Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults

Heparin Versus Saline: A Comparative Study to Support Practice Change Within an Organization

This nurse-led research study investigates the comparative effectiveness of heparin versus 0.9% sodium chloride locking in blood cancer patients with peripherally inserted central catheters (PICCs). Subjects were randomly assigned to receive either heparin or 0.9% sodium chloride locking for up to 7 days. Results show no significant difference in maintaining the PICCs' patency between the 2 locking methods. Additionally, heparin was associated with more side effects, higher costs, and increased nursing time compared to 0.9% sodium chloride. These findings support adopting 0.9% sodium chloride for PICC maintenance in blood cancer patients, aiming to enhance patient safety and reduce costs.

The regulatory effects of mesedin and beditin alpha2-adrenoblockers on the functional activity of the nervous, cardiovascular, and endocrine systems in rats under the hypoxic conditions

One of the reasons of the development of pathologies causing death is hypoxia. The purposes of this study were (1) to study some physiological and biochemical mechanisms of α2-adrenoblockers, which ensure the tissue resistance increase to hypoxia; (2) to offer new drugs contributing to the increase of tissues' stability towards the hypoxic affection; and (3) to submit new medications to surpass by their anti-hypoxic activity of those already used in modern medicine and have some advantages. The reactivity of postsynaptic vascular α2-adrenoceptors was determined on the damaged spinal cord expressed by the blood pressure increase in response to intravenous administration of azepexole that selectively binds to α2-adrenoceptors. Determination of the systemic hemodynamic values and the vascular resistance to the blood flow was performed by the method with plastic microspheres of marked isotopes. pO2 in the blood and the oxygen-transporting function were determined in a sample of 0.1 ml of blood in 30, 90, and 180 min after the α2-adrenoblockers' injections. It has been found that one of the major hemodynamic effects of mesedin and beditin was an improvement in cardiac output, as well as a prolonged increase in coronary blood flow and vasodilation of the heart vessels. Some anti-hypoxic mechanisms of the studied α2-adrenoblockers are an improvement of blood oxygen-transporting function followed by tissue oxygenation and the increased level of corticosterone and resistance to hypoxia. Revealing the mechanisms of action of the postsynaptic α2-adrenoceptors suggests that mesedin and beditin are potentially effective therapeutic means for many hypoxic conditions.

S3-Leitlinie Heimenterale und heimparenterale Ernährung der Deutschen Gesellschaft für Ernährungsmedizin (DGEM)

Medizinische Ernährungstherapie, die enterale und parenterale Ernährung umfasst, ist ein wesentlicher Teil der Ernährungstherapie. Medizinische Ernährungstherapie beschränkt sich nicht auf die Krankenhausbehandlung, sondern kann effektiv und sicher auch zu Hause eingesetzt werden. Dadurch hat sich der Stellenwert der Medizinischen Ernährungstherapie deutlich erhöht und ist zu einem wichtigen Bestandteil der Therapie vieler chronischer Erkrankungen geworden. Für Menschen mit chronischem Darmversagen, z. B. wegen Kurzdarmsyndrom ist die Medizinische Ernährungstherapie sogar lebensrettend. In der Leitlinie wird die Evidenz für die Medizinische Ernährungstherapie in 161 Empfehlungen dargestellt. Die Leitlinie wendet sich in erster Linie an Ärzte, Ernährungsfachkräfte und Pflegekräfte, sie dient der Information für Pharmazeuten und anderes Fachpersonal, kann aber auch für den interessierten Laien hilfreich sein.

Clinical application of 4% sodium citrate and heparin in the locking of central venous catheters (excluding dialysis catheters) in intensive care unit patients: A pragmatic randomized controlled trial

OBJECTIVES

The feasibility of utilizing 4% sodium citrate as an alternative locking solution for central venous catheters (CVCs) (excluding dialysis catheters) was assessed.

