Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Exploring clinicians' insertion experience with a new peripheral intravenous catheter in the emergency department

BACKGROUND

Hospitals frequently introduce new medical devices. However, the process of clinicians adapting to these new vascular access devices has not been well explored. The study aims to explore clinicians' experience with the insertion of a new guidewire peripheral intravenous catheter (PIVC) introduced in the emergency department (ED) setting.

METHODS

The study was conducted at two EDs in Queensland, Australia, utilising a qualitative explorative approach. Interviews were conducted with guidewire PIVC inserters, including ED doctors and nurses, and field notes were recorded by research nurses during insertions. Data analysis was performed using inductive content analysis, from which themes emerged.

RESULTS

The study compiled interviews from 10 participants and field notes from 191 observation episodes. Five key themes emerged, including diverse experience, barriers related to the learning process, factors influencing insertion success, and recommendations to enhance clinicians' acceptance. These themes suggest that the key to successful adoption by clinicians lies in designing user-friendly devices that align with familiar insertion techniques, facilitating a smooth transfer of learning.

CONCLUSION

Clinician adaptation to new devices is vital for optimal patient care. Emergency nurses and doctors prefer simplicity, safety, and familiarity when it comes to new devices. Providing comprehensive device training with diverse training resources, hands-on sessions, and continuous expert support, is likely to enhance clinician acceptance and the successful adoption of new devices in ED settings.

Effect of intensive training and education of health care workers on the maintenance bundle of venous access devices in critically ill patients at a tertiary care academic hospital

BACKGROUND

The maintenance bundle of care for all venous access devices (peripheral intravenous catheters, PIVC; central venous catheters, CVCs; hemodialysis ports) is important to prevent secondary sepsis in critically ill patients. This quality improvement project analyzed the effect of intensive training and education of health care workers (HCWs) on maintenance bundles for venous access devices.

METHODS

The study period comprising of preintervention phase (3-months) included 25 random visits to the intensive care unit for point observations regarding maintenance of all venous access devices in-situ in all intensive care unit patients on the day of the visit. The observations were categorized as appropriate or inappropriate practices based on American Society of Anesthesiologists (ASA) guidelines for CVC 2020, INICC guidelines for PIVC 2017, and Australian Commission on Safety and Quality in Health Care (ACQHCS) for PIVC and hemodialysis ports, December 2019. While the intervention phase (1-month) comprised intensive training and education of HCWs, postintervention phase 3 (3-months) included similar visits and point observations as during the preintervention phase.

RESULTS

The maintenance of PIVC improved significantly in terms of the condition of site (from 82.7% appropriate observations to 97.8%, P < .05); condition of connectors (45.7%-56.8%, P < .05), and any attached unused IV sets (90.5%-98.56%, P < .05). For CVC, there was significant improvement in condition of insertion site (66%-94%, P < .01); condition of connectors (0%-44.37%, P < .01); fixation (91%-99.3%, P < .05); any attached unused IV sets (38.9%-97.3%, P < .01) and knowledge of HCW (96.52%-100%, P = .05). For hemodialysis ports, no significant improvement was observed.

CONCLUSIONS

Intensive training and education of HCWs led to significant improvement in the maintenance bundle of care for PIVC and CVC.

Paramedic insertion of peripheral intravenous catheters, unused catheter rates, and influencing factors: A retrospective review

BACKGROUND

Peripheral intravenous catheters (PIVCs) are associated with adverse events such as bloodstream infections; thus clinically appropriate practice is important. However, there is limited research on PIVC use in ambulance settings. This study investigated the incidence of paramedic-inserted PIVCs, unused PIVCs, and factors that influenced practice.

METHODS

Electronic patient care records for Western Australian ambulance service patients who attended between January 1 and December 31, 2020 were retrospectively reviewed. Patient, environmental, and paramedic characteristics were explored. Binominal logistical regression models were used to identify factors associated with PIVC insertion and unused PIVCs.

RESULTS

A total of 187,585 records were included; 20.3% had a PIVC inserted and 44% remained unused. Factors associated with PIVC insertion were gender, age, problem urgency, chief complaint, and operational region. Age, chief complaint, and paramedic years of experience were associated with unused PIVCs.

