Risk of thrombosis and infections of central venous catheters and totally implanted access ports in patients treated for cancer

Machine learning risk prediction model for bloodstream infections related to totally implantable venous access ports in patients with cancer

Objective

This study aimed to develop and validate a machine learning-based risk prediction model for catheter-related bloodstream infection (CRBSI) following implantation of totally implantable venous access ports (TIVAPs) in patients.

Methods

A retrospective cohort study design was employed, utilizing the R software package mlr3. Various algorithms including logistic regression, naive Bayes, K nearest neighbor, classification tree, and random forest were applied. Addressing class imbalance, benchmarks were used, and model performance was assessed using the area under the curve (AUC). The final model, chosen for its superior performance, was interpreted using variable importance scores. Additionally, a nomogram was developed to calculate individualized risk probabilities, enhancing clinical utility.

Results

The study involved 755 patients across both development and validation cohorts, with a TIVAP-CRBSI rate of 14.17%. The random forest model demonstrated the highest discrimination ability, achieving a validated AUC of 0.94, which was consistent in the validation cohort.

Conclusions

This study successfully developed a robust predictive model for TIVAP-CRBSI risk post-implantation. Implementation of this model may aid healthcare providers in making informed decisions, thereby potentially improving patient outcomes.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Risk Factors of Catheter-Related Infection in Unplanned Extubation of Totally Implantable Venous-Accessportsin Tumor Patients

Background

Totally implantable intravenous ports (TIVAPs) are mostly used for long-term intravenous infusion therapy in cancer patients and can be left in the body for long periods of time for easy management, making them a simple and safe infusion device. Although the risks associated with long-term retention of fully implantable IV ports are less than those associated with other intravenous catheters, various complications may still occur at the time of implantation or during long-term use.

Purpose

To provide a scientific basis for clinical reduction of implantable intravenous port-associated infection complications by studying the risk factors for catheter-associated infection complications in patients applying implantable intravenous ports.

Methods

A retrospective study was conducted on oncology patients treated with TIVAP at our hospital between January 2017 and November 2021, with a review of patients who were unplanned for extubation. Their demographic data, underlying disease status, and surgery-related data were counted to summarize and analyze the complications and related influencing factors of implantation and postimplantation.

Results

A total of 70 individuals with a mean age of 56.49 ± 12.19 years were included in the study. Among them, 39 were male and 64 had the highest percentage of epithelial tumors, followed by tumors of the lymphopoiesis system and mesenchymal tumors with 4 and 2 cases, respectively. Forty-eight of these patients did not have their ports removed as planned due to the occurrence of catheter-related hematogenous infections. In univariate analysis, BMI and neutropenia were risk factors for catheter-associated infections. In the multivariate analysis, BMI (OR = 1.38, 95% CI: 1.07–1.78, p=0.013) was an independent risk factor for catheter-associated infections.

Conclusions

The overall complication rate of fully implanted intravenous ports was high, but most complications improved with symptomatic management, and no deaths due to port complications were identified. Infection was the most common complication, with catheter-associated bloodstream infection being the most common cause of unplanned port extraction. Patients with a higher BMI were at high risk of developing implantable IV port-associated infections, which may be an independent risk factor for implantable IV port-associated infections.

Retrospective analysis: 5509 cases of "totally implantable venous access port systems implantation (TIVAPS) depth" assisted by digital radiography

PURPOSE

Modern oncological treatment in breast cancer patients requires the precise delivery of chemotherapy infusion into the central venous systems without toxicity. TIVAPS is the significant method of chemotherapy delivery although certain internal or external complications associated with their placement. However, the long-term use of TIVAPS is still a concern to minimize the complications such as venous thrombosis syndrome (VTS) and cardiac defects. The aim of this study is to investigate the potential disadvantages that may be avoided by digital radiography (DR)-assisted measurement of catheter depth pertinent to TIVAPS implanted system.

METHODS

Retrospective analysis related to 5509 TIVAPS recipients of 99% female breast cancer patients and 1% male blood disorder patients registered from April 2013 to November 2017 were included in the study. Patients with TIVAPS catheter tip depth into superior vena cava into upper (group A), middle (group B), and lower (group C) parts were stratified for evaluation during implantation; DR-assisted measurement of TIVAPS was performed to decipher "tip depth of catheter" and determined the relevance of tip depth to complications such as VTS and cardiac defects.

RESULTS

Incidence of VTS complications were significantly higher in TIVAPS recipients of group A (82.7%) than group B (16%) and group C (0.12%) in which the "tip depth of TIVAPS was deeper" (P < 0.01). Defects in heart function are higher in group C (59.6%) than group A (15.8%) and group B (24.6%) in which the "tip depth of TIVAPS was deeper" (P < 0.01).

CONCLUSION

DR-assisted measurement can more accurately determine the depth of TIVAPS catheter implantation, and avoid the incidence of related complications, and provide a better method for surgeons.

Establishment of a Risk Prediction Model for Pulmonary Infection in Patients with Advanced Cancer

Objective

Based on clinical data, the risk prediction model of pulmonary infection in patients with advanced cancer was established to predict the risk of pulmonary infection in patients with advanced cancer, and intervention measures were given in advance.

Methods

The clinical data of 2755 patients were divided into infection group and control group according to whether they were complicated with lung infection. 1609 patients' data from January 2016 to December 2018 served as the training set, and 1166 patients' data from January 2019 to December 2020 served as the testing set. Demographics, whether the primary cancer was lung cancer, lung metastasis, the pathological classification of lung cancer patients, the number of metastases, history of surgery, history of chemotherapy, history of radiotherapy, history of central venous catheterization, history of hypertension, diabetes, and whether with myelosuppression were recorded. The presence of concurrent pulmonary infection was recorded and defined as the primary outcome variable. Stepwise forward algorithms were applied to informative predictors based on Akaike's information criterion. Multivariable logistic regression analysis was used to develop the nomogram. An independent testing dataset was used to validate the nomogram. Receiver-operating characteristic curves and the Hosmer-Lemeshow test were used to assess model performance.

Results

The sample included 2755 patients with advanced cancer. An independently validated dataset included 1166 patients with advanced cancer. In the training dataset, gender, age, lung cancer as primary cancer, the pathological classification of lung cancer patients, history of chemotherapy, history of radiation therapy, history of surgery, the number of metastases, presence of central venous catheterization, and myelosuppression were identified as predictors and assembled into the nomogram. The area under curve demonstrated adequate discrimination in the validation dataset (0.77; 95% confidence interval, 0.74 to 0.79). The nomogram was well calibrated, with a Hosmer-Lemeshow χ 2 statistic of 12.4 (P = 0.26) in the testing dataset.

Conclusions

The present study has proposed an effective nomogram with potential application in facilitating the individualized prediction of risk of pulmonary infection in patients with advanced cancer.

