Thrombolytic therapy for central venous catheter occlusion

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

Life on the line - Incidence and management of central venous catheter complications in intestinal failure

BACKGROUND & AIMS

Loss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs.

METHODS

For this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDTs) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDTs were compared.

RESULTS

Overall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 "CVC-days"). Broviac type "B" was found to be significantly superior to type "A" regarding occlusion, CRI, and material defects (log-rank test: p = 0.05; p = 0.026; p = 0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 389 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications.

CONCLUSIONS

Different complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.

Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice

Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.

Case report: Transected Hickman catheter and its thrombotic occlusion in a patient with idiopathic pulmonary arterial hypertension-can a catheter replacement be avoided?

A 25-year-old female with idiopathic pulmonary arterial hypertension (PAH), who had a Hickman catheter implanted for continuous intravenous epoprostenol infusion, was admitted to the clinic after inadvertently cutting the catheter with nail scissors during a routine dressing change. Approximately 7 cm of the external segment of the Hickman catheter remained intact, with the distal end knotted by paramedics. A decision was made to repair the damaged Hickman catheter. However, it was discovered that its lumen was completely occluded by thrombosis. Therefore, catheter patency was mechanically restored using a 0.035-inch stiff guidewire in a sterile operating theatre setting, under fluoroscopy guidance. Successful aspiration and catheter flushing were achieved. Continuity of the Hickman catheter was then restored using a repair kit (Bard Access Systems) as per the manufacturer's instructions, with no visible leakage thereafter. Epoprostenol infusion through the Hickman catheter was resumed 24 h later, and the patient was discharged in good general condition two days afterward.

Control of Line Complications with KiteLock (CLiCK) in the critical care unit: study protocol for a multi-center, cluster-randomized, double-blinded, crossover trial investigating the effect of a novel locking fluid on central line complications in the critical care population

BACKGROUND

Insertion of a central venous access device (CVAD) allows clinicians to easily access the circulation of a patient to administer life-saving interventions. Due to their invasive nature, CVADs are prone to complications such as bacterial biofilm production and colonization, catheter-related bloodstream infection, occlusion, and catheter-related venous thrombosis. A CVAD is among the most common interventions for patients in the intensive care unit (ICU), exposing this vulnerable population to the risk of nosocomial infection and catheter occlusion. The current standard of care involves the use of normal saline as a catheter locking solution for central venous catheters (CVCs) and peripherally inserted central catheter (PICC) lines, and a citrate lock for hemodialysis catheters. Saline offers little prophylactic measures against catheter complications. Four percent of tetrasodium ethylenediaminetetraacetic acid (EDTA) fluid (marketed as KiteLock Sterile Locking Solution™) is non-antibiotic, possesses antimicrobial, anti-biofilm, and anti-coagulant properties, and is approved by Health Canada as a catheter locking solution. As such, it may be a superior CVAD locking solution than the present standard of care lock in the ICU patient population.

METHODS

Our team proposes to fill this knowledge gap by performing a multi-center, cluster-randomized, crossover trial evaluating the impact of 4% tetrasodium EDTA on a primary composite outcome of the incidence rate of central line-associated bloodstream infection (CLABSI), catheter occlusion leading to removal, and use of alteplase to resolve catheter occlusion compared to the standard of care. The study will be performed at five critical care units.

DISCUSSION

If successful, the results of this study can serve as evidence for a shift of standard of care practices to include EDTA locking fluid in routine CVAD locking procedures. Completion of this study has the potential to improve CVAD standard of care to become safer for patients, as well as provides an opportunity to decrease strain on healthcare budgets related to treating preventable CVAD complications. Success and subsequent implementation of this intervention in the ICU may also be extrapolated to other patient populations with heavy CVAD use including hemodialysis, oncology, parenteral nutrition, and pediatric patient populations. On a global scale, eradicating biofilm produced by antibiotic-resistant bacteria may serve to lessen the threat of "superbugs" and contribute to international initiatives supporting the termination of antibiotic overuse.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04548713, registered on September 9th, 2020.

Catheter-related thrombosis (CRT) in patients with solid tumors: a narrative review and clinical guidance for daily care

Central venous access devices (CVADs) including central venous catheters and peripherally inserted central catheters (PICCs) are essential in the treatment of cancer. Catheter-related thrombosis (CRT) is the most frequent non-infectious complication associated with the use of central lines. The development of CRT may cause to delays in oncologic treatment and increase morbidity leading to potentially life-threatening complications. Several local and systemic risk factors are associated with the development of CRT and should be taken into account to prevent CRT by standardizing appropriate catheter placement and maintenance. The use of primary pharmacological thromboprophylaxis in order to avoid CRT is not routinely recommended, although it can be considered in selected cases. Recommendations for the management of established CRT are based on the extrapolation of anticoagulation for lower limb venous thrombosis. The present review summarizes the current evidence and recommendations for the prevention and management of CRT and identifies areas that require further research.

Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients.

METHODS AND ANALYSIS

OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year.

ETHICS AND DISSEMINATION

Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines.

TRIAL REGISTRATION NUMBER

NL7933.

PROTOCOL VERSION AND DATE

V.5, 25 February 2021.

Sternal Retraction and Subclavian Vein Catheter Occlusion during Cardiac Surgery

Background

Subclavian vein (SV) catheterization is a method for the delivery of fluids, drugs, and blood products, venous blood sampling, and central vein pressure monitoring in cardiac surgery. Catheter occlusion is a serious complication of SV catheterization during cardiac surgery, especially after sternal retractor expansion.

Methods

In this observational study, 303 patients who had successful right infraclavicular SV catheterization from September 2019 to April 2020 were enrolled to determine the incidence of catheter occlusion. After catheterization, the lumens of all catheters were checked for the ability to infuse and withdraw blood from the catheter before and after sternal retractor expansion. The patients’ characteristics, cannulation approach, on-pump or off-pump technique, occlusion of the catheter and its lumens, and any associated complications were recorded. The data were analyzed using IBM SPSS ver. 22.0 (IBM Corp., Armonk, NY, USA).

