Sepsis from triple- vs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients

Detection and prevention of central venous catheter-related infections

Infectious complications of central venous catheterization are an important clinical problem. Although systemic infection complicates only a small fraction of cases, the prevalence of catheter-related sepsis remains high because of the widespread use of these catheters in acutely ill hospitalized patients. The major route of infection is probably by migration of microorganisms from the skin along the outer surface of the catheter and through the subcutaneous catheter tract to the bloodstream. Semi-quantitative catheter tip cultures have become a standard clinical tool for the evaluation for catheter-related infection. Despite the use of this technique and a variety of other proposed methods for evaluating catheter colonization and infection, discriminating catheter-related sepsis from sepsis originating at another site is often difficult. Prevention of these infections is important. There have been many investigations of the factors that contribute to catheter infections. These studies have shown that meticulous attention to sterile technique during catheter insertion and during routine maintenance is critical.

Long-term right atrial catheters in patients with malignancies: an Indian experience

Ninety-eight single lumen and two double lumen silicone right atrial Hickman/Broviac catheters inserted in 91 patients with various malignancies over a period of 36 months were prospectively studied. The average duration of use for all Hickman/Broviac catheters was 7,460 days with an average of 74.6 days. A total of 41 episodes of catheter-related infections were documented in all patients (0.5 per 100 access days). Catheter related bacteremia was the most frequent type of infection (31 out of 41, 75%). Majority of the bacteremias could be controlled with routine antimicrobial therapy. Exit site infections were seen in 5 Hickman/Broviac catheters. Two catheters had to be removed because of catheter tunnel infections. Gram negative bacteremic infections were the most common, with Pseudomonas aeruginosa being the major pathogen. Silicone rubber Hickman/Broviac catheters proved to be convenient, reliable, and easily manageable devices in our experience.

A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters

BACKGROUND

The incidence of infection increases with the prolonged use of central vascular catheters, but it is unclear whether changing catheters every three days, as some recommend, will reduce the rate of infection, It is also unclear whether it is safer to change a catheter over a guide wire or insert it at a new site.

METHODS

We conducted a controlled trial in adult patients in intensive care units who required central venous or pulmonary-artery catheters for more than three days. Patients were assigned randomly to undergo one of four methods of catheter exchange: replacement every three days either by insertion at a new site (group 1) or by exchange over a guide wire (group 2), or replacement when clinically indicated either by insertion at a new site (group 3) or by exchange over a guide wire (group 4).

RESULTS

Of the 160 patients, 5 percent had catheter-related bloodstream infections, 16 percent had catheters that became colonized, and 9 percent had major mechanical complications. The incidence rates (per 1000 days of catheter use) of bloodstream infection were 3 in group 1, 6 in group 2, 2 in group 3, and 3 in group 4; the incidence rates of mechanical complications were 14, 4, 8, and 3, respectively. Patients randomly assigned to guide-wire-assisted exchange were more likely to have bloodstream infection after the first three days of catheterization (6 percent vs. 0, P = 0.06). Insertions at new sites were associated with more mechanical complications (5 percent vs. 1 percent, P = 0.005).

CONCLUSIONS

Routine replacement of central vascular catheters every three days does not prevent infection. Exchanging catheters with the use of a guide wire increases the risk of bloodstream infection, but replacement involving insertion of catheters at new sites increases the risk of mechanical complications.

Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population

PURPOSE

A prospective randomized study was conducted over a 23-month period in an adult medical-surgical intensive care unit to determine whether triple-lumen catheters reduce the need for peripheral vascular access and whether they are associated with a higher rate of infection than single-lumen catheters.

PATIENTS AND METHODS

After the insertion route, internal jugular or subclavian, was selected by the physician, patients were randomized either to single-lumen or triple-lumen catheter groups. Complementary peripheral vascular access was allowed in both groups. Catheters were removed according to preestablished defined reasons: suspicion of catheter-related sepsis, uselessness of central venous access, duration of catheterization of more than 21 days, discharge from the intensive care unit, or death.

