Innovative dressing and securement of tunneled central venous access devices in pediatrics: a pilot randomized controlled trial

Outcomes of tunnelled cuffed centrally inserted central catheter removal: A retrospective cohort study

BACKGROUND

Most children with cancer will require a central venous access device (CVAD) to administer cancer treatment. A commonly used CVAD is a tunnelled cuffed centrally inserted central catheter (TC-CICC). There is little information available to guide best practice when removing this type of CVAD. At our institution, TC-CICCs are removed by using either the traction or dissection methods. This study will describe the outcomes associated with each technique.

METHODS/RESULTS

A retrospective cohort study was undertaken at a quaternary children's hospital in Melbourne, Australia. Data related to characteristics of TC-CICC removal success, post-removal complications and an economic evaluation were carried out. There were 149 patients who underwent traction removal and 100 who had their TC-CICC removed using the dissection technique. In the traction group, 136/149 (91%) patients had their device successfully removed on the first attempt, whereas 99/100 (99%) were removed on the first attempt with dissection. Of the 136 successful traction removals, cuff status was documented in 72 cases. The cuff remained in situ in 46/72 (64%) cases, and six of 72 (8%) patients experienced a complication. There were no documented cases of cuff retention in the dissection group. In the 2019-2020 financial year, the estimated average cost of traction removal was A$387, whereas the estimated average cost of day case surgery was A$2560.

CONCLUSION

This study has highlighted that the traction technique is a safe, efficient and cost-effective approach to TC-CICC removal. Further research is required to understand the patient and family experience of TC-CICC removal.

Use of tissue adhesive for neonatal intravenous access devices: A scoping review

Neonates often require vascular access devices for medication or fluid therapy, but a third of devices fail before treatment completion or end with a complication. For adults and children, securing these devices with tissue adhesive (TA) increases the dwell and reduces complications. However, there is a lack of evidence for the neonatal population. This scoping review aimed to assess the evidence of TA for vascular access devices in neonates. The Arksey and O'Malley's (2005) framework was used. The inclusion criteria covered studies published from 2007 (when TA was first reported for use in vascular access devices) to June 2024, available in English, Portuguese, and Spanish, across six databases. Two independent reviewers assessed the studies using Covidence software, with a third reviewer resolving conflicts. Quality assessment was performed using the Mixed Methods Appraisal Tool. From 981 identified studies, 12 were included. Most studies (n = 5, 41.7%) enrolled between 100 and 500 neonates with vascular access devices. Publications originated from four regions and were observational studies (n = 6, 50%), quasi-experimental (n = 3, 25%), and case series (n = 2, 16.7%) with one randomized controlled trial (8.3%) focusing on umbilical venous catheters (UVC). The most common TA composition used was a combination of n-butyl- and 2-octyl- cyanoacrylate (n = 4, 33.3%). The amount of TA applied varied across studies, and often TA was part of a bundle (n = 7, 58.3%). Most studies applied TA to central venous access devices (n = 10, 83.3%) and 2 (16.7%) in peripheral devices. Although there was variation in device failure, the studies generally indicated a reduction in complications such as dislodgment (central catheter: 11.3% [peripherally inserted central catheter {PICC}] to 24.6% [UVC] in non-TA group vs 0.7% [PICC] to 7.7% [UVC] in TA group), device-associated bloodstream infections (central: 7.7% [UVC] and incidence of 2.76/1000 catheter days [PICC] in non-TA group vs 3.1% [UVC] and incidence of 0.99/1000 catheter day [PICC] in TA group), and phlebitis (13% in non-TA group vs 3% in TA-group), as well as increased dwell time in peripheral catheters. Most studies included both term and preterm neonates but did not differentiate between them in their analyses. Skin assessment, life of first dressing, and follow-up of catheters and patients were not reported in most studies.

CONCLUSION

TA may reduce complications in vascular access devices, but the evidence in neonates is limited and varied. Many studies include TA as part of bundle, making it difficult to isolate its effects. Additionally, the current evidence lacks robustness due to the design limitations of the studies. Future research should focus on randomized controlled trials to evaluate TA's effectiveness and safety in preventing device failures and complications in neonates, considering different subgroups, to ensure the safety of TA in these nuanced populations.

WHAT IS KNOWN

• Research in adults and pediatrics provides evidence supporting the use of tissue adhesive (TA) for vascular access devices, showing a positive impact in reducing failures and complications. • The use of TA in neonates needs to be carefully considered due to their unique characteristics.

WHAT IS NEW

• There is a gap in the literature on the use of TA for securing vascular access devices in neonates, particularly regarding its safety and effectiveness in preventing failures and complications. • Further studies are needed to provide robust evidence verifying the effectiveness and safety of TA in this population.

