Multilumen Central Venous Catheters Research Articles

10 clinical tips for advancing patient safety when using syringe pump systems for microinfusion intravenous drug therapy.

10 clinical tips for advancing patient safety when using syringe pump systems for microinfusion intravenous drug therapy.

Iatrogenic catheterisation of subclavian artery while cannulating internal jugular vein.

Sir, Placement of a central venous catheter (CVC) carries a complication rate of 17.9%.[1] Use of ultrasound guidance has been advocated as standard of care to reduce complications and achieve higher success rate.[234] However, ultrasound-guided cannulation does not altogether negate accidental arterial puncture as has been found in our patient. A 3-year-old female child weighing 16.9 kg and having a midline brain stem tumour with hydrocephalus was posted for elective tumour excision. Following uneventful tracheal intubation and maintenance of anaesthesia with 50% oxygen in air, 1.5% sevoflurane and remifentanil (0.25 μg/kg/min) infusion, it was decided to place an arterial line and a CVC. Positive end expiratory pressure of 4-cmH2O was now momentarily applied, which resulted in a well-dilated right internal jugular vein (IJV) on imaging using linear probe of Mindray ultrasound machine (Shenzhen Mindray Bio-medical Electronics co. Ltd., Zhenzhen 518057, P.R. China). Right IJV was punctured at first attempt by a 4th-year anaesthesia resident with the needle directed at a 45° angulation. After free aspiration of blood, a guide wire was passed through the needle uneventfully. Following dilatation of the cannulation site, a 5.5 Fr paediatric multi-lumen CVC with blue flex tip (Arrow International, Inc, 2400 Bernville Road, PA, USA) was passed. All three ports were checked for free aspiration of blood. The CVC was fixed at 8 cm mark and sterile transparent dressing was applied. At this stage, an intravenous line containing 5% dextrose in 0.45% normal saline was attached to the distal 20-gauge catheter port. Contrary to expectation, there was no flow of the fluid although blood could be freely aspirated from this port. However, a minimal spontaneous backflow of blood was noted in the infusion line. Despite changing to a different port, the infusion was not dripping. At this stage, doubt was raised that the line could be in an artery, and the transducer of the arterial line was connected to the CVC and an arterial waveform was noted. Before removing the catheter, ultrasound imaging was done to confirm the position of the catheter in the artery. As expected, the puncture site and IJV were significantly to the right of the carotid artery. Further scanning and change of probe angle revealed a pulsating vessel underneath the jugular vein, which could be the subclavian artery (SA). Surprisingly, the catheter was seen to pass through the internal jugular lumen and then to lie in the SA [Figure 1]. The CVC was now removed and compression for 5 min was applied. A fresh CVC was placed in the same IJV uneventfully.Figure 1: Internal jugular vein and the subclavian artery with evidence of central venous catheter passing through them. (IJV-Internal jugular vein, SCA-Subclavian artery, CVC-Central venous catheter)We postulate a sequence of events that led to inadvertent SA puncture in our patient. The SA was about 2.5 mm deeper to the IJV as revealed by ultrasound [Figure 1]. The indentation of the wall of IJV while puncturing the vein or displacement of needle tip later after the probe was removed could be the reason for the needle tip entering the SA. We suggest five key points to avoid this mistake while cannulating IJV in paediatric patients where the SA is only a few mm away. First, needle should be kept angulated in relation to skin, close to 30° instead of 45° during puncture as this tangential approach results in less application of posterior forces that tend to collapse the vein wall. Also, angulation helps where the IJV diameter is less than the longitudinal length of bevel of needle.[5] Second, double wall puncture should be kept in mind where the vein diameter is small.[5] Third, it is essential that the tip of the needle be constantly identified with ultrasound as it approaches the vein and puncture is made.[6] Fourth, the path of guide wire should be confirmed by ultrasound prior to dilatation of the vessel. Lastly, a higher neck approach may be adopted in children so as to increase the distance between IJV and the SA, thereby reducing the possibility of its inadvertent puncture. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Central Venous Catheters, a Major Culprit for Pediatric Venous Thrombosis: A Report from the Children's Hospital Acquired Thrombosis (CHAT) Project

