Intravenous literature: Pittiruti, M., Brutti, A., Celentano, D., Pomponi, M., Biasucci, D.G., Annetta, M.G. and Scoppettuolo, G. (2012) Clinical experience with power injectable peripherally inserted central catheters in intensive care patients. Critical Care. 16(1), R21. [Epub ahead of print].

Abstract:

INTRODUCTION: In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters.

METHOD: We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance.

RESULTS: We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications during management were not clinically significant. There was one episode of symptomatic thrombosis during the stay in ICU and one episode after transfer of the patient in a non-intensive ward.

CONCLUSIONS: Power injectable PICCs have many advantages in the ICU: they can be used as multi-purpose central lines for any type of infusion including high flow infusion, for hemodynamic monitoring, and for high-pressure injection of contrast media during radiological procedures. Their insertion is successful in 100% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infective and non-infective complications.

Intravenous literature: Brotschi, B., Grass, B., Weiss, M., Doell, C. and Bernet, V. (2012) In-line filter included into the syringe infusion pump assembly reduces flow irregularities. Intensive Care Med. Jan 12. [Epub ahead of print].

Abstract:

PURPOSE: To evaluate whether an in-line filter inserted in the syringe pump infusion line assembly influences start-up times and flow irregularities during vertical pump displacement at low infusion rates.

METHODS: Fluid delivery after syringe pump start-up and after vertical displacement of the syringe pump by -50 cm was determined gravimetrically at flow rates of 0.5, 1.0 and 2.0 ml h(-1). Measurements were repeated for each flow rate four times with two different syringe pumps with and without an in-line filter incorporated. Data are shown as median and range.

RESULTS: Start-up times were reduced by an in-line filter at 0.5 ml h(-1) flow rate from 355.5 s (0-660) to 115 s (0-320), whereas the effect was attenuated at higher flow rates. Pooling of fluid into the infusion system after lowering the infusion syringe pump was halved in all flow rates tested. Amount of infusion bolus after elevating the syringe pump by 50 cm was not affected by an in-line filter.

CONCLUSION: In the evaluated model in-line filters help to reduce flow irregularities and delay in drug delivery of syringe pumps at low flow rates and represent an option to optimize continuous administration of highly concentrated short-acting drugs at very small infusion rates.

Intravenous literature: Harding, A.D. (2012) Increasing the use of ‘smart’ pump drug libraries by nurses: a continuous quality improvement project. The American Journal of Nursing. 112(1), p.26-35.

Abstract:

The use of infusion pumps that incorporate “smart” technology (smart pumps) can reduce the risks associated with receiving IV therapies. Smart pump technology incorporates safeguards such as a list of high-alert medications, soft and hard dosage limits, and a drug library that can be tailored to specific patient care areas. Its use can help to improve patient safety and to avoid potentially catastrophic harm associated with medication errors. But when one independent community hospital in Massachusetts switched from older mechanical pumps to smart pumps, it neglected to assign an “owner” to oversee the implementation process. One result was that nurses were using the smart pump library for only 37% of all infusions.To increase pump library usage percentage-thereby reducing the risks associated with infusion and improving patient safety-the hospital undertook a continuous quality improvement project over a four-month period in 2009. With the involvement of direct care nurses, and using quantitative data available from the smart pump software, the nursing quality and pharmacy quality teams identified ways to improve pump and pump library use. A secondary goal was to calculate the hospital’s return on investment for the purchase of the smart pumps. Several interventions were developed and, on the first of each month, implemented. By the end of the project, pump library usage had nearly doubled; and the hospital had completely recouped its initial investment.

Intravenous literature: Schrijvers, L.H., Beijlevelt-van der Zande, M., Peters, M., Schuurmans, M.J. and Fischer, K. (2012) Learning intravenous infusion in haemophilia: experience from the Netherlands. Haemophillia. Feb 1. [Epub ahead of print].

Abstract:
Summary.  Nowadays, nearly all severe haemophilia patients in the Netherlands practice self infusion at home. Learning intravenous administration of clotting factor requires time and effort. In order to inform patients about the burden and time-investment needed to learn intravenous infusion, we performed a two-centre retrospective study. All data on the learning processes, involving haemophilia patients born between 1980 and 2010 treated in Utrecht or Amsterdam, were extracted from patient files. A total of 154 patients and their parents were analysed (168 learning processes). Almost all patients had severe haemophilia and started prophylaxis at a median age of 2.7 years. 152/154 patients successfully learned intravenous infusion, including nine patients who temporally stopped and succeeded later. Overall, parents or patients needed a median of eight visits (IQR 4.3-14) in a median of 7 weeks (IQR 4-14.8) to learn home treatment. Parents who began to infuse by CVAD started at a median age of 1.9 years and succeeded within a median of 12 visits during 7.5 weeks. Parents who learned to perform intravenous infusion started at a median age of 4 years and needed 11 visits during 9 weeks. In 77% of cases, the mother was the first who started learning to infuse the child. Patients started with self infusion at a median age of 12.9 years, requiring a median of five visits in 12 weeks. The majority of patients and parents were able to learn intravenous infusion, with 50% of all parents and patients succeeding within eight visits during 7 weeks.

