Quality of life in women with breast cancer undergoing neoadjuvant chemotherapy: comparison between PICC and PICC-port.

BACKGROUND: Peripherally inserted central catheters (PICCs) and new type of arm-port, the PICC-port, are currently used for neoadjuvant chemotherapy treatment in patients with breast cancer. We aimed to compare Quality of Life (QoL) of patients receiving one of these two devices investigating overall satisfaction, psychological impact, as well as the impact on professional, social and sport activities, and local discomfort. METHODS: We did a prospective observational before-after study of PICCs versus PICC-ports. Adult (aged ≥ 18 years) females with breast cancer candidate to neoadjuvant chemotherapy were included. The primary outcome was QoL according to the Quality-of-Life Assessment Venous Device Catheters (QLAVD) questionnaire assessed 12 months after device implantation. RESULTS: Between May 2019 and November 2020, of 278 individuals screened for eligibility, 210 were enrolled. PICC-ports were preferred over PICCs with a QLAVD score of 29 [25; 32] vs 31 [26; 36.5] (p = 0.014). Specifically, most QLAVD constructs related to psychological impact, social aspects, and discomfort were in favor of PICC-ports vs PICC, especially in women under the age of 60. Overall, pain scores at insertion and during therapy administration were not significantly different between the two groups, as well as infection, secondary malpositioning, thrombosis, or obstruction of the device. CONCLUSIONS: In women with breast cancer undergoing neoadjuvant chemotherapy, PICC-ports were overall better accepted than PICCs in terms of QoL, especially in those who were younger. Device-related complications were similar.

Flow Analysis of Central Venous Outflow Tract: A New Approach to Understanding Pulse-Synchronous Tinnitus.

OBJECTIVE: Pulse-synchronous tinnitus (PST) has been linked to multiple anatomical variants of the central venous outflow tract (CVOT) including sigmoid sinus (SS) dehiscence and diverticulum. This study investigates flow turbulence, pressure, and wall shear stress along the CVOT and proposes a mechanism that results in SS dehiscence and PST. STUDY DESIGN: Case series. SETTING: Tertiary Academic Center. METHODS: Venous models were reconstructed from computed tomography scans of 3 patients with unilateral PST. Two models for each patient are obtained: a symptomatic and contralateral asymptomatic side. A turbulent model-enabled commercial flow solver was used to simulate the pulsatile blood flow over the cardiac cycle through the models. Fluid flow through the transverse and SS junction was analyzed to observe the velocity, pressure, turbulent kinetic energy (TKE), and shear stress over a simulated cardiac cycle. RESULTS: Fluid flow on the symptomatic side showed increased vorticity in the presence of an SS diverticulum. Higher TKE with periodicity following the cardiac cycle was observed on the symptomatic side, and a sharp increase was observed if SS diverticulum was present. Shear stress was highest near the narrowest segments of the vessel. Pressure was observed to be lower on the symptomatic side at the transverse-SS junction for all 3 patients. CONCLUSION: Computational fluid dynamics modeling of blood flow through the CVOT in PST suggests that low pressure may be the cause of dehiscence, and tinnitus may result from periodic increases in TKE.

Rare Central Venous Catheter Malpositions: A Case Series.

Central venous catheters are a procedure that provides vascular access, allowing the application of various clinical treatments and the measurement of some hemodynamic values. It provides access to the internal jugular vein, subclavian vein, and, femoral vein with a large-bore catheter. There are mechanical, infectious, and thromboembolic complications resulting from central venous catheter placement and care. Central venous catheter malposition is a rare catheter complication that may be encountered. The location of the central venous catheter can be evaluated with imaging techniques such as posteroanterior chest radiograph, ultrasonography, central venous catheter waveform, and transesophageal echocardiography. Five malposition cases detected by imaging after the central venous catheter procedure in our clinic are presented.

Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure.

This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.

Subclavian line infiltration causing neck compartment syndrome and bradycardic arrest: A case report.

