Central Venous Catheter Duration Research Articles

Associations Between Clinical Factors and Postoperative Thrombosis in Pediatric Cardiac Surgery Patients: A Single-Center Retrospective Study.

Postoperative thrombosis is a significant complication in pediatric cardiac surgery patients, contributing to morbidity and mortality. Identifying clinical factors associated with thrombosis can improve patient outcomes by guiding early detection and intervention. This study aimed to assess factors associated with postoperative thrombosis or thromboembolism in pediatric patients under 12 months old who underwent surgery for congenital heart disease (CHD). Design, Setting, and Participants: This retrospective cohort study analyzed electronic medical records from pediatric patients admitted to the Pediatric Cardiovascular Intensive Care Unit (PCICU) at the German Paediatric Heart Center, Bonn, between March 1, 2020, and March 1, 2021. A total of 197 children under 12 months old who underwent cardiac surgery were included in the analysis. Thrombosis was diagnosed postoperatively using imaging modalities such as ultrasound, echocardiography, and computed tomography. The primary outcome was the incidence of thrombosis and its association with clinical factors such as age, central venous catheter (CVC) duration, CRP levels, and D-dimer levels. Among 197 patients, the incidence of thrombosis was 8.63%, predominantly venous (70.6%). Initial associations were observed between thrombosis and younger age, lower body weight, higher hematocrit, cyanosis, longer central venous catheter (CVC) use, and elevated C-reactive protein (CRP) and d-dimer levels. Receiver operating characteristic analysis indicated a higher risk in patients with d-dimer levels above 5.47 mg/L. The stepwise multiregression analysis identified longer CVC duration in situ (β = 0.553; p < 0.001), higher CRP levels (β = 0.217; p = 0.022), and younger age at admission (β = -0.254; p = 0.006) as significant predictors of thrombosis. Decision tree analysis identified CVC use longer than 12.5 days and CRP levels above 118.01 mg/L as the most critical risk factors. Postoperative thrombosis is a notable risk in pediatric CHD patients, particularly in neonates. Prolonged CVC use and elevated CRP levels are critical risk factors. Routine monitoring of D-dimer and CRP levels, along with timely sonographic screening, can aid early thrombosis detection and intervention. Further research is warranted to optimize thrombosis prevention strategies in this population.

Providing very low-birth-weight infants with fast enteral feeding reduced how long they needed a central venous catheter.

To determine the impact of the protocol change from slow to fast enteral feeding progression on duration of central venous catheter placement, and the rates of late-onset sepsis and necrotising enterocolitis. We compared the evolution of all very low-birth-weight infants admitted on their first postnatal day in neonatal intensive care unit during a 12-month period, before (2021 Cohort) and after (2022 Cohort) implementation of a new feeding protocol. Linear regression model was used to adjust for confounding factors. A total of 343 VLBW infants were included (median gestational age ± SD 28.3 ± 1.7 weeks; median birth weight ± SD 980 ± 300 g). Median initial duration of central venous catheter was 5 days in 2022 cohort compared with 9 days in 2021 cohort (unadjusted p = 0.006, adjusted p = 0.001). Median time to achieve full enteral feeding was 8 days versus 12 days, p < 0.001, with no significant difference in late-onset sepsis or necrotising enterocolitis rates. The change from slow to fast enteral feeding progression for very low-birth-weight infants significantly decreased the central venous catheter duration with no adverse outcomes. This is consistent with recent randomised study results and supports the safe implementation in neonatal intensive care units.

Central Venous Catheter-associated Venous Thromboembolism in Children: A Prospective Observational Study.

