Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis

Venous access devices (Review)

Venous access devices can be categorized based on the termination site of the tip of the catheter into central and peripheral access devices. Selecting the type of venous access device depends on various factors, including the condition of the patient, the anticipated duration of therapy, the use of vesicant or hyperosmolar therapies and the potential risk of complications. Peripheral intravenous catheters provide adequate venous access in the majority of hospitalized patients; however, their use is associated with high failure rates. Non-tunneled central venous access catheters are typically used in critically ill patients and are ideally suited for short-term use, while tunneled central catheters are utilized in those who require long-term intravenous therapy due to their extended dwell times. Each of these devices has unique characteristics requiring an in-depth understanding of the indications and current evidence-based recommendations to optimize their use. The present narrative review aimed to describe the different types of venous access devices and recommendations for their use based on current evidence-based recommendations. A narrative review of the literature was performed based on searches of the PubMed and Google Scholar database from 1990 through November 1, 2024. The type of device used, the insertion site, patient characteristics and clinical needs, and the risk of complications are factors that a provider needs to consider when ordering the placement of a venous access device are discussed. The present review also discusses the prevention of negative adverse events, such as bloodstream infections and thrombosis, associated with specific devices. In addition, current evidence-based recommendations for device selection and indications for use are described. The present narrative review provides a detailed examination of venous access devices that are essential in the care and treatment of patients. Since venous access is associated with inherent risks, device selection and meticulous post-insertion care are paramount in ensuring patient safety and successful therapy.

A dynamic online nomogram for predicting nutritional risk in nasopharyngeal carcinoma patients after radiotherapy

PURPOSE

Malnutrition is a prevalent and detrimental complication in patients with nasopharyngeal carcinoma (NPC) undergoing radiotherapy. Early identification and intervention are crucial for optimizing outcomes.

METHODS

We retrospectively analyzed data from 383 patients with NPC who underwent radiotherapy. We employed logistic regression analysis to identify risk factors for malnutrition and developed a nomogram for its prediction. The nomogram was internally and externally validated using bootstrap methods and calibration curves.

RESULTS

Body mass index (BMI), chemotherapy cycles, central venous catheter (CVC), and alanine aminotransferase (ALT) were identified as independent risk factors for malnutrition. The nomogram demonstrated good discriminatory ability (AUC: 0.786 in the training set, 0.687 in the validation set) and clinical utility, with high net benefit in decision curve analysis.

CONCLUSIONS

This nomogram offers a practical tool for predicting nutritional risk in patients with NPC undergoing radiotherapy. Its application can facilitate early identification of at-risk patients and guide targeted interventions to improve clinical outcomes.

Enhancing the quality and safety of central venous catheter insertion using projection mapping: a prospective observational simulation study with eye-tracking glasses

OBJECTIVES

We aimed to evaluate the effect of projection mapping (PM) on the quality and safety of central venous catheter (CVC) insertion under real-time ultrasound guidance.

DESIGN

Prospective, observational, simulation study.

SETTING

This study was conducted at the Yokohama City University Medical Center (Yokohama, Japan). Volunteer residents were enrolled over 12 months from January to December 2023.

PARTICIPANTS AND METHODS

12 rotating residents (postgraduation year (PGY) 1 and 2) and eight anaesthesia residents (PGY 3-5) placed the CVC in the internal jugular vein in a simulator under the real-time ultrasound guidance using the short-axis out-of-plane approach. The ultrasound image was provided either just caudad to the puncture site using the PM method or on the monitor of the ultrasound machine (conventional method) placed next to the simulator's right shoulder. Each resident performed four punctures alternating between the PM and conventional methods, and the first method for each resident was chosen randomly. Eye-tracking analysis was also used to evaluate differences in gaze behaviour.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the procedure time defined as the time from the application of the ultrasound probe on the puncture field until successful puncture of the vein. The secondary outcomes were incidence of complications and eye-tracking analysis data.

RESULTS

The time to complete the line placement was significantly shorter for the PM than for the conventional method (median (IQR) 22.5 (15.5-30.6) s vs 30.0 (20.4-95.4) s; p=0.02, Wilcoxon's signed-rank test). The incidence of posterior vessel wall puncture was significantly lower in the PM method (0% vs 25%; p=0.02, McNemar's test). Eye-tracking analysis revealed that the percentage of time spent gazing at the ultrasound image was higher in the PM than in the conventional method (61.6% (55.0-69.2) vs 45.7% (34.1-54.5); p<0.01).

CONCLUSIONS

The PM method facilitates ultrasound-guided CVC placement while preventing excessive needle advancement in the inexperienced operators. This was accompanied by enhanced fixation of the participants' line-of-sight on the ultrasound image.

