Central Venous Catheter Occlusion Research Articles

Expert consensus on safety management of vascular access devices for patients with digestive system cancer (2024)

The rational selection and standardized management of vascular access devices is an urgent issue in the treatment of digestive system cancer. The purpose of this consensus is to develop solutions for the safe management of intravenous vascular access devices for patients with digestive system cancer and to provide evidence for clinical decision-making. This consensus is developed by a group of experts from multiple-disciplines in China International Exchange and Promotive Association for Medical and Health Care Clinical Nutrition Health Branch, Clinical Nutrition Branch of Chinese Nutrition Society, Chinese Society for Parenteral and Enteral Nutrition. It is based on the best current evidence and combined with Chinese clinical practice experience. The recommendations were discussed and on the following topics: how to choose vascular access devices for patients with digestive system cancer; optimal selection of puncture sites and positioning of the tip for peripherally inserted central catheters; prevention and management of complications post-central venous catheterization; strategies for prevention and treatment of central venous catheter occlusion; criteria for central venous catheter removal; indications for the use of venous port access and criteria for peripheral venous catheter in patients with digestive system cancer.

Life on the line - Incidence and management of central venous catheter complications in intestinal failure

Background & AimsLoss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. MethodsFor this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDT) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/ port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDT were compared. ResultsOverall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 “CVC-days”). Broviac type “B” was found to be significantly superior to type “A” regarding occlusion, CRI, and material defects (log-rank test: p=0.05; p=0.026; p=0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 388.5 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. ConclusionsDifferent complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.

Flushing and locking management related to central venous catheter occlusion rate among adult patients in acute care: a best practice implementation project.

A central venous catheter (CVC)-a type of central venous access device (CVAD)-is the most common intervention for critical illnesses. Obstruction of the CVC can lead to fatal consequences. Thus, it is critical to maintain catheter lumen patency. The CVC occlusion rate in a hospital in Taiwan was 33%. This project aimed to decrease the CVC occlusion rate in acute care. This project was conceptually informed by the JBI Evidence-Based Model of Healthcare, in particular, the conceptualization of evidence implementation as inclusive of context analysis, implementation, and evaluation of outcomes using evidence-based quality indicators. As part of the seven-phase implementation process, we used audit and feedback in a pre- and post-test design to measure baseline compliance. Based on the initial audit, we developed an implementation strategy responsive to the identified gaps in compliance. We then undertook a final audit to measure changes in compliance to evaluate our implementation effects. The JBI software, PACES, and the situational analysis software, GRiP, were used for data collection and implementation planning. There were six evidence-based criteria, with a sample size of 30 nurses for each criterion. The team carried out the project from September 2022 to January 2023. Post-implementation audit compliance rates increased to 100% for the following criteria: the organization had a standardized flushing and locking solution protocol (0%), the CVAD lumen was locked upon completion of the final flush (10%), a single-dose system was used for flushing and locking the CVAD (60%), and preservative-free 0.9% sodium chloride was used to flush the CVAD (60%). Furthermore, the CVC occlusion rate decreased from 33% to 5%. The project successfully decreased the rate of CVC occlusion and increased the competence of nurses in acute care settings. The implementation of best practices in clinical care should focus on leadership, cross-department coordination, education, and innovation.

Patency, assessment, and management of central catheter occlusion in adult patients in the intensive care unit: a best practice implementation project.

Cannulation with a central venous catheter (CVC) is a common procedure used in critical care. One of the main complications is occlusion, which can lead to delayed treatment, prolonged hospital stay, and increased health care costs. The aim of this project was to promote evidence-based practice for nurses caring for patients with a CVC in a Spanish intensive care unit. The project also aimed to reduce CVC occlusion and ensure CVC patency. This project was guided by the JBI Model of Evidence-based Healthcare and the JBI Evidence Implementation Framework. Seven phases were followed using evidence-based auditing and feedback. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tools were used to support data collection, data analysis, and implementation planning. After project implementation, the following results were obtained. Criterion 1 (assessing the CVC, flushing, and aspirating) reached 100% compliance in both audits. Criterion 2 (occlusion documentation) showed a modest improvement, rising from 13.33% to 36.67%. Improvement for Criterion 3 (the need for a policy and protocol) was excellent, rising from 0% at baseline to 100% following implementation. Criterion 4 (rapid instillation of an appropriate thrombolytic agent if a CVC is occluded) remained at 0% compliance in both audits. Criterion 5 (continuing education for health care professionals) improved from 10% to 60%. Criterion 6 (flushing and locking before procedures) improved from 90% to 100%. The project objectives were largely met and resulted in a protocol, which has been shared with other departments within the hospital. The implementation of best clinical practice will be continued, including the use of thrombolytic agents. http://links.lww.com/IJEBH/A200.

