Central line-associated bloodstream infection trend in Brazilian adult intensive care units: an ecological study.

INTRODUCTION: Central line-associated bloodstream infections are the second most frequent infection in intensive care units. It represents an adverse event of significant magnitude, thus threatening the patient safety. The aim of this study was to analyze the historical trend of central line-associated bloodstream infections in patients in intensive care units, the rate of infection, central venous catheter utilization ratio, type of pathogen and their antimicrobial resistance pattern. METHODOLOGY: This ecological study was performed at 42 intensive care units from a state capital of the Midwest region of Brazil. Central line-associated bloodstream infections notifications were collected from two databases, the Municipal Coordination for Patient Safety and Infection Control at Healthcare Services, from 2012-2016, and the FormSUS (National Health System Data Processing Company), from 2014-2016. RESULTS: The incidence of central line-associated bloodstream infections was high and stationary in the period (incidence rate of 2.3 to 3.2 per 1,000 catheter days, central venous catheter utilization ratio average 56,9%). The most frequent microorganisms were coagulase-negative Staphylococcus, Klebsiella pneumoniae, Acinetobacter spp. and Pseudomonas aeruginosa. Resistance to 3rd and 4th generation cephalosporins and carbapenems were detected among Gram-negative bacteria, and resistance to oxacillin among Gram-positive bacteria. CONCLUSIONS: Central line-associated bloodstream infections incidence rates were high, however the historical trend remained stationary in adult intensive care units. Infections were mostly caused by coagulase-negative Staphylococcus, K. pneumoniae, Acinetobacter spp. and Pseudomonas aeruginosa, including multi-drug resistant organisms. These findings point to the need of educational strategies addressing the adherence to established preventive measures and to the rational use of antimicrobials.

Pediatric Venous Thromboembolism: Different Rates of Incidence, Anatomic Locations, and Risk Factors Between Orthopaedic and Nonorthopaedic Related Patients.

BACKGROUND: The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and nonorthopaedic pediatric related patients to determine if important differences exist. METHODS: Computed tomography and ultrasound data were reviewed for children (below 19 y old) with a diagnosed VTE between January 1, 2009 and December 31, 2016. Demographic and clinical data, including VTE anatomic location and risk factors, were recorded. Two major cohorts were identified: orthopaedic-related (ORTH) and nonorthopaedic-related (NORTH) VTEs. Incidence rates were estimated and risk factors were compared using χ2 testing. RESULTS: There were 373 children diagnosed with a VTE (average age 10.3 y) of a total of 810,097 treated as in-patients for an incidence rate of 4.60 per 10,000 cases (95% confidence interval=4.15 to 5.10 per 10,000 cases). The rate of ORTH VTEs (28 of 188,669 orthopaedic patients, 1.48 per 10,000 cases) was significantly lower than that of NORTH VTEs (345 of 621,428 nonorthopaedic patients, 5.55 per 10,000 cases; P<0.001). For the ORTH cohort, there was a significant difference in the proportion of deep vein thrombosis in the lower extremity (91%) compared with the upper extremity (9%) (P<0.001), while a more even distribution of NORTH deep vein thrombosis in the upper (50%) and lower (41%) extremities was appreciated. The primary risk factors for ORTH VTEs included surgery (93%; P<0.001), change in ambulatory status (61%; P<0.001), and trauma (18%; P<0.001), while the primary risk factors for NORTH VTEs included intravenous peripheral inserted central catheter/central line (61%; P<0.001) and cancer (27%; P=0.001). CONCLUSIONS: Pediatric ORTH VTEs have a significantly lower incidence rate and different primary risk factors than those of NORTH VTEs. This information is useful for health care providers when making decisions regarding risk and prophylaxis in pediatric patients with orthopaedic and nonorthopaedic conditions. LEVEL OF EVIDENCE: Level III.

Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators.

OBJECTIVE: Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU). METHODS: We conducted a retrospective observational study from 2008-2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU. RESULTS: Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08). CONCLUSION: In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Impact of Checklist for Early Recognition and Treatment of Acute Illness on Treatment of Critically Ill Septic Patients in a Low-Resource Medical Intensive Care Unit.

