Triple-lumen Catheter Research Articles

Mapping Colorectal Distribution of Cell-free and Cell-associated HIV Surrogates Following Simulated Anal Intercourse to Aid Rectal Microbicide Development.

Anal sex remains the greatest HIV transmission risk for men who have sex with men and carries substantial population attributable risk among women. Despite a growing array of HIV pre-exposure prophylaxis (PrEP) options, rectal microbicides remain desirable as on demand, non-systemic PrEP. Rectal microbicide product development for PrEP requires understanding the spatiotemporal distribution of HIV infectious elements in the rectosigmoid to optimize formulation development. Outpatient setting with healthy research participants. Six healthy men underwent simulated receptive anal sex with an artificial phallus fitted with a triple lumen catheter in the urethral position. To simulate ejaculation of HIV-infected semen, autologous seminal plasma laden with autologous blood lymphocytes from apheresis labeled with 111Indium-oxine (cell-associated) and 99mTechnetium-sulfur colloid (cell-free) as HIV surrogates were injected into the rectal lumen through the phallic urethra. Spatiotemporal distribution of each radioisotope was assessed using SPECT/CT over eight hours. Analysis of radiolabel distribution used a flexible principal curve algorithm to quantitatively estimate rectal lumen distribution. Cell-free and cell-associated HIV surrogates distributed to a maximal distance of 15 and 16 cm, respectively, from the anorectal junction (∼19 and ∼20 cm from the anal verge), with a maximal signal intensity located 6 and 7 cm, respectively. There were no significant differences in any distribution parameters between cell-free and cell-associated HIV surrogate. Cell-free and cell-associated HIV surrogate distribution in the rectosigmoid can be quantified with spatiotemporal pharmacokinetic methods. These results describe the ideal luminal target distribution to guide rectal microbicide development.

Guided, motor, and mental imagery adjuncts to teaching central venous access.

Mental, motor, and guided imagery techniques are commonly used in sports psychology, but less often in medical education. Utilization of imagery-based techniques (IBTs) in combination with traditional teaching methods may provide a low-cost, innovative approach to improving outcomes in graduate medical education. The objective was to assess whether medical students demonstrate greater proficiency in the ability to obtain central venous access in simulation trainers following exposure to guided, mental, and motor imagery teaching methods in comparison to traditional methods. Volunteer fourth-year medical students during their emergency medicine rotation were randomly assigned to two groups, traditional plus imagery teaching or traditional teaching alone. The control group watched a video tutorial on central line placement methods. The study group watched the same video with the addition of imagery components. Participants filled out survey questions before and after the video and again after line placement. Proctors blinded to student group assignments then observed student placement of an internal jugular triple-lumen catheter on a simulation trainer and completed a standardized performance rubric. Sixty medical students participated. Two were excluded for having performed five or more lines either clinically or in a previous simulation. There was no difference in self-perceived competence in line placement prior to watching the video or in the number of lines previously performed between groups. The imagery group (n = 25) averaged 1.3 errors/need for intervention compared to 2.2 errors/need for intervention in the control group (n = 33; p = 0.045, 95% confidence interval [CI] 0.02 to 1.61). Time to place the line was similar-8.9 min for the control group versus 8.6 min for the imagery group (p = 0.74, 95% CI -1.39 to 1.95). The use of IBTs may be a promising adjunct to traditional medical teaching of procedures in emergency medicine.

Early Mobility in Patients With Femoral Catheters

Early Mobility in Patients With Femoral Catheters

364 A Dangerous Case of the “Goldilocks Effect”: Experimental Demonstration of Potential Vascular Injury Mechanism with Central Venous Catheter Insertion

364 A Dangerous Case of the “Goldilocks Effect”: Experimental Demonstration of Potential Vascular Injury Mechanism with Central Venous Catheter Insertion

Design and Development of a Disposable Superfine Catheter for Visual Examination of Bile Ducts and Related Animal Experiments.