Effects of the low-speed continuous infusion catheter technique on double-lumen central venous catheters: A randomized controlled trial

BackgroundCentral venous catheters are widely used in clinical practice, and the incidence of central venous catheter occlusion is between 25 % and 38 %. The turbulence caused by the pulsatile flushing technique is harmful to the vascular endothelium and may lead to phlebitis. The low-speed continuous infusion catheter technique is a new type of continuous infusion that ensures that the catheter is always in a keep-vein-open state by continuous low-speed flushing; hence, avoiding the problem of catheter occlusion. ObjectiveTo investigate the effectiveness of the low-speed continuous infusion catheter technique and the routine care of double-lumen central venous catheters. DesignThis was a prospective, randomized, controlled, open-label trial. SettingPatients were recruited from 14 medical institutions in China between February and June 2023. ParticipantsIn total, 251 patients were recruited, with 125 in the intervention group and 126 in the control group. MethodsPatients who used double-lumen central venous catheters for infusion treatment were selected, and those who met the sampling criteria were randomly divided into intervention and control groups using the random envelope method. The intervention group used low-speed continuous infusion catheter technique to maintain catheter patency, whereas the control group used routine care with a trial period of 7 days. The primary outcome was occlusion rate. The secondary outcomes included nursing satisfaction and complication rates of the two groups. ResultsAfter 7 days, the rate of catheter occlusion was 28.0 % (35/125, 95 % confidence intervals (CI):0.203,0.367) in the intervention group and 53.97 % (68/126,95%CI:0.449 ~ 0.629) in the control group, with a statistically significant difference (χ2 = 17.488, p < 0.001); at 3 days of intervention, the rate of catheter blockage was 8.0 % (10/125，95%CI: 0.039 ~ 0.142) in the intervention group and 23.8 % (30/126，0.167 ~ 0.322) in the control group, with a statistically significant difference (χ2 = 11.707，p < 0.001). Nurse satisfaction was significantly higher in the intervention group (115/125，92.0 %，95%CI: 0.858 ~ 0.961) than in the control group (104/126, 82.54 %,95%CI: 0.748 ~ 0.887) (χ2 = 5.049, p = 0.025). There were no statistically significant complication rates in either group (p = 0.622). ConclusionThe low-speed continuous infusion catheter technique helps maintain catheter patency, improves nurse satisfaction, and provides a high level of safety. RegistrationChinese Clinical Trial Registry (ChiCTR2200064007，www.chictr.org.cn). The first recruitment was conducted in February.https://www.chictr.org.cn/showproj.html?proj=177311

Problem-solving processes for central venous catheter occlusion within pediatric cancer care: A qualitative study

PurposeCentral venous access devices play a crucial role in healthcare settings. However, there is concern regarding the high incidence of blockages occurring before the completion of treatments and existing guidelines for occlusion management are not consistently followed. To explore the decision-making and problem-solving process of occlusion management and identify enablers and barriers to implementing evidence for occlusion management in pediatric cancer care. MethodsA qualitative design with individual semi-structured interviews. Participants were selected by purposeful sampling from a tertiary-referral pediatric facility, and semi-structured interviews were conducted. ResultsA total of 13 clinicians and 5 parents were interviewed. The thematic analysis revealed four main decision-making/problem-solving themes: 1) clinical reasoning and judgement for central venous access devices occlusion, 2) capability in central venous access devices occlusion management, 3) colleague collaboration in the escalation process and 4) lack of adequate support to manage the occlusion. This study identified positive and negative influences on the problem-solving process, including clinicians' psychological capabilities, social and physical resources, and beliefs about consequences. ConclusionThis study found that clinicians in pediatric cancer care were able to manage central venous access device occlusions using clinical reasoning and judgment skills, which may conflict with evidence-based practices. The study confirmed the importance of a team approach and prior experience in managing central venous access devices in pediatric oncology settings and identified potential conflicts between clinician decisions based on the patient's current and anticipated conditions and implementation of evidence-based practice. Improving documentation and providing visual aids could benefit clinicians' problem-solving processes.

