Withholding/Withdrawing Life-Sustaining Treatment in a Multiethnic Critical Care Setting: An Ethnographic Study.

Background: Critical care physicians often have to make challenging decisions to withhold/withdraw life-sustaining treatments. As a result of society's increasingly cultural diversity such decision making often involves patients from ethnic minority groups, which might pose extra challenges. Objective: To investigate withholding/withdrawing life-sustaining treatments with patients from ethnic minority groups and their families during critical care. Design: Ethnographic fieldwork (observations, in-depth interviews and reading patients' medical files). Setting/Subjects: Eighteen patients from ethnic minority groups, their relatives, physicians and nurses were studied in one intensive care unit of a multi-ethnic urban hospital (Belgium). Results: During decision making physicians had a very central role. The contribution of patients and nurses was limited, while families' input was more noticeable. Decision making was hampered by communication difficulties between: (1) staff and relative(s), (2) relatives, and (3) patient and relative(s). Different approaches were used by physicians to overcome difficulties, which often reflected their tendency to control decision making, for example, stressing their central role. At times their approaches reflected their inability to align families' wishes with their own, for example, when making decisions without explicitly informing relatives. Conclusions: Withholding/withdrawing life-sustaining treatments in a multi-ethnic critic care context has a number of alarming difficulties, such as how to take families' input correctly into account. It is important that decision making happens in a cultural sensitive way and with involvement tailored to patients' and relatives' needs and in close consultation with interprofessional health care workers/other services.

Preventing Conflicts Between Nurses and Families of a Multi-ethnic Patient Population During Critical Medical Situations in a Hospital.

Introduction: Little is known about how to avoid intercultural nurse-family conflicts in critical care settings. In this article, strategies are discussed that may be useful to prevent or mitigate intercultural nurse-family conflicts during critical medical situations in hospital. Method: Strategies are based on an ethnographic study by Van Keer et al., other literature, and expert opinion. Results: Sufficient structural measures are needed. First, institutions must create appropriate ward policies, such as including nurses in end-of-life communication. Second, nurses should be coached in the workplace. Third, institutions must provide adapted, visual, ward information to families. Additionally, education and research are needed. These measures should be actively stimulated by nurse managers and reflect a multicultural program supported by the hospital. Discussion: Intercultural nurse-family conflict prevention or mitigation should take into account organizational aspects, on hospital units and in hospital as a whole, and the crucial role of education and research.

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study.

OBJECTIVE: During critical care, physicians are frequently confronted with bad-news communication because of patients' frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context. METHODS: Ethnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients' medical records. Data were thematically analysed. RESULTS: Bad-news communication was primarily dominated by physicians. Patients' and relatives' input and other professionals' involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out. CONCLUSION: Delivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved. PRACTICE IMPLICATIONS: The challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.

Using patient companions as interpreters in the Emergency Department: An interdisciplinary quantitative and qualitative assessment.

OBJECTIVES: To explore the perceived and actual quality of communication and the conversational mechanisms through which misunderstandings arise in linguistically diverse Emergency Department consultations. METHODS: A mixed method approach was used, based on audio-records of consultations which rely on patient companions for linguistic support, and ethnographic contextual data. Interpreting errors and their potential impact on the clinical reasoning process and doctor-patient relationships were quantitatively assessed. Complementary qualitative ethnographic research provided a richer understanding of the context. The study involved interdisciplinary collaboration with specialists in applied linguistics, medicine, and psychology. RESULTS: Accurate interpretation occurred in as few as 19% of interpreter speech turns. Answering for the patient and omitting information were the most frequent errors. The nature and severity of the impact of the errors varied. Answering for the patient had the greatest clinical impact. The omission of messages from the doctor to the patient negatively affected doctor-patient relationships. CONCLUSION: Gaps were observed between the perceived and the actual quality of communication, although patient companions often provided useful information. PRACTICE IMPLICATIONS: In addition to raising awareness among doctors on the potential risks of using AHIs, EDs should adjust their management to increase the utilization of onsite and remote PIs.

Hypotension and a positive fluid balance are associated with delirium in patients with shock.

