Double-lumen Central Venous Catheter Research Articles

#2430 Comparison of the efficacy of gentamicin-citrate and gentamicin-citrate/Taurolock-urokinase locks for non-tunneled catheters in hemodialysis patients

Abstract Background and Aims Catheter-related complications, such as dysfunction, thrombosis and infection, are associated with significant morbidity and mortality in patients on hemodialysis (HD) receiving dialysis through temporary non-tunneled double-lumen central venous catheters (CVC). Catheter lock solutions containing antibiotics and antitrombolytics are commonly used to prevent such complications. The aim of the present study was to compare impact of a different prophylactic catheter lock solutions on the incidence of catheter-related complications (catheter-related bloodstream infection (CRBSI) and catheter thrombosis) and mortality compared with heparin catheter locks. Method We performed a single-centre prospective, randomized, single-blinded controlled trial of 96 adult patients undergoing HD in our institution from Jun 2018 to Jun 2023. Patients were randomized 1:1:1 to receive either a lock solution combining gentamicin-citrate twice a week with taurolidine-citrate (Taurolock)/urokinase at the end of the third hemodialysis session before the end of the week (TAURO group) or gentamicin-citrate at the end of all hemodialysis sessions (GENTAM group) or unfractionated heparin 5000 U/mL thrice weekly as control (HEPARIN group). Catheter lock solutions were administered for 3 months after insertion of CVC and patients were followed for at least 6 months after insertion of CVC. Demographic, clinical and laboratory parameters, as well as used medications, were analyzed. Episodes of acute catheter thrombosis and incidence of CRBSI were recorded, along with dialysis adequacy (Kt/V) and adverse events. Results The study population (96 patients, 32 in each group) had a median age of 60 years (range 19–85 years), 56.3% man. In the majority of patients (88.5%) the indication for placement of the CVC was the initiation of dialysis, while in the remaining patients indication was thrombosis of the existing vascular access. The most important baseline clinical and laboratory values are presented in Table 1. The catheter median length of stay was of 125.94 ± 87.48 (from 50 to 535) days in TAURO group, 113.44 ± 35.68 (from 54 to 233) days in GENTAM group and 108.59 ± 37.84 (from 42 to 212) days in HEPARIN group (p = 0.831). There was no difference between groups with regard to catheter thrombosis (3.3 events/1000 catheter-days in all groups). The CRBSI rate of 3.2 episodes/1000 catheter-days in TAURO group was slightly lower than the rate of 5.3 episodes/1000 catheter-days in GENTAM group (p = 0.479) and 4.3 episodes/1000 catheter-days in control HEPARIN group (p = 0.705). The CRBSI-free survival time in TAURO group was 197 ± 220 (from 28 to 447) days, longer than in the GENTAM group (38 ± 33 days, from 8 to 86) and HEPARIN group (37 ± 35 days, from 4 to 86), p = 0.21. Impact of catheter lock solution on dialysis adequacy as measured by Kt/V in time is presented in Fig. 1. No significant differences were found between study groups in survival after 6 months (p = 0.810) and at the end study period (p = 0.096)-presented in Fig. 1. Conclusion We observed no difference in the incidence of catheter thrombosis and mortality rate in groups with prophylactic catheter lock solutions and control group. The use of Gentamicin-citrate/Taurolock-urokinase as a dialysis catheter lock solution, as compared with gentamicin-citrate or heparin administered three times a week, led to a nonsignificant reduction of CRBSI incidence and longer CRBSI-free survival time in patients on HD receiving dialysis through temporary non-tunneled double-lumen CVC.

On the way to the azygos vein: a road of return rather than ruined

BackgroundThe malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter.Case presentationA 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications.ConclusionsCVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases.

Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases. Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022). Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p<.0001; for bacteremia double-lumen CVC (HR 3.2, p<.0001); for mechanical complications age at CVC insertion under median (HR 4.5, p<.0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p=.01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p=.0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p<.0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p<.0001. Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

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

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

Numerical Study on the Impact of Central Venous Catheter Placement on Blood Flow in the Cavo-Atrial Junction.

