Central Venous Catheter Insertion Site Research Articles

Transoesophageal echocardiography and central line insertion

We investigated the potential utility of transoesophageal echocardiography (TOE) in facilitating central venous catheter (CVC) insertion in patients undergoing cardiac surgery. Thirty five patients undergoing elective cardiac surgery and CVC insertion were prospectively included in the observational, single-centre clinical investigation. Following induction of general anaesthesia and tracheal intubation, the TOE probe was inserted and the bicaval view obtained prior to CVC insertion (site at discretion of the anaesthesiologist). Prospectively collected data included site and sequence of CVC insertion attempts, information regarding ease of guidewire insertion, whether or not guidewire was visualized via TOE, and other pertinent information. In 1 patient, the TOE bicaval view could not be readily obtained because of right atrial (RA) distortion. In 31 patients, the TOE bicaval view was obtained and CVC access was successful at the site of first choice (guidewire visualized in all). Three patients had noteworthy CVC insertions. In one, CVC insertion was difficult despite visualization ofguidewire in the RA. In another, multiple guidewire insertions met with substantial resistance and without visualization of guidewire in the RA. One patient was found to have an unanticipated large mobile superior vena cava thrombus that extended into the RA, which changed clinical management by prompting initial CVC insertion into the femoral vein (potentially avoiding morbidity associated with thrombus dislodgement). Our prospective observational clinical study indicates that routine use of TOE during CVC insertion may help avoid potential complications associated with this intervention. If both CVC insertion and TOE are going to be used in the same patient, the benefits of TOE should be maximized by routine visualization of the bicaval view during guidewire insertion.

Microbial Etiology of Hemodialysis Related Central Venous Catheter Exit Site Infections Following Use of Triple Antibiotic Ointment to Insertion Site

BACKGROUND/OBJECTIVES: Catheter related infections are a serious and common complication in Hemodialysis (HD) patients who are dependent on central venous catheters (CVC) for their access. Applying Triple Antibiotic Ointment a broad spectrum topical antibacterial ointment containing Polymyxin B Sulfate, Bacitracin Zinc and Gramicidin to the CVC insertion site has been found to reduce the incidence of catheter related infections. OBJECTIVE: To assess the frequency of exit site infections and the proportion due to Candida sp after instituting a practice of applying Triple Antibiotic Ointment to the insertion site of CVC catheters. METHODS: The patient population included in this project was a convenience subset of a Regional Dialysis population. All HD patients in 4 of 17 HD units within our Renal Program using a permanent tunneled and cuffed CVC for their HD access were included. Patients were surveyed from January 1 to March 31 2005. During this period a thin film of Triple Antibiotic Ointment was applied by dialysis nurses 3 times /week before each HD episode. Patient dialysis charts and culture reports from swabs of CVC sites were regularly reviewed. The Canadian definition for exit site infections was used to determine the presence or absence of infection. RESULTS: There were 306 HD patients and 147 patients used a permanent tunneled and cuffed CVC for their HD access. There were fifteen exit site infections in 15 patients during the 3 month survey, 2.7 per 1000 patient runs, 1.16 per 1000 catheter days. Of the 15 infections five (33%) were yeast infections. Other identified pathogens were Coagulase-negative Staphylococcus, Staphylococcus aureus, Enterococcus sp, Pseudomonas aeruginosa and Diphtheriods . CONCLUSIONS: Following implementation of topical antibacterial prophylaxis of CVC exit sites, there has been an apparent increase in Candida sp as a cause of CVC site infections. A longer term study is warranted to confirm these results.

Central Venous Catheter Colonization in Critically Ill Patients: A Prospective, Randomized, Controlled Study Comparing Standard with Two Antiseptic-Impregnated Catheters

In this prospective, randomized, controlled, unblinded study, we compared colonization rates of a standard, unimpregnated central venous catheter (CVC) with rates for silver-coated and chlorhexidine-silversulfadiazine (CH-SS)-impregnated CVC. Patient characteristics, CVC insertion site, indwelling time, and colonization detected by semiquantitative and quantitative microbiologic techniques were documented. Two-hundred-seventy-five critically ill patients were included into the study protocol. One-hundred-sixty standard, 160 silver (S)-coated, and 165 externally impregnated CH-SS CVC were inserted. There was a significant difference in CVC colonization rates among study groups (P = 0.029). There was no difference in the colonization rate and the colonization per 1000 catheter days between standard and S-coated (P = 0.564; P = 0.24) or CH-SS-coated CVC (P= 0.795; P = 0.639). When comparing antiseptic CVC with each other, colonization rates were significantly less with CH-SS-impregnated than with S-coated CVC (16.9% versus 7.3%; P = 0.01; 18.2 versus 7.5 of 1000 catheter days; P = 0.003; relative risk, 0.43; 95% confidence interval, 0.21-0.85). Whereas standard and S-coated CVC were first colonized 2 and 3 days after insertion, respectively, CH-SS CVC were first colonized only after 7 days. In conclusion, antiseptic-impregnated CVC could not prevent catheter colonization when compared with standard polyurethane catheters in a critical care setting with infrequent catheter colonization rates and CVC left in place for >10 days.

