Cost-effectiveness of taurolidine-citrate in a cohort of patients with intestinal failure receiving home parenteral nutrition.

BACKGROUND: Catheter-related bloodstream infections (CRBSIs) in patients receiving home parenteral nutrition (HPN) for chronic intestinal failure (CIF) are associated with significant morbidity and financial costs. Taurolidine is associated with a reduction in bloodstream infections, with limited information on the cost-effectiveness as the primary prevention. This study aimed to determine the cost-effectiveness of using taurolidine-citrate for the primary prevention of CRBSIs within a quaternary hospital. METHODS: All patients with CIF receiving HPN were identified between January 2015 and November 2022. Data were retrospectively collected regarding patient demographics, HPN use, CRBSI diagnosis, and use of taurolidine-citrate. The direct costs associated with CRBSI-associated admissions and taurolidine-citrate use were obtained from the coding department using a bottom-up approach. An incremental cost-effective analysis was performed, with a time horizon of 4 years, to compare the costs associated with primary and secondary prevention against the outcome of cost per infection avoided. RESULTS: Forty-four patients received HPN within this period. The CRBSI rates were 3.25 infections per 1000 catheter days before the use of taurolidine-citrate and 0.35 infections per 1000 catheter days after taurolidine-citrate use. The incremental cost-effectiveness ratio indicates primary prevention is the weakly dominant intervention, with the base case value of $27.04 per CRBSI avoided. This held with one-way sensitivity analysis. CONCLUSION: Taurolidine-citrate in the primary prevention of CRBSIs in patients with CIF receiving HPN is associated with reduced hospital costs and infection rates.

Definition and clinical management of haemodialysis central venous catheter local infections (exit site and tunnel infection): An international consensus assessment.

AIM: To evaluate the relevance of signs and symptoms for the clinical identification of ESI and TI in HD-CVC, by means of international expert consensus, and to reach a consensus on a definition and clinical management (CM) for these infections. BACKGROUND: A recent systematic review showed a high heterogeneity in the signs/symptoms used for determining exit site infection (ESI) and tunnel infection (TI) of haemodialysis central venous catheter (HD-CVC). DESIGN: A modified Delphi ranking process was carried out between November 2020 and March 2021, consisting of four rounds using an online questionnaire with a panel of 26 experts from 12 countries. METHODS: Experts responded on the level of relevance for the identification of ESI and TI, based on a list of 22 signs/symptoms obtained from a previous systematic review, using a 4-point Likert-type scale. After reaching consensus on the signs/symptoms, they followed the same method to reach consensus on the CM. The STROBE Checklist was used to report this study. RESULTS: A high degree of consensus was reached to identify the presence of ESI based on nine signs/symptoms: presence of pain at the exit site (ES) during interdialysis period, with fever ≥38°C do not suspect other cause, local signs at the ES (inflammation, induration, swelling, hyperemia/erythema ≥2 cm from ES) and obvious abscess or purulent exudate at ES; and of TI. Likewise, 5 cm were agreed upon. CONCLUSION: This Delphi study provides international expert consensus definitions of ESI and TI in HD-CVC, laying the groundwork for the validation of an HD-CVC ES clinical assessment scale for early identification of ESI. RELEVANCE TO CLINICAL PRACTICE: In addition, this study provides a series of attitudes to consensual clinics regarding signs/symptoms of local infections in HD-CVC, which may be useful as expert opinion in clinical practice guidelines, when there is insufficient scientific evidence.

Longer length peripheral catheters in sickle cell treatment: a more efficient and cost-effective care pathway.

Patients with sickle cell disease require frequent venous access for red blood cell exchange transfusions to manage their condition. Such frequent access can lead to scar tissue formation, increased pain on insertion, and difficult vascular access for the patients. Previous attempts at achieving successful venous access for patients with difficult venous access has been made with central venous lines, usually femoral lines, which required a large amount of nursing input and resulted in anxiety and pain on insertion for patients. In this article, the author reports on a new pathway with a longer-length peripheral intravenous catheter that reduces the nursing time burden during line insertion, requires less equipment and, crucially, results in a less painful procedure for patients. The increased efficiency of the pathway resulted in a cost saving of £149 per insertion, and patient feedback revealed that the longer-length catheter was preferred over femoral lines.

Improving assessment and escalation of threatened haemodialysis access: results of a nursing-led program.

