Central venous pressure monitoring in critical care settings

Evaluating needle-free connectors associated backflow in Midline and peripherally inserted central catheters: A top bench study

BACKGROUND

Needle-free connectors (NFCs) are closure systems for vascular catheters largely used because effectively reduce needlestick incidents. They are classified based on their impact on the fluid column within the catheter as positive (fluid displacement into the vein), negative (fluid displacement back from the vein into the catheter), neutral (minimal displacement), or anti-reflux (equipped with additional anti-reflux valve). Each category has specific usage and clamping procedures. This study aimed to evaluate the backflow volume (BV) when different NFC categories and clamping sequences are used with a peripherally inserted central catheter (PICC) and a Midline catheter (MC).

METHODS

In this bench study, four types of NFCs with different flow displacement behavior were studied. Each NFC was evaluated using two different catheters: a 4 Fr × 60 cm single-lumen catheter (PICC), and a 4 Fr × 25 cm single-lumen catheter (MC). The experimental model simulated the physiological blood pressure of the superior vena cava. Three operators performed specific sealing sequences for each combination of NFC and catheter. After that, the BV (mm3) inside the catheter for every NFC was assessed.

RESULTS

None of the four NFCs was able to avoid the BV into the catheter. Positive NFC showed a lower BV as compared to the other three NFCs when tested with PICC: 0.83 [0.76-0.95] mm3 versus 1.14 [0.95-1.53] mm3 of Q-SYTE, versus 1.27 [1.02-1.59] mm3 of Neutron, versus 1.24 [0.95-1.84] mm3 of Bionector, whereas no differences were observed when tested with Midline. No differences were observed between different clamping sequences when used with neutral and anti-reflux NFCs.

CONCLUSION

This study examined the performance of various NFC technologies with PICC and Midline. While no device eliminates BV, positive displacement NFCs showed lower flow reflux compared to the others when used with PICC. No difference between clamping sequences was observed for neutral and anti-reflux NFCs.

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.

Effect of different sealing caps on the backflow of short-term dialysis catheters: A bench study

BACKGROUND

Needle-free connectors (NFCs) are recommended as closure systems for peripheral and central vascular catheters to reduce needlestick injuries and infections, while potentially reducing blood reflux. However, their performance in short-term dialysis catheters has never been evaluated. The aim of this study was to evaluate the backflow associated with two NFCs (Neutron™ and Tego™) compared to the standard closure.

METHODS

In this bench study, the physiological blood pressure of the superior vena cava was simulated. Expert operators performed three sealing sequences for each combination of connector and lumens of the catheter, with and without closing the clamp. After that, the backflow was measured in millimeters using a high-precision digital caliper.

RESULTS

No combination of caps, lumens, or clamping sequences eliminated the backflow. No differences were observed between standard caps and NFCs in both lumens, apart from the Tego™/No clamp combination in the proximal lumen that showed higher backflow (standard cap 15 [11; 17] mm vs Tego™ 23 [19; 25] mm, p < 0.001). Clamping reduced backflow in both the proximal (13 [11; 17] mm vs 20 [13; 25] mm) and distal lumens (12 [11; 16] mm vs 14 [12; 17] mm). No differences were found between standard caps and NFCs in the distal lumen, regardless of clamping. Proximal lumen consistently exhibited larger backflow (14 [12; 22] mm) compared to distal lumens (13 [11; 17] mm, p = 0.005).

CONCLUSION

NFCs do not seem to introduce any advantage on backflow reduction as compared to a standard cap combined with lumen and clamping. Our data suggest that clamping should become standard practice when NFCs are used in the management of short-term dialysis catheters.

Device associated healthcare associated infection (DA-HAI): a detailed analysis of risk factors and outcomes in a university hospital in Rome, Italy

Introduction

This study investigates the impact of invasive procedures on healthcare-associated infections (HAI) at Policlinico Universitario Tor Vergata in Rome, Italy, aiming to understand their role in device-associated HAI and to inform prevention strategies.

Methods

A retrospective cohort analysis was conducted, examining mandatory discharge records and microbiology data from 2018 across all departments. The study focused on adult patients, analysing the correlation between invasive procedures and HAI through univariate and multivariate logistic regression.

Results

Of the 12,066 patients reviewed, 1,214 (10.1%) experienced HAI. Univariate analysis indicated an association between invasive procedures and HAI (OR = 1.81, P < 0.001), which was not observed in multivariable analysis. Specific procedures significantly raised HAI risks: temporary tracheostomy (AOR = 22.69, P <0.001), central venous pressure monitoring (AOR = 6.74, P <0.001) prolonged invasive mechanical ventilation (AOR = 4.44, P <0.001), and venous catheterisation (AOR = 1.58, P <0.05). Aggregated high-risk procedures had an increased likelihood of HAI in multivariable analysis (OR = 2.51, P < 0.001). High-risk departments were also notably associated with HAI (OR = 6.13, P < 0.001).

Conclusions

This study suggests that specific invasive procedures, such as temporary tracheostomy, significantly increase HAI risks. The results highlighting the need for targeted infection prevention and control procedures and supports the need for innovative methods such as record-linkage in policymaking to address HAI. These findings inform clinical practice and healthcare policy to improve patient safety and care quality.

The effect of different bed head angles on the hemodynamic parameters of intensive care patients lying in the supine position: A quasi-experimental study

AIMS

The aim of this study was to research the effect of different bed head angles on the hemodynamic parameters of intensive care patients lying in the supine position.

METHODS

This study was a non-randomized and non-controlled, quasi-experimental repeated measures study. The study was conducted with 50 intensive care patients aged 18 and over in a general surgery intensive care unit in Turkey. With each patient in the supine position, the bed head was raised to an angle of 0°, 20°, 30°, and 45° without a pillow, and the hemodynamic parameters of central venous pressure, systolic and diastolic blood pressure, heart rate, breathing rate, and peripheral oxygen saturation were recorded after 0 and 10 min.

RESULTS

It was found that the mean central venous pressure value measured at min 0 and 10 was higher when the intensive care patients' bed head angle was raised to 45° than when the bed head was at an angle of 0° or 20° (p < .05). It was found that the patients' other hemodynamic parameters were not affected by different bed head angles.

CONCLUSIONS

It was concluded as a result of this research that in intensive care patients in the supine position, only central venous pressure was affected by bed head angle, and that central venous pressure measurement can be reliably made at a bed head angle of 30°.

Venous excess ultrasound score and acute kidney injury in patients with acute coronary syndrome

AIMS

Systemic venous congestion is associated with an increased risk of acute kidney injury (AKI) in critically ill patients. Venous Excess Ultrasound Score (VExUS) has been proposed as a non-invasive score to assess systemic venous congestion. We aimed to evaluate the association between VExUS and AKI in patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

This is a prospective study including patients with the diagnosis of ACS (both ST elevation and non-ST elevation ACS). VExUS was performed during the first 24 h of hospital stay. Patients were classified according to the presence of systemic congestion (VExUS 0/≥1). The primary objective of the study was to determine the occurrence of AKI, defined by KDIGO criteria. A total of 77 patients were included. After ultrasound assessment, 31 (40.2%) patients were categorized as VExUS ≥1. VExUS ≥1 was more frequently found in inferior vs. anterior myocardial infarction/non-ST-segment elevation acute myocardial infarction (48.3 vs. 25.8 and 22.5%, P = 0.031). At each increasing degree of VExUS, a higher proportion of patients developed AKI: VExUS = 0 (10.8%), VExUS = 1 (23.8%), VExUS = 2 (75.0%), and VExUS = 3 (100%; P < 0.001). A significant association between VExUS ≥1 and AKI was found [odds ratio (OR): 6.75, 95% confidence interval (CI): 2.21-23.7, P = 0.001]. After multivariable analysis, only VExUS ≥1 (OR: 6.15; 95% CI: 1.26-29.94, P = 0.02) remained significantly associated with AKI.

CONCLUSION

In patients hospitalized with ACS, VExUS is associated with the occurrence of AKI. Further studies are needed to clarify the role of VExUS assessment in patients with ACS.

Haemodynamic monitoring in acute heart failure - what you need to know

Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.