Innovation in Central Venous Access Device Security: A Pilot Randomized Controlled Trial in Pediatric Critical Care

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis

CONTEXT

Indwelling invasive devices inserted into the body for extended are associated with infections.

OBJECTIVE

This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) postinsertion infection complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported.

RESULTS

A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58).

CONCLUSIONS

Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: A systematic review and meta-analysis

BACKGROUND

Central venous catheters are commonly used in healthcare, but they come with a range of potential complications. Over the last 15 years, an influx of securement and dressing products has been released, with unknown overall effectiveness to prevent these complications.

OBJECTIVE

To compare the effects of dressings and securement devices for central venous catheters on a range of common complications including catheter-related bloodstream infection, catheter tip colonisation, entry/exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing durability and mortality.

DESIGN

Systematic review with meta-analysis.

METHODS

Following standard Cochrane methods, a systematic search of Cochrane Wounds Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, EBSCO CINAHL, and multiple clinical trial registries was completed in November 2022. Randomised controlled trials evaluating the effectiveness of dressing and securement devices for all CVC types were included. A random-effects model was used during the meta-analysis. Results were expressed using risk ratio (RR), rate ratio, or mean difference (MD), with 95 % confidence intervals (CIs). Methodological quality and bias were assessed.

RESULTS

We included 46 studies involving 10,054 participants. All studies had either an unclear or high-performance bias. The blinding of outcome assessment was unclear in most studies. Chlorhexidine gluconate-impregnated dressings, compared with standard polyurethane dressings, may reduce the incidence (7 studies; N = 5816; RR 0.60, 95 % CI 0.44-0.83; low certainty evidence) and rate (4 studies; N = 4447; RR 0.51, 95 % CI 0.32-0.79; moderate certainty evidence) of catheter-related bloodstream infection and catheter tip colonisation (8 studies; N = 4788; RR 0.70, 95 % CI 0.52-0.95; very low certainty evidence). Medication-impregnated dressings may reduce the incidence of catheter-related bloodstream infection (6 studies; N = 5687; RR 0.60, 95 % CI 0.39-0.93; low certainty evidence) and catheter-tip colonisation (7 studies; N = 4769; RR 0.60, 95 % CI 0.47-0.76; low certainty evidence) relative to non-impregnated dressing types. Tissue adhesive may increase the risk of skin irritation or damage compared with integrated securement dressings (3 studies; N = 166; RR 1.88, 95 % CI 1.09-3.24; low certainty evidence) or sutureless securement devices (4 studies; N = 241; RR 1.64, 95 % CI 1.10-2.44; moderate certainty evidence). Tissue adhesive increased dressing durability compared with integrated securement dressings (MD 43.03 h, 95 % CI 4.88-81.18; moderate certainty evidence) and sutureless securement devices (MD 42.90 h, 4.64-81.16; moderate certainty evidence). Tissue adhesive increased failed catheter securement rate compared with suture (2 studies; N = 103; RR 9.33, 95 % CI 1.10-79.21; moderate certainty evidence).

CONCLUSIONS

The findings of the review provide insights and guidance for clinicians in selecting the appropriate dressings and securements for catheters. Findings should be interpreted with caution due to heterogeneity in catheters and patient types.

REGISTRATION

#CD010367.

TWEETABLE ABSTRACT

Time to implement chlorhexidine gluconate-impregnated dressings to prevent catheter-related bloodstream infections; a meta-analysis by @GraceNP and team.

Development and validation of a nomogram model for central venous access device-related thrombosis in hospitalized children

This study aimed to develop and validate a nomogram model of central venous access device-related thrombosis (CRT) for hospitalized children. A total of 503 consecutive cases from a hospital in Changsha City, Hunan Province were stochastically classified into the training set and internal validation set at a ratio of 7:3, and 85 consecutive cases in two hospitals in Urumqi City, Xinjiang Uygur Autonomous Region were collected as an external validation set. Univariate analysis and multivariate analysis on CRT-related risk factors of hospitalized children were conducted, a logistic regression model was employed to establish the nomogram, and the discrimination, calibration, and decision curve analysis was performed to assess the proposed nomogram model. The nomogram model involved seven independent risk factors, including blind catheterization, abnormal liver function, central line-associated bloodstream infection, infection, number of catheter lines, leukemia, and bed rest > 72 h. The discrimination results showed that the area under the receiver operating characteristic curve of the training set, internal validation set, and external validation set was 0.74, 0.71, and 0.76 respectively, and the accuracy rates of the proposed nomogram model were 79%, 72%, and 71% in the training set, internal validation set, and external validation set. The calibration results also showed that the calibration curve had great fitness for each dataset. More importantly, the decision curve suggested that the proposed nomogram model had a prominent clinical significance.

CONCLUSION

The nomogram model can be used as a risk assessment tool to reduce the missed diagnosis rate and the incidence of CRT in hospitalized children.

WHAT IS KNOWN

• Central venous access device-related thrombosis is generally asymptomatic for hospitalized children, causing the missed diagnosis of central venous access device-related thrombosis easily. • No risk prediction nomogram model for central venous access device-related thrombosis in hospitalized children has been established.

WHAT IS NEW

• A visual and personalized nomogram model was built by seven accessible variables (blind catheterization, abnormal liver function, central line-associated bloodstream infection, infection, number of catheter lines, leukemia, and bed rest > 72 h). • The model can effectively predict the risk of central venous access device-related thrombosis for hospitalized children.

