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Central venous access devices (CVADs) are vital instruments in pediatric healthcare, enabling the administration of critical treatments such as chemotherapy and parenteral nutrition. However, despite their advantages, CVADs carry a significant risk of complications, including infections, mechanical failures, and thrombotic events. From the current literature, it is unknown whether previous CVAD placements lead to an increased risk for complications in subsequent CVAD placements. We retrospectively analyzed data regarding tunneled, surgically implanted CVADs in children over a period of 2 years at a single tertiary pediatric center regarding their complications. Between 2021 and 2022, 328 CVAD implantations were performed in 313 children. The average age at implantation was 6.6 ± 5.5 years, while most of the patients were younger than 5 years old. During the study period, a total of 102 complications occurred in 96 patients. Most frequent complications were infections (18.29% of all implantations), followed by dislocation of the catheter tip (6.4 0%) and mechanical dysfunctions (4.27%). No patient died from a complication. The choice of catheter type (Port versus Broviac) showed a significant influence on the occurrence of complications (hazard ratio of 3.964 (95% CI 1.993–7.886; p  < 0.001). The risk of infection and dislodgement was also higher when comparing Broviac with Ports implantations (infection: HR = 3.236; 95% CI 1.239–8.454; p  = 0.017; dislodgement: HR = 5.781; 95% CI 1.229–27.193; p  = 0.026). Cox regression showed a statistically significant higher risk of complications (especially infections) when the catheter was inserted via venous cutdown instead of percutaneous puncture technique (complications: HR = 6.709; 95% CI 1.776–25.337; p  = 0.005; infections: HR = 7.28; 95% CI 1.096–48.379; p  = 0.04). Cox regression did not show a statistically significant influence on complications for neither of the following factors: age, gender, weight, and oncological/non-oncological diagnosis. The complication rate for patients with previous CVAD was nearly the same as for patients who received a CVAD for the first time (previous CVAD: 29.17%; no previous CVAD: 30.74%). Conclusion : Our study challenges conventional assumptions regarding the impact of previous CVAD placements on complication rates. Nevertheless, ongoing vigilance and adherence to standardized protocols remain crucial in mitigating risks and improving outcomes in pediatric CVAD management. What is Known: • Risk factors predisposing for CVAD-related complications remain insufficiently understood. • It is unknown whether previous CVAD placements lead to an increased risk for complications in subsequent CVAD placements. What is New: • The complication rate for patients with previous CVAD appears to be the same as for patients who receive a CVAD for the first time.

Background: Low-risk and realistic simulation strategies are needed to train clinical learners to perform hands-on invasive procedures. This follow-up study compares the utility of landmark-guided palpation-based to ultrasound-guided teaching techniques for subclavian central venous access using formalin-embalmed cadavers. Methods: The subclavian veins of 3 cadavers were imaged with ultrasound to evaluate vein patency before palpation- based venous access was attempted. Twenty-three first-year medical students were trained to access the subclavian vein using palpation-based techniques. Training involved ten minutes of didactic orientation and ten minutes of hands-on practical instruction using cadavers. Participant confidence was measured using a 10-point Likert scale on pre- and post-training questionnaires. Objective skills testing for each participant included quantifying the number of skin punctures and recording the time elapsed from first skin puncture to fluid flashback into the syringe. Data was analyzed using a generalized linear model (GLM) approach. Results: Participant confidence significantly increased following training in both ultrasound and palpation training groups across all questionnaire items (P<0.001). The ultrasound group had fewer skin punctures (P <0.001) and fewer failures (1) than the palpation group (6). Participants in the ultrasound group were more confident than those in the palpation group in their ability to locate the vein and select the optimal site for needle access (P<0.05). Conclusion: Formalin-embalmed cadavers provide a safe, stress-free, and effective means by which to train students in subclavian vein access using both palpation and ultrasound-based techniques. Repeated practice accessing and aspirating fluid from a cadaveric subclavian vein significantly increases trainee confidence, an essential factor in physician performance that may lead to fewer complications. Introducing this type of low-risk and hands-on practice may be beneficial for trainees before they attempt subclavian vein access on live patients. Keywords: education, medical, catheterization, central venous, landmark-guided central venous access, ultrasound- guided central venous access, formalin embalmed cadaver

