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Copyright of Nefrologia is the property of Revista Nefrologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: Central venous catheterization (CVC) carries inherent risks which can be mitigated through the use of appropriate ultrasound-guidance during needle insertion. This study aims to comprehensively understand patient anatomy as it is visualized during CVC by employing a semi-automated image analysis method to track the internal jugular vein and carotid artery throughout recorded ultrasound videos. Methods: The ultrasound visualization of 50 CVC procedures were recorded at Penn State Health Milton S. Hershey Medical Center. The developed algorithm was used to detect the vessel edges, calculating metrics such as area, position, and eccentricity. Results: Results show typical anatomical variations of the vein and artery, with the artery being more circular and posterior to the vein in most cases. Notably, two cases revealed atypical artery positions, emphasizing the algorithm's precision in detecting anomalies. Additionally, dynamic vessel properties were analyzed, with the vein compressing on average to 13.4% of its original size and the artery expanding by 13.2%. Conclusion: This study provides valuable insights which can be used to increase the accuracy of training simulations, thus enhancing medical education and procedural expertise. Furthermore, the novel approach of employing automated data analysis techniques to clinical recordings showcases the potential for continual assessment of patient anatomy, which could be useful in future advancements. [ABSTRACT FROM AUTHOR]

Copyright of Journal of the Japanese Society of Pediatric Surgery is the property of Japanese Society of Pediatric Surgeons and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Pediatric chronic intestinal failure (PIF) is a rare and heterogeneous condition characterized by the inability of the patient's intestine to adequately absorb the required fluids and/or nutrients for growth and homeostasis. As a result, patients will become dependent on home parenteral nutrition (HPN). A MEDLINE search was performed in May 2024 with keywords "intestinal failure", "parenteral nutrition" and "pediatric". Different underlying conditions which may result in PIF include short bowel syndrome, intestinal neuromuscular motility disorders and congenital enteropathies. Most common complications associated with HPN are catheter-related bloodstream infections, catheter-related thrombosis, intestinal failure-associated liver disease, small intestinal bacterial overgrowth, metabolic bone disease and renal impairment. Treatment for children with PIF has markedly improved with a great reduction in morbidity and mortality. Centralization of care in specialist centers and international collaboration between centers is paramount to further improve care for this vulnerable patient group. A recently promising medical therapy has become available for children with short bowel syndrome which includes glucagon-like peptide 2, a naturally occurring hormone which is known to delay gastric emptying and induce epithelial proliferation. Despite advances in curative and supportive treatment, further research is necessary to improve nutritional, pharmacological and surgical care and prevention of complications associated with parenteral nutrition use. [ABSTRACT FROM AUTHOR]

Purpose: Patients with intestinal failure (IF) require long-term parenteral nutrition using central venous catheters (CVCs), which often require replacement. We adopted a less fallible guidewire replacement (GWR) method and verified its effectiveness and validity. Methods: We enrolled 108 cases that underwent a CVC replacement with "GWR" method with IF at our department between 2013 and 2023. We retrospectively reviewed patients' clinical details with tunneled CVC (Hickman/Broviac catheter). For the analysis, we compared for the same time period the catheter exchange method "Primary placement"; newly inserted catheter by venipuncture. Results: The success rate of catheter replacement using GWR was 94.4%. There were six unsuccessful cases. A log-rank test showed no significant difference in catheter survival between primary placement and the GWR, and the time to first infection was significantly longer in the GWR (p = 0.001). Furthermore, no significant differences were observed between the two methods until the first infection, when the exchange indication was limited to infections. In the same way, when the indication was restricted to catheter-related bloodstream infection, there was no significant difference in catheter survival between the two approaches. Conclusion: Our GWR procedure was easy to perform and stable, with a high success rate and almost no complications. Moreover, using a guidewire did not increase the frequency of catheter replacement and the infection rate. [ABSTRACT FROM AUTHOR]

Introduction: Cannulation with a central venous catheter (CVC) is a common procedure used in critical care. One of the main complications is occlusion, which can lead to delayed treatment, prolonged hospital stay, and increased health care costs. Objective: The aim of this project was to promote evidence-based practice for nurses caring for patients with a CVC in a Spanish intensive care unit. The project also aimed to reduce CVC occlusion and ensure CVC patency. Methods: This project was guided by the JBI Model of Evidence-based Healthcare and the JBI Evidence Implementation Framework. Seven phases were followed using evidence-based auditing and feedback. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tools were used to support data collection, data analysis, and implementation planning. Results: After project implementation, the following results were obtained. Criterion 1 (assessing the CVC, flushing, and aspirating) reached 100% compliance in both audits. Criterion 2 (occlusion documentation) showed a modest improvement, rising from 13.33% to 36.67%. Improvement for Criterion 3 (the need for a policy and protocol) was excellent, rising from 0% at baseline to 100% following implementation. Criterion 4 (rapid instillation of an appropriate thrombolytic agent if a CVC is occluded) remained at 0% compliance in both audits. Criterion 5 (continuing education for health care professionals) improved from 10% to 60%. Criterion 6 (flushing and locking before procedures) improved from 90% to 100%. Conclusion: The project objectives were largely met and resulted in a protocol, which has been shared with other departments within the hospital. The implementation of best clinical practice will be continued, including the use of thrombolytic agents. [ABSTRACT FROM AUTHOR]

