Central Venous Line Insertion Research Articles

Direct Species Identification in Positive Blood Culture Bottles From Patients With Hematologic Malignancies.

Background In patients with hematologic malignancies, faster species identification is particularly important in the management of bloodstream infection because of their immunocompromised and neutropenic status. In the present study, we analyzed direct species identification in patients with hematologic malignancies, and the factors that might influence the results of species identification. Methods We performed direct species identification using a Sepsityper® kit (Bruker Corporation, Billerica, Massachusetts, United States) and compared the results with a conventional method in patients with hematologic malignancies. Forty-five positive blood culture bottles containing single microorganisms from 37 patients were analyzed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS). And patients' clinical data were compared between the groups with spectral scores at acceptable and unacceptable levels. Results Direct species identification correctly identified 42 of 45 isolates and three were misidentified.While 35 of 45 isolates showed a spectral score ≥1.7 (acceptable identification), 10 isolates had a spectral score <1.7 (unacceptable identification) including three misidentified isolates. The group with a spectral score ≥1.7 had significantly lower white blood cell (p<0.01), neutrophil (p<0.01), and platelet (p<0.01) counts in addition to more frequent central venous (CV) line insertion (p=0.01). Multivariate analysis revealed that pathogen type (gram-positive or negative) and CV line insertion were associated with spectral scores. Conclusion Direct species identification using the Sepsityper kit is an upcoming approach for blood culture bottles, which were flagged as positive even in patients with hematologic malignancies when the spectral score was ≥ 1.7. Our study also indicates that direct identification is more accurate in patients with CV lines, and may be less accurate when gram-positive bacteria are detected.

Effect of Back-Cut Point Needle Bevel Angle on Deterioration After Multiple Punctures in Central Vein Simulation.

Multiple needle punctures during central venous line insertion can lead to serious complications. Needle deterioration owing to repeated punctures may be a major cause. We hypothesized that there is an optimal bevel angle for a back-cut point needle that is resistant to deterioration. In this study, we examined the effect of bevel angle differences in a back-cut point needle on needle tip deterioration caused by multiple punctures. The resin target was punctured perpendicularly using back-cut point needles with three bevel angles (15°, 17°, and 19°; n=8 for each angle) at a speed of 200 mm/min. The same needle was used for ten consecutive punctures at different locations on the target. The force applied to the needle was recorded as puncture force. The puncture force waveform is bimodal. The second peak values, which formed the maximum values of puncture force, were the focus of the main analysis. We considered a 5% elevation from the first to the 10th puncture force as needle deterioration, and the average slope value of the regression line between the puncture number and puncture force was used. When the upper limit of the 95% confidence interval (CI) of the slope value was less than 0.008889, the needle was considered to be resistant to deterioration. The slopes of the second peak values during 10 consecutive punctures for each bevel angle (15°, 17°, 19°) were 0.003011 ± 0.01085 [-0.006056, 0.012077], 0.006116±0.007431 [-0.000096, 0.012328], and 0.001515 ± 0.005783 [-0.003320, 0.006349], respectively (mean ± standard deviation [95% CI]). Only the 19° angle needle had a smaller upper limit of the 95% CI for a slope value of 0.008889. The 19° bevel angle back-cut point needle was more resistant to deterioration than the 15° and 17° angle needles were.