BACKGROUND: Optimal vascular access is critical to successful haemodialysis. Acute thrombosis of haemodialysis access often leads to unplanned hospital admissions and interventions to restore patency. Western Health is a large health service in Victoria, Australia. During the period February 2019 to January 2020, the rate of arteriovenous fistula (AVF) and arteriovenous graft (AVG) at Western Health satellite dialysis units was 0.33 episodes per 1000 patient-days, higher than the reported rate in the literature of 0.24 events per 1000 patient-days, and was associated with a cumulative total of 139 days of inpatient stay (2.2 per 1000 patient-days). METHODS: The above results prompted creation of an education and escalation pathway for threatened haemodialysis access, based upon clinical markers of vascular access stenosis or imminent thrombosis assessed by nursing staff in satellite haemodialysis centres. In the period February 2020 to January 2021, the education and escalation pathway was implemented. We assessed referrals via the pathway, rates of AVF/AVG thrombosis and associated hospital length of stay in the following 12-month period (February 2021 to January 2022). RESULTS: Following introduction of the pathway, rates of AVF/AVG thrombosis declined to 0.15 per 1000 patient-days (p = 0.02), associated with a decline in attributable cumulative inpatient stay to 55 days (0.69 per 1000 patient-days). CONCLUSIONS: Our program demonstrates that the majority of thrombosed vascular access can be predicted and potentially averted with vigilant and well-practiced routine clinical assessment by trained nursing staff. Our nursing-led education and escalation program successfully identified vascular access at risk of imminent thrombosis, reduced rates of acute thrombosis and associated healthcare costs. Despite these improvements, there are still disparities in outcomes for patients with thrombosed vascular access, with regards to length of stay and requirement for insertion of a temporary central venous catheter (CVC) for urgent dialysis whilst awaiting intervention, and these are areas for further investigation and improvement.

Ultrasound assessment of abdominal adhesions in neonates: data over dogma for re-operative timing.

INTRODUCTION: Neonatal abdominal reoperation is difficult and can be complicated by abdominal adhesions. Identifying patients who could safely undergo early reoperation would save TPN and central line days, decrease associated infection and liver injury, and NICU and hospital length of stay. We sought to determine if ultrasound (US) could accurately assess the location and severity of adhesions in neonates as an objective dynamic marker capable of informing reoperation timing. METHODS: After IRB approval, we conducted a prospective observational study including neonates undergoing abdominal operations. Patients received surgeon-performed US approximately every 2 weeks until reoperation or discharge. Adhesions were assessed in five zones: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ) and peri-incision (INC). RESULTS: Over a 6-month study period, 16 neonates were enrolled. Median gestational age was 34 weeks at birth and median weight 2.2 kg. 6 underwent reoperation within initial NICU admission. At time of operation US correctly identified the absence or presence and severity of adhesions in: RUQ (3/3); RLQ (6/6); LUQ (4/5); LLQ (6/6); and INC (5/5). CONCLUSION: US can identify location and severity of post-operative adhesions in neonates, potentially identifying patients who can safely undergo reoperation earlier than predetermined wait periods. LEVEL OF EVIDENCE: IV.

Assessment of an umbilical venous catheter dwell-time of 8-14 days versus 1-7 days in very low birth weight infacts (UVC - You Will See): a pilot single-center, randomized controlled trial.

BACKGROUND: Umbilical venous catheters (UVCs) are used for central vascular access in preterm infants, but controversy exits with regard to the optimum dwell-time. PATIENTS AND METHODS: Prospective, randomized controlled trial at a level III University neonatal intensive care unit (NICU), comparing a UVC dwell-time of 1-7 days (control group) to 8-14 days (intervention group) in very low birth weight (VLBW) infants. PRIMARY OUTCOME PARAMETER: Number of infants requiring additional peripherally inserted central catheters (PICC) after removal of UVC. SECONDARY OUTCOME PARAMETERS: Total number of central lines (CL = UVC and PICCs) until time point of full enteral feeds (130-160 mL/kg/d), total number of intravenous vascular catheters, number of CL-associated complications (infection, thrombosis/emboli, organ injury, secondary CL dislocation), number of X-rays for assessment of CL positioning, and days of therapy (DOT) (teicoplanin) for CL-associated blood stream infections (CLABSI). RESULTS: Of 116 patients screened for eligibility, 63 patients were enrolled - control group: 31 infants, mean gestational age (GA) 280 weeks (standard deviation (SD) 2.6 weeks), mean birth weight (BW) 988.9 g (SD 322.0 g); intervention group: 32 infants, mean GA 285 weeks (SD 3.0 weeks), mean BW 1078.9 g (SD 324.6 g). In the control group, 28 infants required additional PICCs versus 16 in the intervention group (p < 0.001); total number of CLs: control group n = 58 versus intervention group n = 28; p < 0.001, and the total number of venous vascular devices was also significantly higher in the control group (109 versus 61; p = 0.04). No significant differences were seen with regard to CL-associated complications (p = 0.09). The number of X-rays for assessment of correct CL-position significantly lower in the intervention group (144 versus 96; p = 0.03). In the intervention group, length of hospital stay was significantly shorter (88.1 (SD: 35.3 days) versus 68.1 (SD: 32.6 days); p = 0.03) and GA significantly lower at discharge from the hospital (404: SD: 33 weeks) versus 385: SD: 25 weeks; p = 0.02. No differences existed with regard to neonatal morbidities and mortality at 36 weeks gestational age. CONCLUSIONS: A longer UVC dwell-time of up to 14 days significantly decreased the number of painful invasive vascular procedures and radiation exposure, and shortened the length of the hospital stay. The findings of our pilot study should be confirmed in a larger, multi-center RCT with the primary focus on catheter-associated complications.

