Intermittent heparinised saline flushes for maintaining indwelling peripheral and central intravenous catheters in diabetic dogs

Intermittent low-dose heparinised saline flushes were found to be efficacious for maintaining patency of indwelling peripheral and central intravenous catheters in diabetic dogs. The catheters were flushed with 1 mL of 1 U/mL heparinised saline every two hours immediately following blood sample collection, or every 12 hours when not being used for sampling. Central catheters were flushed with saline solution first to clear the line before instillation of the heparinised saline. Patency of 54/57 (95%) of the peripheral catheters and 30/32 (94%) of the central catheters was achieved for up to 36 hours and five days, respectively. No phlebitis, or local or systemic infections were observed and, in each case, catheter failure was attributable to obstruction or extravasation. It is unlikely that there will be any contraindications to this flushing technique and its introduction may improve intravenous catheter survival and reduce catheter-associated complications in hospitalised dogs.

Salvage of long-term central venous catheters during an outbreak of Pseudomonas putida and Stenotrophomonas maltophilia infections associated with contaminated heparin catheter-lock solution

objective. To describe the management of patients with long-term central venous catheters (CVCs) during an outbreak of infection due to Pseudomonas putida and Stenotrophomonas maltophilia associated with contaminated heparin catheter-lock solution. design. Descriptive study. setting. Private, 250-bed tertiary-care hospital. methods. In March 2003, we identified 2 febrile cancer patients with P. putida bacteremia. Over 2 days, 7 cases of bacteremia were identified; lots of syringes prefilled with heparin catheter-lock solution, supplied by a compounding pharmacy, were recalled and samples were cultured. More cases of bacteremia appeared during the following days, and any patient who had had a catheter lock infused with the suspect solution was asked to provide blood samples for culture, even if the patient was asymptomatic. Isolates that were recovered from culture were typed by pulsed-field gel electrophoresis. Antimicrobial salvage treatment of long-term CVCs was attempted. results. A total of 154 patients had had their catheter lock infused with solution from the lots that were suspected of being contaminated. Only 48 of these patients had CVCs. By day 7 of the outbreak, 18 of these patients had become symptomatic. Twenty-six of the remaining 30 asymptomatic patients then also provided blood samples for culture, 10 of whom developed fever shortly after samples were collected. Thirty-two patients were identified who had P. putida bacteremia; 9 also had infection due to S. maltophilia. Samples from 1 of the 3 lots of prefilled syringes in use at the time of the outbreak also grew P. putida on culture. Molecular typing identified 3 different clones of P. putida from patients and heparin catheter-lock solution, and 1 clone of S. maltophilia. A total of 27 patients received antimicrobial therapy regimens, some of which included decontamination of the catheter lock with anti- infective lock solution. Of 27 patients, 19 (70%) retained their long-term CVC during the 6-month follow-up period. conclusions. To our knowledge, this is one of the largest prospective experiences in the management of bloodstream infection associated with long-term CVCs. The infections were caused by gram-negative bacilli and were managed without catheter removal, with a high response rate. We emphasize the risks of using intravenous formulations of medications supplied by compounding pharmacies that produce large quantities of drugs.

Bacterial colonization in hemodialysis temporary dual lumen catheters: A prospective study

Aims. The use of hemodialysis temporary dual-lumen catheters is often complicated by infections, which may be a significant cause of death among patients with end stage renal disease (ESRD). The aim of this study was to assess the incidence of bacteremia and bacterial colonization related to non-tunneled, non-cuffed, dual-lumen temporary catheters in patients with ESRD submitted to hemodialysis. Methods. This study included 29 patients with ESRD. After catheter implantation, patients were monitored throughout the period of catheter permanence by means of blood samples collected weekly from a peripheral vein. Bacteria were isolated and identified according to CLSI recommendations. When catheters were removed for any reason, their tips were evaluated microbiologically. Results. A total of 194 blood samples from the 29 patients implanted with 55 catheters were analyzed. Of these, 15.5% (30 samples) demonstrated bacterial growth, principally Staphylococcus epidermidis (64.5%). Twenty patients (68.9%) presented at least one positive blood culture during follow-up. The median time for catheter colonization was 18.5 days (95% CI: 16.8-30.3). Of the 55 catheters implanted, 28 (50.9%) showed bacterial colonization, corresponding to 23.4 episodes/1000 catheter/days and 9.2 episodes of bacteremia /1000 catheter/days. Fifteen of 28 catheter tips analyzed showed bacterial growth (53.5%). In 14 of these (93.3%), there was agreement between the isolates from the catheter tip and blood cultures. Of 24 episodes of positive blood cultures from 20 different patients in 17 episodes (70.8%), the patients showed no clinical signs or symptoms of bacteremia. Conclusions. The high incidence of catheter colonization, the correlation between blood and catheter tip cultures, and the occurrence of frequent cases of asymptomatic bacteremia justify the proposal of routine peripheral blood collections to monitor patients undergoing hemodialysis with temporary dual-lumen catheters.

