The effect of low-dose heparin on maintaining peripherally inserted percutaneous central venous catheters in neonates

Effect of adding heparin to parenteral nutrition on catheter intraluminal obstruction based on scanning electron microscopy in preterm neonates: A non-inferiority, randomized controlled trial

OBJECTIVES

This study aimed to assess the need for adding heparin to parenteral nutrition (PN) on reducing catheter intraluminal obstruction based on scanning electron microscopy (SEM) of peripherally inserted central catheter (PICC) in preterm neonates.

METHODS

In this randomized controlled blinded non-inferiority trial, neonates with gestational age <32 weeks requiring PICC to receive PN were enrolled and randomly divided into two groups. In the heparin group, 0.5 IU/mL heparin was added to PN for continuous infusion through PICC; while in the no-heparin group, there was no heparin added. All catheter tips were collected for SEM of catheter intraluminal obstruction. The primary outcome was the ratio of intraluminal obstructed area at catheter tip calculated by SEM. A non-inferiority margin of 0.1 was chosen. The duration of catheter patency, incidence of catheter-related complications, and heparin-related side effects were analyzed.

RESULTS

Between June 1, 2021, and May 31, 2022, 91 neonates (gestational age of 28.17 ± 1.77 weeks) were ultimately enrolled. In the intention-to-treat analysis, the average ratio of intraluminal obstructed area at catheter tip indicated by SEM in no-heparin group was 0.313, and 0.362 in the heparin group (95% confidence intervals of the differences was -0.028 to 0.147). The lower bound of the one-side 95% confidence intervals was greater than -0.1, indicating non-inferiority. No statistically significant differences existed in the duration of catheter patency, the incidence of catheter-related complications between two groups.

CONCLUSIONS

PN without heparin was non-inferior to the addition of 0.5 IU/mL heparin to PN during infusion on reducing catheter intraluminal obstruction based on SEM of PICC in preterm neonates. These findings could reduce the unnecessary exposure to heparin in preterm neonates.

Incidence and risk factors of neonatal peripherally inserted central catheter-related thrombosis: A systematic review and meta-analysis

BACKGROUND

Catheter-related thrombosis is a common complication of the peripherally inserted central catheter (PICC) in neonates, leading to unintended tube removal and significantly affecting neonatal health and safety. Despite widespread reporting on the estimated occurrence and factors contributing to neonatal PICC-related thrombosis, these findings have not been synthesized.

OBJECTIVES

The purpose of this study was to determine the incidence and risk factors of neonatal PICC-related thrombosis.

DESIGN

Systematic literature review and meta-analysis.

METHODS

Two independent researchers systematically explored multiple databases-such as PubMed, Medline, Embase and the Cochrane Library-from their inception until October 2023. Our study aggregates and scrutinizes studies specifically addressing the incidence and risk factors of neonatal PICC-related thrombosis. Employing the RevMan 5.3 software, a meta-analysis was executed to determine the incidence of both thrombosis and odds ratios (OR), accompanied by their respective 95% confidence intervals (CI) for the risk factors.

RESULTS

A total of 327 articles were screened, and data from 24 studies were used in synthesis. Neonatal PICC-related thrombosis incidence varied from 0.23% to 17.91%. The pooled incidence was 2% (95% CI: 1%-2%; I2 = 94%; p < .0001). The study identified 12 risk factors, including insertion sites in the lower extremities (OR = 0.22; 95% CI: 0.09-0.56; p = .001), gestational age <28 weeks, abdominal pathology, fresh frozen plasma by day 5 > 50 mL/kg, PICC tip location (proximal placement), two lumens, three lumens, prolonged hospital stay, infection, mothers' use of anticoagulants, patients with cardiac insufficiency and being twin-to-twin transfusion syndrome donor.

CONCLUSIONS

The analysis indicates an overall pooled incidence of neonatal PICC-related thrombosis of 2%. Twelve factors were identified as risks associated with neonatal PICC-related thrombosis. Understanding the risk factors can provide evidence-based recommendations for improving awareness, control and treatment and better nursing management.