Evidence-based summary of preventive care for central venous access device-related thrombosis in hospitalized children

PURPOSE

This study aims to summarize the latest and best evidence on central venous access device-related thrombosis (CRT) in hospitalized children, which provides theoretical support for standardizing the preventive care practice of CRT in hospitalized children.

METHODS

Relevant guidelines, systematic reviews and expert consensuses were reviewed through ten guideline websites, six professional association websites and seven databases. The literature evaluation was conducted, and the best evidence from qualified studies was extracted and summarized. Furthermore, the best evidence was summarized through expert consultation and localized for the preventive care practice of CRT in hospitalized children in China.

RESULTS

A total of 14 topics and 68 best evidence were collected, including personnel qualification and quality management, pediatric patient selection, risk assessment, central venous access device (CVAD) selection and use, tip position, catheter maintenance, basic prevention, drug prevention, imaging examination, health education, nursing records, follow-up, CVAD removal and others.

CONCLUSION

In this study, the best evidence based on evidence-based nursing was summarized, and expert consultation was adopted to localize the best evidence collected. It is of great significance to standardize the clinical practice of pediatric nurses and ensure the effectiveness of CRT preventive care for hospitalized children, thus guaranteeing the safety of hospitalized children with CVAD catheterization.

Preventing adverse events during paediatric cancer treatment: protocol for a multi-site hybrid randomised controlled trial of catheter lock solutions (the CLOCK trial)

INTRODUCTION

Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock.

METHODS AND ANALYSIS

This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers.

ETHICS AND DISSEMINATION

Ethics approval has been provided by Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000499785.

Octyl-butyl-cyanoacrylate glue for securement of peripheral intravenous catheters: A retrospective, observational study in the neonatal population

BACKGROUND

Evidence-based insertion and maintenance strategies for neonatal vascular access devices (VAD) exist to reduce the causes of VAD failure and complications in neonates. Peripheral intravenous catheter failure and complications including, infiltration, extravasation, phlebitis, dislodgement with/without removal, and infection are majorly influenced by catheter securement methods.

METHODS

A retrospective, observational study using routinely collected data on intravenous device use in a large neonatal intensive care unit in Qatar. A 6-month historical cohort was compared with a 6-month cohort after the introduction of an octyl-butyl-cyanoacrylate glue (CG). In the historical cohort, the catheter was secured using a semi-permeable transparent membrane dressing while in the CG cohort, CG was applied at the insertion site on initial insertion and after any dressing change. This was the only variable intervention between both groups.

RESULTS

A total of 8330 peripheral catheters were inserted. All catheters were inserted and monitored by members of the NeoVAT team. 4457 (53.5%) were secured with just a semi-permeable transparent dressing and 3873 (46.5%) secured a semi-permeable transparent dressing with the addition of CG. The odds ratio for premature failure after securement with CG was 0.59 (0.54-0.65) when compared to the catheters secured with a semi-permeable transparent dressing, which was statistically significant (p < 0.001). The correlation between the occurrence of a complication and the use of CG for device securement was significant (p < 0.001).

CONCLUSIONS

The risk of developing device-related phlebitis and premature device removal, increased significantly if CG was not used for adjunct catheter securement. In parallel with the currently published literature, this study's findings support the use of CG for vascular device securement. When device securement and stabilization concerns are most pertinent CG is a safe and effective adjunct to reducing therapy failures in the neonatal patient population.

Pediatric invasive device utility and harm: a multi-site point prevalence survey

BACKGROUND AND AIMS

Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals.

METHODS

In 2022-2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics.

RESULTS

Of the 285 patients audited, 78.2% had an invasive device (n = 412 devices), with a median of 1 device-per-patient (interquartile range 1-2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices (n = 223; 54.1%), followed by gastrointestinal devices (n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices).

CONCLUSIONS

The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings.

IMPACT

A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices (n = 223; 54.1%), however, 16% (n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.

Peripherally inserted central catheter securement with cyanoacrylate glue and bloodstream infection: A retrospective cohort study

BACKGROUND

Treatment via a peripherally inserted central venous catheter is important for anticancer treatment, perioperative management, and nutrition management. In this study, we aimed to investigate the usefulness of cyanoacrylate glue (CG) in managing peripherally inserted central venous catheters in adults.

METHODS

This retrospective cohort study enrolled 411 adults requiring a central venous catheter for treatment in the Chiba University Esophageal-Gastro-Intestinal Surgery department between January 2021 and October 2022. The preventive effect of CG in reducing adverse events, including infection, tip migration, and thrombus formation, was evaluated by reviewing electronic medical records, chest radiographs, and contrast-enhanced computed tomography scans.

RESULTS

CG and other dressings were used in 158 (CG group) and 253 (control group) patients, respectively. The incidence of catheter infection based on the clinical course was lower in the CG group (3.2%) than in the control group (9.1%; P = 0.03). However, cases of infection confirmed by blood or catheter cultures did not differ between the CG (1.3%) and control (1.9%) groups (P = 1.0). Chest radiographs revealed that catheter tip migration (mean ± SD) was lesser in the CG group (8.2 ± 6.7 mm) than in the control group (15.0 ± 15.8 mm; P < 0.01). There were two cases of venous thrombus formation in the control group.