DISCUSSION

This study identified multiple modifiable factors for the unnecessary insertion of PIVCs, which may be addressed through better education and mentoring of paramedics supported by clearer clinical guidelines.

CONCLUSIONS

This is, to our knowledge, the first Australian state-wide study to report unused paramedic-inserted PIVC rates. As 44% remained unused, clinical indication guidelines and intervention studies to reduce PIVC insertion are warranted.

Arterial Line Placement Using Modified Seldinger Technique: A Novel Approach

How to cite this article: Srinivasan A, Naidu V, Dhivya P. Arterial Line Placement Using Modified Seldinger Technique: A Novel Approach. Indian J Crit Care Med 2023;27(7):515-516.

UK Vessel Health and Preservation Framework 2020: a users' survey

The review and update of the UK Vessel Health and Preservation Framework 2020 (VHP2020) was undertaken by a working group that included members of the Infection Prevention Society, the Royal College of Nursing, the National Infusion and Vascular Access Society and the Medusa Advisory Board and was launched in 2020. The VHP working group developed a survey to understand whether the VHP2020 had reached its intended audience, and what respondents thought were the benefits and drawbacks of its use in practice. Although the survey response was lower than expected, the responses received were largely positive and have provided feedback on how the VHP2020 is being used and some of the benefits. Most importantly, the survey has highlighted the need to communicate the benefits of the framework more effectively to reach a wider audience.

A pilot randomized controlled trial of securement bundles to reduce peripheral intravenous catheter failure

BACKGROUND

Peripheral intravenous catheters (PIVCs) are ubiquitous in acute care settings however failure rates are unacceptably high, with around half failing before prescribed treatment is complete. The most effective dressing and securement option to prolong PIVC longevity is unclear.

OBJECTIVES

To determine feasibility of conducting a definitive randomized controlled trial (RCT) investigating evidence-based securement bundles (medical adhesive tapes and supplementary securement products) to reduce PIVC failure.

METHODS

In this pilot non-masked 3-group RCT, adults requiring a PIVC for >24 hrs were randomized to Standard care (bordered polyurethane dressing plus non-sterile tape over extension tubing), Securement Bundle 1 (two sterile tape strips over PIVC hub plus Standard care) or Securement Bundle 2 (Bundle 1 plus tubular bandage) with allocation concealed until study entry.

EXCLUSIONS

laboratory-confirmed positive blood culture, current/high-risk of skin tear, or study product allergy.

PRIMARY OUTCOME

feasibility (eligibility, recruitment, retention, protocol fidelity, participant/staff satisfaction).

SECONDARY OUTCOMES

PIVC failure, PIVC dwell time, adverse skin events, PIVC colonization and cost.

RESULTS

Of 109 randomized participants, 104 were included in final analyses. Feasibility outcomes were met, except eligibility criterion (79%). Absolute PIVC failure was 38.2% (13/34) for Bundle 2, 25% (9/36) for Bundle 1 and 23.5% (8/34) for Standard care. Incidence rate ratio for PIVC failure/1000 catheter days, compared to Standard care, was 1.1 (95% confidence interval [CI] 0.4-2.7) and 2.1 (95% CI 0.9-5.1) for Bundles 1 and 2, respectively.

CONCLUSIONS

A large RCT testing securement bundles is feasible, with adjustment to screening processes. Innovative dressing and securement solutions are needed to reduce unacceptable PIVC failure rates. Trial registration ACTRN12619000026123.

Safety and Efficacy of Peripherally Inserted Central Catheter Placement by Surgical Intensivist-Led Vascular Access Team

Purpose

This study aimed to evaluate the safety and efficacy of bedside peripherally inserted central catheter (PICC) placement under ultrasonography (USG) guidance in the general ward by a surgical intensivist-led vascular access team versus that of PICC placement in the intensive care unit (ICU) or fluoroscopy unit.

Materials and Methods

We conducted this retrospective study of all patients who underwent PICC placement between March 2021 and May 2022. Clinical, periprocedural, and outcome data were compared for PICC placement in the ICU, general ward, and fluoroscopy unit groups, respectively.