Venous Thromboembolism in Hematopoietic Stem Cell Transplantation

Background: Venous thromboembolism (VTE) is an underappreciated complication seen amongst allogeneic and autologous hematopoietic stem cell transplant (HSCT) patients and a major cause of morbidity and mortality. Despite these challenges, VTE in HSCT remains understudied, with a paucity of established guidelines on thrombosis surveillance, prevention, and treatment. Balancing risk of bleeding and thrombosis is particularly challenging as HSCT patients are concurrently pancytopenic and coagulopathic. We aimed to describe the incidence, predictors, and adverse events of VTE amongst patients at 90 days post-HSCT. Methods: We conducted a retrospective cohort study of adult patients, age &amp;gt;18-years-old, who underwent HSCT for a hematological malignancy between January 1, 2011 and December 31, 2021 at a tertiary care centre in Canada. Patients were followed from transplant until Day 90 post-transplant, or death. Baseline, transplant, laboratory, and cancer characteristics were analyzed. Results: Four Hundred and Seventy Six (476) HSCT patients were included (age range 18 - 74), 285 (59.9%) of our patients were male, and 191 (40.1%) were female. Three Hundred and Seventeen (317) (66.6%) patients underwent autologous transplant, and 159 (33.4%) patients underwent allogeneic transplant ( Table 1). Forty Seven (47) patients (9.8%) suffered from VTE within 90 days post-HSCT; 74.5% were catheter related. 9.43% of allogeneic, versus 10.09% autologous patients were diagnosed with VTE (p=0.820). 11.9% of allogeneic, versus 4.1% of autologous patients (p=0.001) suffered from bleed unrelated to anticoagulation. There was significant association of VTE post-HSCT with history of unprovoked DVT (p = 0.026), previous treatment with steroids (p = 0.032), infectious complications (including bacteremia (p = 0.025), and skin and soft tissue infection (p &amp;lt; 0.001)), use of peripherally-inserted central catheters (PICCs (p &amp;lt;0.001), left-sided CVC placement (p = 0.007), second central venous line insertion (due to complications from the first) (p &amp;lt; 0.001), and blocked or malfunctioning central venous catheter (p = 0.003). There was no significant association of VTE post-HSCT with transplant graft (autologous versus allogeneic), underlying hematological malignancy, age, BMI, or sex. Mortality rate at 90 days amongst VTE patients was 14.89%, versus 3.27% in non-VTE patients (p &amp;lt; 0.001) ( Figure 1). Conclusion: The majority of VTE post-HSCT were catheter-related and were more frequently associated with use of PICCs. VTE post-HSCT was associated with higher mortality. VTE prophylaxis or active surveillance could be considered in patients with the above-mentioned risk factors balancing the risk of bleeding, particularly in allogeneic stem cell transplant patients, and those who are concurrently thrombocytopenic.

Complications associated with central venous catheterization in pediatric ICU of a tertiary care hospital of Pakistan.

Objective: To determine the frequency of complications of central venous line insertion among children admitted in Pediatric Intensive Care Unit (PICU). Study Design: Cross-sectional study. Setting: PICU of Shifa International Hospital, Islamabad, Pakistan. Period: March 2022 to February 2023. Material &amp; Methods: Children of either gender aged between 2 months to 16 years admitted in PICU during study period and underwent central venous catheterization(CVC) during admission were analysed. The patients were observed for immediate and late complications of CVC. Results: In a total of 160 children, 89 (55.6%) were boys. The mean age at the time of admission was 6.00±4.87 years. Immediate complications occurred among 9 (5.6%) children including catheter malposition, pneumothorax, hematoma, and arterial puncture observed in 4 (2.5%), 2 (1.3%), 2 (1.3%) and 1 (0.6%) children respectively. The CLABSI rate was 16.8 per 1,000 catheter days. The most common micro-organisms causing CLABSI were Methicillin Resistant Staph Epidermidis (MRSE), and Klebsiella, reported in 3 (21.4%) cases each. Younger age (p&lt;0.001), relatively low body weight (p&lt;0.001), and increased duration of central venous line placed (p&lt;0.001) were found to be significantly associated with CLABSI. Conclusion: In this study, CLABSI rate was found to be 16.8 per 1,000 catheter days which is comparable to the regional data. Common immediate complications of CVC were catheter malposition, pneumothorax, hematoma, and arterial puncture. Younger age and increased duration of CVC were associated with CLABSI.

Reliability of intra-atrial ECG method of insertion of central venous line through right internal jugular vein when compared to formula and radiological landmark method: a prospective randomized study