Intravenous literature: Isayama, K., Nakatani, T., Tsuda, M. and Hirakawa, A. (2012) Current status of establishing a venous line in CPA patients by Emergency Life-Saving Technicians in the prehospital setting in Japan and a proposal for intraosseous infusion. International Journal of Emergency Medicine. 5(1), p.2.

Abstract:

INTRODUCTION: It is important to have a venous line in cardiopulmonary arrest (CPA) patients as an emergency treatment measure in prehospital settings, but establishment of a peripheral venous line is difficult in such patients. This study aimed to investigate the current status of intravenous infusion (IVI) in CPA patients by Emergency Life-Saving Technicians (ELSTs) in Japan. We also considered alternative measures in case IVI was difficult or impossible.

METHODS: We investigated a nationwide database between 1 January 2005 and 31 December 2008. From a total of 431,968 CPA cases, we calculated the IVI success rate and related parameters.The Bone Injection Gun (BIG) and simulator legs (adult, pediatric, and infant) were used by 100 ELSTs selected for the study to measure the time required and the success rate for intraosseous infusion (IOI).

RESULTS: The number of CPA patients, IVI, adrenaline administration, and the IVI success rate in adult CPA patients increased every year. However, the IVI success rate in pediatric CPA patients did not increase. Although adrenaline administration elevated the ROSC rate, there was no improvement in the 1-month survival rate. The time required for IOI with BIG was not different among the leg models. The success rates of IOI with BIG were 93%, 94%, and 84% (p < 0.05 vs. adult and pediatric) in adult, pediatric, and infant models, respectively.

CONCLUSIONS: The rate of success of IVI in adult CPA patients has been increased yearly in Japan. However, as establishing a peripheral venous line in pediatric patients (1-7 years old) by ELSTs is extremely difficult in prehospital settings, there was no increase in the IVI success rate in such patients. As the study findings indicated IOI with BIG was easy and rapid, it may be necessary to consider IOI with BIG as an alternative option in case IVI is difficult or impossible in adult and pediatric patients.

Intravenous literature: Reyes, J.A., Habash, M.L. and Taylor, R.P. (2012) Femoral central venous catheters are not associated with higher rates of infection in the pediatric critical care population. AJIC: American Journal of Infection Control. 40(1), p.43-47.

Abstract:

Background: Adult data show a difference in central venous catheter (CVC) infection rates between 3 major sites: subclavian (SC), internal jugular (IJ), and femoral veins. We hypothesized that in patients in pediatric intensive care units (PICUs), there is no difference in rates of CVC infection among these three sites, but specifically the femoral compared to all other sites.

Methods: In this retrospective cohort study, data from January 1999 to January 2008 were collected prospectively for internal review and quality assurance. All PICU patients with a CVC were enrolled. The rate of CVC infection was determined using Cox regression survival analysis to account for various durations of CVC placement at the various sites, then adjusted for severity of illness, number of lumens, and patient age. Mortality was compared in patients with a CVC infection versus those without.

Results: A total of 4,512 patients with a CVC were enrolled. No site was associated with an increased risk of infection compared with the other sites, with hazard ratios of 0.951 (95% confidence interval [CI], 0.612-1.478) for the SC site, 0.956 (95% CI, 0.593-1.541) for the IJ site, and 1.120 (95% CI, 0.753-1.665) for the femoral site. No significant association between mortality and presence of CVC infection was found when adjusted for age, severity of illness, and duration of CVC placement. An association was found between the presence of a CVC infection and prolonged PICU length of stay (3.98 days longer; P < .001).

Conclusion: Femoral CVCs are not associated with higher rates of infection in the PICU. In addition, the presence of CVC infection does not affect mortality, but is associated with longer PICU admission.

Intravenous literature: Jett, G.A. (2012) A call for consideration of needlestick injury data in evaluating staffing effectiveness. AJIC: American Journal of Infection Control. 40(1), p.81.

