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Abenante A, Squizzato A, Bertù L, Arioli D, Buso R, Carrara D, Ciarambino T, Dentali F. Predictors for the prescription of pharmacological prophylaxis for venous thromboembolism during hospitalization in Internal Medicine: a sub-analysis of the FADOI-NoTEVole study. Intern Emerg Med 2024:10.1007/s11739-024-03770-w. [PMID: 39333275 DOI: 10.1007/s11739-024-03770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 09/08/2024] [Indexed: 09/29/2024]
Abstract
Patients hospitalized in Internal Medicine Units (IMUs) may frequently experience both an increased risk for thrombosis and bleeding. The use of risk assessment models (RAMs) could aid their management. We present a post-hoc analysis of the FADOI-NoTEVole study, an observational, retrospective, multi-center study conducted in 38 Italian IMUs. The primary aim of the study was to evaluate the predictors associated with the prescription of thromboprophylaxis during hospitalization. The secondary objective was to evaluate RAMs adherence. Univariate analyses were conducted as preliminary evaluations of the variables associated with prescribing pharmacological thromboprophylaxis during hospital stay. The final multivariable logistic model was obtained by a stepwise selection method, using 0.05 as the significance level for entering an effect into the model. Thromboprophylaxis was then correlated with the RAMs and the number of predictors found in the multivariate analysis. Thromboprophylaxis was prescribed to 927 out of 1387 (66.8%) patients with a Padua Prediction score (PPS) ≥ 4. Remarkably, 397 in 1230 (32.3%) patients with both PPS ≥ 4 and an IMPROVE bleeding risk score (IBS) < 7 did not receive it. The prescription of thromboprophylaxis mostly correlated with reduced mobility (OR 2.31; 95% CI 1.90-2.81), ischemic stroke (OR 2.38; 95% CI 1.34-2.91), history of previous thrombosis (OR 2.46; 95% CI 1.49-4.07), and the presence of a central venous catheter (OR 3.00; 95% CI 1.99-4.54). The bleeding risk assessment using the IBS did not appear to impact physicians' decisions. Our analysis provides insight into how indications for thromboprophylaxis were determined, highlighting the difficulties faced by physicians with patients admitted to IMUs.
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Affiliation(s)
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese-Como, Italy
| | - Lorenza Bertù
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese-Como, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Area, AUO Modena, Modena, Italy
| | - Roberta Buso
- Internal Medicine Department, University Hospital of Ca' Foncello, Treviso, Italy
| | - Davide Carrara
- Internal Medicine Unit, Hospital of Versilia, AUSL Toscana Nord-Ovest, Pisa, Italy
| | - Tiziana Ciarambino
- Internal Medicine Department, Hospital of Marciabise, ASL Caserta, Caserta, Italy
| | - Francesco Dentali
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese-Como, Italy.
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Tian L, Feng X, Luo H, Li W, Liu M, Jiang J, Li Y. Evidence-based summary of preventive care for central venous access device-related thrombosis in hospitalized children. BMC Nurs 2024; 23:664. [PMID: 39294683 PMCID: PMC11409775 DOI: 10.1186/s12912-024-02294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/26/2024] [Indexed: 09/21/2024] Open
Abstract
PURPOSE This study aims to summarize the latest and best evidence on central venous access device-related thrombosis (CRT) in hospitalized children, which provides theoretical support for standardizing the preventive care practice of CRT in hospitalized children. METHODS Relevant guidelines, systematic reviews and expert consensuses were reviewed through ten guideline websites, six professional association websites and seven databases. The literature evaluation was conducted, and the best evidence from qualified studies was extracted and summarized. Furthermore, the best evidence was summarized through expert consultation and localized for the preventive care practice of CRT in hospitalized children in China. RESULTS A total of 14 topics and 68 best evidence were collected, including personnel qualification and quality management, pediatric patient selection, risk assessment, central venous access device (CVAD) selection and use, tip position, catheter maintenance, basic prevention, drug prevention, imaging examination, health education, nursing records, follow-up, CVAD removal and others. CONCLUSION In this study, the best evidence based on evidence-based nursing was summarized, and expert consultation was adopted to localize the best evidence collected. It is of great significance to standardize the clinical practice of pediatric nurses and ensure the effectiveness of CRT preventive care for hospitalized children, thus guaranteeing the safety of hospitalized children with CVAD catheterization.
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Affiliation(s)
- Lingyun Tian
- Department of Nursing, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Xinyu Feng
- Centre for Smart Health, School of Nursing, The Hong Kong Polytechnic University, Kowloon City, Hong Kong SAR, China
| | - Hui Luo
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Weijuan Li
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Mengyuan Liu
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Jing Jiang
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Yinglan Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China.
- National Clinical Research Center of Geriatric Disorder, Xiangya Hospital of Central South University, Changsha, Hunan, China.
- School of Nursing, Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, China.
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Gifford AH, Hinton AC, Jia S, Nasr SZ, Mermis JD, Lahiri T, Zemanick ET, Teneback CC, Flume PA, DiMango EA, Sadeghi H, Polineni D, Dezube RH, West NE, Dasenbrook EC, Lucas FL, Zuckerman JB. Complications and Practice Variation in the Use of Peripherally Inserted Central Venous Catheters in People With Cystic Fibrosis: The Prospective Study of Peripherally Inserted Venous Catheters in People With Cystic Fibrosis Study. Chest 2023; 164:614-624. [PMID: 37019356 PMCID: PMC10504599 DOI: 10.1016/j.chest.2023.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are used commonly to administer antibiotics to people with cystic fibrosis (CF), but their use can be complicated by venous thrombosis and catheter occlusion. RESEARCH QUESTION Which participant-, catheter-, and catheter management-level attributes are associated with increased risk of complications of PICCs among people with CF? STUDY DESIGN AND METHODS This was a prospective observational study of adults and children with CF who received PICCs at 10 CF care centers in the United States. The primary end point was defined as occlusion of the catheter resulting in unplanned removal, symptomatic venous thrombosis in the extremity containing the catheter, or both. Three categories of composite secondary outcomes were identified: difficult line placement, local soft tissue or skin reactions, and catheter malfunction. Data specific to the participant, catheter placement, and catheter management were collected in a centralized database. Risk factors for primary and secondary outcomes were analyzed by multivariate logistic regression. RESULTS Between June 2018 and July 2021, 157 adults and 103 children older than 6 years with CF had 375 PICCs placed. Patients underwent 4,828 catheter-days of observation. Of the 375 PICCs, 334 (89%) were ≤ 4.5 F, 342 (91%) were single lumen, and 366 (98%) were placed using ultrasound guidance. The primary outcome occurred in 15 PICCs for an event rate of 3.11 per 1,000 catheter-days. No cases of catheter-related bloodstream infection occurred. Other secondary outcomes developed in 147 of 375 catheters (39%). Despite evidence of practice variation, no risk factors for the primary outcome and few risk factors for secondary outcomes were identified. INTERPRETATION This study affirmed the safety of contemporary approaches to inserting and using PICCs in people with CF. Given the low rate of complications in this study, observations may reflect a widespread shift to selecting smaller-diameter PICCs and using ultrasound to guide their placement.
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Affiliation(s)
- Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH; Division of Pediatric Pulmonology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | | | - Shijing Jia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Samya Z Nasr
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Joel D Mermis
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS
| | - Thomas Lahiri
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Vermont Children's Hospital, Division of Pulmonary Disease & Critical Care Medicine, Department of Medicine, the University of Vermont Medical Center, Burlington, VT
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Charlotte C Teneback
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Vermont Children's Hospital, Division of Pulmonary Disease & Critical Care Medicine, Department of Medicine, the University of Vermont Medical Center, Burlington, VT
| | - Patrick A Flume
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Emily A DiMango
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and the Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Hossein Sadeghi
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Deepika Polineni
- Division of Pulmonary, Critical Care and Sleep Medicine, Washington University at St. Louis, St. Louis, MO
| | - Rebecca H Dezube
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
| | - Natalie E West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
| | | | - F Lee Lucas
- Maine Medical Center Research Institute, Scarborough, ME
| | - Jonathan B Zuckerman
- Maine Medical Center Research Institute, Scarborough, ME; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Maine Medical Center, Portland, ME.
