Guarding the central venous access device: a new solution for an old problem.

HIGHLIGHTS: CLABSIs are a major concern in both the adult and pediatric patient population. Contamination of catheter hubs is a common cause of CLABSI. A novel, transparent line guard protects CVAD hubs from gross contamination. Central line-associated blood stream infections (CLABSIs) are a serious and potentially deadly complication in patients with a central venous access device (CVAD). CVADs play an essential role in modern medicine, serving as lifelines for many patients. To maintain safe and stable venous access, infection prevention bundles are used to help protect patients from complications such as CLABSI. Despite most CLABSIs being preventable, rates have been on the rise, often disproportionately impacting critically ill children. New solutions are needed to strengthen infection prevention bundles and protect CVADs from pathogen entry at catheter hubs and line connections. A novel, Food and Drug Administration-listed device has become available recently to guard CVADs from sources of gross contamination, addressing this apparent gap in infection prevention technology and practice.

Factors associated with intraoperative intravenous catheter extravasation in children.

SummaryThis retrospective study aimed to determine the incidence of and factors associated with peripheral intravenous extravasation in paediatric patients in the intraoperative setting. We conducted a retrospective study of 56,777 patients who underwent general anaesthesia and had peripheral intravenous catheter placement at Cincinnati Children's Hospital between 1 January 2015 and 1 January 2017. Data collected included age, American Society of Anesthesiologists Physical Status Classification, catheter site, number of cannulation attempts, ultrasound use for cannulation, surgery duration, and surgery class. Primary outcome was peripheral intravenous extravasation using an extravasation assessment tool. Some 64,814 peripheral venous catheters were placed in patients undergoing general anaesthesia. Significant extravasation was documented in 40 catheters with an estimated incidence of 1 in 1620 venous catheters (0.06%). Of those 40 catheters, 47.5% (n = 19) were placed using ultrasound and 37.5% (n = 15) required more than one cannulation attempt. In multivariable analysis, peripheral intravenous catheter extravasation was associated with American Society of Anesthesiologists Physical Status Classification (3, 4, 5) versus (1, 2) (odds ratio 2.42 (95% CI 1.08 to 5.41)), inpatient versus outpatient surgeries (odds ratio 2.99 (95% CI 1.31 to 6.81)), and intravenous catheters placed with ultrasound guidance (odds ratio 8.01 (95% CI 4.12 to 15.57)). Our study identified factors associated with intraoperative peripheral intravenous extravasation, and will help develop mitigation strategies to minimise harm to patients.

Standardizing Preoperative Evaluation for Pediatric Central Venous Access: A Care Algorithm to Improve Safety.

Central vascular access device (CVAD) placement is a common procedure in children. When selecting a CVAD, available evidence and specified indications should be used to choose the device that best supports the patient's treatment and carries the lowest risks. A multidisciplinary team developed a care algorithm to standardize preoperative screening before pediatric CVAD placement, with 3 major parts: CVAD selection, patient risk stratification, and preoperative evaluation. Using a stepwise approach of provider education and incorporation into the electronic health record, the team achieved 82% stratification among inpatients. The team's algorithm integrates the existing literature and recommendations for safe and effective CVAD placement.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC.

OBJECTIVES: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts. METHODS: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds. RESULTS: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized. CONCLUSIONS: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children.

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Reducing risk of harm from extravasation: a 3-tiered evidence-based list of pediatric peripheral intravenous infusates.

Extravasation of medications during peripheral intravenous (PIV) therapy can result in harm to pediatric patients. These medications have physical and/or biologic factors that cause tissue damage. To assist in clinical decisions when using these infusates, an evidence-based table of medications stratified by their relative risk of causing harm if extravasated was developed. Local data and experience, a systematic review of the pediatric literature, and measured pH and osmolality of common pediatric preparations of PIV infusates were used to create a 3-tiered table of PIV infusates categorized by relative risk of causing harm if extravasated.

Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric patients.

