Prospective clinical study on the incidence of catheter-related complications in a neurological intensive care unit: 4 years of experience

INTRODUCTION

Over the past decades, significant efforts have been made to reduce early and late catheter-related complications in critically ill patients, using approaches based on bundles of evidence-based interventions.

METHODS

In this prospective clinical study, the authors evaluated the incidence of catheter-related complications in their neuro-intensive care unit during a 4-year period, adopting systematically the GAVeCeLT bundles for the insertion and management of all central venous access devices: centrally inserted central catheters (CICCs), peripherally inserted central catheters (PICCs) and femorally inserted central catheters (FICCs). All early/immediate and late complications were recorded.

RESULTS

On 486 central lines (328 CICCs, 149 PICCs and 9 FICCs), the only clinically relevant early/immediate complication was primary tip malposition (1%). In regards late infective complications, the authors did not record any case of catheter-related bloodstream infection; though, they observed one case of central line associated blood stream infection (one CICC; 0.14/1000 catheter days), and 15 cases of catheter colonization (12 CICCs and 3 PICCs; 2.09 episodes/1000 catheter days). Late non-infective complications were few: 14 accidental dislodgments (2.9%), 18 irreversible lumen occlusions (3.7%), and no episodes of symptomatic catheter-related thrombosis or tip migration.

CONCLUSION

The systematic adoption of the GAVeCeLT bundles for CVAD insertion and maintenance was associated with a minimization of catheter-related complications. The strict adherence to the recommendations included in these bundles was the major determinant for clinical success.

Venous Access: National Guideline and Registry Development (VANGUARD): Advancing Patient-Centered Venous Access Care Through the Development of a National Coordinated Registry Network

There are over 8 million central venous access devices inserted each year, many in patients with chronic conditions who rely on central access for life-preserving therapies. Central venous access device-related complications can be life-threatening and add tens of billions of dollars to health care costs, while their incidence is most likely grossly mis- or underreported by medical institutions. In this communication, we review the challenges that impair retention, exchange, and analysis of data necessary for a meaningful understanding of critical events and outcomes in this clinical domain. The difficulty is not only with data extraction and harmonization from electronic health records, national surveillance systems, or other health information repositories where data might be stored. The problem is that reliable and appropriate data are not recorded, or falsely recorded, at least in part because policy, payment, penalties, proprietary concerns, and workflow burdens discourage completeness and accuracy. We provide a roadmap for the development of health care information systems and infrastructure that address these challenges, framed within the context of research studies that build a framework of standardized terminology, decision support, data capture, and information exchange necessary for the task. This roadmap is embedded in a broader Coordinated Registry Network Learning Community, and facilitated by the Medical Device Epidemiology Network, a Public-Private Partnership sponsored by the US Food and Drug Administration, with the scope of advancing methods, national and international infrastructure, and partnerships needed for the evaluation of medical devices throughout their total life cycle.

Complications of Central Venous Access Devices Used in Palliative Care Settings for Terminally Ill Cancer Patients: A Systematic Review and Meta-Analysis

(1) Background: Central venous access devices (CVADs) have been commonly employed during various courses of anticancer treatment. Currently, there are a few types of clinically available CVADs, which are associated with short-term and long-term complications. However, little is known about the complication rates when CVADs are used only in palliative care settings. We therefore performed a systematic review and meta-analysis of all the published literature to evaluate the complication rates of CVADs in this clinical setting. (2) Methods: A systematic review and meta-analysis were conducted to identify publications from PubMed/MEDLINE, Embase (Ovid), Scopus, Cochrane Library, CINAHL, Google Scholar, and trial registries. Publications reporting the complication rates of PICCs, central lines, and PORTs in palliative settings for terminally ill cancer patients were included, while those on the use of systemic anticancer therapy and peripheral venous catheters were excluded. The outcome measures included overall complication rate, rate of catheter-related bloodstream infection (CRBSI), and rate of thromboembolism (TE). This systematic review was registered with PROSPERO (CRD42023404489). (3) Results: Five publications with 327 patients were analyzed, including four studies on PICCs and one study on central lines. No studies on PORTs were eligible for analysis. The overall complication rate for PICCs (pooled estimate 7.02%, 95% CI 0.27-19.10) was higher than that for central lines (1.44%, 95% CI 0.30-4.14, p = 0.002). The risk of CRBSI with PICCs (2.03%, 95% CI 0.00-9.62) was also higher than that with central lines (0.96%, 95% CI 0.12-3.41, p = 0.046). PICCs also had a trend of a higher risk of TE (2.10%, 95% CI 0.00-12.22) compared to central lines (0.48%, 95% CI 0.01-2.64, p = 0.061). (4) Conclusions: PICCs for palliative cancer care were found to have greater complications than central lines. This might aid in the formulation of future recommendation guidelines on the choice of CVAD in this setting.