The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an \"out-of-plane\" and an \"in-plane\" technique. There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

Purpose To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. Methods An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. Results The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. Conclusions These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Central venous access devices (CVADs) are integral to cancer treatment. However, catheter-related thrombosis (CRT) poses a considerable risk to patient safety. It interrupts treatment; delays therapy; prolongs hospitalisation; and increases the physical, psychological and financial burden of patients. Our study aims to construct and validate a predictive model for CRT risk in patients with cancer. It offers the possibility to identify independent risk factors for CRT and prevent CRT in patients with cancer. We prospectively followed patients with cancer and CVAD at Xiangya Hospital of Central South University from January 2021 to December 2022 until catheter removal. Patients with CRT who met the criteria were taken as the case group. Two patients with cancer but without CRT diagnosed in the same month that a patient with cancer and CRT was diagnosed were selected by using a random number table to form a control group. Data from patients with CVAD placement in Qinghai University Affiliated Hospital and Hainan Provincial People’s Hospital (January 2023 to June 2023) were used for the external validation of the optimal model. The incidence rate of CRT in patients with cancer was 5.02% (539/10 736). Amongst different malignant tumour types, head and neck (9.66%), haematological (6.97%) and respiratory (6.58%) tumours had the highest risks. Amongst catheter types, haemodialysis (13.91%), central venous (8.39%) and peripherally inserted central (4.68%) catheters were associated with the highest risks. A total of 500 patients with CRT and 1000 without CRT participated in model construction and were randomly assigned to the training ( n  = 1050) or testing ( n  = 450) groups. We identified 11 independent risk factors, including age, catheterisation method, catheter valve, catheter material, infection, insertion history, D-dimer concentration, operation history, anaemia, diabetes and targeted drugs. The logistic regression model had the best discriminative ability amongst the three models. It had an area under the curve (AUC) of 0.868 (0.846–0.890) for the training group. The external validation AUC was 0.708 (0.618–0.797). The calibration curve of the nomogram model was consistent with the ideal curve. Moreover, the Hosmer–Lemeshow test showed a good fit ( P  > 0.05) and high net benefit value for the clinical decision curve. The nomogram model constructed in this study can predict the risk of CRT in patients with cancer. It can help in the early identification and screening of patients at high risk of cancer CRT.

Background Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation. Methods A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data. Results From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies ( n  = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies. Conclusion Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Safety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. We investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. The procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. This study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Background Insertion of a central venous access device (CVAD) allows clinicians to easily access the circulation of a patient to administer life-saving interventions. Due to their invasive nature, CVADs are prone to complications such as bacterial biofilm production and colonization, catheter-related bloodstream infection, occlusion, and catheter-related venous thrombosis. A CVAD is among the most common interventions for patients in the intensive care unit (ICU), exposing this vulnerable population to the risk of nosocomial infection and catheter occlusion. The current standard of care involves the use of normal saline as a catheter locking solution for central venous catheters (CVCs) and peripherally inserted central catheter (PICC) lines, and a citrate lock for hemodialysis catheters. Saline offers little prophylactic measures against catheter complications. Four percent of tetrasodium ethylenediaminetetraacetic acid (EDTA) fluid (marketed as KiteLock Sterile Locking Solution™) is non-antibiotic, possesses antimicrobial, anti-biofilm, and anti-coagulant properties, and is approved by Health Canada as a catheter locking solution. As such, it may be a superior CVAD locking solution than the present standard of care lock in the ICU patient population. Methods Our team proposes to fill this knowledge gap by performing a multi-center, cluster-randomized, crossover trial evaluating the impact of 4% tetrasodium EDTA on a primary composite outcome of the incidence rate of central line-associated bloodstream infection (CLABSI), catheter occlusion leading to removal, and use of alteplase to resolve catheter occlusion compared to the standard of care. The study will be performed at five critical care units. Discussion If successful, the results of this study can serve as evidence for a shift of standard of care practices to include EDTA locking fluid in routine CVAD locking procedures. Completion of this study has the potential to improve CVAD standard of care to become safer for patients, as well as provides an opportunity to decrease strain on healthcare budgets related to treating preventable CVAD complications. Success and subsequent implementation of this intervention in the ICU may also be extrapolated to other patient populations with heavy CVAD use including hemodialysis, oncology, parenteral nutrition, and pediatric patient populations. On a global scale, eradicating biofilm produced by antibiotic-resistant bacteria may serve to lessen the threat of “superbugs” and contribute to international initiatives supporting the termination of antibiotic overuse. Trial registration ClinicalTrials.gov NCT04548713, registered on September 9th, 2020. 

