Using Chlorhexidine-Coated Dialysis Catheter Caps to Reduce Central Venous Dialysis Catheter Infection Rates: A Quality Improvement Project.

Objective The clinical data of 69 patients with temporary central venous catheterization hemodialysis were analyzed and the advantage and disadvantage of clinical application were discussed. Methods From January to December 2017, 69 patients were selected from the blood purification center of Wujin people’s Hospital of Changzhou City for hemodialysis. Among them, 42 cases were males and 27 cases were females. The average age was (61.06 ±15.09) years. The primary diseases, the location and time of catheter indwelling, the incidence of ductal thrombus and the incidence of ductal thrombus were recorded in 69 patients. The effects of different catheterization sites on the efficacy and safety of hemodialysis were comparatively analyzed. Results The primary diseases of 69 patients with temporary central venous catheterization were chronic glomerulonephritis (n=30), tumor associated nephropathy (n=12) and diabetic nephropathy (n=9). The direct cause included 17 cases of acute renal failure, 43 cases of immature internal fistula for the first time dialysis of chronic renal failure, 9 cases of failure of internal fistula. The prognosis of disease included 14cases 7 cases of improvement and 33 cases of chronic hemodialysis, 5 cases of chronic hemodialysis. One patient with peritoneal dialysis (1.45%) gave up treatment. 4 cases (5.79%) developed catheter-related infection. The infection rate was 1.47/1 000. Thrombosis occurred in 12 patients (17.39%), 3 of them (25.00%) had no effect of thrombolysis, and catheterization was re-inserted. The remaining 9 patients (75.00%) were treated with thrombolysis to maintain adequate blood flow. The average number of thrombolysis was (3.44±1.84) times. Among 69 hemodialysis patients with temporary central venous catheters, 39 patients (56.52%) chose internal jugular vein and 30 patients (43.48%) chose femoral vein, respectively. There was no difference in catheter placement time between different sites [(39.64±25.43) d ratio (38.86±26.77) d, P>0.05], but catheter-related infection rates of internal jugular vein catheters (0.65 times/1 000 catheter days vs 2.57/1 000 catheter days) and thrombosis rate [5.13% (2/39)vs 33.33%(10/30), P<0.05]was lower than that of femoral vein. Conclusion Temporary central venous catheterization is a safe, fast and reliable temporary vascular access for dialysis patients, which is worth popularizing in clinical application, but it also increases the infection rate and thrombosis rate of dialysis patients. Key words: Central vein catheterization; Hemodialysis; Complication

Central venous catheter-related infections

Implantable venous access devices (VADs) are used in sickle cell disease (SCD) for patients with poor venous access to facilitate chronic blood transfusions and manage acute complications. We attempted to define the frequency of bloodstream infections (BSI) and thrombosis in adults and children with SCD and VADs. We performed a single-institution, retrospective review of VAD-associated infection and thrombosis in patients with SCD. Thirty-two patients (median age 20 years, range, 1-59) had 86 VADs placed (median, 2.7 VADs per patient, range, 1-7) with a total of 41,292 catheter days (median, 1,376 days; range, 323-3,999). Mean catheter lifespan in adults (691 days ± 123) was not significantly higher than children (614 days ± 154). A total of 66 VAD-associated BSI (1.59 infections per 1,000 catheter days) occurred in 17 of 32 (53%) patients. Children with VADs had fewer BSI (3 of 10; 30%) than adults (14 of 22; 64%, P = 0.08). 24 catheter-associated thromboses (0.49 thromboses per 1,000 catheter days) occurred in 10 of 32 (41%) of patients. Children also had fewer VAD-associated-thrombosis (1 of 10; 10%) than adults (9 of 22; 40%, P = 0.08). In conclusion, the use of VADs in SCD was linked to a significant rate of infection and thrombosis.

A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.

BackgroundCentral line-associated blood stream infections (CLABSI) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVCs) placement. To improve vascular access device choice and reduce the potential risk of CLABSIs, we implemented a quality improvement initiative compromised of a new vascular access algorithm with introduction of midline utilization and sought to evaluate the impact of midline use on CLABSI rates.MethodsA prospective quality improvement assessment from October 2017 through March 2018 analyzed the infection rates of midline catheters and CVCs. When a consult was placed for a peripherally inserted central catheter (PICC) that the patient would be evaluated via the vascular access algorithm (Figure 1) for whether they should receive a midline catheter, a PICC or a traditional CVC. The midline catheters, PICCs, and CVCs were monitored for duration of indwell and bloodstream infections consistent with reportable CLABSI definitions.ResultsIn the month prior to implementation, the institutional CLABSI rate was 1.36 per 1,000 CVC (including PICC) days. Since October 2017, there have been 4,588 midline catheter days, with two midline infections, for a cumulative rate over those 6 months of 0.435 midline catheter infections per 1,000 midline days. This was compared with 26,575 CVC days, with 33 documented CLABSIs, for a rate of 1.242 per 1,000 CVC days. Since the vascular algorithm was implemented, the infection rate from the compilation of CVC and midline catheters is 1.12 per 1,000 catheter days.ConclusionThe implementation of a vascular access algorithm including midlines may effectively reduce central line insertions and thereby decrease CLABSIs through appropriate utilization of a lower risk device (midline). Further research into comparing additional risks, benefits, complications and costs of midline catheters and all styles of central venous catheters is warranted.DisclosuresAll authors: No reported disclosures.