Unrecognized central venous catheter (CVC) infiltration is an uncommon but potentially life-threatening complication. For instance, a malpositioned subclavian line can infuse into the mediastinum, pleural cavity, or interstitial space of the neck. We present the case of a 30-year-old male with gunshot wounds to the right chest, resuscitated with an initially functional left subclavian CVC, which later infiltrated into the neck causing compression of the carotid sinus and consequent bradycardic arrest. Return of spontaneous circulation (ROSC) was achieved following intravenous epinephrine, cardiac massage, and emergency neck exploration and cervical fasciotomy. Our case highlights the importance of frequent reassessment of lines, especially those placed during fast-paced, high-intensity clinical situations. We recommend being mindful when using rapid transfusion devices as an interstitial catheter may not mount enough back pressure to trigger the system's alarm before significant tissue damage or compartment syndrome occurs.

The relationship between perioperative central venous oxygen saturation and postoperative complications in highly invasive gastroenterological surgery.

Purpose: Operations for malignant diseases of the bile duct, pancreas, and esophagus are the most invasive gastroenterological surgeries. The frequency of complications after these surgeries is high, which affects the postoperative course and mortality. In patients who undergo these types of surgeries, continuous monitoring of the perioperative central venous oxygen saturation (ScvO2) is possible via a central venous catheter. We aimed to investigate the relationship between continuously monitored perioperative ScvO2 values and postoperative complications. Methods: The medical records of 115 patients who underwent highly invasive gastroenterological surgeries and ScvO2 monitoring from April 2012 to March 2014 were analyzed. Sixty patients met the inclusion criteria, and their ScvO2 levels were continuously monitored perioperatively. The relationship between ScvO2 levels and major postoperative complications, defined as Clavien-Dindo grade ≥ III, was examined using uni- and multivariate analysis. Results: Thirty patients developed major postoperative complications. The adequate cut-off value derived from receiver operating curves of the postoperative average ScvO2 levels for predicting major complications was 75%. Multivariate analysis revealed that low average postoperative ScvO2 levels (p = 0.016) and blood loss ≥ 1000 mL (p = 0.039) were significant predictors of major postoperative complications. Conclusions: Low perioperative ScvO2 values were associated with an increased risk of major postoperative complications. Continuous ScvO2 monitoring will help prevent postoperative complications.

Central Venous Catheter Misplacement Into Pleural Cavity Causing Hypertensive Pleural Effusion: A Case Report.

Central venous catheter (CVC) insertion is a routine procedure in the management of critically ill patients. We report a clinical case of inadvertent placement of an internal jugular vein CVC into the right pleural cavity, despite employing clinical and imaging-based techniques to ensure proper catheter positioning. Infusion of fluids and vasopressors through this misplaced catheter led to hypertensive pleural effusion and subsequent cardiorespiratory arrest. Return of spontaneous circulation was achieved after two cycles of cardiopulmonary resuscitation. While multiple imaging modalities are recommended for confirming appropriate CVC placement, each method has inherent limitations. This case highlights the imperative need for a high index of suspicion to avert such complications and pretends to review some of each method's limitations.

The use of Guyton's approach to the control of cardiac output for clinical fluid management.

Infusion of fluids is one of the most common medical acts when resuscitating critically ill patients. However, fluids most often are given without consideration of how fluid infusion can actually improve tissue perfusion. Arthur Guyton's analysis of the circulation was based on how cardiac output is determined by the interaction of the factors determining the return of blood to the heart, i.e. venous return, and the factors that determine the output from the heart, i.e. pump function. His theoretical approach can be used to understand what fluids can and cannot do. In his graphical analysis, right atrial pressure (RAP) is at the center of this interaction and thus indicates the status of these two functions. Accordingly, trends in RAP and cardiac output (or a surrogate of cardiac output) can provide important guides for the cause of a hemodynamic deterioration, the potential role of fluids, the limits of their use, and when the fluid is given, the response to therapeutic interventions. Use of the trends in these values provide a physiologically grounded approach to clinical fluid management.

Nurses' evidence-based knowledge and self-efficacy in venous access device insertion and management: Development and validation of a questionnaire.