RELEVANCE TO CLINICAL PRACTICE

This systematic review and meta-analysis illuminates the incidence and risk factors linked to neonatal PICC-related thrombosis, delivering essential insights pivotal for clinical decision-making and enhancing patient care within neonatal health care settings.

Heparin versus normal saline for the care of peripheral intravenous catheters in children: A meta-analysis

AIM

To conduct a meta-analysis to evaluate the role of heparin versus normal saline lock in the care of peripheral intravenous catheters.

DESIGN

A meta-analysis.

METHODS

This meta-analysis searched nine databases for randomized controlled trials (RCTs) on heparin versus normal saline for the care of peripheral intravenous catheters in children up to April 5, 2023. The quality of included RCTs was evaluated using the risk of bias tool of Cochrane library. RevMan5.3 software was used for data analysis.

RESULTS

Ten RCTs with a total of 1255 children were involved. Meta-analysis indicated that heparin lock reduced the incidence of blockage of peripheral intravenous catheter [OR = 2.01, 95% CI (1.42,2.84), p < 0.001], prolonged the duration of peripheral intravenous catheter indwelling[MD = -0.43, 95% CI (-0.75, -0.11), p = 0.008]. There were no statistical differences in the incidence of phlebitis [OR = 1.02, 95% CI (0.59, 1.74), p = 0.95 W].

PUBLIC CONTRIBUTION

Heparin may have more benefits in the nursing care of peripheral intravenous catheters compared with normal saline.

The Endothelial Glycocalyx and Neonatal Sepsis

Sepsis carries a substantial risk of morbidity and mortality in newborns, especially preterm-born neonates. Endothelial glycocalyx (eGC) is a carbohydrate-rich layer lining the vascular endothelium, with important vascular barrier function and cell adhesion properties, serving also as a mechano-sensor for blood flow. eGC shedding is recognized as a fundamental pathophysiological process generating microvascular dysfunction, which in turn contributes to multiple organ failure and death in sepsis. Although the disruption of eGC and its consequences have been investigated intensively in the adult population, its composition, development, and potential mechanisms of action are still poorly studied during the neonatal period, and more specifically, in neonatal sepsis. Further knowledge on this topic may provide a better understanding of the molecular mechanisms that guide the sepsis pathology during the neonatal period, and would increase the usefulness of endothelial glycocalyx dysfunction as a diagnostic and prognostic biomarker. We reviewed several components of the eGC that help to deeply understand the mechanisms involved in the eGC disruption during the neonatal period. In addition, we evaluated the potential of eGC components as biomarkers and future targets to develop therapeutic strategies for neonatal sepsis.

[Operation and management guidelines for peripherally inserted central catheter in neonates (2021)]

Peripherally inserted central catheter (PICC) has been widely used in the neonatal intensive care unit (NICU) in recent years, but there are potential risks for complications related to PICC. Based on the current evidence in China and overseas, the operation and management guidelines for PICC in neonates were developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) in order to help the NICU staff to regulate the operation and management of PICC.

The equations of the inserted length of percutaneous central venous catheters on neonates in NICU

BACKGROUND

In neonatal intensive care units, a percutaneous central venous catheter (PCVC) is inserted peripherally and threaded into a central venous location, when intravenous access is anticipated for an extended period of time. The tip location of PCVCs should be checked by an X-ray after the procedure. The present study aimed to determine an equation to estimate the optimal insertion length of PCVCs in neonates prior to the procedure.

METHODS

The data of all neonates who had PCVC insertion between May 1st 2015 and April 30^th 2016 was reviewed. Their gender, body weight and body length at the insertion date, any complications and the tip culture of their PCVCs were recorded. The tip location of the PCVC, which was confirmed by X-ray, was either in the inferior vena cava near to the diaphragm or in the superior vena cava before the right atrial junction, depending on the insertion site. We analyzed the correlation among inserted length of PCVCs, body weight and body length by linear regression to determine an equation for estimating the optimal insertion length of PCVCs. The accuracy of the equations was evaluated prospectively by Pearson's correlation analysis, and the adjusting rate of PCVCs after the initial insertion was compared between the traditional method and using the equation.

