Consecutive Central Venous Catheters Research Articles

The Effect of Residence Time of No-tunneled Hemodialysis Catheters on Infection and Thrombosis Outcome. Identification of CVC’s Time Cut-off

Introduction: Permanent vascular access (arteriovenous fistula (AVF), arteriovenous graft (AVG)) is susceptible to acute events that reduce patency. The temporary central venous catheter (CVC) constitutes bridging therapy for primary vascular access dysfunction. The impact of “residence time” on the rate of dysfunction/thrombosis or infection remains to be explored. AIM: 1) To evaluate the impact of CVC residence time on outcomes (infection or Thrombosis/dysfunction) in consecutive temporary CVCs adjusted for the insertion site (upper site vs. lower site). 2) To establish a cut-off resident time. Patients and methods: Seventeen prevalent hemodialysis patients with three consecutive CVCs are followed up prospectively in an observational study for a period equivalent to the permanence of the CVCs. The data is recorded at the beginning of the CVC time. The diagnosis of catheter-related bloodstream infection and thrombosis/dysfunction is made following the K-Doqi 2019 guidelines. Statistical analysis: Seventeen hemodialysis patients (51 CVCs) were included. The ‘CVC resident time’ of each individual patient ((i.e. βcoefficient (log-transformed)*AUC)) was determined using LMM and then inserted into multivariate Cox models to assess infection and dysfunction/thrombosis outcomes (Joint Models). The AUC was calculated at various baseline levels of CVC time (10th……50th percentile). The cut-off point for thrombosis in CVC time corresponds to the mean of the CVC time at the 30th percentile of all CVCs. Results: The CVC time is different for CVC’s site insertion and sequence. From the analysis of multivariate joint models, CVC resident time appears not to be significant for infection, but heterogenicity for the insertion site (ref3-4=upper site) is significant for the outcome of thrombosis/dysfunction. From the study of survival analysis, the free survival from outcomes by CVC site insertion appears to be significant for thrombosis/dysfunction. The average time of CVCs’ calculation at the 30th percentile is 14 days (cut-off). Conclusion: No tunneled hemodialysis Catheter (NTHC) residence time is considered not to be a risk factor for infection, but it represents a risk factor for lower access thrombosis. After the cut-off time of 14 days, the advantage of the higher NTHCs is lost.

Development and validation of a multivariable prediction model of central venous catheter-tip colonization in a cohort of five randomized trials

BackgroundThe majority of central venous catheters (CVC) removed in the ICU are not colonized, including when a catheter-related infection (CRI) is suspected. We developed and validated a predictive score to reduce unnecessary CVC removal.MethodsWe conducted a retrospective cohort study from five multicenter randomized controlled trials with systematic catheter-tip culture of consecutive CVCs. Colonization was defined as growth of ≥103 colony-forming units per mL. Risk factors for colonization were identified in the training cohort (CATHEDIA and 3SITES trials; 3899 CVCs of which 575 (15%) were colonized) through multivariable analyses. After internal validation in 500 bootstrapped samples, the CVC-OUT score was computed by attaching points to the robust (> 50% of the bootstraps) risk factors. External validation was performed in the testing cohort (CLEAN, DRESSING2 and ELVIS trials; 6848 CVCs, of which 588 (9%) were colonized).ResultsIn the training cohort, obesity (1 point), diabetes (1 point), type of CVC (dialysis catheter, 1 point), anatomical insertion site (jugular, 4 points; femoral 5 points), rank of the catheter (second or subsequent, 1 point) and catheterization duration (≥ 5 days, 2 points) were significantly and independently associated with colonization . Area under the ROC curve (AUC) for the CVC-OUT score was 0.69, 95% confidence interval (CI) [0.67–0.72]. In the testing cohort, AUC for the CVC-OUT score was 0.60, 95% CI [0.58–0.62]. Among 1,469 CVCs removed for suspected CRI in the overall population, 1200 (82%) were not colonized. The negative predictive value (NPV) of a CVC-OUT score < 6 points was 94%, 95% CI [93%–95%].ConclusionThe CVC-OUT score had a moderate ability to discriminate catheter-tip colonization, but the high NPV may contribute to reduce unnecessary CVCs removal. Preference of the subclavian site is the strongest and only modifiable risk factor that reduces the likelihood of catheter-tip colonization and consequently the risk of CRI.Clinical Trials Registration: NCT00277888, NCT01479153, NCT01629550, NCT01189682, NCT00875069.

