Central Venous Catheter Group Research Articles

The incidence of catheter-related bloodstream infections in different central venous access devices: a network meta-analysis of randomized controlled trials

IntroductionDirect paired meta-analyses and network meta-analysis were conducted to compare the incidence of Catheter-associated bloodstream infections (CRBSIs) in different types of central venous access devices (CVADs).Material and methodsThe PubMed, EMBASE, Web of Science, Cochrane databases, CNKI and CBM were systematically searched from inception to May 31, 2024 for randomized controlled trials (RCTs) comparing the incidence of CRBSIs across various types of CVADs. Literature screening, data extraction, and risk bias evaluation were all independently conducted by two individuals. Direct paired meta-analyses and network me-ta-analysis were performed using RevMan5.3 and Stata14.0 software, respectively.ResultsA total of five literatures were included. Paired meta-analyses revealed that the incidence of CRBSIs was lower in the peripherally inserted central catheters (PICCs) group compared to the central venous catheters(CVCs) group(RR=0.23, 95%CI(0.13-0.43), P<0.00001). The incidence of CRBSIs in PICCs group was observed to be lower compared to that in totally implantable venous access ports(TIVAPs) group (RR=0.45, 95%CI(0.23-0.87), P=0.02). Descriptive analysis revealed a higher incidence of CRBSIs in CVCs group compared to the TIVAP group (RR=2.97, 95%CI(1.65-5.17), P=0.0002). The network meta-analysis revealed a significantly lower incidence of CRBSIs in the PICCs group compared to the CVCs group. However, no statistically significant differences were observed in other comparisons. Based on the cumulative ranking curve test, the incidence of CRBSIs in various CVADs was ranked as follows: PICCs(97.20%)> TIVAPs(50.00%)>CVCs(2.80%).ConclusionsThe available evidence suggests that PICCs exhibit the lowest incidence of CVADs, followed by TIVAPs. Therefore, PICCs should be prioritized when selecting CVADs.

Complications after peripherally inserted central catheter versus central venous catheter implantation in intensive care unit: propensity score analysis using a nationwide database

ABSTRACT Background It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups. Research design and methods Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses. Results We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32–2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38–3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16–2.99), and phlebitis (OR, 1.72; 95% CI, 1.27–2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39–3.04). Conclusions Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications.

Central venous catheters do not increase the hemorrhagic risk in acute promyelocytic leukemia patients during induction therapy.

In acute promyelocytic leukemia (APL), hemorrhage, particularly intracranial hemorrhage, is the most common cause of early death. A central venous catheter (CVC) may provide a greater guarantee of safety and comfort to APL patients. However, CVCs have seldom been attempted in APL patients during induction therapy because of concerns about increasing the risk of hemorrhagic complications after this invasive procedure. To evaluate the hemorrhagic risk after CVC placement in APL patients during induction therapy, we retrospectively analyzed 95 newly diagnosed patients with APL from January 2010 to December 2022. Among these patients, 39 patients in the CVC group and 56 patients in the non-CVC group were included. Laboratory and clinical parameters of the two groups were collected and compared. There were no significant differences in median platelet, fibrinogen (Fbg), D-dimer, prothrombin time (PT), white blood count (WBC) and hemoglobin (Hb) between the CVC and non-CVC groups on the first day of the visit (day 0) and the following days (day 4, day 7, day 11, day 14, day 18 and day 21) (p = 0.382, p = 0.805, p = 0.456, p = 0.902, p = 0.901 and p = 0.097, respectively). The consumption of transfused platelets and Fbg was not significantly different between the CVC group and non-CVC group (5.0 vs. 4.5 units, p = 0.34, and 6.8 vs. 6.0, p = 0.36, respectively). The last day of platelet and Fbg transfusion was also not significantly different (21 vs. 19, p = 0.238 and 7.5 vs. 8.5, p = 0.684, respectively). The incidences of total hemorrhagic events and hemorrhagic death were lower in the CVC group than in the non-CVC group (17.9% vs. 37.5%, p = 0.04 and 0% vs. 16.1%, p = 0.01, respectively). The 30-day survival rate was not significantly different (92.3% vs. 82.1%, respectively, p = 0.145) for the CVC group compared with the non-CVC group. Our study suggested that CVCs did not increase the hemorrhagic risk in APL patients during induction therapy and that a CVC should be considered in this type of clinical situation.