Results

A total of 354 PICC placements were made in 301 patients. Among them, USG-guided PICC placement was performed in 103 and 147 cases in the ICU and general ward, respectively, while fluoroscopy-guided PICC placement was performed in 104 cases. USG-guided PICC placement more often required post-procedural catheter repositioning than fluoroscopy-guided PICC placement (P<0.001), but there was no significant difference in any adverse events (P=0.796). In addition, USG-guided PICC placement in the general ward was more efficient than fluoroscopy-guided PICC placement (0.73 days vs. 5.73 days, respectively; P<0.001). In the multivariate analysis, previous PICC placement within 6 months was an independent risk factor for a PICC-associated bloodstream infection (odds ratio, 2.835; 95% confidence interval, 1.143-7.034; P=0.025).

Conclusion

USG-guided PICC placement in the general ward by a surgical intensivist-led vascular access team has comparable safety and efficiency to that of USG-guided PICC placement in the ICU or fluoroscopy-guided PICC placement.

Disinfection of needleless connectors to reduce Staphylococcus aureus bacterial load

HIGHLIGHTS

Compare effectiveness of chemical disinfectants in reducing S. aureus. Five disinfectants reduced the bacterial load, especially chlorhexidine solutions. Focus on Brazilian clinical practice of needleless connector disinfection.

PURPOSE

This study aimed to gain further knowledge about the comparative effectiveness of chemical disinfectants in reducing the bacterial load of NCs inoculated with S. aureus.

METHODS

Disinfection of needleless connectors was undertaken in vitro against S. aureus comparing 70% isopropyl alcohol (IPA), 70% ethanol, 0.5% and 2% chlorhexidine in 70% IPA applied with gauze, and 70% IPA single-use cap (Site-Scrub®).

RESULTS

All disinfectants reduced the bacterial load (P<0.001), especially the chlorhexidine solutions. Mechanical friction should follow guidelines.

CONCLUSION

This study found that all tested disinfectants effectively reduced the bacterial load and more clinical studies must be developed with a focus on the Brazilian clinical practice of needleless connector disinfection.

Impact of the COVID-19 pandemic on subcutaneous venous port-related complications in patients with cancer: a retrospective case-control study

BACKGROUND

Vascular access in cancer patients is of great importance in order to deliver tumour-specific therapy and continues to be so during exceptional conditions. This study aimed to examine the impact of the coronavirus disease 2019 pandemic on the care and complication rates associated with subcutaneous venous port (PORT) insertion in cancer treatment.

METHODS

We retrospectively studied all adult cancer patients that received a PORT in 2020 at a Swedish county hospital, including insertion characteristics and in-dwell complication rates for up to 6 months after implantation; these estimates were compared with historic data.

RESULTS

Data from 257 patients, of which 56 were haematological patients, were included and compared with those of 168 patients in the control group. The group characteristics were similar, except for the inclusion of haematological patients in the study group. Insertion characteristics showed a shorter waiting time and higher rates of antibiotic and sedative use during the pandemic. The rates of postoperative haematoma and catheter occlusion during the study period were higher than otherwise. The rates of adverse events related to the PORT in the solid tumour group were comparable to those in the control group (18.4% vs. 14.9%). Patients with haematological malignancies were more likely to experience adverse events (37.5% vs. 18.4%) and deep venous thrombosis (7.1% vs. 1.0%) than those with solid tumours.

CONCLUSION

In conclusion, the present findings suggest that PORTs remain a safe venous access system even during a pandemic, indicating a robust vascular access service.

Peripheral intravenous catheter failure: A secondary analysis of risks from 11,830 catheters

BACKGROUND

Peripheral intravenous catheters are an essential medical device which are prone to complications and failure.

OBJECTIVES

Identify patient, provider and device risk factors associated with all-cause peripheral intravenous catheter failure as well as individual complications: phlebitis, infiltration/occlusion, and dislodgement to improve patient outcomes.

DESIGN

Secondary analysis of twelve prospective studies performed between 2008 and 2020.

SETTINGS

Australian metropolitan and regional hospitals including one paediatric hospital.

PARTICIPANTS

Participants were from medical, surgical, haematology, and oncology units.

METHODS

Multilevel mixed-effects parametric survival regression was used to identify factors associated with all-cause peripheral intravenous catheter failure, phlebitis, occlusion/infiltration, and dislodgement. We studied patient (e.g., age, gender), device (e.g., gauge), and provider (e.g., inserting clinician) variables. Stepwise regression involved clinically and p<0.20 significant variables entered into the multivariable model. Results were expressed as hazard ratios (HRs) and 95% confidence intervals (CI); p<0.01 was considered statistically significant.