CONCLUSION

In a population dominated by esophago-gastroenterological malignancy, peripherally inserted central catheter securement via CG was associated with decreased catheter removal because of suspected catheter infection. Further research on larger cohorts is needed to determine if other adverse events decrease following peripherally inserted central catheter securement via CG.

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.

Pediatric Central Venous Access Device Lock Solutions: A Network Meta-analysis

CONTEXT

Central venous access device (CVAD) locks are routine interventions used to prevent and treat complications, such as infection, thrombosis, and catheter occlusion.

OBJECTIVE

To compare and rank lock-solutions for prevention or treatment of complications in pediatrics. Design Systematic review and network meta-analysis.

DATA SOURCES

Five databases and 2 clinical trial registries were searched.

STUDY SELECTION

Published and unpublished randomized controlled trials that enrolled pediatric patients with a CVAD and compared the effectiveness of lock-solutions.

DATA EXTRACTION

Data extraction was conducted by 2 reviewers. Odds ratio (OR) for prevention or treatment of CVAD-associated bloodstream infection (BSI), thrombosis, occlusion, CVAD-failure, and mortality were calculated, with point estimates ranking lock-solutions.

RESULTS

Twenty-nine studies were included. Chelating agents and antibiotic locks given as prevention were associated with lower odds (OR: 0.11; 95% confidence interval [CI]: 0.02-0.67; moderate-quality; OR: 0.19; 95% CI: 0.05-0.79, high-quality, respectively) of CVAD-associated BSI compared with heparinized saline (reference). Preventative thrombolytic agents had lower odds (OR: 0.64, 95% CI: 0.44-0.93; low-quality) of CVAD occlusion, whereas ethanol had higher odds (OR: 2.84, 95% CI: 1.31-6.16; high-quality) compared with heparinized saline (reference). No lock solution had effects on thrombosis prevention or treatment, CVAD-failure, CVAD-associated BSI treatment failure, or mortality.

LIMITATIONS

There was substantial uncertainty around the point estimates because of the limited number of studies for outcomes and study heterogeneity. More high-quality studies are needed to confirm the efficacy of lock solutions.

CONCLUSIONS

Chelating agents and antibiotic locks may be effective for CVAD-associated BSI prevention in pediatrics. Thrombolytic agents can be an option for CVAD occlusion prevention, whereas ethanol may not be recommended.

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.

Safe and effective removal of cyanoacrylate vascular access catheter securement adhesive in neonates

Neonatal vascular access continues to pose challenges. Recent times have seen considerable innovations in practice and the design and manufacture of materials used to provide infusion-based therapies with the intent of reducing the incidence and severity of vascular access-related complications. However, despite these efforts, vascular access-related complication rates remain high in this patient group and research evidence remains incomplete. In neonates, a medical-grade formulation of cyanoacrylate adhesive is widely used to secure percutaneously inserted central venous catheters and is beginning to establish a role in supporting the effective securement of other devices, such as umbilical and peripheral intravenous catheters. This Perspective article considers issues specific to the removal of cyanoacrylate used to secure vascular access devices from neonatal skin before its bonding releases due to natural skin exfoliation processes. The aim of this information is to ensure the safe and effective removal of octyl-cyanoacrylate adhesive-secured vascular access catheters from neonatal skin and stimulate professional discussion.

Experiences of children with central venous access devices: a mixed-methods study

BACKGROUND

Our study aims to explore the experience of having a central venous access device (CVAD) from the perspective of the child and family and how movements within and outside of hospital environments influence this experience.

METHODS

A mixed-methods study was conducted across Children's Health Queensland (Australia), including inpatient and home-care settings. Children less than 18 years with CVADs were eligible and followed for 3 months or CVAD removal. A subgroup of primary caregivers participated in semi-structured interviews. Quantitative and qualitative measures of child and family CVAD experiences were explored.

RESULTS

In total, 163 patients with 200 CVADs were recruited and followed for 6993 catheter days (3329 [48%] inpatients; 3147 [45%] outpatients; 517 [7%] home). Seventeen participants were interviewed. Experiences of having a CVAD were complex but predominantly positive primarily related to personalized CVAD care, healthcare quality, and general wellbeing. Their experience was shaped by their movements through hospital and home environments, including care variation and distress with procedures. Device selection and insertion location further influenced experience, including safety, impairments in activities of daily living, school, and recreation.

CONCLUSIONS

CVAD experiences were influenced by nonmodifiable (e.g., diagnosis) and modifiable factors (e.g., education; care variation). Clinical approaches and policies that account for family and child considerations should be explored.