Closed thoracic drainage in elderly patients with chronic obstructive pulmonary disease complicated with spontaneous pneumothorax: A retrospective study.

Chronic obstructive pulmonary disease (COPD) combined with spontaneous pneumothorax, is characterized by significant decline in lung function, and even cause cardiopulmonary failure and hypoxia. To evaluate the clinical effectiveness of central venous catheters and indwelling pleural catheters (IPC) in managing closed thoracic drainage in patients diagnosed with COPD with concomitant by spontaneous pneumothorax. Retrospective analysis was conducted on the clinical information of 60 elderly patients with COPD complicated by spontaneous pneumothorax admitted to the Shexian Branch of the second affiliated hospital of Zhejiang university school of medicine between March 2020 and March 2023. The clinical efficacy, complications, hospitalization duration, and costs were compared between patients with an indwelling thoracic catheter and those with a central venous catheter. Univariate logistic regression was used to analyze the causes of catheter displacement. According to our findings, there were significant differences in the IPC group's clinical efficacy, catheter operation time, and lung recruitment time (P < 0.05). Comparing the complications after catheter treatment between the two groups revealed statistically significant variations in the incidence of postoperative analgesics, catheter abscission, catheter blockage, and subcutaneous emphysema in the IPC group (P < 0.05). Univariate analysis demonstrated significant differences between patients with and without catheter dislodgement regarding duty nurse's working years (less than three), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (less than 15), lack of catheter suture fixation, and the proportion of catheters not fixed twice (P < 0.05). Our results demonstrated that when treating elderly COPD patients with spontaneous pneumothorax, indwelling thoracic catheters are more effective than the central venous catheter group. Patients' catheter shedding is influenced by the primary nurse's working years, APACHE II scores, and catheter fixation technique.

Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study.

Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.

#5014 VALIDATION AND APPLICABILITY OF A MONITORING SYSTEM FOR VASCULAR ACCESS IN HAEMODIALYSIS: A MULTICENTRE STUDY

Abstract Background and Aims Routine systems for monitoring vascular access (VA) performance are lacking. We recently showed that with a VA triage system it is possible to improve the average value of a number of VA efficiency parameters and that the VA triage score was associated with clinical outcomes. The triage categorization is generated monthly by a scoring system which is based on a number of parameters (blood flows, VA pressure values, end HD circuit clots and a dedicated score of the external VA examination, KT/V) recorded at each session by the staff on a dedicate electronic spreadsheet. According to threshold values, triage classified each VA in Green (G), Yellow (Y) or Red (R), thus indicating the VA performance and the clinical risk of complication linked to VA. In our open label single centre study, with three years of follow-up, the average VA score improved significantly and G VA associated with lower mortality, compared to the Y and R VA. Aims: To validate the ability of the triage system to early identify VA with increased risk of complications. Methods In this interventional prospective, blinded multicentre study, each centre used the VA triage electronic spreadsheet without knowledge of the generated triage. After six months of system implementation, two years of follow-up (01/01/2020 - 01/12/2021) were planned to record VA related events. Two external reviewers evaluated the records. A minimum of three months VA follow up was necessary for patients enrolment. Results From 18 HD centres we enrolled 757 patients, aged 64,5±15,5 y.o.; 27% diabetics; HD since 24,4±32,4 months; 369 (48,7%) with arteriovenous fistula (AVF) and 388 (51,3%) with permanent central venous catheter (CVC). During 11,4±5,6 months of follow-up (range 3-23), 108537 HD sessions were recorded on the triage electronic spreadsheet, with 214 total clinical events and an event free time of 224,5 ±172 days (range 4-713). The VA related events were 150 (70,1%) during 16,3±2,2 months of follow up (range 3-23) with an event free time of 230±160 days (range 11-713). The VA Triage was: 60% Green, 35% Yellow and 5% Red. In the 369 patients with AVF the VA Triage was: 61% Green, 36% Yellow and 3% Red; The AVF Triage Green group showed: lower incidence of VA related events respect to the AVF Triage Yellow and Red group (30% vs 48%; P: 0.05); higher time-free from VA events (AVF Green vs AVF Yellow-Red: log-rank test: 0.04). Similar results were confirmed in the CVC groups: VA events incidence Triage Green 15% vs Triage Yellow-Red 40% (p: 0.001; time-free from VA events log-rank Test 0.001). Conclusion Our VA triage system identifies 40% of vascular accesses as yellow-red triage. These VA were not identified as at elevated clinical risk by the dialysis staff and only the Triage system was able to highlight them as critical. Notably the VA access with Yellow and Red Triage independently from the VA typology had an higher risk of clinical complications that according to the time survival curve could be detectable roughly 237,8 days before the event developed. The Triage system was able to identify early the VA with increased clinical risk and it may be a useful tool to prevent VA complication.

