Multiple Central Venous Catheters Research Articles

Identifying risk factors for pediatric central-line–associated bloodstream infections

Background: Pediatric patients often require central venous catheters (CVCs) for a variety of clinical indications, including medication administration, parenteral nutrition, and venous blood sampling. Patients with CVCs are at risk for central-line–associated bloodstream infections (CLABSI). These hospital-acquired infections are often preventable and may lead to increased morbidity and mortality. Clinicians at a 477-bed, freestanding pediatric academic hospital completed a quality improvement project to identify factors that place pediatric patients at increased risk for CLABSI and to outline strategies aimed at CLABSI reduction for our highest-risk patients. Methods: Project leaders completed a literature review to evaluate current research on the topic and then assembled a project team. The team completed a retrospective analysis and categorization of CLABSI cases and reviewed internal CLABSI root-cause analysis data. The group then completed a case–control analysis to identify risk factors in patients with CVCs who developed CLABSIs, compared to patients with CVCs who did not develop CLABSI. Following this analysis, the team created a CLABSI risk-factor tool for use by bedside nurses. This tool described patients with CLABSI risk factors and outlined best practices for CLABSI prevention. Results: Based upon literature review, root-cause analysis data, and retrospective CLABSI case review over the period from 2017 to 2021, an initial list of 9 potential CLABSI risk factors was compiled. A case–control analysis was performed comparing 97 CLABSI cases with 103 matched controls. Univariate, multivariate, and additional covariate analyses were employed to identify 3 factors placing pediatric patients at increased risk for CLABSI. These included (1) multiple enteral devices (ie, 2 or more devices, including gastrostomy tube, jejunostomy tube, gastrostomy or jejunostomy tube, ostomy, and peritoneal drain); (2) multiple CVC entries (ie, CVC used for medications and venous sampling); and (3) long-term CVC plus parenteral nutrition (CVC in place for >21 days and receiving parenteral nutrition and/or intralipids). Conclusions: Pediatric patients with central venous access are vulnerable to CLABSI, and certain patients may be at increased risk. Frontline clinicians may be able to identify these patients and adopt best practices to prevent infection. A tool for use by bedside nurses can be a useful adjunct to existing CLABSI prevention practices.Disclosures: None

Evaluation of venous thromboembolism risk factors reveals subtype heterogenicity in children with central venous catheters: a multicenter study from the Children’s Hospital Acquired Thrombosis consortium

BackgroundAcutely ill and medically complex children frequently rely on central venous catheters (CVCs) to provide life-sustaining treatment. Unfortunately, catheter-related thrombosis (CRT) is a serious and common complication. Little is known why some with a CVC develop CRT and others develop venous thromboembolism unrelated to the CVC (non-CRT). ObjectivesThe aim of this study was to identify factors associated with CRT in children with hospital-acquired venous thromboembolism (HA-VTE). MethodsThis case-case study included participants in the Children’s Hospital Acquired Thrombosis Registry with HA-VTE and CVC aged 0 to 21 years from 8 US children’s hospitals. Participants were excluded if they developed HA-VTE prior to CVC insertion or if the CVC insertion date was unknown. Logistic regression models were used to assess associations between clinical factors and CRT status. ResultsThere were 1144 participants with HA-VTE who had a CVC. CRT developed in 833 participants, and 311 developed non-CRT. Multivariable analysis showed increased odds of CRT (compared with non-CRT) in participants with peripherally inserted central catheters (odds ratio [OR], 3.80; 95% CI, 2.04-7.10; p < .001), CVCs inserted in the femoral vein (OR, 4.45; 95% CI, 1.70-11.65; p = .002), multiple CVCs (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and CVC malfunction (OR, 3.30; 95% CI, 1.80-6.03; p < .001). ConclusionThe findings of this study provide new insights on risk factor differences between CRT and non-CRT. Prevention efforts should be directed at modifying the type of CVC, insertion location, and/or number of CVCs placed, if possible, to decrease the incidence of CRT.

Inpatient Transition From Intravenous to Inhaled Treprostinil in a Pediatric Patient.

We report a case of a 7-year old male with idiopathic pulmonary arterial hypertension, successfully transitioned from an intravenous infusion to inhaled treprostinil during inpatient admission, after his intentional removal of multiple central venous catheters. He had no clinical, echocardiographic, or serum biomarker evidence of loss of control of pulmonary arterial hypertension during the 4-day transition. The patient was discharged home without complications, and 3 weeks after discharge the patient's pulmonary hypertension remained well controlled per clinical and echocardiographic evidence, including a significantly improved 6-minute walk distance test.