Introduction: Treatment of sepsis and septic shock can be a challenge even for intensive care units (ICUs) in high income countries, but it is especially difficult for ICUs with limited resources. Aim: To evaluate the impact of CERTAIN on treatment of critically ill septic patients in low-resource medical ICU. Materials and Methods: In a before-and-after study design, we compared clinical outcomes, processes, and complications (hospital acquired infections) 1 year before and 2 years after (2016 and 2017) introduction of CERTAIN. Results: A total of 125 patients with sepsis were prospectively identified for a 3-year period. Mean patient age, gender distribution, number of patients on mechanical ventilation (33 [76.7%] vs. 42 [84%] vs. 24 [75%]) and vasopressor use (23 [53.5%] vs. 34 [68%] vs. 24 [75%]) were similar before (2015) and 2 years after (2016 and 2017) the implementation of CERTAIN. Severity of illness (Simplified Acute Physiology Score II [SAPS II score]) was higher after the implementation. The checklist was incorporated in the daily practice with 100% adherence to its use. The duration of mechanical ventilation (5.3 ± 5.3 vs. 4.2 ± 3.6 vs. 3.7 ± 5.5), antibiotic treatment (8.2 ± 5.4 vs. 6.9 ± 4.1 vs. 5.8 ± 5.6), central venous catheter use (6.2 ± 5.7 vs. 5.7 ± 4.6 vs. 4.2 ± 6.1), ICU stay (8.4 ± 5.4 vs. 7.1 ± 4.1 vs. 5.8 ± 5.6), and the incidence of nosocomial infection (33.3% vs. 30% vs. 12.5%) decreased in the period after the onset of the intervention, but the results did not reach statistical significance. When adjusted for baseline characteristics, CERTAIN was not associated with hospital mortality (odds ratio 0.88, 0.38-2.04). Conclusion: CERTAIN was readily adopted in the ICU workflow and was associated with improvement in treatment of critically ill patients with sepsis.

International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS).

RATIONALE & OBJECTIVE: Optimizing vascular access use is crucial for long-term hemodialysis patient care. Because vascular access use varies internationally, we examined international differences in arteriovenous fistula (AVF) patency and time to becoming catheter-free for patients receiving a new AVF. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 2,191 AVFs newly created in 2,040 hemodialysis patients in 2009 to 2015 at 466 randomly selected facilities in the Dialysis Outcomes and Practice Patterns Study (DOPPS) from the United States, Japan, and EUR/ANZ (Belgium, France, Germany, Italy, Spain, Sweden, United Kingdom, Australia, and New Zealand). PREDICTORS: Demographics, comorbid conditions, dialysis vintage, body mass index, AVF location, and country/region. OUTCOMES: Primary/cumulative AVF patency (from creation), primary/cumulative functional patency (from first use), catheter dependence duration, and mortality. ANALYTICAL APPROACH: Outcomes estimated using Cox regression. RESULTS: Across regions, mean patient age ranged from 61 to 66 years, with male preponderance ranging from 55% to 66%, median dialysis vintage of 0.3 to 3.2 years, with 84%, 54%, and 32% of AVFs created in the forearm in Japan, EUR/ANZ, and United States, respectively. Japan displayed superior primary and cumulative patencies due to higher successful AVF use, whereas cumulative functional patency was similar across regions. AVF patency associations with age and other patient characteristics were weak or varied considerably between regions. Catheter-dependence following AVF creation was much longer in EUR/ANZ and US patients, with nearly 70% remaining catheter dependent 8 months after AVF creation when AVFs were not successfully used. Not using an arteriovenous access within 6 months of AVF creation was related to 53% higher mortality in the subsequent 6 months. LIMITATIONS: Residual confounding. CONCLUSIONS: Our findings highlight the need to reevaluate practices for optimizing long-term access planning and achievable AVF outcomes, especially AVF maturation. New AVFs that are not successfully used are associated with long-term catheter exposure and elevated mortality risk. These findings highlight the importance of selecting the best access type for each patient and developing effective clinical pathways for when AVFs fail to mature successfully.