Trimmed central venous catheters do not increase endothelial injury in an ovine model.

Central venous catheters (CVCs) are often trimmed during heart transplantation and pediatric cardiac surgery. However, the risk of endothelial injury caused by the cut tip of the CVC has not been evaluated. We hypothesized that there is no difference in the degree of endothelial injury associated with trimmed CVCs versus standard untrimmed CVCs. In four adult male sheep, the left external jugular vein was exposed in three segments, one designated for an untouched control group, one for the trimmed CVC group, and one for the untrimmed CVC group. Trimmed and untrimmed CVC tips were rotated circumferentially within their respective segments to abrade the lumen of the vein. The vein samples were explanted, and two representative sections from each sample were analyzed using hematoxylin and eosin (H&E) staining, as well as with immunohistochemistry against CD31, von Willebrand factor (vWF), endothelial nitric oxide synthase (eNOS), and caveolin. Higher immunohistochemical stain distributions and intensities are associated with normal health and function of the venous endothelium. Data are presented as counts with percentages or as means with standard error. H&E staining revealed no evidence of endothelial injury in 6/8 (75%) samples from the untouched control group, and no injury in 4/8 (50%) samples from both the trimmed and untrimmed CVC groups (p = 0.504). In all remaining samples from each group, only mild endothelial injury was observed. Immunohistochemical analysis comparing trimmed CVCs versus untrimmed CVCs revealed no difference in the percentage of endothelial cells staining positive for CD31 (57.5% ± 7.2% vs 55.0% ± 9.2%, p = 0.982), vWF (73.8% ± 8.0% vs 62.5% ± 9.6%, p = 0.579), eNOS (66.3% ± 4.2% vs 63.8% ± 7.5%, p = 0.962), and caveolin (53.8% ± 5.0% vs 51.3% ± 4.4%, p = 0.922). There were no significant differences between the groups in the distributions of stain intensity for CD31, vWF, eNOS, and caveolin. Trimmed CVCs do not increase endothelial injury compared to standard untrimmed CVCs.

Lower risk of bloodstream infections for peripherally inserted central catheters compared to central venous catheters in critically ill patients

BackgroundPeripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous access in hospitalized patients. Although a number of studies suggest that PICCs are associated with a lower risk of central line-associated bloodstream infections (CLABSIs) than CVCs, recent data concerning specific patient groups support the contrary. In this regard, we are comparing CVC- and PICC-related CLABSI rates developed in a selected group of critically ill inpatients and evaluating the CLABSI microbiological distribution.MethodsThe study was conducted at a tertiary care hospital in Greece between May 2017 and May 2019. We performed a two-year retrospective analysis of the data collected from medical records of consecutive adult patients who underwent PICC or CVC placement.ResultsA total of 1187 CVCs placed for 9774 catheter-days and 639 PICCs placed for 11,110 catheter-days, were reported and analyzed during the study period. Among CVCs, a total of 59 (4.9%) CLABSIs were identified, while among PICCs, 18 (2.8%) cases presented CLABSI (p = 0.029). The CLABSI incidence rate per 1,000 catheter-days was 6.03 for CVC group and 1.62 for PICC group (p < 0.001). The CLABSI rate due to multidrug-resistant organisms (MDROs) among the two groups was 3.17 in CVC group and 0.36 in PICC group (p < 0.001). Within CLABSI-CVC group, the most common microorganism detected was MDR Acinetobacter baumannii (27.1%) followed by MDR Klebsiella pneumoniae (22%). In CLABSI-PICC group, the predominant microorganism was Candida spp. (33.3%) followed by non-MDR gram-negative pathogens (22.2%).ConclusionsPICC lines were associated with significantly lower CLABSI rates comparing to CVC although they were in place longer than CVC lines. Given their longer time to the development of infection, PICCs may be a safer alternative for prolonged inpatient IV access. The high prevalence of CLABSI-MDROs depicts the local microbial ecology, emphasizing the need of public health awareness.

