Using an indwelling catheter for the domiciliary management of malignant effusions
Background: Many patients with malignant pleural effusions and ascites require repeated hospital visits for paracentesis. Materials and Methods: Patients and caregivers were taught to drain malignant effusions at home, using an indwelling catheter inserted into the pleural/ peritoneal cavity. The catheter, (ARROW 14 wire gauge with three additional side holes made to prevent blockage) was inserted using the Seldenger technique for central venous cannulation and secured with a stitch. A three way stopcock was used to regulate fluid drainage. The caregiver was taught to do biweekly dressings with antiseptic ointment. Results: The catheter has been used in 200 patients over a period of five years. Two patients developed infections in the pleural cavity, which were managed with antibiotics. Two patients needed catheter change because of blockage. Other patients retained the catheter till last follow up or death. The procedure can be carried out as a day case. This article describes practical guidelines for inserting and maintaining the catheter.
Keywords: malignant effusions, paracentesis, indwelling catheter, palliative care, domiciliary management
This procedure can be of benefit in patients with rapidly recurring effusions that require repeated drainage despite diuretics. It can also be considered in patients who are not tolerating diuretic therapy and in those who do not have easy access to a hospital. There should be a carer who is able and willing to perform drainage and dressings at home.
The single lumen catheter has three small holes near the tip. To allow better drainage make three additional holes in the catheter using the fine scissors and the aspiration needle. The holes should be made in the distal portion of the catheter, as the proximal 5-7 cms will be within the abdominal wall.
Confirm the presence of significant ascites by checking for shifting dullness or fluid thrill. If necessary use ultrasonogram screening to check if there are loculated pockets or large tumour masses, and to identify a good site for insertion of the catheter. If there are multiple loculations the catheter should be inserted into the largest collection. Occasionally, in such cases multiple catheters may be needed.
Obtain informed consent.
Place the patient supine for ascites drainage. For pleural drainage let the patient be seated with arms crossed over the chest, hands on the opposite shoulders, or arms abducted and hands crossed behind the head. Alternatively, let the patient sit leaning forward over a small supporting table.
Select the site of puncture, either as previously marked by ultrasonogram screening or clinically- in the iliac fossa for ascites, and in the mid or posterior axillary line in the 6th or 7th intercostal space for thoracocentesis.
Clean with povidone iodine and spirit.
Drape with the hole towel leaving the needle entry site uncovered.
Infiltrate local anaesthetic solution.
Fix the 5cc syringe to the aspiration needle. Then introduce the needle into the pleural/peritoneal cavity and aspirate to confirm the presence of fluid.
Disconnect the syringe and thread the guide wire through the needle into the cavity.
Remove the needle and introduce the dilator over the guide wire to widen the entry track.
Thread the catheter over the guide wire into the cavity.
Pull out the guide wire and connect the catheter to the extension tube with the 3 way stopcock.
Securely affix the catheter to the skin with stitches through the fixing holes.
Clean and dress with mupirocin or povidone iodine ointment and cover the insertion site with adhesive plaster.
To drain, connect the catheter to the IV tubing, open the 3 way stopcock and allow fluid to flow into a bottle.
For pleural drainage, always keep the drainage tube well below chest level. Use an underwater seal e.g. with normal saline, in the drainage battle.
Teach the patient and care giver how to use the 3 way stop cock to drain fluid.
Teach them to dress the site twice a week using povidone iodine or mupirocin ointment.
Instruct them to drain fluid when symptoms are troublesome or when there is leakage of fluid from the puncture site.
Catheter blockage If fluid does not flow freely, aspirate with a syringe. If this is unsuccessful, inject sterile saline through the catheter to check patency. One of our patients with a pleural drain needed the catheter changed to a new site as the catheter track got blocked because of malignant infiltration. Blockage has not been a problem since we started making additional side holes in the catheter.
Infection Treat with systemic antibiotics, based on culture and sensitivity reports. Local infection occurred in two of our patients but there were no serious systemic problems. Systemic antibiotics were administered and the catheter was retained. In one case Cefuroxime, 1.5 G was also instilled into the pleural cavity.
Fluid leakage Fluid may leak through the skin puncture sites if intra abdominal pressure is high and the tube is kept closed. If this happens allow fluid to drain regularly for about half an hour daily.