An Unusual Case of Hematemesis

Question: A 68-year-old African-American man with history of end-stage renal disease with multiple previous indwelling central venous catheters and current left-side arteriovenous fistula, essential hypertension, and no known history of liver disease presented to the emergency department after an episode of large-volume hematemesis during his routine session of hemodialysis. His blood pressure on presentation was 81/52 with a heart rate of 106 beats per minute. Physical examination was notable for venous distention in the neck and anterior chest wall.

O31 Central venous access in ventilated COVID-19 patients: a vascular surgery perspective

IntroductionThe number of patients on intensive care units (ICU) increased manifold during the initial COVID-19 surge and medical staff were relocated to help compensate. The need for central venous catheters (CVCs) increased accordingly and comprised a significant workload under challenging circumstances. Several models were proposed to manage the lines. We assigned a vascular team of vascular surgeons and interventional radiologists for CVCs in ICU. We report on the workload, outcomes and lessons learned.Method50 consecutive ventilated COVID-19 patients in ICU (median age 63 years, 80% male) who had a CVC inserted by the vascular team from March to May 2020 were assessed. Median follow up was 18 days (range 14– 29 days) after ICU admission.Result166 CVCs (80 VasCaths) were inserted. Femoral access was preferred. Each patient required a median of 3 lines (IQR 2–4). CVCs were exchanged after median 7 days (IQR 4–9) for thrombosis (35%), infection (24%) or prophylactically (41%). Our learning curve included the establishment of an online referral pathway, CVC teams of two operators, extended disposable CVC kits and ICU based ultrasound scanners. Additional staffing and retraining were avoided. There were no technical complications.ConclusionVentilated COVID-19 patients require multiple CVCs which is a challenging workload during a pandemic. Vascular surgeons and interventional radiologists with endovascular skills are well positioned to perform central venous cannulation to alleviate the burden on critical care teams. Our lessons learned can help to provide a safe and efficient model amidst the ongoing national outbreaks.Take-home MessageWith the postponement of many elective vascular procedures during the pandemic crisis, the involvement of vascular surgeons in a dedicated Lines team is an important way that they can contribute given their proficiency with wires and cannulation equipment, as well as familiarity in femoral triangle and jugular anatomy. The retraining of staff and additional on-call rotas can then be avoided.

Children with CVC-VTE: A Very High Risk Group for Recurrent Thrombosis

Background: Venous thromboembolism (VTE) is the second most common contributor to harm in hospitalized pediatric patients.The presence of a central venous catheter (CVC) remains the most potent risk factor for the development of VTE in children. Children with chronic illnesses often require multiple CVCs throughout their lifetime. There is limited evidence regarding either risk factors for recurrent VTE with subsequent CVC placement or efficacy of secondary prophylaxis. Methods: We performed a single center retrospective cohort study and included subjects from 0-18 years of age with an initial CVC-associated VTE (CVC-VTE) that occurred between 1-1-2003 to 12-31-2013. Subject data was collected from the initial CVC-VTE event until either the end of the study period (9-30-2014) or a recurrent VTE event. Data collection included demographics, CVC details (total number of CVCs placed during the study period, line type, and duration), underlying medical conditions (acute and chronic), thrombophilia, and anticoagulation regimens. During the study period, our clinical practice included secondary VTE prophylaxis with enoxaparin for subsequent CVCs as long as a contraindication to anticoagulation did not exist. The enoxaparin dosing for prophylaxis dosing varied throughout the study period. The association between CVC-VTE recurrence and VTE risk factors for the first subsequent CVC was assessed using logistic regression. A forward stepwise selection approach was used for model building. Variables with a p-value Results: During the study period, 432 subjects had an initial CVC-associated VTE with a mean follow-up time of 27.3 ± 29.6 months. 222 (51.4%) had 1 or more additional CVCs placed with a mean of 1.8 ± 1.3 CVC per subject (Figure 1). For the entire cohort, 111/432 (25.7%) had a recurrent CVC-VTE. Limiting the analysis to the first additional CVC placement, 76/222 (34%) patients had a recurrent CVC-VTE. 67/222 (30%) of patients did not receive secondary prophylaxis. Demographics and distribution of VTE risk factors are listed in Table 1. On univariate analyses, congenital heart disease (OR 8.22; 95% CI 1.74, 38.8) and TPN dependence (OR 5.28; 95%CI 1.12, 25) were associated with an increased risk for VTE recurrence with the first additional CVC placement (Table 2). On multivariable analysis, none of the VTE risk factors remained statistically significant (Table 2). Conclusions: Over half (222/432) of all children with CVC-VTE in our study required a subsequent CVC. In those who had a subsequent CVC, 50% (111/222) experienced a recurrent CVC-VTE. This is an extremely high risk of thrombosis in a heterogeneous group of children with chronic medical conditions. On multivariable analysis we were unable to identify additional risk factors for VTE recurrence. While the use of secondary prophylaxis either prophylactic (0.76, 95%CI 0.31-1.88) or full dose (0.58, 95%CI 0.28-1.2) had associated odds ratios consistent with a decrease in VTE recurrence, they did not meet statistical significance. A history of a prior CVC-VTE is likely the strongest risk factor for recurrent CVC-VTE. This very high risk group (patients with prior CVC-VTE who require a subsequent CVC) is an ideal population to target in future interventional studies. Download : Download high-res image (132KB) Download : Download full-size image Disclosures Raffini: Green Cross Inc: Consultancy; CSL Behring: Consultancy; Bayer: Consultancy; Genetech: Consultancy.