Comparison of use of central venous catheter and arteriovenous fistula as initial vascular access in 735 patıents with end-stage renal disease

Aim: Although arteriovenous fistula (AVF) has been shown as the first choice for hemodialysis (HD), its superiority over central venous catheter (CVC) is still controversial considering the risk factors. Aim was to compare AVF and CVC, which should be is used as the first vascular access in HD.&#x0D; Material and Methods: Patients were divided into two groups according to the use of AVF and CVC. The groups were compared in terms of age, gender, body mass index (BMI), comorbidities, use of antiplatelet and anticoagulant agents, HD sessions per week, end stage renal disease (ESRD) duration, HD treatment duration, patency of vascular acces and number of changes. &#x0D; Results: When patients were grouped, 499 patients were in the CVC group and 235 patients were in the AVF group. The mean age of patients in the AVF group was higher than that of the CVC group (p=0.010). The difference between the median ESRD duration of the patients in the CVC and AVF groups was statistically significant (5 vs 6 months) (p=0.004). The duration of HD treatment was significantly longer in the AVF group (p=0.031). The median patency of their CVC was 3 months, while the median patency of their AVF was 48 months (p

Pregnancy outcomes in patients with late-onset severe OHSS following different methods of ascetic fluid drainage and a comparison with non-OHSS IVF patients.

In this study, we aimed to identify whether there are any differences in pregnancy outcomes in patients with severe ovarian hyperstimulation syndrome (OHSS) following the drainage of ascites by central venous catheter or paracentesis. We also aimed to identify differences in pregnancy outcomes between severe OHSS patients and non-OHSS IVF patients. This was a retrospective cohort analysis carried out in a university-affiliated reproductive center between 2012 and 2019 featuring 359 women with severe OHSS following ascites draining and 345 non-OHSS women (matched by age and the number of oocytes retrieved). We investigated the rates of clinical pregnancy, multiple pregnancies, miscarriage, live birth, and preterm delivery, between the two groups. Within the OHSS group (central venous catheter group vs paracentesis group), we also analyzed the odds ratios and 95% confidence intervals of clinical pregnancy. The rate of biochemical pregnancy loss in non-OHSS patients was significantly higher than that of severe OHSS patients (11.1% vs. 0.6%; P < 0.05). Live birth rate and the rate of multiple pregnancy (twin pregnancy) were much higher in the severe OHSS group than in the non-OHSS group (88.9% vs. 73.5%; 57.6% vs. 28.1%, respectively). There was no significant difference between the rate of singleton and twin preterm delivery, and neonatal birth weight between the OHSS and the non-OHSS groups. Binary logistic regression analysis revealed that multiple pregnancy and the long superovulation protocol had high odds ratios (odds ratio (OR) = 2.53), thus suggesting that these are significant risk factors for severe OHSS. When considering the patients with severe OHSS and the manner in which they underwent ascites drainage, we found that the volume of ascites in the central venous catheter group was significantly higher than that in the abdominal paracentesis group (P < 0.05). There were no significant difference between the two groups with regards to the number of live births and the birth weight of singletons and twins (P>0.05), although the premature birth rate of singletons in abdominal paracentesis group was 9.3% (10/107), compared with 3.75% in the central venous catheter group (P < 0.05). Analysis indicated that for women undergoing in vitro fertilization embryo transfer (IVF-ET), a higher number of antral follicle count, COS long protocol, and multiple pregnancy may be risk factors for late-onset OHSS. Both paracentesis and central venous catheters are effective modalities for the management of ascites in patients with severe OHSS. Catheters represent a safe and effective way to treat patients who need to undergo repeated paracentesis.

Randomized controlled trial of an alternative drainage strategy vs routine chest tube insertion for postoperative pain after thoracoscopic wedge resection

