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Byline: Alfonso Perez-Parra (1,3), Patricia Munoz (1,2), Jesus Guinea (1,2), Pablo Martin-Rabadan (1), Maria Guembe (1), Emilio Bouza (1,2) Keywords: Central vascular catheters; Candidemia; Invasive candidiasis; Catheter tip colonization; Antifungal agents; Critically ill patients Abstract: Purpose To assess the influence of antifungal therapy on the outcome of non-candidemic adult patients with central vascular catheter (CVC) tips colonized by Candida species. Methods A retrospective analysis of the outcome of patients with Candida colonization of their CVC tip and no concurrent candidemia was made over a 4-year period. Patients who either died or developed candidemia-invasive candidiasis (poor outcome) were compared with those who improved. Results We finally included 58 patients for analysis. Almost all (91.4%) had to be admitted to the ICU during their hospital stay. Independent predictors for outcome were a McCabe and Jackson score corresponding to ultimately fatal underlying disease [odds ratio (OR) 11.98 95% confidence interval (CI), 1.37--104.97 P = 0.02], and maximum severity corresponding to severe sepsis, septic shock or multiorgan failure (OR: 6.16, CI 95%: 1.00--37.93 P = 0.05). We were unable to demonstrate that antifungal therapy was an independent variable influencing outcome (OR 0.82 95% CI, 0.27--2.47 P = 0.73). Conclusions Our data suggest that, in non-neutropenic critically ill patients with no concomitant candidemia and with CVC tips colonized by Candida, antifungal therapy does not seem to have a significant influence on clinical outcome. Author Affiliation: (1) Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Maranon, Universidad Complutense, Madrid, Spain (2) CIBER de Enfermedades Respiratorias (CIBER RES), CD06/06/0058, Palma de Mallorca, Spain (3) Servicio de Microbiologia Clinica y Enfermedades Infecciosas, Hospital General Universitario 'Gregorio Maranon', C/. Dr. Esquerdo, 46, 28007, Madrid, Spain Article History: Registration Date: 27/01/2009 Received Date: 18/07/2008 Accepted Date: 19/12/2008 Online Date: 11/02/2009 Article note: This article is discussed in the editorial available at: doi: 10.1007/s00134-009-1432-5.

Byline: Cristobal Leon (1), Sergio Ruiz-Santana (2), Jordi Rello (3), Maria V. Torre (4), Jordi Valles (5), Francisco Alvarez-Lerma (6), Rafael Sierra (7), Pedro Saavedra (8), Francisco Alvarez-Salgado (2) Keywords: Central venous catheters; Minocycline and rifampin-impregnated catheters; Non-impregnated catheters; Rate of colonization; Bloodstream infection; Clinical infectious complications Abstract: Objective To determine the efficacy of minocycline and rifampin-impregnated catheters compared to non-impregnated catheters in critically ill patients. Design Prospective, randomized, double-blind, controlled, multicenter trial. Setting Intensive care units of seven acute-care teaching hospitals in Spain. Patients Intensive care unit patients requiring triple-lumen central venous catheter for more than 3 days. Interventions At catheter insertion, 228 patients were randomized to minocycline and rifampin-impregnated catheters and 237 to non-impregnated catheters. Skin, catheter tip, subcutaneous segment, hub cultures, peripheral blood and infusate cultures were performed at catheter withdrawal. The rate of colonization, catheter-related bloodstream infection (CRBSI) and catheter-related clinical infectious complications (purulence at the insertion site or CRBSI) were assessed. Measurements and main results In the intention-to-treat analysis (primary analysis), the episodes per 1000 catheter days of clinical infectious complications decreased from 8.6 to 5.7 (RR =0.67, 95% CI 0.31--1.44), CRBSI from 5.9 to 3.1 (RR =0.53, 95% CI 0.2--1.44) and tip colonization from 24 to 10.4 (RR =0.43, 95% CI 0.26--0.73). Antimicrobial-impregnated catheters were associated with a significant decrease of coagulase-negative staphylococci colonization (RR =0.24, 95% CI 0.13--0.45) and a significant increase of Candida spp. colonization (RR =5.84, 95% CI 1.31--26.1). Conclusions The use of antimicrobial-impregnated catheters was associated with a significantly lower rate of coagulase-negative staphylococci colonization and a significant increase in Candida spp. colonization, although a decrease in CRBSI, increase in 30-day survival or reduced length of stay was not observed. Author Affiliation: (1) Intensive Care Unit, Hospital Universitario de Valme, Universidad de Sevilla, Carretera de Cadiz s/n, 41014, Sevilla, Spain (2) Intensive Care Unit, Hospital Universitario Dr. Negrin, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain (3) Intensive Care Unit, Hospital Universitari Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain (4) Intensive Care Unit, Hospital Ntra. Sra. de la Victoria, Malaga, Spain (5) Intensive Care Unit, Hospital Parc Tauli, Sabadell, Barcelona, Spain (6) Intensive Care Unit, Hospital Universitari del Mar , Universitat AutA2noma de Barcelona, Barcelona, Spain (7) Intensive Care Unit, Hospital Universitario Puerta del Mar, Universidad de Cadiz, Cadiz, Spain (8) Mathematics Department, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain Article History: Registration Date: 15/06/2004 Received Date: 02/10/2003 Accepted Date: 04/06/2004 Online Date: 20/07/2004 Article note: This study was supported by a grant from Cook Europe. Electronic Supplementary Material Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134-004-2378-2