Our objective was to study the proportion of children developing Catheter-related thrombosis (CRT) following central venous Catheter (CVC) insertion and the risk factors of CRT in pediatric patients with CVC. One hundred four children aged 29 days to 18 years who had a percutaneous non-tunneled CVC inserted were enrolled. Ultrasonogram (USG) with venous Doppler scan was performed within 48 hours of CVC removal to diagnose CRT. The major indications for CVC insertion were surgical care 34 (32.6%) and ICU care 28(26.9%). The median age of the patients was 3 years, and 75% were males. The median number of CVC days was 10 (IQR 5.15). CRT was seen in 45(43.3%), of which 33 (73.3%) were asymptomatic. The rate of CRT was 35.69 cases per 1000 CVC days (95% CI 26.03-47.75). The number of days a catheter was in place and USG-guided catheter insertion was a significant risk factor. The multivariate logistic regression model showed that the duration of CVC in situ was independently associated with the development of CRT (OR, 1.06; 95% CI 1.0-1.1; P =0.02). CVC duration was a major risk factor for the development of CRT. There was a higher risk of developing a symptomatic CRT with central venous catheters than hemodialysis sheaths.

Targeting prolonged short-term central venous catheters to reduce hospital-wide catheter days and CLABSI rates

The risk of central line-associated bloodstream infection (CLABSI) is associated with central venous catheter (CVC) dwelling time. We implemented a hospital-wide intervention aimed to alert physicians to CVC duration and necessity and to improve the monitoring of CLABSI prevention process measures outside the intensive care unit (ICU). A retrospective, before-after study that evaluated short-term, nonhemodialysis CVCs in and out of the ICU. The intervention included enhanced bundle-prevention measures monitoring and staff "sensitization" regarding prolonged (>7 days) CVCs (pCVCs). The ICU intervention also included daily CVC-stewardship visits. We assessed CVC utilizations and CLABSI episodes 20 months before to 19 months after the intervention using Mann-Whitney tests. Out of the ICU, CVC-utilization ratio (CVC-UR) and pCVC-UR reduced significantly (4.1-2.7/100 hospital days, P=.005; and 28%-21%,P=.02, respectively). Bundle-prevention measures improved, and CLABSI rates reduced postintervention (7.9-3.6/1,000 CVC days, P=.03). In the ICU, pCVC-UR reduced significantly (29%-15%, P<.0001). Baseline ICU-CLABSI rates were low and did not reduce postintervention. Sensitizing physicians to the existence and duration of CVCs accompanied by improved bundle-prevention measures, resulted in reduction of pCVCs, and outside the ICU, also in reduction of CVC-UR and CLABSI rates.

CAT Study: Pediatric Catheter-Associated Thrombosis: A Retrospective Electronic Record Review

Highlights CAT is a significant problem in pediatric patients with CVCs and other risk factors. CAT was found in 4% of the sample with estimated 0.23 events per 1,000 CVC days. Incidence of CAT was lower than anticipated but consistent with published evidence. Median LOS was substantial in the CAT group suggesting increased disease burden. Specific clinical modifiers and CVC factors were more common in the CAT group. Findings provide valuable foundation for future CAT research and risk models. Clinicians and researchers should collaborate to reduce CAT incidence. Abstract Background: Catheter-associated thrombosis (CAT) is a serious condition, especially among pediatric surgical patients. This study describes the CAT incidence rate and clinical, demographic, and central venous catheter (CVC)-specific risk factors that may be associated with CAT, for a cohort of pediatric surgical patients. Methods: An electronic record review of 124 pediatric surgical patients with indwelling CVCs receiving parenteral nutrition (PN) cared for in a single pediatric hospital between 2016 and 2018 was performed. Results: Of the 297 CVCs, 4% of patients (n = 5) developed CAT, resulting in an estimated incidence rate of 0.23 events per 1,000 CVC days (95% confidence interval 0.15–0.31). Patients diagnosed with CAT had a higher burden of anemia, blood product administration, chronic lung disease, congenital heart disease, sepsis, prolonged mechanical ventilation, extracorporeal membrane oxygenation use, increased surgical complexity, and longer hospital stays. They also had a higher frequency of peripherally inserted central catheters, small caliber size CVCs, double lumen CVCs, extended PN and lipid course, lack of ethanol prophylaxis, higher rates of intravenous antibiotics, lower rates of treatment-dose heparin, and prolonged CVC duration. Conclusion: The incidence of CAT in this study was consistent with published rates for hospitalized pediatric patients with CVCs. The study provides additional foundational evidence about clinical, demographic, and CVC-specific risk factors associated with CAT in pediatric surgical patients with CVCs. It can help guide future research and collaborative efforts to develop risk assessment and other preventative strategies to reduce CAT incidence and improve patient care outcomes.

