Umbilical arterial catheter duration as risk factor for Bell's Stage III necrotizing enterocolitis in preterm neonates.

Objectives: To explore risk factors for Stage-III necrotizing enterocolitis (NEC-III) in preterm neonates. Methods: This was a retrospective case-control study of neonates born <33 weeks gestational age (GA) who were admitted to a tertiary neonatal intensive care unit, between 2015 and 2018. NEC-III cases were compared with Stage-II NEC (NEC-II) and non-NEC controls. Two to four non-NEC controls were matched by GA ± 1 week and date of birth ± 3 months, to one NEC-III case. Univariate and multivariate analyses were used to examine risk factors for NEC-III. Results: Of 1360 neonates born <33 weeks, 71 (5.2%) had NEC-II and above, with 46% being NEC-III. Mean age of onset of NEC-III was 13.7 days versus 23.9 days for NEC-II (p = 0.01). Neonates with NEC-III were of lower GA (NEC-III 25.4 weeks, NEC-II 27.3 weeks, and non-NEC 26 weeks; p = 0.0008) and had higher Score for Neonatal Acute Physiology Perinatal Extension-II scores (NEC-III 47.5, NEC-II 28.4 and non-NEC 37, p = 0.003). Multivariate analysis showed duration of umbilical arterial catheter (UAC) >5 days was significantly associated with the development of NEC-III with adjusted odds ratio (AOR) 3.8; 95% confidence interval (CI) (1.05-13.66) for NEC-III versus non-NEC and AOR 5.57; 95% CI (1.65-18.73), p = 0.006 for NEC-III versus NEC-II. Rupture of membranes (ROM) >1 week was associated with NEC-III (AOR 6.93; 95% CI [1.56-30.69] vs. non-NEC and AOR 11.74; 95% CI [1.14-120.34] vs. NEC-II). Conclusion: The increased association of NEC-III with duration of UAC and ROM could be further examined in prospective studies, and an upper limit for UAC duration could be considered in NEC prevention bundles.

Peripheral arterial catheters in extremely preterm infants born at less than 28 weeks of gestation-a single-center experience.

The aim of this study was to perform a retrospective data analysis of established peripheral artery catheters (pAC) in extremely preterm infants. The primary outcome was the pAC life span and its correlation to gestational age, birth weight, localizations, and pAC removal. Retrospective data analysis of electronic patient records of all extremely preterm infants (born less than 28 weeks gestation) admitted to the neonatal intensive care unit in Graz (Austria) between January 2014 and December 2020. A total of 196 preterm infants with a median (IQR) gestational age of 25.7 (24.6-26.6) weeks and a birth weight of 730 (614-898) g were included. In 155 (79%) of these preterm infants, 286 pAC and six umbilical artery catheters were inserted successfully. The first pAC was inserted 2.5 (1.4-7.4) h after birth, and the median pAC life span was 57.5 (22.-107.2) h. Gestational age, birth weight, and catheter localization did not correlate with the pAC life span. The pAC localizations were the radial artery (63%), tibial posterior artery (21%), ulnar artery (6%), dorsal artery of the foot (6%), others (1%), and not documented (3%). Adverse reactions including temporarily impaired peripheral perfusion, local inflammation, extravasation, or bleeding were reported in 13% of all pAC, but none of these resulted in long-term sequelae. A median (IQR) of 9 (5-18) arterial blood samples were drawn via pAC, resulting in a notable reduction of pain stimuli.Conclusion: The use of pAC in extremely preterm infants is feasible and safe. Neither gestational age, birth weight nor localization did affect the life span of pAC. No long-term sequelae were observed, and pain events were reduced by using pAC for blood drawing. What is Known: • Peripheral artery catheters can be used for continuous blood pressure measurement and blood draw even in extremely preterm infants. • (Severe) adverse reactions such as bleeding, necrosis, or amputation occur between 1 and 4%. • What is New: • The median peripheral arty catheter life span is 58 h and is not affected by gestational age, birth weight, nor localization. • A median of nine blood samples can be taken per each single pAC and, therefore, prevent pain events in extremely preterm infants.

