Central Venous Catheter Tip Research Articles

Accuracy of electrocardiography guidance for depth of insertion of central venous catheters in children: A prospective observational study

Context: Central venous catheters (CVCs) have become integral in the pediatric intensive care setting as well as in the operating room (OR). In the OR, these lines are usually used without prior confirmation of correct position, and a chest radiograph is performed postoperatively, several hours later. Hence, it is desirable to confirm the correct CVC position immediately after placement. Aim: This observational study was designed to evaluate the accuracy of electrocardiography (ECG) guidance on correct CVC positioning in pediatric population. Settings and Design: This was a prospective observational study. Subjects and Methods: Patients till 12 years of age were included in the study. Ultrasound was used to guide initial cannulation of the vessel. Certodyn® universal adaptor was connected to the guidewire via a sterile alligator clip. The CVC along with the guidewire was advanced till it lies in the right atrium which was seen by an increase in the amplitude of P-wave on the intracardiac ECG. The CVC was then withdrawn slowly until the P-wave morphology returned to normal or preprocedural configuration. Statistical Analysis Used: Data were expressed as percentage. Results: Out of the 68 patients, the percentage of patients having appropriate position of CVC tip was 95.5% (65 patients). Out of the three patients with incorrect tip position, in two patients, the tip was distal to the appropriate position and in one case, the ECG changes could not be appreciated. Conclusions: ECG-guided CVC placement has high accuracy of correct positioning in infants and children.

Practical anatomical landmark for optimal positioning of left-sided long-term central venous catheter (a pilot study).

Background:Long-term central venous catheter (CVC) insertion in dialysis patients is an accepted method of hemodialysis. The appropriate CVC tip placement may reduce both early and late complications related to catheter and increase patency rate. This study aimed to evaluate a new, simple, and feasible method based on surface anatomy for the proper placement of tunneled CVC in the left internal jugular vein for hemodialysis or chemotherapy.Materials and Methods:The study was carried out as a quasi-experimental model at Saint Al-Zahra Education Hospital in 2016. A total of forty patients with an indication of left-sided (upper) long-term CVC insertion were enrolled. The length of catheter to be inserted in the left internal jugular vein was considered as the sum of distance from the insertion point of the needle up to sternal notch plus the total distance between the left and right sternoclavicular joint and half-length of the sternum. The right atrium (RA) or superior vena cava-RA junction was the correct region for inserting the catheter tip. The collected data were analyzed using Fisher's exact test and t-test using SPSS (version 22).Results:The patients were 63.75 ± 17.96 years of age, weighed 67.33 ± 13.20 kg, and height of 166.92 ± 8.99 cm. Catheters were inserted successfully in 95% of patients (n = 38). No significant relationship was found between the success of new method and age, gender, height, weight, body mass index, and sternum half-length plus the distance between the right and left sternoclavicular joint.Conclusion:“The mid – sternal length plus sternoclavicular joints spacing” as a new formula (based on anatomical landmarks) was found practical and safe and could easily be used among adult patients who undergo tunneled CVC in the left internal jugular vein.

A Novel Objective Approach Towards Physicians' Knowledge and Practice Patterns to Optimize Central Venous Catheter Placement: A Cross-sectional Study

Study objective: Central venous catheterization is an essential component of intensive care of critically ill patients, and proper positioning of the catheter is essential to prevent position-related complications. This study was conducted by using digital tape measurement to objectively assess clinician preferences for central venous catheter positioning based on specific position levels and landmarks on post-procedural chest radiographs. Design: A cross-sectional study using electronic questionnaire survey. Setting: Single academic teaching hospital participated in this study. Participants: The study enrolled 276 physicians from multiple clinical disciplines. Interventions: None. Measurements: A seven-level reference system labeled on a sample chest radiograph was used to identify the acceptable lower and upper limits and landmarks used to determine the optimal central venous catheter tip position as well as the pattern of clinical practices based on the specialty and level of experience of participants. Main results: Among the 276 respondents, the ratio of cumulative acceptance for the lower and upper catheter tip limit was 62% and 66.3% within a 4-cm range below or above the carina, respectively. Intensive care unit (ICU) physicians showed a greater tendency to choose a catheter tip 4 cm below and 6 cm above the carina (p = 0.004 and 0.002, respectively) as did experienced physicians (p = 0.007 and < 0.001, respectively). The commonest reason for catheter tip withdrawal was arrhythmia (50% of cases). Physicians in the ICU and experienced physicians were more concerned about the risk of cardiac perforation than other respondents (p < 0.001 and < 0.001, respectively). The carina was the most commonly used landmark in 71.7% of all physicians, although 50% of radiologists also used other landmarks. Conclusions: The acceptable limit of the catheter tip is 4 cm above and below the carina (-4 to +4), as determined on chest radiography, without a need for tip adjustment.