The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) <65 mmHg or diastolic pressure <60 mmHg, and hypoxemia, defined as peripheral oxygen saturation (SpO2) <90% for more than one minute or any arterial oxygen concentration (PaO2) <90 mmHg, were recorded during the first 5 days of the ICU stay. Fluid balance was evaluated daily and the 5-day cumulative fluid balance recorded. Delirium was assessed using the Confusion Assessment Method for the ICU. A total of 252 patients were admitted with shock during the study period; 185 (73%) developed delirium. Patients who developed delirium also had more episodes of hypotension with a low MAP (p = 0.013) or diastolic pressure (p = 0.018) during the first five days of the ICU stay than those who did not. Patients with a higher cumulative fluid balance during the same period were also more likely to develop delirium (p = 0.01); there was no significant difference in the occurrence of hypoxemia between groups. Joint modeling, combining a linear-mixed model and an adjusted Cox survival model showed that low diastolic pressure (alpha effect = -0.058±0.0013, p = 0.043) and a positive cumulative fluid balance (alpha effect = 0.04±0.003, p = 0.021) were independently associated with delirium. In conclusion, low diastolic pressure and a cumulative positive fluid balance but not hypoxemia were independently associated with development of delirium in patients with shock.

Impact of a VAP bundle in Belgian intensive care units.

BACKGROUND: In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure control, oral care with chlorhexidine and semirecumbent position, was launched in 2011-2012. This report will document the impact of this campaign. METHODS: On 1 day, once a year from 2010 till 2016, except in 2012, Belgian ICUs were questioned about their ventilated patients. For each of these, data about the application of the bundle and the possible treatment for VAP were recorded. RESULTS: Between 36.6 and 54.8% of the 120 Belgian ICUs participated in the successive surveys. While the characteristics of ventilated patients remained similar throughout the years, the percentage of ventilated patients and especially the duration of ventilation significantly decreased before and after the national VAP bundle campaign. Ventilator care also profoundly changed: Controlling cuff pressure, head positioning above 30° were obtained in more than 90% of cases. Oral care was more frequently performed within a day, using more concentrated solutions of chlorhexidine. Subglottic suctioning also was used but in only 24.7% of the cases in the last years. Regarding the prevalence of VAP, it significantly decreased from 28% of ventilated patients in 2010 to 10.1% in 2016 (p ≤ 0.0001). CONCLUSION: Although a causal relationship cannot be inferred from these data, the successive surveys revealed a potential impact of the VAP bundle campaign on both the respiratory care of ventilated patients and the prevalence of VAP in Belgian ICUs encouraging them to follow the guidelines.

Mental well-being of patients from ethnic minority groups during critical care: a qualitative ethnographic study.

OBJECTIVES: To investigate the state of the mental well-being of patients from ethnic minority groups and possible related risk factors for the development of mental health problems among these patients during critical medical situations in hospital. DESIGN: Qualitative ethnographic design. SETTING: Oneintensive care unit (ICU) of a multiethnic urban hospital in Belgium. PARTICIPANTS: 84 ICU staff members, 10 patients from ethnic-minority groups and their visiting family members. RESULTS: Patients had several human basic needs for which they could not sufficiently turn to anybody, neither to their healthcare professionals, nor to their relatives nor to other patients. These needs included the need for social contact, the need to increase comfort and alleviate pain, the need to express desperation and participate in end-of-life decision making. Three interrelated risk factors for the development of mental health problems among the patients included were identified: First, healthcare professionals' mainly biomedical care approach (eg, focus on curing the patient, limited psychosocial support), second, the ICU context (eg, time pressure, uncertainty, regulatory frameworks) and third, patients' different ethnocultural background (eg, religious and phenotypical differences). CONCLUSIONS: The mental state of patients from ethnic minority groups during critical care is characterised by extreme emotional loneliness. It is important that staff should identify and meet patients' unique basic needs in good time with regard to their mental well-being, taking into account important threats related to their own mainly biomedical approach to care, the ICU's structural context as well as the patients' different ethnocultural background.

