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Aim: To summarise and critique existing knowledge and evidence relating to the utility, and post‐insertion complications surrounding tunnelled non‐cuffed central venous catheters (tncCVCs) in infants. Methods: A scoping review of original research studies reporting the use of, and post‐insertion complications associated with, tncCVCs in infants was completed. MeSH terms were used to formulate a systematic search, and data were extracted using a customised data extraction form. Data were analysed descriptively across key themes based on the research questions. Study quality was evaluated using the Mixed Methods Appraisal Tool. Results: The systematic search generated 3994 studies, of which 9 studies met final inclusion criteria. Studies included 644 tncCVCs in infants based in the USA, Europe and Australia. Most studies were retrospective cohort studies. The most common vein of insertion, where individually specified, was the internal jugular (n = 177). Tunnel length, where reported, was 2.5–5 cm. Infection rates were most commonly reported (eight studies), with results ranging from 0 to 12.8%, and device dislodgements of up to 20% reported. Participant follow‐up and definition of complications varied greatly between studies. Study quality across all papers was sound. Conclusions: This review has identified only a small number of studies, with small participant numbers, reporting the performance of tncCVCs in infants. Definitions of complications measured varied significantly between studies, and vastly different patient follow‐up protocols were reported. Further larger‐scale studies on the performance of tncCVC, employing internationally recognised reporting standards is warranted to ensure clinicians can make informed choices for medication and infusion delivery. [ABSTRACT FROM AUTHOR]

Background: Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. Aims: The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. Methods: A prospective cross‐sectional web‐based survey was sent through email and CICM e‐newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post‐hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. Results: A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty‐five percent of the participants inserted 0–5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1‐year period. Two‐thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. Conclusion: The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU. [ABSTRACT FROM AUTHOR]

Aim: Central venous access devices (CVADs) are vital medical devices to support the treatment of paediatric cancer; however, device occlusion is common, which disrupts treatment. This study aimed to improve the identification and management of CVAD occlusions in children with cancer, as well as to identify the demographic, clinical and device characteristics associated with increased risk for CVAD occlusion. Methods: A pre–post‐implementation study was conducted at a metropolitan paediatric oncology facility in Australia, using the Theoretical Domains Framework. Patients with a CVAD for anti‐cancer therapy were prospectively followed for occlusive events pre‐ and post‐ the implementation of clinical resources to support the identification and management of CVAD occlusive events. CVAD occlusion and management data were collected and compared pre‐ and post‐implementation. Risk factors for CVAD occlusion were described by mixed‐effects Poisson regression and incident rate ratios (IRR). Results: A total of 133 CVADs were inserted into 131 patients for a total of 6784 catheter days. The incidence of CVAD‐related occlusion pre‐implementation was 59.7 (95% confidence interval (CI) 51.4–69.0, per 1000 catheter days); compared to 31.6 (95% CI 26.4–37.6); P < 0.01) post‐implementation of clinical resources. In multivariate models, other than post‐implementation phases (IRR 0.51 (95% CI 0.32–0.81)), only neutropaenia significantly increased the risk of CVAD occlusion (IRR 2.14 (95% CI 1.15–3.97)). Conclusion: CVAD occlusions in paediatric oncology are common. The development and implementation of CVAD occlusion resources to guide the identification and management of occlusive episodes led to a significant decrease in occlusive events. [ABSTRACT FROM AUTHOR]

Aim: To explore the current practices related to the insertion, management and removal of dialysis central venous catheters (CVCs) used in patients with chronic kidney disease requiring haemodialysis. Methods: This qualitative descriptive study involved semi‐structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal researchers involved in the care of patients with chronic kidney disease requiring haemodialysis. Data were collected from staff at eight hospitals in six states and territories of Australia. Thirty‐eight face‐to‐face interviews were conducted. A modified five‐step qualitative content analysis approach was used to analyse the data. Results: Improved visualization technology and its use by interventional radiologists has steered insertions to specialist teams in specialist locations. This is thought to have decreased risk and improved patient outcomes. Nurses were identified as the professional group responsible for maintaining catheter access integrity, preventing access failure and reducing access‐related complications. While best practice was considered important, justifications for variations in practice related to local patient and environment challenges were identified. Conclusion: The interdisciplinary team is central in the insertion, maintenance, removal and education of patients regarding dialysis CVCs. Clinicians temper research‐based decision‐making about central dialysis access catheter management with knowledge of individual, environmental and patient factors. Strategies to ensure guidelines are appropriately translated for use in a wide variety of settings are necessary for patient safety. Summary at a Glance: A semi‐structured interview study on the perspectives of clinicians on the management of central venous catheters in patients on dialysis. Multidisciplinary involvement in the insertion, maintenance and removal of catheters can support better management of central venous catheters for patients on dialysis. [ABSTRACT FROM AUTHOR]