BackgroundIdeal position of central venous catheter tip should be within 2 cm above and 1 cm below superior vena cava–right atrium (SVC-RA) junction. The objective of the study was to compare intra-atrial ECG method of Central venous catheterization of right internal jugular vein (IJV) with traditional methods. A prospective randomized trial enrolling 90 patients were alternatively allocated to three groups and comparison of intra-atrial electrocardiography, radiological landmark and Pere’s formula method for correct positioning of central venous catheter tip were done and tip position were confirmed with post-procedural TEE (transesophageal echocardiography).ResultsCatheter tip was present at the ideal position in 100% cases in intra-atrial ECG method compared to only 23.4% in formula method and 93.3% in landmark method (p value 0.001). In intra-atrial method group, the central venous catheter tip was placed perfectly in all patients, position of the catheter tip was not acceptable in 71.4% of the patients where formula method is used and not acceptable in 11.1% when landmark method is used (p value 0.001). However, we did not encounter any catheter related complications in any of these groups.ConclusionsIntra-atrial ECG method carries the advantage of ideal positioning of the central venous catheter tip by right IJV route in almost all cases when compared to conventional formula and landmark method to some extent. Also, immediate confirmation and real time verification of central venous catheter (CVC) tip is possible, thereby avoids the need for post-procedural chest X-ray and other methods of central venous placement confirmation like arterial blood gas analysis etc., Hence, intra-atrial ECG method is cost effective and safer for confirmation of CVC tip in all the situations.

Central venous pressure line insertion for the primary health care physician

Central venous access is an important procedure to understand and perform not only in the emergency unit but also for prolonged reliable venous access. All clinicians must be familiar and confident with this procedure. This paper will focus on applied anatomy in respect of common anatomical sites for venous access, the indications, the contraindications, the technique and complications that may arise following the procedure. This article is part of a series on vascular access. We have previously written on the intra osseous procedure and an article on umbilical vein catheterisation will follow.

EFFECT OF POSITIVE END EXPIRATORY PRESSURE ON CENTRAL VENOUS PRESSURE IN PATIENTS UNDER MECHANICAL VENTILATION

A majority of patients who are kept under mechanical ventilation may also require central venous (CV) line insertion for different reasons such as inability to access peripheral vein, blood transfusion, or administration of vasoactive agent.(1) Central venous pressure (CVP) is a good indicator of circulatory volume and cardiac function. The normal range of CVP is 8 - 12 cmH2O. It increases to 12 - 16 cmH2O in patients under mechanical ventilation.(1,2)

Timing of Central Venous Line Insertion During Induction in Children With Acute Lymphoblastic Leukemia.

Central venous lines (CVL) in children with acute lymphoblastic leukemia (ALL) provide comfortable administration of intensive chemotherapy and blood sampling. The optimal time for the insertion of CVL in patients with ALL during induction therapy is controversial. This study aimed to investigate the frequency of CVL-related complications in children with ALL concerning the time of CVL insertion. We reviewed the records of 52 pediatric ALL patients with CVL. CVL placement before or on treatment day 15 was defined as "early insertion", and after treatment day 15 was defined as "late insertion". Demographics, preoperative blood counts, type of central line, time of CVL placement, CVL-related complications, and blood counts during complications were all noted. All the data were collected from those with the first catheter use. CVL was placed ≤15 days in 26 patients (50%) and after 15 days in 26 patients (50%). Regarding the infection rates, no statistical difference was found between early and late CVL-inserted groups (P=n.s.). Five patients developed thrombosis, and risk was found to be similar between early and late CVL-inserted groups (P=n.s.). Catheter-related mechanical complications were recorded in 7 patients (3 in early and 4 in late CVL-inserted group, (P=n.s.). The present study showed no relation between the timing of CVL placement during induction therapy and the occurrence of infection and thrombosis. Our results suggest that CVL can be placed safely at the time of diagnosis or early induction treatment to provide a comfortable administration of chemotherapy and decrease painful blood samplings.

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

Modified Seldinger technique for internal jugular open central venous line insertion in neonates: merging two different manoeuvers

BackgroundCentral venous line insertion in neonates is an important and lifesaving procedure. It can carry significant risks and complications, including death, at the time of insertion or later. We aimed to retrospectively assess the modified Seldinger technique for open placement of a central venous catheter in neonates, regarding its safety, feasibility, operative time, and preservation of the patency of the internal jugular vein. This study was conducted on 120 neonates from March 2018 to March 2020. We closely monitored the pulse for the detection of arrhythmia or bradycardia, which might be caused during the insertion of the guide wire or the tip of the catheter. Post-operative X-ray was done immediately after the end of the procedure for all cases, to determine the site of the central venous catheter and to detect the presence of pneumothorax.ResultsArrhythmia was observed in 9 cases (7.5%), and blood oozing in 5 cases (4.1%). There were 3 cases of pneumothorax (2.5%), 2 cases of neck hematoma in two cases (1.6%), 6 cases of internal jugular vein thrombosis (5%), and dislodging of the catheter in 3 cases (2.5%). There were no cases of arterial puncture, failure of cannulation, or haemothorax in our study.ConclusionsThe modified Seldinger technique insertion for open central venous line in neonates is a safe, accessible, and feasible method, especially in centers that lack the experience of ultrasound-guided insertion in neonates.

