Colonization of central venous catheters

We studied etiologic factors important in colonization of 179 central venous catheters (CVCs) in patients randomized into group 1 (who received daily topical applications of povidone-iodine) or group 2 (who received only dry dressing changes). Colonization rates of CVC tips were similar between group 1 (18/84 or 21%) and group 2 (22/95 or 23%). Peripheral blood cultures grew Candida in eight hyperalimented patients (evenly divided between groups 1 and 2), S epidermidis in four other patients (also evenly divided), and gram-negative bacteria in three patients. Colonization rates for CVCs in place for 0 to seven days was 15.6% (17/109) and 76.7% (23/30) if used from eight to 30 days. Inflammatory signs at CVC sites were often absent when CVCs became colonized or produced bacteremia. Unimportant determinants of CVC colonization included skin securement of CVCs, antibiotic infusions through CVC lines, and masking and gowning of physicians before CVC placement. Daily applications of povidone-iodine did not reduce colonization of CVCs as compared to dry dressing changes.     

Catheter-related infection in critically ill patients

Objective To describe the incidence of the catheter-related local infection (CRLI) and catheter-related bloodstream infection (CRBSI) of central venous catheters (CVCs) and arterial catheters (ACs).Design Prospective, observational study.Setting A 24-bed medical-surgical intensive care unit of a 650-bed university hospital.Patients We included 988 consecutive patients admitted to the ICU during 18 months.Measurements The incidence density of CRLI and CRBSI, per 1000 catheter-days, of CVC and AC.Results Central venous catheters had a significantly higher incidence density of CRLI (4.74 vs 0.97/1,000 catheter-days; p<0.001) than ACs. Femoral venous access had a higher incidence density of CRLI than subclavian (13.15 vs 1.81/1,000 catheter-days, p=0.003) and than peripheral access (13.15 vs 2.30/1,000 catheter-days, p<0.001). Jugular venous access had a higher incidence density of CRLI (6.29 vs 1.81/1,000 catheter-days, p<0.001) than subclavian access. We found no significant differences in the incidence density of CRLI and CRBSI between the different AC accesses.Conclusions In the CDC guidelines, catheter insertion at the subclavian site is recommended in preference to femoral and jugular accesses, and there is no recommendation about AC site insertion. Our data support these recommendations about CVCs. Because the AC infection rate was very low, our study suggests that the access site is probably not of major importance for this type of catheter.     

Infection control issues in central venous catheter care.

Central venous catheters (CVCs) are now a routine part of patient management in the intensive care unit (ICU). Over time, a vast amount of literature associated with the use and care of CVCs has accumulated. The purpose of this article is to discuss the literature associated with the care of these devices in a narrative format. Although particular attention is paid to infection control issues, other fundamental areas such as catheter design, dressings, line changing and post insertion management are also discussed. The article goes on to look at the future of CVC design and concludes with an analysis of future developments related to CVCs.     

The safety of prolonging the use of central venous catheters: a prospective analysis of the effects of using antiseptic-bonded catheters with daily site care

OBJECTIVE: To determine rates of catheter colonization and catheter-related bloodstream infection (CRBSI) when antiseptic-bonded central venous catheters (CVCs) and standardized daily site care are used with no predetermined interval for removal. DESIGN: Prospective observational study. SETTING: Two major trauma centers. PATIENTS: All trauma patients admitted to two major trauma centers that received a CVC from May 1996 through May 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Catheters were semiquantitatively cultured to identify bacterial colonization and CRBSI. Monitored variables included total catheter days, anatomical site of catheter insertion, and area in hospital of catheter insertion. CVC tips and intracutaneous segments were semiquantitatively cultured. A total of 460 (92%) of 501 catheters placed in 324 trauma patients were evaluable, representing 95.5% of all catheter days during the study period. Rates of catheter colonization and CRBSI were 5% (5/1000 catheter days) and 1.5% (1.511000 catheter days), respectively. Subclavian catheters were in place longer than femoral or internal jugular catheters (p < .0001), but the colonization rate was significantly lower (p = .03; relative risk, 0.34; 95% confidence interval, 0.15-0.77). No differences in CRBSI rates among anatomical sites or between catheters used < or =14 days and those used >14 days were identified. CONCLUSION: Femoral and internal jugular antiseptic-bonded CVCs develop bacterial colonization earlier than subclavian CVCs. Subclavian antiseptic-bonded CVCs combined with standardized daily site care may be safely used >14 days in trauma patients.     