RESULTS

Data on 129 central venous catheters were collected from 91 consecutive patients. Twenty-five of 68 patients from the single-lumen group and 1 of 61 patients from the triple-lumen group needed peripheral vascular access (p less than 0.001). Catheter-related sepsis rates, defined either by clinical signs and positive qualitative tip cultures (8.9% versus 11.5%) or by quantitative tip cultures (16.2% versus 11.5%), were identical in the single-lumen and triple-lumen groups (type II error: 8%).

CONCLUSION

In intensive care units, the use of triple-lumen catheters is associated with a dramatic decrease in the need for peripheral vascular access. The incidence of central venous catheter-related sepsis appears identical for single- and triple-lumen catheters.

Long-term central venous catheters: issues for care

Long-term central venous catheters allow the safe administration of chemotherapy, blood and blood products, total parenteral nutrition, fluids, and other medications. Despite their benefits, the risk of certain complications (e.g., fibrin sleeve and mural thrombus formation, infection, catheter occlusion, extravasation, and catheter malposition) exist for every person who has a catheter. Thus, preventative measures, recognition of early signs and symptoms of complications, and adequate care of utmost importance.

Experimental study of hub contamination: effect of a new connection device: the I system

Experimental studies of hub contamination of intravenous catheters were done comparing the standard connection method (Luer-Lock connector) with a newly invented connection method (I system). Immersion of the connection sites into a bacteria-containing solution showed no bacterial contamination of the medium in any tubing. The second experiment investigated whether bacterial contamination would occur during a tubing change procedure. A high incidence of bacterial contamination was seen with the Luer-Lock connector, but no bacterial contamination occurred with the I system. These experiments suggest that the use of Luer-Lock connectors is associated with a high risk of bacterial contamination during tubing change, but the I system can prevent contamination during tubing change, which cannot be avoided with Luer-Lock connector.

Placement and complications of monitoring catheters

Vascular access is a necessary evil in critically ill patients, a population that is at high risk for complications. Appropriate planning and attention to detail minimize the associated risks while maximizing the benefits derived from catheter use.

Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting

We prospectively studied the risk of catheter-related sepsis (CRS) in 75 critically ill patients who received total parenteral nutrition (TPN) through 158 pulmonary artery catheters (PACs) and 214 triple-lumen catheters (TLCs). We relied on semiquantitative cultures of the catheter tips, peripheral blood cultures in febrile patients and clinical response to catheter removal to diagnose catheter-related sepsis. The infection rate was 2.5% (4/158) of PACs and 6.5% (14/214) of TLCs (p = 0.124). Colonization rates were 29.1% for PACs and 32% for TLCs. PACs were left in place a significantly shorter length of time than TLCs, 3.1 vs 5.1 days (p less than 0.005). Guidewire exchanges and subclavian vein insertions were associated with a decreased rate of CRS when compared to new insertions and internal jugular vein insertions, respectively. We conclude that pulmonary artery catheters can be used safely for the delivery of hyperalimentation in critically ill patients with no increased risk for catheter-related sepsis compared to triple-lumen catheters. The use of the PAC in this manner allows for the use of a single central venous catheter for the delivery of hyperalimentation and hemodynamic monitoring.

Central venous catheter related sepsis: a clinical review

Central venous catheterization is one of the most common invasive vascular procedures performed in hospitals today. Though catheter related sepsis occurs only in a small percentage of catheterized patients, this complication has a tremendous impact due to the ubiquitous use of central venous catheters and consequent morbidity and even mortality. Recent studies have considerably advanced our knowledge regarding the pathogenesis, diagnosis, and prevention of catheter sepsis. In this paper, current concepts regarding catheter-related sepsis are reviewed, regarding the incidence, pathophysiology, diagnosis, prevention, and therapy of this complication. Particular emphasis is placed upon recent research and clinical advances in this field, which have clarified important question and suggested promising approaches to the prevention and treatment of catheter bacteremia. The excessive morbidity and mortality due to catheter-related sepsis can be markedly decreased, by attention to simple infection control methods, and by future implementation of new experimental techniques.