A comparative Study between Tube Feeding versus Parenteral Nutrition in GIT Cancer Patients in ICU

Abstract Objectives Our study is designed to determine whether providing nutrition via parenteral route or enteral route is better in patients with GIT cancer after surgery in ICU. Background Patients with gastrointestinal malignancy have a higher risk of postoperative complications and alterations resulting from their pre and postadmission nutritional status. Malnutrition and subsequent weight loss have long been among the leading causes of morbidity and mortality, as well as increased costs with other organs dysfunction associated to cancer patients undergoing surgery. Methods A prospective randomized clinical trial conducted in critical care units in Ain Shams University Hospitals from August 2017 to February 2019.Eighty patients with GIT cancer were included. Half of them received enteral nutrition and the other half received parenteral nutrition. All patients were compared regarding demographic data, hemodynamic parameters, complications (Infection, GIT symptoms, and central venous line insertion), signs of malnutrition (weight loss and hypoalbuminaemia), time to pass flatus, ICU stay and mortality. An informed written consent was obtained from patients and/or their relatives. Results Postoperative complications occurred in 20 (50%) patients fed enterally versus 23 (57.5%) patients fed parenterally with p = 0.501.Infectious complications happened in 5 (12.5%) patients fed enterally versus 9 (22.5%) patients fed parenterally with p = 0.239.Surgical complications occurred in 3(7.5%) patients fed enterally versus 4(10%) patients fed parenterally with p = 0.905.GIT complications occurred in 9 (22.5%) patients fed enterally versus 6 (15%) patients fed parenterally with p = 0.872.Respiratory complications occurred in 4 (10%) patients fed enterally versus 2(5%) patients fed parenterally with p = 0.708. Time to flatus (days) was 2.90 ±1.0 in enteral group versus 3.78 ±0.8 in parentral group with p = 0.003. ICU stay (days) was 5.50 ±1.8 in enteral group versus 9.83 ±3.40 in parentral group with p = 0.003. Mortality n (%) was 1 (2.5%) in enteral group versus 2 (5.0%) in parentral group with p = 1.000. Albumin after 7 days and albumin after 14 days were increased statistically significantly in patients of enteral nutrition than parenteral nutrition group (p = 0.021) and (p = 0.003) respectively. There was a statistically significance improvement of albumin level within the same group (P = 0.003). There was a statistically significant improvement of weight in patients who had received enteral nutrition (p = 0.003) while There was a statistically significant decrease in weight in patients who had received parenteral nutrition (p = 0.003). Conclusion Enteral nutrition showed better results in comparison to parenteral nutrition regarding time to pass flatus, ICU stay, albumin after 7 days and albumin after 14 days. Both types of nutrition are equal statistically regarding complications and infection, mortality rate, post-operative weight after 7 days (kg) and weight after 14 days (kg).

Incidental finding of left sided superior vena cava in a patient for tunneled central venous line insertion and review of literature

Left sided superior vena cava (SVC) is a rare anatomic variant of the normal anatomy of the heart and the venous system that has clinical implications. The presence of this variant is relevant to central venous catheter placement, cardioverter defibrillator placement, coronary artery bypass grafting, and numerous other medical procedures. In this report, we describe a rare case of left sided SVC, which was diagnosed during central venous catheter insertion. We also discuss the vascular and anesthetic considerations for individuals with this uncommon variant. Key words: Superior vena cava; Anatomical anomaly; Central venous catheter Citation: Imtiaz D, Sadaqat S, Rehman SU. Incidental finding of left sided superior vena cava in a patient for tunneled central venous line insertion and review of literature. Anaesth. pain intensive care 2021;25(4):547–549 DOI: 10.35975/apic.v25i4.1577 Received: April 29, 2021, Reviewed: June 1, 2021, Accepted: June 4, 2021

The Successful Resuscitation in a Neonate with Down Syndrome after 45 minutes: A Case Report