Central venous catheter tip position on chest radiographs: a reply

Central venous catheter tip position on chest radiographs: a reply

Bedside Ultrasound in the Pediatric Intensive Care Unit: Newer Uses

To explore recent advancements in the use of point-of-care ultrasound in the pediatric intensive care unit or during the perioperative period. Ultrasound is useful for selecting an appropriate endotracheal tube size, predicting postextubation stridor, assessing vocal cord paralysis, performing ultrasound-guided lung recruitment, assessing circulatory volume status, performing transcranial Doppler for assessment of cerebral perfusion, assessing intracranial hypertension, assessing central venous catheter tip position, and performing arterial line cannulation. There has been rapid progress in the use of point-of-care ultrasound in pediatric critical care, which can revolutionize daily clinical practice. However, further studies are required to verify that some of these areas of clinical application are translatable and scalable to widespread adoption.

547. Multidrug-Resistant Pseudomonas aeruginosa in an Academic Regional Burn Intensive Care Unit

Background Pseudomonas aeruginosa infection can lead to morbidity, mortality and increased hospital length of stay especially in Burn Intensive Care Units (BICU) patients. Reports of multi-drug-resistant Pseudomonas aeruginosa outbreaks in the BICU are increasing. We investigated the epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) in our BICU.MethodsClinical and laboratory characteristics of all CRPA isolates identified between 5/8/16 and 3/14/19, in an 11-bed BICU in an academic 870-bed public safety-net hospital were reviewed and defined as Meropenem MIC 4 or greater. Retained isolates were sent for pulse-field gel electrophoresis (PFGE). Infection prevention (IP) observations and interventions were intensified and environmental cultures were collected. Patient charts were reviewed.Results27 patients between ages 5–61 years old were found to have CRPA (only 2 patients < 18 years). 21/27 (77.7%) were male. 21/27 (77.7%) had >40% total body surface area (TBSA) burns, 3/27 (11.1%) had 20–39% TBSA burn and 1/27 (3.7%) had < 20% TBSA burn. 19/27 (70.3%) patients had bacteremia, 6 had respiratory infections with 3 (11.1%) Infection-related Ventilator-Associated Complications (IVAC), 3 had urinary tract infection, and 1 had CRPA from a central venous catheter tip. There were very few co-morbidities. Twenty isolates from 11 different patients were typed and revealed 2 different clonal strains. 5/11 (45%) patients had strain A, and 2/11 (18%) patients had strain B. 3/11 (27.2%) patients had unique strains. CRPA was isolated from 5 different rooms. Water cultures did not reveal CRPA. Failure of hand hygiene, non-adherence to isolation/PPE protocols and clutter were found. Each failure was corrected. No new CRPA patient isolates have been identified.ConclusionTransmission was halted by reinforcement of IP measures. Importantly water was not a source of CRPA in this setting and the data suggest transmission due to environmental contamination.DisclosuresTrish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant

Application of modified microbubble test in peripherally inserted central venous catheters tip positioning

