Life on the line - Incidence and management of central venous catheter complications in intestinal failure.

BACKGROUND & AIMS: Loss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. METHODS: For this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDTs) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDTs were compared. RESULTS: Overall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 "CVC-days"). Broviac type "B" was found to be significantly superior to type "A" regarding occlusion, CRI, and material defects (log-rank test: p = 0.05; p = 0.026; p = 0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 389 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. CONCLUSIONS: Different complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.

Exploration of clinical predictors of the degree of ventricular catheter obstruction: a multicenter retrospective study.

OBJECTIVE: The aim of this study was to explore how clinical factors, including the number of lifetime revision surgeries and the duration of implantation, affect the degree of obstruction and failure rates of ventricular catheters (VCs) used to manage hydrocephalus. METHODS: A total of 343 VCs and their associated clinical data, including patient demographics, medical history, and surgical details, were collected from 5 centers and used for this analysis. Each VC was classified by the degree of obstruction after macroscopic analysis. Univariate, multivariate, and binned analyses were conducted to test for associations between clinical data and degree of VC obstruction. RESULTS: VCs from patients with 0 to 2 lifetime revisions had a larger proportion of VC holes obstructed than VCs from patients with 10 or more revisions (p = 0.0484). VCs implanted for less than 3 months had fewer obstructed holes with protruding tissue aggregates than VCs implanted for 13 months or longer (p = 0.0225). Neither duration of implantation nor the number of lifetime revisions was a significant predictor of the degree of VC obstruction in the regression models. In the multinomial regression model, contact of the VCs with the ventricular wall robustly predicted the overall obstruction status of a VC (p = 0.005). In the mixed-effects model, the age of the patient at their first surgery emerged as a significant predictor of obstruction by protruding tissue aggregates (p = 0.002). VCs implanted through the parietal entry site were associated with more holes with nonobstructive growth and fewer empty holes than VCs implanted via other approaches (p = 0.001). CONCLUSIONS: The number of lifetime revisions and duration of implantation are correlated with the degree of VC obstruction but do not predict it. Contact of the VC with the ventricular wall and the age of the patient at their first surgery are predictors of the degree of VC obstruction, while the entry site of the VC correlates with it.

Peripherally inserted central catheter obstruction in packed red blood cell transfusions in neonates.

OBJECTIVES: to estimate incidence and free time of peripherally inserted central catheter obstruction in newborns undergoing red blood cell transfusion in the first 24 hours after the procedure. METHODS: a longitudinal study, carried out with neonates in Neonatal Intensive Care Unit at a teaching hospital in Paraná, between January and July 2019. The sample consisted of 46 transfusion events performed in neonates through a peripherally inserted central catheter. Analysis performed according to descriptive statistics. RESULTS: thirty-one catheters were analyzed, inserted in 24 neonates, through which 46 red blood cell transfusions were performed. Most neonates were male, gestational age <32 weeks, weight <1,500 grams, hospitalized mainly for prematurity. Among the 31 catheters, one (3.2%) presented obstruction after transfusion. CONCLUSIONS: The occurrence of obstructions immediately after transfusion was low and the catheters remained complication free for the next 24 hours.

Alteplase for the treatment of midline catheter occlusions: a retrospective, single-cohort descriptive study.

BACKGROUND: Despite the increasing popularity of midline catheters, data on the use of alteplase for restoring midline catheter patency is scarce. AIMS: This study aimed to evaluate off-label use of alteplase for midline catheter occlusions. METHOD: Adults who received alteplase into a midline catheter between January 2015 and May 2018 within a multi-hospital health system were included in this study. The primary outcome was restoration of infusion or withdrawal function from at least one lumen of a treated midline catheter. FINDINGS: Following alteplase administration, withdrawal function was restored in 47% (25/53) of occlusion events, infusion function was restored in 65% (11/17) of complete occlusion events, and infusion or withdrawal function was restored in 58% (31/53) of occlusion events. Only 34% (17/50) of catheters were replaced because of malfunction. Local bleeding was documented in 9% (n=5) of occlusion events after alteplase administration. CONCLUSION: Most midline catheter occlusions treated with alteplase demonstrated restoration of infusion or withdrawal function.

