The effects of different central venous line dressing changes on bacterial growth in a pediatric oncology population

Skin antisepsis for reducing central venous catheter-related infections

BACKGROUND

The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

OBJECTIVES

To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities.

SEARCH METHODS

In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs).

MAIN RESULTS

Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events.

AUTHORS' CONCLUSIONS

It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

WITHDRAWN: Gauze and tape and transparent polyurethane dressings for central venous catheters

This review has been withdrawn as the topic is covered by Ullman AJ, Cooke ML, Mitchell M, Lin F, New K, Long DA, Mihala G, Rickard CM. Dressings and securement devices for central venous catheters (CVC). Cochrane Database of Systematic Reviews 2015 , Issue 9 . Art. No.: CD010367. DOI: 10.1002/14651858.CD010367.pub2 .

The editorial group responsible for this previously published document have withdrawn it from publication.

Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review

OBJECTIVES

To compare the available dressing and securement devices for central venous access devices (CVADs).

DESIGN

Systematic review of randomised controlled trials.

DATA SOURCES

Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews and of Effects, NHS Economic Evaluation Database, Ovid MEDLINE, CINAHL, EMBASE, clinical trial registries and reference lists of identified trials.

REVIEW METHODS

Studies evaluated the effects of dressing and securement devices for CVADs. All types of CVADs were included. Outcome measures were CVAD-related bloodstream infection, CVAD tip colonisation, entry and exit site infection, skin colonisation, skin irritation, failed CVAD securement, dressing condition and mortality. We used standard methodological approaches as expected by The Cochrane Collaboration.

RESULTS

We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. It is unclear whether there is a difference in the rate of CVAD-related bloodstream infection between securement with gauze and tape and standard polyurethane (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated dressings and standard polyurethane (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93). There is moderate quality evidence that chlorhexidine gluconate-impregnated dressings reduce the frequency of CVAD-related bloodstream infection per 1000 patient days compared with standard polyurethane dressings (RR 0.51, 95% CI 0.33 to 0.78). There is moderate quality evidence that catheter tip colonisation is reduced with chlorhexidine gluconate-impregnated dressings compared with standard polyurethane dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and standard polyurethane are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence).

CONCLUSIONS

Medication-impregnated dressing products reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types. There is some evidence that chlorhexidine gluconate-impregnated dressings, relative to standard polyurethane dressings, reduce CVAD-related bloodstream infection for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of CVAD-related bloodstream infection. Most studies were conducted in intensive care unit settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVADs.

Dressings and securement devices for central venous catheters (CVC)

BACKGROUND

Central venous catheters (CVCs) play a vital role in the management of acute and chronic illness. Dressings and securement devices must ensure CVCs do not dislodge or fall out, provide a barrier protection from microbial colonisation and infection, and be comfortable for the patient. There is a large range of dressing and securement products available for clinicians to use.

OBJECTIVES

To compare the available dressing and securement devices for CVCs, in terms of catheter-related bloodstream infection (BSI), catheter colonisation, entry- and exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing condition and mortality.

SEARCH METHODS

In June 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); NHS Economic Evaluation Database (NHSEED); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; six clinical trial registries and reference lists of identified trials. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effects of dressing and securement devices for CVCs. All types of CVCs were included, i.e. short- and long-term CVCs, tunnelled and non-tunnelled, port-a-caths, haemodialysis catheters, and peripherally-inserted central catheters (PICCs).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Collaboration methods including independent review of titles and abstracts for relevance, data extraction, and risk of bias assessment of the included studies by two review authors. Results are expressed using risk ratio (RR) for categorical data with 95% confidence intervals (CIs). For outcomes best presented as a rate-per-time-period, rate ratios and standard errors have been used. We performed multiple treatment meta-analyses to rank the effectiveness of each intervention for each outcome.

