Types Of Central Venous Catheters Research Articles

Life on the line - Incidence and management of central venous catheter complications in intestinal failure

Background & AimsLoss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. MethodsFor this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDT) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/ port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDT were compared. ResultsOverall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 “CVC-days”). Broviac type “B” was found to be significantly superior to type “A” regarding occlusion, CRI, and material defects (log-rank test: p=0.05; p=0.026; p=0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 388.5 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. ConclusionsDifferent complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases.

Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases. Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022). Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p<.0001; for bacteremia double-lumen CVC (HR 3.2, p<.0001); for mechanical complications age at CVC insertion under median (HR 4.5, p<.0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p=.01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p=.0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p<.0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p<.0001. Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

Sellado antibiótico de reservorios subcutáneos: estabilidad de soluciones con vancomicina

Subcutaneous reservoirs are a type of central venous catheter. When using central venous catheters, healthcare workers need to avoid two major risks: clot formation and bacterial infections. To prevent and avoid catheter contamination in both hospitalized patients and outpatients, several strategies have been carried out, such as the so-called ” antibiotic-based catheter lock solution”. Therefore, it has been suggested to implement the use of solutions with antimicrobial agents, to which anticoagulant and/or antibiofilm substances are often added. However, the stability of such solutions needs to be tested by techniques such as high performance liquid chromatography (HPLC), in addition to antimicrobial efficacy testing, in order to establish patient safety. In consequence, this literature review aims to include the most clinically representative research towards these aspects, to demonstrate the behaviour of antibiotic-based catheter lock solutions under different conditions of storage and use. In particular, this review focuses on solutions containing vancomycin. According to the studies consulted, vancomycin solutions with sodium citrate (chelating agent) present the best stability characteristics in terms of physicochemical properties and efficacy.. Keywords: Vancomycin; heparin; sodium citrate; stability; subcutaneous implantable central venous device

Clinical Factors Associated with Catheter-Related VTE in Patients Undergoing Hematopoietic Cell Transplantation

Introduction: In patients undergoing allogeneic hematopoietic cell transplantation (HCT), venous thromboembolism (VTE) is associated with increased morbidity and worse survival. Central venous catheters (CVC) are placed for administration of both stem cell products and other supportive measures. CVC are a common etiology of VTE during HCT. This study examines the associations between patient- and CVC-related variables and the incidence of catheter-related thrombosis (CRT) in patients undergoing allogeneic HCT. Methods: We selected consecutive patients who underwent their first allogeneic HCT from MD Anderson Cancer Center between 2016-2020. The electronic medical records (EMR) of these patients were examined using ICD 9/10 codes, and radiology reports using a natural language processing (NLP) algorithm to look for VTE events. All VTE events were confirmed via manual chart review. Details on the type of CVC, anatomic venous location, laterality, and size were extracted. For this study, CVC was defined as a catheter that extends into the superior vena cava; these catheters were classified as either a peripherally induced central catheter (PICC), non-tunneled CVC, or tunneled CVC. Unadjusted and multivariable Cox proportional hazards models were used to assess the association between patient and transplant factors and time to CRT. Acute graft versus host disease and active infection were included in the models as categorical time varying covariates. Cumulative incidence competing risk model was used to assessed CRT incidence with death as a competing cause. Results: There were 1371 adult patients included in the study. Most patients had non-tunneled CVC as their central access, with the subclavian vein being the most used location (Table 1). A total of 207 patients had VTE during the first year post-HCT, with 153 having isolated CRT and 54 having other VTE (Table 1). The incidence of CRT was 7.7% at 100-day and 11.3% at 1-year, with the incidence rate at a near constant estimate in the first 100 days. The cumulative incidence of DVT/PE with death as a competing risk factor was 1.17% at 100-day and 4.08% at 1-year. In Cox regression models for CRT by 100 days, history of VTE, higher platelet count, acute GVH disease stage 3-4, and infection were statistically associated with time to CRT (Table 2). The type of CVC (non-tunneled CVC and PICC vs. tunneled CVC) was non-significantly associated with increased risk of CRT. Conclusion: In our cohort of patients undergoing allogeneic HCT, the incidence of CRT appeared to be higher than that reported in the literature. Significant risk factors associated with CRT occurred included VTE history, higher pre-transplant platelet count, and development of severe acute GVHD or active infection. While the type of CVC did not reach statistical significance due to the majority of patients receiving non-tunneled CVC as a standard institutional practice, there was a trend of increased CVC in this group of patients. Future multi-center studies that incorporate different types of CVC will further elucidate this potential association with CRT post-transplant.