Introduction: Patients with Down syndrome (DS due to relative macroglossia and dynamic airway collapse) are vulnerable to significant upper airway complications. Obstructive sleep apnea (OSA) is a common condition and noted in about 79% of these children . Children with OSA, with or without DS, are sensitive to respiratory depression by drugs such as sedatives, opioids and hypnotics. Abnormalities of the cardiovascular system are also common in Down syndrome. Case Report: A nine_ day old male preterm newborn with DS (e.g. gestational age of 35 weeks) was brought to operation room (OR) for insertion of central venous line and surgery of duodenal atresia. During transportation to NICU, in OR he arrested and then after 45 minutes resuscitation, he returned to life. Conclusion: The placement of CVL could precipitate triggers of cardiac arrest, particularly in preterm newborn.

A184 INCIDENCE OF VENOUS THROMBOTIC EVENTS AND RISK FACTORS IN CHILDREN HOSPITALIZED WITH INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE, CASE-CONTROL STUDY

Abstract Background Limited research has been published to describe the incidence of venous thromboembolism (VTE) and relevant risk factors in Canadian children with inflammatory bowel disease (IBD). Aims The present study aimed to investigate the incidence of VTE amongst hospitalized pediatric IBD patients over a 10-year period and identify risk factors for the development of VTE. Methods A retrospective, matched case-control study was performed at McMaster Children’s Hospital. Hospitalized pediatric patients with IBD (&amp;lt;18 years old) from September 2009 to August 2020 were selected. Inpatient data was extracted from the medical record database, including baseline demographic data, thromboembolic events and potential risk factors for VTE. Results There were 890 hospitalizations of IBD patients during the study period. 15 (1.69%) were diagnosed with a VTE, including 4 males and 11 females (mean age 13.4±2.9 years old). 12 ulcerative colitis (UC) (80%) and 3 Crohn’s disease (CD) (20%) hospitalizations were comprised in the VTE group. There was a significant difference in VTE rate between females (2.7%) and males (0.8%) (P = 0.03). The VTE rate in the UC group (4.2%) was significantly higher than in the CD group (0.6%) (P = 0.001). The incidence of VTE amongst hospitalized IBD patients did not vary over the 10-year period (P = 0.496). Length of stay in hospital, albumin level and central venous catheter were shown to be significantly different, although they were not identified as independent risk factors (P &amp;gt;0 .05). Of the 15 hospitalizations with VTE, 6/15 (40%) were superficial VTEs in the extremities and 9/15 (60%) had a deep vein thrombosis (DVT) including 6 in the extremities and 3 in the abdomen. VTEs were associated with a peripheral line in 7 patients and with a PICC line in 4 hospitalizations. 2 of 9 (22%) with extremity DVT developed symptomatic pulmonary embolism. An inherited thrombotic condition was identified in 2 of 15 with VTEs. 12/15 (80%) with VTEs were symptomatic and all VTE related symptoms happened in patients with extremity thrombosis and pulmonary embolism. 7 of 15 (47%) VTEs were treated with anticoagulation therapy for 1–6 months. VTE related symptoms and repeat imaging tests significantly improved, and no patient developed a bleeding complication as a result of treatment. Conclusions The VTE rate in pediatric IBD patients was relatively low at McMaster Children’s hospital. Children with VTE were disproportionately females with ulcerative colitis compared with children with no VTE. Central venous line insertion may be correlated with the risk for VTE in children with IBD. Most VTEs and related symptoms happened in patients with extremity thrombosis and secondary pulmonary embolus. Anticoagulation therapy in children with IBD with active disease appears to be safe. Funding Agencies Kids Dig Health Funding from McMaster Children’s Hospital, McMaster University

Clinico-etiological profile of children who had unplanned extubation and subsequent re-intubation in level-4 pediatric intensive care unit

