Central Venous Line Placement Research Articles

The superiority of point of care ultrasound in localizing central venous line tip position over time.

The primary objective was to study agreement between X-rays and point of care ultrasound (POC-US) in determining central venous line (CVL) tip position. The secondary objective was to examine malposition rates over time using POC-US. Fifty-six neonates were enrolled who had a CVL placed. Initial X-rays and POC-US were obtained. POC-US was performed daily thereafter for the total of 6days. US video clips were acquired in four standard echocardiographic views: subcostal, four-chamber, and short- and long-axis parasternal views. Gwet's agreement coefficient (AC1) for agreement measured inter-rater reliability of X-rays and POC-US (correct position/malposition). A generalized linear mixed model for binary clustered data estimated malposition rate over time. All analyses were conducted using SAS version 9.4 and Agree Stat. The study included 108 "pairs" of X-rays and POC-US images. Agreement coefficient (AC1), with respect to correct position/malposition of CVL tip, was high AC1 = 0.872 (UVC-AC1 = 0.814, PICC-AC1 = 0.94). Among birth weight (BW) < 1000g, 1000-1499g, and BW > 1500g, AC1 values were 0.922, 0.774, and 0.873, respectively. CVL tip malposition rate decreased over time.Conclusions: Agreement between POC-US and X-rays for CVL tip position was high, with the highest in BW < 1000g. The data suggest that POC-US can be used for initial confirmation and follow up of CVL tip position. What is Known • X-ray is currently the gold standard for localizing central venous line (CVL) tip position. • Malposition of CVL tip can lead to life-threatening complications. What is New • POC-US is superior to X-ray as it can follow CVL tip position over time, detecting malpositioned lines, adjusting them in a timely manner thus preventing complications. • Standardizing CVL placement, X-ray acquisition, POC-US acquisition with four views with video clips and ultrasound operator training increases accuracy and thus agreement between X-ray and POC-US. • UVC tip is more likely to be malpositoned than PICC tip. Malposition of UVC tip using POC-US decreased over time due to shrinking of the umbilical cord in the first 48 of life.

Simple preoperative radiation safety interventions significantly lower radiation doses during central venous line placement in children

PurposeThe purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job-instruction model with a preradiation time-out. MethodsWe reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013–2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph. Results100 patients with valid DAP measurements were identified for analysis (59 preintervention, 41 postintervention). Following implementation of the radiation safety process, there was a 79% decrease in median DAP (61.4 vs 13.1 rad*cm2, P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01). ConclusionA preoperative radiation safety briefing and a radiation safety time-out supported by a job-instruction model were effective in significantly lowering the absorbed doses of radiation in children undergoing CVL insertion. Type of studyCase–control study. Level of evidenceLevel III.

Variability in Critical Care–Related Charge Markups in Medicare Patients

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care-related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60-6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts (P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care-related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients

BackgroundCentral line-associated bloodstream infections (CLABSI) are a major source of sepsis in modern intensive care medicine. Some years ago bundle interventions have been introduced to reduce CLABSI. The use of checklists may be an additional tool to improve the effect of these bundles even in highly specialized institutions. In this study we investigate if the introduction of a checklist reduces the frequency of CLABSI.MethodsDuring the study period from October 2011 to September 2012, we investigated the effect of implementing a checklist for the placement of central venous lines (CVL). Patients were allocated either to the checklist group or to the control group, roughly in a 1:2 ratio. The frequency of CLABSI was compared between the two groups.ResultsDuring the study period 4416 CVL were inserted; 1518 in the checklist group and 2898 in the control group. The use of the checklist during CVL placement resulted in a lower CLABSI frequency. The incidence in the checklist group was 3.8 per 1000 catheter days as compared to 5.9 per 1000 catheter days in the control group (IRR = 0.57; p = 0.001). The use of the checklist also reduced the frequency of catheter colonisation significantly, 36.3 per 1000 catheter days in the checklist group vs 21.2 per 1000 catheter days in the control group, respectively (IRR = 0.58; p < 0.001).ConclusionThe introduction of a checklist to improve the adherence to hygiene standards while placement of central venous lines reduced the frequency of infections significantly.

Presenting predictors and temporal trends of treatment-related outcomes in diabetic ketoacidosis.