Central Venous Access: An Update on Modern Techniques to Avoid Complications

Background: Central venous catheterization (CVC) is a frequently performed procedure in anesthesia and critical care settings. Modern procedures have improved significantly, particularly with increasingly sophisticated venous verification methods and ultrasound guidance. While the associated historical complication rates reflect this improvement, complications such as inadvertent arterial puncture, arterial cannulation, pneumothorax, deep vein thrombosis, and catheter-associated infection are still significant risks. Methods: This narrative review was constructed from a literature review using a search strategy of the MESH terms central venous access, central venous line, complications, insertion, and puncture, published between 2015 and 2025. Inclusion criteria included peer-reviewed full-text articles. Supplementary articles were included to construct the historical perspectives on central venous access and complications. Results: Our review offers a simple management algorithm for the mechanical complications of CVC insertion. This algorithm focuses on inadvertent arterial puncture/cannulation, with steps ranging from external compression to endovascular repair or surgical intervention. Conclusions: Moving forward, clinicians are encouraged to look into the future to predict what complications may arise as our modern patient cohort evolves. When complications develop, clinicians should know how to manage them to prevent further patient morbidity.

Improving Resident Comfort with Central Venous Catheter Supervision: Use of an Error Management Training Approach

Background

Simulation is a well-established component of central venous catheter (CVC) training. However, there is little published regarding how to train residents to supervise CVC insertion.

Purpose

We describe a curriculum designed to help trainees identify potential procedural errors and improve their comfort with supervising CVC insertion.

Patients and Methods

We conducted a one-group, pre-post-posttest study. All participants completed a pre-simulation assessment (Time 1) that evaluated residents' ability to identify potential complications with CVC insertion and their procedural completion and procedural supervision comfort. Residents then participated in a simulation in which they supervised a mock proceduralist insert a CVC and commit five pre-specified errors. Participants completed the same comfort assessment immediately following the simulation (Time 2) and repeat knowledge and comfort assessments five months later (Time 3).

Results

Forty-seven interns participated in the study. Relative to Time 1 (M = 3.00, SD = 1.02), interns were significantly more comfortable supervising CVC insertion at Time 2 (M = 3.75, SD = 0.85) and at Time 3 (M = 4.08, SD = 0.58).

Conclusion

We describe a simulation designed to help residents identify errors when supervising CVC insertion. Due to a poor survey response rate, no comparisons between pre- and post-simulation error identification could be determined. However, following our CVC supervisor simulation, participants reported immediate and sustained increases in their comfort supervising CVC placement.

The effectiveness of a three-dimensional printed model for training novice healthcare professionals in central venous catheter insertion: A cross-sectional study in a critical care setting

BACKGROUND

We have previously used three-dimensional printing to develop a novel manikin for simulation training of central venous catheter insertion in critical care. The objective of this study was to evaluate the fidelity of the model by testing with novice and experienced operators.

METHODS

A convenience sample of intensivist physicians experienced in central venous catheter insertion and critical care nurses without prior central venous catheter training was assembled. Participants were offered a video educational clip and a one-on-one demonstration. All participants were then asked to insert a central venous catheter into the model. Outcomes included requests for assistance, success rate, time to insertion, and subjective feedback.

RESULTS

Thirteen intensivists and 14 nurses participated. Nurses were more likely to view the demonstration video prior to the procedure (13/14; 92.9% vs. 7/13; 53.9%; p = 0.033). Intensivists were more likely male (11/13; 84.6% vs. 3/14; 21.4%; p = 0.002) and tended to be older, with a higher proportion in the 35- to 44-year and 45- to 54-year age ranges than the nurses (92.3% vs. 71.4%; p = 0.426). Nurses requested more assistance and received more guidance but had similar overall success (100.0% vs 92.3%; p = 0.481). The median time taken for the procedure was 19 min and 59 s for nurses and 8 min and 14 s for intensivists (p = 0.004). All participants agreed that the model effectively prepared trainees for their first human central venous catheter insertion. Nurses also reported a significant increase in procedural confidence post simulation. Additionally, most participants agreed or strongly agreed that the model realistically simulated the femoral vein, an essential aspect of the central venous catheter insertion.

CONCLUSIONS

Nurses required additional assistance and took longer to complete the insertion, demonstrating preliminary evidence for the model's construct validity. Furthermore, the model was deemed a realistic training tool with successful insertion by nearly all participants.

Forearm-only transarterial and transvenous approach for endovascular intervention of dural arteriovenous fistula

BackgroundTransradial arterial access has become widely used as a less invasive approach in neuroendovascular therapy, but the forearm venous approach has rarely been reported.ObjectivesThis study aimed to assess the safety and efficacy of forearm transvenous neurointervention for intracranial lesions. We present our experience with a simultaneous forearm-only transarterial and venous approach (fTAVA) for dural arteriovenous fistulas (dAVFs).MethodsWe retrospectively reviewed a prospective database of consecutive patients who underwent fTAVA for dAVFs between 2021 and 2024. fTAVA was performed using the right radial artery and superficial forearm vein as puncture sites. Arterial closure was achieved using a radial compression device, whereas bandage compression was used for venous closure. Procedural success, angiographic results, procedure-related complications and patient satisfaction were evaluated.ResultsOverall, 13 (8 carotid-cavernous sinus and 5 transverse-sigmoid sinus fistulas) procedures using fTAVA were successfully performed with favorable outcomes. Arterial puncture was performed at the distal radial artery in nine cases. The venous puncture site was the median cubital vein in nine cases and the forearm cephalic vein in four cases. The targeted fistulas were distal to the right jugular vein in four cases and the left jugular vein in nine cases. They were successfully accessed in all cases. The angiographic result was total occlusion in eleven cases and subtotal occlusion in two cases. There was one patient with minor access-site complication in distal radial artery.ConclusionsThe fTAVA is a safe and effective method for the endovascular treatment of dAVFs and is associated with reduced patient discomfort.

