Infectious Complications of Central Venous Catheters Increase the Risk of Catheter-Related Thrombosis in Hematology Patients: A Prospective Study

Central Venous Catheter-associated Venous Thromboembolism in Children: A Prospective Observational Study

Our objective was to study the proportion of children developing Catheter-related thrombosis (CRT) following central venous Catheter (CVC) insertion and the risk factors of CRT in pediatric patients with CVC. One hundred four children aged 29 days to 18 years who had a percutaneous non-tunneled CVC inserted were enrolled. Ultrasonogram (USG) with venous Doppler scan was performed within 48 hours of CVC removal to diagnose CRT. The major indications for CVC insertion were surgical care 34 (32.6%) and ICU care 28(26.9%). The median age of the patients was 3 years, and 75% were males. The median number of CVC days was 10 (IQR 5.15). CRT was seen in 45(43.3%), of which 33 (73.3%) were asymptomatic. The rate of CRT was 35.69 cases per 1000 CVC days (95% CI 26.03-47.75). The number of days a catheter was in place and USG-guided catheter insertion was a significant risk factor. The multivariate logistic regression model showed that the duration of CVC in situ was independently associated with the development of CRT (OR, 1.06; 95% CI 1.0-1.1; P=0.02). CVC duration was a major risk factor for the development of CRT. There was a higher risk of developing a symptomatic CRT with central venous catheters than hemodialysis sheaths.

Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis

BACKGROUND

The risk factors for central venous access device-related thrombosis (CRT) in children are not fully understood. We used evidence-based medicine to find the risk factors for CRT by pooling current studies reporting risk factors of CRT, aiming to guide clinical diagnosis and treatment.

METHODS

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang databases was conducted. RevMan 5.4 was employed for data analysis.

RESULTS

The review included 47 studies evaluating 262,587 children with CVAD placement. Qualitative synthesis and quantitative meta-analysis identified D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection as the most critical risk factors for CRT. Primarily due to observational design, the quality of evidence was regarded as low certainty for these risk factors according to the GRADE approach.

CONCLUSION

Because fewer high-quality studies are available, larger sample sizes and well-designed prospective studies are still needed to clarify the risk factors affecting CRT. In the future, developing pediatric-specific CRT risk assessment tools is important. Appropriate stratified preventive strategies for CRT according to risk assessment level will help improve clinical efficiency, avoid the occurrence of CRT, and alleviate unnecessary suffering of children.

IMPACT

This is the latest systematic review of risk factors and incidence of CRT in children. A total of 47 studies involving 262,587 patients were included in our meta-analysis, according to which the pooled prevalence of CRT was 9.1%. This study identified several of the most critical risk factors affecting CRT in children, including D-dimer, insertion location, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection (CLABSI).

Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study

BACKGROUND

Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice's method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis.

RESULTS

Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000*cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000*cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed.

CONCLUSIONS

CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.

Effect of a Multifaceted Intervention on the Incidence of Hemodialysis Catheter Dysfunction in a National Stepped-Wedge Cluster Randomized Trial

Introduction

Effective strategies to prevent hemodialysis (HD) catheter dysfunction are lacking and there is wide variation in practice.

Methods

In this post hoc analysis of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a national (REDUCCTION) stepped-wedge cluster randomized trial, encompassing 37 Australian nephrology services, 6361 participants, and 9872 catheters, we investigated whether the trial intervention, which promoted a suite of evidence-based practices for HD catheter insertion and management, reduced the incidence of catheter dysfunction, which is defined by catheter removal due to inadequate dialysis blood flow. We also analyzed outcomes among tunneled cuffed catheters and sources of event variability.

Results

A total of 873 HD catheters were removed because of dysfunction over 1.12 million catheter days. The raw incidence was 0.91 events per 1000 catheter days during the baseline phase and 0.68 events per 1000 catheter days during the intervention phase. The service-wide incidence of catheter dysfunction was 33% lower during the intervention after adjustment for calendar time (incidence rate ratio = 0.67; 95% confidence interval [CI], 0.50-0.89; P = 0.006). Results were consistent among tunneled cuffed catheters (adjusted incidence rate ratio = 0.68; 95% CI, 0.49-0.94), which accounted for 75% of catheters (n = 7403), 97.4% of catheter exposure time and 88.2% of events (n = 770). Among tunneled catheters that survived for 6 months (21.5% of tunneled catheters), between 2% and 5% of the unexplained variation in the number of catheter dysfunction events was attributable to service-level differences, and 18% to 36% was attributable to patient-level differences.

Conclusion

Multifaceted interventions that promote evidence-based catheter care may prevent dysfunction, and patient factors are an important source of variation in events.

Venous thromboembolism in hematopoietic stem cell transplantation: A narrative review

Venous thromboembolism (VTE) is a common complication of hematopoietic stem cell transplantation (HSCT) and its treatment has significant effects on morbidity and non-relapse mortality. There is a complex interplay on balancing the risk for thrombosis and bleeding in these patients, making treatment decisions particularly challenging. Despite this, there are currently no validated risk assessment models or guidelines to aid clinical decision making on thromboprophylaxis and VTE treatment in this population of patients. Herein, we review the many risk factors for VTE in HSCT patients, categorized into patient, disease, catheter, treatment, laboratory, and transplant-related variables. This review also discusses current thromboprophylaxis and VTE management strategies in HSCT patients, with scope into the development of risk assessment models that allow for identification of high-risk subgroups who may benefit from targeted intervention.