Background: Reported bleeding incidences following central venous catheter (CVC) placement highly depend on methods of bleeding assessment. To determine the direction and magnitude of the bias associated with retrospective data collection, we used data from the PACER randomized controlled trial and a previous retrospective cohort study. Study Design and Methods: A patient‐level comparison of CVC‐related bleeding severity was made among (1) the prospectively collected clinical bleeding assessment of the PACER trial, (2) centralized assessment of CVC insertion site photographs, and (3) retrospective chart review. Interrater reliability for photographic bleeding assessment and retrospective chart review was assessed using Cohen's κ. The magnitude of underreporting of both methods compared to prospective clinical bleeding assessment at different cutoff points of clinically relevant bleeding was assessed using McNemar's test. Results: Interrater reliability was acceptable for both methods (κ = 0.583 and κ = 0.481 for photographic assessment and retrospective chart review, respectively). Photographic bleeding assessment led to significant underreporting of bleeding complications at all cutoff points. Retrospective chart review led to significant underreporting of minor bleeding complications, with an odds ratio (95% CI) of 0.17 (0.044–0.51) for the cutoff point grade 1 (i.e., self‐limiting or requiring at most 20 min of manual compression) or higher. There was no significant underreporting of major bleeding complications with retrospective chart review. Discussion: Centralized photographic bleeding assessment and retrospective chart review lead to biased bleeding assessment compared to prospective clinical bleeding assessment. [ABSTRACT FROM AUTHOR]

Background: One of the main drawbacks of tunneled central venous catheters (CVCs) is catheter-related bloodstream infections (CRBSIs). Antibiotic lock therapy (ALT) can be combined with systemic antibiotics to achieve catheter salvage. Our objectives are to describe cases of CRBSI and our experience with ALT in a pediatric oncology–hematology ward. Methods: a retrospective descriptive study of pediatric CRBSI cases in a Spanish oncology–hematology unit from 2007 to 2017 was conducted. We collected demographic, clinical, and microbiological data from all patients. Results: fifty-eight CRBSIs were diagnosed in thirty-nine patients; 72.9% of these patients were male, with a median age of 42.1 months. The main underlying diseases were leukemia/lymphoma (51.7%) and solid tumors (32.7%). Thirty-five (60.3%) CRBSIs were caused by Gram-positive cocci, of which 70.6% were coagulase-negative Staphylococci, and sixteen (27.6%) were caused by Gram-negative bacilli. We treated 41/58 (71%) cases with ALT. A total of 12/17 (71%) CVCs that were not treated with adjunctive ALT were removed, compared with 13/41 (32%) that were treated with ALT (relative risk (RR), 0.449; confidence interval (CI), 95%: 0.259–0.778, p = 0.004). Major reasons to remove the CVC in the CRBSI-ALT group were local insertion/pocket site infection (23%), persistent symptoms (23%), and infectious' relapses (15%). Conclusions: ALT was shown to be an effective approach to keeping the CVC in place, with no added adverse effects. [ABSTRACT FROM AUTHOR]

SUMMARY: Central venous catheters (CVCs) are essential in modern healthcare but are associated with significant risks, particularly catheter-related bloodstream infections (CRBSIs). Current guidelines do not recommend routine replacement of CVCs based on time alone. However, recent evidence challenges this recommendation. A comprehensive literature review was conducted, focusing on studies exploring the risk-factors of short-term, non-hemodialysis CVCs, that were published in the last two decades while including seminal older works for context. The guidelines regarding scheduled CVC-replacement are not based on sufficiently convincing data. Current literature establishes the significance of CVC-duration as a major risk-factor for CRBSI occurrence, especially after 9–14 days of catheter-dwelling. The daily CRBSI risk is probably not constant, and the cumulative risk may reach high rates after 9–14 days, especially for femoral and jugular insertions compared to the subclavian site, suggesting potential benefits of scheduled CVC replacement, especially for non-subclavian catheters.

Introduction: Totally implantable venous access devices (TIVADs) offer significant advantages for long-term intravenous therapy, but their use is not without potential complications. Catheter migration is one of them. Case presentation: An 11-year-old boy with a primitive neuro-ectodermal tumor (PNET) undergoing chemotherapy was a candidate for a TIVAD placement. A TIVAD was implanted through the right internal jugular vein and secured to the pectoralis major in a right thoracic subcutaneous pouch without complications. Approximately six months later, port malfunction was noticed. Physical examination revealed that the port was no longer palpable, and a chest X-ray confirmed that the port was displaced. Subsequent chest X-rays showed different locations of the port and the catheter. With the hypothesis that the port had entered the pleural space and was moving freely, we did an exploratory thoracoscopy. We confirmed the intrapleural position of the port and catheter and removed both without complications. The patient was discharged four days later. Conclusion: Although rare, TIVADs can migrate from the chest wall into the pleural cavity. Frequent evaluation of their function and position is critical for the early detection of complications.