A multi-national survey of experience and attitudes towards managing catheter related blood stream infections for home parenteral nutrition

Catheter-related bloodstream infection (CRBSI) is the most common complication of home parenteral nutrition (HPN) in patients with chronic intestinal failure (CIF). The aim of this study was to assess the broad range of practices of international multi-disciplinary teams involved in the care of this complication occurring in CIF patients. An online questionnaire was designed and distributed to members of the European Society for Clinical Nutrition and Metabolism (ESPEN) and distributed to colleagues involved in managing patients with CIF. A total of 47 responses were included from centers across 21 countries. The centers had been delivering HPN for a median 21 years (IQR 11-35) and were actively following a median 58 patients (27-120) per center for benign CIF in 80% of cases (67-95). Tunneled catheters were the most common type of central venous catheters (CVC), representing 70% (47-86) of all CVC in use. For the management of CRBSI, written procedures were provided in 87% of centers. First measures included simultaneous central and peripheral blood cultures (90%), stopping HPN infusion (74%), and administrating an antibiotic lock and systemic antibiotics (44%). Immediate removal of the CVC was more likely in case of fungal infection (78%), Staphylococcus aureus (53%), or in case of PICC catheter (52%) (all p<0.01). After the first CRBSI, 80% of centers used preventive CVC locks (taurolidine in 84% of cases, p<0.001). We observed a large heterogeneity in practices regarding preparation, duration, reaspiration, and volume of CVC locks, and monitoring of CRBSI (timing of blood cultures, radiological work-up). In this international survey of HPN expert centers, we observed a significant consensus regarding the initial management of CRBSI and the use of secondary preventive CVC locks, while areas of variation exist. Management of CRBSI may be improved with clearer recommendations based on the micro-organism and the type of CVC, including PICC lines which are increasingly used yet insufficiently studied in HPN patients.

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.

Outcomes in Pediatric Central Line-associated Bloodstream Infections Treated With Antimicrobial Locks: A 14-Year Retrospective Analysis.

Central line-associated bloodstream infections (CLABSI) are the most common healthcare-associated infection in children. Antimicrobial lock therapy (ALT) is a recommended component of CLABSI treatment; however, studies characterizing pediatric ALT-based CLABSI therapy are few. All CLABSI treated with ALT at a single tertiary-care pediatric hospital for years 2004-2018 were identified by retrospective chart review and demographic, clinical, microbiological and pharmacy data were extracted. Three clinical outcomes were defined: CLABSI clearance, central venous catheter (CVC) removal and infection recurrence. Factors associated with these outcomes were examined and patterns in pathogen occurrence were described. During the study period, 1188 CLABSI treated with ALT were identified. In all, 969 (85%) CLABSI initially cleared. In the CLABSI with initial clearance, CVCs were retained a median of 63 days after infection onset, and 20% recurred. Skin-colonizing microbes ( Staphylococcus aureus , coagulase-negative Staphylococci) were more likely to produce monomicrobial infections, whereas bowel-colonizing microbes ( Escherichia coli , Enterococci) were more associated with polymicrobial infections. In a multivariate model, infection history, resistant pathogens and CVC type were strongly correlated with infection recurrence, whereas bone marrow transplant status, neutrophil count and line type were correlated with CVC removal. Optimal therapeutic approaches to pediatric CLABSI remain uncertain, including the utility of ALT. Prior reports of ALT use in children have been smaller in size and largely described hematology-oncology or hemodialysis populations. We describe trends in pediatric CLABSI, including efficacy among solid organ transplant recipients and children with short-gut syndrome. These data provide guidance on selecting CLABSI for optimal ALT use.