Prevention and treatment of catheter-related venous thrombosis in long-term parenteral nutrition: A SINuC position statement

The implementation of long-term parenteral nutrition (PN) often requires the placement of central venous access, a procedure that carries a considerable risk of catheter-related venous thrombosis (CRT). The occurrence of CRT represents a major event in the natural history of patients in PN since it can lead to central venous access loss and PN failure. Despite the importance of this topic in clinical nutrition, the prevention and treatment of CRT in PN represents one of the "gray areas" of the literature of the presence of few randomized controlled clinical trials and the generally low level of evidence of published scientific papers. Through a narrative review of the literature and a Delphi consensus, the Italian Society of Clinical Nutrition and Metabolism (SINuC) aimed to collect some practical recommendations regarding the current state-of-the-art in the prevention, diagnosis, and treatment of CRT in patients undergoing long-term PN.

Central venous access device locking practices in the adult critical care setting: a single-centre, observational study establishing duration of locking per catheter lumen

PURPOSE

Central line complications remain a problem in critical care patient populations. Various interventions to prevent or treat complications, such as central line-associated bloodstream infection and occlusion, have been the focus of recent research. Although alternative catheter locking solutions have been shown to be effective in other patient populations, their applicability to the critical care setting remains unclear. Due to the high acuity of critical care patients, it is uncertain whether their central lines remain locked for a duration long enough for alternative locking solutions to provide any effect.

METHODS

This single-centre, prospective, observational study aimed to gather information about the length of time central line lumens remain in a locked state in the average critical care patient. Baseline rates of various central line complications were also tracked.

RESULTS

Results of this study indicate that the majority of central lines will have at least one lumen locked for an average of 36.6% of their time in situ.

CONCLUSIONS

It is anticipated that this length of time provides enough exposure for alternative locking solutions to potentially make a difference in central line complications in this patient population. Results of this study can be used for planning future multi-centre, randomized controlled trials investigating the efficacy of novel central line locking solutions to prevent central line complications in critically ill patients.

Hemocompatibility Multi-in-One Hydrogel Coating with ROS-Triggered Inflammation Suppression and Anti-Infection Properties for Blood-Contacting Device

In traditional blood-contacting medical devices, infection and thrombosis are easily formed on the surface of the materials. In addition, inflammation is also a clinical complication that cannot be ignored. More importantly, there is a mutually promoting relationship between the inflammatory response and the infection as well as thrombosis. In this work, we propose a self-adaptive anti-inflammatory coating strategy combined with anti-infection and anticoagulant capacity, which was accomplished based on nano-Ag particles and dexamethasone (Dex)-loaded hydrogel coating. The coating loaded with nano-Ag endows it with good bactericidal performance, including Gram-positive and Gram-negative bacteria. As an anti-inflammatory drug, Dex was grafted onto hydrogel coating by a reactive oxygen species (ROS)-cleavable thioketal (TK) bond and released upon the trigger of an inflammatory environment, blocking further inflammatory cascade, providing self-adaptive anti-inflammatory properties, and avoiding side effects of the drug. It was demonstrated that the coating worked as a precise strategy to resist coagulation, infection, and inflammation, provided a new perspective for designing clinical complication-conformable coatings, and had great application prospects on blood-contacting medical devices.

Management of pediatric intestinal failure related to short bowel syndrome

Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.

Reduction of perioperative venous thrombus formation by antithrombotic peripherally inserted central catheter in esophageal cancer

PURPOSE

Although a central venous catheter (CVC) is often needed perioperatively for intraoperative and nutritional management of esophageal cancer (EC), the catheter placement impacts the risk of venous thrombosis. We examined the risks of thrombus formation by catheter type, placement, and duration.

METHODS

In total, 226 patients with EC were enrolled in this retrospective study. Patients were classified into one of three groups: those with a conventional CVC (cCVC), a peripherally inserted central catheter (PICC), or an antithrombogenic agent-coated PICC (secPICC). The thrombus formation and clinicopathological features were examined.

RESULTS

The frequency of all types of thrombosis was significantly lower in the secPICC group (p < 0.01). Although deep vein thrombosis was frequent in the cCVC group, catheter thrombosis was frequent in the PICC group. In a univariate analysis in patients with the PICC and secPICC groups, less thrombus formation was observed in the secPICC (p = 0.01), short placement time (p = 0.02), and right-sided placement (p < 0.01). Furthermore, a multivariate analysis revealed that secPICC (p = 0.049) and right-sided placement (p = 0.04) significantly reduced rates of thrombus formation.

CONCLUSION

In patients with EC, secPICC and right-sided placement reduce perioperative venous thrombus formation.