What do we know about flushing for intravenous catheter maintenance in hospitalized adults?

OBJECTIVE: to evidence the use of flushing to prevent complications from intravenous therapy. METHODS: an integrative review in databases, using descriptors and selection criteria. Data were collected in 12 articles using an instrument and later classified, summarized and aggregated for knowledge synthesis. RESULTS: it was evident that: the pre-filled syringe resulted in a lower occurrence of catheter obstruction; irregular flushing frequency caused advanced phlebitis; the use of Venous Arterial Blood Management Protection (VAMP) generated a lower incidence of blood infection; heparinized solution did not result in a lower central catheter failure rate; flushing volume and frequency were not predictors of catheter failure; flushing practice was not shown to be incorporated among professionals. CONCLUSION: there are disagreements about the volume, frequency, solution and devices used in flushing. New technologies can reduce complications such as obstruction and infection.

A prospective, randomized study assessing different modalities for flushing totally implanted vascular access device in children with malignancy.

BACKGROUND: The totally implanted vascular access device (TIVAD) is commonly used in patients with malignant tumors requiring chemotherapy or long-term intravenous infusion and those with difficulty placing peripheral venous catheters. It could also be used to draw blood in pediatric patients. Thus, how to maintain the patency and longevity of TIVAD is always emphasized. METHODS: In this prospective study, TIVAD was randomly infused in patients under 18 years with three different concentrations of heparinized solutions: 10 mL with 100 U/mL heparin, 20 mL with 10 U/mL heparin, and 30 mL with 10 U/mL heparin. RESULTS: A total of 81 patients (46 males and 35 females) were enrolled in this study from August 2, 2013 to February 1, 2017. The mean age of those who received TIVAD implantation was 7.2 ± 5.3 years, and the mean duration of using TIVAD was 1027.6 ± 369.1 days. Patients without catheter occlusion events experienced significantly shorter hospitalizations, fewer admissions, and fewer punctures than those with catheter occlusion events (p < 0.05). The administration and frequency of blood transfusions, history of bacteremia, and medication history did not increase the risk of catheter occlusion, but puncture frequency increased this risk. In patients with catheter occlusion events (38/81, 46.9%), catheter patency was restored after instillation of urokinase solution. CONCLUSION: In this study, the risk of TIVAD catheter occlusion was only related to puncture frequency regardless of the heparin flush composition or patient characteristics. A high puncture frequency of TIVAD during the 3.5-year study period significantly increased the risk of catheter occlusion. Besides, flushing and locking solutions for TIVAD using heparin at 10 U/mL was effective as using heparin at 100 U/mL regardless of the flushing volume of 10, 20, or 30 mL.

Insufficient procedural anticoagulation during leadless pacing led to catheter-related thrombosis in a hemodialysis patient.

BACKGROUND: Leadless pacemaker was a promising innovation than traditional transvenous pacemaker, the procedural complications were prone to be bleeding-related. However, very few reports also concerned about the thrombus formation during the procedure. CASE PRESENTATION: A hemodialysis patient with diabetic gangrene of right foot suffered from catheter-related thrombosis during leadless pacing, resulting in failure of recapture the pacemaker. A low activated clotting time (ACT) level of 104 s confirmed the insufficiency of anticoagulation. Finally, the whole delivery catheter had to be removed from the delivery sheath, another new pacemaker system was applied and successfully implanted after adjusting the ACT level to 248 s. CONCLUSION: Catheter-related thrombosis could be a large obstacle for leadless pacemaker implantation. In addition to routine anticoagulation, ACT monitoring might be necessary during the procedure.

Development of an In Vitro Hemorrhagic Hydrocephalus Model for Functional Evaluation of Magnetic Microactuators Against Shunt Obstructions.