The sink as a potential source of transmission of carbapenemase-producing Enterobacteriaceae in the intensive care unit.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are emerging pathogens that represent a major public health threat. In the University Hospital of Brussels, the incidence of new patients with CPE rose from 1 case in 2010 to 35 cases in 2015. Between January and August 2015, five patients became infected/colonized with CPE during their stay in the same room in the intensive care unit (ICU). Since the time period between those patients was relatively short and the strains belonged to different species with different antibiograms and mechanisms of resistance, the hypothesis was that the environment could be a possible source of transmission. METHODS AND RESULTS: Environmental samples suggested that a contaminated sink was the source of the outbreak. Besides other strains, Citrobacter freundii type OXA-48 was frequently isolated from patients and sinks. To investigate the phylogenetic relationschip between those strains, pulsed-field gel electrophoresis was performed. The strains isolated from patients and the sink in the implicated room were highly related and pointed to sink-to-patient transmission. In total, 7 of 8 sinks in the isolation rooms of the ICU were found to be CPE contaminated. To control the outbreak, the sinks and their plumbings were replaced by new ones with another structure, they were flushed every morning with a glucoprotamin solution and routines regarding sink practices were improved leading to discontinuation of the outbreak. CONCLUSIONS: This outbreak highlights that hospital sink drains can accumulate strains with resistance genes and become a potential source of CPE.

High prolactin levels are associated with more delirium in septic patients.

PURPOSES: We investigated whether high prolactin levels were associated with delirium in septic patients because neuropsychiatric disorders are frequently associated with hyperprolactinemia. MATERIALS AND METHODS: Prolactin levels were measured daily for 4 days in 101 patients with sepsis. Delirium was assessed using the Richmond Agitation Sedation Scale and the Confusion Assessment Method in the ICU. RESULTS: Delirium developed in 79 patients (78%) and was more common in patients older than 65 years. Prolactin levels were higher in patients with delirium than in those without over the 4 days of observation (P = .032). In patients with delirium, higher prolactin levels were associated with a lower incidence of nosocomial infection (P = .006). Multivariable logistic regression showed that the Sequential Organ Failure Assessment score at intensive care unit admission (odds ratio, 1.24; 95% confidence interval, 1.04-1.48; P = .002) and the combined effect of prolactin levels with age (odds ratio, 1.018; 95% confidence interval, 1.01-1.031; P = .006) were associated with the development of delirium. CONCLUSIONS: High prolactin levels may be a risk factor for delirium in septic patients.

Conflicts between healthcare professionals and families of a multi-ethnic patient population during critical care: an ethnographic study.

BACKGROUND: Conflicts during communication in multi-ethnic healthcare settings is an increasing point of concern as a result of societies' increased ethno-cultural diversity. We can expect that conflicts are even more likely to arise in situations where difficult medical decisions have to be made, such as critical medical situations in hospital. However, in-depth research on this topic is rather scarce. During critical care patients are often unable to communicate. We have therefore investigated factors contributing to conflicts between healthcare professionals and family members from ethnic minority groups in critical medical situations in hospital. METHODS: Ethnographic fieldwork was done in one intensive care unit of a multi-ethnic urban hospital in Belgium over 6 months (January 2014 to June 2014). Data were collected through negotiated interactive observation, in-depth interviews with healthcare professionals, from patients' medical records, and by making notes in a logbook. Data were analysed by using grounded theory procedures. RESULTS: Conflicts were essentially related to differences in participants' views on what constitutes 'good care' based on different care approaches. Healthcare professionals' views on good care were based predominantly on a biomedical care model, whereas families' views on good care were mainly inspired by a holistic lifeworld-oriented approach. Giving good care, from the healthcare professionals' point of view, included great attention to regulations, structured communication, and central decision making. On the other hand, good care from the families' point of view included seeking exhaustive information, and participating in end-of-life decision making. Healthcare professionals' biomedical views on offering good care were strengthened by the features of the critical care context whereas families' holistic views on offering good care were reinforced by the specific characteristics of families' ethno-familial care context, including their different ethno-cultural backgrounds. However, ethno-cultural differences between participants only contributed to conflicts in confrontation with a triggering critical care context. CONCLUSIONS: Conflicts cannot be exclusively linked to ethno-cultural differences as structural, functional characteristics of critical care substantially contribute to the development of conflicts. Therefore, effective conflict prevention should not only focus on ethno-cultural differentness but should also take the structural organizational characteristics of the critical care context sufficiently into account.

