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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.

ABSTRACT Central venous catheters (CVCs) are widely used for intravenous medication administration. However, biofilm formation along the catheter surface is the main most important cause of catheter-related bloodstream infections. Nowadays, several antimicrobial-coated catheters are available to prevent biofilm development. In this study, we introduced a new dynamic in vitro model to evaluate the antimicrobial activity against bacterial biofilms on CVCs. Rifampicin–minocycline-coated catheters and control catheters without antimicrobial component were assembled into the model to test the antimicrobial activity on external surface and internal surface. After 1 h irrigation of Staphylococcus epidermidis or Staphylococcus aureus preculture and 23 h irrigation of Trypticase Soy Broth, the viable adherent organism was collected and counted. The enumeration results showed that the number of bacteria attached to antibacterial catheter was significantly less than that of the control catheter, both on external surface (P < 0.05) and internal surface (P < 0.05). The results were further confirmed by the scanning electron microscopy. In conclusion, the dynamic in vitro model can be applied to evaluate the antimicrobial activity against bacterial biofilms grown on the external and internal surfaces of CVCs used in clinical practice.IMPORTANCEFor the first time, a new dynamic in vitro model was constructed to evaluate the antimicrobial activity against bacterial biofilms on central venous catheters (CVCs) on both external surface and internal surface. This model could be applied to evaluate the antimicrobial activity against bacterial biofilms not only on CVCs but also other types of catheters.

Case Presentation: We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein.Discussion: Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

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.

Abstract Background The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter. Case presentation A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications. Conclusions CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.

Introduction: Stuck tunneled central venous catheters (CVCs) have been increasingly reported. In rare cases, the impossibility of extracting the CVC from the central vein after regular traction is the result of rigid adhesions to the surrounding fibrin sheath. Forced traction during catheter removal can cause serious complications, including cardiac tamponade, hemothorax, and hemorrhagic shock. Knowledge and experience on how to properly manage the stuck catheter are still limited. Case Presentation: Here, we present two cases that highlight the successful removal of the stuck tunneled CVC via thoracotomy through the close collaboration of multidisciplinary specialists in the best possible way. Both patients underwent an unsuccessful attempt at thrombolytic therapy with urokinase, catheter traction under the guidance of digital subtraction angiography and intraluminal balloon dilation. And we reviewed the literature on stuck catheters in the hope of providing knowledge and effective approaches to attempted removal of stuck catheters. Conclusion: There is no standardized procedure for dealing with stuck catheters. Intraluminal percutaneous transluminal angioplasty should be considered as the first-line treatment, while open surgery represents a second option only in the event of failure. Care must be taken that forced extubation can cause patients life-threatening.

Jiewei Cui,1,&ast; Yang Li,2,&ast; Qingyan Du,3,&ast; Yuanhui Wei,1 Jinxia Liu,1 Zhixin Liang1 1College of Pulmonary & Critical Care Medicine, 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, People’s Republic of China; 2Department of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, 030001, People’s Republic of China; 3Jiamei Dental Hospital, Beijing, 100143, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Zhixin Liang, Email liangzhixin301@163.comObjective: Bloodstream infection (BSI) is characterized by high mortality, especially among these increasing super-elderly patients (≥ 85 years), and this study was conducted to understand the species distribution, typical clinical features and risk factors for poor prognosis of super-elderly patients with BSI.Methods: Based on previous work, this retrospective study was performed by reviewing an ongoing prospective medical database in a comprehensive tertiary center in China, and all super-elderly patients with BSI in the past 6 years were enrolled in this study.Results: Out of 5944 adult-patients with BSI, there were totally 431 super-elderly patients (≥ 85 years old) enrolled in this study and age ≥ 90 years accounted for 31.1% (134/431). Among these 431 super-elderly patients with BSI, 40 patients (9.3%) were diagnosed with BSI and the remained 401 super-elderly patients (90.7%) were defined as hospital-acquired BSI. The typical feature of these super-elderly patients with BSI was the high proportion of patients with various comorbidities, such as cardiovascular disease (83.8%), ischemic cerebrovascular disease (63.3%) and pulmonary infection (61.0%). The other typical feature was that most (60.1%) of these patients had been hospitalized for long time (≥ 28 days) prior to the onset of BSI, and most patients had received various invasive treatments, such as indwelling central venous catheter (53.1%) and indwelling urinary catheter (47.1%). Unfortunately, due to these adverse features above, both the 7-day short-term mortality (13.2%, 57/431) and the 30-day long-term mortality (24.8%, 107/431) were high. The multivariate analysis showed that both chronic liver failure (OR 7.9, 95% CI 2.3– 27.8, P=0.001) and indwelling urinary catheter (OR 2.3, 95% CI 1.1– 4.7, P=0.023) were independent risk factors for 7-day short-term mortality, but not for 30-day long-term mortality. In addition, the microbiology results showed that the most common species were associated with nosocomial infection or self-opportunistic infection, such as Staphylococcus hominis (18.3%), Staphylococcus epidermidis (11.8%), Escherichia coli (9.7%), Klebsiella pneumoniae (9.3%) and Candida albicans (8.6%, fungi).Conclusion: Super-elderly patients with BSI had typical features, regardless of the pathogenic species distribution and their drug resistance, or clinical features and their risk factors for poor prognosis. These typical features deserved attention and could be used for the prevention and treatment of BSI among super-elderly patients.Keywords: bloodstream infection, elderly, species, risk factor, mortality, aging, central venous catheter, clinical feature