This study examines temporal trends in treatment-related outcomes surrounding a diabetic ketoacidosis (DKA) performance improvement intervention consisting of mandated intensive care unit admission and implementation of a standardized management pathway, and identifies physical and biochemical characteristics associated with outcomes in this population. A retrospective cohort of 1225 children with DKA were identified in the electronic health record by international classification of diseases codes and a minimum pH less than 7.3 during hospitalization at a quaternary children's hospital between April, 2009 and May, 2016. Multivariable regression examined predictors and trends of hypoglycemia, central venous line placement, severe hyperchloremia, head computed tomography (CT) utilization, treated cerebral edema and hospital length of stay (LOS). The incidence of severe hyperchloremia and head CT utilization decreased during the study period. Among patients with severe DKA (presenting pH < 7.1), the intervention was associated with decreasing LOS and less variability in LOS. Lower pH at presentation was independently associated with increased risk for all outcomes except hypoglycemia, which was associated with higher pH. Patients treated for cerebral edema had a lower presenting mean systolic blood pressure z score (0.58 [95% confidence interval (CI) -0.02-1.17] vs 1.23 [1.13-1.33]) and a higher maximum mean systolic blood pressure (SBP) z score during hospitalization (3.75 [3.19-4.31] vs 2.48 [2.38-2.58]) compared to patients not receiving cerebral edema treatment. Blood pressure and cerebral edema remained significantly associated after covariate adjustment. Treatment-related outcomes improved over the entire study period and following a performance improvement intervention. The association of SBP with cerebral edema warrants further study.

Using Augmented Reality Glasses in Central Venous Line Placement Simulations

Central venous lines are used to administer medicines, nutrients, and blood products to the heart via the large internal jugular vein. This technology is used when medications cannot be administered orally or injected through smaller veins. The procedure involves a high level of precision and there is little room for error. The goal of this research is to investigate the feasibility of using augmented reality (AR) glasses in central line simulation by novice operators and comparing its efficacy to standard central line simulation/teaching. With the Brother AiRScouter augmented reality glasses, the learner controls the timing of each step and receives real‐time information from the AR glasses. A grader documented the time to AR glasses placement, time to venipuncture, number of attempts, and completion of a pre‐determined checklist. This study used a prospective randomized enrollment of 32 novice operators. Subjects were randomized on a 1:1 basis to either a simulation using the augmented reality glasses or a simulation using only conventional instruction. There was a total of 32 subjects participating in this study. Mean age of participants was 39.8±7.8 years; 5 Females and 27 Males; 11 Physicians, 19 Respiratory Therapists, and 2 Sleep Technologists. The mean time for AR placement in the AR group was 71 ± 43 secs and time to IJ cannulation was 316 ± 112 sec. There was no significant difference in median (min, max) time (seconds) to IJ cannulation for those who were in the AR group and those who were not (339 (130, 550) vs 287 (35, 475), p=0.09), respectively. There was also no significant median difference between the two groups in total procedure time (524 (329, 792 vs 469 (198, 781), p=0.29), respectively. Our results are consistent with the idea that AR‐simulation of central venous catheters is feasible and efficacious for novice operators. AR technology is likely to be generally applicable to both procedural and fundamental medical education.Support or Funding InformationBrother Augmented Reality glasses were provided by Brother‐USA. Tom &amp; Vi Zapara School of Business at La Sierra University supported this study.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Abstract 259: Pre-Procedure Checklist and Morning Huddle as Part of Patient Evaluation for Cardiac Catheterisation