IMPACT

Variation in decision making and management for pediatric CVADs is accepted by many clinicians, but the influence this variation has on the health experience of children and their families is less well explored. This is the first study to draw from a broad range of children requiring CVADs to determine their experience within and outside of healthcare facilities. Interdisciplinary clinicians and researchers need to work collaboratively with children and their families to provide resources and support services to ensure they have positive experiences with CVADs, no matter where they are managed, or who they are managed by.

Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study

BACKGROUND

Within every neonatal clinical setting, vascular access devices are considered essential for administration of fluids, nutrition, and medications. However, use of vascular access devices is not without danger of failure. Catheter securement adhesives are being evaluated among adult populations, but to date, studies in neonatal settings are scant.

PURPOSE

This research describes the prevalence of peripherally inserted central catheter failure related to catheter securement before and after the introduction of tissue adhesive for catheter securement. The identified modifiable risks might be used to evaluate efficacy, to innovate neonatal practice and support future policy developments.

METHOD AND SETTING

This was a retrospective observational analysis of routinely collected anonymized intravenous therapy-related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar.

RESULTS

The results showed that the use of an approved medical grade adhesive for catheter securement resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight, and catheter type.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In parallel with currently published international literature, this study's findings support catheter securement with an octyl-based tissue adhesive in use with central venous catheters. When device stabilization is most pertinent, securement with tissue adhesive is a safe and effective method for long-term vascular access among the neonatal population.

A Revolutionary, Proven Solution to Vascular Access Concerns: A Review of the Advantageous Properties and Benefits of Catheter Securement Cyanoacrylate Adhesives

Intravascular catheters are widely used among hospitals; however, their failure rates are high, up to 50%, when secured by traditional techniques, such as tape and gauze. The use of catheter securement cyanoacrylate adhesives provides a unique approach to the issues surrounding the use of traditional securement techniques for vascular access devices by providing significant securement strength, barrier properties, antibacterial properties, hemostatic properties, and flexibility. The purpose of this research was to perform a thorough and systematic review of the current literature existing regarding the use of cyanoacrylate adhesive for the care and maintenance of vascular access devices.

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.

Routine Catheter Lock Solutions in Pediatric Cancer Care: A Pilot Randomized Controlled Trial of Heparin vs Saline

BACKGROUND

Central venous access devices (CVADs) are integral to cancer care provision. Despite the high prevalence of CVAD complications in children with cancer, preventative strategies are understudied.

OBJECTIVE

The aim of this study was to assess study feasibility, occlusive events, thrombolytic use, adverse events, and direct costs of catheter lock solutions.

METHODS

A single-center, parallel-group, pilot randomized controlled trial was undertaken at a tertiary-referral pediatric hospital in Australia. Children 18 years or younger with an oncological or malignant hematological condition and a CVAD were eligible. Participants were 1:1 randomized to (1) normal or (2) heparinized (10-100 U/mL; CVAD-type dependent) saline lock solutions.

RESULTS

Of 217 children assessed for eligibility, 61 were recruited and randomized to normal (n = 30; 3850 CVAD days) or heparinized (n = 31; 4036 CVAD days) saline. Eligibility (52%) and recruitment (54%) feasibility targets were not met. Protocol adherence was high (95% assessments), with no attrition. Parent/clinician satisfaction of interventions was high (median, 10/10 clinicians/parents). Complete CVAD occlusion occurred in heparin only (n = 2, 6.7% CVADs; incidence rate [IR], 0.49/1000 CVAD days [0.06-1.78]). Central venous access device partial occlusion was detected in 23.3% of CVADs in heparin (n = 7; IR, 2.73/1000 CVAD days [1.36-4.87]) and 13.8% of CVADs in normal saline (n = 4; IR, 2.59/1000 CVAD days [1.24-4.77]). Thrombolytic agents were used in 16.7% heparin (5 CVADs) and 3.5% normal saline (1 CVAD). Adverse events did not differ between groups.

CONCLUSION

Multisite randomized controlled trials examining CVAD locks are safe, but strategies and resources to increase recruitment and eligibility are required.

IMPLICATIONS FOR PRACTICE

Both routine CVAD lock solutions seem safe but may not prevent all forms of CVAD-associated harm.

Complications of peripherally inserted central catheters in adult hospitalized patients and outpatients in the KTFIXPICC study: A randomized controlled trial evaluating a fixation device KT FIX Plussystem

BACKGROUND

Poor securement potentiates Peripherally inserted central catheters (PICC) complications. A dressing device (KT FIX Plus) offers stronger skin attachment, which may reduce the risk of dressing disruption. We aimed to evaluate this device.

METHODS

We conducted a single-center parallel-group open-label randomized controlled trial. Hospitalized and outpatient consecutive adults requiring PICCs were randomized to KT FIX Plus or standard of care (SOC). The primary endpoint was the composite of PICC-associated complications until removal, including occlusion, migration, accidental withdrawal, infection, thrombosis, and hematoma.

