Peripherally inserted central venous catheters: factors affecting patient satisfaction

OBJECTIVE: We studied factors that affect satisfaction of patients who have undergone placement of peripherally inserted central venous catheters (PICCs) by interventional radiologists and patients' willingness to undergo placement of future PICCs. SUBJECTS AND METHODS: This longitudinal prospective consecutive cohort study included 85 patients referred for PICC placement. A record was made of catheter type, time taken for placement, patient age, and possible complications. Follow-up was obtained by telephone interview to determine the effect of site of placement in the arm, residence time of catheter, additional complications, and interference with activities of daily living on patient willingness to undergo future PICC placement at the same site. Logistic regression analysis was used to determine factors statistically predictive of patient willingness to undergo placement of future PICCs. RESULTS: Patients having PICCs placed above the elbow were more often satisfied (55 of 61 respondents) with catheter location than patients having placements at the elbow (three of 17 respondents). Patient willingness to undergo future PICC placement was strongly related to catheter location (p < .0001) and interference with activities of daily living (p < .0001). Catheter type, residence time, time taken for the placement, age, and complications were not associated with patient willingness to undergo future PICC placement. CONCLUSION: PICC placement above the elbow is more acceptable to patients than placement at the elbow. PICC placement above the elbow and patients' perception of less interference by the PICC with activities of daily living are positively related to patient willingness to undergo future PICC placement.     

Risk factors for early infection of central venous catheters in pediatric patients

OBJECTIVE: To compare standard nurse-based pain therapy with a patient-controlled analgesia (PCA) regimen. DESIGN: Prospective, randomized study. SETTING: Single-institutional, clinical investigation in an urban, university-affiliated hospital. PARTICIPANTS: Sixty patients undergoing elective first-time cardiac surgery were included. INTERVENTIONS: In 30 patients, a standard analgesic regimen was used, and in 30 patients, a PCA regimen was used. The perioperative and postoperative management was similar for all patients. MEASUREMENTS AND MAIN RESULTS: Degree of sedation, satisfaction, and pain (by visual analog scale [VAS]) was assessed within the first 3 postoperative days. Vital capacity (VC) and forced expiratory volume in 1 second (FEV1) were measured using a portable spirometry system. Cortisol and troponin T (TnT) plasma levels were also measured. The expectation of pain was similar in both groups, and the postoperative pain score was significantly lower in the PCA than in the standard group throughout the study period. Significantly more piritramid was used in the PCA (total, 75.6 +/- 33.4 mg) than in the standard group (total, 20.1 +/- 31.9 mg). VC and FEV1 were significantly lower in the standard group compared with the PCA patients. Cortisol and TnT plasma levels were similar in both groups. Frequency of side effects were similar for both groups. CONCLUSION: Because of the beneficial effects with regard to degree of pain and satisfaction, pain management using PCA systems can be recommended for cardiac surgery patients. It appears to be superior to standard nurse-based pain therapy.     

Comparison of push-pull versus discard method from central venous catheters for blood testing

This article evaluates recent research results comparing two different methods for obtaining complete blood cell counts and chemistry profiles from central venous catheters. Complete blood cell count and chemistry profile samples were obtained from 25 patients at three hospital-based infusion clinics. The results indicate no appreciable difference between these two methods. Minimizing risks of blood loss, blood exposure to healthcare personnel, potential specimen contamination, and erroneous reporting are benefits of the push-pull method.     

Complications of indwelling, silastic central venous access catheters in dogs and cats

RATIONALE AND OBJECTIVES: We investigated the effects of various metallic stents on the aortic wall. METHODS: The wires of Gianturco-type expandable metallic stents were plated with gold, silver, or copper or coated with Teflon or silicone. Stents were inserted into the aortas of 15 adult mongrel dogs. The time course of radiologic, macroscopic, and histologic changes in the aorta at the site of the stent was investigated at 1, 2, and 4 weeks after implantation. RESULTS: The gold-plated stent appeared to produce fewer macroscopic and histopathologic changes in the aorta than the other types of stents. The neointima was thinnest with gold (83.9 +/- 40.3 microns), followed by stainless steel (103.6 +/- 57.0 microns), Teflon (115.0 +/- 30.2 microns), silicone (209.6 +/- 25.9 microns), silver (228.6 +/- 33.8 microns), and copper (unmeasurable). With the copper-plated stent, the aorta suffered severe erosion of the vessel wall, marked thrombus formation, and aortic rupture. CONCLUSION: Gold is a useful intravascular material because it reacts only minimally with the vessel wall.     