Octenidine Hydrochloride for the Care of Central Venous Catheter Insertion Sites in Severely Immunocompromised Patients

To determine the efficacy and tolerability of octenidine hydrochloride, a non-alcoholic skin antiseptic, for the care of central venous catheter (CVC) insertion sites. Prospective, observational study. Bone marrow transplantation unit of a university hospital. All consecutive patients with a nontunneled CVC were enrolled prospectively after informed consent. Octenidine hydrochloride (0.1%) was applied for disinfection at the CVC insertion site during dressing changes. The following cultures were performed weekly as well as at the occurrence of any systemic inflammatory response syndrome criteria: cultures of the skin surrounding the CVC entry site, cultures of the three-way hub connected to the CVC, blood cultures, and cultures of the CVC tip on removal. Enhanced microbiological methods (skin swabs of a 24-cm2 standardized area, roll plate, and sonication of catheter tips) were applied. One hundred thirty-five CVCs were inserted in 62 patients during the study period and remained for a mean period of 19.1 days, corresponding to 2,462 catheter-days. Bacterial density at the insertion site declined substantially over time, and most cultures became negative 2 weeks after insertion. Only 6 patients had a documented catheter-related bloodstream infection. The incidence density was 2.39 catheter infections per 1,000 catheter-days. No side effects were noted with application of the antiseptic. Disinfection with a skin antiseptic that contains octenidine hydrochloride is highly active and well tolerated. It leads to a decrease in skin colonization over time and may be a new option for CVC care.

WARP - A multicentre prospective randomised controlled trial (RCT) of thrombosis prophylaxis with warfarin in cancer patients with central venous catheters (CVCs)

LBA8004 Background: CVC-related thrombosis is a significant cause of morbidity and mortality in cancer patients. Prophylactic practice is varied. We report a large pragmatic RCT of thrombosis prophylaxis in cancer patients receiving chemotherapy via CVCs. The utility of warfarin and 2 dosing strategies was investigated. Methods: Patients, over 16 years old, with solid or haematological malignancies receiving chemotherapy via a CVC, with adequate haematological, hepatic and renal function and no contraindication to, or not currently on warfarin, were randomised according to clinicians’ prescribing practices: Uncertain indication - randomised to control vs warfarin (1mg or dose adjusted warfarin (DAW) to maintain INR between 1.5 and 2.0) Certain indication - randomised to 1mg warfarin vs DAW Patients were stratified by CVC insertion site, chemotherapy regimen and infusion duration. Analysis is on intention-to-treat and the primary endpoint is the number of radiologically proven CVC-related thrombotic events. Thrombosis rates will be compared using a test for proportions. The secondary endpoints of catheter longevity, toxicity and mortality will be investigated using chi-squared and logrank tests. The sample size was calculated to provide 90% power to detect a 10% difference in thrombosis rates between warfarin and no warfarin and 80% power to detect a 7% difference in the warfarin dose comparison (both 2p=0.05). Results: 1590 patients were randomised. In terms of the primary endpoint, patients are followed up for the duration of their CVC and the current median longevity is 105 days (inter-quartile range: 62 to 163). Conclusions: The results of WARP, whether showing benefit for warfarin or not, will impact on clinical practice internationally. No significant financial relationships to disclose.

Epidemiologic and molecular characterization of an outbreak of Candida parapsilosis bloodstream infections in a community hospital.

Candida parapsilosis is an important cause of bloodstream infections in the health care setting. We investigated a large C. parapsilosis outbreak occurring in a community hospital and conducted a case-control study to determine the risk factors for infection. We identified 22 cases of bloodstream infection with C. parapsilosis: 15 confirmed and 7 possible. The factors associated with an increased risk of infection included hospitalization in the intensive care unit (adjusted odds ratio, 16.4; 95% confidence interval, 1.8 to 148.1) and receipt of total parenteral nutrition (adjusted odds ratio, 9.2; 95% confidence interval, 0.9 to 98.1). Samples for surveillance cultures were obtained from health care worker hands, central venous catheter insertion sites, and medical devices. Twenty-six percent of the health care workers surveyed demonstrated hand colonization with C. parapsilosis, and one hand isolate was highly related to all case-patient isolates by tests with the DNA probe Cp3-13. Outbreak strain isolates also demonstrated reduced susceptibilities to fluconazole and voriconazole. This largest known reported outbreak of C. parapsilosis bloodstream infections in adults resulted from an interplay of host, environment, and pathogen factors. Recommendations for control measures focused on improving hand hygiene compliance.