In children, there are two main techniques for placing a tunneled central venous catheter: single-incision (single puncture) and conventional (two punctures). Both have unique advantages and disadvantages. The modified single-stick technique combines the two aforementioned techniques to access the central venous system in an optimized way. This technique is feasible to perform particularly in young children and has a short learning curve for adult interventional radiologists. [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]

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]

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]

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]

In acute promyelocytic leukemia (APL), hemorrhage, particularly intracranial hemorrhage, is the most common cause of early death. A central venous catheter (CVC) may provide a greater guarantee of safety and comfort to APL patients. However, CVCs have seldom been attempted in APL patients during induction therapy because of concerns about increasing the risk of hemorrhagic complications after this invasive procedure. To evaluate the hemorrhagic risk after CVC placement in APL patients during induction therapy, we retrospectively analyzed 95 newly diagnosed patients with APL from January 2010 to December 2022. Among these patients, 39 patients in the CVC group and 56 patients in the non-CVC group were included. Laboratory and clinical parameters of the two groups were collected and compared. There were no significant differences in median platelet, fibrinogen (Fbg), D-dimer, prothrombin time (PT), white blood count (WBC) and hemoglobin (Hb) between the CVC and non-CVC groups on the first day of the visit (day 0) and the following days (day 4, day 7, day 11, day 14, day 18 and day 21) (p = 0.382, p = 0.805, p = 0.456, p = 0.902, p = 0.901 and p = 0.097, respectively). The consumption of transfused platelets and Fbg was not significantly different between the CVC group and non-CVC group (5.0 vs. 4.5 units, p = 0.34, and 6.8 vs. 6.0, p = 0.36, respectively). The last day of platelet and Fbg transfusion was also not significantly different (21 vs. 19, p = 0.238 and 7.5 vs. 8.5, p = 0.684, respectively). The incidences of total hemorrhagic events and hemorrhagic death were lower in the CVC group than in the non-CVC group (17.9% vs. 37.5%, p = 0.04 and 0% vs. 16.1%, p = 0.01, respectively). The 30-day survival rate was not significantly different (92.3% vs. 82.1%, respectively, p = 0.145) for the CVC group compared with the non-CVC group. Our study suggested that CVCs did not increase the hemorrhagic risk in APL patients during induction therapy and that a CVC should be considered in this type of clinical situation. [ABSTRACT FROM AUTHOR]

Background: The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter. Case presentation: A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications. Conclusions: CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement. [ABSTRACT FROM AUTHOR]

