Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry.

OBJECTIVES: Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. DESIGN: Analysis of extracorporeal life support organization registry from January 2010 to December 2018. SETTING: Multicenter worldwide registry. PATIENTS: Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. INTERVENTIONS: Venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis. CONCLUSIONS: The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation.

OBJECTIVE: Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival. METHODS: We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival. RESULTS: Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63). CONCLUSIONS: The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.

Incidence and risk factors of sepsis in hemodialysis patients in the United States.

BACKGROUND: Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States. METHODS: All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ2, and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate. RESULTS: A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001). CONCLUSIONS: Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD.

Reasons for long-term tunneled dialysis catheter use and associated morbidity.

OBJECTIVE: Tunneled dialysis catheters (TDCs) are generally used as a temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have long-term catheter-based hemodialysis because of the lack of alternatives for other dialysis access. Our objective was to evaluate characteristics of patients with, reasons for, and mortality associated with long-term TDC use. METHODS: A retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Kaplan-Meier analysis compared mortality between patients with long-term TDC use and a comparison cohort who underwent AV access creation with subsequent TDC removal. RESULTS: We identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42% of patients with subsequent removal after alternative access was established. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed (occluded) AV access (34%), nonmaturing AV (nonoccluded) access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%) occurred. Overall, 47.6% required a catheter exchange during the prolonged TDC period. The majority (76.4%) had the catheter removed because of established alternative access during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer male patients (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC group compared with the comparator group (93.6% vs 92.7%; P = .28). CONCLUSIONS: Patients with long-term TDCs experienced significant TDC-related morbidity. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference. There was no difference in survival between the groups.

Risk Factors for Early Port Infections in Adult Oncologic Patients.

PURPOSE: The purpose of this study was to retrospectively investigate risk factors for chest port (port) infections within 30 days of placement (early port infections) in adult oncologic patients. MATERIALS AND METHODS: This single-institution, three-center retrospective study identified 1,714 patients (868 males, 846 females; median age 60.0 years old) who underwent port placement between January 2013 and August 2017. All patients received an intravenous antibiotic prior to port placement. The median absolute neutrophil count was 5,260 cells/µL, the median white blood cell (WBC) count was 7,700 cells/µL, and the median serum albumin was 4.00 g/dL at the time of port placement. Double-lumen ports were most commonly implanted (74.85%) more frequently in an outpatient setting (72.69%). Risk factors for early port infections were elucidated using univariate and multivariate proportional subdistribution hazard regression analyses. RESULTS: A total of 20 patients (1.2%) had early port infections; 15 patients (0.9%) had positive blood cultures. The mean time to infection was 20 days (range, 9-30 days). The port-related 30-day mortality rate was 0.2% (4 of 1,714 patients). Most bloodstream infections were attributed to Staphylococcus spp. (n = 11). In multivariate analysis, hematologic malignancy (hazard ratio [HR], 2.61; 95% confidence interval (CI), 1.15-5.92.; P = .02), hypoalbuminemia (albumin <3.5 g/dL; HR, 3.52; 95% CI: 1.48-8.36; P = .004), leukopenia (WBC <3,500 cells/µL; HR, 3.00; 95% CI: 1.11-8.09; P = .03), and diabetes mellitus (HR, 3.71; 95% CI: 1.57-8.83) remained statistically significant risk factors for early port infection. CONCLUSIONS: Hematologic malignancy, hypoalbuminemia, leukopenia, and diabetes mellitus at the time of port placement were independent risk factors for early port infections.

The long-term impact of peripheral cannulation for redo cardiac surgery.

