Cyanoacrylate tissue adhesives - effective securement technique for intravascular catheters: in vitro testing of safety and feasibility

Comparison of ECG Saline-Conduction Technique and ECG Wire-Based Technique for Peripherally Inserted Central Catheter Insertion: A Randomized Controlled Trial

(1) Background: The peripherally inserted central catheter (PICC) is commonly used in medicine. The tip position was shown to be a major determinant in PICC function and related complications. Recent advances in ECG guidance might facilitate daily practice. This study aimed to compare two ECG techniques, in terms of their tip-position accuracy, puncture site layout, and signal quality; (2) Methods: This randomized open study (1:1) included 320 participants. One PICC guidance technique used ECG signal transmission with saline (ST); the other technique used a guidewire (WT). Techniques were compared by the distance between the catheter tip and the cavoatrial junction (DCAJ) on chest X-rays, insertion-point hemostasis time, and the extracorporeal catheter length between the hub and the insertion point; (3) Results: The mean DCAJs were significantly different between ST (1.36 cm, 95% CI: 1.22-1.37) and WT (1.12 cm, 95% CI: 0.98-1.25; p = 0.013) groups. When DCAJs were classified as optimal, suboptimal, or inadequate, the difference between techniques had limited clinical impact (p = 0.085). However, the hemostasis time at the puncture site was significantly better with WT (no delay in 82% of patients) compared to ST (no delay in 50% of patients; p < 0.001). Conversely, ST achieved optimal and suboptimal extracorporeal lengths significantly more frequently than WT (100% vs. 66%; p < 0.001); (4) Conclusions: ECG guidance technologies achieved significantly different tip placements, but the difference had minimal clinical impact. Nevertheless, each technique displayed an important drawback at the PICC insertion point: the extracorporeal catheter was significantly longer with WT and the hemostasis delay was significantly longer with ST.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial

OBJECTIVE

To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs).

STUDY DESIGN

This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis.

RESULTS

In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%).

CONCLUSIONS

In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments.

TRIAL REGISTRATION

UMIN-CTR Clinical Trial; Registration number: R000045844.

Effectiveness of cyanoacrylate glue in the fixation of midline catheters and peripherally inserted central catheters in hospitalised adult patients: Randomised clinical trial (CIANO-ETI)

Objective

The objective of the study was to assess the efficacy of the use of cyanoacrylate glue (CAG) as a means of securing midline catheters and peripherally inserted central catheters with the modified micro-Seldinger technique in adult hospitalised patients.

Methods

Randomised clinical trial with two groups (1:1): control and intervention. The control group received a securement method with a sutureless device plus transparent dressing and the intervention group received the same securement method plus the CAG. The study was approved by the Drug Research Ethics Committee of the Lleida Health Region.

Results

A total of 216 patients were assessed. The two groups of the trial were homogenously distributed in terms of sociodemographic and clinical variables. The intervention group had a statistically significant lower incidence of peri-catheter bleeding and/or oozing during the 7-day study period (odds ratio (OR), 0.6; 95% confidence level (CI), 0.44-0.81; p < 0.001) and a statistically significant lower incidence of catheter dislodgements during the first 24 h (OR, 0.2; 95% CI, 0.04-0.91; p = 0.03). There were no statistically significant differences in the incidence of phlebitis (OR, 1.30; 95% CI, 0.60-2.83; p = 0.56) or catheter-related pain (OR, 0.88; 95% CI, 0.40-1.94; p = 0.84).

Conclusion

Midline catheters and peripherally inserted central catheters secured with CAG had fewer complications than catheters not secured with this adhesive.

Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study

BACKGROUND

Within every neonatal clinical setting, vascular access devices are considered essential for administration of fluids, nutrition, and medications. However, use of vascular access devices is not without danger of failure. Catheter securement adhesives are being evaluated among adult populations, but to date, studies in neonatal settings are scant.

PURPOSE

This research describes the prevalence of peripherally inserted central catheter failure related to catheter securement before and after the introduction of tissue adhesive for catheter securement. The identified modifiable risks might be used to evaluate efficacy, to innovate neonatal practice and support future policy developments.

METHOD AND SETTING

This was a retrospective observational analysis of routinely collected anonymized intravenous therapy-related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar.

RESULTS

The results showed that the use of an approved medical grade adhesive for catheter securement resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight, and catheter type.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In parallel with currently published international literature, this study's findings support catheter securement with an octyl-based tissue adhesive in use with central venous catheters. When device stabilization is most pertinent, securement with tissue adhesive is a safe and effective method for long-term vascular access among the neonatal population.

A Revolutionary, Proven Solution to Vascular Access Concerns: A Review of the Advantageous Properties and Benefits of Catheter Securement Cyanoacrylate Adhesives

Intravascular catheters are widely used among hospitals; however, their failure rates are high, up to 50%, when secured by traditional techniques, such as tape and gauze. The use of catheter securement cyanoacrylate adhesives provides a unique approach to the issues surrounding the use of traditional securement techniques for vascular access devices by providing significant securement strength, barrier properties, antibacterial properties, hemostatic properties, and flexibility. The purpose of this research was to perform a thorough and systematic review of the current literature existing regarding the use of cyanoacrylate adhesive for the care and maintenance of vascular access devices.

Ten years of clinical experience with cyanoacrylate glue for venous access in a 1300-bed university hospital

In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.

Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae

BACKGROUND

One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites.

METHODS

Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h.

RESULTS

Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis.

CONCLUSIONS

N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.

