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.     

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.     

Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonisation of central venous catheters

Objective Central venous catheter (CVC)-related infections may be caused by micro-organisms introduced from the skin surface into deeper tissue at the time of CVC insertion. The optimal disinfection regimen to avoid catheter-related infections has not yet been defined. This study compares three different approaches.Design Prospective randomised trial.Setting A tertiary care hospital.Patients and participants One hundred nineteen patients scheduled electively to receive 140 CVCs.Interventions Skin disinfection was performed with either povidone-iodine 10% (PVP-iodine), chlorhexidine 0.5%/propanol 70%, or chlorhexidine 0.5%/propanol 70% followed by PVP-iodine 10%. Prior to disinfection, a swab from the site of insertion was taken for culture. CVCs were removed if no longer needed or infection was suspected. All catheters were cultured quantitatively after removal.Measurement and results Bacteria could be isolated from 20.7% of the catheter tips. Bacterial growth was found in 30.8% of the catheters placed after skin disinfection with povidone-iodine, in 24.4% after disinfection with propanol/chlorhexidine and in 4.7% after disinfection with propanol/chlorhexidine followed by povidone-iodine (p=0.006). In 15 cases, the same organism was isolated from the skin swab and the catheter tip. Ten of these paired isolates showed the same pattern in a pulsed-field gel electrophoresis analysis.Conclusions Skin disinfection with propanol/chlorhexidine followed by PVP-iodine was superior in the prevention of microbial CVC colonisation compared to either of the regimens alone. These results support the concept that catheter infections can originate from bacterial translocation at the time of catheter insertion.     

锁骨下静脉穿刺置中心静脉导管并发症的护理对策

经锁骨下静脉穿刺置中心静脉导管应用于患,长期间歇使用化疗药物或静脉高营养,给患带来了便利。但护理不恰当会引起并发症的出现,常见的并发症有导管破裂或脱出、管腔阻塞、误刺锁骨下动脉,此外气胸及感染威胁着患的生命,并发症的出现给护理也带来了障碍。做好中心静脉导管护理能安全保证患长期建立中心静脉通道,有助提高患生存质量。     

Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices

Goals  Central venous catheter (CVC)-related bloodstream infection (CR-BSI) is a significant complication in hematology patients. A range of CVC devices may be used, and risks for the development of complications are not uniform. The objectives of this study were to determine the natural history and rate of CVC-related complications and risk factors for CR-BSI and to compare device-specific complications in a hematology population. Patients and methods  An observational cohort of patients with hematologic malignancy was prospectively studied following CVC insertion. Participants were reviewed until a CVC-related complication necessitated device removal, completion of therapy, death, or defined end-of-study date. The National Nosocomial Infection Surveillance definition for CR-BSI was used. Overall and device-specific rates of infective and noninfective complications were calculated and potential risk factors were captured. Main results  One hundred six CVCs (75 peripherally inserted central venous catheters [PICCs], 31 nontunneled CVCs) were evaluated in 66 patients, over 2,399 CVC days. Thrombosis occurred in 16 cases (15.1%), exit-site infection in two (1.9%), and CR-BSI in 18 (7.5 per 1,000 CVC days). No significant differences were found when complication rates in PICC and nontunneled devices were compared. An underlying diagnosis of acute myeloid leukemia was negatively associated with CR-BSI (odds ratio (OR) 0.14, p = 0.046), and a previous diagnosis of fungal infection was associated with infection (OR 22.82, p = 0.031). Conclusions  CR-BSI rates in our hematology population are comparable to prior reports. A low rate of exit-site infection and high proportion of thrombotic complications were observed. No significant differences in thrombotic or infective complications were evident when PICC and nontunneled devices were compared. PICC devices are a practical and safe option for management of hematology patients.     

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.     