METHODS

Using heparin saline and 4% sodium citrate as locking solution, then 152 patients in ICU undergoing infusion with central venous catheters, were randomly assigned to receive either 10 U/mL heparin saline or 4% sodium citrate. The used outcome indicators include: four indexes of blood coagulation at 10 minutes after locking and 7 d after the first locking, bleeding around the puncture site and subcutaneous hematoma rate, gastrointestinal bleeding rate, catheter indwelling time, catheter occlusion rate, catheter-related bloodstream infection (CRBSI) rate, rate of ionized calcium < 1.0 mmol/L. The main outcome indicator was the activated partial thromboplastin time (APTT) at 10 min after tube locking. The trial was approved by relevant authorities (Chinese Clinical Trial Registry, no: ChiCTR2200056615, registered on February 9, 2022, http://www.chictr.org.cn; Ethics Committee of People's Hospital of Zhongjiang County, no: JLS-2021-034, approved at May 10, 2021, and no: JLS-2022-027, approved at May 30, 2022).

RESULTS

Among the main outcome measures, the heparin group showed a significant increase in APTT compared to the sodium citrate group at 10 min after locking (LSMD = 8.15, 95%Cl 7.1 to 9.2, P < 0.001). Among the secondary outcome measures, the heparin group demonstrated a significant increase in prothrombin time (PT) compared to the sodium citrate group at 10 minutes after locking (LSMD = 0.86, 95%CI 0.12 to 1.61, P = 0.024). It is found that APTT (LSMD = 8.05, 95%CI 6.71 to 9.4, P < 0.001), PT (LSMD = 0.78, 95%CI 0.14 to 1.42, P = 0.017) and fibrinogen (FB) (LSMD = 1.15, 95%CI 0.23 to 2.08, P = 0.014) at 7 d after locking are increased in the heparin group compared to sodium citrate group. There was no significant difference in catheter indwelling time between the two groups (P = 0.456). The incidence of catheter blockage was lower in sodium citrate group (RR = 0.36, 95%CI 0.15 to 0.87, P = 0.024). No CRBSI occurred in the two groups. Among the safety evaluation indexes, the incidence of bleeding around the puncture site and subcutaneous hematoma was lower in sodium citrate group (RR = 0.1, 95%CI 0.01 to 0.77, P = 0.027). There was no significant difference in the incidence of calcium ion < 1.0 mmol/L between the two groups (P = 0.333).

CONCLUSIONS

In ICU patients using CVCs (excluding dialysis catheters) infusion, employing 4% sodium citrate as a locking liquid can reduce the risk of bleeding and catheter occlusion without any hypocalcemia.

Safety and feasibility assessment of extending the flushing interval in totally implantable venous access port flushing during the non-treatment stage for patients with breast cancer

Aim

To investigate the safety and feasibility of extending the flushing interval for the totally implantable venous access port (TIVAP) during the non-treatment stage in patients with breast cancer (BC) by retrospectively analyzing the patients’ clinical data, including the incidence of TIVAP-related complications.

Methods

This single-center retrospective study included patients with BC who underwent TIVAP implantation at our hospital between January 2018 and March 2021 during their non-treatment phase and visited the hospital regularly for TIVAP flushing. Among the 1013 patients with BC who received TIVAP implantation, 617 patients were finally included on the basis of the inclusion and exclusion criteria and divided into three groups according to the length of the flushing interval: group 1 (≤30 days, n = 79), group 2 (31–90 days, n = 66), and group 3 (91–120 days, n = 472). The basic characteristics of patients in each group and the incidence of TIVAP-related complications (catheter obstruction, infection, and thrombosis) were analyzed.

Results

No significant intergroup differences were observed in age, body mass index (BMI), tumor stage, pathological staging, implantation approach, chemotherapy regimen, duration of treatment, and TIVAP-related blood return rate (P &gt; 0.05). Among patients from all three groups, 11 cases of catheter pump-back without blood and eight cases of TIVAP-related complications such as infection, thrombosis, and catheter obstruction were recorded. However, no significant differences in TIVAP-related complications were observed among the three groups (P &gt; 0.05).

Conclusion

Extending the TIVAP flushing interval beyond three months during the non-treatment stage in BC patients is safe and feasible and did not increase the incidence of TIVAP-related complications.

Comparison of the Effect of Heparinized Normal Saline Solution Versus Saline Solutions in Arterial and Central Venous Catheters on Complete Blood Count After Cardiac Surgery

Background

Heparinized and saline solutions can prevent clot formation in arterial and central venous catheters. However, heparin can decrease the platelet count and induce thrombocytopenia. Patients undergoing cardiac surgeries are more likely to develop heparin-induced thrombocytopenia.