The effect of chemotherapy type and timing among the other factors on patency of totally implantable vascular access devices in colorectal carcinoma

PURPOSE

Catheter-related complications are observed in infusion of chemotherapy, and these were encountered with targeted therapies. Our principle is to study non-mechanical effects of type and initiation time of chemotherapy among the other factors on patency of totally implantable vascular access devices (TIVAD) inserted in patients with colorectal carcinoma.

METHODS

This is a one-center retrospective cohort study. We analyzed TIVAD related complications in 624 patients with colorectal carcinoma. The patients were categorized by chemotherapy type (non-target-directed chemotherapy agents (Group A), bevacizumab (Group B), and cetuximab (Group C)). Additionally, we divided the patients into groups by the time interval between TIVAD insertion and chemotherapy initiation. According to our study, a 3-day period was optimal. Therefore, we named the groups as within 3 days and beyond 3 days, and called this process 3 days cut-off. Age, gender, jugular-subclavian access, platelet count, INR, the types of chemotherapy, and the initiation time of chemotherapy were investigated by survival tests. We compared chemotherapy type groups both one-by-one and combined into one group.

RESULTS

The TIVADs were removed due to the complications in 11 patients of Group A, 6 patients of Group B, and 3 patients of Group C. Only chemotherapy type was significant (p = 0.011) in Cox regression test. A clear difference (p = 0.010) was detected between the catheter patency of Group A and combination of Groups B and C, because of skin necrosis and thrombosis. Within 3 days of their first chemotherapy day, an important difference between Group A and Group C (p = 0.013) was observed in the TIVAD patency. The same observation was made between Group A and Group B (p = 0.007). Beyond this period, no major difference was detected (p = 0.341).

CONCLUSION

A major effect on catheter patency was detected by using the target-directed chemotherapy agent within 3 days, which should be considered in target-directed chemotherapy.

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)

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.

Venous thromboembolism after esophagectomy for cancer: a systematic review of the literature to evaluate incidence, risk factors, and prophylaxis

PURPOSE

Although esophagectomy remains the preferred treatment for esophageal cancer, it is still associated with a number of complications, including post-operative venous thromboembolism (VTE). The aim of this study was to summarize the reported incidence of VTE after esophagectomy, its risk factors, and prevention strategies.

METHODS

We conducted a systematic search of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Fourteen studies met our inclusion criteria and were selected in the present review. Overall, we identified 9768 patients who underwent esophagectomy, with a post-operative VTE rate of 4% (440 patients). The reported risk factors for VTE included advanced age, American Society of Anesthesiologists (ASA) class III or IV, a history of cardiovascular or pulmonary disease, and the implementation of preoperative chemo-radiotherapy. Postoperative acute respiratory distress syndrome was also associated with VTE. No universally applied prevention strategies for VTE after esophagectomy were identified in the literature.

CONCLUSIONS

Despite advances in perioperative care, VTE after esophagectomy still represents a source of morbidity for about 4% of patients. Low molecular weight heparin is suggested as the routine standard prophylactic regimen after esophageal cancer surgery.

The Effect of Immediate Versus Delayed Port Access on 30-Day Infection Rate

This study compared the 30-day infection risk of chest ports accessed on the same day as placement and chest ports with delayed initial access. The aim was to evaluate a larger data set that provided evidence for the development of port access guidelines. A retrospective chart review of 3322 chest port placement procedures performed between October 15, 2003, and June 10, 2015, was conducted at the interventional radiology department of a single institution. Procedure notes and health records were reviewed to determine time of initial port access, evidence of infection within a 30-day window of port placement, and causal organism(s) of infection. The results demonstrated that 64 ports (1.93%) met infection criteria within 30 days of placement, including 30 of the 945 ports immediately accessed and 34 of the 2377 ports not immediately accessed (3.17% vs 1.43%; P < .005). Dual lumen devices had a statistically significant higher rate of infection compared with single lumen devices (P = .006). This study concluded that there is a statistically significant higher rate of infection if a port is accessed immediately versus when access is deferred to later than 24 hours after placement.

Identifying Risk Factors for Anthracycline Chemotherapy-induced Phlebitis in Women with Breast Cancer: An Observational Study

AIMS

Anthracycline chemotherapy administered via a peripheral cannula results in severe anthracycline chemotherapy-induced phlebitis (ACIP) in about 20-30% of patients. Administering chemotherapy via a central venous catheter (CVC) prevents ACIP. However, CVCs are associated with an increased risk of thrombosis and sepsis. Our aim was to identify risk factors associated with severe ACIP and to provide evidence about the individual risk of developing symptoms.

MATERIALS AND METHODS

A prospective observational study of 263 women with breast cancer receiving peripheral administration of anthracycline chemotherapy at a UK cancer centre was conducted between May 2016 and January 2018. Data were collected at baseline and every 3 weeks following each chemotherapy treatment, using both healthcare professional- and participant-reported symptom assessments.

RESULTS

After three cycles of chemotherapy, 27% of participants experienced severe ACIP. Factors associated with symptom severity were identified as: arm used for chemotherapy administration, epirubicin dose, age, pre-existing hypertension, comorbidity, ethnic group and pain during chemotherapy administration. The sequence of arm used for chemotherapy administration was the single most significant factor (P < 0.001). When alternating arms were used no other risk factor was influential. Where alternating arms were not used, younger age and higher dose were associated with higher-grade symptoms, with age being more influential than dose. The cumulative effect of increasing symptom severity with repeated cycles was also identified (P < 0.001).

CONCLUSION

It is recommended that a CVC is not routinely required for women with breast cancer who have not undergone an axillary node clearance and receive chemotherapy in alternate arms. The need for a CVC for women who are planned to receive all anthracycline chemotherapy cycles in the same arm should be assessed in the light of peripheral venous access assessment and the key risk factors of age, dose and number of cycles.

Risk of venous thromboembolism associated with totally implantable venous access ports in cancer patients: A systematic review and meta-analysis

BACKGROUND

Totally implantable venous access ports (TIVAPs) for chemotherapy are associated with venous thromboembolism (VTE). We aimed to quantify the incidence of TIVAP-associated VTE and compare it with external central venous catheters (CVCs) in cancer patients through a meta-analysis.

METHODS

Studies reporting on VTE risk associated with TIVAP were retrieved from medical literature databases. In publications without a comparison group, the pooled incidence of TIVAP-related VTE was calculated. For studies comparing TIVAPs with external CVCs, odds ratios (ORs) were calculated to assess the risk of VTE.

RESULTS

In total, 80 studies (11 with a comparison group and 69 without) including 39 148 patients were retrieved. In the noncomparison studies, the overall symptomatic VTE incidence was 2.76% (95% confidence interval [CI]: 2.24-3.28), and 0.08 (95 CI: 0.06-0.10) per 1000 catheter-days. This risk was highest when TIVAPs were inserted via the upper-extremity vein (3.54%, 95% CI: 2.94-4.76). Our meta-analysis of the case-control studies showed that TIVAPs were associated with a decreased risk of VTE compared with peripherally inserted central catheters (OR = 0.20, 95% CI: 0.09-0.43), and a trend for lower VTE risk compared with Hickman catheters (OR = 0.75, 95% CI: 0.37-1.50). Meta-regression models suggested that regional difference may significantly impact on the incidence of VTE associated with TIVAPs.