Background: Patient quality of life is widely used as a non-clinical determinant of care. For patients undergoing hemodialysis, vascular access is vital to the delivery of hemodialysis and its function may affect not only the clinical outcome of treatment but also the overall quality of life of the patient, highlighting the need for increased efforts to improve the quality of hemodialysis vascular access care. The objective of this study was to evaluate the correlation between vascular access perception and quality of life in patients undergoing hemodialysis. Methods: A total of 202 patients with active hemodialysis vascular access were included in the study. Quality of life was assessed using the Kidney Disease Quality of Life Instrument (KDQOL™) questionnaire, while vascular access perception was evaluated using the Vascular Access Questionnaire (VAQ). Results: The study presented evidence on the influence of vascular access for hemodialysis patients on their quality of life. This impact is related to factors directly associated with vascular access, such as the type of access and the patient's subjective evaluation of the access. Conclusions: The perception of vascular access is one of the factors that determines the quality of life of hemodialysis patients. The quality of life of hemodialysis patients decreases as the number of vascular access-related problems increases. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement. Methods: All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post‐procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as 'any tip misplacement', 'minor tip misplacement' or 'major tip misplacement'. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements. Results: A total of 8556 central venous catheter insertions in 5587 patients were included. Real‐time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3–4.1)% of the catheterisations, and 2.1 (1.8–2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk. Conclusions: In this large prospective multicentre cohort study, performed in the ultrasound‐guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3–4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement. [ABSTRACT FROM AUTHOR]

Simulation is a technique to replace and amplify real experiences with guided ones that evoke or replicate substantial aspects of the real world in a fully interactive fashion. In nephrology (a particularly complex specialty), simulation can be used by patients, nurses, residents, and attending physicians alike. It allows one to learn techniques outside the stressful environment of care such as central venous catheter placement, arteriovenous fistula management, learning about peritoneal dialysis, or performing a kidney biopsy. Serious games and virtual reality are emerging methods that show promise. Simulation could also be important in relational aspects of working in a team or with the patient. The development of simulation as a teaching tool in nephrology allows for maintaining high-quality training for residents, tailored to their future practice, and minimizing risks for patients. Additionally, this education helps nephrologists maintain mastery of technical procedures, making the specialty attractive to younger generations. Unfortunately, the inclusion of simulation training programmes faces occasional logistical or funding limitations that universities must overcome with the assistance and innovation of teaching nephrologists. The impact of simulation-based teaching on clinical outcomes needs to be investigated in clinical studies. [ABSTRACT FROM AUTHOR]

The use of outpatient parenteral antimicrobial therapy (OPAT) for children has several advantages, including reduced length of hospital stay and costs. A reliable vascular access is key to delivering safe and effective pediatric OPAT. In recent years, midline catheters (MC) have been increasingly used for short-term intravenous antibiotic therapy in children. However, there are no studies investigating the use of MCs in the OPAT setting. The main aim of this paper was to evaluate the success and complications of using MCs for pediatric OPAT. This was a retrospective cohort study from a tertiary academic pediatric hospital. All MCs inserted at the hospital and used for OPAT were eligible for study inclusion. The primary objective was to describe the percentage of patients able to complete OPAT without the need for additional venous access. Forty-one MCs were included in the study. Patient mean (SD) age was 5.9 (4.9) years. In 31 cases (76%, 95% CI 62–86%), the iv therapy could be successfully completed using only the MC. Imbalances between the groups suggested unfavorable outcome for saphenous vein catheters as well as for shorter and smaller-sized catheters. Fourteen patients (34%) were subjected to a MC-related complication. Pain on injection in the MC was the most frequent complication (n = 10, 24%). Conclusion: Midline catheters could be an alternative to central venous access for pediatric OPAT. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase MC success rate. No severe MC-related complication was found. Further randomized studies comparing different catheter types are needed. What is Known: • For selected patients, pediatric outpatient parenteral antimicrobial therapy (OPAT) is safe and provides health-economic, psychosocial, and medical advantages compared to in-hospital care. • A reliable venous access is one of the key factors to the success of OPAT, but this can be a challenge in children. What is New: • Using midline catheters, 76% of patients could complete their intended iv therapy without the need for additional venous access. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase the success rate. • Thirty-four percent of catheters were subject to some kind of complication, the most common being pain on injection in the catheter. [ABSTRACT FROM AUTHOR]

Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement. How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality? This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P =.015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P =.002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P =.001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line. Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective To explore the application of healthcare failure mode and effect analysis (HFMEA) concept combined with refined nursing in improving the nursing quality of central venous catheter in the neurological intensive care unit (ICU). Methods A total of 312 patients admitted to ICU of neurology department of our hospital from January 2021 to August 2022 who received central venous catheter therapy were selected as study subjects and divided into the observation group and the control group according to the time of admission, with 156 cases in each group. The control group adopted the conventional nursing plan, and the observation group adopted the HFMEA concept combined with the refined nursing plan, The risk priority number(RPN), nursing quality and patients' satisfaction with nursing work were compared between the two groups. Results Compared with the control group, the RPN of health education [(109.20±13.04) points vs. (83.78±7.64) points], patient factor [(110, 44±12,60) points vs. (75.47±7.60) points],catheter factor [(93.57±12.78) points vs. (75.24±9.06) points], piping operation factors [(93.92±12.79) points vs. (70.75±7.78)points], punching and sealing operation [(82.26±9.25) points vs. (67.60±6.42) points], and post-piping management [(98.44±11.82) points vs. (69.99±6.84) points] was significantly decreased in the observation group (P<0.05). The the total score of nursing quality [(461,06±12.04) points vs. (478,32± 7.34) points were significantly increased(P<0.05), and the score of patients' satisfaction [(85.65±5.70) points vs. (90.83±5.03)points were also significantly increased(P<0.05). Conclusion HFMEA combined with refined nursing can significantly reduce the risk level in the process of central venous catheter nursing, improve the nursing quality and patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Port catheters facilitate the administration of chemotherapy, antibiotics, blood products, fluid and parenteral nutritional support to pediatric patients with hematological malignancies. However, as its use has become widespread, local, and systemic catheter-related infections have emerged as important causes of morbidity and mortality. In our study, we aimed to evaluate the success of antibiotic lock therapy in port catheter- related infections of pediatric patients followed up with acute leukemia. Methods: Port catheter cultures taken from a total of 182 pediatric patients with acute lymphoblastic/myeloblastic leukemia who were followed up at Ankara City Hospital Pediatric Hematology Clinic between August 2019 and August 2023 were evaluated retrospectively. Results: Bacterial growth was identified in 739 port catheter culture specimens of 182 patients. Closure or removal of the port was required in 91, and removal of the port catheters in 49 patients due to port catheter-related infections. Antibiotic lock therapy was started in 56 patients with bacterial growth in the port catheter. With antibiotic lock therapy, port catheter-related infections of 42 patients were eradicated, and their catheters began to be used again. As a result, the port catheter-related infections of 42 of 56 (75%) patients whose ports were closed and also received systemic antibiotherapy were eradicated, and no recurrence of infection was observed. Conclusion: Adding antibiotic lock therapy to systemic antibiotics in pediatric patients may be beneficial in terms of catheter salvage.

Background: Central venous catheter (CVC) thrombosis is one of the most common complications of CVC that occurs in children and adults. Prevention of this blockage improves the treatment process and reduces treatment costs. Due to the lack of studies on preventive methods of CVC thrombosis, this study aimed to examine the effect of NS flushing heparinized and prophylactic dose of enoxaparin in prevention of CVC induced thrombosis in hospitalized patients in pediatric intensive care unit (PICU). Methods: Eighty pediatrics with Central venous catheter admitted to the PICU enrolled in this trial and were divided into two groups as receiving heparinized normal saline was flushed every 8 hours under sterile conditions and receiving enoxaparin trough injection subcutaneously every 12 hours. The incidence of CVC-related thrombosis, diagnosed using color Doppler ultrasound of the vein containing the catheter was measured. Patients were monitored daily in terms of clinical symptoms related to thrombosis. Results: There was no statistically significant difference in gender, age, anthropometric findings and vital sign as well as risk factors between two groups of the trial (P>0.05). Additionally, the finding showed a statistically significant relationship between major surgery (P=0.01) and heart disease (P=0.03) with symptomatic and asymptomatic thrombosis between the enoxaparin and heparinized normal saline groups. The rate of sepsis and bleeding were lower in enoxaparin group but it was not significant between study groups. Conclusion: These findings indicate that enoxaparin may be considered as a clinical approach in thrombosis management and more clinical trials are needed.