Perioperative arterial catheterization: A prospective evaluation of ultrasound, infection, and patient-focused outcomes.

BACKGROUND: There is little information regarding complications of arterial catheterization in modern clinical care. We aimed to determine the incidence of abnormal duplex vascular ultrasound and catheter related infections following perioperative arterial catheterization. METHODS: Patients requiring arterial catheterization for elective surgery were included and insertion details collected prospectively. Duplex ultrasound evaluation was performed 24 h after catheter removal. Symptomatic patients were identified by self-reported questionnaire. On Day 7, patients answered questions by telephone, related to the insertion site, pain, and function. Results of catheter tip and blood culture analyses were sought. Univariate associations of patient and surgical characteristics with abnormal ultrasound were assessed with p < 0.05 considered significant. RESULTS: Of 339 catheterizations, 105 (40%) had ultrasound evaluation. Catheters were indwelling for median (IQR, range) duration of 6.0 h (4.4-8.2, 1.8-28) with no catheter-related infections. There were 16 (15.2%, 95% CI 9.0%-23.6%) abnormal results, including 14 radial artery thromboses, one radial artery dissection, and one radial vein thrombosis. Those with abnormal ultrasound results were more likely to have had Arrow catheters inserted (68.8% vs 27%, p = 0.023) and more than one skin puncture (37.5% vs 26.8%, p = 0.031). Two of the 16 (12.5%) patients with abnormal ultrasound results reported new symptoms related to the hand compared with nine of the 88 (10.2%) with normal results (p = 0.1). No patients required urgent referral for management. CONCLUSIONS: Thrombosis was the most common abnormality and was usually asymptomatic. There were no infections, few post-operative symptoms, and minimal functional impairment following arterial catheterization.

A Direct Assessment of Noninvasive Continuous Blood Pressure Monitoring in the Emergency Department and Intensive Care Unit.

INTRODUCTION: Noninvasive continuous blood pressure monitoring has the potential to improve patient treatment in the hospital setting. Such noninvasive devices can be applied earlier in the treatment process to empower nurses and clinicians to react more quickly to patient deterioration with the added benefit of eliminating the risks associated with invasive monitoring. However, emerging technologies must be capable of reproducing current clinical measures for medical decision making. METHODS: This study aimed to determine the usability and willingness of nurses to implement a noninvasive continuous blood pressure monitoring device. The secondary aim directly compared the systolic blood pressure, diastolic blood pressure, and mean arterial pressure values recorded by the device (VitalStream; CareTaker Medical LLC, Charlottesville, VA) with the "gold standard" brachial cuff and arterial line measures recorded in the emergency department and intensive care unit settings. RESULTS: VitalStream was similarly received by nurses in the emergency department and intensive care setting, but ultimately had greater promotion from emergency nurses. Despite some statistical similarity between measurement methodologies, all direct comparisons were found to not meet the Association for the Advancement of Medical Instrumentation 2008 and Association for the Advancement of Medical Instrumentation / European Society of Hypertension / International Organization for Standardization 2019 consensus statement criteria for acceptable blood pressure measure differences between the VitalStream and "gold standard" clinical measures. In all instances, the standard deviation of the Bland-Altman bias exceeded 8 mm Hg with less than 85% of paired differences falling within 10 mm Hg of the "gold standard." DISCUSSION: Taken together, the tested device requires additional postprocessing for medical decision making in trauma or emergent care.

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Risk factors for arterial catheter failure and complications during critical care hospitalisation: a secondary analysis of a multisite, randomised trial.