Objective: To assess whether the initiation of vasopressor infusions via peripheral venous catheters (PVC) compared to central venous catheters (CVC) in ED patients with early septic shock was associated with differences in processes of care and outcomes. Methods: We conducted a post‐hoc analysis of the ARISE trial. We compared participants who had a vasopressor infusion first commenced via a PVC versus a CVC. The primary outcome was 90 day mortality. Results: We studied 937 participants. Of these, 389 (42%) had early vasopressor infusion commenced via a PVC and 548 (58%) via a CVC. Trial participants who received a vasopressor infusion via a PVC were more severely ill, with higher median (interquartile range [IQR]) Acute Physiology And Chronic Health Evaluation (APACHE II) scores (17 [13–23] versus 16 [12–21], P = 0.003), and higher median (IQR) lactate (mmol/L) (3.6 [1.9–5.8] versus 2.5 [1.5–4.5], P < 0.001). After adjusting for baseline covariates, the estimated odds ratio for mortality for PVC‐treated patients was 1.26 (95% confidence interval 0.95–1.67, P = 0.11). Trial participants who had vasopressors commenced via PVC had a shorter median (IQR) time to commencement of antimicrobials (55 [32–96] versus 71.5 [39–119] min, P < 0.001) and a shorter median (IQR) time to commencement of vasopressors (2.4 [1.3–3.9] versus 4.9 [3.5–6.6] h, P < 0.001). Conclusion: The practice of commencing a vasopressor infusion via a PVC was common in the ARISE trial and more frequent in trial participants with higher severity of illness. Commencement of a vasopressor infusion via a PVC was associated with some improvements in processes of care and, after adjustment, was not associated with an increased risk of death. [ABSTRACT FROM AUTHOR]

Aim: Dialysis catheter‐associated infections (CAI) are a serious and costly burden on patients and the health‐care system. Many approaches to minimizing catheter use and infection prophylaxis are available and the practice patterns in Australia and New Zealand are not known. We aimed to describe dialysis catheter management practices in dialysis units in Australia and New Zealand. Methods: Online survey comprising 52 questions, completed by representatives from dialysis units from both countries. Results: Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 79% of the dialysis population in both countries. Nephrologists (including trainees) inserted non‐tunnelled catheters at 60% and tunnelled catheters at 31% of units. Prophylactic antibiotics were given with catheter insertion at 21% of units. Heparin was the most common locking solution for both non‐tunnelled (77%) and tunnelled catheters (69%), with antimicrobial locks being predominant only in New Zealand (80%). Eight different combinations of exit site dressing were in use, with an antibiotic patch being most common (35%). All units in New Zealand and 84% of those in Australia undertook CAI surveillance. However, only 51% of those units were able to provide a figure for their most recent rate of catheter‐associated bacteraemia per 1000 catheter days. Conclusion: There is wide variation in current dialysis catheter management practice and CAI surveillance is suboptimal. Increased attention to the scope and quality of CAI surveillance is warranted and further evidence to guide infection prevention is required. SUMMARY AT A GLANCE: This study describes significant variability in management of dialysis catheters in Australia and New Zealand. The data presented might help renal units establish effective strategies for management of dialysis catheters. [ABSTRACT FROM AUTHOR]

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n = 84) in 2016 and a post-intervention audit (n = 84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph. [ABSTRACT FROM AUTHOR]