Introduction: Incidence of venous thromboembolism (VTE), a potentially life-threatening condition, has increased in hospitalized pediatric patients by over 70% in the last decade leading to increased morbidity, mortality, and longer hospitalizations. In contrast to standardized thromboprophylaxis interventions for hospitalized adults, routine implementation of VTE prevention strategies have not been established in children. To develop a risk-prediction model for pediatric hospital-acquired VTE (HA-VTE) and identify a high-risk group in need of thromboprophylaxis, an observational case-cohort study was created, using the multi-institutional Children's Hospital Acquired Thrombosis (CHAT) Registry. Preliminary CHAT data confirm prior reports that central venous catheters (CVCs) are the greatest risk factor for pediatric HA-VTE. We describe clinical and CVC characteristics for Registry subjects with a CVC-related HA-VTE.Methods: An institutional review board-approved, multi-center CHAT Registry was created for this project to collect retrospective clinical and laboratory data on hospitalized subjects age 0-21 years diagnosed with imaging-confirmed HA-VTE, along with admission year matched controls. Seven hundred and fifty HA-VTE subjects hospitalized since January 1, 2012 are included in the Registry. Data include demographics (age and past medical history); hospital course (duration, infection, mobility, surgeries, trauma, etc.); VTE specifics (location, symptoms, treatment, prophylaxis); CVC details (type, brand, lumen number, duration, infection history); and pertinent laboratory data (thrombophilia and coagulation testing). Pertinent CVC related data were selected for analysis.Results: To date, 658 subjects with HA-VTE have been entered into the CHAT Registry from 01/01/12 to 07/01/2017 from five pediatric tertiary care centers. CVC-VTE was identified in 486 (74%) subjects. Most subjects with a CVC-VTE were male (58%) and the median age at diagnosis was 2 years (IQR 0.3-12.7). Infants <1 year of age accounted for 214 (44%) of CVC-VTE cases (Figure 1). In contrast, subjects diagnosed with a non-CVC-related VTE had a median age of 5 years (IQR 0.3-13.3) at diagnosis, with only 45 (29%) being <1 year. The average time from CVC placement to VTE diagnosis was 23 days. Time from femoral line placement to VTE was 7 days, peripherally inserted central catheters (PICC) placement to VTE was 16 days and tunneled line to VTE was 114 days. Mean hospital length of stay was 48 days for those diagnosed with a CVC-VTE.Subjects with PICCs made up 62% (310) of the CVC-VTE cases and 19% (95) were in subjects with femoral catheters (Figure 2). The majority of CVC-VTEs, 336 (67%), were with multi-lumen CVCs.Upper extremity CVCs were placed in 271 (54%) cases and 203 (41%) were in the lower extremity. The remaining 26 (5%) had CVCs in the umbilical vein or were unknown. CVC's were found to have a malfunction (damage to the line, fibrin sheath, medication precipitation or other blockage) prior to VTE diagnosis in 122 cases (24%), and tissue plasminogen activator (tPA) was used in 91 (75%) cases of malfunction.Conclusions: CVCs are a prominent risk factor for pediatric HA-VTE, yet a paucity of evidence exists to guide clinicians toward strategies to decrease pediatric CVC-VTE. Our preliminary analysis has shown the majority of subjects with a CVC-related HA-VTE were male, had a PICC, and almost half were less than 1 year of age. Subjects also tended to have multi-lumen CVCs placed in the upper extremity. This novel analysis of specific CVC characteristics in CVC-related HA-VTE among hospitalized patients from the CHAT Registry represents a first step in determining the true risk factors for CVC-related VTE in children.Once all control subjects are entered a more robust analysis of risk factors will be performed and a VTE risk prediction model will be created and prospectively validated for HA-VTE, including a specific CVC-related VTE model. This information will be essential for future risk-prediction models of pediatric HA-VTE that may guide randomized control trials to evaluate safety and efficacy of various thromboprophylaxis strategies in this population. [Display omitted] DisclosuresJaffray:CSL Behring: Consultancy; Bayer: Consultancy, Speakers Bureau. Croteau:ATHN/Hemophilia of Georgia: Research Funding; Aptevo, Baxalta/Shire, Bayer, CSL Behring, Genentech, Novo Nordisk, Octapharma, Pfizer: Consultancy; Octapharma: Honoraria; Baxalta, Dimension Therapeutics, Genentech, Pfizer: Research Funding. Silvey:Pfizer, CSL Behring, Octapharma: Consultancy. Young:Novo Nordisk: Consultancy; CSL Behring: Honoraria.