Cortisol is an associated-risk factor of brain dysfunction in patients with severe sepsis and septic shock.

OBJECTIVES: To investigate cortisol levels in brain dysfunction in patients with severe sepsis and septic shock. METHODS: In 128 septic and sedated patients, we studied brain dysfunction including delirium and coma by the evaluation of Richmond Agitation Sedation Scale (RASS), the Confusion Method Assessment in the ICU (CAM-ICU) after sedation withdrawal and the measurement of serum S100B biomarker of brain injury. Serum cortisol and S100B were measured within 12 hours after ICU admission and daily over the next four days. RESULTS: Brain dysfunction was observed in 50% (64/128) before but in 84% (107/128) of patients after sedation withdrawal, and was more common in the patients older than 57 years (P = 0.009). Both cortisol (P = 0.007) and S100B levels (P = 0.028) were higher in patients with than patients without brain dysfunction. Cortisol levels were associated with ICU mortality (hazard ratio = 1.17, P = 0.024). Multivariate logistic regression showed that cortisol (odds ratio (OR): 2.34, 95% CI (2.01, 3.22), P = 0.02) and the combination effect of cortisol with age (OR: 1.004, 95% CI (1.002, 1.93), P = 0.038) but not S100B were associated with brain dysfunction. CONCLUSIONS: Cortisol was an associated-risk factor of brain dysfunction in patients with severe sepsis and septic shock.

Serum S100B protein could help to detect cerebral complications associated with extracorporeal membrane oxygenation (ECMO).

BACKGROUND: To investigate if serum S100B protein levels could early detect cerebral complications under treatment extracorporeal membrane oxygenation (ECMO). METHODS: Serum S100B levels were measured over 5 days in 32 patients with cardiogenic and septic shock, including 15 patients who treated by ECMO and 17 who did not. Cerebral complications included hemorrhage, stroke, encephalopathy with myoclonus, and brain death. Delirium was identified by the positive Confusion Assessment Method in the ICU. RESULTS: S100B levels were elevated in 24/32 patients (75 %) at ICU admission. Five patients developed cerebral complications (2 hemorrhages with 1 brain death, 1 encephalopathy with myoclonus in the ECMO group and 2 strokes in the non-ECMO group). At day 5, S100B levels were higher in the 5 patients with cerebral complications than in the 27 without cerebral complications, regardless of ECMO (0.426 [0.421, 0.652] vs. 0.102 [0.085, 0.135] µg/L, p = 0.011). S100B levels were also more elevated in 3 patients with than in 12 without cerebral complications associated with ECMO (0.799 [0.325, 0.965] vs. 0.102 [0.09, 0.607] µg/L, p = 0.033). S100B levels were not associated with delirium after sedation withdrawal. CONCLUSIONS: Measurement serum S100B could be useful to detect cerebral complications in deeply sedated patients associated with ECMO but not for monitoring delirium after sedation withdrawal.

Introducing a new generation indirect calorimeter for estimating energy requirements in adult intensive care unit patients: feasibility, practical considerations, and comparison with a mathematical equation.

PURPOSE: Indirect calorimetry (IC) is increasingly advocated for individualizing nutritional therapy in critically ill adult patients, but questions remain regarding its practical implementation. MATERIALS AND METHODS: During 12 weeks, we prospectively assessed utility and practical aspects of IC use. Adult medico-surgical intensive care unit (ICU) patients were daily screened for malnutrition. Indirect calorimetry was planned in subjects considered unable to meet energy requirements on day 3 after admission. Measured energy expenditure (MEE) was compared with calculated (resting/total) energy expenditure. RESULTS: A total of 940 evaluations were performed in 266 patients (age, 63±16 years; 59% males; Acute Physiology and Chronic Health Evaluation II score, 14±8). A total of 230 patients (86.5%) were at risk for malnutrition, and in 118 of them, IC was indicated. Practical considerations precluded measurements in 72 cases (61%). Forty-six calorimetric evaluations revealed an MEE of 1649±544 kcal per 24 hours that poorly correlated with calculated resting energy expenditure (r2=0.19) and calculated total energy expenditure (r2=0.20). Indirect calorimetry measurements were not time-consuming. CONCLUSIONS: Indirect calorimetry was indicated in half but effectively performed in only 20% of a representative intensive care unit population at risk for malnutrition. Correlation between MEE and CEE was poor. CLINICAL RELEVANCY STATEMENT: Indirect calorimetry is increasingly advocated for individualizing nutritional therapy in critically ill adult patients. Practical feasibility is tested in this study. Large differences between measured and calculated energy expenditure are observed. Together with patients' characteristics, feasibility results can guide clinicians or institutes in using IC in their daily clinical practice.