OBJECTIVE: Occlusion of ventriculoperitoneal shunts placed after intraventricular hemorrhage occurs frequently. The objective of this study was to develop a hemorrhagic hydrocephalus model to assess the ability of an oscillating microactuator within the ventricular catheter (VC) to prevent shunt obstruction. METHODS: An in vitro hydrocephalus model with extreme risk of shunt obstruction was created. Phosphate-buffered saline, blood, and thrombin were driven through ventriculoperitoneal shunts for 8 hours. Five VCs were fitted with a microactuator and compared with 5 control VCs. The microactuator was actuated by an external magnetic field for 30 minutes. Pressure within the imitation lateral ventricle was measured. RESULTS: In the 5 control shunts, 6 obstructions developed (3 VC, 3 valve-distal catheter) compared with 1 obstruction (VC) in the 5 microactuator shunts. In the control and microactuator groups, the median volume exiting the shunts in 8 hours was 30 mL versus 256 mL. Median time to reach an intraventricular pressure of 40 mm Hg (13.8 minutes vs. >8 hours), median total time >40 mm Hg (6.2 hours vs. 0.0 hours), and median maximum pressure (192 mm Hg vs. 36 mm Hg) were significantly improved in the microactuator group (P < 0.01). CONCLUSIONS: In addition to protecting the VC, the microactuator appeared to prevent hematoma obstructing the valve or distal catheter, resulting in a much longer duration of low intraventricular pressures. A microactuator activated by placing the patient's head in an external magnetic field could reduce shunt obstructions in hemorrhagic hydrocephalus.

Multimodal intervention for preventing peripheral intravenous catheter failure in adults (PREBACP): a multicentre, cluster-randomised, controlled trial.

BACKGROUND: 2 billion peripheral intravenous catheters (PIVC) are inserted into inpatients worldwide each year. Almost one in two PIVCs fail before completion of intravenous therapy. We aimed to determine the efficacy and costs of a multimodal intervention to reduce PIVC failure among hospitalised patients. METHODS: PREBACP was a cluster-randomised, controlled trial done at seven public hospitals in Spain. Clusters (hospital wards) had at least 70% permanent staff and data were collected from patients aged 18 years and older with one or more PIVCs at the start of intravenous therapy. Clusters were randomly assigned (1:1) to the multimodal intervention or control group using a centralised, web-based randomisation software, and stratified by type of setting. We concealed randomisation to allocation, without masking patients or professionals to the intervention. An intervention using a multimodal model and dissemination of protocols, education for health-care professionals and patients, and feedback on performance was implemented for 12 months in the intervention group. The control group received usual care. The primary outcome was all-cause PIVC failure at 12 months (phlebitis, extravasation, obstruction, or infections). Subsequently, through an amendment to the protocol approved on July 25, 2021, we included dislodgement as part of PIVC failure. Analysis was by modified intention to treat, which included all randomly assigned hospital wards for whom data on the primary endpoint were available. This trial is registered with the ISRCTN Registry, ISRCTN10438530. FINDINGS: Between Jan 1, 2019, and March 1, 2020, we randomly assigned 22 eligible clusters to receive the multimodal intervention (n=11 clusters; 2196 patients, 2235 PIVCs, and 131 nurses) or usual practice in the control group (n=11 clusters; 2282 patients, 2330 PIVCs, and 138 nurses). At 12 months, the proportion of PIVC failures was lower in the intervention group than in the control group (37·10% [SD 1·32], HR 0·81 [95% CI 0·72 to 0·92] vs 46·49% [2·59], HR 1·23 [1·04 to 1·39]; mean difference -9·39% [95% CI -11·22 to -7·57]; p<0·0001). Per-protocol-prespecified analysis of the primary outcome excluding dislodgement also showed the intervention significantly reduced PIVC failure compared with the control group at 12 months (33·47% [SD 2·98], HR 0·85 [95% CI 0·75 to 0·96] vs 41·06% [4·62], HR 1·18 [1·04 to 1·33]; mean difference -7·59% [95% CI -11·05 to -4·13]; p<0·0001). INTERPRETATION: A multimodal intervention reduced PIVC failure, thereby reducing potentially serious complications for hospitalised patients. The findings of PREBACP enabled a deeper understanding of decision making, knowledge mobilisation, and sense making in routine clinical practice. FUNDING: The College of Nurses of the Balearic Islands. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

A multicenter retrospective study of heterogeneous tissue aggregates obstructing ventricular catheters explanted from patients with hydrocephalus.

