Preventing complications of central venous catheterization

Wireless, non-invasive, wearable device for continuous remote monitoring of hemodynamic parameters in a swine model of controlled hemorrhagic shock

Accurate and continuous monitoring of critically ill patients is frequently achieved using invasive catheters, which is technically complex. Our purpose was to evaluate the validity and accuracy of a photoplethysmography (PPG)-based remote monitoring device compared to invasive methods of arterial line (AL) and Swan-Ganz (SG) catheters in a swine model of controlled hemorrhagic shock. Following a baseline phase, hemorrhagic shock was induced in 11 pigs by bleeding 35% of their blood volume, followed by a post-bleeding follow-up phase. Animals were monitored concomitantly by the PPG device, an AL and a SG catheter, for a median period of 447 min. Heart rate (HR), systolic and diastolic blood pressure (SBP and DBP, respectively), and cardiac output (CO) were recorded continuously. The complete data set consisted of 1312 paired observations. Correlations between the PPG-based technique and the invasive methods were significant (p < 0.001) during baseline, bleeding and follow-up phases for HR (r = 0.90–0.98), SBP (r = 0.90–0.94), DBP (r = 0.89–0.93), and CO (r = 0.76–0.90). Intraclass correlations for all phases combined were 0.96, 0.92, 0.93 and 0.87 for HR, SBP, DBP and CO, respectively. Correlations for changes in CO, SBP and DBP were significant (p < 0.001) and strong (r > 0.88), with concordance rates (determined by quadrant plots) of 86%, 66% and 68%, respectively. The novel PPG-based device was accurate and valid compared to existing invasive techniques and might be used for continuous monitoring in several clinical settings following further studies.

[Multiple Stroke Syndrome Caused by Air Embolism Following Removal of a Central Venous Catheter]

The removal of a central venous catheter on a ward leads to a paradox air embolism in a 53-year-old male patient with an unknown ventricular septal defect. The patient undergoes sufficient cardiopulmonary resuscitation but suffers from a multiple stroke syndrome with serious neurological deficits.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Peripherally Inserted Central Venous Catheter for Pediatric and Young Adult Patients With Hematologic and Malignant Diseases

BACKGROUND

Long-term venous access is essential when treating malignant diseases. As an alternative to conventional central venous catheters, peripherally inserted central venous catheter (PICC) are now widely used. The aim of this study is to evaluate the safety, efficacy, and reliability of PICCs in comparison with previous reports, and to describe significant complications associated with their use.

PATIENTS AND METHODS

From June 2009 to November 2017, PICCs were inserted 258 times in a total of 160 pediatric and young adult patients at our institution. We retrospectively evaluated our data regarding catheter life, a note of caution during insertion, reasons for removal, infection, and other notable complications.

RESULTS

The 258 PICCs were placed for a total of 30,901 catheter-days with a median catheter life of 102 days ranging from 2 to 471 days. The most suitable vein for the insertion was a basilic vein. The insertion depth from the cubital fossa to the point of the lower third superior vena cava was found to have a strong correlation with body surface area. Suspected catheter infection requiring catheter removal was observed 30 times (0.97/1000 catheter-days) and catheter-related bloodstream infection was observed 2 times (0.06/1000 catheter-days). All the responsible pathogens were Staphylococcus epidermidis. As notable complications, fibrin sheath formation were seen in 4 patients and catheter tip migration to the thorax in 1 patient.

CONCLUSIONS

Our data suggest that PICC is safe and effective in pediatric and young adult patients receiving long-term treatment. However, clinicians should be aware of the possible complications during PICC use.

Previous peripherally inserted central catheter (PICC) placement as a risk factor for PICC-associated bloodstream infections

BACKGROUND

Peripherally inserted central catheter (PICC) -associated bloodstream infection (BSI) is a concern.

METHODS

A case-control study was conducted to assess risk factors for PICC-associated BSI.

RESULTS

A total of 1,215 cases and 31,874 catheter days were analyzed. In total, 54 cases of PICC-associated BSI were detected giving an infection rate of 1.69 per 1,000 catheter-days. The most frequently isolated pathogens were coagulase-negative staphylococci (26%), followed by Enterococcus species (22%), Candida species (17%), and Staphylococcus aureus (11%). Multivariable analysis identified the significant risk factors for PICC-associated BSI as a prior PICC placement (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.36-4.53), medical department admission (OR, 1.89; 95% CI, 1.03-3.46), and older age (OR, 1.03; 95% CI, 1.00-1.05). With increasing frequency of previous PICC placement, the rates of PICC-associated BSI increased: 3.5% (31/883) without previous placement, 7.6% (13/171) in once, and 9.9% (9/32) in twice or more.

DISCUSSION

The previous PICC placement was an independent risk factor for PICC-associated BSI and the risk proportionally rose with the increasing frequency of prior PICC placement.

CONCLUSIONS

Patients with repeatedly inserted PICC should be managed more carefully for prevention and should be monitored for the development of PICC-associated BSI.

Managing central venous access during a health care crisis

OBJECTIVE

During 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.

METHODS

We 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.

RESULTS

Participants 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).

CONCLUSIONS

Implementation 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.

Development and application of a swine model for training ultrasonography-guided central venous access

INTRODUCTION

simulation based teaching is a powerful tool in medical education, allowing hands on practice under a controlled environment and with repeated maneuvers. Central venous access venipuncture is one of the most frequent procedures carried out in the hospital setting, due to its various clinical indications and, when performed with the help of ultrasonography, the risk of adverse events is minimized. Aim: to develop, to describe and to test a porcine model that simulates the central venous access puncture aided by ultrasonography.

METHOD

a low cost porcine model was developed to train medical students and residents on central venous access guided by ultrasonography. Both students and medical residents underwent a theoretical training regarding the model, followed by a hands-on training session. Afterwards, the participants assessed the model by answering a questionnaire.

RESULTS

there were 51 participants. The average score regarding the similarity between the model and the human anatomy was 9.15. When the characteristics were separately assessed, the mean scores regarding the similarity of the vessels, anatomic disposition and ultrasonographic characteristics as well as the venipuncture were, respectively, 9.27; 9.31; 9.54 and 8.86.

CONCLUSION

The model was approved and considered appropriate for the training of central venous venipuncture by all the participants. Furthermore, it is a low cost, simple and reproducible model, that presents high similarity with the human anatomy. Therefore, it may be used as an aid to train people on ultrasonography guided central venous access.