Risk Factors for Catheter-Related Thrombosis in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation

Background and Objectives: Cancer associated thrombosis (CAT) is a common complication of neoplasms. Multiple myeloma (MM) carries one of the highest risks of CAT, especially in the early phases of treatment. Autologous stem cell transplantation (ASCT) as the standard of care in transplant-eligible patients with MM carries a risk of catheter-related thrombosis (CRT). The aim of this study was identification of the risk factors of CRT in MM patients undergoing ASCT in 2009–2019. Materials and Methods: We retrospectively analyzed patients with MM undergoing ASCT. Each patient had central venous catheter (CVC) insertion before the procedure. The clinical symptoms of CRT (edema, redness, pain in the CVC insertion area) were confirmed with Doppler ultrasound examination. We examined the impacts of four groups of factors on CRT development: (1) patient-related: age, gender, Body Mass Index (BMI), obesity, Charlson comorbidity index, hematopoietic stem cell transplantation comorbidity index, renal insufficiency, and previous thrombotic history; (2) disease-related: monoclonal protein type, stage of the disease according to Salmon–Durie and International Staging System, number of prior therapy lines, and MM response before ASCT; (3) treatment-related: melphalan dose, transplant-related complications, and duration of post-ASCT neutropenia; (4) CVC-related: location, time from placement to removal. Results: Symptomatic CRT was present in 2.5% (7/276) of patients. Univariate analysis showed an increased risk of CRT in patients with a catheter-related infection (OR 2.4, 95% CI; 1.109–5.19, p = 0.026), previous thrombotic episode (OR 2.49, 95% CI; 1.15–5.39, p = 0.021), previous thrombotic episode on initial myeloma treatment (OR 2.75, 95% CI; 1.15–6.53, p = 0.022), and gastrointestinal complications of ASCT such as vomiting and diarrhea (OR 3.87, 95% CI; 1.57–9.53, p = 0.003). In multivariate analysis, noninfectious complications were associated with higher CRT incidence (OR 2.75, 95% CI; 1.10–6.19, p = 0.031). Conclusions: The incidence of symptomatic CRT in ASCT in MM was relatively low. Previous thrombotic events, especially during the induction of myeloma treatment, increased CRT risk during ASCT. Dehydration following gastrointestinal complications may predispose to higher CRT incidence.

Cationic Alternating Polypeptide Fixed on Polyurethane at Multiple Sites for Excellent Antibacterial and Antifouling Properties

Bacterial infection and blockage are severe problems for polyurethane (PU) catheters and there is an urgent demand for surface-functionalized polyurethane. Herein, a cationic alternating copolymer comprising allyl-substituted ornithine and glycine (allyl-substituted poly(Orn-alter-Gly)) with abundant carbon-carbon double bond functional groups (C═C) is designed. Polyurethane is prepared with a large quantity of C═C groups (PU-D), and different amounts of allyl-substituted poly(Orn-alter-Gly) are grafted onto the PU-D surface (PU-D-2%AMPs and PU-D-20%AMPs) via the C═C functional groups. The chemical structures of the allyl-substituted poly(Orn-alter-Gly) and polyurethane samples (PU, PU-D, PU-D-2%AMPs, and PU-D-20%AMPs) are characterized and the results reveal that allyl-substituted poly(Orn-alter-Gly) is decorated on the polyurethane. PU-D-20%AMPs shows excellent antibacterial activity against Escherichia coli, Enterococcus faecalis, and Staphylococcus aureus because of the high surface potential caused by cationic allyl-substituted poly(Orn-alter-Gly), and it also exhibits excellent long-term antibacterial activity and antibiofilm properties. PU-D-20%AMPs also has excellent antifouling properties because the cationic copolymer is fixed at multiple reactive sites, thus avoiding the formation of movable long chain brush. A strong surface hydration barrier is also formed to prevent adsorption of proteins and ions, and in vivo experiments reveal excellent biocompatibility. This flexible strategy to prepare dual-functional polyurethane surfaces with antibacterial and antifouling properties has large potential in biomedical implants.

Temporal and anatomic relationship between superficial and deep vein thromboses in hospitalized children

BACKGROUND

Recent publications have increasingly demonstrated a link between superficial-vein thrombosis (SVT) and deep-vein thrombosis (DVT) in the adult population and have led to changes in SVT treatment considerations. A similar relationship between SVT and DVT in pediatric populations, however, is not currently well established.

OBJECTIVES

We sought to evaluate the temporal and anatomic relationship between SVT and DVT among pediatric inpatients in order to determine to what degree SVT is associated with DVT.

METHODS

We first retrospectively reviewed our institution's local prospective hospital-acquired VTE (HA-VTE) registry to identify all children (age 0-21 years, inclusive) admitted to Children's Hospital Colorado for more than 48 h between January 2012 and September 2017 who developed a DVT while hospitalized. We then reviewed each patient's electronic health record for evidence of SVT to identify SVT + DVT cases. Afterwards, we utilized a list of ICD codes to identify all patients during this time frame who developed an SVT and removed patients whom we previously identified as SVT + DVT cases to obtain the number of patients with isolated SVT.

RESULTS

Of 59,910 patients admitted during the study period, 438 (0.7%) developed a thrombosis while hospitalized - 197 (0.3%) with isolated SVT, 161 (0.3%) with isolated DVT, and 80 (0.1%) with both SVT + DVT. These 80 SVT + DVT patients represent 33% of the 241 total DVT patients and 29% of the 277 total SVT patients. Of the 12 SVT + DVT patients in whom the SVT was diagnosed before the DVT, the subsequent DVT occurred within a mean of 6.4 (range 1-22) days and at the same anatomic site in 6 (50%). The age breakdown for this cohort was: 0 (0%) 0-1 months, 2 (17%) 1 month-2 years, 3 (25%) 2-12 years, 3 (25%) 12-16 years, and 4 (33%) 16-21 years.