RESULTS

No statistically significant difference was observed in terms of complications: 67 (35%) in the KT FIX Plus group vs 36 (37%) in the SOC group (log-rank P = 0.76). In multivariate Cox analysis, independent risk factors for PICC-associated complications were obesity (adjusted hazard ratio (aHR), 1.08, P < .001) and diabetes (aHR, 1.85, P = .039), adjusting for chronic renal failure, number of lumens, catheter/vein diameter ratio and duration of home-based care. Multiple lumen catheters increased the risk of accidental withdrawal and migration (HR, 2.4, P = .008).

CONCLUSIONS

In our study, the use of KT FIX Plus did not reduce the risk of complications adjusting for other risk factors such as obesity and diabetes. The number of catheter lumens is one of the modifiable factors to reduce complications. Further studies are required to find the best securement and dressing system.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Inserting central lines via the peripheral circulation in neonates

Peripherally inserted central catheters (PICCs) are extensively used in neonatal intensive and high-dependency care settings. These intravenous catheters provide medium to longer-term access to the circulatory system for the delivery of medications, parenteral nutrition and the like. Catheters are available in a variety of bespoke designs and materials, each with their unique characteristics, benefits and limitations. PICCs are frequently inserted in a sterile zone cot-side procedure, one that requires an advanced knowledge base, technical skill and training. This article relates some important practical advice around managing minor complications that can be encountered while using the modified Seldinger technique (MST) to insert neonatal PICCs, which can make this procedure a less stressful experience for both infants and health professionals.

Venous catheter at alternate exit site in a 2-year-old requiring long-term antibiotics for osteomyelitis: A case report

In the pediatric population, vascular access is often challenging to secure and to maintain, especially for long-term intravenous (IV) treatment. The traditional approach for patients who require long-term IV antibiotics is placement of a peripherally inserted central catheter (PICC). The challenge in the pediatric population is the high risk of dislodgement after PICC placement, as these patients tend to pull their line out accidentally or purposefully. Current bedside options to prevent catheter dislodgement include adhesive securement devices, subcutaneous securement devices, sutures, and wrapping the site in gauze. However, these modalities often fail, leading to delay in administration of IV therapies, including life-saving antibiotics.A novel approach to this very common and serious issue is to tunnel the catheter subcutaneously, thereby placing the exit site in a location difficult for the patient to reach. Tunneled catheters generally are placed in children for long-term vascular access and insertion has primarily been reserved for surgeons in the operating room or by interventional radiologists. The following case report describes a central venous access catheter placed in the internal jugular vein and tunneled to the medial dorsal thoracic region successfully at the bedside, using intracavitary electrocardiogram (ECG) navigation under moderate sedation. Although a novel exit site, the technique of tunneling and use of the jugular vein is no different than traditional tunneling techniques therefore it was not deemed necessary to seek internal review board approval.

A decision tree to guide long term venous access placement in children and adolescents undergoing surgery for renal tumors

BACKGROUND/PURPOSE

While many children with renal tumors require long term venous access (VA) for adjuvant chemotherapy, certainly not all do. This study develops and tests a VA decision tree (DT) to direct the placement of VA in patients with renal tumors.

METHODS

Utilizing data readily available at surgery a VADT was developed. The VADT was tested retrospectively by 2 independent reviewers on a historic cohort. The ability of the VADT to appropriately select which patients would benefit from VA placement was tested.

RESULTS

160 patients underwent renal tumor surgery between 2005 and 2018. 70 (43.8%) patients met study criteria with median age of 45.1 months (range 1.1-224); 73% required VA. Using the VADT, VA placement was "needed" in 67.1% of patients and "deferred" in 32.9%. Interrater reliability was very high (kappa = 0.97, 95% CI 0.91-1, p < 0.001). The sensitivity and specificity of the VADT to correctly decide on VA placement were 0.92 (0.8-0.98) and 1 (0.79-1). Using the VADT, no patient would have undergone unnecessary VA placement. In reality, 4.3% of patients had an unnecessary VA placed which required a subsequent removal.

CONCLUSIONS

These preliminary data support the continued study of this VADT to guide intraoperative decisions regarding VA placement in patients with renal tumors.

LEVEL OF EVIDENCE

III - Study of diagnostic test.

Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics

AIM

To test the feasibility of an efficacy trial comparing different flushing frequencies and volumes to reduce peripheral intravenous cannula (PIVC) failure in paediatric inpatients.

METHODS

Pilot, 2 × 2 factorial, randomised controlled trial comparing PIVC flushing techniques in intervention pairs: (i) low volume (3 mL) versus high volume (10 mL); and (ii) low frequency (24 hourly) versus high frequency (6 hourly). Patients were excluded if: fluids were restricted, weight < 5 kg, PIVC already in situ for >24 h or continuous infusion. The primary end-point was feasibility (eligibility, recruitment, retention, protocol adherence, missing data and sample size estimates) of a large trial. Secondary end-points were PIVC failure (composite and individual), bloodstream infection and mortality.