AIM: To develop and psychometrically test an instrument to assess nurses' evidence-based knowledge and self-efficacy regarding insertion and management of venous access devices (short peripheral catheter (SPC), long peripheral catheter/midline (LPC) and PICC) and the management of totally implantable central venous catheter (Port) in adult patients. DESIGN: Multicenter cross-sectional observational study with questionnaire development and psychometric testing (validity and reliability). METHODS: An evidence-based instrument was developed including a 34-item knowledge section and an 81-item self-efficacy section including four device-specific parts. Nineteen experts evaluated content validity. A pilot study was conducted with 86 nurses. Difficulty and discrimination indices were calculated for knowledge items. Confirmatory factor analyses tested the dimensionality of the self-efficacy section according to the development model. Construct validity was tested through known group validity. Reliability was evaluated through Cronbach's alpha coefficient for unidimensional scales and omega coefficients for multidimensional scales. RESULTS: Content validity indices and results from the pilot study were excellent with all the item-content validity indices >0.78 and scale-content validity index ranging from 0.96 to 0.99. The survey was completed by 425 nurses. Difficulty and discrimination indices for knowledge items were acceptable with most items (58.8%) showing desirable difficulty and most items (58.8%) with excellent (35.3%) or good (23.5%) discrimination power, and appropriate to the content. The dimensionality of the model posited for self-efficacy was confirmed with adequate fit indices (e.g., comparative fit index range 0.984-0.996, root mean square error of approximation range 0.054-0.073). Construct validity was determined and reliability was excellent with alpha values ranging from 0.843 to 0.946 and omega coefficients ranging from 0.833 to 0.933. Therefore, a valid and reliable tool based on updated guidelines is made available to evaluate nurses' competencies for venous access insertion and management.

A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis.

OBJECTIVE: This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting. DATA SOURCES: PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022. REVIEW METHODS: Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence. RESULTS: Thirty nine studies reporting outcomes in 1539 patients were included in the meta-analysis. Primary patency up to 1 year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after 1 year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low. CONCLUSION: Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to 1 year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after 1 year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programme.

Implementation frameworks, strategies and outcomes in optimizing central venous access device practice in paediatrics: A scoping review.

Paediatric patients with complex or acute conditions may require a central venous access device, however, almost one-third of these devices have associated complications (e.g. infections). Implementation of evidence-based practices regarding central venous access devices can reduce and potentially prevent complications. AIMS: This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens. DESIGN: This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool. DATA SOURCES: Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL). RESULTS: Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre-post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health-professional education, bundles and working groups. Bundle compliance and reductions in central line-associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes. CONCLUSION: Translation of evidence-based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from 'quality improvement') is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself. IMPLICATIONS FOR PATIENTS: Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies. IMPACT: Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care. Adhered to best reporting guidelines as per PRISMA-ScR (Tricco et al., 2018). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

The Study of the Feasibility of Ultrasound-guided Catheterization of the Right Brachiocephalic Vein in Adult Patients: A Prospective Observational Study.

Background: The brachiocephalic vein (BCV) is a feasible option for central venous access in the pediatric population and is rapidly developing as an alternative site for insertion of the central line in young children with faster insertion times, fewer attempts, and lower rates of complications. However, studies demonstrating the feasibility of BCV catheterization in adult patients are insufficient. The current study sought to assess the safety and effectiveness of ultrasound-guided supraclavicular right BCV cannulations in adults. Methods: A linear array Ultrasound (US) probe was used to obtain a longitudinal picture of the BCV beginning at the junction of the internal jugular vein and the subclavian vein in the supraclavicular region. Under US supervision, the needle was guided into the BCV using the in-plane approach. A prospective study was performed on 80 adult patients scheduled for elective and emergency operative procedures under general anesthesia requiring a central venous catheter (CVC). Success rates and complications that occurred during catheter insertion were analyzed. Results: CVC placement was successful in all adults. The procedure was successful at the first attempt in 74 cases (92.5%) and after 2 attempts in six patients (7.5%). The time to guide wire insertion was 31.26 s (19-58 s), and catheter insertion took 88.44 s (63-145 s). The mean length of catheter insertion was 10.46 cm. No complications were noted. Conclusion: Ultrasound-guided supraclavicular BCV catheterization offers a new and safe method for central venous line catheterization in adults. However, larger trials and meta-analyses are needed to confirm these findings and evaluate the safety of this technique.

Recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein: A case report.

A fibrin sheath with central venous occlusion is a common complication after central venous catheterization, and these patients often experience catheter dysfunction. A calcified fibrin sheath can cause a catheter to be stuck, and typically necessitates catheter removal or replacement. From another point of view, a calcified fibrin sheath can be seen in ultrasound and computed tomography, and the original fibrin sheath channel between the internal jugular vein and the atrium is unusually strong. When central vein occlusion occurs, the remnant calcified fibrin sheath of the internal jugular vein can be punctured under ultrasound guidance, allowing the guidewire to enter the atrium directly through the fibrin sheath. Here, we report a case in which we achieved easy recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein.

Incidence of catheter-related thrombosis and its association with outcome in critically ill patients: A prospective observational study.

BACKGROUND: Incidence of central venous catheter (CVC)-related thrombosis in critically ill patients remains ambiguous and its association with potential hazardous sequelae unknown. The primary aim of the study was to evaluate the epidemiology of CVC-related thrombosis; secondary aims were to assess the association of catheter-related thrombosis with catheter-related infection, pulmonary embolism and mortality. METHODS: This was a single-center, prospective observational study conducted at a tertiary intensive care unit (ICU) in the Netherlands. The study population consisted of CVC placements in adult ICU patients with a minimal indwelling time of 48 h. CVC-related thrombosis was diagnosed with ultrasonography. Primary outcomes were prevalence and incidence, incidence was reported as the number of cases per 1000 indwelling days. RESULTS: 173 CVCs in 147 patients were included. Median age of patients was 64.0 [IQR: 52.0, 72.0] and 71.1 % were male. Prevalence of thrombosis was 0.56 (95 % CI: 0.49, 0.63) and incidence per 1000 indwelling days was 65.7 (95 % CI: 59.0, 72.3). No association with catheter-related infection was found (p = 0.566). There was a significant association with pulmonary embolism (p = 0.022). All 173 CVCs were included in the survival analysis. Catheter-related thrombosis was associated with a lower 28-day mortality risk (hazard ratio: 0.39, 95 % CI: 0.17, 0.87). CONCLUSION: In critically ill patients, prevalence and incidence of catheter-related thrombosis were high. Catheter-related thrombosis was not associated with catheter-related infections, but was associated with pulmonary embolism and a decreased mortality risk.

Effectiveness of nanoparticle-based antimicrobial agents in the prevention and treatment of Central Venous Catheter-Associated Bloodstream Infections.

BACKGROUND: In healthcare settings, Central Venous Catheter-Associated Bloodstream Infections (CVC-BSIs) present a serious problem since they raise morbidity, mortality, and medical expense rates. The management of these illnesses is made more challenging by the development of antimicrobiotic resistance. Nanotechnology has attracted interest recently as a viable method for creating new antimicrobial agents. By putting antibacterial nanomaterials onto the catheter's appear, that may reduce the likelihood of getting sick by stopping germs from adhering and growing. Antimicrobial additives can be released gradually finishes, protecting over time through bioengineering sectors. To prevent and treat CVC-BSIs, this study will assess the efficacy of antimicrobial medicines based on nanoparticles. METHODS: In the network Meta-Analyses (MA) and Systematic Review (SR), we looked for studies published from January 2010 to September 2021 using the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAHL, and Web of Science databases. Ten papers in all were included in the review following the screening of the publications using inclusion and exclusion criteria. RESULTS: In contrast to conventional catheters, the implementation of Antimicrobial Catheters (AC) and the use of chlorhexidine (CHG) or Silver Sulfadiazine (SS) demonstrated notably reduced occurrences of Central Venous Catheter-Associated Bloodstream Infections (CVC-BSIs) per 1000 Catheter Days (CD) (with Odds Ratios (ORs) and 95% Credibility Intervals (CrIs) of 0.66 and 0.54, respectively) by bioengineering sectors. Moreover, these interventions were linked to the lowest rate of Catheter Colonization (CC), with ORs as well as 95% CrIs of 0.45 and 0.31, respectively, underscoring their potential as effective strategies for minimizing the risk of infections associated with catheter use as well as bioengineering sectors innovations. CONCLUSIONS: As a result, CVC-BSI has shown significant promise for prevention and treatment with nanoparticle-based antimicrobial medicines. Due to their special characteristics and modes of action, they are strong candidates for improving the security and effectiveness of central venous catheter use in clinical settings. Due to ongoing research and development in this area, nanoparticle-based coatings and therapies may be used to lessen the impact of CVC-BSIs and enhance patient outcomes.