Sensitivity to antibiotics in coagulase-negative staphylococci isolated from patients with central venous catheters

We examined 25 coagulase-negative staphylococci isolated from children, of whom 17 with leukaemia and 8 with terminal renal failure. Strain identification performed by api Staph system revealed the presence of S. epidermidis in 21 children, S. hominis in 3 patients and S. haemolyticus in 1 patient. By diffusion method we examined the activity of penicillin, methicillin, cephalexin, cephtriaxon, lincomycin, erythromycin, vancomycin, co-trimoxasol, gentamicin, amikacin, chloramphenicol, rifampicin and fusidic acid. MICs of seven antibiotics were obtained by agar dilution method. MIC50 and MIC90 were as follows: /ml Methicillin 3.13 mg/ml and 50 mg/ml, lincomycin 100 mg/ml and 100 mg/ml, gentamicin 25 mg/ml and 100 mg/ml, chloramphenicol 6.25 mg/ml and 50 mg/ml, amikacin 1.56 mg/ml and 100 mg/ml, rifampicin 0.09 mg/ml and 12.5 mg/ml, fusidic acid 6.25 mg/ml and 12.5 mg/ml, vancomycin 1.56 mg/ml and 3.13 mg/ml. These data show that the examined strains are highly resistant to numerous antibiotics. Thirty six percent of all strains were resistant to methicillin, 88% to lincomycin, 60% to gentamicin, 52% to chloramphenicol, 24% to amikacin, 52% to rifampicin and 56% to fuscidic acid. All the examined strains were sensitive to vancomycin.     

Sonographically guided placement of peripherally inserted central venous catheters: review of 355 procedures

OBJECTIVE: To test whether Wallerian degeneration (WD) of the pyramidal tract as signaled by MRI affects rehabilitation outcome in patients with subcortical infarction (internal capsule or corona radiata). BACKGROUND: Recent radiologic evidence suggests that WD occurs no earlier than 3 months after a subcortical infarction. METHODS: A total of 77 consecutive patients with pure motor hemiparesis due to an initial subcortical infarction were assessed on admission and discharge with the Functional Independence Measure (FIM) for disability and Stroke Impairment Assessment Set (SIAS, full = 25) for impairment. WD was defined by a high-intensity area detected along the pyramidal tract below the level of lesion on T2-weighted MR image (WD+). RESULTS: Age, sex, side of stroke, Mini-Mental State Examination score, and volume of lesion were comparable for each group. Length of stay (LOS) was significantly longer (p < 0.05) in WD+ (130 days) than in WD- (105 days). There was no difference in the change of FIM (WD+, 99 to 111; WD-, 95 to 107) or SIAS measures (WD+, 12 to 16; WD-, 13 to 16) made on admission and discharge, nor was there any effect of the timing of the rehabilitation experience (< or = 90 days or >90 days after stroke). CONCLUSIONS: After stroke, apparent WD of the pyramidal tract may slow functional recovery but does not limit final rehabilitation outcome of pure motor hemiparesis. Study of the mechanisms of compensation for this delayed pyramidal tract degeneration will enhance the scientific basis for rehabilitation.     

Cardiac tamponade: a rare but life-threatening complication of central venous catheters in children

The widespread use of central venous catheters in the treatment of pediatric patients has caused an increased incidence of complications. A rare, but potentially fatal complication occurs when the heart is perforated by the catheter tip causing a cardiac tamponade. This perforation of the heart generally is associated with the insertion procedure, but may also occur after some time because of displacement of the catheter tip. The authors present three cases in which the placement of a central venous catheter resulted in lethal cardiac tamponade. Proper positioning of the catheter tip in the superior vena cava and a high index of suspicion are essential in preventing this serious complication. Contrast-enhanced chest x-ray after insertion of the catheter must be performed to ascertain a correct position of the tip.     

