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Objectives We explored the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against central venous catheter-associated deep venous thrombosis in critically ill children. Design Post hoc analysis of a Bayesian phase 2b randomized clinical trial. Setting Seven PICUs. Patients Children less than 18 years old with newly inserted central venous catheter. Interventions Enoxaparin started less than 24 hours after insertion of central venous catheter and adjusted to anti-Xa level of 0.2-0.5 international units/mL versus usual care. Measurements and main results Of 51 children randomized, 24 were infants less than 1 year old. Risk ratios of central venous catheter-associated deep venous thrombosis with prophylaxis with enoxaparin were 0.98 (95% credible interval, 0.37-2.44) in infants and 0.24 (95% credible interval, 0.04-0.82) in older children greater than or equal to 1 year old. Infants and older children achieved anti-Xa level greater than or equal to 0.2 international units/mL at comparable times. While central venous catheter was in situ, endogenous thrombin potential, a measure of thrombin generation, was 223.21 nM.min (95% CI, 8.78-437.64 nM.min) lower in infants. Factor VIII activity, a driver of thrombin generation, was also lower in infants by 45.1% (95% CI, 15.7-74.4%). Median minimum platelet count while central venous catheter was in situ was higher in infants by 39 × 103/mm3 (interquartile range, 17-61 × 103/mm3). Central venous catheter:vein ratio was not statistically different. Prophylaxis with enoxaparin was less efficacious against central venous catheter-associated deep venous thrombosis at lower factor VIII activity and at higher platelet count. Conclusions The relatively lesser contribution of thrombin generation on central venous catheter-associated thrombus formation in critically ill infants potentially explains the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin.

Objectives We obtained preliminary evidence on the efficacy of early prophylaxis on the risk of central venous catheter-associated deep venous thrombosis and its effect on thrombin generation in critically ill children. Design Bayesian phase 2b randomized clinical trial. Setting Seven PICUs. Patients Children less than 18 years old with a newly inserted central venous catheter and at low risk of bleeding. Intervention Enoxaparin adjusted to anti-Xa level of 0.2-0.5 international units/mL started at less than 24 hours after insertion of central venous catheter (enoxaparin arm) versus usual care without placebo (usual care arm). Measurements and main results At the interim analysis, the proportion of central venous catheter-associated deep venous thrombosis on ultrasonography in the usual care arm, which was 54.2% of 24 children, was significantly higher than that previously reported. This resulted in misspecification of the preapproved Bayesian analysis, reversal of direction of treatment effect, and early termination of the randomized clinical trial. Nevertheless, with 30.4% of 23 children with central venous catheter-associated deep venous thrombosis on ultrasonography in the enoxaparin arm, risk ratio of central venous catheter-associated deep venous thrombosis was 0.55 (95% credible interval, 0.24-1.11). Including children without ultrasonography, clinically relevant central venous catheter-associated deep venous thrombosis developed in one of 27 children (3.7%) in the enoxaparin arm and seven of 24 (29.2%) in the usual care arm (p = 0.02). Clinically relevant bleeding developed in one child randomized to the enoxaparin arm. Response profile of endogenous thrombin potential, a measure of thrombin generation, was not statistically different between trial arms. Conclusions These findings suggest the efficacy and safety of early prophylaxis that should be validated in a pivotal randomized clinical trial.

Objectives Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU. Design Multicenter, cohort study. Setting One-hundred forty-eight participating Virtual PICU Systems, LLC hospital PICU sites. Patients Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015. Interventions None. Measurements and main results Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters. Conclusions Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

