Citrate versus heparin lock in hemodialysis catheter’s complications; a randomized clinical trial

BACKGROUND AND AIMS Haemodialysis catheters are frequently dysfunctional due to catheter-related thrombosis, which potentially compromises dialysis adequacy and may limit catheter survival. Strategies to prevent haemodialysis catheter dysfunction include catheter locks, that are generally either heparin or citrate. Our haemodialysis unit converted to locking all central venous haemodialysis catheters with sodium citrate 4% instead of heparin 10 000 U/mL. A retrospective analysis was conducted to evaluate whether replacing heparin with sodium citrate 4% would ensure cost-effective satisfactory catheter function. METHOD Our haemodialysis unit converted to locking all central venous haemodialysis catheters with sodium citrate 4% instead of heparin 10 000 U/mL as a unit policy change. In the heparin period, all catheters were locked with concentrated heparin 10 000 U/mL, in the citrate period, all catheters were locked with sodium citrate 4%. Partially or fully clotted catheters were treated with rt-PA. A retrospective analysis compared the outcomes of the 6 months prior and after the conversion. We included all patients in whom a central venous haemodialysis catheter was used during at least part of each period. Exclusion criteria included patients with a contraindication to systemic anticoagulation, documented or suspected heparin-induced thrombocytopaenia, or known allergy to citrate. Age, gender, dialysis vintage and comorbidities were analysed. The compared outcomes were incidence of catheter thrombosis, catheter-related infection, flow-related catheter exchange rate, dialysis efficiency measured by Kt/V and catheter dysfunction. RESULTS A total of 23 patients were included, with an age of 68 ± 16 years. Dialysis vintage was 2.8 ± 2 years. The patients had multiple comorbidities, with a mean Charlson comorbidity index of 7 ± 2. Regarding catheter characteristics, 19 (83%) had a right jugular vein tunnelled catheter, the remaining 4 (17%) had a left jugular vein tunnelled catheter. These 23 patients were dialyzed using a central venous haemodialysis catheter during both the heparin and citrate lock period, so the patient characteristics are the same in both groups. Between the two audit periods, the rate of catheter thrombosis measured by a number of treatments with rt-PA was 0 (0/1000 catheter days) and 7 (2.78/1000 catheter days) during the heparin and citrate period respectively (P = 0.08). The number of catheter exchanges due to catheter dysfunction was 0 (0/1000 catheter days) during the heparin period and just 1 (0.39/1000 catheter days) during the citrate period (P = 0.317). There were no catheter-related infections in either group. Dialysis adequacy measured by Kt/V was 1.55 ± 0.34 in the heparin group and 1.59 ± 0.34 in the citrate group (P = 0.725). Regarding catheter dysfunction (inability to achieve and maintain a blood flow of more than 350 mL/min), it was recorded in 146 sessions (12.3%) in the heparin period and 59 sessions (14.7%) in the citrate period (P =0.729). CONCLUSION When comparing catheter lock with heparin versus citrate, this study did not find any statistically significant differences regarding major catheter-related outcomes. However, there was a trend favouring heparin locking. In our institution, the direct cost of citrate locking is considerably less than the cost of heparin locking. Given the lack of major differences in outcomes, the total cost-benefit is likely to be greater with citrate locking (although cost related to thrombolytic use was not assessed). Besides potential financial advantages in switching to citrate locking, there are other potential advantages, namely the minimization of heparin-related side effects or limitations. In conclusion, citrate locking is an effective and less expensive alternative to heparin locking of haemodialysis catheters.

The effects of heparin versus sodium citrate 4% as a lock solution on catheter-related infections (CRIs), catheter patency, and hospitalizations in long-term hemodialysis patients with central venous catheters (CVCs) were compared. Data for patients receiving heparin lock solutions were collected from July 2008 to July 2009. Data on patients receiving sodium citrate 4% lock solution were collected from September 2009 through December 2010. Patients who were receiving the heparin lock solution who continued to have a CVC in September 2009 were transitioned from heparin to sodium citrate catheter 4% lock solution. New patients with CVCs placed after September 2009 received sodium citrate 4% without a period of using heparin lock solution. Pertinent information on patient medical history, bleeding or clotting events, infections, and hospitalization was collected. Data were collected retrospectively for the heparin group and prospectively for the sodium citrate group. Data were collected from 360 patient-months among 60 patients during the heparin treatment period and from 451 patient-months among 58 patients during the sodium citrate period. Thirty-three patients were common to both study groups. There were significantly more CRIs and CRIs per 1000 catheter-days in the heparin than the sodium citrate treatment group. Secondary outcomes of hospitalizations and catheter thrombosis were comparable. CRIs and thrombosis led to significantly more catheter exchanges or removals in the heparin group than the sodium citrate group. In patients with long-term hemodialysis catheters, a lock solution of sodium citrate 4% was associated with fewer CRIs and similar effectiveness when compared with heparin 5000 units/mL.