Lack of clinical benefit from subcutaneous tunnel insertion of central venous catheters in immunocompromised patients

To date, several methods have been developed to determine the activity of plasma lipid transfer proteins. These methods have largely involved the addition of the transfer protein in question to labeled substrates, followed by prolonged incubation (4 to 18 hours) and subsequent evaluation of the radioactivity transferred to precipitated low-density lipoprotein (LDL). While adequate for determining the activity of cholesteryl ester transfer protein (CETP), these methods generally do not take into account the composition or levels of lipoproteins present within a given individual plasma because pools of high-density lipoprotein (HDL) are labeled and used for the transfer experiments. Both the direction and the extent of lipid transfer are dependent on the composition and relative abundance of both donor and acceptor particles as well as the activity of the lipid transfer protein(s). Here we describe a new method for the determination of the capacity of plasma samples to facilitate cholesteryl ester transfer from HDL to LDL and very-low-density lipoprotein (VLDL), a method that has several advantages. First, the subject's HDL is labeled and used for transfer. Second, the labeled HDL, in a quantity equivalent to 1% of the plasma HDL mass, is added to the subject's plasma, and therefore the relative abundance of both donor and acceptor particles is preserved at their physiological levels. Third, both cholesteryl ester mass and radioactivity are determined, allowing the net mass transfer of cholesteryl ester and cholesteryl ester exchange to be quantified separately.(ABSTRACT TRUNCATED AT 250 WORDS)     

Importance of Doppler analysis of transmitted atrial waveforms prior to placement of central venous access catheters

Cardiac fibrosis is linked to aldosterone-induced hypertension, but the effects on in vivo left ventricular (LV) function are not established. We studied the relations between in vivo LV function and aldosterone/salt cardiac fibrosis. Adult guinea pigs (GPs) were treated for 3 months with an aldosterone infusion and high-salt diet. This treatment induced arterial hypertension (+35%) and moderate LV hypertrophy (LVH; +60%) without right ventricular (RV) hypertrophy. Echo-Doppler LV assessment demonstrated unaltered cardiac output, stroke volume, or LV relaxation. Type I collagen messenger RNA (mRNA) was significantly increased in both ventricles (LV, +48%; RV, +77%) and accompanied by a significant increase in total collagen deposition (LV, from 0.52% in controls to 4.4% in treated GPs; RV, from 0.82 to 5.5% in treated GPs). Plasma norepinephrine levels increased 2.6-fold (p < 0.01) and correlated with the increase in collagen deposition in both ventricles. Collagen content was not correlated with hypertension or LVH. We conclude that aldosterone administration induces cardiac collagen accumulation and a sympathetic stimulation, which might preserve systolic and diastolic function.     

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.     

Calcified catheter "cast": a rare complication of indwelling central venous catheters in infants

Peri-catheter calcification is an unusual and previously unreported complication of central venous (CV) catheterization in infants. A 1. 9 Fr Silastic CV catheter was placed in a term infant for administration of total parenteral nutrition and antibiotics following intra-abdominal sepsis. The catheter was removed, without complication, at a later date after another septic episode. Imaging studies performed in the investigation of a possible intra-abdominal abscess revealed a cylindrical density within a clot in the inferior vena cava (IVC). The density was presumed to be a retained catheter fragment. Further investigation indicated total occlusion of the IVC. Surgical exploration of the IVC revealed only a calcified thrombus. This case represents a rare and previously unreported complication of CV catheterization in infants. Diagnosing this condition on radiographic evidence alone can be difficult. It is hoped that awareness of the potential for this complication will avoid unnecessary invasive procedures in the future. We also suggest a high level of clinical suspicion and routine Doppler ultrasound investigations to detect IVC thrombosis when indwelling CV catheters are used in infants.     

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.     

The placement of central venous catheters in infants with cardiac shunts: safety measures and false alarms

We report a case of RVT, diagnosed at 34 weeks' gestation in a case of fetal distress occurring four days after an acute maternal gastroenteritis. The typical ultrasonic pattern included renal enlargement, with parenchymal hyperechogenicity and venous echoic streaks, loss of the cortico-medullary boundary and lack of definition of renal sinus echoes. Color Doppler velocimetry confirmed the absence of venous flow with an increased vascular resistance in the renal artery. After delivery by an emergency caesarean section the infant had a full anatomical and functional recovery of his affected kidney at the seventh day of life.