Hickman Catheter Research Articles

Use of arteriovenous fistula in children with bleeding disorders

Abstract Haemophilia and associated bleeding disorders are chronic conditions that require easy, accessible, and reliable venous access for treatment. Peripheral venous access is traditionally the first option considered for prophylaxis. The initial introduction of prophylaxis to a child is during the first two years of life, and peripheral access can be problematic. Central venous catheters (CVC), for example port-a-caths, are widely used among this group; however, these devices require surgical insertion and are not without their own complications. Data were collected on venous access methods used at the paediatric centre at the Evelina London Children’s Hospital, where 242 children are registered at the comprehensive care centre, 48 of whom have a severe bleeding disorder. Of these 48, 27 have a CVC currently (PICC n=1, Port-a-Cath n=25, Hickman line n=1) and 3 have an arteriovenous fistula (AVF). Patient 1 is a 12 year-old boy with severe haemophilia A and an intracranial haemorrhage at the age of 9 months. He remains on prophylaxis and had an AVF created 5 years ago following repeated port-a-cath infections and poor venous access. Patient 2 is a 7 year-old boy with severe haemophilia B and an inhibitor, who has also had repeated port-a-cath infections. An AVF was constructed 2 years ago. Patient 3 is a 12 year-old girl with type III von Willebrand disease and an inhibitor. Due to need for regular factor treatment in the context of poor venous access, an AVF was formed. We have had a 100% success rate with all three AVFs at a follow-up period of 8-69 months. Our experience suggests AVF is a viable option of venous access in patients with haemophilia and other bleeding disorders, especially so for children with repeated CVC infections or poor peripheral venous access. However, this is not a straightforward option and further evidence on long-term use based on multicentre research will be beneficial in managing AVF in this group of patients.

Abstract No. 607 - Percutaneous IR insertion of Hickman lines in anticoagulated children with cardiac failure and Berlin Heart Ventricular Assist Device receiving dual antiplatelet therapy—is it safe?

Abstract No. 607 - Percutaneous IR insertion of Hickman lines in anticoagulated children with cardiac failure and Berlin Heart Ventricular Assist Device receiving dual antiplatelet therapy—is it safe?

External jugular venous cut down technique for placement of chemotherapy port and Hickman catheter: a study of 23 cases

Background: Intravenous access devices are an integral part of cancer treatment today as these devices solve the most important problem of venous access for long duration while delivering chemotherapeutic drugs. We used external jugular venous cut down method for insertion of the catheter into central veins in twenty three consecutive patients and studied the outcomes. Methods: We analysed 23 patients who were considered for placement of chemotherapy ports and catheters for various indications. Uniform insertion procedure was followed in all patients. The outcome factors analysed were total operative time, type of anaesthesia, blood loss, and incidence of complications like hematoma and hem pneumothorax, correct placement of the tip, time to start chemotherapy, wound infection. Results: In all the patients, operative time was less than 30 minutes, total blood loss was insignificant which was measured as less than a gauze piece soakage, procedure was comfortably done under local anaesthesia in all the patients, none of the patients had hematoma or chest cavity collections, tip was well placed in superior vena cava except in one where the tip migrated into contralateral brachiocephalic vein, all patients started chemotherapy the next day and there was no wound infection. Conclusion: External jugular venous cut down technique is a very useful easily performed technique with excellent safety profile, very short procedure duration. Hence may be done even by those without a previous exposure to such device placement.

Complications of central venous catheter in patients transplanted with hematopoietic stem cells in a specialized service.

Objective: to identify the model, average length of stay on site and complications of central venous catheter in patients undergoing transplant of hematopoietic stem cells and verify the corresponding relationship between the variables: age, gender, medical diagnosis, type of transplant, implanted catheter and insertion site. Method: a retrospective and quantitative study with a sample of 188 patients transplanted records between 2007 and 2011. Results: the majority of patients used Hickman catheter with an average length of stay on site of 47.6 days. The complication fever/bacteremia was significant in young males with non-Hodgkin's lymphoma undergoing autologous transplant, which remained with the device for a long period in the subclavian vein. Conclusion: nurses should plan with their team the minimum waiting time, recommended between the catheter insertion and start of the conditioning regimen, as well as not to extend the length of time that catheter should be on site and undertake their continuing education, focusing on the prevention of complications.