Catheter infection risk related to the distance between insertion site and burned area

A prospective observational study of central venous catheters (CVC) was carried out in order to determine if a CVC inserted near an open burn wound increases catheter infection risk in burned patients. The study was carried out during a 12-month period (1998-1999) at the Benaim Foundation's Burn Unit in Buenos Aires (C.E.P.A.Q.). Eighty-three CVCs were inserted in 20 burned patients during the study period. Twenty-six catheters were inserted near an open wound (NOW) and 57 far from an open wound (FOW). NOW CVCs were considered when 25 cm2 surrounding the catheter's insertion site overlapped the wound. Colonization rates were 84% (22/26 CVCs) in those inserted NOW and 47% (27/57 CVCs) in FOW (P = 0.001). Colonization relative risk of NOW-CVCs was 1.79 (95% confidence interval, 1.3-2.46). Bacteremia rates were 27% (7/26 CVCs) in CVCs inserted NOW and 6% (3/57 CVCs) in FOW (P = 0.004). Bacteremic risk of NOW-CVCs was 5.12 (95% confidence interval, 1.44-18.22). Colonization rates were higher and sooner in NOW-CVCs than in FOW-CVCs. We suggest that insertion of catheters near an open burn wound should be avoided and, if inevitable, should not be left in place for period exceeding 3 days.     

Bench-to-bedside review: Challenges of diagnosis,care and prevention of central catheter-related bloodstream infections in children

Central venous catheters (CVCs) are indispensable in modern pediatric medicine. CVCs provide secure vascular access, but are associated with a risk of severe complications, in particular bloodstream infection. We provide a review of the recent literature about the diagnostic and therapeutic challenges of catheter-related bloodstream infection (CRBSI) in children and its prevention. Variations in blood sampling and limitations in blood culturing interfere with accurate and timely diagnosis of CRBSI. Although novel molecular testing methods appear promising in overcoming some of the present diagnostic limitations of conventional blood sampling in children, they still need to solidly prove their accuracy and reliability in clinical practice. Standardized practices of catheter insertion and care remain the cornerstone of CRBSI prevention although their implementation in daily practice may be difficult. Technology such as CVC impregnation or catheter locking with antimicrobial substances has been shown less effective than anticipated. Despite encouraging results in CRBSI prevention among adults, the goal of zero infection in children is still not in range. More high-quality research is needed in the field of prevention, accurate and reliable diagnostic measures and effective treatment of CRBSI in children.     

Central venous catheter infections: Concepts and controversies

Central venous catheters (CVCs) are widely used in critically ill patients in intensive care units. However, infectious complications are common and may limit their utility. We critically review the literature to determine the impact of CVC design amd composition, insertion site selection, insertion procedures, care and removal of temporary CVCs on infectious complications. Relevant articles were identified and selected for review using a database search (Medline and manual of the English language literature) based upon study design and sample size with an emphasis on prospective randomized trials. To minimize infectious complications and maintain a reasonable cost-benefit ratio, we recommend: i) use a single lumen catheter unless clear indications for a multi-lumen catheter exist; ii) insert the catheter via the subclavian vein if no relative contraindication exists (bleeding diathesis, positive pressure ventilation); iii) disinfect the insertion site employing sterile technique; iv) apply a dry, sterile dressing and change the dressing every other day; v) inspect the insertion site for signs of infection and remove the catheter if pus is present; vi) if a catheter-related infection is suspected, change the catheter over a guidewire and culture the distal segment. The replacement catheter should be removed if an original catheter segment culture is positive.     

Central venous catheter infection in adults in acute hospital settings

As well as the human cost, central venous catheter (CVC)-related bloodstream infections significantly inflate hospital costs, mainly through increased length of stay in hospital, particularly in intensive care. This literature review appraises recent research on measures used to minimize CVC-related infection and compares it with current best practice. Randomized controlled trials and systematic reviews published on the subject between 2000 and 2005 were reviewed, concentrating on non-tunnelled, short-term CVCs in the acute hospital setting. The new evidence mainly backs up current best practice. However, skin disinfection could be improved by using alcoholic chlorhexidine followed by aqueous povidone-iodine before CVC insertion. Also, alcoholic chlorhexidine is the preferred solution for cleaning the hubs/connectors before accessing the CVC. Good hand hygiene and quality control and education programmes are vital to improve patient care. More research is needed to clarify the effectiveness of certain interventions and technologies, such as antimicrobial CVCs.     