BackgroundThoracoscopic surgery has greatly alleviated the postoperative pain of patients, but postsurgical acute and chronic pain still exists and needs to be addressed. Indwelling drainage tubes are one of the leading causes of postoperative pain after thoracic surgery. Therefore, the aim of this study was to explore the effects of alternative drainage on acute and chronic pain after video-assisted thoracoscopic surgery (VATS).MethodsNinety-two patients undergoing lung wedge resection were selected and randomly assigned to the conventional chest tube (CT) group and the 7-Fr central venous catheter (VC) group. Next, the numeric rating scale (NRS) and pain DETECT questionnaire were applied to evaluate the level and characteristics of postoperative pain.ResultsNRS scores of the VC group during hospitalization were significantly lower than those of the CT group 6 h after surgery, at postoperative day 1, at postoperative day 2, and at the moment of drainage tube removal. Moreover, the number of postoperative salvage analgesics (such as nonsteroidal anti-inflammatory drugs [(NSAIDs]) and postoperative hospitalization days were notably reduced in the VC group compared with the CT group. However, no significant difference was observed in terms of NRS pain scores between the two groups of patients during the follow-up for chronic pain at 3 months and 6 months.ConclusionIn conclusion, a drainage strategy using a 7-Fr central VC can effectively relieve perioperative pain in selected patients undergoing VATS wedge resection, and this may promote the rapid recovery of such patients after surgery.Trial registrationClinicalTrials.gov, NCT03230019. Registered July 23, 2017.

Validation and Implementation of the Use of Peripherally Inserted Central Catheter (PICC) for the Administration of Peripheral Blood Stem Cells (PBSC): A Single-Institution Experience

Background:Infusion of peripheral blood stem cell (PBSC) in patients undergoing autologous transplantation (ASCT) has been conventionally performed using central venous catheters (CVC) inserted through the subclavian or internal jugular vein. Peripheral inserted central catheters (PICC) are routinely used for infusion of blood products and medication, but its use for PBSC infusion has not been well established. Our study aimed to evaluate the feasibility and safety of using PICC to deliver PBSC for ASCT through an in-vitro lab-based validation process, followed by a clinical review.Methods: •Lab based validationIn vitro infusion of 6 cryopreserved PBSCs was performed, 3 infused PICC whist 3 via CVC. Each product was thawed for the same amount of time and drained by gravity. Pre-infusion and post-infusion total nucleated cell counts (TNC), CD34 counts and CD34 viability of the PBSCs were analysed by flow-cytometry and compared using paired T test. In vitro infusion rates were also compared between PICC and CVC groups. •Clinical Outcome AnalysisThe clinical study included 31 patients (Lymphoma N=21, myeloma N=5, Others, N=4) who underwent ASCT at National University Cancer Institute, Singapore (NCIS) from September 2019 to July 2021. All patients had a 19G BARDS dual lumen PICC inserted in either the brachial or basilic veins and used for PBSC infusion. The PBSC infusion rate, infusion associated complications, time to absolute neutrophil count (ANC) >1, and platelet count engraftment >100K were analysed.Clinical outcomes in the lymphoma cohort, who received BEAM conditioning (N=17) were also compared with a control group, matched for conditioning, cell dose and age, who had PBSC infused via CVC.Results: •In vitro findings:Overall flow rates for infusion through PICC was slower (mean 0.1mls/s vs 0.3mls/s, p < 0.05). However, there were no significant % differences in TNC counts (5% vs 9%, p=0.4), CD34 counts (17% vs 15%, p=0.9) and viability (4% vs 7%, p=0.2) between pre and post infusion samples for PICC and CVC.. •Clinical findings:30 patients (Lymphoma N=21, myeloma N=5, N=4) were included. 15 (50% of patients) had a for ASCT while 15 (50%) had an existing PICC. For patients with an existing PICC, the median duration of catheter in situ was 86 days. New lines were inserted 2-7 days prior to the PBSC infusion. The median age of the patients was 54 (20-71) with 19 males (63%). . There were 5 infusion related complications, 2 in an existing PICC and 3 in new PICCs. 4 were related to slow flow rate and 1 was related to sediments seen in the line. None led to a need for alternative line for infusion. The median time to ANC recovery was 10 (range 9-14), 10 (range 9-11) and 11 days (range 10-12), while the median time to platelet engraftment was 18 (range 10-195), 20 (range 15-55) and 22 (16-85 days) for the lymphoma BEAM conditioning (N=17), lymphoma Carmustine/ Thiotepa conditioning (N=4), and the myeloma (N=5) cohorts respectively.Clinical outcomes in the lymphoma cohort, who also compared with a control group matched for conditioning, cell dose and conditioning. The in-vivo infusion rate was slower in the PICC group, compared to the CVC group (3.1 mls/min vs 4.5mls/min, p<0.05).There was however no differences in engraftment with median time to ANC recovery 10 days (range 9-14) vs 11 days (range 9-13) (p>0.05) and median time to platelet engraftment 18 (range 14-195) vs 19 days (range 14 -57) (p>0.05) in the PICC vs CVC groups respectively.Conclusion:Our in-vitro and clinical findings confirmed that the use of PICC for PBSC infusion is safe and efficacious and reduces the need for CVC insertion. Our findings have led to change in clinical practice with utilization of PICCs for PBSC infusions for ASCT. DisclosuresNo relevant conflicts of interest to declare.