Standardizing Preoperative Evaluation for Pediatric Central Venous Access: A Care Algorithm to Improve Safety

Central vascular access device (CVAD) placement is a common procedure in children. When selecting a CVAD, available evidence and specified indications should be used to choose the device that best supports the patient's treatment and carries the lowest risks. A multidisciplinary team developed a care algorithm to standardize preoperative screening before pediatric CVAD placement, with 3 major parts: CVAD selection, patient risk stratification, and preoperative evaluation. Using a stepwise approach of provider education and incorporation into the electronic health record, the team achieved 82% stratification among inpatients. The team's algorithm integrates the existing literature and recommendations for safe and effective CVAD placement.

Predicting the optimal depth of ultrasound-guided right internal jugular vein central venous catheters in neonates

BACKGROUND

Poor positioning of a central venous catheter (CVC) can cause severe complications. The objective is to create a formula that predicts the optimal insertion depth of a real time ultrasound-guided CVC in the right internal jugular vein (RIJV) in newborns.

METHODS

Between 2015 and 2017, 91 newborns that required a CVC were included in a prospective observational study. Variables such as gestational age, gender, weight, height, and neck length were studied. On the chest x-ray, the distance between the insertion site on the skin and the catheter tip was measured.

RESULTS

Of the patients included, 50 (54.9%) were males and 40 (44.4%) females; 64 (70.3%) were preterm. Mean gestational age was 33.44 (25 to 41) weeks, weight 2020 (580 to 3980) g, and height 43.04 (26 to 53) cm. Variables were correlated with catheter length and an algorithm was modeled for the introduction method, in which the highest corrected determination coefficient was obtained for weight (R² = 0.723).

CONCLUSION

This study demonstrated that the weight of the newborn was the most significant individual predictor of optimal insertion depth of a CVC in the RIJV. The formula Y = 2.6 + 0.7 (weight in kg) that we suggest is practical and reproducible.

LEVEL OF EVIDENCE

Level IV.

Reconsidering the GAVeCeLT Consensus on catheter-related thrombosis, 13 years later

Catheter-related thrombosis represents one of the most common complications following central venous access insertion. Despite the amount of available studies, many aspects surrounding catheter-related thrombosis remain controversial. Thirteen years ago, the Italian Study Group for Long Term Central Venous Access (GAVeCeLT) developed a nationwide Consensus in order to clarify some key aspects on this topic. Despite most of them still remain valid, however, knowledge around catheter-related thrombosis has greatly evolved over the last decade, with a natural evolution in terms of catheter technologies, insertion techniques, and management bundles. Aims of this editorial are to readdress conclusions of the 2007 GAVeCeLT Consensus in the light of the new relevant evidences that have been added in the last 13 years and to analyze some unsolved issues that still remain debated.

Complete Blood Count Collected Via Venipuncture Versus Peripherally Inserted Central Catheter in Hematological Patients: A Comparison of 2 Methods

BACKGROUND

The use of peripherally inserted central catheters (PICCs) in cancer care is increasing over traditional central venous catheters. Nurses frequently collect blood by venipuncture when a PICC is inserted, as there is no available evidence to confirm the reliability of blood tests collected through PICCs in adults.

OBJECTIVE

The aim of this study was to assess the reliability of blood samples for complete blood count (CBC) obtained through PICCs as an alternative to venipuncture.

METHODS

A cross-sectional design was used to recruit adult hematological patients. The blood samples were collected within 5 minutes of each other by a specialist nurse. Hemoglobin, hematocrit, and platelet count were evaluated. To determine method comparison, Passing-Bablok regression, test of linearity, Pearson product-moment correlation coefficient, and Bland-Altman plots were used.

RESULTS

Thirty paired blood samples were collected in 29 hematological patients with a mean age of 66.8 years. A statistical difference was found for hemoglobin (P = .001) and hematocrit (P = .001) levels, but no clinical difference. The regression models revealed no systematic differences and no proportional differences with a linear relationship between the methods. Bland-Altman plots highlighted a good agreement between methods.

CONCLUSION

Blood samples for CBC drawn by PICCs are as reliable as those collected via venipuncture. Blood sampling via PICC could be recommended in people with hematological malignancies in needs of frequent blood tests.

IMPLICATIONS FOR PRACTICE

Sampling through a PICC provides reliable laboratory results for CBC, and it could reduce patients' discomfort and increase the safety of professionals reducing the risk of accidental percutaneous needlestick injuries.

Transvenous Endomyocardial Biopsy: A Comparison of 2 Approaches

BACKGROUND

Endomyocardial biopsy (EMB) is a well-established procedure for the diagnosis of specific myocardial diseases and represents the gold standard in monitoring allografts after heart transplantation. In our study, we compared 2 different approaches for harvesting EMB in order to optimize patient safety and efficacy of the procedure.

METHODS

As a standard approach for harvesting EMB, a venous introducer sheath was inserted percutaneously via the internal jugular vein using the Seldinger technique. Thereafter, a bioptome was repeatedly introduced throughout this sheath into the right ventricle (RV), each time passing the tricuspid valve (TV). Alternatively, a coronary sinus catheter was inserted via an introducer sheath placed in the subclavian vein and only once was introduced into RV cavity. Hence, just a unique passage of TV was required. Thereafter, a bioptome was introduced via this catheter and precisely guided to the targeted biopsy site.

RESULTS

A standard approach was used with 34 patients, and a modified technique was used with 37 patients. Patient characteristics were comparable in both cohorts, and analyses of peri-procedural parameters identified only marginal differences between the groups. Interestingly, the number of harvested tissue samples per procedure was higher in the modified approach compared to the standard approach. No complications occurred.

CONCLUSION

The modified approach for EMB is a safe procedure. The facilitated bioptome-guidance and enhanced protection of TV may prevent periprocedural complications.

[Catheterization of the subclavian vein and the risk of pneumothorax : Mechanical ventilation increases the risk of pneumothorax during infraclavicular landmark-guided subclavian vein puncture: a prospective randomized study]

BACKGROUND

Infraclavicular subclavian vein (SCV) catheterization is a standard procedure in anesthesia and intensive care. There is a lack of evidence on how mechanical ventilation during venipuncture of the SCV influences pneumothorax rates.

OBJECTIVE

Primary hypothesis: non-inferiority of continuing vs. discontinuing mechanical ventilation during infraclavicular puncture of the SCV with respect to the pneumothorax rate.