CONCLUSIONS

Current evidence suggests that the cancer patients with TIVAP are less likely to develop VTE compared with external CVCs. This should be considered when choosing the indwelling intravenous device for chemotherapy. However, more attention should be paid when choosing upper-extremity veins as the insertion site.

<p>Central Venous Catheter Insertion in Colorectal Cancer Patients, PICC or PC?</p>

Purpose

Methods

Results

Conclusion

Surveillance of home health central venous catheter care outcomes: Challenges and future directions

BACKGROUND

Limited data are available regarding central venous catheter (CVC)-related complications that occur in home care. A practical out-of-hospital surveillance mechanism is needed.

METHODS

Home health/infusion agencies in 4 states submitted monthly data from January 2011 through March 2015. Data were collected by patient age and included number of patients on service with a CVC, device days, central line-associated bloodstream infection (CLABSI), CVC-occlusions, doses of fibrinolytics administered, and number of patients receiving fibrinolytics.

RESULTS

Ten agencies from 4 states contributed data across the study period. A total of 913 occlusions and 73 CLABSIs occurred during the 51-month surveillance period. The CLABSI rates per 1,000 device days per year across the study surveillance period ranged from 0-0.40 for pediatric and from 0-0.37 for adult patients, whereas occlusion rates per 1,000 device days ranged from 0.26-1.59 for pediatric and from 2.59-33.29 for adult patients. Doses of fibrinolytic agents administered per 1,000 device days ranged from 0.26-1.80 in pediatric and 3.53-33.85 in adult patients.

CONCLUSIONS

Opportunities exist to further expand efforts to quantify the presence of CVCs in home settings to enable improvements with measuring and tracking patient outcomes as they relate to CVC care. Exploration of continued sustainability of surveillance and data validation are warranted to optimize home health/infusion care practices and outcomes.

Epirubicin chemotherapy in women with breast cancer: Alternating arms for intravenous administration to reduce chemical phlebitis

OBJECTIVE

To establish whether using alternating arms for peripheral intravenous epirubicin administration affects the severity or duration of epirubicin-induced phlebitis.

METHODS

An observational study of women with breast cancer (n = 237) in a UK Cancer Centre. Data were analysed after receiving three treatment cycles according to the arm used for epirubicin administration: same, alternating or mixed arm (two consecutive cycles in one arm and one in the alternate arm). Phlebitis severity was graded by clinical staff after each treatment; participants also self-reported symptoms during treatment and for up to 6 months after.

RESULTS

The alternating arm group experienced significantly less severe symptoms than the other arm use groups, 6% (4 of 64) compared with 34% (p < 0.001, odds ratio: 0.13 (95% CI: 0.043-0.38) alternating arm compared with same arm group). The alternating arm group reported less pain (p = 0.013), lower overall impact (p = 0.009), lower effect on function (p = 0.032) and shorter duration of symptoms (p = 0.001) than the other arm use groups.

CONCLUSION

Using alternating arms for peripheral administration of epirubicin significantly reduces the severity and duration of chemical phlebitis and is recommended to improve patient experience and reduce the need for central venous access devices.

A Day in the Life of a CVAD

Patients are increasingly receiving therapy at home via central vascular access devices (CVADs). Limited data exist regarding patients' experiences with outpatient CVADs. This study characterized outpatient CVAD care via 14-day patient diaries. Information included location, frequency, and purpose of CVAD access episodes and who performed CVAD care. Across all patients, 77% of care was provided in the patient's home compared with other sites. Home care was provided via self-care (48%), by a family member/caregiver (25%), or by a nurse (27%). Flushing the device was the most frequent reason for device access (52%). An occlusion rate of 9.57 per 1000 device days was also noted. Further examination of CVAD maintenance and patient/care provider education is warranted.

Investigation of Complications Following Port Insertion in a Cancer Patient Population: A Retrospective Analysis

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.

The risk of bloodstream infection associated with totally implantable venous access ports in cancer patient: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to provide evidence-based guidance to better understand the risk of central line-associated bloodstream infection (CLABSI) in cancer patients who received totally implantable venous access ports (TIVAPs) compared with those who received external central venous catheters (CVCs).

METHODS

A systematic search of PubMed, Web of science, Embase, and the Cochrane Library was carried out from inception through Oct 2018, with no language restrictions. Trials examining the risk of CLABSI in cancer patients who received TIVAPs compared with those who received external CVCs were included. Two reviewers independently reviewed, extracted data, and assessed the risk of bias of each study. A random-effect model was used to estimate relative risks (RRs) with 95% CIs.

RESULTS

In all, 26 studies involving 27 cohorts and 5575 patients reporting the incidence of CLABSI in patients with TIVAPs compared with external CVCs were included. Pooled meta-analysis of these trials revealed that TIVAPs were associated with a significant lower risk of CLABSI than were external CVCs (relative risk [RR], 0.44; 95% confidence interval [CI], 0.31-0.62; P < 0.00001), which was confirmed by trial sequential analysis for the cumulative z curve entered the futility area. Subgroup analyses demonstrated that CLABSI reduction was greatest in adult patients (RR [95% CI], 0.35 [0.22-0.56]) compared with pediatric patients who received TIVAPs (RR [95% CI], 0.55 [0.38-0.79]).

CONCLUSIONS

TIVAP can significantly reduce the risk of CLABSI compared with external CVCs.

Totally implanted venous access-associated adverse events in oncology: Results from a prospective 1-year surveillance programme

INTRODUCTION

During the last decade, most studies on totally implanted venous access-associated adverse events (TIVA-AE) were conducted retrospectively and/or were based on a limited sample size. The aim of our survey was two-fold: to estimate the incidence of TIVA-AE and to identify risk factors in patients with cancer.

METHODS

Data from our routine surveillance of TIVA-AE were collected prospectively between October 2009 and January 2011 in two oncology referral centers in Northern France. The open cohort under surveillance during the same time period was reconstituted retrospectively using data from the hospital information systems. Incidences of first TIVA-AE per 1000 TIVA-days were calculated. Risk factors were identified using multivariate logistic regressions.

RESULTS

We included 2286 cancer patients, corresponding to 582,347 TIVA-days. Among the 133 first TIVA-AE observed (incidence 0.23 per 1000 TIVA-days [0.19-0.27]), there were 50 infectious AE (incidence 0.09 [0.06-0.11]) and 83 non-infectious AE (incidence 0.14 [0.11-0.17]). Compared to non-metastatic solid cancers, metastatic cancers (aOR=2.3 [0.9-6.0]), and hematologic malignancies (aOR=3.2 [1.1-8.8]) tended to be associated with a higher risk of infectious TIVA-AE (P=0.087). Solid cancer type was associated with non-infectious TIVA-AE (P=0.030), especially digestive cancers.