Background: World Health Organization (WHO) Surgical Safety Checklist had a significant impact on surgical outcomes(1). In 2009, The United Kingdom National Patient Safety Agency required the use of this checklist(2). A pre procedure checklist for central venous line placements was one of the first commonly used checklists, and since then, the concept has been expanded to include venous thromboembolism prophylaxis, patient discharge, and many more(3). In 2016, Society of Cardiovascular Angiography and Interventions (SCAI) published a best practices consensus statement Update, which included a pre-procedure checklist for cardiac catheterizations(4). Objectives: The goals of the project were two-fold. First, to formalize the pre-procedure evaluation of patients referred to the cardiac catheterization laboratory, and second, to introduce a ‘Morning Huddle’ for all team members. The huddle is directed by a physician and includes a brief patient history and procedural plan to ensure everyone has a clear understanding of the procedure indication, patient specific risks, and procedural equipment needed. It would also provide an opportunity for group questions or to raise concerns. Methods: Safety Attitudes Questionnaire (SAQ) was used with permission from University of Texas Health Science Center at Houston, to assess the attitudes towards safety of the staff working at the cardiac catheterization laboratory, as well as the general cardiology fellows. Cardiology fellows were provided with pre-catheterization checklist, adapted from the SCAI best practices consensus statement Update, as well as an outline for the format of the ‘Morning Huddle’. Results: The total number of responses obtained were 23. The survey revealed that the majority of the staff felt that the physicians and nurses worked in a well-coordinated team (95.7%, 22 of 23). Almost 26% (6 of 23) of the staff interviewed reported difficulty in speaking up when a problem was perceived. Communication breakdown was not noted to be a problem by the majority interviewed, although a small percentage did disagree (26%, 6 of 23). Conclusions: Although the survey was overwhelmingly positive at baseline, room for improvement was noted. It is anticipated that the intervention will allow the staff an opportunity to speak up when a problem is perceived, and improve communication, by empowering the team during the ‘Morning Huddle’. Our overarching goal is to improve the safety climate in the catheterization laboratory.

Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room

BackgroundCentral venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management. Methods200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access. ResultsIn 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed. ConclusionRoutine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.

Prevalence and risk factors for venous thromboembolism in children with sickle cell disease: an administrative database study

AbstractA hypercoagulable state resulting in increased venous thromboembolism (VTE) has been described in adults with sickle cell disease (SCD), but similar data for children are lacking. The objective of this retrospective cohort study was to describe the rate of VTE and risk factors associated with VTE in children with SCD across tertiary-care children's hospitals in the United States between the years 2009 and 2015. We used the Pediatric Health Information System database to investigate all pediatric patients with SCD admitted to 1 of 48 participating institutions between 1 January 2009 and 30 September 2015. International Classification of Disease, Ninth Edition, Clinical Modification codes were used to identify index thromboembolic events and chronic medical conditions known to be associated with VTE. Billing codes were used to identify central venous line (CVL) placement and pharmaceutical billing codes to identify estrogen containing oral-contraceptive use. Logistic regression analysis was used to study the association among unique patient characteristics, VTE, and death. 10 454 eligible subjects with SCD were identified. Median age (±interquartile range) of study cohort was 10 (±11) years. 181 subjects (1.7%) developed an index venous thromboembolic event during the study period. Median age at VTE diagnosis was 15.9 (±7.4) years. On multivariable logistic regression analysis, CVL placement, chronic renal disease, history of stroke, female sex, length of hospitalization, intensive care unit utilization, and older age were associated with VTE. After adjusting for other variables, VTE was independently associated with death. In summary, VTE can occur in pediatric patients with SCD. CVL placement is a modifiable risk factor for VTE development.

BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy.

BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy.

A Medium-Term Venous Access Alternative for Infants Undergoing Congenital Heart Surgery.

We describe a strategy aimed at maximizing the safety and minimizing the thrombogenicity of central venous lines for neonates with congenital heart defects. Our method involves the use of a tunneled technique to place a 4.2 Fr single-lumen (Broviac) catheter in the subpericardial space, with minimal intravascular course and a tip placed in the lower right atrium. Using this technique, we potentially eliminated the requirement for percutaneous placement of central venous lines postoperatively as well as potentially decreased the risk of intrapericardial bleeding associated with transthoracic lines.

Placement of central venous lines for sepsis in the elderly has markedly increased—Evidence from a cohort of New Jersey (USA) emergency departments

