Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone?

BACKGROUND: Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT). METHODS: We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors. RESULTS: Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083). CONCLUSIONS: PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.

In-lake measures for phosphorus control: The most feasible and cost-effective solution for long-term management of water quality in urban lakes.

Both in-lake and catchment measures designed to reduce phosphorus (P) loading were implemented as part of a 12.3 million USD restoration project for the Minneapolis Chain of lakes in Minnesota (USA). Treatment wetlands, 'in-pipe' measures, and in-lake aluminum sulfate (alum) treatment were applied to restore water quality in the four urban lakes. Different alum dosing methods led to between 4 and 20+ (modeled) years of water quality improvements in these lakes after treatment and only one of the four lakes continues to meet water quality goals approximately 25 years after the project started. Due to limited space and poor performance, reduction of total external loads was low (1-13%) for three lakes. Changes to internal P sediment release rates after application of alum correlated well with epilimnetic total P (TP) concentrations in these lakes, indicating that improvements in water quality were mainly driven by reduced internal loading via in-lake measures. Substantial reductions to external P loading were only achieved at Cedar Lake (49%) via conversion of an existing natural area to a treatment wetland, but even Cedar Lake is no longer meeting management goals. When expressed in terms of dollars spent per unit P removed, in lake alum treatment was on average 50 times more effective than in-catchment measures. The results of this study indicate that substantial external nutrient reductions may not be adequate to sustainably maintain water quality in urban lakes and that continued in-lake management of P accumulated in lake sediment will not only be necessary, but will also be more cost efficient relative to in-catchment measures.