An in silico study is performed to investigate fluid dynamic effects of central venous catheter (CVC) placement within patient-specific cavo-atrial junctions. Prior studies show the CVC infusing a liquid, but this study focuses on the placement without any liquid emerging from the CVC. A 7 or 15-French double-lumen CVC is placed virtually in two patient-specific models; the CVC tip location is altered to understand its effect on the venous flow field. Results show that the CVC impact is trivial on flow in the superior vena cava when the catheter-to-vein ratio ranges from 0.15 to 0.33. Results further demonstrate that when the CVC tip is directly in the right atrium, flow vortices in the right atrium result in elevated wall shear stress near the tip hole. A recirculation region characterizes a spatially variable flow field inside the CVC side hole. Furthermore, flow stagnation is present near the internal side hole corners but an elevated wall shear stress near the curvature of the side hole's exit. These results suggest that optimal CVC tip location is within the superior vena cava, so as to lower the potential for platelet activation due to elevated shear stresses and that CVC geometry and location depth in the central vein significantly influences the local CVC fluid dynamics. A thrombosis model also shows thrombus formation at the side hole and tip hole. After modifying the catheter design, the hemodynamics change, which alter thrombus formation. Future studies are warranted to study CVC design and placement location in an effort to minimize CVC-induced thrombosis incidence.

Efficacy of Ultrasound-Guided Double Lumen Central Venous Catheter Insertion in Minimizing Mechanical Complications and Bloodstream Infections: An Empirical Evidence of Pakistan

The aim of the study was to compare the outcomes of ultrasound-guided double-lumen central venous catheter (DLC) insertion and without ultrasound guidance in reducing mechanical complications and bloodstream infections. This quasi-experimental study was conducted at Urology Department in collaboration with the Anesthesia department at GMC Teaching Hospital Gujranwala. The study had 60 insertions in each group. The insertion duration ranged from 8-50 days in Group A and 9-60 days in the B group. Placements were done at the right internal jugular and right subclavian veins. Four patients in Group A and five patients in Group B experienced catheter-related bloodstream infections (CRBSI), but the difference was not significant. The Charlson Comorbidity Index (CCI) was 0-10 in Group A and 0-8 in Group B. Group A had no mechanical complications, while three patients in Group B experienced manageable complications. In conclusion, ultrasound-guided DLC placement improves safety but does not reduce CRBSI.

#4772 DOUBLE FILTRATION PLASMAPHERESIS DURING HETEROLOGOUS FERTILIZATION PREGNANCY FOR THE TREATMENT OF HETEROZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA

Abstract Background and Aims Pregnancy in women affected by familial hypercholesterolemia is rare. Estrogen and progesterone fluctuations, featuring pregnancy, adversely influence lipid metabolism, causing considerable increase of LDL-C, triglyceride and lipoprotein A levels. These changes in fatty metabolism, essential for embryonic development, might be critical for placental circulation and for mother's health. Indeed, high lipoprotein amount can raise uteroplacental vascular resistance and it is associated with intrauterine growth restriction because of oxidative stress, whereas hypertriglyceridemia and hypercholesterolemia might cause an increased risk of cardiovascular accidents and pancreatitis. Lipid-lowering drugs, such as statins, ezetimibe or PCSK9 inhibitors are discontinued due to possible teratogen effects. Thus, LDL apheresis is the only available therapy for severe hypercholesterolemia during pregnancy. Method A 46 years old woman affected by heterozygous familial hypercholesterolemia in treatment with PCSK9 inhibitors and statins, decided to undergo an heterologous in vitro fertilization with oocyte donation. Hence, pharmacological therapy was stopped to avoid teratogen effects. We started a 10-months apheresis program with double filtration plasmapheresis (DFPP). The treatment was performed by a temporary double lumen central venous catheter. Initially, she underwent apheresis twice a month with an average exchange volume of 1.2, low blood flow (≤ 90 ml/min) and incremental plasma flow (from 5 to 30 ml/min every 10 minutes of treatment), to ensure a physiological procedure. We gradually modulated the exchange volume monitoring blood levels of LDL-C, Lp(a) and triglycerides before and after each procedure. We aimed to keep mean LDL-C level &amp;lt; 200 mg/dl. We did not use anti-coagulation during the procedure, monitoring TMP values and arterial-venous pressure. Results LDL-C levels remained about 227.2 ± SD 91 mg/dl, with a median of 186.8 mg/dl, complying with the target range (Figure 1). Mean triglycerides and Lp(a) values were, respectively, 180.3±94 mg/dl (median 146 mg/dl) and 77.3±36.3 mg/dl (median 55.7 mg/dl) (Figure 1). Our patient did not face any complications related to pregnancy or to the procedure, and gave birth at 38th gestational week to an healthy full-term male baby of 52 centimeters and 3.34 kilograms. Conclusion Although there is a widespread hesitation in performing extracorporeal blood purification treatment in pregnancy, this case underlines the essential role of LDL apheresis in in this setting, giving spark to standardize the procedure and to encourage its use also in pregnancy.