Surveillance of catheter-related bloodstream infections in haemato-oncology patients: comparison of two definitions

In the Netherlands, the PREZIES surveillance is used for registration and surveillance of central venous catheter (CVC) -related bloodstream infections (CRBSI). We investigated how this Dutch definition correlated with internationally used definitions for CRBSI, central line-associated bloodstream infections (CLABSI) and mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBI). We determined that the Dutch PREZIES definition of CRBSI is appropriate for surveillance control of CVC care bundle use in haemato-oncology patients managed with multi-lumen CVCs.

Peripherally inserted central catheters lead to a high risk of venous thromboembolism in children

AbstractVenous thromboembolism (VTE) incidence in children has sharply increased with the majority of cases secondary to central venous catheters (CVCs). Among CVCs, the number of peripherally inserted central catheters (PICCs) placed has risen significantly. In this multicenter, prospective, observational cohort study, we enrolled patients aged 6 months to 18 years with newly placed PICCs or tunneled lines (TLs). We evaluated the incidence of VTE, central line–associated bloodstream infections (CLABSIs), and catheter malfunctions in PICCs and TLs, and risk factors of CVC-related VTE. A total of 1967 CVCs were included in the analysis. The incidence of CVC-related VTE was 5.9% ± 0.63%. The majority of the cases, 80%, were in subjects with PICCs, which had a significantly higher risk of catheter-related VTE than subjects with TLs (hazard ratio [HR] = 8.5; 95% confidence interval [CI], 3.1-23; P < .001). PICCs were significantly more likely to have a CLABSI (HR = 1.6; 95% CI, 1.2-2.2; P = .002) and CVC malfunction (HR = 2.0; 95% CI, 1.6-2.4; P < .001). Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR = 23; 95% CI, 4-127; P < .001), multilumen CVC (HR = 3.9; 95% CI, 1.8-8.9; P = .003), and leukemia (HR = 3.5; 95% CI, 1.3-9.0; P = .031). Children with PICCs had a significantly higher incidence of catheter-related VTE, CLABSI, and CVC malfunction over TLs. The results suggest that pause be taken prior to placing CVCs, especially PICCs, due to the serious complications they have been shown to cause.

1168. Trends in Central-Line-Associated Blood Stream Infections in a Community Teaching Hospital: A Multi-Intervention Quality Improvement Project

BackgroundCentral line-associated bloodstream infection (CLABSI) is a preventable medical condition that results in increased patient morbidity and mortality as well as increased medical costs. We sought to describe the impact of various quality improvement interventions on the incidence of CLABSI in a large 990-bed community teaching hospital from the period of January 1, 2013 to December 31, 2017.MethodsRetrospective study of CLABSI events as defined by the CDC’s National Healthcare Safety Network was completed. Between 2013 to 2017, we introduced mandatory real-time root cause analysis for each CLABSI event to identify defects that could be used for quality improvement interventions. We implemented a bundle of interventions for proper central venous catheter (CVC) insertion and maintenance based on CDC recommendations and the results of the internal analysis. Interventions included utilizing chlorhexidine gluconate (CHG) skin preparation and maximum sterile barrier precautions, optimal site selection (avoiding femoral site), using antimicrobial-coated CVCs and antithrombotic Bioflo peripherally inserted central catheters (PICC), minimizing multi-lumen CVC and PICC use, de-escalating CVC to midline or preferential use of midline catheters while minimizing unnecessary PICC and CVC insertion, adding Curos disinfection caps on central lines and other vascular access sites, weekly scheduled CVC site dressing changes with Tegaderm CHG I.V. Securement Dressing, CHG baths for patients with CVCs, avoidance of blood culture draws from central lines, and daily review of line necessity with timely removal. Medical staff members received ongoing education on the implementation of the CLABSI bundle. Both ICU and non-ICU CLABSI cases in the adult patient population were analyzed.ResultsA comparison of 2013 with 2017 shows a 69% decline in a number of CLABSI cases from 36 to 11 patients (Figure 1). There was a 30% decline in CVC days from years 2014 to 2017 (No CVC days data for 2013 due to change in data collection system). Over the same period, CLABSI events per 1,000 CVC days decreased from 0.624 to 0.362 (Figure 2)—a 42% decline.ConclusionStudy findings show that our comprehensive bundle of interventions for CVC insertion and maintenance resulted in decreased rates of CLABSI. Disclosures All authors: No reported disclosures.