CONCLUSIONS

Our results indicate a temporal and anatomic relationship between SVT and DVT in hospitalized children, particularly those with central venous catheters.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures

BACKGROUND

Children frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear.

METHODS

Children undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI.

RESULTS

Of 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d.

CONCLUSIONS

The type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

Early prophylaxis of central venous catheter-related thrombosis using 1% chlorhexidine gluconate and chlorhexidine-gel-impregnated dressings: a retrospective cohort study

To determine the prophylactic effect of using combined 1% alcoholic chlorhexidine gluconate and chlorhexidine gel-impregnated dressings (CGCD) on catheter-related thrombosis (CRT) in critically ill patients. This retrospective cohort study was performed in an intensive care unit from November 2009 to August 2014. The CRT incidence diagnosed with ultrasound examination was compared between patients applying CGCD and combined 10% aqueous povidone-iodine and standard transparent dressings (PITD) after central venous catheter insertion into the internal jugular vein for ≥ 48 h. CRT was stratified into early (within 7 days) and late (days 8-14) thromboses. Multivariate analyses using logistic regression models clarified the relationships between early- and late-CRT risks and skin antiseptic and catheter site dressing combinations. CRT occurred in 74 of 134 patients (55%), including 52 with early CRT and 22 with late CRT. Patients receiving CGCD had a significantly lower incidence of early CRT than those receiving PITD (odds ratio = 0.18; 95% confidence interval = 0.07-0.45, p  < .001). No significant association was evident between using CGCD and late CRT (p  = .514). Compared to PITD, CGCD reduced the CRT risk over 7 days in critically ill patients.UMIN Clinical Trials Registry: UMIN000037492.

Minimising Blood Stream Infection: Developing New Materials for Intravascular Catheters

Catheter related blood stream infection is an ever present hazard for those patients requiring venous access and particularly for those requiring long term medication. The implementation of more rigorous care bundles and greater adherence to aseptic techniques have yielded substantial reductions in infection rates but the latter is still far from acceptable and continues to place a heavy burden on patients and healthcare providers. While advances in engineering design and the arrival of functional materials hold considerable promise for the development of a new generation of catheters, many challenges remain. The aim of this review is to identify the issues that presently impact catheter performance and provide a critical evaluation of the design considerations that are emerging in the pursuit of these new catheter systems.

Jugular venous catheter-associated thrombosis and fatal pulmonary embolism: A case report

INTRODUCTION

Central venous catheters related thrombosis (CRT) insertion has been shown to increase the risk of venous thromboembolism, particularly pulmonary embolism (PE). Nevertheless, deaths cased due to PE have been rarely reported.

PATIENT CONCERNS

A central venous catheter was introduced through the right jugular vein during the operation due to severe septic shock from a 57-year-old male patient. Two days after surgery, the hemodynamics was stable. On the 7th day, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest, and received emergency cardiopulmonary resuscitation.

DIAGNOSIS

Jugular venous catheter-associated thrombosis and fatal PE. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein. The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle, widened and fixed inferior vena cava, and no variation with respiration. Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased. Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing "D" sign. Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased.

INTERVENTIONS

One and a half million units of urokinase were immediately given trough intravenous drip.

OUTCOMES

Twenty minutes after thrombolysis, the patient's autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later.

CONCLUSION

Recent clinical practice guidelines recommend against the routine use of any anticoagulant thromboprophylaxis in patients with central venous catheters, but for patients at particularly high risk for CRT, consideration can be given to using higher doses of anticoagulant as prophylaxis, although there are virtually no data to support this approach.

Lewitus D. The Grafting of Multifunctional Antithrombogenic Chemical Networks on Polyurethane Intravascular Catheters

Intravascular catheters (IVCs) and other medical tubing are commonly made of polymeric materials such as polyurethane (PU). Polymers tend to be fouled by surface absorption of proteins and platelets, often resulting in the development of bacterial infections and thrombosis during catheterization, which can lead to embolism and death. Existing solutions to fouling are based on coating the IVCs with hydrophilic, anti-thrombogenic, or antimicrobial materials. However, the delamination of the coatings themselves is associated with significant morbidity, as reported by the United States Food and Drug Administration (FDA). We developed a lubricious, antimicrobial, and antithrombogenic coating complex, which can be covalently attached to the surface of industrial PU catheters. The coating complex is pre-synthesized and comprises 2-methacryloyloxyethyl phosphorylcholine (MPC) as an antifouling agent, covalently attached to branched polyethyleneimine (bPEI) as a lubricating agent. The two-step coating procedure involves PU-amine surface activation using a diisocyanate, followed by chemical grafting of the bPEI-S-MPC complex. Compared with neat PU, the coating was found to reduce the coefficient of friction of the IVC surface by 30% and the hemolysis ratio by more than 50%. Moreover, the coating exhibited a significant antimicrobial activity under JIS Z2801:2000 standard compared with neat PU. Finally, in in-vivo acute rabbit model studies, the coating exhibited significant antithrombogenic properties, reducing the thrombogenic potential to a score of 1.3 on coated surfaces compared with 3.3 on uncoated surfaces. The materials and process developed could confer lubricious, antithrombogenic, and antimicrobial properties on pre-existing PU-based catheters.