DISCUSSION

We report accurate estimations of TIVA-AE incidences in one of the largest populations among previously published studies. As in previous studies, metastatic cancers and hematologic malignancies tended to be associated with a higher risk of infectious TIVA-AE. Further studies are warranted to confirm the effect of digestive cancers.

Role of Lock Therapy for Long-Term Catheter-Related Infections by Multidrug-Resistant Bacteria

The management of long-term central venous catheter (LTCVC) infections by multidrug-resistant (MDR) bacteria in cancer patient is a challenge. The objectives of this study were to analyze outcomes in cancer patients with LTCVC-associated infection, identify risks for unfavorable outcomes, and determine the impact of MDR bacteria and antibiotic lock therapy (ALT) in managing such infections. We evaluated all LTCVC-associated infections treated between January 2009 and December 2016. Infections were reported in accordance with international guidelines for catheter-related infections. The outcome measures were 30-day mortality and treatment failure. We analyzed risk factors by Cox forward-stepwise regression. We identified 296 LTCVC-associated infections; 212 (71.6%) were classified as bloodstream infections (BSIs). The most common agent was Staphylococcus aureus Forty-six (21.7%) infections were due to MDR Gram-negative bacteria. ALT was used in 62 (29.2%) patients, with a 75.9% success rate. Risk factors identified for failure of the initial treatment were having a high sequential organ failure assessment (SOFA) score at diagnosis of infection and being in palliative care; introduction of ALT at the start of treatment was identified as a protective factor. Risk factors identified for 30-day mortality after LTCVC-associated infection were a high SOFA score at diagnosis, infection with MDR bacteria, and palliative care; introduction of ALT at the start of treatment, hematological malignancies, and adherence to an institutional protocol for the management of LTCVC-associated infection were identified as protective factors. Despite the high incidence of infection with MDR bacteria, ALT improves the outcome of LTCVC-associated infection in cancer patients.

Polyurethane versus silicone port a cath: What's going on at removal?

BACKGROUND

Port-a-cath (PAC) is an essential device in the management of the patients of chronic illness, but despite theirs benefits there are many complications either at the time of insertion or at time of removal. Our aim of this study is to evaluate the fracture rate of the catheter at removal time in comparison with catheter type either polyurethane or silicone.

METHODS

A retrospective monocentric study of all PACs which were removed at our university pediatric hospital between 1 January 2006 and 31 December 2016. Two groups were compared: polyurethane group and silicone group.

RESULTS

Total of 216 central lines were removed, the mean age at the time of extraction was 9.7±4.9years and the mean time for both catheter was 2.7±1.6years, fracture occurred in 11 catheter of the polyurethane group (n=119), with no fracture of silicone group (n=86), in the polyurethane group, the risk of catheter fracture is significantly related to the duration of the PAC in place.

CONCLUSION

We found that the polyurethane-based catheters are more vulnerable for rupture and retained fragment in the blood vessels, especially if left in place for long time, for this reason we have switched to silicone-based catheter and all catheters should be remove within duration maximal of 2years.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Upper-Extremity Deep Vein Thrombosis in Patients With Breast Cancer With Chest Versus Arm Central Venous Port Catheters

Most of the patients undergoing treatment for cancer require placement of a totally implantable venous access device to facilitate safe delivery of chemotherapy. However, implantable ports also increase the risk of deep vein thrombosis and related complications in this high-risk population. The objective of this study was to assess the incidence of upper-extremity deep vein thrombosis (UEDVT) in patients with breast cancer to determine whether the risk of UEDVT was higher with chest versus arm ports, as well as to determine the importance of previously reported risk factors predisposing to UEDVT in the setting of active cancer. We retrospectively reviewed the medical records of 297 women with breast cancer who had ports placed in our institution between the dates of December 1, 2010, and December 31, 2016. The primary outcome was the development of radiologically confirmed UEDVT ipsilateral to the implanted port. Overall, 17 of 297 study subjects (5.7%) were found to have UEDVT. There was 1 documented case of associated pulmonary embolism. Fourteen (9.5%) of 147 subjects with arm ports experienced UEDVT compared with only 3 (2.0%) of 150 subjects with chest ports (P = .0056). Thus, implantation of arm ports as opposed to chest ports may be associated with a higher rate of UEDVT in patients with breast cancer.

Right or left? Side selection for a totally implantable vascular access device: a randomised observational study

BACKGROUND

Totally implantable vascular access device (TIVAD)-related complications interfere in the anticancer treatment and increase medical expenses. We examined whether the implantation side of central line TIVADs is associated with the occurrence of thrombotic or occlusion events.

METHODS

We enrolled patients with cancer who required central line TIVADs and randomised them to receive the TIVAD implantation on either the left or right side. The primary endpoint was the occurrence of catheter-related thrombotic or occlusion events.

RESULTS

We randomised 240 patients, of which 235 received TIVAD implantation according to the protocol. In the per-protocol cohort, 117 and 118 patients received implantation on the left and right sides, respectively. Catheter-related thrombotic or occlusion events occurred in 9 (4%) patients, accounting for 0.065 events per 1000 catheter-days. Between the patients with left- and right-sided implantations, the occurrence rates (P=0.333) and the time from catheter implantation to the occurrence of thrombotic or occlusion events (P=0.328) were both similar. In the multivariate analysis, the side of implantation remained unassociated with the occurrence of thrombotic or occlusion events.

CONCLUSIONS

The side of central line TIVAD implantation was not associated with the occurrence of catheter-related thrombotic or occlusion events in patients with cancer.

Pneumothorax and Subclavian Vein Thrombosis in Patients With Venous Access Device Implantation

The primary aim is to assess the length of hospitalization due to iatrogenic pneumothorax as a main complication of totally implantable venous access device (TIVAD) implantation. Secondary aim is to analyze the thrombogenic effects of different catheter diameters on the subclavian vein. Pneumothorax is a rare and may be underestimated, underdocumented, but serious complication in TIVAD of implantation using the subclavian vein puncture method. A total of 1155 consecutive patients with TIVAD implantation were assessed retrospectively over a 14-year time period. As primary outcome the length of hospitalization due to iatrogenic pneumothorax and as secondary outcome subclavian vein thrombosis (SVT) in relation to different TIVAD catheter sizes were analyzed. Pneumothoraces occurred 6 times (0.52%) and only when the subclavian vein was punctured. The median hospitalization for these patients was 8 days (5 of the 6 patients needed a chest drain). No pneumothoraces occurred when a peripheral vein was used for access (980 patients). SVTs were detected in 13 patients (1.1%) without any correlation to the diameter of the catheter. There was no significant correlation detected between the different tumor types and the complication rates. Iatrogenic pneumothorax may lead to hospitalization of 1 week or more. The costs then increase with additional chests x-rays, chest drain insertions, and hospitalization days. When making the choice for surgical venous cutdown or subclavian vein puncture to implant TIVAD, the consequences of iatrogenic pneumothorax should be considered as pneumothorax is a rare but serious complication of TIVAD implantation inherent to subclavian vein puncture.