Complications of implanted port catheters and peripherally inserted central catheters in chemotherapy-treated cancer patients: A meta-analysis.

One of the most significant advancements in nursing technology for cancer patients has been the development of implantable port catheters and peripherally inserted central venous catheters. They create an essential, dependable route for subjects to receive chemotherapy, long-term infusions and nutritional care, and provide a site for regular blood draws. We performed a meta-analysis to evaluate the complications of implanted port catheters and peripherally inserted central catheters in chemotherapy-treated cancer patients. A systematic literature search up to April 2022 was performed and a total of 11,801 articles have been retrieved. Of these, 5017 concerned peripherally inserted central catheters and 6784 implanted port catheters to administer chemotherapy. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (95% CIs) were calculated to assess the complications of implanted port catheters and peripherally inserted central catheters in chemotherapy-treated cancer patients using dichotomous and contentious methods with randomor fixed-effects models. Peripherally inserted central catheters had significantly higher incidence of occlusion complications (OR: 5.43, 95% CI: 3.46-8.52, p < 0.001), longer durations of local infection (OR: 2.94, 95% CI: 2.17-4.00, p < 0.001), higher incidence of catheter-related infection (OR: 2.13, 95% CI: 1.19-3.83, p = 0.01), higher rate of malposition (OR: 6.46, 95% CI: 2.93-14.27, p < 0.001), higher rates of catheter-related thrombosis (OR: 2.71, 95% CI: 1.90-3.87, p < 0.001), higher incidence of phlebitis complications (OR: 6.67, 95% CI: 2.94-15.11, p < 0.001), higher incidence of accidental removal (OR: 3.38, 95% CI: 1.97-5.81, p < 0.001), and a shorter catheter lifespan (MD: -233.16, 95% CI: -449.52--16.80, p = 0.03) in subjects undergoing chemotherapy compared to those in whom implanted port catheters were used. Implantable port catheter has advantages over peripherally inserted central catheter in decreasing cancer patients' complications. The outcomes provide evidence for practitioners to select which type of central venous catheters is better for cancer chemotherapy subject.

