Line Insertion Research Articles

Investigation of Time to Line Placement and Treatment Initiation in Pediatric Oncology Patients Utilizing a Pediatric Vascular Access Team

Background:Once diagnosis of malignancy is made in pediatric patients, it can be important to initiate therapy to prevent delay in benefits derived from treatment. In certain diagnoses, prompt initiation of chemotherapy can help reduce complications such as hyperleukocytosis, mass effect from solid tumors, and spread of malignancy. These patients require provision of central vascular access in order to begin treatment. In children's hospitals patients often receive central venous catheters in the operating room under general anesthesia. However, this requires scheduling for the operating room, availability of pediatric surgeons, appropriate anesthesia consent and examination ahead of time for safety of proceeding. The benefit of having a pediatric vascular access team (PVAT) is that these providers are flexible with their availability, the time required to place the lines is often less and it eliminates the need for general anesthesia as well as the cost of the operating room. The aim of this study was to compare vascular access provision by a designated pediatric vascular access team with surgical placement of central venous access in pediatric oncology patients.Methods:This was an IRB-approved retrospective medical record review of subjects diagnosed with an oncologic malignancy with inclusion criteria: ages 0-21 years of age, treatment for pediatric malignancy at the University of Maryland Children's Hospital between 1/1/2017-12/31/2019. We performed bivariate analyses comparing variables between patients who had line placement by PVAT vs surgical placement. Analyses was performed using SAS 9.4.Results:We identified 69 patients who met inclusion criteria with 39% (n=27) having undergone line placement by PVAT. Surgical placement occurred for 55% (n=38), with interventional radiology (IR) or other placement making up the remainder 6% of patients (n=4). The mean age was noted to be younger in the surgical group (8.6 +/- 6 years) in comparison to the PVAT group (13+/-6.3 years), p=0.0061. The mean time from consult to line placement was 10 (+/-9) hours in the PVAT group vs 76 (+/-56) hours in the surgery group (p<0.0001). There was a statistically significant difference in procedure duration, with PVAT placement requiring less time (27+/-12 minutes) vs surgical placement (48+/-19 minutes), p=0.0005. There were no statistically significant differences among groups in race, sex, time-to-initiation of treatment after line placement, or complications. There was a small difference in mean number of attempts, with surgical requiring 1 (+/-0) vs. PVAT 1.2 (+/-0.4) attempts. Compared to complications of surgical line placement, the complications experienced by our PVAT team were largely related to need for revision of line placement, although not frequent enough to be statistically significant.Conclusion:Data show that having a PVAT for central line insertions demonstrates good safety profiles, successful insertion and low complication rates. PVAT has also increased the efficiency of vascular access at large academic institutions. The presence of vascular access teams allows for initiation of therapy in a timely fashion and allows central line placement under anesthesia to occur at a safer time. At our institution, having a PVAT in house has allowed for more efficient line placements, shorter time to provision of access and transition to placement of surgical lines when more stable. This allows for not only patients to receive care faster, but also to have lines placed in shorter times while optimizing patient safety.1.Schultz TR, Durning S, Niewinski M, Frey AM. A multidisciplinary approach to vascular access in children. J Spec Pediatr Nurs. 2006;11(4):254-256. doi:10.1111/j.1744-6155.2006.00078. DisclosuresNo relevant conflicts of interest to declare.

The Compliance of Healthcare Providers to Care Bundles in a Tertiary Hospital in Riyadh Region

This study aimed to describe the compliance rate of healthcare providers to care bundles in a tertiary hospital in Riyadh Region. The overall compliance rate of hand hygiene was low (less than 80%). The overall compliance rates of urinary catheter bundle, central line insertion bundle, and central line maintenance bundle were high (more than 95 %). The compliance rate to SSI bundle, ventilator bundle, safe injection practice, and using personal protective equipment was high. It is important to increase the compliance rate of the care bundles elements to 95 percent or greater, particularly the compliance to hand hygiene to improve patient care.

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion.

Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

The Venerable Subclavian Line.