MAIN RESULTS

We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. The extent of blinding of outcome assessment was unclear in most studies. The quality of evidence varied between different comparisons and outcomes. We mainly downgraded the quality of evidence for imprecision, indirectness, risk of bias and inconsistency.It is unclear whether there is a difference in the rate of catheter-related BSI between securement with gauze and tape and standard polyurethane (SPU) (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated (CGI) dressings and SPU (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of catheter-related BSI relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93).There is moderate quality evidence that CGI dressings reduce the frequency of catheter-related BSI per 1000 patient days compared with SPU dressings (RR 0.51, 95% CI 0.33 to 0.78).There is moderate quality evidence that catheter tip colonisation is reduced with CGI dressings compared with SPU dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and SPU are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). It is unclear if there is a difference in rates of skin irritation or damage when CGI dressings are compared with SPU dressings (moderate quality evidence) (RR 11.17, 95% CI 0.84 to 149.48).A multiple treatment meta-analysis found sutureless securement devices as likely to be the most effective at reducing the incidence of catheter-related BSI (low quality evidence), with CGI dressings ranked second (low quality evidence).

AUTHORS' CONCLUSIONS

Medication-impregnated dressing products reduce the incidence of catheter-related BSI relative to all other dressing types. There is some evidence that CGI dressings, relative to SPU dressings, reduce catheter-related BSI for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of catheter-related BSI. A multiple treatment meta-analysis found that sutureless securement devices are likely to be the most effective at reducing catheter-related BSI though this is low quality evidence. Most studies were conducted in intensive care unit (ICU) settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVCs. Future research may adjust the estimates of effect for the products included in this review and is needed to assess the effectiveness of new products.

Gauze and tape and transparent polyurethane dressings for central venous catheters

BACKGROUND

Central venous catheters (CVCs) facilitate venous access, allowing the intravenous administration of complex drug treatments, blood products and nutritional support, without the trauma associated with repeated venepuncture. However, CVCs are associated with a risk of infection. Some studies have indicated that the type of dressing used with them may affect the risk of infection. Gauze and tape, transparent polyurethane film dressings such as Tegaderm® and Opsite®, and highly vapour-permeable transparent polyurethane film dressings such as Opsite IV3000®, are the most common types of dressing used to secure CVCs. Currently, it is not clear which type of dressing is the most appropriate.

OBJECTIVES

To compare gauze and tape with transparent polyurethane CVC dressings in terms of catheter-related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised adults and children.

SEARCH METHODS

For this third update, we searched The Cochrane Wounds Group Specialised Register (10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2011, Issue 2), Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 11, 2011); Ovid EMBASE (1980 to 2011 Week 18); and EBSCO CINAHL (1982 to 6 May 2011).

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating the effects of dressing type (e.g. gauze and tape versus transparent polyurethane dressings) on CVC-related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for missing information.

MAIN RESULTS

Six studies were included in earlier versions of the review. In this update two of the previously included papers have been excluded and two new trials have been added. Of these six trials, four compared gauze and tape with transparent polyurethane dressings (total participants = 337) and two compared different transparent polyurethane dressings (total participants = 126). Catheter-related bloodstream infection was higher in the transparent polyurethane group when compared with gauze and tape; OR 4.19 (95%CI 1.02 to 17.23) however these small trials were at risk of bias so this evidence is graded low quality. There was no evidence of a difference between highly permeable polyurethane dressings and other polyurethane dressings in the prevention of catheter-related bloodstream infection (low quality evidence). No other significant differences were found.

AUTHORS' CONCLUSIONS

We found a four-fold increase in the rate of catheter related blood stream infection when a polyurethane dressing was used to secure the central venous catheter however this research was at risk of bias and the confidence intervals were wide indicating high uncertainty around this estimate; so the true effect could be as small as 2% or as high as 17-fold. More, better quality research is needed regarding the relative effects of gauze and tape versus polyurethane dressings for central venous catheter sites.

Interventions other than anticoagulants and systemic antibiotics for prevention of central venous catheter-related infections in children with cancer

BACKGROUND

Use of central venous catheters (CVC) in treatment of children with cancer is associated with infective complications. Current evidence-based guidelines to prevent catheter-related infections are mainly relevant to the adult population. They are not cancer (especially not childhood cancer) specific. Two existing Cochrane reviews have looked at prophylactic antibiotics and anticoagulants to prevent CVC-related infections.

