Percutaneous Central Venous Lines Research Articles

1049: IMPROVING CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION RATES VIA RISK SCREENING AND INTERVENTION

Introduction: Central venous lines are essential tools in the pediatric ICU (PICU). However, Central-line-associated bloodstream infections (CLABSI) cause significant morbidity and mortality. There are well-described CLABSI risk factors and mitigation strategies. Our smart aim was to decrease the CLABSI rate in the PICU by 30% in 1 year through the development of a risk screening and mitigation tool deployed by a quality improvement (QI) team embedded in daily rounds. Methods: All patients with central venous access were screened daily by the QI team, for the following risk factors: acute behavioral health need, > 72 hours of central access, permanent line, ≥ 25 line accesses per day, impaired skin integrity, immunologic dysfunction, parental nutrition use, extracorporeal support. Any risk factor triggered a CLABSI huddle focused on line necessity, enteral medication conversion, and access reduction. Simultaneous nursing interventions involved prevention education and bundle performance audits. Process measures were followed for the first four months with the primary outcome followed for one year. Results: In the first four months, 19.1% (N=121) patients screened positive for high CLABSI risk, most commonly due to ≥25 line accesses per day (41.7%, n=73). Median total criteria met on initial positive screen was 1 (IQR 1-2). Among positive screens, percutaneous central venous lines (40.5%) and femoral vein location (25.6%) were most prevalent. The most common admitting diagnosis was respiratory failure (22%). Of the 614 positive screens, huddle compliance was 95.9% with ≥ 1 mitigation intervention applied following 20.2% of the huddles. Interventions included line removal (35.7%, n=45), lab modifications (33.3%, n=42), and enteral medication conversion (30.9%, n=39). The annual CLABSI rate decreased from 1.88/1000 line days to 1.18/1000 line days (37.2% decrease). Conclusions: Targeted screening and risk factor mitigation, implemented by dedicated QI team members embedded in rounds, led to a 37.2% reduction in the CLABSI rate in this single center. While this is a promising improvement, sustainability and external validity need to be investigated. Multidisciplinary commitment to reduction of this important complication of critical illness is paramount.

Strategies to reduce line infections in a small child with homozygous familial hypercholesterolaemia who cannot yet receive LDL apheresis

Patients with homozygous familial hypercholesterolaemia are optimally treated with low-density lipoprotein apheresis. Young patients who do not meet a weight threshold (25 kg) receive regular plasmapheresis. This approach may remove...

Anaesthetic management of thoraco‐omphalopagus twins with congenital heart disease for separation surgery

SummaryConjoined twins' separation surgery poses challenges to anaesthetists due to the variable degree of cross circulation, difficulty in positioning, bleeding and limitations of space for sharing between two anaesthetic teams. We present the anaesthetic management for separation surgery of three‐months old conjoined twins. Both babies had congenital heart disease, with one baby hypertensive and commenced on enalpril pre‐operatively. A pre‐operative multi‐disciplinary meeting between all stake holders and a full environment simulation was performed and was helpful. The problems encountered included difficulty in percutaneous central venous line placement requiring surgical cut down and intra‐operative bleeding requiring vasopressor therapy and postoperative intensive care unit stay.

Subclavian Vein Cannulation Success Rate in Neonates and Children.

Background:Central vein cannulation allows the administration of large volumes of fluids in short times and at high osmolarities for rehydration, volume replacement, chemotherapy, and parenteral nutrition. Percutaneous central venous line insertion has replaced peripheral venous cut-down as the primary mode of short-term venous access in children.Objectives:The aim of our study was to delineate some aspects of this procedure as well as its success rate and relative risk in pediatrics.Patients and Methods:Totally, 3264 subclavian vein cannulations in neonates and children were analyzed regarding successful catheterization attempts and early complication rates after the procedure retrospectively in Mofid Hospital (Tehran, Iran).Results:There were 1340 newborn patients (first 28 days of life) in our study population. In these newborns, only 55 cannulations failed; one patient was complicated with pneumothorax; guide wires malfunctioned in 21 cases; and first- attempt cannulation success was reported in only 981 cases. In the remaining 1924 patients, between one month and 8 years old, only 14 attempts at the cannulation of the subclavian vein failed and 1655 cases had first-attempt cannulation success.Conclusions:The cannulation of the central vein in neonates and children in a skilled hand would be performed with great success rate and low complications.