Comparison of Heparin and Saline for Prevention of Central Venous Catheter Occlusion in Pediatric Oncology: A Systematic Review and Meta-Analysis

ObjectiveThe management of central venous catheter (CVC) occlusion remains an area without clear evidence-based guidelines. Studies have been conducted that compare the use of heparin and normal saline for reducing thrombosis, but the evidence is not strong enough to suggest a significant advantage of one over the other. Therefore, the study aimed to assess the effectiveness of heparin and normal saline flushing in preventing CVC occlusion in pediatric patients with cancer. Data SourcesA comprehensive search was conducted in PubMed, Web of Science, Cochrane, MEDLINE, CINAHL, Embase, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov platform using specific keywords. The search was conducted until March 2022. Five randomized controlled trials are included in this study. ConclusionFive studies with a total of 316 pediatric cancer patients met the inclusion criteria. The studies were found to be heterogeneous due to variations in the types of cancer, heparin concentration, flushing frequency of CVCs, and methods used to measure occlusion. Despite these differences, there was no significant difference in the effect of flushing with heparin and normal saline in preventing CVC occlusion. The analysis revealed that normal saline is as effective as heparin in preventing CVC occlusion among pediatric cancer patients. Implications for Nursing PracticeThis systematic review and meta-analysis demonstrated that there is no significant difference between the use of heparin and normal saline flushing in preventing CVC occlusion among pediatric cancer patients. Considering the potential risks of heparin, the use of normal saline flushing may be recommended to prevent CVC obstruction.

Effectiveness of Antimicrobial Lock Therapy for the Treatment of Catheter-Related and Central-Line-Associated Bloodstream Infections in Children: A Single Center Retrospective Study.

Antimicrobial lock solutions (ALT) in combination with systemic antibiotics can represent a valid option to attempt central venous catheter (CVC) salvage in the case of catheter-related and central-line-associated bloodstream infections (CRBSI and CLABSI). However, data concerning the effectiveness and safety of ALT in children are limited. We aimed to share our center's experience in order to contribute to investigations into the causes of ALT failure in the pediatric population. All children consecutively admitted to Meyer Children's Hospital, University of Florence, Italy, from 1 April 2016 to 30 April 2022, who received salvage ALT to treat an episode of CRBSI/CLABSI, were reviewed. According to ALT failure or success, children were compared with the aim of identifying the risk factors for unsuccessful ALT outcome. Data from 28 children, 37 CLABSI/CRBSI episodes, were included. ALT was associated with clinical and microbiologic success in 67.6% (25/37) of children. No statistically significant differences were observed between the two groups, successes and failures, considering age, gender, reason for use, duration, insertion, type and presence of insertion site infection of the CVC, laboratory data and number of CRBSI episodes. Nevertheless, a trend towards a higher success rate was observed for a dwell time of 24 h for the entire duration of ALT (88%; 22/25 vs. 66.7%; 8/12; p = 0.1827), while the use of taurolidine and the infections sustained by MDR bacteria were associated with a tendency toward greater failure (25%; 3/12 vs. 4%; 1/25; p = 0.1394; 60%; 6/10 vs. 33.3%; 8/24; p = 0.2522). No adverse events, except one CVC occlusion, were observed. ALT combined with systemic antibiotics appears to be an effective and safe strategy for treating children with CLABSI/CRBSI episodes.

The effect of an intermediate dose of Heparin solution in the Prevention of Central Venous Catheter occlusion on ICU admitted patients: A randomized Controlled Trial

Background and aim: Central venous catheters (CVC) are widely used in critical care units. Due to the high prevalence of central venous catheter dysfunction, the cost, and the complications of their replacement, finding the right way to prevent catheter occlusion becomes important. The current study aimed to evaluate the effect of an intermediate dose of heparin solution in the prevention of central venous catheter occlusion in ICU-admitted patients.Method: This randomized controlled trial was performed in the Adult Intensive Care Unit (AICU) of Imam Reza Hospital from 2019 to 2020. In each patient (153 patients), the lines were divided into two categories: active or inactive. Inactive lines in the intervention group (76 patients) were washed every 8 hours with 10 ml of saline solution and then filled with 1.5 ml of heparin solution (at a concentration of 100 units per ml). In the control group (77 patients) only washing with 10 ml of saline solution was performed. The active lines in the intervention group were first washed with 10 ml of saline solution after each use and filled with 1.5 ml of heparin solution if not used immediately. In the control group, only saline washing was performed. Each line was examined once daily during the morning shift to determine whether it was open or closed.Result: In the studied lines in 153 patients admitted to the intensive care unit who were divided into two groups of intervention (heparin) and control (saline), no significant difference was observed in the occlusion of the catheter lines (p&gt;0.05).Conclusion: After 14 days of examination of central venous catheters in patients, the effectiveness of an intermediate dose of heparin in preventing catheter obstruction was not more than the saline solution.