In this treatise, we will address one of the higher-risk procedures, subclavian vein cannulation, that a practitioner may undertake in the care of complex patients. All cardiothoracic surgeons and their trainees will need, on occasion, to put in central lines in a variety of circumstances, including in the operating room, in the intensive care unit, in emergency circumstances, and, occasionally, when other practitioners have been unsuccessful in their attempts to place a central line. We will describe, in detail, the anatomy of the subclavian vein, the preparation of the patient for subclavian vein cannulation, the infraclavicular approach to cannulation of the vein, and a few notes about the supraclavicular approach to the subclavian vein. It is self-evident that the priorities of central venous cannulation include safety of insertion, minimizing clot formation, and avoiding infection. We will dwell primarily on the principles of safe subclavian line insertion.

65 Complication rate of cuffed versus uncuffed PICC lines placed by interventional radiology in pediatric patients

Abstract Primary Subject area Paediatric Radiology Background Peripherally inserted central catheters are commonly used in pediatrics to offer stable access for administering prolonged courses of antibiotics, chemotherapy, parenteral nutrition, or other intravenous fluids. Objectives To assess the complication rates of cuffed versus uncuffed PICCs in a pediatric tertiary referral centre. Design/Methods Research ethics board approval was sought and granted. A dual arm study design was employed with a retrospective chart review of PICCs inserted between June 2017 - June 2018, and a prospective chart review of PICCS inserted between January 2019 - June 2019 at a large tertiary pediatric referral center. Data collected from the electronic record included age, weight, and diagnosis. Line type, size, location, insertion and removal dates, and indications were recorded. Primary outcome was removal of PICC after completion of therapy or premature removal due to the following complications: infection, thrombosis, or mechanical failure (defined as catheter breakage, blockage, or dislodgement). Results The study included 266 patients. Across all patients weighing &amp;lt; 10 kg, 90.5% of those with cuffed PICCs and 65% of those with uncuffed catheters completed therapy. The predominant complication resulting in premature removal was mechanical failure, but this was only observed in patients with uncuffed catheters (25%). Infection was also observed only in uncuffed catheters (10%), and thrombosis (4.8%) was only in the cuffed lines. For patients weighing ≥ 10 kg, 86% of those with cuffed PICCs and 77.2% with uncuffed catheters completed therapy. More complications were observed in uncuffed catheters (infection 7.7%, mechanical failure 6.6%, thrombosis 5%). Infection resulting in premature removal occurred in 7% of cuffed catheters. There was no reported mechanical failure or thrombosis in the cuffed group. The distribution of diagnoses was relatively homogenous between the groups for most diagnoses. However, there was a higher percentage of oncology patients in the uncuffed group (23%) than the cuffed group (7%) due to the need for power-injectable lines, which were not available in a cuffed variant during this study. Conclusion All-cause pediatric PICC-associated complications rate in the neonate group for patients &amp;lt; 10kg in the uncuffed group is 35% and in the cuffed group is 4.8%. Whereas in the pediatric group ≥ 10kg, all-cause pediatric PICC-associated complications rate in the uncuffed group is 19.3% and in the cuffed group is 7%. There were no mechanical complications in the cuffed group and the vast majority of lines made it to completion of therapy. This work supports utilization of cuffed PICC lines in selected pediatric patients.

Bridging the gap: introduction of an antimicrobial peripherally inserted central catheter (PICC) in response to high PICC central line-associated bloodstream infection incidence.

To reduce the incidence of central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters (PICC) through the introduction of an antimicrobial (AM) catheter as recommended in evidence-based guidelines and standards. Quality improvement project comparing incidence of infections pre-implementation and postimplementation of the new catheter. A 582-bed community teaching hospital in Northwest Indiana. Pre-implementation analysis of surveillance data indicated that 50% of CLABSIs occurred inpatients with PICCs in situ. A gap analysis was performed to review institutional practices against evidence-based recommendations. The use of an AM catheter was supported in each of the documents consulted. After introduction of the new device, performance was measured in a prospective manner using standardized Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance protocols for CLABSI and internal data sources for other measures. After 30 months of data collection, the PICC CLABSI incidence reduced from a baseline rate of 1.83/1000 PICC days to 0.162/1000 PICC days (91.15% reduction, P=0.0002). Combined with continued compliance with basic prevention strategies (ie use of a central line insertion checklist/insertion bundle) and optimization of device selection and lumen justification, the introduction of an antimicrobial/antithrombogenic (AM/AT) PICC was associated with a significant reduction in CLABSI.

