Prevention of peripherally inserted central line-associated blood stream infections in very low-birth-weight infants by using a central line bundle guideline with a standard checklist: a case control study

[Advances in clinical management of neonatal sepsis]

Neonatal sepsis, as a significant cause of various complications and adverse outcomes in neonates, remains a serious health burden both domestically and internationally. Strategies such as antibiotic prophylaxis during delivery, the utilization of early-onset sepsis risk calculators, and quality improvement initiatives in neonatal wards are beneficial in alleviating the disease burden of neonatal sepsis. This paper provides a review of the epidemiology, risk factors, and recent advances in clinical management of neonatal sepsis.

Using phlebotomy to remove a difficult peripherally inserted central catheter insertion and removal in very low birth weight infants: case report of a rare complication

Background

A peripherally inserted central catheter (PICC) is an important way to supply long-term intravenous infusion or parenteral nutrition for premature infants, especially very low birth weight (VLBW) infants. PICC removal difficulties occur mostly during use. It is rare to have difficulty removing a PICC due to reverse folding during catheterization. We presented a case to explore the nursing experience of caring for a VLBW infant with difficult PICC removal.

Case Description

A 30-week, 1,240-g infant, suffered a difficult PICC removal during the catheterization adjustment process. The X-ray images showed that the tip of the catheter was bent at the elbow joint and formed three abnormal bends in the blood vessel. The result was that the catheter was removed by a multidisciplinary team, and the reasons for the difficulty were analyzed. We used multidisciplinary team collaboration to solve a clinical problem. First, we analyzed the possible causes of a difficult removal by consulting PICC nurses, vascular interventional surgeons, and venous specialist nurses. Second, we used nonsurgical treatment methods to try to solve the problem. Finally, the catheter was completely removed using phlebotomy. Healing of wound and the growth of blood vessel are both well.

Conclusions

In neonates, PICC may have obstacles in insertion and removal, methods such as posture changes, wet and hot compresses, and local massage can help. Multidisciplinary cooperation can improve the success rate of removal with minimal trauma. Individualized analysis of causes and measures are key steps to solve the difficulty of PICC insertion and removal.

Care bundles and peripheral arterial catheters

HIGHLIGHTS

What we know about the topic: Recommendations for the use of vascular access care bundles to reduce infection are followed for different devices. The risk of arterial catheter-related infection is comparable with short-term, non-cuffed central venous catheters. There are practice concerns for clinicians inserting and caring for peripheral arterial catheters. What this paper adds: The selected studies had a theme of decreased infection after using bundled strategies for all devices. Few studies addressed use of bundles for care of peripheral arterial catheters. High-quality research should be performed about using care bundles for insertion and care of arterial catheters.

INTRODUCTION

A scoping review of the literature was performed.

AIMS/OBJECTIVES

To find information on the use of care bundles for care of arterial, central, and peripherally inserted venous catheters.

METHODS

Data was extracted by 2 independent researchers using standardized methodology.

RESULTS

Results of 84 studies included 2 (2.4%) randomized controlled trials, 38 (45.2%) observational studies, 29 (34.5%) quality projects, and 15 (17.9%) reviews. Populations had more adults than pediatric patients. All studies had the most prominent theme of decreased infection in all devices after using bundle strategies.

DISCUSSION AND CONCLUSIONS

The mapping of available evidence strongly supports the use of care bundles to reduce infection in the care of all intravascular devices. However, deficiencies regarding practice concerns about insertion and care of arterial catheters highlight areas for future research with the aim to eliminate the gap in the evidence of studies of care bundles for peripheral arterial catheters.

A new perfusion system to reduce the burden of central-venous-line-associated bloodstream infections in neonates

BACKGROUND

Central-venous-line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in preterm infants. As there is large variation in the reported effect of multi-modal preventive strategies, it could be relevant to propose new additional strategies.

AIM

To assess the impact of a new perfusion system on CLABSI rate.

METHODS

A before-and-after study was performed in infants born at <32 weeks of gestation or with birth weight <1500 g who required a multi-perfusion system connected to a central venous line. In the first 12-month period ('before'), the pre-existing perfusion system (multiple stopcocks) was used. An intervention period then occurred with implementation of a new perfusion closed system, without change in 'bundles' related to various aspects of central line care. During the second 12-month period ('after'), the CLABSI rate was assessed and compared with the pre-intervention period.