Byline: J. Ferrari (3), H. Baumgartner (1), S. Tentschert (3), V. Dorda (3), W. Lang (3), A. Willfort-Ehringer (2), P. Probst (1), W. Lalouschek (3) Keywords: microembolism; congenital heart disease; transcatheter closure Abstract: Abstract. Background: Although transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has become a commonly performed intervention, the incidence of cerebral embolism with or without neurological deficits during such procedures has not been studied. Methods: We monitored the middle cerebral artery in two different depths (48 mm and 53 mm) by continuous transcranial Doppler ultrasound during transcatheter PFO closure in 35 consecutive patients (F/M 20/15, mean age 47 +- 11 years) and during ASD closure in 8 patients (F/M 7/1, mean age 45 +- 5 years). All automatically detected high intensity transient signals (HITS) were manually reviewed to eliminate artifacts. Results: HITS were detected in 33 of 35 patients (96%) with a median rate of 8 (interquartile range 4--19, range 2--29) HITS. The highest rates were observed when the septum was crossed with the guide wire (median 2 IQR 0--12 range 0--25) and when the left atrial disc was deployed (median 2 IQR 1--4 range 0--13). Despite this high rate of cerebral microembolism no clinically apparent neurological or neuropsychological deficit was observed. Conclusions: Silent cerebral embolism frequently occurs during transcatheter PFO and ASD closure. The peak of HITS at the time of crossing the septum with the guide wire may support the hypothesis that cerebral emboli in patients with PFO may originate from the septum itself. This may represent an alternative mechanism to the generally assumed paradoxical embolism. Author Affiliation: (1) Clinical Department of Cardiology, University of Vienna, Vienna (2) Clinical Department of Angiology, University of Vienna, Vienna (3) University Clinic of Neurology, Clinical Department for Clinical Neurology, Waehringer Guertel 18--20, 1097, Vienna, Austria Article History: Registration Date: 01/01/2004 Received Date: 09/09/2003 Accepted Date: 06/02/2004

Byline: Michael D. Klein (1), Kim Rood (1), Pam Graham (1) Keywords: CVC sepsis; Central venous catheter sepsis Abstract: We examined central venous catheter (CVC) sepsis in newborn surgical patients, as this group appeared to have a higher incidence of this complication. During a 3-year period 79 patients on the surgical service required a tunneled, cuffed, Broviac CVC. Nineteen patients (24% or 9.9 episodes per 1000 catheter days) had proven sepsis and 8 (10% or 1.9/1000 catheter days) had suspected sepsis. An intestinal stoma was definitely related to CVC sepsis (p&lt 0.001). Other risk factors included lower gestational age, more operations, and younger age at first stoma. Temperature, white blood cell (WBC) count, and platelet count did not correlate with CVC sepsis. We found no better indicator of CVC sepsis than the presentation of an ill child. Certainly temperature, WBC, and platelet count are not reliable indicators. Surgeons have little control over the factors that were found to be related to CVC sepsis. It would appear reasonable from these results to maintain a high index of suspicion in the high-risk groups, to use peripherally inserted central catheters (PIC lines) as the first line of long-term vascular access, and to bring CVCs out of a nonabdominal site, perhaps the scalp, in patients with stomas. Author Affiliation: (1) Departments of Surgery and Pediatric Surgery, Wayne State University School of Medicine and the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI , 48201, USA Article History: Accepted Date: 28/10/2002 Online Date: 02/08/2003