Chromosomal disorders manifest with multiple congenital anomalies, which is associated with high morbidity as well as mortality. Trisomy 18 also known as Edward’s syndrome is a rare chromosomal disorder. We report a case of Edwards’ syndrome in a 15-day-old female neonate, with typical syndromic features. Infant’s clinical condition was superimposed by respiratory distress, necessitating a comprehensive, multidisciplinary management involving neonatologist, anesthesiologists, and orthopedic specialists. Considering the intricacies of Edwards’ syndrome and hence contributing to refining protocol for enhanced care and meticulous support. Furthermore, emphasizes the requirement for further research to advance understanding of the clinical condition and propagate future management.

Subclavian artery injuries during internal jugular vein puncture when attempting central venous catheter insertion are rare. A 60-year-old man undergoing treatment for neuromyelitis optica with paralysis and sensory loss developed a complication during catheter placement into his right internal jugular vein for plasmapheresis. His previous physician felt resistance and discontinued the procedure. The patient later developed mild dyspnea and dysphagia. Computed tomography scans indicated thrombus formation and tracheal deviation. Contrast-enhanced computed tomography scans showed right subclavian artery injury with extravasation and a large pseudoaneurysm.Following transferal to our hospital, he was stable and asymptomatic; however, contrast-enhanced computed tomography scans showed a pseudoaneurysm located proximal to the right subclavian artery. Considering challenges with compression hemostasis and the invasiveness of open surgery, endovascular treatment was selected using a VIABAHN stent graft. A balloon occlusion test of the right vertebral artery was performed to assess stroke risk. Prophylactic embolization of the right vertebral artery, internal thoracic artery, and thyrocervical trunk were performed to prevent a type 2 endoleak. On hospital day 5, our patient showed no postoperative complications and was transferred to the referring hospital. Follow-up imaging showed the graft was intact with no pseudoaneurysm, confirming successful treatment. Endovascular treatment with a stent graft is highly effective for peripheral artery injuries. Using a balloon occlusion test to assess collateral blood flow and stroke risk is essential pretreatment, especially when a graft might occlude the vertebral artery. Balloon occlusion tests are recommended when planning treatment for iatrogenic and other types of subclavian artery injuries.

The Ralstonia species (RB) and Burkholderia species (BB) are bacteria responsible for nosocomial infections in frail patients such as hemodialyzed (HD) patients. Here, we report how we managed an outbreak caused by RB and BB that occurred in a dialysis unit. From the 7th to the 16th of April 2021, an infection due to RB and BB occurred in 7 out of 39 (17.9%) HD patients with central venous catheter (CVC). Disinfectants, CVC-lock therapy solutions, water by reverse osmosis unit (ROW) and dialysis concentrates were cultured, including the biofilm from the loading plastic tubes (LPTs) that connect the hemodialysis consoles (HCs) to the ROW delivery line. The antibiotic treatment was successful for all patients. RB and BB were isolated in the biofilm of 11/37 LPTs. Three out of 11 positive LPTs were associated with the infected patients. The ROW delivery line was modified to provide a whole disinfection with the HCs connected, avoiding the risk of new contamination of the LPTs. A filtration module of 0.01 mm was added prior to the ROW delivery line. Our experience suggests that outbreaks sustained by unusual bacteria such as RB and BB should be promptly investigated to treat the infected patients with the appropriate therapy and to identify the possible source of infection, making the needful changes to achieve a safer dialysis unit.

Resumen: Los dispositivos intravasculares son esenciales para el abordaje diagnóstico y terapéutico de múltiples enfermedades en pediatría, siendo especialmente importantes los catéteres venosos centrales (CVC). Una de las complicaciones más frecuentes es la infección de estos dispositivos, lo cual conlleva una elevada morbimortalidad. Estas infecciones presentan una gran complejidad, precisando de un elevado consumo de recursos, tanto para su diagnóstico como para su tratamiento, afectando de manera más frecuente a pacientes pediátricos vulnerables ingresados en unidades de alta complejidad. La evidencia para su abordaje en pediatría es menor que en adultos, y no hay documentos de consenso realizados en nuestro medio. El objetivo de este documento, realizado entre la Sociedad Española de Enfermedades Infecciosas Pediátricas (SEIP) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP), es dar recomendaciones de consenso basadas en la mayor evidencia disponible para optimizar el diagnóstico y tratamiento de las bacteriemias y fungemias relacionadas con el catéter. Este documento se centrará en pacientes pediátricos no neonatales, sin entrar en discusión sobre la prevención de estas infecciones. Abstract: Intravascular devices are essential for the diagnostic and therapeutic approach to multiple diseases in paediatrics, and central venous catheters (CVCs) are especially important. One of the most frequent complications of these devices is the infection, which is associated with a high morbidity and mortality. These infections are highly complex, requiring the use of substantial resources, both for their diagnosis and treatment, and affect vulnerable paediatric patients admitted to high-complexity units more frequently vulnerable. There is less evidence on their management in paediatric patients compared to adults, and no consensus documents on the subject have been published in Spain. The objective of this document, developed jointly by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Intensive Care (SECIP), is to provide consensus recommendations based on the greatest degree of evidence available to optimize the diagnosis and treatment of catheter-related bloodstream infections (CRBSIs). This document focuses on non-neonatal paediatric patients with CRBSIs and does not address the prevention of these infections.