FINDINGS

In total, 313 infants were included in this study (before: N=163; after: N=150), and 46% had birth weight <1000 g. The change in perfusion system resulted in a significant decrease in CLABSI rate from 11.3 to 2.2 per 1000 catheter-days (P<0.001). The period was independently associated with an 88% reduction in the risk of CLABSI after implementation of the new perfusion system [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.03-0.39; P<0.001]. The duration of central line use was also associated with CLABSIs (for each additional day: OR 1.05, 95% CI 1.02-1.07; P<0.001).

CONCLUSIONS

Implementation of the new perfusion system was feasible in a large neonatal unit, and reduced the CLABSI rate soon after implementation.

The positioning of the catheter tip with an intracavitary electrocardiogram in epicutaneo-caval catheter placement via lower limbs in newborns: A retrospective study

OBJECTIVE

Few studies have been conducted on whether catheterisation via the lower limb pathway is suitable for intracavitary electrocardiogram (ECG) technology. This study explored the positioning of the epicutaneo-caval catheter (ECC) tip with intracavitary ECG via the lower limbs in newborns to determine its optimal placement and to improve the success rate of ECC placement using this method.

METHODS

Twenty-eight cases were selected for the observation group. The tip location with intracavitary ECG method was used to observe the changes in specific atrial depolarisation (P-wave) during the catheterisation process to determine whether the catheter tip was in the correct position. For comparative observation, chest X-rays and abdominal radiographs were taken within 24 h to determine sensitivity and specificity. The control group included 28 cases where the ECCs were inserted via the lower limbs, and chest X-rays and abdominal radiographs were taken within 24 h after the line was placed to confirm the correct positioning.

RESULTS

The success rate of the observation group was 91.30% (there were two cases of primary malposition), and the success rate of the control group was 78.57% (there were six cases of primary malposition). The success rate of the observation group was higher compared with the control group.

CONCLUSION

The tip location with intracavitary ECG method improved the success rate of ECC placement via the lower limbs in neonates. This method can effectively prevent the occurrence of lower limb primary catheter malposition and has significant clinical application value.

Antiseptic solutions for skin preparation during central catheter insertion in neonates

BACKGROUND

Central venous catheters (CVC) are associated with potentially dangerous complications such as thromboses, pericardial effusions, extravasation, and infections in neonates. Indwelling catheters are amongst the main risk factors for nosocomial infections. The use of skin antiseptics during the preparation for central catheter insertion may prevent catheter-related bloodstream infections (CRBSI) and central line-associated bloodstream infections (CLABSI). However, it is still not clear which antiseptic solution is the best to prevent infection with minimal side effects.

OBJECTIVES

To systematically evaluate the safety and efficacy of different antiseptic solutions in preventing CRBSI and other related outcomes in neonates with CVC.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and trial registries up to 22 April 2022. We checked reference lists of included trials and systematic reviews that related to the intervention or population examined in this Cochrane Review.  SELECTION CRITERIA: Randomised controlled trials (RCTs) or cluster-RCTs were eligible for inclusion in this review if they were performed in the neonatal intensive care unit (NICU), and were comparing any antiseptic solution (single or in combination) against any other type of antiseptic solution or no antiseptic solution or placebo in preparation for central catheter insertion. We excluded cross-over trials and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