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Oncology Patients

Introduction Pediatric oncology patients are at increased risk for hospital-acquired venous thromboembolism (HA-VTE), which is associated with increased morbidity in this population. Up to 20% of pediatric oncology patients with central venous catheters (CVC) experience HA-VTE. However, much debate exists over the use of pharmacologic thromboprophylaxis to prevent HA-VTE in the pediatric oncology population, primarily due to lack of evidence regarding safety and efficacy. Pediatric oncology patients have many well-established risk factors for VTE including adolescence, obesity, CVC presence, and receipt of asparaginase chemotherapy. Given the uncertainty regarding prevention strategies in this population, research is needed regarding the use of prophylactic anticoagulation in pediatric oncology patients. Objective: To evaluate the use of prophylactic anticoagulation in pediatric oncology patients at risk for HA-VTE. Methods A retrospective, single center chart review of pediatric oncology patients who received clinical care at a tertiary care children's hospital was performed. Over 1600 patients were captured from a departmental database of all new oncologic diagnoses identified between January 1, 2014 and December 31, 2014. Patients were excluded if they received care at another institution or did not have an additional risk factor for HA-VTE outside of cancer diagnosis. Defined risk factors were age >12 years, body mass index (BMI) >30, CVC placement, receipt of asparaginase, and history of thrombosis. 514 patients met inclusion criteria. Patient age, BMI, history of thrombophilia, type of CVC, cancer type, steroid administration and asparaginase administration were analyzed as potential risk factors for VTE. Logistic regression was used to model odds of thrombus as a function of risk factors. A classification and regression tree (CART) model was also fitted to identify predictors of thrombus. Results Of 514 patients identified as high-risk for VTE, only 19 (3.7%) received prophylaxis. Most patients received enoxaparin for prophylaxis. Almost 15% (75/514) developed VTE during the study period. Of those who developed a VTE, 9% (7/75) were on prophylaxis at the time of VTE. 100% of the patients that developed VTE had a CVC in place. Obese patients were most likely to develop VTE with an odds ratio of 2.2 (95% CI 1-4.3, p 0.032). 28% (18/65) of obese patients developed VTE, yet only 6% (4/65) of obese patients received prophylaxis. Of these obese patients, 50% (2/4) developed VTE despite prophylaxis. Patients age >12 years were more likely to have VTE than those age <12 years (OR 1.1; 95% CI 1-1.1, p 0.023). Patients with Hickman catheters also had twice the odds of developing VTE (OR 2.1; 95% CI 1-4.1, p 0.046). In evaluating VTE occurrence by malignancy type, patients with hepatic tumors had the highest occurrence of thrombosis (8/12; 87%) followed by patients with myeloid leukemia (10/36; 28%), and lymphoblastic leukemia (28/170; 16%). The CART model was able to accurately predict occurrence or non-occurrence of thrombus in 87% of patients in the dataset based on the risk factors of obesity, age, and cancer type. Discussion It is well-established that malignancy is a significant risk factor for the development of VTE in pediatric oncology patients. Yet due to concern for bleeding events in these patients who frequently have thrombocytopenia, pharmacologic prophylaxis may not be used despite additional high-risk factors for VTE. This study demonstrates that pharmacologic prophylaxis is rarely used, even among high-risk pediatric oncology patients. For each risk group, most patients prescribed prophylaxis did not develop thrombus, however VTE still occurred in some. Risk stratification for pediatric oncology patients is essential given potential bleeding risk. We were able to identify additional high-risk features such as obesity, type of CVC, and cancer type. The CART model for high-risk pediatric populations had high specificity (88%) but poor sensitivity (23%). Application of this model could inform appropriate use of thromboprophylaxis in pediatric oncology patients to reduce the incidence of HA-VTE in this population. Further research is needed regarding safety and efficacy of prophylaxis, but this study provides important data to guide future steps.

Tunneled Central Venous Catheters in Young Children: Complication Profile Can Guide Choice of Line

IntroductionPlacement of tunneled central venous catheters (CVCs) is one of the most common procedures performed in children and can either be externally accessed or internally accessed. However, there are no data-driven guidelines on when to offer each line type, particularly in small children aged less than 5 y. Our hypothesis is that the two types of lines have different complication profiles and indications that can guide providers and families in this decision. MethodsA single-institution retrospective chart review was performed for patients aged less than 5 y who underwent initial placement of a tunneled CVC between 2014 and 2016. Patients were included if they underwent initial tunneled CVC placement within the study period and were excluded if line was emergently placed for hemodynamic instability or was a replacement catheter. Data were compared by type of CVC, weight more than or less than 10 kg, indications for CVC, complications, and duration of catheter. ResultsWe identified 148 patients who underwent initial tunneled CVC during study period. Seventy one patients (48%) received an externally accessed type and 77 (52%) received internally accessed type. The indications for line placement were TPN in 24 patients (16%), chemotherapy in 67 (45%), vascular access in 45 (31%), and nonchemotherapy infusions in 12 (8%). Externally accessed catheters had higher late complications (> 30 d) in patients > 10 kg compared to internally accessed catheters (63% versus 21%, P < 0.01). ConclusionsWhile some diagnoses determine line type, there are other indications that may qualify patients for either line. Our data demonstrate a lower long-term complication rate with internally accessed catheters and suggest they be considered over externally accessed lines in appropriate patients.

Home Parenteral Nutrition in Patients with Advanced Cancer: Quality Outcomes from a Centralized Model of Care Delivery.

