A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.     

Domiciliary intravenous antibiotic therapy

BACKGROUND: To assess the efficiency and safety of intravenous antibiotic therapy (IAT) when performed through the traditional simple infusion system by gravity in the home setting. PATIENTS AND METHODS: The clinical records of patients undergoing intravenous antibiotic therapy through the traditional gravitational infusion system in the home care unit over a five year period were reviewed retrospectively. RESULTS: 120 patients were treated (44 F/76 M), with a mean age of 48 years (44-52). 67% of the total had chronic diseases. Infections were most commonly found in bones and joints (38%), followed by the skin and soft tissues. A wide variety of antibiotics was used, 61% as monotherapy. 76% of them were given intermittently. 161 intravenous catheters were used, 53% of which were central catheters with peripheral insertion, 27% inserted centrally and 20% peripheral catheters. The overall incidence of phlebitis was 18% without associated bacteremia. 91% of our patients evolved well, 6% had to become in-patients, none of them due to problems with the infusion system or by their own petition. The intravenous treatment lasted a mean of 17 days at home and 25 days at both home and hospital, which represents a decrease of 2,040 hospital stays. CONCLUSIONS: The traditional gravitational system of infusion is an effective and safe method for intravenous antibiotic administration at home. For these therapies to be successful, suitable patients must be selected and continuous attention is required. This treatment at home satisfies the patient and permits hospital stays to be reduced, thus improving the use of hospital resources.     

Pharmacokinetics and concentration-effect relationship after propofol infusion

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical-surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple-lumen catheters most frequently as their CVC for TPN (80.3%). A povidone-iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter-related infection and sepsis rates were within the national average, although < 50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.     

Prevention of indwelling central venous catheter sepsis

In an attempt to decrease the incidence of central venous catheter sepsis in children with cancer, we conducted a study to evaluate the benefit of adding broad-spectrum antibiotics to the catheter "flush solution." In a prospective, placebo-controlled, double-blinded, randomized trial, 69 children with different types of malignancies were studied. The central venous catheters in these children were flushed with either the standard solution (normal saline + 100 U/ml of heparin) or the study solution (25 microgram/ml of both amikacin and vancomycin added to the standard solution). At the conclusion of the study, 64 children with a total of 67 indwelling central venous lines were assessable. The total catheter days on study were 20,700 days, with a median of 323 catheter days per patient. We documented 10 events of catheter-related infections (0.49 events/1,000 catheter days at risk). Five of these events were catheter-related sepsis (0.24 sepses/1,000 catheter days): two were fungal and three were bacterial. Due to the low incidence of catheter-related sepsis in this study, no statement regarding the prophylactic use of antibiotics could be made. The extremely low rate of catheter-related sepsis reported herein may be retrospectively attributed to continuous staff education regarding aseptic techniques in handling these catheters. Staff education is essential, and probably the most effective factor in preventing catheter-related sepsis.     

Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients

OBJECTIVE: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. DESIGN: One-year prospective audit. SETTING: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. PATIENTS AND PARTICIPANTS: 400 patients with non-tunnelled CVCs. Interventions: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. MEASUREMENTS AND RESULTS: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8%) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95% confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. CONCLUSIONS: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population.     

Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study

The aim of this prospective study was to compare differential blood cultures and quantitative catheter tip cultures for the diagnosis of catheter-related sepsis. Over a period of 2 years, 283 central venous catheters were inserted in 190 adult patients. Catheters were removed when they were no longer needed or when infection was suspected. Immediately before removal of the central venous catheters, blood cultures were performed, with blood drawn simultaneously from the catheter and the peripheral vein. After removal, quantitative catheter culture was performed according to the Brun-Buisson modified Cleri technique. Fifty-five quantitative catheter cultures were positive. They were classified as contaminated (n = 18), colonized (n = 23), or infected (n = 14). Differential blood cultures correctly identified 13 infections. With a catheter/peripheral cfu ratio of 8, differential blood cultures had a sensitivity of 92.8% and a specificity of 98.8%. When the catheters were removed because of suspected infection, differential blood cultures had a sensitivity of 92.8% and a specificity of 100%. Differential blood culture, a technique that does not necessitate catheter removal, seems effective in the diagnosis of catheter-related sepsis in patients in the intensive care unit.     