EP.WE.577Chest air-leak complications in critically ill COVID-19 Patients: a retrospective single-centre cohort study

IntroductionCOVID-19 has caused a global pandemic with a proportion of patients admitted to intensive care with viral pneumonia and respiratory failure. Spontaneous air leaks have been reported in patients with COVID-19. We report on a phenomenon of significant chest air-leak manifestations on a cohort of critically unwell intubated COVID-19 patients in our single centre.MethodsAll patients admitted to our single-centre intensive care unit during the initial outbreak of COVID-19 in the UK were identified. Individual electronic notes and imaging were screened to look for complications of: surgical emphysema, pneumomediastinum and/or pneumothorax.Results158 patients were admitted to our intensive care and eleven (7.0%) of patients were found to have suffered air leak complications unrelated to line insertion. Five suffered surgical emphysema only, one surgical emphysema with pneumomediastinum and two with the full triad of surgical emphysema, pneumomediastinum & pneumothorax. Two patients had unilateral pneumothoraces and one patient experienced a tension pneumothorax. Four patients were managed conservatively and seven had chest drains inserted. Overall outcomes were: one patient was discharged home, one discharged to ward, two transferred to an outside hospital and seven died.ConclusionAir-leak complications in COVID-19 patients, both spontaneous and ventilation associated are an under-recognised phenomenon. In the critically ill population literature suggests there is a > 5% incidence and risk reduction strategies should be considered. We advocate for early diagnosis and decompressive therapy with chest drains to avoid tamponade in intubated patients. Virus spread from air-leak should also be considered and health-care professionals adequately protected.

Catheter-associated bloodstream infection in patients with cancer: comparison of left- and right-sided insertions

There is limited research on the relationship between side of insertion of central venous catheter (CVAD) and bloodstream infection risk in patients with cancer. To conduct an exploratory analysis of data from a randomized control trial (RCT) and data from a prospective cohort study to compare infection rates for right- and left-sided insertions. The study populations were patients aged >14 years with cancer from two tertiary hospitals in Brisbane, Australia. The primary endpoint was catheter-associated bloodstream infection (CABSI) adjudicated by blinded assessors. For the RCT, randomized intention-to-treat comparisons were conducted between left- and right-side allocated insertion for early (≤14 days) and late (>14 days) infection using Cox proportional hazards regression. The RCT data were also combined with cohort study data collected from one of the hospitals prior to the RCT and non-randomized comparisons conducted between left- and right-sided insertions. In 634 randomly allocated CVADs there were 141 CABSIs. Analysis showed strong evidence of right-side allocated insertions having an increased risk of early infection by 2.5 times (95% confidence interval (CI): 1.3-4.7); however, there was no evidence of increased risk for late infection (hazard ratio: 1.06; 95% CI: 0.71-1.59). Results from analysis of the RCT and cohort study data combined (2786 CVADs and 385 CABSIs) were similar. There appears to be an increased risk of CABSI in patients with cancer for CVAD inserted into the right-side for around two weeks after line insertion. The mechanism underpinning the increased risk is unknown.

A physician-led medical emergency team increases the rate of medical interventions: A multicenter study in Korea.