BACKGROUND: Redo cardiac surgery carries an inherent risk for adverse short-term outcomes and worse long-term survival. Strategies to mitigate these risks have been numerous, including initiation of cardiopulmonary bypass via peripheral cannulation before resternotomy. This study evaluated the impact of central versus peripheral cannulation on long-term survival after redo cardiac surgery. METHODS: This was an observational study of open cardiac surgeries between 2010 and 2018. Patients undergoing open cardiac surgery that utilized cardiopulmonary bypass, who also had more than equal to 1 prior cardiac surgery, were identified. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of peripheral cannulation on survival. To isolate long-term survival, patients with operative mortality were excluded and survival time was counted from the date of discharge until the date of death. RESULTS: Of the 1660 patients with more than equal to 1 prior cardiac surgery, 91 (5.5%) received peripheral cannulation. After excluding patients with operative mortality and after multivariable risk-adjustment, the peripheral cannulation group had significantly increased hazard of death, as compared to the central cannulation group (HR 1.53, 95% CI: 1.01, 2.30, P = .044). Yet, there were no relevant differences for other postoperative outcomes, including blood product requirement, prolonged ventilation (>24 hours), pneumonia, reoperation for bleeding, stroke, sepsis, and new dialysis requirement. CONCLUSIONS: This is the first study reporting the long-term impact of peripheral cannulation for redo cardiac surgery after excluding patients with operative mortality. These data suggest that central cannulation may to be the preferred approach to redo cardiac surgery whenever safe and possible.

Jury verdicts and outcomes of malpractice cases involving arteriovenous hemodialysis access.

OBJECTIVE: To analyze malpractice cases involving hemodialysis access to prevent future litigation and improve physician education. METHODS: Jury verdict reviews from the WESTLAW database from 1 January 2005 to 1 January 2015 were reviewed. The search terms "hemodialysis," "dialysis," "graft," "fistula," "AVG," "AVF," "arteriovenous," "catheter," "permacatheter," and "shiley" were used to compile data on the demographics of the defendant, plaintiff, allegation, complication, and verdict. RESULTS: Sixty-six cases involving the litigation pertaining to hemodialysis catheter, arteriovenous fistula (AVF) or arteriovenous grafts (AVGs) were obtained. Of these, 55% involved catheter-based hemodialysis access, 18% involved AVF, and 27% involved AVG. The most frequent physician defendants were vascular surgeons (36%), internists (14%), nephrologists (14%), general surgeons (9%), and interventional radiologists (6%). Of the patients, 38% involved were male and the average patient age was 56.3 (standard deviation (SD) = 20.1) years. Region of injury was 50% in the neck or chest, 42% in the arm, and 8% in the groin. Injury was listed as death in 79% of cases. Of the deaths, 95% involved bleeding at some point in the chain of events. The most common claims related to the cases were failure to perform the surgery or procedure safely (44%), failure to diagnose and treat in a timely manner (30%), and negligent hemodialysis treatment (11%). The most common complications cited were hemorrhage (62%), loss of function of limb (15%), and ischemia due to steal syndrome (11%). A total of 26 cases (39%) were found for the plaintiff or settled. The median award was US$463,000 with a mean of US$985,299 (SD = US$1,314,557). CONCLUSION: While popular opinion may indicate that steal syndrome is a commonly litigated complication, our data reveal that the most common injury litigated is death which may frequently be the result of a hemorrhagic episode. In addition to hemorrhage, the remaining most common complications included steal syndrome and loss of limb function. Therefore, steps to better prevent, diagnose and treat bleeding, nerve injury, and steal syndrome in a timely manner are critical to preventing hemodialysis-access-associated litigation.

Vascular access creation in octogenarians: The effect of age on outcomes.

BACKGROUND: The prevalence of end-stage renal disease is accelerating among older age groups. Patient-specific factors in the elderly patient group might advocate for a different vascular access creation approach, in which patency, risk of nonmaturation, and time to cannulation with accompanied prolonged catheter use should be of primary importance. The aim of this study was to determine which vascular access has the best outcomes and to determine whether age is associated with different outcomes after vascular access surgery. METHODS: Data were obtained from a prospectively maintained database of patients treated between November 2004 and December 2017. Two different patient groups were identified: the octogenarian group, consisting of patients aged ≥80 years; and the control group, consisting of all the other patients. A total of 694 vascular access procedures were included in this study, 65 in the octogenarian group and 629 in the control group. Primary, primary assisted, and secondary patency rates were calculated and compared between groups and vascular accesses. Multivariable analysis was used to determine whether age is an effect modifier in the association between type of vascular access and different patency outcomes. RESULTS: Mean follow-up was 23.2 months in the octogenarian group and 21.2 months in the control group (P = .210). No significant differences were found in patient survival, with a 5-year survival rate of 63.8% (±5.9%) in the octogenarian group and 57.2% (±2.2%) in the control group (P = .866). Within the octogenarian group, primary failure rate was highest in the radiocephalic arteriovenous fistula (AVF) patients, 42.1% (P = .006). Brachiocephalic AVF had significantly improved assisted patency compared with the other vascular accesses among the octogenarians (P = .016). Age was not an effect modifier in the association between type of vascular access and different patency outcomes. The adjusted analysis, corrected for octogenarian age, diabetes mellitus, hypertension, and sex, showed that brachiocephalic AVF was significantly associated with an increase in primary patency (hazard ratio, 0.70; 95% confidence interval, 0.54-0.90; P = .006) and primary assisted patency (hazard ratio, 0.58; 95% confidence interval, 0.39-0.86; P = .006) compared with other vascular accesses. CONCLUSIONS: The results of our study support primary placement of a brachiocephalic AVF in the octogenarian patient. A low primary failure rate was achieved with significant improved patency rates compared with the other vascular accesses.