Results

Of the 303 patients studied, 205 were male (67.7%) and 98 were female (32.3%). Catheter occlusion occurred in 11 patients with on-pump cardiopulmonary bypass (CPB) (227 patients) and 4 patients with off-pump CPB (76 patients) (p=0.863). The incidence of catheter occlusion was 4.95% (15 of 303 patients) with no cases of simultaneous 3-lumen occlusion in a catheter. The most commonly occluded lumen was the distal lumen (57.92%). Simultaneous 2-lumen occlusion occurred in 4 patients. Catheter occlusion was found in 3 of 13 malpositioned catheters (23.07%).

Conclusion

The current study showed that malpositioning of the catheter tip was a risk factor for catheter occlusion and that the distal lumen of a triple-lumen catheter was the most commonly occluded lumen.

Effectiveness of mechanical recanalization for intraluminal occlusion of totally implantable venous access ports

PURPOSE

To evaluate if the mechanical injection of saline is effective in restoring patency of a totally implantable venous access port (TIVAP) with an intraluminal occlusion.

MATERIALS AND METHODS

From January 2017 to June 2019, 64 cases of dysfunction of a TIVAP were referred to interventional radiology. Among these, 16 cases showed normal function of the TIVAP, 19 cases the showed the appearance of a fibroblastic sheath, and 29 cases showed intraluminal occlusion. Mechanical recanalization was performed for intraluminal occlusion of the TIVAP with an indeflator and a 20G non-coring needle. Linograms were performed in all recanalized cases. The success or failure of recanalization and the pressure of the indeflator were recorded. Linograms were evaluated for breakage or migration of catheters. Medical records were retrospectively reviewed.

RESULTS

Among the 29 intraluminal occlusion cases, 24 cases (82.7%) were recanalized by mechanical recanalization via an indeflator. The pressure of the indeflator ranged from 29 to 220 psi (median: 118 psi). Linograms revealed breakage of the catheter of the TIVAP in two failed cases. The median interval from implantation to dysfunction was 405 days (range: 43-1723 days). The median interval from last use to dysfunction was 8 days (mean: 15.4 days; range: 1-119 days). The median re-occlusion free period after successful mechanical recanalization was 100.5 days (range: 6-859 days).

CONCLUSION

In the absence of an available thrombolytic agent, mechanical injection of saline was a tolerable alternative method for restoring occluded catheters and sustaining the function of catheters. Because breakage of the catheter can occur during mechanical recanalization of a TIVAP, a linogram should follow the procedure.

Atypical use of PICC as centrally inserted central catheter in infants and neonates: Report of a 10-year experience

PURPOSE

The aim was to determine the success, safety and post procedure complications of peripherally inserted central catheters as centrally inserted central catheters (CICC).

MATERIALS AND METHOD

One hundred and sixty-one consecutive infants and neonates, who underwent image guided tunnelled central venous catheter insertion were retrospectively evaluated between April 2008 and April 2018. Patient's demographics, site of access and procedure details were recorded. Outcomes included technical success and post procedure complications.

RESULTS

One hundred and eighty-two CICCs were inserted in 161 patients (49.7%, n = 80 male). Mean patient age was 100 days (range: 0-342) with a mean weight of 4.20 kg (range 1.80-9.40). The most common indication was for antibiotics administration (41%; n = 66). Technical success was 99% (181/182). Early complications (<7 days) were seen in 8.8% (n = 13). This included inadvertent line removal in 5.5%, catheter-related bloodstream infection in 1.1% and catheter occlusion in 2.2% (n = 4). Average line functional duration prior to removal was 26 days (range 0-180). 77.5% of the lines lasted for the intended duration of treatment. In the neonate subgroup, 84.1% (37/44 lines) of lines remained in situ for the intended duration of treatment.

CONCLUSION

Tunnelled central venous catheters using non-cuffed peripherally inserted central catheters in infants is a safe technique with excellent success rate and minimal complications rates.

Outcomes of Thrombolytic Therapy of Tunnelled Hemodialysis Catheter Dysfunction

INTRODUCTION

Intraluminal thrombolytic therapy is the first step treatment of thrombotic malfunction of tunneled hemodialysis catheters (THC). The factors that affect catheter restoration and also catheter survival following thrombolytic therapy are not well described. In this study, we aimed to reveal the predictors that affect the success of the procedure and also present post-restoration catheter patency after intraluminal thrombolytic administration.

METHOD

This retrospective study included 62 patients with tunneled THC thrombosis treated with alteplase between 2017 and2020 in the study center. Age, comorbidities, the use of antiplatelet and anticoagulants, a history of catheter thrombosis, time on dialysis, the duration of the catheter were investigated as possible predictors of procedural success. The independent predictive factors for procedural success were evaluated by using backward stepwise likelihood ratio logistic regression analysis. Primaryand assisted patencieswere presented with Kaplan-Meier graphs.

RESULTS

Thrombolityc was administered to 62 patients 102 times. The median primary patency from the first thrombolytic administration to a second catheter thrombosis was 9 months (range 1-20 months). The overall median patency was 12 months (range 2-23 months). The overall procedural success rate was 79.4% (81/102).Multivariate analyses revealed that a history of prior catheter thrombosis was the only risk factor for procedural success (OR: 0.49; 95% CI: 0.26-0.91; p = 0.004). The need for a second dwell time among patients with prior history of thrombolysis was significantly higher compared to patients without a history of catheter thrombosis (12/26 patients, 46.2% and 6/55 patients, 10.9%; respectively; p = 0.001).

CONCLUSION

The success of thrombolysis in subsequent de novo THC thrombosis decreases in patients who previously required intraluminal thrombolytic administration. Identifying patient subgroups with a high risk for THC thrombosis may be useful to investigate effective secondary prevention strategies.

Approach to Intestinal Failure in Children

PURPOSE OF REVIEW

Pediatric intestinal failure is a complex condition requiring specialized care to prevent potential complications. In this article, we review the available evidence supporting recent advances in care for children with intestinal failure.

RECENT FINDINGS

Multidisciplinary intestinal rehabilitation teams utilize medical and surgical management techniques to help patients achieve enteral autonomy (EA) while preventing and treating the complications associated with intestinal failure. Recent advances in lipid management strategies, minimization of intestinal failure associated liver disease, prevention of central line-associated blood stream infections, and loss of access, as well as development of promising new hormone analogue therapy have allowed promotion of intestinal adaptation. These advances have decreased the need for intestinal transplant. There have been recent advances in the care of children with intestinal failure decreasing morbidity, mortality, and need for intestinal transplantation. The most promising new therapies involve replacement of enteroendocrine hormones.

Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

ABSTRACT

Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters in haematology and oncology patients (PASSPORT 2)

BACKGROUND

Central venous catheter dysfunction may be associated with intraluminal clots, drug precipitates and lipid residues or extra luminal causes such as fibroblastic sleeve, tip malposition, pinch-off syndrome and venous thrombosis at the tip of central venous catheter. Failure to restore patency after addressing these causes, empirical treatment with thrombolytic agents should be considered. Urokinase is used widely as a thrombolytic agent but very few outcome studies have been published.

METHODS

A multicentre group conducted a prospective audit of management of central venous catheter dysfunction after exclusion of common causes using in centre standardised doses of urokinase from September 2017 to February 2018 in haematology and oncology units. Data of catheter blood flow were collected anonymously following administration of 5000- to 25,000-IU urokinase in dysfunctional central venous catheter.

RESULTS

A total of 117 patients were recruited from eight centres, 54 females and 63 males, median age was 60 (46-68). In total, 53% presented as partial withdrawal occlusion and 47% total occlusion. In partial withdrawal occlusion, patency was restored in 80% of interventions, in 82% of interventions using push lock and in 76% using dwell lock. In total occlusion, patency was restored in 88% of the interventions. The central venous catheter clearance rate was dose dependent; patency was restored in 83% of central venous catheter with 5000 IU, 89% with 10,000 IU and 92% with high dose of 25,000 IU. No adverse events were recorded.

CONCLUSION

In this study, treatment of dysfunctional central venous catheter using standardised urokinase doses was safe and effective in restoring patency when no other mechanical causes could account for central venous catheter dysfunction.

Challenges of Vascular Access in the Pediatric Population

The incidence and prevalence of renal replacement therapy has continued to increase in the pediatric population. Recent data have shown that hemodialysis was the most frequently used dialysis modality, especially in pediatric ESRD patients (age 0-21 years). A well-functioning vascular access is required for effective hemodialysis and choosing the best vascular access option for pediatric patients can be difficult. Pediatric vascular options include arteriovenous fistula, arteriovenous graft, and central venous catheters (CVCs). There is a national initiative for fistula first-catheter last approach; however, CVCs have been reported as the most conventionally utilized vascular access option in pediatric patients. The use of CVCs should be minimized or avoided as they are associated with high risk of infections, thrombosis, and other complications. Thus, it is important for practitioners to plan appropriately in advance, practice good clinical judgment, and assure that the best vascular access is placed according to the patient's needs. Therefore, this article reviews the different types of pediatric vascular access and the associated benefits and potential complications of each.

Interventions for Occluded Central Venous Catheters: A Meta-analysis

CONTEXT

Thrombotic occlusion is 1 of the most frequent complications in catheters implanted in children.

OBJECTIVE

To identify the interventions used to treat thrombotic events in long-term central venous catheters in pediatric patients with cancer.

DATA SOURCES

Electronic searches were performed in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, LIVIVO, PubMed, Scopus, Web of Science, Google Scholar, OpenGrey, and ProQuest databases. There were no restrictions on language or publication period.

STUDY SELECTION

This systematic review was performed in 2 phases and included clinical trials and observational studies on drugs used to treat thrombotic catheter events in pediatric patients with cancer. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist, and the protocol was registered at PROSPERO (identifier CRD42018083555).

DATA EXTRACTION

The authors evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies and Grading of Recommendations Assessment, Development and Evaluation methods. The meta-analysis was performed by using Stata software.

RESULTS

Ten studies were included. The drugs used to restore catheter function were alteplase, urokinase, and streptokinase. A meta-analysis of 6 studies revealed an overall restoration rate of 88% for alteplase.

LIMITATIONS

Reference studies were excluded when it was not possible to reliably extract data that met the inclusion criteria of this review. Sampling issues (absence of randomization, blinding, or a control group) were the main methodologic concerns for the included articles.

CONCLUSIONS

On the basis of the evidence obtained, thrombolysis is effective and potentially safe in this population.

Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis

BACKGROUND

Around the globe, protocols for flushing the catheter to maintain the patency of central venous catheter (CVC) vary by institution to institution or by practitioner to practitioner. Therefore, this review was carried out with the aim of evaluating the efficacy of heparin flush vs. normal saline flush to maintain the patency of CVC among adult patients.

METHODS

We followed the guidelines of Cochrane handbook for interventions and searched in MEDLINE, Embase, Cochrane library, Clinical trials database, and reference list of related articles, which were published from Jan. 2012 to 31 Dec. 2018 in English language. We included only randomized controlled trials, and nine studies were included in this review. The pooled standard mean difference and relative risk were calculated by using Rev Man Review Manager 5.

RESULTS

We identified nine eligible studies with a total number of 3,113 participants. Consolidated results from eight studies conveyed little favorable effect to maintain patency of CVC with heparin when compared with normal saline as evident by risk ratio 0.83, 95% CI 0.50 - 1.40; P = 0.13. We also carried out analysis for secondary outcomes, and there was no evidence that heparin was better than normal saline in terms of safety except heparin-induced thrombocytopenia.

CONCLUSIONS

Heparin has little favorable effects to maintain patency of catheter than normal saline but not in secondary outcomes. As the quality of evidence was very low, therefore, results should be comprehend with care.

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters (PASSPORT 1)

OBJECTIVES

Tunnelled central venous catheters dysfunction can be defined as failure to provide blood flow above 200 mL/min during dialysis often caused by thrombosis. Although urokinase is used routinely for thrombolysis, there is wide variation in dose regimens. A multidisciplinary group was formed to address this issue and offer guidance.

METHODS

Dialysis centres that used urokinase in the United Kingdom took part in a prospective study to determine the safety and outcomes of thrombolysis using agreed protocols. Data were collected anonymously from September 2017 until February 2018. Catheter blood flow was measured before and after the following interventions: catheter dwell or push locks with 12,500-50,000 IU or catheter infusion with 100,000-250,000 IU of urokinase. Interventions were repeated if the blood flow remained below 200 mL/min.