Using a standardized algorithm to decrease central venous catheter utilization

Central venous catheters (CVCs) have many benefits in patient care but are associated with increasing risks with catheter duration. A level II trauma-certified community hospital sought to decrease CVC duration utilizing a daily assessment algorithm in the critical care unit. After implementation, CVC days decreased from 490 CVC days per 1,000 patient days to 452 (odds ratio 0.86, P<.01) and catheter duration decreased from 7.71 days to 6.57 (P=.19).

AHP P06 Optimizing Coagulation Screen Practices in CVC Removal Amongst Surgical Patients: A Retrospective Audit Assessing Necessity, Compliance, and Implications

Abstract Background Conflicting findings in recent literature question the significance of traditional coagulation variables in predicting bleeding associated with central venous catheter (CVC) removal. This audit evaluates the necessity and compliance of conducting same-day coagulation screens at Churchill Hospital. The study assesses the practice's relevance, compliance rates, and associated costs, offering implications for clinical decision-making, resource utilization, and potential modifications to current practices. The findings may lead to the adoption of new predictive factors or a targeted approach to coagulation testing, optimizing patient care and resource allocation in CVC removals. Methods This retrospective audit focused on surgical patients in the upper gastrointestinal, hepatobiliary and pancreatic, lower gastrointestinal, and transplant surgery departments at the Churchill Hospital. The study encompassed all instances of central venous catheter (CVC) removal that occurred between January 1st, 2022, and December 31st, 2022. Data retrieval was conducted using electronic patient records, and coagulation test results were interpreted utilizing the reference ranges available in the electronic patient record system (INR 0.9-1.2, PT 9-12, APTT 20-30). Results 78 patients had an average age of 53 years and a mean hospital stay of 35 days. The average duration of CVC in-situ was 8.9 days. Patients underwent an average of 5.07 coagulation tests per stay, equivalent to 0.28 tests per admission day. Among the audited patients (n=67), 41.8% had same-day coagulation screens, 17.9% had the screen one day prior to CVC removal, and 40.3% had the screen more than one day before removal. Analysis showed that 88% had normal INR values, with only eight patients having abnormal values. Furthermore, 74.6% and 58.2% had normal PT and APTT values, respectively. Conclusions This retrospective audit of CVC removals in surgical patients at Churchill Hospital revealed a concerning in-compliance rate of 44% with coagulation screens during CVC removals. Most patients had normal coagulation parameters, questioning the need for same-day screens. Delays and high costs (£64.76 per patient, £12.95 per screen) were incurred. Individualized risk-based approach, considering bleeding history, could be more efficient. Implementing targeted coagulation testing saves costs and optimizes resource utilization. Further evaluation required to improve patient care and resource allocation in CVC removals, reducing reliance on routine same-day screens.

Risk factors for healthcare-associated infections in newborns after surgery in a neonatal intensive care unit.

Health care-associated infections (HAIs) are a common cause of morbidity and mortality. There is little information on the risk factors associated with HAI in surgical newborns. To identify the risk factors associated with healthcare-associated infections in surgical newborns. Nested case-control study carried out during 2016-2017. Cases were newborns with healthcare-associated infections and controls were newborns without infection. Perinatal characteristics, use of antimicrobial prophylaxis, use of central venous catheter (CVC), mechanical ventilation, parenteral nutrition, age, and weight at the time of surgery, type of surgery, surgical wound classification, duration of surgery, number of surgical procedures, postsurgical HAIs and type of infection were registered. Univariate and multivariate analyses were performed. Seventy-one cases and 142 controls were included. The most frequent HAI was bloodstream infection (36.6%); the main microorganisms isolated in blood cultures were gram-positive cocci. Independent risk factors associated with HAIs in the multivariate analysis were CVC duration > 8 days (aOR = 17.2, 95% CI = 3.8-49.1), ≥ 2 surgeries (aOR = 16.5, 95% CI 5.8 -42.1) and abdominal surgery (aOR = 2.6, 95% CI = 1.2-6.6). Newborns undergoing surgery, mainly those with risk factors, require close monitoring during the postoperative period. CVC should be withdrawn as soon as possible.

