New Directions in Ensuring Catheter Safety.

Tunneled dialysis catheters remain the most common vascular access used to initiate hemodialysis. Unfortunately, their use is associated with higher morbidity and mortality when compared with arteriovenous fistulae or grafts. Different types of catheters with different designs and material properties function differently. Additional devices and medications can be used to decrease the rates of infection and thrombosis. The current available tunneled dialysis catheters remain far from the desired goal and innovation in the field of dialysis vascular access remains in dire need.

Long peripheral catheters: Is it time to address the confusion?

Long peripheral catheters are 6-15 cm peripheral dwelling catheters that are inserted via a catheter-over-needle or direct Seldinger (catheter-over-guidewire) technique. When inserted in the upper extremity, the distal tip terminates before reaching the axilla, typically no further than the mid-upper arm. This is distinct from a midline catheter, which is inserted via a modified Seldinger technique and terminates at the axilla. The nomenclature of this catheter is confusing and inconsistent. We have identified over a dozen labels in the literature, all describing the same device. These include '15 cm catheter', 'catheter inserted with a Seldinger method', 'extended dwell/midline peripheral catheter', 'Leaderflex line', 'long catheter', 'long IV catheter', 'long peripheral cannula', 'long peripheral catheter', 'long peripheral venous catheter', 'long polyurethane catheter', 'midline cannula', 'mini-midline', 'peripheral intravenous catheter', 'Seldinger catheter', 'short midline catheter', 'short long line' and 'ultrasound-guided peripheral intravenous catheter'. The purpose of this editorial is to achieve some level of standardisation in the nomenclature of this device. Is it time to address the confusion? We suggest adopting 'long peripheral catheter'. However, we encourage discussion and debate in reaching a consensus.

Short-term intra-arterial infusion chemotherapy for head and neck cancer patients maintaining quality of life.

PURPOSE: Head and neck cancer treatment achieves good locoregional tumor control rates while causing severe side effects. Therapy with chemotherapeutic drugs administered intravenously is limited because either the concentrations at the tumor site are too low or the total dosages are too high. The evaluation of a technique for short-term intra-arterial infusion chemotherapy is described herein. METHODS: In a retrospective study, we reviewed the medical records of 97 patients with head and neck cancers who received short-term intra-arterial infusion chemotherapy (62 patients previously untreated, 35 patients with prior radiotherapy). All patients refused further radiotherapy. Response rates, overall survival and adverse effects were the study endpoints. The blood supply of the tumors was controlled with indigocarmine blue infusion and staining of the tumor region. RESULTS: Complete or partial response was found in 67%, 52% and 63% of previously untreated patients and in 25%, 30% and 29%, respectively, of previously irradiated patients for staging groups I-III, IVA and IVB/C. Patients with T3/T4 tumors who were previously irradiated showed a median overall survival of 9 months, and those without pretreatment showed a median overall survival of 22.5 months. None of the patients required tube feeding. No new case of dysphagia, xerostomia, or functional speech and hearing loss was reported. Pain and clinical symptoms were reduced for all patient groups. Indigocarmine staining showed reduced tumor blood supply in previously irradiated regions but good blood supply in untreated regions. CONCLUSIONS: Short-term intra-arterial infusion chemotherapy achieves promising response rates and lacks severe adverse effects.

Analysis of chest X-ray plain film images of intravenous ports inserted via the superior vena cava.