Peripherally Inserted Central Catheters Lead to a High Risk of Venous Thromboembolism in Children

Background: The incidence of venous thromboembolism (VTE) in children has seen a sharp increase in recent years with the majority of cases secondary to central venous catheters (CVCs). Among CVCs, the number of peripherally inserted central catheters (PICCs) placed in children has risen significantly. Methods: In this multi-center, prospective, observational cohort study, we enrolled patients aged 6 months to 18 years with newly placed PICCs or tunneled lines (TLs) and compared the incidence of VTE between them. We also evaluated the incidence and risk factors of CVC-related VTE, central line associated bloodstream infections (CLABSIs) and catheter malfunctions in PICCs and TLs. Findings: A total of 1967 CVCs placed in 1742 unique subjects were included in the analysis. The incidence of catheter-related VTE was 5.9±0.63%. The majority of the cases, 80%, were in subjects with PICCs which had a significantly higher risk of catheter-related VTE than subjects with TLs (HR=8.5, 95%CI, 3.1-23, p<0.001). PICCs were also significantly more likely to have a CLABSI (HR=1.6, 95%CI: 1.2-2.2, p=0.002) and CVC malfunction (HR=2.0, 95%CI: 1.6-2.4, p<0.001) compared to TLs. Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR=23, 95%CI: 4-127, p<0.001), multi-lumen CVC (HR=3.9, 95%CI: 1.8-8.9, p=0.003) and leukemia (HR=3.5, 95%CI: 1.3-9.0, p=0.031). Interpretation: Children with PICCs had a significantly higher incidence of catheter-related VTE, CLABSI and CVC malfunction over TLs. The results suggest that pause be taken prior to placing a CVC, especially PICCs, due to the serious complications they have been shown to cause. Funding Statement: The authors state: there was no funding source for this study. Declaration of Interests: The authors declare that they do not have any conflicts of interest. Ethics Approval Statement: This study was approved by the ethics committee at each participating institution.

Do we need a running line for administration of vasopressors through the multi-lumen central venous catheter during neurosurgical cases?

Do we need a running line for administration of vasopressors through the multi-lumen central venous catheter during neurosurgical cases?

Three-year prospective, observational study of central line–associated bloodstream infections in a 600-bed Japanese acute care hospital

Central line-associated bloodstream infection (CLABSI) is an important concern associated with central venous catheter (CVC) use. The objective of this study was to determine the influences of CVC access sites, CVC types, and presumed causative microorganisms on CLABSI occurrence in an acute care hospital. We conducted a prospective, observational study of CLABSI occurrence for 3 consecutive years in a 600-bed Japanese acute care hospital. Data collected included patient characteristics, CVC access sites, CVC types, and microorganisms isolated by blood culture. For 1,650 CVCs used for 1,237 patients, 39 cases of infection were identified. Most infections had occurred within 1 month of CVC insertion. Maximal sterile barrier precautions had been used for most cases (97.3%). The average CLABSI occurrence days with internal jugular vein access were shorter than those with subclavian vein access and femoral vein access. CLABSI rates were 1.1 and 0.7 for single- and multilumen CVCs, respectively. CLABSI occurrence tended to be shorter when gram-positive cocci were isolated and tended to be longer when fungi (Candida spp) were isolated. Most CLABSI cases had occurred within 1 month of CVC insertion. Longer CVC duration increased chance of fungal infection.

Complications Related to Insertion and Use of Central Venous Catheters (CVC).

ABSTRACTIntroduction:Central Venous Catheters (CVC) are essential in everyday medical practice, especially in treating patients in intensive care units (ICU). The application of these catheters is accompanied with the risk of complications, such as the complications caused during the CVC insertion, infections at the location of the insertion, and complications during the use of the catheter, sepsis and other metastatic infections.Patients and methods:This study is a retrospective-prospective and it was implemented in the period 1st January 2011- 31st December 2012. It included 108 examinees with CVC placed for more than 7 days.Results:The most common complications occurring in more than 2 attempts of CVC applications are: hearth arrhythmias in both groups in 12 cases, 7 in multi-lumen (12.72%) and 5 in mono-lumen ones (9.43%). Artery puncture occurs in both groups in 7 cases, 5 in multi-lumen (9.09%) and 2 in mono-lumen ones (3.77%). Hematoma occurred in both groups in 4 cases, 3 in multi-lumen CVCs (5.45%) and 1 in mono-lumen ones (1.88%). The most common complication in multi-lumen catheters was heart arrhythmia, in 20 cases (36.37%). The most common complications in mono-lumen CVCs was hearth arrhythmias, in 20 cases as extrasystoles and they were registered in 16 catheter insertions (30.18%). Out of total number of catheters of both groups, out of 108 catheters the complications during insertion occurred in 49 catheters (45.40%). The most common complications in both groups were heart arrhythmias, artery punctures and hematomas at the place of catheter insertion.