ObjectiveTo design and develop a disposable superfine catheter system for visual examination of bile and pancreatic ducts and predict its clinical application value.MethodsThe superfine triple-lumen catheter and miniature photography technology were used to design and produce a disposable superfine catheter for visual examination of bile and pancreatic ducts, and animal experiments were conducted to compare said catheter and SpyGlass™.ResultsThe designed and developed disposable superfine catheter for visual examination of bile ducts with a diameter of 2.4 mm could enter the third-order and fourth-order bile ducts in the animal liver and also the gallbladder via the cystic duct for observation. The said catheter has a water injection rate of 0.8 mL/s, 0.16 megapixels, a resolution of 400 × 400, a depth of field of 0.3 to 20 mm, and a tilting up angle >90°.ConclusionThe new disposable catheter for visual examination of bile ducts has a superfine diameter, easier operation, and clearer imaging, and is expected to have a higher clinical practical value.

344 Risk of CLABSI With Dual-Lumen Versus Triple-Lumen Catheters in Hemodialysis Patients: A Quality Improvement Initiative

344 Risk of CLABSI With Dual-Lumen Versus Triple-Lumen Catheters in Hemodialysis Patients: A Quality Improvement Initiative

Sternal Retraction and Subclavian Vein Catheter Occlusion during Cardiac Surgery.

BackgroundSubclavian vein (SV) catheterization is a method for the delivery of fluids, drugs, and blood products, venous blood sampling, and central vein pressure monitoring in cardiac surgery. Catheter occlusion is a serious complication of SV catheterization during cardiac surgery, especially after sternal retractor expansion.MethodsIn this observational study, 303 patients who had successful right infraclavicular SV catheterization from September 2019 to April 2020 were enrolled to determine the incidence of catheter occlusion. After catheterization, the lumens of all catheters were checked for the ability to infuse and withdraw blood from the catheter before and after sternal retractor expansion. The patients’ characteristics, cannulation approach, on-pump or off-pump technique, occlusion of the catheter and its lumens, and any associated complications were recorded. The data were analyzed using IBM SPSS ver. 22.0 (IBM Corp., Armonk, NY, USA).ResultsOf the 303 patients studied, 205 were male (67.7%) and 98 were female (32.3%). Catheter occlusion occurred in 11 patients with on-pump cardiopulmonary bypass (CPB) (227 patients) and 4 patients with off-pump CPB (76 patients) (p=0.863). The incidence of catheter occlusion was 4.95% (15 of 303 patients) with no cases of simultaneous 3-lumen occlusion in a catheter. The most commonly occluded lumen was the distal lumen (57.92%). Simultaneous 2-lumen occlusion occurred in 4 patients. Catheter occlusion was found in 3 of 13 malpositioned catheters (23.07%).ConclusionThe current study showed that malpositioning of the catheter tip was a risk factor for catheter occlusion and that the distal lumen of a triple-lumen catheter was the most commonly occluded lumen.

Tunneled and routine peripherally inserted central catheters placement in adult and pediatric population: review, technical feasibility, and troubleshooting.

Vascular access procedures are crucial for the management of various critically ill pediatric and adult patients. Venous access is commonly performed in the form routine as well as tunneled peripherally inserted central catheters (PICC). These venous accesses are commonly used in emergency, surgical as well as ICU settings, for various infusions, total parenteral nutrition, long term intravenous antibiotics, frequent blood draws, etc. PICC insertion is guided using ultrasound and fluoroscopic guidance, which decreases the risk of complications that are otherwise seen with central venous accesses like triple lumen catheters, etc. PICC insertion and care is very simple and can be performed by specially trained PICC nurses and that helps in decreasing the overall cost of healthcare. This review article is written with educational intent for the readers to discuss indications, contraindications, procedure techniques, imaging, care of routine as well as tunneled PICC.