Home Parenteral Nutrition in Patients with Advanced Cancer: Quality Outcomes from a Centralized Model of Care Delivery.

Lack of expertise in home parenteral nutrition (HPN) management has been reported as a barrier to its initiation in patients with advanced cancer (AC), and there are limited data describing hospital readmissions and HPN-related complications. We aimed to assess a centralized approach for managing HPN in AC and evaluate associated outcomes, including hospital readmissions and HPN-related complications. This was a cohort study of adults with AC requiring palliative HPN between 2010–2018 at a tertiary intestinal failure (IF) center, primarily utilizing a centralized model of HPN oversight to discharge patients remotely from an oncology center to their homes over a wide geographic area. A total of 126 patients were included, with a median distance between the patient’s home and the IF center of 17.5 km (IQR 10.9–39.1; maximum 317.4 km). A total of 28 (22%) patients experienced at least one HPN-related complication, the most common being a central venous catheter (CVC) occlusion and electrolyte abnormalities. The catheter-related bloodstream infection (CRBSI) rate was 0.49/1000 catheter days. The CVC type, administration of concomitant chemotherapy via a distinct CVC lumen separate from PN, venting gastrostomy and distance between the patient’s home and the IF center were not associated with CRBSI or mechanical CVC complications. A total of 82 (65.1%) patients were readmitted while on HPN, but only 7 (8.5%) of these readmissions were HPN-related. A total of 44 (34.9%) patients died at home, 41 (32.5%) at a hospice and 41 (32.5%) in a hospital. In conclusion, this study demonstrates that a centralized approach to IF care can provide HPN to patients over a large geographical area while maintaining low HPN-related complications that are comparable to patients requiring HPN for benign conditions and low hospital readmission rates.

Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults.

Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency and performance. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% sodium chloride (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to normal saline, to see if the evidence establishes whether one is better than the other. This is an update of an earlier Cochrane Review. To evaluate the benefits and harms of intermittent locking of CVCs with heparin versus normal saline in adults to prevent occlusion. We used standard, extensive Cochrane search methods. The latest search date was 20 October 2021. We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus normal saline. We excluded studies on infants and children from this review. We used standard Cochrane methods. Our primary outcomes were occlusion of CVCs and duration of catheter patency. Our secondary outcomes were CVC-related bloodstream infections and CVC-related colonisation, mortality, haemorrhage, heparin-induced thrombocytopaenia, CVC-related thrombosis, number of additional CVC insertions, abnormality of coagulation profile and allergic reactions to heparin. We used GRADE to assess the certainty of evidence for each outcome. We identified one new RCT with 30 participants for this update. We included a total of 12 RCTs with 2422 participants. Data for meta-analysis were available from all RCTs. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access). Five studies included ICU (intensive care unit) patients, two studies included oncology patients, and the remaining studies included miscellaneous patients (chronic kidney disease, haemodialysis, home care patients, etc.). Primary outcomes Overall, combined results may show fewer occlusions with heparin compared to normal saline but this is uncertain (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; 10 studies; 1672 participants; low-certainty evidence). We pooled studies that used participant or catheter as the unit of analysis. We carried out subgroup analysis by unit of analysis. No clear differences were detected after testing for subgroup differences (P = 0.23). We found no clear evidence of a difference in the duration of catheter patency with heparin compared to normal saline (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; 6 studies; 1788 participants; low-certainty evidence). Secondary outcomes We found no clear evidence of a difference in the following outcomes: CVC-related bloodstream infections (RR 0.66, 95% CI 0.08 to 5.80; 3 studies; 1127 participants; very low-certainty evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; 3 studies; 1100 participants; very low-certainty evidence); haemorrhage (RR 1.54, 95% CI 0.41 to 5.74; 3 studies; 1197 participants; very low-certainty evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; 3 studies; 443 participants; very low-certainty evidence). The main reasons for downgrading the certainty of evidence for the primary and secondary outcomes were unclear allocation concealment, suspicion of publication bias, imprecision and inconsistency. Given the low-certainty evidence, we are uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. Although we found no evidence of differences in safety (CVC-related bloodstream infections, mortality, or haemorrhage), the combined studies were not powered to detect rare adverse events such as heparin-induced thrombocytopaenia. Further research conducted over longer periods would reduce the current uncertainties.

