Central venous catheters: Which, when and how

Ultrasound findings of unplanned extraction of tunneled central venous catheters due to complications within subcutaneous tissue

PURPOSE

Tunneled central venous catheters (CVC) are essential medical devices for pediatric patients facing extended treatment periods. This study aimed to demonstrate the usefulness of ultrasound in evaluating complications in subcutaneous tissue associated with unplanned extraction of tunneled CVC.

METHODS

Twenty-five patients who underwent ultrasound examination for suspected complications in the subcutaneous tissue associated with tunneled areas from CVC were included. The following patient characteristics and imaging findings were evaluated: infection in subcutaneous tissue, high echogenicity and hypoechoic effusion around the catheter within the subcutaneous tissue, and hyperechoic foci around the catheter. Patients with CVC were classified into two groups: those with and those without unplanned extraction of tunneled CVC. Fisher's exact test was used to compare the two groups.

RESULTS

Nine patients had unplanned extraction of tunneled CVC. A significant difference was found in infection at tunneled areas (presence/absence in patients with vs. those without unplanned extraction = 7/2 vs. 2/14, P = 0.002), as well as in hypoechoic effusion around the catheter within the subcutaneous tissues (presence/absence in patients with vs. those without unplanned extraction = 9/0 vs. 3/13, P < 0.001). However, no significant differences were found in the presence or absence of high echogenicity (presence/absence in patients with vs. those without unplanned extraction = 7/2 vs. 6/10, P = 0.097) or hyperechoic foci around the catheter (presence/absence in patients with vs. those without unplanned extraction = 3/6 vs. 1/15, P = 0.116).

CONCLUSION

The ultrasound findings were useful for determining the necessity of tunneled CVC extraction. These results will be helpful for improving management of pediatric patients with CVC.

Assessment of Chemotherapy Knowledge and Practices Among Breast Surgeons in India: Identifying Gaps and Areas for Improvement

This cross-sectional survey aimed to assess the knowledge and current practice of chemotherapy among breast surgeons in India. The objective was to evaluate their familiarity with chemotherapy protocols, treatment preferences, and utilisation of emerging technologies to identify areas for improvement and potential gaps in the delivery of breast cancer care. The survey employed a questionnaire-based approach using the Google Forms platform. A total of 264 breast surgeons actively involved in the clinical management of breast cancer participated in the study. The questionnaire consisted of 19 closed-ended questions covering various aspects of breast cancer management. The survey was distributed to participants via WhatsApp or email. The survey involved 264 surgeons, 60.6% employed at a cancer centre and 27.2% at a teaching hospital. A total of 43.1% reported routinely administering chemotherapy to patients with breast cancer, 32.8% took a selective approach, and 24.1% had never administered chemotherapy to breast cancer patients. In addition, 39.7% consistently discussed cases in a multidisciplinary team (MDT) setting, 24.8% preferred MDT discussions but not on every occasion, and 35.5% did not have access to an MDT. Regarding central venous access device (CVAD) utilisation, 10.3% always used CVADs, 67.2% used them selectively, and 22.4% did not routinely employ CVADs. Furthermore, 96.6% of respondents consistently inquired about molecular subtypes, while 53.4% advised patients about genetic testing. For management strategies, 86.2% considered NACT for selected EBC patients. The sandwich protocol was used for large operable breast cancer by 53.4%, and 58.6% used it for LABC. Only 36.2% considered SLNB in post-NACT cases, while 11.7% performed SLNB in this setting. These findings highlight the need for continued research, professional development training, consensus-building, and adherence to evidence-based guidelines to ensure optimal and standardised care for breast cancer patients in India.