Lack of expertise in home parenteral nutrition (HPN) management has been reported as a barrier to its initiation in patients with advanced cancer (AC), and there are limited data describing hospital readmissions and HPN-related complications. We aimed to assess a centralized approach for managing HPN in AC and evaluate associated outcomes, including hospital readmissions and HPN-related complications. This was a cohort study of adults with AC requiring palliative HPN between 2010–2018 at a tertiary intestinal failure (IF) center, primarily utilizing a centralized model of HPN oversight to discharge patients remotely from an oncology center to their homes over a wide geographic area. A total of 126 patients were included, with a median distance between the patient’s home and the IF center of 17.5 km (IQR 10.9–39.1; maximum 317.4 km). A total of 28 (22%) patients experienced at least one HPN-related complication, the most common being a central venous catheter (CVC) occlusion and electrolyte abnormalities. The catheter-related bloodstream infection (CRBSI) rate was 0.49/1000 catheter days. The CVC type, administration of concomitant chemotherapy via a distinct CVC lumen separate from PN, venting gastrostomy and distance between the patient’s home and the IF center were not associated with CRBSI or mechanical CVC complications. A total of 82 (65.1%) patients were readmitted while on HPN, but only 7 (8.5%) of these readmissions were HPN-related. A total of 44 (34.9%) patients died at home, 41 (32.5%) at a hospice and 41 (32.5%) in a hospital. In conclusion, this study demonstrates that a centralized approach to IF care can provide HPN to patients over a large geographical area while maintaining low HPN-related complications that are comparable to patients requiring HPN for benign conditions and low hospital readmission rates.

Development and validation of a multivariable prediction model of central venous catheter-tip colonization in a cohort of five randomized trials

BackgroundThe majority of central venous catheters (CVC) removed in the ICU are not colonized, including when a catheter-related infection (CRI) is suspected. We developed and validated a predictive score to reduce unnecessary CVC removal.MethodsWe conducted a retrospective cohort study from five multicenter randomized controlled trials with systematic catheter-tip culture of consecutive CVCs. Colonization was defined as growth of ≥103 colony-forming units per mL. Risk factors for colonization were identified in the training cohort (CATHEDIA and 3SITES trials; 3899 CVCs of which 575 (15%) were colonized) through multivariable analyses. After internal validation in 500 bootstrapped samples, the CVC-OUT score was computed by attaching points to the robust (> 50% of the bootstraps) risk factors. External validation was performed in the testing cohort (CLEAN, DRESSING2 and ELVIS trials; 6848 CVCs, of which 588 (9%) were colonized).ResultsIn the training cohort, obesity (1 point), diabetes (1 point), type of CVC (dialysis catheter, 1 point), anatomical insertion site (jugular, 4 points; femoral 5 points), rank of the catheter (second or subsequent, 1 point) and catheterization duration (≥ 5 days, 2 points) were significantly and independently associated with colonization . Area under the ROC curve (AUC) for the CVC-OUT score was 0.69, 95% confidence interval (CI) [0.67–0.72]. In the testing cohort, AUC for the CVC-OUT score was 0.60, 95% CI [0.58–0.62]. Among 1,469 CVCs removed for suspected CRI in the overall population, 1200 (82%) were not colonized. The negative predictive value (NPV) of a CVC-OUT score < 6 points was 94%, 95% CI [93%–95%].ConclusionThe CVC-OUT score had a moderate ability to discriminate catheter-tip colonization, but the high NPV may contribute to reduce unnecessary CVCs removal. Preference of the subclavian site is the strongest and only modifiable risk factor that reduces the likelihood of catheter-tip colonization and consequently the risk of CRI.Clinical Trials Registration: NCT00277888, NCT01479153, NCT01629550, NCT01189682, NCT00875069.

Risk factors for unplanned removal of central venous catheters in hospitalized children with hematological and oncological disorders.