RESULTS

10 centres took part and recruited 200 patients; 45.5% were female and 54.5% were male with mean age of 63.6 (±15.2) years. The cumulative success rate for thrombolysis was 90.5% after first intervention, 97% after second intervention, and 99% after more than 2 interventions. Although there was trend towards benefit with dose increments, the success rate between push/dwell locks and high-dose infusion of urokinase was not significantly different (p = 0.069). Seventeen (8.5%) tunnelled central venous catheters were removed due to failure of treatment. No urokinase-related adverse events were reported.

CONCLUSION

In this study, urokinase was safe and efficacious; there was no difference between dwell and push locks. There was some benefit with high-dose infusion of urokinase compared to the dwell and push lock.

Efficacy of management for obstruction caused by precipitated medication or lipids in central venous access devices: A systematic review and meta-analysis

At present, central venous access devices (CVADs) are widely used in clinical practice. The reasons for CVAD obstruction caused by precipitated medication or lipids are increasingly complex. However, there is no clear treatment program for CVAD obstruction caused by precipitated medication or lipids. The target of this study was to analyze data regarding obstruction caused by precipitated medication or lipids in CVADs and to calculate the efficacy of different treatment methods. A systematic review with meta-analysis was conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The PubMed, Web of Science, EMBASE, Cochrane Library, CINAHL, and China National Knowledge Internet databases were searched for original research published before 2018. There were 1356 publications initially screened, with one additional study identified through snowballing. Seven studies met the inclusion criteria. The reasons for obstruction, except for clot formation, primarily included the following: mechanical complications; lipid deposition; mineral deposition; or drug precipitation. Meta-analysis showed that sodium hydroxide resulted in the highest recanalization rate in lipid deposition, followed by ethanol, and the difference was significant. The efficacy analysis revealed that hydrochloric acid and l-cysteine have similar effects on mineral deposition and drug precipitation. According to this review, the most effective methodology was shown to be the intravenous perfusion of sodium hydroxide in several treatments when the obstruction is caused by lipid deposition. In contrast, mineral deposition and drug deposition are best treated with l-cysteine to recover the patency of central venous access devices.

Interventions to obstructive long-term central venous catheter in cancer patients: a meta-analysis

PURPOSE

The aim of this systematic review was to identify the interventions used to treat obstructive events, whether thrombotic or non-thrombotic, in long-term central venous catheters (LT-CVC) in cancer patients.

METHODS

This review included clinical trials and observational studies reporting the drugs used to treat obstructive catheter events in cancer patients. The authors developed specific search strategies for CINAHL, Cochrane CENTRAL, LILACS, PubMed, Scopus, Web of Science, Google Scholar, Open Grey, and ProQuest. The authors evaluated methodological quality of included studies using criteria from Cochrane's Collaboration Tool and the Methodological Index for non-randomized studies (MINORS). The quality of evidence was analyzed by using GRADE's software.

RESULTS

More than 9000 articles were found across the databases. After duplicates removed, the studies were selected in 2 phases. After that, only 15 studies were included. The drugs used to restoration of catheter function were urokinase (53.3%), alteplase (20%), tenecteplase (13.3%), reteplase (6.7%), recombinant urokinase (6.7%), and staphylokinase (6.7%). The results of meta-analysis of 14 studies showed an overall restoration rate of ~ 84%. The drug type meta-analysis demonstrates a success rate of ~ 84%, ~ 92%, and ~ 84% for urokinase, alteplase, and tenecteplase groups, respectively. The main methodological problem in included articles concerns the sample. The quality of evidence ranged from very low to high.

CONCLUSION

The most common interventions used to treat thrombotic catheter occlusion in cancer patients were urokinase and alteplase. No evidence was found about the treatment for non-thrombotic occlusion, thus elucidating an important gap to be investigated.

Quantitative assessment of reflux in commercially available needle-free IV connectors

INTRODUCTION

Blood reflux is caused by changes in pressure within intravascular catheters upon connection or disconnection of a syringe or intravenous tubing from a needle-free connector (NFC). Changes in pressure, differing with each brand of NFC, may result in fluid movement and blood reflux that can contribute to intraluminal catheter occlusions and increase the potential for central-line associated bloodstream infections (CLABSI).

METHODS

In this study, 14 NFC brands representing each of the four market-categories of NFCs were selected for evaluation of fluid movement occurring during connection and disconnection of a syringe. Study objectives were to 1) theoretically estimate amount of blood reflux volume in microliters (μL) permitted by each NFC based on exact component measurements, and 2) experimentally measure NFC volume of fluid movement for disconnection reflux of negative, neutral and anti-reflux NFC and fluid movement for connection reflux of positive displacement NFC.

RESULTS

The results demonstrated fluid movement/reflux volumes of 9.73 μL to 50.34 μL for negative displacement, 3.60 μL to 10.80 μL for neutral displacement, and 0.02 μL to 1.73 μL for pressure-activated anti-reflux NFC. Separate experiment was performed measuring connection reflux of 18.23 μL to 38.83 μL for positive displacement NFC connectors.

CONCLUSIONS

This study revealed significant differences in reflux volumes for fluid displacement based on NFC design. While more research is needed on effects of blood reflux in catheters and NFCs, results highlight the need to consider NFCs based on performance of individual connector designs, rather than manufacturer designation of positive, negative and neutral marketing categories for NFCs without anti-reflux mechanisms.

Echocardiogram in the Evaluation of Hemodynamically Stable Acute Pulmonary Embolism: National Practices and Clinical Outcomes

RATIONALE

Societal guideline recommendations vary with regard to the role of routine trans-thoracic echocardiography to screen for right ventricular strain in patients with hemodynamically stable acute pulmonary embolism.

OBJECTIVE

To characterize national patterns in use of early trans-thoracic echocardiography for the evaluation of patients with hemodynamically stable acute pulmonary embolism and determine associations between trans-thoracic echocardiography use and patient outcomes.

METHODS

Retrospective cohort study using Premier, Inc. database of approximately 20% of patients hospitalized in the United States with hemodynamically stable acute pulmonary embolism between 2008 and 2011. Multivariable, risk-adjusted hierarchical regression models were used to evaluate hospital variation in use of trans-thoracic echocardiography for pulmonary embolism and associations between hospital trans-thoracic echocardiography rates and patient outcomes. Patient-level trans-thoracic echocardiography exposure was used in sensitivity analyses.