Infections related to central venous catheters

Infection is a potentially life-threatening complication of central venous catheterization. Although line-related bacteremias and sepsis are relatively uncommon, the frequent use of central lines in the intensive-care unit makes these infections a common consideration. Semiquantitative culture techniques for analysis of the catheter tip provide evidence for the diagnosis of catheter-related infections. Bacterial growth of more than 15 colony-forming units/plate is typically considered significant. Preventive measures include using sterile insertion techniques, providing meticulous care for the local site, and minimizing the duration of catheter use. The practice of changing lines over a guidewire is controversial. For treatment of most catheter-related infections, the catheter should be removed and antibiotics should be administered if associated systemic infection occurs.

Colonization and bacteremia related to duration of triple-lumen intravascular catheter placement

The increased use of triple-lumen catheters has brought with it an increase in sepsis. We undertook a study to determine whether this increase was related to the length of time a catheter was in place. Culture of the fluid in each of the three lumens of all triple-lumen catheters in the medical intensive care units was done daily for a 6-month period. In 14 of 31 catheters, 28 of 93 lumens showed bacterial or fungal growth. A temporal relationship between the time a catheter was placed and the onset of catheter colonization and patient sepsis was established (p less than 0.01). Catheter colonization preceded sepsis in three of four patients who became bacteremic with the same organisms that were cultured from the lumens and the catheter tips. As a result of this study, centrally placed intravascular lines are now changed every 7 days in our institution with a noticeable decrease in line-related sepsis.

Lack of protection against bacterial infections in patients with advanced cancer treated by biologic response modifiers

A survey of patients with advanced cancer treated by biologic response modifiers (BRMs), including (i) recombinant interleukin-2 and lymphokine-activated killer cells, (ii) recombinant interleukin-2 and alpha interferon, and (iii) tumor necrosis factor, was done. A total of 52 patients were reviewed. A total of 73 courses of BRMs were administered. Prior to the initiation of therapy, all patients were infection free and not receiving antibiotics. Twelve patients developed bacteremia during treatment with these BRMs. Five of these 12 patients had catheter-related bacteremia. Six patients had bacteremic infections without an obvious source, and one patient had a urinary tract infection with bacteremia. Staphylococcus epidermidis accounted for six of the isolates. Other organisms were Staphylococcus aureus, group B streptococci, viridans group streptococci, and gram-negative bacilli. This was an unexpectedly high incidence of bacterial infections in patients treated with BRMs. These BRMs have been previously shown to be efficacious against infections (by bacteria and other intracellular organisms) in experimental animals. In this study BRMs did not influence host defense mechanisms or offer protection against bacterial infections.

A 2 year experience of a nutritional support service: prospective study of 229 non-intensive care patients receiving parenteral nutrition

During a 2 year period, 229 non-intensive care patients received total parenteral nutrition (TPN) for a mean of 23.2 days. Nutritional parameters of weight, triceps skin-fold thickness (TSF), mid-arm muscle circumference (MAMC), total lymphocyte count (TLC), serum albumin and serum transferrin were measured prior to commencement of TPN and then at weekly intervals. All parameters showed an upward trend during the period of TPN. This was small and not statistically significant for weight, TSF, MAMC and albumin; the trends were greater and statistically significant for transferrin (P = 0.001) and TLC (P = 0.002). In contrast, in the 14.4% of patients who died, albumin, transferrin and TLC all fell. Patients who died had a significantly lower initial albumin (P = 0.05), transferrin (P = 0.04) and TLC (P = 0.04). The last values obtained in patients who died were very significantly lower for albumin (P less than 0.001), transferrin (P less than 0.001) and TLC (P = 0.003). Single-lumen tunnelled subclavian catheters had a significantly lower incidence of catheter sepsis (4.8%) compared with double-lumen (17.4%) and triple-lumen (13.7%) catheters (P = 0.01). There was also a greater incidence of mechanical and thrombotic complications with multiple-lumen catheters compared with single-lumen catheters (P = 0.02). This study shows that the nutritional indices albumin, transferrin and TLC have prognostic significance. Single-lumen rather than multiple-lumen catheters should be used for administration of TPN whenever possible.