PC.128 National Survey on Imaging of Percutaneous Longlines in Tertiary Neonatal Intensive Care Units

IntroductionPercutaneous long lines (LL) are routinely used in preterm babies for providing parenteral nutrition (PN). Malpositioning of LL tips is associated with serious complications.1–5 No national guidelines exist outlining the...

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Introduction: Children with congenital heart disease (CHD) are the largest identifiable pediatric group with thrombosis. The purpose of this study was to identify risk factors associated with venous thrombosis (VTE) in pediatric patients with heart disease. Methods: As part of a quality improvement evaluation, patients with heart disease who developed symptomatic VTE over a 10-month period were retrospectively evaluated to determine potential risk factors. Ultrasounds, Xrays, coagulation lab tests and fluid balance were evaluated. Results: 15 patients with heart disease were identified to have VTE. 9/15 (60%) had single ventricle anatomy at time of thrombus formation: 3 with Stage I Norwood or Damus-Kaye Stansel, 3 with Glenn shunts, 2 with Blalock-Taussig (BT) shunts and 1 with a pulmonary artery band. The remaining patients had CHD with 2-ventricle anatomy (n=5) and 1 had normal cardiac anatomy with severe pulmonary hypertension and biventricular heart failure. 53% were male. Patients ranged in age from 4 days to 18 months (mean age 5.3 months). 93% patients had at least 1 VTE associated with a central venous line (CVL) detected by ultrasound, with 1 patient developing thrombus in a BT shunt. 46.7% had >1 location with VTE. 78.6% had percutaneous CVLs, with line tip not within vena cava in 63.6%. Mean number of days from central line insertion to thrombus discovery was 8.6 days. 33% of patients were on heparin at time of thrombus discovery to maintain shunt patency, but none had systemic levels of heparin. General inflammatory state, line association, and surgery 200 ml/day) developed VTE. Only 2 patients were found to have a genetic prothrombotic predisposition. Conclusions: Patients with heart disease are at high risk for VTE development due to multiple risk factors; this can be particularly worrisome in single ventricle patients who rely on patent neck and chest venous connections for appropriate function of palliated cardiac shunts. These risk factors can help further develop anticoagulation protocols and VTE management for this complex population.

Segmental percutaneous central venous line cultures for diagnosis of catheter-related sepsis

ObjectiveCulture of percutaneous central venous line (PCVL) segments may assist the diagnosis of line colonisation and catheter-related sepsis (CRS). The authors aimed to determine if the diagnosis of CRS and...

Factors Relating to Development of Catheter Associated Sepsis : A Prospective Study

Background and aim: Insertion of percutaneous central venous lines (PCVLs) is an everyday procedure in the neonatal unit. The presence of PCVL is an important risk factor for catheter-related sepsis. We aimed to study the characteristics of infants with indwelling PCVLs who develop catheter-associated sepsis (CAS).Design and Methods: Prospective study in two tertiary neonatal units of all infants with a PCVL indwelling for >24h. CAS was defined as an unwell baby with an indwelling PCVL who developed clinical signs of sepsis with no other cause for sepsis identified. We examined various factors/ characteristics to see which were associated with likelihood of development of CAS.Results: 189 PCVLs were studied over a 14-month period. 47 neonates were clinically-septic at the time of line removal. Babies with clinically-suspected sepsis were significantly lower in gestational age and birth weight compared to well babies (p < 0.01). Comparatively, PCVLs were inserted at an earlier postnatal age in well babies than in those with suspected sepsis (p < 0.01). In the suspected sepsis group, a significant proportion of the PCVLs were inserted via the lower limb (P=0.04) compared to well babies. Babies with suspected sepsis were significantly more likely to have had a smaller caliber PCVL inserted than well babies (28 gauge vs. 24 gauge, p=0.002).Conclusion: CAS occurs more commonly in babies of smaller gestation and birth weight. Preferential insertion of PCVLs via upper limbs may entail a lower risk of CAS because of the smaller length of in vivo foreign body liable to colonisation.