RESULTS

A total of 919 children were screened from April to November 2015, with 55 enrolled. Screening feasibility criteria were not met, mainly due to continuous infusions and PIVCs in situ >24 h or planned for imminent removal. However, 80% of eligible participants consented, 2% withdrew, protocol adherence was 100%, and there was no missing primary end-point data. PIVC failure was significantly higher (hazard ratio = 2.90, 95% confidence interval: 1.11-7.54) in the 3 mL compared to the 10 mL group. There was no difference in failure between frequency groups (hazard ratio = 0.91, 95% confidence interval: 0.36-2.33). There was no interaction effect (P = 0.22).

CONCLUSION

Trial feasibility proved challenging due to eligibility criteria, which could be improved with additional recruiting staff. Firm conclusions cannot be made based on this small sample, but flush volume may impact PIVC failure.

Global Pediatric Peripheral Intravenous Catheter Practice and Performance: A Secondary Analysis of 4206 Catheters

PURPOSE

To describe worldwide characteristics, performance and risk factors of peripheral intravenous catheters (PIVCs), in pediatrics.

DESIGN

A secondary, subgroup analysis of pediatric (<18 years) data was undertaken, using a global, cross-sectional study of PIVCs. Practice characteristics included: demographic, diagnostic, utility, management, performance and resources. Multivariate regression identified complication risks factors.

RESULTS

Data from 4206 children in 278 hospitals across 47 countries. Most PIVCs (outside of Australia, New Zealand) were inserted by nurses (71%; n = 2950), with dedicated teams only common in North America (23.2%; n = 85). Large gauges (≤18G) were mostly used in South America, Europe and Africa. Regions predominantly placed 24G (49%; n = 2060) except in Australia and New Zealand, who more commonly placed 22G (38.7%; n = 192). The most common placement was the hand (51%; n = 2143), however North America, Australia and New Zealand frequently utilised the antecubital fossa (24.5%, n = 90; 21.4%; n = 106). Polyurethane dressings were most used (67.1%; 2822), and many were not clean, dry and intact (17.1%; n = 715). Over 8% of PIVCs were idle, with the highest rates in North America (21.2%; n = 78). PIVC local complication risk factors included: >2 years age (odds ratio [OR] > 1.58; 1.2-2.1); ambulance/emergency insertion (OR 1.65; 1.2-2.3); upper arm/antecubital placement (OR 1.44; 1.1-2.0); poor dressing integrity (OR 5.4; 4.2-6.9); and 24-72 h dwell (OR > 1.9; 1.3-2.6).

CONCLUSIONS

There is global inconsistency in pediatric PIVC practice, which may be causing harm.

CLINICAL IMPLICATIONS

Improvements in pediatric PIVC placement, dressings, and gauge selection are needed.

Central venous access device Securement and dressing effectiveness: The CASCADE pilot randomised controlled trial in the adult intensive care

INTRODUCTION

Central venous access devices (CVADs) are a vital medical device for intensive care (ICU) patients; however, complications and failure are common, yet potentially prevented through effective dressings and securement.

OBJECTIVES/AIMS

The objective of this study was to test the feasibility of a randomised controlled trial (RCT) comparing standard care with three dressing and securement products to prevent CVAD failure. Secondary aims included comparing dressing and securement products on CVAD failure, microbial colonisation, and intervention costs.

METHODS

A single-centre pilot RCT of ICU adult patients requiring CVADs for >24 h were randomised to four groups: (i) sutures plus chlorhexidine gluconate (CHG) dressing (standard care); (ii) standard care plus tissue adhesive (TA); (iii) two sutureless stabilisation devices (SSD) plus CHG dressing; (iv) sutures, CHG disc plus integrated securement dressing (ISD). Descriptive statistics assessed feasibility. Incidence rates (IRs) of CVAD failure were reported, with group differences compared using the Fisher exact and log-rank tests. Cox regression explored univariable risks for failure. A substudy examined bacterial colonisation of catheter tips, dressings, and skin. Cost estimates of the intervention were compared.

RESULTS

A total of 121 participants were randomised. Study feasibility was established with no withdrawal and moderate staff acceptability; however, recruitment was low at 12%. Overall CVAD failure was seen in 14 of 114 (12%) CVADs (19 per 1000 catheter-days); highest in the SSD group (IR: 27.3 per 1000 catheter-days [95% confidence interval {CI}: 11.4-65.6]), followed by the standard care group (IR: 22.3 per 1000 catheter-days [95% CI: 8.38-59.5]) and TA group (IR: 20.6 per 1000 catheter-days [95% CI: 6.66-64.0]), and lowest in the ISD group (IR: 8.8 per 1000 catheter-days [95% CI: 2.19-35.0]). The majority of complications (11/14, 79%) were suspected central line-associated bloodstream infection (CLABSI), of which only one was laboratory confirmed (standard care group). The cost per patient was lowest in the standard care group by an average difference of AUD $14.