Moisture in hemodialysis catheter dressings and the risk of infection: an integrative review

Introduction: In hemodialysis care, the nurse is involved in most care for the patient using a double-lumen central venous catheter; in this regard, it is necessary to instruct the renal patient about measures to protect venous access regarding humidity during bathing, as a wet dressing over the device insertion site increases the risk of infection. Aim: To identify in the literature the relationship between moisture in hemodialysis catheter dressings and the risk of infection. Outlining: Integrative review performed in MEDLINE databases via PubMed, CINAHL, Web of Science, Scopus, Cochrane, BDENF, LILACS bibliographic index and references of the articles included. The sample consisted of 10 primary studies. The results were analyzed descriptively and organized into categories. Results: Six (60%) addressed the humidity related to the bath, three (30%) addressed the humidity related to perspiration and one (10%) discussed the humidity related to secretions from the ostium of the hemodialysis catheter. Implications: Wetting the hemodialysis catheter while bathing is not the best recommendation. Moisture resulting from perspiration was associated with risk of infection.

The effect of single dose prophylactic vancomycin before semi-permanent catheterization to prevent catheter related infection; a randomized controlled trial, phase II

Introduction: Catheter-related infections are a common complication and a major cause of morbidity and mortality in hemodialysis patients with tunneled central venous catheters. The optimal strategy for the management and prevention of catheter-related infections is unclear. Objectives: This study is aimed to evaluate the single-dose prophylactic vancomycin efficacy before semi-permanent catheterization to prevent catheter-related infection. Patients and Methods: This randomized double-blind controlled clinical trial was conducted on patients with chronic renal failure requiring hemodialysis and insertion of a double-lumen central venous catheter admitted to Ahvaz Golestan Hospital. The intervention group (n=30) received 1 g of vancomycin intravenously one hour before catheter insertion and the control group (n=30) received an equal amount of normal saline. The incidence of catheter-related infections and other complications for 6 months was evaluated. Results: During the 6-month follow-up, hospitalization due to catheter-related infection and the need for antibiotic administration was observed in 9 patients (30.0%) who received vancomycin and 14 patients (46.7%) in the control group (P=0.184). Catheter extraction due to infection was observed in 4 patients of the vancomycin group (13.3%) and 6 patients of the control group (20.7%) (P=0.451). Complications other than infection were observed in four patients (13.3%) in each group (P=1.000). The mean time to onset of infection was 2.43 ±0.38 months in the control group and 3.85 ± 0.42 months in the vancomycin group (P=0.002). Conclusion: Although a single dose of intravenous vancomycin one hour before insertion of a bi-luminal hemodialysis catheter did not show a significant effect on preventing catheter-related infections over 6 months, it significantly delayed the onset of infection. Trial Registration: The trial protocol was approved by Iranian Registry of Clinical Trial (Ethical code: IR.AJUMS.HGOLESTAN.REC.1399.106 and IRCT code: IRCT20201206049617N1; https://www.irct.ir/trial/52832).