A Study of Use of "PORT" Catheter in Patients with Cancer: A Single-Center Experience

Background:

Effective and reliable venous access is one of the cornerstones of modern medical therapy in oncology.

Materials and methods:

This is a prospective observational study, which collected data of patients who require “PORT” catheter insertion for any cancer, at a tertiary care oncology hospital in Ahmadabad, Gujarat, India, during a 2-year period.

Aims and objectives:

The main objective of this study was to study the various complications and outcomes related to “PORT” catheters.

Results:

“PORT” catheter was inserted in 100 patients and was most commonly used in solid malignancies (n = 86, 86%), followed by hematologic malignancies (n = 14, 14%). Among the solid malignancies, breast cancer (38, 38%) was the most common underlying disease, whereas among the hematologic malignancies, acute lymphoblastic leukemia (6, 6%) was the most common underlying disease for “PORT” catheter insertion. Chemotherapy was started on the first day of “PORT” catheter in 74% of patients in the “PORT” study group. The various complications developed in the “PORT” study group in the descending order are as follows: 4 patients (4%) developed early infection (⩽30 days after “PORT” placement), 4 (4%) late infection (⩾30 days after “PORT” placement), 4 (4%) bloodstream infection, 2 (2%) local skin infection at the “PORT” insertion site, 2 (2%) dislodgment of the “PORT” catheter, 2 (2%) fracture of the “PORT” catheter, and 1 recurrent pleural effusion. One patient (1%) developed thrombosis as the complication of “PORT” catheter insertion.

Conclusions:

The most disturbing aspect of treatment for a patient with cancer is multiple painful venipunctures made for administration of cytotoxic agents, antibiotics, blood products, and nutritional supplements. The focus of this prospective observational research is to study the various underlying diseases for which “PORT” catheter is needed in different solid and hematologic malignancies and the various complications and outcomes in pediatric and adult patients with cancer.

Impact of Time-Varying Treatment Exposures on the Risk of Venous Thromboembolism in Multiple Myeloma

Multiple myeloma (MM) has one of the highest risks of venous thromboembolism (VTE) of all cancers due to pathologic changes and treatment-related exposures. This study assessed the one-year incidence of VTE in newly diagnosed MM and to determine the baseline and time-varying treatment-related factors associated with VTE risk in a U.S.-based cohort. MM patients were identified and age, gender, and baseline comorbidities were determined. Treatment-related exposures included thalidomide derivatives (IMIDs), proteasome inhibitors, cytotoxic chemotherapy, steroids, erythropoietin-stimulating agents (ESAs), stem cell transplants (SCT), hospitalizations, infection, and central venous catheters (CVC). Multiple statistical models were used including a baseline competing risks model, a time-varying exposure Cox proportional hazard (CPH) model, and a case-time-control analysis. The overall incidence of VTE was 107.2 per 1000 person-years with one-half of the VTEs occurring in the first 90 days. The baseline model showed that increasing age, heart failure, and hypertension were associated with one-year incidence of VTE. MM-specific IMID treatment had lower than expected associations with VTE based on prior literature. Instead, exposure to ESAs, SCT, CVC, and infection had higher associations. Based on these results, VTE risk in MM may be less straightforward than considering only chemotherapy exposures, and other treatment-related exposures should be considered to determine patient risk.

A community collaborative to develop consensus guidelines to standardize out-of-hospital maintenance care of central venous catheters

Central venous catheter (CVC) maintenance is integral to preventing complications and improving outcomes. This process is made more challenging when patients transition from hospital to home care or to an outpatient infusion setting, because different CVC maintenance practices and care parameters confuse patients and care providers alike. Through collaboration and consensus building, a group of metropolitan home health and home infusion agencies developed a standardized approach to CVC maintenance care. This article discusses the multiagency collaborative and resulting guideline and other educational materials that better enable providers, patients, and families to maintain CVC integrity and achieve optimal outcomes.

Phase II Trial on Extending the Maintenance Flushing Interval of Implanted Ports

PURPOSE

Retrospective studies suggest that it may be safe to extend the maintenance flushing interval of implanted ports from once every month, as recommended by the manufacturer, to once every 3 months, but no prospective cohort studies have been done specifically assessing the safety and feasibility of this intervention.

METHODS

This was a phase II study in oncologic patients who retained a functional port after completion of systemic chemotherapy. Patients enrolled in the study had their port flushed once every 3 months and were observed until completion of five scheduled flushes (one on enrollment and four additional flushes, one every 3 months) or development of any port-related complication, including infections, thrombosis, and occlusions. The primary end points were frequency of port-related complications and port failure requiring removal.

RESULTS

A total of 87 patients were enrolled in the study. The median follow-up time was 308 days, accounting for a total of 24,202 catheter-days. There were 10 port-related complications (11.49%; 95% CI, 4.85% to 18.14%). No infection or symptomatic thrombosis occurred. The mean time to port-related complication was 184 days. No patients developed port failure while on protocol, but on subsequent medical record review, four patients developed a complication that required port removal or port revision within 30 days of being removed from the trial (4.6%; 95% CI, 0.4% to 8.8%; 0.17/1,000 catheter-days).

CONCLUSION

Extending the maintenance flushes of implanted ports in adult oncologic patients to once every 3 months is safe, effective, and likely to increase patient adherence and satisfaction while decreasing the associated cost.

Incidence and Risk Factors of Thromboembolism with Multiple Myeloma in the Presence of Death as a Competing Risk: An Empirical Comparison of Statistical Methodologies

Multiple myeloma (MM) has an inherent high risk of thromboembolic events associated with patient as well as disease- and treatment-related factors. Previous studies have assessed the association of MM-related thromboembolism using "traditional" Kaplan-Meier (KM) and/or Cox proportional hazard (PH) regression. In the presence of high incidence of death, as would be the case in cancer patients with advanced age, these statistical models will produce bias estimates. Instead, a competing risk framework should be used. This study assessed the baseline patient demographic and clinical characteristics associated with MM-related thromboembolism and compared the cumulative incidence and the measures of association obtained using each statistical approach. The cumulative incidence of thromboembolism was 9.2% using the competing risk framework and nearly 12% using the KM approach. Bias in the measures of covariate risk associations was highest for factors related to risk of death such as increased age (75% bias) and severe liver disease (50%) for the Cox PH model compared to the competing risk model. These results show that correct specification of statistical techniques can have a large impact on the results obtained.