PURPOSES: The optimal tip position for an intravenous port and the angle between the locking nut and the catheter are still debatable. This study evaluates the use of chest X-ray plain films for screening patients with potential intravenous port complications. METHODS: We reviewed, retrospectively, 1505 patients who had an intravenous port implanted between January 1 and December 31, 2006 at Chang Gung Memorial Hospital, and were followed up until June 30, 2010. Of the 1119 patients with an intravenous port implanted via the superior vena cava (SVC), 279 underwent re-interventions for complications. There were four different types of single lumen port, and entry vessels on the right side were utilized as the predominant entry sites through the vessel cut-down method for catheter cannulation. The anatomic catheter tip was confirmed on the postero-anterior view of plain chest X-ray films. We used the Picture Arching and Communicating System (PACS) (GE, Fairfield, CT, USA) to record the angle and distance in degrees and centimeters, respectively. RESULTS: The tracheal carina was seen easily on the chest X-ray plain film and the location of the catheter tip and the angle between the locking nut and the catheter were identified. The location of the catheter tip was significantly related to migration (p < 0.0001). The cut-off value of the receiver operating characteristic (ROC) curve for location and migration was 0.68 cm below the carina. The area under the curve (AUC) was 0.8385 and had favorable predictive power. CONCLUSION: The ideal position of an intravenous port to avoid migration is 0.68 cm below the carina. For surgeons, a quantified reference may minimize technical errors. Patients with shallow tip location should be followed up regularly and aggressive intervention initiated for any intravenous port malfunction.

[Types of hemodialysis vascular access in patients on renal replacement therapy and its complications during a one year observation period]. / Rodzaje dostepu naczyniowego do hemodializy u chorych leczonych nerkozastepczo i ich powiklania w okresie jednorocznej obserwacji.

UNLABELLED: The type of vascular access is an important determinant of complications in the dialysis population. The aim of the study was to evaluate types of hemodialysis vascular access at hemodialysis start, in the course of treatment and complications during a one year observation period. The study group consisted of 213 patients [126 (59%) males; 87 (41%) females] treated for 54 months (range from 2 to 384 months) by maintenance hemodialysis at the Nephrology Department of the University Hospital. Mean age of the patients equaled 57.4 years and ranged from 21 to 91 years. The observation period began on June 1st, 2009 and finished on May 31st, 2010. At the start of the dialysis therapy - 99 (46.5%) patients had arterio-venous fistula (AVF), 81 (38.0%) temporary catheters (TC), and 33 (15.5%) permanent catheters (PC). At the beginning of the one-year observation period, 161 (75.6%) of the patients were treated using an AVF, 37 (17.4%) using a CP, 11 (5.1%) CT, and 4 (1.9%) using an artificial graft (AVG). At the end of the one year observation period - 179 (84%) patients were dialyzed using AVF, while 30 (14.1%) patients on PC, and 4 (1.9%) using a AVG. Statistically significant differences in possessing AVF were noted between start of renal replacement therapy and the start and finish of the one year observation period (p < 0.0001), as well as beginning and finish of the observation period (p < 0.002). During the observation period - 37 (20.7%) patients with an AVF required intervention due to complications associated with vascular access; where 4 from 11 (36.4%) patients in this group had AVF located on the arm and 33 from 150 (22.0%) on the forearm. The most common complications associated with AVF were thrombosis (23 = 14.3%), narrowing of the fistula (9 = 5.6%), too high output flow (HOF) 2 = 1.2% and the steal syndrome (SS) 3 (1.9%). Infectious complications were noted in 4 from 37 patients with PC (10.8%), and significantly less with AVF-4 from 161 (2.5%) (p < 0.0001). AVG infection occurred in 2 (50%) individuals of this group. CONCLUSIONS: AVF created using patients' own vessels of the forearm is characterized with decreased risk of complications in comparison to fistulas made of artificial materials or permanent catheters. However, fistula thrombosis of the AVF is still the most common complication requiring surgical intervention.

[Vascular access models cause heterogeneous results in the centres of one community]. / Los modelos de atención al acceso vascular condicionan resultados heterogéneos en los centros de una misma comunidad.

INTRODUCTION: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area. PURPOSE: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results. MATERIAL AND METHODS: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared. MAIN VARIABLES: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery. RESULTS: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0). LIMITS: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated. CONCLUSIONS: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

What are those tubes for? What you need to know about central venous access devices.