How should we manage subclavian vein thrombosis?: Paget-Schroetter syndrome

Subclavian vein thrombosis is a rare condition affecting 1-2 per 100,000 population. While thrombolysis and anticoagulation remain the main stay of treatment for subclavian vein thrombosis due to feeding lines and Hickman's lines, treatment of this condition due to thoracic outlet compression involves a different approach. Better understanding of the pathophysiology of subclavian vein thrombosis has led to staged management with improved outcome. In this brief review I have looked at the current knowledge regarding the structural abnormality that exists at the thoracic outlet, the mechanism of subclavian vein thrombosis, the modality for investigation and the rationale for a staged approach based on personal and available literature evidence.

Use of Antibiotic Lock for Salvage of Tunneled Central Venous Catheters with Catheter Colonisation and Catheter Related Blood Stream Infection in a Tertiary Care Hematopoietic Stem Cell Transplantation Unit- a Strategy Revisited

Background: Catheter Related Blood Stream Infection (CRBSI ) and catheter colonization (CC) represent a significant problem encountered in hematopoietic stem cell transplantation (HSCT) setting adding to the morbidity, mortality and cost of healthcare in such patients. Unlike non-tunneled central venous catheters (CVCs), the higher complication rates and added cost associated with reinsertion of a tunneled CVC makes it important to devise effective strategies for catheter salvage.We report the incidence of CRBSI and CC of tunneled CVCs in our patients and use of antibiotic locks to salvage these catheters.Materials and Methods:All patients who underwent HSCT between September 2008 and December 2013 in our centre were included in this study. These patients underwent tunneled CVC (Hickman) insertion through internal jugular vein by Seldinger technique. Wherever possible, triple lumen Hickman catheters were used for patients undergoing allogeneic transplant, whereas double lumen catheters were used for those undergoing autologous transplant. Post insertion, surveillance blood cultures from all lumina of the catheter were taken. Catheter colonization (CC) was defined as growth of an organism from any lumen of the catheter without any evidence of fever as part of surveillance strategy. CRBSI was defined as growth of a recognized pathogen from catheter without growth from peripheral vein or growth from catheter with similar growth from peripheral vein with 2 hours lesser incubation for catheter in the presence of fever (>38o C), chills or hypotension. Antibiotic lock was used in all patients with CC according to the suceptibility patterns of the isolates, which included a third generation cephalosporin- β-lactamase inhibitor combination, aminoglycoside or carbapenem for gram negative bacteria; vancomycin, teicoplanin or linezolid for gram positive organism and amphotericin B or voriconazole for candida species. These patients did not receive systemic antibiotics. Systemic antibiotics were used in all cases of CRBSI. Catheters were removed in cases with persistent fever ( >72h), hemodynamic instability and repeated culture positivity. Antibiotic lock was continued for a total of 14 days with repeat cultures taken on 4th, 5th, 6th, 7th and 14th day of lock.Results: Two hundred and twenty four patients (95 allogeneic and 129 autologous) underwent HSCT. The incidence of CC was 9.8 % (22/224) while CRBSI was seen in 10.7 % (24/224). Coagulase Negative Staphylococcus (CONS) and gram negative organisms (Pseudomonas aeruginosa-3, E.Coli-2, Acinetobacter baumanni-2, Klebsiella pneumonia-2 and Sphingobacterium thalpophilum-1) were seen in 10 each (45%) of CC. One case of Candida tropicalis causing CC was noted. Antibiotic lock was used in 21 of 22 CC cases. Catheter salvage was successful in 95% (20 / 21) cases. One case of CC progressed to CRBSI and required systemic antibiotics. Amongst CRBSI, gram negative bacteria accounted for 83% (20 / 24) of the cases ( Pseudomonas aeruginosa-6, Acinetobacter baumanni-4, E coli-4, Klebsiella pneumonia-3, Ralstonia picketti-3, Stenothrophomonas maltilophila-2, Sphingomonas paucimobilis-1 and Ochrobactrum anthropi-1). Forty-five percent of E. coli & Klebsiella pneumonia confirmed to be Extended Spectrum β-Lactamase (ESBL) producers. Vancomycin resistant enterococci (VRE) and Candida parapsilosis related CRBSI were seen in 1 patient each. Antibiotic lock was used for 15 of the 24 cases of CRBSI. Catheter salvage was successful in 86% (13 / 15) patients. Two patients had a second episode of CRBSI, after an interval of 50 and 10 days respectively from last documented negative culture. The organisms in both these cases were gram negative bacteria.Conclusion: More than 80% of patients with catheter colonization and CRBSI could be salvaged with appropriate antibiotic locks in our setting. The use of antibiotic lock for tunneled CVCs is an effective strategy for catheter salvage in HSCT patients with CC and CRBSI. DisclosuresNo relevant conflicts of interest to declare.