Objectives

This study aimed to investigate the effect of heparinized and saline solutions of arterial and central venous catheters on complete blood count (CBC) after cardiac surgery.

Methods

This randomized controlled trial was conducted on 100 participants. All subjects underwent cardiac surgery at Rajaie Cardiovascular, Medical, and Research Center, Tehran, Iran. Patients were randomly divided into two groups intervention (A) for whom heparinized normal saline solution was used to maintain central arterial and venous catheters, and control (B) for whom normal saline solution was used. The CBC of subjects was monitored for three days (before surgery and the first and second days after surgery).

Results

In the present study, there were no significant differences between CBC, white blood cell differential count, prothrombin time, partial thromboplastin time (PTT), and international normalized ratio in groups A and B. However, we found significant differences in platelet count (P = 0.049), red blood cell count (P = 0.0001), hemoglobin (P = 0.0001), and hematocrit (P = 0.0001) between before surgery and the second day after surgery in group A. Platelet count (P = 0.027) and PTT (P = 0.0001) before and after surgery were significantly different in group B.

Conclusions

According to the results of this study, normal saline solution catheters have fewer side effects and can be a suitable replacement for heparinized catheters.

Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults

BACKGROUND

Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency and performance. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% sodium chloride (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to normal saline, to see if the evidence establishes whether one is better than the other. This is an update of an earlier Cochrane Review.

OBJECTIVES

To evaluate the benefits and harms of intermittent locking of CVCs with heparin versus normal saline in adults to prevent occlusion.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 20 October 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus normal saline. We excluded studies on infants and children from this review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were occlusion of CVCs and duration of catheter patency. Our secondary outcomes were CVC-related bloodstream infections and CVC-related colonisation, mortality, haemorrhage, heparin-induced thrombocytopaenia, CVC-related thrombosis, number of additional CVC insertions, abnormality of coagulation profile and allergic reactions to heparin. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We identified one new RCT with 30 participants for this update. We included a total of 12 RCTs with 2422 participants. Data for meta-analysis were available from all RCTs. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access). Five studies included ICU (intensive care unit) patients, two studies included oncology patients, and the remaining studies included miscellaneous patients (chronic kidney disease, haemodialysis, home care patients, etc.). Primary outcomes Overall, combined results may show fewer occlusions with heparin compared to normal saline but this is uncertain (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; 10 studies; 1672 participants; low-certainty evidence). We pooled studies that used participant or catheter as the unit of analysis. We carried out subgroup analysis by unit of analysis. No clear differences were detected after testing for subgroup differences (P = 0.23). We found no clear evidence of a difference in the duration of catheter patency with heparin compared to normal saline (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; 6 studies; 1788 participants; low-certainty evidence). Secondary outcomes We found no clear evidence of a difference in the following outcomes: CVC-related bloodstream infections (RR 0.66, 95% CI 0.08 to 5.80; 3 studies; 1127 participants; very low-certainty evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; 3 studies; 1100 participants; very low-certainty evidence); haemorrhage (RR 1.54, 95% CI 0.41 to 5.74; 3 studies; 1197 participants; very low-certainty evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; 3 studies; 443 participants; very low-certainty evidence). The main reasons for downgrading the certainty of evidence for the primary and secondary outcomes were unclear allocation concealment, suspicion of publication bias, imprecision and inconsistency.

AUTHORS' CONCLUSIONS

Given the low-certainty evidence, we are uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. Although we found no evidence of differences in safety (CVC-related bloodstream infections, mortality, or haemorrhage), the combined studies were not powered to detect rare adverse events such as heparin-induced thrombocytopaenia. Further research conducted over longer periods would reduce the current uncertainties.

Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Pediatric Patients With Cancer

BACKGROUND

There is insufficient evidence of the effects of intermittent flushing with normal saline versus heparin to prevent occlusion or increased alteplase use in pediatric patients with central venous catheters.

OBJECTIVES

The primary objective was to evaluate the effectiveness of a new standard flushing practice in the management of central venous access devices in pediatric patients with cancer. A secondary objective was to assess the cost of heparin flushing supplies to patients and financial impact.

METHODS

New flushing guidelines included tunneled lines flushed with saline in the push-pause method twice daily in the inpatient setting. The outpatient setting required saline lock while receiving care and heparin lock on discharge. Alteplase usage was monitored for five months in all pediatric patients with cancer who had tunneled central lines.

