Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial.

BACKGROUND: Hickman-type tunnelled catheters (Hickman), peripherally inserted central catheters (PICCs), and totally implanted ports (PORTs) are used to deliver systemic anticancer treatment (SACT) via a central vein. We aimed to compare complication rates and costs of the three devices to establish acceptability, clinical effectiveness, and cost-effectiveness of the devices for patients receiving SACT. METHODS: We did an open-label, multicentre, randomised controlled trial (Cancer and Venous Access [CAVA]) of three central venous access devices: PICCs versus Hickman (non-inferiority; 10% margin); PORTs versus Hickman (superiority; 15% margin); and PORTs versus PICCs (superiority; 15% margin). Adults (aged ≥18 years) receiving SACT (≥12 weeks) for solid or haematological malignancy from 18 oncology units in the UK were included. Four randomisation options were available: Hickman versus PICCs versus PORTs (2:2:1), PICCs versus Hickman (1:1), PORTs versus Hickman (1:1), and PORTs versus PICCs (1:1). Randomisation was done using a minimisation algorithm stratifying by centre, body-mass index, type of cancer, device history, and treatment mode. The primary outcome was complication rate (composite of infection, venous thrombosis, pulmonary embolus, inability to aspirate blood, mechanical failure, and other) assessed until device removal, withdrawal from study, or 1-year follow-up. This study is registered with ISRCTN, ISRCTN44504648. FINDINGS: Between Nov 8, 2013, and Feb 28, 2018, of 2714 individuals screened for eligibility, 1061 were enrolled and randomly assigned, contributing to the relevant comparison or comparisons (PICC vs Hickman n=424, 212 [50%] on PICC and 212 [50%] on Hickman; PORT vs Hickman n=556, 253 [46%] on PORT and 303 [54%] on Hickman; and PORT vs PICC n=346, 147 [42%] on PORT and 199 [58%] on PICC). Similar complication rates were observed for PICCs (110 [52%] of 212) and Hickman (103 [49%] of 212). Although the observed difference was less than 10%, non-inferiority of PICCs was not confirmed (odds ratio [OR] 1·15 [95% CI 0·78-1·71]) potentially due to inadequate power. PORTs were superior to Hickman with a complication rate of 29% (73 of 253) versus 43% (131 of 303; OR 0·54 [95% CI 0·37-0·77]). PORTs were superior to PICCs with a complication rate of 32% (47 of 147) versus 47% (93 of 199; OR 0·52 [0·33-0·83]). INTERPRETATION: For most patients receiving SACT, PORTs are more effective and safer than both Hickman and PICCs. Our findings suggest that most patients receiving SACT for solid tumours should receive a PORT within the UK National Health Service. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.

Outcomes following out-of-hospital cardiac arrest: What is the potential for donation after circulatory death?

We conducted a prospective observational study on 100 consecutive patients admitted to intensive care units at Leeds General Infirmary following out-of-hospital cardiac arrest. In the non-survivors, we reviewed their potential for organ donation via donation after circulatory death. Out of the 100 patients, 53 did not survive to hospital discharge. Out of these non-survivors, 13 died very suddenly within the intensive care unit and 3 other patients subsequently died in a general ward following discharge from the intensive care unit. One patient became brainstem dead, with out-of-hospital cardiac arrest secondary to a subarachnoid haemorrhage, rather than a primary cardiac cause. This patient went on to donate via the brain death mode. The remaining 36 patients had treatment withdrawn in the intensive care unit. Of these, 29 were referred to the transplant team for potential donation after circulatory death, and 14 were deemed to be medically suitable for organ donation. However, the families of only seven agreed to proceed with the donation process. Of these seven, only one went on to donate, primarily because the majority did not die within the 3-h window for acceptable warm ischaemia. In this series, the potential for donation after circulatory death following out-of-hospital cardiac arrest was limited. We would suggest an open dialogue between intensive care unit staff and transplant teams about the realistic potential for organ donation in each case. When clinicians believe it is unlikely that donation after circulatory death will proceed due to a failure to die within the pre-requisite time, then not starting with the donation after circulatory death process should be seriously considered.

