Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access

Access to the central venous circulation for hemodialysis has traditionally been achieved via the subclavian or jugular venous routes. With ongoing improvements in medical management, many hemodialysis recipients develop exhaustion of these routes and require alternative means of central venous access. Inferior vena caval (IVC) catheters have been placed with a percutaneous translumbar approach to allow central venous access for chemotherapy, harvesting of stem cells, and total parenteral nutrition. Translumbar placement of IVC catheters has become accepted by some as a useful and reliable alternative in patients who require long-term hemodialysis but have exhausted traditional access sites. IVC catheters have been placed in patients with IVC filters, and IVC filters have been placed in patients with IVC catheters. Complications include those associated with central venous catheters, for example, sepsis, fibrin sheaths, and thrombosis. A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins. Translumbar placement of IVC catheters is performed only in patients considered to have few or no other medical options and is not intended as a primary means of central venous access.     

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.     

Comparison of toxicity induced by HT-2 toxin on human and rat granulo-monocytic progenitors with an in vitro model

Catheter-associated bloodstream infections remain an important cause of nosocomial infection, with an estimated 50,000-100,000 cases occurring each year in the United States. Central venous catheters are believed to be responsible for 90% of such infections. The cumulative risk of acquiring a catheter-related bloodstream infection has ranged between 1 and 10% for central venous catheters in general and 6% for total parenteral nutrition catheters. The skin is the most common source of organisms causing catheter-related infections. Recent prospective studies have shown that the incidence density per catheter day does not increase with duration of catheterization and that routine changes, either over a guidewire or by new site puncture, do not appear to lower the risk of infection. Diagnosis of infection can be difficult in intensive care patients but is usually easier in less ill patients with a central venous catheter. Quantitative or semiquantitative laboratory techniques can be used to confirm the diagnosis in the appropriate clinical setting. A variety of preventive measures have been shown to minimize the risk of development of catheter-related bloodstream infection, including use of maximal aseptic technique for insertion, use of special teams for care of the catheter, limiting manipulation of the catheter, use of povidone-iodine ointment and cotton gauze dressings for recently inserted catheters, a silver-impregnated collagen cuff and antiseptic-impregnated catheters.     

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.     

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.     

Hydrothorax caused by intravasal triple-lumen subclavian catheter

A case in which a patient developed right-sided hydrothorax due to extravasal infusion of total parenteral nutrition (TPN) is reported. The catheter was a triluminal catheter and the tip was shown to be correctly placed in the superior vene cava by x-ray after injection of radio-opaque contrast. The most proximal injection port located 4.5 cm from the tip of the catheter was documented to be sited in the superior mediastinum outside the vena cava. The infusion was given through the proximal port of the catheter. The mechanisms underlying this complication are discussed. The case emphazises the need to control the position of all infusion ports regularly when using central venous catheters with more than one lumen.     

Detection of antagonistic cellular regulatory functions by the gene-gene interference method in yeast

The objective of the study is, on one hand, to determine the etiology and the clinical implications as a function of the isolated germ, of central venous catheterization in patients with parenteral nutrition in our hospital, and on the other hand, to determine which factors are associated with the selection of germs of central venous catheterization in parenteral nutrition. For this we included venous catheters, colonized for 5 years, and with a study of the different segments (connection, insertion point, and tip). As a function of the appearance of associated clinical symptoms, of the results of the blood culture, and of the clinical evolution of the patient, the variables which determine the level of pathogenicity of the different groups of germs in the central venous catheterization, are defined; for the study of the factors associated with the selection of the different groups of germs, 8 variables were chosen. The data obtained are statistically treated, and the results are considered to be significant if p < 0.05. The understanding of the different factors associated with the selection of germs, and the level of clinical pathogenesis of the different groups, allows a better level of the clinical action in the prevention of the infection associated with the catheter.     

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.     

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.     

Transient up-regulation of ciliary neurotrophic factor receptor-alpha mRNA in axotomized rat septal neurons

PURPOSE: To determine prospectively the feasibility, complications, and mid- and long-term advantages of peripheral insertion of central catheters in infants and children. MATERIALS AND METHODS: During a 15-month period between March 1995 and June 1996, a total of 285 catheter placement attempts were made to peripherally insert central catheters in 183 pediatric patients (89 boys, 94 girls). Phlebographic guidance was used, and the catheters were inserted below the elbow in 99% of cases. Catheter insertion was indicated for prolonged antibiotic therapy in 108 patients (158 catheter placement attempts), hematologic or oncologic care in 24 patients (40 attempts), total parenteral nutrition in 16 patients (46 attempts), and venous access for fluid or blood in 35 patients (41 attempts). The success rate and complications were recorded along with the indication, patient age, and duration of catheter placement. RESULTS: One hundred fifty-two of 158 (96%) catheter placement attempts were successful in outpatients (n = 108), 124 of 127 (98%) in hospitalized patients (n = 75), and 70 of 73 (96%) in patients aged less than 1 year. Infection and pericatheter venous thrombosis were the main complications and were seen in 17 of 276 (6%) and one of 276 (0.3%) catheter placement attempts, respectively. Catheter occlusion occurred in 23 of 276 (8%) catheter placement attempts. CONCLUSION: Peripheral insertion of central catheters was highly feasible in infants and children with this protocol. Such catheters were well tolerated in the pediatric population with a low frequency of complications.     