OBJECTIVES: Arterial catheters (ACs) are critical for haemodynamic monitoring and blood sampling but are prone to complications. We investigated the incidence and risk factors of AC failure. METHODS: Secondary analysis of a multi-centre randomised controlled trial (ACTRN 12610000505000). Analysis included a subset of adult intensive care unit patients with an AC. The primary outcome was all-cause device failure. Secondary outcomes were catheter associated bloodstream infection (CABSI), suspected CABSI, occlusion, thrombosis, accidental removal, pain, and line fracture. Risk factors associated with AC failure were investigated using Cox proportional hazards and competing-risk models. RESULTS: Of 664 patients, 173 (26%) experienced AC failure (incidence rate [IR] 37/1000 catheter days). Suspected CABSI was the most common failure type (11%; IR 15.3/1000 catheter days), followed by occlusion (8%; IR 11.9/1,000 catheter days), and accidental removal (4%; IR 5.5/1000 catheter days). CABSI occurred in 16 (2%) patients. All-cause failure and occlusion were reduced with ultrasound-assisted insertion (failure: adjusted hazard ratio [HR] 0.43, 95% CI 0.25, 0.76; occlusion: sub-HR 0.11, 95% CI 0.03, 0.43). Increased age was associated with less AC failure (60-74 years HR 0.63, 95% CI 0.44 to 0.89; 75 + years HR 0.36, 95% CI 0.20, 0.64; referent 15-59 years). Females experienced more occlusion (adjusted sub-HR 2.53, 95% CI 1.49, 4.29), while patients with diabetes had less (SHR 0.15, 95% CI 0.04, 0.63). Suspected CABSI was associated with an abnormal insertion site appearance (SHR 2.71, 95% CI 1.48, 4.99). CONCLUSIONS: AC failure is common with ultrasound-guided insertion associated with lower failure rates. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000); date registered: 18 June 2010.

Adverse events associated with umbilical vascular catheters in the neonatal intensive care unit: A retrospective cohort study.

BACKGROUND: Umbilical catheters are commonly inserted in newborns in the neonatal intensive care unit (NICU) yet are associated with serious adverse events (AEs) such as malposition, migration, infection, thrombosis, hepatic complications, cardiac effusion, and cardiac tamponade. There is a need to determine the incidence and risk factors for AEs to inform safe practice. OBJECTIVES: The objective of this study was to determine the incidence and risk factors for AEs (all-cause and individual types) associated with umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) in the NICU. METHODS: A retrospective cohort study was conducted in an Australian level-VI NICU over a 3-year period. Any newborn who had both a UVC and UAC insertion attempt was included. RESULTS: There were 236 neonates who had 494 catheters (245 UVCs and 249 UACs). Of these, 71% of UVCs (95% confidence interval [CI]: 65.6-76.9%; incidence rate: 181.1-237.3 per 1000 catheter days) and 43.8% of UACs (95% CI: 38-50.5%; incidence rate: 102.0-146.3 per 1000 catheter days) were associated with an AE. The most common AE was malposition on first X-ray for UVCs (60.1%, 95% CI: 55.1-67.3) and UACs (32.6%, 95% CI: 26.8-39.6). A dwell time of ≥7 days was a significant predictor of UAC failure (incidence risk ratio: 1.5, 95% CI: 1.1-2.1, p = 0.006) and migration of the UVC (incidence risk ratio: 3.5, 95% CI: 1.0-11.5, p = 0.043). CONCLUSION: Adverse events related to insertion occurred in a relatively high percentage of umbilical catheters placed. Increased dwell time remains a significant risk factor for catheter migration and overall failure. Practice change and consideration of risk factors for both individual and overall AE risk are necessary to reduce complications.

Percutaneous retrieval of embolized umbilical arterial catheter in extreme premature infant.

BACKGROUND: Umbilical arterial catheterization is a common procedure performed on critically ill neonates, especially those with extreme prematurity. Various complications have been described following umbilical artery catheter (UAC) placement including thrombosis, embolism, vasospasm, vascular perforation, hemorrhage, and infection. However, treatment of these complications is challenging due to the small size of this very fragile subset of patients. METHODS: A 3-day old extremely preterm infant was referred to our institution for percutaneous removal of a fragmented and embolized umbilical arterial catheter. RESULTS: Catheter retrieval was successful via a carotid approach utilizing techniques from percutaneous closure of PDA in preterm infants and trans-carotid access for PDA stent and aortic interventions. CONCLUSION: This case report describes the successful percutaneous retrieval of an embolized UAC fragment in an extremely preterm infant, the smallest documented in literature to date.