Acridine orange leukocyte cytospin test for central venous catheter--related bloodstream infection: a pediatric experience

The aim of this study was to evaluate the acridine orange leukocyte cytospin (AOLC) test for the rapid diagnosis of septicemia caused by central venous catheters (CVCs), without removing the catheter, in a pediatric intensive care unit population. Twenty-six patients admitted in the pediatric intensive care unit of Azienda Ospedaliera "Ospedali Riuniti di Bergamo", Italy, were prospectively evaluated for CVC-related infection. Blood for culture was taken from all patients. Quantitative endoluminal cultures of the removed catheter tip by Cleri's technique and semiquantitative superficial cultures of the hub were performed. Gram staining and an AOLC smear were done according to Kite's technique. Four Staphylococcus CVC-related bloodstream infections were identified. CVC colonization was detected in 8 patients. Four had septicemia (Enterococcus faecalis, Escherichia coli, Klebsiella oxytoca, Candida glabrata) without CVC involvement. However, Gram staining and the AOLC test were negative in all cases. We conclude that cytocentrifugation and acridine orange staining of blood withdrawn by Kite's method from an in situ catheter, although simple, quick, and inexpensive, did not aid diagnosis in this pediatric population.     

The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters

OBJECTIVE: Short-term, noncuffed, percutaneously inserted central venous catheters (CVCs) are widely used and cause more than 250,000 bloodstream infections (BSIs) in hospitals each year in the United States. We report a prospective study undertaken to determine the pathogenesis of CVC-related BSI. DESIGN AND SETTING: Prospective cohort study in a university hospital 24-bed medical-surgical intensive care unit. PATIENTS AND PARTICIPANTS: Patients participating in two randomized trials during 1998-2000-one studying the efficacy of a 1% chlorhexidine-75% alcohol solution for cutaneous antisepsis and the other a novel chlorhexidine-impregnated sponge dressing-formed the study population; CVC-related BSIs were considered to be extraluminally acquired if concordance was identified solely between isolates from catheter segments, skin, and blood cultures and intraluminally acquired if concordance was demonstrated only between hub or infusate and blood culture isolates, as confirmed by DNA subtyping of isolates from blood and catheter sites or infusate. RESULTS: Of 1,263 catheters (6075 CVC days) prospectively studied, 35 (2.7%) caused BSI (5.9 per 1000 CVC days); 27 were caused by coagulase-negative staphylococci. Overall, 45% of infections were extraluminally acquired, 26% were intraluminally derived, and the mechanism of infection was indeterminate in 29%. In the pooled control groups of the two trials, 25 CVC-related BSIs occurred (7.0 per 1000 CVC days), of which 60% of infections were extraluminally acquired, 12% were intraluminally derived and 28% were indeterminate. In contrast, CVC-related BSIs in the treatment groups were most often intraluminally derived (60%, p=0.006). CONCLUSIONS: Most catheter-related BSIs with short-term percutaneously inserted, noncuffed CVCs were extraluminally acquired and derived from the cutaneous microflora. Strategies achieving successful suppression of cutaneous colonization can substantially reduce the risk of catheter-related BSI with short-term CVCs.     