Extract:

“Dr Larson, I applaud the effort to promote improved understanding of contributing factors to occupational injuries and bloodborne pathogen exposures that Patrician, Prior, Fridman, and Loan discussed in their June 2011 article. As the authors posit, the impact of staffing on the prevalence of needlesticks and other injuries among nurses has received limited attention to date. In my experience in occupational health nursing and infection prevention, the primary targets of needlestick injury follow-up investigations are typically individual behavioral factors and the use of engineered safety devices. This approach is an appropriate initial step but fails to determine potential root causes for the injury event. Other research has demonstrated scheduling and work factors such as extended-hour shifts, sequential shifts with inadequate time away from work, and night or weekend shifts to significantly increase the risk of needlestick injuries. We must place significantly greater attention on the multifactorial contributors to needlestick injuries. This includes consideration of workforce injuries and exposure event data in evaluating staffing effectiveness in health care organizations. Infection preventionists, occupational health nurses, and health care leaders should incorporate nursing workload indicators into their analysis of injury data to better understand and decrease the prevalence of needlestick injuries.”

Intravenous literature: Patrician, P.A., Pryor, E., Fridman, M. and Loan, L. (2012) Response to “A call for consideration of needlestick injury data in evaluating staffing effectiveness”. AJIC: American Journal of Infection Control. 40(1), p.81.

Extract:

“Mr Jett, my coauthors and I thank you for your thoughtful letter concerning our June 2011 paper on the association of needlestick injuries among inpatient staff nurses and nurse staffing. We particularly applaud your regard for the multifactorial nature of needlestick injuries. Despite advances in needleless devices, needlestick injuries continue to occur, and, as our data show, contaminated needles are still a serious threat to the occupational safety of nursing personnel, not to mention others who work in hospitals (eg, housekeeping staff) whom we did not study. Just as with the patient safety movement, we need to seriously consider not only the actions of the individual nurses but the systems in which they provide nursing care, or the context of their respective work environments, if we are to better understand the multifactorial nature of such adverse events.”

Intravenous literature: Safdar, N., Mittelstadt, K., Jacobs, E.A. and Gaines, M.E. (2012) Patient awareness of the risks of central venous catheters in the outpatient setting. AJIC: American Journal of Infection Control. 40(1), p.87-88.

Extract:

“Bloodstream infection remains the most common life-threatening complication of central venous access. Central venous catheters (CVCs) are the most frequent cause of nosocomial bloodstream infection with 250,000 to 500,000 episodes occurring in the United States annually. In the last several years, widespread implementation of evidence-based interventions to prevent central line-associated bloodstream infection (CLABSI) in the intensive care unit has been undertaken with commensurate reduction in CLABSI rates. Nonetheless, CLABSI remains one of the most important life-threatening complications of central venous access. Patient education regarding CVC insertion and risk of CLABSI has been recommended, as outlined in the 2011 Patient Safety goals from the Joint Commission. However, data on patient education regarding CLABSI are scant. We undertook a survey to assess patients’ awareness of the risk and consequences of CLABSI at the University of Wisconsin hospital, a 592-bed acute care tertiary referral hospital.”

Intravenous literature: Oliveira, C., Nasr, A., Brindle, M. and Wales, P.W. (2012) Ethanol Locks to Prevent Catheter-Related Bloodstream Infections in Parenteral Nutrition: A Meta-Analysis. Pediatrics. 129(2), p.318-329.

Abstract:

OBJECTIVE: Patients with pediatric intestinal failure (IF) depend on parenteral nutrition for growth and survival, but are at risk for complications, such as catheter-related bloodstream infections (CRBSIs). CRBSI prevention is crucial, as sepsis is an important cause of IF-associated liver disease and mortality. We aim to estimate the pooled effectiveness and safety of ethanol locks (ELs) in comparison with heparin locks (HLs) with regard to CRBSI rate and catheter replacements for pediatric IF patients with chronic parenteral nutrition dependence.

METHODS: A systematic review without language restriction was performed on Medline (1948–2010), Embase (1980–2010), and conference programs and trial registries up to December 2010. Search terms included “Catheter-Related Infections,” “Catheter,” “Catheters, Indwelling,” “alcohol,” “ethanol,” and “lock.” Two authors identified 4 retrospective studies for the pediatric IF population. Double, independent data extraction using predefined data fields and risk of bias assessment (Newcastle-Ottawa scale) was performed.

RESULTS: In comparison with HLs, ELs reduced the CRBSI-rate per 1000 catheter days by 7.67 events and catheter replacements by 5.07. EL therapy decreased the CRBSI rate by 81% and replacements by 72%. One hundred eight to 150 catheter days of EL exposure were necessary to prevent 1 CRBSI and 122 to 689 days of exposure avoided 1 catheter replacement. Adverse events were rare and included thrombotic events.

CONCLUSIONS: In pediatric patients with IF, EL is a more effective alternative to HL. Adverse events include thrombotic events.