BackgroundEarly goal directed therapy for sepsis patients requires placement of central lines (CVPL) to measure central pressure. ObjectiveWe hypothesized that the percentage of CVPL placed for sepsis has increased over time, whereas the frequency of lines placed for other conditions has not changed. MethodsThis was a retrospective cohort study. Investigators analyzed records from consecutive ED patients in nine hospitals over a 10-year period. Patients >65 years identified with CVPL by CPT codes and diagnoses established by ICD-9 codes.We computed the annual number of patients that had a CVPL placed for sepsis and other conditions. We calculated the change from 2005 and 2014 in the normalized number of patients >65 with sepsis and other conditions and the 95% confidence intervals (CIs).We normalized the annual number of CVPLs by the average number of total annual visits for those >65 years as the annual visits in the >65 years cohort increased by > 25% over the course of the study. We then plotted the annual number of normalized CVPLs for sepsis and other conditions placed versus year and computed the linear regression coefficients (R2). Alpha was set at 0.05. ResultsOf the 3,772520 visits in the data base there were 711,435 visits by patients >65 years; 3184 (0.45%) had CVPL placed and 784 of those patients were treated for sepsis. The percent of patients with CVPL for sepsis increased 212% (95% CI: 115% to 356%) from 2005 to 2014, but there was no statistically significant annual change in percent of CVPL placed for other conditions (10% decrease, 95% CI: −26% to 9%). The linear regression coefficient for the plot of annual normalized number of CVPLs vs. year (See table and plot) was statistically significant for sepsis (R2 = 0.94, p < 0.001) but not for other conditions (R2 = 0.09, p = 0.80). ConclusionWe found that CVPL placed for sepsis tripled from 2004 to 2011, whereas CVPL placed for other conditions did not change significantly.

Age related inverse dose relation of sedatives and analgesics in the intensive care unit

Sedative and analgesic practices in intensive care units (ICUs) are frequently based on anesthesia regimes but do not take account of the important patient related factors. Pharmacologic properties of sedatives and analgesics change when used as continuous infusions in ICU compared to bolus or short-term infusions during anesthesia. In a prospective observational cohort study, we investigated the association between patient related factors and sedatives/analgesics doses in patients on mechanical ventilation (MV) and their association with cessation of sedation/analgesia. We included patients expected to receive MV for at least 24 hours and excluded those with difficulty in assessing the depth of sedation. We collected data for the first 72 hours or until extubation, whichever occurred first. Multivariate analysis of variance, multivariate regression as well as logistic regression were used. The final cohort (N = 576) was predominantly male (64%) with mean (SD) age 61.7 (15.6) years, weight 63.4 (18.2) Kg, Acute Physiology and Chronic Health Evaluation II score 28.2 (8) and 30% hospital mortality. Increasing age was associated with reduced propofol and fentanyl doses requirements, adjusted to the weight (p<0.001). Factors associated with higher propofol and fentanyl doses were vasopressor use (Relative mean difference (RMD) propofol 1.56 (95% confidence interval (CI) 1.28–1.90); fentanyl 1.48 (1.25–1.76) and central venous line placement (CVL, RMD propofol 1.64 (1.15–2.33); fentanyl 1.41 (1.03–1.91). Male gender was also associated with higher propofol dose (RMD 1.27 (1.06–1.49). Sedation cessation was less likely to occur in restrained patients (Odds Ratio, OR 0.48 (CI 0.30–0.78) or those receiving higher sedative/analgesic doses (OR propofol 0.98 (CI 0.97–0.99); fentanyl 0.99 (CI 0.98–0.997), independent of depth of sedation. In conclusion, increasing age is associated with the use of lower doses of sedative/analgesic in ICU, whereas CVL and vasopressor use were associated with higher doses.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children.

To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population. A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals. A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0kg (SD 2.9); mean age 10months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n=18). The median duration of line placement was 140days (IQR 146). The most common indications for removal were completion of therapy (n=7, 39%) and infection (n=5, 28%). There were no early complications. Long-term complications included infection (n=5) or catheter malfunction (n=3). Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

Thromboelastometry versus standard coagulation tests versus restrictive protocol to guide blood transfusion prior to central venous catheterization in cirrhosis: study protocol for a randomized controlled trial

BackgroundLiver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far.The aim of this study is to compare three transfusion strategies (routine coagulation test-guided – ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis.Methods/designDesign and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil. Inclusion criteria: adults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis.DiscussionThis study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy.Trial registrationClinicalTrials.gov, identifier: NCT02311985. Retrospectively registered on 3 December 2014.

Anaesthetic management of thoraco‐omphalopagus twins with congenital heart disease for separation surgery

SummaryConjoined twins' separation surgery poses challenges to anaesthetists due to the variable degree of cross circulation, difficulty in positioning, bleeding and limitations of space for sharing between two anaesthetic teams. We present the anaesthetic management for separation surgery of three‐months old conjoined twins. Both babies had congenital heart disease, with one baby hypertensive and commenced on enalpril pre‐operatively. A pre‐operative multi‐disciplinary meeting between all stake holders and a full environment simulation was performed and was helpful. The problems encountered included difficulty in percutaneous central venous line placement requiring surgical cut down and intra‐operative bleeding requiring vasopressor therapy and postoperative intensive care unit stay.