Pathogenic bacteria features of central line-associated bloodstream infections in ICU patients: focus on the early predictive value of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios

Objective

Explore and analyze CLABSI pathogenic bacteria characteristics in ICU patients and the value of PCT, NLR, PLR in early infection prediction.

Methods

926 ICU patients with central venous catheters in Minhang Hospital from January 2021 to December 2023 were enrolled. They were grouped by co-infection status. PCT, NLR and PLR levels were measured, patient data analyzed, pathogenic bacteria characteristics summarized, and their predictive value evaluated via ROC curve.

Results

From January 2021 to December 2023, among the 926 patients with CVC, 73 were diagnosed with CLABSI, with an infection rate of 7.88%. A total of 81 strains of pathogenic bacteria were isolated, including 60.50% (49/81) Gram - positive bacteria, 35.80% (29/81) Gram - negative bacteria, and 3.70% (3/81) fungi. The main Gram - positive bacteria exhibited high resistance to penicillin, erythromycin, clindamycin, and oxacillin, with a resistance rate exceeding 70%, yet were sensitive to vancomycin, linezolid, and tetracycline. The main Gram - negative bacteria had high resistance to piperacillin, piperacillin/tazobactam, Aztreonam, and gentamicin, with a resistance rate over 70%, and were more sensitive to cefoperazone/sulbactam, imipenem, and amikacin. Age, the site of catheterization, the duration of catheterization, and the employment of double - cavity catheters were all factors that exerted an influence on CLABSI among ICU patients (with p < 0.05). The levels of peripheral blood NLR, PLR, and PCT in the infected group were higher than those in the non - infected group (p < 0.05). The areas under the curve (AUCs) of peripheral blood NLR, PLR, and PCT were 0.814, 0.798, and 0.856, respectively, with the largest AUC for PCT. When the cut - off point was 2.75 ng/ml, the Youden index was the largest. The AUCs of the combination of peripheral blood NLR and PLR, NLR and PCT, PLR and PCT, and all three combined were 0.877, 0.903, 0.857, and 0.917.

Conclusion

The early prediction of CLABSI in ICU patients by means of PCT, NLR, and PLR is of remarkable significance. It can provide a precious reference for clinical diagnostic and treatment strategies.

Failure mode and effects analysis applied to central venous catheter placement

Despite diligent efforts, complications continue to occur during the placement of central venous catheters (CVCs). Healthcare Failure Mode and Effect Analysis has been promoted as a process improvement tool and this review describes the strategic application of Failure Mode and Effects Analysis (FMEA) to CVC placement. The objective is to demonstrate the utility of FMEA first as a tool for identifying quality or safety issues and second for guiding mitigation efforts.

Development and validation of machine learning-based prediction model for central venous access device-related thrombosis in children

BACKGROUND

Identifying independent risk factors and implementing high-quality assessment tools for early detection of patients at high risk of central venous access device (CVAD)-related thrombosis (CRT) plays a critical role in delivering timely preventive interventions and reducing the incidence of CRT. Approaches for identifying the risk of CRT in children have not been well-researched.

OBJECTIVE

To identify the critical risk factors for CRT in children and to construct machine learning-based prediction models tailored to this group, providing a theoretical basis and technical support for the prediction and prevention of CRT in these patients.

STUDY DESIGN

Retrospective data of pediatric patients receiving CVAD catheterization from January 1, 2018 to June 31, 2023 in Tongji Hospital were collected and divided into a training set and an internal validation set in a ratio of 7:3. Relevant data from July 1, 2023 to July 1, 2024 were prospectively collected for external validation of the model. LASSO regression was applied to determine CRT independent risk factors. Subsequently, four prediction models were constructed using logistic regression (LR), random forest, artificial neural network, and eXtreme Gradient Boosting.

RESULTS

A total of 1445 children were included in this study and the overall incidence of CRT was 17.4 %. The LASSO regression screened out 11 critical variables, including history of thrombosis, leukemia, number of catheters, history of catheterization, chemotherapy, parenteral nutrition, mechanical prophylaxis, dialysis, hypertonic liquid, anticoagulants, and post-catheterization D-dimer. The LR model outperformed the other models in both internal and external validation and was considered the best model for this study, which was transformed into a nomogram.

CONCLUSIONS

This study identified 11 independent risk factors for CRT in children. The prediction model developed using LR algorithm demonstrated excellent clinical applicability and may provide valuable support for early prediction of CRT.

Aspirin Is as Effective as Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The purpose of our study was to assess the effectiveness and safety of aspirin for venous thromboembolism (VTE) prophylaxis after knee arthroplasty.