Which lumen is the source of catheter-related bloodstream infection in patients with multi-lumen central venous catheters?

Paired blood cultures, drawn from the catheter and a peripheral vein, used for calculation of the differential time to positivity (DTP), have been proposed for the detection of catheter-related bloodstream infections (CRBSIs). The most relevant catheter lumen to be sampled in multi-lumen central venous catheters (CVCs) has not been recommended. Forty-four febrile neutropaenic patients, following haematopoietic stem cell transplantation (HSCT) and with multi-lumen CVCs in place, were investigated using the DTP method of blood samples drawn from every lumen of the CVC and a peripheral vein. Twelve of 44 patients (27 %) had CRBSIs, as determined by the DTP method. In 10 of 12 (83 %) febrile neutropaenic patients, after HSCT, CRBSIs originated from the CVC lumen used for parenteral nutrition and blood products only. 17 % had CRBSI originating from the other CVC lumen (p = 0.039). In most patients, CRBSIs originated from the CVC lumen used for parenteral nutrition and blood products, indicating that this lumen is the main source of CRBSI. However, since 17 % of patients had CRBSIs originating from another lumen, each lumen of multi-lumen CVCs has to be considered as a potential source of CRBSI and should, ideally, be sampled in order to avoid failure in diagnostic procedures.

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Introduction: Pulmonary embolism (PE) is a serious complication among critically ill patients with major trauma. New options for achieving the goal of universal PE prophylaxis in this high-risk population are needed. The Angel™ Catheter combines the functions of an inferior vena cava (IVC) filter and a multilumen central venous catheter. The device is designed for bedside placement to provide both prophylaxis against PE and access to the central venous system. Hypothesis: The objective of this first-in-man pilot clinical trial were to assess the safety and effectiveness of the Ange™Catheter for severely ill medical and surgical patients at increased risk of PE and to evaluate the feasibility of conducting a large clinical trial of this device. Methods: This prospective pilot interventional study was conducted from December 2011 to March 2012. Patients in the intensive care unit (ICU) were recruited for the study and were followed up for 30 days after device retrieval. All patients were at high risk of PE but were not receiving medical thromboprophylaxis because of either increased risk of bleeding or ongoing bleeding. Results: This study included 8 critically ill patients in the ICU. The principal diagnosis resulting in ICU admission was trauma for 7 patients (87%) and subarachnoid hemorrhage for one (13%). Six of the trauma patients had multiple bone fractures and abdominal trauma, and one had a traumatic brain injury. At the time of device insertion, 3 patients had ongoing bleeding and one had a pulmonary embolism. The Angel™ Catheter was placed via the femoral vein with ultrasound guidance in 5 of 8 patients (62.4%) and was advanced to the infrarenal IVC without fluoroscopic guidance. In one patient, the filter trapped a large venous clot and prevented a PE. The mean length of time to catheter retrieval was 4 days (±1.6 days). All devices were retrieved without complications. No new PEs, major bleeding, or catheter-related blood stream infections were diagnosed. One patient died as a result of a septic shock 3 weeks after removal of the catheter. Conclusions: This pilot study supports the safety of the Angel™ Catheter and provides the basis for a future large pivotal clinical trial.