Outcomes after bloodstream infection in hospitalized pediatric hematology/oncology and stem cell transplant patients.

BACKGROUND: Pediatric hematology/oncology (PHO) patients receiving therapy or undergoing hematopoietic stem cell transplantation (HSCT) often require a central line and are at risk for bloodstream infections (BSI). There are limited data describing outcomes of BSI in PHO and HSCT patients. METHODS: This is a multicenter (n = 17) retrospective analysis of outcomes of patients who developed a BSI. Centers involved participated in a quality improvement collaborative referred to as the Childhood Cancer and Blood Disorder Network within the Children's Hospital Association. The main outcome measures were all-cause mortality at 3, 10, and 30 days after positive culture date; transfer to the intensive care unit (ICU) within 48 hours of positive culture; and central line removal within seven days of the positive blood culture. RESULTS: Nine hundred fifty-seven BSI were included in the analysis. Three hundred fifty-four BSI (37%) were associated with at least one adverse outcome. All-cause mortality was 1% (n = 9), 3% (n = 26), and 6% (n = 57) at 3, 10, and 30 days after BSI, respectively. In the 165 BSI (17%) associated with admission to the ICU, the median ICU stay was four days (IQR 2-10). Twenty-one percent of all infections (n = 203) were associated with central line removal within seven days of positive blood culture. CONCLUSIONS: BSI in PHO and HSCT patients are associated with adverse outcomes. These data will assist in defining the impact of BSI in this population and demonstrate the need for quality improvement and research efforts to decrease them.

Prevention and treatment of dilator injuries during central venous catheter placement.

BACKROUND: Misuse of vascular dilators during the placement of central venous catheters has been infrequently reported and can lead to devastating intrathoracic hemorrhage and death. These injuries should be preventable in most cases. If a major intrathoracic vascular injury is recognized intraoperatively, less invasive treatment options are available to minimize the consequences. METHODS: The records of 20 patients who suffered 21 major vascular injuries during insertion of central venous catheters, ports, or dialysis catheters and resulted in malpractice claims over the course of 8 years were analyzed to determine the mechanism of injury, the timing of diagnosis, and how these injuries were treated. How the injury could have been prevented, why earlier diagnosis was not made, and what treatment options were possible were also examined. RESULTS: Twelve women and eight men were documented to have sustained intrathoracic major venous injuries during catheter insertions. There were five injuries to the superior vena cava, six to the right innominate vein, and 10 to the left innominate vein. All procedures were done using fluoroscopic guidance, and resistance to passage of the dilators was documented in eight cases. In most cases, the operator reported inserting the dilators to their maximum length. In four cases, the catheter could be seen intraoperatively in the thoracic cavity. Bleeding was diagnosed in the operating room in 11 cases, in the postanesthesia care unit in seven cases, and on postoperative days 2 and 5 after misplaced catheters were removed. Ten patients underwent thoracotomies and one patient each underwent thoracoscopy and placement of a covered stent in an attempt to stop the hemorrhage. Eight patients died before the diagnosis was made. Seventeen patients died. CONCLUSIONS: In spite of U.S. Food and Drug Administration warnings, dilators are still inserted too far in patients, resulting in devastating hemorrhage. These complications are preventable if proper technique is used. When a catheter is noted to be misplaced, it must not be removed before either a covered stent or thoracoscopy is available; otherwise, uncontrolled hemorrhage into the chest may occur. If a patient becomes unstable in the operating room or immediate postoperative period injury to a major vein must be considered and corrected quickly.

Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection.

OBJECTIVE: The optimal method for arterial cannulation in acute aortic dissection type A (ADA) remains controversial. The aim of this study was to compare central ascending aortic, axillary, and femoral cannulation in patients who underwent surgery for acute ADA. METHODS: Between 2006 and 2017, 584 patients were operated on for acute ADA. Of those, 355 (61%) underwent ascending aortic, 101 (17%) right axillary, and 128 (22%) femoral cannulation for arterial inflow. Clinical features and outcomes were compared after inverse probability weighting. RESULTS: After inverse probability weighting there were no statistical differences in preoperative characteristics. Operative details differed significantly among the 3 groups: hemiarch replacement was performed more often in the central aortic and the femoral group (P < .001), whereas total arch replacement was performed more often in the axillary group (P < .001). Cardiopulmonary bypass (P = .022) and aortic cross-clamp (P = .021) times were shortest in the aortic cannulation group and longest in the femoral cannulation group. Postoperative morbidities were similar; procedure-related stroke (P = .783) and the need for renal replacement therapy (P = .446). In-hospital mortality (P = .680) and long-term survival were similar (log rank, P = .704). Multilevel multivariate mixed effect logistic regression showed that the cannulation strategy was not associated with in-hospital mortality. CONCLUSIONS: Central ascending aortic cannulation in patients with ADA can be used as safely as axillary or femoral cannulation, providing another option for quick and easy establishment of cardiopulmonary bypass.

Utilization, patency, and complications associated with vascular access for hemodialysis in the United States.

BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.

Administration of taurolidine-citrate lock solution for prevention of central venous catheter infection in adult neutropenic haematological patients: a randomised, double-blinded, placebo-controlled trial (TAURCAT).

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is one of the most frequent complications in patients with cancer who have central venous catheters (CVCs) implanted and is associated with substantial morbidity and mortality. Taurolidine is a non-antibiotic agent with broad-spectrum antimicrobial activity, which has been used as a lock solution to prevent CRBSI in some settings. However, little is known about its usefulness in high-risk adult neutropenic patients with cancer. This prospective randomised clinical trial aims to test the hypothesis that taurolidine-citrate lock solution is more effective than placebo for preventing catheter infection in neutropenic haematological patients. METHODS: This study is a prospective, multicentre, randomised, double-blinded, parallel, superiority, placebo-controlled trial. Patients with haematological cancer who are expected to develop prolonged neutropenia (> 7 days) and who have a non-tunnelled CVC implanted will be randomised to receive prophylactic taurolidine-citrate-heparin solution using a lock technique (study group) or heparin alone (placebo group). The primary endpoint will be bacterial colonisation of the CVC hubs. The secondary endpoints will be the incidence of CRBSI, CVC removal, adverse events, and 30-day case-fatality rate. DISCUSSION: The lock technique is a preventive strategy that inhibits bacterial colonisation in the catheter hubs, which is the initial step of endoluminal catheter colonisation and the development of infection. Taurolidine is a nontoxic agent that does not develop antibiotic resistance because it acts as an antiseptic rather than an antibiotic. Taurolidine has shown controversial results in the few trials conducted in cancer patients. These studies have important limitations due to the lack of data on adult and/or high-risk neutropenic patients, the type of catheters studied (tunnelled or ports), and the lack of information regarding the intervention (e.g. dwelling of the solution, time, and periodicity of the lock technique). If our hypothesis is proven, the study could provide important solid evidence on the potential usefulness of this preventive procedure in a population at high risk of CRBSI, in whom this complication may significantly impair patient outcome. TRIAL REGISTRATION: ISRCTN, ISRCTN47102251 . Registered on 9 September 2015.

The feasibility and safety of PICCs accessed via the superficial femoral vein in patients with superior vena cava syndrome.