The incidence and management of complications of venous access in home parenteral nutrition (HPN): A 19 year longitudinal cohort series

BACKGROUNDS AND AIMS

Long term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI). This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access.

METHODS

HPN data were analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days' distributions. Data were not normally distributed and so non-parametric tests were used. Spearman's Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used two sample t-tests to compare the groups.

RESULTS

From 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n = 16) was associated with total time on HPN (r² = 0.187, P < 0.05) and the number of infections (r² = 0.207, P < 0.05). Damage was strongly associated with increasing time on HPN with (r² of 0.494 and P < 0.005). Blockage was not associated with any patient or catheter factors. Overall catheter salvage rate for CRBSI by antibiotic treatment was 61.87%. Success varied according to organism cultured. Catheter salvage was less successful in other complications and overall catheter salvage rate was 41,115 catheters were salvaged from 282 complications.

CONCLUSIONS

This study has provided a baseline for rates of less common venous access complications in HPN and their management. Catheter salvage is possible after at least 41% of complications. It is likely that experience is helpful whether that of individual patient, the team or a clinical network. Our results support the use of smaller central venous catheters, in upper body veins, and the use of Taurolock-Hep100 in patients who have recurrent infections.

Venous thromboembolism in cancer patients: Still looking for answers

Patients with cancer-associated venous thromboembolism (VTE) represent a real challenge in clinical practice. Patients with cancer have a greater risk both of VTE and bleeding. There are only a few studies regarding the therapeutic approach of VTE in patients with cancer, especially after cancer surgery, and on thromboprophylaxis during chemotherapy. Many of the anticoagulation therapy recommendations for cancer patients are extrapolated from trials that are not conducted in cancer cohorts. It is essential to assess the efficacy and safety of VTE prophylaxis in this particular subgroup, which bears higher risks both of VTE recurrence and major hemorrhagic events. The introduction of direct oral anticoagulants in everyday practice represented a major evolution of the anticoagulant treatment. Direct anticoagulants could represent a more appealing alternative to low-molecular-weight heparin in paraneoplastic venous thrombosis, due to the patient comfort, easy administration of the drug and emerging studies that prove similar efficacy and safety as the standard treatment. However, there is limited data on the treatment with direct oral anticoagulants in patients with paraneoplastic venous thromboembolism.

Comparing Incidence of Thrombosis in PICC and Midlines and Evaluating the Role of Anticoagulation, Site of Insertion, and Risk Factors

New practice models are in demand for prevention and reduction in rates of catheter thrombosis that can be devastating to the health care system and patients Risk factors for catheter thrombosis were analyzed retrospectively for their impact Site of insertion and overall use of anticoagulation at the time of catheter placement did not show any significant impact on incidence of thrombosis Several variables (i.e., triple lumen, critically ill) were used to create a clinical prediction score model

Blood coagulation response and bacterial adhesion to biomimetic polyurethane biomaterials prepared with surface texturing and nitric oxide release

A dual functional polyurethane (PU) film that mimics aspects of blood vessel inner surfaces by combining surface texturing and nitric oxide (NO) release was fabricated through a soft lithography two-stage replication process. The fabrication of submicron textures on the polymer surface was followed by solvent impregnation with the NO donor, S-nitroso-N-acetylpenicillamine (SNAP). An in vitro plasma coagulation assay showed that the biomimetic surface significantly increased the plasma coagulation time and also exhibited reduced platelet adhesion and activation, thereby reducing the risk of blood coagulation and thrombosis. A contact activation assay for coagulation factor XII (FXII) demonstrated that both NO release and surface texturing also reduced FXII contact activation, which contributes to the inhibition of plasma coagulation. The biomimetic surface was also evaluated for bacterial adhesion in plasma and results demonstrate that this combined strategy enables a synergistic effect to reduce bacterial adhesion of Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas aeruginosa microorganisms. The results strongly suggest that the biomimetic modification with surface texturing and NO release provides an effective approach to improve the biocompatibility of polymeric materials in combating thrombosis and microbial infection. STATEMENT OF SIGNIFICANCE: (1) Developed a dual functional polyurethane (PU) film that mimics blood vessel inner surface by combining surface texturing and nitric oxide (NO) release for combatting biomaterial associated thrombosis and microbial infection. (2) Studied the blood coagulation response and bacterial adhesion to such biomimetic PU surfaces, and demonstrated that the combination of surface texturing and NO release synergistically reduced the platelet adhesion and bacterial adhesion in plasma, providing an effective approach to improve the biocompatibility of biomaterials used in blood-contacting medical devices. (3) The NO releasing surface significantly inhibits the plasma coagulation via the reduction of contact activation of FXII, indicating the multifunctional roles of NO in improving the biocompatibility of biomaterials in blood-contacting medical devices.

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.