Intraoperative accurate assessment of septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM)

Surgical restoration of the left ventricular outflow tract (LVOT) is necessary for patients suffering from hypertrophic obstructive cardiomyopathy (HOCM), when symptoms are present despite the administration of medical treatment. One point of great significance during the procedure is the evaluation of the LVOT gradient after completion of septal myectomy. Most physicians choose to measure this value by transesophageal echocardiography (TEE) in combination with the direct measurement with the use of needles inserted into the aorta and left ventricle. In this article, we present the implementation of a new technique to estimate the peak-to-peak pressure gradient between the left ventricle and the aorta intraoperatively using a single double lumen central venous catheter inserted through the antegrade cardioplegia cannulation site across the aortic valve into the left ventricle.

Red blood cell exchange in children with sickle cell disease.

The aim of our study was to assess the efficacy of red blood cell exchange (RBCx) using a Spectra Optia® automated apheresis system in children with sickle cell disease (SCD). We used automated RBCx to treat acute and chronic complications in 75 children with SCD who had a median age of 10years [7-13]. We analyzed 649 RBCx sessions. Peripheral venous access was limited in a number of the children, and thus a femoral double-lumen central venous catheter was required. We recommend heparin locking with 500 units in each lumen of the catheter. To prevent complications, we ensured that all patients had achieved a post-RCE HbS level of < 30%. For chronic transfusion, with a post-RCE Hb level of approximately 10-11g/dL, a blood exchange volume of ≥ 32mL/kg, and an interval between each RBCx procedure of ≤ 30days, the residual HbS level was maintained below 30%. For acute transfusion, a post-exchange Hb level ≥ 10g/dL (p < 0.001) and a total exchange volume ≥ 35mL/kg (p = 0.001) were the best way to reduce HbS to < 30%. AUC was 0.84. Our results show that erythrocytapheresis was useful and safe for children with SCD.

Innovator Filgrastim versus Generic Filgrastim in Hematopoietic Stem Cell Transplantation Mobilization.

Methods This is a retrospective study. G-CSF was administered in the dose of 10 μg/kg subcutaneous as a single dose for 4 days. On day 5, peripheral blood stem cell (PBSC) apheresis was performed using Haemonetics MCS plus or COBE Spectra apheresis machine through a double-lumen central venous catheter. Primary outcome parameters were the total number of CD34+ HSCs/kg of recipient weight mobilized in peripheral blood and the number of days required for neutrophil and platelets engraftment, respectively. Objective We compared the effectiveness and safety of innovator filgrastim versus generic filgrastim in patients who underwent hematopoietic stem cell transplantation (HSCT). Results A total of 91 stem cell mobilizations was analyzed. There were 58 normal healthy donors for allogeneic HSCT and 33 patients for autologous HSCT. There was no statistically significant difference among groups in terms of total collected CD34+ cells value ( p = 0.609). The mean time to neutrophil engraftment was 13.7 days in the innovator group and 13.2 days in the Grafeel group ( p = 0.518). The mean time to platelet engraftment was 16.2 days in the innovator group and 14.8 days in the generic group ( p = 0.435). The patient who received generic filgrastim had more febrile episodes during the course of transplantation ( p = 0.020). Conclusion Generic filgrastim was found to be comparable to original filgrastim for peripheral blood stem cell mobilization in normal healthy donors for allogeneic HSCT and patients for autologous HSCT.

Staphylococcus aureus accumulation at the tip of hemodialysis catheters with or without tip side holes in catheter related bloodstream infection in a large animal.

Eighty percent of hemodialysis patients start their dialysis with a tunneled hemodialysis catheter. Catheter related bacteremia is the second most common cause of death in these patients. Side holes near the tips of the tunneled cuffed central venous catheters are associated with accumulation of thrombus, which can lead to catheter dysfunction and, possibly, also to catheter-related infection. To assess the hypothesis that a catheter without side holes would be associated with less bacterial growth, this study compared the susceptibility of a side-hole-free catheter to accumulation of pathogenic bacteria at the catheter tip with that of two catheters which have side holes. Eight tunneled cuffed double-lumen central venous catheters were inserted into both jugular veins of four sheep; one side-hole-free and one control catheter with side holes at the tip in each animal. Staphylococcus aureus bacteria were then infused intravenously to cause bacteremia. Six hours later, the catheters were removed, the clots that accumulated in their tips were collected and cultured, and the bacterial colonies were counted after additional 12 h of incubation. Bacteria grew on culture plates seeded with the clot homogenate obtained from the tips of all catheters. The colony counts from the catheters with side holes at the tip exceeded the colony counts of bacteria accumulated in the tips of the side-hole-free hemodialysis catheters by one or more orders of magnitude, with a difference of at least two orders of magnitude observed in three of the four intra-animal comparisons. In paired intra-animal post-inoculation comparison made in this limited study, fewer colony forming units of pathogenic bacteria accumulated at the tip of the side-hole-free catheters than at the tips of the catheters which have side holes. This may translate to a decreased rate of catheter-related blood stream infections in the side-hole-free catheters.