Peripherally inserted central catheter versus totally implanted venous port for delivering medium- to long-term chemotherapy: A cost-effectiveness analysis based on propensity score matching

BACKGROUND

Peripherally inserted central catheters (PICCs) and totally implanted vascular access ports (PORTs) have been widely used for medium- to long-term chemotherapy. PICCs are associated with lower insertion cost, but higher complication rates than PORTs. However, there is a paucity of cost-effectiveness comparisons between the devices. We aimed to compare the cost-effectiveness of PICCs and PORTs for medium- to long-term chemotherapy from catheter insertion to removal.

METHODS

A cost-effectiveness analysis was conducted based on propensity score matching (PSM) from the hospital perspective. Data were collected from a retrospective cohort study. The total cost outcome comprised insertion, maintenance, removal and complication costs. The effectiveness outcome was the complication-free rate. The primary and supplemental outcomes were cost-effectiveness ratios (CERs) and incremental cost-effectiveness ratios (ICERs).

RESULTS

A total of 1050 patients (after PSM for 417 patients) were included. The average total cost for 3-6 month ($603.55 ± 78.68 vs $1270.21 ± 128.84), 6-9 month ($731.40 ± 42.97 vs $1414.48 ± 155.43), and 9-12 month ($966.83 ± 53.78 vs $1587.76 ± 160.56) dwell times were all significantly lower for PICCs than for PORTs (p < 0.001). PICCs were associated with significantly lower complication-free rates than PORTs during the 3-6 month (65.22% vs 90.58%, p < 0.001), 6-9 month (53.33% vs 91.80%, p < 0.001), and 9-12 month (44.44% vs 88.46%, p = 0.015) dwell times. Ultimately, PICCs were associated with lower CERs than PORTs for the 3-6 month (928.54 vs 1395.84) and 6-9 month (1380.00 vs 1537.48) but higher CER for the 9-12 month (2197.34 vs 1804.27) dwell times. ICERs were 2564.08 and 1751.49 with dwell times of 3-6 months and 6-9 months, respectively.

CONCLUSION

This study provided economic evidence that informs vascular access device choice for medium- to long-term chemotherapy. For 3-9 month dwell times, PICCs were more cost-effective than PORTs. Furthermore, ICERs were applied and the choice was determined by willingness-to-pay. For 9-12 month dwell times, PORTs might be more cost-effective than PICCs, and studies with larger sample size would be needed to verify this finding in the future.

Utilization and Complications of Central Venous Access Devices in Oncology Patients

Purpose: To describe how central venous access devices (CVADs) are utilized for ambulatory oncology patients and to evaluate the rate of complications. Method: Single institution retrospective study of oncology patients with CVADs who received systemic treatment at the Walker Family Cancer Centre (WFCC) between 1 January and 31 December 2018. Results: A total of 480 CVADS were placed in 305 patients, of which 408 (85%) were peripherally inserted central catheters (PICCs) and 72 (15%) were implanted vascular access devices (PORTs). The incidence of early and late complications was 9% and 24%, respectively. For the entire cohort, the rate of venous thromboembolism (VTE) was 16%, of which 9% were CVAD-related thrombosis (CRTs) and 7% were distant VTE. The CRT rates were similar for PICCs and PORTs (9% vs. 7%). A total of 6% of CVADs were complicated by infection (i.e., localized infections and bacteremia), with a total infection rate of 0.43 and 0.26 per 1000 indwelling days for PICCs and PORTs, respectively. The incidence of central line associated bloodstream infections (CLABSI) was greater for PICCs than PORTs, at a rate of 0.22 compared with 0.08 per 1000 indwelling days, respectively. The premature catheter removal rate was 26% for PICCs and 18% for PORTs. PORTs required more additional hospital visits. Conclusions: PICCs were utilized more frequently than PORTs and had a higher rate of premature removal. The rates of VTE and CRT were similar for both CVAD types. PORTs had a lower rate of infection per 1000 indwelling days. However, the management of PORT related complications required more visits to the hospital and oncology clinic.