Bedside calculation of energy expenditure does not guarantee adequate caloric prescription in long-term mechanically ventilated critically ill patients: a quality control study.

Nutrition is essential in critically ill patients, but translating caloric prescriptions into adequate caloric intake remains challenging. Caloric prescriptions (P), effective intake (I), and caloric needs (N), calculated with modified Harris-Benedict formulas, were recorded during seven consecutive days in ventilated patients. Adequacy of prescription was estimated by P/N ratio. I/P ratio assessed accuracy of translating a prescription into administered feeding. I/N ratio compared delivered calories with theoretical caloric needs. Fifty patients were prospectively studied in a mixed medicosurgical ICU in a teaching hospital. Basal and total energy expenditure were, respectively, 1361 ± 171 kcal/d and 1649 ± 233 kcal/d. P and I attained 1536 ± 602 kcal/d and 1424 ± 572 kcal/d, respectively. 24.6% prescriptions were accurate, and 24.3% calories were correctly administered. Excessive calories were prescribed in 35.4% of patients, 27.4% being overfed. Caloric needs were underestimated in 40% prescriptions, with 48.3% patients underfed. Calculating caloric requirements by a modified standard formula covered energy needs in only 25% of long-term mechanically ventilated patients, leaving many over- or underfed. Nutritional imbalance mainly resulted from incorrect prescription. Failure of "simple" calculations to direct caloric prescription in these patients suggests systematic use of more reliable methods, for example, indirect calorimetry.

Uncommon cause of psychotic behavior in a 9-year-old girl: a case report.

Anti-N-methyl-D-aspartate receptors encephalitis (ANMDARE) is a well-defined, life threatening, but treatable disorder that often occurs as a paraneoplastic manifestation of ovarian teratomas in adult women. We report a child with this disorder who displayed a subacute onset of delirium, seizures, and autonomic instability. Antibodies against NMDA receptor were detectable in the serum and in the cerebrospinal fluid. No teratoma or other tumour was detected. We speculate that the previous viral/mycoplasma infection may be the trigger of this encephalitis. This patient showed a reversal of the neurological symptoms after intravenous immunoglobulin. Prompt recognition of this disorder followed by immunotherapy results in full neurological recovery.

Development of a nursing practice based competency model for the Flemish master of nursing and obstetrics degree.

The aim was to identify a set of competences for the Flemish academic Master of Nursing and Obstetrics degree that answer perceived needs in health care. The competency model was to demonstrate a degree of consensus among key nurses. The study was conducted in all Flemish hospitals registered to have 400 beds or more. Head nurses of surgery, geriatrics and intensive care units were eligible to participate, as well as one nurse from administration per hospital. A two round Delphi process allowed participants to comment on items identified in an analysis of existing international competency profiles of master level nurses and adapted to the Flemish context. Competences agreed to by 90% of the respondents were considered to have consensus. Fifteen out of 19 eligible hospitals were recruited in the study, 45 nurses participated in the Delphi panel. Consensus was reached on 31 competences that can be assigned to 5 nurse's roles: nursing expert, innovator, researcher, educator and manager. The resulting competency profile is in accordance with published profiles for similar programs. The reported study demonstrates a practical method to develop a consensus competency model for an academic master program based on the input of key individuals in mainstream nursing.

Drotrecogin alfa (activated) may attenuate severe sepsis-associated encephalopathy in clinical septic shock.