Ultrasound-Guided Catheter Insertion Did Not Decrease Catheter-Related Blood Stream Infection in Hematological Oncology Care Unit

Background: Central venous catheters (CVCs) are necessary for critically ill patients requiring intravenous pharmacological intervention and subsequent parenteral nutritional support. Although CVCs allow delivery of medications and nutritional support that cannot be administered safely through central venous, their use is inevitably associated with adverse events, mechanical complication and catheter-related infection. While ultrasound guide has already been proven to decrease mechanical complications, it is not fully elucidated whether ultrasound guide decrease the risk of catheter-related infection.Methods: We observed consecutive CVC insertions between April 2009 and January 2013. In total, 395 insertion cases were surveyed in the hematological oncology unit. We divided the research period into two terms: before December 2011 (early term) and after January 2012 (latter term). Between the early and latter terms, there were substantial differences regarding the use of ultrasound guides. Because insertion maneuvers changed from blind to ultrasound-guided approach after 2012. SMAC Plus MicroNeedle (15G, 13 cm or 12G, 20 cm; Covidien Tokyo, Japan) was used. Practitioners determined which CVC device and which insertion site was preferred for each patient. To determine the clinical efficacy of chlorhexidine gluconate dressing (CHGD) at catheter insertion site, we performed matched cohort analysis among the patients who underwent stem cell transplantation. Total 44 cases were included in the cohort from the total study population.Results: Underlying diseases included hematological malignancies and immunological disorders such as auto-immune diseases and solid organ malignancies. A total of 235 and 160 cases were included in early and latter terms, respectively. Insertion duration was a median 26 days (range, 2-126 days) in the early term and 18 days (range, 2-104) in the latter term. During the early term, the insertion sites were 22.6%, 40.2%, and 25.7% at the cervical, subclavian, and femoral veins, respectively, and 32.3%, 16.9%, and 25.4% in the latter term, respectively. The ultrasound-guided insertion method became a routine practice in the latter term. The frequency of catheter-related blood stream infection (CRBSI) was 8.46/person-days and 13.62/person-days in the early and latter terms, respectively. Mechanical comorbidities decreased from 0.39 (13/33) incidences/month to 0.00 (0/13) after the introduction of the ultrasound-guided insertion method. Using subgroup analysis, detected causative pathogens of CRBSI did not differ between the two terms: gram-positive coccus, gram-positive bacillus, and gram-negative bacillus were 68.9%, 11.5%, and 14.8% in the early term and 68.2%, 11.4%, and 18.2% in the latter term, respectively. Controlled-cohort study revealed CHGD decreased CRBSI caused by Staphylococcus spp. significantly, but not overall other organisms.Conclusion: Ultrasound-guided insertion did not decrease the incidence of CRBSI. However, in our survey, insertion through the cervical vein approach clearly increased after the introduction of the ultrasound-guided method, and mechanical complications decreased significantly. Ultrasound guide and cervical vein approach trended for patients with hematological diseases who required CVC and those who concurrently harbored multiple risks, including thrombocytopenia. The prevalence of CRBSI slightly increased with this trend. With respect to CRBSI, the preventative effect of CHGD in patients undergoing allogeneic stem cell transplantation was promising. We advocate trending of ultrasound-guided, cervical approach CVC with CHGD can provide the safest parental alimentation for the patients with hematological malignancies. DisclosuresNo relevant conflicts of interest to declare.

Safety and Efficacy of An Educational Program in Reducing Complications of Peripherally Inserted Central Catheters (PICCs) in Haematological Patients,