This study examined the safety and efficacy of placing both a central venous dialysis catheter and a central venous catheter for infusion in the right internal jugular vein compared to only a central venous dialysis catheter. We conducted a retrospective chart review for all adult patients who underwent the placement of the right internal jugular dialysis catheter by a single surgeon. Patients were grouped based on whether they received a tunneled dual lumen dialysis catheter alone or in combination with a central venous infusion catheter in the right internal jugular vein. Catheter-related thrombosis, line infections, line malfunctions, pneumothorax, and need for line replacement were evaluated. There were 97 patients in the dialysis catheter and central venous infusion line group and 63 patients in the dialysis catheter only group. The two groups were not different with regard to age (62.1 ± 16.3 years vs 57.9 ± 17.6 years) and gender (47.4% male vs 55.6% male). No significant differences were found in the incidence of thrombosis (1.0 % vs 0.0%, p > 0.999), line infection (2.1% vs 0.0%, p = 0.519), or line malfunctions (2.1% vs 0.0%, p = 0.516) in patients who did or did not have a central venous infusion catheter placed concomitantly with the dialysis catheter, respectively. No patients in either group had a pneumothorax. Although not currently utilized with frequency, these preliminary data indicate that placing both a dual lumen dialysis catheter and central venous infusion catheter in the right internal jugular simultaneously could be a viable option.

Background and Aims In addition to nephrologists who use central venous catheters (CVCs) as venous access for hemodialysis, it is also a routine practice for hematologists to benefit from them for their medical applications. There may be immediate or delayed complications of CVC placement and infections are accepted as delayed complications. We aimed to compare CVC-related infections in hematology and hemodialysis patients groups both of whose CVCs were placed by interventional nephrologists. Group specific infectious agents as well as infection risk factors were analyzed in order to develop guides and practices to decrease infection rates for the future. Method The number of patients who were placed a CVC in bone marrow transplantation (BMT) unit was 69 (37 males, 32 females) in the year of 2019. These patients were 47,5 ± 14,3 years old. Their CVC infection numbers and rates as well as infection agents were analyzed. This group was compared with hemodialysis patients that have non-cuffed hemodialysis catheters and who were age and sex matched with the BMT group. Infection rates for 1000 catheter days were calculated separately for both groups. Catheter infections were defined as hemoculture positivity of samples obtained from catheter lumens and/or identification of any microorganism in the catheter tip. Cases were followed up from insertion day of the catheters until when infection was identified or until the day of catheter removal. Results Catheters remained in a central vein for a median of 25 days in hemodialysis group [range: 10-51 days] while these duration was 16 days [range:8-29 days] for BMT group. The number of cases in whom a catheter related infection was identified was 17 for BMT (24%) and nine (13%) for hemodialysis group. Infection rate was 23 for 1000 catheter days in BMT group while it was 11 for 1000 catheter days in hemodialysis patients. BMT patients have a wider range of infection agents; 78% of them being gram positives and 19% of them being gram negatives. It was noteworthy that all of the catheter related infections in hemdialysis patients were related to gram positive bacteria. Rate of infections due to extended spectrum beta lactamase (ESBL) secreting E.coli or Klebsiella was 24% and infection risk of ESBL secreting agents was directly proportional to the time spent with the catheter. Infection findings in the catheter exit site (e.g. erythema, crusts or effusions) was found as statistically significant risk factors for bloodstream infections in BMT patients while these factors were not statistically significant for hemodialysis patients. Conclusion Gram positive infections make up the majority of CVC-related infections both for hematology and hemodialysis patients. Infection risks due to resistant species is proportional to the time spent with catheters. Catheter exit site findings should be cautionary for probable bloodstream infections especially for immunosuppressed patients.

Central venous dialysis access: experience with a dual-lumen, silicone rubber catheter.