We used the standard methods from Cochrane Neonatal. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included three trials that had two different comparisons: 2% chlorhexidine in 70% isopropyl alcohol (CHG-IPA) versus 10% povidone-iodine (PI) (two trials); and CHG-IPA versus 2% chlorhexidine in aqueous solution (CHG-A) (one trial). A total of 466 neonates from level III NICUs were evaluated. All included trials were at high risk of bias. The certainty of the evidence for the primary and some important secondary outcomes ranged from very low to moderate. There were no included trials that compared antiseptic skin solutions with no antiseptic solution or placebo. CHG-IPA versus 10% PI Compared to PI, CHG-IPA may result in little to no difference in CRBSI (risk ratio (RR) 1.32, 95% confidence interval (CI) 0.53 to 3.25; risk difference (RD) 0.01, 95% CI -0.03 to 0.06; 352 infants, 2 trials, low-certainty evidence) and all-cause mortality (RR 0.88, 95% CI 0.46 to 1.68; RD -0.01, 95% CI -0.08 to 0.06; 304 infants, 1 trial, low-certainty evidence). The evidence is very uncertain about the effect of CHG-IPA on CLABSI (RR 1.00, 95% CI 0.07 to 15.08; RD 0.00, 95% CI -0.11 to 0.11; 48 infants, 1 trial; very low-certainty evidence) and chemical burns (RR 1.04, 95% CI 0.24 to 4.48; RD 0.00, 95% CI -0.03 to 0.03; 352 infants, 2 trials, very low-certainty evidence), compared to PI. Based on a single trial, infants receiving CHG-IPA appeared less likely to develop thyroid dysfunction compared to PI (RR 0.05, 95% CI 0.00 to 0.85; RD -0.06, 95% CI -0.10 to -0.02; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 10 to 50; 304 infants). Neither of the two included trials assessed the outcome of premature central line removal or the proportion of infants or catheters with exit-site infection. CHG-IPA versus CHG-A The evidence suggests CHG-IPA may result in little to no difference in the rate of proven CRBSI when applied on the skin of neonates prior to central line insertion (RR 0.80, 95% CI 0.34 to 1.87; RD -0.05, 95% CI -0.22 to 0.13; 106 infants, 1 trial, low-certainty evidence) and CLABSI (RR 1.14, 95% CI 0.34 to 3.84; RD 0.02, 95% CI -0.12 to 0.15; 106 infants, 1 trial, low-certainty evidence), compared to CHG-A. Compared to CHG-A, CHG-IPA probably results in little to no difference in premature catheter removal (RR 0.91, 95% CI 0.26 to 3.19; RD -0.01, 95% CI -0.15 to 0.13; 106 infants, 1 trial, moderate-certainty evidence) and chemical burns (RR 0.98, 95% CI 0.47 to 2.03; RD -0.01, 95% CI -0.20 to 0.18; 114 infants, 1 trial, moderate-certainty evidence). No trial assessed the outcome of all-cause mortality and the proportion of infants or catheters with exit-site infection.

AUTHORS' CONCLUSIONS

Based on current evidence, compared to PI, CHG-IPA may result in little to no difference in CRBSI and mortality. The evidence is very uncertain about the effect of CHG-IPA on CLABSI and chemical burns. One trial showed a statistically significant increase in thyroid dysfunction with the use of PI compared to CHG-IPA. The evidence suggests CHG-IPA may result in little to no difference in the rate of proven CRBSI and CLABSI when applied on the skin of neonates prior to central line insertion. Compared to CHG-A, CHG-IPA probably results in little to no difference in chemical burns and premature catheter removal. Further trials that compare different antiseptic solutions are required, especially in low- and middle-income countries, before stronger conclusions can be made.

Preventable contributors to the neonatal healthcare-associated infections: a uni-center analytical study from South India

BACKGROUND

Globally, neonatal healthcare-associated infections (HAIs) are known to cause high mortality. HAIs is a preventable condition related to the healthcare environment. The current study explored the contributors to neonatal HAIs in one of the largest tertiary care referral hospitals in South India.

METHODS

Neonates from December 2016 to June 2018 were observed for the occurrence of healthcare-associated infections and compared with the matched control group. Various observations on neonatal demography, maternal contributors, and medical procedures were made and recorded to explore and analyse the contributors to neonatal HAIs. Univariate and multivariate analysis was carried out to find the contributors. The Odds ratio with 95% CI was also computed and reported.

RESULTS

Bloodstream infection (83%) was prevalent among neonates; the maternal contributor was only preterm labor (Odds ratio of 11.93; 95% CI; 6.47-21.98; p<.05) to acquire HAIs. On univariate analysis, mechanical ventilation for > 3days duration, NIV for > five days, and PICC line insertion procedure were significant (p<0.05) contributors to neonatal HAIs. IV cannulation for more than three times in four consecutive days was found in 100(85%) neonates considered being associated with neonatal HAIs. On multivariate analysis, NIV, PICC line, preterm labor, and low birth weight were significant (p<0.05) contributors to neonatal HAIs.