MATERIAL AND METHODS

This prospective, randomized and single-blinded study was approved by the local ethics committee. A total of 1021 eligible patients who underwent cranial neurosurgery in 2 different university hospitals were assessed between August 2014 and October 2017. Patients were randomly assigned to two groups directly before induction of anesthesia. Intervention groups for venipuncture of the SCV were mechanical ventilation: tidal volume 7 ml/kg ideal body weight, positive end expiratory pressure (PEEP) ideal body weight/10, n = 535, or apnea: manual/spontaneous, APL valve 0 mbar, n = 486. Patients and the physicians who assessed pneumothorax rates were blinded to the intervention group. Venipuncture was carried out by both inexperienced and experienced physicians.

RESULTS

The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17-27.2; p = 0.031). A lower body mass index (BMI) was associated with a higher pneumothorax rate, OR 0.89 (95% CI: 0.70-0.96; p = 0.013).

CONCLUSION

In this study landmark-guided infraclavicular SCV catheterization was associated with a significantly higher rate of pneumothorax when venipuncture was performed during mechanical ventilation and not in apnea. If a short phase of apnea is justifiable in the patient, mechanical ventilation should be discontinued during the venipuncture procedure.

Comparison of semi-quantitative and quantitative methods for diagnosis of catheter-related blood stream infections: a systematic review and meta-analysis of diagnostic accuracy studies

Catheter-related blood-stream infections (CRBSIs) are the most common healthcare-associated blood-stream infections. They can be diagnosed by either semi-quantitative or quantitative methods, which may differ in diagnostic accuracy. A meta-analysis was undertaken to compare the diagnostic accuracy of semi-quantitative and quantitative methods for CRBSI. A systematic search of Medline, Scopus, Cochrane and Embase databases up to January 2020 was performed and subjected to a QUADAS (quality assessment of diagnostic accuracy studies 2) tool to evaluate the risk of bias among studies. The pooled sensitivity and specificity of the methods were determined and heterogeneity was evaluated using the χ2 test and I2. Publication bias was assessed using a Funnel plot and the Egger's test. In total, 45 studies were analysed with data from 11 232 patients. The pooled sensitivity and specificity of semi-quantitative methods were 85% (95% CI 79-90%) and 84% (95% CI 79-88%), respectively; and for quantitative methods were 85% (95% CI 79-90%) and 95% (95% CI 91-97%). Considerable heterogeneity was statistically evident (P < 0.001) by both methods with a correspondingly symmetrical Funnel plot that was confirmed by a non-significant Deek's test. We conclude that both semi-quantitative and quantitative methods are highly useful for screening for CRBSI in patients and display high sensitivity and specificity. Quantitative methods, particularly paired quantitative cultures, had the highest sensitivity and specificity and can be used to identify CRBSI cases with a high degree of certainty.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique

BACKGROUND

Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel 'suck out' technique for bedside guidewire retrieval and compared this against traditional retrieval methods.

METHODS

Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the 'suck out' method were compared for efficacy using Fisher's exact test.

RESULTS

Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the 'suck out' technique was 90% effective (p < 0.001).

CONCLUSION

The 'suck out' technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study

BACKGROUND

Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax.

METHODS

This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen's κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound.

RESULTS

In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen's κ-coefficient of 0.50 (95% CI, 0.19 to 0.80).

CONCLUSIONS

This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax.

Detection of anatomical variation during left internal jugular vein cannulation under ultrasound: A case report

RATIONALE

The left internal jugular vein has a higher possibility of anatomical variation than the right side. Therefore, the complication risk during cannulation is expected to be higher.

PATIENT CONCERNS

A 74-year-old woman was scheduled for elective surgery for left upper lobe wedge resection. We observed an anatomical abnormality at the location of the common carotid artery (CCA) and left internal jugular vein (IJV).

DIAGNOSIS

During the ultrasound, the left IJV was detected at the medial side of the CCA, and this anatomical variation was confirmed by color Doppler ultrasonography. Enhanced chest computed tomography showed that the left CCA ran across the left IJV from medial to lateral at the level of the clavicle.

INTERVENTION

A triple-lumen central venous catheter was inserted at the right IJV to avoid complications caused by the anatomical variation.

OUTCOMES

There were no intraoperative or postoperative complications.

LESSONS

Anesthesiologists should consider anatomical variation during central venous cannulation, especially with the left IJV approach. Because of anatomical variation, ultrasound-guided intervention is highly recommended to prevent procedure-related complications.

The practical integration of a hybrid model of ultrasound-guided peripheral venous access in a large apheresis center

BACKGROUND

Apheresis treatments require adequate venous access using peripheral intravenous (PIV) catheterization or central venous catheters (CVC). Ultrasound-guided PIV (USGPIV) can be used to decrease the need of CVC insertions for apheresis procedures.

METHOD

A hybrid model of USGPIV and standard of care (SOC) for PIV access was developed. Nurses performed USGPIV on all patients considered for PIV access if felt SOC PIV access was not possible. Information was collected regarding nurses' confidence with access, number of attempts required, site of access, complications, and need for CVC.

RESULTS

In all, 226 PIV access attempts were made during a 2-month period. All apheresis procedure types were represented. A total 65% were accessed by SOC and 35% by USGPIV. USGPIV was successful on first try on 90% draw/inlet access and 87% successful on first try on return access. Access above the antecubital fossa was required in 31% of USGPIV for draw/inlet veins, and 22% of return veins. Nurses' confidence with accessing PIV was increased by USGPIV, based on 7-point Likert scale assessments. During the recording period, 2/226 (0.9%) apheresis procedures required a CVC. In a separate cohort of only hematopoietic progenitor cell collections, CVC insertion was required in 44/238 (18.5%) patients, in 7 months prior to adoption of USGPIV and 5/152 (3.3%) patients in 7 months following adoption of USGPIV.

CONCLUSION

A hybrid model of using SOC and USGPIV for PIV access for apheresis procedures resulted in decreased need for CVC access, high levels of successful initial access attempts, and increased nursing confidence in PIV access.

Totally Implanted Port May Be an Alternative to Centrally Inserted Central Catheter for Measurement of Central Venous Pressure

Background

A conventional centrally inserted central catheter (CICC) is frequently used to measure central venous pressure (CVP) to monitor the cardiocirculatory status of patients. The tip of the totally implanted port (TIP) is inserted at the same location in the superior vena cava as that of a CICC, and the TIP has been implanted in many patients with cancer. Measurements of CVP using CICC (CICCP) and TIP (TIPP) may be closely related. Material and Methods. Ten patients with TIPs in an intensive care unit were prospectively studied, and 121 records of 4536 paired CICCP and TIPP measurements were collected. A bench test in a static or dynamic setting was performed, and 598 paired measurements taken using CICC and TIP were recorded.