Complications of intravenous feeding catheters

Complications of intravenous nutrition are uncommon but may prove problematic in patients requiring long-term nutritional support. This article reviews the complications associated with intravenous catheters with particular emphasis on problems associated with insertion, catheter-related sepsis, venous thrombosis, catheter occlusion, endocarditis and intracardiac thrombus formation.

Subclavian catheter infections

We retrospectively studied subclavian catheter infection rates involving 481 patients from October 1983 to September 1985. Over this period of time 496 subclavian catheters including 252 single lumen catheters (SLC) and 244 triple lumen catheters (TLC) were inserted. These studies involved all catheters inserted during the 24-month period. The Methodist Hospital IV Team regularly cared for and recorded catheter-related problems. Charts were then retrospectively reviewed and data accumulated. The incidence of catheter tip infections in SLC was 4/248 (1.6%) compared to an incidence of 12/232 (4.9%) for TLC, p = 0.065. There was no significant difference between the incidence of infections at the insertion site of TLCs, 1/243 and SLCs, 1/251. We believe that the increase in catheter-related infections in the TLC is related to the increased utilization afforded by the multiple injection ports.

Effect of frequent guidewire changes on triple-lumen catheter sepsis

Frequent guidewire changes of single-lumen (SLC) and triple-lumen (TLC) catheters have been proposed to decrease catheter sepsis. We placed TLC in 126 patients needing total parenteral nutrition (TPN) and multiple venous access, prospectively randomizing them to two groups: group I received a guidewire change every 3 days, and group II received guidewire changes for mechanical or septic complications only. Tips were cultured at each line change and tips and blood for each septic episode. Catheter sepsis was defined by the criteria of the Association for Practitioners in Infection Control (APIC). There were 67 positive cultures in 52 patients, but most produced very few colonies or grew the same organisms in other infection sites. Forty-seven% of all cultures grew Staphylococci, and 23% grew Candida. APIC-defined catheter sepsis was detected in 12.7% of group I and 15.9% of group II. Although we observed no statistically significant difference in the two techniques, if we assume that a 20% difference in the incidence of catheter-induced sepsis would be important to detect, the probability of failing to detect such a difference is 0.24 with an 0.05 level of significance (two-sided). Prophylactic guidewire changes did not alter the incidence of catheter sepsis in patients with TLC who required TPN. The high rate of sepsis and Candida infection may be due to the critical illness of the immunocompromised population studied.

An attachable silver-impregnated cuff for prevention of infection with central venous catheters: a prospective randomized multicenter trial

PURPOSE

Percutaneously inserted central venous catheters are widely used. Catheter-related bacteremia or fungemia is the most frequent serious complication of these catheters. In an attempt to reduce the frequency of such infections, a subcutaneous cuff constructed of a biodegradable collagen matrix impregnated with bactericidal silver was developed. Our goal was to assess, in a multicenter clinical trial, the effectiveness of this cuff in preventing catheter-related infection.

MATERIALS AND METHODS

Central venous catheters needed for fluid or drug therapy, hemodynamic monitoring, or hyperalimentation in patients in three centers were randomly assigned to be inserted with or without the cuff. Patients and catheters in the two groups were comparable in terms of risk factors predisposing to infection, including colonization of skin about the insertion site.

RESULTS

The results with 234 catheters inserted into a new site showed that catheters inserted with the cuff were threefold less likely to be colonized on removal (more than 15 colony-forming units) than were control catheters (28.9 percent versus 9.1 percent, p = 0.002) and were nearly fourfold less likely to produce bacteremia (3.7 percent versus 1.0 percent). Adverse effects from the cuff were not seen. The cuff did not confer protection, however against infection with catheters inserted over a guidewire into old sites. Most of the catheter-related infections identified in this study, including four of the six bacteremias, appear to have been caused by microorganisms colonizing skin about the insertion site, affirming the pathogenetic basis for benefit seen with the cuff in this clinical trial; two may have derived from contamination of the catheter hub.

CONCLUSION

This novel, silver-impregnated, attachable cuff can substantially reduce the incidence of catheter-related infection with most percutaneously inserted central venous catheters, can extend the time catheters can be left in place safely, and can prove cost-beneficial.