FINDINGS

There was no statistically significant difference in alteplase usage rate pre- to postimplementation. A formal flushing guideline was recommended using saline and lower heparin concentrations for tunneled catheters.

Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer

BACKGROUND

This is an updated version of a Cochrane Review last published in 2013. Long-term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram-positive bacteria. Antimicrobial prevention strategies aimed at these micro-organisms could potentially decrease the majority of CVC-related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram-positive infections in people with cancer who have long-term CVCs.

OBJECTIVES

To assess the effects of administering antibiotics prior to the insertion of long-term CVCs or as a flush/lock solution, or both during long-term CVC access to prevent gram-positive CVC-related infections in adults and children receiving treatment for cancer.

SEARCH METHODS

The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long-term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non-antibiotic flush/lock solution in long-term CVCs, in adults and children receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram-positive catheter-related infection events and total number of CVCs and CVC days. We pooled the data using a random-effects model for meta-analyses. We used the GRADE approach to assess the certainty of the evidence.  MAIN RESULTS: For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long-term CVC. One study did not observe any CVC-related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram-positive CVC-related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate-certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low.   Antibiotics as a flushing or locking solution Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin-only solution for flushing or locking the long-term CVC after use. One study did not observe any CRS events and was not include this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long-term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram-positive CVC-related infections compared to a heparin-only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC-days; 5 studies, 443 participants; moderate-certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low.  AUTHORS' CONCLUSIONS: Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long-term CVCs to prevent gram-positive CVC-related infections. Flushing or locking long-term CVCs with an antibiotic solution likely reduces gram-positive CVC-related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high-risk people or if the baseline CVC-related infection rates are high. Further research is needed to identify high-risk groups most likely to benefit from these antibiotic flush/lock solutions.

Anti-cancer therapy made easier: a 25-year update

In 1993, the Internal Medicine Journal published ‘Chemotherapy made easier’, outlining developments in supportive care of patients undergoing chemotherapy. This described the contemporary state of anti‐emetics, colony stimulating factors, cardiac toxicity, neurotoxicity, development of drug analogues and venous access devices. Twenty‐five years later, we update the measures that improve the tolerability of the plethora of new anti‐cancer therapies, which have extended well beyond traditional chemotherapy agents to include immunotherapy and targeted therapies. Optimisation of supportive care is paramount to allow safe delivery with the least possible impact on quality of life of these new treatments, many of which have resulted dramatically improved outcomes across multiple cancer types. This state of the art update summarises advances in supportive care therapies relating to improving the patient experience during and after anti‐cancer treatment, including new anti‐emetics, hair preservation techniques, bone marrow support and improved venous access devices; the ongoing challenge of neurotoxicity; and the advent of multidisciplinary sub‐specialised fields such as cardio‐oncology and oncofertility. Supportive care medications for immuno‐oncology therapies is a new section; these highly effective (although not universally so) agents were a mere illusion in 1993.

Comparing the Effects of Pulsatile and Continuous Flushing on Time and Type of Peripheral Intravenous Catheters Patency: A Randomized Clinical Trial

Introduction: Peripheral intravenous catheters (PICs) patency techniques such as flushing are being developed. According to some studies, flushing can be used continuously or in pulsatile forms. This study aimed to compare the effects of pulsatile flushing (PF) and continuous flushing (CF) on time and type of PICs patency. Methods: In this double-blind randomized clinical trial, 71 patients were randomly assigned into two groups of PF (n=35) and CF (n=36). The PF protocol was performed as successive injections of 1 mL normal saline (N/S) per second (sec) with a delay of less than 1 sec until the completion of 5 mL of solution. However, CF protocol was performed by injecting 5 mL N/S within 5 sec without any delay before and after each medicine administration. Data related to the time and type of PICs patency were collected using a patency checklist every 12 hours (h) up to 96 h. The statistical analysis was done by R statistical software (Version 3.5.1). Results: The results showed that the number of PICs remaining open was not significantly different between PF and CF groups during 96 h. The highest number of PICs excluded from the study was related to the time of 96 h as a result of partial patency in the two groups. Conclusion: There was no difference between CF and PF regarding the time and type of PICs patency. Thus, both techniques can be used to maintain the catheter patency.