Results

The measurement of TIPP was highly correlated with that of CICCP in patients with cancer, especially those in a calm state. Patients with a calm state and ≥3 consecutive identical TIPP were recorded (≥30 seconds), and 90% of the mean difference between CICCP and TIPP was ≤2 mmHg. The pressure measurements recorded using CICC and TIP were identical in both the static and dynamic bench tests.

Conclusions

TIP may be an alternative to CICC for measuring CVP.

Indirect Burst Pressure Measurements for the Mechanical Assessment of Biological Vessels

IMPACT STATEMENT

Vascular tissue engineering (VTE) is a rapidly expanding field, with numerous approaches being explored both in preclinical and clinical settings. A pivotal factor in the development of VTE techniques is patient safety, notably with respect to the mechanical properties of the vessels. Of the mechanical properties, the bursting strength, representing the ability of a vessel to withstand the forces exerted on it by blood pressure, is the most important. The burst pressure is commonly assessed using one of three methods proposed by the ISO 7198. In this study, we evaluate the three burst pressure assessment methods exactly as they are presently in the field of VTE. We show that the indirect assessment methods, as they are presently used, provide inconsistent and therefore unreliable estimates of the true yield stress of a vessel.

Appropriate duration of peripherally inserted central catheter maintenance to prevent central line-associated bloodstream infection

BACKGROUND/AIM

Prolonged maintenance of central venous catheters, including peripherally inserted central catheters (PICCs), is a major risk factor for central line-associated bloodstream infection (CLABSI). This study was conducted to evaluate the appropriate duration of PICC maintenance to prevent CLABSI.

METHODS

A single-center retrospective study was conducted at an 824-bed tertiary hospital in Korea between January 2010 and December 2017. All hospitalized patients who underwent ultrasound-guided PICC insertion were enrolled. CLABSI was diagnosed according to the definitions of the National Health Safety Network. CLABSI caused by PICC was defined as PICC-associated bloodstream infection (PABSI). To identifying statistical correlations between catheter days and PABSI, the odds ratio for PABSI on the basis of the continuous value of catheter days was analyzed using restricted cubic spline splits with five knots. The optimal cut-off value for catheter days was identified by maximizing the area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

A total of 1,053 patients underwent ultrasound-guided PICC insertion during the study period. Among them, 36 were confirmed as having a PABSI (3.5%, 36/1014; 1.14 per 1000 catheter days). In the restricted cubic spline regression, catheter days showed a dose-dependent relationship with the risk of PABSI. The AUC of the ROC curve for developing a PABSI according to the duration of catheter maintenance was 0.715 (95% CI, 0.639-0.790); the calculated optimal cut-off value was 25 days.

CONCLUSION

The incidence of PABSI was 1.14 per 1000 catheter days and the optimal cut-off value of catheter days to avoid a PABSI was 25 days.

Bowel Puncture During Insertion of a Femoral Central Line in the Emergency Department

BACKGROUND Central venous catheter (CVC) insertion is commonly performed in the emergency department. The femoral vein is often chosen for insertion of CVCs due to its lower risk for complication. We present a rare complication of bowel puncture during insertion of a femoral CVC in the emergency department in a 46-year-old female. CASE REPORT A 46-year-old female with a history of partial gastrectomy and colostomy was transported to the emergency department after being found unconscious. Despite multiple attempts, intravenous access could not be obtained. The emergency physician proceeded to insert a left femoral CVC to obtain venous access. Ultrasound was not used due to perceived urgency, as well as a bedside assessment that the patient's anatomy was straight forward. Stool-like material was aspirated upon inserting the introducer needle, which was quickly removed. An upright x-ray showed no free air, but due to the patient history, an exploratory laparotomy was performed. A single-side perforation in the mid-sigmoid with a small hematoma along the antimesenteric wall was found. The puncture was over sewn, and the patient recovered well; the patient's initial presentation was ultimately considered to be due to medication misuse. CONCLUSIONS This case highlights the importance of using caution in blind attempts at femoral CVC in patients with prior abdominal surgery. It is also important to note the need to avoid insertion of CVCs without the use of ultrasound or when in a rush. If venous access is needed quickly, peripheral or intraosseous venous access can be obtained much more quickly and safely.

Single-access ultrasound-guided tunneled femoral lines in critically ill pediatric patients

Central venous access is an essential aspect of critical care for pediatric patients. In the critically ill pediatric population, image-guided procedures performed at the bedside expedite care and may reduce risks and logistical challenges associated with patient transport to a remote procedure suite such as interventional radiology. We describe our institutional technique for ultrasound-guided tunneled femoral venous access in neonates and infants and provide technical pearls from our experience, with an intended audience including specialists performing point-of-care ultrasound-guided procedures as well as interventional radiologist making their services available in the intensive care unit.

Peripherally inserted central catheter placement in a multidisciplinary intensive care unit: A preliminary study demonstrating safety and procedural time in critically ill subjects

OBJECTIVE

Peripherally inserted central catheters are a popular means of obtaining central venous access in critically ill patients. However, there is limited data regarding the rapidity of the peripherally inserted central catheter procedure in the presence of acute illness or obesity, both of which may impede central venous catheter placement. We aimed to determine the feasibility, safety, and duration of peripherally inserted central catheter placement in critically ill patients, including obese patients and patients in shock.

METHODS

This retrospective cohort study was performed using data on 55 peripherally inserted central catheters placed in a 30-bed multidisciplinary intensive care unit in Mayo Clinic Hospital, Phoenix, Arizona. Information on the time required to complete each step of the peripherally inserted central catheter procedure, associated complications, and patient characteristics was obtained from a prospectively assembled internal quality assurance database created through random convenience sampling.

RESULTS

The Median Procedure Time, beginning with the first needle puncture and ending when the procedure is complete, was 14 (interquartile range: 9-20) min. Neither critical illness nor obesity resulted in a statistically significant increase in the time required to complete the peripherally inserted central catheter procedure. Three (5.5%) minor complications were observed.

CONCLUSION

Critical illness and obesity do not delay the acquisition of vascular access when placing a peripherally inserted central catheter. Concerns of delayed vascular access in critically ill patients should not deter a physician from selecting a peripherally inserted central catheter to provide vascular access when it would otherwise be appropriate.

Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters

PURPOSE

Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography.

METHODS

We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS.

RESULTS

Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion.

CONCLUSIONS

Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

[Progress Report on Cases of Peripherally Inserted Central Catheter (PICC) Management in Our Hospital, Including Elderly Patients]

AIM

In our hospital, the number of cases in which peripherally inserted central catheters (PICCs) are used has increased; these patients include elderly people who cannot take medications orally, patients with low levels of awareness, and patients with dysphagia. We report the situation at this time mainly with regard to the number of days on which PICCs were used.

METHODS

Fifteen elderly patients (male, n=7; female, n=8; average age, 89.3±5.3 years) underwent PICC insertion at our hospital from August 2016 to October 2018. Among these patients, 6 had cerebrovascular disorders, 5 had aspiration pneumonia, 2 had Parkinson's syndrome, 1 had consciousness disorder resulting from asphyxia caused by foreign body aspiration, and 1 had interstitial pneumonia. Seven patients received home management. In each patient, we measured the length of time that the PICC was in place.

RESULTS

The average duration for which a PICC was in place was 92.9±25.4 days (in cases of home care management, 159.5±48.3 days). The longest duration was 342 days, in a patient with aspiration pneumonia. The endpoints were death and discharge from hospital. Complications/accidents occurred as a result of catheter infection in 2 cases (both patients recovered after catheter removal) and as a result of self-extraction in 1 case.

CONCLUSIONS

These results suggest that PICC is useful and does not cause serious adverse effects, even in elderly patients who require central parenteral nutrition management.

Contemporary postoperative imaging practices among pediatric surgeons for image-guided central venous line placement: A survey of the American Pediatric Surgical Association

BACKGROUND/PURPOSE

Rare life-threatening complications after central venous line (CVL) placement in children may encourage the routine use of postoperative imaging, despite multiple studies demonstrating the limited utility of this practice. The aim of this study was to investigate the nature of this discordance.

METHODS

A 10-question survey was sent to 1,239 members of the American Pediatric Surgical Association (APSA) addressing contemporary practices regarding CVL placement and postoperative imaging.

RESULTS

Five hundred eighteen (42%) surveys were completed. The majority of respondents routinely obtain a chest radiograph (CXR) after image-guided CVL placement (52%). Years in practice, operative volume, and practice type were not statistically associated with postoperative CXR usage (all p > 0.05). 'Routine' users were more likely to cite "standard of care" (p < 0.001), position verification (p < 0.001), and complication identification (p < 0.001) as indications for use than those who use CXR selectively.

CONCLUSION

Routine use of postoperative CXR after image-guided CVL placement remains common among pediatric surgeons. Significant variation exists in the indication for this study, with considerable disagreement between 'selective' and 'routine' users. Consideration should be given for an APSA standardized guideline utilizing a clinically-driven approach to CVL placement and postoperative imaging to align with evidence-based practice.

LEVEL OF EVIDENCE

N/A - descriptive analysis of survey results.

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature

Objectives: Central venous catheter (CVC) implementation is now usual in emergency department. The most common complications are misplacement, bleeding, pleural perforation, thrombosis and sepsis. Forgetting a guide wire in the patient's body after catheterization is an underestimated complication of this procedure; only 76 cases are described. Even if the majority of patients remained asymptomatic, severe complications can happened even years later. This article's aim is to identify the sequence of elements that led to the event occurrence and to suggest recommendations of good practice to minimize complications related to central catheter placement.Method: After reviewing all the complications related to central venous catheterization and their frequencies, we analyse from a case report and a review of the literature the sequence of elements that led to the medical error. We use an Ishikawa diagram to show our results and the links between them.Results: Our Ishikawa diagram shows that material, human resources, procedural and radiological involvement factors are the main elements on which we can act to reduce the complications rate after central venous catheterization. We advocate for the establishment of standardized procedures before, during and after the technical gesture.Conclusions: Because of human nature, errors will always be possible when taking care of a patient. However, we propose good practice recommendations to avoid the repetition of a forgetting guide wire after central venous catheterization.

Central venous catheter insertion and maintenance: Evidence-based clinical recommendations

OBJECTIVE

To share with clinicians supporting evidence of the safest and the most effective processes for central venous catheter insertion and maintenance as a strategy to prevent catheter-associated bloodstream infections.

METHODS

A literature search was conducted in the Medline via PubMed, Embase Central and Lilacs databases based on a set of clinical questions aimed at improving safety and effectiveness at key moments in the process of central venous catheter insertion and maintenance. The rapid literature review methodology was used. The studies identified were assessed from the quality point of view, using the Joanna Briggs Institute (JBI) tools for qualitative and quantitative studies and for systematic reviews. Clinical practice guidelines were assessed using the AGREE II tool. The evidence is presented in the form of evidence-based clinical recommendations, which were graded in accordance with the JBI methodology.

RESULTS

Twelve clinical evidence summaries containing evidence related to the safe and effective use of central venous catheters are presented, including the following topics: central venous catheter insertion (CVC), peripherally inserted central catheters (PICC), preoperative assessment, the use of analgesia, field preparation, choice between CVC or PICC, CVC care and maintenance, prevention of complications, and general considerations pertaining to the use of central venous catheters in oncologic patients and in parenteral nutrition.

CONCLUSIONS

Recommendations on the safe and effective use of central venous access catheters in relation to CVC insertion and maintenance processes are presented in the evidence-based summary model. It is necessary to evaluate their implementation in health outcomes in the institutions where they are developed.

Complication risk factors related to central venous catheter in pediatric

BACKGROUND

A prospective epidemiological study was carried out in the pediatric intensive care unit (ICU), at the Mayotte Hospital Center (MHC). The purpose of the study was to identify and to evaluate complications risk factors related to central venous catheterization. Improving side effects prevention and patients care was the second goal.

METHOD

Data collection took place over a period of 10 months. The central approaches followed in the study were femoral, jugular and subclavian. Since the database is composed of qualitative and quantitative variables, the Chi² test has been used to measure the association between two variables.

RESULTS

The study was carried out on 101 patients. Five infectious risk factors on the 10 variables evaluated have been significantly highlighted: the number of punctures, the number of repair of the dressing, the duration of the catheterization, the exposure time and the parenteral nutrition administration.

CONCLUSIONS

Evaluation of practices through audits, an appropriate training for the staff, the update and the standardization of procedures, development of standardized assembly of the devices should lower the incidence of complications related to the venous approach.