OBJECTIVE To identify prognostic factors for the development of venous thromboembolism in the ICU. DATA SOURCES We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception to March 1, 2021. STUDY SELECTION We included English-language studies describing prognostic factors associated with the development of venous thromboembolism among critically ill patients. DATA EXTRACTION Two authors performed data extraction and risk-of-bias assessment. We pooled adjusted odds ratios and adjusted hazard ratios for prognostic factors using random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach. DATA SYNTHESIS We included 39 observational cohort studies involving 729,477 patients. Patient factors with high or moderate certainty of association with increased odds of venous thromboembolism include older age (adjusted odds ratio, 1.15; 95% CI, 1.02-1.29 per 10 yr), obesity (adjusted odds ratio, 1.25; 95% CI, 1.18-1.32), active malignancy (adjusted odds ratio, 1.70; 95% CI, 1.18-2.44), history of venous thromboembolism (adjusted odds ratio, 4.77; 95% CI, 3.42-6.65), and history of recent surgery (adjusted odds ratio, 1.77; 95% CI, 1.26-2.47). ICU-specific factors with high or moderate certainty of association with increased risk of venous thromboembolism include sepsis (adjusted odds ratio, 1.41; 95% CI, 1.12-1.78), lack of pharmacologic venous thromboembolism prophylaxis (adjusted odds ratio, 1.80; 95% CI, 1.14-2.84), central venous catheter (adjusted odds ratio, 2.93; 95% CI, 1.98-4.34), invasive mechanical ventilation (adjusted odds ratio, 1.74; 95% CI, 1.36-2.24), and use of vasoactive medication (adjusted odds ratio, 1.86; 95% CI, 1.23-2.81). CONCLUSIONS This meta-analysis provides quantitative summaries of the association between patient-specific and ICU-related prognostic factors and the risk of venous thromboembolism in the ICU. These findings provide the foundation for the development of a venous thromboembolism risk stratification tool for critically ill patients.

Item does not contain fulltext OBJECTIVES: Decreasing morbidity and mortality by rationalizing drug treatment in the critically ill is of paramount importance but challenging as the underlying clinical condition may lead to large variation in drug disposition and response. New microtracer methodology is now available to gain knowledge on drug disposition in the intensive care. On the basis of studies in healthy adults, physicians tend to assume that oral doses of acetaminophen will be completely absorbed and therefore prescribe the same dose per kilogram for oral and IV administration. As the oral bioavailability of acetaminophen in critically ill children is unknown, we designed a microtracer study to shed a light on this issue. DESIGN: An innovative microtracer study design with population pharmacokinetics. SETTING: A tertiary referral PICU. PATIENTS: Stable critically ill children, 0-6 years old, and already receiving IV acetaminophen. INTERVENTIONS: Concomitant administration of an oral C radiolabeled acetaminophen microtracer (3 ng/kg) with IV acetaminophen treatment (15 mg/kg every 6 hr). MEASUREMENTS: Blood was drawn from an indwelling arterial or central venous catheter up to 24 hours after C acetaminophen microtracer administration. Acetaminophen concentrations were measured by liquid chromatography-mass spectrometry and C concentrations by accelerated mass spectrometry. MAIN RESULTS: In 47 patients (median age of 6.1 mo; Q1-Q3, 1.8-20 mo) the mean enteral bioavailability was 72% (range, 11-91%). With a standard dose (15 mg/kg 4 times daily), therapeutic steady-state concentrations were 2.5 times more likely to be reached with IV than with oral administration. CONCLUSIONS: Microtracer studies present a new opportunity to gain knowledge on drug disposition in the intensive care. Using this modality in children in the pediatric intensive care, we showed that enteral administration of acetaminophen results in less predictable exposure and higher likelihood of subtherapeutic blood concentration than does IV administration. IV dosing may be preferable to ensure adequate pain relief.

Selection of central venous catheter insertion site in ICU patients could help reduce catheter-related infections. Although subclavian was considered the most appropriate site, its preferential use in ICU patients is not generalized and questioned by contradicted meta-analysis results. In addition, conflicting data exist on alternative site selection whenever subclavian is contraindicated.To compare catheter-related bloodstream infection and colonization risk between the three sites (subclavian, internal jugular, and femoral) in adult ICU patients.We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, CINAHL, and ClinicalTrials.gov.Eligible studies were randomized controlled trials and observational ones.Extracted data were analyzed by pairwise and network meta-analysis.Twenty studies were included; 11 were observational, seven were randomized controlled trials for other outcomes, and two were randomized controlled trials for sites. We evaluated 18,554 central venous catheters: 9,331 from observational studies, 5,482 from randomized controlled trials for other outcomes, and 3,741 from randomized controlled trials for sites. Colonization risk was higher for internal jugular (relative risk, 2.25 [95% CI, 1.84-2.75]; I = 0%) and femoral (relative risk, 2.92 [95% CI, 2.11-4.04]; I = 24%), compared with subclavian. Catheter-related bloodstream infection risk was comparable for internal jugular and subclavian, higher for femoral than subclavian (relative risk, 2.44 [95% CI, 1.25-4.75]; I = 61%), and lower for internal jugular than femoral (relative risk, 0.55 [95% CI, 0.34-0.89]; I = 61%). When observational studies that did not control for baseline characteristics were excluded, catheter-related bloodstream infection risk was comparable between the sites.In ICU patients, internal jugular and subclavian may, similarly, decrease catheter-related bloodstream infection risk, when compared with femoral. Subclavian could be suggested as the most appropriate site, whenever colonization risk is considered and not, otherwise, contraindicated. Current evidence on catheter-related bloodstream infection femoral risk, compared with the other sites, is inconclusive.

