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.

Case management. A means to improve quality and control the costs of cure in children with acute myelogenous leukemia.

UNLABELLED: Acute myelogenous leukemia (AML) is a costly disease to treat, as patients experience many hospital stays secondary to chemotherapy, the side effects of treatment, and bone marrow transplantation. The trend for some medical centers has been to reduce costs and increase quality through case management. The case manager uses critical pathways and one-on-one interaction to facilitate the patients' progress through the hospital system and to decrease delays and duplication. CONCLUSION: Case management and critical pathways could become an indispensable tool for the management of pediatric patients with cancer.

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.

Central venous catheters in the emergency department: access, utilization, and problem solving.

As the number of children with central venous catheters cared for at home continues to escalate, the physician is increasingly confronted with a wide variety of devices in the emergency setting. The most common presenting complaints are fever (infection), occlusion (thrombus), breakage, and dislodgement. Familiarity with the basic characteristics of these devices and their variations, as well as the approaches to specific complaints, will lead to prompt, efficient, and definitive emergency care for these patients.

Removal of an aspirated gold crown utilizing the laparoscopic biopsy forceps: a case report.

An aspirated gold crown could not be removed with standard instruments. The crown was successfully grasped and removed with a large biopsy forceps commonly used in the performance of laparoscopic cholecystectomy.