BACKGROUND: Implantation of ventricular catheters (VCs) to drain cerebrospinal fluid (CSF) is a standard approach to treat hydrocephalus. VCs fail frequently due to tissue obstructing the lumen via the drainage holes. Mechanisms driving obstruction are poorly understood. This study aimed to characterize the histological features of VC obstructions and identify links to clinical factors. METHODS: 343 VCs with relevant clinical data were collected from five centers. Each hole on the VCs was classified by degree of tissue obstruction after macroscopic analysis. A subgroup of 54 samples was analyzed using immunofluorescent labelling, histology and immunohistochemistry. RESULTS: 61.5% of the 343 VCs analyzed had tissue aggregates occluding at least one hole (n = 211) however the vast majority of the holes (70%) showed no tissue aggregates. Mean age at which patients with occluded VCs had their first surgeries (3.25 yrs) was lower than in patients with non-occluded VCs (5.29 yrs, p < 0.02). Mean length of time of implantation of occluded VCs, 33.22 months was greater than for non-occluded VCs, 23.8 months (p = 0.02). Patients with myelomeningocele had a greater probability of having an occluded VC (p = 0.0426). VCs with occlusions had greater numbers of macrophages and astrocytes in comparison to non-occluded VCs (p < 0.01). Microglia comprised only 2-6% of the VC-obstructing tissue aggregates. Histologic analysis showed choroid plexus occlusion in 24%, vascularized glial tissue occlusion in 24%, prevalent lymphocytic inflammation in 29%, and foreign body giant cell reactions in 5% and no ependyma. CONCLUSION: Our data show that age of the first surgery and length of time a VC is implanted are factors that influence the degree of VC obstruction. The tissue aggregates obstructing VCs are composed predominantly of astrocytes and macrophages; microglia have a relatively small presence.

Root cause determination of intraperitoneal catheter obstructions: Insulin amyloid aggregates vs foreign body reaction.

Continuous intraperitoneal insulin infusion, from an implanted insulin pump connected to a catheter that delivers insulin directly to the peritoneal cavity has many clinical advantages for patients with Type 1 diabetes. However, the ongoing incidence of catheter obstructions remains a barrier to the widespread use of this therapy. To date, the root cause of these obstructions remains unknown. Here, a two-year clinical investigation was conducted, along with the development of an animal model to enable a mechanistic investigation into this issue. This novel animal model was able to mimic the catheter obstructions that occur in patients and, fortuitously, at an accelerated rate. This model allowed for independent assessment of each potential cause associated with catheter obstructions to help identify the root cause. Both macroscopic and microscopic analysis were conducted with regards to the onset and progression of catheter obstructions, along with monitoring of insulin delivery. Interestingly, although insulin aggregation occurs in insulin pumps and insulin aggregates were found in some catheter obstructions, insulin is unlikely to be the root cause, since obstructions also occurred in the control groups where only diluent (no insulin) was administered to the animals. Inflammatory cells, different phenotypes of fibroblasts, as well as collagen were observed in all obstructed catheters explanted from the patients and the animals. The presence of these cells and collagen is indicative of a typical foreign body reaction. In addition, the dynamic change in the fibroblasts with respect to morphology, phenotype, and spatial distribution suggests that tissue irritation-mediated epithelial to mesenchymal transition plays a role in catheter obstructions.

British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters.