Background: There are few studies on unplanned extubation (UE) in pediatric intensive care units (PICU). This study is to identify factors associated with UE in PICUs.Subjects and Methods: In this observational study, the data of UE from January 1, 2013, to May 31, 2019, in a level-4 PICU were analyzed with an objective to study the etiology of UE and its impact on therapeutic outcomes.Results: Of 7079 patients hospitalized in PICU, 1721 were invasively ventilated (mean ventilator days 4.33 days). UE occurred in 39 patients (2.26% of intubated patients) at 0.52 UE events per 100 ventilation days. The median age was 14 months. The most common cause of UE was inadequate sedation (n = 24, 61.53%), endotracheal tube suctioning (n = 05, 20.8%), one during adjusting ET tube (4.1%), one during central venous line insertion (4.1%), and one during Foley's catheter insertion (4.1%) and 7 unexplained (29.1%). As long as the appropriate nurse: patient ratio was maintained, the incidence of UE was un-affected by day versus night shift or high versus low bed occupancy rates. Re-intubation rate in UE cohort was higher (74.35%) than planned-extubation cohort 0.11% (P < 0.001). All re-intubations were within 2 h of UE. Most common cause of re-intubation following UE was respiratory distress (72.41%), stridor (17.24%), and apnea (10.34%). Re-intubations following UE showed higher incidence of ventilator-associated pneumonia but statistically not significant (P = 0.54).Conclusion: UE is associated with a significantly high incidence of re-intubations and associated complications arising from re-intubations. Maintaining a pool of skilled nurses in adequate nurse-to-patient ratio may play an important role in preventing UE. UE can be minimized by optimizing sedation and monitoring during common ICU procedures. Multicentric studies are warranted to design a uniform standard of care of ventilated patients aimed at reducing the incidence of UE.

Use of Peripherally Inserted Central Catheter (PICC) for the Infusion of Peripheral Blood Stem Cell Products Is Safe and Effective

Introduction: Cryopreserved peripheral blood stem cell (PBSC) products are thawed at bedside and infused by gravity through a large bore central venous line (CVL). Peripherally inserted central venous catheters (PICC) are routinely used for infusion of blood products and medications but are rarely used to administer hematopoietic progenitor cells (HPC). The rationale for this practice is not well established but the general assumption is that the smaller gauge sizes of the PICC and resultant decreased infusion rates would damage the HPCs. The use of PICC to infuse HPCs can have many benefits, such as patient comfort, cost effectiveness, and reducing potential line-related complications from the insertion of a large bore, and often additional, CVL. These line-related complications include infections, pneumothorax, haematomas, etc. The aim of this prospective observational study is to present the experience of using PICC in lymphoma patients receiving autologous PBSC transplantation in terms of the safety and efficacy. Methodology: From September 2019 to June 2020, a prospective observational study involving 16 patients with lymphoma undergoing autologous PBSC transplantation was conducted in National University Cancer Institute, Singapore (NCIS). The patients were divided into 2 groups - the first group included 9 lymphoma patients who received their autologous PBSC transplant via PICC, while the second/control group included 7 lymphoma patients who received the treatment via a large bore CVL. The types of PICC and CVL inserted for the patients were standardized - 19G dual lumen PICC and 7Fr triple lumen non-tunnelled CVL respectively. All the CVLs were inserted in the right internal jugular vein, while the PICC were inserted in either the brachial or basilic veins. All patients in both groups underwent BEAM conditioning transplantation regime prior to autologous PBSC transplantation. The duration of the catheter-in-situ, catheter-associated complications, PBSC infusion rate, CD34 cell dose, total nucleated cell dose infused, and the time for absolute neutrophil and platelet count engraftment were analysed for the study. Results: The baseline characteristics and results for both groups are shown in Table 1. It is important to highlight that for the first group using PICC, none of them had any adverse event from PBSC transplantation. 44.4% of the patients had only minor issues during the PBSC infusion, mainly due to slower infusion rate and sediments were seen in the tubing of the PICC. These issues were quickly overcome by manual flushing of the PICC with normal saline fluid boluses. Only 1 out of 9 had a mild skin irritation at the insertion site of the PICC. For the second/control group using CVL, 43% of them had both PICC and CVL in-situ at one point of their treatment. These patients underwent an additional procedure for CVL insertion and the CVL was removed within 2 weeks of insertion. Only 1 out of 7 patients had minor issue of severe nausea during the PBSC infusion. There was no adverse event during the PBSC infusion or catheter associated complication. Conclusion: Our study showed that the use of PICC is safe and effective for patients receiving autologous PBSC transplantation, compared to the conventional large bore central venous catheters. Despite having longer PBSC infusion rate for PICC, the time taken for neutrophil and platelet recovery between both groups were comparable and there were no serious complications. Table Disclosures Chng: Celgene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Abbvie: Honoraria; Novartis: Honoraria.