Heparin versus 0.9% saline solution to maintain patency of totally implanted venous access ports in cancer patients: A systematic review and meta-analysis

AIM

The use of heparin and 0.9% saline solution is always controversial for central venous catheters. However, there is no systematic review or guideline about whether saline solution can replace heparin solution in adult cancer patients with totally implantable venous access ports (TIVAPs). The purpose of this review is to evaluate whether saline solution can replace heparin saline to lock TIVAPs.

METHODS

The following databases were searched: PubMed, the Cochrane Library, Web of Science, Embase, CINAHL and Ovid (January 1, 1982, and February 21, 2020). All statistical analyses of the meta-analysis were completed using the Review Manager 5.3.

RESULTS

A total of 201 studies were identified from these databases after initial review, and four studies met inclusion criteria, including 2652 cases. There was little heterogeneity among the included studies (I² < 30%), and all analyses were conducted by the fixed-effects model. The total complications, catheter occlusions, catheter-related bloodstream infections and other complication rates in the heparin solution group were higher than in the saline solution group. In the subgroup analysis of heparin concentration, total complication rates in the saline solution group were higher than with 50 U of heparin and lower than with 100 U of heparin. However, the differences in these complications were small, and no significant difference was observed (all P > 0.05).

CONCLUSIONS

Based on existing clinical studies, we recommend that saline solution can replace 50 or 100 U/ml of heparin as a safe and effective flush solution for TIVAPs.

Brief Report on Double-Chamber Syringes Patents and Implications for Infusion Therapy Safety and Efficiency

This review aimed to map the existing patents of double-chamber syringes that can be used for intravenous drug administration and catheter flush. A search was conducted in the Google patents database for records published prior to 28 October 2020, using several search terms related to double-chamber syringes (DCS). Study eligibility and data extraction were performed by two independent reviewers. Of the initial 26,110 patents found, 24 were included in this review. The 24 DCS that were found display two or more independent chambers that allow for the administration of multiple solutions. While some of the DCS have designated one of the chambers as the flushing chamber, most patents only allow for the sequential use of the flushing chamber after intravenous drug administration. Most DCS were developed for drug reconstitution, usually with a freeze-dried drug in one chamber. Some patents were designed for safety purposes, with a parallel post-injection safety sheath chamber for enclosing a sharpened needle tip. None of the DCS found allow for a pre- and post-intravenous drug administration flush. Given the current standards of care in infusion therapy, future devices must allow for the sequential use of the flushing chamber to promote a pre-administration patency assessment and a post-administration device flush.

Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein may reduce central line-associated bloodstream infection in preterm infants

The objective of this study was to assess the risk of central line-associated bloodstream infection (CLABSI) of ultrasound (US)-guided cannulation of the brachiocephalic vein (BCV) compared to standard epicutaneous cava catheters (ECCs) in preterm infants. This was a retrospective cohort study in preterm infants with a birth weight of less than 1500 g. Each BCV catheter was matched 1:3 with ECCs according to sex, birth weight, and year of insertion. The main outcome was the CLABSI density rate per 1000 days. Secondary outcomes included CLABSI episodes, CLABSI episodes per infant, and CLABSI/death. A multivariate Cox regression analysis was performed to assess whether the type of catheter (ECC vs. BCV) was associated with CLABSI risk. Ninety-six catheters (21 BCVs and 75 ECCs) in 79 infants were included (993 catheter days). BCV catheters were associated with a reduced CLABSI density rate compared to ECCs (3.05/1000 days vs 21.1/1000 days; p < 0.001). ECCs were associated with increased CLABSI risk compared to BCV catheters in multivariate analysis (hazard ratio 36; (95% CI, 2.5-511); p = 0.008).Conclusion: US-guided supraclavicular cannulation of the BCV was associated with a reduced risk of CLABSI compared to ECCs. This finding deserves further multicenter research. What is Known: • An epicutaneous-cava catheter (ECC) is commonly used in preterm infants for routine care (eg. delivery of nutrition and antibiotics) but this device may not suffice in infants who need high-intensity care (multiple drugs, hemodynamic monitoring, fluid resuscitation etc.). • Ultrasound-guided brachiocephalic vein (BCV) catheterization has shown a high success rate and few immediate complications in neonates and small infants but it has never been compared to standard ECCs. What is New: • When the operator in properly trained, US guided cannulation of the BCV in preterm infants is feasible, safe and may reduce the risk of CLABSI compared to standard ECCs. • This fact may expand the use of BCV catheters in selected high-risk preterm infants who need a large bore venous access.