Lesion Type Analysis of Hemodialysis Patients Who Underwent Endovascular Management for Symptomatic Central Venous Disease.

PurposeCentral venous lesions (CVLs) can adversely affect hemodialysis access maturation and maintenance, which in turn worsen patient morbidity and access circuit patency. In this study, we assessed several clinical variables, patient characteristics, and clinical consequences of symptomatic central vein stenosis and obstruction in patients who underwent renal replacement therapy in the form of hemodialysis.Patients and MethodsThe medical records of all hemodialysis patients with clinically symptomatic CVLs who underwent digital subtraction angiography treatment at King Abdullah University Hospital between January 2017 and December 2019 were retrieved. Patient characteristics and the clinical and anatomical features of CVLs were analyzed retrospectively. Pearson’s chi-square tests of association were used to identify and assess relationships between patient characteristics and CVLs.ResultsThe study cohort comprised 66 patients with end-stage renal disease who developed symptomatic central vein stenosis. Of the 66 patients, 56.1% were men, and their mean age was approximately 52 years. Most (62.1%) of the patients were determined to have a history of central catheter insertion into the jugular vein. Hypertension was the most common comorbidity (78.8%, p<0.001), followed by type 2 diabetes mellitus (47.0 %, p<0.01). The incidence of stenosis was found to be significantly higher in the brachiocephalic vein than in other central veins (43.9%, p<0.001). A repeated central catheter insertion in a patient was predictive of central venous occlusion (p<0.05). Stenotic lesions were found to be associated with a significantly higher success rate than occlusive lesions (91.2%, p<0.01).ConclusionMultiple central venous catheters (CVCs) are found to be associated with occlusive CVLs and unfavorable recanalization outcomes. Multiple CVC should be avoided by creating a permanent vascular access in a timely fashion for patients with chronic kidney disease and by avoiding the ipsilateral insertion of CVC and AVF.

Impact of a Best Practice Prevention Bundle on Central Line-associated Bloodstream Infection (CLABSI) Rates and Outcomes in Pediatric Hematology, Oncology, and Hematopoietic Cell Transplantation Patients in Inpatient and Ambulatory Settings.

Pediatric hematology, oncology, and hematopoietic cell transplantation (HCT) patients are at increased risk for bloodstream infections. The authors sought to evaluate the influence of a standardized best practice central venous catheter (CVC) maintenance bundle on the burden of and risk factors for mucosal barrier injury (MBI) and non-MBI central line-associated bloodstream infections (CLABSIs) across a common inpatient and ambulatory continuum in this high-risk population. A retrospective cohort study of patients with underlying malignancy, hematologic disorders, and HCT recipients with a CVC in place at the time of CLABSI diagnosis in both inpatient and ambulatory settings from January 1, 2012 to December 31, 2016. Descriptive, nonparametric statistics were used to describe patient characteristics and outcomes. Logistic regression analyses were applied to identify potential risk factors for inpatient versus ambulatory and MBI versus non-MBI CLABSI. During the 5-year period, 118 of 808 (14.6%) patients had 159 laboratory-confirmed CLABSIs for ambulatory and inpatient CLABSI rates of 0.27 CLABSI/1000 and 2.2 CLABSI/1000 CVC days, respectively. CLABSI occurred more frequently in hospitalized patients after HCT and with underlying leukemia, most frequently caused by Gram-negative bacteria. MBI CLABSI accounted for 42% of all CLABSI with a 3-fold higher risk in hospitalized patients. Having multiple CVC or a CVC that was not a port independently associated with higher CLABSI risk. In our cohort, non-MBI CLABSI continued to account for the majority of CLABSI. CVC type is independently associated with higher overall CLABSI risk. Further studies are needed to reliably define additional prevention strategies when CLABSI maintenance bundles elements are optimized in this high-risk population.

Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study.

A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.

A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion

Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. Retrospective multicenter observational study. 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June2018. Application of the IOA approach to gain vascular access. The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. No comparison to other methods to place CVCs and the observational study design. The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

Chlorhexidine bathing of the critically ill for the prevention of hospital-acquired infection.

Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications, permanent disability or death. Whilst all hospital-based patients are susceptible to infections, prevalence is particularly high in the ICU, where people who are critically ill have suppressed immunity and are subject to increased invasive monitoring. People who are mechanically-ventilated are at infection risk due to tracheostomy and reintubation and use of multiple central venous catheters, where lines and tubes may act as vectors for the transmission of bacteria and may increase bloodstream infections and ventilator-associated pneumonia (VAP). Chlorhexidine is a low-cost product, widely used as a disinfectant and antiseptic, which may be used to bathe people who are critically ill with the aim of killing bacteria and reducing the spread of hospital-acquired infections. To assess the effects of chlorhexidine bathing on the number of hospital-acquired infections in people who are critically ill. In December 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We included randomised controlled trials (RCTs) that compared chlorhexidine bathing with soap-and-water bathing of patients in the ICU. Two review authors independently assessed study eligibility, extracted data and undertook risk of bias and GRADE assessment of the certainty of the evidence . We included eight studies in this review. Four RCTs included a total of 1537 individually randomised participants, and four cluster-randomised cross-over studies included 23 randomised ICUs with 22,935 participants. We identified one study awaiting classification, for which we were unable to assess eligibility.The studies compared bathing using 2% chlorhexidine-impregnated washcloths or dilute solutions of 4% chlorhexidine versus soap-and-water bathing or bathing with non-antimicrobial washcloths.Eight studies reported data for participants who had a hospital-acquired infection during the ICU stay. We are uncertain whether using chlorhexidine for bathing of critically ill people reduces the rate of hospital-acquired infection, because the certainty of the evidence is very low (rate difference 1.70, 95% confidence interval (CI) 0.12 to 3.29; 21,924 participants). Six studies reported mortality (in hospital, in the ICU, and at 48 hours). We cannot be sure whether using chlorhexidine for bathing of critically-ill people reduces mortality, because the certainty of the evidence is very low (odds ratio 0.87, 95% CI 0.76 to 0.99; 15,798 participants). Six studies reported length of stay in the ICU. We noted that individual studies found no evidence of a difference in length of stay; we did not conduct meta-analysis because data were skewed. It is not clear whether using chlorhexidine for bathing of critically ill people reduced length of stay in the ICU, because the certainty of the evidence is very low. Seven studies reported skin reactions as an adverse event, and five of these reported skin reactions which were thought to be attributable to the bathing solution. Data in these studies were reported inconsistently and we were unable to conduct meta-analysis; we cannot tell whether using chlorhexidine for bathing of critically ill people reduced adverse events, because the certainty of the evidence is very low.We used the GRADE approach to downgrade the certainty of the evidence of each outcome to very low. For all outcomes, we downgraded evidence because of study limitations (most studies had a high risk of performance bias, and we noted high risks of other bias in some studies). We downgraded evidence due to indirectness, because some participants in studies may have had hospital-acquired infections before recruitment. We noted that one small study had a large influence on the effect for hospital-acquired infections, and we assessed decisions made in analysis of some cluster-randomised cross-over studies on the effect for hospital-acquired infections and for mortality; we downgraded the evidence for these outcomes due to inconsistency. We also downgraded the evidence on length of stay in the ICU, because of imprecision. Data for adverse events were limited by few events and so we downgraded for imprecision. Due to the very low-certainty evidence available, it is not clear whether bathing with chlorhexidine reduces hospital-acquired infections, mortality, or length of stay in the ICU, or whether the use of chlorhexidine results in more skin reactions.

Malposition of the central venous catheter: A diagnostic dilemma

A 50-year-old male was admitted to Intensive Care Unit with head and chest injury needed multiple central venous catheter (CVC) for the long-term intravenous access. Right internal jugular vein was cannulated uneventfully, and the tip of CVC was confirmed in the chest radiograph along the right border of the mediastinum. After few days, left subclavian vein was cannulated and the procedure was uneventful. However, the postprocedure Chest X-ray showed the CVC along the left border of mediastinum rather than the right border. Possibility of CVC in one of the tributaries of left brachiocephalic vein was thought. Due to uncertainty in position of left CVC, we inserted CVC in right-sided subclavian vein, which was in normal position along the right border of mediastinum. Left subclavian CVC was removed. Reviewing the patient's thoracic computed tomography scan revealed, patient had congenital anomaly and double superior vena cava that explained the abnormal course of left subclavian CVC along the left border of mediastinum.