OBJECTIVE: To look at best evidence and expert opinion to provide advice in the form of a consensus statement lead by Female, Neurological and Urodynamic Urology (FNUU) section of the British Association of Urological Surgeons (BAUS) in conjunction with the British Association of Urological Nurses (BAUN). METHODS: Initially a literature search was performed with incorporation of aspects of the existing guidance and further informed by UK best practice by core members of the group. The document then underwent reviews by the FNUU Executive Committee members, the BAUN executive committee, a separate experienced urologist and presented at the BAUS annual meeting 2020 to ensure wider feedback was incorporated in the document. RESULTS: Complications of long-term indwelling catheters include catheter-associated urinary tract infections (CAUTI), purple urine bag syndrome, catheter blockages, bladder spasms (causing pain and urinary leakage), loss of bladder capacity, urethral erosion ("catheter hypospadias")/dilatation of bladder outlet and chronic inflammation (metaplasia and cancer risk). CONCLUSIONS: We have provided a list of recommendations and a troubleshooting table to help with the management of the complications of long term catheters.

Risk factors for the development of venous thrombosis in patients with a central venous catheter admitted to the intensive care unit of the Roberto Gilbert Elizalde children's hospital / Factores que condicionan el desarrollo de trombosis venosa en pacientes con catéter venoso central ingresados en la unidad de cuidados intensivos del hospital de niños Roberto Gilbert Elizalde

Introduction: Advances in the management and survival of severe pediatric disease have led to an increase in thromboembolic phenomena, given the frequent need for central venous catheters (CVC). The present study describes the conditions in which venous thrombosis oc-curs in pediatric patients with CVC in a public referral center in Guayaquil. Methods: This is an observational, cross-sectional study with the objective of identifying fac-tors that are associated with the development of venous thrombosis in patients with CVC ad-mitted to the Intensive Care Unit. Information was collected in a pre-designed chart of all patients with CVC for more than 7 days. A venous Doppler ultrasound was performed to de-termine the presence or absence of thrombi. Descriptive statistics were used for univariate analysis and Odds Ratio was used for the bivariate analysis. Results: 35 patients were included in the study, 14/35 (40%) young infants, 24/35 males (69%), 19 cases (54%) with malnutrition, 10 cases (29%) with congenital heart disease, and 18 cases (51%) admitted for infections. The puncture site was femoral in 11 cases (31%), the procedure was performed by the fellow in 20 cases (57%), on a scheduled basis in 27 cases (77%), and performed in a single attempt in 28 cases (80%). The tip of the catheter was located in the superior vena cava in 23 cases (66%). The prevalence of thrombosis was 14% (95% CI 12.33-16.25). Bivariate analysis showed that none of the variables were associated with the presence of CVC thrombosis. Conclusions: 14% of patients with CVC use for more than 7 days develop secondary venous thrombosis. The factors associated with CVC including nutritional status and related proce-dures could not be determined.

Weak organic acid synergy towards the prevention of catheter blockages.

BACKGROUND: Up to 50% of all long-term catheterized individuals experience recurrent episodes of urinary catheter infections and blockages, leading to urine retention, pyelonephritis and septicaemia if the catheter is left in situ. We have previously reported the synergistic activity of weak organic acid (WOA) combinations against nosocomial uropathogens. AIM: To investigate the efficacy of selected WOAs, citric acid and propionic acid, alone and in combination, on prevention of crystalline biofilm formation and catheter blockages. METHODS: Static crystallization assays and dynamic in vitro bladder model assays, with scanning electron microscopy, were performed for determination of bacterial viability, urinary pH and time to catheter blockage. FINDINGS: The rate of encrustation around the catheter eyeholes was reduced in the presence of the citric acid/propionic acid combination, extending the time to blockage three-fold. CONCLUSION: Synergistic WOA combinations identified herein represent promising alternatives to antibiotics to combat the global healthcare burden of catheter-associated urinary tract infections and related blockages.

Repair of central venous access devices in intestinal failure patients is safe and cost-effective: A retrospective single centre cohort study.