Successful Double-Catheter Coil Embolization of an Iatrogenic Subclavian Artery to Internal Jugular Vein Fistula After Minimally Invasive Cardiac Surgery

It is essential to establish cardiopulmonary bypass by percutaneous insertion of a large-bore catheter via both the femoral vein and internal jugular vein (IJV) for minimally invasive cardiac surgery (MICS). Complications associated with IJV catheterization during MICS have been reported in the literature; however, vascular injury of the subclavian artery (SCA) is rare. We herein present a rare case in which an iatrogenic arteriovenous fistula (AVF) between the right SCA and IJV after MICS was successfully treated by endovascular coil embolization. A 61-year-old man who had undergone mitral valve repair by MICS 10 months before presentation was referred because of pulsatile cervical bruit and tinnitus. Radiographic examination revealed a right SCA pseudoaneurysm associated with an AVF located between the right common carotid artery and vertebral artery. The AVF was completely occluded with detachable coils using a double-catheter technique to avoid coil migration into the IJV. This technique has been used to treat high-flow or complex AVFs, including pulmonary and renal AVFs. As shown in the present case, it is also useful to treat an iatrogenic AVF between the SCA and IJV.

Side-by-Side Stenting Repair of a Traumatic Pseudoaneurysm at a Venous Confluence

OBJECTIVES

The incidence and prevalence of iatrogenic vascular trauma in the United States is staggering. This has led to the advent and implementation of more efficient and effective vascular repair methods. Although open surgical repair may still be considered gold standard, new endovascular solutions have emerged as other viable options. When using an endovascular approach, proper stent sizing is vital to a successful repair.

METHODS

We present a case of a traumatic injury and pseudoaneurysm formation at the confluence of the right internal jugular and right subclavian veins during a central line placement. This iatrogenic pseudoaneurysm was treated with endovascular placement of side-by-side stents. A mathematical formula, which we have designated "Matteo's law," was utilized to select properly sized stent grafts to reconstruct the confluence and prevent infolding and endoleaks.

RESULTS

After deployment of kissing stents at the confluence of the right internal jugular and right subclavian veins, a venogram was performed, which demonstrated successful exclusion of the pseudoaneurysm and no endoleaks. Clinical follow-up confirms continued wide open flow through the reconstructed venous confluence at 8 months post-procedure.

CONCLUSION

In reconstruction of a venous confluence, selection of properly sized stent grafts is paramount to preventing infolding and endoleaks. Matteo's law states that the circumference of the native receiving vessel must equal the sum of the circumferences of both kissing stent grafts, subtracting the redundant material where the 2 stents interface.

Randomized multicenter study on long-term complications of peripherally inserted central catheters positioned by electrocardiographic technique

BACKGROUND

The intracavitary electrocardiogram (IC-ECG) method has been used for the tip location of central venous access devices for the advantage of being safe, accurate and highly cost effective. However, long-term follow-up is rare. This randomized clinical trial aimed to evaluate the long-term complications of peripherally inserted central catheters (PICCs) positioned by the IC-ECG method.

METHODS

We randomized 2250 patients who needed PICC placement to either a landmark length estimation supplemented by IC-ECG positioned group (ECG group) or the traditional landmark length estimation alone group (control group) in a 2:1 allocation. Post-procedural chest X-rays were applied to confirm tip position. Follow-up was performed monthly to six months. Standard statistics analyses were performed with the SAS 9.13 software, and p < 0.05 was considered significant.

RESULTS

As evaluated by post-procedural chest X-ray, tip location in the ECG group had a first-attempt success (catheter tip located at optimal position) of 91.7% (95% confidence interval (CI): 90.3%-93.1%), significantly higher than 78.9% (95% CI: 76.0%-81.9%) observed in the control group (p < 0.001). At six-month follow-up, in the control group, frequency of total complications was 9.5%, including the exit site infection (4.0%), phlebitis (1.3%), deep venous thrombosis (1.5%), liquid extravasation (2.9%) and mechanical failure (1.9%). The IC-ECG group had significantly lower rates of complications (6.4%, p < 0.001), including the exit site infection (2.7%, p > 0.05), phlebitis (1.1%, p > 0.05), deep venous thrombosis (1.2%, p > 0.05), liquid extravasation (2.4%, p > 0.05) and mechanical failure (1.2%, p > 0.05). In the univariable logistic regression analysis, ECG method, other diseases and upper arms were the independent protective factors, and the number of adjustment procedures (n ≥ 2) were the independent risk factors of the complications.

CONCLUSIONS

The intra-procedural tip location by IC-ECG is more safe and accurate than the traditional method of verifying tip location only post-procedurally, by chest X-ray.

Central venous catheterization in cancer patients with severe thrombocytopenia: Ultrasound-guide improves safety avoiding prophylactic platelet transfusion

Prior research has revealed that ultrasound (US) guided central venous catheterization (CVC) is associated with a reduction in the complication rate such as pneumothorax and an improved first-pass success placing CVC in the internal jugular vein. The present study investigated if US-guided CVC, in a subset of cancer patients with severe thrombocytopenia, reduced bleeding risk and avoided prophylactic platelet transfusion. The efficacy and safety of US-guided CVC placement in cancer patients with severe thrombocytopenia was retrospectively analyzed over a period of 9 years (Dec 2000-Jan 2009), 1,660 and 207 patients with cancer underwent US-guided CVC placement into internal jugular vein respectively at the Department of Onco-Haematology, Hospital of Piacenza. The first group of patients included patients in active antitumor treatment, while the second group included patients in the palliative phase. A total of 110 (5.89%) of these 1,867 patients exhibited severe thrombocytopenia defined as platelet count ≤20x109/l, and formed the basis of this study. All procedures were evaluated for bleeding complications as defined by the National Institute of Health Common Terminology Criteria for Adverse Events (CTCAE 3.0). In the subgroup of the 110 patients with severe thrombocytopenia a single needle puncture of the vein was employed in 121 of the 122 procedures (99.18%) and no attempt failures were registered. No pneumothorax, no major bleeding and no nerve and arterial puncture were reported, only one self-limiting hematoma (0.90%) at the site of CVC insertion was reported (CTCAE 3.0 grade 1). No platelet transfusions were performed in the 110 patients, pre and post CVC placement. We believe that US-guided CVC insertion procedures into the internal jugular vein makes the difference in safety, also in thrombocytopenic patients avoiding prophylactic or post procedure platelet transfusion.