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time. Advantages of ports include a simple nursing process, low risk of infection and embolism, and high patient comfort. In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications, the Chinese Research Hospital Association Digestive Tumor Committee, the Chinese Association of Upper Gastrointestinal Surgeons, the Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nation-wide expert letter reviews and on-site seminars, and formulated an expert consensus of the operation guidelines.

Low molecular weight heparin for prevention of central venous catheter-related thrombosis in children

BACKGROUND

The prevalence of children diagnosed with thrombotic events has been increasing in the last decades. The most common thrombosis risk factor in neonates, infants and children is the placement of a central venous catheter (CVC). It is unknown if anticoagulation prophylaxis with low molecular weight heparin (LMWH) decreases CVC-related thrombosis in children. This is an update of the Cochrane Review published in 2014.

OBJECTIVES

To determine the effect of LMWH prophylaxis on the incidence of CVC-related thrombosis and major and minor bleeding complications in children. Further objectives were to determine the effect of LMWH on occlusion of CVCs, number of days of CVC patency, episodes of catheter-related bloodstream infection (CRBSI), other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis) and mortality during therapy.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 7 May 2019. We undertook reference checking of identified trials to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials comparing LMWH to no prophylaxis (placebo or no treatment), or low-dose unfractionated heparin (UFH) either as continuous infusion or flushes (low-dose UFH aims to ensure the patency of the central line but has no systemic anticoagulation activity), given to prevent CVC-related thrombotic events in children. We selected studies conducted in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible studies, which were assessed for study methodology including bias, and extracted unadjusted data where available. In the data analysis step, all outcomes were analysed as binary or dichotomous outcomes. The effects of interventions were summarised with risk ratios (RR) and their respective 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

One additional study was included for this update bringing the total to two included studies (with 1135 participants). Both studies were open-label RCTs comparing LMWH with low-dose UFH to prevent CVC-related thrombosis in children. We identified no studies comparing LMWH with placebo or no treatment. Meta-analysis found insufficient evidence of an effect of LMWH prophylaxis in reducing the incidence of CVC-related thrombosis in children with CVC, compared to low-dose UFH (RR 0.68, 95% CI 0.27 to 1.75; 2 studies; 787 participants; low-certainty evidence). One study (158 participants) reported symptomatic and asymptomatic CVC-related thrombosis separately and detected no evidence of a difference between LMWH and low-dose UFH (RR 1.03, 95% CI 0.21 to 4.93; low-certainty evidence; RR 1.17, 95% CI 0.45 to 3.08; low-certainty evidence; for symptomatic and asymptomatic participants respectively). There was insufficient evidence to determine whether LMWH impacts the risk of major bleeding (RR 0.27, 95% CI 0.05 to 1.67; 2 studies; 813 participants; low-certainty evidence); or minor bleeding. One study reported minor bleeding in 53.3% of participants in the LMWH arm and in 44.7% of participants in the low-dose UFH arm (RR 1.20, 95% CI 0.91 to 1.58; 1 study; 158 participants; very low-certainty evidence), and the other study reported no minor bleeding in either group (RR: not estimable). Mortality during the study period was reported in one study, where two deaths occurred during the study period. Both were unrelated to thrombotic events and occurred in the low-dose UFH arm. The second study did not report mortality during therapy per arm but showed similar 5-year overall survival (low-certainty evidence). No additional adverse effects were reported. Other pre-specified outcomes (including CVC occlusion, patency and CRBSI) were not reported.

AUTHORS' CONCLUSIONS

Pooling data from two RCTs did not provide evidence to support the use of prophylactic LWMH for preventing CVC-related thrombosis in children (low-certainty evidence). Evidence was also insufficient to confirm or exclude a difference in the incidence of major and minor bleeding complications in the LMWH prophylaxis group compared to low-dose UFH (low and very low certainty respectively). No evidence of a clear difference in overall mortality was seen. Studies did not report on the outcomes catheter occlusion, days of catheter patency, episodes of CRBSI and other side effects of LMWH (allergic reactions, abnormal coagulation profile, heparin-induced thrombocytopaenia and osteoporosis). The certainty of the evidence was downgraded due to risk of bias of the included studies, imprecision and inconsistency, preventing conclusions in regards to the efficacy of LMWH prophylaxis to prevent CVC-related thrombosis in children.

Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children

BACKGROUND

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015.

OBJECTIVES

To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long-term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random-effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review.

MAIN RESULTS

We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low-certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate-certainty evidence), and not reported in the remaining studies.

AUTHORS' CONCLUSIONS

The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC-associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains.

Inactivation kinetics of antibiotic resistant Escherichia coli in secondary wastewater effluents by peracetic and performic acids

While disinfection processes have been central for public health protection, new concerns have been raised with respect to their ability to control the spread of antibiotic resistance in the environment. In this study, we report the inactivation kinetics by peracetic and performic acids of a typical indicator, Escherichia coli and its corresponding antibiotic-resistant subpopulation, in secondary settled wastewater effluent. Performic acid always showed greater inactivation efficiency than peracetic acid, whether or not the indicator was Ampicillin-resistant. Observed inactivation data, fitted with an exposure-based inactivation model, predicted very well the inactivation profile of both total and ampicillin resistant Escherichia coli. Notably, the antibiotic resistance percentage decreased significantly in treated wastewater compared to untreated wastewater thus making the peracid-based disinfection processes beneficial in controlling antibiotic resistance in secondary settled wastewater. Moreover, the minimum inhibitory concentration values remained unchanged. Finally, antibiotic-resistant-specific inactivation kinetics were used to predict the disinfection efficiency in continuous-flow reactors under ideal and non-ideal hydraulics thus providing useful information for future design and operation of disinfection process in antibiotic-resistance controlling mode.

Pharmaceutical Aspects of Artificial Nutrition

Artificial nutrition, including enteral (EN) and parenteral (PN) nutrition, is indicated whenever adequate oral nutrition fails to sufficiently supply the necessary nutrients to the body. It is a convenient, efficacious, safe, and well-tolerated form of clinical nutrition in the hospital and home setting. EN is administered via nasogastric tube or ostomies while PN usually requires a central venous access for administration, straight into the blood stream. The infused nutrients can then be taken up directly by the different organs. PN is targeted as a single daily portion formulated as an oil-in-water emulsion providing the necessary substrates for the catabolic and anabolic metabolism including macro- and micronutrients and fluids. PN has a complex pharmaceutical composition-all-in-one admixture-and its compounding or ready-to-use preparation. The use of PN is more challenging and more expensive compare to the use of EN, commercially available as ready-to-use formulations. EN and concomitant medication is highly challenging. Upon incorrect handling and administration, PN is associated with potentially severe or even fatal complications, mostly relating to the central venous access (e.g., catheter-related sepsis) or to a metabolic intolerance (e.g., hyperglycemia, refeeding syndrome) because of inappropriate administration. A correct order of admixing, correct dosing, and administration of the artificial is crucial for safety and efficacy; clinical and biochemical monitoring of the patient and treatment regimen adaption are necessary. The high number of reactive solutes allow only limited stability of a ready-to-use PN admixture. The potential for numerous incompatibilities and interactions renders PN admixtures generally unsuitable as drug vehicle. Laboratory compatibility and stability testing and pharmaceutical expertise are a prerequisite to define the PN composition including nutrients or even drugs admixed to define the appropriate and individualized nutrition and medication regimen. The aim of this narrative review is to present the actual state-of-the-art to deliver best quality artificial nutrition with special regard on pharmaceutical aspects such as instabilities, incompatibilities, and concomitant co-medication.

Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis

BACKGROUND

Around the globe, protocols for flushing the catheter to maintain the patency of central venous catheter (CVC) vary by institution to institution or by practitioner to practitioner. Therefore, this review was carried out with the aim of evaluating the efficacy of heparin flush vs. normal saline flush to maintain the patency of CVC among adult patients.

METHODS

We followed the guidelines of Cochrane handbook for interventions and searched in MEDLINE, Embase, Cochrane library, Clinical trials database, and reference list of related articles, which were published from Jan. 2012 to 31 Dec. 2018 in English language. We included only randomized controlled trials, and nine studies were included in this review. The pooled standard mean difference and relative risk were calculated by using Rev Man Review Manager 5.