Benjamin Palić,1,2 Marija Goluža Sesar,3 Kristina Galić,3 Gojko Bogdan,4 Zrinko Prskalo1 1Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina; 2Department of Pathophysiology, School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina; 3Department of Pulmonology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina; 4Department of Radiology, University Clinical Hospital Mostar, Mostar, Bosnia and HerzegovinaCorrespondence: Benjamin Palić, Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina, Email benjamin314palic@gmail.comAbstract: Guidewire loss is a rare complication of central venous catheterization. A 65-year-old male was hospitalized in a high-dependency unit for exacerbation of chronic obstructive pulmonary disease, pneumonia, erythrocytosis, and clinical signs of heart failure. Upon admission, after an unsuccessful right jugular approach, a left jugular central venous catheter was placed. The next day, chest radiography revealed the catheter located in the left parasternal region, with suspected retention of the guidewire, visually confirmed by the presence of its proximal end inside the catheter. The left parasternal location of the catheter and the typical projection of the guidewire in the coronary sinus, later confirmed by echocardiography, raised suspicion of a persistent left superior vena cava (PLSVC). Agitated saline injected into the left antecubital vein confirmed bubble entry from the coronary sinus into the right atrium. After clamping the guidewire, the catheter was carefully retrieved along with the guidewire without any complications. This is the first reported case of guidewire retention in PLSVC and coronary sinus. It underscores the potential causes of guidewire loss and advocates preventive measures to avoid this potentially fatal complication.Keywords: intraoperative complication, central venous catheter, persistent left superior vena cava, congestive heart failure, chronic obstructive lung disease

Abstract Background Maintaining venous access is of great clinical importance. Running a slow continuous infusion to keep the vein open (KVO) is often used in peripheral intravenous catheters (PIVCs). Previous studies have compared the effects of intermittent flushing and continuous infusion via peripherally inserted central catheters (PICCs). In this study, we applied KVO to central venous catheters (CVCs) and compared the occlusion rate of this technique with that of the intermittent flushing technique. Method This is a randomized controlled trial of 14 hospitals in China. A total of 250 patients will be recruited in this study, and they will be randomized at a 1:1 ratio. After study inclusion, patients who will undergo CVC insertion will receive intermittent flushing with prefilled saline syringes (control group) or KVO infusion with elastic pumps (test group). All the catheters will be checked for patency by scoping Catheter Injection and Aspiration (CINAS) Classification on Days 3 and 7. The primary outcome is the rate of catheter occlusion in 7 days. Patients will be followed up until 9 days after CVC insertion, catheter occlusion, or catheter removal. The secondary outcomes are the rate of catheter occlusion in 3 days, nurse satisfaction, cost-effectiveness, adverse event rate, catheter-related bloodstream infection rate, catheter-related thrombosis rate, extravasation rate, phlebitis rate, and catheter migration. Discussion We expect that the trial will generate findings that can provide an evidence-based basis for the improvement and optimization of clinical catheter flushing techniques. Trial registration Chinese Clinical Trial Registry, ChiCTR2200064007. Registered on 23 September 2022. https://www.chictr.org.cn/showproj.html?proj=177311 .

Abstract Background The aim of this experimental study was to elucidate whether different distances between central venous catheter tips can affect drug clearance during continuous renal replacement therapy (CRRT). Central venous catheters (CVCs) are widely used in intensive care patients for drug infusion. If a patient receives CRRT, a second central dialysis catheter (CDC) is required. Where to insert CVCs is directed by guidelines, but recommendations regarding how to place multiple catheters are scarce. There are indications that a drug infused in a CVC with the tip close to the tip of the CDC, could be directly aspirated into the dialysis machine, with a risk of increased clearance. However, studies on whether clearance is affected by different CVC and CDC tip positions, when the two catheters are in the same vessel, are few. Methods In this model with 18 piglets, gentamicin (GM) and vancomycin (VM) were infused through a CVC during CRRT. The CVC tip was placed in different positions in relation to the CDC tip from caudal, i.e., proximal to the heart, to cranial, i.e., distal to the heart. Serum and dialysate concentrations were sampled after approximately 30 min of CRRT at four different positions: when the CVC tip was 2 cm caudally (+ 2), at the same level (0), and at 2 (− 2) and 4 (− 4) cm cranially of the tip of the CDC. Clearance was calculated. A mixed linear model was performed, and level of significance was set to p