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Ali H, Pamarthy R, Bolick NL, Ali E, Paleti S, Kapuria D. Downhill esophageal varices: a systematic review of the case reports. EXPLORATION OF MEDICINE 2022. [DOI: 10.37349/emed.2022.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim: The etiologies, presentation, and management of downhill varices in the era of modern medicine are relatively under-explored and mostly limited to case reports or case series.
Methods: Published case reports/series of patients ≥ 18 years old with proven/probable downhill esophageal varices were searched on Ovid MEDLINE and Ovid EMBASE for all published cases up to January 2021.
Results: The mean age was 50.9 (standard deviation ± 17.6) years old for all downhill variceal cases. End-stage renal disease was the most common comorbidity (43.9%), followed by thyroid disease (12.2%), Behçet’s disease (9.8%), and pulmonary hypertension (7.3%). Dialysis catheters, central venous grafts, or additional catheters were additional risk factors (51.2%). Variceal bleeding presenting as hematemesis, melena, or both was the most common presenting symptom (80.5%).
Conclusions: Dialysis catheter-associated superior vena cava obstruction resulted in an increased risk of downhill varices. Other causes include thyroid malignancies, pulmonary hypertension, and Behçet’s disease.
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Affiliation(s)
- Hassam Ali
- 1Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Rahul Pamarthy
- 1Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Nicole Leigh Bolick
- 2Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Eslam Ali
- 3Department of Gastroenterology, East Carolina University, Greenville, NC 27834, USA
| | - Swathi Paleti
- 4Department of Gastroenterology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Devika Kapuria
- 5Department of Gastroenterology, Washington University in St. Louis, St. Louis, MO 63130, USA
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5
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Puri A, Dai H, Giri M, Wu C, Huang H, Zhao Q. The incidence and risk of venous thromboembolism associated with peripherally inserted central venous catheters in hospitalized patients: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:917572. [PMID: 35958406 PMCID: PMC9360324 DOI: 10.3389/fcvm.2022.917572] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background Venous thromboembolism (VTE) can be fatal if not treated promptly, and individual studies have reported wide variability in rates of VTE associated with peripherally inserted central catheters (PICC). We thus conducted this meta-analysis to investigate the overall incidence and risk of developing PICC-related VTE in hospitalized patients. Methods We searched PubMed, Embase, Scopus, and Web of Science databases from inception until January 26, 2022. In studies with a non-comparison arm, the pooled incidence of PICC-related VTE was calculated. The pooled odds ratio (OR) was calculated to assess the risk of VTE in the studies that compared PICC to the central venous catheter (CVC). The Newcastle-Ottawa Scale was used to assess methodological quality. Results A total of 75 articles (58 without a comparison arm and 17 with), including 109292 patients, were included in the meta-analysis. The overall pooled incidence of symptomatic VTE was 3.7% (95% CI: 3.1–4.4) in non-comparative studies. In the subgroup meta-analysis, the incidence of VTE was highest in patients who were in a critical care setting (10.6%; 95% CI: 5.0–17.7). Meta-analysis of comparative studies revealed that PICC was associated with a statistically significant increase in the odds of VTE events compared with CVC (OR, 2.48; 95% CI, 1.83–3.37; P < 0.01). However, in subgroup analysis stratified by the study design, there was no significant difference in VTE events between the PICC and CVC in randomized controlled trials (OR, 2.28; 95% CI, 0.77–6.74; P = 0.13). Conclusion Best practice standards such as PICC tip verification and VTE prophylaxis can help reduce the incidence and risk of PICC-related VTE. The risk-benefit of inserting PICC should be carefully weighed, especially in critically ill patients. Cautious interpretation of our results is important owing to substantial heterogeneity among the studies included in this study.
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Affiliation(s)
- Anju Puri
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyun Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mohan Giri
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengfei Wu
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanhuan Huang
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinghua Zhao
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Qinghua Zhao,
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Suh J, Lee SW. Preoperative prediction of the need for arterial and central venous catheterization using machine learning techniques. Sci Rep 2022; 12:11948. [PMID: 35831346 PMCID: PMC9279292 DOI: 10.1038/s41598-022-16144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/05/2022] [Indexed: 11/09/2022] Open
Abstract
Some surgical patients require an arterial or central venous catheterization intraoperatively. This decision relied solely on the experience of individual anesthesiologists; however, these decisions are not easy for clinicians who are in an emergency or inexperienced. Therefore, applying recent artificial intelligence techniques to automatically extractable data from electronic medical record (EMR) could create a very clinically useful model in this situation. This study aimed to develop a model that is easy to apply in real clinical settings by implementing a prediction model for the preoperative decision to insert an arterial and central venous catheter and that can be automatically linked to the EMR. We collected and retrospectively analyzed data from 66,522 patients, > 18 years of age, who underwent non-cardiac surgeries from March 2019 to April 2021 at the single tertiary medical center. Data included demographics, pre-operative laboratory tests, surgical information, and catheterization information. When compared with other machine learning methods, the DNN model showed the best predictive performance in terms of the area under receiver operating characteristic curve and area under the precision-recall curve. Operation code information accounted for the largest portion of the prediction. This can be applied to clinical fields using operation code and minimal preoperative clinical information.
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Affiliation(s)
- Jungyo Suh
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Wook Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Kirschner M, do Ó Hartmann N, Parmentier S, Hart C, Henze L, Bisping G, Griesshammer M, Langer F, Pabinger-Fasching I, Matzdorff A, Riess H, Koschmieder S. Primary Thromboprophylaxis in Patients with Malignancies: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO), the Society of Thrombosis and Hemostasis Research (GTH), and the Austrian Society of Hematology and Oncology (ÖGHO). Cancers (Basel) 2021; 13:2905. [PMID: 34200741 PMCID: PMC8230401 DOI: 10.3390/cancers13122905] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer, both hematologic and solid malignancies, are at increased risk for thrombosis and thromboembolism. In addition to general risk factors such as immobility and major surgery, shared by non-cancer patients, cancer patients are exposed to specific thrombotic risk factors. These include, among other factors, cancer-induced hypercoagulation, and chemotherapy-mediated endothelial dysfunction as well as tumor-cell-derived microparticles. After an episode of thrombosis in a cancer patient, secondary thromboprophylaxis to prevent recurrent thromboembolism has long been established and is typically continued as long as the cancer is active or actively treated. On the other hand, primary prophylaxis, even though firmly established in hospitalized cancer patients, has only recently been studied in ambulatory patients. This recent change is mostly due to the emergence of direct oral anticoagulants (DOACs). DOACs have a shorter half-life than vitamin K antagonists (VKA), and they overcome the need for parenteral application, the latter of which is associated with low-molecular-weight heparins (LMWH) and can be difficult for the patient to endure in the long term. Here, first, we discuss the clinical trials of primary thromboprophylaxis in the population of cancer patients in general, including the use of VKA, LMWH, and DOACs, and the potential drug interactions with pre-existing medications that need to be taken into account. Second, we focus on special situations in cancer patients where primary prophylactic anticoagulation should be considered, including myeloma, major surgery, indwelling catheters, or immobilization, concomitant diseases such as renal insufficiency, liver disease, or thrombophilia, as well as situations with a high bleeding risk, particularly thrombocytopenia, and specific drugs that may require primary thromboprophylaxis. We provide a novel algorithm intended to aid specialists but also family practitioners and nurses who care for cancer patients in the decision process of primary thromboprophylaxis in the individual patient.