Byline: Kees H. Polderman (1), Armand R. Girbes (1) Keywords: Central venous catheters Mechanical complications Risk factors Location Material Preventive strategy Literature review Abstract: Central venous catheters are being increasingly used in both intensive care units and general wards. Their use is associated with both mechanical and infectious complications. This review will focus on short- and medium-term mechanical complications of catheter placement infectious complications will be discussed in a separate article. The most important risk factors are patient characteristics (morbidity, underlying disease and local anatomy), the expertise of the doctor performing the procedure, and nursing care. Placement aids, such as ultrasound-guided catheter insertion, are also discussed. Author Affiliation: (1) Department of Intensive Care, University Medical Centre, Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, The Netherlands Article History: Received Date: 20/08/2001 Accepted Date: 14/09/2001 Article note: Electronic Publication

Byline: K. Polderman (1), A. Girbes (1) Keywords: Central venous catheter Infectious complications Catheter-related bacteraemia Colonisation Catheter-related sepsis Preventive strategy Literature review Abstract: Central venous catheters (CVCs) are used with increasing frequency in the intensive care unit and in general medical wards. Catheter infection, the most frequent complication of CVC use, is associated with increased morbidity, mortality, and duration of hospital stay. Risk factors in the development of catheter colonisation and bloodstream infection include patient factors (increased risk associated with malignancy, neutropenia, and shock) and treatment-related factors (increased risk associated with total parenteral nutrition, ICU admission for any reason, and endotracheal intubation). Other risk factors are prolonged catheter indwelling time, lack of asepsis during CVC insertion, and frequent manipulation of the catheter. The most important factor is catheter care after placement. Effects of CVC tunnelling on infection rates depend to a large extent on indwelling time and the quality of catheter care. Use of polyurethane dressings can increase the risk of colonisation compared to regular gauze dressing. Thrombus formation around the CVC tip increases the risk of infection low-dose anticoagulants may decrease this risk. New developments such as CVC impregnation with antibiotics may reduce the risk of infection. Reducing catheter infection rates requires a multiple-strategy approach. Therefore, ICUs and other locations where CVCs are used should implement strict guidelines and protocols for catheter insertion, care, and maintenance. Author Affiliation: (1) Department of Intensive Care, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands Article History: Received Date: 20/08/2000 Accepted Date: 14/09/2001 Article note: Electronic Publication

Byline: N. C. Fisher (1), D. J. Mutimer (1) Keywords: Key words Central venous cannula; Liver diseases; Coagulopathy; Fresh frozen plasma Abstract: Objective: To determine the incidence of vascular complications associated with central venous cannulation in patients with liver disease and coagulopathy. Design: A prospective audit of all cannulation episodes in patients with liver disease and a prothrombin (INR) more than 1.5 and/or platelet count of 150 x 10.sup.9/l or less. Setting: A specialist liver unit between January 1996 and September 1997. Patients: Patients with acute or chronic liver diseases and patients undergoing liver transplantation or other hepatobiliary surgery. Measurements and results: Vascular complications of central venous cannulation were classified as major (any haemodynamically significant haemorrhage) or minor (superficial oozing or haematoma). We recorded 658 cannulations (subclavian, 352, and internal jugular, 306). The median INR was 2.4 (range 1--16) in the subclavian group and 2.7 (1--17) in the internal jugular group (p < 0.05) median platelet counts were 81 x 10.sup.9/l (range 9--1088) and 83 x 10.sup.9/l (10--425), respectively (difference not significant). One patient developed a haemothorax after accidental subclavian artery puncture (INR was 1.5, platelets 68 and regional prostacyclin therapy was being given for haemofiltration). There were no other major vascular complications. Risk factors for minor vascular complications included internal jugular cannulation, more than one needle pass into the vein, failure to pass any guidewire, a high INR and low platelets for haematoma formation, and low platelets and heparin therapy for superficial oozing. Conclusions: The incidence of major vascular complications following central venous cannulation in patients with liver disease and coagulopathy was low in this audit. In liver disease the presence of a raised INR alone should not be considered a contra-indication to central venous cannulation. Author Affiliation: (1) Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2TH, UK, GB Article note: Received: 18 September 1998 Final revision received: 4 January 1999 Accepted: 24 February 1999