Clinical applications and research progress of totally implantable venous access ports: a literature review

Totally implantable venous access port (TIVAP), a novel intravenous infusion system that is used for long-term intravenous treatment, has become increasingly popular among cancer patients undergoing chemotherapy and other patients requiring long-term intravenous infusions. This technology has been introduced into clinical practice in China, with successful results. Nevertheless, there are still certain problems; for instance, China has not set up a specialized regulatory agency to oversee research and set guidelines for the comprehensive life-cycle management of TIVAP. Additionally, there exists a disparity in standardized operations and complication management related to TIVAP, which has resulted in variable outcomes, complications, and patient satisfaction with TIVAP implantation across different medical units in China. Therefore, this article aims to provide a systematic overview of the clinical applications and maintenance of TIVAP, both domestically and internationally. Furthermore, this review investigated the latest strategies and associated research on TIVAP implantation and complication management, aiming to provide a basis for standardized surgical and maintenance procedures, protocols to minimize complications, and approaches for enhancing the overall quality of life for patients.

Evaluation of external and radiological landmark methods for optimizing ultrasound-guided right internal jugular venous catheterization depth in cardiac surgery

The formula-based estimation of the right internal jugular venous (IJV) catheterization depth can be inaccurate when using ultrasound guidance. External landmark-based and radiological landmark-based methods have been proposed as alternatives to estimate the insertion depth. This study aimed to evaluate these methods using transesophageal echocardiography (TEE)-guided insertion depth as the reference. Ninety-seven adult cardiac surgery patients underwent real-time ultrasound-guided right IJV catheterization, with placement at the superior vena cava-right atrium (SVC-RA) junction under TEE guidance. The primary outcome compared the accuracy of external-landmark and radiological-landmark methods in estimating optimal catheter position (2 cm above to 1 cm below the SVC-RA junction), while secondary outcomes assessed their reliability and agreement with TEE. The external-landmark method proved more accurate than the radiological-landmark method (91.8% vs. 68%, p < 0.001) and had a higher correlation with TEE (r = 0.83 vs. 0.67). Bland-Altman analysis showed a mean difference of 0.08 cm between external-landmark and TEE methods (limits of agreement: -1.75 to 1.90 cm) and 0.43 cm for radiological-landmark (limits of agreement: -2.63 to 3.49 cm). Overall, the external-landmark method is a reliable and simple technique for estimating right IJV catheter depth and is more useful in cardiac surgery compared to the radiological-landmark method.Trial registration Thai Clinical Trials Registry (TCTR20200410012). Date registered April 9, 2020.

Retrospective review of the development and implementation of a bedside tunneled dialysis catheter program

BACKGROUND

The decision to place a subcutaneously tunneled catheter is an infection prevention strategy for long term venous access allowing the proceduralist to access a vein and relocate the catheter exit site to a region on the body where care and maintenance can be safely performed. Subcutaneously tunneled centrally inserted dialysis catheter (ST-CIDC) placement is commonly performed in patients with renal disease and is traditionally performed with fluoroscopy in the interventional radiology suite or the operating theater. However, today's interventional radiologists and surgeons perform advanced invasive procedures that can be time-consuming resulting in delays in the scheduling of elective tunneled catheter placements.

METHODS

In this retrospective case series, we present data from a quality improvement initiative aimed at integrating available evidence for bedside tunneled dialysis catheter placement with electrocardiograph (ECG) tip positioning, to expedite care, improve patient safety outcomes, and reduce healthcare costs associated with the procedure.

RESULTS

Most patients in the study had end-stage renal disease (59%) or acute kidney injury (37%) and were receiving placement for the first time (91%). The right jugular vein was cannulated in 84% of the placements and rates of post-insertion complications were <1%, regardless of the vessel cannulated. Performing bedside tunneled dialysis catheter placement resulted in a cost savings of $385,938.76 over a 2-year period.

CONCLUSIONS

The placement of ultrasound guided tunneled dialysis catheters at the bedside following a pre-procedural evaluation of the right jugular, brachiocephalic, and femoral veins is a safe option resulting in expedited patient care, decreased resource utilization, and significant cost savings. Non-bedside techniques performed in interventional radiology, or the operating room should remain a consideration for patients requiring left sided venous access, signs of central stenosis, a history of multiple tunneled catheters, or patients requiring moderate sedation outside of the ICU.