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Affiliation(s)
- Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
| | - Nicole do Ó Hartmann
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
| | - Stefani Parmentier
- Oncology and Hematology, Tumor Center, St. Claraspital, 4058 Basel, Switzerland;
| | - Christina Hart
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Larissa Henze
- Department of Medicine, Clinic III—Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, 18057 Rostock, Germany;
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, 48431 Rheine, Germany;
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, 32429 Minden, Germany;
| | - Florian Langer
- II.Medical Clinic and Polyclinic, Center for Oncology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Ingrid Pabinger-Fasching
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, 16303 Schwedt, Germany;
| | - Hanno Riess
- Medical Department, Division of Oncology and Hematology, Campus Charité Mitte, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.K.); (N.d.Ó.H.)
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany
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Rabinstein AA, Hellickson JD, Macedo TA, Lewis BD, Mandrekar J, McBane RD. Sequential Pneumatic Compression in the Arm in Neurocritical Patients with a Peripherally Inserted Central Venous Catheter: A Randomized Trial. Neurocrit Care 2021; 32:187-192. [PMID: 31236782 DOI: 10.1007/s12028-019-00765-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peripherally inserted central venous catheters (PICCs) are increasingly used for parenteral access in critically ill hospitalized patients, but they increase the incidence of upper extremity deep venous thrombosis (UE DVT). Sequential compression devices (SCDs) applied to the legs effectively reduce lower extremity DVT, but have not been tested in the arms. Our objective was to determine whether SCDs applied to the arm may reduce the risk of PICC-associated UE DVT. METHODS This was a retrospective study of randomized, single-center, controlled clinical trial on patients hospitalized in the intensive care unit with critical neurological illness who had a PICC and were not receiving anticoagulants. Between January 2014 and October 2016, patients were randomized 1:1 to an intervention group having a custom SCD applied to the arm harboring the PICC or to a control group. The primary endpoint was ultrasound-detected UE DVT. RESULTS Following randomization of 77 subjects, the study was terminated due to excess DVT in the treatment arm. UE DVT was detected in 18 subjects (29.0%), and it was more frequent among those in the SCD group (13/31 [41.9%] vs. the control group 5/31 [16.1%]; p = 0.049). After accounting for crossovers, the difference was still significant (12/28 [43.0%] vs. 6/34 [17.6%]; p = 0.048). Yet, symptomatic UE DVT (n = 3) and pulmonary embolism without evidence of lower extremity DVT (n = 2) were only observed in patients who were not wearing the SCD on the arm. CONCLUSIONS Although UE DVT is commonly associated with PICC use, the results of this trial do not support the use of SCD on the arm for DVT prevention. Further research on this strategy may nonetheless be justified. TRIAL REGISTRATION This trial was registered in ClinicalTrials.gov under the identifier NCT01670188.
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Affiliation(s)
| | | | | | | | - Jay Mandrekar
- Department of Health Sciences Research (Division of Biomedical Statistics and Informatics), Mayo Clinic, Rochester, MN, USA
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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9
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Ponsoye M, Espinasse F, Coutte L, Lepeule R, Gnamien S, Hanslik T. [The use of venous catheter : Which ones to choose, how to prevent their complications?]. Rev Med Interne 2020; 42:411-420. [PMID: 33234320 DOI: 10.1016/j.revmed.2020.10.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/08/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022]
Abstract
Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.
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Affiliation(s)
- M Ponsoye
- Hôpital Foch, 40 rue Worth, 92150 Suresnes, France.
| | - F Espinasse
- AP-HP, hôpital Ambroise Paré, Equipe Opérationnelle Hygiène, 92100 Boulogne-Billancourt, France
| | - L Coutte
- AP-HP, hôpital Ambroise Paré, service de médecine interne, 92100 Boulogne-Billancourt, France
| | - R Lepeule
- Unité transversale de traitement des infections, département de virologie, bactériologie-hygiène, parasitologie-mycologie, hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - S Gnamien
- AP-HP, hôpital Ambroise Paré, unité des dispositifs médicaux stériles, Pharmacie, 92100 Boulogne-Billancourt, France
| | - T Hanslik
- AP-HP, hôpital Ambroise Paré, service de médecine interne, 92100 Boulogne-Billancourt, France; Université Versailles Saint Quentin en Yvelines, UFR des sciences de la santé Simone Veil, 78000 Versailles, France
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10
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Yamashita T, Takamori A, Nakagawachi A, Tanigawa Y, Hamada Y, Aoki Y, Sakaguchi Y. Early prophylaxis of central venous catheter-related thrombosis using 1% chlorhexidine gluconate and chlorhexidine-gel-impregnated dressings: a retrospective cohort study. Sci Rep 2020; 10:15952. [PMID: 32994455 PMCID: PMC7525449 DOI: 10.1038/s41598-020-72709-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
To determine the prophylactic effect of using combined 1% alcoholic chlorhexidine gluconate and chlorhexidine gel-impregnated dressings (CGCD) on catheter-related thrombosis (CRT) in critically ill patients. This retrospective cohort study was performed in an intensive care unit from November 2009 to August 2014. The CRT incidence diagnosed with ultrasound examination was compared between patients applying CGCD and combined 10% aqueous povidone-iodine and standard transparent dressings (PITD) after central venous catheter insertion into the internal jugular vein for ≥ 48 h. CRT was stratified into early (within 7 days) and late (days 8-14) thromboses. Multivariate analyses using logistic regression models clarified the relationships between early- and late-CRT risks and skin antiseptic and catheter site dressing combinations. CRT occurred in 74 of 134 patients (55%), including 52 with early CRT and 22 with late CRT. Patients receiving CGCD had a significantly lower incidence of early CRT than those receiving PITD (odds ratio = 0.18; 95% confidence interval = 0.07-0.45, p < .001). No significant association was evident between using CGCD and late CRT (p = .514). Compared to PITD, CGCD reduced the CRT risk over 7 days in critically ill patients.UMIN Clinical Trials Registry: UMIN000037492.
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Affiliation(s)
- Tomoko Yamashita
- Intensive Care Unit, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan.
| | - Ayako Takamori
- Clinical Research Center, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Akira Nakagawachi
- Intensive Care Unit, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Yoshinori Tanigawa
- Intensive Care Unit, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Yohei Hamada
- Division of Infectious Disease and Hospital Epidemiology, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Yosuke Aoki
- Division of Infectious Disease and Hospital Epidemiology, Saga University Hospital, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
| | - Yoshiro Sakaguchi
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1, Nabeshima, Saga City, Saga, 849-8501, Japan
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11
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Wang J, Wang L, Shang H, Yang X, Guo S, Wang Y, Cui C. Jugular venous catheter-associated thrombosis and fatal pulmonary embolism: A case report. Medicine (Baltimore) 2020; 99:e20873. [PMID: 32590793 PMCID: PMC7328945 DOI: 10.1097/md.0000000000020873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Central venous catheters related thrombosis (CRT) insertion has been shown to increase the risk of venous thromboembolism, particularly pulmonary embolism (PE). Nevertheless, deaths cased due to PE have been rarely reported. PATIENT CONCERNS A central venous catheter was introduced through the right jugular vein during the operation due to severe septic shock from a 57-year-old male patient. Two days after surgery, the hemodynamics was stable. On the 7th day, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest, and received emergency cardiopulmonary resuscitation. DIAGNOSIS Jugular venous catheter-associated thrombosis and fatal PE. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein. The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle, widened and fixed inferior vena cava, and no variation with respiration. Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased. Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing "D" sign. Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased. INTERVENTIONS One and a half million units of urokinase were immediately given trough intravenous drip. OUTCOMES Twenty minutes after thrombolysis, the patient's autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later. CONCLUSION Recent clinical practice guidelines recommend against the routine use of any anticoagulant thromboprophylaxis in patients with central venous catheters, but for patients at particularly high risk for CRT, consideration can be given to using higher doses of anticoagulant as prophylaxis, although there are virtually no data to support this approach.