Reduction in Gram Negative Rod Sepsis Rate in Intensively Treated Patients with AML Achieved through Identification of Unexpected Potential Environmental Source: A Successful Root-Cause Analysis

Sepsis remains a major cause of death during intensive chemotherapy for acute myeloid leukaemia (AML). There are few published studies documenting speciation and origin of episodes of sepsis in AML chemotherapy, and recent guidelines suggest that gram-negative rods (GNR) now account for proportionally fewer cases of febrile neutropenia. Infection with GNR is associated with a greater complication and mortality rate than other bacterial species. GNR are thought to translocate from inflamed gut mucosa due to cytotoxic chemotherapy.Our institutional practice is to give piperacillin/tazobactam for febrile episodes, add gentamicin for the hemodynamically unstable, switch to meropenem at 48 hours unresolved fever, add teicoplanin for soft tissue or line infection & empirical antifungal agent at 72-96 hours. Antibiotics are rationalised based on cultures. Blood cultures are taken prior to initiating and switching antimicrobials, and subsequently every 48-72 hours if fever remains unresolved.An increase in GNR septicaemia was noted at our centre. The objective of this retrospective study was to evaluate the microbiology of neutropenic sepsis episodes, identify risk factors including neutropenia duration and mucositis severity, and identify potential environmental contaminants including intravenous long-lines in order to reduce risk. All newly diagnosed patients eligible for intensive chemotherapy over a three-year period (n=35) were identified and analysed by pathology database and casenote review.Patients were aged between 25 and 69, median age 52. During intensive chemotherapy the total number of days of severe neutropenia (<0.5) ranged from 7 to 165 (median 60). A total of 696 blood cultures were taken, 80% were culture negative. Of the positive cultures, 5% grew multiple species, 49% overall grew GNRs. 51% grew other species, predominantly coagulase-negative Staphylococcus. Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa accounted for 70% of GNR+ cultures, with 9% beingStenotrophomonus maltophilia. Infection with the latter species had a 75% mortality. 45% of patients had notes available for review. All note-assessable patients required a switch to second line antibiotics and 56% received antifungal agents. 23 lines were inserted in these 16 patients (4 peripherally inserted central catheters and 19 Hickman lines) with median insertion duration 58 days. 8 (35%) lines were removed due to suspected infection, but no line tips grew bacteria on culture, hence could not be definitively proven as source of ongoing sepsis. 87% of patients experienced oral mucositis although only 2 (13%) required a diamorphine pump for analgesia. Median diarrhea duration was 11 days (range 0-26).100% patients in the latter half of the study period experienced at least one episode of GNR septicaemia, compared to only 38% of patients in the early half of the study period. Root cause analysis of this trend focussed on changes in practice temporally coinciding with this increased rate. This included incorporation of chlorhexidine-impregnated bungs into standard line care, discontinuation of use of sterile gloves for line handling (as per international guidelines reinforcing no-touch technique over sterile glove use) and installation of personal fridges into siderooms. Antibiotic prophylaxis and long-line type preference were not changed during this time.Cultures were taken from all fridges and staff line-access technique observed. Line handling practice and training were deemed adequate on observation. Cultures from fridges grew all GNR species encountered in the septic patients. Fridges were consequently removed from patient side-rooms and bung use discontinued. The removal of these fridges and possible reduced line-handling conferred by discontinuing modified bung use has coincided with a marked reduction in GNR infection.In conclusion, an unexpected peak in GNR sepsis rates apparently coincided with installation of fridges found later to be contaminated with multiple bacterial species including the same GNR, as well as use of chlorhexidine-impregnated bungs. Reduction in GNR sepsis rate was successfully achieved by discontinuing these interventions. This study documents the necessity of close audit of microbial growth patterns in this high risk patient population and the success of root-cause analysis in uncovering potential aetiologies. DisclosuresNo relevant conflicts of interest to declare.