Epidemiology, prevalence and risk factors for infections in burn patients: results from a regional burn centre's analysis.

Burn patients are at high risk of infections due to severe impairment of immunity and loss of skin barrier function. We aimed to describe the epidemiology, incidence and risk factors for infection in a cohort of burns patients. Two hundred patients were retrospectively enrolled and subdivided into infected (N = 81) and uninfected groups (N = 119). The cumulative prevalence of infections was 27% on day 7 and 43.8% on day 28. Skin and soft tissue infections (32%) were the most frequent. Carbapenem-resistant Acinetobacter baumannii (28%), Pseudomonas aeruginosa (26%) and methicillin-resistant Staphylococcus aureus (25%) infections were most prevalent. An indwelling central venous catheter (CVC; sub-hazard ratio [SHR] 7.41, 95% confidence interval [CI] 3.78-14.62) and revised Baux score (RBS; SHR 2.08, 95% CI 0.98-4.42) were associated with higher incremental infection rate while surgical treatment resulted in a protective factor (SHR 0.45, 95% CI 0.29-0.75). RBS may be useful to stratify the infection risk: a strict collaboration between surgeons and infectious disease specialists is needed to implement source control and antimicrobial surveillance.

Bacterial and fungal coinfections in COVID-19 patients hospitalized during the New York City pandemic surge.

We observed bacterial or fungal coinfections in COVID-19 patients admitted between March 1 and April 18, 2020 (152 of 4,267, 3.6%). Among these patients, mortality was 57%; 74% were intubated; 51% with bacteremia had central venous catheters. Time to culture positivity was 6-7 days, and 79% had received prior antibiotics. Metallo-ß-lactamase-producing E. cloacae coinfections occurred in 5 patients.

Tempo de permanência e motivos de retirada do cateter venoso central de pacientes renais crônicos em hemodiálise ambulatorial / Duration of use and reasons for removal of central venous catheter in patients with chronic kidney disease undergoing ambulatory hemodialysis

Introdução: A permanência prolongada de Cateter Venoso Central (CVC) em Hemodiálise (HD) está relacionado a maior risco de complicações. O objetivo deste estudo foi avaliar o tempo, em dias, de permanência e o motivo de retirada do CVC em pacientes renais crônicos submetidos à HD ambulatorial em um seguimento de 10 meses. Métodos: Estudo longitudinal, retrospectivo, realizado em unidade de HD de um hospital público no sul do Brasil, no período de janeiro a setembro/2019. A coleta de dados foi realizada pelos pesquisadores a partir de prontuário eletrônico e planilha de registros dos doentes renais crônicos em hemodiálise por CVC de curta e longa permanência no período em estudo. Projeto aprovado no Comitê de Ética em Pesquisa da instituição. Resultados: Foram avaliados 91 cateteres de 55 pacientes, com prevalência do sexo feminino 33 (60%), média de idade 55 ± 18 anos e cor branca 42 (76,3%). Quarenta e sete (52%) dos CVCs eram de curta permanência, e 70 (76,9%) inseridos em veia jugular direita. O tempo de hemodiálise com CVCs de curta permanência variou de quatro a 190 dias com mediana de 47 dias (21, 7-69, 3) e os de longa permanência de 47 a 1.486 dias, com mediana de 231 (95-676). O principal motivo de retirada dos cateteres foi a troca por outro CVC 17 (36,2%). A taxa de suspeita e/ou infecção foi de 14 (15,4%). Conclusão: O tempo de permanência dos CVC foi prolongado o que expõe os pacientes a riscos. O principal motivo para retirar o CVC não foi a confecção de Fístula Arteriovenosa (FAV), apontando para a necessidade de revisar os processos assistenciais visando modificar e priorizar essa prática. (AU)