Candida spp. infection frequency and risk factors in malignant critical care patients

Aims: Candida spp. can cause fatal infections in the person in case of immunosuppression such as malignancy. The aim of our study is to examine the frequency, prognosis and risk factors of candida-related infections in our patients with malignancies followed in our intensive care unit (ICU). Methods: ICU patients with malignancy with fungal infection accepted as the case group and the patients without candida were considered as the control. Demographic characteristics, risk factors and candida risk scores were recorded and compared in both groups. Results: Candida spp. reproduction was observed at a very high rate with 24%. However, there was no difference in mortality between the two groups with and without candida infection. In our study; candida risk score, presence and duration of central venous catheter, antibiotic and steroid use in the last 1 month were found to be the factors determining the risk of candida infection. Conclusion: The contribution of the presence of fungal infection to mortality in our cancer patients does not seem different from others. However, in this patient group, it is difficult to distinguish colonization from invasive fungal infections. At this stage, the use of treatment decisions using risk factors and risk scoring comes to the fore.

Evaluation of the Incidence of Central Venous Catheter-Associated Infections in Patients Admitted in the Intensive Care Unit of a Tertiary Hospital in Nigeria

Background: Presence of a central venous catheter (CVC) though useful may lead to CVC-associated bloodstream infections (CVCBSIs), resulting in increased morbidity and mortality. Objectives: The objectives of the study were to determine the incidence of CVCBSIs, the predominant causative microorganisms, the antibiotic sensitivity pattern of the microorganisms, and the associated risk factors. Materials and Methods: This prospective observational study evaluated the incidence of CVCBSIs in patients who had the catheter inserted on admission into the intensive care unit (ICU) of a tertiary hospital in South-East, Nigeria. Sixty-eight patients were recruited for the study. Blood samples were collected aseptically from a peripheral vein on admission, 72 h after the insertion of CVC, and at removal of CVC for blood culture. The distal 5 cm of the CVC was also collected at removal for microscopy, culture, and sensitivity testing. Results: Six out of all the patients recruited developed CVCBSIs, giving an incidence rate of 9.2%, whereas 48% (n = 31) developed catheter bacterial colonization. Over one-fifth (22.7%) of the patients with catheter duration beyond 5 days had CVCBSIs. Patients whose CVC duration was beyond 5 days had a higher risk of CVCBSIs (P = 0.015) than others. The commonest microorganism isolated was Staphylococcus aureus, whereas the most susceptible antibiotic was aminoglycoside (gentamycin). Conclusion: The incidences of CVCBSIs and CVC colonization were 9.2% and 48%, respectively. The duration of catheterization was found to be a major risk factor for CVCBSIs. The most predominant organism isolated was S. aureus. The most sensitive antibiotic agent was the aminoglycoside (gentamycin). It is therefore recommended that catheter care bundle which includes hand hygiene, use of chlorhexidine for skin preparation during insertion, use of barrier precautions during insertion, and the removal of unnecessary central lines should be strictly adhered to. Gentamycin should be used as empirical antibiotics in the ICUs.

Central Line Access Is Predictive of Diagnostic Blood Loss and Transfusion in the Surgical Intensive Care Unit.

Most patients in the surgical intensive care unit (SICU) have anemia and undergo extensive diagnostic laboratory testing (DLT). Consequently, patients undergo RBC transfusion, and many are discharged with anemia, both of which are associated with poorer outcomes. To characterize DLT blood loss in the SICU. We performed a 1-year retrospective study of 291 patients admitted to a SICU. The number of draws, average volume, and estimated discard volume were recorded, along with clinical and laboratory findings. Patients who underwent greater amounts of DLT had lower hemoglobin levels at discharge (P ≤ .001). Admissions requiring central venous catheter (CVC) access (49.8%) demonstrated significantly higher DLT draws and rates of transfusion. Findings from this study suggest that DLT blood loss contributes to anemia in the SICU, and that the presence and duration of CVC leads to increased testing, anemia, and RBC transfusion.