Acinetobacter calcoaceticus septicemia in patients with cancer

At our institution, 95 cases of Acinetobacter septicemia occurred over a ten-year period (1973 to 1982) in patients being treated for cancer. In 24 patients the infection was polymicrobial, while Acinetobacter ssp was the only offending pathogen in 71 patients. In 76 patients (80%), the infection was related to an indwelling central venous catheter (CVC). A sharp increase in the frequency of Acinetobacter septicemia was noticed in the years 1981 and 1982 and coincided with a marked increase in the number of indwelling CVCs in use. Acute leukemia and breast cancer were the malignancies most commonly associated with Acinetobacter septicemia. The isolates of Acinetobacter calcoaceticus from the patients in this study were highly susceptible to the aminoglycosides and moderately susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), carbenicillin, and tetracycline. Seventy-nine patients recovered from their infection with removal of the CVC and antimicrobial chemotherapy. Acinetobacter sp was the cause of death in none of the 16 patients who died. A calcoaceticus is an important nosocomial pathogen causing infections predominantly in immune compromised patients and frequently associated with indwelling catheters.     

The risk of infection related to radial vs femoral sites for arterial catheterization

To evaluate risk factors for infections associated with indwelling arterial catheters, 186 catheters were randomly allocated for either femoral or radial insertion in 155 critically ill patients. Femoral catheters were easier to insert and it was easier to obtain blood specimens from them. Rates of local infection at the insertion sites and rates of positive catheter-tip cultures were similar for femoral and radial catheters. Evidence of local infection was not predictive of a positive catheter-tip culture. Percutaneously inserted femoral and radial artery catheters had a similarly low incidence of catheter-associated infections. There was only one catheter-related infection, and no cultured catheter was judged the cause of bacteremia. Routine prophylactic replacement of arterial catheter systems may be unnecessary in critical care units where rates of arterial catheter-associated infections are low.     

Influence of insertion site on central venous catheter colonization and bloodstream infection rates

OBJECTIVE: To compare colonization and catheter-related bloodstream infection (CR-BSI) rates among three insertion sites (subclavian, internal jugular, femoral) used for central venous catheter (CVC) placement. DESIGN: Twenty-four-month prospective study, with relative effects analyzed by Cox proportional hazards regression. SETTING: Eight-bed intensive care unit. PATIENTS: Four hundred and ten critically ill patients requiring CVC placement. MEASUREMENTS AND RESULTS: All short-term multi-lumen CVCs, including antimicrobial-coated devices, were studied with management standardized. Six hundred and five CVCs (4,040 catheter days) were analyzed. Colonization and CR-BSI incidence were, respectively, 15.1 (95% CI 13.5-21.0) and 1.8 (95% CI 1.2-4.2) per 1,000 catheter-days. Colonization was higher at the internal jugular (HR 3.64; 95% CI 1.32-10.00; p=0.01) and femoral (HR 5.15; 95% CI 1.82-14.51; p=0.004) sites than at the subclavian site. The femoral site carried a greater risk of being colonized by non-S. epidermidis species than the subclavian and internal jugular sites combined (HR 4.15; 95% CI 1.79-9.61; p=0.001). CVCs inserted in the Department of Emergency Medicine were more colonized than those inserted in the ICU or operating room (HR 2.66; 95% CI 1.27-5.56; p=0.01), and CVCs were less colonized in females than in males (HR 0.49; 95% CI 0.26-0.89; p=0.02). No difference in CR-BSI rates was noted between the three sites. CONCLUSIONS: Colonization was lowest at the subclavian site. Regional differences exist with respect to type of pathogen isolated. Colonization was influenced by insertion location and gender. The incidence of CR-BSI was not different.     