RESULTS

We identified 64,037 patients (mean age, 61.7 years; 54% women; 68% white) hospitalized at 363 U.S. hospitals. Trans-thoracic echocardiography rates for hemodynamically stable acute pulmonary embolism varied widely among hospitals (median trans-thoracic echocardiography rate, 41.4%; range, 0-89%; interquartile range, 32.7-51.7%). Hospital rates of trans-thoracic echocardiography were not associated with significant differences in risk-adjusted mortality (trans-thoracic echocardiography rate quartile 4 vs. quartile 1: odds ratio, 0.88; 95% confidence interval, 0.69-1.13) or use of thrombolytics (odds ratio, 1.28; 95% confidence interval, 0.84-1.96), but rates of intensive care unit admission (odds ratio, 1.57; 95% confidence interval, 1.18-2.07), hospital length of stay (relative risk, 1.08; 95% confidence interval, 1.03-1.15), and costs (relative risk, 1.15; 95% confidence interval, 1.07-1.23) were significantly higher at hospitals with high trans-thoracic echocardiography rates. Analyses of patient-level trans-thoracic echocardiography exposure produced similar results, except with higher rates of thrombolysis (odds ratio, 5.58; 95% confidence interval, 4.40-7.09) and bleeding (odds ratio, 1.37; 95% confidence interval, 1.24-1.51) among patients receiving trans-thoracic echocardiography.

CONCLUSIONS

Trans-thoracic echocardiography use in the evaluation of patients with hemodynamically stable acute pulmonary embolism varied widely between hospitals. Hospitals with high rates of pulmonary embolism-associated trans-thoracic echocardiography use did not achieve different patient mortality outcomes but had higher resource use and costs. Our findings support the 2016 American College of Chest Physicians guidelines for management of pulmonary embolism, which recommend selective, rather than routine, use of trans-thoracic echocardiography to risk stratify patients with hemodynamically stable pulmonary embolism.

Venous Ports in Infants

PURPOSE

To evaluate technical success and the incidences of, and risk factors for, mechanical and infectious complications of venous port placement in infants.

MATERIALS AND METHODS

This was a retrospective single-institution cohort study of port placement in infants (age < 1 y) from January 2006 through June 2016 (mean age, 7.5 mo ± 3.3; mean weight, 8.1 kg ± 1.9). Age, weight, sex, side of placement, tip position, and indication for placement (chemotherapy vs other) were recorded. Total catheter-days (CDs), mechanical complications, and central catheter-associated bloodstream infections (CCABSIs) were identified.

RESULTS

During the study years, 64 ports were placed in 64 infants, with a technical success rate of 100%. The mean catheter life was 321 days (total range, 4-1,917 d; interquartile range [IQR], 107-421 d). There were 13 CCABSI events (0.63 per 1,000 CDs); of these, 8 (12.5% among 64 patients) required port removal for infection. There was an increase in CCABSIs in patients with left-sided port placement (relative risk [RR], 3.22; 95% confidence interval [CI], 1.02-10.14; P = .05). There were 8 mechanical complications of the port reservoir or catheter (0.39 per 1,000 CDs). Of these, 2 (3.1%) required removal. Patients in the lowest weight quartile were at an increased risk of mechanical complications (RR, 4.37; 95% CI, 1.09-17.48; P = .04).

CONCLUSIONS

Venous ports can be placed with a high rate of technical success in infants. Left-sided ports and low weight are associated with increased infectious and mechanical complications, respectively.

Vascular Access Complications: An Emergency Medicine Approach

Millions of central venous and arterial catheters are placed across the United States annually as mechanisms of obtaining advanced hemodynamic monitoring and facilitating acute resuscitation. Although presumably life saving or sustaining in many circumstances, current literature identifies the preprocedural and postprocedural complications of infection, thrombosis, embolism, and iatrogenic injury as resulting in patient morbidity and mortality. Today, through the application of aseptic technique, performance of operator training, and the utilization of ultrasound, emergency physicians may limit vascular access complications and improve patient outcomes.

Evaluation of the need for chest X-rays in the management of asymptomatic, intraluminal vascular access device occlusion in childhood cancer

BACKGROUND

Venous access device (VAD) occlusion from intraluminal thrombus is a common complication during childhood cancer treatment. Current practice at many institutions is to assess VAD position with a chest X-ray (CXR) prior to intraluminal administration of tissue plasminogen activator (tPA). We aimed to determine the utility of this practice.

PROCEDURE

A retrospective chart review of children with newly diagnosed cancer with a VAD, treated at The Hospital for Sick Children between 2010 and 2011, was performed. Episodes of line occlusion were identified both by reviewing patient CXRs for indication and identifying tPA doses dispensed. These episodes were reviewed to determine whether CXR findings resulted in management other than tPA. Cases in which the X-ray resulted in a change in management were further reviewed to determine whether administration of tPA could have resulted in potential patient harm.

RESULTS

A total of 330 patients with newly diagnosed cancer with VADs were identified. Eighty-five (25.8%) patients experienced 123 episodes of VAD occlusion. VAD occlusions occurred more frequently in patients with tunneled external central venous lines (16/39, 41.5%) and peripherally inserted central catheters (PICC) (27/73, 37.0%) versus PORT (42/216, 19.4%; P = 0.001). There were nine (8.1%) episodes of VAD occlusion evaluated with a CXR in which the findings led to a change in management other than administering tPA. In each case, multiple specialists independently concluded that administration of tPA would have been unlikely to cause patient harm.

CONCLUSION

Routine CXRs prior to the administration of tPA for asymptomatic VAD occlusion can safely be omitted.

Cateteres venosos centrais de inserção periférica: alternativa ou primeira escolha em acesso vascular?