Challenges of Vascular Access in the Pediatric Population

The incidence and prevalence of renal replacement therapy has continued to increase in the pediatric population. Recent data have shown that hemodialysis was the most frequently used dialysis modality, especially in pediatric ESRD patients (age 0-21 years). A well-functioning vascular access is required for effective hemodialysis and choosing the best vascular access option for pediatric patients can be difficult. Pediatric vascular options include arteriovenous fistula, arteriovenous graft, and central venous catheters (CVCs). There is a national initiative for fistula first-catheter last approach; however, CVCs have been reported as the most conventionally utilized vascular access option in pediatric patients. The use of CVCs should be minimized or avoided as they are associated with high risk of infections, thrombosis, and other complications. Thus, it is important for practitioners to plan appropriately in advance, practice good clinical judgment, and assure that the best vascular access is placed according to the patient's needs. Therefore, this article reviews the different types of pediatric vascular access and the associated benefits and potential complications of each.

Comparison between ultrasonography and X-ray as evaluation methods of central venous catheter positioning and their complications in pediatrics

PURPOSE

This study evaluates the capacity of ultrasonography as a diagnostic method to confirm the proper positioning of central venous catheter (CVC) when compared to the current gold standard, chest radiography (CR).

METHODS

A prospective study was performed including children from 0 to 14 incomplete years, who underwent CVC placement between March and May 2018 at a teaching hospital in Brazil. A four-chamber view of the heart was performed with ultrasound during a rapid injection of saline solution to identify hyperechoic images and confirm the central position of the catheter. After that, a CR was performed. The diagnostic quality of ultrasound was evaluated based on accuracy, sensitivity, specificity, positive and negative predictive values.

RESULTS

A total of 21 patients were analyzed. The mean age was 3.95 ± 4.01 years. The preferred puncture site was the right internal jugular vein (71.4%). Ultrasound accuracy to detect CVC positioning was 81%. Sensitivity, specificity and positive and negative predictive values were 33%, 100%, 100% and 79%, respectively.

CONCLUSION

Ultrasound is a reliable method for detection of CVC positioning. Even so, with the four-chamber cardiac view, this method is unable to identify catheters inside heart chambers, therefore, needing to confirm the positioning with CR.

PIÑATA: Pinpoint insertion of intravenous needles via augmented reality training assistance

Conventional needle insertion training relies on medical dummies that simulate surface anatomy and internal structures such as veins or arteries. These dummies offer an interesting space to augment with useful information to assist training practices, namely, internal anatomical structures (subclavian artery and vein, internal jugular vein and carotid artery) along with target point, desired inclination, position and orientation of the needle. However, limited research has been conducted on Optical See-Through Augmented Reality (OST-AR) interfaces for training needle insertion, especially for central venous catheterization (CVC). In this work we introduce PIÑATA, an interactive tool to explore the benefits of OST-AR in CVC training using a dummy of the upper torso and neck; andexplore if PIÑATA complements conventional training practices.. Our design contribution also describes the observation and co-design sessions used to collect user requirements, usability aspects and user preferences. This was followed by a comparative study with 18 participants - attending specialists and medical residents - that performed needle insertion tasks for CVC with PIÑATAand the conventional training system. The performance was objectively measured by task completion time and number of needle insertion errors. A correlation was found between the task completion time in the two training methods, suggesting the concurrent validity of our OST-AR tool. An inherent difference in the task completion time (p =0.040) and in the number of errors (p = 0.036) between novices and experts proved the construct validity of the new tool. The qualitative answers of the participants also suggest its face and content validity, a high acceptability rate and a medium perceived workload. Finally, the result of semi-structured interviews with these 18 participants revealed that 14 of them considered that PIÑATA can complement the conventional training system, especially due to the visibility of the vessels inside the simulator. 13 agreed that OST-AR adoption in these scenarios is likely, particularly during early stages of training. Integration with ultrasound information was highlighted as necessary future work. In sum, the overall results show that the OST-AR tool proposed can complement the conventional training of CVC.

The incidence and management of complications of venous access in home parenteral nutrition (HPN): A 19 year longitudinal cohort series

BACKGROUNDS AND AIMS

Long term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI). This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access.

METHODS

HPN data were analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days' distributions. Data were not normally distributed and so non-parametric tests were used. Spearman's Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used two sample t-tests to compare the groups.

RESULTS

From 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n = 16) was associated with total time on HPN (r² = 0.187, P < 0.05) and the number of infections (r² = 0.207, P < 0.05). Damage was strongly associated with increasing time on HPN with (r² of 0.494 and P < 0.005). Blockage was not associated with any patient or catheter factors. Overall catheter salvage rate for CRBSI by antibiotic treatment was 61.87%. Success varied according to organism cultured. Catheter salvage was less successful in other complications and overall catheter salvage rate was 41,115 catheters were salvaged from 282 complications.

CONCLUSIONS

This study has provided a baseline for rates of less common venous access complications in HPN and their management. Catheter salvage is possible after at least 41% of complications. It is likely that experience is helpful whether that of individual patient, the team or a clinical network. Our results support the use of smaller central venous catheters, in upper body veins, and the use of Taurolock-Hep100 in patients who have recurrent infections.

Bailout subclavian artery stenting in a sick child with iatrogenic subclavian artery perforation: a case report

Background

Subclavian artery injury during internal jugular vein catheterization is a rare yet potentially life-threatening complication leading to hemothorax and exsanguination. The percutaneous endovascular approach offers a less invasive and effective alternative to the high-risk surgical repair in emergent situations.

Case presentation

We present a case of a 6-year-old child suffering from hemolytic uremic syndrome requiring urgent hemodialysis, for which IJV (internal jugular vein) cannulation was attempted. This procedure led to iatrogenic subclavian arterial perforation causing massive hemothorax with hemodynamic compromise. CT angiogram showed a through and through perforation in the first part of right subclavian artery between common carotid and vertebral artery. A definitive assessment of the extent of ongoing leak was made through an invasive angiogram in the catheterization laboratory. The perforation was successfully closed percutaneously with a covered stent without compromising any branch vessels.

Conclusion

Arterial injury although rare is a potentially life-threatening complication of IJV cannulation which warrants immediate attention and corrective measures. Ultrasound guidance can reduce the risk of such life-threatening complications. Percutaneous management offers a less invasive, less time consuming, and effective alternative in critically ill patients in emergency situations.