RESULTS

Of 11,830 peripheral intravenous catheters (8,200 participants) failure occurred in 36% (n = 4,263). Occlusion/infiltration incidence was 23% (n = 2,767), phlebitis 12% (n = 1,421), and dislodgement 7% (n = 779) of catheters. Patient factors significantly associated with failure and complications were: female gender (phlebitis; (HR 1.98, 95% CI 1.72-2.27), (infiltration/occlusion; HR 1.45, 95% CI 1.33-1.58), (failure; HR 1.36, 95% CI 1.26-1.46); and each year increase in age (phlebitis; 0.99 HR, 95% CI 0.98-0.99), (failure; 0.99 HR, 95% CI 0.99-0.99). The strongest provider risk factor was intravenous antibiotics (infiltration/occlusion; HR 1.40, 95% CI 1.27-1.53), (phlebitis; HR 1.36, 95% CI 1.18-1.56), (failure; HR 1.26, 95% CI 1.17-1.36). Catheters inserted by vascular access teams were less likely to dislodge (HR 0.53, 95% CI 0.42-0.67). Device risk factors most associated with all-cause failure were wrist/hand (HR 1.34, 95% CI 1.23-1.46), antecubital fossa peripheral intravenous catheters (HR 1.29, 95% CI 1.16-1.44) and 22/24 gauge (HR 1.27, 95% CI 1.12-1.45) catheters.

CONCLUSION

Factors identified, including the protective aspect of vascular access team insertion, and high catheter failure associated with intravenous antibiotic administration, will allow targeted updates of peripheral intravenous catheter guidelines and models of care.

Idle peripheral intravenous cannulation: an observational cohort study of pre-hospital and emergency department practices

BACKGROUND

Unused ('idle') peripheral intravenous catheters (PIVC) are those not used within 24 hours of insertion. There is little data on cannulation practices and idle PIVC rates in emergency settings, especially the pre-hospital environment.

METHODS

This was an observational cohort study set in south-east Queensland, Australia using data from a large tertiary level emergency department (ED) and the local statutory ambulance service. Demographic, clinical and PIVC data were collected over two periods; 9 February-18 March 2017 and 5 January-4 February 2018. Adult patients were included if they were allocated an Australasian triage scale (ATS) category between 2 and 5, and had a PIVC inserted in the pre-hospital setting or ED. PIVC use was defined as idle if no fluids, medications or contrast were administered intravenously within 24 hours of insertion. Comparisons between pre-hospital and ED practice and idle PIVC status were undertaken using descriptive statistics and logistic regression.

RESULTS

A total of 1249 patients with a PIVC (372 pre-hospital; 877 ED) were included. Overall, 366 PIVCs (29.3%; 95% CI 26.9%-31.9%) remained idle at 24 hours. In the pre-hospital group, 147 (39.5%) PIVCs inserted were not used pre-hospital, and 74 (19.9%) remained idle. In comparison, 292 (33.3%) PIVCs placed in the ED remained idle. ED staff more frequently inserted PIVCs in the antecubital fossa than paramedics (65.5% vs. 49.7%), where forearm PIVC insertion was more common pre-hospital than in ED (13.7% vs. 7.4%). Nursing staff inserted idle PIVCs at a rate of (35.1%) compared to doctors (29.6%) and paramedics (19.9%). Having a PIVC inserted in the ED was the only factor significantly (p ≤ .001) predicting an idle outcome (Odds Ratio: 2.4; 95% CI 1.7-3.3).

CONCLUSION

One-third of PIVCs inserted within the emergency setting remained idle, suggesting unnecessary risk and costs. Pre-hospital and ED PIVC insertion practices differed, with idle PIVCs 2.4 times more prevalent if inserted in the ED than pre-hospital and with greater use of antecubital insertion. Reasons for these differences are not well understood and requires more targeted research.