Effect of Clinical Nursing Pathway Intervention Based on Evidence-Based Medicine on Venous Thrombosis in Long-Term Bedridden Patients

Background

Venous thrombosis is a type of medical condition that establishes as deep vein thrombosis of the limb or pulmonary embolism. This disease arises as a result of interrelating hereditary, ecological, and interactive risk aspects. Clinical nursing pathways also known as critical pathways are pathways that guide nurses when developing a patient's care plan. However, the effect of nursing intervention on venous thrombosis in long-term bedridden patients from the perspective of evidence-based medicine had not been reported.

Methods

A total of 170 patients hospitalized in the hospital from January 2021 to October 2021 were selected, and the bed time was more than 2 weeks. The patients were randomly divided into the control group and observation group. 85 cases in the control group received routine nursing in cardiology, and 85 cases in the observation group received clinical nursing pathway. Venous thrombosis, lower limb pain, swelling, D-dimer level, hemodynamic parameters, and nursing satisfaction were compared in two groups.

Results

The incidence of deep venous thrombosis in the observation group was 8.2%, lower than 24.7% in the control group (P < 0.05). The incidence of lower limb pain and elevated D-dimer in the observation group was lower than that in the control group (P < 0.05). The improvement of hemodynamic parameters such as SBP, DBP, CBV, PR, CI, and CO in the study group was better than that in the control group (P < 0.05). The satisfaction of the observation group was 90.58%, which was higher than that of the control group (82.35%) (P < 0.05).

Conclusion

Clinical nursing pathway can improve patients' nursing efficiency, improve the treatment effect, shorten hospital stay, and improve nursing satisfaction.

Ten years of clinical experience with cyanoacrylate glue for venous access in a 1300-bed university hospital

In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.

Pediatric central venous access devices: practice, performance, and costs

BACKGROUND

Healthcare delivery is reliant on a functional central venous access device (CVAD), but the knowledge surrounding the burden of pediatric CVAD-associated harm is limited.

METHODS

A prospective cohort study at a tertiary-referral pediatric hospital in Australia. Children <18 years undergoing insertion of a CVAD were screened from the operating theatre and intensive care unit records, then assessed bi-weekly for up to 3 months. Outcomes were CVAD failure and complications, and associated healthcare costs (cost of complications).

RESULTS

163 patients with 200 CVADs were recruited and followed for 6993 catheter days, with peripherally inserted central catheters most common (n = 119; 60%). CVAD failure occurred in 20% of devices (n = 30; 95% CI: 15-26), at an incidence rate (IR) of 5.72 per 1000 catheter days (95% CI: 4.09-7.78). CVAD complications were evident in 43% of all CVADs (n = 86; 95% CI: 36-50), at a rate of 12.29 per 1000 catheter days (95% CI: 9.84-15.16). CVAD failure costs were A$826 per episode, and A$165,372 per 1000 CVADs. Comparisons between current and recommended practice revealed inconsistent use of ultrasound guidance for insertion, sub-optimal tip-positioning, and appropriate device selection.

CONCLUSIONS

CVAD complications and failures represent substantial burdens to children and healthcare. Future efforts need to focus on the inconsistent use of best practices.

IMPACT

Current surveillance of central venous access device (CVAD) performance is likely under-estimating actual burden on pediatric patients and the healthcare system. CVAD failure due to complication was evident in 20% of CVADs. Costs associated with CVAD complications average at $2327 (AUD, 2020) per episode. Further investment in key diverse practice areas, including new CVAD types, CVAD pathology-based occlusion and dislodgment strategies, the appropriate use of device types, and tip-positioning technologies, will likely lead to extensive benefit.

Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: A randomized controlled trial

BACKGROUND

The aim of this study was to compare chlorhexidine gluconate (CHG)-impregnated dressing and standard dressing with respect to the frequency of central-line-associated bloodstream infection (CLABSI), catheter-related bloodstream infection, primary bloodstream infection, and catheter colonization in critically ill pediatric patients with short-term central venous catheters.

METHODS

Children who were admitted to the pediatric intensive care unit of a tertiary institution between May 2018 and December 2019 and received placement of a short-term central venous catheter were included in this single-center randomized controlled trial. Patients were grouped according to the type of catheter fixation applied.

RESULTS

A total of 307 patients (151 CHG-impregnated dressing, 156 standard dressing), with 307 catheters (amounting to a collective total of 4,993 catheter days), were included in the study. The CHG-impregnated dressing did not significantly decrease the incidence of CLABSI (6.36 vs 7.59 per 1,000 catheter days; hazard ratio (HR): 0.93, P = 0.76), catheter related bloodstream infection (3.82 vs 4.18 per 1,000 catheter days; HR: 0.98; P = 0.98), and primary bloodstream infection (2.54 vs 3.42 catheter days; HR: 0.79; P = 0.67). The CHG-impregnated dressing significantly decreased the incidence of catheter colonization (3.82 vs 7.59 per 1,000 catheter days; HR: 0.40; P = 0.04). In both groups, the most frequent microorganisms isolated in CLABSI or catheter colonization were Gram-positive bacteria (the majority were coagulase-negative staphylococci).

CONCLUSIONS

The use of CHG-impregnated dressing does not decrease CLABSI incidence in critically ill pediatric patients but it significantly reduced catheter colonization. Coagulase-negative staphylococci were the most common microorganisms causing CLABSI or catheter colonization.