Intracavitary electrocardiography for tip location during central venous catheterization: A narrative review of 70 years of clinical studies

Intracavitary electrocardiography is an accurate and non-invasive method for central venous access tip location. Using the catheter as a traveling intracavitary electrode, intracavitary electrocardiography is based on the increase in the detected amplitude of the P wave while approaching the cavoatrial junction. Despite having been adopted diffusely in clinical practice only in the last years, this method is not novel. In fact, it has first been described in the late 40s, during electrophysiological studies. After a long period of quiescence, it is in the last two decades of the XX century that intracavitary electrocardiography became popular as an effective mean of central venous catheters tip location. But the golden age of this technique began with the new millennium, as documented by high-quality studies in this period. In fact, in those years, intracavitary electrocardiography has been studied broadly, and important achievements in terms of comprehension of the technique, accuracy, and feasibility of the method in different populations and conditions (i.e. pediatrics, renal patients, atrial fibrillation) have been gained. In this review, we describe the technique, its history, and its current perspectives.

Infective Endocarditis in Patients With Intestinal Failure: Experience From a National Referral Center

BACKGROUND

Infective endocarditis (IE) is a recognized complication of central line-associated bloodstream infection (CLABSI). Central venous access devices (CVADs) are essential for the delivery of long-term parenteral nutrition (PN), yet there are no published data as to the prevalence, characteristics and outcomes of IE in this population.

METHODS

A prospectively maintained database of patients with intestinal failure (IF) types 2 and 3, managed by a national intestinal failure center between January 2010 and December 2018, was analyzed retrospectively and relevant factors extracted from case records.

RESULTS

A total of 745 patients with IF and CVADs in situ on admission, or placed during their stay, were admitted over the duration of this study, 640 with type 2 IF and 105 with type 3 IF. Two hundred eighty-two echocardiograms were performed to investigate potential IE associated with a CLABSI event. Four cases of IE were identified in the entire cohort of 782,666 catheter days (IE incidence rate: 0.005 per 1000 catheter days and 187 per 100,000 person-years for the entire cohort; 0.048 per 1000 inpatient catheter days for acute type 2 IF, 0.0026 per 1000 outpatient catheter days [ie, 99 per 100,000 person-years for outpatients with type 3 IF]).

CONCLUSION

IE is rare in the type 3 IF population and a rare consequence of CLABSI in inpatient acute type 2 IF. However, mortality and morbidity are high. Routine echocardiography may not be warranted for investigation of CLABSI unless there is a high risk of IE or a virulent organism is involved.

Central Venous Access Device Complications in Patients Receiving Parenteral Nutrition in General Ward Settings: A Retrospective Analysis

BACKGROUND

Central venous access devices (CVADs) are used widely in acute clinical settings for the infusion of parenteral nutrition (PN) in patients who are unable to meet their nutrition requirements via the oral or enteral routes. The aim of this study was to characterize the frequency and nature of CVAD complications in patients receiving PN in general ward settings.

METHODS

A retrospective analysis of CVAD-related outcomes for adult patients who received PN from January 2014 to December 2016 was conducted.

RESULTS

A total of 629 CVADs were placed in 475 patients for parenteral administration in general ward settings during the 3-year study period. A total 104 (16.53%) episodes of CVAD-associated complications were reported during this period, including suspected line infection, leak at site, catheter blockage, and generalized patient sepsis. Overall, 13 CVAD catheter-related bloodstream infections (CRBSIs) were diagnosed in the patient cohort over 8695 PN feeding days, giving an incidence of 1.49 CVAD infections per 1000 PN feeding days.

CONCLUSION

The results showed that patients receiving PN through CVADs within general ward settings experience CRBSI at rates no different from those reported within critical care settings. These findings demonstrate that with appropriate nursing care, CVADs appear safe when used for the administration of PN in general ward settings.

Tetrasodium EDTA Is Effective at Eradicating Biofilms Formed by Clinically Relevant Microorganisms from Patients' Central Venous Catheters

The colonization of catheters by microorganisms often precludes their long-term use, which can be a problem for human patients that have few body sites available for new catheters. The colonizing organisms often form biofilms, and increasingly these organisms are resistant to multiple antibiotics, making them difficult to treat. In this article, we have taken microorganisms that are associated with biofilm formation in catheters from two Canadian hospitals and tested them with tetrasodium EDTA, a new antimicrobial catheter lock solution. Tetrasodium EDTA was effective at eliminating Gram-positive, Gram-negative, and fungal species and represents a promising alternative to antibiotic treatment with less chance of the organisms developing resistance. We expect that our results will be of interest to researchers and clinicians and will lead to improved patient care.