Abstract 4219 Purpose.Patients with haematological disorders frequently require the insertion of medium or long-term central venous catheters (CVCs) for stem-cell transplantation, the administration of chemotherapy, or transfusion of blood products. Although peripherally inserted central catheters (PICCs) have been in use for many years, little data exist on their use in patients receiving intensive chemotherapy. Methods:Evidence-based interventions were implemented in our department in December 2010, and include:1.An high level nurse education program for correct practices and prevention of catheter-associated complications. was developed for PICC nursing team;2) The use of ultrasound guide for the insertion of the tip of PICCs, thanks to a special operator training; 3) Bedside placement and confirmed PICC tip placement by chest radiography after removal of the guidewire and before the securing of the catheter; 4) Maintenance of maximum sterile barrier precautions during PICC insertion and aftercare; 5) chlorhexidine preparation, replace 10% povidone iodine for skin antisepsis; 6) adoption of PICC patient nurse archive, including the information of weekly PICC line review at our department for each patient. Here, we carried out a clinical investigation to determine the efficacy of these interventions in reducing the rate of PICC-related complications (thrombotic events, exit site infection and other complications requiring early removal of PICCs) and to compare PICCs-specific complications (CR-BSI) with a cohort population defined as each consecutive CVC non tunneled inserted over a 6-month period (May–November 2009), and before these evidence-based interventions. Results:Ninety-five PICCs were in place for a total of 7,295 PICC days ( range, 1–331 days; mean, 76,7 days), and fifty-one CVCs were inserted before these interventions (range, 3–577 days; mean, 176,2 days). Sixty-six PICCs were inserted during severe thrombocytopenia (platelets < 50 × 10(9)/L), and 70 during severe neutropenia (neutrophils < 0.5 × 10(9)/L). The majority of the patients were affected by leukaemia, and PICCs were inserted to ensure adequate access throughout chemotherapy. There were 2 thrombotic complications PICC-related (0,27 per 1,000 CVC days), and only one CRBSI (0,14 per 1,000 CVC days) during neutropenia. Other mechanical complications occurred in 11 catheters, and were accidental dislodgement (4), catheter break (3), catheter inadequate (4). Compared with CVCs group, the PICCs group was associated with a lower incidence of CRBSI complication rate (1,05% vs 41,17%, 0,14 vs 3,67 per 1,000 CVC days) [odds ratio (OR) 0,051; relative odds reduction (ROR) 0,98]. Conclusions:Our results indicate that a training and competence assessment program is effective in reducing the main complications PICCs-related in haematological setting.Tab 1Catheter outcomes, by devicen=95 PICCsn=51 CVCsNumberPercentage (%)NumberPercentage (%)Male4850.5%3058,8%Female4749,40%2141,2%Mediane AgeRange 17–82 years49.1Range 23–78 years50,5Type of catheter:Silicon rubber66.3%CVC ST (short term)3568,63%Polyurethane33.1%CVC LT (Long term)1631,37%Polyurethane power injectable8690.5%Definite CRBSI% infectionPer 1000 CVC daysrange (days)Means (days)ORPICCs (n.95)1,050,141–33176,790.0151CVCs (n.51)41,173,673–577176,2CRBSI catheter-related bloodstream infection. PICC peripherally inserted CVC. CVC central venous catheter. Disclosures:No relevant conflicts of interest to declare.

Mechanical Complications of Central Venous Catheters

We analyzed 385 consecutive central venous catheter (CVC) attempts over a 6-month period. All critically ill patients 18 years of age or older requiring a CVC were included. The rate of mechanical complications not including failure to place was 14%. Complications included failure to place the CVC (n = 86), arterial puncture (n = 18), improper position (n = 14), pneumothorax (n = 5 in 258 subclavian and internal jugular attempts), hematoma (n = 3), hemothorax (n = 1), and asystolic cardiac arrest of unknown etiology (n = 1). Male patients had a significantly higher complication rate than female patients (37% vs 27%, P = .04). The subclavian approach had a higher complication rate than the internal jugular or the femoral approach (39% vs 33% vs. 24%, P = .02). The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than 2 punctures were required.

Incidence of thrombotic complications in patients with haematological malignancies with central venous catheters: a prospective multicentre study

This prospective, observational and multicentre study assessed the incidence of, and risk factors for, symptomatic venous thrombotic complications after central venous catheter (CVC) positioning in patients with haematological malignancies. A total of 458 consecutive CVC insertions were registered in 416 patients (81.2% of whom had severe thrombocytopenia). Over the observation period (3 months or up to catheter removal), the incidence of events was: CVC-related deep vein thrombosis (DVT), 1.5%; lower limb DVT, 0.4%; pulmonary embolism (PE), 1.3%; fatal PE, 0.6%; CVC-related superficial thrombophlebitis, 3.9%; CVC-occlusion/malfunction of thrombotic origin, 6.1%; major arterial events, 1.1%. Severe bleeding and CVC-related infections were observed in 3.5% and 4.6% of cases respectively. A composite end point (any venous thromboembolism or superficial thrombophlebitis or CVC occlusion/malfunction) was defined in order to consider venous thrombotic events with a significant impact on clinical practice. With this criterion, the overall incidence was 12.0% (2.54 cases/1000 catheter days). No factor helped to predict venous thrombotic complications: only thrombocytopenia was associated with a weak trend for a reduced risk (odds ratio 0.52; 95% confidence interval 0.26-1.07). No severe bleeding was observed in those patients who received antithrombotic prophylaxis. This study shows that the impact on clinical practice of symptomatic CVC-related thrombotic complications is not negligible in patients with haematological malignancies.