CONCLUSION

The increased duration of invasive and non-invasive therapeutic devices and catheters contributes to neonatal HAIs. Neonates are acquiring bloodstream infections; low birth weight (LBW) neonates are more susceptible to acquiring HAIs.

Essentials of Neonatal-Perinatal Medicine fellowship: part 2 - clinical education and experience

This is the second article in a seven-part series in the Journal of Perinatology that aims to critically examine the current state of Neonatal-Perinatal Medicine (NPM) fellowship training from the structure and administration of a program, to the clinical and scholarly requirements, and finally to the innovations and future careers awaiting successful graduates. This article focuses on the current clinical requirements; recent changes to the clinical environment and their effect on learning; and additional challenges and opportunities in clinical education.

Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review

BACKGROUND

Health care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements).

METHODS

Five electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively.

FINDINGS

3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control.

INTERPRETATION

The 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap.

FUNDING

This work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the "la Caixa" Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).

A clinical study on the tip localization of peripherally inserted central catheter (PICC) guided by intracavitary electrocardiography in newborns: a randomised trial

BACKGROUND

The present study aimed to investigate the P-wave changes in intracavitary electrocardiography (IC-ECG) during catheterization with a peripherally inserted central catheter (PICC) in order to provide guidance for the accurate localization of the tip of the PICC.

METHODS

A total of 106 newborns who needed a PICC were randomly divided into two groups-a study group and a control group-using a random number table, with 53 cases in each group. In the study group, the ECG monitor was connected after the successful puncture and insertion of the PICC into the right sternoclavicular joint, and the position of the catheter tip was determined according to the P-wave changes on the IC-ECG. Localization X-rays were taken at the same time. In the control group, after the successful routine puncture and insertion of the PICC into the location to a predetermined length, localization X-rays were taken. The accuracy, procedure duration, and cost of the two localization methods were evaluated.

RESULTS

The accuracy of the localization in the study group was 92.5%, but the difference was not significant when compared with the control group (P>0.05). The duration of the procedure in the study group was 5.12±1.57 minutes, and the cost was 7.12±0.56 yuan, both of which were significantly different when compared with the control group (P<0.05).

CONCLUSIONS

P-wave changes during IC-ECG have high accuracy in determining the location of the tip of the PICC. It is also a simple method and has certain clinical application value.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (number: ChiCTR2100047660).

Surgical site infection prevention bundle for children submitted to cardiac surgery

OBJECTIVE

To build and validate the content and appearance of a surgical site infection prevention bundle for children submitted to cardiac surgery.

METHOD

Methodological study in two phases: 1) Bundle construction from an integrative literature review from which interventions have been extracted to compose the instrument; 2) Bundle content and appearance validation by 24 judges.

RESULTS

The 24 found articles presented 17 interventions for surgical site infection prevention in this population. Out of them, seven intervention proposals have been chosen to compose the bundle and sent for assessment by judges. The final proposal includes all the seven items chosen in the construction phase and has achieved a content validity index over 0.8 in all items referring to content and appearance.

CONCLUSION

The content and appearance of the developed bundle proposes care for the prevention of surgical site infection throughout the perioperative period.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients

The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.

Methods

All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.

Results

We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.

Conclusions

Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Bundle para manuseio do cateter central de inserção periférica em neonatos

Resumo Objetivo Construir um bundle para prevenção de infecção primária da corrente sanguínea relacionada a cateter que contemple cuidados de enfermagem para manuseio do cateter de acesso venoso central por inserção periférica em neonatos. Métodos Pesquisa metodológica, desenvolvida no ano de 2017 em três etapas: levantamento bibliográfico, construção do instrumento e validação de conteúdo por cinco juízes. O instrumento para validação foi composto por 21 cuidados de enfermagem selecionados na primeira etapa. O índice de validade de conteúdo acima de 80% foi utilizado para avaliar a concordância entre os juízes, esta etapa foi realizada em uma única rodada. Resultados Dos 21 itens avaliados pelos juízes, dez foram excluídos por apresentarem índice de validade de conteúdo menor que 0,80 e três foram agrupados ao demais cuidados elencados. A versão final do bundle foi composta por oito itens. Os cuidados incluídos foram relacionados a higienização das mãos antes e após as manuseio, o uso de seringas com calibre adequado, troca e desinfecção das dânulas e dos conectores com álcool 70%, teste de permeabilidade e cuidados com curativos. Conclusão O estudo permitiu elaborar e validar junto a juízes um bundle para manuseio do cateter central de inserção periférica em neonatos com vistas a redução de infecção primária da corrente sanguínea relacionada ao cateter de acesso venoso central por inserção periférica.

