Vascular catheter-related infections: an endemic disease in healthcare institutions. An opinion paper of the Spanish Society of Cardiovascular Infections (SEICAV).

Catheter-related infections (CRI) are a serious healthcare problem due to their potential to cause serious complications, including bacteraemia or infective endocarditis, and to increase patient morbidity and mortality. In addition, these in fections significantly prolong hospital stay and cost. Preventing CRI is crucial and is considered a criterion for quality and safety in healthcare. For these reasons, the Spanish Society of Cardiovascular Infections (SEICAV) has considered it pertinent to review this topic, with experts in different areas including clinical microbiologists, infectious disease specialists, surgeons and nurses. The data were presented at a session held at the Ramón Areces Foundation, which was organised in the form of specific questions grouped into three round tables. The first panel analysed the scale of the problem including epidemiological, clinical and diagnostic aspects; the second panel addressed advances in the treatment of CRI; and the third panel reviewed developments in the prevention of CRI. The recorded session is available on the Areces Foundation website and we believe it maybe of interest not only to health professionals, but also to any non-expert citizen interested in the subject.

Spontaneous pulmonary air embolism in a child undergoing procedural deep sedation: case report and review of the literature.

We performed a systematic review of the literature starting from a real case of venous air embolism (VAE) in a young infant undergoing central catheterization during procedural sedation. Air embolism due to internal jugular vein catheterization during procedural sedation is very rare, but it is a potentially life-threatening complication of central catheterization that warrants attention. To our knowledge, this is the first case published in a similar scenario.

Preventing hospital malnutrition: a survey on nutritional policies in an Italian University Hospital.

BACKGROUND: A proper strategy for fighting hospital malnutrition should include nutritional screening of all hospitalized patients, adequate utilization of the Hospital facilities - such as Clinical Nutrition Services or Nutrition Teams - and an adequate algorithm for the adoption of proper nutrition support (oral, enteral or parenteral) with proper timing. The main aim of the present study was to investigate the current policies of different non-intensive wards of our institution (a 1100 beds University Hospital) in terms of prevention of hospital malnutrition. METHODS: We conducted a one-day survey to verify the current policies of nutritional screening and the indication to nutritional support in adult patients, interviewing nurses and physicians of our non-intensive hospital wards. RESULTS: A total of 29 wards were considered, which sum up to 755 hospitalized patients. We found that nutritional screening at admission is routinely assessed only in 41% of wards and that oral nutrient intake is controlled regularly only in 72%. Indication to clinical nutrition support and specifically to artificial nutrition is not consistent with the current international guidelines. Only 14% of patients were receiving artificial nutrition at the moment of the survey and the majority of them were given parenteral nutrition rather than enteral feeding. CONCLUSION: Our survey confirmed that in large hospitals the main barriers to the fight against hospital malnutrition are the lack of knowledge and/or commitment by nurses and physicians as well as the lack of well-defined hospital policies on early nutritional screening, surveillance of nutritional status and indication to nutrition support.

Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training.

There is a lack of standard minimal requirements for the training of insertion techniques and maintenance of central venous access devices (CVADs). An international evidence-based consensus task force was established through the World Congress of Vascular Access (WoCoVA) to provide definitions and recommendations for training and insertion of CVADs. Medical literature published from February 1971 to April 2012 regarding 'central vascular access', 'training', 'competency', 'simulation', and 'ultrasound' was reviewed on Pubmed, BioMed Central, ScienceDirect, and Scopus databases. The GRADE and the GRADE-RAND methods were utilized to develop recommendations. Out of 156 papers initially identified, 83 papers described training for central vascular access placement. Sixteen recommendations are proposed by this task force, each with an evidence level, degree of consensus, and recommendation grade. These recommendations suggest central venous access education include didactic or web-based teaching with insertion procedure, infection prevention, complications, care, and maintenance of devices, along with laboratory models and tools for simulation practice incorporating ultrasound. Clinical competence should be determined by observation during clinical practice using a global rating scale rather than by the number of procedures performed. Ensuring safe insertion and management of central venous devices requires standardized education, simulation practice, and supervised insertions.