Optimizing the Effectiveness of Short Peripheral Catheters

Hospitalized adult patients often require more than 1 short peripheral catheter (SPC) to complete the prescribed intravenous (IV) therapy attributed to catheter failure and the practice of routinely replacing SPCs. The purpose of this quality improvement project was to increase the number of SPCs that dwell for the complete duration of the IV therapy in hospitalized adult patients using a bundled approach. Implementation of an engineered securement device (ESD), education pertaining to modifiable risk factors, and changing the practice to removal on clinical indication were methods used to reduce the number of SPC insertions and catheter failures. This study was conducted at a rural Midwestern hospital using a convenience sample (N = 405) and an observational, descriptive cohort design in 6 phases between September 2019 and March 2020. After the practice changes, there was a reduction of SPC replacement (24%), catheter failures (24% to 13%), SPCs per patient (M = 2.9-2.2; P = .045), SPC insertions (4000 per year), and catheter-related bloodstream infections (0.26 per 1000 catheter days to 0.0), as well as a significant increase of SPCs remaining in situ (M = 2.6-3.8 days; P < .001), resulting in an estimated cost savings of at least $285,000. The results demonstrated that the risk of failure significantly increased when SPCs were inserted in the wrist (P = .007) and upper arm (P = .026) and significantly reduced when inserted in the forearm (P = .39). Study findings suggest that using an ESD, promoting SPC insertion in the forearm, avoiding the wrist and upper arm, and changing practice to removal when clinically indicated reduced the number of SPC insertions and rate of catheter failures.

Effectiveness of securing central venous catheters with topical tissue adhesive in patients undergoing cardiac surgery: a randomized controlled pilot study

BACKGROUND

Central venous catheters (CVCs) play an important role during cardiac surgery. Topical tissue adhesives form a thin film of coating that becomes bound to keratin in the epidermis. The advantage of this "super glue" lies in its antimicrobial activity. This study aimed to evaluate fixation of CVCs with topical tissue adhesive in patients (prone to bleed) undergoing cardiac surgery regarding its ability to reduce the incidence of pericatheter leakage.

METHODS

This randomized controlled trial included 150 patients > 15 years of age who were (1) scheduled to undergo elective cardiac surgery, (2) required CVC insertion at the internal jugular vein, and (3) scheduled for transfer postoperatively to the cardiac intensive care unit. We randomly assigned patients to a topical tissue adhesive group (TA) or a standard control group (SC). The primary outcome was a change in dressing immediately postoperatively due to pericatheter blood oozing. Secondary outcomes were the number of dressings, total dressings per catheter day, and composite outcome of catheter failure within 3 days. Both intention-to-treat and per-protocol analyses were performed. Seven patients violated the protocol (three TA patients and four SC patients).

RESULTS

Regarding the primary outcome, the SC group exhibited a significantly increased incidence of dressing change immediately postoperatively due to pericatheter leakage compared with the TA group in both the intention-to-treat analysis (5.33% vs 18.67%, RR 0.25 [95% CI 0.08 to 0.79], P = 0.012) and the per-protocol analysis (5.56% vs 16.90%, RR 0.289 [95% CI 0.09 to 0.95], P = 0.031). No significant differences were noted in the number of dressings, total dressings per catheter day, or composite outcome of catheter failure within 3 days between the two groups. Multiple logistic regression analysis was performed to adjust baseline characteristics that were different in the per-protocol analysis. The results showed that the risk ratio of immediate postoperative dressing change in TA patients was 0.25 compared to the SC group ([95% CI 0.07 to 0.87], P = 0.029) in the per-protocol analysis.

CONCLUSION

The use of a topical tissue adhesive can reduce the incidence of immediate postoperative pericatheter blood oozing.

TRIAL REGISTRATION

TCTR20180608004 , retrospectively registered on June 06, 2018.

In vitro testing of cyanoacrylate tissue adhesives and sutures for extracorporeal membrane oxygenation cannula securement

BACKGROUND

Extracorporeal membrane oxygenation (ECMO), an invasive mechanical therapy, provides cardio-respiratory support to critically ill patients when maximal conventional support has failed. ECMO is delivered via large-bore cannulae which must be effectively secured to avoid complications including cannula migration, dislodgement and accidental decannulation. Growing evidence suggests tissue adhesive (TA) may be a practical and safe method to secure vascular access devices, but little evidence exists pertaining to securement of ECMO cannulae. The aim of this study was to determine the safety and efficacy of two TA formulations (2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate) for use in peripherally inserted ECMO cannula securement, and compare TA securement to 'standard' securement methods.

METHODS

This in vitro project assessed: (1) the tensile strength and flexibility of TA formulations compared to 'standard' ECMO cannula securement using a porcine skin model, and (2) the chemical resistance of the polyurethane ECMO cannulae to TA. An Instron 5567 Universal Testing System was used for strength testing in both experiments.

RESULTS

Securement with sutures and n-butyl-2-octyl cyanoacrylate both significantly increased the force required to dislodge the cannula compared to a transparent polyurethane dressing (p = 0.006 and p = 0.003, respectively) and 2-octyl cyanoacrylate (p = 0.023 and p = 0.013, respectively). Suture securement provided increased flexibility compared to TA securement (p < 0.0001), and there was no statistically significant difference in flexibility between 2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate (p = 0.774). The resistance strength of cannula polyurethane was not weakened after exposure to either TA formulation after 60 min compared to control.

CONCLUSIONS

Tissue adhesive appears to be a promising adjunct method of ECMO cannula insertion site securement. Tissue adhesive securement with n-butyl-2-octyl cyanoacrylate may provide comparable securement strength to a single polypropylene drain stitch, and, when used as an adjunct securement method, may minimise the risks associated with suture securement. However, further clinical research is still needed in this area.

Dressings and Securement Devices of Peripheral Arterial Catheters in Intensive Care Units and Operating Theaters: A Systematic Review

BACKGROUND

Hemodynamic monitoring, implemented by the placement of peripheral arterial catheters (PACs), is a characterizing aspect of the intensive care units. Peripheral arterial catheters can continually detect blood pressure and quickly conduct blood sampling. The use of PACs is generally considered safe, without serious complications. Currently, only 25% of the implanted catheters are actually subject to complications, including accidental removal, dislocation, occlusion, and infection. All of these complications arise from inadequate catheter stabilization at the level of the skin. This study aimed to summarize and describe the effectiveness and characteristics of dressings and securement devices for catheter stabilization.

METHODS

A systematic review of literature from the following databases was conducted: MEDLINE, CINAHL, Cochrane, EMBASE, and OvidSP. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to guide article selection and reporting.

RESULTS

Herein 626 articles were referred, with 5 directly related to the topic under discussion. We found 3 studies that describe PAC failure and 4 about dislodgement. We described 6 types of dressings or securement devices and classified them into 3 categories for classifying PAC dressings or securement devices. These were detected and grouped as adhesive tissues, sutureless devices, and transparent polyurethane dressings.

CONCLUSIONS

Current research indicates that transparent polyurethane dressings offer the most effective catheter stabilization, but adhesive tissues may constitute a valid alternative. However, there are limited high-quality studies about effective dressings and securement devices for PACs.

“Sticking It to Them”—Reducing Migration of Peripherally Inserted Central Catheters

TA for stabilization and securement of PICCs reduced catheter migration. This solution to catheter migration was safe, inexpensive, and highly effective. TA reduced migration rates from 19.35% to 1.4% in more than 411 inpatients. There was no evidence of phlebitis, cellulitis, or microbial contamination. There also was no evidence of central line infections.

Central venous access device Securement and dressing effectiveness: The CASCADE pilot randomised controlled trial in the adult intensive care

INTRODUCTION

Central venous access devices (CVADs) are a vital medical device for intensive care (ICU) patients; however, complications and failure are common, yet potentially prevented through effective dressings and securement.

OBJECTIVES/AIMS

The objective of this study was to test the feasibility of a randomised controlled trial (RCT) comparing standard care with three dressing and securement products to prevent CVAD failure. Secondary aims included comparing dressing and securement products on CVAD failure, microbial colonisation, and intervention costs.

METHODS

A single-centre pilot RCT of ICU adult patients requiring CVADs for >24 h were randomised to four groups: (i) sutures plus chlorhexidine gluconate (CHG) dressing (standard care); (ii) standard care plus tissue adhesive (TA); (iii) two sutureless stabilisation devices (SSD) plus CHG dressing; (iv) sutures, CHG disc plus integrated securement dressing (ISD). Descriptive statistics assessed feasibility. Incidence rates (IRs) of CVAD failure were reported, with group differences compared using the Fisher exact and log-rank tests. Cox regression explored univariable risks for failure. A substudy examined bacterial colonisation of catheter tips, dressings, and skin. Cost estimates of the intervention were compared.

RESULTS

A total of 121 participants were randomised. Study feasibility was established with no withdrawal and moderate staff acceptability; however, recruitment was low at 12%. Overall CVAD failure was seen in 14 of 114 (12%) CVADs (19 per 1000 catheter-days); highest in the SSD group (IR: 27.3 per 1000 catheter-days [95% confidence interval {CI}: 11.4-65.6]), followed by the standard care group (IR: 22.3 per 1000 catheter-days [95% CI: 8.38-59.5]) and TA group (IR: 20.6 per 1000 catheter-days [95% CI: 6.66-64.0]), and lowest in the ISD group (IR: 8.8 per 1000 catheter-days [95% CI: 2.19-35.0]). The majority of complications (11/14, 79%) were suspected central line-associated bloodstream infection (CLABSI), of which only one was laboratory confirmed (standard care group). The cost per patient was lowest in the standard care group by an average difference of AUD $14.

CONCLUSION(S)

A large multisite RCT examining forms of securement and dressing is feasible. ISD is the highest priority to test further as it had the lowest failure rate.

TRIAL REGISTRATION

ACTRN12615000667516 PROTOCOL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368765.

Cyanoacrylate tissue adhesive: a new tool for the vascular access toolbox

Health professionals are responsible for preventing and minimising complications related to vascular access devices. This is important from the perspectives of both the patient and the health economy. Practitioners have many tools at their disposal and evidence is available to assist in using these tools to enhance best practice. A relatively new tool has been acknowledged as having a role in vascular access as well as previously recognised roles in other areas of healthcare. Cyanoacrylate tissue adhesive has been approved for use with vascular access devices and the benefits of this aid to device securement are now being recognised.

Innovation in Central Venous Access Device Security: A Pilot Randomized Controlled Trial in Pediatric Critical Care

OBJECTIVES

Central venous access devices enable many treatments during critical illness; however, 25% of pediatric central venous access devices fail before completion of treatment due to infection, thrombosis, dislodgement, and occlusion. This is frequently attributed to inadequate securement and dressing of the device; however, high-quality research evaluating pediatric central venous access device securement innovation to prevent central venous access device failure is scarce. This study aimed to establish the feasibility of a definitive randomized control trial examining the effectiveness of current and new technologies to secure central venous access devices in pediatrics.

DESIGN

Single-center, parallel group, superiority, pilot randomized control trial.

SETTING

Anesthetic and intensive care departments of a tertiary pediatric hospital SUBJECTS:: One-hundred eighty pediatric patients with nontunneled central venous access device INTERVENTIONS:: Participants were randomized to receive central venous access device securement via standard care (bordered polyurethane dressing, with prolene sutures, chlorhexidine gluconate disc), tissue adhesive (Histoacryl, B Braun, Melsungen, Germany) in addition to standard care; or integrated dressing securement (SorbaView SHIELD [Centurion Medical Products, Franklin, MA], with prolene sutures and chlorhexidine gluconate disc).

OUTCOMES

Primary: Feasibility (including effect size estimates, acceptability); central venous access device failure; central venous access device complications; secondary: individual central venous access device complications, skin damage, dressing performance, and product cost.

MEASUREMENTS AND MAIN RESULTS

Feasibility criteria were achieved as recruitment occurred with acceptable eligibility, recruitment, missing data, and attrition rates, as well as good protocol adherence. Family members and staff-reported comparable levels of acceptability between study arms; however, tissue adhesive was reported as the most difficult to apply. Overall, 6% of central venous access devices failed, including 6% (3/54; incident rate, 13.2 per 1,000 catheter days) standard care, 2% (1/56; incident rate, 3.65 per 1,000 catheter days) integrated, and 8% (5/59; 25.0 per 1,000 catheter days) tissue adhesive.

CONCLUSIONS

It is feasible to conduct an efficacy randomized control trial of the studied interventions. Further research is required to definitively identify clinical, cost-effective methods to prevent central venous access device failure by examining new dressing and securement technologies and techniques.

Tissue adhesive for vascular access devices: who, what, where and when?

Despite vascular access devices (VADs) being vital for patient care, device failure rates are unacceptably high with around 25% of central venous devices, and 30-40% of peripheral venous devices, developing complications that result in VAD failure. The use of tissue adhesive is a novel method of securing VADs and is gaining popularity, however the evidence base guiding its clinical use is still emerging. This article aims to review the types and properties of tissue adhesives, provide an overview of the existing evidence base, and discuss how tissue adhesives may be used in clinical practice.

[Case report on deviant care measures of a PICC line on a palliative patient]

A PICC line is a peripheral, through a vein inserted, central venous catheter. There are different engineered stabilisation devices - some are with and some without a sutural. This is an individual case-report which only looks at one concrete fixing system with an adhesive plate (StatLock®).In an internet search on 12/2017 the usual care-recommendation refers mainly to a document of Charité - Universitätsmedizin Berlin (04/2014). It is recommended to change the adhesive plate and the plaster every seven days. Also irrigations during the change of the adhesive plate and after each use of the PICC line are recommended. This procedure also includes the take off and new fixation of the adhesive plate as well as the disinfection and cleaning of the skin and the fixation of the plaster.This case report looked at a 65 years old masculine, cachectic, palliative patient with a metastasizing prostate cancer in a weak condition. He was able to move within his residential area. He had no cognitive or psychological impairment.The installation of the PICC line on the left upper arm was done in 04/2017. When the patient came to our mobile palliative team one of the lines was used for pain therapy with a PCA-pump. The second line was irrigated with 10 ml NaCl by his wife daily.At the beginning the adhesive plate was changed every 14 days. Because of skin irritations and pain during the change of the bandage the patient decided at the 10.8.2017 to do no more further changes of the adhesive plate.The adhesive plate was controlled through the transparent plaster and the transparent plaster was changed for the first time on the 20.10.2017 without removing the adhesive plate. The change of the adhesive plate itself was done on the 13.12.2017 without any complications.In this described case there were no complications even after more than 4 months (20 weeks) although there was no change of the adhesive plate during this time.It is suggested to individualize the interval of the change of the adhesive plate for palliative patient even more. Larger studies could give more detailed guidelines for an extend change interval. Thereby the comfort and the safety of the patient should be more important than the economic aspects (less effort and smaller costs because of the extended intervals of change).

Mussel-inspired fabrication of pH-sensitive biomimetic hydrogels based on greenhouse gas carbon dioxide

Biomimetic hydrogels were prepared from carbon dioxide using a facile method. The PPC block and catechol groups contained in PPC-PU-LDA enable the hydrogel to have good cell compatibility and adhesion.

Tissue adhesives to secure peripheral intravenous catheters: A randomized controlled trial in patients over 65 years

Introduction

Peripheral venous catheterization is one of the most used medical procedures in hospitals worldwide. Recent researches state that using intravascular devices is a risk factor for both local and systemic complications. In this study, we aimed to test that addition of tissue adhesive to the insertion site of peripheral intravenous catheters (PIVC) in the emergency department (ED) would reduce the device failure rate at 6 h and 24 h following insertion.

Material and methods

We designed a single-site, two-arm, randomized, controlled trial. We inserted 115 PIVCs into 115 adult patients.

Results

PIVC device failure for the 6th hour follow up was 15.4% in the tissue adhesive group (95% CI: 4.1–26.7) vs. 25.6% with standard care group (95% CI: 11.9–39.3). There was no statistically significant difference between two groups (p = 0.33).

The number of patients for 24 h follow-up was not enough and the obtained data could not be included in the study.

Discussion

In this study, the routine use of tissue adhesives in addition to standard care to reduce PIVC failure for patients 65 years or older in ED was not supported due to not clear benefits and cost effectivity.

Conclusion

Even though the routine use of tissue adhesives is not recommended according to the study results, it may be reasonable to use tissue adhesives for long term hospitalization expected patients to protect from related complications due to current literature.

Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial

BACKGROUND

Two billion peripheral intravenous catheters (PIVCs) are used globally each year, but optimal dressing and securement methods are not well established. We aimed to compare the efficacy and costs of three alternative approaches to standard non-bordered polyurethane dressings.

METHODS

We did a pragmatic, randomised controlled, parallel-group superiority trial at two hospitals in Queensland, Australia. Eligible patients were aged 18 years or older and required PIVC insertion for clinical treatment, which was expected to be required for longer than 24 h. Patients were randomly assigned (1:1:1:1) via a centralised web-based randomisation service using random block sizes, stratified by hospital, to receive tissue adhesive with polyurethane dressing, bordered polyurethane dressing, a securement device with polyurethane dressing, or polyurethane dressing (control). Randomisation was concealed before allocation. Patients, clinicians, and research staff were not masked because of the nature of the intervention, but infections were adjudicated by a physician who was masked to treatment allocation. The primary outcome was all-cause PIVC failure (as a composite of complete dislodgement, occlusion, phlebitis, and infection [primary bloodstream infection or local infection]). Analysis was by modified intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000769987.

FINDINGS

Between March 18, 2013, and Sept 9, 2014, we randomly assigned 1807 patients to receive tissue adhesive with polyurethane (n=446), bordered polyurethane (n=454), securement device with polyurethane (n=453), or polyurethane (n=454); 1697 patients comprised the modified intention-to-treat population. 163 (38%) of 427 patients in the tissue adhesive with polyurethane group (absolute risk difference -4·5% [95% CI -11·1 to 2·1%], p=0·19), 169 (40%) of 423 of patients in the bordered polyurethane group (-2·7% [-9·3 to 3·9%] p=0·44), 176 (41%) of 425 patients in the securement device with poplyurethane group (-1·2% [-7·9% to 5·4%], p=0·73), and 180 (43%) of 422 patients in the polyurethane group had PIVC failure. 17 patients in the tissue adhesive with polyurethane group, two patients in the bordered polyurethane group, eight patients in the securement device with polyurethane group, and seven patients in the polyurethane group had skin adverse events. Total costs of the trial interventions did not differ significantly between groups.

INTERPRETATION

Current dressing and securement methods are commonly associated with PIVC failure and poor durability, with simultaneous use of multiple products commonly required. Cost is currently the main factor that determines product choice. Innovations to achieve effective, durable dressings and securements, and randomised controlled trials assessing their effectiveness are urgently needed.

FUNDING

Australian National Health and Medical Research Council.

Extracorporeal membrane oxygenation line-associated complications: in vitro testing of cyanoacrylate tissue adhesive and securement devices to prevent infection and dislodgement

Background

Extracorporeal membrane oxygenation (ECMO) delivers cardiac and/or respiratory support to critically ill patients who have failed conventional medical therapies. If the large-bore cannulas used to deliver ECMO become infected or dislodged, the patient consequences can be catastrophic. ECMO cannula-related infection has been reported to be double the rate of other vascular devices (7.1 vs 3.4 episodes/1000 ECMO days respectively). The aim of this study was to assess the ability of cyanoacrylate tissue adhesive (TA) to inhibit bacterial growth at the ECMO cannulation site, and the effectiveness of TA and securement devices in securing ECMO cannulas and tubing.

Methods

This in vitro study tested the (1) antimicrobial qualities of TA against standard transparent dressing with ECMO cannula; (2) chemical compatibility between cannula, TA and removal agent; (3) pull-out strength of transparent dressing and TA at the cannula insertion site; and (4) pull-out strength of adhesive bandage and commercial sutureless securement devices (SSDs) on circuit tubing. Fisher’s exact test was used to evaluate differences in bacterial growth observed between the transparent dressing and TA groups. Data from mechanical testing were analysed using one-way ANOVA, followed by Tukey’s multiple comparison test or t test as appropriate. Statistical significance was defined as p < 0.05.

Results

No bacterial growth occurred under TA-covered cannulas compared with transparent dressing-covered cannulas (p = 0.002). Compared to plates lacking TA or transparent dressing, growth was observed at the insertion point and under the dressing in the transparent dressing group; however, no growth was observed in the TA group (p = 0.019). TA did not weaken the cannulas; however, the TA removal agent did after 60 min of exposure, compared with control (p < 0.01). Compared with transparent dressing, TA increased the pull-out force required for cannula dislodgement from the insertion point (p < 0.0001). SSDs significantly increased the force required to remove the tubing from the fixation points compared with adhesive bandage (p < 0.01).

Conclusions

Our findings suggest that the combined use of TA at the cannula insertion site with a commercial device for tubing securement could provide an effective bedside strategy to prevent or minimise infection and line dislodgement.

A Pilot Randomized Controlled Trial of Novel Dressing and Securement Techniques in 101 Pediatric Patients

PURPOSE

To evaluate feasibility of an efficacy trial comparing peripherally inserted central catheter (PICC) dressing and securement techniques to prevent complications and failure.

MATERIALS AND METHODS

This pilot, 3-armed, randomized controlled trial was undertaken at Royal Children's Hospital and Lady Cilento Children's Hospital, Brisbane, Australia, between April 2014 and September 2015. Pediatric participants (N = 101; age range, 0-18 y) were assigned to standard care (bordered polyurethane [BPU] dressing, sutureless securement device), tissue adhesive (TA) (plus BPU dressing), or integrated securement dressings (ISDs). Average PICC dwell time was 8.1 days (range, 0.2-27.7 d). Primary outcome was trial feasibility including PICC failure. Secondary outcomes were PICC complications, dressing performance, and parent and staff satisfaction.

RESULTS

Protocol feasibility was established. PICC failure was 6% (2/32) with standard care, 6% (2/31) with ISD, and 3% (1/32) with TA. PICC complications were 16% across all groups. TA provided immediate postoperative hemostasis, prolonging the first dressing change until 5.5 days compared with 3.5 days and 2.5 days with standard care and ISD respectively. Bleeding was the most common reason for first dressing change: standard care (n = 18; 75%), ISD (n = 11; 69%), TA (n = 4; 27%). Parental satisfaction (median 9.7/10; P = .006) and staff feedback (9.2/10; P = .002) were most positive for ISD.

CONCLUSIONS

This research suggests safety and acceptability of different securement dressings compared with standard care; securement dressings may also reduce dressing changes after insertion. Further research is required to confirm clinically cost-effective methods to prevent PICC failure.

Bioadhesive Nanoaggregates Based on Polyaspartamide-g-C18/DOPA for Wound Healing

Biocompatible adhesive nanoaggregates were synthesized based on polyaspartamide copolymers grafted with octadecylamine (C18) and 3,4-dihydroxyphenylalanine (DOPA), and their adhesive properties were investigated with regard to wound healing. The chemical structure and morphology of the synthesized polyaspartamide-g-C18/DOPA nanoaggregates were analyzed using ¹H-nuclear magnetic resonance spectroscopy (¹H NMR), dynamic light scattering (DLS), and transmission electron microscope (TEM). The in vitro adhesive energy was up to 31.04 J m^-2 for poly(dimethylacrylamide) gel substrates and 0.1209 MPa for mouse skin, and the in vivo wound breaking strength after 48 h was 1.8291 MPa for C57BL/6 mouse. The MTT assay demonstrated that the synthesized polymeric nanoaggregates were nontoxic. The polyaspartamide-g-C18/DOPA nanoaggregates were in vivo tested to mouse model and demonstrated successful skin adhesion, as the mouse skin was perfectly cured in their dermis within 6 d. As this material has biocompatibility and enough adhesive strength for wound closure, it is expected to be applied as a new type of bioadhesive agent in the human body.

