Suppurative thrombosis of the superior vena cava: a lethal complication of central venous catheters

A case is described, in which suppurative thrombosis of the superior vena cava, complicated central venous catheterization. Persistent septicaemia resulted which was unresponsive to medical management and was ultimately fatal.     

Influence of infusion flow rates on central venous pressure measurements through multi-lumen central venous catheters in intensive care

Objective To study the influence on central venous pressure (CVP), measured at the distal port, of crystalloid infusions administered through the proximal port(s) of a central venous multi-lumen catheter. Patients Thirty-one intensive care patients. Interventions CVP was measured at the distal port of a multi-lumen catheter inserted in the subclavian or internal jugular vein. Using the proximal port(s), saline (0.9%) was infused at rates varying from 2 ml/h to 14,340 ml/h. Results CVP measured before the infusion and during infusion (after 30 s to 1 min) were not significantly different. Positive pressure ventilation with PEEP (5.6 ± 2.5 cmH₂O) and/or norepinephrine infusion (0.25 ± 0.21 μg kg⁻¹ min⁻¹) did not produce any significant change in CVP during infusion. Conclusion The administration of crystalloids at different flow rates through the proximal port(s) of a multi-lumen catheter placed in the superior vena cava does not affect CVP measurement at the distal port, even in mechanically ventilated patients or patients receiving vasopressors.     

Thromboembolic complications related to indwelling central venous catheters in children with oncological/haematological diseases: a retrospective study of 362 catheters

Indwelling central venous catheters (CVC) are essential devices in the management of children with oncological/haematological diseases being treated with chemotherapy or undergoing bone marrow transplantation. Our study was aimed at detecting the incidence of important thrombotic events caused by CVC in children, and the coexistence of coagulation disorders in children affected with thromboembolic disease related to CVC. Therefore, we describe some antithrombotic strategies which have been successfully applied to solve functioning problems of correctly inserted CVC. We retrospectively evaluated the clinical records of 308 children (age range 2 months to 14 years) with oncological/haematological diseases undergoing insertion of 362 indwelling CVC from January 1994 to December 1998 at the Gaslini Children's Hospital. We collected data on seven serious asymptomatic thrombotic episodes diagnosed between 1994 and 1998 following catheter malfunctioning and one case of suspected lung embolism with symptoms. Coagulation tests allowed us to identify one case of probable heterozygosis of Protein C deficiency and one case of G20210A prothrombotic prothrombin mutation. This finding suggests the need for further evaluation for thrombophilia in all patients presenting with thrombotic complications of CVC. We therefore emphasise the importance of prophylaxis with low-dose heparin in children with malignancies receiving CVC. A prospective study, which has already been started, should identify the exact role of thromboembolic complications in children with indwelling CVC for oncological/ haematological malignancies.     

Sonographically guided venous puncture and fluoroscopically guided placement of tunneled,large-bore central venous catheters for bone marrow transplantation—high success rates and low complication rates

BACKGROUND AND OBJECTIVE: Traditionally, large lumen, tunneled central venous catheters have been implanted by surgeons. We used a technique of sonographically guided jugular venous puncture and fluoroscopically guided catheter placement to achieve a high rate of technical success and to reduce complication rates. MATERIALS AND METHODS: Between June 2002 and December 2006, 186 Patients have been referred to the Radiology Department for 211 implantations of large-lumen, tunneled, central venous catheters. Insertions were performed under maximum sterile barrier in the angio suite using combined sonographic guidance for puncture of the internal jugular vein and fluoroscopy for placement of a triple lumen 12.5 F catheter (Hickman, BARD Murray Hill, NJ, USA). All interventions were performed under local anesthesia without need for anesthesiologic surveillance. Peri- and postinterventional complications were recorded using standardized international recommendations. RESULTS: Catheter implantation was technically successful in 207 of 211 cases (98.1%). Technical failure resulted in four patients due to chronic occlusions of the superior vena cava. No major complications were recorded. Four (1.9%) accidental arterial punctures occurred periinterventionally; 24 (11.4%) early complications (bleeding, dysfunction, catheter rupture, and infection) and ten (4.7%) late complications (infection, dysfunction) were recorded. A clinically suspected catheter infection required catheter removal in 21 (10%) cases; 11 of 13 non-infectious catheter complications (bleeding, dysfunction, rupture) could be treated successfully by interventional-radiological treatment. CONCLUSION: Percutaneous implantation of large-lumen, tunneled, central venous catheters can be achieved with a high technical success rate and a low complication rate under combined sonographic and fluoroscopic guidance. In cases of mechanical complications, catheter rescue by interventional techniques is possible in the vast majority of cases.     

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.     

Securing central venous catheters: a comparison of sutures with staples

Methods: Prospective, randomised trial of 20 patients requiring insertion of a central venous catheter during elective surgery.

Results: Mean (SD) times were significantly shorter in the staples group than in the sutures group (staples 10.1 (3.5) seconds; sutures 50.5 (9.6) seconds; p<0.0001). However, 3 of 10 central venous catheters in the staples group were accidentally pulled out within the first three days.

Conclusions: The use of staples significantly reduces the time to secure a central venous catheter. However, staples failed to secure the central venous catheters adequately and therefore cannot be recommended instead of sutures.

     

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

Purpose

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

Methods

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

Results

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

Conclusions

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

     

Cardiopulmonary needle embolization: a complication of central venous drug abuse

A great variety of complications secondary to drug abuse have been reported in the literature. We report a case of multiple cardiopulmonary needle embolization. A drug addict who had resorted to central venous drug abuse was found on chest roentgenograms to have multiple asymptomatic needle fragments within her chest. In this instance chest roentgenograms and tomographs were more helpful in needle localization than computed tomography. Complications of intracardiac foreign bodies are also briefly reviewed. In attempts to diagnose this complication, a high index of suspicion is necessary as central venous drug abuse becomes increasingly more prevalent.     

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.     

Hydrothorax,a complication of the insertion of central venous cannulae

Hydrothorax developing in a patient after insertion of a central venous cannula is described. The cannula appeared to be in the superior vena cava on chest X-ray, and the condition only became apparent 48 hours after insertion.     

Managing central venous catheters: a prospective randomised trial of two methods.

A randomised, prospective study was conducted to evaluate the impact on central venous catheter (CVC) infection when fluids and lines connected to a CVC were changed using a 'sterile' compared to an 'aseptic, non-touch' technique. The study sought to determine whether there were any differences in CVC tip colonisation (CTC) or CVC-related bacteraemia (CRB) as a result of the technique used for fluid and line changes. In the sterile technique (control) group, fluids and tubing were changed using full sterile technique. In the aseptic, non-touch (experimental) group, fluids and tubing attached to the CVC were changed using only a small sterile drape and a 2-minute clinical hand wash. When the CVC was removed, the tip was sampled and cultured using the semi-quantitative method. Blood cultures were also collected. In all, 111 samples from 79 patients were included in the trial: 61 in the sterile technique group and 50 in the non-touch, aseptic technique group. Results showed a CTC rate of 31 per cent in the control group and 14 per cent in the experimental group, while the CRB rate was 8.2 per cent and 6 per cent respectively. The most common organisms cultured were Staphylococcus aureus and S. epidermis respectively. This study indicates that it is safe to change fluids and lines attached to CVCs using the aseptic, non-touch technique, which has resulted in significant financial savings through less use of equipment and less nursing time required to perform fluid and line changes.     

Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis

OBJECTIVE: Since the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters. DATA SOURCE: Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents. DATA ABSTRACTION: Two independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality. DATA SYNTHESIS: A total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00-4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92-3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50-3.41). CONCLUSIONS: Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.