Central venous catheters-related-thrombosis and risk factors in oncological patients: A retrospective evaluation of recent risk scores.

Insertions of central venous catheters (CVC) has become a common practice in Onco-Hematologic Units to administer systemic treatments. Unfortunately they can cause complications influencing patient's care-pathway significantly. Oncological patients have a higher thrombotic risk than the general population, therefore specific recent risk scores are spreading through the clinical practice, such as Khorana, Protecht, COMPASS-CAT, and Michigan scores. A retrospective cohort of 177 out of a total of 3046 outpatients accessing the Medical Day Hospital of Istituto Nazionale Tumori di Milano from March 2019 to February 2021 aged ⩾ 18 years who developed CVC complications was analyzed extracting clinical data from their medical records. Focusing on the risk factors, especially through recent risk scores to estimate the thrombotic risk we used Wilcoxon-test for continuous variables and the Pearson-Chi-Square test for categorical variables. Anticoagulants resulted a protective factor mostly for partial CVC occlusion (p = 0.0001), preventing CVC occlusions. CVC occlusions were significantly associated with epitelial tumor histotype, (p = 0.0061). Complete CVC occlusions were significantly associated with peripherical inserted central venous catheters (PICC) (p < 0.0001). Catheter-related-thrombosis (CRT) was significantly associated with peripherical-inserted-central-venous-catheter, both when it was diagnosed clinically (p = 0.0121) and radiographically (p = 0.0168).There was a strong association between CRT and a high grade of Khorana Score (p = 0.0195), Protecht Score (p = 0.0412), COMPASS-CAT Score (p = 0.0027). A positive statistical trend was observed between the Michigan Score and CRT in patients carrying PICC (p = 0.053). There are many different and various factors associated with higher or lower risk of CVC thrombotic complications, so it could be useful to test the recent risk scores to estimate thrombotic risk in oncological patients in clinical practice.

Mechanical Complications in Central Lines Using Taurolidine Versus Ethanol Lock Therapy in Children With Intestinal Failure.

Ethanol lock therapy (ELT) is effective in reducing rates of catheter-related-bloodstream infections (CRBSI) in the pediatric intestinal failure (IF) population; however, ELT may increase the risk of line occlusion and breakage, significantly impacting preservation of vascular access. During a period of ethanol shortage, Health Canada temporarily approved the use of taurolidine lock therapy (TLT) in pediatric iF patients previously utilizing ELT. This provided a unique opportunity to directly compare rates of central venous catheter (CVC) complications, including CRBSi, breaks, occlusions, repairs and replacements in patients who utilized both ELT and TLT. A retrospective study of pediatric IF patients managed by three Western Canadian intestinal rehabilitation programs was performed. Event rates in patients who used both ELT and TLT during the study period were compared using Poisson regression analysis. In 13 patients with 10,187 catheter days (CDs), TLT (vs ELT) had lower rates of CVC breaks (1.11 vs 5.19/1000 CDs, P < 0.001), occlusions (0.83 vs 4.06/1000 CDs, P = 0.01) and repairs (1.94 vs 5.64/1000 CDs, P = 0.01). There was no difference in CRBSI rates (0.83 vs 2.03/1000 CDs, P = 0.25) or rates of CVC replacements due to mechanical events (0.28 vs 1.81/1000 CDs, P = 0.08). Although there was no difference in CRBSI rates, TLT was associated with lower rates of mechanical complications compared to ELT in this study. Taurolidine may be a suitable alternative to ethanol in preventing CRBSI and may be associated with improved preservation of central lines in children with IF.