OBJECTIVES

The primary objective was to find which interventions, if any, were effective in preventing CVC-related infections in children with cancer. Further objectives were to examine the effectiveness of each intervention in the following subgroups: implanted versus external catheters, haematological versus non-haematological malignancies, and in those receiving haematopoietic stem cell transplants (HSCT) versus no HSCT.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2008, Issue 4), MEDLINE (January 1950 to January 2009), EMBASE (January 1980 to January 2009) and CINAHL(R) (January 1982 to March 2009). We also searched reference lists of relevant articles and proceedings of relevant international conferences (2004 to 2008).

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing any intervention (other than anticoagulants, systemic antibiotics and antibiotic lock techniques) versus no intervention, placebo or any other intervention to prevent CVC-related infections in children with cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed trial quality and extracted data. Where necessary, we contacted study authors for further data and clarification of methods.

MAIN RESULTS

Three trials involving two different interventions were included. Two trials involving 680 children compared flushing CVC with urokinase (with or without heparin) versus heparin alone. Neither of these trials reported on the primary outcome of catheter-related blood stream infection (CRBSI). There was a non-significantly decreased rate of catheter-associated infection (CAI) (Rate Ratio 0.72, 95% confidence interval 0.12 to 4.41) in the urokinase (with or without heparin) arm compared with the heparin arm.One trial involving 113 children compared frequency of catheter dressing change every 15 days versus every 4 days. It did not report on CRBSI or CAI. There were no premature catheter removals for infection in either of the trial arms.

AUTHORS' CONCLUSIONS

Three RCTs for only two types of interventions to prevent CVC-related infections in children with cancer have been identified. Flushing CVC with urokinase (with or without heparin) compared to heparin alone possibly leads to decrease in CAI rates. Changing catheter dressings every 15 days versus every 4 days does not lead to more premature catheter removals due to infection although data were insufficient to assess if catheter-related infection rates were changed.

O cuidado de enfermagem e o cateter de Hickman: a busca de evidências

INTRODUÇÃO: Os pacientes submetidos ao transplante de medula óssea (TMO) necessitam de um acesso venoso seguro para a infusão da medula óssea. A implantação de um cateter venoso central é parte da terapêutica, sendo o de Hickman o mais utilizado atualmente; entretanto, sua presença impõe riscos, sendo a infecção, o mais preocupante. OBJETIVO: Revisão integrativa da literatura, que teve como objetivo buscar e avaliar as evidências sobre os cuidados de enfermagem relacionados ao cateter de Hickman. MÉTODO: Para a seleção dos artigos utilizamos as bases de dados Lilacs, Medline, Cinahl e o periódico Bone Marrow Transplantation, e a amostra constituiu-se de 18 artigos. RESULTADOS: O curativo recomendado é o de poliuretano trocado a cada 7 dias. O método de coleta de sangue observado foi o de descarte, sendo que a dosagem de ciclosporina não deve ser coletada da mesma via onde foi infundida. A redução do número de manipulações do cateter é considerada uma medida eficaz na prevenção e no controle de infecção. CONSIDERAÇÕES FINAIS: As evidências extraídas dos estudos analisados podem auxiliar a implementação de cuidados de enfermagem eficazes relacionados ao cateter de Hickman.

Central venous catheter use in the pediatric patient: mechanical and infectious complications

OBJECTIVE

Following the introduction and widespread use of central venous catheters (CVCs) in adults, these devices are being used with increasing frequency in the pediatric population. This review will focus on differences between adults and children regarding CVC use and its potential complications. Both mechanical and infectious complications will be discussed.

DATA SOURCES

Systematic review of the literature.

CONCLUSIONS

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

Central venous catheter dressings: a systematic review

BACKGROUND

Gauze and tape or transparent polyurethane film dressings such as Tegaderm, Opsite or Opsite IV3000 are the most common types of dressing used to secure central venous catheters (CVCs). Currently, there are no clear guidelines as to which type of dressing is the most appropriate.

AIMS

To identify whether there are any differences between gauze and tape and/or transparent polyurethane film dressings in the incidence of CVC-related infection, catheter-related sepsis, catheter security, tolerance to dressing material, dressing condition and ease of application in hospitalized patients.

METHODS

The Cochrane Controlled Trials Register and Medline, Embase and CancerLit databases were searched to identify any controlled trials comparing the effects of gauze and tape and/or transparent polyurethane dressings on CVCs. Additional references were sought from published and non-published literature. Twenty-three studies were reviewed. Data were extracted independently from each paper by two members of the review team and results compared. Differences were resolved either by consensus or referral to a third person. Authors were contacted for missing information.