OBJECTIVE: To investigate the feasibility and safety of the peripherally inserted central catheters (PICCs) accessed via the superficial femoral vein in patients with superior vena cava syndrome (SVCS). METHODS: From October 2010 to December 2014, 221 cancer patients with SVCS in our center received real-time ultrasound-guidance of the superficial femoral vein inserted central catheters (FICCs) at the mid-thigh. PICC insertion via upper extremity veins had also been investigated in 2604 cancer patients without SVCS as control. The average catheterization time, one-time puncture frequency, catheter duration and complications were compared between two groups. RESULTS: In the FICC group, the mean catheterization time was 31.60 ± 0.15 minutes, one-time puncture frequency was 1.05 ± 0.08, and catheter duration was 168.95 ± 20.47 days. There was no significant difference compared with the upper extremity veins PICC group: 31.11 ± 3.86 minutes, 1.03 ± 0.30, and 173.58 ± 39.81 days, respectively. The major complications included skin allergy to chlorhexidine gluconate (CHG) dressings, exudation, catheter-related infection, catheter occlusions, unplanned catheter withdrawal, venous thrombosis, mechanical phlebitis, and catheter malposition. It is interesting that a higher rate of catheter malposition was observed in the upper extremity veins PICC group than in the FICC group (2.15% vs. 0.00%). There were no significant differences in other complications between the two groups. CONCLUSIONS: Real-time ultrasound-guided PICCs accessed via the superficial femoral vein at the mid-thigh is a new modified technique with low complications, which can be a feasible and safe alternative venous access for patients with SVCS.

Central Cannulation as a Viable Alternative to Peripheral Cannulation in Extracorporeal Membrane Oxygenation.

Arterial cannulation for veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is most commonly established via the aorta, axillary, or femoral vessels, yet their inherent complications are not well characterized. The purpose of this study was to compare the outcomes and complication rates of central vs peripheral cannulation. Adult patients undergoing VA ECMO between June 2009 and April 2015 were reviewed in this retrospective single-center study. Patient characteristics, clinical outcomes, and details related to deployment were extracted from the medical record. Complications and survival rates were compared between patients by cannulation strategy. Of 131 VA ECMO patients, there were 36 aortic (27.5%), 16 axillary (12.2%), and 79 femoral (60.3%) cannulations. Other than a lower mean age with femoral cannulations (53.9 ± 13.9 years) vs aortic (60.3 ± 12.2 years) and axillary (59.8 ± 12.4 years) (P = 0.032), the baseline patient characteristics were not statistically different. Central cannulation was more common in patients transferred from outside facilities (74.3% central vs 51.6% peripheral) (P = 0.053). Seven of 36 aortic cannulations were via anterior thoracotomy (19.4%). Forty of 131 patients underwent extracorporeal cardiopulmonary resuscitation (30.5%), 33 of whom were femorally cannulated. Peripheral cannulation carried a 29.5% rate of vascular complications compared with an 11.1% rate of mediastinal bleeding with central cannulation. Incidence of stroke and overall survival between groups were not statistically different. Central cannulation is a viable alternative to peripheral cannulation. Central cannulation avoids high rates of extremity morbidity without causing significant risks of alternative morbidity or death.

Central Venous-to-Arterial Carbon Dioxide Partial Pressure Difference in Patients Undergoing Cardiac Surgery is Not Related to Postoperative Outcomes.

OBJECTIVE: The objective of this study was to assess the association between increased central venous-to-arterial carbon dioxide difference (ΔPCO2) following cardiac surgery with cardiopulmonary bypass and postoperative morbidity and mortality. DESIGN: A prospective, observational, non-interventional study. PATIENTS: Three hundred ninety-three patients undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: The primary endpoint was the occurrence of one or more major postoperative complications. A ΔPCO2 ≥ 6 mmHg was considered to be abnormal. Data were first analyzed globally, and then according to 4 subgroups based on time course of ΔPCO2 during the study period: [(1) persistently normal ΔPCO2; (2) increasing ΔPCO2; (3) decreasing ΔPCO2; and (4) persistently high ΔPCO2]. RESULTS: A total of 238 of the 393 (61%) patients developed complications. The major postoperative complication rate did not differ among the 4 groups: 64% (n = 9) in group 1, 62% (n = 21) in group 2, 53% (n = 32) in group 3, and 62% (n = 176) in group 4 (p = 0.568). Mortality rates did not differ among the 4 groups (p > 0.05). ΔPCO2 was correlated weakly with perfusion parameters. CONCLUSIONS: These results suggested that ΔPCO2 is not predictive of postoperative complications or mortality.