CLE3AR Study

Problem/PurposeIntraluminal thrombotic catheter occlusions are associated with a greater risk of delayed treatment, morbidity, and mortality and higher healthcare costs.MethodsThe Vascular Access Specialist Team at Hartford Hospital used Lean Six Sigma methodology to identify and address waste, variability, and defects associated with occlusion management.InterventionsBeginning in 2015, all central venous catheter occlusions in acute inpatient care were assessed by a vascular access nurse specialist. First, the decisions to treat with tissue plasminogen activator were determined using a catheter patency algorithm. Second, negative displacement needleless connectors were replaced by antireflux needleless connectors to reduce unintentional blood reflux and other complications associated with intraluminal thrombotic catheter occlusion.ResultsA total of 159 934 central line days were reported between 2014 and 2020. The hospital achieved a 71.3% reduction in annual tissue plasminogen activator used for occlusions over the study period. There was a sustained decrease in annual average needleless connector consumption of 41% after switching to antireflux needleless connectors in 2015. The 5-year cost savings for these 2 interventions were estimated to be $356 005.ConclusionsLean occlusion management interventions were associated with reduced pharmacy use, medical supply waste, and spending, which have been sustained for over a 5-year period.

Needle-free connectors to prevent central venous catheter occlusion at a tertiary cardiac center: A prospective before and after intervention study.

To evaluate the effectiveness of needle-free connectors to maintain Central Venous Catheter-CVC patency. Loss of patency is a common complication associated with CVC. For patients, this can be stressful and painful, and can result in a delay in infusion therapy. Pressure-activated anti-reflux needle-free connectors are one of the most modern devices; however, no studies have compared this connector with the open-system three-way stopcock in terms of the incidence of CVC occlusion. This study is a prospective before and after intervention study. From March to August 2018, an observation phase was conducted with the three-way stopcock as the standard central venous catheter hub and closure system (phase 1). After implementation of needle-free connectors (phase 2), post-intervention observations were made from September 2019 to January 2020 (phase 3). Of 199 CVCs analyzed, 41.2% (40/97) occluded in at least one lumen in the first phase, and 13.7% (14/102) occluded after introducing the technological device, absolute risk reduction 27.5% (95% confidence interval 15.6%-39.4%). The lumens supported by needle-free connectors showed a higher probability of maintaining patency compared with three-way stopcocks. No differences were observed in the rate of infection. Pressure-activated anti-reflux needle-free connectors are effective and safe devices suitable for the management of vascular access in cardiac patient care. Staff training, even on apparently simple devices, is essential to avoid the risk of infection.

Infusion Pump Flow Rates In Central Venous Catheters: Thrombus Reflux And Aspiration Clot

Aggressive infusion pump flow rates can lead to central venous catheter (CVC) occlusion resulting from thrombus reflux into the CVC lumen. &#x0D; &#x0D; Methods: A single-center prospective comparative study was performed, including all consecutive cases of occlusion events in hematology oncology patients using a CVC (Hickman® nº7) since August 2018 to September 2019 (Phase 1), and October 2019 to September 2020 (Phase 2) at the Onco-Hematology Department of the Portuguese Institute of Oncology (Porto). Two phases were described:&#x0D; Phase 1: Observational period using a platinum-based regime (DHAP) undergoing continuous infusion pump rate ≥ 200 mL/hr.&#x0D; Phase 2: Intervention period using a platinum-based regime (DHAP) undergoing continuous infusion pump rate ≤ 200 mL/hr.&#x0D; &#x0D; Results: Overall, 39 DHAP regimens were reported with a total number of 43 occlusions identified in the study period (phase 1, n=28 vs phase 2, n=15). Occlusion risk associated with the infusion pump rates between phases was higher in phase 1 (phase 1, n=11 vs phase 2, n=3, RR 3.313 [1.010 to 13.863], ≤0.05). When aspiration clot (n=5) was identified, CVC always was removed. No aspiration clot was observed in phase 2. &#x0D; &#x0D; Conclusion: Aggressive infusion pump flow rates can increase occlusion risk resulting from thrombus reflux into the CVC lumen and aspiration clot.

Outcomes of interventions for central venous catheter occlusions in patients with intestinal failure on home parenteral nutrition

Outcomes of interventions for central venous catheter occlusions in patients with intestinal failure on home parenteral nutrition

Low molecular weight heparin for prevention of central venous catheter-related thrombosis in children.

