Central Venous Catheter Tip Research Articles

Clinical significance of isolated Staphylococcus aureus central venous catheter tip cultures

This retrospective cohort study examined the clinical significance of isolated Staphylococcus aureus central venous catheter (CVC) tip cultures (i.e., positive tip cultures without concomitant positive blood cultures). Subsequent S. aureus bacteraemia was found in nine (12%) of 77 patients at a median time of 4 days after CVC removal. A high co-morbidity score and no effective antibiotic treatment within 48 h of CVC removal were independent risk-factors for septic complications following multivariate analysis. A matched case-control study that compared the above cohort with patients with CVC tip cultures negative for S. aureus supported the significance of these findings.

Central Venous Catheter Tip Placement: Determination of Posterior Malposition—A Case Study

Abstract Methods for determining central venous catheter (CVC) tip placement vary among facilities. In most institutions, a single-view, anterior chest radiograph is used to visualize and evaluate the CVC catheter for malposition and/or position of the catheter tip. However, this method does not identify the posterior malposition of the catheter tip, which, on the anterior view, may appear correctly placed. In this article, the author (a) identifies the need for double-view chest radiographs for accurate determination of CVC tip placement and (b) emphasizes the importance of expertise of vascular access practitioners in the determination of catheter-tip placement and the identification of malposition and complication of CVC placement.

The carina as a radiological landmark for central venous catheter tip position

Many publications, including the instructions accompanying central venous catheters, state that it is negligent to site the catheter tip in the right atrium. If the catheter tip is above the carina on a post-procedure radiograph then it is generally accepted that the catheter lies outside the right atrium. It is also recommended that the catheter tip should lie in the long axis of the superior vena cava without acute abutment to the vein wall. We performed a retrospective audit of the position of central venous catheter tips on routine post-procedure chest radiographs in intensive care unit patients, to see if these potentially conflicting requirements had been met. We identified 213 central venous catheters suitable for analysis, within a study population of 200 consecutive cases. We measured the distance of the central venous catheter tip above or below the carina and the angle of the central venous catheter tip to the vertical (a surrogate marker for the angle of abutment of the tip to the approximately vertical superior vena cava wall). For right-sided catheters there was a high (74/163) number placed with their tips below the carina, but a very low number (4/163) with their tips at a steep (>40 degrees ) angle to the vertical. For left-sided catheters very few (7/50) were placed with their tips below the carina, but for those 43 sited above the carina most could be considered to be in suboptimal positions. This was because they were either too high and had not even crossed the midline (9), or had an acute angle (>40 degrees ) between the tip and the vertical (27). We suggest that for left-sided catheters placement of the tip below the carina is more likely to result in a satisfactory placement.

Depth of a central venous catheter tip: length of insertion guideline for pediatric patients

In pediatric patients, several studies have been undertaken to establish central venous catheter (CVC) tip optimal depth. Assessments of catheter tip position using chest radiographs may be misleading, whereas transesophageal echocardiography (TEE) has been shown to accurately monitor catheter tip placement at the superior vena cava-right atrial (SVC-RA) junction. The aim of this study was to issue a guideline for ideal catheter insertion depth, from the right internal jugular vein (IJV) using TEE to confirm the position of the catheter tip at the SVC-RA junction. Over a 6-month period, we studied 60 right internal jugular vein catheterizations in infants and children undergoing surgery for congenital heart disease. Positions of CVC tips were confirmed to be at the SVC-RA junction by TEE. Distance from the skin puncture site to the SVC-RA junction, height, weight, and age were recorded. Distances measured were found to be highly correlated with patient height. The following guideline allows the CVC tip to be positioned above the RA in 97.5% of patients with an accuracy of 95%: optimal depth of insertion (cm) = 1.7 + (0.07 x height) in patients whose height is between 40 and 140 cm. The model proposed for the insertion of the CVC tip in pediatric patients could be used to prevent inadvertent catheter tip placement into the atrium.

Diagnosis of central venous catheter-related thrombus by transesophageal echocardiography

Thrombus at the tip of central venous catheters is a problem frequently seen in patients receiveing intensive chemotherapy. Because many catheter-related thrombi are asymptomatic, the true incidence of this complication is difficult to assess and is likely underestimated. The major complication of the thrombus is pulmonary embolism. The thrombus incidence observed by TEE in asymptomatic patients is reported 12.5%. Our aim was to assess the frequency of central venous catheter-related thrombus before catheter removal in patients with hematological diseases by using TEE and to assess if the D-dimer test can predict the presence of a central venous catheter-related thrombus.

Voies veineuses centrales chez l'enfant : quoi de neuf ?