CONCLUSION(S)

A large multisite RCT examining forms of securement and dressing is feasible. ISD is the highest priority to test further as it had the lowest failure rate.

TRIAL REGISTRATION

ACTRN12615000667516 PROTOCOL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368765.

Cyanoacrylate tissue adhesive: a new tool for the vascular access toolbox

Health professionals are responsible for preventing and minimising complications related to vascular access devices. This is important from the perspectives of both the patient and the health economy. Practitioners have many tools at their disposal and evidence is available to assist in using these tools to enhance best practice. A relatively new tool has been acknowledged as having a role in vascular access as well as previously recognised roles in other areas of healthcare. Cyanoacrylate tissue adhesive has been approved for use with vascular access devices and the benefits of this aid to device securement are now being recognised.

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

OBJECTIVES

Central venous access devices enable many treatments during critical illness; however, 25% of pediatric central venous access devices fail before completion of treatment due to infection, thrombosis, dislodgement, and occlusion. This is frequently attributed to inadequate securement and dressing of the device; however, high-quality research evaluating pediatric central venous access device securement innovation to prevent central venous access device failure is scarce. This study aimed to establish the feasibility of a definitive randomized control trial examining the effectiveness of current and new technologies to secure central venous access devices in pediatrics.

DESIGN

Single-center, parallel group, superiority, pilot randomized control trial.

SETTING

Anesthetic and intensive care departments of a tertiary pediatric hospital SUBJECTS:: One-hundred eighty pediatric patients with nontunneled central venous access device INTERVENTIONS:: Participants were randomized to receive central venous access device securement via standard care (bordered polyurethane dressing, with prolene sutures, chlorhexidine gluconate disc), tissue adhesive (Histoacryl, B Braun, Melsungen, Germany) in addition to standard care; or integrated dressing securement (SorbaView SHIELD [Centurion Medical Products, Franklin, MA], with prolene sutures and chlorhexidine gluconate disc).

OUTCOMES

Primary: Feasibility (including effect size estimates, acceptability); central venous access device failure; central venous access device complications; secondary: individual central venous access device complications, skin damage, dressing performance, and product cost.

MEASUREMENTS AND MAIN RESULTS

Feasibility criteria were achieved as recruitment occurred with acceptable eligibility, recruitment, missing data, and attrition rates, as well as good protocol adherence. Family members and staff-reported comparable levels of acceptability between study arms; however, tissue adhesive was reported as the most difficult to apply. Overall, 6% of central venous access devices failed, including 6% (3/54; incident rate, 13.2 per 1,000 catheter days) standard care, 2% (1/56; incident rate, 3.65 per 1,000 catheter days) integrated, and 8% (5/59; 25.0 per 1,000 catheter days) tissue adhesive.

CONCLUSIONS

It is feasible to conduct an efficacy randomized control trial of the studied interventions. Further research is required to definitively identify clinical, cost-effective methods to prevent central venous access device failure by examining new dressing and securement technologies and techniques.

Tissue adhesive for vascular access devices: who, what, where and when?

Despite vascular access devices (VADs) being vital for patient care, device failure rates are unacceptably high with around 25% of central venous devices, and 30-40% of peripheral venous devices, developing complications that result in VAD failure. The use of tissue adhesive is a novel method of securing VADs and is gaining popularity, however the evidence base guiding its clinical use is still emerging. This article aims to review the types and properties of tissue adhesives, provide an overview of the existing evidence base, and discuss how tissue adhesives may be used in clinical practice.

Nosocomial infection prevalence in patients undergoing extracorporeal membrane oxygenation (ECMO): protocol for a point prevalence study across Australia and New Zealand

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) provides cardiac and/or respiratory support when other therapies fail. Nosocomial infection is reported in up to 64% of patients receiving ECMO and increases morbidity and mortality. These patients are at high risk of infection due, in part, to the multiple invasive devices required in their management, the largest being the cannulae through which ECMO is delivered. Prevalence of nosocomial infection in ECMO patients, including ECMO cannula-related infection, is not well described across Australia and New Zealand.

METHODS AND ANALYSIS

This is a prospective, observational point prevalence study of 12 months duration conducted at 11 ECMO centres across Australia and New Zealand. Data will be collected for every patient receiving ECMO during 12 predetermined data collection weeks. The primary outcome is the prevalence of laboratory-confirmed bloodstream infection, and suspected or probable nosocomial infections; and the secondary outcomes include describing ECMO cannula dressing and securement practices, and adherence to local dressing and securement guidelines. Data collection will be finalised by March 2019.

