Outcomes of peripherally inserted double lumen central catheter in very low birth weight infants

Co-administration of Intravenous Drugs: Rapidly Troubleshooting the Solid Form Composition of a Precipitate in a Multi-drug Mixture Using On-Site Raman Spectroscopy

Intravenous drugs are often co-administrated in the same intravenous catheter line due to which compatibility issues, such as complex precipitation processes in the catheter line, may occur. A well-known example that led to several neonatal deaths is the precipitation due to co-administration of ceftriaxone- and calcium-containing solutions. The current study is exploring the applicability of Raman spectroscopy for testing intravenous drug compatibility in hospital settings. The precipitation of ceftriaxone calcium was used as a model system and explored in several multi-drug mixtures containing both structurally similar and clinically relevant drugs for co-infusion. Equal molar concentrations of solutions containing ceftriaxone and calcium chloride dihydrate were mixed with solutions of cefotaxime, ampicillin, paracetamol, and metoclopramide. The precipitate formed was collected as an "unknown" material, dried, and analyzed. Several solid-state analytical methods, including X-ray powder diffraction, Raman spectroscopy, and thermogravimetric analysis, were used to characterize the precipitate. Raman microscopy was used to investigate the identity of single sub-visual particles precipitated from a mixture of ceftriaxone, cefotaxime, and calcium chloride. X-ray powder diffraction suggested that the precipitate was partially crystalline; however, the identity of the solid form of the precipitate could not be confirmed with this standard method. Raman spectroscopy combined with multi-variate analyses (principal component analysis and soft independent modelling class analogy) enabled the correct detection and identification of the precipitate as ceftriaxone calcium. Raman microscopy enabled the identification of ceftriaxone calcium single particles of sub-visual size (around 25 μm), which is in the size range that may occlude capillaries. This study indicates that Raman spectroscopy is a promising approach for supporting clinical decisions and especially for compatibility assessments of drug infusions in hospital settings.

Frequently acquired drugs in neonatal intensive care and their physical compatibility

AIM

Incompatibility of intravenous drugs is dangerous and therefore undesirable. The aim of this study was to identify the most commonly acquired intravenous drugs in five neonatal intensive care units and test these for compatibility.

METHODS

The most frequently acquired drugs in five key hospitals in the South-Eastern district of Norway for 2019 and 2020 served as a proxy for the prevalence of use. Representatives were selected from the three most prevalent groups based on the Anatomical Therapeutic Chemical classification system. Co-administration of drug pairs was simulated using clinically relevant concentrations and infusion rates representing mixing ratios in the catheter. Particle formation was assessed by particle counting and size measurement, by visual examination using Tyndall beam, by turbidity and by measuring pH of mixed samples.

RESULTS

The most frequently acquired drug groups were anti-infectives, neurological agents and cardiovascular drugs. Compatibility testing revealed that both ampicillin and benzylpenicillin were incompatible with morphine. Flecainide and fluconazole showed no signs of incompatibility with morphine. No information on these combinations in a neonatal-relevant setting is available.

CONCLUSION

We recommend to abstain from co-administering ampicillin and benzylpenicillin with morphine in neonatal intensive settings. Morphine co-administered with flecainide and fluconazole in neonatal patients were evaluated as safe.

Central Subclavian Catheterization in Newborns: Single-Center Experience

Our main aim of this article was to show that central venous catheter (CVC) can be an easy-to-use, less-complicated catheter application such as peripherally inserted central catheter and umbilical catheter placement in the neonatal intensive care unit. We here described our experience with subclavian vein catheterization. Neonates who had venous access through subclavian central catheterization were assessed retrospectively. Data such as gestational age, age at the time of catheter insertion, birth weight, and gender were collected. In addition, problems related to catheterization during hospitalization were documented. This study comprised 40 newborns, 22 male and 18 female, with a mean gestational week of 29.57 ± 3.80 weeks and a mean gestational weight of 2067.50 ± 545.97 g. Due to occlusion, catheters were switched in five cases twice and in three cases once, totaling 53 catheterizations on 40 newborns. None of our patients had pneumothorax or hemothorax. On the postoperative 8th and 21st days, the catheter was withdrawn due to catheter infection in two (5%) patients, and catheter cultures revealed coagulase negative Staphylococcus aureus in both cases. Even in preterm infants, subclavian central venous catheterization is a safe and straightforward technique of gaining venous access in expert hands in the neonatal intensive care unit.