BackgroundAccording to the rapid response system’s team composition, responding teams were named as rapid response team (RRT), medical emergency team (MET), and critical care outreach. A RRT is often a nurse-led team, whereas a MET is a physician-led team that mainly plays the role of an efferent limb. As few multicenter studies have focused on physician-led METs, we comprehensively analyzed cases for which physician-led METs were activated.MethodsWe retrospectively analyzed cases for which METs were activated. The study population consisted of subjects over 18 years of age who were admitted in the general ward from January 2016 to December 2017 in 9 tertiary teaching hospitals in Korea. The data on subjects’ characteristics, activation causes, activation methods, performed interventions, in-hospital mortality, and intensive care unit (ICU) transfer after MET activation were collected and analyzed.ResultsIn this study, 12,767 cases were analyzed, excluding those without in-hospital mortality data. The subjects’ median age was 67 years, and 70.4% of them were admitted to the medical department. The most common cause of MET activation was respiratory distress (35.1%), followed by shock (11.8%), and the most common underlying disease was solid cancer (39%). In 7,561 subjects (59.2%), the MET was activated using the screening system. The commonly performed procedures were arterial line insertion (17.9%), intubation (13.3%), and portable ultrasonography (13.0%). Subsequently, 29.4% of the subjects were transferred to the ICU, and 27.2% died during hospitalization.ConclusionsThis physician-led MET cohort showed relatively high rates of intervention, including arterial line insertion and portable ultrasonography, and low ICU transfer rates. We presume that MET detects deteriorating patients earlier using a screening system and begins ICU-level management at the patient’s bedside without delay, eventually preventing the patient’s condition from worsening and transfer to the ICU.

HOSPITAL TEACHING STATUS ON THE INCIDENCE OF POSTPROCEDURAL PNEUMOTHORAX: A RETROSPECTIVE NATIONAL IN-PATIENT SAMPLE STUDY

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Postprocedural pneumothorax (iatrogenic) is a patient safety indicator resulting from invasive procedures such as insertion of subclavian central line, pacemaker/ implantable cardiac defibrillator (ICD) placement, transbronchial lung biopsy and transthoracic pulmonary biopsy. This study examines if any of these invasive procedures have a higher predisposition to iatrogenic pneumothorax in teaching hospitals as compared to non-teaching hospital. METHODS: Cohort of patients aged 18 or older who had percutaneous lung biopsy, trans-bronchial lung biopsy, subclavian central line placement, and pacemaker/ICD placement were identified from the National Inpatient Sample (NIS) database from the years 2016 to 2017 using ICD 10-procedure codes. Diagnosis of iatrogenic pneumothorax was identified using ICD 10 – diagnosis code. Incidence of post-procedural pneumothorax were estimated for overall hospital encounter and for each of the procedures. The incidence rate was compared between teaching hospital group (TH) and non-teaching hospital (NTH) using chi-square statistical test. Odds ratio (OR) comparing both group were estimated with logistic regression. RESULTS: Iatrogenic pneumothorax was identified in 2,951 of 13,575 (21.7%) transthoracic lung biopsy, with 21.6% in TH group vs 22.1% in NTH group ( OR 0.96, 95% CI 0.88 – 1.05, p = 0.41). Among patients who had trans-bronchial lung biopsy, post-procedural pneumothorax occurred in 890 out of 26,793 (3.3%) with 3.6% in TH vs 2.6% in NTH ( OR 1.37, 95% CI 1.17 – 1.59, p = <0.001). Across 568,677 subclavian central line insertions, incidence of post-procedural pneumothorax was also higher in TH group (0.43% in TH vs 0.34% in NTH, OR 1.26, 95% CI 1.15 – 1.39, p = <0.001). Pacemaker/ICD placement in 83,033 patients resulted in 1.17% incidence of iatrogenic pneumothorax in TH vs 1.44% in NTH (OR 0.81, 95% CI 0.71 – 0.92, p = 0.02). Overall, a total of 18,703 cases of iatrogenic pneumothorax out of the 14 million (unweighted) hospital admissions were identified between 2016 to 2017 with incidence of 144 events per 100,000 hospital encounters in the TH group and 103 events per 100,000 hospital encounters in the NTH. CONCLUSIONS: Our study showed a significantly higher incidence of post-procedural pneumothorax in teaching hospitals among patients undergoing trans-bronchial lung biopsy and subclavian central line insertion. And a lower incidence in patients undergoing pacemaker/ICD placement. Incidence of iatrogenic pneumothorax in patients undergoing transthoracic lung biopsy was not significantly different between the two groups. Overall, iatrogenic pneumothorax was more prevalent in teaching hospitals. Randomized controlled studies are needed to identify the etiology of our findings. CLINICAL IMPLICATIONS: Our study raises the concern that physicians-in-training due to lack of experience may be a major factor accounting for a higher incidence of iatrogenic pneumothorax in teaching hospital DISCLOSURES: no disclosure on file for Tewabe Belay; No relevant relationships by Sahai Donaldson, source=Web Response no disclosure on file for Daniel Larbi; No relevant relationships by Alem Mehari, source=Web Response No relevant relationships by Richard Ogunti, source=Web Response No relevant relationships by Lamiaa Rougui, source=Web Response No relevant relationships by Mahbubur Sumon, source=Web Response