Totally implantable venous access port systems and associated complications: A single-institution retrospective analysis of 2,996 breast cancer patients

Totally implantable venous access port systems (TIVAPS) are widely used in breast cancer patients. However, complications are frequent and may necessitate device replacement or removal, resulting in additional patient stress and treatment delays. The aim of this study was to investigate possible risk factors for complications. A total of 2,996 consecutive female breast cancer patients, with a median age of 50.2 years (range, 21.2-85.5 years) were enrolled in this observational, single-centre study between December, 2008 and April, 2014. TIVAPS implantation was principally performed using local anaesthesia and the blind puncture or Seldinger technique through internal jugular or subclavian vein access. A retrospective chart review was conducted to obtain information associated with TIVAPS and patient data. Insertion performed by blind puncture and Seldinger technique had a success ratio of 96.34 and 99.80%, respectively (χ²=29.905, P<0.001). However, the success ratio of the puncture technique group was 99.76% when the TIVAPS was implanted in the right internal jugular vein. The most common complications were late complications, with an overall incidence rate of 5.41% (162/2,996) during the entire device duration. The most common late complications included fibrin formation (1.84%, 55/2,996), port-related bacteraemia (1.44%, 43/2,996) and deep vein thrombosis (0.63%, 19/2,996). No patient died during the study. Our results demonstrated that insertion of TIVAPS by blind puncture or the Seldinger technique through internal jugular or subclavian vein access is convenient, and insertion by the Seldinger technique through the right internal jugular vein is the preferred method. Therefore, TIVAPS is safe for continuous infusional chemotherapy regimens for breast cancer patients.

Health care-associated infections in patients with head and neck cancer treated with chemotherapy and/or radiotherapy

BACKGROUND

The incidence of health care-associated infections in patients with head and neck cancer receiving chemotherapy and/or radiotherapy (RT) is unknown. This retrospective study investigated the most common pathogens and their antibiotic sensitivity/resistance patterns in patients with head and neck cancer.

METHODS

Infection rates in patients with head and neck cancer were analyzed over 2 periods (January 2005 to December 2009 and January 2010 to November 2012).

RESULTS

In the first period, 140 health care-associated infections were observed among 2288 admissions, mostly because of gram-negative pathogens affecting the respiratory tract. In the second period, 212 health care-associated infections were observed. An increase in antibiotic resistance was reported. Health care-associated infections were more frequent with: male sex, age <65 years, important comorbidities, smoking, proton pump inhibitors (PPIs), prophylaxis, and/or central venous catheter (CVC), locally advanced disease, and chemotherapy/RT, especially after the third week of treatment.

CONCLUSION

Health care-associated infections increased over time, with corresponding increases in gram-negative pathogens and resistant strains. Prevention and treatment protocols should be implemented in institutions treating patients with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1009-E1013, 2016.

Improving cancer patients' knowledge about totally implantable access port: a randomized controlled trial

PURPOSE

Providing patients with written information about totally implantable access ports (TIAPs) is recommended during the pre-implantation period to reduce anxiety and to help recalling information. No study tested the effectiveness of information about TIAP neither with oral communication nor with booklets. This study aimed at evaluating the effectiveness of an information booklet, alone or together with answers to clarification questions, both in improving patients' short- and long-time knowledge about TIAP and in decreasing patients' physiological indicators of anxiety immediately after TIAP implantation.

METHODS

This is a randomized controlled trial with three parallel groups: group A (n = 34) receiving only the booklet, group B (n = 34) receiving the booklet with answers to clarification questions, and group C (n = 37) receiving routine care.

RESULTS

After 3 months, pair comparisons revealed a significant improvement in knowledge of TIAP in each group (p < 0.001), together with a significant difference in group C compared with groups A (p < 0.001) and B (p < 0.001), similar to each other. Physiological indicators of anxiety decreased in the intervention groups compared to control group immediately after TIAP implantation.

CONCLUSIONS

The interventions provided resulted effective in decreasing patients' physiological indicators of anxiety immediately after TIAP implantation and improving patients' knowledge about TIAP immediately and at 3 months. Adding answers to clarification questions to the booklet was not more effective than the booklet alone. A well-designed booklet with attention both to scientific content and to communication techniques is useful in improving patients' knowledge about TIAP and reducing anxiety.

Sepsis in head and neck cancer patients treated with chemotherapy and radiation: Literature review and consensus

The reporting of infection/sepsis in chemo/radiation-treated head and neck cancer patients is sparse and the problem is underestimated. A multidisciplinary group of head and neck cancer specialists from Italy met with the aim of reaching a consensus on a clinical definition and management of infections and sepsis. The Delphi appropriateness method was used for this consensus. External expert reviewers then evaluated the conclusions carefully according to their area of expertise. The paper contains seven clusters of statements about the clinical definition and management of infections and sepsis in head and neck cancer patients, which had a consensus. Furthermore, it offers a review of recent literature in these topics.

[Pharmacological study and pharmaceutical intervention to reduce intravenous injection-induced vascular injury]

Intravenous injection often causes vascular injury such as venous irritation, vascular pain, and phlebitis. Vascular injury deteriorates the patient's QOL and sometimes limits the continuation of injection therapy. Pharmaceutical intervention and pharmacological mechanisms used to reduce vascular injury induced by vinorelbine and epirubicin were reviewed. A multivariate logistic regression analysis revealed that the dose of vinorelbine (≥40 mg) was a significant predictor for venous irritation. Alteration of the volume of normal saline for vinorelbine dissolution, from 50 to 100 mL, significantly decreased the grade of venous irritation. On the other hand, the phlebitis scores were significantly higher in patients treated with epirubicin ready-to-use solution compared with lyophilized powder. The change of formulation of epirubicin to lyophilized powder decreased the risk of venous irritation. The concentration inducing 50% cell viability inhibition was lower in the order of vesicant, irritant, and nonvesicant drugs on porcine aorta endothelial cells (PAECs), suggesting that the injuring effects of anticancer drugs on PAECs may be relevant as an indicator of the frequency of their vascular injury. The exposure to vinorelbine of PAECs rapidly depleted intracellular glutathione levels and increased intracellular reactive oxygen species production. Moreover, exposure to epirubicin increased intracellular lipid peroxide levels and enhanced the phosphorylation of p38 mitogen-activated protein kinase. These results demonstrate that oxidative stress plays an important role in vinorelbine- and epirubicin-induced endothelial cell injury, and may therefore increase the potential for vascular injury upon intravenous injection.

Increased rates of local complication of central venous catheters in the targeted anticancer therapy era: a 2-year retrospective analysis

PURPOSE

Totally implantable central venous accesses (port-a-cath) are often used for chemotherapy administration or prolonged intravenous infusions in cancer patients. Local and systemic complications may occur both during and after placement of port-a-cath despite the well-established techniques for its placement and care. Out of other catheter-related local complications, thrombosis and infections represent the most common. Complications related to central venous catheter may be associated with infusion of both conventional chemotherapy and molecularly targeted therapy. Incidence and nature of complications of central venous catheter have been well established for long-term chemotherapy. However, very sparse data exists on the incidence of complications of molecularly targeted therapies administered through a central venous catheter. Hence, we decided to retrospectively analyze the local complications of a central venous catheter in patients receiving molecularly targeted therapy and conventional chemotherapy, respectively.