This study assessed the microbial agents that cause CRBSIs and their antibiotic resistance patterns among patients with CVC undergoing maintenance haemodialysis. Patients undergoing maintenance haemodialysis (MHD) via CVC, at a tertiary hospital, between September 2021 to April 2022 were assessed in a cross-sectional study. Microbial cultures with respective antibiotic sensitivity patterns were determined for samples taken from blood, catheter insertion sites, catheters’ lumen, and tips. Antibiotic sensitivity patterns were determined using the disc diffusion methods.The culture positivity rate was 32.7% with a CRBSI prevalence rate of 34.2%. 47.1% of the bacteria cultured were Gram positive and 52.9% of the organisms cultured were Gram negative. Among the Gram positives, Coagulase negative Staphylococci (20.6%) was the most cultured organism, and these organisms were highly sensitive to vancomycin. Acinetobacter baumannii (17.6%) was the most common Gram negative organism isolated. All Gram negative organisms were susceptible to amikacin except for one resistant isolate of Acinetobacter baumannii.There is a high rate of antimicrobial resistance among patients on haemodialysis using CVCs. From the antibiogram, vancomycin and amikacin should be used as empiric antibiotics in treating CRBSIs among patients on MHD.

Abstract Background Central venous catheter (CVC) insertion using simulation is an essential skill for anesthesiologists. Simulation training is an effective mean to master this skill. Given the large number of residents and the limited duration of training sessions, the active practice time is limited and residents remain observers of their colleagues for much of the session. To improve learning during observation periods, the use of an observer tool (OT) has been advocated but its educational effectiveness is not well defined. Methods Incoming anesthesia residents were randomized to use an OT (i.e. procedural skill-based checklist) (OT+) or not (OT-) when observing other residents during a simulation bootcamp. The primary outcome was a composite score (total 60 points) evaluating CVC procedural skills rated immediately after the training. This score covers theoretical knowledge explored by multiple choice questions (MCQs) (/20), perceived improvement in knowledge and skills (/20), perceived impact on future professional life (/10) and satisfaction (/10). Measurements were repeated 1 month later. Residents in each group recorded the number of CVCs placed and their clinical outcomes (attempts, complications) during the first month of their clinical rotation using a logbook. Results Immediately after training, the composite score was similar between the two groups: 45.3 ± 4.2 (OT+, n = 49) and 44.4 ± 4.8 (OT-, n = 42) (p = 0.323). Analysis of sub-items also showed no difference. Results at 1 month were not different between groups. Analysis of the logbook showed no difference between groups. No serious complications were reported. Conclusions The use of a procedural task-based OT by incoming anesthesia residents and used during CVC insertion simulation training was not associated with better learning outcomes, neither immediately after the session nor when re-evaluated 1 month later. The training at least once on simulator of all residents could limit the impact of OT. Further studies are necessary to define the place of OT in simulation training.

Abstract Introduction Children may require durable central venous catheters (CVCs) for various reasons. CVC-related integrity complications are common and can often be repaired at the bedside to increase lifetime. Variability in repair techniques can lead to complications, including the need for repeat repair and Central Line Associated Blood Stream Infection (CLABSI). Methods The impact of an educational curriculum to standardize tunneled CVC repairs for trainees on a pediatric surgery service was studied, focusing on comfort level with tunneled CVC repair and to determine the impact on complication rates. Rotating trainees studied a dedicated audiovisual educational curriculum comprised of a video, educational slides, and a practical component from November 2020 through January 2022. Experience and comfort level with tunneled CVC repairs were assessed before and after the rotation. CVCs repaired during the duration of the study were evaluated and compared to the period prior. Results Forty-nine individuals completed the pre- and post-training survey. Respondents (34.7%, n = 17) most commonly reported one year of surgical experience, and (79.6%, n = 39) had never observed or assisted in a repair previously. Following training, respondents felt more comfortable with all aspects of the CVC repair process (p

While insertion of a central venous catheter (CVC) for intravascular access, diagnosis, and intensive care medical treatment is frequently needed in critically ill patients, retention of the guidewire used for CVC placement with Seldinger's technique is a very rare complication. In patients treated with extracorporeal membrane oxygenation (ECMO), significant negative pressures in the thoracal and abdominal venous system are generated by the venous ECMO drainage cannula. Therefore, during CVC placement in patients treated with ECMO, special vigilance is required because the significant negative pressures generated by the venous ECMO drainage cannula facilitate venous suction of an unsecured guidewire. [ABSTRACT FROM AUTHOR]