RESULTS

The equation of PCVCs inserted in the foot was "insertion length (cm) = 16 + 4.27 × body weight (kg)", in the femoral vein was "inserted length (cm) = 9.8 + 1.7 × body weight (kg)", in the popliteal vein was "inserted length (cm) = -0.3 + 0.45 × body length (cm)", in the hand was "inserted length (cm) = 4.46 + 0.32 × body length (cm)", and in the axillary vein was inserted length (cm) = 1 + 0.18 × body length (cm). The adjusting rate of PCVCs after initial insertion was decreased from 73.5% to 53% following use of the equation.

CONCLUSIONS

Equations provided a convenient and accurate method to estimate the optimal insertion length of PCVCs before their placement.

Association between histamine-2 receptor antagonists and adverse outcomes in neonates: A systematic review and meta-analysis

Background

The use of histamine-2 receptor antagonists (H₂RA) in neonates is still debated because of possible risk of infection, necrotizing enterocolitis (NEC) and increased mortality.

Aim

To review whether the use of H₂RA in neonates admitted to neonatal intensive care units (NICU) is associated with infection, NEC or mortality.

Materials and method

We performed a systematic search in PubMed, Web of Science and SCOPUS databases using the terms “histamine-2 receptor antagonists”, “infection”, “necrotizing enterocolitis”, “mortality”, “neonates” and related terms to identify studies published up to April 30, 2017. We included studies conducted in hospitalized neonates and exposed to H₂RA. The primary outcomes were infection, NEC and mortality. We included reports of infections with clinical signs and positive culture, and NEC according to Bell stages (stage ≥II) based on standardised clinical and radiologic criteria. Among 1,144 studies identified, 10 fulfilled the selection criteria. Information extracted included study design, sample size and number of participants, along with the outcomes of interest. We conducted a meta-analysis of adjusted data and pooled estimates of infection, NEC and mortality are reported as odds ratios (OR) and 95% confidence intervals (95%CI).

Results

Ten studies were analysed. There were substantial associations between H₂RA and infection (pooled OR: 2.09; 95%CI: 1.35–3.24; P = 0.001) and NEC (pooled OR: 2.81, 95%CI: 1.19–6.64; P = 0.02) but not with the mortality risk (pooled OR: 1.76; 95%CI: 0.50–6.16; P: 0.38).

Conclusion

Current evidence suggests that H₂RA is associated with an increased risk of infection and NEC, but not with mortality in neonates admitted to NICU. The use of H₂RA in neonates must be stringently considered when necessary.

Use of ranitidine is associated with infections in newborns hospitalized in a neonatal intensive care unit: a cohort study

BACKGROUND

The inhibition of gastric acid secretion with ranitidine is frequently prescribed off-label to newborns admitted to neonatal intensive care units (NICU). Some studies show that the use of inhibitors of gastric acid secretion (IGAS) may predispose to infections and necrotising enterocolitis (NEC), but there are few data to confirm this association. This study aimed to compare the rates of neonatal infections and NEC among preterm infants (<37 weeks gestation) hospitalised in a NICU exposed or not to treatment with ranitidine.

METHODS

A retrospective cohort study was conducted with all consecutive preterm newborns admitted to a NICU between August-2014 and October-2015. The rates of infection, NEC, and death of newborns exposed or not to ranitidine were recorded.

RESULTS

A total of 300 newborns were enrolled, of which 115 had received ranitidine and 185 had not. The two groups were similar with regard to the main demographic and clinical characteristics. Forty-eight (41.7%) of the 115 infants exposed to ranitidine and 49 (26.5%) of the 185 infants not exposed were infected (RR = 1.6, 95%CI 1.1-2.2, p = 0.006). The late onset (>48 h) blood culture positive infection rate was higher in the group exposed to ranitidine than in the untreated group (13.0% vs. 3.8%, p = 0.001). There was no significant association between the use of ranitidine and NEC (Bell stage >II) (p = 0.36). The mortality rate risk was 4-fold higher in infants receiving ranitidine (16.5% vs. 8.6%, p < 0.001).