Background: Ultrasound has become the standard of care for the insertion of central venous catheters (CVCs) in the intensive care unit. With the introduction of ultrasonography in CVC insertion, there has been an improvement in the success rate and a dramatic decrease in the rate of complications. Aims and Objectives: The aim of this study was to compare the safety and ease of insertion of ultrasonically guided cannulation of the internal jugular vein (IJV) with that of the supraclavicular subclavian vein (SCV) in adult patients undergoing various surgical procedures. Materials and Methods: All the patients in whom central venous cannulation was planned were assigned to two groups. Group I underwent ultrasound-guided IJV while as Group II underwent cannulation ultrasound-guided SCV cannulation. A comparison was made between the two groups, of the success rates, durations of procedure, number of attempts at needle redirections, difficulties if any during insertion of guidewires, and the complications encountered. Results: The IJV group had a higher proportion of first-attempt success (93.2% versus 62.7%). The IJV group had a lesser incidence (3.2%) of complications such as guidewire progression and needle redirections compared with SCV (15.2%). The frequency of adverse events did not differ between the two study groups with an incidence in 3.2% in IJV group and 9.6% in the subclavian group. Higher first-attempt success rates and fewer procedural complications were seen with ultrasound-guided IJV. Conclusion: IJV central venous catheterization is an easier and less invasive and less risky procedure for patients.

Resumen: El desarrollo de derrames pleurales en el postoperatorio de pacientes sometidos a cirugía cardiaca es una complicación frecuente. Se han desarrollado diferentes sistemas de drenaje, entre los cuales, aquellos basados en el método Seldinger demuestran mayor seguridad y menor invasividad. La toracocentesis con catéter venoso central supone una maximización de estos aspectos, demostrándose eficaz en la evacuación de derrames pleurales en el contexto del postoperatorio de cirugía cardiaca. Describimos nuestra experiencia incorporando modificaciones técnicas al procedimiento con la utilización de aguja de Tuohy de 18 G para la punción. Abstract: Pleural effusions are frequent complications in the postoperative period of patients undergoing cardiac surgery. Different drainage systems have been developed, and those based on the Seldinger method demonstrate greater safety and less invasiveness. Thoracentesis with a central venous catheter maximizes these aspects, providing effective evacuation of pleural effusions in the postoperative period of cardiac surgery. We describe our experience adding technical modifications based on puncture with 18 G Tuohy needles.

Background: The significance of vascular access devices for patients in the emergency department (ED) is undeniable. When it comes to evaluating the effectiveness of interventions, randomised controlled trials (RCTs) stand out as the most reliable sources of evidence compared with other study designs. Aim: To explore and synthesise the findings from RCTs related to vascular access devices in the ED setting. Methods: A systematic search will be conducted in electronic medical databases including the Cochrane Central Register of Controlled Trials, Pubmed, CINAHL and Embase databases. All RCTs focusing on peripheral intravenous catheters, central venous catheters and intraosseous catheters, published in English and Chinese in peer-reviewed journals within the past decade, will be included. Conclusion: This scoping review will summarise the current state of evidence for vascular access devices in the ED setting. This will identify gaps in the literature and, in turn, assist clinicians and researchers in pinpointing areas for future exploration and provide a valuable guide for future research. [ABSTRACT FROM AUTHOR]

Introduction: Double vena cava is the most common thoracic abnormality and is mainly caused by persistence of the left superior vena cava and are usually described incidentally after placement of central venous accesses. Objective: Presentation of a clinical case where a double superior vena cava was identified after the placement of a Mahurkar-type catheter. Clinical case: A 54-year-old man was admitted to the nephrology department with a diagnosis of angioaccess-associated infection. Mahurkar catheter was placed without complications, atypical location was observed by chest X-ray, so CT angiography was requested suggestive images of left superior vena cava persistence with a central venous catheter inside are reported. Discussion: The identification of superior double vena cava in most cases occurs incidentally after the placement of a central venous access, after taking a plain chest x-ray where a persistent left superior vena cava can be observed, and it may be accompanied by other abnormalities. Conclusions: Knowing the possible vascular alterations helps prevent complications during procedures such as central venous catheter placement. [ABSTRACT FROM AUTHOR]

Background Cardiac tamponade is a life-threatening compression of the heart caused by the accumulation of fluid in the pericardial sac. Although central venous catheters (CVCs) are essential in modern medicine, they carry a certain risk of complications including cardiac tamponade. Case summary A 12-year-old female was involved in a road accident reporting multiple severe traumatic injuries, including a left humerus fracture and subdural haemorrhage. After 2 days in the intensive care unit, she suddenly developed hypotension and cardiac tamponade was diagnosed. Analysis of the pericardial fluid showed high glucose levels comparable to the parenteral nutrition that she was receiving. Retraction of the CVC allowed resolution of the effusion. Discussion Cardiac tamponade is a rare but serious adverse event after CVC insertion, mostly among younger patients. Awareness of this risk allows physicians to promptly recognize and treat this dangerous complication. [ABSTRACT FROM AUTHOR]

Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. Furthermore, waiting to initiate these medications until central access is obtained can lead to delays in care. Conversely, valid concerns remain regarding the risk of tissue extravasation associated with peripheral vasopressors, which can be life and limb threatening. We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers. [ABSTRACT FROM AUTHOR]