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12
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Norris AH, Shrestha NK, Allison GM, Keller SC, Bhavan KP, Zurlo JJ, Hersh AL, Gorski LA, Bosso JA, Rathore MH, Arrieta A, Petrak RM, Shah A, Brown RB, Knight SL, Umscheid CA. 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2020; 68:e1-e35. [PMID: 30423035 DOI: 10.1093/cid/ciy745] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 12/16/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.
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Affiliation(s)
- Anne H Norris
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita P Bhavan
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - John J Zurlo
- Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Lisa A Gorski
- Wheaton Franciscan Home Health & Hospice, Part of Ascension at Home, Milwaukee, Wisconsin
| | - John A Bosso
- Departments of Clinical Pharmacy and Outcome Sciences and Medicine, Colleges of Pharmacy and Medicine, Medical University of South Carolina, Charleston
| | - Mobeen H Rathore
- University of Florida Center for HIV/AIDS Research, Education and Service and Wolfson Children's Hospital, Jacksonville
| | - Antonio Arrieta
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County Division of Pediatrics, University of California-Irvine School of Medicine
| | | | - Akshay Shah
- Metro Infectious Disease Consultants, Northville, Michigan
| | - Richard B Brown
- Division of Infectious Disease Medical Center, University of Massachusetts School of Medicine, Worcester
| | - Shandra L Knight
- Library & Knowledge Services, National Jewish Health, Denver, Colorado
| | - Craig A Umscheid
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia
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13
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Jose A, Eckman MH, Elwing JM. Anticoagulation in pulmonary arterial hypertension: a decision analysis. Pulm Circ 2019; 9:2045894019895451. [PMID: 31903185 PMCID: PMC6928543 DOI: 10.1177/2045894019895451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 01/16/2023] Open
Abstract
Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43-0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66-1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Vose J, Odunayo A, Price JM, Daves M, Schildt JC, Tolbert MK. Comparison of heparinized saline and 0.9% sodium chloride for maintaining central venous catheter patency in healthy dogs. PeerJ 2019; 7:e7072. [PMID: 31183263 PMCID: PMC6546076 DOI: 10.7717/peerj.7072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Julieann Vose
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Joshua M. Price
- Office of Information Technology, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Maggie Daves
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Julie C. Schildt
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - M. Katherine Tolbert
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, USA
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15
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Skelton WP, Franke AJ, Welniak S, Bosse RC, Ayoub F, Murphy M, Starr JS. Investigation of Complications Following Port Insertion in a Cancer Patient Population: A Retrospective Analysis. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2019; 13:1179554919844770. [PMID: 31040735 PMCID: PMC6482646 DOI: 10.1177/1179554919844770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/27/2019] [Indexed: 11/24/2022]
Abstract
Central venous access devices, specifically implantable ports, play an essential role in the care of oncology patients; however, complications are prevalent. This retrospective single-institutional review was performed to identify rates of complications from port placement and potential factors associated with these events. A retrospective analysis of 539 cancer patients who underwent port insertion between March 2016 and March 2017 at our institution was conducted. Data examining 18 potentially predictive factors were collected, and multivariate analysis was conducted using logistic regression and odds ratios (ORs) with standard errors to determine predictive factors. Out of 539 patients, 100 patients (19%) experienced 1 complication, and 12 patients (2%) experienced 2 or more complications. An overall lower rate of complications was seen in patients on therapeutic anticoagulation (OR: 0.17, P < .001) or on antiplatelet agents (OR: 0.47, P = .02). No patients on therapeutic anticoagulation developed venous thromboembolism (VTE; 0%). Right-sided port insertion was associated with decreased rates of infection (OR: 0.44, P = .04). Insertion as inpatient was associated with an increased risk for mechanical failure (OR: 4.60, P < .01). This analysis identified multiple predictive factors that can potentially put patients at a higher risk of experiencing complications following port insertion. Our data show lower rates of VTE for patients on anticoagulation or antiplatelet therapy. Further analysis is also necessary to determine why port insertion as an inpatient places patients at a higher risk of complications. This study highlights the risks associated with port placement and prompts the clinician to have an informed discussion with the patient weighing the risks and benefits.
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Affiliation(s)
- William Paul Skelton
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Aaron J Franke
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Samantha Welniak
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Raphael C Bosse
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fares Ayoub
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Martina Murphy
- Division of Hematology & Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jason S Starr
- Division of Hematology & Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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16
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Catheter-Related Venous Thrombosis in Hospitalized Pediatric Patients with Inflammatory Bowel Disease: Incidence, Characteristics, and Role of Anticoagulant Thromboprophylaxis with Enoxaparin. J Pediatr 2018; 198:53-59. [PMID: 29628414 DOI: 10.1016/j.jpeds.2018.02.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/24/2018] [Accepted: 02/14/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To describe the incidence and characteristics of central venous catheter (CVC)-related thrombosis in hospitalized pediatric patients with active inflammatory bowel disease (IBD) and report the potential usefulness of anticoagulant thromboprophylaxis (AT). STUDY DESIGN We conducted a retrospective study of patients who were admitted to our children's hospital in the last 2 years with active IBD and required a CVC and identified all patients with an objectively confirmed symptomatic CVC-related thrombosis. To assess the usefulness of a recently implemented institutional AT protocol, we compared the frequency of CVC-related thrombosis, nadir hemoglobin, and red blood cell transfusion requirements in patients who received AT with those who did not during the study period. RESULTS A total of 40 patients with IBD who required 47 consecutive hospitalizations were included. AT was administered during 24 of 47 hospitalizations (51%). Patients who received AT were similar to those who did not receive AT with regard to demographics, IBD phenotypes, extent of colonic involvement, and thrombotic risk factors. CVC-related thrombosis occurred in 5 of 23 hospitalizations (22%) in which AT was withheld compared with 0 of 24 hospitalizations (0%) in which patients received AT (P = .02). The red blood cell transfusion requirements and nadir hemoglobin were not significantly different between the 2 groups. CONCLUSIONS We observed a high incidence of CVC-related thrombosis in hospitalized children with IBD. Administration of AT in our population was associated with significant reduction in CVC-related thrombosis without evidence of increased bleeding.
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17
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Shaw CM, Shah S, Kapoor BS, Cain TR, Caplin DM, Farsad K, Knuttinen MG, Lee MH, McBride JJ, Minocha J, Robilotti EV, Rochon PJ, Strax R, Teo EYL, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Central Venous Access. J Am Coll Radiol 2018; 14:S506-S529. [PMID: 29101989 DOI: 10.1016/j.jacr.2017.08.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 01/15/2023]
Abstract
Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Colette M Shaw
- Principal Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Shrenik Shah
- Research Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | - Drew M Caplin
- Hofstra Northwell School of Medicine, Manhasset, New York
| | | | | | - Margaret H Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Elizabeth V Robilotti
- Memorial Sloan Kettering Cancer Center, New York, New York; Infectious Diseases Society of America
| | - Paul J Rochon
- University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | | | - Elrond Y L Teo
- Emory University School of Medicine, Atlanta, Georgia; Society of Critical Care Medicine
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18
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Barco S, Heuschen CBBCM, Salman B, Brekelmans MPA, Serlie MJ, Middeldorp S, Coppens M. Home parenteral nutrition-associated thromboembolic and bleeding events: results of a cohort study of 236 individuals. J Thromb Haemost 2016; 14:1364-73. [PMID: 27122107 DOI: 10.1111/jth.13351] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 04/22/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Essentials Sparse or outdated studies focus on thrombotic and bleeding risk in home parenteral nutrition (HPN). 236 HPN patients followed at a single center for a total of 684 patient-years were evaluated. Rates of venous thrombosis and major bleeding, and prevalence of vena cava syndrome are provided. Anticoagulants might reduce thrombosis risk, but population-specific safety concerns remain. SUMMARY Background Home parenteral nutrition (HPN) is necessary for patients with intestinal failure. Recurrent catheter-related thrombosis (CRT) is common, leading to infectious complications, pulmonary embolism, vascular access loss and intestinal transplantation. The efficacy and safety of anticoagulants are unknown in this setting and based on sparse and low-quality observational data. Objectives Our aim was to estimate the incidence of thromboembolic, bleeding and anticoagulant-related complications in HPN patients, and evaluate risk factors for first venous thrombosis (VT). Methods This retrospective cohort study included all adult patients followed for long-term HPN at our center between 1986 and 2014. Primary outcomes were symptomatic objectively diagnosed VT, encompassing CRT and venous thromboembolism, and major bleeding. Secondary outcomes were vena cava syndrome and heparin-induced thrombocytopenia or hypersensitivity. Results A total of 236 patients were included (median HPN duration, 17 months) and 136 received anticoagulants at HPN onset (57.6%). Overall, the annual incidence of first VT was 11.4% (95% confidence interval [95% CI], 8.6-14.7%); VT was associated with a personal history of thrombosis (adjusted hazard ratio, 2.22; 95% CI, 1.06-4.64), whereas anticoagulation seemed to account only for a mild protection (adjusted hazard ratio, 0.72; 95% CI, 0.36-1.44). The annual incidence of major bleeding was 4.3% for patients on anticoagulants vs. 1.8% for those off anticoagulants. Vena cava syndrome developed in 20.7% of patients with VT. One patient had isolated heparin-induced thrombocytopenia (0.6%) and four had heparin hypersensitivity (2.5%). Conclusions Patients on HPN have a significant risk of venous thrombosis, major bleeding and vena cava syndrome. Anticoagulants might reduce thrombosis risk, but population-specific safety concerns remain.