Peripherally inserted central catheters in an acute-care hospital

BACKGROUND: Peripherally inserted central catheterization is a relatively new approach for intravenous therapy in acute-care hospitals. Few studies are available on peripherally inserted central catheters (PICCs) used in adult patients in an acute-care setting. We examine the natural history and outcome of PICC use in our hospital. METHODS: A retrospective review was undertaken of all hospitalized patients who had PICCs inserted in an acute-care, metropolitan teaching hospital for any reason from July 1991 through July 1992. Patients who had PICCs inserted, used, and then removed in the same hospitalization were evaluated. RESULTS: A total of 135 PICCs were inserted in 114 patients. Six PICCs (4.4%) were inserted in intensive care unit settings and 129 (95.6%) in general medical or surgical service. The mean duration catheters were in place before removal was 14.1 days. Sixty-three catheters (46.7%) were removed following completion of therapy. The rate of PICC-related infection was 2.2% (three catheters). The occlusion rate was higher for 20-gauge catheters (18.4%) than for 18-gauge catheters (8.2%) (P = .08). When the rate of complications was compared as a function of catheter use (total parenteral nutrition vs any other use), there was no statistically significant difference (P = .12). Overall complications related to catheter insertion and removal were uncommon. CONCLUSIONS: Based on our study, we conclude that the PICC provides a reasonable and safe alternative to other centrally placed venous devices. In addition, the convenience of maintaining a PICC compared with peripheral intravenous access makes this an attractive method for in-hospital use.     

A new complication of chemotherapy administered via permanent indwelling central venous catheter

BACKGROUND: The use of permanent intravenous access devices for chemotherapy administration has become a common practice in clinical oncology. Therefore, awareness of potential complications is important. The authors previously reported the use of high dose 5-fluorouracil (5-FU) (2600 mg/m2) and leucovorin (500 mg/m2) as a weekly 24-hour infusion for patients with colorectal carcinoma. In this report, a new complication of permanent indwelling catheters with high dose 5-fluorouracil (2600 mg/m2) and leucovorin (500 mg/m2) as a weekly 24-hour infusion for colorectal carcinoma is described. METHODS: Twenty-two patients in the previous Phase II trial on weekly high dose 5-FU and leucovorin were included in this study. All patients had either a single-lumen Port-o-cath (Pharmacia Deltec, St. Paul, MN) or Hickman catheter (Travenol Laboratories, Deerfield, IL). Occluded catheters were explanted, and the material found in their lumen was analyzed using infrared spectroscopy. RESULTS: Eleven of 22 patients had catheter blockage, and calcium carbonate formation (Calcite 100%) was identified within these catheters. CONCLUSION: Calcite formation causing catheter occlusion is a new and important complication resulting from using intravenous access devices for chemotherapy administration. Oncologists should be alerted to this phenomenon when high dose 5-FU and leucovorin are administered for 24 hours by continuous infusion using a single-port port-o-cath.     

Prospective study of infective complications in newborns with fine silicone catheters used for parenteral nutrition infusion

OBJECTIVE: Percutaneous silastic central venous catheters have contributed to improve the care of neonates. They are quite safe; however, sometimes complications occur, with infections being the most frequent. A prospective study was undertaken in our NICU to know the rate of catheter-related sepsis, the influence of the duration of catheterization, the predominant portal of entry and the microorganisms isolated. PATIENTS AND METHODS: Fifty-two catheters were analyzed. Cultures were obtained once a week by aspiration from the catheter hub, the luer-lock connection and parenteral nutrition solution directly from the bag. If sepsis was suspected, blood cultures were obtained from a different vein. The tip was cultured after catheter withdrawal by the semiquantitative technique of Maki. RESULTS: Nineteen catheters (36.5%), 19 luer-lock connections (21.3%) and 7 parenteral nutrition solutions were colonized. We found a significant increase of the rate of colonization after the catheter had been in place 3 weeks or more (p < 0.05). Coagulase negative Staphylococcus was isolated in 75.7% of the samples. The rate of catheter related sepsis was 15.4% (7/8 caused by coagulase negative Staphylococcus). CONCLUSIONS: Catheter related sepsis may be more frequent than expected it colonization of the catheter were analyzed systematically. Screening catheter colonization allows an earlier diagnosis of pathogens if sepsis develops. Finally, we believe that the use of sterile techniques to handle the catheter and connections will further decrease catheter related infections.     