Background: The aim of this experimental study was to elucidate whether different distances between central venous catheter tips can affect drug clearance during continuous renal replacement therapy (CRRT). Central venous catheters (CVCs) are widely used in intensive care patients for drug infusion. If a patient receives CRRT, a second central dialysis catheter (CDC) is required. Where to insert CVCs is directed by guidelines, but recommendations regarding how to place multiple catheters are scarce. There are indications that a drug infused in a CVC with the tip close to the tip of the CDC, could be directly aspirated into the dialysis machine, with a risk of increased clearance. However, studies on whether clearance is affected by different CVC and CDC tip positions, when the two catheters are in the same vessel, are few. Methods: In this model with 18 piglets, gentamicin (GM) and vancomycin (VM) were infused through a CVC during CRRT. The CVC tip was placed in different positions in relation to the CDC tip from caudal, i.e., proximal to the heart, to cranial, i.e., distal to the heart. Serum and dialysate concentrations were sampled after approximately 30 min of CRRT at four different positions: when the CVC tip was 2 cm caudally (+ 2), at the same level (0), and at 2 (− 2) and 4 (− 4) cm cranially of the tip of the CDC. Clearance was calculated. A mixed linear model was performed, and level of significance was set to p < 0.05. Results: Clearance of GM had median values at + 2 cm, 0 cm, − 2 cm and − 4 cm of 17.3 (5.2), 18.6 (7.4), 20.0 (16.2) and 26.2 (12.2) ml/min, respectively (p = 0.04). Clearance of VM had median values at + 2 cm, 0 cm, − 2 cm and − 4 cm of 16.2 (4.5), 14.7 (4.9), 19.0 (10.2) and 21.2 (11.4) ml/min, respectively (p = 0.02). Conclusions: The distance between CVC and CDC tips can affect drug clearance during CRRT. A cranial versus a caudal tip position of the CVC in relation to the tip of the CDC led to the highest clearance. [ABSTRACT FROM AUTHOR]

Aims Design Data Sources Results Conclusion Implications for Patients Impact Patient or Public Contribution Paediatric patients with complex or acute conditions may require a central venous access device, however, almost one‐third of these devices have associated complications (e.g. infections). Implementation of evidence‐based practices regarding central venous access devices can reduce and potentially prevent complications.This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens.This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool.Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL).Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre‐post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health‐professional education, bundles and working groups. Bundle compliance and reductions in central line‐associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes.Translation of evidence‐based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from ‘quality improvement’) is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself.Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies.Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care.Adhered to best reporting guidelines as per PRISMA‐ScR (Tricco et al., 2018).No patient or public contribution. [ABSTRACT FROM AUTHOR]

Background There are no systematic measures of central line–associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA). Methods Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days. Results A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20–44 years, 11.2 [95% confidence interval, 1.46–86.22]; 45–64 years, 20.88 [2.84–153.58]; ≥65 years, 22.50 [2.98–169.93]) and lack of insurance (2.46 [1.08–5.59]), and it decreased with CVC removal (0.57 [.39–.84]). Conclusions CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings. [ABSTRACT FROM AUTHOR]

Background: Maintaining venous access is of great clinical importance. Running a slow continuous infusion to keep the vein open (KVO) is often used in peripheral intravenous catheters (PIVCs). Previous studies have compared the effects of intermittent flushing and continuous infusion via peripherally inserted central catheters (PICCs). In this study, we applied KVO to central venous catheters (CVCs) and compared the occlusion rate of this technique with that of the intermittent flushing technique. Method: This is a randomized controlled trial of 14 hospitals in China. A total of 250 patients will be recruited in this study, and they will be randomized at a 1:1 ratio. After study inclusion, patients who will undergo CVC insertion will receive intermittent flushing with prefilled saline syringes (control group) or KVO infusion with elastic pumps (test group). All the catheters will be checked for patency by scoping Catheter Injection and Aspiration (CINAS) Classification on Days 3 and 7. The primary outcome is the rate of catheter occlusion in 7 days. Patients will be followed up until 9 days after CVC insertion, catheter occlusion, or catheter removal. The secondary outcomes are the rate of catheter occlusion in 3 days, nurse satisfaction, cost-effectiveness, adverse event rate, catheter-related bloodstream infection rate, catheter-related thrombosis rate, extravasation rate, phlebitis rate, and catheter migration. Discussion: We expect that the trial will generate findings that can provide an evidence-based basis for the improvement and optimization of clinical catheter flushing techniques. Trial registration: Chinese Clinical Trial Registry, ChiCTR2200064007. Registered on 23 September 2022. . [ABSTRACT FROM AUTHOR]