Concentrated heparin solutions are instilled into the catheter lumens after each hemodialysis session to prevent catheter thrombosis. The heparin lock concentration at many centers has been decreased recently to reduce the risk of systemic bleeding and contain costs. However, the effect of this change on catheter patency is unknown. We compared catheter patency between two heparin lock solutions: 1000 versus 5000 units/ml. With use of a prospective, computerized, vascular access database, 105 patients with newly placed tunneled hemodialysis catheters, including 58 patients receiving a 5000 units/ml heparin lock and 47 patients receiving a 1000 units/ml heparin lock, were retrospectively identified. The primary endpoint was cumulative catheter patency and the secondary endpoint was frequency of thrombolytic instillation. Cumulative catheter survival was similar in the two groups, being 71% versus 73% at 120 days in the low- and high-concentration heparin lock groups (hazard ratio of catheter failure, 0.97; 95% confidence interval, 0.45 to 2.09; P = 0.95). The frequency of tissue plasminogen activator instillation was significantly greater in the low-concentration heparin group (hazard ratio, 2.18; 95% CI, 1.26 to 3.86; P = 0.005). No major bleeding complications were observed in either treatment group. The overall drug cost for maintaining catheter patency was 23% lower with the low-concentration heparin lock ($1418 versus $1917) to maintain catheter patency for 1000 days. Low-concentration heparin lock solutions do not decrease cumulative dialysis catheter patency, but require a twofold increase in thrombolytic instillation to maintain long-term patency.

We investigated physical and chemical stability of daptomycin and vancomycin in heparin or sodium citrate lock solutions. The aim of this study was to find the optimal combination of antimicrobials and additives for lock solutions, which maximized patient safety. Vancomycin and daptomycin were diluted with heparin or sodium citrate to achieve final concentrations of vancomycin-heparin 2.5 mg/mL-833.33 U/mL, vancomycin-citrate 2.5-33.3 mg/mL, daptomycin-heparin 5 mg/mL-800 U/mL, and daptomycin-citrate 5-32 mg/mL and they were stored at room temperature (+25°C), 4°C, -20°C, and 37°C. Physical and chemical stability were analyzed for each antibiotic-anticoagulant combination in all conditions immediately after preparation, at 24, 48, 72 h and at different time points until unstable concentrations were obtained. Daptomycin-sodium citrate microbiological activity was also studied by evaluating two Staphylococcus aureus cultures in a calcium enriched medium with a daptomycin E test, with and without sodium citrate. After incubation at 37°C vancomycin and daptomycin combined with heparin retained at least 90% of the initial concentration over 48 h. Vancomycin-sodium citrate solution stored at 37°C reduced more than 10% of the initial concentration at 24 h. On the other hand, daptomycin-sodium citrate preparation was stable at 37°C for 72 h but the microbiological activity of daptomycin was lower in the presence of sodium citrate. The purpose is to prepare vancomycin and daptomycin lock solutions combined with heparin. They should be changed at 48 h and its stability is over 3 days at 25°C and 7 days at 4°C, which allow Hospital Pharmacy Services to manage their stocks. Daptomycin-sodium citrate combination is more stable for extended periods but its bioactivity has not been demonstrated.

Currently, normal saline lock or normal saline containing heparin lock are routinely used after IVH or intermittent peripheral infusion in the clinical setting. Up till now, however, there has been no evidence for the optimal concentration of heparin in the lock solution for preventing thrombus formation in peripheral vein catheters and central venous catheters.The purpose of this study was to evaluate the effectiveness of normal saline against normal saline containing 10 U/mL or 100 U/mL heparin for preventing blood clotting in peripheral vein catheters. Patients (N=60) in Kanazawa University Hospital were randomized to 3 groups (saline lock group, 10 U/mL heparin lock group and 100 U/mL heparin lock group : N=20 for each). We evaluated the rates of thrombus formation and thrombus protein content after 24 hours of lock in peripheral vein catheters.Our results indicated that when the 100 U/mL heparin lock solution was used, both thrombus formation rates catheters and protein contents were significantly lower than for the other 2 groups. However, at 100 U/mL, the heparin lock solution caused most pain at the insertion site, though the reason for this was not clearly known.In conclusion, as compared with the normal saline solution and the 10 U/mL heparin lock solution, the 100 U/mL heparin lock solution was more effective in preventing the thrombus formation in the peripheral vein catheter.

Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters.Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access. To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement. We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD. Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE. We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported. Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.

The employment of dialysis catheters can result in catheter-related blood stream infections (CRBSI), leads to hospitalization, morbidity, and mortality. Citrate-taurolidine lock solution can lower the occurrence of CRBSI. This study was done to evaluate Citrate-taurolidine lock solution for decreasing CRBSI. This retrospective study included 89 patients who received hemodialysis for at least 6 months via a tunneled catheter. A comparison was made between patients who were administered TauroLock-Hep500™ (taurolidine, citrate, and heparin) or heparin lock solution for catheter-related infection and catheter dysfunction. In this study, 47 patients received heparin lock-solution and 42 patients received Taurolock lock-solution. During a total of 7560 catheter days, the Taurolock group experienced CRBSI in 3 patients. In contrast, the heparin group had 15 patients with CRBSI over a span of 8140 catheter days. This corresponds to an incidence rate of 0.39 episodes of CRBSI per 1000 catheter days in the Taurolock group and 1.84 episodes per 1000 catheter days in the heparin group. Catheter dysfunction rates were similar in the Taurolock group compared to the heparin lock solution. In addition, in the Heparin group, two patients necessitated catheter removal, whereas no patients in the Taurolock group required catheter removal. Our study demonstrates a higher incidence of CRBSI in the Heparin group compared to the Taurolock solution and a similar effectiveness of the Taurolock solution in preventing catheter dysfunction over Heparin.

Background A significant proportion of incident and prevalent hemodialysis patients have central venous catheters for vascular access. No consensus is available on the prevention of catheter dysfunction or catheter-related bloodstream infections in patients undergoing hemodialysis by means of catheter lock solutions. Method We reviewed the effects of single and combined anticoagulants with antibacterial catheter lock solutions or other antimicrobials for the prevention of thrombosis or infections in hemodialysis patients. Relative risks with 95% confidence intervals for trials of the same type of catheter locking solution were pooled. Sources of information We included original research articles in English from PubMed, EMBASE, SpringerLink, Elsevier and Ovid using the search terms ‘hemodialysis,’ ‘central venous catheter,’ ‘locking solution,’ ‘UFH,’ ‘low molecular weight heparin,’ ‘EDTA,’ ‘citrate,’ ‘rt-PA,’ ‘urokinase,’ ‘gentamicin,’ ‘vancomycin’, ‘taurolidine,’ ‘sodium bicarbonate,’ ‘hypertonic saline’ and ‘ethanol’ and ‘catheter’. Findings Low-dose heparin lock solution (< 5000 U/ml) can efficiently achieve anticoagulation and will not increase the risk of bleeding. Low-concentration citrate (< 5%) combined with rt-PA can effectively prevent catheter infection and dysfunction. Catheter-related infections may be minimized by choosing the appropriate antibiotic and dose. Limitations There is a lack of follow-up validation data for LMWH, EDTA, taurolidine, sodium bicarbonate, ethanol, and other lock solutions. Implications Since catheterization is common in hemodialysis units, studies on long-term treatment and preventative strategies for catheter dysfunction and catheter-related infection are warranted.