A multicentre analysis of catheter-related infection based on a hierarchical model

Purpose

To decrease intensive care unit (ICU)-acquired catheter-related infections (CRI), it is essential that healthcare workers receive training and that quality improvement programmes are in place. The aim of our study was to evaluate risk factors for catheter colonisation and infection, focussing specifically on local care bundles.

Methods

Data were collected prospectively in 51 ICUs [7,188 patients, 8,626 central venous catheters (CVCs)] during two 6-month periods in 2007 and 2008, using a standardized questionnaire on catheter insertion, care and removal. Colonisation and CRI incidence were 6.1 and 2.2/1,000 CVC-days, respectively. A hierarchical mixed logistic model was used to identify risk factors for CRI and colonisation.

Results

Written CVC protocols were available in 46 (90?%) ICUs and were strictly followed in 38 ICUs. Factors significantly associated with CRI fell into three overall categories: (1) patient-related factors—immunosuppression [odds ratio (OR) 1.42, p?=?0.02], medical diagnosis at admission (OR 1.64, p?=?0.03) and trauma patient (OR 2.54, p?p?p?p??4); (3) centre-related factors—quantitative tip culture method (OR 2.55, p?=?0.005) and alcohol-based povidone-iodine [OR 0.68, 95?% confidence interval (CI) 0.49–0.96] or alcohol-based chlorhexidine preparations (OR 0.69, 95?% CI 0.34–1.39) as compared to an aqueous povidone-iodine preparation (p?Conclusions We identified several risk factors for CRI that are amenable to improvement (preference for the subclavian route and use of an antiseptic solution containing alcohol). However, several patient-related factors were also found, and the use of quantitative catheter culture methods increased culture sensitivity, thereby increasing the CRI rate. Case-mix issues and the culture method should be taken into account when assessing the risk of CRI across centres.     

超声引导中长导管置入可降低导管相关血流感染发生率

目的探讨超声引导置入中长导管对急诊重症患者导管相关血流感染(CRBSI)发生率的影响。方法选取2018年3月至2019年12月急诊重症医学科收治529例患者为研究对象,按是否开展超声引导中长导管(MC)置入技术分为MC组(n=278)和对照组(n=251),MC组应用超声引导置入MC作为早期拔除中心静脉导管(CVC)的序贯方法,对照组采用留置针作为CVC拔除后的静脉序贯治疗方法。统计CVC、MC、留置针留置时间,比较两组CVC使用率,绘制Kaplan-Meier生存曲线描述两组的CVC留置时间并进行Log-rank检验,Cox回归分析CVC留置时间的影响因素,比较CRBSI和其他导管相关并发症发生率。结果MC组CVC留置时间显著短于对照组(8 d vs.13 d,P=0.000),CVC使用率显著低于对照组(49.83%vs.80.45%,P=0.000);Cox回归分析显示困难静脉、ICU住院时间延长、置管部位和未开展超声引导MC置入均是CVC留置时间延长的独立危险因素(P=0.000);MC组CRBSI发生率显著低于对照组(0.571‰vs.3.802‰,P=0.038),两组其他导管相关并发症发生率差异无统计学意义(P=0.403)。结论开展超声引导置入MC可缩短CVC留置时间,减少CVC使用率,降低CRBSI发生率,值得临床推广。     

Incidence,risk factors and microbiology of central vascular catheter-related bloodstream infection in an intensive care unit

Although there are many studies about catheter related infection in industrialized countries, very few have analyzed it in emerging countries. The aim of our study was to determine the incidence, microbiological profile and risk factors for catheter-related bloodstream infection (CRBSI) in a Tunisian medical intensive care unit. Over eight months (1 January 2012–30 August 2012) a prospective, observational study was performed in an 18-bed medical surgical intensive care unit at Tunis military hospital. Patients who required central venous catheter (CVC) placement for a duration greater than 48 h were included in the study. Two hundred sixty patients, with a total of 482 CVCs were enrolled. The mean duration of catheterization was 9.6 ± 6.2 days. The incidence for CRBSI and catheter colonization (CC) was 2.4 and 9.3 per 1000 catheter days, respectively. Risk factors independently associated with CRBSI were diabetes mellitus, long duration of catheterization, sepsis at insertion and administration of one or more antibiotics before insertion. The mortality rate among the CRBSI group was 21.8%. The predominant microorganisms isolated from CRBSI and CC episodes were Gram negative bacilli. All Gram negative organisms isolated among dead patients in CRBSI group were Extensive Drug Resistant (XDR). In our study the mortality rate among patients with CRBSI was high despite a low incidence of CRBSI. This high rate can be explained by the high-virulent status of Gram negative bacteria involved in CRBSI.     

Do position control methods for central venous catheters prevent complications? Hydromediastinum caused by an initially correctly placed tri-lumen subclavian catheter by using intra-atrial ECG recording--a case report

Central venous catheters (CVCs) can be associated with various complications which arise during insertion, with the catheter in situ or upon its removal. Here we report a case of secondary CVC malposition that occurred despite checks of CVC position by different methods. A subclavian triple-lumen catheter was retracted until intra-atrial ECG indicated reversal to a normal P-wave. Blood was successfully aspirated through all three lumens, and the catheter was fixed at 11 centimeters intracorporal length and used intraoperatively. A postoperative chest X-ray demonstrated an intravenous CVC length of only a few centimeters, which was accepted because of the inconspicuous results of previous monitoring. Fifteen hours after CVC insertion, the patient developed a swelling in the subclavian and right neck region, a pronounced hydromediastinum and small bilateral pleural effusions caused by paravenous infusion through the most proximal CVC lumen. After instantaneous removal of the catheter, the patient recovered without further complications. This case demonstrates that even carefully-fixed multi-lumen catheters can partially dislocate due to a patient's movements or changes of position. Therefore, repeated aspiration of blood from the most proximal lumen should be performed to detect secondary CVC malposition. Moreover, repeated chest radiographs are useful in verifying a correct CVC position and detecting late complications. In summary, CVC complications can occur with delay, are potentially life-threatening and may necessitate repeated checks of catheter position. This case report discusses different approaches to detecting malposition and reviews rare CVC complications.     

Clinical epidemiology of central venous catheter–related bloodstream infections in an intensive care unit in China

Background

Central venous catheters (CVCs) are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk. At present, there are few studies on catheter-related bloodstream infections (CRBSIs) that are comparable with international similar research. The aim of this study was to determine the rate, risk factors, and outcomes of CRBSIs in patients of an intensive care unit (ICU) in China.

Methods

A prospective study was performed in the Affiliated Shengjing Hospital of China Medical University. All patients admitted to the ICU from June 2007 to May 2008 who had a central line placed were monitored for the development of BSI from insertion until 48 hours after removal. One hundred seventy-four patients with 178 admissions to the ICU, 219 CVCs and 1913 CVC days, 21 episodes of CRBSI in 21 patients were enrolled.

Results

The mean rate of CRBSI was 11.0 per 1000 CVC days with a catheter utilization rate of 72.8%. Analyses of the pathogens showed that gram-negative organisms were predominant. The univariate analysis showed that 3 things seemed to directly impact the occurrences of CRBSI. These were the number of lines insertion, the applications of antibiotics before CRBSI, and the duration of catheter. In a multiple logistic regression analysis of the risk factors, patients with multiple central lines (odds ratio = 5.981; 95% confidence intervals, 1.660-21.547; P = .006) and with the applications of multiple antibiotics before CRBSI (odds ratio = 6.335; 95% confidence interval, 2.001-20.054; P = .002) were more likely to develop CRBSI.

Conclusions

The CRBSI rate in our ICU is higher compared with that reported by the National Nosocomial Infection Surveillance and was associated with the applications of antibiotics before CRBSI and with the number of placed CVCs. Catheter-related bloodstream infections may be associated with a higher mortality rate and a higher incidence of ventilator-associated pulmonitis, which might lead to an increase in the total costs and medicine expenditures.