A randomized trial of 5 versus 7 French guiding catheters for transfemoral percutaneous coronary stent implantation

Comparative studies between 5 French guiding catheter and others of larger size using the transfemoral approach to coronary stenting have not been described. Coronary stent implantation was performed in 90 patients in a randomized trial. The primary end-point was to compare the incidence of successful uncomplicated stent implantation per lesion with the 5F and 7F guiding catheters. Patients were excluded for excessive vessel tortuosity or anticipated need for equipment not fitting through a 5 catheter. Baseline characteristics and the use of direct stenting did not differ between the two groups. The primary success rate was 97.8% per patient in both groups and 98% per lesion in the 5 French and 97.9% in the 7 French. Guiding catheter change was necessary in 1 patient in each group to successfully complete the procedure in both groups. The amount of contrast used was 63 +/- 27.3 mL in the 5 French and 76 +/- 25 mL in the 7 French groups (P < 0.05). Vascular complications and blood transfusions occurred somewhat more frequently in the 7 French group (P = 0.058). The manual compression time after sheath removal was 5.1 +/- 2.0 min and 8.0 +/- 4.3 min, respectively, in the 5 and 7 French groups (P < 0.01). In conclusion, the 5 French guiding catheters showed a similar success rate with coronary stenting when compared to the 7 French, but the amount of contrast used and manual compression time after sheath removal, as well as the rate of vascular and bleeding complications, were reduced in the 5 French group.

Endovascular techniques for placement of long-term chemotherapy catheters

PURPOSE: To analyze the results from using endovascular techniques to place long-term chemotherapy catheters when advancing the catheter using the external jugular vein is difficult due to obstructions or kinking. METHODS: Between July 1997 and August 2000, 320 long-term chemotherapy catheters were placed, and in 220 cases the external jugular vein was used as the primary venous approach. In 18 of these patients, correct positioning was not achieved and several endovascular techniques were then utilized to overcome these obstacles, including manipulation of a J-wire with a moveable core, venography, and the exchange wire technique. RESULTS: In 94.5% of the patients with difficulties in obtaining the correct positioning, we were able to advance the long-term catheter to the desired position with the assistance of endovascular techniques. CONCLUSIONS: Venography and endovascular guidance techniques are useful for the placement of long-term catheters in the external jugular vein.

Placement of hemodialysis catheters through stenotic or occluded central thoracic veins.

A method for hemodialysis catheter placement in patients with central thoracic venous stenosis or occlusion is described and initial results are analyzed. Twelve patients, with a mean age of 63.2 years (42-80 years), with central venous stenosis or occlusion, and who required a hemodialysis catheter were reviewed. All lesions were confirmed by helical CT or phlebography. Five patients had stenosis while seven patients were diagnosed with an occlusion of thoracic central veins. All patients were asymptomatic, without sign of superior vena cava syndrome. After percutaneous transstenotic catheterization or guidewire-based recannalization in occlusions, a balloon dilatation was performed and a stent was placed, when necessary, prior to catheter placement. Technical success was 92%. Three patients had angioplasty alone and nine patients had angioplasty with stent placement. Dialysis catheters were successfully inserted through all recannalized accesses. No immediate complication occurred, nor did any patient develop superior vena cava syndrome after the procedure. The mean follow-up was 21.8 months (range, 8-48 months). Three patients developed a catheter dysfunction with fibrin sheath formation (at 7, 11, and 12 months after catheter placement, respectively). Two were successfully managed by percutaneous endovascular approach and one catheter was removed. In conclusion, for patients with central venous stenosis or occlusion and those who need a hemodialysis catheter, catheter insertion can be reliably achieved immediately after endovascular recannalization with acceptable technical and long-term success rates. This technique should be considered as an alternative procedure for placing a new hemodialysis catheter through a patent vein.

High vancomycin resistance among biofilms produced by Staphylococcus species isolated from central venous catheters

Biofilm production is an important mechanism that allows microbes to escape host defences and antimicrobial therapy. Vancomycin has been used largely for the treatment of methicillin-resistant staphylococcal infections. Here, we determined the minimal inhibitory concentration (MIC) and minimal biofilm eradication concentration (MBEC) for 82 Staphylococcus species isolated from central venous catheters (CVC). Our results showed that the 41 strong and moderate-biofilm-producing isolates presented a higher MBEC/MIC ratio for vancomycin than the 24 weak-biofilm-producing isolates, illustrating the importance of biofilm production ability and the difficulty in treating biofilm-related infections. The MBEC was significantly higher in moderate-biofilm-producing isolates than in weak-biofilm-producing isolates (p < 0.001) and in strong-biofilm-producing isolates than in weak-biofilm-producing isolates (p = 0.001). The correlation between the MIC and the MBEC was poor. Based on our results, we recommend that bacterial biofilms be suspected in all cases of CVC infection.