FC 097INTERMITTENT HEMODIALYSIS WITHOUT ANTICOAGULATION

Abstract Background and Aims Dialysis therapy of patients at increased risk of bleeding is a well-known clinical problem. Systemic anticoagulation with heparin increases the risk of severe hemorrhage. Alternative strategies include the use of heparin-coated dialysis membranes, regional citrate anticoagulation, airless dialysis tubing, flushing the dialyzer with saline and earlier regional heparin anticoagulation with protamine reversal. However, either special devices (e.g. airless or heparin coated tubing) are needed, or the procedures are complex and require additional time and personnel resources for administration and monitoring. Current data on heparin-free dialysis are rare. After a pilot study from 282 dialysis sessions we reviewed 949 dialysis protocols from 2.5 years of 480 hospitalized and outpatient dialysis patients who were treated without systemic anticoagulation due to an increased risk of bleeding or a manifest hemorrhage. The duration of each dialysis session and the number of dialyses with or without clotting were evaluated. Method A total of 949 dialysis sessions of 480 patients were reviewed from October 2017 to January 2021. Dialysis were performed with Fresenius 4008/5008 (FX80,FX50, KF-210) and Gambro Artis (Poly170H, Theranova). All dialysis sessions were performed via AV-fistula with double-needle puncture or via single- or double-lumen central venous catheters (CVC). No additional technical devices or procedures were used beside standard hemodialysis or hemodiafiltration. Some of the patients had coagulopathies (sepsis, liver cirrhosis), thrombocytopenia or were on systemic anticoagulant therapy (vitamin K antagonists, DOAKs, heparin independent from dialysis therapy). The primary outcome was the need to interrupt the dialysis session because of clotting events due to a complete coagulation of the circuit, a partial coagulation of the circuit or a significant rise in the venous pressure. Results In 81 procedures (8.5%) systemic clotting made a discontinuation of the dialysis session necessary. In only 10 sessions (1%), the dialysis treatment had to be continued with new tubing and filter. More than one change of a system was never necessary. In the other 71 sessions, dialysis had to be stopped with retransfusion 5 minutes until 1.5 hours before the scheduled end of therapy, and therapy was considered as clinically sufficient. The frequency of clotting did not correlate with dialysis time (Fig.1.). Regarding the venous access clotting happened in 14.6% of acute CVC, in 12.6% of tunneled CVCs and in 9.4 % of AV-fistulas or -grafts, (Fig 2). Conclusion Dialysis without anticoagulation can be performed routinely with modern synthetic filters and dialysis concentrates. Patients at high risk of bleeding, with manifest hemorrhage or before surgery can undergo dialysis treatment for up to five hours without complications. In the present study clotting did not correlate with dialysis time. Patient-specific factors, as the venous access seem to play a more important role. In summary additional cost intensive devices, personnel intensive procedures and complex treatment protocols are only rarely needed to perform heparin-free dialysis for patients at risk.

P0251 / #1820: PAEDIATRIC THERAPEUTIC PLASMA EXCHANGE. A MALAYSIAN TERTIARY PAEDIATRIC INTENSIVE CARE UNIT EXPERIENCE.