The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: a retrospective, observational, quasi-experimental study

BackgroundA central venous catheter (CVC) is an important medical device, but it could be preceding infection and the risk of central line-associated bloodstream infection (CLABSI). CLABSI is a common healthcare-associated infection but results in high cost and mortality; therefore, various efforts to reduce CLABSI have been attempted.MethodsThis is a retrospective, observational, quasi-experimental study in the intensive care unit (ICU) of a single tertiary care hospital. We reviewed and analysed the data of CLABSI rates and days from the insertion to the removal of the temporary CVC between January 2018 and June 2021 with transient periods over 9 months. Sequentially, all patients with the CVC in the ICU underwent the following interventions: maximal barrier precaution, automatic notification of catheter days and 2% chlorhexidine gluconate bathing. A segmented regression analysis of interrupted time series was conducted to compare the CLABSI rates before and after the introduction of multimodal interventions. During study periods, the impact of interventions on CLABSI was evaluated using multivariate logistic regression analyses.ResultsA total of 76,504 patient-days, 28,312 catheter days and 66 CLABSI cases were reviewed in ICU-hospitalised patients. As additional interventions, the CLABSI rate declined from 3.1 per 1000 CVC days to 1.2 per 1000 CVC days in post-interventions. In the pre-intervention and post-intervention periods, 4146 patents had one more short-term CVC. In the multivariate logistic regression analyses, multimodal intervention was one of determinants reducing CLABSI rates (odds ratio (OR), 0.52 [95% confidence interval {CI}, 0.28–0.94]). Indwelling time of CVC over 10 days was the risk factor for CLABSI rates (OR, 6.27 [95% CI, 3.36–12.48]). Of the three interventions, the automatic notification of catheter days was associated with decreased median monthly total CVC days and duration of CVC days per patient.ConclusionsMultidisciplinary and evidence-based interventions could lead to a decrease in the CLABSI rates. Moreover, the automatic notification of catheter days of the electronic medical healthcare system has shortened the time of indwelling CVC.

De Novo Central Vein Stenosis in Hemodialysis Patients Following Initial Tunneled Central Vein Catheter Placement.

Central vein stenosis (CVS) is a common complication in hemodialysis patients following tunneled central venous catheter (CVC) insertion. Little is known about its incidence, association with patient characteristics, or relationship with duration of CVC placement. We systematically evaluated central vein stenosis in hemodialysis patients receiving their first CVC exchange at a large medical center. All new hemodialysis patients underwent an ultrasound before their internal jugular tunneled CVC placement, to exclude venous stenosis or thrombosis. After the initial CVC insertion, if the patients were referred for CVC exchange due to dysfunction, a catheterogram/venogram was performed to assess for hemodynamically significant (≥50%) central vein stenosis. During a 5-year period (January 2016 to January 2021), we quantified the incidence of CVS in patients undergoing CVC exchange. We also evaluated the association of central vein stenosis with patient demographics, comorbidities, and duration of CVC dependence before exchange. During the study period, 273 patients underwent exchange of a tunneled internal jugular vein CVC preceded by a catheterogram/venogram. Hemodynamically significant CVS was observed in 36 patients (13%). CVS was not associated with patient age, sex, race, diabetes, hypertension, coronary artery disease, peripheral artery disease, or CVC laterality. However, the frequency of CVS was associated with the duration of CVC dependence (26% versus 11% for CVC duration ≥6 versus <6 months: odds ratio (95% CI), 3.17 (1.45 to 6.97), P=0.003). Among incident hemodialysis patients receiving their first tunneled internal jugular CVC exchange, the overall incidence of de novo hemodynamically significant central vein stenosis was 13%. The likelihood of CVS was substantially greater in patients with at least 6 months of CVC dependence.