METHODS

Over a 2-year period, 459 devices were placed in two academic Italian institutions. Patients' characteristics, catheter-related complications, and their relationship with targeted therapy administration were retrospectively assessed.

RESULTS

Catheter-related complications occurred in 30 out of the 459 analyzed cancer patients (7 %). Local complications occurred in 12 (40 %) and 18 (60 %) patients receiving standard chemotherapy and biological drugs, respectively. Eighteen (72 %) out of 25 patients developing biological complications (BC) were receiving biological drugs. Infusion of a biological drug through a central venous catheter has been shown to increase the risk of central venous catheter complications (p = 0.02). No difference between the incidence of complication between anti-angiogenic and anti-epidermal growth factor receptor (EGFR) agents was observed in our study despite the statistically significant early development of port-a-cath complication in the anti-EGFR group. Treatment with a biological drug and the stage of disease, in univariate analysis, had independent effect on the duration for development of catheter-related complications.

CONCLUSIONS

Molecularly targeted therapy may influence the occurrence of BCs, i.e., infection and dehiscence. Onset of BCs occurred earlier in patients receiving biological drugs (more frequently with bevacizumab than with anti-EGFR therapy) than those undergoing traditional chemotherapy. Further studies are needed to ascertain the findings of our study and to elucidate the reason for the higher incidence of catheter-related complications.

[Comparison between implantation costs of peripherally inserted central catheter and implanted subcutaneous ports]

INTRODUCTION

Peripherally Inserted Central Catheter or PICC Line and implanted subcutaneous ports are two types of central catheters allowing drug administration and blood samplings. These two devices are very controversial (because of infectious and thrombotic complications), it seemed interesting to estimate their cost of implantation and to correlate them with the reimbursement by the Health Insurance.

MATERIALS AND METHODS

Direct (material and drugs) and indirect (use of the room and staff) costs were prospectively evaluated for PICC Lines and implanted subcutaneous ports.

RESULTS

The global costs of the implantation of a PICC Line and of an implanted subcutaneous port in the interventional radiology room and in the operating room were respectively evaluated at 220.2 €, 286.6 € and 666.3 €.

DISCUSSION-CONCLUSION

Only a PICC Line in outpatients can be reimbursed by the health insurance; which amounts to 110.4 €. The establishment therefore loses money with every implantation. However, PICC Lines offer to the patients a fast access to a central venous way and thus an optimal therapeutic care, fulfilling one of the main missions of the public health institutions. Implanted subcutaneous ports are economically worth being implanted only in ambulatory inpatients. Its implantation in radiology seemed more profitable because the indirect costs were much more moderate.

Central venous thrombosis and thrombophilia in cystic fibrosis: A prospective study

BACKGROUND AND AIMS

Catheter venous thrombosis may result in life-threatening embolic complications. Recently, a thrombophilic tendency was described in cystic fibrosis (CF), the significance of which remains unclear. The aims of this study were to (1) document the frequency of catheter venous thrombosis detected by colour-Doppler-ultrasound (Doppler-US), (2) assess genetic and acquired thrombophilia risk factors for catheter venous thrombosis and hypercoagulability status and (3) provide recommendations on laboratory screening when considering insertion of a totally implantable vascular access device (TIVAD) in CF patients.

METHODS

We designed a multicentre prospective study in patients selected at the time of catheter insertion. Doppler-US was scheduled at 1 and 6months after insertion and before insertion in case of a previous central line. Blood samplings were drawn at insertion and at 1 and 6months later.

RESULTS

One-hundred patients received a TIVAD and 90 completed the 6-month study. Prevalence of thrombophilia abnormalities and hypercoagulability was found in 50% of the cohorts. Conversely, catheter venous thrombosis frequency was low (6.6%).

CONCLUSION

Our data do not support biological screening at the time of a TIVAD insertion. We emphasise the contribution of a medical history of venous thromboembolism and prospective Doppler-US for identifying asymptomatic catheter venous thrombosis to select patients who may benefit from biological screening and possible anticoagulant therapy.

Epidemiology and natural history of central venous access device use and infusion pump function in the NO16966 trial

Background:

Central venous access devices in fluoropyrimidine therapy are associated with complications; however, reliable data are lacking regarding their natural history, associated complications and infusion pump performance in patients with metastatic colorectal cancer.

Methods:

We assessed device placement, use during treatment, associated clinical outcomes and infusion pump perfomance in the NO16966 trial.

Results:

Device replacement was more common with FOLFOX-4 (5-fluorouracil (5-FU)+oxaliplatin) than XELOX (capecitabine+oxaliplatin) (14.1% vs 5.1%). Baseline device-associated events and post-baseline removal-/placement-related events occurred more frequently with FOLFOX-4 than XELOX (11.5% vs 2.4% and 8.5% vs 2.1%). Pump malfunctions, primarily infusion accelerations in 16% of patients, occurred within 1.6–4.3% of cycles. Fluoropyrimidine-associated grade 3/4 toxicity was increased in FOLFOX-4-treated patients experiencing a malfunction compared with those who did not (97 out of 155 vs 452 out of 825 patients), predominantly with increased grade 3/4 neutropenia (53.5% vs 39.8%). Febrile neutropenia rates were comparable between patient cohorts±malfunction. Efficacy outcomes were similar in patient cohorts±malfunction.

Conclusions:

Central venous access device removal or replacement was common and more frequent in patients receiving FOLFOX-4. Pump malfunctions were also common and were associated with increased rates of grade 3/4 haematological adverse events. Oral fluoropyrimidine-based regimens may be preferable to infusional 5-FU based on these findings.

A retrospective clinical study: complications of totally implanted central venous access ports

Background

When managing patients who require repeated venous access, gaining a viable intravenous route has been problematic. To improve the situation, various studies on techniques for venous access have been conducted. The aim of this study is to evaluate the clinical results of complications following totally implanted central venous access port (TICVAP) insertion.

Methods

A retrospective analysis was conducted on 163 patients, from December 2008 to March 2013. The occurrence of complications was studied in three separate periods of catheter use: the intraoperative period, postoperative period, and period during the treatment.

Results

A total of 165 cases of TICVAP insertions involving 156 patients were included in the final analysis. There were 35 complications (21%) overall. Among these, 31 cases of complications (19%) occurred during the treatment period and the other 4 cases were intraoperative and postoperative complications (2%). There were no statistically significant differences in age and gender of the patients between the two groups to be risk factors (p=0.147, p=0.08). Past history of chemotherapy, initial laboratory findings, and the locations of TICVAP insertion also showed no statistical significance as risk factors (p>0.05).

Conclusion

Because the majority of complications occurred after port placement and during treatment, meticulous care and management and appropriate education are necessary when using TICVAPs.