Aims & Objectives: To review indications, prescriptions, complications, and treatment outcomes of patient underwent therapeutic plasma exchange in Paediatric intensive Care Unit (PICU), Penang Hospital. Methods: A retrospective descriptive study. All patients from 1 month old to 18 years old who underwent therapeutic plasma exchange in our center will be included. Results: A total of 20 sessions of therapeutic plasma exchange (TPE) were performed in 4 patients from January 2016 to August 2018. All cases were due to demyelinating disorders of the nervous system. The median disease duration at time of TPE was 56.5 days. The vascular accesses for all sessions were through femoral vein using a double lumen central venous catheter. The median exchange volume was 50 ml/kg (range: 48 – 80 ml/kg), corresponding to exchange volume of 1.0 (range 1.0 –1.5). Mixture of Fresh Frozen Plasma (FFP) & 5% albumin were used as replacement fluid in 17/20 (85%). The median proportion was 69.2 % (range: 56.8% – 80%) for 5% albumin and 30.8% (range: 20% – 45%) for FFP. 5% albumin alone was used in 3/20 (15%) TPE in view of anaphylaxis towards FFP. We observed complications in 18 (90%) sessions. All patients showed favorable outcomes without mortality. Conclusions: Neurological disorders were the commonest indications for TPE in our center. TPE appeared to improve neurological outcomes in our patients.

Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children.

Introduction:We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization.Methods:We conducted a single-center prospective quality improvement initiative at a 30-bed PICU in a large, freestanding, academic children’s hospital. We created an electronic report to identify patients with an indwelling CVC for 7 days and older (defined as long term). We discussed the ongoing need for each long-term CVC with PICU clinicians at weekly interdisciplinary structured “CVC stewardship rounds.” We then made recommendations around expedited removal of CVCs. We conducted multiple Plan-Do-Study-Act cycles to categorize CVC indications, identify modifiable factors, and educate PICU clinicians. We hypothesized that CVC stewardship rounds would decrease long-term CVC utilization in our PICU.Results:From October 2016 to September 2017, 607 long-term CVCs were eligible for the stewardship intervention. Compared to the preintervention period, we recorded a significant increase in peripherally inserted central catheters and a decrease in nontunneled CVCs (P < 0.001). Most patients had single- or double-lumen CVCs in both the preintervention and intervention periods (86% and 91%, respectively). The utilization of overall long-term CVC devices, and those with modifiable indications, decreased during the intervention period.Conclusions:A single-center QI intervention focused on PICU CVC stewardship was associated with a decrease in CVC utilization.

Risk Factors for Central Line-Associated Bloodstream Infection in Critically Ill Neonates.

To identify independent risk factors to develop a central line- associated bloodstream infection (CLABSI) in critically ill neonates with major underlying diseases. A nested case-control study was conducted in a neonatal intensive care unit (NICU). Patients with a central venous catheter (CVC) were included. Cases were neonates who developed a CLABSI and controls were patients without CLABSI. Variables included: perinatal history, characteristics of the catheter, installation and catheter use, surgical interventions, and hospital stay. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. X2, Fisher exact, and Mann-Whitney U tests were used when appropriate. Variables with a p value ≤0.10 in the univariate analysis were introduced in a non-conditional logistic regression model. Seventy four cases and 105 controls were analyzed. Univariate risk factors were: any surgery, abdominal surgery, length of hospitalization (≥14 d), double-lumen CVC, surgical cut-down technique, complications, CVC placement in internal jugular vein, dressing type, blood transfusions, parenteral nutrition, and number of CVC manipulations (>200). In the logistic regression analysis, independent risk factors with a p value <0.05 were: double-lumen catheter (OR 5.8, 95% CI 1.2-30), length of hospitalization ≥14 d (OR 4.6, 95% CI 1.8-11.4), abdominal surgery (OR 2.7, 95% CI 1.2-6.2) and blood transfusions (OR 2.5, 95% CI 1.2-5.3). One risk factor was related to the catheter itself. Management of underlying diseases in specialized NICU contributes to a greater extent to the development of a central line-associated bloodstream infection.

Evolution of Technology for Continuous Renal Replacement Therapy: Forty Years of Improvement.