Central venous catheter use

Central venous catheters (CVCs) are used with increasing frequency in the intensive care unit and in general medical wards. Catheter infection, the most frequent complication of CVC use, is associated with increased morbidity, mortality, and duration of hospital stay. Risk factors in the development of catheter colonisation and bloodstream infection include patient factors (increased risk associated with malignancy, neutropenia, and shock) and treatment-related factors (increased risk associated with total parenteral nutrition, ICU admission for any reason, and endotracheal intubation). Other risk factors are prolonged catheter indwelling time, lack of asepsis during CVC insertion, and frequent manipulation of the catheter. The most important factor is catheter care after placement. Effects of CVC tunnelling on infection rates depend to a large extent on indwelling time and the quality of catheter care. Use of polyurethane dressings can increase the risk of colonisation compared to regular gauze dressing. Thrombus formation around the CVC tip increases the risk of infection; low-dose anticoagulants may decrease this risk. New developments such as CVC impregnation with antibiotics may reduce the risk of infection. Reducing catheter infection rates requires a multiple-strategy approach. Therefore, ICUs and other locations where CVCs are used should implement strict guidelines and protocols for catheter insertion, care, and maintenance.     

Chlorhexidine versus povidone-iodine for central venous catheter site care in children

The number of children receiving central venous catheters (CVCs) for the administration of medications is at an all-time high. Unfortunately, placement of these CVCs is not without risks. Infection of CVC insertion sites is one of the most common, yet often preventable, causes of nosocomial bacteremia in both children and adults worldwide. Throughout the years, multiple practice recommendations have been made regarding the proper site care of CVCs. The most popular antimicrobial solution used for site care has traditionally been povidone-iodine. Chlorhexidine gluconate solution, however, has been shown to be more effective than povidone-iodine in preventing CVC-related infections in adults. There continues to be controversy regarding the efficacy and safety of antimicrobial solutions for pediatric CVC site care. An evidence-based approach was used to determine current recommendations for CVC site care in children.     

Accurate placement of central venous catheters using a 16-cm catheter

We determine if use of 16-cm central venous catheters (CVC) minimizes dangerous intracardiac catheter placements. We conducted a prospective study in a large community teaching hospital. Consecutive patients (n = 127) who required a CVC via either the internal jugular (IJV) or the subclavian vein (SCV) were assessed using 16 (n = 102) or 20-cm (n = 25) catheters. The main outcome measurements were (1) intracardiac placement of central venous catheters, and (2) relationship of right- or left-sided internal jugular or subclavian vein insertions to intracardiac catheter placement. Use of a 20-cm CVC resulted in 14 of 25 (56%) intracardiac placements compared with 11 of 102 (11%) using a 16-cm catheter (p < 0.0001). All intracardiac placements with the 16-cm CVC were from right-sided approaches: IJV 7 of 38 (16%), SCV 4 of 18 (18%). Use of a 16-cm CVC to access the central circulation from either the SCV or the IJV results in a significantly greater proportion of safe catheter placements than using longer CVCs, and it should become the standard of care.     

Urokinase for restoring patency of malfunctioning or blocked central venous catheters in children with hemato-oncological diseases

Goals of work To evaluate differences in success rate between two dosages of intraluminal urokinase (IL-UK) for treatment of withdraw occlusion in central venous catheters (CVC) and to confirm the efficacy of a salvage protocol with low-dose systemic urokinase (S-UK) in case of failure of IL-UK or of complete catheter obstruction.Patients and methods All malfunctioning or occluded partially implanted indwelling catheters inserted in a 29-month period in children with cancer at two tertiary care centers (Genoa and Turin) in Italy were eligible for this study. In cases of withdraw occlusion, IL-UK was used as first-line treatment with different schedules of administration in the two centers: a 5,000 IU/ml dose was used in Genoa and a 25,000 IU/ml dose in Turin (Protocol A). In case of failure of the front-line protocol or in case of complete CVC occlusion, S-UK at 1,000 IU/kg per hour for 3 h was used as a salvage protocol in both centers (Protocol B).Main results There were 81 episodes of malfunction and three of occlusion recorded in 68 CVCs. Protocol A was successful in 75 (92.5%) of the malfunction episodes. In particular, the dose of 5,000 IU of IL-UK was successful in 42 (89%) CVCs while the 25,000 IU dose resolved 33 (97%) of the episodes (not significant). The six patients with CVC refractory to IL-UK and the three subjects with complete CVC occlusion were treated with S-UK. Patency was obtained in seven cases (78%); the remaining two catheters had to be removed.Conclusions We found that 5,000 IU of IL-UK were as effective as 25,000 IU to resolve withdrawal occlusion in partially implanted CVCs and that systemic treatment with urokinase may rescue a significant proportion of CVCs refractory to IL-UK or that are apparently completely occluded.     