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Affiliation(s)
- S Barco
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, University Medical Center Mainz, Mainz, Germany
| | - C B B C M Heuschen
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - B Salman
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M P A Brekelmans
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M J Serlie
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - S Middeldorp
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M Coppens
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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19
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Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis. On behalf of the coagulation defects working group and the supportive therapy working group of the Italian Association of Pediatric Hematology and Oncology (AIEOP). Ann Hematol 2015; 94:1765-76. [DOI: 10.1007/s00277-015-2481-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/17/2015] [Indexed: 01/06/2023]
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20
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Crawford JD, Liem TK, Moneta GL. Management of catheter-associated upper extremity deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 4:375-9. [PMID: 27318061 DOI: 10.1016/j.jvsv.2015.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 06/12/2015] [Indexed: 02/02/2023]
Abstract
Central venous catheters or peripherally inserted central catheters are major risk factors for upper extremity deep venous thrombosis (UEDVT). The body and quality of literature evaluating catheter-associated (CA) UEDVT have increased, yet strong evidence on screening, diagnosis, prevention, and optimal treatment is limited. We herein review the current evidence of CA UEDVT that can be applied clinically. Principally, we review the anatomy and definition of CA UEDVT, identification of risk factors, utility of duplex ultrasound as the preferred diagnostic modality, preventive strategies, and an algorithm for management of CA UEDVT.
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Affiliation(s)
- Jeffrey D Crawford
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, Ore
| | - Timothy K Liem
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, Ore
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, Ore.
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21
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Geerts W. Central venous catheter-related thrombosis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:306-311. [PMID: 25696870 DOI: 10.1182/asheducation-2014.1.306] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Thrombotic complications associated with the use of central venous catheters (CVCs) are common and lead to distressing patient symptoms, catheter dysfunction, increased risk of infections, long-term central venous stenosis, and considerable costs of care. Risk factors for catheter-related thrombosis include use of larger, multilumen, and peripherally inserted catheters in patients with cancer receiving chemotherapy. Symptomatic catheter-related thrombosis is treated with anticoagulation, generally without removing the catheter. The intensity and duration of anticoagulation depend on the extent of thrombosis, risk of bleeding, and need for continued use of a CVC. To date, the clinical benefit of prophylactic doses of anticoagulant has been disappointing and these agents are not used routinely for this purpose. This chapter focuses on recent evidence, remaining controversies, and practical approaches to reducing the burden of thrombosis associated with CVCs.
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Affiliation(s)
- William Geerts
- Thromboembolism Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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22
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Vidal E, Sharathkumar A, Glover J, Faustino EVS. Central venous catheter-related thrombosis and thromboprophylaxis in children: a systematic review and meta-analysis. J Thromb Haemost 2014; 12:1096-109. [PMID: 24801495 PMCID: PMC4107177 DOI: 10.1111/jth.12598] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/29/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also systematically reviewed the pediatric trials on thromboprophylaxis to evaluate its efficacy and to identify possible pitfalls in the conduct of these trials. PATIENTS/METHODS We searched MEDLINE, EMBASE, Web of Science and the Cochrane Central Register for Controlled Trials for articles published until December 2013. We included cohort studies and trials on patients aged 0-18 years with central venous catheters who underwent active surveillance for thrombosis with radiologic imaging. We estimated the pooled frequency of thrombosis and the pooled risk ratio (RR) with thromboprophylaxis by using a random effects model. RESULTS From 2651 articles identified, we analyzed 37 articles with 3128 patients. The pooled frequency of thrombosis was 0.20 (95% confidence interval [CI] 0.16-0.24). In 10 trials, we did not find evidence that heparin-bonded catheters (RR 0.34; 95%CI 0.01-7.68), unfractionated heparin (RR 0.93; 95% CI 0.57-1.51), low molecular weight heparin (RR 1.13; 95% CI 0.51-2.50), warfarin (RR 0.85; 95%CI 0.34-2.17), antithrombin concentrate (RR 0.76; 95% CI 0.38-1.55) or nitroglycerin (RR 1.53; 95%CI 0.57-4.10) reduced the risk of thrombosis. Most of the trials were either not powered for thrombosis or were powered to detect large, probably unachievable, reductions in thrombosis. Missing data on thrombosis also limited these trials. CONCLUSIONS Catheter-related thrombosis is common in children. An adequately powered multicenter trial that can detect a modest, clinically significant reduction in thrombosis is critically needed. Missing outcome data should be minimized in this trial.
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Affiliation(s)
- E Vidal
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
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Zwicker JI, Connolly G, Carrier M, Kamphuisen PW, Lee AYY. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12:796-800. [PMID: 24548519 DOI: 10.1111/jth.12527] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 02/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- J I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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de Oliveira EB, Reis MA, Avelar TM, Vieira SC. Totally implantable central venous catheters for chemotherapy: experience with 793 patients. Rev Col Bras Cir 2013; 40:186-90. [PMID: 23912364 DOI: 10.1590/s0100-69912013000300004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 08/20/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To retrospectively study the results obtained with the implementation of totally implantable catheters in patients undergoing chemotherapy. METHODS 815 totally implantable catheters placed in 793 patients undergoing chemotherapy regimen, preferably using the right cephalic vein. We evaluated early and late complications. RESULTS The retrospective analysis showed an average duration of 339 days of the catheters. In 733 (90%) catheters there was no observe complication. Among early complications we observed one pneumothorax, one bad positioning of the catheter, one arterial puncture, one bleeding, one hemothorax and hemomediastinum and six hematomas in the implantation site. As for late complications, there were 35 catheter-related infections ten, infections in the surgical site, six obstructions and 20 thromboses. We removed 236 catheters, 35 due to complications and 201 by the end of treatment. CONCLUSION totally implantable catheters for chemotherapy are a safe means for the administration of substances, in view of the low number of complications observed in this study.