Introduction: The prolonged permanence of Central Venous Catheter (CVC) in Hemodialysis (HD) is related to an increased risk of complications. The aim of this study was to evaluate duration of use, in days, and reasons for removal of central venous catheter (CVC) in patients with chronic kidney disease undergoing ambulatory hemodialysis in a 10-month follow-up. Methods: This longitudinal, retrospective study was conducted at the hemodialysis unit of a public hospital in southern Brazil, from January to September 2019. Data collection was performed by the researchers using electronic medical records and a spreadsheet of records of patients with chronic kidney disease undergoing hemodialysis by short- and long-term CVC in the study period. The project was approved by the institution's Research Ethics Committee. Results: Ninety-one catheters from 55 patients were evaluated. Thirty-three participants were female (60%), mean age was 55 ± 18 years, and 42 were white (76.3%). Forty-seven (52%) CVCs were short-term, and 70 (76.9%) CVCs were inserted in the right jugular vein. Hemodialysis duration with short-term CVCs ranged from four to 190 days with a median of 47 (21.7-69.3) days, and long-term CVCs ranged from 47 to 1486 days with a median of 231 (95-676) days. The main reason for removing the catheter was replacing it with another CVC, in 17 cases (36.2%). The number of cases of infection or suspected infection was 14 (15.4%). Conclusions: The duration of CVC use was prolonged, which exposes patients to risks. The main reason for removing the CVC was not related to creating an arteriovenous fistula, demonstrating the need to review the care processes aiming to modify and prioritize this practice. (AU)

The risk factors analysis and establishment of an early warning model for healthcare-associated infections after pediatric cardiac surgery: A STROBE-compliant observational study.

The aim of this study was to identify the main risk factors for health-care-associated infections (HAIs) following cardiac surgery and to establish an effective early warning model for HAIs to enable intervention in an earlier stage.In total, 2227 patients, including 222 patients with postoperative diagnosis of HAIs and 2005 patients with no-HAIs, were continuously enrolled in Beijing Anzhen Hospital, Beijing, China. Propensity score matching was used and 222 matched pairs were created. The risk factors were analyzed with the methods of univariate and multivariate logistic regression. The receiver operating characteristic (ROC) curve was used to test the accuracy of the HAIs early warning model.After propensity score matching, operation time, clamping time, intubation time, urinary catheter time, central venous catheter time, ≥3 blood transfusions, re-endotracheal intubation, length of hospital stay, and length of intensive care unit stay, still showed significant differences between the 2 groups. After logistic model analysis, the independent risk factors for HAIs were medium to high complexity, intubation time, urinary catheter time, and central venous catheter time. The ROC showed the area under curve was 0.985 (confidence interval: 0.975-0.996). When the probability was 0.529, the model had the highest prediction rate, the corresponding sensitivity was 0.946, and the specificity was 0.968.According to the results, the early warning model containing medium to high complexity, intubation time, urinary catheter time, and central venous catheter time enables more accurate predictions and can be used to guide early intervention after pediatric cardiac surgery.

Local signs at insertion site and catheter-related bloodstream infections: an observational post hoc analysis using individual data of four RCTs.

BACKGROUND: Little is known on the association between local signs and intravascular catheter infections. This study aimed to evaluate the association between local signs at removal and catheter-related bloodstream infections (CRBSI), and which clinical conditions may predict CRBSIs if inflammation at insertion site is present. METHODS: We used individual data from four multicenter randomized controlled trials in intensive care units (ICUs) that evaluated various prevention strategies for arterial and central venous catheters. We used multivariate logistic regressions in order to evaluate the association between ≥ 1 local sign, redness, pain, non-purulent discharge and purulent discharge, and CRBSI. Moreover, we assessed the probability for each local sign to observe CRBSI in subgroups of clinically relevant conditions. RESULTS: A total of 6976 patients and 14,590 catheters (101,182 catheter-days) and 114 CRBSI from 25 ICUs with described local signs were included. More than one local sign, redness, pain, non-purulent discharge, and purulent discharge at removal were observed in 1938 (13.3%), 1633 (11.2%), 59 (0.4%), 251 (1.7%), and 102 (0.7%) episodes, respectively. After adjusting on confounders, ≥ 1 local sign, redness, non-purulent discharge, and purulent discharge were associated with CRBSI. The presence of ≥ 1 local sign increased the probability to observe CRBSI in the first 7 days of catheter maintenance (OR 6.30 vs. 2.61 [> 7 catheter-days], pheterogeneity = 0.02). CONCLUSIONS: Local signs were significantly associated with CRBSI in the ICU. In the first 7 days of catheter maintenance, local signs increased the probability to observe CRBSI.