The Edwards Acumen IQ system using peripheral arterial catheter-based waveforms to estimate cardiac output is not accurate as compared to thermodilution in dogs.

OBJECTIVE: To assess the agreement between cardiac output (CO) estimated via evaluation of the arterial pressure waveform by a novel monitoring system (Edwards Acumen IQ sensor and HemoSphere Advanced Monitor Platform [HS-IQ]; Edwards LifeSciences) and measured by thermodilution (TD) in anesthetized, normovolemic, and hypovolemic dogs. To assess the agreement between the HS-IQ CO measurements in the radial artery and dorsal metatarsal artery. ANIMALS: 8 purpose-bred Beagles. METHODS: Dogs were placed under general anesthesia. CO was measured via TD and via the HS-IQ at radial and dorsal metatarsal arterial catheters. CO measurements were obtained at 4 time points including normovolemic and multiple hypovolemic states. Paired measurements of CO were evaluated via the method of Bland and Altman with acceptable limits of agreement (LOA) defined as < 30%. RESULTS: A total of 24 (dorsal metatarsal) and 21 (radial) paired measurements were collected in 8 dogs. The overall bias (CI) for comparison of TD to radial arterial HS-IQ CO measurements was -0.09 L/min. LOA and proportional LOA were -2.66 to 2.49 L/min and -140.72% to 104.94%. The overall bias (CI) for comparison of TD to dorsal metatarsal arterial HS-IQ CO measurements was -0.26 L/min. LOA and proportional LOA were -2.76 to 2.24 L/min and -135.96% to 93.25%. The overall proportional error for radial arterial was -17.9% and for dorsal metatarsal was -21.4%. CLINICAL RELEVANCE: CO measurements with the HS-IQ were easy to obtain but did not produce results within a clinically acceptable range for either measurement site, with a very wide LOA. The CO estimations from the HS-IQ are not appropriate for clinical use at this time.

Clinical application and complication analysis of umbilical arterial catheterization in premature infants / 中国新生儿科杂志

Objective:To study the clinical application and complications of umbilical arterial catheterization (UAC) in premature infants.Methods:From January 2021 to December 2022, premature infants with UAC successfully inserted in NICU of our hospital were enrolled. According to birth weight (BW), the infants were assigned into three groups: <1 000 g, 1 000~1 499 g and ≥1 500 g. The perinatal data, UAC usage, UAC-related complications and risk factors of UAC-related complications were retrospectively analyzed.Results:A total of 39 premature infants received UAC, with gestational age 29.3(27.3, 30.4) weeks and BW 1 100 (900, 1 310) g. The insertion length (IL) of UAC was calculated using the average value of two formulas: a, IL (cm) =4×BW (kg) +7; and b, IL(cm) =3×BW (kg)+9. The accuracy of tube end position was determined using chest/abdomen radiography. 30(76.9%) cases had accurate position, 6(15.4%) had higher position and 3(7.7%) had lower position. The proportion of appropriately positioned tube end in <1 000 g, 1 000~1 499 g and ≥1 500 g groups were 80.0%, 76.5% and 71.4%, respectively, without statistically significant differences ( P>0.05) .No significant differences existed among the three groups in UAC duration and UAC routinely removal rate ( P>0.05). 9 cases (23.1%) of UAC were removed for specific reasons, including 4 cases of arterial spasm, 2 cases of withdrawal of treatment, 1 case of tube end displacement, 1 case of abdominal distension and 1 case of death. 21 cases received 1 U/ml heparin (0.9%NaCl solution) 0.5~1 ml/h arterial infusion. 23.8% (5/21) had hypernatremia and the level of sodium became normal after reducing the concentration of NaCl solution. Arterial vasospasm occurred in 4 patients with skin color changes of one side of the lower extremities. After UAC removal, the skin color returned to normal. Conclusions:UAC is helpful and safe for preterm infants, however, its complications should be alerted to.