Daily point-of-care ultrasound-assessment of central venous catheter-related thrombosis in critically ill patients: a prospective multicenter study.

PURPOSE: Central venous catheter (CVC)-related thrombosis (CRT) is a known complication in critically ill patients. However, its clinical significance remains unclear. The objective of the study was to evaluate the occurrence and evolution of CRT from CVC insertion to removal. METHODS: A prospective multicenter study was conducted in 28 intensive care units (ICUs). Duplex ultrasound was performed daily from CVC insertion until at least 3 days after CVC removal or before patient discharge from the ICU to detect CRT and to follow its progression. CRT diameter and length were measured and diameter > 7 mm was considered extensive. RESULTS: The study included 1262 patients. The incidence of CRT was 16.9% (95% confidence interval 14.8-18.9%). CRT was most commonly found in the internal jugular vein. The median time from CVC insertion to CRT onset was 4 (2-7) days, and 12% of CRTs occurred on the first day and 82% within 7 days of CVC insertion. CRT diameters > 5 mm and > 7 mm were found in 48% and 30% of thromboses. Over a 7-day follow-up, CRT diameter remained stable when the CVC was in place, whereas it gradually decreased after CVC removal. The ICU length of stay was longer in patients with CRT than in those without CRT, and the mortality was not different. CONCLUSION: CRT is a frequent complication. It can occur as soon as the CVC is placed and mostly during the first week following catheterization. Half of the thromboses are small but one-third are extensive. They are often non-progressive and may be resolved after CVC removal.

Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU.

The goal of the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was to define indications and appropriate practices for peripherally inserted central catheters (PICC) use; however, MAGIC recommendations virtually reduced the use of PICC in hospital settings, including critical care. The aim of this review is to present an assessment of the MAGIC guidelines, considering contemporary evidence to date. The validity of the MAGIC recommendations and their applicability to current practice are called into question given important concerns with the methodology for their development (e.g. high volume of clinical scenarios for evaluation) and the supporting evidence used. There is a considerable amount of contemporary evidence not considered in MAGIC that reports on evolving practices, techniques, and technologies targeted to reduce complications associated with central venous access devices (CVADs). Recent evidence dictates that CVADs are necessary in the intensive care unit (ICU), and that PICCs are a safe, reliable, and appropriate type of central lines, which cannot be replaced in several ICU situations. In light of evolving evidence and practice, as well as the methodological concerns identified, the MAGIC guidelines should be revisited. It is also recommended to create a clinical assessment tool that identifies potential uses of specific CVADs, based on patient needs. The choice of the CVAD should be based on unique clinical considerations and current scientific evidence, not on fears informed by antiquated data.

Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model.

INTRODUCTION: Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices. METHODS: We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model. RESULTS: The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation. CONCLUSION: In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.

Assessment of the Hawthorne effect during central venous catheter manipulation.