Interleukin-12 enhancement of antigen-specific lymphocyte proliferation correlates with stage of human immunodeficiency virus infection

OBJECTIVE: The purpose of this study was to evaluate the use and complication rate of tunneled femoral hemodialysis catheters placed in patients with no remaining thoracic venous access sites. MATERIALS AND METHODS: Over a 3-year period, 41 tunneled femoral vein catheters (35 right, six left) were placed in 21 patients (15 women, six men; 21-89 years old; mean, 52 years). Catheters ranged in length from 40 to 60 cm. Tips were positioned immediately above the iliac bifurcation, at the mid inferior vena cava (IVC), or at the junction of the IVC and right atrium. Catheters were exchanged through the existing tract if the flow rate decreased to less than 200 ml/min. Catheters were removed if an episode of bacteremia did not resolve with antibiotics or if the insertion site became infected. RESULTS: Technical success of placement was 100%. The 30-, 60-, and 180-day primary patency rates were 78%, 71%, and 55%, respectively. The 30-, 60-, and 180-day secondary patency rates were 95%, 83%, and 61%, respectively. Average time of function per intervention was 61 days. Infections requiring catheter removal occurred at a rate of 2.4 per 1000 catheter days. One episode of partial IVC thrombosis occurred after a catheter infection developed 78 days after initial catheter placement. No episodes of symptomatic pulmonary embolism occurred. Total length of follow-up was 2506 catheter days. CONCLUSION: Femoral vein catheters require more frequent interventions than do thoracic catheters and are more susceptible to infection. However, in patients with difficult central venous access, the common femoral vein may be successfully used for permanent tunneled hemodialysis access.     

A case of mediastinal neurilemmoma originating from the intrathoracic vagal nerve

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are commonly used intravenous access devices in children. Although PICCs are intended to be placed in central veins, many fail to reach this location. These noncentral PICCs are used for administration of medications and isotonic solutions. OBJECTIVES: To examine the efficacy of noncentral PICCs for completion of therapy, the complications associated with their use, and the effectiveness of noncentral PICCs as compared with PICCs placed in a central vein. DESIGN: A prospective cohort study of children in whom PICCs were inserted, from January 1, 1994, to January 1, 1996. SETTING: A university-affiliated teaching institution. MAIN OUTCOME MEASUREMENT: Completion of intravenous therapy. RESULTS: A total of 587 PICCs were studied. Thirty-nine percent of PICCs were placed in noncentral veins. Centrally placed PICCs had significantly longer catheter duration compared with those placed noncentrally (16.6 vs 11.4 days, respectively). However, central and noncentral PICCs had similar therapy completion rates (73% and 69%, respectively). Catheter failure because of occlusion and accidental dislodgment were similar for central and noncentral PICCs. Likewise, complications caused by exit-site infection, phlebitis, and catheter-associated sepsis were also similar for catheters in the 2 locations. Catheter survival curves were similar for central and noncentral PICCs. CONCLUSIONS: Our study demonstrates that PICCs placed in noncentral veins provide reliable and safe intravenous access for administration of many medications and isotonic solutions for about 2 weeks' duration. The placement of PICCs in central veins may be restricted to those children who need central vascular access because of the type of intended therapy.     

Percutaneous central venous catheters in neonates: a descriptive analysis and evaluation of predictors for sepsis

The article describes the experience with percutaneous central venous catheters in 565 neonates with birth weights of 400 to 6810 g. The catheter-related sepsis incidence was 19.1%, or 13.5 infections per 1000 catheter days. By discriminant function analysis, 86% of all neonates studied were correctly classified into the confirmed sepsis and no sepsis groups on the basis of six predictor variables. The model did not accurately predict the neonates who would develop confirmed sepsis. The weight at catheter insertion and length of time for which the catheter was in place were identified as variables that contributed significantly to differentiation between sepsis and no sepsis groups.     