Byline: R. Babu (1,3), A. Turner (2), G. Nicholls (1), R. D. Spicer (1) Keywords: Central venous catheter; Hickman catheter; Complications; Sepsis; Children Abstract: Catheter-related sepsis (CRS) is a major cause of morbidity in patients receiving chemotherapy and prolonged parenteral nutrition. To determine whether avoiding emergency insertions by using a planned elective list and adopting a 'no-touch' technique has a role in reducing CRS, all cuffed central venous catheters inserted by the open method between 1999 and 2000 were prospectively followed for a total duration of 12 months. The incidence of early sepsis (within 30 catheter days) that could be attributed to surgical factors was studied. CRS was defined as the presence of any two of the following: (1) signs of clinical sepsis without an obvious focus (2) positive cultures in blood obtained from the catheter and (3) clinical improvement following removal. A total of 146 catheters were inserted in 130 patients 15 had a second and 1 had a third catheter inserted. Early CRS was encountered in 13 cases (9%) 95 catheters were inserted on an elective list and 51 on an emergency basis. The distributions of age, sex, number of lumens, neutrophil count, and underlying diagnosis were similar between the groups. There was no significant difference (P = 1) between elective (9/95) and emergency (4/51) insertions. A total of 47 catheters were inserted by the 'no-touch' technique and 48 by the manual technique. There was no significant difference in early sepsis (P = 0.7) between the two techniques (6/47 vs 3/48). Thus avoiding emergency insertion or adopting a 'no-touch' technique does not reduce early CRS. Larger prospective studies are warranted to identify surgical risk factors. Author Affiliation: (1) Department of Paediatric Surgery, Royal Hospital for Sick Children, Bristol, BS2 8BJ, UK (2) Department of Microbiology, Royal Hospital for Sick Children, Bristol, BS2 8BJ, UK (3) 17, Heath mead, Heath, Cardiff, CF14 3PJ, UK Article History: Registration Date: 01/01/2002 Accepted Date: 08/11/2001 Online Date: 05/05/2004

Byline: Richeek. Pal, Baisakhi. Laha, Sabyasachi. Nandy, Rajasree. Biswas Sir, Central venous catheters (CVC) are traditionally used for access in the intensive care unit setting and in burn patients for [...]

Byline: S. K. Chowdhary (1), K. Parashar (1), R. G. Buick (1), P. Gornall (1), J. J. Corkery (1) Keywords: KeywordsaCentral venous line; Percutaneous sialastic long line Abstract: aA long Percutaneous silastic IV line is frequently used in surgical neonates for infusion of hyperosmolar parenteral nutrition fluid into a central vein for several days without the need for operative insertion of a Broviac catheter or risks of direct puncture of a central vein. Our study was aimed at auditing the performance of 125 consecutive lines over a 2-year period. During this period, insertion was attempted in 125 babies in 13 cases the line could not be inserted because of technical problems. The gestational ages varied between 25 and 41 weeks and weights between 630g and 4.2kg. Success did not appear to be related to the age or weight of the baby. The mean duration of complication-free performance was 22.4 days. There was a significant difference between the complication rate of lines inserted in the operating theatre versus those on the ward (P&lt 0.05). There was no significant increase in complications in lines used for over 4 weeks. The technique adopted by us for inserting these lines is likely to succeed in the majority of cases, including premature and small-for-dates babies. In our experience, lines inserted in the controlled theatre environment either before or after abdominal surgery performed better. The manufacturer's recommendation to electively change the line every 4 weeks needs further prospective evaluation. Author Affiliation: (1) Diana, Princess of Wales Children's Hospital, Steel House Lane, Birmingham B46NH, UK, GB (2) Department of Paediatric Surgery, Advanced Paediatric Centre, PGIMER, Chandigarh 160012, India, IN Article note: Accepted: 29 July 2000

Byline: Amitabh. Kumar, Kapil. Gupta, Shyam. Bhandari, Ram. Singh Sir, The central venous pressure (CVP) monitoring is a useful tool for assessment of the status of intravascular volume. Malpositioning of [...]

Byline: Gaurav. Tomar, Akhilesh. Tiwari, Darshan. Jain, Sonali. Chawla, Rohan. Sinha Introduction Central venous catheterization (CVC) via infraclavicular subclavian approach in neurosurgical patients is very common practice in view of [...]

Byline: Randeep. Kaur, Ashu. Mathai, John. Abraham Background: Central venous catheters (CVC) are associated with mechanical, infectious and thrombotic complications. Aims: To study (a) the incidence of mechanical and infectious [...]

Byline: Sumit. Kapadia, Rajiv. Parakh, Tarun. Grover, Ajay. Yadav Totally implantable venous devices (TIVD) are increasingly being utilized for venous access for chemotherapy of oncological patients. These devices considerably improve [...]