OBJECTIVES: To describe the compliance to the practices of hand hygiene and hub disinfection before manipulation of the central venous catheter in two moments: before and after educational intervention. Adherence to hand hygiene was assessed with two methods: direct observation and video camera. METHODS: Before and after study conducted with the nursing team in an adult intensive care unit, in São Paulo, Brazil, including 180 observations using video cameras and direct observation. Hand hygiene compliance before catheter manipulation and compliance with the correct technique and the hub disinfection for five seconds were observed. RESULTS: When video cameras recording was observed, hand hygiene compliance increased from 46% to 66% and the use of the proper technique increased from 23% to 46% (p < 0.05). Regarding hub disinfection compliance, no difference was observed between the periods. Hand hygiene compliance in direct observation increased from 83% to 87% and in indirect observation, from 46% to 66% after the intervention. CONCLUSION: After the educational intervention, hand hygiene compliance before CVC manipulation and the use of the correct technique improved. When observed indirectly, the adherence to these practices was lower, reinforcing the Hawthorne effect.

Overview of hemodialysis access and assessment.

OBJECTIVE: To provide family physicians with an evidence-based overview on the various methods of vascular access for hemodialysis (HD) and to provide a framework for the clinical assessment of HD access. SOURCES OF INFORMATION: A MEDLINE literature search was conducted using the MeSH terms arteriovenous fistula, arteriovenous graft, central venous catheter, and hemodialysis (or haemodialysis), including all relevant English-language articles published between January 1995 and September 2021. MAIN MESSAGE: The main types of permanent vascular access for HD are arteriovenous fistulas, arteriovenous grafts, and central venous catheters. A pragmatic, patient-centred approach is required when choosing the type of access for an individual. Common complications of vascular access creation include thrombosis, central venous stenosis, dialysis access steal syndrome, and arteriovenous fistula aneurysms. CONCLUSION: Family physicians play an important role in the clinical assessment and monitoring of HD vascular access. A thorough clinical assessment can detect a failing arteriovenous fistula and any associated complications, which can allow for prompt investigation and intervention to restore functionality, maintain access longevity, and improve patient quality of life.

Effectiveness and cost-efficacy of diuretics home administration via peripherally inserted central venous catheter in patients with end-stage heart failure.

BACKGROUND: End-stage heart failure (ESHF) is characterized by severe cardiac dysfunction with persistent disabling symptoms and recurrent acute decompensated heart failure (ADHF), despite guideline-directed medical therapy. The aim of this study was to evaluate the efficacy and safety of intravenous diuretics administration at home through a peripherally inserted central venous catheter (PICC) in ESHF patients. METHODS AND RESULTS: Forty-one ESHF patients received PICC implantation for intravenous diuretic administration at home. The primary efficacy endpoint was the patient-level number of HF hospitalizations in the short (1-3 months), medium (six months), and long term (1 year), before and after PICC implantation. Pre- and post-PICC ADHF-free days were also evaluated as co-primary endpoint. Secondary endpoints comprised changes in clinical, laboratory and echocardiographic parameters, and device safety. A cost-effectiveness analysis was performed to estimate the economic impact of using PICC. For each time frame analyzed, a significant reduction in the number of hospitalizations due to ADHF was observed, resulting in a significant increase in ADHF-free days (71 ± 44 vs. 163 ± 136, p = 0.003). In matched patients' analysis, significant decrease in body weight (68 ± 16 kg vs. 63 ± 10 kg, p = 0.041) and mitral regurgitation grade 3/4 (55% vs. 18%, p < 0.001) were also observed. Freedom from PICC-related complications was observed in 61% of patients. A significant reduction in overall ADHF-hospitalizations cost was observed. CONCLUSIONS: This proof-of-concept study demonstrates the effectiveness and safety of home administration of intravenous diuretic therapy via PICC in ESHF patients. This palliative cost-effective strategy can be taken in consideration for selected end-stage patients no longer responsive to conventional therapies.

Cost-effectiveness Analysis of Peripherally Inserted Central Catheters Versus Central Venous Catheters for in-Hospital Parenteral Nutrition.

OBJECTIVE: Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN). METHODS: The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods. RESULTS: We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC. CONCLUSIONS: Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.

Provision of Kidney Disease Education Service Is Associated with Improved Vascular Access Outcomes among US Incident Hemodialysis Patients.