Evaluation of the Efficacy of a Novel Dermatotomy Device for Central Venous Cannulation.

OBJECTIVE: To test the effectiveness of a novel wire-guided scalpel (Guideblade) to create a precise dermatotomy incision for central venous catheter (CVC) insertion. DESIGN: Prospective, nonrandomized interventional study. SETTING: Stanford University, single-center teaching hospital. PARTICIPANTS: Cardiac and vascular surgical patients (n = 100) with planned CVC insertion for operation. INTERVENTIONS: A wire-guided scalpel was used during CVC insertion. RESULTS: A total of 188 CVCs were performed successfully with a wire-guided scalpel without the need for additional equipment in 100 patients, and 94% of CVCs were accomplished with only a single dermatotomy attempt. "No bleeding" or "minimal bleeding" at the insertion site was observed in 90% of patients 30 minutes after insertion and 80.7% at the conclusion of surgery. CONCLUSION: The wire-guided scalpel was effective in performing dermatotomy for CVC with a 100% success rate and a very high first-attempt rate. The wire-guided scalpel may decrease bleeding at the CVC insertion site.

Bleeding assessment following central venous catheter placement, a direct comparison of prospective and retrospective analyses.

BACKGROUND: Reported bleeding incidences following central venous catheter (CVC) placement highly depend on methods of bleeding assessment. To determine the direction and magnitude of the bias associated with retrospective data collection, we used data from the PACER randomized controlled trial and a previous retrospective cohort study. STUDY DESIGN AND METHODS: A patient-level comparison of CVC-related bleeding severity was made among (1) the prospectively collected clinical bleeding assessment of the PACER trial, (2) centralized assessment of CVC insertion site photographs, and (3) retrospective chart review. Interrater reliability for photographic bleeding assessment and retrospective chart review was assessed using Cohen's κ. The magnitude of underreporting of both methods compared to prospective clinical bleeding assessment at different cutoff points of clinically relevant bleeding was assessed using McNemar's test. RESULTS: Interrater reliability was acceptable for both methods (κ = 0.583 and κ = 0.481 for photographic assessment and retrospective chart review, respectively). Photographic bleeding assessment led to significant underreporting of bleeding complications at all cutoff points. Retrospective chart review led to significant underreporting of minor bleeding complications, with an odds ratio (95% CI) of 0.17 (0.044-0.51) for the cutoff point grade 1 (i.e., self-limiting or requiring at most 20 min of manual compression) or higher. There was no significant underreporting of major bleeding complications with retrospective chart review. DISCUSSION: Centralized photographic bleeding assessment and retrospective chart review lead to biased bleeding assessment compared to prospective clinical bleeding assessment.

Consensus document of the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Intensive Care (SECIP) for the diagnosis and treatment of central venous catheter-related infections in paediatric care.

Intravascular devices are essential for the diagnostic and therapeutic approach to multiple diseases in paediatrics, and central venous catheters (CVCs) are especially important. One of the most frequent complications is the infection of these devices, which is associated with a high morbidity and mortality. These infections are highly complex, requiring the use of substantial resources, both for their diagnosis and treatment, and affect vulnerable paediatric patients admitted to high-complexity units more frequently. There is less evidence on their management in paediatric patients compared to adults, and no consensus documents on the subject have been published in Spain. The objective of this document, developed jointly by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Intensive Care (SECIP), is to provide consensus recommendations based on the greatest degree of evidence available to optimize the diagnosis and treatment of catheter-related bloodstream infections (CRBSIs). This document focuses on non-neonatal paediatric patients with CRBSIs and does not address the prevention of these infections.