Central venous catheterisation under two-dimensional ultrasound (US) guidance has been proved to be quicker and safer than the classical landmark method in both adults and children. In the literature US guidance with sterile dressing of the probe is the ‘gold-standard’. Another way to use US is simple preoperative US location followed either by blind puncture, either by US guided puncture when difficulties are expected: small infants (< 15 kg), small diameter or collapses of the vein, multiple unsuccessful attempts during blind technique. Ideal location of the tip of central venous catheters is no more controversial but can depend on age and weight. In 2002 a French agency (Afssaps) study showed that the risk of perforation and tamponade was especially high in small weight prematures with 27 gauge polyurethane catheters when tip was located in the cardiac cavities. In children and adults venous thrombosis and catheter malfunction are closely related to short catheters whose tip is above T3–T4. Excepted polyurethane catheters in small weight prematures, the best location of long-term central venous catheters tip is the superior vena cava–right auricle junction. At this time routine antithrombotic prophylaxis is not recommended for children with long-term central venous catheters.

The carina as a landmark for central venous catheter placement in small children

Central venous devices are frequently used in children to monitor haemodynamic status, to administer fluids, medication, parenteral nutrition and for blood sampling. Life-threatening complications that may occur on insertion if the central venous catheter (CVC) is misplaced, are cardiac tamponade or a hydro-/haemopericardium. There is still controversy over the optimum catheter tip position in paediatric patients, whether to place the CVC tip in the superior vena cava, outside the pericardial boundaries or in the right atrium. However, the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is a radiographic marker for CVC placement, suggested on the basis of studies with conserved and fresh adult cadavers. In order to confirm this landmark for children, the present study was performed with 31 fresh cadavers of small children (mean age 12.5+/-3.4 months) that had been selected for autopsy in the Institute of Legal Medicine. Results clearly demonstrate that the carina was 0.5+/-0.04 cm above the pericardial duplication as it transversed the SVC. In no infant cadaver was the carina inferior to the pericardium. Thus, the results are analogous to those in adults and confirm that the carina is a simple anatomical-radiological landmark, superior to the pericardial reflection, that can be used to identify the placement of CVC even in newborn and small children.

Central Venous Catheter Tip Placement: Determination of Posterior Malposition—A Case Study

Methods for determining central venous catheter (CVC) tip placement vary among facilities. In most institutions, a single-view, anterior chest radiograph is used to visualize and evaluate the CVC catheterfor malposition and/or position of the catheter tip. However, this method does not identify the posterior malposition of the catheter tip, which, on the anterior view, may appear correctly placed. In this article, the author (a) identifies the needfor double-view chest radiographs for accurate determination of CVC tip placement and (b) emphasizes the importance of expertise of vascular access practitioners in the determination of catheter-tip placement and the identification of malposition and complication of CVC placement.

Correlation of mixed venous and central venous oxygen saturation and its relation to cardiac index

Background and Aim: The clinical applicability of substitution of central venous oxygen saturation for mixed venous oxygen saturations in monitoring global tissue hypoxia is still a matter of controversy. Hence aim of the study is comparison of paired samples of mixed venous and central venous oxygen saturation and comparison in relation to cardiac index in varying hemodynamic conditions. Materials and Methods: Prospective clinical observation: Postoperative cardiac surgical ITU: 60 adult patients, >18 years of age of either sex: A PAC was inserted through® IJV, triple lumen catheter was inserted through® IJV. Blood samples were taken from distal tip of PAC and central venous catheters. An arterial blood sample was drawn from either radial or femoral arterial line. Measurements: Continuous cardiac output monitoring. Analysis of blood samples for hemoglobin concentration and oxygen saturation. Mixed venous oxygen saturations and central venous oxygen saturations were compared. The study was carried over a period of 30h in the postoperative period and samples were taken at 6h intervals. Patients were classified into three groups as follows depending on the CI: Low ( 2 ), medium (2.5-4 L/m 2 ), high (> 4 L/m2) and correlated with Svo 2 and Scvo 2 . Results: 298 Comparative sets of samples were obtained. Svo 2 was consistently lower than Scvo 2 throughout the study period. The difference was statistically significant. By using Bland - Altman plot, the mean difference between Svo 2 and Scvo 2 (Svo 2 -Scvo 2 ) was - 2.9% ± 5.14 and confidence limits are + 7.17% and - 12.97%. The co-efficient r is > 0.7 throughout the study period for all paired samples. The correlation Svo 2 and Scvo 2 with cardiac index in all the three groups were >0.7. Conclusion: Scvo 2 and Svo 2 are closely related and are interchangeable. Even though individual values differ trends in Scvo2 may be substituted for trend in Svo 2

Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediatric patients

Several reports have proposed radiographic landmarks for the proper positioning of central venous catheters (CVC). The carina is one of the proposed landmarks in adults. Here, we evaluate the possibility of using the carina as a radiographic landmark for the identification of proper positioning of the CVC tip in paediatric patients. We studied 57 right internal jugular vein catheterizations in infants and children undergoing surgery for the treatment of congenital heart disease. After placing the CVC tip at the junction of the superior vena cava and the right atrium (SVC-RA junction) via intraoperative transoesophageal echocardiography, and by taking postoperative anterior-posterior chest radiographs, we measured the longitudinal distance from the carina to the SVC-RA junction, using the Picture Archiving and Communicating System. The average distance between the carina and the SVC-RA junction was 1.5 cm (95% CI 1.3-1.8 cm). No catheter tip was above the carina. Although there was no particular relationship between this distance and the patient's age, height, or weight, the distance between the carina and the SVC-RA junction tended to be more variable in younger and smaller children. The carina can be used as a radiographic landmark for the proper CVC tip placement in paediatric patients. If the tip of the CVC is not distal to the carina the chances are minute that it is in the right atrium.

Cathéters centraux et épanchements péricardiques en période néonatale : étude rétrospective multicentrique

Objective. – To evaluate the use of neonatal central venous catheters (CVC) in 38 french neonatal units and occurrence of pericardial effusion (PCE) over the past 5 years. Materials and methods. – We surveyed 38 units with a questionnaire and studied the cases of PCE in five units. Results. – Response rate was 89% (34/38). Accepted CVC tip positions were: junction of right atrium (RA) and vena cava (VC) 76%, VC 58%, RA 11%. Fifty percent of the centers had been exposed to PCE. 16 cases of PCE were studied. Median gestational age was 31 weeks (range: 26.1 to 40 weeks). Median time from insertion: 3.2 days (range: 0.4–13.5). In all cases CVC tip was intracardiac at insertion with inadequate withdrawing in 13 cases. Sudden cardiac collapse was reported in eight cases, and unexplained cardiorespiratory instability in six cases. Echography showed PCE in 14 cases. One diagnosis was post-mortem. CVC was withdrawn in 12 patients and 13 underwent pericardiocentesis. Four patients died and two had neurological sequelae. Conclusion. – PCE was associated with intracardiac CVC tip. The CVC tip should be controlled with radiography or echography outside the cardiac silhouette. PCE diagnosis must be considered in face of unexplained cardiovascular decompensation of neonate with CVC.

Octenidine Hydrochloride for the Care of Central Venous Catheter Insertion Sites in Severely Immunocompromised Patients

To determine the efficacy and tolerability of octenidine hydrochloride, a non-alcoholic skin antiseptic, for the care of central venous catheter (CVC) insertion sites. Prospective, observational study. Bone marrow transplantation unit of a university hospital. All consecutive patients with a nontunneled CVC were enrolled prospectively after informed consent. Octenidine hydrochloride (0.1%) was applied for disinfection at the CVC insertion site during dressing changes. The following cultures were performed weekly as well as at the occurrence of any systemic inflammatory response syndrome criteria: cultures of the skin surrounding the CVC entry site, cultures of the three-way hub connected to the CVC, blood cultures, and cultures of the CVC tip on removal. Enhanced microbiological methods (skin swabs of a 24-cm2 standardized area, roll plate, and sonication of catheter tips) were applied. One hundred thirty-five CVCs were inserted in 62 patients during the study period and remained for a mean period of 19.1 days, corresponding to 2,462 catheter-days. Bacterial density at the insertion site declined substantially over time, and most cultures became negative 2 weeks after insertion. Only 6 patients had a documented catheter-related bloodstream infection. The incidence density was 2.39 catheter infections per 1,000 catheter-days. No side effects were noted with application of the antiseptic. Disinfection with a skin antiseptic that contains octenidine hydrochloride is highly active and well tolerated. It leads to a decrease in skin colonization over time and may be a new option for CVC care.

Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter–related bacteremia in intensive care units*

To compare the rates of positive quantitative culture (PQC) of arterial catheter (AC) and central venous catheter (CVC) tips and of CVC- and AC-related bacteremia in intensive care unit patients undergoing placement of both ACs and CVCs. Prospective, descriptive survey. To control for a difference in the severity of patients having an AC or CVC, only patients having both an AC and a CVC were included. An adult, nine-bed medical/surgical intensive care unit at a university teaching hospital. The analysis included 308 CVCs and 299 ACs inserted in 212 severely ill patients, with a mean +/- sd Simplified Acute Physiology Score II of 52 +/- 22 and an intensive care unit mortality of 33% (69 of 212). None. The same insertion and maintenance procedures were used for both types of catheter. A PQC was defined by a catheter tip culture yielding >/=10(3) colony forming units/mL. Catheter-related bacteremia was defined by a PQC and a blood culture positive for the same microorganism. The cumulative incidence (PQCs/number of catheters inserted) was 9.4% (29/308) for CVCs and 7.7% (23/299) for ACs (p = .44). Incidence density (PQCs/1,000 catheter days) was 12.0 for CVCs versus 9.3 for ACs. At the femoral site, there was no significant difference between CVCs and ACs in the cumulative incidences and incidence densities of PQCs. Two instances of catheter-related bacteremia were observed, one involving a CVC and one involving an AC. Among severely ill patients with both CVCs and ACs, the epidemiology of PQCs of CVCs and ACs is comparable when the same infection control measures are used for the insertion and maintenance of both types of catheters.

Audit on safe placement of the central venous catheter tip

Jaleel, S.1; Govindaswamy, R.2; Lakshmanan, S.2; Giri, R.2; Pugsley, W.1; Bhabra, M.1; Frost, A.2 Author Information

Usefullness of carina as a radiographic landmark of central venous catheter tip position in pediatric patients

Usefullness of carina as a radiographic landmark of central venous catheter tip position in pediatric patients

Placement of Peripherally Inserted Central Catheters without Fluoroscopy in Children: Initial Catheter Tip Position

To determine how often placement of peripherally inserted central catheters (PICCs) without imaging guidance results in an initially correct central venous catheter tip location. This study was approved by the hospital's institutional review board, which waived the requirement for informed consent. In a children's hospital, 843 PICCs were placed in 698 patients (age range, 0 days to 26 years; mean, 6.9 years) during a 14-month study period. All PICCs were placed by a specialized team of PICC nurses and interventional radiology technologists in an angiography suite with the supervision of pediatric interventional radiologists. All catheters were threaded blindly to a previously estimated length by either a PICC nurse or a pediatric interventional radiologist, according to National Association of Vascular Access Networks guidelines, and the initial PICC tip location was then determined by means of spot fluoroscopy. PICC tips were regarded as central if they resided anywhere within the superior vena cava (SVC). All catheters were then manipulated with intermittent fluoroscopic guidance to achieve a final central position in the distal third of the SVC. A chi2 test was used to compare initial and final PICC tip locations according to patient age, catheter size, accessed vein, and need for radiologist assistance. A t test was used to compare procedure time with and without radiologist assistance. Analysis included 843 consecutively placed pediatric PICCs, of which 723 (85.8%) had a noncentral initial PICC tip position and required additional manipulation. After catheter repositioning performed with intermittent fluoroscopic guidance, a final central PICC tip location was achieved in 760 PICCs (90.2%). Pediatric PICC placement without fluoroscopic guidance required catheter manipulation of initial PICC tip position in 723 cases (85.8%). PICC placement with fluoroscopic guidance is highly successful, and the authors believe it is best performed in an angiography suite.

Management of a large organized intraatrial catheter-tip thrombus in a child with acquired immunodeficiency syndrome using escalating tissue plasminogen activator infusions

To describe the dissolution of a large organized intraatrial catheter-tip thrombus using a novel aggressive dose escalation of tissue plasminogen activator infusion. Case report. A six-bed pediatric intensive care unit (ICU) at a university hospital. An 8-yr-old with acquired immunodeficiency syndrome with a large organized intraatrial thrombus at the tip of an indwelling central venous catheter placed for total parenteral nutrition 2 months before presentation. Escalating dose of tissue plasminogen activator infusion. A large intraatrial catheter-tip thrombus (2.5 x 3 cm) was an incidental finding on an echocardiogram done to assess cardiac function. The thrombus occupied almost half the right atrial cavity and hit the tricuspid valve with each heartbeat without obstruction of tricuspid inflow. The catheter had no blood return from either lumen for >1 month. Protein C, protein S, and antithrombin III were normal, and factor V Leiden and prothrombin gene mutations were absent. Blood cultures were negative. Pediatric and cardiovascular surgeons recommended open-heart surgery as the safest option for catheter removal to avoid the risk of superior vena cava occlusion, vascular rupture, or embolization. A second opinion concurred. A trial of thrombolytic therapy with tissue plasminogen activator infusions was started at 0.1 mg/kg/hr for 6 hrs daily. No change in thrombus size was seen on a followup echocardiogram after 4 days. An aggressive dose escalation (0.15, 0.2, 0.25 mg/kg/hr for 6 hrs) was done over the next 5 days in an attempt to avoid open-heart surgery. Risks regarding disseminated intravascular coagulation and bleeding were presented to the parents. Followup echocardiogram on day 10 showed complete resolution of the thrombus. No changes in respiratory/hemodynamic status or oxygen saturation were observed. Studies for disseminated intravascular coagulation remained stable, and no clinical bleeding was seen. The catheter was safely removed surgically; pathology examination showed no residual thrombus. Prolonged infusion of tissue plasminogen activator in escalating doses was safe and effective in the management of a large intracardiac catheter-tip thrombus and helped avoid open-heart surgery. In view of the potential hazards of tissue plasminogen activator, close pediatric ICU monitoring is indicated with the use of high-dose tissue plasminogen activator infusions.