CONCLUSION

Ranitidine use in neonates was associated with an increased risk of infections and mortality, but not with NEC.

Randomized controlled trials in central vascular access devices: A scoping review

BACKGROUND

Randomized controlled trials evaluate the effectiveness of interventions for central venous access devices, however, high complication rates remain. Scoping reviews map the available evidence and demonstrate evidence deficiencies to focus ongoing research priorities.

METHOD

A scoping review (January 2006-December 2015) of randomized controlled trials evaluating the effectiveness of interventions to improve central venous access device outcomes; including peripherally inserted central catheters, non-tunneled, tunneled and totally implanted venous access catheters. MeSH terms were used to undertake a systematic search with data extracted by two independent researchers, using a standardized data extraction form.

RESULTS

In total, 178 trials were included (78 non-tunneled [44%]; 40 peripherally inserted central catheters [22%]; 20 totally implanted [11%]; 12 tunneled [6%]; 6 non-specified [3%]; and 22 combined device trials [12%]). There were 119 trials (68%) involving adult participants only, with 18 (9%) pediatric and 20 (11%) neonatal trials. Insertion-related themes existed in 38% of trials (67 RCTs), 35 RCTs (20%) related to post-insertion patency, with fewer trials on infection prevention (15 RCTs, 8%), education (14RCTs, 8%), and dressing and securement (12 RCTs, 7%). There were 46 different study outcomes reported, with the most common being infection outcomes (161 outcomes; 37%), with divergent definitions used for catheter-related bloodstream and other infections.

CONCLUSION

More high quality randomized trials across central venous access device management are necessary, especially in dressing and securement and patency. These can be encouraged by having more studies with multidisciplinary team involvement and consumer engagement. Additionally, there were extensive gaps within population sub-groups, particularly in tunneled devices, and in pediatrics and neonates. Finally, outcome definitions need to be unified for results to be meaningful and comparable across studies.

Factors Associated With Continuous Low-Dose Heparin Infusion for Central Venous Catheter Patency in Critically Ill Children Worldwide

OBJECTIVES

To identify patient, hospital, and central venous catheter factors that may influence the use of low-dose heparin infusion for central venous catheter patency in critically ill children.

DESIGN

Secondary analysis of an international multicenter observational study.

SETTING

Fifty-nine PICUs over four study dates in 2012, involving seven countries.

PATIENTS

Children less than 18 years old with a central venous catheter who were admitted to a participating unit and enrolled in the completed Prophylaxis against Thrombosis Practice study were included. All overflow patients were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 2,484 patients in the Prophylaxis against Thrombosis Practice study, 1,312 patients had a central venous catheter. Five hundred seven of those patients used low-dose heparin infusion. The frequency of low-dose heparin infusion was compared across various patient, hospital, and central venous catheter factors using chi-square, Mann-Whitney U, and Fisher exact tests. In the multivariate analysis, age was not a significant factor for low-dose heparin infusion use. Patients with pulmonary hypertension had decreased low-dose heparin infusion use, whereas those with active surgical or trauma diagnoses had increased low-dose heparin infusion use. All centrally inserted central venous catheters were more likely to use low-dose heparin infusion when compared with peripherally inserted central venous catheters. The Asia-Pacific region showed increased low-dose heparin infusion use, along with community hospitals and smaller ICUs (< 10 beds).

CONCLUSIONS

Patient, central venous catheter, and hospital factors are associated with the use of low-dose heparin infusion in critically ill children. Further study is needed to evaluate the efficacy and persistence of low-dose heparin infusion use.

Anticoagulants for the prevention and treatment of catheter-related thrombosis in adults and children on parenteral nutrition: a systematic review and critical appraisal

BACKGROUND

Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral nutrition guidelines suggest anticoagulation for the primary prevention of catheter-related thrombosis during long-term parenteral nutrition. We conducted a systematic review of the efficacy, safety and feasibility of anticoagulant use for preventing and treating catheter-related thrombosis during parenteral nutrition.