41 The Need for Speed - Rapid Infusion Catheters versus Central Venous Catheters for Large Volume Infusions: A Preliminary Study and Literature Review

There are many options to choose from when considering the type of catheter through which to infuse fluids into our patient’s circulatory system. These options range from standard peripheral intravenous catheters (termed PIV) to invasive central venous catheters (termed CVC). Somewhere in the middle lies a useful and intriguing device called a Rapid Infusion Catheter (R), or RIC line, manufactured by Arrow Inc. It involves a catheter-over-guidewire technique that requires an existing peripheral IV to be in place at the level of the antecubital fossa or higher, through which a guidewire is inserted for exchange with the RIC large bore catheter. The RIC line ranges in size, with typical sizes being 7 french (fr) and 8.5 fr. When functioning properly with large bore IV tubing, they can infuse volumes up to 1 liter per minute: an impressive volume without the associated risks of CVC insertion. The use of rapid infusion catheters in critical hypotension and trauma shock patients has never been reviewed in the emergency medicine literature in regards to flow rates, time to insertion and complications rates. An in-situ infusion rate study was conducted for common large-volume infusion catheters with the Level 1 infusion pump (R) (Smiths Medical) and thirteen different vascular catheters. The second experiment involved timed vascular access simulation with emergency medicine residents at all levels of training measuring time-to-insertion for Rapid Infusion Catheters and Multi-lumen Access Catheter (R) (Arrow brand). Thirteen different types of infusion catheters were compared in the infusion rate study. 8.5 french (fr) RIC line infusion rate (1000 ml/min) was superior to all other lines except the 9 fr sheath introducer to which it was equivalent. Fourteen emergency medicine residents participated in the time-to-insertion study, with RIC line insertion being completed faster than MAC line (mean time 0:28 vs 0:52, t-statistic = -4.2467, degrees of freedom = 13, p-value = 0.000953). Complication rates in the literature for RIC lines are 1.6% compared to 4-7% for central venous lines. We report for the first time in emergency medicine literature through this preliminary study and literature review that RIC lines have higher infusion rates, fewer complications, and require less time to insert than CVC lines. There will always be strong indications for obtaining central venous access, but we suggest that RIC lines be used more often in cases of critical hypovolemia and the resuscitation of shock patients. Additional studies are needed to determine if there are clinically different outcomes depending on the type of access obtained in these critical patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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).

Pleural Ultrasonography versus Chest Radiography for the Diagnosis of Pneumothorax

Abstract Background Pneumothorax (PTX) is an emergency that requires urgent management to avoid catastrophic consequences. PTX is also an important cause of respiratory failure in the emergency department, and may occur frequently as a complication of central venous catheter insertion. Aim The aim of this study is to compare the diagnostic accuracy of bedside lung US with those for anteroposterior (AP) chest X ray (CXR) for the detection of PTX in critically ill patients. Methods This study was conducted on fifty adult patients from both sexes, mechanically ventilated at least 48 hours and planned for central line insertion. We excluded overt pneumothorax, patients requiring immediate invasive intervention, pregnancy and lactation. Lung ultrasound was done to all patients after 30 minutes from central line insertion followed by CXR to confirm the diagnosis of pneumothorax. Pneumothorax was confirmed using CT chest. Results Results showed that ultrasound is superior to chest X Ray in detection of PTX.Ultrasound showed sensitivity of 94.87%, specificity of 81.82%, positive predictive value of 94.87%, negative predictive value of 21.82% and accuracy of 92.0% in detection of PTX, while Chest X Ray showed sensitivity of 76.92%, specificity of 63.64%, positive predictive value of 88.24%, negative predictive value of 43.75% and accuracy of 74.0% in detection of PTX. Conclusions In conclusion, US represent a good approach for the evaluation of PTX, with advantages of timeliness, high accuracy and high reliability.