Objective:We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.Data Sources:PubMed, Embase, Cochrane Central Register of Controlled Trials, r

OBJECTIVES In pediatric patients, indwelling peripheral venous catheters are sometimes displaced to extravascular positions, causing infiltration or extravasation. No reliable techniques are available to confirm accurate IV catheterization. However, ultrasonographic detection of micro-bubble turbulence in the right atrium after saline injection has been reported to be useful in confirming central venous catheter positions in both adults and children. This study evaluated whether this micro-bubble detection test can offer better confirmation of peripheral venous catheter positions compared with the smooth saline injection technique in pediatric patients. DESIGN Randomized controlled study. SETTING Single tertiary PICU. PATIENTS Pediatric patients (weighing < 15 kg) who already had or required a peripheral venous catheter. INTERVENTIONS Patients were randomly allocated to either of the two groups (150 patients per group): undergoing either the micro-bubble detection test (M group) or the smooth saline injection test (S group). MEASUREMENTS AND MAIN RESULTS The peripheral venous catheters were confirmed to be IV located in the final position in 137 and 139 patients in the M and S groups, respectively. In properly located catheters, the tests were positive in 100% (n = 137/137; sensitivity, 100%; 95% CI, 97.8-100), and in 89% (n = 124/139; 95% CI, 82.8-93.8) of the M and S groups, respectively (p = 0.0001). Among the catheters located in extravascular positions, the tests were negative in 100% (n = 13/13; specificity, 100%; 95% CI, 79.4-100), and in 64% (n = 7/11; 95% CI, 30.8-89.1) of the M and S groups, respectively (p = 0.017). CONCLUSIONS The micro-bubble detection test is a useful technique for detecting extravasation and confirming proper positioning of peripheral IV catheters in pediatric patients.

To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required.Cross-sectional internet-based survey with deliberate sampling.United States pediatric critical care medicine fellowship programs.Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs.None.A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important.Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors' abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.

Central venous catheter insertions may lead to preventable adverse events. Attending physicians' central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians' simulated central venous catheterinsertion performance to published competency standards.Prospective cohort study of attending physicians' simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training.Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago.A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents.None.Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians' simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents' baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents' internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p0.001).This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.Retrospective chart review.Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.None.Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

OBJECTIVES To evaluate whether a single-operator ultrasound-guided, right-sided, central venous catheter insertion verifies proper placement and shortens time to catheter utilization. DESIGN Prospective observational study with historical controls. SETTING Adult ICUs. PATIENTS Sixty-four consecutive patients undergoing ultrasound-assisted right-sided central venous catheterization compared with 92 serial historic controls who had unassisted central catheter insertion at the same sites. INTERVENTIONS Subcostal transthoracic echocardiography during catheter insertion. MEASUREMENTS AND MAIN RESULTS The primary outcome was the correct placement of the catheter tip determined by postprocedural chest radiography. The subclavian site was used in 41 patients (64%) (inserted without ultrasound guidance) in the ultrasound-assisted group and 62 (67%) in the control group, whereas the jugular vein was used in the remaining patients. The tip was accurately positioned in 59 of 68 patients (86.7%) in the ultrasound-assisted group compared with 51 of 94 (54.8%) in the control group (p < 0.001). The median time from end of the procedure to catheter utilization after chest radiography approval was 2.4 hours. CONCLUSIONS A single-operator ultrasound-guided central venous catheter insertion is effective in verifying proper tip placement and shortens time to catheter utilization.