RESULTS

Of the 23 studies reviewed, 15 were excluded. Of the remaining eight, data were available for meta-analysis from six studies. Of the six included studies, two compared gauze and tape with Opsite IV3000, two compared Opsite with Opsite IV3000, one compared Tegaderm with Opsite IV3000, and one compared Tegaderm with Opsite.

CONCLUSIONS

There was no evidence of any difference in the incidence of infectious complications between any of the dressing types compared in this review. Each of these comparisons was based on no more than two studies and all of these studies reported data from a small patient sample. Therefore it is unlikely that any of these comparisons would have had sufficient power to detect any differences between groups.

Chlorhexidine versus povidone-iodine for central venous catheter site care in children

The number of children receiving central venous catheters (CVCs) for the administration of medications is at an all-time high. Unfortunately, placement of these CVCs is not without risks. Infection of CVC insertion sites is one of the most common, yet often preventable, causes of nosocomial bacteremia in both children and adults worldwide. Throughout the years, multiple practice recommendations have been made regarding the proper site care of CVCs. The most popular antimicrobial solution used for site care has traditionally been povidone-iodine. Chlorhexidine gluconate solution, however, has been shown to be more effective than povidone-iodine in preventing CVC-related infections in adults. There continues to be controversy regarding the efficacy and safety of antimicrobial solutions for pediatric CVC site care. An evidence-based approach was used to determine current recommendations for CVC site care in children.

Central venous catheter site care for blood and marrow transplant recipients

Treatment-induced neutropenia, long central venous catheter (CVC) dwell times, and the use of immunosuppressive agents place blood and marrow transplant recipients at high risk for CVC infection. The most common causative organisms of CVC infection are ubiquitous skin flora of hospitalized patients. A great deal of research on CVC care, including dressing change procedures and frequency, has been conducted; however, variations in study design, patients studied, and terminology used to define CVC infection limit the generalizability of the findings. This article reviews significant studies of CVC care and infection rates and describes the findings of a survey of CVC care practices of Blood and Marrow Stem Cell Transplant Special Interest Group members of the Oncology Nursing Society.

Gauze and tape and transparent polyurethane dressings for central venous catheters

BACKGROUND

Central venous catheters facilitate venous access, allowing the intravenous administration of complex drug treatments, blood products and nutritional support, without the trauma associated with repeated venepuncture. However, central venous catheters are associated with a risk of infection. Some studies have indicated that the type of dressing used for central venous catheters may affect the risk of infection. Gauze and tape or transparent polyurethane film dressings such as Tegaderm, Opsite or Opsite IV3000 are the most common types of dressing used to secure central venous catheters. Currently, it is not clear which type of dressing is the most appropriate.

OBJECTIVES

To compare gauze and tape and transparent polyurethane central venous catheter dressings in terms of catheter related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised adults and children.

SEARCH STRATEGY

The Cochrane Wounds Group Specialised Trials Register (October 2002), the Cochrane Controlled Trials Register (4th Quarter 2002) and the databases; MEDLINE (1966-December 2002, CINAHL (1982-October 2002) and EMBASE (1980-December 2002) were searched to identify any randomised controlled trials comparing the effects of gauze and tape and/or transparent polyurethane dressings for central venous catheter sites. Additional references were identified from bibliographies of published literature and were also sought from other sources.

SELECTION CRITERIA

All randomised controlled trials evaluating the effects of dressing type (i.e. gauze and tape and/or transparent polyurethane dressings) on central venous catheter related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised patients.

DATA COLLECTION AND ANALYSIS

Twenty-three studies were reviewed. Data was extracted from each paper by two members of the review team independently and results then compared. Differences were resolved either by consensus or by referral to a third member of the review team. Authors were contacted for missing information.

MAIN RESULTS

Of the 23 studies reviewed, 14 were excluded. Nine studies were included. Data was only available for meta-analysis from six of the nine included studies. Of the six included studies with available data, two compared gauze and tape with Opsite IV3000, two compared Opsite with Opsite IV3000, one compared gauze and tape with Tegaderm, and one compared Tegaderm with Opsite. There was no evidence of any difference in the incidence of infectious complications between any of the dressing types compared in this review. Each of these comparisons was based on no more than two studies and all of these studies reported data from a small patient sample. Therefore it is probable that the finding of no difference between dressing types is due to the lack of adequate data.