Central venous catheters (CVCs) are essential devices in the treatment of pediatric patients with hematological and oncological disorders; however, the most suitable type of CVC for these patients remains unclear. We retrospectively compared risk factors for unplanned removal of two commonly used CVCs, peripherally inserted central catheters (PICCs) and tunneled CVCs, to propose which is the better device. We followed 89 patients fitted with a tunneled CVC (total 21,395 catheter-days) and 84 fitted with a PICC (total 9177 catheter-days) between January 1, 2013 and December 31, 2015, until catheter removal. Patients with a PICC had a significantly higher 3-month cumulative incidence of catheter occlusion (5.2% vs. 0%, p = 4.08 × 10-3) and total unplanned removals (29.0% vs. 6.9%, p = 0.0316) than those with tunneled CVCs. However, the cumulative incidence of central line-associated bloodstream infection did not differ significantly by CVC type. Multivariable analysis identified younger age (< 2years) [sub-distribution hazard ratio (SHR) 2.29; 95% confidence interval (CI) 1.27-4.14] and PICC (SHR 2.73; 95% CI 1.48-5.02) as independent risk factors for unplanned removal. Thus, our results suggest that tunneled CVCs are preferable in pediatric patients with hematological and oncological disorders requiring long-term, intensive treatment.

Internal Jugular Central Venous Catheter Tip Migration: Patient and Procedural Factors.

Background: The ideal central venous catheter (CVC) tip position placement is controversial, and CVCs do not remain in a fixed position after placement. This study evaluates both patient and procedural factors which may influence CVC tip migration and subsequent catheter dysfunction. Materials and Methods: This study evaluates CVC placements at a single institution. Patient age, gender, body mass index (BMI), catheter laterality, CVC type and indication for central venous access were recorded. Catheter tip location relative to the carina was measured at time of placement and removal utilizing supine fluoroscopic imaging. Patients’ electronic medical records were reviewed for evidence of catheter dysfunction. Statistical analysis was performed utilizing odds ratios and two tailed Student’s t-test. Results: 177 patients were included (101 female; mean age 55; mean BMI 29.2). Catheter types included 122 ports, 50 tunneled large bore central venous catheters (≥9 French), and 5 tunneled small bore central venous catheters (<9 French). 127 were right sided catheters, and 50 were left sided. Left sided CVCs had a mean cranial tip migration of 3.2 cm (standard deviation ±2.9 cm) compared to 0.8 cm (standard deviation ±1.9 cm) for right sided catheters (p = 0.000008). Catheters that migrated cranially by >2 cm had more than 7× greater risk of dysfunction compared to catheters that migrated ≤2 cm (odds ratio of 7.2; p = 0.0001). Left sided CVCs were significantly more likely to have >2 cm of cranial migration (odds ratio 6.9, 95% CI 3.4–14.2, p < 0.0001) and had a higher rate of dysfunction, likely due to this cranial migration (32% vs. 4.7%; p = 0.00001). Gender and BMI were not found to be associated with catheter dysfunction or an increased odds ratio of >2 cm cranial migration. Conclusions: Left-sided CVCs migrate an average of 2.4 cm cranially more than right-sided catheters. Additionally, when migration occurs, left-sided catheters are more likely to be dysfunctional. These suggest that lower initial placement may be beneficial in left-sided catheters.

An audit of central venous catheter insertion and management practices in an Australian tertiary intensive care unit: A quality improvement project

IntroductionCentral venous catheters are often used in managing critically ill patients. Clinical practice guidelines and care bundles exist to prevent central line associated blood stream infections; however, detailed adherence to these guidelines and care bundles is unclear. AimThis study was aimed to describe clinicians’ adherence to recommended practices in central venous catheter insertion and management. MethodA cross-sectional prospective observational study was conducted in the intensive care unit of an Australian tertiary hospital over a four-month period. We observed a total of 50 nurses during post insertion management, and 10 physicians during central venous catheter insertion using purposely designed observation tools. ResultsOur audit identified 90% adherence to recommended practices in central venous catheter insertion and 60% to post insertion management. However, there were areas where participants’ practices were not congruent with evidence-based recommendations, including choice of central venous catheter insertion site, type of central venous catheters, dressing choice, aseptic technique, and documentation. ConclusionOur audit showed a detailed picture of clinician’s adherence to recommended practices in central venous catheter insertion and management. A clearer understanding of the barriers and facilitators of issues identified is needed to inform the design of future interventions to reduce central line related blood stream infections in the unit.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates.