POS-560 HEMODIALYSIS CATHETER ASSOCIATED BLOODSTREAM INFECTIONS (CABSI) AT A TERTIARY CARE HOSPITAL IN NORTH INDIA: INCIDENCE,OUTCOME AND ANTIBIOGRAM OF THE ISOLATED ORGANISMS

Infections are common complications among patients on hemodialysis. In North India, emergency dialysis initiation with hemodialysis catheter is the norm. Thereafter patients defer AV-Fistula construction for financial and logistic reasons, with <50% having a functional AV-Fistula even 4 months after dialysis initiation. Hemodialysis patients with a catheter have a 2- to 3-fold increased risk of hospitalization for infection and death compared with patients with an arteriovenous fistula or graft. Prompt diagnosis for early treatment is essential to avoid complications including catheter removal and endocarditis. We studied the incidence, microbiological spectrum and outcomes of CABSI at a tertiary care hospital in North India. In this retrospective-prospective observational cohort study, all adult (>18 years) patients who underwent tunnelled or non-tunnelled hemodialysis catheter insertions were screened during a period of 2 ½ years (January 2018 to June 2020). Patients who were suspected to have CABSI were confirmed by CDC guidelines for diagnosis of central line-associated bloodstream infections. 1010 patients underwent catheter insertion during this period and 160 patients fulfilled the diagnostic criteria. CABSI incidence was 27.33 episodes per 1000 catheter days and median infection-free survival of the catheter was 3.28 weeks. The cumulative hazard for CABSI was 1.3, 10.6, 41.2 and 65% at 1, 2, 3 and 4 weeks respectively. Median catheter days for tunneled catheter were 117 days and for non-tunneled catheter were 23 days. The incidence of CABSI among femoral and triple lumen catheters was higher as compared to jugular and double lumen catheters respectively (p value <0.0001). The majority of patients (52.5%) were between 51-70 years of age and were mostly male. Hypertension was present in majority (96.25%) of patients, followed by Diabetes mellitus. The most common symptom was fever, followed by chills and hypotension. 100 patients were managed in ICU, 45 patients were managed in the ward and 15 patients were managed on OPD basis. Gram negative were the dominant organisms, followed by common commensals, gram positive and fungi (Figure 1). E. coli was the most commonly grown gram negative organism. High total leucocyte count and high serum procalcitonin distinguished Gram-positive and Gram-negative infections from those by common commensals. 58 antibiotic resistant strains (36.25%) were cultured. The rise in Acinetobacter positive cases and the growing resistance against third generation cephalosporins, carbapenems was a notable phenomenon amongst gram negative organism. In 139 cases of CABSI, catheter was removed once CABSI was diagnosed. The need for hospitalization and complications was significantly higher in gram positive, gram negative, fungal as compared to common commensals (p value=0.006). Mortality was significantly higher in gram positive, fungal as compared to gram negative and common commensals (p value=0.02). 12 CABSI were complicated by endocarditis. Mortality rate was 17.5%, sepsis being the most common cause of death. In this study, CABSI occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon. Growing prevalence of gram-negative bacteria has been related to the immunocompromised state of patients, contaminated infusate and overexposure of antibiotics.

Adverse hemodynamic response due to malposition of central venous catheter

Central venous catheter (CVC) is an inescapable requirement of any cardiac surgery for administering drugs including inotropes, cardiac pacing, and invasive monitoring during the perioperative period. Central venous access involves triple-lumen catheter inserted in the internal jugular or femoral vein. The preferred vein for CVCs is the right internal jugular vein because of straighter course to the right heart, better visibility on ultrasonography, lowest risk of the venous stenosis and thrombosis, and also keeping in mind the nature of surgery involved and patient positioning. Malposition of the catheter is a relatively common complication (5.01%) which results in the malfunction of catheters. We report a case of a malposition of a CVC in a 70-year-old male who underwent mitral and aortic valve replacement along with coronary artery grafting for the posterior descending artery on cardiopulmonary bypass.