Each lumen is a potential source of central venous catheter-related bloodstream infection

OBJECTIVE: To determine the relative rates of microbial colonization of individual lumens in triple-lumen central venous catheters (CVCs) and calculate the chance of detecting catheter-related blood stream infection (CRBSI) if only one lumen is sampled. DESIGN: Prospective evaluation of CVCs from suspected and nonsuspected CRBSI cases. SETTING: University teaching hospital. PATIENTS: Triple-lumen CVCs from 50 cases of suspected CRBSI (a raised peripheral white blood cell count, temperature >37 degrees C, and/or local signs of infection at the catheter skin entry site) were evaluated. For comparison, 50 triple-lumen CVCs routinely removed at the end of use were evaluated. MEASUREMENTS: In both groups, peripheral blood cultures were taken before CVC removal. After CVC removal, each lumen was sampled in vitro using the endoluminal brush, and the tip was then cultured using the Maki roll technique. MAIN RESULTS: CVCs causing CRBSI had significant microbial colonization in one, two, or three lumens in ten (40%), ten (40%), or five (20%) cases, respectively. Overall, random sampling of only one lumen in CVCs causing CRBSI had a 60% chance of detecting significant colonization. CONCLUSIONS: If only one CVC lumen is sampled, a negative result does not reliably rule out infection. Each lumen of multiple-lumen CVCs should be considered as a potential source of CRBSI.     

Elective removal of cuffed central venous catheters in children

Background Subcutaneously tunneled, cuffed central venous catheters (CVCs) are commonly used in children undergoing cytotoxic chemotherapy or hematopoietic stem-cell transplantation. When their use is no longer indicated or precluded by mechanical or infectious complications, CVCs have to be removed. General instructions on how cuffed CVC should be removed are available in the medical texts but none is adapted for use in children. Materials and methods A literature search from the MEDLINE and EMBASE to identify articles describing the procedure of removing CVC or complications arising from the procedure was carried out. Results Specific guidance on the removal of CVC in children was not found. Venous air embolism appeared to be the most common complication associated with catheter removal but none involved pediatric patients. On the other hand, three out of the five incidents of catheter fracture with or without embolization happened in children. Conclusion Further studies are needed to define the optimal management of CVC removal in pediatric patients. A sequence of positioning the child, use of sedation, dissecting out the cuff, pulling off the catheter, closing the exit wound, and handling of the removed catheter is suggested.     

Partial occlusion of indwelling central venous catheters

Partial occlusion of indwelling central venous catheters (CVCs) developed as a clinical problem following the trend to leave CVCs in place for the duration of intravenous therapy, which can last for more than 1 year in some cases. The primary manifestation of partial catheter occlusion is the ability to infuse but not aspirate fluids through an indwelling CVC. There is evidence that the problem is at least partially related to a residue of blood products deposited within some CVCs and implanted ports each time blood is aspirated or infused. Over time, these deposits may act as a ball valve when aspiration from the CVC is attempted while still allowing fluid or drug infusions. A preliminary investigation has indicated that this partial occlusion can be corrected by the use of a fibrinolytic drug to "cleanse" the CVC of residual blood products through lysis, thus restoring full CVC patency. Controlled studies are still needed to determine how often the CVC should be cleansed to prevent buildup of blood products in the indwelling CVC.     

Are central venous catheter tip cultures reliable after 6-day refrigeration?