METHODS

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were two independent researchers who conducted literature searches based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies comparing aspirin and oral anticoagulants (OACs) for VTE prophylaxis after knee arthroplasty. Our meta-analysis included seven randomized controlled trials with 2,323 participants.

RESULTS

The relative risk (RR) of VTE following knee arthroplasty was 1.29 (95% confidence interval [CI], 0.78 to 2.14) when comparing aspirin to OACs. Similar results were observed for deep vein thrombosis (RR, 1.33; 95% CI, 0.71 to 2.50) and pulmonary embolism (RR, 1.01; 95% CI, 0.25 to 4.03). No notable differences were found in bleeding, wound complications, or mortality between two groups. Analyses of subgroups based on factors like region, publication year, VTE type, VTE events, aspirin dose, comparator types, use of mechanical thrombosis prophylaxis, trial quality, and study support revealed no substantial differences in VTE incidence between two groups. Overall, the quality of evidence for VTE and deep vein thrombosis outcomes was moderate.

CONCLUSIONS

Existing randomized controlled trial evidence suggests that aspirin is equally effective and safe as OACs in preventing VTE.

Recent Progress in Antibacterial Surfaces for Implant Catheters

Catheter-related infections (CRIs) caused by hospital-acquired microbial infections lead to the failure of treatment and the increase of mortality and morbidity. Surface modifications of the implant catheters have been demonstrated to be effective approaches to improve and largely reduce the bacterial colonization and related complications. In this work, we focus on the last 5-year progress in the surface modifications of biomedical catheters to prevent CRIs. Their antibacterial strategies used for surface modifications are further divided into 5 classifications through the antimicrobial mechanisms, including active surfaces, passive surfaces, active and passive combination surfaces, stimulus-type response surfaces, and other types. Each feature and the latest advances in these abovementioned antibacterial surfaces of implant catheters are highlighted. Finally, these confronting challenges and future prospects are discussed for the antibacterial modifications of implant catheters.

Fluid Dynamic and in Vitro Blood Study to Understand Catheter-Related Thrombosis

PURPOSE

Central venous catheters (CVCs) provide a direct route to the venous circulation but are prone to catheter-related thrombosis (CRT). A known CRT risk factor is a high catheter-to-vein ratio (CVR), or a large catheter diameter with respect to the indwelling vein size. In this study, the CVR's effect on CVC hemodynamics and its impact on CRT is investigated with in vitro and in silico experiments.

METHODS

An in vitro flow loop is used to characterize the hemodynamics around CVCs using particle image velocimetry. In addition, CRT is investigated using an in vitro flow loop with human blood and clinical catheters. The wall shear rate of flow around the CVC is computed numerically. CVRs of 0.20, 0.33, and 0.49 and Reynolds numbers of 200, 800, and 1300 are evaluated. No flow is used through CVC lumens to model chronic indwelling catheters.

RESULTS

Results show CVR ≥ 0.33 promotes platelet-rich clot growth at the device tip and at an increased rate compared to lower CVR cases. A high wall shear rate gradient on the CVC tip and an extended wake distal to the tip exists for higher CVR cases, promoting the aggregation of platelets and subsequent stagnation for clot formation. Further, the combination of the CVR and Reynolds number are crucial to CRT potential, not the CVR alone. Specifically, thrombosis risk is increased with low (stasis driven) and/or high (platelet activation driven) flow conditions, with the CVR and CVC's geometry playing an additional role in promoting fluid mechanic driven thrombus development. A high CVR (≥ 0.33) and high flow condition (≥ 1300) results in the highest risk for clot growth at the tip of the device; other locations of the device are at risk for thrombus development in lower flow conditions, regardless of the CVR. The importance of the device geometry and flow in promoting thrombus and fibrin sheath formation is also shown for the device investigated.

CONCLUSIONS

This work demonstrates that the CVR, flow, and device geometry affect CRT. For clinical cases with CVR ≥ 0.33 and/or Re ≥ 1300, the device tip may be monitored more consistently for clot formation. Thrombosis risks remain on the entire catheter, regardless of the flow condition, for a CVR = 0.49. Device placement should be chosen carefully with respect to the combination of the Reynolds number and CVR. Further study is needed on the effect of catheterization to confirm these findings.

Evaluation of a novel central venous access port for direct catheter insertion without a peel-away sheath

PURPOSE

This study retrospectively evaluated the feasibility and safety of implanting a newly developed central venous access port (CV-port) that allows catheter insertion into a vein without the use of a peel-away sheath, with a focus on its potential to minimize risks associated with conventional implantation methods.

MATERIALS AND METHODS

All procedures were performed using a new device (P-U CelSite Port™ MS; Toray Medical, Tokyo, Japan) under ultrasound guidance. The primary endpoint was the implantation success rate. The secondary endpoints were the safety and risk factors for infection in the early postprocedural period (< 30 days).