Accepted but Unacceptable: Peripheral IV Catheter Failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Etiology and Management of Upper-Extremity Catheter-Related Thrombosis in Cancer Patients

Central venous access devices are a critical instrument in the treatment and supportive care delivery for oncology patients. Catheter-related thrombosis (CRT) is a common complication of central venous access devices in oncology patients. Risk factors for CRT include patient-, device-, and treatment-related risk factors. Treatment of CRT is indicated to reduce symptoms, prevent catheter malfunction, prevent recurrent DVT or thromboembolic pulmonary embolism, and minimize the risk of post-thrombotic syndrome. Minimal prospective data exist on the prevention and treatment of catheter-related thromboses in cancer patients. As such recommendations largely are derived from data in the lower-extremity DVT and PE studies in cancer and non-cancer patients. Based on the available literature, primary pharmacologic prophylaxis against CRT is not recommended in cancer patients. Treatment options for CRT include catheter removal, anticoagulation, catheter-directed thrombolysis, or surgical thrombectomy. Current evidence-based guidelines recommend LMWH as the anticoagulant of choice. However, recent data showing efficacy and safety of DOACs in cancer-related VTE may be extrapolated to treatment of CRT in cancer patients. In patients with CRT, catheter removal should be pursued if continued vascular access is no longer needed, the catheter is dysfunctional, a catheter-associated infection is present, or if CRT symptoms do not resolve with anticoagulation alone. Catheter-directed thrombolysis is reserved for rare severe cases of CRT. Herein we discuss the pathophysiology, clinical presentation, diagnosis, and general management of CRT in cancer patients.

Incidence and outcomes of catheter related thrombosis (CRT) in patients with acute leukemia using a platelet-adjusted low molecular weight heparin regimen

Patients with acute leukemia frequently develop catheter-related thrombosis (CRT) despite concurrent thrombocytopenia. The incidence, treatment and outcomes of this complication are poorly documented. We undertook this study to determine the incidence of CRT in patients with acute leukemia and assess the safety and effectiveness of a treatment strategy using a platelet-adjusted low molecular weight heparin (LMWH) dosing protocol. Patients (18 years and older) with newly diagnosed acute leukemia from January 2014 to December 2015 who received central venous catheters were included. The clinical data were reviewed up to 12 months from acute leukemia diagnosis to capture objectively documented CRT events. The outcome events including recurrent venous thromboembolism (VTE), bleeding events, infectious or mechanical complications, and death were reported up to 3 months from the time of CRT diagnosis. The incidence of CRT among 214 patients was 10.7% (23 patients) in the first 12 months after acute leukemia diagnosis. Among 18 patients who were treated with anticoagulation, 14 (78%) received reduced LMWH dosing due to concurrent thrombocytopenia. There were no recurrent VTE episodes, but 3 patients experienced bleeding events while on anticoagulation. Fifteen patients (83%) completed a minimum of 3 months anticoagulation. Twelve patients (52%) experienced an infectious complication, which was the main reason for catheter removal. Deaths occurred in 2 patients, related to underlying acute leukemia during 3 months period following CRT. Symptomatic CRT is frequent in patients with acute leukemia. Platelet-adjusted LMWH dosing may be effective and well tolerated despite thrombocytopenia.

Antimicrobial Efficacy of a New Chlorhexidine-based Device Against Staphylococcus aureus Colonization of Venous Catheters

Vascular catheters are a major cause of nosocomial bloodstream infections. ChloraLock (ATTWILL Medical Solutions, Inc, West Jordan, UT, and ICU Medical, Inc, San Clemente, CA) is a novel antimicrobial device containing chlorhexidine digluconate (CHG) that is fitted onto a syringe and infuses CHG into the catheter lumen during locking. The objective of this study was to evaluate the antimicrobial efficacy of ChloraLock with in vitro tests and its ability to reduce Staphylococcus aureus contamination of catheters in the external jugular veins of Yorkshire swine. ChloraLock significantly reduced the bacterial load in the in vitro tests by up to 6 log₁₀ colony-forming units (CFU) and by 3 to 4 log₁₀ CFU/lumen in vivo in a swine model with 0.9% NaCl catheter locks.

Implantable Device-Related Infection

Over half of the nearly two million healthcare-associated infections can be attributed to indwelling medical devices. In this review, we highlight the difficulty in diagnosing implantable device-related infection and how this leads to a likely underestimate of the prevalence. We then provide a length-scale conceptualization of device-related infection pathogenesis. Within this conceptualization we focus specifically on biofilm formation and the role of host immune and coagulation systems. Using this framework, we describe how current and developing preventative strategies target specific processes along the entire length-scale. In light of the significant time horizon for the development and translation of new preventative technologies, we also emphasize the need for parallel development of in situ treatment strategies. Specific examples of both preventative and treatment strategies and how they align with the length-scale conceptualization are described.

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter-Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center

BACKGROUND/AIMS

Catheter-related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk.

METHODS

All patients with IF discharged with HPN from 1970-2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days.

RESULTS

The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter-related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter-related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018).

CONCLUSION

Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.