Nurse-Performed Ultrasound-Guided Technique for Difficult Peripheral Intravenous Access in Critically Ill Patients: A Randomized Controlled Trial

Highlights

Abstract

Purpose: The aim of this study was to compare nurse-performed ultrasound (US)-guided technique with standard of care (SOC) technique for difficult peripheral intravenous (PIV) access among patients admitted to the intensive care unit (ICU).

Materials and Methods: This was a randomized, prospective, open-label single-site study. ICU nurses completed a standardized training program for US-guided PIV access placement before patient enrollment. ICU patients with difficult PIV access were randomized to either nurse-performed US-guided technique or SOC technique. Primary outcome was success rate on the first attempt. Secondary outcomes were success rate after 2 attempts and frequency of complications after successful placement.

Results: A total of 60 patients were enrolled; 30 were randomized to receive US-guided technique, and 30 to SOC technique. Success rate on the first attempt was significantly higher with US-guided technique compared with SOC technique (70% vs 40%; P &lt; 0.05). Success rates after 2 attempts were 73.3% for US-guided technique and 46.6% for SOC technique (P = 0.065). Extravasation after successful placement occurred in 13.6% of patients with US-guided technique, and 28.6% of patients with SOC technique (P = 0.394).

Conclusions: Among ICU patients with difficult PIV access, US-guided PIV access placement by nurses who underwent standardized training was more successful than placement with SOC technique.

Drug Thrombus Resulting in Superior Vena Cava Syndrome: A Case Report

INTRODUCTION

Superior vena cava syndrome is one of the more serious complications of central venous catheter insertion. Drug interactions of administered drugs used in association with these catheters can lead to formation of precipitations and consequently thrombus formation. These interactions can be either anion-cation or acid-base based and more commonly present in clinical practice than expected.

CASE PRESENTATION

The case of a 31-year old female who was admitted to an intensive care unit with an intracranial haemorrhage, is presented. Occlusion of the superior vena cava was caused by a drug-induced thrombus, formed by the precipitation and clotting of total parenteral nutrition and intravenous drugs. Given the nature of the thrombus and a recent intracranial haemorrhage, the patient was treated with a central thrombectomy supported by a heparin-free extracorporeal membrane oxygenation.

CONCLUSION

Knowledge of drug interactions is crucial in order to heighten awareness for the dangers of concomitant drug administration, especially in combination with total parenteral nutrition in critically ill patients.

Emergency medicine physicians infrequently perform pediatric critical procedures: a national perspective

Objective

To our knowledge, this is the first comprehensive study using a nationally representative database to estimate the frequency of critical procedures (endotracheal tube intubation [ETI], cardiopulmonary resuscitation [CPR], and central line insertion [CLI]) in children and adults.

Methods

The study was based on the secondary analysis of the 2010-2014 National Hospital Ambulatory Medical Care Survey. We included adult and pediatric patients undergoing critical procedures in the emergency department. We extracted demographic and clinical information, including the performance of critical procedures. For frequent procedures (≥1 per year), we estimated the annual number of critical procedures per emergency physician (EP) by dividing the total number of annual critical procedures by the total number of EPs (estimated at 40,000). For infrequent procedures, we calculated the average interval between procedures. We summarized the data with descriptive statistics and 95% confidence intervals (CIs).

Results

There were an estimated 668 million total emergency department visits (24% pediatric). On average, a single EP performed 8.6 (95% CI, 5.5 to 11.7) CLIs, 3.7 (95% CI, 2.4 to 5.0) CPRs, and 6.3 (95% CI, 5.3 to 7.4) ETIs per year in adults. In comparison, a single EP performed one pediatric CLI, CPR, and ETI every 3.2 (95% CI, 1.9 to 9.8), 5.2 (95% CI, 2.8 to 33.5), and 2.8 (95% CI, 1.6 to 8.9) years, respectively.

Conclusion

Our nationwide findings confirm those of previous smaller studies that critical procedures are significantly fewer in children than adults. We suggest that methods to retain skills in pediatric critical procedures should be developed for general EPs to ensure that they deliver the highest level of care across the entire age spectrum.

Complications and pitfalls of central venous port catheters: experience with 782 patients with cancer

BACKGROUND

The clinical use of port catheters has become widespread because they provide a safe and easy vascular route. Such widespread use of vascular port catheters has revealed early and late complications.

AIM

This study was evaluated the early and late noninfectious complications and present precautions and pitfalls to handle these complications.

METHODS

The retrospective observational study comprised 801 vascular port catheters inserted into 782 adult patients for various reasons between 2010 and 2018. Patient demographic, indications for port catheter implantation, port catheter types, and insertion sides were noted. Port catheter implantation related early and late complications were recorded.

RESULTS

The subclavian vein was selected as a target vein in almost all of the interventions (98.9%). Similarly, right-sided veins were used in about 90% of patients. The most common problem was technical issues related to the interventions. If venous cannulation was challenging, ultrasonography and fluoroscopy guidance roadmap technique were used. Most serious complication was pneumothorax in 7 patients. In the late period, the most common problem was thrombotic occlusion of the catheter. In two-thirds of these patients, thrombolytic therapy for thrombosed port catheters may rescue some catheters and avoid secondary port catheter insertions.

CONCLUSIONS

Despite these benefits, port catheters are associated with various complications. However, most of these complications can be effectively prevented by proper techniques and easily applied precautions.

Anatomical Morphology Analysis of Internal Jugular Veins and Factors Affecting Internal Jugular Vein Size

Background and objectives: There is a paucity of research on the shape of internal jugular vein (IJV) and their association with an individual's morphology and various chronic diseases. Therefore, this study aimed to analyze the anatomy of the IJV across various patients and to relate the differences in anatomy to basic patient characteristics. Materials and Methods: This retrospective study included a total of 313 patients who underwent contrast-enhanced neck computed tomography between January 2017 and December 2018. The circumferences of the right and left IJVs were measured at three locations (hyoid bone, cricoid cartilage, and first thoracic vertebra) and parameters affecting the size of the IJV were analyzed. Results: The right IJV was significantly larger than the left IJV at each position (p < 0.001), and the area of the lumen was the largest at the cricoid cartilage level (p < 0.001). After dividing the right IJV data into two groups (above and below the median area), multivariate logistic regression analysis showed that age (odds ratio (OR) 1.040; 95% confidence interval (CI) 1.022-1.058, p < 0.001) and body mass index (BMI, OR 1.080; 95% CI 1.011-1.154, p = 0.0.23) affected size. Conclusions: The right IJV is larger than the left and has a rhomboid morphology. Age and BMI are significant factors affecting the IJV size.