REVIEWER'S CONCLUSIONS

There is a high level of uncertainty regarding the risk of infection with the central venous catheter dressings identified in this review. Therefore, at this stage it appears that the choice of dressing for central venous catheters can be based on patient preference. To identify the most appropriate central venous catheter dressings, further research is necessary. It is paramount that any future studies investigating this issue must be rigorously performed randomised controlled trials.

End of life in pediatric oncology: how clinical practice leads to research

In pediatric oncology nursing, and across practice disciplines in general, clinical research serves as the cornerstone for improving patient care. Historically, advances made in the care and cure of childhood cancer have stemmed directly from clinical research. The developments of new research questions are varied in their origin--some questions are based on previous work that leads logically to the next question, some are based on a clinical problem that requires more immediate attention, and then there are those that arise from an individual clinical experience. This last category provides clinicians with a poignant reason to search for answers on how to provide the most optimal care for all future patients. As the number of advanced practice nurses in pediatric oncology increases, there is the likelihood of an increased pursuit of clinical research. This article describes how one clinician's experience with dying children resulted in the pursuit of answers to clinical research questions. By reflecting on clinical practice and incorporating our practice in the development of research questions, we can improve the quality of care provided to all children with cancer.

Developing an evidence-based procedure: maintenance of central venous catheters

This article describes the creation of an evidence-based guideline as part of a learning experience of a group of clinical nurse specialists. The guideline was the product of a utilization-focused integrated review of the literature conducted with the guidance of a nurse researcher. Key aspects of the evidence-based recommendations, as well as factors that facilitated or hindered this effort, are shared.

Empirical tests of the Neuman systems model: relational statement analysis

To be a valid test of the Neuman systems model, researchers' relational statements must be congruent with Neuman's axioms and must also be congruent at the conceptual, theoretical, and operational levels. Guided by Cooper's five-stage integrative review method, 92 quantitative research studies (dissertations and journal articles) were collected and categorized according to an expanded version of Silva's levels of theory testing. Nine studies, with explicit relational statements, were analyzed at three levels of abstraction, and interpretations of the studies' results were explored. Recommendations are made for the establishment of a program of research.

Use of occlusive dressings on central venous catheter sites in hospitalized children

Although the use of occlusive dressings in adults has been criticized in the literature, there has been little written on their use in the pediatric population. Management of dressing sites requires nursing judgement unique to this population. This study focused on the progression of microbial colonization and signs of inflammation occurring beneath repeated occlusive dressings applied to central venous catheter (CVC) insertion sites among 104 hospitalized children (neonate to 18 years). A noninvasive skin culture was obtained within 24 hours of CVC placement, 3 to 7 days later before the next routine dressing change, and at the time the CVC was discontinued or the child was discharged, whichever occurred first. Results showed a significant increase in microbial growth (p < or = .001) at the second dressing change, when serosanguinous drainage was heaviest, and continued significant growth (p < or = .001) when the dressing was discontinued. This microbial growth pattern was curious in the face of a 0.3% systemic sepsis rate. When neonates under 1,800 g were excluded from calculation, the pattern was not notable (p = .2119). Findings suggest the use of occlusive dressings during prolonged hospitalization for tunnelled CVCs does not lead to increased site infections in children over 1,800 g.

Nursing research--moving forward through networking, collaboration, and mentorship

Numerous pediatric oncology nurses have provided the specialty with research that has established a foundation for the nursing care of children and adolescents with cancer. The research committee within APON is committed to facilitating further research development among pediatric oncology nurses. Research growth within APON will continue with the development of precongress research workshops for nurses interested in developing research projects, an advanced nursing research session to be held at the next national conference, and the organization of networking among pediatric oncology nurse researchers. Additionally, the research column will provide nurses with a review of the research process over the next several issues. Knowledge building is an evolving, dynamic process that is rapidly changing due to the newness of the specialty. As the pediatric oncology specialty continues to grow, networking, collaboration, and mentorship must become the keys to facilitating future research growth within APON.