Improving practice in accessing haemodialysis central venous catheters.

In children, haemodialysis is used as a form of renal replacement therapy and is typically delivered via a central venous catheter (CVC). It is necessary to access the CVC for dialysis and blood sampling regularly, and safe line practice is essential to minimise complications associated with CVCs, including infection. The authors had concerns about the rate of CVC infection in their children's haemodialysis unit, which prompted a practice review. A questionnaire was emailed to all other children's haemodialysis units in the UK, which identified variations in practice and training. The authors subsequently modified their unit's CVC access guidelines and blood sampling technique, and developed a new competency-based 'haemodialysis CVC access only' training programme for nursing staff. A willingness to review practice in the unit, supported by comparison and communication with other units, assisted in implementing this change in practice.

Brazilian Dialysis Census: analysis of data from the 2009-2018 decade / Censo Brasileiro de Diálise: análise de dados da década 2009-2018

ABSTRACT Introduction: National data on chronic dialysis treatment are essential for the development of health policies that aim to improve patient treatment. Objective: To present data from the Brazilian Society of Nephrology on patients with chronic dialysis for kidney disease in July 2018, making a comparative analysis of the past 10 years. Methods: Data collection from dialysis units, with filling in an online questionnaire for 2018. Data from 2009, 2013 and 2018 were compared. Results: 288 (36.6%) centers answered the questionnaire. In July 2018, the estimated total number of patients on dialysis was 133,464. Estimates of the prevalence and incidence rates of patients undergoing dialysis treatment per million of the population (pmp) were 640 and 204, respectively, with average annual increases of 23.5 pmp and 6 pmp for prevalence and incidence, respectively. The annual gross mortality rate was 19.5%. Of the prevalent patients, 92.3% were on hemodialysis and 7.7% on peritoneal dialysis, with 29,545 (22.1%) on the waiting list for transplantation. Median bicarbonate concentration in the hemodialysis bath was 32 mEq/L. Venous catheters were used as access in 23.6% of the hemodialysis patients. The prevalence rate of positive serology for hepatitis C showed a progressive reduction (3.2%). Conclusion: The absolute number of patients and rates of incidence and prevalence in dialysis in the country increased substantially in the period, although there are considerable differences in rates by state. There has been a persistent increase in the use of venous catheters as an access for dialysis; and reduction in the number of patients with positive serology for hepatitis C.

RESUMO Introdução: Dados nacionais sobre o tratamento dialítico crônico são essenciais para a elaboração de políticas de saúde que almejem melhora no tratamento dos pacientes. Objetivo: Apresentar dados do inquérito da Sociedade Brasileira de Nefrologia sobre pacientes com doença renal crônica dialítica em julho de 2018, fazendo análise comparativa dos últimos 10 anos. Métodos: Coleta de dados a partir das unidades de diálise, com preenchimento de questionário on-line referentes a 2018. Foram comparados dados de 2009, 2013 e 2018. Resultados: 288 (36,6%) centros responderam ao questionário. Em julho de 2018, o número total estimado de pacientes em diálise foi de 133.464. Estimativas das taxas de prevalência e incidência de pacientes em tratamento dialítico por milhão da população (pmp) foram de 640 e 204, respectivamente, com médias de aumento anuais de 23,5 pmp e 6 pmp para prevalência e incidência, respectivamente. Taxa anual de mortalidade bruta foi de 19,5%. Dos pacientes prevalentes, 92,3% estavam em hemodiálise e 7,7%, em diálise peritoneal, com 29.545 (22,1%) em fila de espera para transplante. Concentração mediana de bicarbonato no banho de hemodiálise foi de 32 mEq/L. Cateter venoso era usado como acesso em 23,6% dos pacientes em hemodiálise. Taxa de prevalência de sorologia positiva para hepatite C apresentou redução progressiva (3,2%). Conclusão: Número absoluto de pacientes e taxas de incidência e prevalência em diálise no país aumentaram substancialmente no período, embora haja diferenças consideráveis nas taxas por estado. Tem havido persistente aumento no uso de cateter venoso como acesso para diálise; e redução de pacientes com sorologia positiva para hepatite C.

Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children.

BACKGROUND: Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015. OBJECTIVES: To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long-term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random-effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. MAIN RESULTS: We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low-certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate-certainty evidence), and not reported in the remaining studies. AUTHORS' CONCLUSIONS: The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC-associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains.

Brazilian Dialysis Census: analysis of data from the 2009-2018 decade.

INTRODUCTION: National data on chronic dialysis treatment are essential for the development of health policies that aim to improve patient treatment. OBJECTIVE: To present data from the Brazilian Society of Nephrology on patients with chronic dialysis for kidney disease in July 2018, making a comparative analysis of the past 10 years. METHODS: Data collection from dialysis units, with filling in an online questionnaire for 2018. Data from 2009, 2013 and 2018 were compared. RESULTS: 288 (36.6%) centers answered the questionnaire. In July 2018, the estimated total number of patients on dialysis was 133,464. Estimates of the prevalence and incidence rates of patients undergoing dialysis treatment per million of the population (pmp) were 640 and 204, respectively, with average annual increases of 23.5 pmp and 6 pmp for prevalence and incidence, respectively. The annual gross mortality rate was 19.5%. Of the prevalent patients, 92.3% were on hemodialysis and 7.7% on peritoneal dialysis, with 29,545 (22.1%) on the waiting list for transplantation. Median bicarbonate concentration in the hemodialysis bath was 32 mEq/L. Venous catheters were used as access in 23.6% of the hemodialysis patients. The prevalence rate of positive serology for hepatitis C showed a progressive reduction (3.2%). CONCLUSION: The absolute number of patients and rates of incidence and prevalence in dialysis in the country increased substantially in the period, although there are considerable differences in rates by state. There has been a persistent increase in the use of venous catheters as an access for dialysis; and reduction in the number of patients with positive serology for hepatitis C.

The 100 top-cited systematic reviews/meta-analyses in central venous catheter research: A PRISMA-compliant systematic literature review and bibliometric analysis.

OBJECTIVE: The central venous catheter is used extensively worldwide. The purpose of this bibliometric analysis was to identify the 100 top-cited systematic reviews/meta-analyses in the literature on central venous catheters and to capture the most important trends in this area of research. RESEARCH METHODOLOGY: A search was performed in the Web of Science Core Collection on studies published prior to November 12th, 2019. The search terms included central venous catheter, systematic review and meta-analysis. Retrieved studies were ranked by citation number and selected by two of the authors. Information such as citation number, author, institution, country and year of publication was collected. RESULTS: The 100 top-cited studies published between 1992 and 2017 were reviewed, with the largest proportion published in 2008 (n = 17). The number of citations ranged from 14 to 660. The country with the largest number of studies was the United States of America (n = 36). Critical Care Medicine published the greatest number of these studies (n = 13). The largest number of these studies were focused on central venous catheter-related infection (n = 56) and thrombosis (n = 19). CONCLUSION: Developed countries were the most productive in the field of central venous catheters. Most meta-analyses focused on complications associated with central-venous catheters such as infection and thrombosis.

The validity of validation: A practical assessment.