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.

An audit of central venous catheter insertion and management practices in two French university hospitals

OBJECTIVE

To assess the compliance with French guidelines for the prevention of central venous catheter (CVC)-related infections in two university hospitals.

METHODS

An observational audit was conducted in 7 wards using a digital tool.

RESULTS

The prerequisite of hand hygiene (HH) were respected by 90% of health-care worker; 86% performed HH prior to equipment preparation and 59% repeated it prior to infusion. Wearing gloves when necessary and rinsing were respected in 46.7% and 75.6% of the observations.

CONCLUSION

Findings showed an acceptable level of adherence to recommended practices for CVC management. However, barriers of unrespect evidence-based recommendations need to be investigated in depth.

Epidemiology and Clinical Insights of Catheter-Related Candidemia in Non-ICU Patients with Vascular Access Devices

INTRODUCTION

Vascular access devices (VADs), namely peripheral VADs (PVADs) and central venous VADs (CVADs), are crucial in both intensive care unit (ICU) and non-ICU settings. However, VAD placement carries risks, notably catheter-related bloodstream infections (CRBSIs). Candida spp. is a common pathogen in CRBSIs, yet its clinical and microbiological characteristics, especially in non-ICU settings, are underexplored.

METHODS

We conducted a monocentric, retrospective observational study at Luigi Sacco Hospital from 1 May 2021 to 1 September 2023. We reviewed medical records of non-ICU adult patients with CVADs and PVADs. Data on demographics, clinical and laboratory results, VAD placement, and CRBSI occurrences were collected. Statistical analysis compared Candida spp. CRBSI and bacterial CRBSI groups.

RESULTS

Out of 1802 VAD placements in 1518 patients, 54 cases of CRBSI were identified, and Candida spp. was isolated in 30.9% of episodes. The prevalence of CRBSI was 3.05%, with Candida spp. accounting for 0.94%. Incidence rates were 2.35 per 1000 catheter days for CRBSI, with Candida albicans and Candida non-albicans at 0.47 and 0.26 per 1000 catheter days, respectively-patients with Candida spp. CRBSI had more frequent SARS-CoV-2 infection, COVID-19 pneumonia, and hypoalbuminemia.

CONCLUSIONS

During the COVID-19 pandemic, Candida spp. was a notable cause of CRBSIs in our center, underscoring the importance of considering Candida spp. in suspected CRBSI cases, including those in non-ICU settings and in those with PVADs.

A Comparison of Techniques of Internal Jugular Vein Cannulation: Anatomical Landmark, Ultrasound Guided Pre-location, and Real-Time Ultrasound Guided

OBJECTIVE

The objective of our study is to compare the success rate, duration, and incidence of complications of a right internal jugular vein (IJV) cannulation by using three different techniques.

METHODOLOGY

A randomised controlled trial was conducted at a tertiary care teaching hospital. A total of 201 patients were randomly allocated to one of the following three groups (67 in each group). Techniques were categorised as anatomical landmark technique group (Group ALT), ultrasound guided pre-location group (Group USG-Pre), and real-time ultrasound-guided technique group (Group USG-RT).

INTERVENTIONS

Central venous catheter insertion via three techniques.

RESULTS

In 138 (73.01%) patients' IJV canulated in the first attempt, USG-RT, USG-Pre, and ALT were 51 (83.6%), 44 (72.1%), and 43 (64.2%), respectively. On the other hand, 37 (19.57%) patients were required in the second attempt, while only 14 (7.40%) patients were required in the third attempt for successful IJV cannulation. The success rates, as defined in our study, were only 138 (73%) as, in 51 (27%), we cannulated in more than a single attempt or switched to another technique. We found a significant difference in preparation time in all techniques as P-value <0.05, but no significant difference was found in venous access time, cannulation time, and duration of the procedure.

CONCLUSIONS

Any technique can be used for IJV cannulation, but the most acceptable is the real-time US technique. However, no difference in the overall procedure time among all three techniques was noted, and no major incidence of complication was found.