Background: Central venous access device (CVAD) associated complications are a preventable source of patient harm, frequently resulting in morbidity and delays to vital treatment. Dressing and securement products are used to prevent infectious and mechanical complications, however current complication rates suggest customary practices are inadequate. The aim of this study was to evaluate the feasibility of launching a full-scale randomized controlled efficacy trial of innovative dressing and securement products for pediatric tunneled CVAD to prevent complication and failure.Methods: An external, pilot, four-group randomized controlled trial of standard care (bordered polyurethane dressing and suture), in comparison to integrated securement-dressing, suture-less securement device, and tissue adhesive was undertaken across two large, tertiary referral pediatric hospitals in Australia. Forty-eight pediatric participants with newly inserted tunneled CVADs were consecutively recruited. The primary outcome of study feasibility was established by elements of eligibility, recruitment, attrition, protocol adherence, missing data, parent and healthcare staff satisfaction and acceptability, and effect size estimates for CVAD failure (cessation of function prior to completion of treatment) and complication (associated bloodstream infection, thrombosis, breakage, dislodgement or occlusion). Dressing integrity, product costs and site complications were also examined.Results: Protocol feasibility was established. CVAD failure was: 17% (2/12) integrated securement-dressing; 8% (1/13) suture-less securement device; 0% tissue adhesive (0/12); and, 0% standard care (0/11). CVAD complications were: 15% (2/13) suture-less securement device (CVAD associated bloodstream infection, and occlusion and partial dislodgement); 8% (1/12) integrated securement-dressing (partial dislodgement); 0% tissue adhesive (0/12); and, 0% standard care (0/11). One CVAD-associated bloodstream infection occurred, within the suture-less securement device group. Overall satisfaction was highest in the integrated securement-dressing (mean 8.5/10; standard deviation 1.2). Improved dressing integrity was evident in the intervention arms, with the integrated securement-dressing associated with prolonged time to first dressing change (mean days 3.5).Conclusions: Improving the security and dressing integrity of tunneled CVADs is likely to improve outcomes for pediatric patients. Further research is necessary to identify novel, effective CVAD securement to reduce complications, and provide reliable vascular access for children.Trial Registration: ACTRN12614000280606 ; prospectively registered on 17/03/2014. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Evidence based guidelines for home parenteral nutrition (HPN) were commissioned by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and developed by a multidisciplinary group. The guidelines make recommendations in four domains: patient selection, patient training, formulation and monitoring regimens, and preventing and managing complications. Methods: The Appraisal of Guidelines Research and Evaluation guideline process was used to focus questions and identify evidence by systematic literature reviews of meta-analyses and randomized control trials in the Cochrane Library, Medline, Embase, and Cinahl to mid-2007. Where no randomized control trial evidence was found, the search was broadened to observational studies and expert opinion from related national and international guidelines as assessed by a validated appraisal process. Results: Selection of patients must assess individual risk/benefit and medical ethics. Patient training should be undertaken within a structured framework. Access devices should be selected for lowest risk of complications, including occlusion, sepsis, and breakage and be managed by early diagnosis and treatment. HPN should be formulated according to individual patient requirements by professionals with relevant skills and training. Pumps and ancillary products should conform to quality standards. Other intravenous medications may be prescribed provided these are reviewed for compatibility and effects on metabolic status. Conclusion: Overall there is a lack of randomized control trials to provide high-quality evidence-based guidance but graded recommendations can be made. Multidisciplinary teams in centers with HPN management expertise are required for optimal care. This guideline should improve outcomes and quality of life for HPN patients in Australia and New Zealand. [Copyright &y& Elsevier]

The aim of this retrospective study was to analyse the outcomes of central venous catheter (CVC) placement carried out by an interventional radiology unit. A review of our hospital records identified 331 consecutive patients who underwent insertion of a tunnelled or non-tunnelled CVC between January 2000 and December 2004. Key outcome measures included the technical success rate of CVC insertion and the percentage of immediate (<24 h), early (24 h–30 days) and late (>30 days) complications. A total of 462 CVCs were placed under radiological guidance, with an overall success rate of 98.9%. Immediate complications included one pneumothorax, which was diagnosed 7 days after subclavian CVC insertion, and eight episodes of significant haematoma or bleeding within 24 h of CVC insertion. No cases were complicated by arterial puncture or air embolus. Catheter-related sepsis occurred in 2% of non-tunnelled CVC and 8.9% of tunnelled CVC. The overall incidence of catheter-related sepsis was 0.17 per 100 catheter days. As the demand for chemotherapy and haemodialysis grows with our ageing population, interventional radiology suites are well placed to provide a safe and reliable service for the placement of central venous access devices. [ABSTRACT FROM AUTHOR]