Background: Pre-ESKD Kidney Disease Education (KDE) has been shown to improve multiple CKD outcomes, but its effect on vascular access outcomes is not well studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD. Methods: In this retrospective USRDS analysis, we identified all adult patients on incident hemodialysis with ≥6 months of pre-ESKD Medicare coverage during the first 5 years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE cohort) and nonrecipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1, KDE alone; model 2, multivariate model encompassing model 1 with sociodemographics; model 3, model 2 with comorbidity and functional status; and model 4, model 3 with pre-ESKD nephrology care). Results: Of the 211,990 qualifying patients on incident hemodialysis during the study period, 2887 (1%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (30% and 35%, respectively, compared with 14% and 17%), and pure catheter use about a third lower (40% compared with 65%) in the KDE cohort compared with the non-KDE cohort. The maximally adjusted odds ratios in model 4 for study outcomes were incident AVF use, 1.78, 99% confidence interval, 1.55 to 2.05; incident AVF/AVG use, 1.78, 99% confidence interval, 1.56 to 2.03; incident CVC with maturing AVF/AVG, 1.69, 99% confidence interval, 1.44 to 1.97; and pure CVC without any AVF/AVG, 0.51, 99% confidence interval, 0.45 to 0.58. The benefits of the KDE service were maintained even after accounting for the presence, duration, and facility of ESKD care. Conclusion: The occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the effect of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.

In vitro use of standard fluid infusion central venous catheter for slow continuous ultrafiltration feasibility assessment.

BACKGROUND: Slow continuous ultrafiltration (SCUF) by central venous catheter (CVC) for hemodialysis is a simple extracorporeal ultrafiltration that can reduce and control fluid overload in patients with chronic or acute chronic heart failure unresponsive to medical therapy. In order to avoid complications and risks related to the catheterization with a standard CVC for hemodialysis to provide the SCUF, considering that hospitalized patients affected by congestive heart failure commonly undergo CVC placement for medications delivering, we tested an in vitro model to use a standard CVC for infusion to perform SCUF. METHODS: We performed an in vitro SCUF experimental model through two different lumens of a triple (8Fr × 20 cm Tri-lumen catheter Kit-Envans Extra) and a quad-lumen CVC (8.5Fr × 20 cm Quad-lumen catheter kit-Benefis Medical Devices) commonly used in our Intensive Care Unit for fluids and medications infusions. We used Prismaflex with the HF-20 set (Baxter, IL, USA) to perform the SCUF treatment. RESULTS: Our in vitro data confirm the technical feasibility of the use of standard CVC for fluid infusion to perform a SCUF treatment with a theoretical weight loss of up to 200 ml/h by a blood flow ranging from 30 to 45 ml/min. CONCLUSIONS: The use of standard infusion CVC could be utilized in the intensive care unit to perform SCUF not exposing patients to the risks and complications related to the placement and permanence of CVC for hemodialysis.

Pediatric central venous access devices: practice, performance, and costs.

BACKGROUND: Healthcare delivery is reliant on a functional central venous access device (CVAD), but the knowledge surrounding the burden of pediatric CVAD-associated harm is limited. METHODS: A prospective cohort study at a tertiary-referral pediatric hospital in Australia. Children <18 years undergoing insertion of a CVAD were screened from the operating theatre and intensive care unit records, then assessed bi-weekly for up to 3 months. Outcomes were CVAD failure and complications, and associated healthcare costs (cost of complications). RESULTS: 163 patients with 200 CVADs were recruited and followed for 6993 catheter days, with peripherally inserted central catheters most common (n = 119; 60%). CVAD failure occurred in 20% of devices (n = 30; 95% CI: 15-26), at an incidence rate (IR) of 5.72 per 1000 catheter days (95% CI: 4.09-7.78). CVAD complications were evident in 43% of all CVADs (n = 86; 95% CI: 36-50), at a rate of 12.29 per 1000 catheter days (95% CI: 9.84-15.16). CVAD failure costs were A$826 per episode, and A$165,372 per 1000 CVADs. Comparisons between current and recommended practice revealed inconsistent use of ultrasound guidance for insertion, sub-optimal tip-positioning, and appropriate device selection. CONCLUSIONS: CVAD complications and failures represent substantial burdens to children and healthcare. Future efforts need to focus on the inconsistent use of best practices. IMPACT: Current surveillance of central venous access device (CVAD) performance is likely under-estimating actual burden on pediatric patients and the healthcare system. CVAD failure due to complication was evident in 20% of CVADs. Costs associated with CVAD complications average at $2327 (AUD, 2020) per episode. Further investment in key diverse practice areas, including new CVAD types, CVAD pathology-based occlusion and dislodgment strategies, the appropriate use of device types, and tip-positioning technologies, will likely lead to extensive benefit.

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

OBJECTIVES: The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. DESIGN: Single-center retrospective cohort study. SETTING: Quaternary academic PICU. PATIENTS: Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. CONCLUSIONS: The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.