Ultrasound guidance practices used for the placement of vascular accesses in intensive care units: an observational multicentre study.

BACKGROUND: Central catheters expose ICU patients at risk of catheter-related bloodstream infections. A mechanism by which these infections occur is the contamination of the catheter during its insertion if aseptic techniques are not strictly applied. Recent studies suggest that the use of ultrasound guidance (USG) may increase the risk of catheter contamination during insertion. We assessed current practices regarding the use of USG during catheter insertion, with a focus on identifying breaches of the surgical asepsis required for this invasive procedure. METHODS: In 26 intensive care units, we evaluated the use of USG during catheter insertion, using a questionnaire addressed to intensivists and direct observation of their practices. RESULTS: We analyzed 111 questionnaires and 36 observations of intensivists placing catheters. The questionnaires revealed that 88% of intensivists used USG for catheter insertion. Among those using USG, 56% had received specific training, 17% benefited from specific recommendations, 76% marked the insertion site before skin antisepsis, and during catheter insertion, 96% used sterile gel and 100% used a sterile sheath and sterile gloves. We identified potential deviations from strict aseptic technique, including contact between the sheath and the needle (19.4%), handling of the US system during catheter insertion (2.8%), and use of sterile devices, where they were not yet necessary (during the marking site or skin antisepsis), resulting in their contamination at the time of catheter insertion. CONCLUSIONS: Interventions aimed at ensuring compliance with measures to prevent CRBs should be organized to prevent an increase in infections associated with US-guided catheter insertion.

Central Versus Peripheral Arterial Pressure Monitoring in Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

OBJECTIVE: The aortic-to-radial arterial pressure gradient is described during and after cardiopulmonary bypass (CPB), and can lead to underestimating arterial blood pressure. The authors hypothesized that central arterial pressure monitoring would be associated with lower norepinephrine requirements than radial arterial pressure monitoring during cardiac surgery. DESIGN: An observational prospective cohort with propensity score analysis. SETTING: At a tertiary academic hospital's operating room and intensive care unit (ICU). PARTICIPANTS: A total of 286 consecutive adult patients undergoing cardiac surgery with CPB (central group: 109; radial group: 177) were enrolled and analyzed. INTERVENTIONS: To explore the hemodynamic effect of the measurement site, the authors divided the cohort into 2 groups according to a femoral/axillary (central group) or radial (radial group) site of arterial pressure monitoring. MEASUREMENT AND MAIN RESULTS: The primary outcome was the intraoperative amount of norepinephrine administered. Secondary outcomes included norepinephrine-free hours and ICU-free hours at postoperative day 2 (POD2). A logistic model with propensity score analysis was built to predict central arterial pressure monitoring use. The authors compared demographic, hemodynamic, and outcomes data before and after adjustment. Central group patients had a higher European System for Cardiac Operative Risk Evaluation. (EuroSCORE) compared to the radial group-7.9 ± 14.0 versus 3.8 ± 7.0, p < 0.001. After adjustment, both groups had similar patient EuroSCORE and arterial blood pressure levels. Intraoperative norepinephrine dose regimens were 0.10 ± 0.10 µg/kg/min in the central group and 0.11 ± 0.11 µg/kg/min in the radial group (p = 0.519). Norepinephrine-free hours at POD2 were 38 ± 17 hours versus 33 ± 19 hours in central and radial groups, respectively (p = 0.034). The ICU-free hours at POD2 were greater in the central group: 18 ± 13 hours versus 13 ± 13 hours, p = 0.008. Adverse events were less frequent in the central group than in the radial group-67% versus 50%, p = 0.007. CONCLUSIONS: No differences in the norepinephrine dose regimen were found according to the arterial measurement site during cardiac surgery. However, norepinephrine use and length of stay in the ICU were shorter, and adverse events were decreased when central arterial pressure monitoring was used.