Peripherally inserted central catheters in critically ill patients - complications and its prevention: A review

Peripherally inserted central catheter (PICC) is extensively used in critical care settings, because it plays a vital role in providing safe central venous entry. However, PICC is associated with several complications, which should be detected to shorten the duration of patients' improvement, reduce health care cost, and lessen the incidence of various PICC-related complications. Therefore, this study aimed to outline current literature on PICC procedures, potential complications, and measures for prevention. Understanding evidence-based guidelines regarding insertion technique, early detection of complications, and care bundle of PICC is significant in complication prevention. Implementation of education, training, and appropriate multidisciplinary approaches on PICC care among nurses and caregivers is the key to preventing complications. Thus, the strict care of indwelling PICC lines, the targeted and reasonable PICC-associated complication prevention, and nursing care have a major clinical significance in reducing the occurrence of potential PICC complications.

Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are associated with increased mortality, prolonged hospitalisation and increased healthcare costs. Care bundles have reduced CLABSIs in adult intensive care units (ICUs) but replication in paediatric ICUs has had inconsistent outcomes. A systematic review was performed to assess the evidence for the efficacy of care bundles in reducing CLABSIs in the neonatal unit (NNU).

METHODS

MEDLINE, CINAHL and EMBASE were searched from January 2010 up to January 2017. The Cochrane Library, Web of Science, Zetoc and Ethos were searched for additional studies. Randomised controlled trials (RCTs), quasi-experimental and observational studies were eligible. The primary outcome measure was CLABSI rates per 1000 central line, or patient, days. A meta-analysis was performed using random effects modelling.

RESULTS

Twenty-four studies were eligible for inclusion: six were performed in Europe, 12 were in North America, two in Australia and four were in low/middle-income countries. Five were observational studies and 19 were before and after quality improvement studies. No RCTs were found. Meta-analysis revealed a statistically significant reduction in CLABSIs following the introduction of care bundles (rate ratio=0.40 (CI 0.31 to 0.51), p<0.00001), which equates to a 60% reduction in CLABSI rate.

CONCLUSION

There is a substantial body of quasi-experimental evidence to suggest that care bundles may reduce CLABSI rates in the NNU, though it is not clear which bundle elements are effective in specific settings. Future research should focus on determining what processes promote the effective implementation of infection prevention recommendations, and which elements represent essential components of such care bundles.

Fatores de risco para infecção de corrente sanguínea associada ao cateter central de inserção periférica em neonatos

Resumo Objetivo Identificar os fatores de risco para infecção de corrente sanguínea associada ao cateter central de inserção periférica em neonatos. Métodos Estudo de coorte prospectivo conduzido em unidade de terapia intensiva com recém-nascidos submetidos à instalação de 401 cateteres centrais de inserção periférica. Características clínicas do neonato, técnica de inserção do cateter, terapia intravenosa e tempo de permanência do cateter foram testados como fatores de risco para remoção por infecção de corrente sanguínea associada ao cateter, por meio de análise bivariada e análise multivariada com regressão de Poisson. Resultados Os dados sugerem que as menores médias de peso e idade gestacional corrigida, bem como o maior tempo de permanência do cateter estiveram associados à ocorrência de infecção de corrente sanguínea associada ao cateter. A menor idade gestacional corrigida, os diagnósticos clínicos de transtorno transitório do metabolismo e apneia, e o uso do cateter de duas vias foram identificados como fatores de risco. Conclusão A menor idade gestacional corrigida do neonato, os diagnósticos clínicos de transtorno transitório do metabolismo e apneia, e o uso do cateter de duas vias foram identificados como fatores de risco para infecção de corrente sanguínea associada ao cateter central de inserção periférica em neonatos.