SUMMARY: The use of acute vascular access catheters (AVACs) has facilitated the delivery of haemodialysis to patients lacking functioning access. A review of the experience of a tertiary Australian renal treatment centre, consisting of 205 sequential AVACs in 93 patients, was undertaken over 1 year, to identify issues limiting technique survival. Acute vascular access catheters were inserted as acute dialysis access for patients with chronic renal failure (CRF; 21%), failed grafts or fistulae (18%), acute renal failure (12%), failed chronic ambulatory peritoneal dialysis (CAPD; 8%) or failed prior AVACs (37%). The majority of AVACs were on the right (74%), and the placement site was simple jugular (69%), tunnelled jugular (15%), femoral (12%), or subclavian (4%). During follow up, 198 of 205 AVACs were removed. The mean AVAC survival was superior (P < 0.0001, Fisher's protected least significant difference (PLSD) for tunnelled jugular AVACS (62 ± 46 (SD) days) compared with simple jugular (20 ± 19), subclavian (18 ± 13) and femoral (7 ± 6). Causes for AVAC removal were: elective (47%), blockage (31%), infection (20%) or cracked catheter (1%). Routine postremoval tip cultures grew coagulase negative Staphylococcus (CNS, 46%), negative culture (33%), methicillin-resistant Staphylococcus aureus (MRSA; 9%), Staphylococcus aureus (9%), Gram-negative rods (1%), Pseudomonas (0.5%) or other uncommon organisms (2%). Blood cultures were drawn through the AVAC in the setting of suspected bacteraemia in 42 of 198 AVACs. Blood cultures were negative in 40%. Positive cultures included Staphylococcus species in 55%: including MRSA (19%), Staphylococcus aureus (29%) and CNS (34%). Rare cultures identified Escherichia coli (2%) or Serratia (2%). Infection and blockage significantly reduced AVAC survival, affecting more than 50% of cases. Approaches to minimize these complications are likely to lead to improved clinical outcomes with AVAC use. [ABSTRACT FROM AUTHOR]

Introduction: Central venous catheters are often used in managing critically ill patients. Clinical practice guidelines and care bundles exist to prevent central line associated blood stream infections; however, detailed adherence to these guidelines and care bundles is unclear., Aim: This study was aimed to describe clinicians' adherence to recommended practices in central venous catheter insertion and management., Method: A cross-sectional prospective observational study was conducted in the intensive care unit of an Australian tertiary hospital over a four-month period. We observed a total of 50 nurses during post insertion management, and 10 physicians during central venous catheter insertion using purposely designed observation tools., Results: Our audit identified 90% adherence to recommended practices in central venous catheter insertion and 60% to post insertion management. However, there were areas where participants' practices were not congruent with evidence-based recommendations, including choice of central venous catheter insertion site, type of central venous catheters, dressing choice, aseptic technique, and documentation., Conclusion: Our audit showed a detailed picture of clinician's adherence to recommended practices in central venous catheter insertion and management. A clearer understanding of the barriers and facilitators of issues identified is needed to inform the design of future interventions to reduce central line related blood stream infections in the unit., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The epidemiology of central line-associated bloodstream infections (CLABSI) in Australian intensive care units (ICUs) has not previously been reported. We sought to describe time-trends in CLABSI rates, infections by ICU peer-groups, etiology, and antimicrobial susceptibility of pathogens in a large cohort of Australian ICUs for the period January 1, 2009-December 31, 2013., Methods: Using National Healthcare Safety Network methods, CLABSI surveillance in adult patients was performed by hospitals participating in the Victorian Healthcare Associated Infection Surveillance System (n = 29). Hospitals were grouped by location, sector, and teaching status., Results: Overall, 384 CLABSI events were reported over 303,968 central venous catheter (CVC)-days, corresponding to a rate of 1.26/1,000 CVC-days (95% confidence interval, 1.14-1.40). Every 1-year increase was associated with a 26% reduction in CLABSI risk (risk ratio, 0.74, 95% confidence interval, 0.69-0.80; P < .001). The most frequently identified pathogens were Enterococcus spp (26.3%), followed by Candida spp (15.4%) and Staphylococcus aureus (13.3%). CLABSI due to Enterococcus spp, S aureus, and coagulase-negative Staphylococcus spp displayed significant reductions over time., Conclusions: Internationally accepted surveillance methods have been employed in Australia, demonstrating CLABSI rates comparable to medical/surgical ICUs in the United States and a reduction in pathogen-specific infections over a 5-year period., (Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

A multimodal hospital-wide central line-associated bloodstream infection (CLABSI) risk reduction strategy was implemented over a 20-month period at an Australian center. Reduced CLABSI rates were observed in both intensive care units (ICUs) (incidence rate ratio [IRR], 0.39; P < .001) and non-ICU wards (IRR, 0.54; P < .001). The median time to CLABSI onset was 7.5 days for ICU events and 13 days for non-ICU events. The timing of infection demonstrates the need for more careful attention to postinsertion care and access of central venous catheters., (Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)