Central venous access devices (CVADs) are an essential component of modern health care. However, their prolonged use commonly results in microbial colonization, which carries the potential risk of hospital-acquired bloodstream infections. These infections complicate the treatment of already sick individuals and cost the existing health care systems around the world millions of dollars. The microbes that colonize CVADs typically form multicellular biofilms that are difficult to dislodge and are resistant to antimicrobial treatments. Clinicians are searching for better ways to extend the working life span of implanted CVADs, by preventing colonization and reducing the risk of bloodstream infections. In this study, we analyzed 210 bacterial and fungal isolates from colonized CVADs or human bloodstream infections from two hospitals geographically separated in the east and west of Canada and screened the isolates for biofilm formation in vitro. Twenty isolates, representing 12 common, biofilm-forming species, were exposed to 4% tetrasodium EDTA, an antimicrobial lock solution that was recently approved in Canada for use as a medical device. The EDTA solution was effective at eradicating surface-attached biofilms from each microbial species, indicating that it could likely be used to prevent biofilm growth within CVADs and to eliminate established biofilms. This new lock solution fits with antibiotic stewardship programs worldwide by sparing the use of important antibiotic agents, targeting prevention rather than the expensive treatment of hospital-acquired infections.

IMPORTANCE The colonization of catheters by microorganisms often precludes their long-term use, which can be a problem for human patients that have few body sites available for new catheters. The colonizing organisms often form biofilms, and increasingly these organisms are resistant to multiple antibiotics, making them difficult to treat. In this article, we have taken microorganisms that are associated with biofilm formation in catheters from two Canadian hospitals and tested them with tetrasodium EDTA, a new antimicrobial catheter lock solution. Tetrasodium EDTA was effective at eliminating Gram-positive, Gram-negative, and fungal species and represents a promising alternative to antibiotic treatment with less chance of the organisms developing resistance. We expect that our results will be of interest to researchers and clinicians and will lead to improved patient care.

Clinical report of 14 retrievals with detailed angiographic analysis and review of procedural aspects

Introduction

Totally implantable venous access systems (TIVAS), Swan-Ganz (SG) and central venous catheters (CVC) allow easy and repetitive entry to the central cardiovascular system. Fragments of them may be released inadvertently into the cardiovascular system during their insertion or as a result of mechanical complications encountered during long-term utilization.

Aim

To present results of percutaneous retrieval of embolized fragments of central venous devices or knotted SG and review the procedural aspects with a series of detailed angiographies.

Material and methods

Between January 2003 and December 2012 there were 14 (~0.025%) successful retrievals in 13 patients (44 ±16 years, 15% females) of embolized fragments of TIVAS (n = 10) or CVC (n = 1) or of dislodged guide-wires (n = 2) or knotted SG (n = 1).

Results

Foreign bodies with the forward end located in the right ventricle (RV), as well as those found in the pulmonary artery (PA), often required repositioning with a pigtail catheter as compared to those catheter fragments which were located in the right atrium (RA) and/or great vein and possessed an accessible free end allowing their direct ensnarement with the loop snare (57.0% (4/7) vs. 66.7% (2/3) vs. 0.0% (0/3); p = 0.074 respectively). Procedure duration was 2–3 times longer among catheters retrieved from the PA than among those with the forward edge located in the RV or RA (30 (18–68) vs. 13.5 (11–37) vs. 8 min (8–13); p = 0.054 respectively). The SG catheter knotted in the vena cava superior (VCS) was encircled with the loop snare introduced transfemorally, subsequently cut at its skin entrance and then pulled down inside the 14 Fr vascular sheath.

Conclusions

By using the pigtail catheter and the loop snare, it is feasible to retrieve centrally embolized fragments or knotted central venous access devices.

Endovascular management of acute upper extremity deep venous thrombosis and the use of superior vena cava filters

Upper extremity deep venous thrombosis (UEDVT), though less common than lower extremity DVT, is a significant problem with several possible etiologies. The incidence of UEDVT is on the rise, primarily from the increasing use of central venous access devices. However, there are other causes of UEDVT, including primary venous thrombosis (Paget-Schroetter syndrome) and hypercoagulable states associated with underlying malignancy. The morbidity and mortality associated with UEDVT is largely from pulmonary embolism and the postphlebitic syndrome. Nevertheless, many UEDVTs are asymptomatic or patients may present with nonspecific clinical symptoms; therefore, a high index of suspicion is often necessary to make a correct diagnosis. Currently, there is no standard treatment algorithm for UEDVT. Treatment options may range from systemic anticoagulation to surgical correction depending on the etiology of the thrombus, as well as the patient's associated comorbidities, life expectancy and expected quality of life following treatment.