Catheter-Associated Deep Vein Thrombosis (CADVT) in a Pediatric ICU: A Retrospective Case-Control Study

Highlights Abstract Introduction: Catheter-associated deep vein thrombosis (CADVT) in children has been recognized as a significant hospital-acquired condition. This study was undertaken to retrospectively analyze the impact of CADVT on outcomes and to identify risk factors for the development of deep vein thrombosis in children with central venous catheters. Methods: This was a single-center retrospective case-control study of patients with central venous catheters in a pediatric intensive care unit (ICU) from January 2014 to December 2018. Forty-one patients with central venous catheters who developed CADVT were compared with 100 random controls. Central venous catheter type, along with patient and disease-specific characteristics, were compared between the two groups by univariate and multivariate regression. Outcome comparison was made after adjusting for confounding variables. Results: Median time from insertion to the development of CADVT was 4 days (interquartile range, 2–9). Forty percent (16/40) of patients had a blood urea nitrogen greater than 20 mg/dL, and 86.6% (13/15) had a C-reactive protein greater than 1 mg/dL within 48 hours of development of CADVT. Central venous catheter duration (odds ratio [OR], 1.05), mechanical ventilation (OR, 7.49), and upper versus lower extremity site of the central venous catheter (OR, 0.324) were associated with the development of CADVT. Ultrasound guidance occurred significantly less in patients who developed CADVT (39.3% vs 70.7%); however, it was not independently associated with increased risk. Age, body mass index, mechanical ventilation, and severity of illness–adjusted hospital and ICU length of stay were significantly higher in patients who developed CADVT. Conclusions: CADVT is independently associated with worse outcomes. Ultrasound guidance and site selection are potential modifiable risk factors in the development of CADVT in pediatric patients. Future studies should target an effective chemoprophylaxis regimen.

Use of Tissue Plasminogen Activator as a Surrogate Measure for Central Venous Catheter Dysfunction and Survival Outcome in Children with Cancer: A Population-Based Retrospective Cohort Study

Central venous catheter (CVC) dysfunction is often associated with thrombosis, which in turn has been linked with poorer survival outcomes in cancer patients. Our objective was to examine the association of tissue plasminogen activator (tPA) administration as a surrogate measure of CVC dysfunction with survival in pediatric cancer patients. The present study uses data from a population-based retrospective cohort of pediatric oncology patients from the Canadian Maritime provinces treated between 2000 and 2017 at the IWK Health Centre, Halifax, NS. Demographics, diagnosis, date of death or date of last visit, and tPA use for CVC dysfunction were obtained from clinical databases and the provincial Cancer in Young People in Canada registry. The association between tPA administration and survival was examined using a Cox regression model adjusted for sex, age at diagnosis, cancer type, thrombosis, CVC duration, diagnosis era, and treatment modalities. Out of 821 patients, 206 received one or more doses of tPA during upfront therapy. The death rate was 21% and 15% respectively in patients who did and did not receive tPA. In the adjusted regression model, after receiving one or more doses of tPA, children had significantly poorer survival as compared to those that did not receive tPA (HR: 1.496, 95% CI: 1.019, 2.197). CVC dysfunction may be associated with a poorer prognosis in pediatric cancer patients. Future studies should corroborate these findings in other populations, examine the influence of other potential confounders, and determine the role of CVC dysfunction in prognostic models of cancer survival.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis.

Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients.

Introduction:The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line–associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.Methods:All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.Results:We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.Conclusions:Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Central venous catheter-associated thrombosis in children with congenital hyperinsulinism

SummaryCongenital hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy. To correct hypoglycaemia, high concentrations of dextrose are often required through a central venous catheter (CVC) with consequent risk of thrombosis. We describe a series of six cases of CHI due to varying aetiologies from our centre requiring CVC for the management of hypoglycaemia, who developed thrombosis in association with CVC. We subsequently analysed the incidence and risk factors for CVC-associated thrombosis, as well as the outcomes of enoxaparin prophylaxis. The six cases occurred over a 3-year period; we identified an additional 27 patients with CHI who required CVC insertion during this period (n = 33 total), and a separate cohort of patients with CHI and CVC who received enoxaparin prophylaxis (n = 7). The incidence of CVC-associated thrombosis was 18% (6/33) over the 3 years, a rate of 4.2 thromboses/1000 CVC days. There was no difference in the frequency of genetic mutations or focal CHI in those that developed thromboses. However, compound heterozygous/homozygous potassium ATP channel mutations correlated with thrombosis (R2 = 0.40, P = 0.001). No difference was observed in CVC duration, high concentration dextrose or glucagon infused through the CVC. In patients receiving enoxaparin prophylaxis, none developed thrombosis or bleeding complications. The characteristics of these patients did not differ significantly from those with thrombosis not on prophylaxis. We therefore conclude that CVC-associated thrombosis can occur in a significant proportion (18%) of patients with CHI, particularly in severe CHI, for which anticoagulant prophylaxis may be indicated.Learning points:CVC insertion is one of the most significant risk factors for thrombosis in the paediatric population.Risk factors for CVC-associated thrombosis include increased duration of CVC placement, malpositioning and infusion of blood products.To our knowledge, this is the first study to evaluate CVC-associated thrombosis in patients with congenital hyperinsulinism (CHI).The incidence of CVC-associated thrombosis development is significant (18%) in CHI patients and higher compared to other neonates with CVC. CHI severity may be a risk factor for thrombosis development.Although effective prophylaxis for CVC-associated thrombosis in infancy is yet to be established, our preliminary experience suggests the safety and efficacy of enoxoaparin prophylaxis in this population and requires on-going evaluation.