RESULTS

We identified nine eligible studies with a total number of 3,113 participants. Consolidated results from eight studies conveyed little favorable effect to maintain patency of CVC with heparin when compared with normal saline as evident by risk ratio 0.83, 95% CI 0.50 - 1.40; P = 0.13. We also carried out analysis for secondary outcomes, and there was no evidence that heparin was better than normal saline in terms of safety except heparin-induced thrombocytopenia.

CONCLUSIONS

Heparin has little favorable effects to maintain patency of catheter than normal saline but not in secondary outcomes. As the quality of evidence was very low, therefore, results should be comprehend with care.

What is the best catheter lock solution in preventing catheter-related blood infections? A protocol for a Bayesian network meta-analysis of randomised controlled trials

INTRODUCTION

Catheter-related bloodstream infection (CRBSI) is a major complication after central venous catheter insertion, which is associated with significant morbidity, mortality and additional medical costs. Many lock solutions for CRBSI have been evaluated. However, using traditional pairwise meta-analyses to summarise the evidence does not allow the inclusion of data from treatments that have not been compared head to head, which could impact the precision of pooled estimates in a meta-analysis. Therefore, we evaluated the efficacy and safety of the different lock solutions for CRBSI through a network meta-analysis.

METHODS AND ANALYSIS

The primary outcome of this network meta-analysis is the CRBSI. The secondary outcomes are exit-site infection and catheter-related thrombosis. We will search the PubMed, Embase, Web of Science and the Cochrane Library databases for recent relevant meta-analysis and their reference lists to include randomised controlled trials (RCTs) that compared lock solutions for CRBSI prevention. Two individuals will independently extract data from each included RCT according to a predesigned Excel spreadsheet and will assess the methodological quality using the Cochrane risk of bias tool. We will analyse the data using WinBUGS (V.1.4.3) and Stata (V.15.0). We will also estimate the pooled direct and indirect effects for all lock solutions using the network meta-analysis.

ETHICS AND DISSEMINATION

As the present meta-analysis is performed based on previous published studies, no ethical approval and patient safety considerations are required. This study commenced on 18 January 2019, and its expected completion date is 1 December 2019. We will disseminate the results of our network meta-analysis through an international peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019121089.

Comparison of heparinized saline and 0.9% sodium chloride for maintaining central venous catheter patency in healthy dogs

BACKGROUND

The purpose of this study was to determine whether heparinized saline (HS) would be more effective in maintaining the patency of central venous catheters (CVCs) in dogs compared to 0.9% sodium chloride. This was a prospective randomized blinded study conducted at a University Veterinary Teaching Hospital.

METHODS

A total of 24 healthy purpose-bred dogs were randomized into two groups: a treatment and a control group. A CVC was placed in the jugular vein of each dog. Each dog in the treatment group had their CVC flushed with 10 IU/mL HS, while dogs in the control group had their CVC flushed with 0.9% sodium chloride every 6 h for 72 h. Immediately prior to flushing, each catheter was evaluated for patency by aspiration of blood. The catheter site was also evaluated for phlebitis, and a rectal temperature was obtained in each dog every 6 h. Prothrombin (PT) and activated partial thromboplastin (aPTT) times were evaluated prior to the administration of any flush solution. Results were then compared to values obtained 72 h later.

RESULTS

All CVCs in both groups were patent after 72 h, which was demonstrated by aspiration of blood and ease of flushing the catheter. Two CVCs in the 0.9% sodium chloride group had a negative aspiration at hour 12 and 36, respectively. One CVC in the HS group had a negative aspiration at hour 18. Signs of phlebitis occurred in three dog: two in the 0.9% sodium chloride group and one in the HS group. No dog was hyperthermic (>103 °F). Two catheters were inadvertently removed by dogs in the HS group during the study. There were no significant differences in catheter patency, incidence of phlebitis, or incidence of negative aspirations between both groups. aPTT and PT values remained within the normal reference range for all dogs in both groups. Ultimately, 0.9% sodium chloride was as effective as 10 IU/mL HS in maintaining the patency of CVCs for up to 72 h in healthy dogs. Further evaluation in clinical patients is warranted.