La thrombose liée au cathéter (TLC) est une complication relativement fréquente et potentiellement fatale chez les patients atteints de cancer qui nécessitent la pose d'un cathéter central pour un traitement intraveineux. Malgré sa fréquence et son retentissement clinique, peu de données sont disponibles pour guider le diagnostic et le traitement de la TLC. Aucune étude diagnostique ni aucun essai clinique n'ont été menés chez des patients porteurs d'un cathéter veineux central (CVC) dans un contexte de cancer. De nombreuses questions concernant la prise en charge optimale de la TLC restent ainsi sans réponse. En raison de la rareté de données de haut niveau de preuve, les recommandations sont dérivées des études sur la thrombose veineuse profonde des membres supérieurs pour le diagnostic, et des membres inférieurs pour le traitement. Cet article aborde les questions du diagnostic et de la prise en charge de la TLC à travers une revue de la littérature disponible. Chez les patients symptomatiques, l'échographie veineuse est l'examen d'imagerie le plus approprié en première ligne pour le diagnostic de la TLC, étant non invasive et ayant une performance diagnostique élevée (ce qui n'est pas le cas chez les patients asymptomatiques). En l'absence d'essais cliniques comparatifs directs, nous suggérons de traiter les patients atteints de TLC avec une héparine de bas poids moléculaire (HBPM) à dose curative, ou un inhibiteur direct du facteur Xa par voie orale (DXI), avec ou sans dose de charge. Les anticoagulants doivent être administrés pendant une durée totale d'au moins 3 mois, dont au moins 1 mois après le retrait du cathéter. Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy. [ABSTRACT FROM AUTHOR]

Loss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. For this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDTs) were distinguished by Kaplan–Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDTs were compared. Overall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 "CVC-days"). Broviac type "B" was found to be significantly superior to type "A" regarding occlusion, CRI, and material defects (log-rank test: p = 0.05; p = 0.026; p = 0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 389 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. Different complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce. [ABSTRACT FROM AUTHOR]

This case concentrates on the persistent left superior vena cava (PLSVC), a rare vascular anomaly which contributes to central venous catheter (CVC) misplacement. A 72-year-old woman with renal insufficiency presented to the hospital with recurrent bleeding from her permanent CVC device placed in the right common jugular vein. An initial attempt to replace the device was unsuccessful, necessitating the placement of a secondary catheter in the left jugular vein. Shortly after the procedure, the patient developed swelling of the face and neck. Further diagnostic imaging, including a chest radiograph and computed tomography (CT), revealed CVC misplacement in the PLSVC and coronary sinus, thrombosis of the common jugular vein, and a posterior mediastinal hematoma. Conservative therapy of the mediastinal hematoma was implemented and proved effective in this case. A temporary CVC was inserted into the left femoral vein. Two months later, the catheter underwent further dysfunction and a decision was made to place a long-term permanent CVC via the right femoral vein. The patient is currently awaiting an arteriovenous fistula for dialysis use. This case emphasizes the importance of radiological techniques for CVC procedural placement, as well as the detection of congenital abnormalities. Providers regularly placing CVCs should have an in-depth knowledge of the possible complications and potential anatomical variations, especially as seen in high-risk patients. [ABSTRACT FROM AUTHOR]

Introduction and objectives: A central venous catheter (CVC)—a type of central venous access device (CVAD)—is the most common intervention for critical illnesses. Obstruction of the CVC can lead to fatal consequences. Thus, it is critical to maintain catheter lumen patency. The CVC occlusion rate in a hospital in Taiwan was 33%. This project aimed to decrease the CVC occlusion rate in acute care. Methods: This project was conceptually informed by the JBI Evidence-Based Model of Healthcare, in particular, the conceptualization of evidence implementation as inclusive of context analysis, implementation, and evaluation of outcomes using evidence-based quality indicators. As part of the seven-phase implementation process, we used audit and feedback in a pre- and post-test design to measure baseline compliance. Based on the initial audit, we developed an implementation strategy responsive to the identified gaps in compliance. We then undertook a final audit to measure changes in compliance to evaluate our implementation effects. The JBI software, PACES, and the situational analysis software, GRiP, were used for data collection and implementation planning. There were six evidence-based criteria, with a sample size of 30 nurses for each criterion. The team carried out the project from September 2022 to January 2023. Results: Post-implementation audit compliance rates increased to 100% for the following criteria: the organization had a standardized flushing and locking solution protocol (0%), the CVAD lumen was locked upon completion of the final flush (10%), a single-dose system was used for flushing and locking the CVAD (60%), and preservative-free 0.9% sodium chloride was used to flush the CVAD (60%). Furthermore, the CVC occlusion rate decreased from 33% to 5%. Conclusions: The project successfully decreased the rate of CVC occlusion and increased the competence of nurses in acute care settings. The implementation of best practices in clinical care should focus on leadership, cross-department coordination, education, and innovation. [ABSTRACT FROM AUTHOR]