Central venous catheter occlusions disrupt delivery of needed therapies to vulnerable neonatal and young pediatric patients. Nursing practices that minimize risk of catheter occlusion include proper infusion and flushing techniques. Treatment strategies vary on the basis of the source of the occlusion. Mechanical occlusions can often be resolved by altering the patient's position, correcting catheter kinks, or adjusting clamps. Occlusions caused by precipitation can be cleared through instillation of ethanol, hydrochloric acid, or sodium bicarbonate, depending on the chemistry of the infusates. Finally, the thrombolytic agent alteplase is recommended for treatment of catheter occlusion because of thrombus formation.

Procedural pain management: a position statement with clinical practice recommendations.

The American Society for Pain Management Nursing (ASPMN) has developed a position statement and clinical practice recommendations related to procedural preparation and comfort management. Procedures potentially produce pain and anxiety, both of which should be assessed and addressed before the procedure begins. This position statement refers to "comfort management" as incorporating the management of pain, anxiety, and any other discomforts that may occur with procedures. It is the position of ASPMN that nurses and other health care professionals advocate and intervene based on the needs of the patient, setting, and situation, to provide optimal comfort management before, during, and after procedures. Furthermore, ASPMN does not condone procedures being performed without the implementation of planned comfort assessment and management. In addition to outlining this position with supporting evidence, this paper reviews the ethical considerations regarding procedural comfort management and provides recommendations for nonpharmacologic and pharmacologic management during all phases of the procedure. An appendix provides a summary of this position statement and clinical practice recommendations.

Infiltration and extravasation: update on prevention and management.

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Pediatric peripherally inserted central catheter placement: application of ultrasound technology.

Ultrasound-guided placement of peripherally inserted central catheters has been well documented for adults who require infusion therapy. This same technology is surfacing in the pediatric population to improve outcomes when confronted with the challenges of the smaller vascular system and chubbier body shapes. The scope of practice is addressed in coupling peripherally inserted central catheters with ultrasound imaging, and recommendations are identified for the advancement of nursing practice within the field of imaging technology and application. Obstacles related to successful insertion of peripherally inserted central catheters are defined, and the benefits of ultrasound-guided placement of peripherally inserted central catheters are reviewed.

The impact of needleless connector device design on central venous catheter occlusion in children: a prospective, controlled trial.

BACKGROUND: Intraluminal occlusion is common in children with central venous catheters (CVCs). Although multiple factors predispose CVCs to occlusion, reflux of blood is frequently implicated. We hypothesized that use of either a single-valve or positive-pressure-valve needleless connector device would reduce CVC occlusion rates in comparison to a standard device. We further hypothesized that saline would be as effective as heparinized saline flush in preventing occlusion and infection. METHODS: CVC lumens were prospectively capped with 1 of 3 needleless connector devices in a 4-group design. Group 1 lumens were capped with a standard device, group 2 with a single-valve device, group 3 with a positive-pressure-valve device flushed with heparinized saline, and group 4 with a positive-pressure-valve device flushed with saline. Data were obtained regarding occlusion and infection rates and user satisfaction. RESULTS: Three hundred sixty children with 599 CVC lumens completed the study. Complete occlusion occurred in 19/150 (12.7%) lumens in group 1 in comparison to 2/150 (1.3%) in group 2, 5/149 (3.4%) in group 3, and 6/150 (4%) in group 4 (p < .05). There was a trend toward a 2-fold greater infection rate in group 4. User satisfaction was higher in groups 2, 3, and 4 than group 1 (p < .05). CONCLUSIONS: CVCs capped with a single-valve or positive-pressure-valve needleless connector device have lower complete catheter occlusion rates than those capped with a standard device. Heparinized saline flush affords no advantages over saline in reducing occlusion rate; however, there was a trend toward lower infection rate with the use of heparinized saline.

Peripherally inserted central catheters in children: a survey of practice patterns.