Infection in Central Lines: Antiseptic-Impregnated vs Standard Non-Impregnated Catheters

We report a survey of 196 consecutive central venous catheters (CVCs) placed in 151 patients in the Intensive Care Unit (ICU) over a ten-month period. Over this time the use of a new antiseptic-impregnated triple lumen CVC (Arrowgard Blue, Arrow International Inc., Pennsylvania, U.S.A.) was alternated on a bimonthly basis with the standard triple-lumen CVC (Arrow International Inc., Pennsylvania, U.S.A.). The overall rate of CVC tip infection was lower in the impregnated CVC group (15.6% vs 30.9%, P < 0.05). The impregnated CVC group had a much lower cumulative infection rate when the dwell time in patients was five days or less (3.3% vs 26.9%, P < 0.05). However, the difference between the cumulative infection rate was not statistically significant (P > 0.05) for dwell times of 6, 7 or 8 days respectively. There was no difference in the CVC related bacteraemia rates between the two groups (3.9% vs 3.7%, P > 0.05).

Central venous catheters in neonates less than 3500 g—results of a prospective study

SummaryIn this prospective study we analysed 336 consecutive central venous catheters in neonates less than 3500 g. A protocol standardizing the technique of insertion, the care of the catheter, the preparation of solutions and weekly bacteriological screening was applied to all catheter insertions. Mechanical complications were observed in 15 (6%), catheter dislodgement (5%), obstruction (8%), perforation (2%) and caval vein thrombosis (0.6%). Routine bacteriological cultures of feeding solutions and infusion devices showed a contamination rate of 3.5% and 2%. Skin swab and catheter tip cultures after catheter removal demonstrated positive results in 6% and 4.7%, but catheter related sepsis occurred in only 2.3%. Staphylococcus epidermidis was found in 81% of all positive bacterial cultures. Four point seven per cent of catheters were removed for suspected infection though only one third of them produced a bacteriological growth. We conclude that the risk of mechanical complications and contamination of central venous catheters in neonates can be minimized by the use of a standardized protocol.

Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters

We report the results of a prospective study of catheter-related sepsis (CRS) in 154 gastroenterology paediatric patients treated for medical (n = 102) or surgical (n = 52) disorders. Over 2 years, 185 central venous catheters (CVC) were placed, including 155 Broviac and 30 Jonathan Shaw CVC. CVC remained in place 13,331 days (6,539 days of cyclic parenteral nutrition), with a mean catheter life of 72 days. Forty-eight episodes of CRS occurred, most of them due to coagulase-negative staphylococci (n = 29) and Staphylococcus aureus (n = 17). CRS rate was 0.26, with an overall incidence of 1 infection per 278 days of parenteral nutrition (PN). Factors significantly associated with CRS were: age 1–5 years (p < 0.01), a medical indication for treatment (p < 0.001) and summer months of PN (p < 0.01). Interestingly, CRS occurred predominantly (65%) within the first 2 months following CVC placement and the risk of infection correlated with local haemorrhage at the time of insertion (p < 0.01). Appropriate systemic therapy, without removing the catheter, permitted resolution of 90.9% ( 40 44 ) of all CRS and 100% ( 28 28 ) of CRS due to coagulase-negative staphylococci.

One hundred consecutive central venous catheters in children.

A prospective study of central venous catheterisation for parenteral treatment was carried out. The catheters were used for a variety of purposes, the majority for intravenous feeding alone. Three types of catheter were used - fine silastic tubing, Vygon Leader Caths and cuffed Hickman and Broviac catheters. The mean catheter life was 42 days with a range of 1-400 days. Sixty-two catheters were removed prior to completion of treatment. In this series the Hickman catheters were remarkably trouble-free.