the exit site, or if clinical signs of septic shock are present. 1
• Remove and culture the catheter if blood cultures are positive, or if a catheter exchanged over guidewire shows significant colonization on quantitative/semi-quantitative cultures; place a new catheter at a different site. 1
• Retain the catheter in select patients with coagulase-negative staphylococcal infection without evidence of persistent bacteremia or metastatic complications. 1

Tunneled Catheters and Implantable Ports

For tunneled catheters and ports, attempt salvage with antibiotic lock therapy only for uncomplicated intraluminal infections. 1, 3

Mandatory removal indications include:

• Tunnel infection or port pocket abscess 1, 4
• Clinical signs of septic shock or severe sepsis 1, 4
• Bloodstream infection with S. aureus, fungi, or mycobacteria 3, 4
• Persistent bacteremia/fungemia despite 48-72 hours of appropriate antibiotics 4
• Suppurative thrombophlebitis or endocarditis 4

For salvage attempts in uncomplicated infections:

• Use antibiotic lock therapy for 14 days combined with standard systemic therapy for S. aureus, coagulase-negative staphylococci, and gram-negative bacilli. 1
• Antibiotic lock dwell time should ideally be ≥12 hours. 3

Organism-Specific Management

Staphylococcus aureus:

• Use β-lactam antibiotics (nafcillin or oxacillin) as first-line for methicillin-susceptible strains; vancomycin is inferior and should be reserved for methicillin-resistant strains or severe β-lactam allergies. 1
• Perform transesophageal echocardiography (TEE) to rule out endocarditis in all patients without contraindications, as complicating endocarditis rates are high. 1
• Treat for 14 days if TEE is negative and catheter is removed; treat for 4-6 weeks if endocarditis is present. 1
• Remove non-tunneled CVCs immediately; tunneled catheters may be salvaged with combined systemic and antibiotic lock therapy for 14 days in selected uncomplicated cases. 1

Coagulase-negative staphylococci:

• May treat without catheter removal if no evidence of persistent bacteremia or metastatic complications, though this may require longer therapy duration. 1

Candida species:

• Remove the catheter in nearly all cases, as treatment without removal has low success rates and higher mortality. 1
• For septic thrombosis of great central veins due to Candida, use prolonged amphotericin B therapy or fluconazole if the strain is susceptible. 1

Gram-negative bacilli:

• Remove non-tunneled CVCs and treat for 10-14 days. 1
• For tunneled catheters that cannot be removed, use 14 days of systemic plus antibiotic lock therapy; quinolones (ciprofloxacin with or without rifampin) are preferred as they can be given orally. 1
• Strongly consider removal for Pseudomonas species (other than P. aeruginosa), Burkholderia cepacia, Stenotrophomonas, Agrobacterium, and Acinetobacter baumannii, especially if bacteremia persists despite appropriate therapy. 1

Septic Thrombosis

This is a serious complication requiring aggressive management:

• Remove the involved catheter in all cases. 1
• Perform incision, drainage, and excision of infected peripheral veins and tributaries when suppuration, persistent bacteremia/fungemia, or metastatic infection is present. 1
• Use heparin for septic thrombosis of great central veins and arteries, but not routinely for peripheral vein thrombosis. 1
• Treat with antimicrobials for 4-6 weeks (same duration as endocarditis) for great central vein involvement; vein excision is usually not required. 1
• Do not use thrombolytic agents in addition to antimicrobials for catheter-related bloodstream infection with thrombus formation. 1

Persistent Bacteremia and Endocarditis

If bacteremia or fungemia persists ≥3 days after catheter removal and initiation of appropriate antimicrobial therapy, aggressively evaluate for septic thrombosis, infective endocarditis, and other metastatic infections. 1

• Remove the device in most cases of persistent bloodstream infection. 1
• Treat presumptively for endovascular infection with 4 weeks of antimicrobial therapy if blood cultures remain positive or clinical status is unchanged 3 days after catheter removal. 1
• Empirical therapy must include coverage for staphylococci. 1

Vascular Access Site Complications

Vascular complications occur in approximately 1% of cardiac catheterizations, with 0.5% requiring surgical repair. 5

Risk factors include:

• Age >60 years 5
• Female gender (1.73-fold increased risk for any vascular complication) 6
• Percutaneous coronary intervention versus diagnostic angiography alone (3% versus 1%) 5

Common complications include:

• Pseudoaneurysm, arteriovenous fistula, thromboembolism, infection, and bleeding 5
• Septic complications are more likely with repeat puncturing of the ipsilateral femoral artery or leaving femoral artery sheaths in place >24 hours 7

Management of septic vascular complications:

• Initiate antibiotics effective against gram-positive organisms (skin flora) immediately. 7
• Consider CT scanning or angiography for patients with persistent sepsis, septic emboli, or abdominal/flank pain. 7
• Infected aneurysms require resection or ligation due to rupture risk. 7

Contrast-Related Complications

Renal insufficiency (creatinine >2.0 mg/dL) frequently worsens after contrast administration. 2

Prevention strategies:

• Minimize contrast volume in patients with chronic kidney disease (creatinine clearance <60 mL/min). 2
• Ensure adequate preparatory hydration for all patients receiving contrast media. 2
• Use low-osmolar contrast agents to reduce histamine release and decrease hemodynamic, electrocardiographic, and allergic reactions. 2

Allergic reactions:

• Range from mild urticaria to severe anaphylaxis, occurring more frequently in atopic individuals. 2
• Patients with prior anaphylactoid reactions require appropriate prophylaxis before repeat contrast administration. 2
• Administer morphine sulfate 2-4 mg IV every 5 minutes for severe reactions; some patients require 25-30 mg total. 2
• Reverse morphine-induced respiratory depression with naloxone 0.4 mg IV at up to 3-minute intervals (maximum 3 doses). 2

Life-Threatening Cardiac Complications

Coronary artery dissection or thrombosis requires emergency percutaneous coronary intervention or bypass surgery. 2

Cardiac perforation or great vessel injury necessitates immediate cardiovascular surgical intervention. 2

Ventricular arrhythmias (ventricular fibrillation or ventricular tachycardia) demand immediate defibrillation and advanced cardiac life support. 2

Periprocedural stroke occurs in approximately 1 per 1,000 diagnostic catheterizations; avoid retrograde aortic valve catheterization in severe aortic stenosis due to increased stroke risk. 2

Catheter Reinsertion Timing

After removal of catheters from patients with catheter-related bloodstream infection:

• Non-tunneled catheters may be reinserted after appropriate systemic antimicrobial therapy is begun. 1
• Tunneled devices should be postponed until after appropriate systemic antimicrobial therapy is begun based on susceptibilities, and after repeat blood cultures yield negative results. 1
• Ideally, insert a new tunneled device in stable patients after completing the full antibiotic course and obtaining negative repeat blood cultures 5-10 days later. 1

Prevention Strategies

Administer heparin routinely when nonionic contrast agents are used, as these agents inhibit blood clotting and platelet aggregation less than ionic agents. 2

Maintain activated clotting times >300 seconds to reduce covert brain lesions. 2

Use uninterrupted pre-procedural anticoagulation combined with heparin bolus before trans-septal puncture to reduce thromboembolic complications. 2

Radial artery access reduces access-related bleeding and complications compared to femoral access. 2

Use continuous low-flow irrigation of long left-sided sheath introducers with heparinized saline to prevent intraluminal stasis and thrombus generation. 2

High-Risk Patients Requiring Inpatient Monitoring

The following patients should not undergo ambulatory catheterization and require inpatient monitoring: 2

• Unstable angina or acute myocardial infarction
• Congestive heart failure
• Ejection fraction ≤35%
• Severe ischemia during stress testing
• Recent stroke (within 3 months)
• Pulmonary hypertension or arterial desaturation
• Uncontrolled systemic hypertension
• Anticoagulation or bleeding diathesis

Critical Pitfalls to Avoid

Do not use inadequate cumulative morphine dosing due to fear of respiratory depression or hypotension. 2

Do not perform ambulatory catheterization on patients with any high-risk features listed above. 2

Do not provide inadequate hydration before contrast administration, which increases nephropathy risk. 2

Do not use vancomycin for methicillin-susceptible S. aureus infections, as it has higher failure rates and slower bacteremia clearance than antistaphylococcal penicillins. 1