Continuous arteriovenous hemofiltration (CAVH) was proposed in 1977 as an alternative treatment for acute renal failure in patients in whom peritoneal dialysis or hemodialysis was clinically or technically precluded. In the mid-1980s, this technique was extended to infants and children. CAVH presented important advantages in the areas of hemodynamic stability, control of circulating volume, and nutritional support. However, there were serious shortcomings such as the need for arterial cannulation and limited solute clearance. These problems were solved by the introduction of continuous arteriovenous hemodiafiltration and continuous arteriovenous hemodialysis, where uremic control could be achieved by increasing countercurrent dialysate flow rates to 1.5 or 2 L/h as necessary, or by venovenous techniques utilizing a double-lumen central venous catheter for vascular access. Thus, continuous venovenous hemofiltration replaced CAVH because of its improved performance and safety. From the initial adoptive technology, specific machines have been designed to permit safe and reliable performance of the therapy. These new machines have progressively undergone a series of technological steps that have resulted in the evolution of highly sophisticated equipment utilized today. A significant number of advances have taken place since the time continuous renal replacement therapy was initiated. In particular, there have been successful experiments with high-volume hemofiltration and high-permeability hemofiltration. The additional and combined use of sorbent has also been tested successfully. Progress has been made in the technology as well as the understanding of the pathophysiology of acute kidney injury. Today, new biomaterials and new devices are available and new frontiers are on the horizon. Although improvements have been made, a lot remains to be done. Critical care nephrology is expected to further evolve in the near future, especially in the area of information and communication technology, utilization of big data and large database registries, biofeedback, and assisted prescription and treatment delivery, with high potential for improvement in morbidity and mortality of the most severely ill patients.

Evolution of Technology for Continuous Renal Replacement Therapy: Forty Years of Improvements.

Continuous arteriovenous hemofiltration (CAVH) was proposed in 1977 as an alternative treatment for acute renal failure in patients in whom peritoneal dialysis or hemodialysis was clinically or technically precluded. In the mid-1980s, this technique was extended to infants and children. CAVH presented important advantages in the areas of hemodynamic stability, control of circulating volume, and nutritional support. However, there were serious shortcomings such as the need for arterial cannulation and limited solute clearance. These problems were solved by the introduction of continuous arteriovenous hemodiafiltration (CAVHDF) and continuous arteriovenous hemodialysis (CAVHD) where uremic control could be by increasing countercurrent dialysate flow rates to 1.5 or 2 liters/h as necessary, or by venovenous techniques utilizing a double-lumen central venous catheter for vascular access. Thus, continuous venovenous hemofiltration replaced CAVH because of its improved performance and safety. From the initial adoptive technology, specific machines have been designed to permit safe and reliable performance of the therapy. These new machines have progressively undergone a series of technological steps that have resulted in the highly sophisticated equipment utilized today. A significant number of advances have taken place since the beginning of continuous renal replacement therapy. In particular, there have been successful experiments with high-volume hemofiltration and high-permeability hemofiltration. The additional and combined use of sorbent has also been tested successfully. Progress has been made in the technology as well as the understanding of the pathophysiology of acute kidney injury. Today, new biomaterials and new devices are available and new frontiers are on the horizon. Although improvements have been made, a lot remains to be done. Critical care nephrology is expected to further evolve in the near future, especially in the area of information and communication technology, utilization of big data and large database registries, biofeedback, and assisted prescription and treatment delivery, with high potential for improvement in morbidity and mortality of the most severely ill patients.

Efficacy of strategy of optimizing anesthetic management in preventing occurrence of cardiac arrest during thoracic surgery

The strategy of optimizing anesthetic management was carried out in all the patients undergoing thoracic surgery in our hospital from January 1, 2012: the patients were monitored using routine electrocardiogram combined with invasive arterial blood pressure monitoring, double-lumen central venous catheter pathway was established, and when severe bradycardia (heart rate 0.05), and the incidence of cardiac arrest was decreased by 45% after optimizing anesthetic management.In conclusion, the strategy of optimizing anesthetic management is helpful in decreasing the occurrence of cardiac arrest during thoracic surgery. Key words: Anesthesia, general; Thoracic surgical procedures; Heart arrest; Intraoperative complications