Repurposing a Small Community Hospital Surgical Residency Program in an Epicenter of the COVID-19 Pandemic.

COVID-19 put a stop to the operative experience of surgical residents, leaving reassignment of the team, to the frontlines. Each program has adapted uniquely; we discuss how our surgical education changed in our hospital. A retrospective review of changes in general surgery cases, bedside procedures, and utilization of residents before and during the pandemic. Procedures were retrieved from electronic medical records. Operating room (OR) cases 1month before and 5weeks after the executive order were collected. Triple lumen catheter (TLC), temporary hemodialysis catheter (HDC), and pneumothorax catheter (PC) insertions by surgical residents were recorded for 5weeks. Before the pandemic, an average of 27.9 cases were done in the OR, with an average of 10.1 general surgery cases. From March 23 to April 30, 2020, the average number of cases decreased to 5.1, and general surgery cases decreased to 2.2. Elective, urgent, and emergent cases represented 83%, 14.6%, and 2.4% prior to the order and 66.7%, 15.1%, and 18.2%, respectively, after the order. Bedside procedures over 5weeks totaled to 153, 93 TLCs, 39 HDCs, and 21 PCs. Repurposing the surgical department for the concerns of the pandemic has involved all surgical staff. We worked with other departments to allocate our team to areas of need and re-evaluated daily. The strengths of our team to deliver care and perform many bedside procedures allowed us to meet the demands posed by this disease while remaining as a cohesive unit.

Genitourinary Toxicity In Prostate Cancer Patients With History Of Transurethral Resection Of The Prostate Undergoing High Dose Rate Brachytherapy With A Novel Urethral-Sparing Technique

Prior transurethral resection of the prostate (TURP) is traditionally considered a contraindication to high dose rate prostate brachytherapy (HDR-B) due to increased risk of urinary morbidity and poor dose distribution in the prostate. We previously described a novel technique using a modified triple-lumen catheter to visualize and spare the TURP defect during CT-based HDR-B. We now report genitourinary (GU) toxicity in our institutional experience with this urethral-sparing technique. Prostate cancer patients with >3 months follow-up who underwent HDR-B using a modified triple-lumen catheter to visualize the TURP defect were included. Patient demographics, disease characteristics, dosimetry, and clinical outcomes were retrospectively reviewed. Toxicity was graded using NCI CTCAE v5.0 and classified as acute (≤90 days after HDR-B) or late (>90 days). Thirty-three patients met inclusion criteria. Median age was 76 years (IQR 74-80) and median follow up was 17.0 months (range 3.3-64.8). Thirty patients had 1 previous TURP and 3 patients had 2. Median time from most recent TURP to HDR-B was 49.0 months (IQR 6.1-125.8). Twenty-nine patients had newly diagnosed prostate cancer: 9 intermediate risk, 17 high risk, and 3 regional risk disease per NCCN. Among these, 1 patient received HDR-B monotherapy (27 Gy/2 fractions) and 28 received HDR-B boost (15 Gy/1 fraction) combined with external beam radiotherapy (EBRT). Four patients underwent salvage HDR-B for local recurrence 3-12 years after definitive radiotherapy: 1 received EBRT, 1 LDR-B and 2 HDR-B monotherapy. Among these, 2 patients received whole gland monotherapy (15 Gy/1 fraction, 36 Gy/6 fractions), 1 received partial gland monotherapy (27 Gy/2 fractions), and 1 received whole gland boost (18 Gy/3 fractions) combined with EBRT. Twenty-seven (82%) patients did not experience acute G2 or higher GU toxicity. Five (15%) patients experienced G2 toxicity (4 with retention or hematuria requiring temporary catheter placement and 1 with urinary frequency). One patient had G3 hematuria requiring procedural intervention 2 months after HDR-B. Only 2 of 29 newly diagnosed patients experienced acute G2 or higher GU toxicity, compared to 4 of 4 patients receiving salvage HDR-B re-irradiation. Twenty-seven (82%) patients did not experience late G2 or higher GU toxicity. Three (9%) patients experienced G2 hematuria (2 with clot retention requiring catheter placement and 1 requiring hyperbaric oxygen therapy) and 4 (12%) experienced G2 urinary incontinence. Two (6%) patients had late G3 toxicity (hematuria and retention) requiring procedural intervention. HDR-B in prostate cancer patients with a history of TURP has an acceptably low risk of G2 or higher GU toxicity when the urethral defect is adequately spared during CT-based planning. Acute G2 or higher GU toxicity occurred primarily in patients receiving salvage HDR-B re-irradiation and did not predict late G2 or higher GU toxicity.