Estratégia Multidimensional na Redução de Infeção Associada a Cateter Venoso Central em Pediatria

To determine the central-line associated bloodstream infection rate after implementation of central venous catheter-care practice bundles and guidelines and to compare it with the previous central-line associated bloodstream infection rate. A prospective, longitudinal, observational descriptive study with an exploratory component was performed in a Pediatric Intensive Care Unit during five months. The universe was composed of every child admitted to Pediatric Intensive Care Unit who inserted a central venous catheter. A comparative study with historical controls was performed to evaluate the result of the intervention (group 1 versus group 2). Seventy five children were included, with a median age of 23 months: 22 (29.3%) newborns; 28 (37.3%) with recent surgery and 32 (43.8%) with underlying illness. A total of 105 central venous catheter were inserted, the majority a single central venous catheter (69.3%), with a mean duration of 6.8 ± 6.7 days. The most common type of central venous catheter was the short-term, non-tunneled central venous catheter (45.7%), while the subclavian and brachial flexure veins were the most frequent insertion sites (both 25.7%). There were no cases of central-line associated bloodstream infection reported during this study. Comparing with historical controls (group 1), both groups were similar regarding age, gender, department of origin and place of central venous catheter insertion. In the current study (group 2), the median length of stay was higher, while the mean duration of central venous catheter (excluding peripherally inserted central line) was similar in both groups. There were no statistical differences regarding central venous catheter caliber and number of lumens. Fewer children admitted to Pediatric Intensive Care Unit had central venous catheter inserted in group 2, with no significant difference between single or multiple central venous catheter. After multidimensional strategy implementation there was no reported central-line associated bloodstream infection Conclusions: Efforts must be made to preserve the same degree of multidimensional prevention, in order to confirm the effective reduction of the central-line associated bloodstream infection rate and to allow its maintenance.

Chlorhexidine bathing of the critically ill for the prevention of hospital-acquired infection

BACKGROUND Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications, permanent disability or death. Whilst all hospital-based patients are susceptible to infections, prevalence is particularly high in the ICU, where people who are critically ill have suppressed immunity and are subject to increased invasive monitoring. People who are mechanically-ventilated are at infection risk due to tracheostomy and reintubation and use of multiple central venous catheters, where lines and tubes may act as vectors for the transmission of bacteria and may increase bloodstream infections and ventilator-associated pneumonia (VAP). Chlorhexidine is a low-cost product, widely used as a disinfectant and antiseptic, which may be used to bathe people who are critically ill with the aim of killing bacteria and reducing the spread of hospital-acquired infections. OBJECTIVES To assess the effects of chlorhexidine bathing on the number of hospital-acquired infections in people who are critically ill. SEARCH METHODS In December 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared chlorhexidine bathing with soap-and-water bathing of patients in the ICU. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data and undertook risk of bias and GRADE assessment of the certainty of the evidence . MAIN RESULTS We included eight studies in this review. Four RCTs included a total of 1537 individually randomised participants, and four cluster-randomised cross-over studies included 23 randomised ICUs with 22,935 participants. We identified one study awaiting classification, for which we were unable to assess eligibility.The studies compared bathing using 2% chlorhexidine-impregnated washcloths or dilute solutions of 4% chlorhexidine versus soap-and-water bathing or bathing with non-antimicrobial washcloths.Eight studies reported data for participants who had a hospital-acquired infection during the ICU stay. We are uncertain whether using chlorhexidine for bathing of critically ill people reduces the rate of hospital-acquired infection, because the certainty of the evidence is very low (rate difference 1.70, 95% confidence interval (CI) 0.12 to 3.29; 21,924 participants). Six studies reported mortality (in hospital, in the ICU, and at 48 hours). We cannot be sure whether using chlorhexidine for bathing of critically-ill people reduces mortality, because the certainty of the evidence is very low (odds ratio 0.87, 95% CI 0.76 to 0.99; 15,798 participants). Six studies reported length of stay in the ICU. We noted that individual studies found no evidence of a difference in length of stay; we did not conduct meta-analysis because data were skewed. It is not clear whether using chlorhexidine for bathing of critically ill people reduced length of stay in the ICU, because the certainty of the evidence is very low. Seven studies reported skin reactions as an adverse event, and five of these reported skin reactions which were thought to be attributable to the bathing solution. Data in these studies were reported inconsistently and we were unable to conduct meta-analysis; we cannot tell whether using chlorhexidine for bathing of critically ill people reduced adverse events, because the certainty of the evidence is very low.We used the GRADE approach to downgrade the certainty of the evidence of each outcome to very low. For all outcomes, we downgraded evidence because of study limitations (most studies had a high risk of performance bias, and we noted high risks of other bias in some studies). We downgraded evidence due to indirectness, because some participants in studies may have had hospital-acquired infections before recruitment. We noted that one small study had a large influence on the effect for hospital-acquired infections, and we assessed decisions made in analysis of some cluster-randomised cross-over studies on the effect for hospital-acquired infections and for mortality; we downgraded the evidence for these outcomes due to inconsistency. We also downgraded the evidence on length of stay in the ICU, because of imprecision. Data for adverse events were limited by few events and so we downgraded for imprecision. AUTHORS' CONCLUSIONS Due to the very low-certainty evidence available, it is not clear whether bathing with chlorhexidine reduces hospital-acquired infections, mortality, or length of stay in the ICU, or whether the use of chlorhexidine results in more skin reactions.