Midline venous catheters as an alternative to central line catheter placement: a product evaluation

Midline catheters have emerged as a successful alternative to peripheral venous catheters (PVCs) and central venous catheters (CVCs) in select patients. Midline catheters allow for greater duration of access when compared with PVCs and avoid the critical complications associated with CVCs. This article describes the implementation of the Powerwand^® midline at a large paediatric tertiary care facility in acute and intensive care settings, and presents illustrative cases of the catheter in use. Product evaluation was performed by a paediatric vascular access team of registered nurses and included information on patient outcomes, inserter satisfaction, patient satisfaction, and cost effectiveness.

Anatomic suitability for commercially available percutaneous arteriovenous fistula creation systems

OBJECTIVE

The Food and Drug Administration recently approved two percutaneous arteriovenous fistula creation systems: the Ellipsys vascular access (EL) system and WavelinQ EndoAVF (WQ) system. Although the initial clinical trials of each system have demonstrated a high success rate, little detail on anatomic suitability was provided. We sought to determine the real-world applicability of the EL and WQ systems by studying them in a single representative cohort.

METHODS

All patients receiving a first-time arteriovenous access consultation at a single Veterans Affairs institution underwent extensive vein mapping of the bilateral upper extremities. Anatomic suitability was assessed in accordance with the manufacturer's instructions for use (IFU), and clinical usability was determined using additional published anatomic guidelines. The suitability for radiocephalic fistula (RCF) creation was also assessed. To estimate how often these systems would be used in practice, a clinical algorithm was created, with a preference for RCF creation, followed by percutaneous arteriovenous fistula (pAVF) creation, surgical fistula creation at the elbow, and, finally, graft placement.

RESULTS

During the study period, 116 upper extremities were measured in 58 male patients. Per the IFU, the rate of extremity suitability was 93% and 52% for the WQ and EL systems, respectively (P < .0001). In the same population, 32% of the extremities had acceptable anatomy for RCF creation. The overall clinical usability of these systems using more recent published guidelines was 55% for the WQ system and 44% for the EL system (P = .09). The usability of both pAVF systems was most limited by the size of the deep perforating cubital vein. The proximity of the antecubital perforator vein and proximal radial artery additionally limited EL usability. Based on the clinical algorithm, initial access creation would have been RCF creation for 31% of the cohort, followed by the WQ (32%), the EL (23%), surgical fistula creation at the elbow (18%), and graft placement (17%).

CONCLUSIONS

Anatomic suitability was greater for WQ than for EL when considering only the IFU. Once the full requirements for pAVF creation were considered, we found no significant differences in usability between the two systems. Anatomic analysis showed that pAVF creation can constitute a substantial part of a hemodialysis access practice.

Universal adhesive vascular access securement with Grip-Lok devices

The use of sutureless, adhesive securement devices in vascular access has become recommended as best practice, because they are a cost-effective, reliable solution. After a vascular access device has been inserted, catheter securement is one of the most important aspects of care and maintenance. The Grip-Lok® range offers secure, comfortable adhesive securement for all types of vascular access devices. The products use hypoallergenic medical adhesive, which reduces the risk of skin irritation and provides a reliable, adaptable alternative to suturing.

Evaluation of a device to improve non-coring needle insertion into implanted intravenous ports

Implanted intravenous ports (IPs) are increasingly used in health care. The experience of having IPs accessed can vary a great deal for patients. Successful IP access depends on the experience and skill of the health professional and wrongly positioned attempts are not only painful for the patient but can also cause damage to the outer casing of the IP. The more skin punctures made over the port, the higher the risk of infection in the subcutaneous tissue. The Portacator is a sterile, single-use product that sits on the skin over the IP insertion site. Its purpose is to enable the successful insertion of a non-coring needle into the centre of the IP. The device's efficacy was investigated using a port test rig and by conducting a clinical evaluation in two hospital units that support patients with IPs who require regular IV therapy infusions for long-term illness. The device provides an easy reference for central non-coring needle insertion, and users were able to insert the needle closer to the port chamber centre when using the device as only two fingers are used to hold it in place, which gave them a less obstructed view of the site. The device improved the rates of first-time IP puncture success with a non-coring needle. Patient satisfaction increased as they were more confident insertion would be successful first time so they would experience less pain. Nurses felt better supported and more confident they could achieve success at their first attempt at IP access using the device.