Diagnosis and management of upper extremity deep-vein thrombosis in adults

Upper extremity deep-vein thrombosis (UEDVT) is common and can cause important complications, including pulmonary embolism and post-thrombotic syndrome. An increase in the use of central venous catheters, particularly peripherally inserted central catheters has been associated with an increasing rate of disease. Accurate diagnosis is essential to guide management, but there are limitations to the available evidence for available diagnostic tests. Anticoagulation is the mainstay of therapy, but interventional treatments may be considered in select situations. The risk of UEDVT may be reduced by more careful selection of patients who receive central venous catheters and by use of smaller catheters. Herein we review the diagnosis, management and prevention of UEDVT. Due to paucity of research, some principles are drawn from studies of lower extremity DVT. We present a practical approach to diagnosing the patient with suspected deep-vein thrombosis of the upper extremity.

How I treat central venous access device-related upper extremity deep vein thrombosis

Central venous access device (CVAD)-related thrombosis (CRT) is a common complication among patients requiring central venous access as part of their medical care. Complications of CRT include pulmonary embolism, recurrent deep venous thrombosis, loss of central venous access, and postthrombotic syndrome. Patient-, device-, and treatment-related factors can influence the risk of CRT. Despite numerous randomized controlled trials, the clinical benefit of pharmacologic thromboprophylaxis for the prevention of CRT remains to be established. Therefore, minimizing patient exposure to known risk factors is the best available approach to prevent CRT. Venous duplex is recommended for the diagnosis of CRT. Anticoagulation for at least 3 months or the duration of the indwelling CVAD is recommended for treatment of CRT. Thrombolysis should be considered for patients at low risk for bleeding who have limb-threatening thrombosis or whose symptoms fail to resolve with adequate anticoagulation. CVAD removal should be consider for patients with bacteremia, persistent symptoms despite anticoagulation, and if the CVAD is no longer needed. Superior vena cava filters should be avoided. Prospective studies are needed to define the optimal management of patients with or at risk for CRT.

Twenty-five Years of Advances in Vascular Access: Bridging Research to Clinical Practice

Vascular access has become a key component for a multitude of IV therapies, including parenteral nutrition. Access of the central venous system has been long recognized for its associated complications of infection, thrombosis, and occlusion. Over the past 25 years, clinical practice based on research and innovation has attempted to decrease complication rates and therefore improve the safety of vascular access. This article highlights the research and its influence on catheter care procedures, technology, and education that has led to advances in vascular access. An improved understanding of the pathophysiology associated with catheter-related complications and an ongoing evaluation of new treatment modalities has provided clinicians today with new options for improved patient care and the ability to preserve vascular access options for patients.

Surface modification strategies for combating catheter-related complications: recent advances and challenges

This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.

Accepted but unacceptable: peripheral IV catheter failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Incidence and risk factors of superficial and deep vein thrombosis associated with peripherally inserted central catheters in children

Essentials Pediatric studies on peripherally inserted central catheter (PICC)-related thrombosis are scarce. This study analyzes incidence and risk factors for PICC-related venous thrombosis in children. PICC-related thrombosis is a common, and nearly always, asymptomatic complication. Echo-guided insertion and a catheter to vein ratio < 0.33 may notably decrease this complication.

SUMMARY

Background Upper-extremity venous thrombosis is associated with the use of peripherally inserted central catheters (PICCs). Few pediatric studies have focused on this issue. Objectives To determine the incidence and risk factors for PICC-related superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) in children. Patients/methods An observational follow-up cohort study was conducted at a single hospital between June 2012 and June 2015. All patients receiving a PICC were enrolled and followed up, with weekly Doppler ultrasound examination of the catheterized limb until PICC removal. Patient, procedural and follow-up data were analyzed. Results In the study period, 265 PICCs were inserted (median age of patients 6.5 years, interquartile range [IQR] 2.4-13 years; median weight 20 kg, IQR 11-38 kg; 54% males; 67.9% chronically ill), and patients were followed up for a total of 9743 days. The median indwelling time was 21 days (IQR 12-37 days). During follow-up, 88 (33.2% of insertions) PICC-related thromboses (incidence rate [IR] 9.03 per 1000 catheter-days) were diagnosed, 66 (24.9%) as isolated SVT, seven (2.6%) as isolated DVT, and 15 (5.7%) as SVT with associated DVT (IR 6.78, 0.71 and 1.54 per 1000 catheter-days, respectively). Only 9.9% of patients with SVT and 18.2% of those with DVT were symptomatic. The main risk factors for PICC-related SVT and DVT were a catheter/vein ratio of > 0.33 and thrombosis of the catheterized superficial vein, respectively. Conclusions PICC-related thrombosis is a common and nearly always asymptomatic complication in children, the SVT rate being approximately three times higher than the DVT rate. Optimal vein and catheter selection, yielding the lowest possible catheter/vein ratio, may decrease the rate of PICC-related thrombosis.