Differential time to positivity: Vascular catheter drawn cultures for the determination of catheter-related bloodstream infection

Vascular access catheter-related infections are common. The purpose of this study was to evaluate the accuracy of differential time to positivity (DTP) comparing 2 blood cultures drawn through different lumens of a multi-lumen central venous catheter (CVC DTP) for the diagnosis of catheter-related bloodstream infection (CRBSI). This study was performed at a single institution (Health Sciences Centre, Winnipeg, Manitoba, Canada). Microbiology laboratory blood culture records for the period January to November 2009 were retrospectively reviewed. All adult patients with a positive peripheral blood culture and a minimum of 2 positive central line cultures (same organism) drawn from separate lumens of a multi-lumen CVC, all obtained at the same time on the same day, were included in the study. DTP supporting CRBSI diagnosis was defined as a difference in time to positivity of ≥ 2 h between a peripheral blood culture and a CVC blood culture (peripheral DTP), or between 2 CVC blood cultures from different lumens of a multi-lumen catheter (CVC DTP). Peripheral DTP was used as the reference standard for CRBSI diagnosis. Thirty-five episodes of bacteremia from 33 patients were included in this study. CVC DTP had a sensitivity of 76.5% and a specificity of 88.9% for CRBSI diagnosis, using peripheral DTP as the reference standard. These data suggest that CVC DTP may be of benefit in the diagnosis of CRBSI. Further study is required to better define the patient population/catheter type for which CVC DTP would be of greatest benefit.

Characterization of central venous catheter–associated deep venous thrombosis in infants

Deep venous thrombosis (DVT) is a frequent complication in infants with central venous catheters (CVCs). We performed this study to identify risk factors and risk-reduction strategies of CVC-associated DVT in infants. Infants younger than 1 year who had a CVC placed at our center from 2005 to 2009 were reviewed. Patients with ultrasonically diagnosed DVT were compared to those without radiographic evidence. Of 333 patients, 47% (155/333) had femoral, 33% (111/333) had jugular, and 19% (64/333) had subclavian CVCs. Deep venous thromboses occurred in 18% (60/333) of patients. Sixty percent (36/60) of DVTs were in femoral veins. Femoral CVCs were associated with greater DVT rates (27%; 42/155) than jugular (11%; 12/111) or subclavian CVCs (9%; 6/64; P < .01). There was a 16% DVT rate in those with saphenofemoral Broviac CVCs vs 83% (20/24) in those with percutaneous femoral lines (P < .01). Multilumen CVCs had higher DVT rates than did single-lumen CVCs (54% vs 6%, P < .01), and mean catheter days before DVT diagnosis was shorter for percutaneous lines than Broviacs (13 ± 17 days vs 30 ± 37 days, P = .02). Patients with +DVT had longer length of stay (86 ± 88 days vs 48 ± 48 days, P < .01) and higher percentage of intensive care unit admission (82% vs 70%, P = .02). Deep venous thrombosis reduction strategies in infants with CVCs include avoiding percutaneous femoral and multilumen CVCs, screening percutaneous lines, and early catheter removal.

Heparin or 0.9% sodium chloride to maintain central venous catheter patency

To compare heparin (3 mL, 10 units/mL) and 0.9% sodium chloride (NaCl, 10 mL) flush solutions with respect to central venous catheter lumen patency. Single-center, randomized, open label trial. Medical intensive care unit and Surgical/Burn/Trauma intensive care unit at Barnes-Jewish Hospital, St. Louis, MO. Three hundred forty-one patients with multilumen central venous catheters. Patients with at least one lumen with a minimum of two flushes were included in the analysis. Patients were randomly assigned within 12 hrs of central venous catheter insertion to receive either heparin or 0.9% sodium chloride flush. The primary outcome was lumen nonpatency. Secondary outcomes included the rates of loss of blood return, inability to infuse or flush through the lumen (flush failure), heparin-induced thrombocytopenia, and catheter-related blood stream infection. Assessment for patency was performed every 8 hrs in lumens without continuous infusions for the duration of catheter placement or discharge from intensive care unit. Three hundred twenty-six central venous catheters were studied yielding 709 lumens for analysis. The nonpatency rate was 3.8% in the heparin group (n = 314) and 6.3% in the 0.9% sodium chloride group (n = 395) (relative risk 1.66, 95% confidence interval 0.86-3.22, p = .136). The Kaplan-Meier analysis for time to first patency loss was not significantly different (log rank = 0.093) between groups. The rates of loss of blood return and flush failure were similar between the heparin and 0.9% sodium chloride groups. Pressure-injectable central venous catheters had significantly greater rates of nonpatency (10.6% vs. 4.3%, p = .001) and loss of blood return (37.0% vs. 18.8%, p <.001) compared to nonpressure-injectable catheters. The frequencies of heparin-induced thrombocytopenia and catheter-related blood stream infection were similar between groups. 0.9% sodium chloride and heparin flushing solutions have similar rates of lumen nonpatency. Given potential safety concerns with the use of heparin, 0.9% sodium chloride may be the preferred flushing solution for short-term use central venous catheter maintenance.

Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients

To evaluate silver-impregnated (Oligon) central venous catheters and chlorhexidine-gluconate-impregnated sponges for reducing catheter-related colonization and infection, nonbacteremic or bacteremic. Multicenter, prospective, randomized, controlled study. Five general intensive care units in Greece. Intensive care unit patients requiring a multilumen central venous catheter between June 2006 and May 2008. Patients were randomly assigned to receive a standard catheter (standard group), a standard catheter plus chlorhexidine-gluconate-impregnated sponge (chlorhexidine-gluconate-impregnated sponge group), or an Oligon catheter (Oligon group). Catheter colonization was defined as a positive quantitative tip culture (≥10 colony-forming units/mL), catheter-related infection was defined by the previous criterion plus clinical evidence of sepsis, and bacteremia catheter-related infection as catheter-related infection plus a positive peripheral blood culture with the same micro-organism as in the catheter tip. Data were obtained from 465 patients, 156 in the standard-group, 150 in the chlorhexidine-gluconate-impregnated sponge group, and 159 in the Oligon-group. Colonization occurred in 24 (15.4%) standard catheters, 21 (14%) in the chlorhexidine-gluconate-impregnated sponge group, and 25 (15.7%) in the Oligon catheters (p = .35) (20.9, 19.9, 21.8/1000 catheter-days, respectively). Catheter-related infections were recorded in nine (5.8%) standard catheters, six (4%) in the chlorhexidine-gluconate-impregnated sponge group, and seven (4.4%) in the Oligon catheters (p = .58) (7.8/1,000, 5.7/1,000, 6.1/1,000 catheter-days, respectively). No difference was observed between the chlorhexidine- gluconate-impregnated sponge group and the standard group regarding catheter colonization (hazard ratio 1.21; 95% confidence interval 0.56-2.61; p = .64) and catheter-related infections (hazard ratio 0.65; 95% confidence interval 0.23-1.85; p = .42). The Oligon catheter did not reduce colonization or catheter-related infections when compared with the standard catheter (colonization: hazard ratio 1.0; 95% confidence interval 0.46-2.21; p = .98; catheter-related infection: hazard ratio 0.72; 95% confidence interval 0.27-1.95; p = .52). Seven patients (1.5%, 2.09/1,000 catheter-days) presented bacteremic catheter-related infections. Central venous catheters inserted either in the internal jugular or the femoral vein had greater risk to be colonized than catheters inserted in the subclavian vein (internal jugular vs. subclavian: hazard ratio 3.29; 95% confidence interval 1.26-8.61; p = .01; femoral vs. subclavian: hazard ratio 3.36; 95% confidence interval 1.17-9.65; p = .02). Acinetobacter baumannii was the predominant pathogen (37.1% episodes of colonization, 36.4% catheter-related infections, 57.1% bacteremic catheter-related infections). For short-term (median duration 7 days) central venous catheters in intensive care units with high prevalence of multiresistant Gram-negative bacteria, chlorhexidine-impregnated sponges and Oligon catheters as single preventive measures did not reduce catheter colonization or catheter-related infections. As a result of the limited amount of events, no conclusion could be reached regarding bacteremic catheter-related infections. The femoral site was the most frequently colonized insertion site in all types of catheters.

Peripherally inserted central catheters: a walk down memory lane ...

Central venous catheters (CVCs) are essential in the treatment of critically ill patients. For skilled intensive care unit (ICU) physicians, insertion of these catheters in large central veins is routine practice. Peripherally inserted central catheters (PICCs) were used in the early phase of intensive care as a surrogate for centrally inserted lines by less experienced physicians and in some departments (for example, hematology) with very specifi c patient categories. With the development of the ICU, peripherally inserted lines have been abandoned for more than two decades, at least in our center. Many bleeding and more serious local complications occurred. In more skilled hands, these lines were also not very popular, because of spasm of the vein, a tendency to take the wrong route (to the head), and thrombosis of the vein in up to 8% of patients [1]. In a study in the previous issue of Critical Care, Pittiruti and colleagues [2] evaluated 89 patients in whom ultrasound-guided insertion of multi-lumen CVCs in the deep veins of the upper mid arm (PICC) was performed. Besides 13 minor complications at insertion and two cases of sympto matic thrombosis (however, not routinely screened for), few complications occurred, and the authors conclude that PICC can be successfully used in most ICU patients. Before we advocate its routine use in the ICU, we need more and better studies. PICCs cannot compare with the historical experience with centrally inserted central catheters (CICCs). Skilled personnel, routine use of ultrasound, and insertion bundles have lowered the incidence of complications of CICCs. We would advocate a head-to-head comparison before we introduce PICC as more than a last resort.

Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters

IntroductionCT perfusion studies play an important role in the early detection as well as in therapy monitoring of vasospasm after subarachnoid hemorrhage. High-flow injections via central venous catheters are not recommended but may sometimes be the only possibility to obtain high-quality images. Materials and methodsWe retrospectively analyzed our data for CT perfusions performed with power injection of contrast material with an iodine concentration of 400mg/ml via the distal 16G lumen of the Arrow three and five lumen central venous catheter with preset flow rates of 5ml/s. Results104 examinations with central venous catheters were evaluated (67 with five lumen and 37 with three lumen). No complications were observed. Mean flow rates were 4.4±0.5ml/s using the three lumen catheter and 4.6±0.6ml/s using the five lumen catheter respectively. The mean injection pressure measured by the power injector was 200.7±17.5psi for the three lumen central venous catheter and 194.5±6.5psi for the five lumen catheter, respectively. ConclusionFollowing a strict safety protocol there were no complications associated with power injections of contrast material containing 400mg iodine/ml with preset flow rates up to 5ml/s via the distal 16G lumen of the Arrow multi-lumen central venous catheter. However, since power-injections are off-label use with Arrow central venous catheters, this procedure cannot be recommended until potential safety hazards have been ruled out by the manufacturer.

Risk of Extravasation after Power Injection of Contrast Media via the Proximal Port of Multilumen Central Venous Catheters: Case Report and Review of the Literature

Multilumen central venous catheters (CVCs) are not commonly used for power injection. However, in critically ill patients, CVCs-- most of which do not have FDA approval for power injection--may be the only available venous access. The pitfalls of multilumen CVCs are illustrated by a case report of a patient in whom extravasation of intravenously administered contrast medium occurred after power injection in a triple-lumen CVC using the lumen with the port furthest from the catheter tip. The underlying mechanisms for the displacement of the initially correctly placed right subclavian CVC could include elevation of both arms of the obese patient or the power injection itself. The distances between port openings and catheter tips of various commercially available multilumen CVCs are assessed. We examine the possible caveats of ECG-guided CVC placement for optimal tip position, discuss technical difficulties related to power injection via CVCs, and review commonly used drugs that may cause extravasation injury. Knowledge of the distances between CVC port openings and the catheter tip are essential for safe intravasal administration of fluids.

Standardization of infusion solutions to reduce the risk of incompatibility

Although critically ill patients usually have various central intravenous (i.v.) lines, numerous drugs have to be infused simultaneously through the same lines. This can result in potentially harmful in-line incompatibility that can cause decreased drug effectiveness or increased microparticle load. To minimize the risk of these medication errors at an anesthesia intensive care unit (ICU), the preparation and administration of continuously infused drugs were standardized and the practicability in daily clinical routine was evaluated. The concentration and diluent of continuously administered i.v. drugs were standardized. The drugs were grouped according to pH, medical indication, and chemical structure. The ICU staff decided to use multilumen central venous catheters, and each group of drugs was assigned to one lumen. Only drugs that belonged to the same group were infused simultaneously through the same lumen; therefore, intragroup incompatibilities had to be excluded before establishing the new drug administration plan at the ICU. The visual compatibility of 115 clinically reasonable intragroup drug mixtures was investigated. All drug combinations were compatible for six hours except mixtures containing thiopental, which was reassigned to a single-line use. In the following year, the practicability of this drug administration plan was evaluated. No deviations were found in the compliance of the staff prescribing and preparing only standardized concentrations and diluents. Further research to investigate the chemical compatibility of the drugs in these multiple mixtures will follow. A project intended to avoid incompatibility among i.v. drugs infused in the intensive care setting included steps to standardize solutions and determine which could be given together.