Resumo Contexto Os cateteres venosos centrais de inserção periférica (PICC) são dispositivos intravenosos, introduzidos através de uma veia superficial ou profunda da extremidade superior ou inferior até o terço distal da veia cava superior ou proximal da veia cava inferior. Apresentam maior segurança para infusão de soluções vesicantes/irritantes e hiperosmolares, antibioticoterapia, nutrição parenteral prolongada (NPT) e uso de quimioterápicos; demonstram reduzido risco de infecção em comparação a outros cateteres vasculares e maior relação custo/benefício se comparados ao cateter venoso de inserção central (CVCIC). Objetivos Apresentar os resultados de implantes de PICCs ecoguiados e posicionados por fluoroscopia realizados no Hospital e Maternidade São Luiz (HMSL) Itaim, Rede D’or, Brasil. Métodos Estudo prospectivo, não randomizado, realizado entre fevereiro de 2015 e novembro de 2016. Utilizou-se protocolo pré-estabelecido pela instituição em casos de solicitação de acesso vascular. Foram analisadas indicações, doenças prevalentes, tipo do cateter implantado, sucesso técnico, complicações relacionadas ao cateter, e estabelecidos critérios de inclusão e exclusão. Resultados Solicitados 256 acessos vasculares, sendo implantados 236 PICCs (92,1%) e 20 CVCICs (7,9%). Principais indicações: antibioticoterapia prolongada (52,0%), NPT (19,3%) e acesso venoso difícil (16,0%). Houve sucesso técnico em 246 cateteres implantados (96,1%). A veia basílica direita foi a principal veia puncionada em 192 pacientes (75,0%), seguida da braquial direita em 28 pacientes (10,9%). Conclusões O implante dos PICCs ecoguiados e posicionados por fluoroscopia demonstrou baixa incidência de complicações, reduzidos índices de infecção e é seguro e eficaz em casos de acessos vasculares difíceis, sendo esses cateteres considerados dispositivos de escolha em acesso vascular central.

Practice patterns and complication rates of thrombolysis for pulmonary embolism

Practice patterns, bleeding complication rates, and outcomes of thrombolytic use for pulmonary embolism (PE) outside of clinical trials are not well characterized. Retrospective cohort study of patients with PE, using an enhanced administrative database of approximately 20 % of hospitalizations in the United States, 2008-2011. We used hierarchical logistic regression to identify patient- and hospital-level factors associated with thrombolytic use and quantified between-hospital variation in thrombolysis. We calculated rates of hemorrhagic complications and mortality in patients receiving thrombolytics stratified by vasopressor use. We identified 91,860 hospitalizations for PE; thrombolytics were utilized in 13.2 % (578/4363) who received vasopressors and 1.6 % (1320/82,997) who did not receive vasopressors. Patients who received thrombolytics were younger, more likely white, with private insurance, fewer comorbidities and more acute organ failures. Hospitals varied widely in thrombolysis rates for PE (0-100 % of patients on vasopressors, 0-12.5 % not on vasopressors) with 17 % of variation unexplained by patient or hospital characteristics. Bleeding complication rates for patients receiving thrombolytics versus no thrombolytics, respectively, were: ICH (0.8 vs. 0.08 %, p < 0.01), major bleeding (13 vs. 3 %, p < 0.01), and major bleeding with transfusion (2.5 vs. 0.05 %, p < 0.01). Among patients given vasopressors, thrombolytics were not associated with hospital mortality (thrombolysis 41 % vs. no thrombolysis 35 % mortality; adjusted OR 0.97, 95 % CI 0.93-1.01, p = 0.15). There is wide variation in thrombolytic use for PE in the US. Patient characteristics and complications associated with real-world thrombolytic use were similar to published randomized trials.

Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis

BACKGROUND

Heparin saline (HS) is theoretically superior to normal saline (NS) for maintaining the patency of central venous catheters (CVCs), but the comparative efficacy of them remains controversial. The aim of this systematic review and meta-analysis was to assess the efficacy of NS versus HS in the maintenance of the patency of CVCs in adult patients.

METHODS

We searched PubMed, Embase and the Cochrane library databases. Randomized controlled trials (RCTs) evaluating the use of NS vs. HS to maintain the permeability of CVCs among adult patients were included in our meta-analysis. References of relevant papers were reviewed manually. No language restriction was applied. Non-human studies were excluded. Pooled relative risk (RR) was calculated using a Mantel-Haenszel random-effects model. We also performed subgroup analysis examining the effect of the duration of catheter placement on the outcome. All statistical tests were two-sided using a significance level of 0.05.

RESULTS

Ten RCTs involving 7875 subjects (with analysis at patient, catheter, lumen and line access level) were included in this meta-analysis. Whether in terms of pooled or local analysis (RR with 95% confidence interval spans 1), NS can be equally, if not more effective, in keeping the CVCs open. Of studies reporting secondary outcomes (maneuver needed, heparin-induced thrombocytopenia, haemorrhage, central venous thrombosis and catheter-related bloodstream infection), heparinised saline was shown not to be superior to non-heparinised solution. Subgroup analysis in patients with short vs long term CVC placement was consistent with the main outcome partly and in particular for maintenance of catheter patency in patients with a long-term placement i.e. >30 days, the RR was 0.97 (n = 6589; 95% CI = 0.76 to 1.23; P = 0.796). However, for patients in whom the catheter was in place for <30 days, the RR was 1.52 (n = 1286; 95% CI = 1.02 to 2.27; P = 0.041).

CONCLUSIONS

Based on the results of this meta-analysis, HS is not superior to NS in reducing CVCs occlusion. But in the short term, the use of HS is slightly superior to NS for flushing catheters from a statistical point of view.

Catheter-Associated Blood Stream Infections in Intracardiac Lines

Purpose  Right atrial (RA) or intracardiac lines are commonly used for hemodynamic monitoring in children undergoing cardiac surgery. In some institutions, these lines are used as the preferred long-term access line due to concerns for catheter-associated blood stream infections (CABSI) and catheter-related venous thrombosis with central lines in other locations. However, the rates and risk factors for CABSI and other complications are not known for RA lines. We undertook this study to estimate CABSI rates for RA lines in comparison with central catheters of various types and locations and to evaluate the incidence of other complications associated with the use of RA lines. Methods  After approval from the Institutional Review Board, a retrospective review of all patients undergoing cardiac surgery at Arkansas Children's Hospital between the dates of January 1, 2006 and December 31, 2011 was performed. Demographic data, clinical features, and outcomes were summarized on a per-patient level. Type, location of placement, and duration of all centrally placed catheters as well as associated complications were recorded. Central venous lines (CVL) used in our unit include peripherally inserted central catheters (PICC) lines, and antibiotic and heparin coated double or triple lumen lines placed in internal jugular (IJ), femoral (Fem), or RA positions. The data were analyzed using statistical software STATA/MP. Results  A total of 2,736 central lines were used in 1,537 patients. Data on line duration, alteplase use, and percentage of lines developing CABSI are described in the study. Disease severity as assessed by risk-adjusted classification for congenital heart surgery (RACHS) score ( p  < 0.046), year of placement ( p  < 0.001), and line type adjusted for thrombolytic (alteplase) use are significantly associated with risk of any CABSI. Overall, IJ and RA lines had least risk of CABSI while PICC lines had the highest CABSI rates. RA lines are also associated with other medically significant complications. Conclusion  The CABSI rates associated with RA lines are lower than those seen with PICC lines. However, RA line use is associated with other, potentially significant complications. RA lines may be used cautiously as long-term access lines in cardiac patients in whom it is important to preserve venous patency for future interventions.