Methods for microbial needleless connector decontamination: A systematic review and meta-analysis

BACKGROUND

The objective of this review was to compare the effectiveness of connector decontamination with 70% alcohol wipes, alcoholic chlorhexidine gluconate wipes, or alcohol impregnated caps to prevent catheter-associated bloodstream infection (CABSI).

METHODS

A systematic search was conducted in CINAHL, Cochrane Central Register of Controlled Trials, Medline, and PubMed. The primary outcome was CABSI, with randomized and observational studies included. The inclusion criteria were: English language, any age group, no date limitations, and reporting connector decontamination interventions to prevent CABSI. The exclusion criteria were: multimodal interventions, letters, and conference abstracts. Quality assessment with the Newcastle-Ottawa Scale, a narrative synthesis, and meta-analysis were conducted. Pooled data used a random effects model for pair-wise comparisons, due to clinical heterogeneity. Statistical heterogeneity was investigated by visual model inspection, χ², and I² statistics.

RESULTS

Ten studies compared 70% alcohol wipes with 70% alcohol-impregnated caps, and 2 studies (n = 1,216) tested an alcoholic chlorhexidine gluconate wipe. Alcoholic chlorhexidine gluconate wipes were associated with significantly less CABSI than 70% alcohol wipes (risk ratio, 0.28; 95% confidence interval, 0.20-0.39). Alcohol-impregnated caps were associated with significantly less CABSI than 70% alcohol wipes (risk ratio, 0.43; 95% confidence interval, 0.28-0.65). Studies were of low to moderate quality.

CONCLUSIONS

Alcohol impregnated caps and alcoholic chlorhexidine gluconate wipes were associated with significantly less CABSI than 70% alcohol wipes. This requires confirmation in randomized controlled trials.

Incidence of peripheral intravenous catheter failure among inpatients: variability between microbiological data and clinical signs and symptoms

Background

Peripheral intravenous catheters (PIVCs) are the most widely used invasive devices among inpatients. Catheter-related bloodstream infections (CRBSI) are serious yet preventable events for patients. Although the contribution of PIVCs towards these infections is gradually being recognised, its role in the Spanish setting is yet to be determined. We aimed to estimate the rate and incidence of PIVC failure at Manacor hospital (Spain) as baseline within a wider quality improvement initiative.

Methods

Tips from all PIVC removed during December 2017 and January 2018 in hospital wards were cultured semiquantitatively. The study population included all PIVCs inserted in adult patients admitted to any of three medical and one surgical wards, emergency department, critical care unit and operating rooms. Clinical, microbiological and ward information was collected by clinical researchers for each PIVC from insertion to removal on the study sites. CRBSI was defined per international guidelines (i.e., Centers for Disease Control and Prevention, USA). Data was analysed descriptively.

Results

Seven hundred and eleven tips were cultured, with 41.8% (297/711) reported as PIVC failure. The PIVC failure rate density-adjusted incidence for hospital length of stay (HLOS) was 226.2 PIVC failure/1000 HLOS. 5.8% (41/711) tips yielded positive isolates, with most frequent microorganisms Staphylococcus spp (S. epidermidis 29/41, 70.7%, S. aureus 2/41, 4.9%, S. hominis 2/41, 4.9%), and Acinetobacter baumannii (1/41, 2.4%). One S. aureus isolate was methicillin-resistant. 53.6% (22/41) positive cultures were obtained from patients with local signs and symptoms compatible with catheter-related infection (CRI), 2.4% (1/41) were compatible with CRBSI type 2 and that clinical signs improve within 48 h of catheter removal (density-adjusted incidence for hospital stays of 16.7 PIVC-CRI/1000 hospital-stays and 0.76 PVC-BSI/1000 hospital-stays respectively) and no patients were diagnosed CRBSI type 3 with a bacterial growth concordant in tip and blood cultures. Most cases responded favourably to catheter removal and management.

Conclusions

Our findings show that almost 42% PIVCs resulted in unplanned removal, amplifying the importance in terms of morbidity, mortality and patient safety. A high number of positive tip cultures without clinical signs and symptoms was observed. We underpin the importance to remove unnecessary PIVCs for the prevention of CRBSI.

Can variable practice habits and injection port dead-volume put patients at risk?

