Literature Summary

Major Literature

Checklists (Pronovost Checklist, Keystone Initiative) 

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725.

2011 - Epidemiology of Central Line Associated BSI in the PICU (Infection Control and Hospital Epidemiology)

• Methods

  • Prospective observational study of 29 PICUs for the epidemiological portion to look for incidence of BSI and 18 PICUs for the cohort portion to look for risk factors associated with central-line associated BSI (CLA-BSI)

  • Conducted by Dr. Niedner!

• Results

  • Epidemiological study

    • 2.5 BSI per 1000 catheter days

    • Organisms consistent with common skin contaminants were most prevalent

  • Cohort study

    • 2.0 BSI per 1000 catheter days

    • 99% of pts remained BSI free through day 7 (avg daily risk of BSI of 0.14%)

      • After day 7, avg daily risk of BSI doubled to 0.27% and remained steady through day 100

    • No difference in survival between non-tunneled catheters, tunneled catheters, or PICC

    • In pts with central line, mortality higher for pts with BSI vs. pts without (15% vs. 7%)

    • Risk factors for BSI

      • Primary diagnoses of GI disease and oncology

      • Number of catheters per pt, locations of placement, or types of central line not associated with BSI

        • Risk of BSI was significantly lower if placed in jugular vein, but this was no longer significant if analyzed in pts with just 1 central line (which is most often the case in our unit)

• Bottom Line

  • CLA-BSI incidence = 2-3 per 1000 catheter days

  • Risk of BSI increases after 1 week, and we should constantly assess the need for CVC in each pt, especially in pts with GI or oncological disease

2013 - Minimizing Complications Associated with Percutaneous CVC Placement in Children (Peds Critical Care Med)

• Methods

  • Most recent review article on complications of CVC in children

• Results

  • Complications associated with CVC insertion and maintenance

    • Arterial puncture

      • Incidence:  femoral > jugular > subclavian

      • Associated complications:  hematoma, hemothorax, pseudoaneurysm, AV fistulae, embolic events, arterial cannulation

    • Pneumothorax

      • Incidence:  subclavian > jugular

    • Hemothorax

      • Incidence:  subclavian > jugular

    • Malposition (subcutaneous/pericardial/pleural infiltrate, tip in the wrong vessel)

      • Incidence:  subclavian > femoral > jugular

      • Rare but important risk to know

        • Left femoral CVC tip may be misplaced in the ascending lumbar vein --> spinal cord injury --> paraplegia

          • AP AXR = catheter course directly over the vertebral column

          • Lateral AXR = catheter course posterior to the spine

    • Thrombosis

      • Typically develops within a few days of insertion

        • Screening/Surveillance studies showed 12-28% of CVCs with clots

        • Studies with clinically apparent clots only showed 2% of CVCs with clots

      • Risk factors:  infants, pts with trauma, CHD, or cancer

      • Symptomatic clots associated with more ventilator days (perhaps due to PE?)

      • Preventive strategies

        • Periodic assessment for venous return

        • Use diluted heparin infusion

        • Use fibrinolytic drugs to clear occlusion

    • BSI

      • Risk factors:  unscheduled admissions, cardiac disease, longer duration of CVC days, TPN use, transfusion use, corticosteroid use

      • Incidence:  2.2 BSI per 1000 catheter days (2009 NHSN report)

  • Site selection

    • First site success rates:  jugular > femoral > subclavian

    • Femoral site not associated with increased risk of infection in children but association exists in adults

• Bottom Line

  • Symptomatic CVC thrombosis occurs in 2% of catheters

  • BSI occurs in ~2 per 1000 catheter days (similar to Dr. Niedner's study)

  • Femoral CVC does not increase risk of infection in kids

  • Try to avoid femoral CVC in adults

2013 - Risk Factors for PICC Complications in Children (JAMA Pediatrics)

• Methods

  • Prospective observational study of children admitted to Johns Hopkins Children's Center and had PICC placed

  • NICU pts excluded

  • PICC team placed all PICCs

  • PICC categorized as central (SVC, RA junction, IVC, above diaphragm for lower ext lines) or non-central (midline, midclavicular, or other)

• Results

  • 2574 PICCs placed in 1807 pts

    • Median age 5 yrs

    • Median PICC dwell time 13 days

  • Complication rates per 1000 catheter days decreased from 2003 to 2009

    • 2003:  infectious 2.7, non-infectious 14.5

    • 2009:  infectious 1.9, non-infectious 3.6

  • 21% removed due to complications of PICC

    • Infection 4% of 21%

    • Thrombosis 0.5% of 21%

    • Line occlusion 4% of 21%

    • Dislodgement 5% of 21%

  • Risk factors for complications

    • Non-central PICCs had more non-infectious complications than central catheters (44% vs. 16%)

      • 3 times as likely to be removed

    • Younger pts had more complications (highest in <1 yr age group)

    • PICU exposure as oppose to ward only had more infectious complications

  • Risk of infectious complications increase over the first few weeks then plateau

  • Risk of non-infectious complications decrease over the first few weeks then plateau

• Bottom Line

  • PICC has BSI risk (~2 per 1000 catheter days) very similar to CVC's risk from above paper

  • PICC has thrombosis risk (0.5%) that is much lower to CVC's risk from above paper

  • Important that the tip of PICC is located centrally

  • Especially monitor closely for complications in younger pts

2014 - Arterial Catheters as a Source of BSI (Critical Care Med)

• Methods

  • Meta-analysis evaluating art-line as a source of BSI

  • Included human trials published up to 2012

• Results

  • 49 studies met criteria (3 studies in neonates, 1 study in children, 1 study included children and adults, all other studies adults only)

  • CR-BSI

    • Incidence

      • 3.4 per 1000 catheters

      • 1.3 per 1000 catheter days in studies when all catheters screened for infection

      • 0.7 per 1000 catheter days in studies when catheters cultured upon suspected infection

      • Neonates had double the incidence of adults

    • Femoral catheters had double the risk of infection compared to radial catheters

    • 1 study showed full barrier precaution vs. sterile gloves only and found no difference in risk

• Bottom Line

  • BSI from art-line is NOT negligible (~1 per 1000 catheter days), though lower than CVC or PICC related BSI

  • Neonates have the highest BSI rate

  • Attempt to place radial as oppose to femoral art-line to reduce risk of BSI

BOTTOM BOTTOM LINE

• BSI risk:  CVC = PICC >> Art-line

• Thrombosis risk:  CVC > PICC

  • Of note, meta-analysis analyzing risk of venous thromboembolism associated with PICC published in Lancet 2013 showed risk of DVT related to PICC much higher than the risk of CVC (OR 2.55), though it only included adult trials