Increased Incidence of Central Venous Catheter-Related Infection in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy.

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line sepsis is one of a number of potential morbidities. The aim of this study was to calculate the incidence of catheter-related infection (CRI) in a CRS and HIPEC patient population and to assess its influence on length of hospital stay. Methods: Data were collected on consecutive patients who underwent CRS HIPEC between August 2013 and October 2017. Data included patient demographics, timing of CVC insertion/removal, time spent in critical care, and CVC tip/blood culture results. Charts were reviewed for patients with both positive CVC culture and positive blood cultures to assess for evidence of catheter related infection and systemic inflammatory response syndrome (SIRS). Results: Data on 100 consecutive CRS HIPEC operations performed between August 2013 and October 2017 was analyzed. There were 11 CRIs in 100 CVCs, resulting in a CRI rate of 16.2 per 1,000 CVC days. Patients within the CRI group had a longer high-dependency unit (HDU) stay compared with the non-septic group (6 days vs. 4.07 days, p < 0.05). The CVC duration for the CRI and non-CRI group was 8.4 and 7.6 days, respectively (p = 0.12). The CRI group also had an increased total hospital length of stay (LOS; 20.8 days vs. 15.4 days, p < 0.05). On average, CRIs occurred eight days post-operative and four days post-HDU discharge. There was no association identified with longer CVC duration (p = 0.34). There has been an annual decline in CRI rates in CRS and HIPEC patients over the duration of the study period from 19.1 per 1,000 CVC days in 2016 to 8.2 per 1,000 CVC days in 2017. Conclusion: This is the first study to report on CRI rates in patients undergoing CRS and HIPEC. The CRI rate of 16.2 per 1,000 CVC days is higher than the overall national figure of 5.2 per 1,000 for CVC lines inserted in the operating room. Patients who developed line sepsis had longer HDU and longer overall hospital stay. Catheter-related infection was noted post-HDU discharge in all cases. Implementation of a CVC care bundle in the later years of the study period coincided with a reduction in CRI rates.

Predictive Factors for Central Line-Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax.

To assess the prevalence of central line-associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line-associated bloodstream infection. Retrospective single-center cohort study. A PICU located within a tertiary-care academic pediatric hospital. All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014. None. We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line-associated bloodstream infection (23% vs 3.8%; p < 0.001). Patients with both chylothorax and central line-associated bloodstream infection had longer durations of central venous catheter, higher Risk Adjustment Congenital Heart Surgery score, longer PICU stay, and higher mortality compared with patients with chylothorax who did not have a central line-associated bloodstream infection. Multivariable analysis identified higher Risk Adjustment Congenital Heart Surgery score, longer duration of central venous catheter, and higher chest tube output at 24 hours after initiating treatment for chylothorax to be predictive of increased central line-associated bloodstream infection risk in patients with chylothorax. The prevalence of central line-associated bloodstream infection is higher in pediatric patients with chylothorax after heart surgery. In patients with chylothorax, complexity of surgery, central venous catheter duration, and chest tube output are associated with increased risk for developing a central line-associated bloodstream infection. Using this knowledge will allow us to identify patients at increased risk for central line-associated bloodstream infections and to focus extra prevention efforts on them.