Use of occlusive dressings on central venous catheter sites in hospitalized children

Although the use of occlusive dressings in adults has been criticized in the literature, there has been little written on their use in the pediatric population. Management of dressing sites requires nursing judgement unique to this population. This study focused on the progression of microbial colonization and signs of inflammation occurring beneath repeated occlusive dressings applied to central venous catheter (CVC) insertion sites among 104 hospitalized children (neonate to 18 years). A noninvasive skin culture was obtained within 24 hours of CVC placement, 3 to 7 days later before the next routine dressing change, and at the time the CVC was discontinued or the child was discharged, whichever occurred first. Results showed a significant increase in microbial growth (p < or = .001) at the second dressing change, when serosanguinous drainage was heaviest, and continued significant growth (p < or = .001) when the dressing was discontinued. This microbial growth pattern was curious in the face of a 0.3% systemic sepsis rate. When neonates under 1,800 g were excluded from calculation, the pattern was not notable (p = .2119). Findings suggest the use of occlusive dressings during prolonged hospitalization for tunnelled CVCs does not lead to increased site infections in children over 1,800 g.

Prospective Comparison of Two Management Strategies of Central Venous Catheters in Burn Patients

Central venous catheters (CVCs) are associated with sepsis in burn patients. This study was undertaken to compare two strategies of CVC management in patients with major burn injuries. Forty-two burn patients with major burn injuries were randomly assigned to undergo site change every 48 hours of the CVC or to undergo wire guide exchange of the CVC every 48 hours at the same site. Catheter insertion site, distance from the burn wound, cultures of catheter tips, and blood cultures were obtained from all patients in a prospective manner. There was no difference in the incidence of CVC sepsis between the two groups studied. CVCs inserted less than 5 cm from the burn wound developed bacterial contamination at an earlier time than CVCs inserted more than 5 cm from the burn wound. There was no advantage to changing the CVC insertion site every 48 hours. Changing the CVC using the wire guide technique did not prevent, nor predict, CVC bacterial contamination.

Leukemic dermal infiltrates at permanent indwelling central venous catheter insertion sites

Three cases of leukemic dermal infiltrates at permanent indwelling central venous catheter insertion sites in patients with acute myelogenous leukemia are reported. Two patients had a localized soft tissue mass at the previous permanent indwelling catheter insertion site as the sole initial manifestation of relapse after achieving complete remission and undergoing bone marrow transplantation. The third patient had catheter tunnel sepsis preceding leukemic dermal infiltration. A review of the English language literature showed that this condition is rare with no specific pathogenetic mechanisms identified. Patients with unresolved catheter tunnel infections in acute leukemia and persistent chest wall masses that appear after a previous permanent indwelling catheter should have a biopsy done and be treated promptly.

Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters

More than 90% of all intravascular device-related septicaemias are due to central venous or arterial catheters. To assess the efficacy of cutaneous antisepsis to prevent catheter-associated infection, we prospectively studied three antiseptics for disinfection of patients' central venous and arterial catheter insertion sites in a surgical intensive care unit. 668 catheters were randomised to 10% povidone-iodine, 70% alcohol, or 2% aqueous chlorhexidine disinfection of the site before insertion and for site care every other day thereafter. Chlorhexidine was associated with the lowest incidence of local catheter-related infection (2·3 per 100 catheters vs 7·1 and 9·3 for alcohol and povidone-iodine, respectively, p=0·02) and catheter-related bacteraemia (0·5 vs 2·3 and 2·6). Of the 14 infusion-related bacteraemias (4 due to contaminated infusate or catheter hub, 10 due to infected catheters), 1 was in the chlorhexidine group and 13 were in the other two groups (odds ratio 0·16, p=0·04). We conclude that use of 2% chlorhexidine, rather than 10% povidone-iodine or 70% alcohol, for cutaneous disinfection before insertion of an intravascular device and for post-insertion site care can substantially reduce the incidence of device-related infection.

The effects of ether anaesthesia on anaphylaxis: Koontz, A. R., and Shackelford, R. T.: Anesth. & Analg. 19: 194, 1940

As the sciences of vascular access and infection prevention rapidly advance healthcare professionals are often faced with new technologies designed to help, but which are often so complicated to use that they cause unforeseen problems. As a vascular access team at a major mid-western hospital, we evaluated the ease-of-use and the performance characteristics of a new transparent catheter dressing, 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) containing the antimicrobial chlorhexidine gluconate (CHG), with a variety of central venous catheters insertion sites in comparison to a standard non-antimicrobial dressing Tegaderm® (3M Health Care™, St. Paul, MN). Following IRB approval, sixty-three consenting patients were enrolled and randomized; 33 in the CHG antimicrobial dressing group and 30 in the standard dressing group. Thirty six patients had peripherally inserted central catheters (PICCs), 20 had intrajugular insertions (IJ), and 7 had subclavian insertions. The new 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) was evaluated for its ability to permit visualization of the insertion site, ease of use, ease of using correctly, ability to secure the catheter and absorb exudates and remain transparent.The new 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) was found to be as easy to use in central venous catheter care clinical practice as the standard of care non-antimicrobial transparent adhesive dressing. No additional training or education was required to properly use it. This dressing was applied and removed like standard transparent adhesive dressings, but offered many advantages over standard dressings. Advantages include that it is antimicrobial, handles moderate bleeding, remains transparent and appears to offer greater catheter securement than the Tegaderm® (3M Health Care™, St. Paul, MN) standard dressing. The CHG gel pad also conformed well to the catheter.