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

Venous Thromboembolism in Pediatric Cancer Patients with Central Venous Catheter-A Systematic Review and Meta-analysis.

Pediatric cancer patients hold an increased risk of venous thromboembolism (VTE) due to their cancer. Central venous catheters (CVCs) further increase the VTE risk. This systematic literature review elucidates the VTE incidence in pediatric cancer patients with CVC. MEDLINE and EMBASE were searched in August 2020 without time limits. We included studies reporting original data on patients ≤18 years with any CVC type and any cancer type, who were examined for VTE with ≥7 days follow-up. In total, 682 unique records were identified, whereof 189 studies were assessed in full text. Altogether, 25 studies were included, containing 2,318 pediatric cancer patients with CVC, of which 17% suffered VTE. Fifteen studies (n = 1,551) described CVC-related VTE and reported 11% CVC-related VTE. Concerning cancer type, 991 children suffered from acute lymphoblastic leukemia (ALL) and 616 from solid tumors. Meta-analysis revealed VTE incidence (95% confidence interval) of 21% (8-37) for ALL and 7% (0.1-17) for solid tumors. Additionally, 20% of children with tunneled or nontunneled CVC and 12% of children with implantable ports suffered VTE. In conclusion, pediatric cancer patients with CVC have substantial VTE risk. Children with ALL and CVC have higher VTE incidence than children with solid tumors and CVC. Implantable port catheter should be preferred over tunneled or nontunneled CVC to reduce VTE risk. Thrombophilia investigation does not seem relevant in pediatric cancer patients with CVC and VTE. To prevent VTE, intensified catheter care is recommended, especially in children with ALL.

Exploration of the high-risk factors of catheter-related thrombosis in breast cancer

Objective: To explore the high risk factors of catheter-related thrombosis (CRT) in breast cancer patients, and provide the basis for the development of appropriate prevention and treatment strategies. Methods: A total of 1 432 breast cancer patients scheduled to receive central venous catheterization in National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from January 1, 2015 to August 31, 2019 were selected. Baseline information and catheterization information of patients were collected. The occurrence of CRT was confirmed by vascular ultrasound examination, and the influencing factors of CRT were analyzed. Results: The total number of catheter days were 121, 980 days in 1 432 patients with breast cancer, and the average number of catheter days in each patient was 85.2 days. The incidence of CRT was 6.8% (97/1 432), which was 0.79 cases/1 000 catheter days. Among 815 patients with centrally inserted central venous catheters (CICC), 43 (5.3%) had CRT, which was 0.70 cases/1 000 catheter days. Among 617 patients with peripherally inserted central venous catheters (PICC), 54 (8.8%) developed CRT, which was 0.90 cases/1 000 catheter days. CRT was most common in subclavian vein (63.9%). Multivariate regression analysis showed that age ≥ 60 years old (OR=1.712, 95% CI: 1.056-2.775, P=0.029), PICC (OR=1.732, 95% CI: 1.130-2.656, P=0.012), the catheter position except subclavian vein (OR=10.420, 95% CI: 1.207-89.991), secondary adjustment of catheter position (OR=3.985, 95% CI: 1.510-10.521, P=0.005) and high D-Dimer level (OR=1.129, 95% CI: 1.026-1.241, P=0.012)were independent risk factors for CRT. Conclusions: The CRT problem can't be ignored in the clinical treatment of breast cancer patients with central venous catheterization. Screening the appropriate age of patients and the type of central venous catheters, reducing the secondary adjustment of catheter position, and timely monitoring the level of D-dimer are helpful to the prevention and treatment of CRT.