Direct paired meta-analyses and network meta-analysis were conducted to compare the incidence of catheter-associated bloodstream infections (CRBSIs) in different types of central venous access devices (CVADs). The PubMed, EMBASE, Web of Science, Cochrane, CNKI and CBM databases were systematically searched from inception to May 31, 2024 for randomized controlled trials (RCTs) comparing the incidence of CRBSIs across various types of CVADs. Literature screening, data extraction, and risk bias evaluation were all independently conducted by two individuals. Direct paired meta-analyses and network meta-analysis were performed using RevMan 5.3 and Stata 14.0 software, respectively. A total of five studies were included. Paired meta-analyses revealed that the incidence of CRBSIs was lower in the peripherally inserted central catheter (PICC) group compared to the central venous catheter (CVC) group (RR = 0.23, 95% CI (0.13-0.43), < 0.00001). The incidence of CRBSIs in the PICC group was observed to be lower compared to that in the totally implantable venous access port (TIVAP) group (RR = 0.45, 95% CI (0.23-0.87), = 0.02). Descriptive analysis revealed a higher incidence of CRBSIs in the CVC group compared to the TIVAP group (RR = 2.97, 95% CI (1.65-5.17), = 0.0002). The network meta-analysis revealed a significantly lower incidence of CRBSIs in the PICC group compared to the CVC group. However, no statistically significant differences were observed in other comparisons. Based on the cumulative ranking curve test, the incidence of CRBSIs in various CVADs was ranked as follows: PICCs (97.20%) > TIVAPs (50.00%) > CVCs (2.80%). The available evidence suggests that PICCs exhibit the lowest incidence of CVADs, followed by TIVAPs. Therefore, PICCs should be prioritized when selecting CVADs.

PurposeThere is still debate over the safest route for the placement of long-term central venous access devices. The aim of this study was to review a large, single-institution experience to determine the impact of access location on peri-operative complications.MethodsThe records of patients undergoing subcutaneous port (SQP) and tunneled catheter insertion over a seven-year period were reviewed. Vein cannulated (subclavian (SCV) versus internal jugular (IJ) vein), and 30-day complications were assessed. Surgical complications included pneumothorax, hemothorax, infections, arrhythmia or malpositioning requiring intervention.ResultsA total of 1,309 patients were included (618 SQP, 691 tunneled catheters). The location for insertion was SCV (909, 69.4%) and IJ (400, 30.6%). There were 69 complications (5.2%) (41, 4.5% SCV, 28, 7.0% IJV) including: malpositioning/malfunctioning (SCV 13, 1.4% and IJV 14, 3.0%), pneumothorax (SCV 4, 0.4% and IJV 1, 0.3%), hemothorax (SCV 0 and IJV 1, 0.3%), arrhythmia (SCV 1, 0.1%, and IJV 0), and infection within 30 days of placement (SCV 20, 2.2% and IJ 11, 2.8%). The complication rates were not significantly different based on site (p = 0.080).ConclusionThere was no significant difference in complication rates when using the subclavian versus the internal jugular vein as the site for long-term central venous access.Level of evidenceIII, retrospective comparative study.