RESULTS

We assessed 523 CV-port implantations performed in a cumulative total of 523 patients (240 men and 283 women; mean age, 61.6 ± 13.1 years; range, 18-85 years). All implantations were successfully performed using an inner guide tube and over-the-wire technique through 522 internal jugular veins and one subclavian vein. The mean procedural time was 33.2 ± 10.9 min (range 15-112 min). Air embolism, rupture/perforation of the superior vena cava, or hemothorax did not occur during catheter insertion. Eleven (2.1%) intraprocedural complications occurred, including Grade I arrhythmia (n = 8) and subcutaneous bleeding (n = 1), Grade II arrhythmia (n = 1), and Grade IIIa pneumothorax (n = 1). Furthermore, 496 patients were followed up for ≥ 30 days. Six early postprocedural complications were encountered (1.1%), including Grade IIIa infection (n = 4), catheter occlusion (n = 1), and skin necrosis due to subcutaneous leakage of trabectedin (n = 1). These six CV-ports were withdrawn, and no significant risk factors for infection in the early postprocedural period were identified.

CONCLUSION

The implantation of this CV-port device demonstrated comparable success and complication rates to conventional devices, with the added potential benefit of eliminating complications associated with the use of a peel-away sheath.

Outcome-based simulation training for ultrasound-guided central venous catheter placement: clinical impact on preventing mechanical complications

BACKGROUND

Central venous catheter placement has been associated with mechanical complications, some of which can be life-threatening. Recent studies have shown that simulation-based education on ultrasound-guided central venous catheter placement improves puncture success rates; however, its effect on reducing mechanical complications remains unclear. This observational study examined how outcome-based simulation training for ultrasound-guided central venous catheter placement affects the incidence of mechanical complications in a clinical setting.

METHODS

The Safe Central Venous Catheter Placement and Management Committee established a reporting system to monitor central venous catheter placement. In 2016, a skill assessment of ultrasound-guided central venous catheter placement was conducted. Outcome-based simulation training was introduced in 2017. Skills were evaluated using the skill assessment tool developed by the Japanese Society for Medical Simulation.

RESULTS

After implementing skill assessment and outcome-based simulation training, the mechanical complication rate decreased from 2.2% in 2015 to 1.2% in 2023.

CONCLUSIONS

A recent meta-analysis reported a 2.3% mechanical complication rate during ultrasound-guided central venous catheter placement. In comparison, the 1.2% complication rate at our institution is notably lower. This study suggests that outcome-based simulation training for ultrasound-guided central venous catheter placement may help reduce the incidence of mechanical complications in clinical settings.

Assessing infection related to short-term central venous catheters in the perioperative setting

Central venous catheter (CVC) cannulation can be accompanied by serious complications. The appearance of catheter-related infections is associated with high morbimortality. The aim of this study is to evaluate the incidences of colonization and central line-associated bloodstream infections (CLABSI) in short-term CVCs in the elective surgery setting, as well as to analyze the related risk factors. Prospective observational study including patients undergoing elective surgery with a CVC inserted perioperatively. Patients with current infection, taking preoperative antibiotics, those planning to have CVC for longer than 14 days, those under 18 years old, and those refusing to participate were excluded. Patients without cultures at the moment of CVC retrieval were not included. 200 patients were included, with a mean catheter duration of 6.8 ± 3.1 days, and a total duration of 1,358 days. Incidence of colonized catheters was 6% (8.84/1000 catheter-days), and 3.5% had CLABSI (5.15/1000 catheter-days). Catheter duration was longer in patients whose CVCs had been removed due to suspected infection (p < 0.0001). The risk factors for catheter colonization were a history of oncological disease (p = 0.022), ischemic heart disease (p = 0.019), as well as jugular venous catheterization (p = 0.019). No relationship was detected between colonization and operator experience (p = 0.050), ultrasound-guided cannulation (p = 0.565), or number of attempts (p = 0.379). The risk factors for CLABSI were: age over 60 years (p = 0.041) and oncological disease (p = 0.021). CLABSI was neither related to operator experience (p = 0.178), ultrasound-guided cannulation (p = 0.373), or number of attempts (p = 0.379). Although CVCs were in place for a short time and in a controlled setting, we observed high incidences of colonization and CLABSI. The risk of catheter colonization depends on other factors rather than catheter duration.

Vascular Access Device Infections: Current Management Practices and the Role of Multidisciplinary Teams at a Large Hospital in Northern Italy

Introduction: Vascular access device (VAD)-associated infections, including catheter-related (CRBSI) and catheter-associated bloodstream infections (CABSI), present significant challenges in patient care. While multidisciplinary VAD teams (VATs) are equipped with protocols for managing these infections, adherence to these guidelines in real-life practice is inconsistent. This study aims to evaluate the alignment between actual VAD infection management practices and VAT-recommended protocols. Methods: We conducted a retrospective, single-center study at Luigi Sacco Hospital (May 2021-October 2023) involving non-ICU adult patients with diagnosed CRBSI or CABSI. VAT experts independently reviewed infection management choices, which were divided into eight specific procedural options. These options included variations in VAD removal, timing of repositioning, and combinations of antimicrobial lock therapy and systemic therapy. Concordance between real-life practices and VAT recommendations was evaluated using Cohen's kappa coefficient. Results: Of 2419 VAD placements, 146 (6%) developed infections (84 CABSI, 62 CRBSI). Clinicians removed VADs in 66.4% of cases compared to 62.3% per VAT recommendations, with moderate overall agreement (Cohen's kappa = 0.58). Analysis of the eight management categories revealed moderate to low alignment (unweighted kappa = 0.44, weighted kappa = 0.30) between real-life practices and VAT guidance, with slightly improved concordance in CRBSI cases. Conclusions: Our findings underscore a discrepancy between real-life VAD infection management and VAT-recommended protocols, suggesting a need for clearer, more accessible guidelines and increased multidisciplinary collaboration. Enhanced VAT consultation and simplified protocol dissemination may improve consistency in infection management and ultimately lead to better patient outcomes.