Central venous catheter infections

When used wisely, central venous catheters are capable of providing vital circulatory access in any patient with a remarkably low risk of infection or major complication. Tunneled silicone catheters are the route of choice for long-term or outpatient use, particularly for oncology or TPN patients; insertion of such a catheter should occur early in the hospitalization of a newly diagnosed patient on chemotherapy. The greatest experience has accrued with the cuffed silicone catheters (for example, Broviac), but the totally implantable devices (for instance, Port-a-cath) may become the device of choice in pediatric outpatients. For infants, small, percutaneously inserted noncuffed silicone catheters appear to offer the greatest safety. Among acute care patients, percutaneous plastic central venous catheters fulfill a vital role but represent an important source of infection. Scrupulous technique, the minimizing of manipulation, and a readiness to replace the catheter at any suggestion of trouble are important to achieving the best results. Within a given design, it is generally best to use the smallest diameter catheter capable of performing the desired tasks. However, on the basis of currently available data, there need be no hesitation to use a multilumen catheter if the care of the patient demands multiple access ports. The various silicone catheters can usually be left in place while infection is treated, although fungal and certain other infections are more likely to require catheter removal. Percutaneous plastic catheters should be removed or changed over a wire if infection is suspected; if tip culture of the removed catheter is positive, and the catheter was replaced over a wire, then the replacement catheter should be promptly removed.

Infection rate for single lumen v triple lumen subclavian catheters

An infection rate was calculated for all subclavian catheters inserted during a 12-month period. The overall, single lumen, and triple lumen infection rates were 1.7% (42/2,431), 0.4% (8/1,936), and 6.9% (34/495), respectively. After excluding single lumen catheters in patients in a surgical cardiovascular unit who appeared to have a decreased risk of infection, the overall, single lumen, and triple lumen rates were 3.7% (42/1,140), 1.2% (8/645), and 6.9% (34/495), respectively. Within this group, 11.8% (28/237) of the catheters used for total parenteral nutrition (TPN) were infected, whereas 1.6% (14/903) of the non-TPN catheters were infected. Of patients receiving total parental nutrition through a triple lumen catheter, 14.5% (25/172) became infected, whereas 4.6% (3/65) of the patients receiving total parental nutrition through a single lumen catheter became infected. Single and triple lumen patient groups appeared comparable based on average age, death rate, immunosuppression, underlying disease, and duration of catheterization, but the risk of infection was approximately three times greater for patients receiving total parental nutrition through a triple lumen catheter.

Central catheter infections: single- versus triple-lumen catheters. Influence of guide wires on infection rates when used for replacement of catheters

A prospective study was conducted over six months to determine if triple-lumen catheters were associated with a higher rate of infection than single-lumen catheters. A total of 502 central intravascular catheters were prospectively collected from 362 consecutive patients in the adult intensive care units. Semiquantitative and broth cultures were performed on distal and proximal catheter segments, with peripheral blood culture specimens drawn in febrile patients. The overall infection rate for the 502 catheters was 11.8 percent or 2.2 infections per 100 days at risk. The infection rates were: single-lumen lines, 8 percent; triple-lumen lines, 32 percent; and triple-lumen pulmonary artery catheters, 12 percent. When corrected for time at risk, the triple-lumen lines and the triple-lumen pulmonary artery catheters had the same rate of infection, which was three times greater than that of the single-lumen catheters. After correction for confounding variables such as the presence of diabetes mellitus, the use of hyperalimentation, the degree of illness, dialysis, or ultrafiltration, and the use of a guide wire to place a replacement line over a pre-existing one, the risk of infection remained significantly higher for triple-lumen than for single-lumen catheters. The use of a guide wire to place a new line over an old one also was associated with a trend towards an increased risk of infection.