1371 Complications Associated with Insertion of Percutaneous Central Venous Lines

Objective: To analyse the complications involved in insertion of central venous lines (CVL). To determine the association of Coagulase negative staphylococcal (CONS) sepsis with CVL duration. Method: Prospective study of percutaneous CVL insertions over a 4 month period (Aug‘2009-Nov’ 2009) in Nottingham City Hospital (a UK Level 3 non-surgical Neonatal intensive care unit). Data were collected from the notes of those babies in whom a percutaneous CVL was inserted. Results: Twenty seven babies (23-40 weeks gestation, median 32 wks) had 36 percutaneous central venous lines inserted during the study period. The indications were predominantly for administering parental nutrition and/or for inotropes. 35 (97%) of insertions were completely documented in notes using a proforma. Twelve (33%) of the line insertions were associated with complications such as blockage (5), extravasations (2), coiled (2) and CONS sepsis (3). Complications were more common using 1 French lines (10/26) compared to 2 French lines (2/10). Median duration of line placement was 6 days, ranging from 1 to 32 days. Three babies (11%) became unwell with CONS sepsis confirmed by blood cultures, two of these having had the line in for more than 14 days. In all three occasions the line was removed and the baby treated successfully with antibiotics. Conclusion: This study showed a high incidence of percutaneous CVL complications (33%), less frequent when using 2 French lines. Strict aseptic precautions should be adhered to during line insertions and line removal should be considered if sepsis is suspected.

Randomized trial of percutaneous central venous lines versus peripheral intravenous lines

To compare the occurrence of systemic infection or death in preterm infants with elective percutaneous central line (PCVL) placement versus peripheral intravenous catheter (PIV) placement. A total of 96 infants < or =1250 g or < or =30 weeks gestation were randomized by 4 days of age to elective placement of a PCVL or continued use of PIV catheters. The primary outcome of systemic infection (defined as a positive blood or cerebrospinal fluid (CSF) culture treated for at least 5 days) or death was monitored until the infants did not require intravenous (iv) support for 7 consecutive days. Systemic infection or death occurred in 17/46 (39%) infants in the PCVL group and 14/50 (28%) in the PIV group (relative risk (RR)=1.32 with 95% confidence interval (CI) 0.70, 2.53; risk difference (RD)=0.09 with 95% CI -0.10, 0.28). The PCVL group had significantly fewer skin punctures for iv access. There was no significant difference in systemic infection or death (expressed either as a combined outcome or as separate component outcomes) between the groups. The number of skin punctures was significantly reduced in the PCVL group.

Safer central venous access

Safer central venous access

Variation in identifying neonatal percutaneous central venous line position.

The study objective was to obtain data on interpretation, including intra and interobserver variation and action taken for a given line tip location, for a series of radiographs demonstrating neonatal long lines. Nineteen radiographs taken to identify line tip position were digitized and published on an internet site. One film was included twice in order to assess intraobserver variation giving a total of 20 images. Fourteen used radio-opaque contrast and five no contrast. Australian and New Zealand Neonatal Network members and National Women's Hospital NICU staff were invited to participate in the study. For each radiograph, participants were asked to identify if long line tip could be identified, the likely anatomical position and desired action. Interobserver agreement was assessed by the maximum proportion of agreement per radiograph and by the number of different options selected. Intraobserver agreement was assessed by comparing the two reports from the duplicate radiograph. Twenty-seven responses were received. Overall, 50% of the reports stated that the long line tips could be identified. The most commonly reported position was in the right atrium (31%) and most commonly reported action was to pull the line back (53%). The median agreement of whether the line was seen was 68%, agreement on position 62% and agreement on action 86%. On analysis of intraobserver variability, from the identical radiographs, 27% of respondents differed on whether the line tip could be visualized. Interobserver and intraobserver reliability was poor when using radiographs to assess long line tips. The major determinant of line repositioning was the perceived location.

Does radio-opaque contrast improve radiographic localisation of percutaneous central venous lines?