The Influence of a Novel Needleless Valve on Central Venous Catheter Occlusions in Pediatric Patients

BackgroundAlthough it is common for central line catheters to develop a thrombotic occlusion, pediatric patients are at especially high risk of occlusion due to smaller vessels, smaller-gauge catheters, and slower rates of infusion. Mitigating catheter occlusions is costly, requiring tissue plasminogen activator, supplies, and nursing time. Our facility tested a novel neutral displacement needle-free valve designed to reduce occlusion. MethodologyThe organization determined a baseline occlusion rate for Hickman/Broviac catheters, in our 38-bed inpatient hematology/oncology department and our outpatient hematology/oncology clinic from August 2010 through October 2010. In 2011, a premarket test of the Neutron device (ICU Medical, San Clemente, CA) was conducted on the units. Based on the positive trial results, it was decided to implement the device housewide in December 2012. ResultsA comparison of baseline central line complete occlusion rates from August to October 2010 with Neutron trial data from July to October 2011. This pilot project demonstrated a 74.3% reduction (from a rate of 3.82 to a rate of 0.98) in all hematology/oncology department Hickman and Broviac complete catheter occlusions. Subsequently, comparing 5 months of housewide occlusion data from June through October 2012 to 2013, complete occlusions fell by 32.1% (from a rate of 1.56 to a rate of 1.06). ConclusionsThe use of the Neutron needle-free catheter patency device was associated with a reduction in complete occlusions. The corresponding reduction in treatment delays, nursing time spent managing occluded catheters, and fewer needlesticks to patients likely translates to financial benefit for the organization and improved patient and family satisfaction.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients.

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks. Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Guidelines for the diagnosis and management of adult aplastic anaemia.

Sally B. Killick (Writing Group Chair), Nick Bown, Jamie Cavenagh, Inderjeet Dokal, Theodora Foukaneli, Peter Hillmen, Robin Ireland, Austin Kulasekararaj, Ghulam Mufti, John A Snowden, Sujith Samarasinghe, Anna Wood (BCSH Task Force Member), Judith C.W. Marsh on behalf of the British Society for Standards in Haematology. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Northern Genetics Service, Newcastle upon Tyne, St Bartholomew’s Hospital, Barts Health NHS Trust, London, Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, Addenbrooks Hospital, University of Cambridge, Cambridge, Leeds Teaching Hospitals, Leeds, Kings College Hospital NHS Foundation Trust, London, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Great Ormond Street Hospital for Children NHS Foundation Trust, London, West Hertfordshire NHS Trust, Watford.

Vascular access complications during outpatient parenteral antimicrobial therapy at home: a retrospective cohort study.

The need for indwelling vascular access for outpatient parenteral antimicrobial therapy (OPAT) places patients at risk of vascular access complications. The purpose of this study was to describe vascular access complications during OPAT at home, and identify factors associated with their occurrence. All OPAT courses carried out at home for patients at Cleveland Clinic in 2013 were identified from the institution's OPAT registry. The first OPAT course per patient was included. Vascular access complications that occurred during the treatment course were abstracted from the electronic medical record. Only complications that triggered a clinical intervention were included. The 1461 included OPAT courses encompassed 33,579 OPAT days of treatment. One-hundred-and-forty-four vascular access complications occurred in 131 OPAT courses (9% of OPAT courses, 4.29 complications per 1000 OPAT days). The most common complication was occlusion (53% of all complications). Hickman catheters [incidence rate ratio (IRR) 0.20, 95% CI 0.03-0.63] and indwelling ports (IRR 0.25, 95% CI 0.04-0.78) were associated with lower complication rates than peripherally inserted central catheters, as was increasing age (IRR 0.99, 95% CI 0.98-1.00). Log OPAT duration (IRR 1.60, 95% CI 1.28-2.03), female sex (IRR 1.62, 95% CI 1.16-2.28) and injection drug use (IRR 3.32, 1.16-7.46) were associated with increased risk of vascular access complications. Nine percent of OPAT courses at home have at least one vascular access complication requiring clinical intervention. Longer OPAT duration, younger age, female sex and injection drug use are associated with increased risk of vascular access complications.