Impact of Radial Arterial Location on Catheter Lifetime in ICU Surgical Intensive Care.

The use of arterial catheters is frequent in intensive care for hemodynamic monitoring of patients and for blood sampling, but they are often removed because of dysfunction. The primary objective is to compare the prevalence of radial arterial catheter dysfunction according to location in relation to the radiocarpal joint in intensive care patients. DESIGN: Prospective randomized, controlled, single-center study. SETTING: The surgical ICU of the university hospital of Poitiers in France. PATIENTS: From January 2016 to April 2017, all patients over 18 years old admitted to the surgical ICU and requiring an arterial catheter were included. INTERVENTIONS: Randomization into two groups: catheter placed near the wrist (within 4 cm of the radiocarpal joint) and catheter placed away the wrist. The primary endpoint was the prevalence of dysfunction. We also compared the prevalence of infection and colonization. MEASUREMENTS AND MAIN RESULTS: One hundred seven catheters were analyzed (14 failed placements with no difference between the two groups, and 16 catheters excluded for missing data), with 58 catheters in near the wrist group and 49 in away the wrist group. We did not find any significant difference in the number of catheter dysfunctions between the two groups (p = 0.56). The prevalence density of catheter dysfunction was 30.5 of 1,000 catheter days for near the wrist group versus 26.7 of 1,000 catheter days for away the wrist group. However, we observed a significant difference in terms of catheter-related infection in favor of away the wrist group (p = 0.04). In addition, distal positioning of the catheter was judged easier by the physicians. CONCLUSIONS: The distal or proximal position of the arterial catheter in the radial position has no influence on the occurrence of dysfunction. However, there may be an association with the prevalence of infections.

Contamination of Blood Cultures From Arterial Catheters and Peripheral Venipuncture in Critically Ill Patients: A Prospective Multicenter Diagnostic Study.

BACKGROUND: Collecting blood cultures from indwelling arterial catheters is an attractive option in critically ill adult patients when peripheral venipuncture is difficult. However, whether the contamination proportion of blood cultures from arterial catheters is acceptable compared with that from venipuncture is inconclusive. RESEARCH QUESTION: Is contamination of blood cultures from arterial catheters noninferior to that from venipuncture in critically ill adult patients with suspected bloodstream infection? STUDY DESIGN AND METHODS: In this multicenter prospective diagnostic study conducted at five hospitals, we enrolled episodes of paired blood culture collection, each set consisting of blood drawn from an arterial catheter and another by venipuncture, were obtained from critically ill adult patients with cilinical indication. The primary measure was the proportion of contamination, defined as the number of false-positive results relative to the total number of procedures done. The reference standard for true bloodstream infection was blinded assessment by infectious disease specialists. We examined the noninferiority hypothesis that the contamination proportion of blood cultures from arterial catheters did not exceed that from venipuncture by 2.0%. RESULTS: Of 1,655 episodes of blood culture from December 2018 to July 2021, 590 paired blood culture episodes were enrolled, and 41 of the 590 episodes (6.9%) produced a true bloodstream infection. In blood cultures from arterial catheters, 33 of 590 (6.0%) were positive, and two of 590 (0.3%) were contaminated; in venipuncture, 36 of 590 (6.1%) were positive, and four of 590 (0.7%) were contaminated. The estimated difference in contamination proportion (arterial catheter - venipuncture) was -0.3% (upper limit of one-sided 95% CI, +0.3%). The upper limit of the 95% CI did not exceed the predefined margin of +2.0%, establishing noninferiority (P for noninferiority < .001). INTERPRETATION: Obtaining blood cultures from arterial catheters is an acceptable alternative to venipuncture in critically ill patients. CLINICAL TRIAL REGISTRATION: University Hospital Medical Information Network Center (UMIN-CTR); No.: UMIN000035392; URL: https://center6.umin.ac.jp/.