Background: Percutaneous central venous lines (long lines) are commonly used in neonatal practice. The position of these lines is important, because incorrect placement may be associated with complications. Aims: To...

Comparison of risks from percutaneous central venous catheters and peripheral lines in infants of extremely low birth weight: a cohort controlled study of infants &lt; 1000 g

Comparison of risks from percutaneous central venous catheters and peripheral lines in infants of extremely low birth weight: a cohort controlled study of infants &lt; 1000 g

Comparison of risks from percutaneous central venous catheters and peripheral lines in infants of extremely low birth weight: a cohort controlled study of infants < 1000 g

Objective: To evaluate in infants of < 1000 g (extremely low birth weight; ELBW ) the success rate of insertion of percutaneous central venous catheters (PCVC) and their duration; and the short-and long-term complications, i.e. mechanical and infectious, when compared to a control group of infants of the same age treated only with peripheral venous access. Study design: A cohort of 44 ELBW infantsmanaged with PCVC (study group) was compared to a cohort of 44 infants managed only with peripheral venous access (control group). The two groups were matched for birth weight, gestational age and gender,and were comparable for severity of illness (CRIB scores).Results: The success rate of PCVC insertion was 74% with the right axillary vein being the most frequently used site. The mean durationof PCVC treatment was 28 ± 13 days. The reasons for removal of the catheter were: cessation of the total parenteral nutrition administration in 75% of the cases and occlusion in 25%. There were threeinfectious episodes for a total of 1138 catheter days in the PCVC group vs. 12 episodes for a total of 1114 days (p = 0.03) in the control group. Three infants died in the study group and 11 infantsdied in the control group (p = 0.05) of infants of ELBW.Conclusion: Insertion of PCVC is successful in the vast majority of cases and carries a lower risk of infection than multiple insertionsof peripheral lines in infants of ELBW. It prevents repeat and painful introductions of intravenous needles.

Spontaneous correction of the malpositioned percutaneous central venous line in infants: S. Rastogi, A. Bhutada, R. Sahni, et al. Pediatr Radiol 28:694–696, (September), 1998

Spontaneous correction of the malpositioned percutaneous central venous line in infants: S. Rastogi, A. Bhutada, R. Sahni, et al. Pediatr Radiol 28:694–696, (September), 1998

Comparison of Risks from Percutaneous Central Venous Catheters (PCVC) and Peripheral Lines in ELBW Infants: A Cohort Controlled Study

Comparison of Risks from Percutaneous Central Venous Catheters (PCVC) and Peripheral Lines in ELBW Infants: A Cohort Controlled Study

Percutaneous translumbar cardiac catheterization and central venous line insertion: An alternative approach in children with congenital heart disease

Percutaneous translumbar cardiac catheterization and central venous line insertion: An alternative approach in children with congenital heart disease

Spontaneous correction of the malpositioned percutaneous central venous line in infants.

Malpositioning of the percutaneously placed central venous line (PCVL) or percutaneously inserted central catheter (PICC) in infants is not a rare occurrence. It has been occasionally observed that these lines spontaneously correct themselves. This prospective study was done to study the incidence of malposition and spontaneous correction. Using a modification of the standard method, 187 catheters were placed with 98.9 % success. Seven of these were initially malpositioned. All seven corrected themselves within a day when left in and used as a peripheral intravenous line. In many centers malpositioned catheters are taken out and replaced, which imposes great stress on the critically ill infant. Our study suggests that to avoid this stress the catheter should be left in place, since spontaneous correction may occur.

Long term venous access using a totally implantable drug delivery system in patients with cystic fibrosis and bronchiectasis

A completely implantable, subcutaneous, venous access system (Port-a-Cath) has been used for antibiotic therapy in 26 patients with cystic fibrosis or bronchiectasis over a period of 45 months. During this period there were ten complications in eight patients and in four patients all or part of the system had to be replaced. Nevertheless, the actuarial median functional survival of the implanted system exceeded 30 months. The Port-a-Cath system provides longer periods of venous access and has a lower complication rate than conventional, percutaneous central venous lines.