INTRODUCTION: Patients with chronic intestinal failure (IF) require home parenteral nutrition (HPN). Central venous access is needed for prolonged use of PN, usually via a long term central venous access device (CVAD). Post insertion there may be mechanical complications with a CVAD such as catheter rupture or tear. Repair of damaged CVADs is possible to avoid risks associated with catheter replacement in patients with IF. However, catheter related blood stream infections (CRBSI) are a concern when CVAD's are accessed or manipulated. AIMS: To investigate the success of repair of CVADs in patients with IF on HPN, related to repair longevity and incidence of CRBSI following repair. METHOD: Nutrition team records of CVAD repairs carried out in patients with IF were reviewed retrospectively for the period April 2015 to March 2019. RESULTS: Nutrition Clinical Nurse Specialists carried out 38 repairs in 27 patients. Male n = 5, female n = 22; mean age 55 years. Catheter longevity before first repair (n = 27): median 851 days, IQR 137-1484 days. 30/38 (78.9%) of repairs were successful lasting ≥30days. Hospital admission was avoided in 76% of cases. 4 patients in the failed repair group underwent catheter re-insertion where 4 had a further, subsequently successful, repair, an overall success rate of 89.4% (34/38). 30-day CRBSI rate was 0.09/1000 catheter days in repaired catheters. In comparing costs, there is a potential cost saving of 2766GBP for repair compared to replacement of damaged CVADs. CONCLUSION: Repair of tunnelled CVADs in patients with IF is successful and safe with no increased risk of CRBSI. Significant cost savings may be made.

Use of instructional videos to reduce central venous catheter complications in children with intestinal failure receiving home parenteral nutrition.

BACKGROUND: Children with intestinal failure (IF) require parenteral nutrition (PN) at home, delivered through a central venous catheter (CVC) to support growth. CVC-related complications including infection, breakage, and blockage are the most common cause of readmission to the hospital. The objective of this study was to evaluate the use of instructional videos as part of the caregiver home PN-teaching program to reduce CVC-related complications. METHODS: Caregivers of children with IF requiring home PN were surveyed to assess skill confidence and interest in instructional videos for skill acquisition. Videos were then created using a smartphone and free video-editing software. Input from stakeholders (families, care providers) was incorporated in video production. Families were given access to the videos, and CVC-related complications were compared for 2 years prior to and 1 year following video introduction with Welch t-test analysis. RESULTS: After obtaining ethics approval, 11 caregivers were surveyed. Thirty percent reported feeling underconfident in their skills at the time of discharge. After viewing the videos, 100% of caregivers reported that these videos were useful. Catheter-related complication rates significantly decreased in the year following the video introduction from 7.88 to 2.65 complications per 1000 catheter days (P = .046). This included reductions in catheter-related infections, catheter occlusions, and breakages. CONCLUSIONS: Children with IF receiving home PN are at high risk for CVC-related complications, and caregivers are the first line of defense for catheter care. Instructional videos were low-cost to create, were well received by all families, and may contribute to reduced catheter-related complications.

Safety and utility of the alpha-replacer for treatment of intraluminal obstruction of peritoneal catheters by fibrin clots.

BACKGROUND: The Moncrief-Popovich technique of peritoneal catheter implantation has beneficial effects for peritoneal dialysis (PD) initiation. However, it might increase the risk of peritoneal catheter obstruction by fibrin clots, because the catheter is buried under the skin for several weeks to months. Effects of treatment of intraluminal occlusion of PD catheters with tissue plasminogen activator, recommended by the International Society for Peritoneal Dialysis guidelines/recommendations are reportedly limited. We investigated the effectiveness of the 'alpha-replacer' (JMS, Tokyo, Japan) for PD catheter obstruction. METHODS: We retrospectively analyzed a total of 193 patients in whom PD was initiated. PD catheters were embedded using the Moncrief-Popovich technique in 130 of these patients. We assessed the occurrence rates of peritoneal catheter obstruction and the utility of the alpha-replacer for treating intraluminal catheter occlusion by fibrin clots. RESULTS: Catheter obstruction occurred in eight cases with embedded catheters, one due to omental wrapping and the others due to fibrin clots, in which median catheter burial durations were 477 (interquartile range [IQR], 226-510) days. All catheter obstructions due to fibrin clots were successfully treated with the alpha-replacer, leading to improved catheter drainage. The median amount of contrast agent used in catheterography was 10 (IQR 9-10) mL, which did not adversely affect residual renal function. There were no complications. No recurrence occurred during the observation period (median 111, IQR 55.5-141 months). CONCLUSION: Our results suggest that treatment with the alpha-replacer is a safe and effective treatment option for intraluminal obstruction of PD catheters by fibrin clots.