MATERIALS AND METHODS

We searched for interventional and observational studies on adults and children receiving systemic anticoagulants during either short- or long-term parenteral nutrition delivered via central venous access. Primary outcomes were: objectively-confirmed catheter-related thrombosis, pulmonary embolism and bleeding. Secondary outcomes were: heparin-induced thrombocytopenia, prevalence of anticoagulation, and quality of International Normalised Ratio management in vitamin K antagonist-treated patients.

RESULTS

We identified 1,199 studies, of which 23 were included. Seven interventional studies of short-term parenteral nutrition (adult population, n=5) were classified as low-quality: in those, intravenous unfractionated heparin did not prevent catheter-related thrombosis if compared to saline. No interventional studies were conducted in patients on long-term parenteral nutrition. Observational data were sparse, rarely focusing on anticoagulation, and overall of low quality. The reported use of anticoagulants was between 22 and 66% in recent multicentre cohorts.

DISCUSSION

The amount and quality of data in this area are very suboptimal: most studies are outdated and involved heterogeneous populations. Currently, there is insufficient evidence to allow conclusions to be reached regarding the efficacy and safety of anticoagulants in this setting.

Thromboembolism and anticoagulation management in the preterm infant

The incidence of preterm thromboembolism has been increasing due to advances in diagnostic imaging which allow better detection of thrombi in sick preterm infants. At the same time, improvement in neonatal intensive care unit supportive care has increased the number of surviving and living preterm infants with thromboembolic risk factors. Disruption in the fine balance of hemostasis with potential risk factors, specifically septicemia and indwelling catheters, increase the occurrence of thromboembolic events. Treatment strategies in preterm infants are challenging due to limited data.

Three-in-one parenteral nutrition in neonates and pediatric patients: risks and benefits

Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.

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

BACKGROUND

Heparin intermittent flushing is a standard practice in the maintenance of patency in central venous catheters. However, we could find no systematic review examining its effectiveness and safety.

OBJECTIVES

To assess the effectiveness of intermittent flushing with heparin versus 0.9% sodium chloride (normal saline) solution in adults with central venous catheters in terms of prevention of occlusion and overall benefits versus harms.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched December 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11). Searches were also carried out in MEDLINE, EMBASE, CINAHL and clinical trials databases (December 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults 18 years of age and older with a central venous catheter (CVC) in which intermittent flushing with heparin (any dose with or without other drugs) was compared with 0.9% normal saline were included. No restriction on language was applied.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. Trial authors were contacted to retrieve additional information, when necessary.

MAIN RESULTS

Six eligible studies with a total of 1433 participants were included. The heparin concentrations used in these studies were very different (10-5000 IU/mL), and follow-up varied from 20 days to 180 days. The overall risk of bias in the studies was low. The quality of the evidence ranged from very low to moderate for the main outcomes (occlusion of CVC, duration of catheter patency, CVC-related sepsis, mortality and haemorrhage at any site).Combined findings from three trials in which the unit of analysis was the catheter suggest that heparin was associated with reduced CVC occlusion rates (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.29 to 0.94). However, no clear evidence of a similar effect was found when the results of two studies in which the unit of analysis was the participant were combined (RR 0.21, 95% CI 0.03 to 1.70), nor when findings were derived from one study, which considered total line accesses (RR 1.08, 95% CI 0.84 to 1.40). Furthermore, results for other estimated effects were found to be imprecise and compatible with benefit and harm: catheter duration in days (mean difference (MD) 0.41, 95% CI -1.29 to 2.12), CVC-related thrombosis (RR 1.22, 95% CI 0.74 to 1.99), CVC-related sepsis (RR 1.02, 95% CI 0.34 to 3.03), mortality (RR 0.77, 95% CI 0.45 to 1.32) and haemorrhage at any site (RR 1.37, 95% CI 0.49 to 3.85).

AUTHORS' CONCLUSIONS

We found no conclusive evidence of important differences when heparin intermittent flushing was compared with 0.9% normal saline flushing for central venous catheter maintenance in terms of efficacy or safety. As heparin is more expensive than normal saline, our findings challenge its continued use in CVC flushing outside the context of clinical trials.

