ABSTRACT
OBJECTIVE: To evaluate, in critically ill children, the safety and effectiveness of routine central venous catheterisations (CVCs) performed by residents from all disciplines. DESIGN: Prospective audit of all CVCs over a 24-month period. SETTING: Multidisciplinary intensive care unit at Baragwanath Hospital, Soweto. PATIENTS: All critically ill patients 12 years of age or younger requiring CVC. All percutaneous sites (subclavian, internal jugular and femoral) were used; these were selected by the attending doctor and not influenced by the audit. RESULTS: There were 272 catheterisation attempts, of which 241 (88.6%) were successful. Patient age and size but not disease severity influenced incidences of both catheterisation failure and minor bleeding. The latter was the commonest early complication, occurring in 63 (23.2%) successful catheterisations. There were 7 major complications-3 pneumothoraces, 2 tachyarrhythmias and 2 major bleeds, all with subclavian vein catheterisation. Catheter-related infections (CRIs) occurred in 85 (51.2%) of 166 lines and catheter-related septicaemia (CRS) in 10 (5.7%) of 175 lines where there were sufficient data for evaluation. No patient or line factor, including duration of insertion, influenced CRI or CRS. In CRI, Staphylococcus epidermidis was the commonest organism. Other common CRI isolates were Enterococcus faecalis, Klebsiella spp. and Candida albicans. Six different organisms were implicated in CRS. CONCLUSIONS: CVC is a safe procedure with a high success rate. The femoral vein is the recommended percutaneous site of choice as it carries no great risk of sepsis and does not expose the patient to the hazard of intrathoracic complications.
Subject(s)
Catheterization, Central Venous , Critical Illness , Administration, Cutaneous , Catheterization, Central Venous/instrumentation , Catheterization, Central Venous/methods , Child , Child, Preschool , Femoral Vein , Humans , Infant , Infection Control , Jugular Veins , Medical Audit , Prospective Studies , South Africa , Subclavian VeinABSTRACT
We aimed to assess the pharmacokinetics of vancomycin in critically ill infants, and to evaluate the standard recommended dose of 10 mg/kg 6 hourly. All infants admitted to the Baragwanath Hospital ICU who had arterial lines in situ, and for whom vancomycin 10 mg/kg 6 hourly was prescribed for an infective insult and who had parental consent, were included in the study. Vancomycin was infused over 60 minutes. Serum samples were taken immediately before the dose and at 30, 60, 120 and 300 minutes after the end of the vancomycin infusion, on days 2 and 8 of therapy. Extrapolated peak concentration (Cmax), trough concentration (Cmin), apparent volume of distribution (Vd), elimination half-life (t1/2el) and clearance (CL) were determined for each patient. Day 2 values were compared with those of day 8. Day 2 serum concentrations were assayed on 20 patients and day 8 concentrations in 15. The mean vancomycin Vd on day 2 (0.81 l/kg) was significantly (P = 0.007) larger than that on day 8 (0.44 l/kg). The change in Vd resulted in a significant change in mean Cmax (29.1 vs 35.5 micrograms/ml) (P = 0.02) and mean t1/2el (5.3 vs 3.4h) (P = 0.01) over the treatment period. Critically ill infants displayed a large initial volume of distribution which probably resulted from aggressive fluid resuscitation. This also results in a large variation in other pharmacokinetic parameters, namely Cmax and t1/2el. Although the routine monitoring of vancomycin serum concentrations remain controversial, we feel that in view of these large pharmacokinetic variations, the critically ill infant is a specific group where monitoring of vancomycin serum levels is indicated.