Prehospital providers who are trained to access and utilize existing CVADs, including Groshong, Hickman, Broviac, PICC lines and implanted ports, will be able to establish rapid i.v.s. The CVADs, which should be used in critical scenarios like shock, cardiac arrest and critical medical conditions, will allow EMS to administer medications and fluids to patients in whom i.v. access may otherwise be impossible. Providers should review with their medical directors the feasibility and practical application of using these devices, ensuring they have the correct training and equipment to use these potentially lifesaving devices.

Single, percutaneous, femoral venous cannulation for cardiopulmonary bypass.

Percutaneous femoral venous cannulation for cardiopulmonary bypass has emerged as an indispensable technique in the management of cardiac surgical procedures requiring cardiopulmonary bypass. A review of cases at Brigham and Women's Hospital (Boston, MA, USA) relying solely on percutaneous femoral venous cannulation for venous return to the heart-lung machine demonstrated achievable blood flow and complexity of case-load. Operations performed in this manner include, but are not limited to, coronary artery bypass grafting (CABG), valve, CABG/valve, and aortic procedures. Minimally invasive procedures and re-operations comprise a portion of each group. Complications of cardiopulmonary bypass and site-related complications were considered. Percutaneous femoral venous cannulation is a safe method to provide most patients with adequate venous return to perform any cardiac surgery. Patients demanding greater flow than this method will provide, may require a second venous cannula at some time during cardiopulmonary bypass.

Intravascular catheter-related infections: advances in diagnosis, prevention, and management.

Indwelling vascular catheters are a leading source of bloodstream infections in critically ill patients and cancer patients. Because clinical diagnostic criteria are either insensitive or non-specific, such infections are often overdiagnosed, resulting in unnecessary and wasteful removal of the catheter. Catheter-sparing diagnostic methods, such as differential quantitative blood cultures and time to positivity have emerged as reliable diagnostic techniques. Novel preventive strategies include cutaneous antisepsis, maximum sterile barrier, use of antimicrobial catheters, and antimicrobial catheter lock solution. Management of catheter-related bloodstream infections involves deciding on catheter removal, antimicrobial catheter lock solution, and the type and duration of systemic antimicrobial therapy. Such decisions depend on the identity of the organism causing the bloodstream infection, the clinical and radiographical manifestations suggesting a complicated course, the underlying condition of the host (neutropenia, thrombocytopenia), and the availability of other vascular access sites.

Optimization and safety of the intra-aortic balloon pumping balloon catheter.

Tokai Medical Products developed an intra-aortic balloon pumping (IABP) balloon catheter with the following unique characteristics: the balloon can be applied to any patient irrespective of their physical size, and is therefore suitable for Japanese patients of small stature; a long soft tip is used, which is designed to avoid damage to blood vessels; the size of the catheter is reduced to 7 Fr, and the catheter can be used as a multifunctional balloon catheter, such as the Yoshioka type, that allows simultaneous percutaneous coronary intervention (PCI). The safety of this catheter has been proven in scientific studies. In this review, we report the development of our IABP balloon catheter and give an outline of its characteristics.

Central venous access device infections in the critical care unit.

Central venous access devices are indispensable tools in caring for the gravely ill patients in today's critical care units. Unfortunately, they are also one of the major sources for nosocomial infections in the hospital setting. This article explores the pathophysiology and risk factors related to central venous access devices infections, and examine prevention strategies. The critical care nurse, using evidence-based practice guidelines in the care of these lines, can be instrumental in preventing catheter-related infections.

Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia.