The use of central venous catheters as hemodialysis vascular access is a major contributor to high bloodstream infection rate. In our dialysis unit in Shenzhen Guangdong Province China, we have developed and used our own dialysis catheter care protocol since May 2013 with good results. In this study, we would like to share our experience with the other units. We have undertaken a 5-year retrospective analysis to determine our tunneled dialysis catheter-related blood stream infection rate by adding the number of infections divided by total number of catheter days × 1000. The results were compared with another study carried out in Henan Province China. Demographic data were summarized using descriptive statistics. Continuous and categorical variables were compared using t-test and χ2 test respectively. Between 2017 and 2021, a total of 216 tunneled dialysis catheters were managed by following our own dialysis access pathway and catheter care protocol. The tunneled dialysis catheter-related bloodstream infection rate was 0.0229 per 1000 catheter days in the 5-year period. Comparing with other published studies in China, our unit has achieved a very low rate of tunneled dialysis catheter-related bloodstream infection which has been sustained over time. This paper explores how our protocol and implementation might have contributed to the results.

The aim of this study was to construct an experimental model replicating blood flow within human superior vena cava and to determine the degree of the immediate aspiration of the drug introduced via central venous catheter through the distally positioned dialysis catheter. A model replicating superior vena cava was built, catheters were inserted into the model, placing the orifice of the central venous catheter in positions regarding the orifice of the arterial lumen in central venous dialysis catheter (from +2 to -8 cm). Methylene blue was used as a tracer, and the concentration was determined by ultraviolet-visible spectroscopy. Four different sets of samples were generated according to infusion and aspiration speeds: continuous-slow, continuous-fast, bolus-slow, and bolus-fast. The concentration of the tracer was related to the distance between the catheter tips, representing a bimodal dependence. When the central venous catheter was placed distally to the central venous dialysis catheter, the aspiration of the tracer was minimal. When withdrawing the central venous catheter proximally, the aspiration of the tracer increased, reaching its peak at -4 cm with aspiration rates form 4.2% to 140.7%. Furthermore, the infusion speed of the tracer had more effect on the aspirated concentrations than the aspiration speed. Findings of our experimental model suggest that concentration of aspired drug is effected by the distance between the central venous catheter and central venous dialysis catheter, being lowest when the drug is infused distally to central venous dialysis catheter. Furthermore, the concentration of the tracer is directly proportional to the infusion speed and far less effected by the aspiration rate of the drug.

Salvage Antibiotic-Lock Therapy in Critically Ill Pediatric Patients

Introduction:Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population.Methods:In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done.Results:The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock.Conclusions:The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

In intensive care, drugs are commonly administered through central venous catheters (CVC). These catheters and central venous dialysis catheters (CVDC) are often placed in the same vessel for practical reasons. The aim of this experimental study was to investigate if the position of CVC and CVDC influences the elimination of infused drugs, during continuous renal replacement therapy (CRRT). In a randomized, cross-over model, anesthetized piglets received both a CVC and a CVDC in a jugular vein. Another CVDC was placed in a femoral vein for comparison. After baseline measurements, CRRT was performed in either of the CVDC, each CRRT-period separated by another baseline period. Hypotension was induced by peripherally given sodium nitroprusside. In the CVC, both gentamicin and noradrenaline were administered. Noradrenaline was titrated to reach a target blood pressure. When CRRT was performed using the CVDC in the same vessel as the drugs were infused, the plasma concentration of gentamicin was reduced compared with when the infusion and CVDC were in different vessels (5.66 [standard deviation (SD) ± 1.23] vs. 7.76 [SD ± 2.30] mg/l [p = 0.02]). The noradrenaline infusion rate needed to reach the target blood pressure was more than doubled (0.32 [SD ± 0.16] vs. 0.15 [SD ± 0.08] µg/kg/min [p = 0.006]). This experimental study indicates that the removal of drugs is increased if infusion is in close vicinity of the CVDC, during CRRT.

Catheter-related infections in patients with acute type II intestinal failure admitted to a national centre: Incidence and outcomes

The use of central venous catheters (CVC) for acute or chronic dialysis has been a relatively recent innovation in Nephrology. The first problem addressed has been how to allow removal and return of blood at high flow rates throughout a dialysis treatment. Four solutions have emerged: place the lumens within the right atrium; place the removal lumen on the inside of the catheter; use a large catheter size; or provide independent limbs with multiple blood-entry ports to draw and return blood in all directions. Many other requirements include resistance to infection, especially the passage of organisms around the catheter. A subcutaneous Dacron cuff within a tunnel has successfully accomplished this goal for most chronic CVC dialysis catheters, but other immobilizing devices such as plugs have also been successful. Materials for CVC dialysis catheters have improved, providing strength to allow the catheters to last for several years, with flexibility to avoid vein damage (in general). However, component and material failures still occur, and some materials are incompatible with medications placed at the exit site. CVC for dialysis will remain a necessary choice for many patients beginning and continuing dialysis therapy.