A Multicenter Comparison of Rates of Central Venous Catheter-Associated Bloodstream Infections By Central Venous Catheter Type Among Pediatric Patients Receiving Treatment for Newly Diagnosed Acute Myeloid Leukemia

▪Therapy for pediatric acute myeloid leukemia (AML) requires long term central vascular access, which puts patients at risk for central line-associated bloodstream infections and their associated morbidity and mortality. Options for central venous catheter (CVC) access include tunneled external catheters, implanted ports, or peripherally inserted central catheters (PICC). Multiple studies provide conflicting reports on which CVC type is least likely to be associated with bloodstream infections in pediatric hematology-oncology patients. This multicenter cohort of pediatric AML patients is the first to investigate the course-specific incidence of positive CVC blood cultures by line type.The study included patients receiving frontline chemotherapy for AML between 1/1/2012 and 6/30/2017 at 12 US institutions. Trained personnel completed manual chart abstraction from 12/1/2015 to 07/15/2017 to obtain information on demographics, diagnosis, treatment, antibacterial prophylaxis, CVC type at the start of each course, neutropenia duration, and blood culture results obtained from CVC. Abstractors followed a standardized protocol and were required to achieve >95% concordance with trainer before starting formal chart review.Course-specific follow-up began the first day absolute neutrophil count (ANC) fell below 200 cells/uL and continued to the earliest of first positive CVC culture (overall and separately for gram-positive and gram-negative species), ANC recovery, start of conditioning for stem cell transplant, relapse, death or start of next course. Per National Healthcare Safety Network guidance, common commensals were not considered true events with the exception of viridans group streptococci (VGS). Nonbacterial pathogens were also excluded. Covariate distributions were compared by CVC type using chi-square tests. Variability in CVC type by site was examined graphically. Incidence rates for CVC positive blood cultures were reported by line type as per 1000 neutropenic days. Multivariate Poisson regression with log of neutropenia duration as offset was used to compute adjusted rate ratios (aIRR) comparing rates of positive CVC blood cultures by line type, controlling for covariates itemized in Table 1. General estimating equation methods were used to account for non-independence of observations from patients from the same institution.The study population included 357 patients who received 1,164 chemotherapy courses. Median course duration was 38 days (IQR: 34-44) with a median neutropenia duration of 19 days (IQR: 14-25). CVC were present in all patients at the start of each course, with the exception of 11 (3.3%) patients lacking a CVC at the start of Induction I. While tunneled CVC were most prevalent representing 59.1% of courses, PICC and implanted ports were utilized in 28.9% and 11.6% of courses, respectively. There was considerable variation in the distribution of CVC type by treating institution (Figure 1). Age, race, and ethnicity distributions varied by line type (Table 1). Antibacterial prophylaxis was utilized in 47% of courses.In total, there were 300 (25.8%) courses in 199 (55.7%) patients complicated by a positive CVC blood culture during the neutropenic period. The overall incidence rate of positive CVC blood cultures was 6.5 per 1000 neutropenic days. Rates increased over the course of frontline treatment from 3.1 per 1000 neutropenic days in Induction I to 9.6 per 1000 neutropenic days in Intensification II. The rate of gram-positive events (4.2 per 1000 neutropenic days) was higher than gram-negative events (2.0 per 1000 neutropenic days). The most common isolated organisms were VGS at 57.3% and less than 1% of events were polymicrobial infections. Overall rates of positive CVC blood cultures were higher for PICC relative to tunneled CVC (aIRR=1.19, 95% CI: 1.02, 1.38), while rates for implanted ports and tunneled CVC were similar (aIRR=1.06, 95% CI: 0.75, 1.51).While bacteremia is an expected complication during post-chemotherapy neutropenia and not always due to the presence of a CVC, the risk for a positive CVC blood culture is significantly increased for children with PICC compared with those with tunneled CVC or implanted port. Also, the risk was higher after Induction I and increased with age. Given the notable practice variation in line choice, these data highlight an opportunity for standardization with a goal to reduce infectious complications. [Display omitted] DisclosuresFisher:Pfizer: Research Funding; Merck: Research Funding. Gramatges:Bristol Meyer Squibb: Research Funding.