Cephalad origin of the superior vena cava and the level of the central venous catheter tip on chest radiographs

There are suggested radiographic landmarks for the lower margin of the superior vena cava (SVC), but none for the cephalad origin of the SVC in children. Therefore, we determined the cephalad origin of the SVC in relation to the level of thoracic vertebrae in children. Sixty-five patients (2-96 months) scheduled for routine diagnostic cardiac catheterization were the subjects of the study. Vena cavogram was obtained. The crossing point between the SVC and the innominate vein was considered as the cephalad origin of the SVC, then this point was related to the level of the thoracic vertebra as a radiographic landmark. In approximately 90% of the patients studied the proximal origin of the SVC was situated above the level of Th4/5 interspace. We would like to suggest that the position of the tip of central venous line, when inserted via the right internal jugular vein, should optimally be at the level of Th4/5 interspace on the postoperative chest radiograph.

Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter

Antiseptic coating of intravascular catheters may be an effective means of decreasing catheter-related colonization and subsequent infection. The purpose of this study was to assess the efficacy of chlorhexidine and silver sulfadiazine (CH-SS)-impregnated central venous catheters (CVCs) to prevent catheter-related colonization and infection in patients with hematological malignancies who were subjected to intensive chemotherapy and suffered from severe and sustained neutropenia. Proven CVC-related bloodstream infection (BSI) was defined as the isolation of the same species from peripheral blood culture and CVC tip (Maki technique). This randomized, prospective clinical trial was carried out in 106 patients and compared catheter-related colonization and BSI using a CH-SS-impregnated CVC (n=51) to a control arm using a standard uncoated triple-lumen CVC (n=55). Patients were treated for acute leukemia (n=89), non-Hodgkin's lymphoma (n=10), and multiple myeloma (n=7). Study groups were balanced regarding to age, sex, underlying diseases, insertion site, and duration of neutropenia. The CVCs were in situ a mean of 14.3+/-8.2 days (mean+/-SD) in the study group versus 16.6+/-9.7 days in the control arm. Catheter-related colonization was observed less frequently in the study group (five vs nine patients; p=0.035). CVC-related BSI were significantly less frequent in the study group (one vs eight patients; p=0.02). In summary, in patients with severe neutropenia, CH-SS-impregnated CVCs yield a significant antibacterial effect resulting in a significantly lower rate of catheter-related colonization as well as CVC-related BSI.

Candida parapsilosis bloodstream infection in pediatric oncology patients: results of an epidemiologic investigation.

To investigate an outbreak of Candida parapsilosis bloodstream infections (BSIs) involving three patients admitted to a pediatric oncology unit between April and June 2002. After the third case was documented, cultures were performed of the hands of all medical and paramedical staff members in the pediatric oncology unit and of environmental surfaces in the rooms occupied by the three patients. Electrophoretic karyotyping with pulsed-field gel electrophoresis and arbitrarily primed polymerase chain reaction were used to assess the genetic relatedness among C. parapsilosis isolates. The three cases of C. parapsilosis BSI were diagnosed based on blood cultures performed during a 38-day period. Evidence of prior C parapsilosis colonization of the gastrointestinal tract was present in only the first case. Each patient had an indwelling central venous catheter (CVC), which was promptly removed, and semiquantitative catheter tip cultures also revealed C. parapsilosis. None of the 30 environmental cultures performed was positive for C. parapsilosis, but the fungus was isolated from the hands of 6 of the 20 nurses tested. Both molecular typing methods revealed identical DNA fingerprinting patterns for all 13 patient isolates (7 from blood, 3 from CVC tips, and 3 from the gastrointestinal tract) and for 5 of the 6 recovered from the nurses' hands. These findings suggest the possibility of cross-infection with a single C. parapsilosis strain that was transmitted (probably during CVC dressing changes) by nurses whose hands were colonized with it. The role of previous gastrointestinal colonization in the first case cannot be excluded.