Using a multimedia presentation to improve patient understanding and satisfaction with informed consent for minimally invasive vascular procedures

ObjectiveAs vascular procedures become more complex, patient understanding of their treatment(s) can become more difficult. We wished to evaluate the utility of multimedia presentations (MPs) to improve patient understanding of their vascular interventions. MethodsPatients undergoing endovascular aneurysm repair (EVAR), peripheral angioplasty, Hickman catheter and peripherally inserted central catheter (PICC) insertion were randomized into a control group receiving traditional verbal consent, and a MP group that were shown a two minute simplified video of their procedure on an iPad™ computer in addition to the traditional verbal consent. After obtaining consent, all patients completed a questionnaire assessing their comprehension of the procedure, and satisfaction with the consent process. Satisfaction was rated on a 5 point Likert scale with 5 being ‘very helpful’ in understanding the procedure. ResultsNinety-three patients were recruited for this study, 62% of which were male. The intervention significantly increased total comprehension in all procedure types controlling for procedure type (multimedia vs. control; F = 9.14, P = .003). A second ANOVA showed there was a significant main effect by intervention (F = 44.06, p < .000) with those in the intervention group showing higher overall satisfaction scores after controlling for surgery type. ConclusionThis study suggests that patients find the use of MP during the consent process to be helpful in patient understanding and that there is improved satisfaction. Given the rapid rate of innovation in vascular interventions, increased regular use of MPs to help patients understand their procedures would be beneficial in the care of patients undergoing vascular interventions.

Peripherally Inserted Central Venous Catheters Are Associated With High Complication Rates in Patients With Inflammatory Bowel Disease

Introduction: Patients with inflammatory bowel disease (IBD) develop perforating complications and utilize total parenteral nutrition (TPN) as a form of treatment. Central venous catheter (CVC) placement is needed to administer TPN and/or antibiotics. The aim of this study was to identify factors associated with complications in IBD patients undergoing CVC placement. Methods: IBD patients that underwent long-term (>14 days) CVC placement from 2004 until 2013 were identified. Clinical information was extracted from a data repository and review of the medical record. CVC were categorized as ports, Hickman catheters (HC), and peripherally inserted central catheters (PICC). Modifications including antiseptic coatings, cuffs, tunneling and antibiotic/anticoagulant flushes were recorded. Development of CVC-related complications was recorded. Results: 93 patients underwent CVC placement. 74% were Caucasian, 70% were women, and 83% had CD. 47, 36, and 17% of CD patients had ileocolonic, ileal, and colonic disease location. 28% had perianal disease and 74% had perforating behavior. 77% of UC patients had pancolitis. 48 underwent HC, 45 underwent PICC, and none had a port. 24 (26%) developed a complication, including 20 line infections, 3 thrombotic events, and 1 septic thrombosis. 2 patients died. 96% of patients with complications underwent CVC placement to receive TPN. 19 (31%) patients undergoing PICC placement had a complication compared to 5 (19%) patients undergoing HC placement (p < 0.18). Modifications to CVC placement did not decrease the rate of CVC-complications. Patients with an abscess or treated with antibiotics at admission and those that developed post-operative infections were more likely to develop complications (p < 0.05). Methotrexate (MTX) was associated with complications (p < 0.05); however the number of patients treated with MTX was small (n=6). 13 (72%) patients with a history of MRSA, VRE, or CRE developed complications compared to 18% of patients without resistant bacteria (p=0.03). A history of prior CVC-related infection was associated with complications (56 vs. 19%, p=0.001). Patients with peripheral vascular disease and connective tissue diseases were more likely to develop complications (p=0.02). Conclusion: Providers should advocate strongly for HC placement if considering long term CVC use in IBD patients, especially if concurrent infection, prior CVC-related infection, or a history of resistant organisms is present.