To analyze the specificity and sensitivity of the modified microbubble test in identifying the peripherally inserted central venous catheters (PICC) tip based on the chest X-ray location as the "gold standard", and to find out an accurate and noninvasive PICC tip positioning method that can save time and cost. Convenient sampling method was conducted. The patients under PICC guided by ultrasound in intensive care unit (ICU) or PICC clinic of the First Affiliated Hospital of Nanchang University from August 2017 to February 2018 were enrolled. All patients were followed up by ultrasound guided PICC catheter placement, modified microbubble test and chest X-ray localization. The relationship between the density of microbubbles in modified microbubble test and the location of PICC tip in chest X-ray localization was analyzed. Using chest X-ray localization as the "gold standard", the diagnostic evaluation indexes such as specificity and sensitivity of PICC tip identification by modified microbubble test were calculated. A total of 120 patients were enrolled during the study period, excluding those who refused to participate in the study, unclear right atrial ultrasound, conscious intolerance, unclear chest X-ray, and finally 108 patients completed the modified microbubble test and chest X-ray tip localization. According to the chest X-ray localization results of 108 patients, 69 patients (63.9%) were in ideal locations, 33 (30.6%) were in dissatisfactory position, and 6 (5.5%) were in malposition. There was no significant difference in gender, age, tube placement, depth of catheterization, placement of catheterization room, and catheterization among the three groups. In the modified microbubble test, there were 74 patients (68.5%) with grade I microbubble, 25 (23.2%) with grade II microbubble, and 9 (8.3%) with grade III microbubble. There was a correlation between microbubble density and the tip position of the catheter, showing a moderate intensity correlation, and the contingency coefficient was 0.662. The sensitivity of the modified microbubble test for PICC tip positioning was 95.7% (66/69), the specificity was 89.7% (35/39), the rate of missed diagnosis was 4.4% (3/69), the misdiagnosis rate was 10.3% (4/39), the positive predictive value was 94.3% (66/70), the negative predictive value was 92.1% (35/38), and the Youden index was 0.85. The consistency between the two methods was good, and the Kappa value was 0.86. Compared with the chest X-ray localization method, the modified microbubble test method has high sensitivity and specificity in identifying PICC in the position, and the operation is simple, noninvasive, with less time and low cost. The modified microbubble test can be used as a screening test for PICC tip position, especially in ICU. When there are technical limitations or suspicious patient, further chest X-ray is necessary.

Comparison of semiquantitative and differential time to positivity methods for the diagnosis of central line-associated bloodstream infections in an intensive care unit

Introduction Central line-associated bloodstream infections (CLABSIs) adversely affect patients’ hospitalization.Aim We compared semiquantitative roll plate (SQRP) and differential time to positivity (DTP) culture methods in diagnosing CLABSIs.Methodology A retrospective study was conducted in an intensive care unit (ICU) from January 2013 to August 2014. All ICU patients with suspected CLABSIs were included. Blood cultures were taken, while central venous catheter (CVC) tips were cultured using the roll-tip method. DTP was considered positive if CVC lumen blood cultures became positive at least 2 h prior to concurrently drawn peripheral blood cultures with an identical micro-organism. SQRP method was considered positive when ≥15 c.f.u. of a micro-organism identical to that of blood cultures grew. Measures of diagnostic accuracy were calculated.Results SQRP displayed high sensitivity (94.7 %), while DTP showed high specificity (82.5 %). SQRP combined with DTP displayed 100 % sensitivity and negative predictive value.Conclusion SQRP and DTP methods should be evaluated in combination.

A checklist to improve the quality of central venous catheter tip positioning.

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n=84) in 2016 and a post-intervention audit (n=84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.

Distance between the tips of central venous catheters does not depend on same or opposite site access

Distance between the tips of central venous catheters does not depend on same or opposite site access

Dwindling Utilization of Central Venous Catheter Tip Cultures: An Analysis of Sampling Trends and Clinical Utility at 128 US Hospitals, 2009-2014.

At 128 US hospitals, from 2009-2014, a 17% decline occurred annually in central venous catheter tips sent for culture: a 6-fold decrease from blood culture sampling trends. The positive predictive value was low (23%). Tip culture use often does not conform to recommendations and offers limited independent treatment opportunities.

A new way to determine correct depth of central venous catheter insertion using a real-time ultrasound-guided insertion technique in pediatric patients.

Several formulae or methods are reported to predict the ideal central venous catheter insertion depth. However, they are complicated and often unsuitable in cases requiring rapid management. This study aimed to determine a simple and practical method to predict the ideal central venous catheter insertion depth after the real-time ultrasound-guided right internal jugularvein, or left or right supraclavicular approach in pediatric patients. Pediatric patients with congenital heart diseases who underwent cardiovascular surgery between July 2015 and February 2018 in the German Pediatric Heart Center Sankt Augustin were enrolled.Body height, body weight, patient age (months), and central venous catheterinsertion depth were retrieved from the anesthesia records. Idealcentral venous catheter insertion depth was calculated by measuring the distance between the level of the carina tracheae and the central venous catheter tip on the first postoperative chest radiograph. The relationships of body height, body weight, and patient age (months) to ideal central venous catheter insertion depth for the right internal jugular, left supraclavicular, and right supraclavicular approaches were investigated. Body height was the best parameter, providing the best coefficients of determination as well as the simplest relationship. Based on analysis for ideal central venous catheterinsertion depth for every 10-cm increase in body height, there was an ideal central venous catheterinsertion depth for each body height, independent of the anesthesiologist's experience with the approach used. Whereas ideal central venous catheterinsertion depths for the right internal jugular vein approach and the left supraclavicular approach showed no significant difference, ideal central venous catheterinsertion depth for the right supraclavicular approach was significantly shorter than that of the other two approaches. This study successfully determined a visually simple and practical bar graph to predict the ideal central venous catheterdepth inserted using only the real-time ultrasound-guided insertion technique for the right internal jugular vein, left supraclavicular, and right supraclavicular approaches.