Venous Access Devices: Clinical Rounds

Nursing management of venous access devices (VADs) requires knowledge of current evidence, as well as knowledge of when evidence is limited. Do you know which practices we do based on evidence and those that we do based on institutional history or preference? This article will present complex VAD infection and occlusion complications and some of the controversies associated with them. Important strategies for identifying these complications, troubleshooting, and evaluating the evidence related to lack of blood return, malposition, infection, access and maintenance protocols, and scope of practice issues are presented.

Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus

Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.

Safety and Efficacy of Fibrinolytic Therapy in Restoring Function of an Obstructed Tunneled Pleural Catheter

RATIONALE

Tunneled pleural catheters have been established to be safe and effective in the management of recurrent symptomatic pleural effusions. Obstruction of the tunneled pleural catheter is rare; however, when obstructed the catheter fails to achieve its primary goal of symptom palliation. The management of pleural catheter obstruction has not been studied.

OBJECTIVES

We aimed to determine if the use of intracatheter fibrinolytic therapy is safe and effective in restoring catheter function.

METHODS

One hundred seventy-two patients with tunneled pleural catheters placed from 2009 to 2014 were reviewed to identify patients who received fibrinolysis for catheter obstruction, defined by a sudden reduction to less than 10 ml in pleural fluid drainage with fluid visualized in the thorax on ultrasound/radiography. The technique involved intracatheter instillation of 2 to 5 mg of alteplase, which was allowed to remain in the catheter for 60 to 120 minutes, after which drainage was performed.

MEASUREMENTS AND MAIN RESULTS

Obstruction occurred in 37 pleural catheters at a median of 2 months from insertion. One hundred percent (37/37) of obstructed catheters resumed drainage after fibrinolytic instillation, from a median of 4 ml before to 300 ml after fibrinolysis (P < 0.001). Twenty-four (65%) were performed in an outpatient setting, and no complications were encountered during or after fibrinolytic therapy. There were 18 episodes of reobstruction, all of which were successfully treated with intracatheter fibrinolytic therapy without complication.

CONCLUSIONS

Fibrinolytic instillation through a tunneled pleural catheter is safe and effective in restoring function of an obstructed catheter, as evidenced by the lack of complications and success in achieving catheter patency. The procedure can also be performed safely in an outpatient setting. Patients who experience catheter obstruction may be prone to reobstruction; however, fibrinolysis was safe and effective in reestablishing patency of the reobstructed catheter.

A Simple Diagnostic Test to Confirm Correct Placement of Dysfunctional Central Venous Catheters Before Chemotherapy in Children

BACKGROUND

In children undergoing intravenous chemotherapy, partial dysfunction of the central venous catheter (CVC) is common. Fluids can be infused into the catheter; however, blood cannot be aspirated. In those situations, chemotherapy is withheld and a catheter investigation is performed. Usually, a radiographic study with contrast media or therapy with thrombolytic drugs followed by rechecking for blood return is undertaken.

AIM

To evaluate if a previously described method using dilute sodium bicarbonate injection and the resultant rise in measured end-tidal carbon dioxide tracing can confirm correct intravascular placement of a dysfunctional CVC in children at the bedside.

PATIENTS

Cohort group of 22 children scheduled for chemotherapy with partial dysfunction of a CVC in a tertiary hematology-oncology care facility.

RESULTS

All children with a partial dysfunctional CVC that was proven to be intravascular after venogram or thrombolytic therapy had a distinct and predictable increase in end-tidal carbon dioxide response to injected bicarbonate.

CONCLUSION

Injection of 1 mL/kg (maximum 20 mL) of 4.2% dilute sodium bicarbonate is a quick, simple, bedside test allowing confirmation of intravascular location of dysfunctional CVC.

Tunnelled central venous catheter-related problems in the early phase of haematopoietic stem cell transplantation and effects on transplant outcome

OBJECTIVE

Haematopoietic stem cell recipients need central venous catheters (CVCs) for easy administration of intravenous fluid, medications, apheresis, or dialysis procedures. However, CVCs may lead to infectious or non-infectious complications such as thrombosis. The effect of these complications on transplantation outcome is not clear. This manuscript presents the complication rates of double-lumen tunnelled CVCs and their effect on transplantation outcome.

MATERIALS AND METHODS

Data from 111 consecutive patients, of whom 75 received autologous and 36 received allogeneic peripheral blood stem cell transplantations, were collected retrospectively. The data were validated by the Record Inspection Group of the related JACIE-accredited transplantation centre.

RESULTS

Thrombosis developed in 2.7% of recipients (0.9 per 1000 catheter days). Catheter-related infection was identified in 14 (12.6%) patients (3.6 per 1000 catheter days). Coagulase-negative Staphylococcus was the most common causative agent. Engraftment time, rate of 100-day mortality, and development of grade II-IV graft-versus-host disease were not found to be associated with catheter-related complications.

CONCLUSION

These results indicate that adverse events related with tunnelled CVCs are manageable and have no negative effects on transplant outcome.