A Quality Improvement Project to Reduce Unnecessary Use of Multilumen PICCs

Background: Peripherally inserted central catheters (PICCs) are an increasingly common vascular access device. At our institution, &gt;4,000 devices are placed per year by a trained team of vascular access nurses. Although PICCs are generally safe and effective, they do carry the risk of infection and thrombosis, and this risk increases exponentially with increasing number of lumens. As part of a multidisciplinary quality improvement effort to address rising CLABSI rates, we designed interventions to improve PICC utilization. Methods: The project team used 6-σ methodology, specifically following the DMAIC (define, measure, analyze, implement, control) framework to guide analysis and interventions. Process mapping, semistructured interviews with key stakeholders, electronic surveys, and audits were performed to identify gaps and inform interventions. The interventions consisted of 3 components: changes to the electronic ordering system, education (presentations to ordering providers and an online toolkit), and clinical decision support in the form of a team of vascular-access subject-matter experts who provided guidance on line selection. Results: In total, 4,655 PICCs and 434 midlines were inserted in the 12 months before the intervention, and 7,457 PICCs and 929 midlines were placed in the 24 months after the intervention. Following the implementation of the intervention, proportions of triple-lumen catheter utilization decreased from 31.9% to 22.3% (P &lt; .0001). Concurrently, the proportion of single-lumen catheters has increased from 28.5% to 41.9% (P &lt; .0001). Overall PICC utilization decreased in the postintervention period from an average of 387.9 PICCs placed per month to 310.7. The proportion of midline catheters increased from 8.5% of total lines inserted to 11.4% in the postintervention period (P &lt; .001). Conclusions: Our intervention reduced overall PICC use and triple-lumen PICC use and increased relative utilization of single-lumen PICCs and midline catheters. Optimization of electronic orders, in conjunction with targeted education and decision support, can have a sustained impact on provider ordering behaviors and can shift the culture of utilization, even in a large academic medical center with frequent turnover of trainees.Funding: NoneDisclosures: Consulting fee- Merck (Priya Sampathkumar)

Managing central venous access during a health care crisis

ObjectiveDuring the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. MethodsWe conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. ResultsParticipants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). ConclusionsImplementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Venue of catheter insertion does not significantly impact the event of central line-associated bloodstream infection in patients with haematological diseases

SummaryBackgroundCentral line-associated bloodstream infection (CLABSI) is a serious complication of central venous catheter (CVC) placement in patients with haematological diseases associated with neutropenia and immunosuppression. However, whether the venues where CVC are inserted influence CLABSI development remains unclear.MethodsWe investigated whether CVC insertion at venues with different standards of cleanliness altered the occurrence of CLABSI. We evaluated data from 279 patients (545 CVC insertions) with haematological diseases including age, sex, underlying disease, reason for insertion, insertion site, number of lumens, venue, dates of insertion and removal, complete blood counts, percentage of neutrophils and serum albumin concentrations at the time of CVC insertion.FindingsOverall, 55 CLABSI events occurred during a period of 23,434 catheter days (2.35 per 1,000 catheter days). In total, 153 and 190 patients underwent 226 and 305 CVC insertions, respectively in a ward and in an operating room, respectively. Univariate analysis identified the operating room (P = 0.017), allogeneic haematopoietic stem cell transplantation (P < 0.001), triple lumen catheter (P = 0.002), haemoglobin (P = 0.019), white blood cell count (P = 0.012) and percentage of neutrophils (P = 0.012) as significant factors for the development of CLABSI. However, multivariate analysis adjusted for age, reason for insertion, insertion site, number of lumens, haemoglobin, percentage of neutrophils and platelet counts found no significant differences between the venue where CVC were inserted and CLABSI development (P = 0.158).ConclusionThe venue of CVC insertion is unlikely to influence CLABSI development in patients with haematological diseases.