Temporary vascular access is mandatory for acute hemodialysis. Heparin lock solution is the standard of care worldwide. Many lock solutions were studied in terms of thrombosis and catheter-related infection prevention, but none replaced heparin as a standard measure. Our main aim is to investigate the effectiveness of sodium bicarbonate (NaHCO3), a ubiquitous and cheap option as a catheter lock solution, in comparison with traditionally used heparin in non-tunneled hemodialysis catheters. We conducted our prospective study between March 2021 and March 2022. Our study included 441 patients > 18years old who needed either femoral or jugular non-tunneled dialysis catheters. Patients were assigned to either heparin (5000IU/ml) or 8.4% sodium bicarbonate on a consecutive basis. Basic characteristics and information regarding catheters, dialysis sessions, and complications were recorded. We divided patients according to the catheter insertion site as well as the lock solution. We analyzed 426 patients divided into four groups: jugular heparin (n = 113), jugular bicarbonate (n = 113), femoral heparin (n = 113), and femoral bicarbonate (n = 100). Basal characteristics were similar for all groups. The mean time to last effective dialysis in our institution was 10.7 ± 12.1days for heparin vs 11.5 ± 10.8days for the bicarbonate group. 25 (5.9%) patients had some kind of blood flow problems (13 in the heparin and 12 in the bicarbonate group). There was no significant difference in terms of catheter malfunction among groups (p = 0.50). Out of these 25 cases, only 12 (7 in heparin and 5 in the bicarbonate arm) had catheter dysfunction (p = 0.386). Sixty-four patients (28%) with jugular catheters were discharged with patent catheters and continued their dialysis in other facilities. Sodium bicarbonate is as effective as classic unfractionated heparin in preventing catheter lumen thrombosis with a comparable incidence of catheter-related complications. Furthermore, it is a cost-effective option that can be used confidently, especially when heparin is contraindicated. ClinicalTrials.gov Identifier: NCT04772209 (26.02.2021).

Evaluation of anti-Xa activity after injection of a heparin lock for dialysis catheters in intensive care: A prospective observational study

POS-602 TETRASODIUM EDTA REDUCES ALTEPLASE USE IN PATIENTS WITH DYSFUNCTIONAL HEMODIALYSIS CATHETERS

There is wide variation in the use of solutions to "lock" or fill tunneled central venous catheters for dialysis. Some centers use undiluted heparin concentrations ranging from 1000 to 10,000 U/ml and other centers place from 1000 to 10,000 U per lumen. Based on available evidence, it appears that heparin 1000 U/ml, or 4% sodium citrate are suitable choices for lock solution to maintain patency of tunneled central venous catheters for dialysis. Risks from systemic anticoagulation are lower with heparin 1000 U/ml and 4% sodium citrate, compared with higher concentrations of heparin (5000 and 10,000 U/ml). The need for use of tissue plasminogen activator for maintaining catheter patency is increased by using heparin lock at 1000 U/ml, vs. higher concentrations. Higher concentrations of heparin lock should be reserved for patients who have evidence of catheter occlusion or thrombosis when heparin is used at 1000 U/ml. Similar choices for lock solution are sensible for acute hemodialysis catheters. When heparin is used for catheter lock, the injected volume should not exceed the internal volume of the catheter.

The compatibility and stability of telavancin and vancomycin in heparin or sodium citrate lock solutions were evaluated. Telavancin and vancomycin hydrochloride injection powder lyophilized for solution were reconstituted with 0.9% sodium chloride injection at room temperature according to the manufacturer's instructions and then further diluted with (1) commercially available heparin sodium to reach a final heparin concentration of 2500 units/mL or (2) sodium citrate solution 2.2% or 4% to achieve final telavancin and vancomycin concentrations of 2 and 5 mg/mL. Physical stability, chemical compatibility, and biological anticoagulant stability were analyzed for each antibiotic-anticoagulant combination immediately after preparation and at 24, 48, and 72 hours. Changes in coagulation were measured at each time point and compared using two-way analysis of variance. Both telavancin and vancomycin retained at least 90% of the initial concentration after incubation at 37 °C over 72 hours. The biological stability of vancomycin 2 mg/mL and telavancin 2 mg/mL did not significantly alter prothrombin time when compared with that of 0.9% sodium chloride injection. However, telavancin 5 mg/mL and vancomycin 5 mg/mL significantly increased the activated partial thromboplastin time at 72 hours compared with the control solution. Visual precipitation only occurred with vancomycin-containing solutions; however, this dissipated after 10 minutes. Telavancin 2 and 5 mg/mL was physically compatible in combination with heparin 2500 units/mL and with sodium citrate 2.2% and 4% over 72 hours. Vancomycin 2 and 5 mg/mL initially precipitated in the sodium citrate 2.2% formulation, but no precipitation was noted after 10 minutes of incubation at 37 °C. Telavancin and vancomycin 2 and 5 mg/mL retained over 90% of the initial concentration after incubation at 37 °C over 72 hours.