Old and new tools in the diagnosis of central venous catheter-related bloodstream infections: is there a role for brushing?

Bloodstream infections (BSIs) are the third most common nosocomial infections. Catheters and other medical devices are the first exogenous causes of preventable infections in hospital. The estimated attributable mortality for catheter-associated BSI ranges from 1-35%, mainly depending on etiological agents and underlying disease. In considering this, it is necessary to reduce central venous catheter- (CVC)-related BSI prevalence and to obtain a rapid and accurate method for an early diagnosis. This review indicates the advantages and the disadvantages of old and new tools for the early diagnosis of CVC-related BSIs.

Valved central venous catheter connected to subcutaneous port: A multicenter phase IV study based on a cohort of 50 oncology patients.

PURPOSE: Since technical aspects and clinical features of central venous valved catheters are far from being completely understood, a multinational group of investigators has decided to assess a new distally-valved catheter connected to a port, in the clinical setting of oncology patients undergoing chemotherapy, in an attempt to verify its safety and viability, while also investigating its practical features. METHODS: Our project was structured as a phase IV multicenter study. Hospitalized adults (ages 18-80 years) who had solid tumors and were candidate for intravenous chemotherapy met the criteria to enter the study. One single type of port was used (made of titanium, plastic and silicone) connected to a silicone, distally valved catheter (as manufactured by B. Braun Aesculap). A case report form was provided for each treated case; all relevant data regarding implantation and follow-up were entered into the form, mailed to a coordinating center (G. Chevillon, B. Braun Medical, France) and stored in a software database for statistical analysis. RESULTS: 50 patients (from 6 participating centers) were included in this study. No major complications occurred at insertion. The most frequent clinical problem during follow-up was inability to draw blood samples (9% during the first chemotherapy cycle; 8% after the second cycle); blood obtained from the device was defined 'unsuitable for hematology test' in 9% of the cases at first chemotherapy cycle and in 23% of the cases after the second cycle. No catheter obstruction occurred. CONCLUSION: The distally valved catheter port tested in this study was reliable, safe and practical for long-term treatment of an oncology patients' population undergoing chemotherapy. As most other reports and clinical trials dealing with other types of distally valved catheters pointed out, inability to draw viable blood samples (so called withdrawal occlusion) is a major concern in their clinical use. Mechanisms underlying this technical problem are still unclear.

[Central venous catheterization: complications of different placements]. / Accès veineux central: complications des différentes voies d'abord.

STUDY AIM: The aim of this prospective multicentric non-randomised trial was to report the complications of the central venous catheter insertion with different techniques and to assess the advantages of the low lateral approach to the internal jugular vein, according to the technique originally described by Jernigan et al, with our own modifications. PATIENTS AND METHOD: From January 1993 to August 1997, 2,290 CVC (2,286 by percutaneous puncture and 4 by surgical approach) were placed. The following complications were analysed prospectively: pneumothorax, accidental arterial puncture, more than two punctures of the same vein, necessity to shift to another venous approach, complete failure, malposition of catheter. RESULTS: The veins the most frequently used were internal jugular vein (48.7%), femoral vein (27%) and subclavian vein (24.2%). Internal jugular vein was punctured especially by low lateral approach (75%) and subclavian vein by infraclavicular approach (92%). With these two placements, the rate of pneumothorax was 0% and 3.1% respectively (p < 0.001), the rate of accidental arterial puncture was 1% and 2.7% respectively (p < 0.03) and the rate of more than two consecutive punctures was 3.1% and 6.3% respectively (p < 0.008). CONCLUSION: On our experience, we advocate the low lateral approach to the internal jugular vein as first choice technique for venipuncture in both adults and children for both short and long-term central venous approach, because it is associated to high rate of outcome and to low rate of complications in comparison with other techniques.

Non-tunneled central venous catheters in adult stem cell transplantation recipients: An effective option.