Results of the implementation of a triage system of vascular access performance in haemodialysis patients: experience of a single dialysis centre.

Routine systems for monitoring vascular access (VA) performance are lacking. We developed a vascular accesstriage system to evaluate the monthly performanceof the access, developed a specific score and assessed the association betweenscore improvement and clinical outcomes. Vascular access was triaged (Green, Yellow or Red) according to a score generated by dialytic and clinical parameters in all patients who, from 1/1/2014 to 31/03/2014, had been receiving haemodialysis treatment for at least 3 consecutive months in our Unit and who were then followed up for 4 years. We enrolled 130 patients, 78 with arteriovenous fistula (AVF) and 52 with tunnelled central venous catheter (CVC). During a median of29 ± 11months of follow up (range 3-46months), 28 deaths and 303 hospitalizations (lasting 16 ± 30days) were recorded. Vascular accesstriagescores improved over time(2014 vs 2015 vs 2016 vs 2017) in the population with an AVF(Green from 25% to 58% to 77% to 79%, Yellow from 65% to 39% to 18% to 20% and Red from 10% to 3% to 5% to 1%, respectively; χ2 p < 0.01) but not in the CVC group (Green 58% to 57% to 80% to 92%; Yellow 37% to 36% to 20% to 8%; Red 5% to 7% to 0%; χ2 = n.s). Blood pressure and dialysis efficiency improved in the population as a whole and in the two subgroups (AVF and CVC) separately. AVF and CVC populations, stratified separately according to median VA score, had different event-free follow-up, which was higher (p = 0.0085) in patientswith lower scores in the AVF population only. The vascular accessmonitoring system improved the vascular accessscore as well as someclinical and dialytic parameters. Green triage in AVF patients identify those with better outcomes, in agreement with the commonly recognized clinical value of a well-functioning vascular access.

Focal Adhesion Kinase Inhibitor Inhibits the Oxidative Damage Induced by Central Venous Catheter via Abolishing Focal Adhesion Kinase-Protein Kinase B Pathway Activation.

The vascular injury induced by central venous catheter (CVC) indwelling is the basis for the occurrence and development of CVC-related complications, such as phlebitis, venous thrombosis, and catheter-related infections. Focal adhesion kinase (FAK) and FAK-protein kinase B (AKT) signaling pathway are of great significance in tissue repair after trauma. Here, we investigated the role and mechanism of the FAK inhibitor (1,2,4,5-phenyltetramine tetrahydrochloride (Y15)) in oxidative damage caused by CVC. EA.hy926 cells were divided into the control group (normal control), CVCs+scratches group (the intercepted CVC segments coculturing with scratched EA.hy926 cells), and CVCs+scratches+Y15 group (Y15 was added to the cell culture supernatant with CVCs + scratches at a final concentration of 50 μmol·L−1). New Zealand rabbits were randomly divided into the control group (normal control), CVC group (CVC was inserted through the rabbit's right jugular vein to the junction of the right atrium and superior vena cava), and CVC+Y15 group (CVC was immersed in a 50 μmol·L−1 Y15 solutions before insertion). The levels of markers and proteins related to oxidative damage in cells, cell culture supernatant, serum, and external jugular vein were measured by commercial kits and western blot, respectively. We found that Y15 treatment significantly decreased ROS and MDA levels and increased cell viability, NO, and SOD levels in a time-dependent manner in rabbit serum and cell culture supernatant. In addition, Y15 effectively reduced the CVC-induced pathological changes of damaged vascular tissues. Y15 also downregulated the levels of p-FAK Tyr 397 and p-Akt Ser 473 in damaged external jugular vein and EA.hy926 cells. These findings suggest that Y15 alleviated CVC-induced oxidative damage to blood vessels by suppressing focal FAK-Akt pathway activation.