A prospective, randomized, controlled, multi-centre clinical trial was performed to test the effectiveness of an antimicrobial central venous catheter (CVC) made of polyurethane integrated with silver, platinum and carbon black (Vantex). Adults expected to require a CVC for more than 60 h were eligible, and were randomized to receive the test or control catheter. All CVCs were inserted with new venipunctures using full aseptic technique. Following catheter removal, the distal tip and an intracutaneous segment were removed and cultured using semiquantitative and quantitative methods. Peripheral blood samples were obtained and cultured to confirm cases of catheter-related bloodstream infection (CRBSI). Bacterial and fungal organisms were identified by standard microbiological methods. Catheter placement was performed primarily in the intensive care unit (50%) or operating theatre (42%). Complete data could be evaluated for 539 patients (77%). The mean duration of CVC placement was 149.3h (six days). There were no significant differences in colonization or bacteraemia rates between the test and control catheters. The overall colonization rate was not particularly low (24.5%), and yet CVC-related bacteraemia occurred in only 1.4% of patients, and CRBSI occurred in only one patient from the control group (0.2%). Insertion site and dressing change frequency were significantly associated with the colonization rate. Although CVCs with antimicrobial features have been associated with a decrease in catheter-related colonization and bacteraemia, this study demonstrated that infection rates may depend more on non-catheter-related factors, such as adherence to infection control standards, selection of insertion site, duration of CVC placement, and dressing change frequency. As microbial resistance increases, clinicians should make maximal use of these processes to reduce catheter-related infections.

The special needs of children receiving intravenous therapy.

Although the principles of preventing infection associated with intravenous therapy are the same for all patient groups, there are some notable differences when caring for babies and infants. The incidence of nosocomial infections in children is proportional to their age, with the highest incidence occurring in neonates and children under one year of age.

Best practice in urinary catheterisation and catheter care.

In May 2002 a series of 'best practice statements' to encourage a consistent and cohesive approach to care was launched by the former Nursing and Midwifery Practice Development Unit (NMPDU).

Antibiotic sampling from central venous catheters versus peripheral veins.

This study was developed to determine if there are statistically or clinically significant differences in antibiotic levels of blood samples obtained from a central venous catheter (CVC) versus a peripheral vein. Currently there is limited and contradictory information comparing aminoglycoside levels drawn from a central line used for antibiotic infusions versus a separate peripheral blood draw. In this study antibiotic levels drawn from a central line were compared with levels drawn simultaneously from a peripheral vein. Significant clinical and statistical differences were identified based on the type of central catheter in place.

Accidental catheter removal in critically ill patients: a prospective and observational study.

INTRODUCTION: The importance of accidental catheter removal (ACR) lies in the complications caused by the removal itself and by catheter reinsertion. To the best of our knowledge, no studies have analyzed accidental removal of various types of catheters in the intensive care unit (ICU). The objective of the present study was to analyze the incidence of ACR for all types of catheters in the ICU. METHODS: This was a prospective and observational study, conducted in a 24-bed medical/surgical ICU in a university hospital. We included all consecutive patients admitted to the ICU over 18 months (1 May 2000 to 31 October 2001). The incidences of ACR for all types of catheters (both per 100 catheters and per 100 catheter-days) were determined. RESULTS: A total of 988 patients were included. There were no significant differences in ACR incidence between the four central venous access sites (peripheral, jugular, subclavian and femoral) or between the four arterial access sites (radial, femoral, pedal and humeral). However, the incidence of ACR was higher for arterial than for central venous catheters (1.12/100 catheter-days versus 2.02/100 catheter-days; P < 0.001). The incidences of ACR/100 nonvascular catheter-days were as follows: endotracheal tube 0.79; nasogastric tube 4.48; urinary catheter 0.32; thoracic drain 0.56; abdominal drain 0.67; and intraventricular brain drain 0.66. CONCLUSION: We found ACR incidences for central venous catheter, arterial catheter, endotracheal tube, nasogastric tube and urinary catheter that are similar to those reported in previous studies. We could not find studies that analyzed the ACR for thoracic, abdominal, intraventricular brain and cardiac surgical drains, but we believe that our rates are acceptable. To minimize ACR, it is necessary to monitor its incidence carefully and to implement preventive measures. In our view, according to establish quality standards, findings should be reported as ACR incidence per 100 catheters and per 100 catheter-days, for all types of catheters.

Accesos vasculares en neonatología / Vascular access in neonatology

El siguiente artículo explica la técnica de coloración de accesos vasculares en pacientes recién nacidos del área de neonatología. Además de definir lo que se conoce como este tipo de catéteres, se describe la clasificación de los mismos; las indicaciones y contraindicaciones para su colocación, las complicaciones y las precauciones (AU)