PTU-104 Small Bowel Transplantation Does Improve Quality of Life, But Needs A Disease Specific Tool

Introduction Small bowel intestinal transplantation is provided for patients with intestinal failure for whom complications, among other reasons, such as intestinal failure associated liver disease (IFALD), multiple central venous catheter (CVC) infections, loss of venous access or who have intra-abdominal desmoids. In addition, within the American guidelines is quality of life (QoL). There is no robust QoL data collection tool to compared patients undergoing small bowel transplantation compared to those remaining on parenteral nutrition (PN). Methods Data of all patients undergoing small bowel transplant in Oxford, one of the 2 national adult small bowel transplant centres in the UK, are captured on a prospectively entered database. QoL data was recorded using patient related outcome measures (PROM) and using EQ5D both pre and post intestinal transplant. Data was audited in January 2016. The Oxford Intestinal Failure (IF) cohort also had QoL data recorded and was used as a comparator. Results PROM measurements include survival where out of 29 transplants that had occurred, 19 were alive (66%), 1 (5%) was on TPN as an inpatient and 2 (11%) were on home iv fluids, 16 (84%) were on no TPN, iv fluids or tube enteral nutrition support. Questionnaire data utilised the visual analogue scale part of the EQ5D as a global rating scale for the patients to record their assessment of QoL. It was recorded as median (range) for 4 patients who completed questionnaires pre and post transplant giving 4 pre results and 7 post results; pre-transplant 17.5 (10–30) and post-transplant 79.5 (60–85). 4 patients had only filled in pre-transplant questionnaires: 35 (10–50), which included 1 patient who died post-transplant, 2 patients at their assessment and 1 who was post-explant of their graft for chronic rejection and are listed for retransplantation. In addition, 5 patients completed post-transplant questionnaires on 7 occasions 80 (55–90). This compares to the Oxford IF cohort of whom 30 patients filled in a questionnaire on 1 occasion, 15 on a 2 nd at a median of 5 months (1–15) following the first and 3 on a 3 rd occasion at 4 months (3–5) after the second. The median (range) for the Oxford IF cohort was 62.5 (25–100), 65 (30–100), 75 (60–85). Conclusion From this preliminary series, small bowel transplantation does improve quality of life post-transplant compared to pre-transplant. The level post-transplant is better than that experienced by patients on home PN. A better QoL data tool is required to effectively assess patients undergoing small bowel intestinal transplantation that can be effectively compared to patients who remain on PN. Disclosure of Interest V. Blackwell: None Declared, L. Holdaway: None Declared, S. Travis: None Declared, S. Reddy: None Declared, G. Vrakas: None Declared, A. Smith: None Declared, A. Vaidya: None Declared, P. Friend: None Declared, P. Allan Consultant for: Abbvie, Conflict with: BresMed advisor; NPS Pharma educational grant