Peripherally inserted central venous catheters: frequency of complications in premature newborn depends on the insertion site

OBJECTIVE

The use of peripherally inserted central venous catheters (PICC lines) has reduced the mortality and morbidity of premature newborns. The usual sites of insertion are the veins in the upper arms but other locations are being used as well.

STUDY DESIGN

To examine whether using the axillary vein as a site of insertion of a PICC line affects the frequency of complications. Our study has a clinical trial design. A total of 62 neonates that had a PICC line inserted were recruited and randomly divided equally in two groups: in Group A (mean birth weight, standard deviation (s.d.)=1353 (142) g), the PICC line was inserted through the axillary vein, and in Group B (birth weight=1308 (112) g), the PICC line was inserted in other sites further from the axillary vein. The outcomes measured were the total PICC line-related complications, the reason for removing the catheter, the number of total attempts until successful insertion and the mean duration of stay of the catheter. The likelihood of having an adverse outcome was assessed with Mantel-Haenszel odds ratio (OR).

RESULTS

Premature neonates with axillary PICC lines were 12 times less likely to have line-related complications (inflammation, blockage, edema, infection) as compared with any other site of insertion (OR= 95%, confidence interval (CI)=0.10 (0.01 to 0.8)) and they were seven times more likely to have the PICC line removed because they achieved full enteral nutrition as compared with the other causes (OR 95%, confidence interval (CI)=10.35 (4.88 to 21.96)). There was no statistical difference between the two groups in the number of attempts until successful PICC line insertion (P=0.667) and the mean duration of stay of the PICC line (P=0.97).

CONCLUSION

The use of the axillary vein as a site of insertion of a PICC line was correlated with significantly less complications in premature newborns as opposed to the other sites of insertion.

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

BACKGROUND

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

METHOD

A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

Prevention and treatment of intraluminal catheter thrombosis in children hospitalised in a paediatric intensive care unit

AIM

The aim of the study was to develop and implement a protocol for the prevention and treatment of catheter related intraluminal thrombosis in a paediatric intensive care unit

METHODS

A computerised search was carried out on MEDLINE, through PubMed, using the medical subject heading 'central venous catheter', 'central venous access device', 'central venous line' associated with 'occlusion', 'obstruction', 'catheter-related thrombosis', 'critically ill patients' and 'thrombolytic therapy'. References of reviewed articles were also searched for relevant titles as well as non-randomised controlled trials and series of cases when no information of higher level of evidence was available.

RESULTS

With the information gathered, a protocol for the prevention and treatment of catheter related intraluminal thrombosis was elaborated and those recommendations that best suit our environment were included. They were agreed upon by a broad panel of professionals working in the Pediatric Intensive Care Unit and the Pharmacy Department.

CONCLUSIONS

Due to the variety of options available for the pharmacotherapeutic management of intraluminal catheter thrombosis, one measure to improve the quality of the therapy and to diminish the variability in the prescription could be the implementation of a protocol as described in this paper.

Effect of heparin and other factors associated with complications of peripherally inserted central venous catheters in neonates

OBJECTIVE

To identify factors associated with complications necessitating unplanned removal of peripherally inserted central venous catheters (PICCs) in neonates.

STUDY DESIGN

A before-and-after comparison following the exclusion of heparin from continuous infusions through PICCs placed by a designated team. Duration of use was assessed during epochs immediately preceding and following the practice change. Multivariable logistic regression was performed to identify independent risk factors associated with unplanned catheter removal.

RESULT

We analyzed 189 PICC placements with heparin (epoch 1) and 188 with no heparin (epoch 2) added to infusions. Rates of complication (23.7 vs 17.2 per 1000 catheter days) and median durations of use (7 vs 8 days) did not differ significantly between the epochs. Non-central position of the catheter tip, use of dual lumen catheters and placement through the cephalic vein were independently associated with complications (each P<0.05).

CONCLUSION

In neonates requiring short-term intravenous access, heparin may be safely omitted from continuous infusions without compromising catheter usability.