Optimal timing for intravenous administration set replacement.

BACKGROUND: Administration of intravenous therapy is a common occurrence within the hospital setting. Routine replacement of administration sets has been advocated to reduce intravenous infusion contamination. If decreasing the frequency of changing intravenous administration sets does not increase infection rates, a change in practice could result in considerable cost savings. OBJECTIVES: The objective of this review was to identify the optimal interval for the routine replacement of intravenous administration sets when infusate or parenteral nutrition (lipid and non-lipid) solutions are administered to people in hospital via central or peripheral venous catheters. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE: all from inception to February 2004; reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. We did not have a language restriction. SELECTION CRITERIA: We included all randomized or quasi-randomized controlled trials addressing the frequency of replacing intravenous administration sets when parenteral nutrition (lipid and non-lipid containing solutions) or infusions (excluding blood) were administered to people in hospital via a central or peripheral catheter. DATA COLLECTION AND ANALYSIS: Two authors assessed all potentially relevant studies. We resolved disagreements between the two authors by discussion with a third author. We collected data for the outcomes; infusate contamination; infusate-related bloodstream infection; catheter contamination; catheter-related bloodstream infection; all-cause bloodstream infection and all-cause mortality. MAIN RESULTS: We identified 23 references for review. We excluded eight of these studies; five because they did not fit the inclusion criteria and three because of inadequate data. We extracted data from the remaining 15 references (13 studies) with 4783 participants. We conclude that there is no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection. We do not know whether changing administration sets less often than every 96 hours affects the incidence of infection. In addition, we found that there were no differences between participants with central versus peripheral catheters; nor between participants who did and did not receive parenteral nutrition, or between children and adults. AUTHORS' CONCLUSIONS: It appears that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the incidence of infection. There was no evidence to suggest that administration sets which contain lipids should not be changed every 24 hours as currently recommended.

Gauze and tape and transparent polyurethane dressings for central venous catheters.

BACKGROUND: Central venous catheters facilitate venous access, allowing the intravenous administration of complex drug treatments, blood products and nutritional support, without the trauma associated with repeated venepuncture. However, central venous catheters are associated with a risk of infection. Some studies have indicated that the type of dressing used for central venous catheters may affect the risk of infection. Gauze and tape or transparent polyurethane film dressings such as Tegaderm, Opsite or Opsite IV3000 are the most common types of dressing used to secure central venous catheters. Currently, it is not clear which type of dressing is the most appropriate. OBJECTIVES: To compare gauze and tape and transparent polyurethane central venous catheter dressings in terms of catheter related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised adults and children. SEARCH STRATEGY: The Cochrane Wounds Group Specialised Trials Register (October 2002), the Cochrane Controlled Trials Register (4th Quarter 2002) and the databases; MEDLINE (1966-December 2002, CINAHL (1982-October 2002) and EMBASE (1980-December 2002) were searched to identify any randomised controlled trials comparing the effects of gauze and tape and/or transparent polyurethane dressings for central venous catheter sites. Additional references were identified from bibliographies of published literature and were also sought from other sources. SELECTION CRITERIA: All randomised controlled trials evaluating the effects of dressing type (i.e. gauze and tape and/or transparent polyurethane dressings) on central venous catheter related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised patients. DATA COLLECTION AND ANALYSIS: Twenty-three studies were reviewed. Data was extracted from each paper by two members of the review team independently and results then compared. Differences were resolved either by consensus or by referral to a third member of the review team. Authors were contacted for missing information. MAIN RESULTS: Of the 23 studies reviewed, 14 were excluded. Nine studies were included. Data was only available for meta-analysis from six of the nine included studies. Of the six included studies with available data, two compared gauze and tape with Opsite IV3000, two compared Opsite with Opsite IV3000, one compared gauze and tape with Tegaderm, and one compared Tegaderm with Opsite. There was no evidence of any difference in the incidence of infectious complications between any of the dressing types compared in this review. Each of these comparisons was based on no more than two studies and all of these studies reported data from a small patient sample. Therefore it is probable that the finding of no difference between dressing types is due to the lack of adequate data. REVIEWER'S CONCLUSIONS: There is a high level of uncertainty regarding the risk of infection with the central venous catheter dressings identified in this review. Therefore, at this stage it appears that the choice of dressing for central venous catheters can be based on patient preference. To identify the most appropriate central venous catheter dressings, further research is necessary. It is paramount that any future studies investigating this issue must be rigorously performed randomised controlled trials.

Incidence of Mycobacterium paratuberculosis in raw sheep and goats' milk in England, Wales and Northern Ireland.

A blind survey of 104 raw sheep and goats' milk samples (90 goat, 14 sheeps) from bulk tanks on farms throughout England, Wales and Northern Ireland was carried out over a 5-month period (January-May 1998) in order to determine the incidence of Mycobacterium paratuberculosis. Each milk sample (100 ml) was divided into two 50ml portions. One portion was decontaminated with 0.75% hexadecylpyridinium chloride for 5h before culture on slopes of Herrold's egg yolk medium and in BACTEC radiometric medium. The second portion was subjected to immunomagnetic separation followed by IS900 PCR (IMS-PCR). The IMS-PCR assay was employed in order to provide a more rapid indication of the presence of M. paratuberculosis in each milk sample than is possible by culture. Information on the Johne's disease status of the sheep and goat herds that took part in the survey was not sought at the time of milk sampling. However, it subsequently emerged that at least some of the herds whose bulk milk was tested during this study were previously or currently infected with Johne's disease. Overall, during this survey one raw goats' milk sample tested positive for the presence of M. paratuberculosis by IMS-PCR (<1% of milk samples tested) but no viable M. paratuberculosis were isolated by culture. The results of this study suggest that bulk raw sheep and goats' milk from these regions of the UK may not represent significant vehicles of transmission of M. paratuberculosis to humans.