Children's Hospital-Acquired Thrombosis (CHAT) Registry: A Multi-Institutional Registry for Prospective Identification of Independent Risk Factors

Background: Pediatric hospital-acquired venous thromboembolism (HA-VTE) incidence is rising and many centers are instituting pediatric-specific prophylaxis programs despite a lack of evidence-based risk stratification to reduce unnecessary thromboprophylaxis exposure.Objectives: The multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Registry via Research Electronic Data Capture (REDCap) can identify independent HA-VTE risk factors for prospective validation and creation of a risk-assessment scoring system.Methods: This IRB-approved, retrospective registry reveals HA-VTE risk factors from subjects aged 0-21 years with radiographically-validated VTE ≥ 48 hours after hospital admission, or after central venous line placement, at 5 pediatric hospitals from January 2012 - June 2015. Descriptive statistics summarize demographics, medical comorbidities, characteristics of the VTEs themselves and associated laboratory testing for 555 subjects. Further analyses are currently utilizing matched controls and logistic regression to identify specific odds ratios for independent risk factors.Results: The median time to VTE diagnosis was 9 days with interquartile range (IQR) of 5-18.5 days, 34% of VTE occurred in a critical care unit, and 36.8% of subjects had been hospitalized in the 30 days prior to the index hospitalization. 22.7% of VTE events were incidentally found. VTE distribution was: deep vein thromboses of arms/legs (79.6%), cerebral sinus venous thrombosis (7%), abdominal VTE (5%), pulmonary embolism (4.3%), and other (intra-cardiac and superior vena cava/right atrial junction - 5.5%) with overlap due to some subjects with multiple, separate, concurrent VTE events. Demographic characteristics revealed median age of 3.6 years (IQR: 0.4 - 13.6 years) at VTE diagnosis and slight male predominance (55%). 66.1% of subjects had significant past medical history (Table 1) and 7.2% were immobile at baseline.Evaluation of hospital course revealed a multitude of acquired putative risk factors for HA-VTE (Table 2). 70.8% of VTE were associated with a central venous catheter (CVC). Of CVC-related VTE, 70.5% were in the same vein as CVC, 20.1% were in a vein which previously held a CVC, 10.7% surrounded the CVC tip, 2.5% occurred in a vein where CVC placement was attempted but unsuccessful. 55% of subjects had at least one documented infection during hospitalization, 42% of subjects had surgery, 20.7% had a procedure involving intravascular instrumentation (defined as dialysis, plasmapheresis, cardiac catheterization, stent placement/removal, or coiling procedure), 5% of subjects underwent trauma prior to admission with 82% of trauma classified as "major", and 59.5% of subjects were intubated at some point during their admission. Regarding medications, 31.9% of subjects were on steroids at VTE diagnosis and an additional 13.2% of subjects received steroids in the 30 days prior to VTE diagnosis, 2.2% of subjects were on estrogen with all of these subjects having started estrogen within 6 months prior to VTE diagnosis, 4.1% of subjects received asparaginase prior to VTE, 1.6% of subjects received recombinant factor VIIa prior to VTE, and 0.4% of subjects received prothrombin complex concentrates prior to VTE.Laboratory testing of hospitalized patients revealed 43.2% of patients had a d-dimer level obtained at time of VTE and 96.5% of those patients had an elevated level. 48.3% of patients had at least one thrombophilia lab test ordered. 17.8% of subjects received VTE prophylaxis - 55% of which was pharmacologic anticoagulation.Conclusions: The CHAT registry results demonstrate a slight male predisposition and multiple associated chronic medical illnesses and acquired hospital course co-morbidities, particularly CVCs which were involved in the majority of events. Ongoing work includes incorporating additional institutions to reach a goal of 1000 cases and 2000 controls to identify independent risk factors for the development of a risk-assessment scoring system. Long-term goals include prospective validation of the scoring system to serve as the basis of identifying subjects for a future randomized clinical trial of risk-based prevention strategies. Such a trial would evaluate efficacy, safety, and cost-benefit of thromboprophylaxis in hospitalized children and help inform best practices. [Display omitted] [Display omitted] DisclosuresYoung:Novo Nordisk: Consultancy, Speakers Bureau; Kedrion: Consultancy; Baxter: Consultancy; Biogen: Consultancy, Speakers Bureau.