Infection Rate of Hickman Catheters Versus Peripherally Inserted Central Venous Catheters in Oncology Patients

Infection Rate of Hickman Catheters Versus Peripherally Inserted Central Venous Catheters in Oncology Patients

Comparison of complications associated with peripherally inserted central catheters and Hickman™ catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study

Patients with intestinal failure (IF) are dependent on parenteral nutrition delivered through central access such as Hickman™ catheters. The peripherally inserted central catheter (PICC) is becoming increasingly popular for the purpose. The aim of the present study was to compare complication rates between the two types of catheters. Over a six-year period (2008-2014), we included 136 patients with IF receiving home parenteral nutrition (HPN). These patients had a total of 295 catheters (169 Hickman™ catheters and 126 PICCs). Data were collected by reviewing their medical records. Incidences are given per 1000 catheter days. Data are given as means±standard deviation (SD) and compared using independent student's t-tests, Mann-Whitney-Wilcoxon, and X(2)-tests. A survival analysis for time to the first infection was conducted using Cox regression. The total number of catheter days was 54,912 days for Hickman™ catheters (mean dwell time 325±402) and 15,974 days for PICCs (mean dwell time 127±121), respectively. The incidence of catheter-related blood stream infection (CRBSI) per 1000 catheter days was significantly lower for Hickman™ catheters compared to PICCs (0.56 vs. 1.63, p<0.05). The mean time to first CRBSI was significantly shorter for PICCs compared to Hickman™ catheters (84±94 days vs. 297±387 days, p<0.05), which was confirmed with a cox analysis corrected for age and gender. A total of 75 catheters were removed due to CRBSI, 49 Hickman™ catheters and 26 PICCs respectively. In addition, PICCs were more often removed due to local infection/phlebitis and mechanical causes (p<0.001). We found a higher risk and shorter time to first CRBSI in PICCs compared to Hickman catheters supporting that PICCs should mainly be chosen for planned HPN up to 3-6 months. We therefore conclude that the choice of catheter must still be determined on an individual basis.

Sterile v aseptic non-touch technique for needle-less connector care on central venous access devices in a bone marrow transplant population: A comparative study

PurposeThe aim of this study was to determine whether a variation in practice from an aseptic non-touch technique (ANTT) to a sterile technique when changing needleless connectors on central venous access devices (CVAD) was associated with any change in catheter related bloodstream infection (CRBSI) rates in the bone marrow transplant (BMT) population. MethodsA two group comparative study without concurrent controls using a retrospective cohort was conducted in a large metropolitan hospital in Brisbane, Australia. Inclusion criteria: haematological malignancy, Hickman catheter inserted, age ≥18. A tool was developed to extract historical data from medical records and pathology results. Primary outcome: CRBSI. Secondary outcomes: laboratory confirmed bloodstream infection, mucosal barrier injury laboratory confirmed bloodstream infection and skin contaminants. ResultsOne hundred and fifty patients were assessed, 73/150 (49%) in the ANTT group. Demographics: males 95/150 (63%), with 71/150 (47%) receiving an autologous BMT. No difference in CRBSI rates between groups was observed (ANTT n = 3 (4%) vs Sterile n = 1 (2.7%), p = 0.357 Fishers Exact Test). Infection by skin contaminants were identified in a similar number of cases across both groups (ANTT n = 9 (12.3%) vs Sterile n = 6 (7.8%)). ConclusionsNo causal effect can be deduced from this small study; nevertheless results imply that an ANTT was not associated with increased CRBSI. Poor hand hygiene and ANTT were perceived across both groups. Quality and consistent ANTT is a safe method for managing intravascular devices, however education and awareness of pathogen transfer from healthcare worker and patient to their device is required.