Background: Unscheduled dressing changes for central venous lines (CVLs) have been shown to increase the risk of bloodstream infections. Objective: The objective of this study is to determine if the use of an innovative dressing change kit reduces the rate of unscheduled dressing changes. Methods: This pre–post interventional study took place at a large, academic, tertiary care center in metro Detroit, Michigan, the United States. We assessed the impact of the interventional dressing change procedure kit on the rate of unscheduled dressing changes for adult patients who underwent placement of a CVL inclusive of a central catheter, peripherally inserted central catheter, or hemodialysis catheter. Data was collected for the pre-intervention cohort through electronic health records (EHRs), while data for the post-intervention cohort were collected by direct observation by trained research staff in combination with EHR data. The primary outcome was the rate of unscheduled dressing changes. Secondary outcomes included rate of unscheduled dressing changes based on admission floor type, etiology of unscheduled dressing changes, and central line-associated bloodstream infections (CLABSIs). Results: The study included a convenience sample of 1548 CVLs placed between May 2018 and June 2022 with a matched analysis including 488 catheters in each of the pre- and post-intervention groups. The results showed that the unadjusted rate of unscheduled dressing evaluations was significantly reduced from the pre-intervention group (0.21 per day) to the post-intervention group (0.13 per day) (p <.001). The adjusted rate ratio demonstrated the same trend at 1.00 pre- and 0.60 post-intervention (p <.001). Stratifying the analysis based on the highest level of care showed that the intervention was effective in reducing the unadjusted rate of unscheduled dressing evaluations for both the advanced and regular medical floor subgroups pre- to post-intervention; the advanced subgroup had an reduction from 0.22 to 0.15 per day (p =.001), while the regular medical floor subgroup had a reduction from 0.21 to 0.09 per day (p <.001). CLABSIs were similar in both groups (0.6% vs 0.8%; p = 1.00) in pre- and post-intervention groups, respectively. Discussion: Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes and may have a role in reducing CLABSI. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed. [ABSTRACT FROM AUTHOR]

To evaluate the comparative effectiveness and cost-effectiveness of peripherally inserted central catheters (PICCs) compared with centrally inserted central catheters (CICCs). Prospective cohort study was followed by an economic analysis over a 30-day time horizon. Propensity score matching was used to select hospitalized adults with similar indications for PICC or CICC. The composite outcome was device removal or replacement because of complications before the end of treatment. The economic evaluation was based on a decision tree model for cost-effectiveness analysis, with calculation of the incremental cost-effectiveness ratio (ICER) per catheter removal avoided. All costs are presented in Brazilian reais (BRL) (1 BRL = 0.1870 US dollar). A total of 217 patients were followed in each group; 172 (79.3%) of those receiving a PICC and 135 (62.2%) of those receiving a CICC had no device-related complication, respectively. When comparing the events leading to device removal, the risk of composite endpoint was significantly higher in the CICC group (hazard ratio 0.20; 95% CI 0.11-0.35). The cost of PICC placement was BRL 1290.98 versus BRL 467.16 for a CICC. In the base case, the ICER for placing a PICC instead of a CICC was BRL 3349.91 per removal or replacement avoided. On univariate sensitivity analyses, the model proved to be robust within an ICER range of 2500.00 to 4800.00 BRL. PICC placement was associated with a lower risk of complications than CICC placement. Although the cost of a PICC is higher, its use avoided complications and need for catheter replacement before the end of treatment. • For hospitalized patients who need a central venous access device for up to 30 days, a centrally inserted central catheter (CICC) is most often placed; however, it has higher rates of primary bloodstream infection than other devices used for the same purpose, such as the peripherally inserted central catheter (PICC). • Despite the higher cost of these devices (PICC), there has been exponential growth in indications in the last decade, with corresponding financial impact on the health system, especially in publicly funded settings. • This study presents effectiveness and cost-effectiveness of 2 vascular devices (PICC versus CICC) carried out with primary data from a prospective cohort conducted in a public hospital; the CICC presented a greater need for replacement than the PICC. [ABSTRACT FROM AUTHOR]

It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups. Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses. We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32–2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38–3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16–2.99), and phlebitis (OR, 1.72; 95% CI, 1.27–2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39–3.04). Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications. [ABSTRACT FROM AUTHOR]

An in silico study is performed to investigate fluid dynamic effects of central venous catheter (CVC) placement within patient-specific cavo-atrial junctions. Prior studies show the CVC infusing a liquid, but this study focuses on the placement without any liquid emerging from the CVC. A 7 or 15-French double-lumen CVC is placed virtually in two patient-specific models; the CVC tip location is altered to understand its effect on the venous flow field. Results show that the CVC impact is trivial on flow in the superior vena cava when the catheter-to-vein ratio ranges from 0.15 to 0.33. Results further demonstrate that when the CVC tip is directly in the right atrium, flow vortices in the right atrium result in elevated wall shear stress near the tip hole. A recirculation region characterizes a spatially variable flow field inside the CVC side hole. Furthermore, flow stagnation is present near the internal side hole corners but an elevated wall shear stress near the curvature of the side hole's exit. These results suggest that optimal CVC tip location is within the superior vena cava, so as to lower the potential for platelet activation due to elevated shear stresses and that CVC geometry and location depth in the central vein significantly influences the local CVC fluid dynamics. A thrombosis model also shows thrombus formation at the side hole and tip hole. After modifying the catheter design, the hemodynamics change, which alter thrombus formation. Future studies are warranted to study CVC design and placement location in an effort to minimize CVC-induced thrombosis incidence. [ABSTRACT FROM AUTHOR]