Use of Topical Nitroglycerine in the Neonatal Population Following Peripheral Tissue Ischaemia: Case Report and Updates about Safety Concerns

Neonatal thrombosis is a well-described morbidity occurring in the neonatal intensive care unit. Critically ill neonates are most vulnerable to developing thrombosis with serious complications. Fingers and toes ischaemia secondary to vascular occlusion following central lines insertion remains an uncommon occurrence. The therapeutic approach for peripheral tissue injury using local warming, anticoagulants, thrombolytics or topical hyaluronidase showed limited benefits and potential side effects. Here we report an unusual case of finger ischaemia treated successfully using topical nitroglycerine. This complements previous reports confirming the efficacy and safety of this drug and highlighting its potential benefit in neonates.

Role and Responsibility of Nurses in Central Line - Insertion and Maintenance

Introduction -A central venous catheter (CVC) is thin, a flexible tube (catheter) that is placed into a large vein above the Heart. It may be inserted through A vein in the Neck, (internal jugular) chest (subclavian vein. Axillary vein) groin (femoral vein), or through veins in the arms known as a PICC, or peripherally inserted central catheters. Site- Internal jugular vein, subclavian vein, axillary vein, femoral veins, the best approach or access point for Central line insertion. Indications - The indications for central venous access are broad and are often situational. Inability to obtain venous access in emergent situations, chemotherapy administration, medications administration (Vasopressors. inotropic administration Total Parental nutrition administration, Hemodynamic monitoring are common indications for CVC insertion. Contraindication- Local cellulitis, Low platelet count, Local infections, Thrombocytopenia, Congenital anomalies, Trauma are common contraindications of CVC insertion. Complications - Numerous potential complications can occur during the procedural placement of a central venous catheter, but also as a result of the indwelling equipment. Arrhythmias, Arterial puncture, Pulmonary puncture with or without resultant pneumothorax, Bleeding – hematoma formation, which can obstruct the airway, Tracheal injury, Air emboli during venous puncture or removal of the catheter, Pulmonary embolism, Local cellulitis, Catheter infection, Cardiac tamponade, Intravascular loss of guidewire, Hamo thorax, Phrenic nerve injury, Brachial plexus injury, Cerebral infarct from carotid artery cannulation, Bladder perforation, Bowel perforation, Sterile Thrombophlebitis. Post-procedural complications: Catheter-related bloodstream infections – bacterial or fungal, Central vein stenosis, Thrombosis, Delayed bleeding with multiple attempts in a coagulopathic patient Clinical Significance - Ensure that sterile products are not contaminated and that there is no evidence of damage to the packaging. Follow sterile procedures at all times. Central line infections can be a serious and life-threatening illness. Always ensure that the catheter is appropriately placed through one or several methods: radiographic evidence, measurement of CVP, or by analyzing a venous blood gas. Never use excessive force during any part of this procedure. It will lead to damage to local structures. Nursing Responsibility - After a CVC placement, nurses are responsible for maintaining, monitoring, and utilizing central venous catheters. The assigned nurse must check complications such as infections, hematoma, thrombosis of the catheter, and signs of pneumothorax and bleeding. Nurses are also responsible for ensuring that the site is maintained in a clean and sterile fashion. Daily inspection of the access site and device patency should be performed during nursing rounds. In particular, nursing officers must disinfect injection ports, catheter hubs, and needleless connectors with institutionally approved antiseptics. Intravenous administration sets should be changed regularly per hospital policy. The site should be checked for bleeding, hematoma formation, and signs of cellulitis, which include erythema, purulent drainage, and/or warmth. Dressings should be changed if visibly soiled. This must be performed with proper sterile technique. Keywords: CVC, Central Line, Central venous catheter.