Bedside prediction of the central venous catheter insertion depth - Comparison of different techniques.

Background and Aims:Central venous catheterization is a frequently performed procedure in anesthesia and critical care, and is indispensable in the practice of emergency medicine. Correct positioning of the central venous catheter (CVC) tip is often regarded as a secondary goal and there are various complications that can occur due to abnormal position of the catheter tip. Different methods have been advocated to guide accurate prediction of optimal CVC depth insertion before or during the procedure at the bedside.Material and Methods:A prospective randomized double blinded study was conducted in 180 patients aged between 18 to 65 years requiring central venous catheterization. The optimal depth of insertion of right internal jugular vein (IJV) catheter using three different techniques, Peres' formula method, Landmark technique and Intra atrial Electrocardiography (ECG) guided technique was performed and the three techniques were compared with respect to optimal positioning using carina as a landmark in post procedural chest radiograph. Correct position of the catheter tip was considered upto 1 cm above or below the carina in post procedure X ray.Results:The average final depth of insertion was 15.30 ± 0.62 cms in the Formula group, 12.74 ± 0.77 cms in landmark group and 12.64 ± 0.70 cms in ECG group. The vertical distance from carina was 0.91 ± 0.94 cms in formula group, 0.54 ± 0.67 cms in landmark group and 0.53 ± 0.43 cms in ECG group. The CVC tip was properly positioned within 1 cm above and below the carina in 58.33% patients in the formula group, 93.33% patients in landmark group and 96.67% patients in ECG group.Conclusion:We conclude that both landmark guidance and ECG guidance are comparable with regard to accurate central venous catheter tip positioning when CVCs are placed through right internal jugular vein whereas formula based technique is least accurate and results in over insertion of CVCs.

2089. Dwindling Utilization of Central Venous Catheter Tip Cultures: An Analysis of Sampling Trends and Clinical Utility at 128 U.S. Hospitals 2009–2014

BackgroundThe 2009 Infectious Diseases Society of America management guidelines for catheter-related bloodstream infection (CR-BSI) recommend the use of central venous catheter (CVC) tip cultures (TC) to aid in diagnosing CR-BSI. However, reimbursement penalties for CR-BSI and emerging evidence supporting watchful waiting rather than removing CVCs may have impacted sampling tendencies, and as such, the uptake of this recommendation and its clinical utility remain unknown.MethodsInpatient encounters with ≥1 orders for CVC TC and blood culture (BC; irrespective of collection site) respectively were identified in the Cerner Health Facts electronic health record database. Five-year trends (2009–2014) in TC sampling per 10,000 patients were analyzed and annual percent change (APC) in TC vs. BC sampling were compared. The proportions of (a) TCs with growth of noncontaminant microbial taxa and (b) taxon concordant TC–BC pairs sampled within 2 days of each other were calculated.ResultsBetween 2009 and 2014, 18,080 TCs were sampled during 16,092 encounters among 14,844 patients at 128 US hospitals. Over the 5-year period, TC sampling decreased from 22/10,000 patients in 2009 to 8/10,000 patients in 2014 (APC: −14.7% [95% CI −22.3 to −6.4%], P < 0.01), representing a five-fold decrease compared with BC sampling (APC: −2.5% [−5.0 to 0%], P = 0.05; Figure 1). Only 3,561 (20%) TCs displayed any growth of noncontaminant taxa (Figure 2); the most common taxa isolated from TCs were S. aureus (56.5%), Enterobacteriaceae (16%), Candida sp. (13%), and P. aeruginosa (6%). Of the 3,651 positive TCs, 1,631 (46%) were not accompanied by growth in BCs; S. aureus represented 471 (29%) and Candida spp. represented 121 (7%) of isolated TC growth. Of the remaining 1,930 (54%) positive TCs that were accompanied by positive BCs, only 874 (45%) displayed species concordance. ConclusionThe practice of sampling CVC tips for culture is steadily declining at U.S. hospitals. The majority of pathogenic species cultured from CVC tips are either unaccompanied by, or are discordant with, growth in the bloodstream. Barring the isolation of S. aureus or Candida spp. from CVC tips alone, which may represent opportunities to treat, there appears to be limited clinical utility to TC sampling for diagnosing CR-BSI.Disclosures All authors: No reported disclosures.