Upper extremity venous thrombosis in patients with cancer with peripherally inserted central venous catheters: a retrospective analysis of risk factors

PURPOSE

Peripherally inserted central catheters (PICCs) are often used in place of mediport catheters because of cost and lack of operating room time and to prevent delays in therapy. One common complication associated with their use is upper extremity venous thrombosis (UEVT). The purpose of this study was to ascertain risk factors associated with an increased risk of PICC-associated UEVT in patients with cancer.

METHODS

Retrospective analysis identified 237 patients with cancer who received PICCs at the Dallas Veterans Affairs Medical Center from 2006 to 2009. We analyzed many risk factors, including PICC infection (PI), use of erythropoiesis-stimulating agents (ESAs), antiplatelet agents (APAs), treatment dose anticoagulation (TDA), and bevacizumab.

RESULTS

Of 237 patients, 36 (15%) were found to have UEVT. Stepwise logistic regression analysis showed risk factors positively associated with UEVT were use of ESAs (odds ratio [OR], 10.66; 95% CI, 2.25 to 50.49), hospitalization (OR, 2.38; 95% CI, 1.05 to 5.39), PI (OR, 2.46; 95% CI, 1.03 to 5.86), and TDA (OR, 8.34; 95% CI, 2.98 to 23.33), whereas patients receiving APAs had a lower risk of UEVT (OR, 0.25; 95% CI, 0.07 to 0.92).

CONCLUSION

Specific factors significantly increase the risk of UEVT in patients with cancer with PICCs, whereas use of APAs seems to have a protective effect against UEVT. These results may aid in the development of a predictive model for identifying patients at high risk of UEVT who may benefit from APAs, as well as in determining preventive strategies for reducing the risk of PICC-associated UEVT.

Totally implantable central venous catheters for chemotherapy: experience with 793 patients

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.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial

BACKGROUND

Heparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking.

PATIENTS AND METHODS

We randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as 'easy injection, impossible aspiration' at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4.

RESULTS

Three hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%-4.69%) and 3.92% (95% CI 3.09%-4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%-1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group.

CONCLUSION

NS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.

Infection related to implantable central venous access devices in cancer patients: epidemiology and risk factors

OBJECTIVE

To describe the epidemiology of infections related to the use of implantable central venous access devices (CVADs) in cancer patients and to evaluate measures aimed at reducing the rates of such infections.

DESIGN

Prospective cohort study.

SETTING

Referral hospital for cancer in São Paulo, Brazil.

PATIENTS

We prospectively evaluated all implantable CVADs employed between January 2009 and December 2011. Inpatients and outpatients were followed until catheter removal, transfer to another facility, or death.

METHODS

Outcome measures were bloodstream infection and pocket infection. We also evaluated the effects that the creation of a multidisciplinary team for CVAD care, avoiding in-hospital implantation of CVADs, and limiting CVAD insertion in neutropenic patients have on the rates of such infections.

RESULTS

During the study period, 966 CVADs (mostly venous ports) were implanted in 933 patients, for a combined total of 243,792 catheter-days. We identified 184 episodes of infection: 154 (84%) were bloodstream infections, 21 (11%) were pocket infections, and 9 (5%) were surgical site infections. During the study period, the rate of CVAD-related infection dropped from 2.2 to 0.24 per 1,000 catheter-days ([Formula: see text]). Multivariate analysis revealed that relevant risk factors for such infection include surgical reintervention, implantation in a neutropenic patient, in-hospital implantation, use of a cuffed catheter, and nonchemotherapy indication for catheter use.

CONCLUSIONS

Establishing a multidisciplinary team specifically focused on CVAD care, together with systematic reporting of infections, appears to reduce the rates of infection related to the use of these devices.

Totally implantable central venous access port infections in patients with digestive cancer: incidence and risk factors

BACKGROUND

Central venous access port-related bloodstream infection (CVAP-BSI) is associated with morbidity and mortality in patients with cancer. This study examined the incidence rates and risk factors for CVAP-BSI in adult patients with digestive cancer.

METHODS

This prospective observational cohort study was performed from 2007 to 2011 in 2 oncology units of a university hospital. Incidence rate was expressed as number of CVAP-BSI per 1,000 catheter-days. A Cox regression model was used to identify risk factors for CVAP-BSI.

RESULTS

A total of 315 patients were included. CVAP-BSI occurred in 41 patients (13.0%). The overall incidence rate was 0.76/1,000 catheter-days. The rate was higher in patients with esophageal cancer (1.28. P = .05) and pancreatic cancer (1.24; P = .007). Risk factors independently associated with CVAP-BSI were World Health Organization performance status between 2 and 4, catheter utilization-days in the previous month, pancreatic cancer, and parenteral nutrition. Coagulase-negative Staphylococci and enterobacteria were the main microorganisms isolated.

CONCLUSIONS

In adult patients with digestive cancer, pancreatic cancer, cumulative catheter utilization-days, World Health Organization performance status, and parenteral nutrition were identified as independent risk factors for CVAP-BSI. Patients with any of these risk factors could be candidates for preventive strategies.

Effect of neoadjuvant cetuximab, capecitabine, and radiotherapy for locally advanced rectal cancer: results of a phase II study

PURPOSE

The aim of this study was to investigate the efficacy and safety of neoadjuvant cetuximab, capecitabine, and radiotherapy for patients with locally advanced rectal cancer.

METHODS

Sixty-three eligible patients were selectively enrolled in this study. Neoadjuvant treatment consisted of cetuximab and capecitabine for 6 weeks and radiotherapy for 5 weeks. Surgical resection was performed 6-8 weeks after the completion of neoadjuvant treatment. KRAS mutation statuses were analyzed retrospectively after the cetuximab treatment. All the patients underwent a standardized postoperative follow-up for at least 3 years.

RESULTS

A pathological complete response (pCR) was achieved in eight patients (12.7 %). Overall down-staging was found in 49 patients (77.8 %). The 3-year disease-free survival (DFS) rate and overall survival (OS) rate was 76.2 % and 81.0 %, respectively. The most common adverse events during neoadjuvant treatment were acneiform skin rash (82.5 %), radiodermatitis (46.0 %), and diarrhea (36.5 %). KRAS mutations were detected in 19 of 63 (31.2 %) tumors. The down-staging rate in patients with KRAS wild-type (WT) was significantly higher than patients with KRAS mutation (P = 0.020). There was no significant difference in the pCR rate, 3-year DFS rate or 3-year OS rate between KRAS WT patients and KRAS-mutated patients.

CONCLUSION

Neoadjuvant treatment with cetuximab and capecitabine-based chemoradiotherapy is safe and well tolerated. The pCR rate, 3-year DFS rate and OS rate are not superior to the rate of neoadjuvant chemoradiotherapy using two or more cytotoxic agents. The KRAS WT is highly associated with tumor down-staging to cetuximab plus capecitabine-based CRT in patients with LARC.