Co-administration of drugs with parenteral nutrition in the neonatal intensive care unit-physical compatibility between three components

There is a lack of compatibility data for intravenous therapy to neonatal intensive care unit (NICU) patients, and the purpose of this study was to contribute with documented physical compatibility data to ensure safe co-administration. We selected Numeta G13E, the 3-in-1 parenteral nutrition (PN) used at our NICU, together with the frequently used drugs morphine, dopamine and cefotaxime in two- but also three-component combinations. Incompatibility may lead to particle formation (precipitation) and oil-droplet growth (emulsion destabilisation), both which are undesirable and pose a safety risk to already unstable patients. We assessed potential particle formation of three mixing ratios for each combination (always including 1 + 1 ratio) using light obscuration, turbidity and pH measurements combined with visual inspection by focused Tyndall beam. Potential droplet-growth and emulsion destabilisation was assessed by estimating PFAT5 from droplet size measurements and counts, mean droplet diameter and polydispersity index from dynamic light scattering, and pH measurements. Mixed samples were always compared to unmixed controls to capture changes as a result of mixing and samples were analysed directly after mixing and after 4 h to simulate long contact time. None of the samples showed any sign of precipitation, neither in the drug-drug nor in the two- or three-component mixture with PN. Neither did we detect any form of emulsion destabilisation.

CONCLUSION

Dopamine, morphine and cefotaxime were found to be compatible with NumetaG13E, and it is safe to co-administer these drugs together with this PN in NICU patients.

WHAT IS KNOWN

• The need for co-administration of drugs and complex PN admixtures occurs frequently in NICU due to limited venous access. • Available compatibility data are scarce and for combinations of more than two components non-existent.

WHAT IS NEW

• Here we report physical compatibility data of two- as well as three-component combinations of frequently used NICU drugs and a 3-in-1 PN admixture. • Co-administration of Numeta G13E with dopamine and morphine, but also with morphine and cefotaxime is safe in NICU.

A review of neonatal peripherally inserted central venous catheters in extremely or very low birthweight infants based on a 3-year clinical practice: Complication incidences and risk factors

BACKGROUND

The application of peripherally inserted central venous catheters (PICCs) in neonates has proven effective in avoiding repetitive insertions and excessive use of transfusion consumables. However, the frequent occurrence of PICC-associated complications deserves special attention, especially in extremely or very low birthweight (E/VLBW) infants, which in turn affects the quality of neonatal PICC practice. Therefore, we conducted a retrospective study of a 3-year clinical practice of neonatal PICCs in E/VLBW infants to understand the incidences of various catheter-related complications and their risk factors to help form an empirical summary and evidence-based guidance for the improvement of practice.

METHODS

A retrospective study was conducted based on a 3-year practice of neonatal PICCs in E/VLBW infants. Neonatal health records were collected, including demographic characteristics, PICC placement data, and treatment information.

RESULTS

A total of 519 E/VLBW infants were included in this study. There were 77 cases of complications involving 72 infants with an overall incidence of 12.13%. The order of incidences of different complications from high to low was phlebitis (7.71%), malposition (3.66%), leakage (1.35%), pleural effusion (1.15%), central line-associated bloodstream infection (0.58%, 0.25/1,000d), and accidental removal (0.38%). Multivariate analysis revealed that the inserted vessel was an independent risk factor for PICC-associated complications (mainly phlebitis; p = 0.002). Neonatal PICCs inserted in the axillary vein were only one-tenth (p = 0.026) as likely to cause phlebitis as in the basilic vein, whereas when applied in the saphenous vein, neonatal PICCs were five times as likely to cause phlebitis (p = 0.000).

CONCLUSION

E/VLBW infants might be more inclined to develop PICC-associated phlebitis. Catheters inserted in the axillary or basilic vein are preferred if possible.

Hyperosmotic Infusion and Oxidized Surfaces Are Essential for Biofilm Formation of Staphylococcus capitis From the Neonatal Intensive Care Unit

Staphylococcus capitis is an opportunistic pathogen often implicated in bloodstream infections in the neonatal intensive care unit (NICU). This is assisted by its ability to form biofilms on indwelling central venous catheters (CVC), which are highly resistant to antibiotics and the immune system. We sought to understand the fundamentals of biofilm formation by S. capitis in the NICU, using seventeen clinical isolates including the endemic NRCS-A clone and assessing nine commercial and two modified polystyrene surfaces. S. capitis clinical isolates from the NICU initiated biofilm formation only in response to hyperosmotic conditions, followed by a developmental progression driven by icaADBC expression to establish mature biofilms, with polysaccharide being their major extracellular polymer substance (EPS) matrix component. Physicochemical features of the biomaterial surface, and in particular the level of the element oxygen present on the surface, significantly influenced biofilm development of S. capitis. A lack of highly oxidized carbon species on the surface prevented the immobilization of S. capitis EPS and the formation of mature biofilms. This information provides guidance in regard to the preparation of hyperosmolar total parenteral nutrition and the engineering of CVC surfaces that can minimize the risk of catheter-related bloodstream infections caused by S. capitis in the NICU.