Complications of intravenous therapy. Influence of parenteral nutrition, central venous pressure and antibiotics

With regard to the controversy on whether the use of central venous catheters for the perfusion of other solutions as well as parenteral nutrition means an increase in the risk of sepsis caused by the catheter, a prospective study was made on 313 central intravenous catheters placed in patients admitted to the Intensive Medicine Unit of La Paz General Hospital over a one-year period. Collection of data on both catheters and patients was done following a protocol applied in all cases. From the results obtained, it can be concluded that in critical patients in whom a single central venous catheter has been placed, this can be used for the infusion of other liquids, apart from parenteral nutrition, without involving an increased risk of sepsis caused by the catheter. This pathology seems to bear more relation to the amount of time the catheter remains in place.     

Experimental Bacteroides fragilis endocarditis in rabbits

A serum-resistant strain of Bacterioides fragilis that did not produce heparinase was used to study the characteristics of B. fragilis endocarditis in the rabbit experimental model. The infective dose required to produce endocarditis in 50% of rabbits was significantly lower for rabbits with left-sided intracardiac catheters (log10 6.3 colony-forming units +/- 0.6/ml) as compared with right-sided intracardiac catheters (log10 7.7 colony-forming units +/- 0.8/ml). After 3 days of infection, bacterial titers of the tricuspid vegetations were significantly lower than titers of aortic vegetations (P less than 0.01), although at 5 days the titers were similar (P greater than 0.05). The weights of tricuspid vegetations, although similar at 3 days (P less than 0.05). There were no spontaneous deaths during 12 days of infection. In rabbits with the catheter removed before infection, bacterial titers were similar to those titers in rabbits with the catheter continuously in place. This model will permit study of various drug regimens for treatment of this disease.     

Prospective 3-month study of intravascular catheter complications in HIV-infected patients: relation between phlebitis and infection

BACKGROUND: The aim of this study was to evaluate the etiology of phlebitis (chemical or infectious) and the prevalence of infections related to intravascular catheters (IRIC) in patients with HIV infection admitted to a 22-bed Infectious Disease Unit with a high rate of HIV infection. MATERIAL AND METHODS: A 3-month prospective study from November 1, 1994 to January 31, 1995 was carried out following a formula for data collection of all the intravenous catheters used during that time period. Cultures of the catheters withdrawn on Wednesdays and those with signs of phlebitis were performed. RESULTS: One hundred fifty-two intravenous catheters in 71 patients with HIV infection with a mean age of 37 years (range: 21-73) and mean hospital stay of 10.2 days were reported. During the study period 42 phlebitis were produced, of which 37 catheters (7 central and 30 peripheral) were processed. Of the 37 phlebitis processed, 29 (78.9%) were considered to be of physiochemical origin. Of the 21 catheters withdrawn Wednesday, 18 were processed, 8 with phlogotic signs, 2 with IRCI, equivalent to 1.9 IRCI/100 days of catheterization. During the study period no local or severe systemic infections related to the catheter were reported. Staphylococcus epidermidis was the organism involved in all the cases of IRCI. CONCLUSIONS: Despite the high number of immunosuppressed patients in related to HIV infection, a greater incidence of IRCI was not found in these patients. The most frequent cause of phlebitis by catheter was of chemical origin.     

Home parenteral nutrition in children: the Polish experience

BACKGROUND: Home parenteral nutrition has become routine for management of intestinal failure in patients. In Poland the main obstacle to widespread use of home parenteral nutrition is the lack of interest of commercial companies in delivering feedings and ancillaries to patients. METHODS: Twenty-five home parenteral nutrition patients aged from 4 months to more than 13 years were reviewed. The mother or both parents were trained in home parenteral nutrition techniques for 4 to 6 weeks and compounded the nutrients themselves at home. RESULTS: The mean duration of home parenteral nutrition was 10,117 patient days. Hospital stays of patients receiving parenteral feedings were significantly shorter than the duration of administration of home parenteral nutrition (p < 0.001). Eleven children are continuing the home parenteral nutrition program. Eighty-three catheters were used in these patients. The rate of catheter occlusion decreased within the observation period, and in 1997 not one case of occlusion was observed. In 1997 only three catheters were removed during 7.8 patient years, and the overall incidence of catheter-related complications was 0.38 per patient year. The overall occurrence of septicemia was one case in 516 days and of catheter infection was one in 459 days. In 1997 a catheter was infected on average of once every 1419 days. There was significant improvement in the z score for weight during therapy. The average monthly cost of nutrients and ancillary items was approximately $1200 (4200 Polish zlotys [PLN]). These costs are 1.6 to 3 times lower than those recorded in other studies. CONCLUSION: Home parenteral nutrition in children with nutrients mixed by caregivers in the home setting is a safe and appropriate method of treatment that can be used in countries where home parenteral nutrition solutions are not manufactured or where commercial home parenteral nutrition is not economically feasible.     