Present guidelines recommend culturing only central venous catheter (CVC) tips from patients with suspected catheter-related bloodstream infection (CR-BSI). However, a high proportion of these suspicions are not confirmed. Moreover, CVC tip culture increases laboratory workload, and reports of colonization may be meaningless or misleading for the clinician. Our working hypothesis was that CVC tips should be refrigerated and cultured only in patients with positive blood cultures. We evaluated the effect of 6-day refrigeration of 215 CVC tips. We selected all the catheters with a significant count according to the Maki's roll-plate technique and randomly assigned them to 2 groups. In group A, the catheters were recultured after 24 h of refrigeration, and in group B, the catheters were recultured after 6 days more of refrigeration, so that the refrigeration time evaluated would be of 6 days. The yield of refrigerated CVC tips that grow significant colony counts of primary culture in group B was compared with the yield of refrigerated catheter tips in group A. The difference showed that 6-day refrigeration reduced the number of significant CVCs by 15.2%. Only 61 CVCs were obtained from patients with CR-BSI, and in most of them, blood cultures were already positive before CVC culture, so only 0.91% of the CR-BSI episodes would have been misdiagnosed as culture negative after refrigeration. Refrigeration of CVC tips sent for culture and culturing only those from patients with positive blood cultures reduce the workload in the microbiology laboratory without misdiagnosing CR-BSI.     

Rifampicin-impregnated central venous catheters: a meta-analysis of randomized controlled trials

BACKGROUND: The use of antimicrobial-impregnated central venous catheters (CVCs) for the prevention of CVC microbial colonization and catheter-related bloodstream infection (CRBSI) remains controversial. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) evaluating CRBSI and colonization of CVCs impregnated with rifampicin-based antimicrobial combinations. Our main analysis compared the occurrence of CRBSI with rifampicin/minocycline-impregnated CVCs with that of non-rifampicin-impregnated CVCs. The PubMed and Cochrane Central Register of Controlled Trials databases were searched (until October 2006). RESULTS: Eight RCTs were included in the analysis. The main analysis (seven RCTs) demonstrated that rifampicin/minocycline-impregnated CVCs were associated with fewer CRBSIs compared with catheters not impregnated with rifampicin/minocycline (OR 0.23, 95% CI 0.14-0.40). The same was true regarding colonization (OR 0.46, 95% CI 0.31-0.69). Further analysis, comparing rifampicin-based CVCs with non-rifampicin-impregnated CVCs, demonstrated superiority of rifampicin-based CVCs in reducing colonization (OR 0.38, 95% CI 0.24-0.62) and CRBSI (OR 0.24, 95% CI 0.14-0.40). Similar results, suggesting superiority of rifampicin/minocycline-impregnated CVCs, were noted in a subgroup analysis of colonization and CRBSIs in which rifampicin/minocycline-impregnated CVCs were compared with simple, non-tunnelled, non-antimicrobially impregnated CVCs, a subgroup analysis that was performed by excluding low quality RCTs, and a subgroup analysis for colonization comprising studies in which the sonication technique was used. No serious adverse events and no difference in mortality between the two treatment groups were reported. No clear conclusions can be made regarding the impact of the use of rifampicin/minocycline-impregnated CVCs on the development of antimicrobial resistance based on the available data. CONCLUSIONS: The available evidence suggests that rifampicin/minocycline-impregnated CVCs are safe and effective in reducing the rate of catheter colonization and CRBSI. Further research should focus on the possible development of resistance and on pharmacoeconomic issues related to the use of rifampicin/minocycline-impregnated CVCs.     