The Practice and Complications of Midline Catheters: A Systematic Review.

OBJECTIVE: Midline catheters are considered "midway" regarding vascular access. The objective of this systematic review was to explore the current practice, dwell time, and complication rates of midline catheters. DESIGN: Systematic review. SETTING: Search on four databases, PubMed, CINAHL, Scopus, and Embase, were conducted for English language articles published after the year 2000. MEASUREMENTS AND MAIN RESULTS: A total of 987 articles were identified, of which 31 manuscripts met the inclusion criteria and were selected for review. Quality assurance was performed based on the Newcastle-Ottawa score. Average dwell time and complication rates were calculated for studies involving adult patients and adjusted for sample size. This analysis included data from the placement of 18,972 midline catheters across five countries. Aside from two randomized control trials, most of the studies analyzed were cohort studies. One pediatric and two neonatal studies were included. The average dwell time was 16.3 days (n = 4,412). The adjusted mean infection rate was 0.28/1,000 catheter days, with 64% of studies not reporting any infection with midline catheter. The failure rate of midline catheters was 12.5%. Adjusted average rates of other significant complications included the following: deep vein thrombosis (4.1%), dislodgement (5.0%), occlusion (3.8%), phlebitis (3.4%), and infiltration (1.9%). CONCLUSIONS: The dwell times and failure rates of midline catheters compare favorably against published data on other types of catheters. Their infection rates are also lower than the reported rates of central venous catheters; however, they have a higher rate of mechanical complications. Active surveillance of infections due to midline catheters is recommended. More data are needed from pediatric and neonatal populations.

A Randomized Clinical Trial of Low-dose Warfarin Therapy for Improving the Longevity of Permanent Arteriovenous Catheters.

BACKGROUND: The patency of a permanent arteriovenous catheter plays a significant role in the functioning of the catheter among patients dependent on the hemodialysis. Thrombosis formation is one of the most critical reasons for the short-term efficacy of the embedded catheters. The present study aimed to evaluate the efficacy and safety of warfarin for hemodialysis catheter failure prevention. METHODS: This randomized clinical trial has been conducted on patients under hemodialysis using a permanent arteriovenous catheter. The patients were randomly allocated to the control group and the intervention group. The intervention group was treated with warfarin to achieve a target international normalized ratio (INR) of 1.5-2. The control group did not receive any treatment. The patients were followed for 12 months to assess the efficacy defined as the incidence of catheter clotting and safety defined as warfarin-related hemorrhage. RESULTS: Eighty-six patients with end-stage renal disease under hemodialysis were included, among which 43 ones were allocated to the intervention group and the latter ones to the control group. The participants of both groups were similar in terms of demographic, clinical, and baseline laboratory characteristics. Four patients (9.3%) presented with warfarin-induced hematoma, among which the warfarin administration stopped for 5.33 ± 1.44 days and then restarted again. None of the patients was forced to cease warfarin therapy because of significant hemorrhages. The mean duration of catheter functioning was 8.30 ± 1.75 months in the intervention group versus 3.90 ± 1.12 months in the controls (P-value<0.001). CONCLUSIONS: Based on the findings of the present study, the use of warfarin to achieve an INR level of 1.5-2 could effectively lead to a longer duration of permanent hemodialysis catheter functioning.