Improved detection of Mycobacterium avium subsp. paratuberculosis In milk by immunomagnetic PCR.

The potential use of a novel immunomagnetic PCR (IMS-PCR) technique as a rapid method to screen milk samples for the presence of Mycobacterium avium subsp. paratuberculosis (M. ptb) was assessed. Immunomagnetic separation (IMS) for M. ptb, developed at Queen's University, Belfast, was applied to milk samples prior to IS900 PCR in order to selectively concentrate any M. ptb cells present and, at the same time, separate the cells from constituents of milk likely to inhibit subsequent PCR. This increased the sensitivity of IS900 PCR. IMS-PCR sensitivity could be further increased by initial centrifugation (2500 g for 20 min) of larger volumes of milk (10 and 50 ml), and resuspension of the sediment into a 1 ml volume appropriate for IMS treatment. Following IMS, template DNA for IS900 PCR was obtained by heating the bead-cell suspension in a thermal cycler at 100 degrees C for 15 min. It was estimated that the IMS-PCR assay could detect approximately 10(3)CFU of M. ptb per 50 ml of milk (equivalent to 20 CFU/ml), whereas the minimum detection limit of direct IS900 PCR was estimated at 10(5)CFU of M. ptb per 50 ml (equivalent to 2000 CFU/ml). A blind trial was carried out in which a total of 40 spiked (10(6)CFU M. ptb) and unspiked, raw and laboratory-pasteurised milk samples were independently tested by IMS-PCR and conventional IS900 PCR. IMS-PCR correctly identified 97. 5% of milk samples (sensitivity 100%, specificity 95%), including spiked milk samples before and after laboratory-pasteurisation. One false positive result was obtained which may have resulted from carryover between samples during the IMS procedure. Conventional IS900 PCR correctly identified only 72.5% of the same 40 milk samples (sensitivity 23%, specificity 100%). IMS-PCR was also shown to be capable of detecting natural M. ptb infection in raw sheep's milk, and raw and commercially pasteurised cows' milk.

Empowerment through information: supporting rural families of oncology patients in palliative care.

A research project examining the support needs of families caring for a relative in palliative care was conducted in New South Wales in 1997. Data were collected from 19 families and 10 specialist palliative care nurses from eight centres throughout New South Wales using audio-taped interviews. The findings show that information was one of the most important support needs for families to enable them to effectively care for their sick relative. The information provided needed to meet the individual and varying needs of families at different stages of their palliative care journey. Often the families described not knowing what their information needs were until a crisis occurred. Lack of information on a range of areas, from practical resources to providing physical care and managing medications, was problematic. Health professionals need to take responsibility in determining if families are aware of the information available, identify the most appropriate medium for this material and provide it at the pace and time wanted by the individual family.

Cardiac function and behavioral reactivity during infancy.

Longitudinal cardiac data from the end of the fetal period to 21 months of age were examined for change and stability over age and relations to the temperamental characteristics of high and low reactivity at 4 months of age and fear to the unfamiliar in the second year. Heart period and power in the cardiac spectra changed dramatically over the first 2 years, and individual differences were not preserved until 9-14 months of age. Sleep heart period at 2 weeks of age and low frequency power at 2 months of age were better predictors of the temperamental categories than later measures of the same variables, suggesting that cardiac function early in life may be an especially sensitive index of temperamental qualities.

Slow weight gain is associated with increased periodic breathing in healthy infants.

To investigate the hypothesis that weight gain can influence periodic breathing in healthy infants, we prospectively studied, by nocturnal pneumogram technique, respiration and heart rate in 99 full-term infants during the first month of life. Eighty-eight infants had a repeat study at about 2 months of age. Pneumograms were analyzed visually for percent periodic breathing (%PB), and by computer for mean respiratory rate and mean heart rate. We found a median %PB of 0.9 initially and of 0.3 at about 2 months of age. The 95th percentile was 13.5 at 2 weeks and 7.3 at 2 months, higher than previously reported. Between the two ages tested, %PB was inversely correlated with weight gain (P < 0.001, < 0.03, respectively). Infants with greater weight gain had a greater fall in %PB (P < 0.03). We conclude that in the first 2 months of life, slow weight gain is associated with increased periodic breathing.

Apnea and periodic breathing in healthy full-term infants, 12-18 months of age.

Many children older than 12 months of age are now on home monitors. Home pneumograms performed on normal infants have established standards, and have been used to evaluate infants during their first year. However, no standards have been described for infants older than 12 months. We, therefore, recorded the standard pneumogram on 88 full-term healthy infants who were 12-18 months of age. We analyzed the recordings for average respiratory and heart rates, apnea (greater than or equal to 6 seconds) density, longest apnea, periodic breathing, and bradycardia for 12 hours. We compared the values in males vs. females and in infants 12-14.9 months vs. 15.0-18.0 months of age. Since there was no difference in any parameter measured in any group, we combined the values to determine the normal values for this population.

A practical approach to supplier quality improvement.

Although supplier certification programs vary in design, they share the primary objective of increasing supplier participation in long-term quality improvement, cost reduction, and new product development. This paper discusses practical techniques to establish a quality baseline, develop a quality improvement strategy, and measure on-going improvement.

School health and four-year-olds.

The results of comprehensive physical, psychological and developmental assessments of 67 four-year-olds are described. The value of this type of review, and the use of nurses and teachers in preschool medical examinations is discussed.