Stem cell transplantation (SCT) recipients require central venous catheter (CVC) insertion for the administration of chemotherapy, antibiotics and total parenteral nutrition. Traditionally, tunneled CVC have been considered as the golden standard although they require surgery for both insertion and removal. We prospectively evaluated the use of a non-tunneled CVC in 182 consecutive patients who had undergone allogenic or autologous SCT. The median duration of CVC was 4 weeks (range 1-24) with a significant difference between allogenic (8 weeks, range 2-24) and autologous SCT (4 weeks, range 1-24) (p<0.0001). The life expectancy of the CVC was significantly influenced by spontaneous removal, which occurred in 26 patients (13.8%). There was a significant increase of this complication in allogenic SCT (p=0.039). The overall incidence of sepsis was 24.5%, although catheter-related sepsis was microbiologically documented by positive culture of the tip only in 17 cases (9%). Non-tunneled CVC in adult SCT recipients allowed (a) bedside insertion and removal, (b) guidewire replacement for diagnostic or therapeutic purposes (dialysis or pheresis procedures) thus reducing the need for repeated venipunctures. (The Journal of Vascular Access 2001; 2: 168-174).

Morbidity associated with central venous catheter-use in a cohort of 212 hospitalized subjects with HIV infection.

Technical complications and nosocomial bloodstream infections associated with short-term central venous catheterization remain a heavy burden in terms of morbidity, mortality and cost in HIV-positive subjects. Between 1994 and 1997, 327 central venous catheters (CVCs) inserted in 212 patients for a total of 5005 catheter days were investigated. Forty-two technical complications (13%) occurred in 40 patients. Logistic regression analysis revealed that a high APACHE III score was associated with development of CVC-related complications (P = 0.01). One hundred and eight of 327 CVCs (33%) were suspected as being infected. However only 61 episodes (61/327, 19%) were finally diagnosed as CVC-related sepsis. Three variables affecting the rate of CVC-related sepsis were identified: 1) administration of TPN (P = 0.01); 2) low number of circulating CD4+ cells (P = 0.04); 3) high APACHE III score (P = 0. 04). Doctors responsible for AIDS patients should carefully consider the relative risks and benefits of CVC insertion in an individual patient.

Percutaneous intravascular retrieval of embolised fragments of long-term central venous catheters.

Embolisation of a catheter fragment is a rare mechanical complication of long-term central venous access devices. From 1995 to 1999 we observed 10 cases: the cause of embolisation was the 'pinch-off syndrome' in half of the cases, and in 8 cases out of 10 the fragment had embolised in the pulmonary arterial vessels. Percutaneous transvenous retrieval was successful in all cases; it was performed mainly (8 cases out of ten) through the left transfemoral route, using a single-snare-loop device sometimes associated with a pig-tail catheter. We had no mortality and no major complications. On the basis of our experience, we believe that catheter embolisation of long-term central venous devices can be effectively prevented by adequate insertion technique, proper management of the device during its clinical use, and accurate removal technique. Nonetheless, should catheter em-bolisation occur, the patient should be referred to a Centre with adequate experience in the field of interventional radiological techniques. Should the radiological retrieval procedure fail, evidence from the literature suggests that leaving the fragment in embolisation site might be safer than open extraction by surgical thoracotomy, particularly in oncological patients with reduced life expectancy.

Which is the easiest and safest technique for central venous access? A retrospective survey of more than 5,400 cases.

There is an ongoing debate on the technique for central venous catheterization associated with the lowest complication rate and the highest success rate. In an attempt to better define the easiest and safest venous approach, we have reviewed our 7-year experience with 5479 central venous percutaneous punctures (by Seldinger's technique) for the insertion of short-term (n=2109), medium/long-term (n=2627) catheters, as well as double-lumen, large-bore catheters for hemodialysis and/or hemapheresis (n=743). We have analyzed the incidence of the most frequent in-sertion-related complications by comparing seven different venous approaches: jugular vein, low lateral approach; jugular vein, high lateral approach; jugular vein, low axial approach; subclavian vein, infraclavicular approach; subclavian vein, supraclavicular approach; external jugular vein; femoral vein. The results of our retrospective study suggest that the 'low lateral' approach to the internal jugular vein, as described by Jernigan and modified according to our protocol, appears to be the easiest and safest technique for percutaneous insertion of central venous access, being characterized by the lowest incidence of accidental arte-rial puncture (1.2%) and malposition (0.8%), no pneumothorax, and an extremely low rate of repeated attempts (i.e. more than two punctures before successful cannulation) (3.3%). We advocate the 'low lateral' approach to the internal jugular vein as first-choice technique for venipuncture in both adults and children, for both short-term and long-term central venous percutaneous cannulation.