A multidisciplinary intervention to reduce central line-associated bloodstream infection in pediatrics and neonatal intensive care units

To date, central line-associated bloodstream infections (CLABSIs) are the most common healthcare-associated infections in high-risk neonates and children. These infections are associated with significantly longer hospital stays, increased health care cost, and mortality in the health care systems. Application of evidence-based preventive interventions has proven to decrease CLABSI rate. The purpose of this study is to reduce the undesired relative high CLABSI rate through the adoption of standardized quality improvement interventions. and Methods: The study employed a pre-post-intervention design. Phase one is a retrospective calculation of 12 months of surveillance period as a baseline. Phase 2 establishes a multidisciplinary quality improvement intervention, which includes the formation of a dedicated central line insertion team, provision of central line kit at the bedside, training and educating the team, and selecting bundle checklist. In the third phase, we performed auditing and calculating the checklist compliance and monthly feedback for 12 consecutive post-intervention months. During phase 1 and 3, we calculated the following measures; CLABSI per 1000 catheter-days, duration of central line use, and device utilization ratio. During the post-intervention phase the CLABSI rate significantly reduced by 59.5% from 7.5 to 3.0 per 1000 central line day, and the duration of use of the central line decreased from 21.3±9.9 to 11.0±3.2 days (P<0.05). Implementation of quality improvement multidisciplinary intervention; central line insertion and maintenance care bundle, dedicated IV team, education and feedback effectively reduced the rate of CLABSI within our pediatrics and neonatal ICUs.

Appearance can be Deceptive- A Case Report on Central Venous Line Complication

Central venous (CV) lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. Our patient is an 85 years old hypertensive, diabetic female presenting with post COVID fibrosis with aspiration pneumonia with septic shock. After admissions in ICU, CV line was inserted through right sub-clavian venous route for administration of essential medications including inotropes. However, forceful backflow of blood was noticed after insertion of CV line raising the suspicion of arterial insertion. It was later confirmed by CXR, ABG and duplex arterial study. Taking appropriate precautions, we were able to remove the CV line safely without any complications. Sometimes minor and easy things like CV like insertion can become life threatening. But with proper knowledge and planning we can overcome any complications. Cardiovasc j 2021; 14(1): 73-75

Morphology of Mitral Annular Disjunction in Mitral Valve Prolapse

Mitral annular disjunction (MAD) is an abnormal insertion of the hinge line of the posterior mitral leaflet on the atrial wall: the mitral annulus shows a separation or "disjunction" between the leaflet-atrial wall junction and the crest of the left ventricle myocardium. This anomaly is often observed in patients with myxomatous mitral valve prolapse. The anatomical substrate of MAD remains unclear for the following reasons: (1) most studies are focused on the association between MAD and arrhythmias, rather than on pathomorphological aspects of MAD; and (2) the complex anatomic architecture of the posterior mitral annulus is often simply described as the posterior segment of a fibrous ring. The aims of this paper are to review the pertinent normal anatomy of the mitral valve and to propose new hypotheses on the morphological nature of MAD.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study

BackgroundRapid response systems (RRSs) improve patients’ safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS.MethodsPatients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock.ResultsAfter propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients’ overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75).ConclusionsThe presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Adaptive selection signatures in river buffalo with emphasis on immune and major histocompatibility complex genes

River buffalo is an agriculturally important species with many traits, such as disease tolerance, which promote its use worldwide. Highly contiguous genome assemblies of the river buffalo, goat, pig, human and two cattle subspecies were aligned to study gene gains and losses and signs of positive selection. The gene families that have changed significantly in river buffalo since divergence from cattle play important roles in protein degradation, the olfactory receptor system, detoxification and the immune system. We used the branch site model in PAML to analyse single-copy orthologs to identify positively selected genes that may be involved in skin differentiation, mammary development and bone formation in the river buffalo branch. The high contiguity of the genomes enabled evaluation of differences among species in the major histocompatibility complex. We identified a Babesia-like L1 LINE insertion in the DRB1-like gene in the river buffalo and discuss the implication of this finding.