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

Iatrogenic Superior Vena Cava Syndrome With Extensive Thromboembolism Associated With Chronic Indwelling Catheterization

Superior vena cava syndrome (SVCS) results from the partial or complete obstruction of blood flow through the superior vena cava (SVC), which comprises a broad clinical spectrum ranging from asymptomatic cases to rare life-threatening emergencies with upper airway obstruction and increased intracranial pressure. Iatrogenic SVCS is not uncommon given the increasing utilization of intravascular devices in the past decades, suggesting that wider knowledge of the indications for semipermanent venous access and consistent monitoring are warranted in our clinical practice in order to avoid unfavorable outcomes. Here, we present a case of SVCS with respiratory distress due to extensive thromboembolism associated with a chronic indwelling intravenous (IV) catheter.

Diagnostic value of systematic compression ultrasonography for the detection of unrecognized venous thromboembolism in patients admitted to an internal medicine ward for dyspnea

The diagnosis of venous thromboembolism (VTE) is complex, and many cases of pulmonary embolism (PE) and deep vein thrombosis (DVT) go undetected despite validated diagnostic algorithms. This study evaluated the diagnostic performance of compression ultrasound (CUS) when systematically performed in patients admitted to an internal medicine department for dyspnea and/or respiratory failure. We conducted a prospective observational cohort study of consecutive adult hospitalized patients admitted for dyspnea and/or respiratory failure with at least one of the following: tachycardia (> 100 bpm), tachypnea (> 20/min), chest pain, cough, syncope, or hemoptysis. Patients with a previous diagnosis of VTE or who underwent computed tomography pulmonary angiography (CTPA) or CUS during evaluation in the emergency department were excluded. The study included 263 patients (50.2% women, average age 84 years). CUS was positive in 31 patients (11.8%); Bilateral DVT was diagnosed in two patients and unilateral DVT in 29 patients. Of these, 10 underwent CT scan, with PE confirmed in 9 cases. Using the Wells score for DVT (cut-off ≥ 2), only 8 patients (25.8%) were at high risk. The accuracy of the Wells score in identifying PE was suboptimal, as 5 of 9 patients (55.5%) with confirmed PE were in the low-risk group (three-level interpretation) and 8 (89.9%) were in the "EP unlikely" group (two-level interpretation). The systematic use of CUS as a point-of-care tool can improve the diagnostic accuracy for VTE in patients admitted to internal medicine departments with dyspnea/respiratory failure.

NLP-Driven Analysis of Pneumothorax Incidence Following Central Venous Catheter Procedures: A Data-Driven Re-Evaluation of Routine Imaging in Value-Based Medicine

Background: This study presents a systematic approach using a natural language processing (NLP) algorithm to assess the necessity of routine imaging after central venous catheter (CVC) placement and removal. With pneumothorax being a key complication of CVC procedures, this research aims to provide evidence-based recommendations for optimizing imaging protocols and minimizing unnecessary imaging risks. Methods: We analyzed electronic health records from four university hospitals in Salzburg, Austria, focusing on X-rays performed between 2012 and 2021 following CVC procedures. A custom-built NLP algorithm identified cases of pneumothorax from radiologists' reports and clinician requests, while excluding cases with contraindications such as chest injuries, prior pneumothorax, or missing data. Chi-square tests were used to compare pneumothorax rates between CVC insertion and removal, and multivariate logistic regression identified risk factors, with a focus on age and gender. Results: This study analyzed 17,175 cases of patients aged 18 and older, with 95.4% involving CVC insertion and 4.6% involving CVC removal. Pneumothorax was observed in 106 cases post-insertion (1.3%) and in 3 cases post-removal (0.02%), with no statistically significant difference between procedures (p = 0.5025). The NLP algorithm achieved an accuracy of 93%, with a sensitivity of 97.9%, a specificity of 87.9%, and an area under the ROC curve (AUC) of 0.9283. Conclusions: The findings indicate no significant difference in pneumothorax incidence between CVC insertion and removal, supporting existing recommendations against routine imaging post-removal for asymptomatic patients and suggesting that routine imaging after CVC insertion may also be unnecessary in similar cases. This study demonstrates how advanced NLP techniques can support value-based medicine by enhancing clinical decision making and optimizing resources.

Chinese expert consensus on tunneled technique for peripherally inserted central venous catheters

OBJECTIVE

To formulate an expert consensus on an evidence-based overview of all topics related to the Tunneled Peripherally Inserted Central Venous Catheters.