[Central venous catheter-related sepsis: one year experience in a large university hospital] / Sepsi in pazienti con cateteri venosi centrali: un anno di esperienza in un policlinico universitario.

Five hundred two central venous catheters (CVC) inserted in 366 patients were evaluated prospectively over a one-year period to determine the frequency and risk factors associated with CVC-related sepsis. A CVC-related infection was suspected in 190 cases (190/502, 38%). A catheter-related sepsis was established in 50 patients (10%). The infection rate was 0.8 cases of sepsis per 100 catheterdays. Staphylococcus epidermidis, Staphylococcus aureus, and Candida spp. were the most frequently isolated etiological agents of sepsis. On univariate analysis, six variables affecting the rate of catheter-related sepsis were identified: neutropenia > 8 days (p < 0.01); AIDS (p < 0.001); haematological malignancies (p < 0.001); total parenteral nutrition (p = 0.001); duration of site use (p = 0.04); high APACHE II score (p = 0.04). The logistic regression analysis revealed that AIDS and haematological malignancies were independent risk factors of catheter-related sepsis. In conclusion, although the incidence of established catheter infection is much lower than the incidence of suspected infection, in most cases it is wise to change the catheter with the guidewire technique and wait for culture of the tip, rather than to remove the catheter immediately.

The Hohn catheter in the management of haemopoietic stem cell transplant recipients.

Patients undergoing bone marrow transplantation require a reliable venous access. The authors have tested the feasibility and safety of a new, silicone, open-ended, non-tunnelled central venous catheter (CVC), the Hohn catheter (Bard Access System, USA). From January 1994 to December 1996, 58 Hohn were inserted into 56 bone marrow transplant (BMT) patients (26 women: 30 men; mean age 38 years, range 19-62 years). The CVC was inserted percutaneously at the bedside by puncture of the subclavian or the internal jugular vein. No early complications were observed. Significant late complications were infection (documented only in 14%) and accidental removal (11%). The median life of the CVC was 30 days (range 15-180 days). Major causes of removal were end of use (25 patients) and fever (19 patients; but infection was documented only in eight patients). In spite of the relatively small gauge (5 Fr), the Hohn catheter was adequate for rapid or high density infusion. In our experience, the unique features of the Hohn CVC (versatility, optimal biocompatibility, bedside management, low cost) may contribute to making the BMT procedure safer and less expensive.

Pregnancy outcome and total parenteral nutrition in malnourished pregnant women.

OBJECTIVE: We evaluated pregnancy outcome and fetal growth in women requiring total parenteral nutrition (TPN). METHODS: Eleven malnourished pregnant women were treated with TPN in a single institution, starting at a mean gestational age of 20+/-8 weeks (+/- SD). Serial ultrasound evaluations of fetal growth (biparietal diameter, femur length, abdominal circumference) were performed. The paired Student t test and Wilcoxon signed-rank test were used for the statistical analysis: p values <0.05 were considered significant. RESULTS: The duration of TPN ranged from 14 to 220 days. Maternal nutritional state was well preserved and no complications were related to treatment. A gestational age of 35+/-3 weeks at delivery (mean +/- SD), birth weight of 2,251+/-670 g (mean +/- SD) and birth percentile of 29+/-16 (mean +/- SD) were observed. One intrauterine death occurred. The comparison between the sonographic findings, before and 2 weeks after starting TPN, showed a fetal percentile gain with a statistically significant increase in the abdominal circumference percentile (p < 0.05) from a median percentile of 2 (range 2-32) to 33 (range 2-78). CONCLUSIONS: TPN proved to be helpful and lifesaving in malnourished pregnant women and promoted fetal growth, as shown by the longitudinal ultrasonographic evaluations.