Thrombin Generation and Microparticles As Promising Biomarkers for Venous Thromboembolism in Children with Central Venous Lines

Background: Pediatric hospital-acquired venous thromboembolism (HA-VTE) has increased over the past ten years (Raffini et al. Pediatrics 2009; 124; 1001-1008), with an associated increase in both VTE-associated complications and treatment-related adverse events. Children with VTE have a four-fold increase in length of admission compared to children without VTE. There are many known clinical risk factors but the presence of central venous lines (CVLs) has been shown to be among the strongest risk factors in children (Mahajerin et al. Haematologica 2015 Aug; 100(8): 1045-50). Current tools, including clinical risk-prediction scoring systems as well as genetic risk factors, are not sufficient to predict VTE risk at this time. Identification of dependable, rapid and cost-effective biomarkers for the prediction of VTE in children with CVLs is essential in guiding anti-coagulation prophylaxis, thus reducing VTE occurrence among hospitalized children with CVLs.Objectives: Determine the ability of thrombin generation (TG) and microparticle-based phospholipid-dependent procoagulant potential (MP-PPL) to predict VTE occurrence in hospitalized children with CVLs.Methods: Plasma sample were collected from 34 hospitalized acutely ill children between the age of 1 month and 21 years, who are at risk for VTE due to multiple known clinical risk factors, including a newly placed non-tunneled CVL. Children that had undergone a recent cardiac catheterization or on dialysis, plasmapheresis or ECMO were excluded. Samples from 16 age matched healthy controls were also collected. Venous samples were collected prior to CVL placement. Platelet poor plasma (PPP) was obtained according to a strict protocol to minimize pre-analytical variable. All pertinent clinical and laboratory information was extracted, including CVL-related variables and details of VTE in affected subjects. TG was measured by means of the calibrated automated thrombogram (CAT). MP-PPL was measured using two methods: 1) Functional assay that detects the ability of circulating MPs to indirectly facilitate thrombin generation (Zymuphen MP-Activity kit, Hyphen BioMed, France), 2) Clot-based assay that measures phospholipid-dependent, factor Xa initiated clotting time in relation to normal controls (STA-Procoag-PPL, Diagnostica Stago).Results: The median age of our cohort was 10 yrs (IQR 12, range 0 - 19), with a slight male predominance (53%) and increased representation of adolescents (41%). CVLs were placed in an intensive care setting in 38% of subjects and 39% of subjects had an underlying condition associated with chronic inflammation. The median duration of CVL placement from admission was 2 days (IQR 5, range 1 - 19) and the median total duration of CVLs were 14 days (IQR 20, range 5 - 84). Line-associated VTE occurred in 9% (3/34) of children with CVL and one subject had a VTE unrelated to CVL. There was no observed significant difference between children with or without line-related VTE in terms of age, gender, lag of CVL placement from admission, duration of CVLs, caliber of initial vessel of insertion, number of lumens, size of CVL and internal length of the CVL. However, all subjects with line-associated VTE were admitted for acute infection to an intensive care setting, with the majority of VTE occurring within 48 hours from line placement (2/3). Correlation analysis of the two MP-PPL assays was significant (r = -0.659). Even though the MP-PPL functional assay did not show a significant difference between subjects with and without line-associated VTE (p-value 0.189), the MP-PPL clot-based assay showed measurable difference between the two groups, both as an absolute value and as a ratio (p-value: 0.04 and 0.038 respectively, Table 1). Peak thrombin generation (p-value 0.001), estimated thrombin potential (ETP) - (p-value 0.02) and velocity index (p-value 0.001) were significantly higher in subjects with line-associated VTE (see Figure 1). Subject recruitment and sample analyses, involving these assays and other potential biomarker candidates, are ongoing.Conclusion: Given the rising incidence of pediatric VTE, the ability to use biomarkers to stratify patients according to their VTE risk will provide a vital tool to guide preventative efforts, and minimizing unnecessary expense and toxicities. TGA and MP-PPL have shown great potential for differentiating children with CVLs that may develop a line-related VTE as a HA-VTE. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Germany-wide survey on anaesthesia in thoracic surgery