The prevalence of children diagnosed with thrombotic events has been increasing in the last decades. The most common thrombosis risk factor in neonates, infants and children is the placement of a central venous catheter (CVC). It is unknown if anticoagulation prophylaxis with low molecular weight heparin (LMWH) decreases CVC-related thrombosis in children. This is an update of the Cochrane Review published in 2014. To determine the effect of LMWH prophylaxis on the incidence of CVC-related thrombosis and major and minor bleeding complications in children. Further objectives were to determine the effect of LMWH on occlusion of CVCs, number of days of CVC patency, episodes of catheter-related bloodstream infection (CRBSI), other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis) and mortality during therapy. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 7 May 2019. We undertook reference checking of identified trials to identify additional studies. We included randomised controlled trials (RCTs) and quasi-randomised trials comparing LMWH to no prophylaxis (placebo or no treatment), or low-dose unfractionated heparin (UFH) either as continuous infusion or flushes (low-dose UFH aims to ensure the patency of the central line but has no systemic anticoagulation activity), given to prevent CVC-related thrombotic events in children. We selected studies conducted in children aged 0 to 18 years. Two review authors independently identified eligible studies, which were assessed for study methodology including bias, and extracted unadjusted data where available. In the data analysis step, all outcomes were analysed as binary or dichotomous outcomes. The effects of interventions were summarised with risk ratios (RR) and their respective 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. One additional study was included for this update bringing the total to two included studies (with 1135 participants). Both studies were open-label RCTs comparing LMWH with low-dose UFH to prevent CVC-related thrombosis in children. We identified no studies comparing LMWH with placebo or no treatment. Meta-analysis found insufficient evidence of an effect of LMWH prophylaxis in reducing the incidence of CVC-related thrombosis in children with CVC, compared to low-dose UFH (RR 0.68, 95% CI 0.27 to 1.75; 2 studies; 787 participants; low-certainty evidence). One study (158 participants) reported symptomatic and asymptomatic CVC-related thrombosis separately and detected no evidence of a difference between LMWH and low-dose UFH (RR 1.03, 95% CI 0.21 to 4.93; low-certainty evidence; RR 1.17, 95% CI 0.45 to 3.08; low-certainty evidence; for symptomatic and asymptomatic participants respectively). There was insufficient evidence to determine whether LMWH impacts the risk of major bleeding (RR 0.27, 95% CI 0.05 to 1.67; 2 studies; 813 participants; low-certainty evidence); or minor bleeding. One study reported minor bleeding in 53.3% of participants in the LMWH arm and in 44.7% of participants in the low-dose UFH arm (RR 1.20, 95% CI 0.91 to 1.58; 1 study; 158 participants; very low-certainty evidence), and the other study reported no minor bleeding in either group (RR: not estimable). Mortality during the study period was reported in one study, where two deaths occurred during the study period. Both were unrelated to thrombotic events and occurred in the low-dose UFH arm. The second study did not report mortality during therapy per arm but showed similar 5-year overall survival (low-certainty evidence). No additional adverse effects were reported. Other pre-specified outcomes (including CVC occlusion, patency and CRBSI) were not reported. Pooling data from two RCTs did not provide evidence to support the use of prophylactic LWMH for preventing CVC-related thrombosis in children (low-certainty evidence). Evidence was also insufficient to confirm or exclude a difference in the incidence of major and minor bleeding complications in the LMWH prophylaxis group compared to low-dose UFH (low and very low certainty respectively). No evidence of a clear difference in overall mortality was seen. Studies did not report on the outcomes catheter occlusion, days of catheter patency, episodes of CRBSI and other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis). The certainty of the evidence was downgraded due to risk of bias of the included studies, imprecision and inconsistency, preventing conclusions in regards to the efficacy of LMWH prophylaxis to prevent CVC-related thrombosis in children.

Temporary Repair Prior to Permanent Repair of Silicone Tunneled Central Venous Catheters in Intestinal Failure Patients

Highlights Abstract Repeated central venous catheter (CVC) replacement is costly, invasive, requires sedation, and can contribute to loss of a vascular access. It is therefore prudent to attempt to salvage damaged CVCs through repair when possible. Identifying potential etiologies for CVC damage, such as CVC occlusion, is critical, as failure to do so would likely result in unsuccessful repair and further interventions, including CVC exchange/replacement. By introducing the step of a temporary repair, the clinician has the advantage of recognizing the presence of intraluminal CVC occlusion and addressing that through thrombolytic therapy. Once patency in achieved, a permanent repair can be performed.

Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children.

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long-term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random-effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin.Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low-certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate-certainty evidence), and not reported in the remaining studies. The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC-associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains.