[Urokinase in the management of occluded PICC lines]

[Central venous access in interventional radiology]

Some patients require iteratives intravenous administrations on a central catheter, for example in oncology or infectiology, which represents a challenge for ambulatory treatment. Interventional radiology could provide solutions with the implant and monitoring of PICC-lines and ports. These are implanted in sterile environment and under imaging guidance in an interventional radiology room by an operator and with a paramedical team that need to be experienced. This development focus on the interest of one method with respect to the other, as well as the differents ways to do, the complications that could arise and the monitoring of these devices.

Introduction of the use of a pediatric PICC line in a French University Hospital: review of the first 91 procedures

PURPOSE

In order to assess the establishment of a pediatric PICC line service in a University Hospital after the first 91 consecutive procedures.

MATERIALS/PATIENTS AND METHODS

Retrospective study over a period of 24months. The criteria analysed were success or failure of the procedure, indication, age when inserted, type of PICC line, mean length of use and development of complications such as accidental removal, venous thrombosis or infection.

RESULTS

Ninety-one PICC lines were inserted in 74 patients between 4months and 25years old (sex-ratio: 1.1 girls/boys). The procedure was performed under general anaesthesia in four cases (4.4%) and under EMLA and MEOPA in 87 cases (95.6%). The insertion was ultrasound guided through the basilic (n=63, 70%), humeral (n=18, 20%) or cephalic (n=9, 10%) veins in the non-dominant arm (L in 62 cases, R in 28 cases). The insertion success rate was 99% (n=90). The main indications were starting antibiotic therapy (n=47, 52%), chemotherapy (n=34, 38%) and parenteral nutrition (n=5, 5%). The devices used were single lumen 3F (n=4, 4%), single lumen 4F (n=31, 34%), double lumen 4F (n=2, 2.2%), single lumen 5F (n=12, 13%), and double lumen 5F (n=41, 45%). The PICC line was used for an average period of 45days (14 to 300days). The complications found were accidental removal (n=2, 2.2%), catheter fracture (n=2; 2.2%), obstruction (n=5, 5.5%), suspected infection (n=1, 1.1%), and venous thrombosis and pulmonary embolism (n=3, 3.3%). The overall complication rate was 14.4% (n=13) including 4.4% serious complications (n=4).

CONCLUSION

PICC lines are a future solution in pediatrics. This technique is reliable and has a similar complication rate to studies carried out in adults, most of which can be prevented by careful catheter maintenance and informing the care staff.

The complete recanalization of PICC-related venous thrombosis in cancer patients: A series of case reports

In this study, cancer patients with venous thrombosis associated with the use of peripherally inserted central catheters (PICCs) underwent complete recanalization by the administration of Panax notoginseng saponins (PNS), which vary from heparin or urokinase in that they do not have the same risks associated with thrombolysis, including bleeding. To the best of our knowledge, this is the first study concerning the treatment of cancers with PNS to be reported in the literature. Three cancer patients aged 30–50 years old, two females and one male, were subjected to chemotherapy. On the first day of chemotherapy, a PICC was inserted into the right basilic vein with its tip in the superior vena cava. On the third day of chemotherapy, pain, swelling and skin flushing started. In the following days, particularly days 10–13, a Doppler ultrasound examination confirmed a long thrombus along the PICC line in the axillary vein and brachial veins in each patient. The patients rejected the insertion of an inferior vena cava filter, and neither heparin nor urokinase were administered due to contra-indications. An injection of PNS (200 mg) was administered every day. On days 20–28 of chemotherapy, the thrombus in the axillary and brachial veins disappeared in the three patients. It was concluded that PNS promote blood circulation, which prevents blood stasis and reduces the toxicity of cisplatin. The results suggest that PNS are a feasible and effective treatment option for many types of cancer, but have a broader clinical impact on cancer patients with PICC-related venous thrombosis. Therefore, this study is an original case report of particular interest to cancer patients with PICC-related venous thrombosis.

Interventions for restoring patency of occluded central venous catheter lumens

BACKGROUND

Central venous catheters (CVCs) facilitate the administration of intravenous drugs, fluids, blood products and parenteral nutrition to patients with either chronic disease or critical illness. Despite a pivotal role within medical management, a common complication associated with CVC use is occlusion of the CVC lumen(s). CVC occlusion can interrupt and cause serious delays in administration of treatment interventions.

OBJECTIVES

The primary objective of this review was to assess the efficacy and safety of different interventions used to restore patency of occluded CVC lumens, in adults and children.

SEARCH METHODS

We identified trials by searching the Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 9); OvidSP MEDLINE (1950 to September 2011); OvidSP EMBASE (1980 to September 2011) and NHS Evidence CINAHL (1982 to September 2011). We also searched clinical trial registers, handsearched reference lists, contacted pharmaceutical companies and authors of publications that met the inclusion criteria to identify trials.

SELECTION CRITERIA

We selected randomized controlled trials which investigated the efficacy of an intervention (chemical, surgical or drug) used to restore patency to an occluded CVC lumen, in either adults or children.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed those studies that met the inclusion criteria for quality and extracted the relevant data using a standardized form.

MAIN RESULTS

No studies were found that investigated the efficacy and safety of either chemical or surgical interventions.Seven studies (eight papers) with a total of 632 participants were identified from the search. They investigated different comparisons, strengths of thrombolytic or anticoagulant drug interventions for treating CVC lumen occlusion thought to be caused by a thrombus.There was low quality evidence from a meta-analysis of two studies suggesting that urokinase (various strengths) was more effective than placebo for restoring patency to occluded CVC lumens in adults and children with underlying medical conditions (relative risk (RR) 2.09, 95% confidence interval (CI) 1.47 to 2.95), with a number needed to treat of 4 (95% CI 2 to 8). There was insufficient evidence to draw conclusions on the safety of urokinase.The overall quality of the evidence provided by these studies was low to very low due to one or more domains being assessed as either at 'unclear risk of bias' or 'high risk of bias'. Furthermore, the total number of participants in these studies was small and consequently may lead to spurious results.

AUTHORS' CONCLUSIONS

There is inadequate evidence to draw strong conclusions on the efficacy or safety of the drug interventions included in this review. There is some low quality evidence from a meta-analysis of two studies investigating urokinase (various strengths) and some very low evidence from two single studies investigating alteplase 2 mg/2 mL that suggest that these two drug interventions may be effective in treating withdrawal or total occlusion of CVC lumens caused by thrombosis. Further high quality, sufficiently powered research is still required to look at the efficacy and safety of urokinase, alteplase and other chemical, surgical and drug interventions for treating CVC lumen occlusion. Research studies which exclusively include child participants are especially warranted.

Practical considerations in the use of outpatient antimicrobial therapy for musculoskeletal infections

Successful treatment of many musculoskeletal infections often requires an extended course of outpatient antimicrobial therapy, much of which is administered parenterally outside the hospital under the guidance of an infectious disease specialist. Delivery of outpatient parenteral antimicrobial therapy (OPAT) may occur in physicians' offices, ambulatory infusion centers, or hospital clinics but most frequently is done in patients' homes, often by the patients themselves. In this article, we outline the essential elements of outpatient antimicrobial therapy for musculoskeletal infections with particular emphasis on OPAT, including patient selection and evaluation; antimicrobial administration, including the route, duration, and complications of central venous access; and clinical and laboratory monitoring of antimicrobial therapy. We believe that primary care physicians, orthopedists, and infectious disease specialists caring for patients with musculoskeletal infections should become familiar with the use of, indications for, and complications of OPAT.

RN Knowledge of Vascular Access Devices Management

Purpose: To explore the level of RNs knowledge of managing vascular access devices (VADs)- peripherally inserted central catheters (PICCs) and midline catheters, and to determine if nurse characteristics are associated with knowledge level.

Background: Education of nursing staff about VAD management can improve quality of care and assure standards of practice are maintained.

Review of Literature: Minimal research is available on nurses' knowledge of managing VAD catheters.

Methods: Nurses working on a colo-rectal unit who frequently manage VADs in a large tertiary-care medical center voluntarily completed one anonymous, validated, 10-item survey of VAD management themes. Analysis included descriptive and correlational statistics.

Results: Of 36 nurses, (97% female, 53% full time), mean VAD knowledge score was 8.1 ± 1.4 (81% mean sum score). Perceived general level of comfort in flushing PICCs (r=.35, P=0.04), using Alteplase with PICCs (r=.36, P=0.03) and changing dressings (r=.38; P=0.03) were associated with higher knowledge scores. Of 10 items, 4 resulted in scores below 80%: how fast a Midline can be used after insertion, first step in managing a PICC upon admission, steps in dealing with a withdrawal occlusion, and steps post interventional radiology PICC insertion; however, nurse characteristics were not associated with scores above or below 80%.

Conclusions: Nurses working in the colo-rectal unit that frequently treat patients with VADs were generally knowledgeable about their management. Perceived nurse comfort in flushing a PICC, using Alteplase, and changing dressings were associated with higher knowledge.

Implications for Practice: Nurses' impressions of comfort with VAD management should be regularly assessed by nurse managers to assure optimal knowledge.