Microbe Isolation from Blood, Central Venous Catheters, and Fluid Collections after Liver Resections.

Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection. Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected. There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001). Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

Use of Bedside Ultrasonography and Saline Flush Technique for Evaluation of Central Venous Catheter Placement in Children.

Our study investigated the reliability of appearance of rapid atrial swirl flow (RASF) by ultrasonography (US) in the right atrium (RA), which occurred as a result of rapid isotonic saline infusion (RISI) into the central venous catheter (CVC), in predicting catheter tip position. This prospective observational study included 95 CVC procedures performed on 77 pediatric patients (41 boys and 36 girls) with a median age of 0.6 (0.29-1.53) years. Seventy-three (76.84%) catheter tips were found to be correctly placed, and 22 (23.15%) catheter tips were misplaced. While ultrasonographic examination revealed RASF in the RA after 93 catheterization procedures, it was not observed after two catheterization procedures. One of these two catheters was an arterial catheter, and the other was a catheter that was directed toward the subclavian vein after curling around itself. There was no significant difference between the groups with incorrect and correct positioned catheter tip in terms of the appearance of RASF by US after RISI. There was no significant difference between the groups with upward (n = 8) and downward (n = 86) positioned catheter tip in terms of the time until the first appearance of RASF after RISI and the phase of RASF (P > 0.05). There was a significant difference between these two groups in terms of the disappearance time of RASF in the RA (P < 0.001). The mean disappearance time of RASF was 3 (2-3) s for downward positioned catheters and 5 (4-7) s for upward positioned catheters, respectively. When the cut-off for the disappearance time of RASF was set to 3 s, US had a sensitivity of 85.71% and a specificity of 77.91% for detecting upward positioned catheters. In conclusion, the appearance of RASF in the RA in a short time by US is not a reliable finding for correct positioning of the CVC tip in the pediatric patient group. The fact that the disappearance time of RASF in the RA is longer than 3 s indicates upward positioned CVCs. These catheters must never be used without radiological confirmation. In CVCs in which the disappearance time of RASF in the RA is shorter than 3 s, we think that the catheter can be used until radiological confirmation in emergency cases. According to the available literature, our study is the first study in children. There is a need for new studies on this subject.

The "rapid atrial swirl sign" for assessing central venous catheters: Performance by medical residents after limited training.

RationaleCentral venous catheter (CVC) placement is a standard procedure in critical care. Ultrasound guidance during placement is recommended by current guidelines, but there is no consensus on the best method for evaluating the correct CVC tip position. Recently, the “rapid atrial swirl sign” (RASS) has been investigated in a limited number of studies.ObjectivesWe performed a prospective diagnostic accuracy study of focused echocardiography for the evaluation of CVC tip position in our medical ICU and IMC units.MethodsWe performed a prospective diagnostic accuracy study in 100 patients admitted to the Intensive Care Unit and Intermediate Care Unit at our center. The first 10 subjects were assessed by one staff physician investigator (reference cohort), the remaining 90 patients by different residents (test cohort). All patients received a post-procedural chest radiograph (CXR) as gold standard. CVC placement was assessed with focused echocardiography performed by residents after a short training session. A rapid opacification of the right atrium (RASS) after injection of 10 mL of normal saline was regarded as “positive”, flush after more than two seconds was defined as “delayed”, no flush was a “negative” test result.Measurements and main resultsOverall sensitivity of the RASS was 100% (95% CI 73.54–100%), specificity was 94.32% (CI 87.24–98.13%). Positive and negative predictive values were 70.59% (CI 44.04–89.09%) and 100% (CI 95.65–100%), respectively. Median time for echocardiographic testing was 5 minutes (1–28) in the whole cohort, CXRs were available after 49.5 minutes (13–254). Interrater agreement of the RASS was 0.77 (Cohen’s kappa), Measurement of CVC tip position was not different between two observers. Test characteristics were similar among differently experienced residents.ConclusionsPresence of the RASS by focused echocardiography showed excellent sensitivity and specificity and was equally performed by residents after minimal training. In patients with a positive RASS, routine CXR can be safely omitted, reducing time, costs and radiation exposure. A negative RASS should lead to a search for misplaced catheters.Clinical trial registrationThe study was registered with www.clinicaltrials.gov (NCT02661607).

Comparative Study of Three Methods for Depth of Central Venous Catheter Placement in Children: An Observational Pilot Study.