OBJECTIVE: To assess the time to achieve reliable reporting of electronic health record data compared with manual reporting during validation. DESIGN: Secondary analysis of aggregate data for number of patients present, number of patients with a central venous catheter, and number of patients with an indwelling urinary catheter during validation of an electronic health record reporting tool. SETTING: Mayo Clinic Health System in Wisconsin. PARTICIPANTS: Mayo Clinic infection prevention and control staff, unit champions, and all inpatients. METHODS: We simultaneously collected electronic and manual counts of device data and compared discrepancies to determine their source. If manual data entry was incorrect, manual counts were coded as inaccurate. If electronically abstracted data did not reflect an accurate count, errors were attributed to the system. Data were compared using standard statistical methods. RESULTS: Within 30 days after beginning validation of electronic reporting for central venous catheter days and urinary catheter days, electronic counts were durably more reliable than manual counts. CONCLUSIONS: Manual validation for capturing and reporting electronic data and reporting can be shorter than the 90 days currently mandated by National Healthcare Safety Network criteria. Compared with a longer validation period, a shorter validation period may yield substantial savings while achieving the same validity.

Peripherally inserted central venous catheter (PICC) in outpatient and inpatient oncological treatment.

PURPOSE: So far there is little evidence on peripherally inserted central venous catheter (PICC) in radiation oncology patients maintaining the access during the periods of ambulatory and hospital treatment. METHODS: A total of 522 PICC placements in 484 patients were performed between 11/2011 and 07/2016 at the Department of Radiation Oncology and analysed retrospectively for complications and treatment- and patient-related factors during ambulatory and hospital inpatient use. On initial hospitalization, all patients received a multimodal radio-oncological treatment consisting of radiation and intravenous therapy administered via the PICC. RESULTS: A total of 18,292 catheter days were documented. Median follow-up from catheter insertion to their removal was 37 days (1-97). The overall complication rate was 4.1 per 1000 catheter days (n = 75, 14.4%). Complications were similar between the cohort of outpatient 3.6 per 1000 catheter days and the cohort of inpatient 4.8 per 1000 catheter days (OR 0.976; 95% CI [0.598; 1.619]; p = 0.924). Severe bloodstream infections occurred at a rate of 0.60 per 1000 catheter days (n = 11, 2.1%), deep vein thrombosis at a rate of 0.82 per 1.000 catheter days (n = 15, 2.9%) and local inflammation at a rate of 1.26 per 1.000 catheter days (n = 23, 4.4%). Only immunotherapy could be identified as an independent risk factor for complications (OR 5.6; 95% CI [2.4; 13.1]; p < 0.001). CONCLUSION: Using PICC in outpatients is not associated with an elevated risk of complications. Particular attention should be payed to early identification of PICC associated bloodstream infections. Immunotherapy is an independent risk factor for local skin complication.

Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population.

BACKGROUND: Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC). METHODS: To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013. RESULTS: At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft. CONCLUSIONS: Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

A prospective journey of the peripherally inserted central catheter service, at a tertiary paediatric centre in Western Australia.

BACKGROUND: To document the evolution of the Peripherally Inserted Central Catheter service at Princess Margaret Hospital, now Perth Children's Hospital. METHODS: Between January 2012 and June 2013 patients referred to Anaesthesia for a Peripherally Inserted Central Catheter were prospectively followed up. A repeat audit was conducted between January 2015 and June 2016, following the introduction of a number of measures aimed at improving the service. RESULTS: Audit 1: A total of 200 Peripherally Inserted Central Catheter insertions were attempted in 138 patients. Successful placement occurred in 86% of cases (172/200). The median age of patients was 7.71 years (range 0-20). The percentage of Peripherally Inserted Central Catheters remaining in situ for the predicted duration was 49/172 (28.5%). Complications were documented in 78/172 (45.4%) of cases. Audit 2: A total of 310 Peripherally Inserted Central Catheter placements were attempted in 244 patients. Successful insertion rate was 95.5% (296/ 310). The median age of patients was 5.3 years (range 0.0-18.72). The percentage remaining in situ for the predicted duration was 145/296 (49%). Complications were documented in 67/296 (22.6%) of cases. CONCLUSION: The evolution of the Peripherally Inserted Central Catheter service at our free standing Tertiary Paediatric Hospital is well documented following these 2 audits. The introduction of a dedicated Anaesthesia led Peripherally Inserted Central Catheter service at our centre has resulted in improved insertion success rates and a reduction in complications.