This study's objective was to evaluate current thoracic anaesthesia practice in Germany and to quantify potential differences depending on the hospital's level of care. A four-part online survey containing 28questions was mailed to all anaesthesiology department chairs (n= 777) registered with the German Society of Anaesthesiology and Intensive Care Medicine. The general response rate was 31.5 % (n= 245). High monthly volumes (>50operations/month) of intrathoracic procedures, performed by specialized thoracic surgeons are mostly limited to hospitals of maximum care, university hospitals, and specialized thoracic clinics. In hospitals with a lower level of care, intrathoracic operations occur less frequently (1-5/month) and are commonly performed by general (69.3 %) rather than thoracic surgeons (15.4 %). Video-assisted thoracic surgeries are the most invasive intrathoracic procedures for most hospitals with a low level of care (61.5 %). Extended resections and pneumonectomies occur mainly in hospitals of maximum care and university hospitals. Thoracic anaesthesia is primarily performed by consultants or senior physicians (59.9 %). The double lumen tube (91.4 %) is the preferred method to enable one-lung ventilation (bronchial blockers: 2.7 %; missing answer: 5.9 %). A bronchoscopic confirmation of the correct placement of a double lumen tube is considered mandatory by 87.7 % of the respondents. Bronchial blockers are available in 64.7 % of all thoracic anaesthesia departments. While CPAP-valves for the deflated lung are commonly used (74.9 %), jet-ventilators are rarely accessible, especially in hospitals with a lower level of care (15.4 %). Although general algorithms for a difficult airway are widely available (87.7 %), specific recommendations for a difficult airway in thoracic anaesthesia are uncommon (4.8 %). Laryngeal mask airways (90.9 %) and videolaryngoscopy (88.8 %) are the primary adjuncts in store for a difficult airway. While hospitals with a lower level of care admitted patients routinely (92.3 %) to an intensive care unit after thoracic surgery, larger clinics used the postanaesthesia recovery room (12.5 %) and intermediate care units (14.6 %) more frequently for further surveillance. Thoracic epidural catheters (85.6 %) are predominantly chosen for peri- and postoperative analgesia, in contrast to paravertebral blockade (single shot: 8.6 %; catheter: 8.0 %) (multiple answers possible). Ultrasound is generally accessible (84.5 %) and mostly employed for the placement of central venous (81.3 %) and arterial (43.9 %) lines as well as a diagnostic tool for pulmonary pathology (62.0 %). The study reveals considerable differences in the anaesthetic practice in thoracic surgery. These focus mostly on the postoperative surveillance, the availability of bronchial blockers, and the use of regional anaesthetic techniques. Furthermore, it is evident that specific algorithms are needed for the difficult airway in thoracic anaesthesia. A recommendation for the high-tech work environment of thoracic anaesthesia could enhance the structural quality and optimize patient outcomes. Independent of a hospital's level of care, uniform requirements could help establish national quality standards in thoracic anaesthesia.

Locating the optimal internal jugular target site for central venous line placement

Study objectiveHistorically, the placement of internal jugular central venous lines has been accomplished by using external landmarks to help identify target-rich locations in order to steer clear of dangerous structures. This paradigm is largely being displaced, as ultrasound has become routine practice, raising new considerations regarding target locations and risk mitigation. Most human anatomy texts depict the internal jugular vein as a straight columnar structure that exits the cranial vault the same size that it enters the thoracic cavity. We dispute the notion that the internal jugulars are cylindrical columns that symmetrically descend into the thoracic cavity, and purport that they are asymmetric conical structures. DesignThe primary aim of this study was to evaluate 100 consecutive adult chest and neck computed tomography exams that were imaged at an inpatient hospital. We measured the internal jugular on the left and right sides at three different levels to look for differences in size as the internal jugular descends into the thoracic cavity. Main resultsWe revealed that as the internal jugular descends into the thorax, the area of the vessel increases and geometrically resembles a conical structure. We also reconfirmed that the left internal jugular is smaller than the right internal jugular. ConclusionsUnderstanding that the largest target area for central venous line placement is the lower portion of the right internal jugular vein will help to better target vascular access for central line placement. This is the first study the authors are aware of that depicts the internal jugular as a conical structure as opposed to the commonly depicted symmetrical columnar structure frequently illustrated in anatomy textbooks. This target area does come with additional risk, as the closer you get to the thoracic cavity, the greater the chances for lung injury.