ETHICS AND DISSEMINATION

Relevant ethical and governance approvals have been received. Study results will describe the prevalence of suspected and confirmed nosocomial infection in adult, paediatric and neonatal patients receiving ECMO across Australia and New Zealand. It is expected that the results will be hypothesis generating and lead to interventional trials aimed at reducing the high infection rates seen in this cohort. Results will be published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

ANZCTRN12618001109291; Pre-results.

Skin Complications Associated With Pediatric Central Venous Access Devices: Prevalence, Incidence, and Risk

Central venous access devices (CVADs) are vital to enable treatment for children with cancer and other complex health conditions. However, complications effecting the CVAD wound are commonly reported. This study aimed to identify the incidence and prevalence of CVAD-associated skin complications current management, and characteristics associated with complication development, in pediatrics. A prospective observational study performed across medical, oncology, and hematology departments at a tertiary pediatric hospital in Australia, between April and July 2017. Children admitted with CVADs were assessed twice weekly for CVAD-associated skin complications and associated signs and symptoms. The data were analyzed using descriptive statistics (i.e., proportions, frequency) and time-to-event multivariable regression (i.e., hazard ratios [HRs]). Two hundred and seventy-one CVADs were reviewed over 43,787 catheter days, with over one eighth of participants (14%; n = 37) having a CVAD-associated skin complication during their admission (0.95 per 1,000 catheter days, 95% confidence interval [CI; 0.61, 1.17]), most commonly contact dermatitis (11%; n = 29; 0.72 per 1,000 catheter days 95% CI [0.50, 1.04]). Within biweekly checks the median point prevalence of complications varied between 0.4% and 11% and clinical management was wide-ranging. A primary diagnosis of oncology (HR 2.89, 95% CI [1.10, 7.62]) or medical/surgical (HR 2.55, 95% CI [1.04, 6.22]) conditions; plain, nonbordered polyurethane dressings (HR 4.92, 95% CI [2.00, 12.13]); and poor dressing integrity (HR 2.64, 95% CI [1.18, 5.92]) were significantly associated with contact dermatitis. In conclusion, substantial numbers of pediatric patients experience CVAD-associated skin complications, and innovations are necessary to identify, prevent, and treat these health care-associated injuries.

Chlorhexidine-impregnated gel dressing compared with transparent polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients: A pilot randomised controlled trial

BACKGROUND

In patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections.

OBJECTIVES

The objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC.

METHODS

One hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip.

RESULTS

Of 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes.

CONCLUSIONS

Our preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.

Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices

BACKGROUND

Vascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development.

OBJECTIVES

To estimate the incidence of vascular access-associated skin complications, and to identify patient, catheter and healthcare-related characteristics associated with skin complication development.

DESIGN

Secondary data analysis from 13 multi-centre randomised controlled trials and observational studies evaluating technologies and performance of vascular access devices in clinical settings between 2008 and 2017.

SETTINGS

Six hospitals (metropolitan and regional) in Queensland, Australia.

PARTICIPANTS

The 13 studies involved paediatric and adult participants, across oncology, emergency, intensive care, and general hospital settings. A total of 7669 participants with 10,859 devices were included, involving peripheral venous (n = 9933), peripheral arterial (n = 341), and central venous access (n = 585) devices.

ANALYSIS

Standardised study data were extracted into a single database. Clinical and demographic data were descriptively reported. Cox proportional hazards regression models (stratified by peripheral vs central) were used for time-to-event, per-device analyses to examine risk factors. Univariate associations were undertaken due to complexities with missing data in both outcomes and covariates, with p < 0.01 to reduce the effect of multiple comparisons.

RESULTS

Over 12% of devices were associated with skin complication, at 46.2 per 1000 catheter days for peripheral venous and arterial devices (95% confidence interval, CI 42.1-50.7), and 22.5 per 1000 catheter days for central devices (95% CI 16.5-306). The most common skin complications were bruising (peripheral n = 134, 3.7%; central n = 33, 6.8%), and swelling due to infiltration for peripheral devices (n = 296; 2.9%), and dermatitis for central devices (n = 13; 2.2%). The significant risk factors for these complications were predominantly related to device (e.g., skin tears associated with peripheral arterial catheters [hazard ratio, HR 16.0], radial insertion [HR 18.0] basilic insertion [HR 26.0])) and patient characteristics (e.g., poor skin integrity associated with increased risk of peripheral device bruising [HR 4.12], infiltration [HR 1.98], and skin tear [HR 48.4]), rather than management approaches.

CONCLUSIONS

Significant skin complications can develop during the life of peripheral and central vascular access devices, and these are associated with several modifiable and non-modifiable risk factors. Further research is needed to evaluate effectiveness technologies to prevent and treat skin complications associated with vascular access devices.