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.     

Shaken babies--some have no impact injuries

Peripheral parenteral nutrition is an attractive alternative to centrally delivered parenteral nutrition because it obviates the need for central venous cannulation and its attendant complications. Some 45 consecutive patients were fed peripherally using a 22-G polyurethane catheter and a fat-based, low-osmolality feed. Of these patients, 36 were fed for a median of 8.5 (range 3-31) days without peripheral vein thrombophlebitis (PVT). Seven patients developed PVT after a median of 6 (range 5-7) days. The cumulative daily risk of PVT was 0.016 episodes per day. These results suggest that prolonged (more than 7 days) problem-free peripheral parenteral nutrition is possible.     

Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial

BACKGROUND: Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. METHODS: Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (n = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. RESULTS: Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0.05) and were at lower risk of developing septic complications (P < 0.01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. CONCLUSION: This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis.     

Effect of nifedipine and verapamil on hypotensive action of clonidine in rabbits

Infections associated with central venous catheters continue to be a major source of sepsis, particularly in hospitalized patients. In developing a strategy for the prevention of these infections, the source and route of invasion of the causative micro-organisms need to be considered. The main source of micro-organisms is the patient's skin. They can gain access to a catheter at the time of insertion, as well as via the external or internal catheter surfaces. Attempts to reduce the incidence of infections range from the type of skin preparation selected, to care of the insertion site post-catheterization. Improvements in catheter design have also reduced the likelihood of infection and include the development of non-leachable smooth catheters with anti-adhesive coatings. More recently, catheters containing antimicrobial agents have become available and preliminary studies have demonstrated a reduction in microbial colonization and associated sepsis. Future preventative strategies may include the application of low voltage electric current in combination with antimicrobials.     

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.     

The effects of detergents on t-butyl hydroperoxide-induced chemiluminescence

Subcutaneous central venous infusion reservoirs (central venous catheters) are one of the primary devices for administration of intravenous chemotherapy. Usually these devices have few problems, and they provide dependable long term central venous access. Infection of these catheters is a significant problem that usually requires removal. When infection is suspected, it is often difficult to make this determination without actually removing the catheter. Thorough preoperative evaluation may help the surgeon decide which catheters are infected and should be removed. A total of 817 subcutaneous infusion reservoirs were placed at our institution from January 1, 1990 through November 1, 1994. During the same time period, 143 catheters were removed, 63 for suspected infection. The charts of these 63 patients were reviewed to determine to what extent available preoperative information could be used to predict which catheters were infected, thus avoiding unnecessary removal. Twenty-three preoperative parameters were assessed, including physical exam, body temperature, leukocyte count, platelet count, blood cultures from the catheter and peripheral blood, time from placement to removal, whether or not the catheter was functional, and whether it was currently in use. Forty catheters (65%) removed for suspected infection were infected, as demonstrated by a positive culture from the catheter or the wound. Staphylococcus was the most common microorganism. Physical exam (local erythema, tenderness, or swelling) correlated significantly with catheter infection (P = 0.0238). In contrast, blood culture data and the other clinical and laboratory parameters showed no significant association with catheter infection. We conclude that physical exam is the best indicator of catheter infection. Commonly used parameters such as fever, leukocytosis, and positive blood cultures are nonspecific, may not be due to catheter infection, and were not significant in our study. Removal and subsequent restoration of long term intravenous access is associated with significant morbidity and expense. Clinical decision making should not be based on isolated laboratory findings, but must be individualized in each patient with suspected catheter infection.     

Implantable venous access devices in children with hemophilia: a report of low infection rates

OBJECTIVE: The objective of this study was to define the efficacy and complications of implantable venous access devices (IVADs) in children with hemophilia. STUDY DESIGN: Records were reviewed on all patients with congenital blood coagulation disorders monitored at two children's hospitals in whom one or more central venous catheters had been placed. RESULTS: Since 1989 external and implantable central venous catheters have been inserted to enhance venous access for regular factor concentrate infusion in 45 patients with hemophilia ranging in age from 8 months to 19.5 years (median 7.4 years); 37 patients had factor VIII deficiency and 8 factor IX deficiency. Hemorrhagic complications of catheter placement were infrequent and minor. In the 41 patients having one or more IVADs in place for a median of 31 months, only six episodes of bacteremia occurred in 5 patients during 44,070 days of follow-up. The overall rate of bacteremia complicating IVADs in these patients was 0.14 episodes per 1000 catheter days. Other catheter-related complications were uncommon. Catheters are still in place in 33 patients for a median of 32 months. CONCLUSION: The low risk of infection and other complications associated with the use of IVADs makes the use of these devices attractive in the treatment of patients with hemophilia who require frequent venous access for factor concentrate infusions.     

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.     

A proposed mechanism for memory and learning based upon very high frequency signals in the serotonergic neuronal system

Percutaneously placed central venous lines have become an intricate part of the medical management of the very low birth weight infant. It is critically important that health care providers involved with the placement of these catheters be familiar with the possible subtle sites for catheter misplacement. We present two case reports of inadvertent ascending lumbar vein catheterization with a percutaneously placed Silastic catheter where the saphenous vein was used for venous access. The literature is reviewed with regard to the history of use, indications, placement, and associated complications of these catheters.