Although real-time ultrasound guidance during central venous catheter insertion has become a standard of care, postinsertion chest radiograph remains the gold standard to confirm central venous catheter tip position and rule out associated lung complications like pneumothorax. We hypothesize that a combination of transthoracic echocardiography and lung ultrasound is noninferior to chest radiograph when used to accurately assess central venous catheter positioning and screen for pneumothorax.All operating rooms and surgical and trauma ICUs at the institution.Single-center, prospective noninferiority study.Patients receiving ultrasound-guided subclavian or internal jugular central venous catheters.During ultrasound-guided central venous catheter placement, correct positioning of central venous catheter was accomplished by real-time visualization of the guide wire and positive right atrial swirl sign using the subcostal four-chamber view. After insertion, pneumothorax was ruled out by the presence of lung sliding and seashore sign on M-mode.Data analysis was done for 137 patients. Chest radiograph ruled out pneumothorax in 137 of 137 patients (100%). Lung ultrasound was performed in 123 of 137 patients and successfully screened for pneumothorax in 123 of 123 (100%). Chest radiograph approximated accurate catheter tip position in 136 of 137 patients (99.3%). Adequate subcostal four-chamber views could not be obtained in 13 patients. Accurate positioning of central venous catheter with ultrasound was then confirmed in 121 of 124 patients (97.6%) as described previously.Transthoracic echocardiography and lung ultrasound are noninferior to chest x-ray for screening of pneumothorax and accurate central venous catheter positioning. Thus, the point of care use of ultrasound can reduce central venous catheter insertion to use time, exposure to radiation, and improve patient safety.

To report procedural characteristics and outcomes from a central venous catheter placement service operated by advanced practice nurses.Single-center observational study.A tertiary care university hospital in Sydney, Australia.Adult patients from the general wards and from critical care areas receiving a central venous catheter, peripherally inserted central catheter, high-flow dialysis catheter, or midline catheter for parenteral therapy between November 1996 and December 2009.None.Prevalence rates by indication, site, and catheter type were assessed. Nonparametric tests were used to calculate differences in outcomes for categorical data. Catheter infection rates were determined per 1,000 catheter days after derivation of the denominator. A total of 4,560 catheters were placed in 3,447 patients. The most common catheters inserted were single-lumen peripherally inserted central catheters (n = 1,653; 36.3%) and single-lumen central venous catheters (n = 1,233; 27.0%). A small proportion of high-flow dialysis catheters were also inserted over the reporting period (n = 150; 3.5%). Sixty-one percent of all catheters placed were for antibiotic administration. The median device dwell time (in d) differed across cannulation sites (p0.001). Subclavian catheter placement had the longest dwell time with a median of 16 days (interquartile range, 8-26 d). Overall catheter dwell was reported at a cumulative 63,071 catheter days. The overall catheter-related bloodstream infection rate was 0.2 per 1,000 catheter days. The prevalence rate of pneumothorax recorded was 0.4%, and accidental arterial puncture (simple puncture-with no dilation or cannulation) was 1.3% using the subclavian vein.This report has demonstrated low complication rates for a hospital-wide service delivered by advance practice nurses. The results suggest that a centrally based service with specifically trained operators can be beneficial by potentially improving patient safety and promoting organizational efficiencies.

OBJECTIVE:: To determine the most accurate predictor of central venous pressure among three point-of-care venous ultrasound techniques. DESIGN:: Cross-sectional study. SETTING:: Medical ICU in an academic medical center. PATIENTS:: Convenience sample of 67 spontaneously breathing patients who had an intrathoracic central venous catheter to allow measurement of central venous pressure. INTERVENTION:: Measurement of the internal jugular vein height to width ratio (aspect ratio), the inferior vena cava diameter, and the percent collapse of the inferior vena cava with inspiration (collapsibility index) by ultrasound. MEASUREMENTS AND MAIN RESULTS:: Complete data for analysis were available in 65 patients, as the inferior vena cava could not be visualized in two patients. A central venous pressure of 10 mm Hg was chosen a priori as a clinically significant cutoff. The range of central venous pressure values was 1-23 mm Hg with a median value of 7 mm Hg. The maximal inferior vena cava diameter correlated moderately with central venous pressure (R = 0.58), whereas the inferior vena cava collapsibility index and the internal jugular vein aspect ratio showed poor correlation (R = 0.16 and 0.21, respectively). The area under the receiver operating characteristics curve (area under the curve) to discriminate a low central venous pressure (< 10 mm Hg) was 0.91 for inferior vena cava diameter (95% confidence interval 0.84-0.98), which was significantly higher than the internal jugular vein aspect ratio (area under the curve 0.76; 95% confidence interval 0.65-0.89) or the inferior vena cava collapsibility index (area under the curve 0.66; 95% confidence interval 0.51-0.80) (p = 0.0001). An inferior vena cava diameter < 2 cm predicted a central venous pressure < 10 mm Hg with a sensitivity of 85% (95% confidence interval 69% to 94%), specificity of 81% (95% confidence interval 60% to 93%), and positive predictive value of 87% (95% confidence interval 71% to 95%). Inferior vena cava collapsibility index was not an independent predictor of central venous pressure after adjusting for inferior vena cava diameter in a multiple linear regression model. CONCLUSION:: Among spontaneously breathing patients largely without vasopressor support, the maximal inferior vena cava diameter is a more robust estimate of central venous pressure than the inferior vena cava collapsibility index or the internal jugular vein aspect ratio.