Central venous line sepsis in the intensive care unit. A study comparing antibiotic coated catheters with plain catheters

A randomized controlled clinical trial was undertaken to evaluate the efficacy of antibiotic bonded lines in the reduction of central venous catheter infection. One hundred and seventy-six plain and bonded catheters were inserted into one hundred and ten patients in an intensive care unit, many of whom were admitted with evidence of sepsis. The catheters used in the study group, which had been pre-treated by the manufacturers with the cationic surfactant tridodecylmethylammonium chloride, were bonded with vancomycin 1 g made up in 10 ml of water immediately prior to insertion. The catheters used in the control group were neither pre-treated nor bonded with vancomycin. Eighty percent of control group catheters were infected compared with 62% of study catheters (p = 0.01). The most common organism isolated was coagulase negative staphylococcus. We conclude that antibiotic bonding can reduce central venous catheter infection even in a patient population with a high incidence of sepsis.     

Subcutaneously implanted central venous access devices in cancer patients: a prospective analysis

BACKGROUND: Long term intravenous access is a common requirement for cancer patients. This analysis was designed to determine device-related morbidity and factors predictive of poor long term outcome for patients with subcutaneous single lumen intravenous access ports. METHODS: Six hundred eighty patients who underwent subcutaneous intravenous port placement between June 1987 and May 1989 at Memorial Sloan-Kettering Cancer Center were followed prospectively until port removal, death, or a maximum of 1960 days. Indications for and circumstances of placement, patient diagnoses, patient demographics, and subsequent courses of treatment were recorded, as well as technical and microbiologic device-related complications. Total, device specific, and complication free device durations were calculated. RESULTS: The median patient age was 52.4 years (range, 1.6-83.9 years). The female-to-male ratio was 1.5 to 1. Cancer diagnoses included solid organ tumors (84%), leukemia (4%), lymphoma (11%), and others (1%). Indications included access for systemic chemotherapy (98%), total parenteral nutrition (0.5%), and others (1.5%). One insertion complication and six insertion failures occurred, without mortality. The estimated mean overall actuarial device specific duration was 1191 days (range, 2-1960 days). Actuarial mean complication free, device specific duration was 952 days. Complications included sepsis (n = 31; 4.4%), site infection (n = 31; 4.4%), and accessibility failures such as thrombosis and leakage (n = 40, 5.7%). Reasons for end of port duration were patient death (72.4%), end of treatment (13.5%), functional failure or intractable infection (11.2%), and others (2.9%). Independent factors correlating with decreased port specific, complication free duration included placement site, age, tumor type, and catheter tip position. CONCLUSIONS: Subcutaneous intravenous access ports in cancer patients are safe and well tolerated. Long term device duration is primarily influenced by patient survival. In this study, 90% of patients alive at 1 year and 70% of patients alive at 4 years had a functional port.     

Sepsis outcomes in infants and children with central venous catheters: percutaneous versus surgical insertion

OBJECTIVE: To review the literature on central venous catheters (CVCs) in infants and children. DATA SOURCES: Published surgical, medical, nursing, and nutritional studies from 1968 to the present. STUDY SELECTION: More than 250 studies were reviewed; selection criteria for the 64 studies chosen included age, percutaneous CVC (PCVC) or surgical CVC (SCVC) use, and defined rate of sepsis. DATA EXTRACTION: Included study purpose, sample size and age, indications for total parenteral nutrition, insertion method and sites, number of CVCs, and sepsis outcomes. DATA SYNTHESIS: Yielded weighted mean sepsis rates that were 3.5 times higher for SCVC use in neonatal and/or pediatric populations; subanalyses of homogeneous groups of studies yielded rates that were 2.5 to 3.8 times higher. CONCLUSIONS: Percutaneous CVC insertion should be given primary consideration for neonatal and pediatric intensive-care patients.