Injection ports used to administer medications and draw blood samples have inherent dead-volume. This volume can potentially lead to inadvertent drug administration, contribute to erroneous laboratory values by dilution of blood samples, and increase the risk of vascular air embolism. We sought to characterize provider practice in management of intravenous (IV) and arterial lines and measure dead-volumes of various injection ports. A survey was circulated to anesthesiology physicians and nurses to determine practice habits when administering medications and drawing blood samples. Dead-volume of one and four-way injection ports was determined by injecting methylene blue to simulate medication administration or blood sample aspiration and using absorption spectroscopy to measure sample concentration. Among the 65 survey respondents, most (64.52%) increase mainstream flow rate to flush medication given by a 1-way injection port. When using 4-way stopcocks, 56.45% flush through the same injection site. To obtain a sample from an arterial line, 67.74% draw back blood and collect the sample from the same 4-way stopcock; 32.26% use a different stopcock. Mean (SD) dead-volume in microliters ranged from 0.1 (0.0) to 5.6 (1.0) in 1-way injection ports and from 54.1 (2.8) to 126.5 (8.3) in 4-way injection ports. The practices of our providers when giving medications and drawing blood samples are variable. The dead-volume associated with injection ports used at our institution may be clinically significant, increasing errors in medication delivery and laboratory analysis.

Evaluation Efficacy of Ferrous Sulfate Therapy on Headaches of 5-15 Years Old Iron Deficient Children with Migraine

BACKGROUND

Some researches have shown the association between iron deficiency and migraine headache in adults. The aim of present study was to evaluate efficacy of ferrous sulfate treatment on migraine headaches of 5-15 years old migraineur children with iron deficiency.

MATERIALS AND METHODS

In a quasi- experimental study, monthly frequency, severity, duration and disability of headaches of 5-15 years old migraineur children that prophylactic therapy was indicated in them and had iron deficiency who were referred to Pediatric Neurology Clinic of Shahid Sadoughi University of Medical Sciences, Yazd, Iran between 2013 and 2015 and were treated with 2mg/kg/day topiramate plus 4mg/kg/day of ferrous sulfate for three consecutive months, were evaluated and headache characteristics before and after treatment were compared.

RESULTS

In this study, 98 children with mean age of 9.72±3.19 were evaluated that 31children (31.6%) had iron deficiency. Monthly frequency (22.89±7.18 vs.14.5±4.56, P= 0.02), severity score (8.12± 1.76 vs. 5.03±1.15, P= 0.02) and disability score of headache (38.23±10.7vs. 30.12±7.46, P= 0.03) were more in children with iron deficiency. Iron therapy was effective in decreasing of monthlyfrequency 22.89± 7.18 vs. 10.13±4.51, P = 0.001), severity score (8.12±1.76 vs. 5.11±1.62, P =0.001), duration (2.14±1.23 vs.1.14±1.01, P= 0.001) and disability score of headache (38.23±10.7 vs. 22.87±8.65, P= 0.01).

CONCLUSION

In children, iron deficiency increased monthly frequency, severity and disability of migraine headache and ferrous sulfate can be used as a safe and effective drug in migraine prophylaxis.

Implantable Port Devices, Complications and outcome in Pediatric Cancer, a Retrospective Study

BACKGROUND

Peripheral blood vessels, due to availability are used for many years in cancer patients, however in patients with potentially harmful drugs to skin (vesicant drugs) or difficult accessibility to vessels, the use of implantable port (totally implantable venous access port-TIVAP) devices with central vascular access are important.

MATERIALS AND METHODS

In this retrospective study, 85 pediatric cancer patients younger than 16 years, with TIVAP implantation, were followed for their complications and outcome. In addition to demographic data, patients' port complications were assessed and compared with published articles.

RESULTS

Mean days of implanted port usage were 531 ± 358 days in all patients. This period was 287 ±194 days in complicated patients. Complications included as infection (tunnel infection and catheter related blood-stream infection), malfunction and thrombosis, skin erosion, tube avulsion, and tube adhesion to the adjacent vessels were seen in 30.6% of patients.

CONCLUSION

According to the published data and this experience, the most common complications in TIVAP are infection and catheter malfunction. It is important to notice that in order to prolong its efficacious life, effective sterilization methods, prevention of clot formation and trauma, are the most useful measures.

