Avaliação da mortalidade de neonatos e crianças relacionada ao uso do cateter venoso central: revisão sistemática

Knowledge and Practices for Central Line Infection Prevention Among Brazilian Nurses: A Mixed-Methods Study

BACKGROUND

The risk of central line-associated bloodstream infections (CLABSIs) increases when preventive guidelines are not adhered to. However, studies have generally been quantitative and aimed at determining the effectiveness of CLABSI prevention bundles. Few studies have used a mixed-methods approach to investigate nursing professionals' knowledge and practices regarding CLABSI prevention.

PURPOSE

To determine nursing professionals' knowledge and practices regarding CLABSI prevention and identify facilitators and barriers to adherence to CLABSI prevention strategies in a Brazilian neonatal intensive care unit.

METHODS

A mixed-methods approach was used. Nursing professionals answered questionnaires regarding knowledge and practices surrounding CLABSI prevention. Semistructured interviews explored barriers nursing professionals face that hinder adherence to CLABSI preventive practices.

FINDINGS

Nursing professionals had moderate knowledge regarding CLABSI prevention practices. Daily assessment of the continued need for central venous lines (CVLs), hub disinfection before and after handling, and hand hygiene before handling CVLs were practices less adhered to. Interviews revealed barriers to adherence to preventive practices included lack of adequate equipment, resources for hand hygiene, and inadequate physical structure. Increased education and awareness of safe CVL practices and accountability of the entire healthcare team may improve adherence to CLABSI prevention practices. Results of this study reinforce the importance of considering current nursing practices when developing strategies to increase adherence to CLABSI prevention guidelines.

IMPLICATIONS FOR PRACTICE

Providing continuing education may increase adherence to CLABSI prevention strategies.

IMPLICATIONS FOR RESEARCH

Research is needed to develop strategies aimed at increasing nursing adherence to CLABSI prevention strategies.

Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children

BACKGROUND

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015.

OBJECTIVES

To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long-term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random-effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review.

MAIN RESULTS

We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low-certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate-certainty evidence), and not reported in the remaining studies.

AUTHORS' CONCLUSIONS

The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC-associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review

OBJECTIVE

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

DATA SOURCE

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

DATA SYNTHESIS

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

CONCLUSION

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children

BACKGROUND

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion, however there is debate regarding the need for heparin and evidence to suggest 0.9% sodium chloride (normal saline) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost.

OBJECTIVES

To assess the clinical effects (benefits and harms) of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (Issue 3, 2015). We also searched the reference lists of retrieved trials.

SELECTION CRITERIA

Randomised controlled trials that compared the efficacy of normal saline with heparin to prevent occlusion of long term CVCs in infants and children aged up to 18 years of age were included. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. Rate ratios were calculated for two outcome measures - occlusion of the CVC and central line-associated blood stream infection. Other outcome measures included duration of catheter placement, inability to withdraw blood from the catheter, use of urokinase or recombinant tissue plasminogen, incidence of removal or re-insertion of the catheter, or both, and other CVC-related complications such as dislocation of CVCs, other CVC site infections and thrombosis.

MAIN RESULTS

Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin, however, between studies, all used different protocols for the standard and experimental arms with different concentrations of heparin and different frequency of flushes reported. In addition, not all studies reported on all outcomes. The quality of the evidence ranged from low to very low because there was no blinding, heterogeneity and inconsistency between studies was high and the confidence intervals were wide. CVC occlusion was assessed in all three trials (243 participants). We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence). The duration of catheter placement was reported to be similar between the two study arms, in one study (203 participants).

AUTHORS' CONCLUSIONS

The review found that there was not enough evidence to determine the effects of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review

OBJECTIVES

to examine and synthesize the available knowledge in the literature about the effects of preterm birth on the development of school-age children.

SOURCES

this was a systematic review of studies published in the past ten years indexed in MEDLINE/Pubmed, MEDLINE/BVS; LILACS/BVS; IBECS/BVS; Cochrane/BVS, CINAHL, Web of Science, Scopus, and PsycNET in three languages (Portuguese, Spanish, and English). Observational and experimental studies that assessed motor development and/or behavior and/or academic performance and whose target-population consisted of preterm children aged 8 to 10 years were included. Article quality was assessed by the Strengthening the reporting of observational studies in epidemiology (STROBE) and Physiotherapy Evidence Database (PEDro) scales; articles that did not achieve a score of 80% or more were excluded.

SUMMARY OF FINDINGS

the electronic search identified 3,153 articles, of which 33 were included based on the eligibility criteria. Only four studies found no effect of prematurity on the outcomes (two articles on behavior, one on motor performance and one on academic performance). Among the outcomes of interest, behavior was the most searched (20 articles, 61%), followed by academic performance (16 articles, 48%) and motor impairment (11 articles, 33%).

CONCLUSION

premature infants are more susceptible to motor development, behavior and academic performance impairment when compared to term infants. These types of impairments, whose effects are manifested in the long term, can be prevented through early parental guidance, monitoring by specialized professionals, and interventions.