Effect of oval foramen restriction and premature contraction of the arterial catheter on right heart function of fetuses and infants.

Objective: The effect of fetal oval foramen restriction and premature contraction of the arterial catheter for the right heart function of fetuses and infants was studied by evaluating the right and left ventricular (RV/LV) ratios, the tricuspid annular plane systolic excursion (TAPSE) value, and the Tei index of right heart function parameters. Methods: This study was approved by the Ethics Committee of First Affiliated Hospital of Hebei North University (K20190116). We collected 257 fetuses between March 2020 and December 2021. Among these, 98 fetuses that did not have any heart abnormalities were assigned to group A, 91 fetuses with restriction of the left and right atrial channels were assigned to group B, and 68 fetuses with premature contraction of the arterial catheter were assigned to group C. The ventricular transverse diameter, the right heart TAPSE value and the Tei index of fetuses in late pregnancy and 90 days after birth were measured in the three groups, and the diagnostic value of each index for the right heart function injury was evaluated. P < 0.05 indicates significant. Results: The P-value of the TAPSE value and Tei index of infants in BC and AC groups and postnatal infants were less than 0.05, which was significant. In the BC group, the RV/LV ratio of fetuses was compared when P > 0.05, which was not significant; however, P < 0.05 after birth was considered significant. For fetuses and postnatal infants in the BC group, the RV/LV ratio was negatively associated with the TAPSE value. However, it was positively associated with the Tei index; Diagnostic test results. To predict impaired right heart function after birth, TAPSE had low diagnostic value, RV/LV and Tei index had high diagnostic value. Conclusions: Oval foramen restriction and premature contraction of the arterial catheter may affect the right heart function after birth and be related to the degree of the right heart enlargement. Although TAPSE prediction of the fetal and postnatal right heart function is limited, the RV/LV ratio and the Tei index can be used to predict impaired right heart function after birth.

Evaluation of a closed loop-blood sampling system in intensive care: A pilot randomised controlled trial. The ENCLOSE trial.

OBJECTIVE: To test the feasibility of conducting a randomised controlled trial to evaluate the impact of a closed-loop blood sampling system and blood conservation bundle. METHODS: Single site, parallel group, pilot randomised control trial comparing open system sampling to closed system sampling and conservation bundle aligned with national guidelines. Randomisation sequence was generated by an independent statistician and allocation concealment maintained via sealed opaque envelopes. The study setting was the general intensive care unit of a major metropolitan public hospital in Queensland, Australia. Participants were ≥ 18 years who had an arterial catheter inserted in intensive care. Main outcome measures included trial feasibility, blood sample loss, haematocrit (HCT) change, and packed red blood cell transfusion use. RESULTS: Eighty patients were randomised (n = 39 open group, n = 41 closed group). Characteristics in each group were equal at baseline with overall median age 60 years (IQR 48.6-70.4), 58 % male, and median APACHE II score 16 (IQR 11-22). The proportion of patients eligible was 29 % and missed eligible was 65 %. Otherwise, feasibility criteria were met with proportion of eligible patients agreeing to enrolment 99 %, 100 % of patients receiving allocated treatment; only 1 % of data missing. Analysis demonstrated a significant reduction in mean daily blood sample losses (open 32.7 (SD 1.58) mL vs closed 15.5 (SD 5.79) mL, t = -8.454, df = 78, p < 0.001). CONCLUSIONS: A large, multi-site trial is feasible with enhanced eligibility criteria, increased recruitment support. The intervention reduced daily blood sample volumes and transfusion use. Further trials are required to provide both effectiveness and implementation outcomes.

A Concurrent Pseudoaneurysm and an Arteriovenous Fistula Following Percutaneous Radial Artery Access.

