A GAVeCeLT consensus on the indication, insertion, and management of central venous access devices in the critically ill.

Central venous access devices are essential for the management of critically ill patients, but they are potentially associated with many complications, which may occur during or after insertion. Many evidence-based documents-consensus and guidelines-suggest practical recommendations for reducing catheter-related complications, but they have some limitations. Some documents are not focused on critically ill patients; other documents address only some special strategies, such as the use of ultrasound; other documents are biased by obsolete concepts, inappropriate terminology, and lack of considerations for new technologies and new methods. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to offer an updated compendium of the main strategies-old and new-that should be adopted for minimizing catheter-related complications in the adult critically ill patient. The project has been planned as a consensus, rather than a guideline, since many issues in this field are relatively recent, and few high-quality randomized clinical studies are currently available, particularly in the area of indications and choice of the device. Panelists were chosen between the Italian vascular access experts who had published papers on peer-reviewed journals about this topic in the last few years. The consensus process was carried out according to the RAND/University of California at Los Angeles (UCLA) Appropriateness Methodology, a modification of the Delphi method, that is, a structured process for collecting knowledge from groups of experts through a series of questionnaires. The final document has been structured as statements which answer to four major sets of questions regarding central venous access in the critically ill: (1) before insertion (seven questions), (2) during insertion (eight questions), (3) after insertion (three questions), and (4) at removal (three questions).

The longer the catheter, the lower the risk of complications: Results of the HERITAGE study comparing long peripheral and midline catheters.

BACKGROUND: Although widely used in clinical practice, long peripheral (LPCs) and midline catheters (MCs) are often misclassified because of their similar characteristics. Comparative studies on these devices are lacking. This study aimed to explore complications risks in polyurethane LPCs and MCs. METHODS: Prospective cohort study. Catheter-failure within 30days was the primary outcome, catheter-related bloodstream infection (CR-BSI), thrombosis, and fibroblastic sleeve were secondary outcomes. The average number of drugs infused per day was computed to measure the overall intensity of catheters' use. RESULTS: The catheter-failure incidence was 5.7 and 3.4/1,000 catheter-days for LPCs and MCs, respectively. MCs were associated with an adjusted lower risk of catheter-failure (hazard ratio 0.311, 95% confidence interval 0.106-0.917, P = .034). The daily number of drugs infused was higher for MCs (P < .001) and was associated with a greater risk catheter-failure risk (P = .021). Sensitivity analysis showed a decreased catheter-failure risk for MCs starting from day-10 from positioning. The incidence of CR-BSI (0.9 vs 0.0/1,000 catheter-days), thrombosis (8.7 vs 3.5/1,000 catheter-days), and fibroblastic sleeve (14.0 vs 8.1/1,000 catheters-days) was higher for LPC catheters. CONCLUSIONS: Despite more intensive drug administration, MCs were associated with a longer uncomplicated indwelling time.

Complications associated to midline- and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection.

INTRODUCTION: Long peripheral catheters (LPCs) and midline catheters (MCs) are indiscriminately labelled with different names, leading to misclassifications both in primary and secondary studies. The available studies used different methods to report the incidence of catheter-related complications, affecting the possibility of properly comparing the catheter outcomes. The aim of this review was to explore the complications related to LPCs and MCs after reclassifying according to their length. METHODS: Systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, conducted on PubMed, Scopus and CINAHL databases. The study protocol was registered in the International Prospective Register of Systematic Reviews. Data regarding LPCs and MCs were compared. Catheter outcomes were classified into major and minor complications, recomputed and reported as cases/1000 catheter-days. RESULTS: Fourteen studies were included. Over-half of the devices were correctly labelled by the authors, misclassifications affected particularly LPCs improperly labelled MCs. The cumulative incidence of catheter-related bloodstream infections was 0.3 and 0.4/1000 catheter-days, that of symptomatic catheter-related thrombosis was 0.9 and 1.8/1000 catheter-days for MCs and LPCs, respectively. Minor complications and catheter failure were higher for LPCs. CONCLUSIONS: A misclassification exists in the labelling of MCs and LPCs. A widespread heterogeneity of diagnostic criteria adopted to classify the catheters' outcomes was found, exposing the risk of misestimating the incidence of complications and undermining the possibility of effectively comparing results of the published research. We proposed a list of definitions and relevant variables as a first step toward the development of standardized criteria to be adopted for research purposes.

The severity of early fluid overload assessed by bioelectrical vector impedance as an independent risk factor for longer patient care after cardiac surgery.

BACKGROUND AND AIMS: Fluid overload is a common postoperative complication in patients undergoing cardiac surgery. Although this condition is notably associated with relevant adverse outcomes, assessment of hydration status in clinical practice is challenging. Bioelectrical impedance vector analysis (BIVA) has emerged as a potentially effective method to monitor hydration changes, but the available evidence in critically ill patients undergoing cardiac surgery is limited and sometimes conflicting. The aim of this study was to explore by mean of BIVA the evolution over time of hydration status and its impact on relevant outcomes. METHODS: Prospective observational study enrolling 130 patients undergoing cardiac surgery. Height normalized impedance was calculated both before surgery (baseline) and in the first five postoperative days. Relevant clinical and laboratory data were collected daily close to BIVA measurements. Length of mechanical ventilation (MV), intensive care unit (ICU) and hospital stay exceeding the 75th percentile of the study population were considered as study endpoints. RESULTS: Compared to baseline, a significant reduction in impedance was found at first postoperative day, demonstrating a relevant fluid overload. An adjusted impedance at first postoperative day shorter than the best respective threshold was associated to longer MV (7.4 times), ICU stay (4.7 times) and hospital stay (5.6 times). A significant change in impedance and phase angle was documented throughout the observation days (p < 0.001), without returning to the baseline value. The co-existence of low impedance and high plasma osmolarity increased significantly the risk of incurring the study outcomes. CONCLUSIONS: In patients with cardiac surgery-induced fluid overload, recovery to baseline conditions occurs slowly. A relevant early fluid overload should be considered predictive for longer time of MV, ICU and total hospital stay.

The catheter-to-vein ratio at the tip level, not the catheter type, as a risk factor for a catheter failure. A retrospective comparative study of polyurethane midline and long peripheral catheters.

BACKGROUND: In patients requiring a peripheral venous access for more than seven days, long peripheral catheters (LPCs) or midline catheters (MCs) are recommended. Since MCs and LPCs share many characteristics, studies comparing devices made of the same biomaterial are needed. Moreover, a catheter-to-vein ratio >45% at the insertion point has been recognized as a risk factor for catheter related complications, but no study investigated the effect of the catheter-to-vein ratio at the catheter tip level in peripheral venous devices. OBJECTIVES: To compare the catheter failure risk between polyurethane MCs and LPCs, considering the effect of the catheter-to-vein ratio at the tip location. METHODS: Retrospective cohort study. Adult patients having an expected need for a vascular access of more than 7 days and receiving either a polyurethane LPC or MC were included. The catheter uncomplicated indwelling time within 30 days was considered in survival analysis. RESULTS: In a sample of 240 patients, the relative incidences of catheter failure were 5.13 and 3.40 cases for 1,000 catheter days for LPCs and MCs, respectively. In univariate Cox regression, MCs were associated to a statistically significant lower risk of catheter failure (HR 0.330; p = 0.048). After adjusting for other relevant conditions, a catheter-to-vein ratio >45% at the catheter tip location - not the catheter itself - was an independent predictor of a catheter failure (HR 6.762; p = 0.023). CONCLUSIONS: The risk of catheter failure was strongly associated with a catheter-to-vein ratio > 45% at the catheter tip level, irrespective for having used a polyurethane LPC or MC.

Adequacy of protein and calorie delivery according to the expected calculated targets: a day-by-day assessment in critically ill patients undergoing enteral feeding.

BACKGROUND: In critically ill patients requiring mechanical ventilation for longer than 48-72 h enteral nutrition (EN) should be started early. Because EN alone may be unable to reach the target nutritional requirement, supplemental parenteral nutrition (PN) should be administered. This study aimed at describing the daily rate of administered calories and proteins according to the expected calculated targets. The impact of calorie adequacy, deficit or excess on relevant clinical outcomes was explored. METHODS: A retrospective cohort study was conducted in 217 patients undergoing cardiac surgery, admitted postoperatively in intensive care unit and undergoing EN. The effective intake provided via EN, PN, oral nutritional supplements (ONS) and nonnutritional calories (NNC) was documented for a maximum of 20 days. The administered/required calorie and protein ratios (KcalA/R , ProtA/R ) were calculated daily. Patients receiving 80%-100%, <80% or >100% of KcalA/R and ProtA/R were identified. The association between mean KcalA/R between days 4-7 and 30 days' mortality was explored. RESULTS: A mean KcalA/R ratio of 92.0 ± 40.6% was ensured between days 4 and 20. During days 4-7 the 80%-100% calorie target was achieved in 26.9% of patients, whereas 44.9% were below and 28.2% over this range. EN contributed 47.1% and PN 41.2% to the total energy intake. An increase in 30-day mortality risk was documented for patients exceeding 100% of KcalA/R ratio (adjusted-hazard ratio [HR] 5.2; 95% confidence interval [CI] 1.1 -23.9; p = 0.035). CONCLUSIONS: Despite a preliminary estimate of nutritional requirement, a steady daily optimal 80%-100% KcalA/R was not ensured for all patients. EN contributed only partially to both energy and protein intakes so that PN was largely used to achieve the desired nutritional targets.

Pica (Allotriophagy): An Underestimated Risk Factor for Severe Leptospirosis (Weil's Diseases)? Report of a Leptospira Septic Shock Successfully Managed with ECMO.

Leptospirosis is a zoonosis caused by infection with pathogenic strains of the bacterium Leptospira. The disease can be complicated by pulmonary hemorrhages and acute respiratory distress syndrome, with the mortality rate increasing to 51-100%. We report the case of a 37-year-old man who was admitted to the emergency department with a 6-day history of fever, weakness, vomiting and diarrhea, followed by jaundice. On admission, he presented leukocytosis, thrombocytopenia and acute liver and kidney injuries. His clinical course was critical, as it was immediately complicated by sepsis and severe respiratory failure, requiring haemodialysis, mechanical ventilation and broad-spectrum antibiotic therapy. In the following days, a veno-venous extracorporeal membrane oxygenation (VV-ECMO) was started due to a dramatic deterioration in respiratory function; 20 h later, it was switched to veno-arterial ECMO because of refractory cardiogenic shock. Hantavirus or Leptospira infection etiology was suspected, so penicillin G and methylprednisolone were initiated as an empirical therapy and subsequently confirmed after a laboratory diagnosis of leptospirosis. Although the clinical course was further complicated by hemorrhagic pneumonia, a gradual, full recovery occurred, and the patient was discharged from the hospital. After excluding other sources of contact with Leptospira-infected material, an unsuspected abnormal eating behavior was identified as the most probable cause of the patient's Leptospira infection.

GAVeCeLT-WoCoVA Consensus on subcutaneously anchored securement devices for the securement of venous catheters: Current evidence and recommendations for future research.

BACKGROUND: Subcutaneously anchored securement devices (or subcutaneous engineered securement devices) have been introduced recently into the clinical practice, but the number of published studies is still scarce. The Italian Group of Long-Term Central Venous Access Devices (GAVeCeLT)-in collaboration with WoCoVA (World Congress on Vascular Access)-has developed a Consensus about the effectiveness, safety, and cost-effectiveness of such devices. METHODS: After the definition of a panel of experts, a systematic collection and review of the literature on subcutaneously anchored securement devices was performed. The panel has been divided in two working groups, one focusing on adult patients and the other on children and neonates. RESULTS: Although the quality of evidence is generally poor, since it is based mainly on non-controlled prospective studies, the panel has concluded that subcutaneously anchored securement devices are overall effective in reducing the risk of dislodgment and they appear to be safe in all categories of patients, being associated only with rare and negligible local adverse effects; cost-effectiveness is demonstrated-or highly likely-in specific populations of patients with long-term venous access and/or at high risk of dislodgment. CONCLUSION: Subcutaneously anchored securement is a very promising strategy for avoiding dislodgment. Further studies are warranted, in particular for the purpose of defining (a) the best management of the anchoring device so to avoid local problems, (b) the patient populations in which it may be considered highly cost-effective and even mandatory, (c) the possible benefit in terms of reduction of other catheter-related complications such as venous thrombosis and/or infection, and-last but not least-(d) their impact on the workload and stress level of nurses taking care of the devices.

Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study.

BACKGROUND: Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients. OBJECTIVE: The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively. DESIGN: Retrospective cohort study. SETTING: Cardiac-Surgery Intensive Care Unit of a University Hospital. PARTICIPANTS: Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas. METHODS: Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives). RESULTS: In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding. CONCLUSIONS: Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases.

BACKGROUND: Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients. METHODS: A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis. RESULTS: The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060). CONCLUSION: MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment.

BACKGROUND: Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched. AIM: To identify variables that are predictive of ExtF and related outcomes. METHOD: Prospective observational longitudinal study. Consecutively presenting patients ( n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU. RESULTS: The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO2/FiO2 was <150 and 11 times when it was ≥450. Also, a reassuring PaO2/FiO2 value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function. CONCLUSION: The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.

Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects.

BACKGROUND: In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time. OBJECTIVES: Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients' outcomes of delirium. METHODS: Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three-times a day through an adapted versions of the Intensive Care Delirium Screening Checklist. RESULTS: Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS-II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay. CONCLUSIONS: Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Tunnelling a midline catheter: When the traffic light shifts from yellow to green.

INTRODUCTION:: A safe, largely used practice for difficult venous access patients is positioning a catheter in deeper veins under ultrasound guide. However, the risk of complications is increased when there is a high catheter-to-vein ratio or when the insertion site is in a zone with particular anatomical/physiological characteristics. CASE DESCRIPTION:: A 60-year-old woman admitted to a post-operative intensive care unit after cardiac surgery had a complicated post-operative course. After the removal of a central venous catheter, it was necessary to insert a midline catheter. A complete ultrasound evaluation showed that only the axillary vein was suitable for direct cannulation. To avoid creating an exit site in the axillary cavity, the decision was made to tunnel the catheter to locate an exit site in a safer position. A guidewire was introduced through a needle in the axillary vein. A tunnel was created using a subcutaneous injection of lidocaine. A 14 G/13.3 cm peripheral venous catheter was inserted in the subcutaneous tract. A 4 Fr/20 cm catheter was introduced through the peripheral venous catheter and moved to the axillary vein through the previously inserted sheath. No acute complications occurred. The catheter was accessed several times a day during the period following its insertion to infuse drugs and take blood samples. It was removed 50 days after its placement because it was no longer needed. No symptomatic thrombosis or infections occurred. CONCLUSION:: The placement of the tunnelled midline catheter is shown to be a safe and effective way to ensure vascular access for almost 2 months.

Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery.

OBJECTIVES: To analyze success rate, dwell-time, and complications of long peripheral venous catheters (L-PVCs) inserted under ultrasound guidance. BACKGROUND: In difficult venous access (DVA) patients, L-PVC can represent an alternative to central or midline catheters. METHODS: Prospective observational study. L-PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. RESULTS: A 100% placement success rate was documented. The catheter dwell-time was 14.7 ± 11.1 days. Most catheters were removed at end-use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter-days. Two thrombophlebitis (1.91/1000 catheter-days) and 1 catheter-related bloodstream infection (0.96/1000 catheter-days) occurred. CONCLUSIONS: L-PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients' discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications.

Early-onset thrombosis of internal jugular vein associated with introducer catheter for heart catheterization in cardiac surgery.

PURPOSE: In cardiac surgery, Swan-Ganz catheter (SGC) is often necessary and is inserted before the intervention through an introducer catheter. Catheter-related thrombosis (CRT) is a frequent complication of this procedure and often remains subclinical. The aims of this prospective cohort study were to determinate the incidence of CRT after positioning an SGC through an introducer and to identify factors relating to their occurrence. METHODS: One-hundred and sixteen cardiac surgery patients underwent ultrasound examination of the thoracic-cervical vessels, before and after introducer catheter removal. Data about drugs infused through the introducer catheter were also collected. RESULTS: The incidence of internal jugular vein CRT was 26.7%, corresponding to 70.5 cases per 1,000 catheter days. The incidence of "fibrin sleeve" was 28.4%. All introducer catheter tips lay in the brachiocephalic vein or in the upper third of the superior vena cava. The incidence of CRT was not associated with duration of the placement of the introducer catheter (average 3.9±2 days) or the SGC (average of 2.4±1.7 days). Infusion of total parenteral nutrition and dextran showed a significantly increased risk of thrombosis in both univariate and multivariate analyses. An overly proximal position of the introducer catheter tip was strongly associated with CRT incidence. CONCLUSIONS: The presence of an introducer catheter for SGC, even for a short time, is associated with a high incidence of early-onset CRT. This incidence is significantly related to the catheter tip being positioned in the brachiocephalic vein and to its use as a central venous access.