Resident perception of standardization and credentialing for high-risk bedside procedures in cardiothoracic surgery: Results from an institutional pilot study.

Though clear-guidelines are set by the American Board of Thoracic Surgery (ABTS) for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multidisciplinary course designed to standardize common high-risk bedside procedures and credential our trainees. The aim of this study was to survey the attitudes of residents towards and query the efficacy of such a course. The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy, thoracentesis and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands-on simulation session. Knowledge-based pre-and post-evaluations were administered as well as a Likert-based survey regarding multiple aspects of the residents' perceptions of the course and the procedures. Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than by faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail tube thoracostomy, thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pretest and posttest knowledge-based evaluations. Cardiothoracic residents have favorable attitudes towards standardization and credentialing for high-risk bedside procedures and utilizing such courses may help standardize procedural techniques.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

Spectrum of invasive critical procedures performed by clinical fellows in the pediatric intensive care unit of a developing country

Objective: The objective of this study is to describe the frequency of invasive critical procedures (ICPs) performed by pediatric critical care medicine (PCCM) fellows during their training period.Design: This was a retrospective study.Setting: This was a multidisciplinary, closed 6-bed pediatric intensive care unit (PICU) staffed by four pediatric critical care physicians.Methods: We reviewed the electronic medical record and logbook of each fellow from January 2018 to December 2019. Two most commonly performed ICPs included in this study were endotracheal intubation and ultrasound-guided central venous catheter (USG-CVC) insertion. Demographic data and details of ICPs performed were collected on a structured data collection sheet. The primary outcome was the frequency of ICPs performed by clinical fellows during the training period and their success rate.Results: Of the total 1080, 352 ICPs were performed on 560 (51.8%) patients by four PCCM fellows during the 2-year period. Only two most commonly performed procedures, i.e., ET-intubation and UG-CVC insertion were included in this study. These ICPs comprised of endotracheal tube placement (52.85%, n = 186) and USG central venous line insertion (47.15%, n = 166). About 64.4% of patients were under 5 years, 56% were male, and 72% were admitted with cardiorespiratory failure. The frequency of endotracheal intubation was 23/fellow/year and USG-CVC insertion was 21/fellow/year and the success rate was >90%.Conclusion: Our clinical fellows performed adequate numbers of endotracheal intubation and USG-CVC insertion to achieve competency of procedural skills during their training period.

Minimally Invasive Technique of Direct Central Venous Access in Micro Preemies—a Case Series

Central venous line insertion and its maintenance in micro preemies carry significant risk for serious complications considering their small size and the skill involved in insertion. Hence, for uninterrupted and safe administration of essential medications and nutrition in these extreme preemies, we have come up with a minimally invasive technique of central venous access (MICVA technique) using peripherally inserted central catheter (PICC) of smaller caliber. We report a case series of 7 micro preemies who had difficult peripheral venous access because of their long stay in the neonatal intensive care unit (NICU) due to their extreme prematurity. We used a minimally invasive technique wherein under ultrasound guidance, the femoral vein was directly punctured with the splitting introducer needle (24G) available in a PICC set (28G/1Fr catheter with a stylet and splitting needle, Premicath, Vygon) (a size appropriate for micro preemies). Once the blood return was seen, the catheter was advanced up to the premeasured length, and then, the introducer needle was slowly withdrawn out and split. The catheter tip position was then checked with X-ray before starting any infusions. Throughout the procedure, non-pharmacological developmentally supportive care measures were followed. We did not encounter any serious complications except for a small hematoma which was encountered in 2 (28.6%) cases. The Premature Infant Pain Scale (PIPS) score measured for this minimally invasive technique was < 8 for all neonates. In our case series, using this technique (MICVA), we did not concur any serious complications. Local application of 2.5% Prilox cream with 25% oral dextrose and other non-pharmacological measures such as facilitated tuck, swaddling, nesting, and positioning significantly reduced pain and stress during the procedure. We recommend that this technique would be a safe approach in hemodynamically unstable neonates or in difficult venous access scenarios in extreme preterms. Invasive ventilatory support and use of benzodiazepines or opioids can be safely avoided with this technique.