Low-dose heparin lock has been suggested as an effective and safe catheter lock in hemodialysis. However, whether a low-dose lock is superior to a high-dose heparin lock in preventing catheter-related infections and maintaining catheter patency is inconclusive. A systematic review and meta-analysis was performed by searching in NGC (National Guideline Clearinghouse), Cochrane Library, Joanna Briggs Institute Library, MEDLINE, EMbase, RNAO (Registered Nurses' Association of Ontario), Nursing Consult, PubMed, OVID, China Biology Medicine disc (CBMdisc), China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), Wanfang Data Knowledge Service Platform, and major nephrology journals. Patients receiving hemodialysis with central venous catheters. Randomized controlled trials (RCT), controlled clinical trials (CCT), and cohort studies comparing low-dose heparin lock with high-dose heparin lock in hemodialysis patients with central venous catheters. Intervention (exposure): Locking central venous catheters with low-dose heparin lock. Primary outcomes include bleeding-related complications and catheter-related infections. Secondary outcomes include catheter retention time, catheter thrombosis/occlusion incidence, and catheter dysfunction. Five RCTs and three CCTs were eventually identified for the meta-analysis, with 916 patients in total. Meta-analysis showed that, compared with the high-dose heparin group (≥ 5,000 U/mL), the low-dose (< 5,000 U/mL) heparin lock could significantly reduce the incidences of bleeding- related complications RR = 3.29, 95% CI (2.19, 4.94), p < 0.00001) and catheterrelated infections (RR = 1.66, 95% CI (1.01, 2.73), p = 0.04). However, no significant differences were observed in the catheter retention time MD = 9.32, 95% CI (-6.70, 25.35), p = 0.25), catheter thrombosis/occlusion incidence (RR = 0.68, 95% CI (0.28, 1.65), p = 0.39), or catheter dysfunction (RR = 1.07, 95% CI (0.75, 1.53), p = 0.71) between the high- and low-dose heparin groups. Low-dose heparin lock could decrease the incidences of catheter-related infections and bleeding-related complications without influencing the catheter retention time or the incidence of catheter thrombosis/occlusion or catheter dysfunction. Low-dose heparin lock solution should be recommended for the hemodialysis patients using central venous catheter in clinic.

Introdution: Patients with intestinal failure (IF) requiring central venous catheters (CVCs) are at risk for frequent catheter-related bloodstream infections (CRBSIs).[1] Taurolidine is a catheter lock solution used for CRBSI prevention, however only few studies showed efficacy in pediatric patients. This study aimed to compare the use of taurolidine lock versus heparin lock to prevent CRBSI and catheter replacement in pediatric IF patients with chronic parenteral nutrition dependence. Methods: During a study period of 52 months, 28 patients (22 male, 6 female, median age 30 months (range 1-165 months) were enrolled. Inclusion criteria were: a) patients from 2 months through 8 years old; b) who had intestinal failure on PN by tunelled CVC for at least 8 weeks; c) on cyclic PN for at least 2 hours. The exclusion criteria were acquired or primary immunodeficiency or associated diseases requiring recurrent use of antibiotics such as cystic fibrosis. All patients were randomly assigned to one of 2 groups: taurolidine lock + citrate 4% (group A) and control with heparin lock 50 UI/ml (group B) and patients were observed for CRBSIs. Blood cultures were collected at the same time from peripheral and from CVC whenever infection was suspected. The main endpoint was the number of CRBSI/1,000 catheter days and also the number of catheter replacement/patient. Statistical analysis employed Student's t test and X2 for categorical variables. Trial registration ClinicalTrials.gov NCT02515201. Results: The total number of catheter days was 8,260 days, with the following number of days per group: group A=4,371 days; group B=3,889 days. CRBSI infection rate during the hospitalization period was 7.1/1000 on taurolidine and 7.9/1000 on heparin, with no significant difference among them. CRBSI infection rate during home PN period was 0.9/1000 on taurolidine and 2.6/1000 on heparin, with no significant difference among them. The number of catheter replacement during the hospitalization period was 27 on taurolidine and 32 on heparin, with no significant difference among them. Number of catheter replacement on home PN period was 6 on taurolidine and 5 on heparin, with no significant difference among them. Conclusion: In conclusion, our study showed that there was no difference between the incidence of CRBSI in pediatric home PN patients when comparing with heparin lock solution. Reference: 1. Chu HP, Brind J, Tomar R, Hill S. Significant reduction in central venous catheter-related bloodstream infections in children on HPN after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr. 2012;55(4):403–7.