Impact of changes in catheter management on infectious complications among children with central venous catheters.

OBJECTIVES: To characterize and enumerate central venous catheter (CVC)-related complications among children with chronic illnesses, and to reduce the complication rate through changes in CVC management and education. DESIGN: A prospective observational study followed by an educational program and a nonrandomized interventional trial. SETTING: The Children's Hospital of Philadelphia, a tertiary, pediatric facility. PATIENTS: 268 children with Broviac, Hickman, or Infusaport catheters in place during 58,290 catheter days. INTERVENTIONS: Development and implementation of protocols for cleaning insertion site and hub, use of nonocclusive dressings, and manipulation of access; formal staff and parental education about protocols. RESULTS: CVC-related infections fell from 4.58/1,000 catheter-days preintervention to 3.83 postintervention (risk ratio [RR], 0.20; 95% confidence interval [CI95], 0.89-1.622; P = .25); exit-site infections fell from 0.58 to 0.11 (CI95, 1.22-45.64; P = .02); rates among infants on the surgical service fell from 15.46 to 6.67 (RR, 2.31; CI95, 1.10-4.30; P = .02). CONCLUSIONS: Education and changes in management protocols reduced the incidence of exit-site infections among all patients and reduced the overall infectious complication rate among the infants receiving parenteral nutrition on the surgical service. Other interventions are needed to decrease further the infectious complications in these children.

A randomized, controlled trial of the efficacy of a heparin and vancomycin solution in preventing central venous catheter infections in children.

OBJECTIVE: To determine whether adding vancomycin to central venous catheter (CVC) flush solution would significantly reduce the incidence of bacteremia attributable to luminal colonization with vancomycin-susceptible organisms. STUDY DESIGN: Fifty-five children with cancer and eight children given total parenteral nutrition by the surgery or nutrition support services were randomly assigned to receive a heparin CVC flush solution (n = 31) or a heparin-vancomycin CVC flush solution (n = 32). RESULTS: During 9158 catheter days, 6.5% of the patients in the heparin group and 15.6% of the patients in the heparin-vancomycin group had bacteremia attributable to luminal colonization with vancomycin-susceptible organisms (p = 0.43). The mean rates of bacteremia attributable to luminal colonization with vancomycin-susceptible organisms were 0.6/1000 catheter days in the heparin group and 1.4/1000 catheter days in the heparin-vancomycin group (p = 0.25). There was no significant difference between the groups when the time to the first episode of bacteremia attributable to luminal colonization with a vancomycin-susceptible organism was compared by means of Kaplan-Meier survival estimates. Streptococcus viridans infection was not attributable to luminal colonization. CONCLUSION: The addition of vancomycin to heparin CVC flush solution did not reduce bacteremia with vancomycin-susceptible organisms. Bacteremia with Streptococcus viridans was not related to the use of a CVC.

A collaborative practice model for the clinical nurse specialist.

This article describes a model of advanced nursing practice, jointly funded through nursing and medicine. The model is based on a matrix reporting structure with the clinical nurse specialist reporting to both a physician and a director of nursing. The authors discuss how the various role components are enacted and the benefits of the model to the specialist, institution, physicians, staff, and patients and their families.

Assessment and management of conjoined twins.

Although a rare anomaly, conjoined twins provide a unique challenge to the health care professional. At times, the ethical issues present difficult dilemmas for parents and hospital staff. An awareness of the moral dilemmas that tax the emotions of the most experienced hospital staff is the first step toward providing the appropriate support to these families. Nurses must have an understanding of the classification of conjoined twins and the preoperative and postoperative management. Additionally, awareness of the special needs of the family prior to discharge both before and after surgical separation allows for meeting comprehensive care needs. Although the process toward the separation of these twins can be complex, the overall outcome is rewarding.

Simultaneous bilateral central catheters: a safe technique.

Optimal central catheter care includes restriction usage for blood sampling and blood product administration on enhance continued sterility, but our experience with 25 children receiving bone marrow transplants after cytoreduction challenges this concept. Prior to transplantation, bilateral percutaneous subclavian vein silastic catheters were inserted without incident, one utilized for continuous nutritional support in caloric quantity to assure body weight maintenance, and the contralateral catheter utilized for daily venous sampling plus administration of medications including blood products. Patients subsequently entered a protective environment and bi-weekly surveillance cultures were monitored. Nutritional therapy was given for 876 days through 53 catheters. One patient developed culture-proven sepsis, an organism first cultured from the skin. The patient complication rate of 4% and the per diem rate of 0.11% in this immunocompromised population compares favorably to the 10.5 and 0.32% incidence we previously reported for 200 children with unilateral catheters. These data demonstrate that bilateral central catheters can be safely utilized in children for nutrition and sampling.

Nutritional assessment: an integral part of the preoperative pediatric surgical evaluation.

Comprehensive nutritional assessment in adults has revealed that 50% of hospitalized patients suffer from acute protein calorie malnutrition (PCM), a state which correlates with increased surgical morbidity and mortality. We report our results examining the same question in children, and on the basis of these data suggest that nutritional assessment be a routine part of the preoperative evaluation of all pediatric surgical patients. We studied 198 children and found that the overall prevalence of acute PCM was 54%; but if premature and term infants less than three months of age are selected, the prevalence of acute PCM was a striking 63%. If only surgical patients are considered, the prevalence of acute PCM among patients hospitalized for trauma or burns was 31% for elective operation 39%, and for acute but complex operative procedures 64%. These data demonstrate that a remarkably high prevalence of acute PCM exists among hospitalized pediatric and pediatric surgical patients. Whether aggressive perioperative nutritional support can reverse such acute PCM and favorably influence morbidity and mortality is currently speculation, but that acute protein calorie malnutrition is far more prevalent among hospitalized pediatric patients that is generally realized, and that comprehensive nutritional assessment is essential to identify the "at risk" nutritionally deprived pediatric surgical patient, have now been proven.

Route of pediatric parenteral nutrition: proposed criteria revision.

This study reviews the experience of the Nutrition Support Service at the Children's Hospital of Philadelphia over a 13-mo period from 1977 to 1979. Parenteral nutrition was administered to 585 children, 385 by peripheral vein infusion and 200 by central vein infusion. Weight gain was seen in 63% of those patients receiving peripheral vein infusions and 82.5% of those receiving central vein nutrients, and this apparent difference is likely due to the longer duration of therapy in the central vein recipients (33.7 versus 11.4 mean days) and the greater caloric intake delivered to these same patients (128 Kcal/kg/day versus 63.2 Kcal/kg/day). The complication rates were calculated for the more than 11,000 patient days of therapy surveyed; 35 of the 385 peripheral vein patients developed complications, the primary type being solution administration soft tissue sloughs. This amounted to an incidence of 9.08%. Central vein patients in 40 circumstances likewise had complications, 21 being infectious and 12 being metabolic. This accounted for 20% of all central vein recipients, a difference from the peripheral vein group significant to a p value of less than .01. However, when total days of therapy are considered in this complication incidence, a per diem complication rate between these two groups is not different, and in fact, is somewhat worse for the peripheral vein nutrient recipients. Vascular access in this group of patients was via peripheral vein cannulation or via central venous catheter placement, the latter more recenty done exclusively by percutaneous subclavian vein catheter insertions. This technique was safe and allowed repeated access to the central venous system. These data suggest that the only legitimate determining factor for selecting proper nutritional support of the pediatric patient is the caloric need of the individual.