International evidence-based recommendations on ultrasound-guided vascular access.

PURPOSE: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. METHODS: An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. RESULTS: The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter's tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. CONCLUSIONS: These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Tracheostomy in critically ill patients.

Tracheostomy is performed in about a quarter of ICU patients requiring prolonged mechanical ventilation, weaning from assisted ventilation, airway suction and airway protection. Tracheostomy improves patient comfort compared with standard intubation. Tracheostomy performed early upon ICU admission has not shown survival benefits. Percutaneous dilatational techniques are commonly used because the procedure can be performed at the bedside. Surgical tracheostomy is often reserved for cases with abnormal anatomy or failed percutaneous tracheostomy. It is not known which of the percutaneous techniques is safer in terms of perioperative complications. Ultrasound scanning of the neck and routine endoscopy during the procedure appear to reduce early complications. Decannulation is often delayed and an intensivist-led follow-up may facilitate timely removal of tracheostomy tubes in step down areas or wards.

Outcome after admission to ITU following out-of-hospital cardiac arrest: are non-survivors suitable for non-heart-beating organ donation?

We have reviewed retrospective data from two large UK teaching hospitals regarding outcome following out-of-hospital cardiac arrest and the suitability of non-survivors for non-heart-beating organ donation. Patients were selected retrospectively from consecutive admissions from two intensive care units who had presented following out-of-hospital cardiac arrest, to a total of 50 patients in each centre. They had all been resuscitated to achieve a spontaneous cardiac output at the scene, in transit or after arrival in hospital, and required further intensive care support due to cardiovascular, respiratory, or neurological impairment. Eighty-six patients (86%) died in the Intensive Care Unit and only 14 (14%) survived to discharge from the Unit. A further nine (9%) patients died in hospital before discharge home. Four patients (4%) were alive after 6 months and three (3%) were alive after 1 year. Fifty-seven (57%) of patients had active withdrawal of treatment with only four (4%) being potentially suitable for organ procurement having not been excluded because of age, medical history or the length of time to die following withdrawal of treatment. Our results show that only a small increase in donor organs could be potentially achieved from this population. Further work is required to determine whether such patients should be considered as non-heart-beating donors.

Pumpless extracorporeal carbon dioxide removal for life-threatening asthma.

OBJECTIVE: To report the use of pumpless extracorporeal carbon dioxide removal in two cases of acute severe asthma. DESIGN: Case reports. SETTING: Adult general intensive care unit, Leeds General Infirmary, Leeds, UK. PATIENTS: A 74-yr-old male and 52-yr-old female with life-threatening asthma developed progressive hypercapnia and severe acidosis that proved nonresponsive to all other therapies. INTERVENTION: Initiation of extracorporeal arteriovenous carbon dioxide removal using the Novalung device (Novalung GmbH, Lotzenäcker 3, D-72379 Hechingen, Germany). MAIN RESULTS: The addition of extracorporeal carbon dioxide removal to mechanical ventilation corrected hypercapnia and acidosis, allowing reduction of other supportive measures. In both cases, adequate gas exchange was maintained until their underlying condition improved sufficiently for device removal. The two patients were subsequently weaned from mechanical ventilation and made a full recovery. CONCLUSIONS: Extracorporeal carbon dioxide removal proved to be a valuable adjunct to mechanical ventilation and other medical treatment.

Can you justify not using ultrasound guidance for central venous access?

Karakitsos and coworkers, in this journal, reported further compelling evidence on the value of ultrasound in guiding internal jugular vein catheterization. In a large, prospective, randomized study of 900 patients, comparisons were made between patients in whom the procedure was performed using landmark-based techniques and those assigned to ultrasound guidance. The key benefits from use of ultrasound included reduction in needle puncture time, increased overall success rate (100% versus 94%), reduction in carotid puncture (1% versus 11%), reduction in carotid haematoma (0.4% versus 8.4%), reduction in haemothorax (0% versus 1.7%), decreased pneumothorax (0% versus 2.4%) and reduction in catheter-related infection (10% versus 16%). The implications of these findings are discussed, and a compelling case for routine use of ultrasound to guide central venous access is made.