Engineering of plasminogen activators for targeting to thrombus and heightening thrombolytic efficacy

Thrombotic occlusion of the coronary artery, which triggers acute myocardial infarction, is one of the major causes of death in the USA. Currently, arterial occlusions are treated with intravenous plasminogen activators (PAs), which dissolve the clot by activating plasminogen. However, PAs indiscriminately generate plasmin, which depletes critical clotting factors (fibrinogen, factor V, and factor VIII), precipitates a lytic state in the blood, and produces bleeding complications in a large patient population. PAs have been extensively investigated to achieve thrombus specificity, to attenuate the bleeding risk, and to widen their clinical applications. In this review, we discuss various strategies that have been pursued since the beginning of thrombolytic therapy. We review the biotechnological approaches that have been used to develop mutant and chimeric PAs for thrombus selectivity, including the use of specific antibodies for targeting thrombi. We discuss particulate carrier-based systems and triggered-release concepts. We propose new hypotheses and strategies to spur future studies in this research arena. Overall, we describe the approaches and accomplishments in the development of patient-friendly and workable delivery systems for thrombolytic drugs.

Thrombolytic Therapy Using Urokinase for Management of Central Venous Catheter Thrombosis

Purpose:

The management of central venous catheters (CVCs) and catheter thrombosis vary among centers, and the efficacy of the methods of management of catheter thrombosis in CVCs is rarely reported. We investigated the efficacy of bedside thrombolysis with urokinase for the management of catheter thrombosis.

Materials and Methods:

We retrospectively reviewed data from patients who had undergone CVC insertion by a single surgeon in a single center between April 2012 and June 2014. We used a protocol for the management of CVCs and when catheter thrombosis was confirmed, 5,000 U urokinase was infused into the catheter.

Results:

A total of 137 CVCs were inserted in 126 patients. The most common catheter-related complication was thrombosis (12, 8.8%) followed by infection (8, 5.8%). Nine of the 12 patients (75%) with catheter thrombosis were recanalized successfully with urokinase. The rate of CVC recanalization was higher in the peripherally inserted central catheter (PICC) group (87.5%) than the chemoport group (50%). Reintervention for catheter-related thrombosis was needed in only 2.2% of patients when thrombolytic therapy using urokinase was applied. Age <60 years (P=0.035), PICC group (P=0.037) and location of the catheter tip above the superior vena cava (P=0.044) were confirmed as independent risk factors for catheter thrombosis.

Conclusion:

Thrombolysis therapy using urokinase could successfully manage CVC thrombosis. Reintervention was rarely needed when a protocol using urokinase was applied for the management of CVC thromboses.

Central venous catheter-related thrombosis

Thrombotic complications associated with the use of central venous catheters (CVCs) are common and lead to distressing patient symptoms, catheter dysfunction, increased risk of infections, long-term central venous stenosis, and considerable costs of care. Risk factors for catheter-related thrombosis include use of larger, multilumen, and peripherally inserted catheters in patients with cancer receiving chemotherapy. Symptomatic catheter-related thrombosis is treated with anticoagulation, generally without removing the catheter. The intensity and duration of anticoagulation depend on the extent of thrombosis, risk of bleeding, and need for continued use of a CVC. To date, the clinical benefit of prophylactic doses of anticoagulant has been disappointing and these agents are not used routinely for this purpose. This chapter focuses on recent evidence, remaining controversies, and practical approaches to reducing the burden of thrombosis associated with CVCs.

Long-term central IV access in patients with mitochondrial disease

Mitochondrial disease results from alteration in genes that control mitochondrial function. Patients with this disease present with multisystem organ involvement that may include gastrointestinal (GI) tract dysfunction, including obstruction, pseudo obstruction, bowel infarction and malabsorption syndromes. For this reason, care of this population may require long-term central intravenous (IV) access for administration of hyperalimentation, fluid, medications and blood products. Additionally, these patients may be immunosuppressed and at risk of sepsis. With vulnerability across many organ systems, symptom exacerbation can result from any physiological, psychological, or environmental stressor. There is no cure for mitochondrial disease, and quality-of-life goals are paramount. If GI tract dysfunction develops, treatment may require high-acuity level home care that includes the use of a central IV access device. This article presents an overview of this challenging population, and a plan for safe and effective central IV access care.

Use of tissue plasminogen activator in catheters used for extracorporeal renal replacement therapy

Background

Intraluminal thrombosis of central venous catheters used for renal replacement therapy (RRT) decreases the ability to provide adequate treatment. Alteplase is a recombinant tissue plasminogen activator that has been used to improve the function of catheters used for RRT in humans.

Objectives

To retrospectively review alteplase instillation in dysfunctional catheters used for RRT in dogs and cats.

Animals

Seventeen dogs and 8 cats receiving RRT for kidney failure.

Methods

Medical records of patients in which alteplase was used for RRT catheter dysfunction from 2004 to 2012 were retrospectively reviewed to characterize reasons for use, improvement in function, increase in blood flow, and duration of improvement.

Results

Alteplase was instilled 43 times in 29 catheters, most commonly because of suspicion that the catheter would not provide sufficient flow on the next treatment (n = 21). The second most common reason was inability to start a dialysis treatment (n = 12). Catheter function improved after alteplase instillation in 34 of 43 treatments (79%). Median blood flow rate increased by 13% (18 mL/min) in the dialysis session after alteplase instillation. Seven of 29 catheters (24%) were treated with alteplase on >1 occasion (median time to second treatment, 8 days), and 1 catheter had to be replaced because of intractable dysfunction.

Conclusions and Clinical Importance

Alteplase is effective at improving function of central venous catheters used to provide RRT, but the results are short‐lived.

Catheter-related thrombosis in cancer patients

Central venous catheters are commonly used in haematology departments for the administration of chemotherapy, blood products and parenteral nutrition in patients with haematological malignancy. Thrombosis is a recognized complication of such devices especially in oncology patients. Catheter-related thrombi (CRT) may lead to pulmonary embolism and infection, as well as catheter failure and potential delays in treatment. The vast majority of CRT are asymptomatic, thus a high index of suspicion is required in making the diagnosis. Doppler ultrasound or venography may be employed to identify CRT. Once confirmed, the initiation of treatment is a balance between the risks of anticoagulation against potential complications of CRT. A number of risk factors for CRT are discussed along with an overview of catheter types, their appropriate choice and intravascular positioning.

Pediatric Central Venous Catheter Management: A Review of Current Practice

Due to small vessel size, obtaining stable access in pediatric patients is difficult. In addition, because needle stick pain is a concern for patients with chronic illness, central venous catheters are often utilized to provide intravenous treatment. Catheter occlusion is a common complication in pediatric patients and must be addressed to salvage the catheter and ensure successful therapy. The use of fibrinolytics for occlusion treatment have been successful in pediatric populations.