The bacterial colonization in tunneled cuffed dialysis catheter and its effects on residual renal function in incident hemodialysis patients

BACKGROUND

The bacterial colonization of hemodialysis catheter occurs frequently and reaches to the catheter-related bloodstream infections (CRBSIs). We hypothesized bacterial colonization promotes inflammation and that might be associated with renal outcome. The aim of this study was to investigate the colonization status for tunneled cuffed dialysis catheter (TCC) and the factors for contributing to the catheter colonization and explore whether bacterial colonization would be related with declining of residual renal function (RRF).

METHODS

115 patients who received TCC removal operation and underwent catheter tip culture from January 2005 to June 2014 were enrolled. The follow-up data such as urine output (UO), time to anuria and patients' survival were collected from the patients or their family members by telephone in June, 2014.

RESULTS

There were nineteen patients (16.5 %, 19/115) with positive tip culture (colonization group). In the analysis of demographic and biochemical parameters, there were no significant differences between both groups. Fifty of all the subjects responded to the telephone survey and ten patients (20.0 %, 10/50) belonged to colonization group. The monthly decreasing rate of UO was significantly more rapid in colonization group (p = 0.001). The survival analysis showed that colonization group had worse estimated anuria-free survival than non-colonization group (p < 0.001). In multivariate cox regression, bacterial colonization of TCC was an independent factor influencing the loss of RRF (HR 4.29, 95 % CI: 1.905-9.683, p ≤ 0.001).

CONCLUSIONS

Bacterial colonization of TCC was associated with rapid loss of RRF.

[Non-tuberculous mycobacterial infection of a totally implanted perfusion device]

INTRODUCTION

Catheter-related infection by non-tuberculous mycobacteria is rare but difficult to diagnose and the treatment is not standardized.

CASE REPORT

A 64-year-old woman treated for lung cancer with intravenous chemotherapy developed an infection of her totally implanted perfusion device with Mycobacterium chelonae. The infection was cured after surgical removal of the device and treatment with oral clarithromycin.

CONCLUSION

Mycobacteria may infect vascular access devices. Rapid diagnosis of such infections allows early treatment.

Comprehensive understanding of atrial septal defects by imaging studies for successful transcatheter closure

Transcatheter closure of atrial septal defects has become a popular procedure. The availability of a preprocedural imaging study is crucial for a safe and successful closure. Both the anatomy and morphology of the defect should be precisely evaluated before the procedure. Three-dimensional (3D) echocardiography and cardiac computed tomography are helpful for understanding the morphology of a defect, which is important because different defect morphologies could variously impact the results. During the procedure, real-time 3D echocardiography can be used to guide an accurate closure. The safety and efficiency of transcatheter closures of atrial septal defects could be improved through the use of detailed imaging studies.

Burden of complications from needle penetration of plastic ports in children

BACKGROUND

Complications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations.

METHODS

We performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution.

RESULTS

There were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2±21.3 months (range 0.3 to 63.4 months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15).

CONCLUSIONS

There is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.

Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit

OBJECTIVE

Femoral catheters pose a potential barrier to early rehabilitation in the intensive care unit (ICU) due to concerns, such as catheter removal, local trauma, bleeding, and infection. We prospectively evaluated the feasibility and safety of physical therapy (PT) in ICU patients with femoral catheters.

DESIGN, SETTING, AND PATIENTS

We evaluated consecutive medical ICU patients who received PT with a femoral venous, arterial, or hemodialysis catheter(s) in situ.

MEASUREMENTS AND MAIN RESULTS

Of 1074 consecutive patients, 239 (22%) received a femoral catheter (81% venous, 29% arterial, 6% hemodialysis; some patients had >1 catheter). Of those, 101 (42%) received PT interventions, while the catheter was in situ, for a total of 253 sessions over 210 medical ICU (MICU) days. On these 210 MICU days, the highest daily activity level achieved was 49 (23%) standing or walking, 57 (27%) sitting, 25 (12%) supine cycle ergometry, and 79 (38%) in-bed exercises. During 253 PT sessions, there were no catheter-related adverse events giving a 0% event rate (95% upper confidence limit of 2.1% for venous catheters).

CONCLUSIONS

Physical therapy interventions in MICU patients with in situ femoral catheters appear to be feasible and safe. The presence of a femoral catheter should not automatically restrict ICU patients to bed rest.