METHODS

A Chinese consensus based on evidence has provided a definition and indications for Tunneled Peripherally Inserted Central Venous Catheters. The literature on Tunneled Peripherally Inserted Central Venous Catheter was reviewed from its inception to March 2024. The indications were developed using the RAND/UCLA Appropriateness Method.

RESULTS

This consensus presents five indications for Tunneled Peripherally Inserted Central Venous Catheters, covering tunneling definitions, key processes, tunneling devices, various applications, and maintenance. The indications aim to enhance patient safety and optimize the efficacy of tunneled peripherally inserted central venous catheters.

CONCLUSIONS

This consensus is based on critical evidence review and the clinical experts aimed to assist clinicians in applying tunneling techniques. Further prospective studies are needed to evaluate the impact of complications related to the tunneling technique.

Reassessing the need for scheduled replacement of short term central venous catheters: A narrative comprehensive review

Central venous catheters (CVCs) are essential in modern healthcare but are associated with significant risks, particularly catheter-related bloodstream infections (CRBSIs). Current guidelines do not recommend routine replacement of CVCs based on time alone. However, recent evidence challenges this recommendation. A comprehensive literature review was conducted, focusing on studies exploring the risk-factors of short-term, non-hemodialysis CVCs, that were published in the last two decades while including seminal older works for context. The guidelines regarding scheduled CVC-replacement are not based on sufficiently convincing data. Current literature establishes the significance of CVC-duration as a major risk-factor for CRBSI occurrence, especially after 9-14 days of catheter-dwelling. The daily CRBSI risk is probably not constant, and the cumulative risk may reach high rates after 9-14 days, especially for femoral and jugular insertions compared to the subclavian site, suggesting potential benefits of scheduled CVC replacement, especially for non-subclavian catheters.

Analysis of the Integrated Management Model of Medical Care and Medication in Intravenous Treatment for Critically Ill Patients

Objective

To explore the effect of the Integrated Management Model of Doctor-Nurse-Pharmacist Collaboration on the Safety of Intravenous Therapy in Critically Ill Patients.

Methods

1587 patients who were hospitalized in the Intensive Care Department of the Fourth Hospital of Hebei Medical University in China from January 2021 to December 2022 were selected. 768 patients before the implementation of the integrated medical, nursing, and drug management model were selected as the control group, and 819 patients who implemented the integrated medical, nursing, and drug management model were selected as the observation group.

Results

Compared with the control group, the incidence of drug compatibility contraindications in the observation group decreased from 3.5% to 1.5% (χ2=6.957 P=0.008), the central venous catheter (CVC) blockage rate decreased from 2.5% to 1.0% (χ2=5.249 P=0.022), the daily incidence of catheter related bloodstream infections decreased from (1.84 ± 2.17) to (0.91 ± 1.19)(t=6.988 P=0.015), and the incidence of peripheral venous treatment related complications decreased from 10.3% to 2.9% (χ2=16.663 P=0.000). Among them, the incidence of phlebitis decreased from 5% to 1.6% (χ2=4.817 P=0.028). The incidence of drug exudation decreased from 3.4% to 0.8% (χ2=0.031 P=0.019). The incidence of extravasation has decreased from 2.5% to 0.4% (χ2=0.044 P=0.027). The differences were statistically significant (P<0.05).

Conclusion

The Integrated Management Model of Doctor-Nurse-Pharmacist Collaboration significantly reduced the incidence of catheter-related bloodstream infections (CRBSI), drug incompatibility, and other intravenous therapy-related complications, thereby enhancing the safety of intravenous therapy in critically ill patients.

Virtual Reality Training for Central Venous Catheter Placement: An Interventional Feasibility Study Incorporating Virtual Reality Into a Standard Training Curriculum of Novice Trainees

OBJECTIVES

This study assess the feasibility of integrating virtual reality (VR) simulation into the central venous catheter (CVC) placement training curriculum.

DESIGN

The study consists of 3 parts: (1) Evaluating current manikin-based training for CVC placement through surveys for senior first-year anesthesia residents and cardiac anesthesia faculty who supervise resident performing the procedure; (2) Interventional study training novice trainees with VR simulator and assessing their reaction satisfaction; and (3) pilot study integrating VR training sessions into CVC training curriculum for first-year anesthesia residents.

SETTING

Conducted at a single academic-affiliated medical center from December 2022 to August 2023.

PARTICIPANTS

Junior first-year anesthesia residents.

INTERVENTIONS

VR training sessions for CVC placements using the Vantari VR system.

MEASUREMENTS AND MAIN RESULTS

Primary outcome: novice trainees' satisfaction with VR training for CVC procedure. Satisfaction of resident and faculty with standard manikin-based training was also collected. Faculty expressed concerns about residents' confidence and perceived knowledge in performing CVC placement independently. Novice trainees showed high satisfaction and perceived usefulness with VR training, particularly in understanding procedural steps and developing spatial awareness. Pilot integration of VR training into the curriculum demonstrated comparable training times and emphasized structured stepwise training modules to ensure completion of vital procedural steps.

CONCLUSIONS

This study underscores the potential of VR simulation as a complementary training tool for CVC placement rather than a substitution of standard manikin training. VR is offering immersive experiences and addressing limitations of traditional manikin-based training methods. The integration of VR into training curricula warrants further exploration to optimize procedural proficiency and patient safety in clinical practice.

Prevention of complications for hospitalized patients receiving parenteral nutrition: A narrative review

Hospitalized patients may benefit from parenteral nutrition to address their compromised nutrition status attributed to limited oral/enteral intake and increased nutrient/energy requirement during acute illness. Parenteral nutrition, however, can be associated with many complications that can negatively impact patient outcomes. In this review, we focus on potential metabolic and catheter-related complications associated with parenteral nutrition use. We report on potential risk factors for such complications and highlight strategies for prevention and early recognition. To optimize outcomes, key findings include the creation and implementation of evidence-based protocols with proven efficacy. For each hospital unit delivering parenteral nutrition to patients, tracking compliance with established protocols and patient outcomes is crucial for ongoing improvement through identification of gaps, proper reeducation and training, and ongoing refinement of care protocols. Establishment of specialized inpatient nutrition support teams should be considered.

Instrumentless liver suspension for liver retraction in robotic pancreatoduodenectomy

The popularity of robotic pancreatoduodenectomy (RPD) is increasing, yet it remains a complex procedure. Outcomes are influenced by various factors, including patient-specific variables, disease characteristics, and surgical technique. Numerous and intricate details contribute to the technical success of RPD. In this study, our focus is on achieving effective and "gentle" liver retraction. The use of liver retractors has been associated with the risk of retractor-related liver injury (RRLI), which can have serious consequences. Here, we introduce a refined technique for instrumentless liver retraction in RPD, developed progressively through a series of over 300 procedures. The core concept of this technique involves suspending the liver to the diaphragmatic dome. This is accomplished by securing the round ligament to the anterior abdominal wall using transparietal sutures and attaching the fundus of the gallbladder and the anterior margin of liver segment number 3 to the diaphragm. Our consecutive series of over 300 RPDs demonstrates the feasibility and safety of this approach, with no clinically relevant RRLI observed. Instrumentless liver retraction offers a valuable refinement in RPD, streamlining the procedure while reducing potential complications associated with dedicated retractors.

Device associated complications in the intensive care unit

Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.

Treatment of positive catheter tip culture without bloodstream infections in critically ill patients. A case-cohort study from the OUTCOMEREA network

PURPOSE

This study aimed to evaluate the impact on subsequent infections and mortality of an adequate antimicrobial therapy within 48 h after catheter removal in intensive care unit (ICU) patients with positive catheter tip culture.

METHODS

We performed a retrospective analysis of prospectively collected data from 29 centers of the OUTCOMEREA network. We developed a propensity score (PS) for adequate antimicrobial treatment, based on expert opinion of 45 attending physicians. We conducted a 1:1 case-cohort study matched on the PS score of being adequately treated. A PS-matched subdistribution hazard model was used for detecting subsequent infections and a PS-matched Cox model was used to evaluate the impact of antibiotic therapy on mortality.

RESULTS

We included 427 patients with a catheter tip culture positive with potentially pathogenic microorganisms. We matched 150 patients with an adequate antimicrobial therapy with 150 controls. In the matched population, 30 (10%) subsequent infections were observed and 62 patients died within 30 days. Using subdistribution hazard models, the daily risk to develop subsequent infection up to Day-30 was similar between treated and non-treated groups (subdistribution hazard ratio [sHR] 1.08, 95% confidence interval [CI] 0.62-1.89, p = 0.78). Using Cox proportional hazard models, the 30-day mortality risk was similar between treated and non-treated groups (HR 0.89, 95% CI 0.45-1.74, p = 0.73).

CONCLUSIONS

Antimicrobial therapy was not associated with decreased risk of subsequent infection or death in short-term catheter tip colonization in critically ill patients. Antibiotics may be unnecessary for positive catheter tip cultures.

A Double Rarity: Lost intravascular Catheter Guidewire in Persistent Left Superior Vena Cava and Coronary Sinus - A Case Report

Guidewire loss is a rare complication of central venous catheterization. A 65-year-old male was hospitalized in a high-dependency unit for exacerbation of chronic obstructive pulmonary disease, pneumonia, erythrocytosis, and clinical signs of heart failure. Upon admission, after an unsuccessful right jugular approach, a left jugular central venous catheter was placed. The next day, chest radiography revealed the catheter located in the left parasternal region, with suspected retention of the guidewire, visually confirmed by the presence of its proximal end inside the catheter. The left parasternal location of the catheter and the typical projection of the guidewire in the coronary sinus, later confirmed by echocardiography, raised suspicion of a persistent left superior vena cava (PLSVC). Agitated saline injected into the left antecubital vein confirmed bubble entry from the coronary sinus into the right atrium. After clamping the guidewire, the catheter was carefully retrieved along with the guidewire without any complications. This is the first reported case of guidewire retention in PLSVC and coronary sinus. It underscores the potential causes of guidewire loss and advocates preventive measures to avoid this potentially fatal complication.