Peripherally inserted central catheters are equivalent to centrally inserted catheters in intensive care unit patients for central venous pressure monitoring

To determine the equivalency of pressure measurements from peripherally inserted central catheters (PICCs) versus centrally inserted central venous catheters (CVCs) in vitro as well as in vivo. The in vitro study was performed in a clinical laboratory. Static pressure measurements from PICCs and CVCs were obtained in vitro over a physiologic range of 5–25 mmHg. Triple and dual lumen PICCs were directly compared to CVC controls. Dynamic pressure waveforms were recorded to simulate physiologic intravascular pressure variation. The in vivo study was executed in the medical intensive care unit (MICU) of a tertiary-level academic medical center. Data was collected from ten adult patients with both a PICC and a CVC in place for on-going clinical care. Measurements of central venous pressure (CVP) were recorded simultaneously from PICCs and CVCs. Duplicate measurements were taken after a stable waveform was recorded. For the in vitro study, a total of 540 pressure measurements were recorded. The average bias determined by Bland–Altman plot was 0 mmHg for the 5Fr PICC and 0.071 mmHg for the 6Fr PICC. The correlation coefficient for both catheters was 1.0 (P < 0.001). Dynamic pressure waveforms revealed equivalent amplitude. During the in vivo trial, 70 CVP measurements were collected. The paired CVP measurements were found to be highly reliable across subjects (r = 0.99, P < 0.0001). No significance in the average difference in CVP measurement (PICC–CVC) was determined by the Wilcoxon Signed Rank test (S = 1, P = 0.93). In conclusion, PICCs are equivalent to CVCs when measuring static and dynamic pressure in vitro and CVP in ICU patients.     

Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients

Objective: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. Design: One-year prospective audit. Setting: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. Patients and participants: 400 patients with non-tunnelled CVCs. Interventions: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. Measurements and results: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8 %) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95 % confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. Conclusions: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population. Received: 26 February 1998 Accepted: 30 June 1998     

Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term,noncuffed central venous catheters

BACKGROUND: Noncuffed, percutaneously inserted central venous catheters (CVCs) are widely used and cause at least 250,000 bloodstream infections (BSIs) in U.S. hospitals each year. We report a prospective study to determine whether inflammation at the insertion site is predictive of CVC-related BSI. METHODS: Percutaneously inserted, noncuffed CVCs inserted into the subclavian, internal jugular, or femoral vein in two randomized trials during 1998-2000 were prospectively studied; most patients were in an intensive care unit. The condition of the insertion site was evaluated daily by research nurses, quantifying pain (0, 1), erythema (0-2), swelling (0, 1), and purulence (0, 1); the lowest possible overall inflammation score was 0 and the highest was 5. CVC-related BSI was confirmed in each case by demonstrating concordance between isolates from the catheter segment and from blood cultures by restriction-fragment DNA subtyping. RESULTS: Among 1,263 CVCs prospectively studied, 333 (26.3%) were colonized at removal; of these, 35 catheters (2.7%) caused BSIs (5.9 per 1000 CVC days). BSIs were caused by coagulase-negative staphylococci (n = 27), enterococci (n = 4), enteric Gram-negative bacilli (n = 3), or (n = 1). Most insertion sites showed little or no inflammation at the time of removal. There were no significant differences among mean scores for each inflammatory variable examined or overall score among colonized CVCs (0.1 +/- 0.1), catheters causing CVC-related BSI (0.2 +/- 0.4), and noncolonized CVCs (0.1 +/- 0.1). The sensitivity of local inflammation for diagnosis of CVC-related BSI was dismal (0-3%). CONCLUSION: Local inflammation is uncommon with infected CVCs, probably because most catheter-associated infections are currently caused by coagulase-negative staphylococci, a pathogen that incites little local or systemic inflammation. Whereas overt inflammation of the insertion site should raise suspicion of CVC-related BSI caused by or Gram-negative bacilli, especially if the patient has fever or other signs of sepsis, in general, site appearance cannot be relied on to identify catheter colonization or CVC-related BSI.     

A prospective,longitudinal study of central venous catheter‐related deep venous thrombosis in boys with hemophilia

Summary. Background: Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter‐related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC‐related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication. Methods: All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC‐related DVT at two time‐points, 2 years apart. Each boy was evaluated for inherited hypercoagulability. Results: Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC‐related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02–6.7 years). Median duration of CVC placement was 6.4 years (range 3.3–15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level. Conclusions: CVC‐related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for ≥ 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.