Risk of infection accompanying the use of single-lumen vs double-lumen subclavian catheters: a prospective randomized study

A prospective study was undertaken to compare the risks of a multiple-lumen catheter to bilateral subclavian catheters in patients receiving total parenteral nutrition (TPN). All patients had one preexisting subclavian catheter. Patients were randomized into two groups: one group received a double-lumen catheter via a guidewire change of the preexisting single-lumen subclavian catheter. In the second group, a second single-lumen subclavian catheter was inserted and the preexisting single-lumen catheter was changed over a guidewire. Patients were followed by the Nutrition Support Service and were managed identically with regard to solutions given, catheter care, dressing changes, monitoring of mechanical complications, and evaluation of fever. Total infection rates in both groups were identical (22.7%). The difference in mechanical complication rates in the double-lumen catheter group (9%) and the group with bilateral single-lumen catheters (22.7%) was not significant by Fischer's exact test. The multiple-lumen catheter is superior in convenience and as safe as bilateral single-lumen catheters.

Colonization and sepsis from triple-lumen catheters in critically ill patients

Sepsis from central triple-lumen catheters remains a serious and life-threatening problem. Patients requiring triple-lumen catheter placement frequently have multiorgan failure or very serious illness. Every effort should be made to reduce the incidence of catheter-related sepsis. Earlier recognition of catheter sepsis may allow removal of the offending line before sepsis becomes clinically apparent. These data indicate that line colonization occurs early and frequently after triple-lumen catheter placement, and suggests that early, frequent line changes may reduce the incidence of clinical sepsis.

Intrinsic and extrinsic microbial contamination of home total parenteral nutrition manufactured in eva-infusion bags (the i.v. bag)

Microbial contamination of total parenteral nutrition including fat emulsions in 1-3 litres plastic infusion bags (the i.v. bag) was studied during production in the pharmacy and administration both at home and in the hospital. Production contamination was investigated by dispensing test bags containing growth medium mixed with dextrose-salt solution. In this highly sensitive system, contamination was detected in less than 4% of cases. In-use contamination was estimated at the end of the infusion. The average contamination rate (+/- growth) in the five patients studied was 6.7% accompanied by considerable variation. Identification of the contaminants revealed that 85% of the contaminated bags contained staphylococci, indicating skin contamination. An investigation on the effect of the procedure used for attaching the infusion set on the contamination rate, was carried out with bags that contained sterile growth medium. This showed no contamination in 14 cases indicating the catheter as the most plausible source of contamination. It is concluded that both production in the community pharmacy and administration in the home are not associated with a higher microbial contamination than in central hospitals. It is, however, recommended that the microbial quality of the production process and the administration procedure are regularly monitored.

The role of the nutritional support team in preventing and identifying complications of parenteral and enteral nutrition

As the technology of parenteral and enteral nutrition advances, a multidisciplinary nutritional support team (NST) can be used to assure quality care. NST functions include developing and using standard protocols and solutions, monitoring patients, and preventing complications. Interventions by NSTs can save money for the hospital as well. Examples from Truman Medical Center (Kansas City, Missouri) illustrate how the NST can perform these functions.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.

Complications of parenteral nutrition

All hospitalized patients except infants (a total of 1,647 patients) who received central venous TPN solutions at UCDMC from 1981 through 1985 were studied to determine the incidence of complications from the use of TPN. A complication was considered to have occurred if the patient experienced obvious morbidity, mortality, or both; an event known to be deleterious, despite a lack of demonstrable morbidity; or premature loss of the central venous catheter. Complications related to catheter placement occurred in 5.7 percent of patients, sepsis in 6.5 percent, mechanical complications in 9 percent, and metabolic complications in 7.7 percent. The incidence of induction of sepsis increased during 1984 to 1985 due to the introduction of multilumen central venous catheters. The most frequent catheter placement complications were hemorrhage and pneumothorax. Major venous thrombosis and nursing mishaps were the most common mechanical complications. Metabolic complications were infrequent and were generally not severe after adjustment of the protocol in late 1981. Four patients (0.2 percent) died from TPN-associated complications: a child on home TPN who underwent a catheter change and in whom hyperosmolar hyperglycemic coma developed, a patient with end-stage chronic obstructive pulmonary disease in whom tension pneumothorax occurred, a patient who died from complications of subclavian artery laceration, and a patient who died from Candida septicemia. Complications of TPN are frequent and may be severe. Quality assurance mechanisms for identification of these complications are necessary and should form the basis for the establishment of appropriate protocols.