The incidence of radial artery cannulation resulting in the concurrent development of a pseudoaneurysm and an arteriovenous fistula is not well defined. Here, we present the case of a 42-year-old man who developed an iatrogenic pseudoaneurysm (PSA) and a concurrent arteriovenous fistula (AVF) following multiple right radial artery cannulations. Access was obtained for a preoperative diagnostic cardiac catheterization and again for hemodynamic monitoring intraoperatively during a surgical aortic valve replacement. A palpable thrill over the right radial artery developed and persisted for nine months, leading to anxiety and mental fixation on the thrill. There were no other symptoms. Given a failed resolution with conservative care for the same duration, the patient elected to proceed with surgical resection. Following resection, the patient reported resolution of his symptoms and decreased anxiety. A follow-up targeted arterial ultrasound demonstrated no residual PSA or AVF.

The practice of arterial catheters in ICUs and nurses' perceptions of infection prevention: A multicentre cross-sectional study.

BACKGROUND: Peripheral arterial catheters (AC) are increasingly used in intensive care units (ICUs). Arterial catheter-related bloodstream infection is a serious complication that can increase patients' morbidity and length of stay. Standardised infection prevention practices are important when using AC. However, the current practices regarding AC insertion, use and removal and the perceived infection prevention attitudes of nurses in ICUs are unknown. METHODS: This was a multicentre cross-sectional study; 20 tertiary general hospitals were selected with a stratified random method in Beijing, China, using a self-reported internet survey. RESULTS: A total of 981 valid questionnaires were collected. Overall, some infection prevention practices, such as AC insertion and disinfection of the blood sample hub, were generally consistent with clinical guidelines, whereas others were inconsistent: eye protection, skin antiseptic solution, dressing choice, blood sample collection and replacement of AC. More than 60% of participants mentioned occasionally or never having used eye protection. Only 6.0% of them stated using the chlorhexidine dressings. Among the participants, 80.6% reported that they replaced AC routinely rather than based on clinical indications, 64.2% self-rated that they did not routinely culture a catheter specimen after removal and 53.4% of participants positively agreed that AC could cause infection. Nurses with a higher education level were more likely to agree that an infection risk with AC exists (trend χ2 = 5.456, p = 0.019*). CONCLUSIONS: Significant heterogeneity exists across hospitals in China in terms of antiseptic techniques and perception of infection prevention during AC insertion, use and removal. Critical care nurses' practices partially complied with guideline recommendations. Educational level was found to be a risk factor for their perceived infection prevention attitudes. Nurses with a lower education level underestimated the infection risk of AC. Future research may examine optimal preventive strategies for reducing infection.

Outcomes of Femoral Arterial Catheterisation in Neonates: A Retrospective Cohort Study.

BACKGROUND: To review the outcome of all femoral arterial catheter (FAC) insertions in a single, large neonatal unit over a 12 year period, we will describe the incidence of harms arising from FAC insertion and to identify risk factors associated with ischaemic injury. METHODS: Retrospective survey of data relating to all episodes of FAC insertion in a single neonatal intensive care unit over a 12 year period up to 2020. RESULTS: 146 FACs were inserted into 139 babies with a median (interquartile range) gestation and birth weight of 27 (24 to 37) weeks and 1092 (682 to 2870) g. Impaired limb perfusion occurred in 32 (22%). This was transient and recovered with no injury in 26 of the 32. There was an increased risk of impaired limb perfusion in babies with lower weight at the time of insertion; from 5.7% in babies over 3000 g to 34.7% in babies under 1000 g (relative risk 6.1 (1.5 to 24.6)). Six babies (4%) had ischaemic injury. Risk factors for ischaemic injury included weight below 1000 g (four cases), pre-existing partial arterial obstruction (two cases), concerns about limb perfusion prior to FAC insertion (two cases) and a delay in removing the FAC after recognition of the poor perfusion (five cases). Two clinicians inserted 71 (50%) FACs and had no associated injuries. CONCLUSIONS: FAC can be used in neonates, although there is a risk of ischaemic injury, particularly in very small babies. Our data can be used to inform decisions about patient selection for this procedure.