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI). To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort. Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases. Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S.aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population. Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

Temporary central venous catheter at hemodialysis initiation and reasons for use: a cross-sectional study

BackgroundCreating permanent vascular access (VA) is recommended before hemodialysis initiation in patients with end-stage renal disease (ESRD). Although many patients are still introduced to hemodialysis with temporary central venous catheters (CVCs), the reasons for their use remain unclear. We aimed to clarify the characteristics of Japanese patients introduced to hemodialysis using temporary CVCs, the reasons for their use, and whether this rate can be reduced in the future.MethodsWe conducted this cross-sectional study in an acute care general hospital in Japan. We enrolled 393 patients aged ≥ 18 years who received a permanent VA creation for initiating hemodialysis. We classified participants into the temporary CVC group or the permanent VA group according to the VA type at hemodialysis initiation and compared their backgrounds. We identified why permanent VA could not be used at hemodialysis initiation for patients in the temporary CVC group.ResultsOf the 393 patients, 137 (35%) initiated hemodialysis with a temporary CVC, and arteriovenous fistulas (AVFs) were created as the first VA in all patients during hospitalization following hemodialysis initiation. The remaining 256 patients (65%) initiated hemodialysis via AVF cannulation. The duration of predialysis nephrology care was significantly shorter in the temporary CVC group than that in the permanent VA group. The median time from AVF creation to the first successful cannulation was also shorter in the temporary CVC group (8 vs. 66 days, P < 0.001), but the estimated glomerular filtration rate values at hemodialysis initiation did not differ. Reasons for temporary CVC use were varied and complex. Problems on the part of healthcare providers, patient behavioral issues, and characteristics of causative kidney disease itself were underlying reasons. Delayed referral to a nephrologist was less frequent than expected (16%) and the most commonly reported reason (20%) was that a nephrologist was unable to predict the timing of hemodialysis initiation.ConclusionsPatients with ESRD should be referred to a nephrologist earlier for AVF creation. However, given the already relatively high rate of hemodialysis initiation with permanent VA in Japan, we considered it surprisingly difficult to further reduce the temporary CVC usage rate in Japan.

The rate of catheter-related bloodstream infection in renal dialysis patients using central venous catheters: A retrospective study

Background: Globally, haemodialysis patients using central venous catheters remain at a huge risk for blood stream infections. Most of these infections are caused by skin dormant organisms. Patients suffering from blood stream infections have the risk of seeding the infection into distant organs leading to multiple organ failure, fulminant shock and death. Objectives: our primary objective is to calculate the rate of catheter related blood stream infections (CRBSI) in patients inevitably using central venous catheters (CVC) while waiting for their arteriovenous fistula (AVF) maturation, and compare it to the international benchmark. Our secondary objective is to compare the morbidity and mortality outcomes between patients using central venous catheters vs. patients with arteriovenous fistula. Methods: A retrospective single centre study on Tawam hospital outpatient dialysis patients, who underwent dialysis at the SEHA dialysis service (SDS) centre. Data were obtained from 1st January 2015 till 30th Dec 2015. We only included patients needed to temporarily use CVC while waiting for their AV maturation. Data were obtained from Electronic Medical Records, and analysed using SPSS. Results: The total study population was 219 patients, of them; 175 patients of them were using a CVC for their first haemodialysis session. Out of patients using CVC, 53 (30.3%) patients were admitted at least once for an episode of infection during the first year of initiation of dialysis. The number of overall admission days were higher in the CVC group (2172 days) when compared to patients who started their haemodialysis with AVF directly without using CVC initially (588 days). The rate of CRBSI in our patients using CVC temporarily appeared to be 5.2 episodes per 1000 catheter-days. The number of interventional radiology procedures needed were significantly higher in the patients using CVC. There were 16 mortality cases, of which 15 (93.8%) were in the group using CVC. Conclusion: Dialysis through central venous catheter showed to have an increase in the number of admission days (overall and related to CRBSI), morbidity and mortality when compared to arteriovenous fistula. In the light of these findings, the decision of either waiting for fistula maturation or using CVC temporarily should be carefully tailored on case by case basis. Quality improvement projects are needed to address this important problem hospital wide. Decreasing hospitalization decreases the burden and the stretch on health care services and allows to provide better patient centred care.