PTH-213 Breakage of tunnelled central venous catheters: frequency and repair kit outcomes in patients receiving home parental nutrition (HPN)

<h3>Introduction</h3> Complications of tunnelled central venous catheters (CVCs) range from inconvenient to life threatening. Breakages of the external portion can be repaired using a catheter specific repair kit which, when feasible, is preferable to changing the line. Breakage of the external portion is reported to be common but few studies have documented the use of and efficacy of repair kits. At Glasgow Royal Infirmary we recently changed from using 9.6Fr Hickman lines © to 6.6Fr Broviac lines © and thought the repair kits were less efficacious. We carried out this study to assess the frequency of breakages as a complication of tunnelled CVCs and repair kit outcomes in our cohort of HPN patients. <h3>Method</h3> A database prospectively compiling information in all patients receiving HPN in a single institution was searched retrospectively for catheter related complications. Patients with a catheter breakage were identified. The duration of HPN feeding; time from catheter insertion to breakage; catheter size and longevity of repair were calculated. Results are quoted as median and range as a normal distribution of the data could not be assumed. <h3>Results</h3> CVC breakages accounted for 12% (29 in 237) of all catheter related complications with a frequency of 0.17 per 1000 catheter days for the 9.6Fr catheters and 0.32 per 1000 days for the 6.6Fr catheters. The median time from insertion to damage was 592 days (203 to 1238 days) for the 9.6 Fr catheters and 215 days (6 to 374) for the 6.6 Fr. Of the 29 breakages repairs were successful in 13 (of the 21) 9.6 Fr catheters and 3 (of the 8) 6.6Fr catheters. The longevity of the 9.6 Fr catheter repairs ranged from 62 days to 2284 (median 340) compared with 31 to 374 days, median 101 in the 6.6 Fr catheters. There was no relation to catheter location and frequency of breakages. Eleven of the repaired lines were ultimately changed due to infection (4), blockage (2) and further breakages (5) within a time frame of 31 days to 610, median 159. <h3>Conclusion</h3> Tunnelled CVC breakages and repair using a kit is common and can be efficacious. Repair of the 6.6FR catheters was less successful. This has been discussed with the manufacturer and the repair kit modified. Unfortunately it does not seem to be improved and we are looking into different manufacturer’s products. It may be that the potential benefits of a smaller CVC are offset by the difficulty in repairing these smaller catheters. <h3>Disclosure of interest</h3> None Declared.

Environmental Risk Factors for Developing Catheter-Related Bloodstream Infection in Home Parenteral Nutrition Patients: A 6-Year Follow-up Study.

Tunneled, cuffed, central venous catheters, including Hickman catheters and peripherally inserted central venous catheters (PICCs), are the most commonly used venous access for home parenteral nutrition (HPN) therapy. Catheter-related bloodstream infection is the most prevalent and severe complication. This study investigated whether environmental risk factors, including smoking, catheter management by a home care nurse, colectomy with stoma, number of infusion days per week, and C-reactive protein at catheter insertion day, influenced the time to first catheter-related bloodstream infection (CRBSI). In this 6-year (2008-2014) observational cohort study, adult patients with intestinal failure receiving HPN through either Hickman catheters or PICCs were included. Data were obtained by reviewing medical records, and the environmental risk factors were analyzed with the Cox proportional hazards model. A total of 295 catheters (Hickman catheters: n = 169 and PICCs: n = 126) inserted into 136 patients were registered. Using the PICCs, 1 additional infusion day per week showed to significantly decrease the time to first CRBSI by a factor of 2.47. Hickman catheters managed by a home care nurse had a significantly increased mean (SD) incidence of CRBSI of 1.45 (0.68) per 1000 catheter days. Hickman catheters not managed by a home care nurse had a mean (SD) incidence of 0.56 (0.24). Using the PICC, 1 additional infusion day per week decreased the time to first CRBSI, while having the Hickman catheter managed by a home care nurse increased the mean CRBSI incidence. No other risk factors were found.

An artifice in the insertion of the Hickman catheter in small children

Although the Hickman catheter is commonly used in pediatric patients, it is difficult to place this catheter safely in small children, especially infants. A multiple-step method, starting with a thinner catheter, makes the placement easier and safer. Keywords: central venous catheter, children, Hickman catheter

Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors.

In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI. This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles. • Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.