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Chopra V, Anand S, Hickner A, Buist M, Rogers MA, Saint S, Flanders SA. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 2013; 382:311-25. [PMID: 23697825 DOI: 10.1016/s0140-6736(13)60592-9] [Citation(s) in RCA: 418] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are associated with an increased risk of venous thromboembolism. However, the size of this risk relative to that associated with other central venous catheters (CVCs) is unknown. We did a systematic review and meta-analysis to compare the risk of venous thromboembolism associated with PICCs versus that associated with other CVCs. METHODS We searched several databases, including Medline, Embase, Biosis, Cochrane Central Register of Controlled Trials, Conference Papers Index, and Scopus. Additional studies were identified through hand searches of bibliographies and internet searches, and we contacted study authors to obtain unpublished data. All human studies published in full text, abstract, or poster form were eligible for inclusion. All studies were of adult patients aged at least 18 years who underwent insertion of a PICC. Studies were assessed with the Newcastle-Ottawa risk of bias scale. In studies without a comparison group, the pooled frequency of venous thromboembolism was calculated for patients receiving PICCs. In studies comparing PICCs with other CVCs, summary odds ratios (ORs) were calculated with a random effects meta-analysis. FINDINGS Of the 533 citations identified, 64 studies (12 with a comparison group and 52 without) including 29 503 patients met the eligibility criteria. In the non-comparison studies, the weighted frequency of PICC-related deep vein thrombosis was highest in patients who were critically ill (13·91%, 95% CI 7·68-20·14) and those with cancer (6·67%, 4·69-8·64). Our meta-analysis of 11 studies comparing the risk of deep vein thrombosis related to PICCs with that related to CVCs showed that PICCs were associated with an increased risk of deep vein thrombosis (OR 2·55, 1·54-4·23, p<0·0001) but not pulmonary embolism (no events). With the baseline PICC-related deep vein thrombosis rate of 2·7% and pooled OR of 2·55, the number needed to harm relative to CVCs was 26 (95% CI 13-71). INTERPRETATION PICCs are associated with a higher risk of deep vein thrombosis than are CVCs, especially in patients who are critically ill or those with a malignancy. The decision to insert PICCs should be guided by weighing of the risk of thrombosis against the benefit provided by these devices. FUNDING None.
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Affiliation(s)
- Vineet Chopra
- Department of Internal Medicine, Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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Mitchell MD, Agarwal R, Hecht TE, Umscheid CA. Nonpharmacologic interventions for prevention of catheter-related thrombosis: A systematic review. J Crit Care 2013; 28:316.e9-16. [DOI: 10.1016/j.jcrc.2012.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/03/2012] [Accepted: 07/04/2012] [Indexed: 01/08/2023]
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Debourdeau P, Farge D, Beckers M, Baglin C, Bauersachs RM, Brenner B, Brilhante D, Falanga A, Gerotzafias GT, Haim N, Kakkar AK, Khorana AA, Lecumberri R, Mandala M, Marty M, Monreal M, Mousa SA, Noble S, Pabinger I, Prandoni P, Prins MH, Qari MH, Streiff MB, Syrigos K, Büller HR, Bounameaux H. International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost 2013; 11:71-80. [PMID: 23217208 DOI: 10.1111/jth.12071] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although long-term indwelling central venous catheters (CVCs) may lead to pulmonary embolism (PE) and loss of the CVC, there is lack of consensus on management of CVC-related thrombosis (CRT) in cancer patients and heterogeneity in clinical practices worldwide. OBJECTIVES To establish common international Good Clinical Practices Guidelines (GCPG) for the management of CRT in cancer patients. METHODS An international working group of experts was set up to develop GCPG according to an evidence-based medicine approach, using the GRADE system. RESULTS For the treatment of established CRT in cancer patients, we found no prospective randomized studies, two non-randomized prospective studies and one retrospective study examining the efficacy and safety of low-molecular-weight heparin (LMWH) plus vitamin K antagonists (VKAs). One retrospective study evaluated the benefit of CVC removal and two small retrospective studies were on thrombolytic drugs. For the treatment of symptomatic CRT, anticoagulant treatment (AC) is recommended for a minimum of 3 months; in this setting, LMWHs are suggested. VKAs can also be used, in the absence of direct comparisons of these two types of anticoagulants in this setting [Guidance]. The CVC can be kept in place if it is functional, well-positioned and non-infected and there is good resolution under close surveillance; whether the CVC is kept or removed, no standard approach in terms of AC duration has been established [Guidance]. For the prophylaxis of CRT in cancer patients, we found six randomized studies investigating the efficacy and safety of VKA vs. placebo or no treatment, one on the efficacy and safety of unfractionnated heparin, six on the value of LMWH, one double-blind randomized and one non randomized study on thrombolytic drugs and six meta-analyses of AC and CVC thromboprophylaxis. Type of catheter (open-ended like the Hickman(®) catheter vs. closed-ended catheter with a valve like the Groshong(®) catheter), its position (above, below or at the junction of the superior vena cava and the right atrium) and method of placement may influence the onset of CRT on the basis of six retrospective trials, four prospective non-randomized trials, three randomized trials and one meta-analysis. In light of these data: use of AC for routine prophylaxis of CRT is not recommended [1A]; a CVC should be inserted on the right side, in the jugular vein, and distal extremity of the CVC should be located at the junction of the superior vena cava and the right atrium [1A]. CONCLUSION Dissemination and implementation of these international GCPG for the prevention and treatment of CRT in cancer patients at each national level is a major public health priority, needing worldwide collaboration.
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Abstract
Cancer patients are at high risk for venous thromboembolism (VTE), which results in substantial morbidity and mortality. In this narrative review, we present evidence for the use of anticoagulants in the treatment and prevention of VTE in cancer patients. The benefit of perioperative anticoagulant prophylaxis following cancer surgery is well established. However, the risk-benefit trade-offs in non-surgical hospitalized cancer patients and among outpatients receiving chemotherapy are more complex. Emerging evidence suggests that the use of low molecular weight heparin (LMWH) may confer a small survival benefit in cancer patients without VTE. However, specific patient populations that may derive the most benefit have yet to be defined. Guidelines endorse LMWH as the preferred treatment for acute VTE, on the basis of high-quality clinical trial data, but the optimal duration of treatment remains unclear, and practical issues may limit its use outside the clinical trial setting. Novel oral anticoagulants may provide additional treatment and prophylaxis options, but their efficacy and safety in this population have not been established. Despite the significant impact of VTE on the lives of cancer patients and the large body of existing literature regarding treatment and prevention, important unanswered clinical questions remain, emphasizing the need for additional high-quality clinical trial data.
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Affiliation(s)
- D M Siegal
- Division of Hematology and Thromboembolism, McMaster University, Hamilton, Canada Division of Hematology/Oncology, University of New Mexico, Albuquerque, NM, USA
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Lee AYY, Kamphuisen PW. Epidemiology and prevention of catheter-related thrombosis in patients with cancer. J Thromb Haemost 2012; 10:1491-9. [PMID: 22703114 DOI: 10.1111/j.1538-7836.2012.04817.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Central venous catheters are extensively used in patients with cancer to secure delivery of chemotherapy and facilitate phlebotomy. Unfortunately, considerable morbidity can result from early complications or late sequelae, ranging from arterial puncture, pneumothorax and bloodstream infections to catheter-related thrombosis (CRT). Contemporary studies have shown that the incidence of symptomatic CRT is ∼5%, whereas the incidence of asymptomatic CRT is higher, at 14-18%. The significance and mechanisms of catheter design, material, insertion location and technique, position of the catheter tip and other risk factors in contributing to the development of CRT are not well understood. Efforts to reduce thrombotic complications, involving flushing the catheter with heparinized solutions, the use of heparin-bonded catheters, and systemic anticoagulant prophylaxis, have been largely ineffective. More studies are needed to understand the pathophysiology of thrombotic complications, to help identify effective interventions to reduce this adverse outcome.
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Affiliation(s)
- A Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, Canada.