To compare heparin (3 mL, 10 units/mL) and 0.9% sodium chloride (NaCl, 10 mL) flush solutions with respect to central venous catheter lumen patency.Single-center, randomized, open label trial.Medical intensive care unit and Surgical/Burn/Trauma intensive care unit at Barnes-Jewish Hospital, St. Louis, MO.Three hundred forty-one patients with multilumen central venous catheters. Patients with at least one lumen with a minimum of two flushes were included in the analysis.Patients were randomly assigned within 12 hrs of central venous catheter insertion to receive either heparin or 0.9% sodium chloride flush.The primary outcome was lumen nonpatency. Secondary outcomes included the rates of loss of blood return, inability to infuse or flush through the lumen (flush failure), heparin-induced thrombocytopenia, and catheter-related blood stream infection. Assessment for patency was performed every 8 hrs in lumens without continuous infusions for the duration of catheter placement or discharge from intensive care unit. Three hundred twenty-six central venous catheters were studied yielding 709 lumens for analysis. The nonpatency rate was 3.8% in the heparin group (n = 314) and 6.3% in the 0.9% sodium chloride group (n = 395) (relative risk 1.66, 95% confidence interval 0.86-3.22, p = .136). The Kaplan-Meier analysis for time to first patency loss was not significantly different (log rank = 0.093) between groups. The rates of loss of blood return and flush failure were similar between the heparin and 0.9% sodium chloride groups. Pressure-injectable central venous catheters had significantly greater rates of nonpatency (10.6% vs. 4.3%, p = .001) and loss of blood return (37.0% vs. 18.8%, p.001) compared to nonpressure-injectable catheters. The frequencies of heparin-induced thrombocytopenia and catheter-related blood stream infection were similar between groups.0.9% sodium chloride and heparin flushing solutions have similar rates of lumen nonpatency. Given potential safety concerns with the use of heparin, 0.9% sodium chloride may be the preferred flushing solution for short-term use central venous catheter maintenance.

Catheter-related bloodstream infection is the greatest threat to the safety of patients on hemodialysis. Catheter lock solutions containing heparin have been linked to an increased risk of hemorrhage and thrombocytopenia.To ascertain the safety and efficacy for prevention of catheter-related bloodstream infection and catheter loss from patency failure of a novel catheter lock solution with antimicrobial and antithrombotic activity containing 0.24 M (7.0%) sodium citrate, 0.15% methylene blue, 0.15% methylparaben, and 0.015% propylparaben (C-MB-P), compared with heparin.Multicenter, prospective, randomized, open-label trial with patients studied for up to 6 months. An independent clinical evaluation committee assessing trial outcomes was blinded to patients' treatment assignments.Twenty-five outpatient hemodialysis units.Patients with end-stage renal disease receiving maintenance hemodialysis through a percutaneous cuffed and tunneled internal jugular hemodialysis catheters.Participants' catheters were locked between hemodialysis sessions with the C-MB-P lock solution or sterile saline containing 5000 units of unfractionated heparin (control).We recorded and evaluated catheter-related bloodstream infections, catheter loss attributable to luminal thrombosis, and adverse events. A total of 407 patients participated in the trial (49,565 catheter days), 201 in the C-MB-P group and 206 in the heparin group. Patients in the two lock solution groups were comparable for risk factors predisposing to catheter-related bloodstream infection. Catheters locked with C-MB-P were significantly less likely to cause catheter-related bloodstream infection (0.24 vs. 0.82 per 1000 catheter days; relative risk, 0.29; 95% confidence interval, 0.12-0.70; p = .005) and were less likely to be lost because of patency failure (0 vs. 4; log rank, p = .04).The novel C-MB-P lock solution is well tolerated, significantly reduces the risk of catheter-related bloodstream infection, and provides protection comparable to heparin against patency failure.