Pulmonary valve infective endocarditis: A case series

Background and Objectives:Infective endocarditis (IE) involving the native pulmonary valve (PV) is extremely rare, with no data in Indian literature. The objective of this communication is to describe the clinical and diagnostic characteristics, underlying risk factors, microbiological features, and management of PVIE.Methods:This is a retrospective analysis of 8 cases of PVIE managed in a tertiary care center from 1992 to 2020.Results:PVIE was observed in 8 patients with underlying congenital cardiac malformation (Group A, 6 Patients) and in patients with central venous catheter (Group B, 2 patients). All the patients had prolonged febrile illness accompanied by right heart failure 4 (50%), septic pulmonary emboli 2 (25%), and pulmonary regurgitation 3 (37.5%). Trans-thoracic echocardiography demonstrated the vegetations, whereas computed tomography of chest diagnosed pulmonary emboli in 2 (25%), and pulmonary artery aneurysm in 1 (12.5%) patient. The early mortality was extremely high (5, 62.5%). Delayed diagnosis, fulminant septicemia, and multi-organ failure resulted in unfavorable outcomes.Conclusions:IE of the native PV is a rare and potentially lethal illness. Diagnosis should be considered in any febrile patient with an underlying congenital defect, central venous line, bacteremia, and comorbidities. Multi-modality imaging should be utilized to enhance the diagnostic yield and detect complications promptly.

Antimicrobial-impregnated central venous catheters for preventing neonatal bloodstream infection: the PREVAIL RCT.

Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies. The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS. Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England. The randomised controlled trial was conducted in 18 neonatal intensive care units in England. Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size). The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation. Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data. Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days. The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance. No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care. Current Controlled Trials ISRCTN81931394. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.

A45 INFLAMMATION AND INTESTINAL PERMEABILITY IN PEDIATRIC SHORT BOWEL SYNDROME

Abstract Background Both intestinal dysbiosis and central-line associated blood stream infections (CLABSI) have been well documented in children with short bowel syndrome (SBS). Gastrointestinal microbiota prime and regulate mucosal immunity, therefore we hypothesize children with SBS may have longstanding increased intestinal permeability which could lead to mucosal inflammation and predispose to bacteremia. Aims We sought to investigate intestinal permeability as well as both intestinal and systemic activation of the inflammatory cascade in children with SBS. Methods Two cohorts of children with SBS were consented; with Group 1 including children with SBS requiring central venous catheter (CVC) for parenteral nutrition, and Group 2 including children with SBS without CVC. SBS groups were compared to three control groups including age and sex-matched children with CVC for hematologic disease (Group 3), children without a CVC (Group 4) and healthy adult controls (Group 5). To evaluate intestinal permeability, we quantified circulating bacterial products LPS and MDP through the binding of their respective receptors, TLR4 and NOD2. To determine colonic inflammation, fecal calprotectin was quantified from a single stool sample. Cytokine profiles included IFN-γ, IL-Iβ, IL-8, IL-10, IL-17, TNFα were quantified by Multiplex Immunoassay while gene expression of transcription factors FoxP3+, RORγT, TLR2, and TLR4, were determined by RNA extraction and quantitative PCR. Results 22 children were recruited in the study (Group 1 n=6, Group 2 n=6, Group 3 n=5, Group 4 n=5) as well as 10 adult control samples (Group 5). The median age of Group 1 was 67 months with a residual small intestine of 26.5cm (IQR 24.7–40) while those in Group 2 were 51 months with a residual small intestine of 55cm (IQR 31.2–89). Circulating bacterial products of LPS and MDP were not different between SBS groups and control children. Serum analysis of cytokine TNFα was significant (p&amp;lt;0.005) however multiple comparator analysis did not identify within group differences. Other cytokines did not differ between groups. Fecal calprotectin levels were not elevated however statistically lower in Group 1 (median 12.8mg/kg; IQR 9.3- 34.9) compared to in Group 2 (median 96mg/kg, IQR 71.6–188.2;) p &amp;lt;0.01. Relative quantification of RNA expression of FoxP3+, RORγT, TLR2, and TLR4 did not differ between groups. Conclusions Despite concern of compromised intestinal epithelial barrier function in children with SBS, this study did not detect differences in circulating bacterial products compared to control children as an assessment of intestinal permeability nor increased systemic inflammation. Further research is required to investigate intestinal epithelial barrier function over time and the mechanism of bacteremia in children with SBS. Funding Agencies CAGRegional Medical Associates of Hamilton