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Chopra V, Anand S, Krein SL, Chenoweth C, Saint S. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med 2012; 125:733-41. [PMID: 22840660 DOI: 10.1016/j.amjmed.2012.04.010] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 04/09/2012] [Indexed: 01/19/2023]
Abstract
The widespread use of peripherally inserted central catheters (PICCs) has transformed the care of medical and surgical patients. Whereas intravenous antibiotics, parenteral nutrition, and administration of chemotherapy once necessitated prolonged hospitalization, PICCs have eliminated the need for such practice. However, PICCs may not be as innocuous as once thought; a growing body of evidence suggests that these devices also have important risks. This review discusses the origin of PICCs and highlights reasons behind their rapid adoption in medical practice. We evaluate the evidence behind 2 important PICC-related complications--venous thrombosis and bloodstream infections--and describe how initial studies may have led to a false sense of security with respect to these outcomes. In this context, we introduce a conceptual model to understand the risk of PICC-related complications and guide the use of these devices. Through this model, we outline recommendations that clinicians may use to prevent PICC-related adverse events. We conclude by highlighting important knowledge gaps and identifying avenues for future research in this area.
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Affiliation(s)
- Vineet Chopra
- Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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Fletcher JJ, Stetler W, Wilson TJ. The Clinical Significance of Peripherally Inserted Central Venous Catheter-Related Deep Vein Thrombosis. Neurocrit Care 2011; 15:454-60. [DOI: 10.1007/s12028-011-9554-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mai C, Hunt D. Upper-extremity deep venous thrombosis: a review. Am J Med 2011; 124:402-7. [PMID: 21531227 DOI: 10.1016/j.amjmed.2010.11.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 11/08/2010] [Accepted: 11/16/2010] [Indexed: 12/23/2022]
Abstract
Upper-extremity deep venous thrombosis is less common than lower-extremity deep venous thrombosis. However, upper-extremity deep venous thrombosis is associated with similar adverse consequences and is becoming more common in patients with complex medical conditions requiring central venous catheters or wires. Although guidelines suggest that this disorder be managed using approaches similar to those for lower-extremity deep venous thrombosis, studies are refining the prognosis and management of upper-extremity deep venous thrombosis. Physicians should be familiar with the diagnostic and treatment considerations for this disease. This review will differentiate between primary and secondary upper-extremity deep venous thromboses; assess the risk factors and clinical sequelae associated with upper-extremity deep venous thrombosis, comparing these with lower-extremity deep venous thrombosis; and describe an approach to treatment and prevention of secondary upper-extremity deep venous thrombosis based on clinical evidence.
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Affiliation(s)
- Cuc Mai
- University of South Florida, Tampa, FL, USA.
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Massicotte MP, Randolph A, Bauman M. Central venous line thromboprophylaxis: transforming "experience-based care" into "evidence-based care". J Intensive Care Med 2011; 26:341-2. [PMID: 21345882 DOI: 10.1177/0885066610392530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Le point sur la coagulation — Gestion de l’anticoagulation en réanimation. MEDECINE INTENSIVE REANIMATION 2010. [DOI: 10.1007/s13546-010-0035-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mitchell MD, Anderson BJ, Williams K, Umscheid CA. Heparin flushing and other interventions to maintain patency of central venous catheters: a systematic review. J Adv Nurs 2010; 65:2007-21. [PMID: 20568318 DOI: 10.1111/j.1365-2648.2009.05103.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM This paper is a report of a review to assess clinical studies comparing the effectiveness of different means of maintaining central venous catheter patency. BACKGROUND Flushing with heparin is a routine part of central venous catheter maintenance, but it presents risks, including heparin-induced thrombocytopenia. Other techniques used to prevent occlusion of catheters include saline flushes, heparin-bonded catheters and pressure caps. DATA SOURCES A search was conducted using the MEDLINE, CINAHL, EMBASE, Cochrane, National Guideline Clearinghouse and University Healthsystem Consortium databases. METHODS A systematic review of effectiveness was conducted, using GRADE criteria to assess the strength of evidence for each intervention. The review period covered 1982 or earlier to January 2008. RESULTS There is weak evidence that heparin flushing reduces occlusion of catheters, but no evidence that it reduces bloodstream infections. Results from clinical trials of pressure caps are inconsistent regarding their ability to maintain catheter patency, but provide moderate evidence that at least some varieties of caps are associated with increased bloodstream infections. CONCLUSION The evidence base on heparin flushing and other interventions to prevent catheter occlusion is small, and published studies are of low quality. There is insufficient evidence on which to conclude that flushing catheters with heparin is more effective than flushing with saline solution.
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Affiliation(s)
- Matthew D Mitchell
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, USA.
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Galanter W, Liu XF, Lambert BL. Analysis of computer alerts suggesting oral medication use during computerized order entry of i.v. medications. Am J Health Syst Pharm 2010; 67:1101-5. [PMID: 20554597 DOI: 10.2146/ajhp090357] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Compliance with computer alerts suggesting oral medication use during computerized order entry of i.v. medications was analyzed. SUMMARY Using automated computerized clinical decision support (CDS) to suggest converting i.v. medications to oral alternatives can reduce medication costs for hospitalized patients, but prescriber noncompliance limits the effectiveness of such interventions. Clearer understanding of the factors associated with noncompliance to alerts may facilitate the design of more effective CDS systems. Electronic medical record data were retrospectively analyzed to measure the rate of compliance with a CDS alert that suggested converting to an equivalent oral form of a drug at the time of ordering the i.v. formulation. Multiple logistic regression was used to examine the associations among medication type, clinician characteristics, hospital service type, time of order, and compliance with the i.v.-to-oral conversion recommendation. The main outcome was compliance with the alert, measured at the level of the individual medication order. The mean +/- S.E. overall compliance rate was 18.7% +/- 0.6%. Compliance varied among the medications, with methyl-prednisolone having the lowest (8%) and famotidine the highest (32%) (p < 0.05). Nurses had the highest compliance rate (35%) while pharmacists had the lowest (10%) (p < 0.05). Medical house staff (19%) and medical faculty (21%) complied at similar rates. The intensive care units had lower compliance rates than did the medical-surgical ward (15% versus 21%, p < 0.05). CONCLUSION CDS alerts to convert 12 i.v. medications to oral alternatives were developed and implemented in an urban tertiary hospital. Compliance rates for the alerts were relatively low and varied by medication, location, and clinician type.
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Affiliation(s)
- William Galanter
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Galanter WL, Thambi M, Rosencranz H, Shah B, Falck S, Lin FJ, Nutescu E, Lambert B. Effects of clinical decision support on venous thromboembolism risk assessment, prophylaxis, and prevention at a university teaching hospital. Am J Health Syst Pharm 2010; 67:1265-73. [DOI: 10.2146/ajhp090575] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- William L. Galanter
- College of Medicine, Section of General Internal Medicine, and University of Illinois Hospital Information Services, and Clinical Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago (UIC)
| | - Mathew Thambi
- Department of Pharmacy Practice, College of Pharmacy, UIC
| | - Holly Rosencranz
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Bobby Shah
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Suzanne Falck
- Department of Medicine, Section of General Internal Medicine, College of Medicine, UIC
| | - Fang-Ju Lin
- Department of Pharmacy Administration, College of Pharmacy, UIC
| | - Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, UIC
| | - Bruce Lambert
- Department of Pharmacy Administration and Department of Pharmacy Practice, College of Pharmacy, UIC
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Abstract
Recent data suggest that patients with a malignancy have a seven-fold increased risk for venous thromboembolism (VTE) compared with those without cancer, suggesting that these patients may benefit from thromboprophylaxis. Mechanisms for the prevention of thromboembolism can be divided into two broad categories: mechanical and pharmacological. Although generally used in combination with pharmacotherapy, little evidence exists for the efficacy of mechanical modalities either in the broader population of patients at risk for VTE or for patients with cancer specifically. A recent study using graduated compression stockings (GCS) for thromboprophylaxis showed no support for the use of stockings in acute stroke patients. Established pharmacological modalities, including warfarin, unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and the factor Xa inhibitor fondaparinux, have been shown to reduce risk for VTE in general medical and surgical populations. In medical cancer patients, only limited data are available for the efficacy of thromboprophylaxis. In contrast, considerable evidence indicates that thromboprophylaxis is warranted in patients undergoing cancer surgery. The most recent evidence suggests that catheter-related thrombosis is not prevented by current pharmacological modalities. On 22 May 2009, a group of clinicians based in the United Kingdom (UK) met in London, UK, to evaluate recent data on cancer thrombosis. This article (the second of four) briefly reviews key data on the prevention of VTE in medical and surgical oncology patients, providing context for a brief transcript of the surrounding discussion and a consensus statement, developed by meeting attendees, on the implications of this information for UK clinical practice.