When Esophageal Varices Go Downhill

Patient Presentation: A 32 year old female with ESRD secondary to mesangial proliferative glomerulonephritis, recurrent SVC catheters due to failed AVG's, Mixed Connective Tissue Disorder and a failed renal transplant, presented with 2 days of melena and 2 episodes of hematemesis. There was no history of alcoholism, hepatitis, abdominal pain, NSAID or anticoagulant use. Physical examination was significant for tachycardia to 128 BPM, dilated superficial veins on the anterior chest wall, and melenic stool. There was no scleral icterus, abdominal distention, or hepatomegaly. The patient was transferred to the MICU. Work Up/Interventions: Laboratory studies were as follows: Hb 6.0 g/dL, Bilirubin 0.7, μmol/L, AST 7 U/L, ALT 6 U/L, INR 1.06 and Albumin 3.3 g/dL. The patient received transfusion of PRBC. EGD demonstrated F3 esophageal varices in the upper and mid-esophagus and presence of red wale signs and oozing blood. Endoscopic band ligation was performed. The melena resolved and the hemoglobin remained stable. Abdominal ultrasound demonstrated a normal liver. The portal veins were patent with normal direction of flow. The IVC and hepatic veins were patent. CT angiography of the abdomen demonstrated numerous abdominal wall collateral vessels. CT angiography of the chest revealed occlusion of the SVC along with numerous right-sided chest wall collaterals. The occlusion was at the junction of the SVC and the R brachiocephalic vein. A prominent azygous vein was seen. Diagnosis: Downhill esophageal varices secondary to SVC thrombosis due to multiple prior central venous catheters. Therapy: Balloon angioplasty of the SVC successfully improved flow. Subsequent EGD showed improvement of the esophageal varices. Definitive therapy consisted of right axillary vein to right atrium bypass graft.Figure 1Figure 2Figure 3Discussion: Downhill esophageal varices cause less than 0.1% of all variceal bleeds. Occlusion of the SVC results in increased pressure to the azygous and hemiazygous systems responsible for drainage of the venous plexuses of the upper two thirds of the esophagus. If the occlusion does not interfere with azygous drainage to the SVC, only the upper two thirds of the esophagus will be involved, as in the present case. Occlusion of the azygous drainage into the SVC results in varices throughout the esophagus. Treatment of downhill varices focuses on restoring venous drainage. Options include balloon angioplasty, SVC stenting and open surgical therapies. Endoscopic options include proximal banding. Sclerotherapy is avoided due to concerns over embolization.

Transhepatic Central Venous Catheters in Pediatric Patients With Congenital Heart Disease.

Patients with congenital heart disease may have limited venous access routes as a result of multiple central venous catheters, surgical interventions, and catheterization procedures. Unconventional venous access includes transhepatic central venous catheter. We evaluated transhepatic central venous catheter placed in patients with congenital heart disease and risk factors associated with complications and outcomes. Demographic, procedural, and complication data were retrospectively collected on all patients who underwent transhepatic central venous catheter placement at our center over the past 10 years. This study was completed in a tertiary congenital heart center. A total of 92 transhepatic central venous catheters were placed in 54 patients (63% male patients). The median age and weight of the patient population was 5.7 months and 5.5 kg, respectively. Placement of a transhepatic central venous catheter. Successful catheter placement occurred in 96% of cases with median procedure time of 54 minutes with a procedural complication rate of 14%. A total of 86 complications occurred in 54 catheters placed during 2,166 catheter-days (39.7 complications per 1,000 catheter-days). Individual complication rates per 1,000 catheter-days included catheter dysfunction (14.8), dislodgement (8.8), systemic infection (5.1), thrombosis (4.2), local infection (3.7), and bleeding (3.2). Two complications contributed to patient deaths. Factors associated with developing complications included polyurethane central venous catheters (p = 0.03) and catheter duration at least 21 days (p = 0.004). The overall mortality in this population was 50% with median length of hospitalization of 49 days (interquartile range, 33-97). Transhepatic central venous catheters represent a viable option for patients with limited access. Polyurethane catheters and catheter duration at least 21 days are associated with increased transhepatic central venous catheter complications. Although complication rates are higher than more traditional forms of central venous catheters, the long duration of hospitalization and high mortality rates in this patient population attest to their risks for poor outcomes irrespective of venous access.

Favorable Outcome With Teduglutide Treatment of a Young Woman With Long-Standing Intestinal Failure/Short Bowel Syndrome (SBS) With No Remaining Central Venous Access