242.6: Outcome of kidney transplantation from donation after circulatory death.

Background: The use of organs from donors after circulatory death (DCD) has become standard practice in solid organ transplantation in most of the countries. However, it has not contributed much to increase the transplant numbers in India due to lack of proper guidelines for withdrawal of life support in the country’s Transplantation of Human Organs Act 1994. Transplantation of kidneys procured from DCD is being done by only a few centres in the country. This study reviews the outcome of kidney transplantation from donation after circulatory death at our centre. Methods: A retrospective, single-centre analysis of transplantation of kidneys procured from DCD donors. Out of 275 deceased donor transplants performed at our hospital form Feb 2011-Nov 2018, 24 were procured from 15 DCD donors. Seven donors had a cardiac arrest after the first brain death certifying committee evaluation. Five donors had cardiac arrest after brain death certification. Two donors were refused brain death certification due to confounding factors. One patient with terminal lung disease had cardiac arrest in ICU. After declaration of death, chest compressions were continued in 11/15 donors to maintain circulation and ventilation was continued till organ retrieval. Rapid organ retrieval was done using double balloon triple lumen catheter. All recipients received ATG or Simulect induction along with Tacrolimus, Mycophenolate and steroids. Results: During the study period thirty kidneys retrieved from 15 DCD donors, kidneys from 2 donors were not used for transplant due to high resistance during perfusion. One more kidney was not utilized as potential recipient withdrew consent at advanced stage. Rest 24 kidneys were used for transplant. 13 donors had head injury, one had CVA and one had terminal lung failure as cause of death. Mean donor age was 32.8 ± 13.6 years. Mean recipients age was 42.5 ± 11.3 years. All except 5 recipients required dialysis in postoperative period. One kidney had primary non functional whereas in one with dual kidney transplant, both kidneys had to be removed due to persistent severe interaoperative hypotension in the recipient. One graft was lost at 6 years. Mean warm ischemia time was 35.04 ± 11.0 minutes. Mean cold ischemia time was 06:51hrs. Mean creatinine at discharge was 1.49 ± 0.39 mg% and at the last follow-up of 33.9 + 22.7 months was 1.37 + 0.55mg %. Conclusions: Kidney transplantation from DCD donors yields good results in the long term. These DCD grafts may be a good option to cope with increasing organ shortages in order to expand the donor pool.

The Angel catheter for the prevention of pulmonary embolism: combining an IVC filter and a triple-lumen central venous catheter

ABSTRACTIntroduction: Pulmonary embolism is common in critical care patients and carries significant morbidity and mortality. Concurrent risk of severe bleeding in this population may prohibit anticoagulation.Areas covered: The Angel Catheter device is a central venous catheter combined with an inferior vena cava filter inserted at the bedside for pulmonary embolism prevention. Our review examines the role of this device, safety, efficacy and the limitations it presents.Expert commentary: We conclude the Angel catheter should be considered in critical care patients with significant risk of pulmonary embolus as bridging therapy until anticoagulation can be safely resumed.