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Abstract
Acquired thrombotic risk factors include a variety of noninherited clinical conditions that can predispose an individual to an increased risk for venous thromboembolism. For patients in a critical care setting, certain acquired risk factors represent chronic conditions that the patients may have had before the current acute illness (e.g., malignancy, various cardiovascular risk factors, certain medications), whereas others may be directly related to the reason the patient is in an intensive care unit or the patient's management there (e.g., postoperative state, trauma, indwelling vascular access, certain medications). Optimal thromboprophylactic strategies depend on individual patient risk profiles including an assessment of the specific clinical setting. Treatment for patients with acquired thrombotic risk factors includes anticoagulant therapy and, if possible, resolution of the acquired risk factor(s). Heparin-induced thrombocytopenia represents a unique clinical situation in which all sources of heparin must be discontinued and the patient started on an alternative anticoagulant (e.g., a direct thrombin inhibitor) in the acute setting. The duration of anticoagulant therapy would vary depending on the specific clinical setting.
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Calderero Aragón V, de Gregorio Ariza MA, Pazo Cid R, Puértolas Hernández T, Lostalé Latorre F, Artal Cortés A, Antón Torres A. [Role of low molecular weight heparins in prophylaxis of thromboembolic events on oncological patients with indwelling central venous catheter]. Med Clin (Barc) 2009; 133:365-70. [PMID: 19646715 DOI: 10.1016/j.medcli.2009.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 05/06/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Our study was designed to assess the incidence of thrombosis in the upper limbs and of pulmonary embolism in oncological patients with indwelling central venous catheters, and to evaluate, also, the potential role of LMWH to prevent these events. PATIENTS AND METHODS Oncological patients undergoing placement of a central venous acccess (port-a-cath type) were treated with or without bemiparin in a non-randomized fashion. Assessment included clinical and radiological follow-up. A phlebography on the first day and ecodoppler on days 1th, 45th and 90th were performed. Patients received or not prophylactic bemiparin (3500UI/day) in a non-randomized way. The incidence of thrombosis in both groups was assessed as well as its relation with some risk factors. RESULTS One hundred and forty eight patients were eligible; 19 thrombotic events were found. The incidence of symptomatic upper extremity thrombosis was 5.41%, asymptomatic thrombosis in 2.03% ; there was one case of pulmonary embolism ( 0,68%); catheter failure occurred in 2.70%; incidence of lower extremities deep venous thrombosis was 2.03%. There was a higher percentage of events in the group of patients treated with bemiparin than in the not treated individuals (9.4%), although the difference did not reach statistical significance (p=0.27). The only risk factors reaching statistical significance were the prothrombin time, high blood pressure and overweight. CONCLUSIONS Central venous catheters are very useful in oncology. The procedure was related with a low percentage of thrombotic complications. Sodic bemiparin does not reduce the thrombotic risk in these patients.
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Debourdeau P, Kassab Chahmi D, Le Gal G, Kriegel I, Desruennes E, Douard MC, Elalamy I, Meyer G, Mismetti P, Pavic M, Scrobohaci ML, Lévesque H, Renaudin JM, Farge D. 2008 SOR guidelines for the prevention and treatment of thrombosis associated with central venous catheters in patients with cancer: report from the working group. Ann Oncol 2009; 20:1459-1471. [PMID: 19525362 DOI: 10.1093/annonc/mdp052] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND In view of the lack of recommendations on central venous catheter (CVC)-associated thrombosis in cancer patients, we established guidelines according to the well-standardized Standards, Options and Recommendations methodology. MATERIAL AND METHODS A literature review (1990-2007) on CVC-associated thrombosis was carried out. The guidelines were developed on the basis of the corresponding levels of evidence derived from analysis of the 36 of 175 publications selected. They were then peer reviewed by 65 independent experts. RESULTS For the prevention of CVC-associated thrombosis, the distal tip of the CVC should be placed at the junction between the superior cava vein and right atrium; anticoagulants are not recommended. Treatment of CVC-associated thrombosis should be based on the prolonged use of low-molecular weight heparins. Maintenance of the catheter is justified if it is mandatory, functional, in the right position, and not infected, with a favorable clinical evolution under close monitoring; anticoagulant treatment should then be continued as long as the catheter is present. CONCLUSIONS Several rigorous studies do not support the use of anticoagulants for the prevention of CVC-associated thrombosis. Treatment of CVC-associated thrombosis relies on the same principles as those applied in the treatment of established thrombosis in cancer patients.
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Affiliation(s)
- P Debourdeau
- Department of Oncology and Internal Medicine, Desgenettes Hospital, Lyons.
| | | | - G Le Gal
- Department of Internal Medicine, La Cavale-Blanche Hospital, Brest
| | - I Kriegel
- Department of Anesthesiology, Curie Institute, Paris
| | - E Desruennes
- Department of Anesthesiology, Gustave Roussy Institute, Villejuif
| | - M-C Douard
- Department of Anesthesiology, Saint Louis Hospital, Paris
| | - I Elalamy
- Hemostasis Laboratory, Tenon Hospital, Paris
| | - G Meyer
- Department of Pneumology, Georges Pompidou Hospital, Paris
| | - P Mismetti
- Department of Vascular Pathology, Saint-Etienne Hospital, Saint-Étienne
| | - M Pavic
- Department of Oncology and Internal Medicine, Desgenettes Hospital, Lyons
| | | | - H Lévesque
- Department of Vascular Pathology, Bois Guillaume Hospital, Rouen
| | - J M Renaudin
- Department of Vascular Pathology, Georges Pompidou Hospital, Paris
| | - D Farge
- Department of Vascular Pathology, Saint-Louis Hospital, Paris, France
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Elias A, Debourdeau P, Renaudin JM, Desmurs-Clavel H, Mahé I, Elalamy I, Pavic M, Kassab-Chahmi D, Bosquet L, Cajfinger F, Desruennes E, Douard MC, Grange C, Hocini H, Kriegel I, Le Gal G, Meyer G, Mismetti P, Quéré I, Scrobohaci ML, Lévesque H, Farge-Bancel D. Traitement curatif de la maladie thromboembolique veineuse et prise en charge des thromboses veineuses sur cathéter chez les patients atteints de cancer. Presse Med 2009; 38:220-30. [DOI: 10.1016/j.lpm.2008.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 11/20/2008] [Indexed: 11/30/2022] Open
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Burns KEA, McLaren A. A critical review of thromboembolic complications associated with central venous catheters. Can J Anaesth 2008; 55:532-41. [PMID: 18676389 DOI: 10.1007/bf03016674] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications. SOURCE We critically review and synthesize the literature highlighting the incidence of CVC-related thrombosis. We highlight the risk for developing thromboembolic complications and provide approaches to diagnosing and managing RHTE. PRINCIPLE FINDINGS The incidence of CVC-related thrombosis varies depending on patient, site, instrument, and infusate-related factors. Central venous catheters-related thrombosis represents an important source of morbidity and mortality for affected patients. Pulmonary embolism occurs in approximately 15% of patients with CVC-related upper extremity deep venous thrombosis (UEDVT). More frequent use of transesophageal echocardiography, in patients with suspected and confirmed PE, has resulted in increased detection of RHTE. While it is recognized that the occurrence of RHTE, in association with PE, increases mortality, the optimal strategy for their management has not been established in a clinical trial. CONCLUSION Central venous catheter-related thrombosis occurs frequently and represents an important source of morbidity and mortality for affected patients. Our review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE. However, important patient, clot, and institutional considerations mandate that treatment for patients with RHTE and PE be individualized.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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