Central venous cannulation of the internal jugular vein is difficult in paediatric patients because of the small size of the vein and anatomic variations. Many studies have shown the accuracy of various formulae for calculating the depth of placement. The aim of this study was to assess the most reliable method for central venous catheter (CVC) tip placement in paediatric patients. Sixty-nine patients in the age groups from 0 to 12 years were divided in three groups for three published techniques for catheter tip placement. In Group E, catheter tip was placed at the distance measured from entry point to sternal angle. In Groups P and H, Peres and trans-oesophageal echocardiography (TEE)-derived formulae, respectively, were used for catheter placement. Post-procedure chest radiograph was performed for all patients, and tip position was recorded. Appropriate catheter tip position was considered just above or at the level of carina. The number of attempts and complications were recorded. Chi-square test was used for statistical analysis. Of 69 patients, 65% of patients in Group P, 52% in group H and 91% in group E had appropriate CVC tip placement. The chi-square test showed that the difference in the number of patients with appropriately positioned CVC tip among the three groups was statistically significant (p=0.0134), with intergroup analysis showing Group E to be superior. One patient had an episode of arrhythmia during guide wire insertion and was resuscitated successfully. Catheter tip placement by external distance or landmark technique is a more accurate method for catheter placement than the Peres and TEE-based formulae. It does not require measurement of patients' height and reduces the chances of repositioning of catheter.

Efficacy of routine catheter tip culture in a neonatal intensive care unit.

Routine catheter tip cultures are not recommended because some cases of colonization, such as with Staphylococcus aureus, can lead to subsequent bacteremia. To evaluate the safety of colonization without antimicrobial treatment, as well as the effectiveness of routine catheter tip cultures in the neonatal intensive care unit (NICU), we performed a retrospective data analysis in a Japanese community hospital. We reviewed all peripherally inserted central venous catheter tip culture results from the NICU ward between April 2012 and June 2017 and noted outcome (i.e. antimicrobial treatment or subsequent infection). We then performed a cost analysis for routine catheter tip culturing on patients who were symptom free during the study period. Of the 93 positive cases in 80 patients from 1,051 catheter tip cultures, seven patients had suspected infection and were treated with antimicrobials. The other 73 symptom-free, positive patients had no subsequent or exacerbated symptoms indicative of an infection, and did not have antimicrobial treatment. The total cost for catheter tip culturing during the study period was ¥548 731. After excluding patients with symptoms of infection at the time of culture, the efficacy of routine catheter tip cultures on symptom-free patients was estimated to be zero. Symptom-free colonization did not affect clinician management in this study, and all colonized patients without suspected infection were safely managed without antimicrobials. Furthermore, routine catheter tip culturing was not cost-effective; therefore, this practice may be no longer recommended in the NICU.

Comparative evaluation of methods for the detection of biofilm formation in coagulase-negative staphylococci and correlation with antibiogram

IntroductionCoagulase-negative staphylococci (CNS) are normal commensals of human skin and mucous membranes. The objective of the study was to determine the prevalence of CNS among clinical isolates, characterize them up to species level, compare the three conventional methods for detection of biofilm formation, and study their antimicrobial susceptibility pattern.Materials and methodsCNS were obtained from various clinical samples including blood, urine, central venous catheter tips, endotracheal tube aspirate, and pus during a 1-year period (July 1, 2014, to June 30, 2015). Characterization up to species level was done using biochemical tests, and biofilm formation was detected by tube adherence, Congo red agar, and tissue culture plate method. Antimicrobial susceptibility testing was performed following Clinical and Laboratory Standards Institute guidelines.ResultsA total of 71 CNS isolates, comprising of seven species were obtained. Staphylococcus epidermidis was the most common species followed by S. saprophyticus and S. haemolyticus. We detected biofilm formation in 71.8% of isolates. Considering the fact that tissue culture plate method is the gold standard, sensitivity of tube adherence method and Congo red agar method was found as 82% and 78%, respectively. The isolates exhibited high resistance toward penicillin (90%), azithromycin (60%), co-trimoxazole (60%), and ceftriaxone (40%), while all were susceptible to vancomycin and linezolid. Biofilm former isolates showed higher resistance than the non-formers.ConclusionAmong 71 CNS isolated, S. epidermidis was the most common isolate followed by S. saprophyticus and S. haemolyticus. Biofilm formation was detected in 71.8% of the isolates. All of the methods were effective in detecting biofilm-producing CNS strains. The antimicrobial resistance was significantly higher in biofilm formers than non-formers.