Vascular Access Device Complications during Induction Chemotherapy for AML: A Single Institutional Analysis

Introduction: Induction chemotherapy for acute myeloid leukemia (AML) is fraught with complications ranging from minor to life threatening. Central venous access is routinely achieved to administer cytotoxic chemotherapy to avoid damage to peripheral veins. Vascular access devices (VAD), however, are not without complications, ranging from bloodstream infection (BSI) to thrombosis. There is limited data on the safety of VAD, some showing equivalent risk for DVT across devices. In non AML patients, data has shown that risk of complications increase with the number of lumens within the device. We performed a single institutional analysis to investigate the correlation between VAD and infectious and/or thrombotic complications during induction chemotherapy for AML.Method: We retrospectively reviewed medical records of 93 adults [median age 64 (21-89)] with AML at Beaumont Hospital, an academic community center from January 2010 - December 2015. We extracted data regarding type of VAD, thrombosis, and bloodstream infections during the first 60 days of induction chemotherapy.Results: Demographic distribution of the cohort were 52 (56%) white, 4 (4%) African American, 11 (12%) others. Of these patients, 17 (18%) had single lumen mediport, 41 (44%) had peripherally inserted central catheter (PICC), 12 (13%) had tunneled dual lumen catheter (TDL), 23 (25%) had tunneled triple lumen catheter (TDL). Of the patients with PICC, 2 were single lumen, 1 was triple lumen. In the total population, 33 (35%) developed BSI with the following rates per VAD; Mediport 7 (41.8%), PICC 6 (25.6%), TDL 5 (41.7%), TTL 11 (47.8%). Bloodstream infection rate adjusted for skin flora and fungi were as follows; Mediport 6 (35%), PICC 6 (15%), TDL 2 (17%), TTL 6 (23%). Median time to BSI was 11 days (range 5-60) with no difference between type of VAD. Deep vein thrombosis of the upper extremity occurred in 5 of 93 cases, 4 of which were in patients with PICC and 1 with a TDL. Combined BSI and/or upper extremity thrombosis rate were as follows; Mediport 7 (41%), PICC 14 (36%), TDL 5 (42%), TTL 12 (52%). When adjusted for BSI due to skin flora combined with DVT the rates were Mediport 6 (35%), PICC 10 (25.6%), TDL 2 (17%), TTL 7 (30%).Conclusion: In patients undergoing induction chemotherapy for AML, the choice of VAD was associated with different levels of risk of BSI and DVT. The lowest overall BSI rate was with PICC. When adjusted for BSI due to skin flora or fungi, PICC and TDL were similar. The combined risk of BSI and DVT was lowest with PICC, however, if only accounting for BSI due to skin flora or fungi, then TDL was the safest. A lower rate of line associated DVT risk may be achieved with a tunneled VAD compared to PICC. This data suggests that dual lumen PICC or TDL are the optimal VAD for induction chemotherapy in AML patients.Figure 1. Skin flora include S. epidermidis, Acinetobacter, S. aureus, S. viridans.Fungi includeCandida species, R. mucilaginosa. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

ENERGY EXPENDITURE DURING TARGETED TEMPERATURE MANAGEMENT: A PROSPECTIVE COHORT STUDY

SESSION TITLE: Miscellaneous Critical Care SESSION TYPE: Original Investigations PRESENTED ON: 10/10/2018 07:30 AM - 08:30 AM PURPOSE: To measure and quantify the relationship between core body temperature and metabolic consumption during targeted temperature management. METHODS: Ten patients (mean age 39.7, range 24 to 65, 7 males, 3 females) undergoing targeted temperature management after cardiac arrest at 32OC to 33OC were included in this prospective cohort study.Mild therapeutic hypothermia was induced by active cooling using temperature controlled intravenous filters (Zoll Thermoguard XP). A triple lumen catheter was inserted into a femoral vein. Core body temperature was continuously monitored.After ROSC external passive and internal active cooling was started immediately in order to expedite the reduction of body temperature, once the thermometer reached 32O to 33OC the external cooling was stopped and internal active cooling was used to maintain the temperature over a period of 48 hours.The rewarming phase was undertaken over a period of 24 hours (1OC/3 hours).Indirect calorimetry was determined by computerized respiratory gas exchange (Deltatrac II, Datex-Ohmeda). Oxygen consumption and carbon dioxide production were measured every hour during induction, the 48 hours of hypothermia and 24 hours of rewarming. The basal metabolic rate (kilocalories/day) was calculated using the Harris-Benedict equation: RESULTS: Cooling was started within 15±7 minutes after ROSC. The core body target temperature was achieved after 95±30 minutes of initiating cooling. The average drop in temperature compared to the target temperature (32OC- 33OC) was 2.7OC per hour. During the stage of steady state of targeted temperature management, core body temperature was 31.5±0.9OC.The oxygen consumption compared with baseline temperature was reduced by 82 mL/min (95% CI 59 to 107 mL/min; p=0.003).The basal metabolic rate was decreased by 35.6% (95% CI 26.9 to 52.3%; p=0.004) during the stage of steady state targeted temperature management.Future analysis and calculations will compute correlation between temperature, time and energy expenditure as well as estimations of fat and protein oxidation rates by means of mathematical equations. CONCLUSIONS: The main finding of an immediate reduction in oxygen consumption achieved by targeted temperature management was directly proportional to the reduction in core body temperature. Other studies by Bruder, Tokutomi, and Saur have shown similar measured values and results.Some of the limitations of this study are the small number of patients leading to big differences in measurements. Ideally, a similar study with a larger number of patients should be conducted to confirm our results. Another limitation was the use of different core body thermometers for which differences were not calculated. CLINICAL IMPLICATIONS: From a clinical perspective, it would seem reasonable to reduce the caloric intake during targeted temperature management since the basal metabolic rate was decreased by 35.6%. DISCLOSURES: Speaker/Speaker's Bureau relationship with Sunovian Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Honoraria Advisory Committee Member relationship with Astra Zeneca Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Consulting fee No relevant relationships by Emmanuel Urquieta, source=Web Response No relevant relationships by Joseph Varon, source=Web Response

Validation of new marker of fluid responsiveness based on Doppler assessment of blood flow velocity in superior vena cava in mechanically ventilated pigs

BackgroundWe studied a novel approach for the evaluation and management of volemia: minimally invasive monitoring of respiratory blood flow variations in the superior vena cava (SVC). We performed an experiment with 10 crossbred (Landrace × large white) female pigs (Sus scrofa domestica).MethodsHypovolemia was induced by bleeding from a femoral artery, in six stages. This was followed by blood return and then an infusion of 1000 ml saline, resulting in hypervolemia. Flow in the SVC was measured by Flowire (Volcano corp., USA), located in a distal channel of a triple-lumen central venous catheter. The key parameters measured were venous return variation index (VRV)—a new index for fluid responsiveness, calculated from the maximal and minimal velocity time intervals during controlled ventilation—and systolic peak velocity (defined as peak velocity of a systolic wave using the final end-expiratory beat). A Swan–Ganz catheter (Edwards Lifesciences, USA) was introduced into the pulmonary artery to measure pulmonary arterial pressure, pulmonary capillary wedge pressure, and continuous cardiac output measurements, using the Vigilance monitor (Edwards Lifesciences, USA).ResultsWe analyzed 44 VRV index measurements during defined hemodynamic status events. The curves of VRV indexes for volume responders and volume non-responders intersected at a VRV value of 27, with 10% false negativity and 2% false positivity. We compared the accuracy of VRV and pulse pressure variations (PPV) for separation of fluid responders and fluid non-responders using receiver operating characteristic (ROC) curves. VRV was better (AUCROC 0.96) than PPV (AUCROC 0.85) for identification of fluid responders. The VRV index exhibited the highest relative change during both hypovolemia and hypervolemia, compared to standard hemodynamic measurement.ConclusionsThe VRV index provides a real-time method for continuous assessment of fluid responsiveness. It combines the advantages of echocardiography-based methods with a direct and continuous assessment of right ventricular filling during mechanical ventilation.