A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis.

OBJECTIVE: Early cannulation arteriovenous grafts (ecAVGs) are proposed as an alternative to tunneled central venous catheters (TCVCs) in patients requiring immediate vascular access for hemodialysis (HD). We compared bacteremia rates in patients treated with ecAVG and TCVC. METHODS: The study randomized 121 adult patients requiring urgent vascular access for HD in a 1:1 fashion to receive an ecAVG with or without (+/-) an arteriovenous fistula (AVF; n = 60) or TCVC+/-AVF (n = 61). Patients were excluded if they had active systemic sepsis, no anatomically suitable vessels, or an anticipated life expectancy <3 months. The primary end point was the culture-proven bacteremia rate at 6 months, with the trial powered to detect a reduction in bacteremia from 24% to 5% (α = .05, ß = .8). Secondary end points included thrombosis, reintervention, and mortality. A cost-effectiveness analysis was also performed. RESULTS: Culture-proven bacteremia developed in 10 patients (16.4%) in the TCVC arm ≤6 months compared with two (3.3%) in the ecAVG+/-AVF arm (risk ratio, 0.2; 95% confidence interval, 0.12-0.56; P = .02). Mortality was also higher in the TCVC+/-AVF cohort (16% [n = 10] vs 5% [n = 3]; risk ratio, 0.3; 95% CI, 0.08-0.45; P = .04). The difference in treatment cost between the two arms was not significant (£11,393 vs £9692; P = .24). CONCLUSIONS: Compared with TCVC+/-AVF, a strategy of ecAVG+/-AVF reduced the rate of culture-proven bacteremia and mortality in patients requiring urgent vascular access for HD. The strategy also proved to be cost-neutral.

Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis.

BACKGROUND: The decision about the type and location of a hemodialysis vascular access is challenging and can be affected by multiple factors. We explored the effect of several a priori chosen patient characteristics on access outcomes. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through November 13, 2014. We included studies that evaluated patency, mortality, access infection, and maturation of vascular access in adults requiring long-term dialysis. Pairs of reviewers working independently selected the studies and extracted the data. Outcomes were pooled across studies using the random-effects model. RESULTS: Two hundred studies met the eligibility criteria reporting on 875,269 vascular accesses. Overall, studies appeared to have provided incidence rates at low to moderate risk of bias. The overall primary patency at 2 years was higher for fistulas than for grafts and catheters (55%, 40%, and 50%, respectively). Patency was lower in individuals with diabetes, coronary artery disease, older individuals, and in women. Mortality at 2 years was highest with catheters, followed by grafts then fistulas (26%, 17%, and 15%, respectively). CONCLUSIONS: The current evidence remains in support of autogenous access as the best approach when feasible. We provide incidence rates in various subgroups to inform shared decision making and facilitate the conversation with patients about access planning.

Vascular access for elderly hemodialysis patients: what should we aim for?

PURPOSE: Elderly chronic kidney disease (CKD) patients are one of the fastest growing groups in hemodialysis (HD). However, overall mortality and arteriovenous fistulae failure are still high in this population. Therefore, a different vascular access policy may be advised for this group of patients. METHODS: We searched PubMed for relevant articles published in English between the years 2000-2015. Studies investigating vascular access-related outcomes in elderly CKD patients were included. RESULTS: The scarce literature on this topic suggests that elderly CKD patients are more likely to undergo unnecessary vascular access procedures. However, with appropriate vascular evaluation, arteriovenous access placement is a viable strategy for this group of patients and dialysis access-related outcomes are superior for arteriovenous access in comparison with dialysis catheters. CONCLUSIONS: When deciding whether or not to create an arteriovenous vascular access in elderly CKD patients, physicians should consider the probability of CKD progression, the expected life expectancy and quality of life of the patient and the probability of success of an arteriovenous access creation.