Effectiveness of heparin versus 0.9% saline solution in maintaining the permeability of central venous catheters: a systematic review

Abstract OBJECTIVE Determining which is the most effective solution (heparin flush compared to 0.9% saline flush) for reducing the risk of occlusions in central venous catheters (CVC) in adults. METHOD The systematic review followed the principles proposed by the Cochrane Handbook; critical analysis, extraction and synthesis of data were performed by two independent researchers; statistical analysis was performed using the RevMan program 5.2.8. RESULTS Eight randomized controlled trials and one cohort study were included and the results of the meta-analysis showed no difference (RR=0.68, 95% CI=0.41-1.10; p=0.12). Analysis by subgroups showed that there was no difference in fully deployed CVC (RR=1.09, CI 95%=0.53-2.22;p=0.82); Multi-Lumen CVC showed beneficial effects in the heparin group (RR=0.53, CI 95%=0.29-0.95; p=0.03); in Double-Lumen CVC for hemodialysis (RR=1.18, CI 95%=0.08-17.82;p=0.90) and Peripherally inserted CVC (RR=0.14, CI 95%=0.01-2.60; p=0.19) also showed no difference. CONCLUSION Saline solution is sufficient for maintaining patency of the central venous catheter, preventing the risks associated with heparin administration.

Percutaneous central venous catheterization in premature infants: a method for facilitating insertion of silastic catheters via peripheral veins.

Peripheral venous cannulation is the preferred method of inserting central venous silastic catheters in premature infants. The standard techniques are placement of the catheter using a breakaway introducer needle or introduction of the catheter through a cannula. In extremely low birth weight infants (<1000 g) successful cannulation is impeded by the small size of the vessels. After repeated attempts, both procedures can be time-consuming and stressful to the infant. We present a modified insertion technique of the standard 2-French silastic catheter with an increased success rate, thus reducing insertion time, stress to the infant, and costs. The method uses the tip of a 20-gauge cannula as dilator/introducer for the 2-French catheter. This tip is inserted into the vessel with a standard 24-gauge cannula. After successful insertion of the dilator/introducer cannula, the standard 2-French catheter can then be advanced easily.

Initial and Extended Use of Femoral Versus Nonfemoral Double-Lumen Vascular Catheters and Catheter-Related Infection During Continuous Renal Replacement Therapy.

BACKGROUND: The risk of catheter-related infection or bacteremia, with initial and extended use of femoral versus nonfemoral sites for double-lumen vascular catheters (DLVCs) during continuous renal replacement therapy (CRRT), is unclear. STUDY DESIGN: Retrospective observational cohort study. SETTING & PARTICIPANTS: Critically ill patients on CRRT in a combined intensive care unit of a tertiary institution. FACTOR: Femoral versus nonfemoral venous DLVC placement. OUTCOMES: Catheter-related colonization (CRCOL) and bloodstream infection (CRBSI). MEASUREMENTS: CRCOL/CRBSI rates expressed per 1,000 catheter-days. RESULTS: We studied 458 patients (median age, 65 years; 60% males) and 647 DLVCs. Of 405 single-site only DLVC users, 82% versus 18% received exclusively 419 femoral versus 82 jugular or subclavian DLVCs, respectively. The corresponding DLVC indwelling duration was 6±4 versus 7±5 days (P=0.03). Corresponding CRCOL and CRBSI rates (per 1,000 catheter-days) were 9.7 versus 8.8 events (P=0.8) and 1.2 versus 3.5 events (P=0.3), respectively. Overall, 96 patients with extended CRRT received femoral-site insertion first with subsequent site change, including 53 femoral guidewire exchanges, 53 new femoral venipunctures, and 47 new jugular/subclavian sites. CRCOL and CRBSI rates were similar for all such approaches (P=0.7 and P=0.9, respectively). On multivariate analysis, CRCOL risk was higher in patients older than 65 years and weighing >90kg (ORs of 2.1 and 2.2, respectively; P<0.05). This association between higher weight and greater CRCOL risk was significant for femoral DLVCs, but not for nonfemoral sites. Other covariates, including initial or specific DLVC site, guidewire exchange versus new venipuncture, and primary versus secondary DLVC placement, did not significantly affect CRCOL rates. LIMITATIONS: Nonrandomized retrospective design and single-center evaluation. CONCLUSIONS: CRCOL and CRBSI rates in patients on CRRT are low and not influenced significantly by initial or serial femoral catheterizations with guidewire exchange or new venipuncture. CRCOL risk is higher in older and heavier patients, the latter especially so with femoral sites.

Catheterisation. Indwelling catheters in adults. Urethral and suprapubic. Evidence-based guidelines for best practice in urological health care

The EAUN Guidelines Working Group for indwelling catheters have prepared this guideline document to help nurses assess the evidence-based management of catheter care and to incorporate the guidelines’ recommendations into their clinical practice. These guidelines are not meant to be proscriptive, nor will adherence to these guidelines guarantee a successful outcome in all cases. Ultimately, decisions regarding care must be made on a case-by-case basis by healthcare professionals after consultation with their patients using their clinical judgement, knowledge and expertise.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care : a cluster randomised study

BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.