INTRODUCTION: Sepsis-associated encephalopathy (SAE) is a diffuse cerebral dysfunction induced by the immuno-inflammatory response to infection. Elevated levels of the brain-specific S100B protein are present in many septic patients and reflect the severity of SAE. Adjunctive treatment with drotrecogin alfa (activated) (DrotAA), the human recombinant form of activated protein C, has been shown to improve mortality in patients with severe sepsis-induced organ failure. We studied the effect of DrotAA on S100B levels in patients with acute septic shock who presented with increased baseline values of this biomarker. METHODS: All patients received standard goal-directed resuscitation treatment. Patients with pre-existing or acute neurological disorders were excluded. Based on the Glasgow coma scale (GCS), patients were classified into two groups: GCS >or= 13 and GCS <13. DrotAA was given as a continuous infusion of 24 microg/kg/h for 96 h. S100B was measured before sedation and the start of DrotAA (0 h) and at 32 h, 64 h and 96 h and at corresponding time points in patients not treated with DrotAA. The lower limit of normal was < 0.5 microg/L. RESULTS: Fifty-four patients completed the study. S100B was increased in 29 (54%) patients. Twenty-four patients (9 with GCS >or= 13 and 15 with GCS <13) received DrotAA. S100B levels in DrotAA-treated patients with a GCS <13, though higher at baseline than in untreated subjects (1.21 +/- 0.22 microg/L vs. 0.95 +/- 0.12 microg/L; P = 0.07), progressively and significantly decreased during infusion (0.96 +/- 0.22 microg/L at 32 h, P = 0.3; 0.73 +/- 0.12 microg/L at 64 h, P < 0.05; and 0.70 +/- 0.13 microg/L at 96 h, P < 0.05 vs. baseline). This patient group had also significantly lower S100B values at 64 h and at 96 h than their untreated counterparts. In the patients with a GCS >or= 13, S100B levels were not influenced by DrotAA treatment. CONCLUSIONS: S100B-positivity is present in more than half of the patients with septic shock. When increased S100B levels are used as a surrogate for SAE, adjunctive DrotAA treatment seems to beneficially affect the evolution of severe SAE as discriminated by an admission GCS <13.

Di-(2-ethylhexyl)phthalate and deep venous thrombosis in children: a clinical and experimental analysis.

BACKGROUND: Five children with catheter-related deep venous thrombosis were encountered in our PICU. Three types of polyvinyl chloride tubing for the administration of intravenous solutions were in use (Terumo, Codan, and Perfusend). All were di-(2-ethylhexyl)phthalate plasticized. We suspected problems with the Codan tubing. METHODS: Different types of tubing at different time intervals in vitro were investigated. Tubing segments were assessed on structural alterations by surface electron microscopy. High-performance liquid chromatography-diode array detection and liquid chromatography-mass spectrometry-diode array detection were performed to identify and to quantify di-(2-ethylhexyl)phthalate. The hospital's minimal clinical data set (coded with the International Classification of Diseases, Ninth Revision, Clinical Modification) was investigated on catheter-related deep venous thrombosis between 2000 and 2004. RESULTS: Surface electron microscopy demonstrated that the Codan tubing's inner surface was severely altered, showing large particles (34.5 +/- 6.1 microm). High-performance liquid chromatography documented that all Codan samples showed a peak at the di-(2-ethylhexyl)phthalate retention time. The analysis of the minimal clinical data set for total catheter-related deep venous thrombosis showed an unusual high incidence in 2001 (52) compared with the expected 36 per year. CONCLUSIONS: Such occurrence of catheter-related deep venous thrombosis led to the assumption that disintegration of intravenous tubing resulted in intravenous administration of debris. Our data suggested that the particles derived from the tubing are of such size that they might induce catheter-related deep venous thrombosis. The absence of catheter-related deep venous thrombosis caused by the introduction of submicron inline filters outlines the important pathophysiological role of di-(2-ethylhexyl)phthalate-plasticized particles in the onset of catheter-related deep venous thrombosis. Our data indicate that a considerable number of patients might have been exposed to di-(2-ethylhexyl)phthalate, and a major concern is whether this jeopardized the health of the patients at that time.