There is little published information describing standards of practice in the placement, use, and maintenance of peripherally inserted central catheter (PICC) devices in children. A Web-based survey tool was designed to query these issues, and 72 intravenous therapy nurses from 72 hospitals provided complete responses to the survey. The respondents were predominantly (81%) from healthcare organizations inserting 40 or fewer PICC devices per month. These hospitals were equally divided in using 0.9% sodium chloride (USP) (saline) or heparinized saline flush to maintain patency, whereas 76% used catheters for blood sampling. Flushing and blood sampling practices were not related to catheter occlusion rates. From their survey, the authors conclude that the standards of practice for 3-Fr PICC devices, the most commonly used for children, are quite variable and in need of standardization for this specific population.

The efficacy and safety of blood sampling through peripherally inserted central catheter devices in children.

BACKGROUND: The peripherally inserted central catheter (PICC) is commonly used in children for medication and fluid administration. In addition, PICCs are used occasionally for blood sampling as an alternative to venipuncture. Blood sampling from these catheters carries the hypothetical risk of catheter occlusion caused by blood remaining in the catheter, and this practice is not supported by PICC manufacturers. Children often undergo multiple needle punctures, which are associated with pain, anxiety, and dissatisfaction with care. The authors hypothesized that blood sampling through 3-Fr PICC devices is effective and safe for children. METHODS: After placement of a 3-Fr PICC, all the children were sequentially enrolled in one of two groups. The control group included patients that had 3-Fr PICC devices without blood sampling. The blood sampling group included patients with 3-Fr PICC devices through which blood samples were obtained. Demographic data, PICC placement and sampling data, infusate composition, catheter occlusion, mechanical complications, and blood stream infections were recorded. The primary outcome variable was the difference in occlusion rates between the two groups. RESULTS: The analysis included 204 children with 3-Fr PICCs (120 in the blood sampling group and 84 in the control group) who had a mean age, 117.7 +/- 4.9 months. The mean PICC duration was 15.6 +/- 1.0 days. Blood sampling was successful more than 98% of the time from all blood sampling group catheters, with a mean of 4.4 +/- 0.5 samples removed from each catheter. There was a higher occlusion rate in the blood sampling group. However, this result did not reach statistical significance. There were no significant differences between the groups in terms of infection or mechanical complication rates. CONCLUSIONS: Blood sampling is feasible and effective through 3-Fr PICC devices in children. This practice is not associated with a significant increase in occlusion, infection, or mechanical complication rates.

Central venous catheter occlusion: a prospective, controlled trial examining the impact of a positive-pressure valve device.

BACKGROUND: Central venous catheter (CVC) occlusion occurs frequently in children. This problem is often associated with disruption of intravascular therapy and monitoring. Multiple factors may predispose to catheter occlusion, but reflux of blood into the catheter lumen is a common factor. We hypothesized that use of a positive pressure valve device would reduce the incidence of catheter occlusion. METHODS: In phase I of this sequential study design, newly placed CVCs were capped with a standard device. In Phase II, CVCs were capped with a positive-pressure valve device. Data collected included patient demographics, type of catheter, infusate, catheter duration, and complications. Partial and complete catheter occlusions were delineated. A user satisfaction survey was conducted. RESULTS: There were 153 children (mean age 48.0 +/- 7.7 months) with 312 CVC lumens enrolled in the study. Mean catheter duration was 9.4 +/- 0.9 days. There were fewer complete occlusions in CVCs capped with the positive pressure valve device than with the standard device [6/161 (3.7%) vs 18/151 (11.9%) occlusions, respectively; p = .012)]. There were no significant differences in partial occlusions, phlebitis, or catheter-related bloodstream infection between the 2 groups. CONCLUSIONS: CVCs with a positive-pressure valve cap device have a lower incidence of complete catheter occlusion than those with a standard cap device.

Pharmacological versus nonpharmacological techniques in reducing venipuncture psychological trauma in pediatric patients.

Peripherally inserted central catheters (PICCs) provide reliable access for pediatric patients requiring infusion therapy. Our multidisciplinary team includes nurses, physicians, child life specialists, and radiology technicians. In preparing and educating the patient and parent for the procedure, cultural and developmental levels are assessed and planned accordingly.