Effect on Microbial Growth of a New Skin Protectant Formulation

Objective: Evaluate the effect of a new investigational skin protectant formulation on the growth of various microorganisms in vitro. Approach: An in vitro laboratory assay with various species of gram-positive bacteria, gram-negative bacteria, and yeast grown on agar plates was used to verify that a new investigational product used for the management of incontinence-associated dermatitis (IAD) does not support microbial growth. Results: The investigational product did not support the growth of all organisms tested for 48 h in these assays. The results demonstrate the barrier properties of this investigational formulation against bacteria and yeast that are relevant to incontinent patients. Innovation: IAD accompanied by skin damage is difficult to manage with currently available products. A new skin protectant that can be applied as a liquid and polymerizes into a breathable film in situ even in the presence of exudate (as shown previously) has been developed and tested to ensure that it does not support microbial growth. Conclusion: This work verifies that this new product does not support microbial growth in vitro using organisms relevant for the intended application.

Indications for Peripheral, Midline, and Central Catheters: Summary of the Michigan Appropriateness Guide for Intravenous Catheters Recommendations

Patients admitted to acute care frequently require intravenous access to effectively deliver medications and prescribed treatment. For patients with difficult intravenous access; those requiring multiple attempts; and those who are obese, have diabetes, or have other chronic conditions, determining the vascular access device (VAD) with the lowest risk that best meets the needs of the treatment plan can be confusing. Selection of a VAD should be based on specific indications for that device. In clinical settings, requests for central venous access devices are frequently precipitated simply by failure to establish peripheral access. Selection of the most appropriate VAD is necessary to avoid the potentially serious complications of infection and/or thrombosis. An international panel of experts convened to establish a guide for indications and appropriate use for VADs. This article summarizes the work and recommendations of the panel that created the Michigan Appropriateness Guide for Intravenous Catheters.

Infection risks associated with peripheral vascular catheters

BACKGROUND

Peripheral vascular catheters (PVC) are the most frequently used invasive medical devices in hospitals, with 330 million sold each year in the USA alone. One in three UK inpatients at any one time has at least one PVC in situ according to the Scottish National Prevalence survey.

METHOD

A narrative review of studies describing the infection risks associated with PVCs.

RESULTS

It is estimated that 30-80% of hospitalised patients receive at least one PVC during their hospital stay. Despite their prevalence, PVCs are not benign devices, and the high number of PVCs inserted annually has resulted in serious catheter-related bloodstream infections and significant morbidity, prolonged hospital stay and increased healthcare system costs. To date, PVC infections have been under-evaluated. Most studies focus on central venous catheter rather than PVC-associated bloodstream infections. Risks associated with PVC infection must be addressed to reduce patient morbidity and associated costs of prolonged hospital admission and treatment.

DISCUSSION

This article discusses the sources and routes of PVC-associated infection and outlines known effective prevention and intervention strategies.

A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients

PURPOSE

To improve jugular central venous access device (CVAD) securement, prevent CVAD failure (composite: dislodgement, occlusion, breakage, local or bloodstream infection), and assess subsequent trial feasibility.

MATERIALS AND METHODS

Study design was a 4-arm, parallel, randomized, controlled, nonblinded, pilot trial. Patients received CVAD securement with (i) suture+bordered polyurethane (suture + BPU; control), (ii) suture+absorbent dressing (suture + AD), (iii) sutureless securement device+simple polyurethane (SSD+SPU), or (iv) tissue adhesive+simple polyurethane (TA+SPU). Midtrial, due to safety, the TA+SPU intervention was replaced with a suture + TA+SPU group.

RESULTS

A total of 221 patients were randomized with 2 postrandomization exclusions. Central venous access device failure was as follows: suture + BPU controls, 2 (4%) of 55 (0.52/1000 hours); suture + AD, 1 (2%) of 56 (0.26/1000 hours, P=.560); SSD+SPU, 4 (7%) of 55 (1.04/1000 hours, P=.417); TA+SPU, 4 (17%) of 23 (2.53/1000 hours, P=.049); and suture + TA+SPU, 0 (0%) of 30 (P=.263; intention-to-treat, log-rank tests). Central venous access device failure was predicted (P<.05) by baseline poor/fair skin integrity (hazard ratio, 9.8; 95% confidence interval, 1.2-79.9) or impaired mental state at CVAD removal (hazard ratio, 14.2; 95% confidence interval, 3.0-68.4).

CONCLUSIONS

Jugular CVAD securement is challenging in postcardiac surgical patients who are coagulopathic and mobilized early. TA+SPU was ineffective for CVAD securement and is not recommended. Suture + TA+SPU appeared promising, with zero CVAD failure observed. Future trials should resolve uncertainty about the comparative effect of suture + TA+SPU, suture + AD, and SSD+SPU vs suture + BPU.

APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI)

This document is an executive summary of the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). It describes key evidence-based care components of the Central Line Insertion and Maintenance Bundles and its implementation using the quality improvement methodology, namely the Plan-Do-Study-Act (PDSA) methodology involving multidisciplinary process and stakeholders. Monitoring of improvement over time with timely feedback to stakeholders is a key component to ensure the success of implementing best practices. A surveillance program is recommended to monitor outcomes and adherence to evidence-based central line insertion and maintenance practices (compliance rate) and identify quality improvement opportunities and strategically targeting interventions for the reduction of CLABSI.

Skin Glue Reduces the Failure Rate of Emergency Department-Inserted Peripheral Intravenous Catheters: A Randomized Controlled Trial

STUDY OBJECTIVE

Peripheral intravenous catheters are the most common invasive device in health care yet have very high failure rates. We investigate whether the failure rate could be reduced by the addition of skin glue to standard peripheral intravenous catheter care.

METHODS

We conducted a single-site, 2-arm, nonblinded, randomized, controlled trial of 380 peripheral intravenous catheters inserted into 360 adult patients. The standard care group received standard securement. The skin glue group received standard securement plus cyanoacrylate skin glue applied to the skin insertion site. The primary outcome was peripheral intravenous catheter failure at 48 hours, regardless of cause. Secondary outcomes were the individual modes of peripheral intravenous catheter failure: infection, phlebitis, occlusion, or dislodgement.

RESULTS

Peripheral intravenous catheter failure was 10% lower (95% confidence interval -18% to -2%; P=.02) with skin glue (17%) than standard care (27%), and dislodgement was 7% lower (95% confidence interval -13% to 0%; P=.04). Phlebitis and occlusion were less with skin glue but were not statistically significant. There were no infections.

CONCLUSION

This study supports the use of skin glue in addition to standard care to reduce peripheral intravenous catheter failure rates for adult emergency department patients admitted to the hospital.

Catheter securement systems: comparison of two investigational devices to a sutureless securement device, a securement dressing, and sutures in a pig model

BACKGROUND

Catheter securement is critical for the success of infusion therapy and to prevent complications. Our purpose was to compare the strength of catheter securement achieved with two investigational adhesive securement devices to two securement products and also to sutures using an in vivo animal model.

METHODS

Twenty-five live pigs were prepared for aseptic abdominal surgery. Four central venous catheters were inserted per animal into the epigastric veins and secured with four of the five securement systems studied, following a balanced incomplete randomized block design. A peak axial pull force test method was used to measure the force required to dislodge the catheter 1 cm from the insertion site and/or cause failure of the device and/or dressing. This pull test was done 10 min after device application, per constraints of the animal model. Comparison analysis was carried out using a mixed effects model with pig, sample, and sample location as factors. Non-inferiority testing was carried out using 95 % confidence intervals with a margin of 4.52 N or 1 lb (454 g). Tukey's method was used to adjust for multiple pairwise comparisons.

RESULTS

Results showed that the two investigational devices displayed the highest mean peak axial pull forces (40-41 N) and were significantly better than sutures (28 N, p < 0.0001) and the securement dressing (17 N, p < 0.0001) and non-inferior to the securement device (37 N) in this test. The securement device required a higher mean peak axial pull force than sutures (p = 0.0007) and the securement dressing (p < 0.0001) for failure to occur. Finally, there was also a statistical difference between sutures and the securement dressing, with sutures requiring a higher mean peak axial pull force for catheter dislodgement than the securement dressing (p < 0.0001).

CONCLUSION

The two investigational devices appear to be a promising alternative for catheter securement, superior to sutures and the securement dressing, and non-inferior to the securement device.

Securing All intraVenous devices Effectively in hospitalised patients--the SAVE trial: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Over 70% of all hospital admissions have a peripheral intravenous device (PIV) inserted; however, the failure rate of PIVs is unacceptably high, with up to 69% of these devices failing before treatment is complete. Failure can be due to dislodgement, phlebitis, occlusion/infiltration and/or infection. This results in interrupted medical therapy; painful phlebitis and reinsertions; increased hospital length of stay, morbidity and mortality from infections; and wasted medical/nursing time. Appropriate PIV dressing and securement may prevent many cases of PIV failure, but little comparative data exist regarding the efficacy of various PIV dressing and securement methods. This trial will investigate the clinical and cost-effectiveness of 4 methods of PIV dressing and securement in preventing PIV failure.

METHODS AND ANALYSIS

A multicentre, parallel group, superiority randomised controlled trial with 4 arms, 3 experimental groups (tissue adhesive, bordered polyurethane dressing, sutureless securement device) and 1 control (standard polyurethane dressing) is planned. There will be a 3-year recruitment of 1708 adult patients, with allocation concealment until randomisation by a centralised web-based service. The primary outcome is PIV failure which includes any of: dislodgement, occlusion/infiltration, phlebitis and infection. Secondary outcomes include: types of PIV failure, PIV dwell time, costs, device colonisation, skin colonisation, patient and staff satisfaction. Relative incidence rates of device failure per 100 devices and per 1000 device days with 95% CIs will summarise the impact of each dressing, and test differences between groups. Kaplan-Meier survival curves (with log-rank Mantel-Cox test) will compare device failure over time. p Values of <0.05 will be considered significant. Secondary end points will be compared between groups using parametric or non-parametric techniques appropriate to level of measurement.

ETHICS AND DISSEMINATION

Ethical approval has been received from Queensland Health (HREC/11/QRCH/152) and Griffith University (NRS/46/11/HREC). Results will be published according to the CONSORT statement and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ACTRN); 12611000769987.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

Examining the Role of Securement and Dressing Products to Prevent Central Venous Access Device Failure: A Narrative Review

Objective: To describe the underpinning principles involved in central venous access device (CVAD) securement and dressing products to prevent CVAD failure and complications through a synthesis of research studies.

Background: Functional, dependable CVADs are a necessary part of patient care. Dressing and securement products are used to prevent CVAD failure and complications, but there is a large variety of products available for clinicians to access, with variable effectiveness.

Methods: A narrative review of studies describing the mechanisms for CVAD securement and dressing products to prevent failure and complication was undertaken. After a systematic search, 20 clinical and laboratory studies were included in the review.

Discussion: The major mechanisms by which CVAD dressing and securement products prevent failure are providing a barrier to microbial contamination and motion reduction. CVAD securement and dressing products provide these functions using coating, adhesion, antimicrobial properties, absorbency, and moisture vapor transmission without causing irritation to skin and maintaining visibility of the insertion site. The complexity of patients requiring CVAD securement and dressing means that universal recommendations across CVAD populations and broad generalization of studies from single populations (eg, intensive care) or devices (eg, peripherally inserted central catheters) are ill advised.

Conclusions: CVAD securement and dressing products provide important, multifaceted functions to prevent CVAD failure and complication.

Securement Methods for Peripheral Venous Catheters to Prevent Failure: A Randomised Controlled Pilot Trial

Purpose

To assess the effectiveness of four securement methods to prevent peripheral intravenous catheter (PIVC) failure.

Methods

A single-centre, four-arm, randomised, controlled, non-blinded, superiority pilot trial was conducted in a tertiary referral hospital in Queensland (Australia), between November 2012 and January 2013. Adult patients, with a PIVC expected to remain in situ for ≥24 hours and admitted to general medical or surgical wards, were randomly allocated to standard polyurethane dressing (control, SPU), tissue adhesive (TA) with an SPU, bordered polyurethane dressing (BPU) or sutureless securement device (SSD) with an SPU, experimental groups. The primary endpoint was PIVC failure, defined as premature device removal before the end of therapy because of pain, blockage, leaking, accidental removal and local or catheter-related bloodstream infection.

Results

PIVCs were used for an average of 2.6 days across all study groups (n = 85). Catheter failure was lowest in the TA group (3/21, 14%) and highest in the control group (8/21, 38%), with BPU and SSD failure at 5/20 (25%) and 5/23 (22%), respectively. The adjusted hazard ratio of catheter failure was lowest in the TA group (0.50, 95% CI: 0.13-1.98), and then the BPU (0.52, 95% CI: 0.15-1.78) and SSD (0.61, 95% CI: 0.20-1.91) groups. No patient was suspected of a local or catheter-related bloodstream infection.

Conclusions

Current SPU dressings alone do not prevent many cases of PIVC failure. TA appears promising as an innovative solution, but may not be suitable for all patients. A larger Australian National Health and Medical Research Council (NHMRC)-funded trial has commenced.

Peripheral intravenous catheter duration and failure in paediatric acute care: A prospective cohort study

OBJECTIVE

Children admitted to hospital commonly require peripheral intravenous catheters (PIVCs) for treatment. This study sought to address a gap in the literature about current practice in the securement and dressing of PIVCs in paediatric acute care, and to ascertain the duration and failure of these devices.

METHODS

A prospective cohort study conducted at the Royal Children's Hospital in Queensland, Australia. All patients aged 0-15 years, who presented to the ED between 16 July and 16 October 2012, and had a PIVC inserted prior to emergent admission to the hospital were included.

RESULTS

Of 458 participants, median device duration was 29 h (IQR 13-58 h), and ranged from less than 1 h to 16 days. One quarter (113/456, 24.8%) of PIVCs were removed due to device failure, presenting as: infiltration (65/456, 14.3%); accidental dislodgement (23/456, 5.0%); blockage (12/456, 2.6%); phlebitis (7/456, 1.5%); or 'other' (6/456, 1.3%). PIVC securement and dressings were predominantly bordered polyurethane dressings and splints (n = 457/458, 99.8%). PIVC placement in the antecubital fossa, in comparison to the hand, was significantly associated with an increased risk for failure (P = 0.03). No other patient and device characteristics had a significant association with device failure (P > 0.05). The median dwell time of PIVCs that failed was significantly longer than the PIVCs that did not fail (44.0 vs 25.5 h; P = 0.002). Less than half (53/113, 46.9%) of failed catheters were replaced with a new PIVC.

CONCLUSIONS

Observed failure rates were high for a clinically essential device; however, there is no established rate of acceptability against which the results can be benchmarked against to facilitate effectiveness of practice. Many PIVCs appeared to remain in place longer than needed. Dressing and securement practice was homogenous. PIVC placement in the antecubital fossa should be minimised to reduce the risk of paediatric PIVC failure.

Value of information analysis optimizing future trial design from a pilot study on catheter securement devices

Background:

Value of information analysis has been proposed as an alternative to the standard hypothesis testing approach, which is based on type I and type II errors, in determining sample sizes for randomized clinical trials. However, in addition to sample size calculation, value of information analysis can optimize other aspects of research design such as possible comparator arms and alternative follow-up times, by considering trial designs that maximize the expected net benefit of research, which is the difference between the expected cost of the trial and the expected value of additional information.

Purpose:

To apply value of information methods to the results of a pilot study on catheter securement devices to determine the optimal design of a future larger clinical trial.

Methods:

An economic evaluation was performed using data from a multi-arm randomized controlled pilot study comparing the efficacy of four types of catheter securement devices: standard polyurethane, tissue adhesive, bordered polyurethane and sutureless securement device. Probabilistic Monte Carlo simulation was used to characterize uncertainty surrounding the study results and to calculate the expected value of additional information. To guide the optimal future trial design, the expected costs and benefits of the alternative trial designs were estimated and compared.

Results:

Analysis of the value of further information indicated that a randomized controlled trial on catheter securement devices is potentially worthwhile. Among the possible designs for the future trial, a four-arm study with 220 patients/arm would provide the highest expected net benefit corresponding to 130% return-on-investment. The initially considered design of 388 patients/arm, based on hypothesis testing calculations, would provide lower net benefit with return-on-investment of 79%.

Limitations:

Cost-effectiveness and value of information analyses were based on the data from a single pilot trial which might affect the accuracy of our uncertainty estimation. Another limitation was that different follow-up durations for the larger trial were not evaluated.

Conclusion:

The value of information approach allows efficient trial design by maximizing the expected net benefit of additional research. This approach should be considered early in the design of randomized clinical trials.

Mussel-inspired hyperbranched poly(amino ester) polymer as strong wet tissue adhesive

Current medical adhesives based on cyanoacrylates typically exhibit cellular toxicity. In contrast, fibrin adhesives are non-toxic but have poor adhesive properties. To overcome these drawbacks we designed a simple and scalable adhesive precursor inspired by marine mussel adhesion that functioned with strong adhesion in wet conditions and with low cytotoxicity. Dopamine, an-amine derivative of an amino acid abundantly present in mussel adhesive proteins, was co-polymerised with a tri-functional vinyl monomer, to form a hyperbranched poly(β-amino ester) polymer termed poly(dopamine-co-acrylate) (PDA). A variety of molecular weights and crosslinking methods were analysed using an ex vivo porcine skin model and an almost 4 fold increase in wet adhesion strength was observed compared to TISSEEL(®) fibrin sealant. With a fast curing time, degradable properties and low cytotoxicity, PDA is highly attractive for medical purposes and could have a broad impact on surgeries where surgical tissue adhesives, sealants, and haemostatic agents are used.