Incidence of catheter-related thrombosis in acute leukemia patients: a comparative, retrospective study of the safety of peripherally inserted vs. centrally inserted central venous catheters

Central venous catheters are a leading cause of upper-extremity deep vein thrombosis. Concomitant severe thrombocytopenia makes anticoagulation for catheter-related thrombosis (CRT) in patients with acute leukemia (AL) a challenge. Incidence of CRT has been reported to be increased in those with peripherally inserted central catheters (PICC) vs. those with centrally inserted ones (CICC). Our objective is to compare the incidence rate of CRT in leukemia inpatients who received either a PICC vs. CICC. We retrospectively reviewed adult inpatients admitted to hematology wards with a new diagnosis of AL and who received either a PICC or a CICC. Baseline patient and catheter characteristics were recorded. Our primary outcome was the incidence rate of CRT in each group. The secondary outcomes included rates of infectious and mechanical complications. Six hundred sixty-three patients received at least one PICC (338) or CICC (325) insertion. A total of 1331 insertions were recorded, with 82 (11.7 %) and 41 (6.5 %) CRT in the PICC and CICC groups, respectively. The incidence rates were 1.89 and 0.52 per 1000 catheter day in the PICC and CICC groups, respectively. A PICC, when compared to CICC, was a significant risk factor for CRT (sHR 2.5, p < 0.0001). The prevalence and incidence rates of CRT in our AL patients were higher than predicted for a general cancer patient population. These rates were higher in the PICC group compared to the CICC group. We recommend careful consideration of thrombotic and bleeding risks of AL inpatients when choosing a central venous catheter.

Risk factors associated with catheter-related upper extremity deep vein thrombosis in patients with peripherally inserted central venous catheters: a prospective observational cohort study: part 2

This is the second part of a 2-part series that reports on the results of a prospective observational cohort study designed to examine risk factors associated with symptomatic upper extremity deep vein thrombosis (UEDVT) in patients with peripherally inserted central catheters (PICCs). Part 1, published in the May/June 2014 issue of the Journal of Infusion Nursing, provided an extensive review and critique of the literature regarding risk factors associated with catheter-related UEDVT and identified 28 suspected risk factors. A study was undertaken to examine each of the risk factors among 203 acute care patients with PICCs, 13 of whom experienced a UEDVT, yielding an incidence of 6.4%. The most common reason for admission was infection (33.5%), and the primary reason for insertion of the PICC was venous access (58.6%). Hypertension (P = .022) and obesity (P = .008), defined as a body mass index ≥30, were associated with UEDVT. The clinical symptoms of edema (P < .001) and a 3-cm or more increase in arm circumference (P < .001) in the PICC arm after PICC placement were associated with UEDVT. All other variables were not statistically significant. The results suggest that patients who are obese and hypertensive may be at greater risk for the development of UEDVT and that the physical finding of edema and increased arm circumference in the PICC arm are possibly suggestive of UEDVT.

Central venous thrombosis in children with intestinal failure on long-term parenteral nutrition

PURPOSE

Central venous thrombosis (CVT) is a serious complication of long-term central venous access for parenteral nutrition (PN) in children with intestinal failure (IF). We reviewed thse incidence of CVT and possible risk factors.

METHODS

Children with IF on home PN (2010-2014) with central venous imaging were reviewed. Patient demographics, catheter characteristics and related complications, and markers of liver function were compared between children with and without CVT. Serum thrombophilia markers were reviewed for patients with CVT.

RESULTS

Thirty children with central venous imaging were included. Seventeen patients had thrombosis of ≥1 central vein, and twelve had ≥2 thrombosed central veins. Patients with and without CVT had similar demographics and catheter characteristics. Patients with CVT had a significantly lower albumin level (2.76±0.38g/dL vs. 3.12±0.41g/dL, p=0.0223). The most common markers of thrombophilia in children with CVT were antithrombin, protein C and S deficiencies, and elevated factor VIII. There was a statistically significant correlation between a combined protein C and S deficiency and having >1 CVT.

CONCLUSIONS

Children with IF on long-term PN are at high risk for CVT potentially owing to low levels of natural anticoagulant proteins and elevated factor FVIII activity, likely a reflection of liver insufficiency and chronic inflammation.

Presentation and impact of catheter-associated thrombosis in patients with infected long-term central venous catheters: a prospective bicentric observational study

BACKGROUND

Catheter-associated thrombosis (CAT) in patients with infected long-term central venous catheter (LTCVC) has been poorly studied.

METHODS

We prospectively included patients with infected LTCVC and collected clinical data. Doppler ultrasound was systematically performed to screen for CAT. Outcome (death or infection relapse) was evaluated 12 weeks after infection diagnosis.

RESULTS

90 patients were included and CAT was diagnosed in 27 (30%). Local signs suggesting infection were more frequent in patients with CAT than without (11/27 versus 8/63, p = 0.03). Outcome was similar in patients with and without CAT. However, median duration of antimicrobials was longer (18 versus 14 days, p = 0.02), catheter removal tended to be more frequent (24/27 versus 46/63, p = 0.08), and anticoagulant therapy more often prescribed (17/27 versus 6/63, p < 0.01) in patients with CAT than without. Patients with occlusive thrombosis were more likely to have Staphylococcus aureus infections (4/7 versus 1/17, p = 0.02) and prolonged positivity of blood-cultures (3/7 versus 1/15, p = 0.02), than patients with non-occlusive thrombosis.

CONCLUSION

CAT is associated with local signs suggesting infection. A more aggressive treatment in CAT cases allowed a similar outcome at 12 weeks between patients with and without CAT. Occlusive thrombosis represented a subgroup of patients at risk of delayed clearance of bacteremia.