Introduction: Describe treatment with teduglutide (rDNA origin) in a 23-year-old patient with longstanding intestinal failure/SBS due to congenital jejunal atresia Case Report: Our patient is a 23-year-old female born with jejunal atresia, who experienced intestinal failure due to SBS as a neonate. She has absence of the corpus callosum, seizure disorder, and neurodevelopmental delay. Her gastrointestinal history is significant for eosinophilic colitis, enteritis, gastro-esophageal reflux disease, and malabsorption due to SBS. She had a history of multiple prior central venous catheters. One year prior to this report, due to feeding intolerance and partial bowel obstruction, she underwent surgery with extensive lysis of adhesions, Ladd’s procedure, and serial transverse enteroplasty procedure (STEP). After surgery, we attempted to wean her off parenteral nutrition (PN). Following a catheter-associated central venous thrombosis, she was placed on treatment with fondaparinux to prevent progression of thrombosis. However, the catheter would no longer infuse, and she had no further central venous access for PN. Enteral feedings were increased with elemental formula to meet her estimated energy needs. Her daily fluid needs were partially met with ORS and additional peripheral intravenous fluids (IVF) to compensate for high fecal losses and electrolyte and mineral deficiencies. She developed pneumatosis intestinalis (PI) on this regimen. Once the PI resolved, she was placed on a low-carbohydrate enteral formula and oral rehydration solution (ORS) via G-tube with supplemental fluid, electrolyte, magnesium (Mg), and phosphorus (Phos.) administered via peripheral vein, based on stool output, serum electrolyte, and mineral levels. Peripheral IVs were changed frequently and with great difficulty by the hospital IV team. Due to lack of central venous access and inability to transition the patient from IVF, electrolytes, and minerals, she was started on teduglutide 0.05 mg/kg daily subcutaneously. She was monitored in the hospital for adverse effects, daily weights, fluid intake and output, serum electrolytes, and minerals. She experienced recurrence of PI and elevated lipase levels that resolved within 4-5 days with conservative management. Six weeks after starting teduglutide, the patient no longer required additional IVF, IV electrolyte, or mineral supplementation. After 9 weeks of teduglutide, she continues to tolerate G-tube feeds and ORS with normal serum electrolytes, Mg, and Phos. without IV supplementation at home.Table 1: Results

Not all probiotics are the same: Gut microbiota modulation with a multistrain probiotics

The highest incidence of invasive candidiasis infection (ICI) occurs in low birth weight infant with an estimated incidence of 4% and of 15% in extremely low birth weight infant. Low birth weight is an important risk factor. The other main risk factors associated with invasive candidiasis are the use of multiple antibiotics and central venous catheters, immunosuppression, parenteral nutrition, fungal colonization, and necrotizing enterocolitis. In this population, ICI cause high mortality, lead to significant neurodevelopmental impairment, and result in increate length of hospitalization and cost.[1] Originality of the study is the use of probiotics combination Alkem Batch PWS3002C comprising Bifidobacterium infantis, Lactobacillus acidophilus, Bifidobacterium longum, and Bifidum lactis. These preparations are considered more effective than single probiotic strain, characterized instead by a single bacterial strain. In fact, a recent study showed that the use of a multistrain probiotics have an action of greater efficacy.[2] Important focal point is gastrointestinal symptoms. Another interesting result of this study is that the control group presented a higher percentage of gastrointestinal symptoms than did the probiotic group, which showed an increased food tolerance, shortening the period of parenteral nutrition probably due to its changes in intestinal flora, improvement in mucosal barrier and anti-infiammatory properties. Reduction of stool fungal colonization is an important principal outcome parameter in the probiotics group by reduced invasive fungal sepsis is an important outcome parameter in the probiotics group because reduced invasive fungal sepsis 55.4% in probiotics group versus 75% in the control group.[3] Also the number of days to full enteral feeds and duration of hospitalization was less in probiotic group. Candida albicans is the most commonly isolated species, although C. parapsilosis. These species are commonly isolated in invasive candidiasis, while C. glabrata and C. krusei are isolated only in 3% of ICI. The published data show that fluconazolo use since birth is highly effective in preventing both colonization and infection in preterm neonates. This can lead to a high prevalence of azole-resistant Candida species.[4] In this study 35 (7%) newborns of control group presented C. glabrata infection, while the probiotics group presented only C. albicans. Loss of gut commensals, such as Bifidobacteria and Lactobacilli, due to the difficulties in oral feeding, translates into an increased susceptibility to pathogenic gut colonization. Probiotics are increasingly being used for their beneficial properties, considered to be particularly useful in reducing some symptoms related to gastrointestinal disorders.[5] In particular, preparations of a multistrain, consisting of different bacterial strains but belonging to the same species or anyway similar species are considered more effective than single probiotic strain. Evidence regarding the potential beneficial effects of probiotics supplementation in preterm infants is encouraging. Further studies to assess clinically relevant outcomes are needed.

The Effect of Multiple Concurrent Central Venous Catheters on Central Line Associated Bloodstream Infections

Central line associated bloodstream infection (CLABSI) rates are used to publicly compare quality of care and for Pay for Performance measures across hospitals. The National Healthcare Safety Network CLABSI denominator does not take into consideration the presence of multiple lines. The intensity of line use is believed to increase the risk for infection. However, sicker patients are more likely to need central lines, and it is difficult to distinguish the independent influence of disease severity and central line use on infection risk.