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PubMed2003

Relevance and complications of intravenous infusion at the emergency unit at Nice university hospital.

OBJECTIVE: Insertion of peripheral venous catheters (PVCs) is current practice within the hospital environment and particularly in the emergency department (ED). This simple yet invasive technique may result in venous thrombosis, infection or mechanical complications. We conducted a prospective study at the Nice University Hospital ED in order to determine the frequency, relevance and complications of peripheral venous cannulation. PATIENTS AND METHODS: Fourteen 24 h periods were surveyed over the months of May and June 2000, during which 2515 patients over 16 years of age attended the unit. Demographic and medical data were recorded for every patient who received a PVC. These patients were followed at 12 h intervals until the catheter was removed. Reasons for PVC, time left in place, and eventual complications were recorded. Justification for PVC was evaluated upon arrival at the ED, upon exiting the ED and in some cases within the hospital ward. RESULTS: Six hundred and thirty of 2515 patients (25%) received a PVC (290 women (46%) and 340 men (54%); meanage 58 years). Indication for the PVC was considered unjustified in 24.8% of cases upon arrival at the ED, and 33.8% upon leaving the ED. Upon admission in a hospital ward after passing through the ED, out of 318 patients, the PVC was left in place for no reason in 63 (20%). Overall, 390 PVCs were followed until the time of their removal. Mean duration of IV infusion was 28 h. Among these 390 patients, 62 (15.9%) developed complications, of which 54 (13.6%) had thrombophlebitis and 9 (2.3%) developed local infection. Mean duration of PVC left in place for patients with complications was 50 h vs 25 h for patients with no complications (P<0.001). CONCLUSION: Insertion of a PVC is common practice especially in EDs. The excessive use of this procedure leads to extra cost and iatrogenic complications. A renewed definition of its indication and raised awareness among hospital staff concerning the risks involved with this standard procedure should result in less use of PVC and fewer complications.

Catheterization, Peripheral↗

PubMed2005

Child life intervention during angiocatheter insertion in the pediatric emergency department.

OBJECTIVE: Current literature is deficient regarding the scope of procedures for which certified child life specialist (CCLS) services are effective in the pediatric emergency department. The purpose of this study is to analyze the effect of CCLS intervention during routine peripheral venous angiocatheter insertion on child procedure-related distress. METHODS: Eligible children were aged 2 to 16 years. Subjects were randomly assigned to CCLS intervention or standard care. The Observation Scale of Behavior Distress-revised (OSBD-r) [J Pediatr Psychol 12 (1987) 543] was recorded during the procedure. Secondary outcomes included child and parent State Trait Anxiety Inventories [Manual for the State-Trait Anxiety Inventory (1973) and Manual for the State-Trait Anxiety Inventory for Children (1973)] and an adapted parent customer satisfaction survey [Eval Program Plann 5 (1982) 233; Eval Program Plann 6 (1983) 299; and J Paediatr Child Health 31 (1995) 435]. Explanatory and intention-to-treat analyses were performed. RESULTS: One hundred forty-nine children completed the study. Although there was no statistical difference in mean total OSBD-r in the intention-to-treat analysis, the mean difference of 0.61 OSBD units (95% confidence interval, 0.04-1.19) in the anticipation phase in the 4- to 7-year age group was statistically significant. When the patients with only 1 insertion attempt were analyzed (n = 121), the total OSBD-r, anticipation, and preparation phase differences were statistically significant in the intention-to-treat analysis. In the explanatory analysis (n = 138), a mean significant difference in total OSBD-r score of 1.80 (95% confidence interval, 0.19-3.42) was found. There were no significant differences in child or parent anxiety or customer satisfaction between groups. CONCLUSIONS: CCLS intervention may reduce the behavioral stress associated with angiocatheter insertion, especially in children aged 4 to 7 years. These data further support the role of the CCLS as a patient and family advocate during routine procedures.

Adaptation, Psychological↗

PubMed1997

Prehospital care, importance of early intervention on outcome.

The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF) In a retrospective analysis 1223 polytraumatized patients treated during 1984 and 1994, with an injury severity of more than 20 points according to the Injury Severity Score = ISS, on-scene therapy ("field stabilization") was evaluated. We could show that a sufficient preclinical airway management has major influence on late prognosis (MOF). We therefore definitely recommend early intubation at the scene in these patients. The intravenous access at the emergency place is always necessary independent whether the patient is in hemorrhagic shock or not. Loss of time can increase shock mechanisms making intravenous access even more difficult. If there is already a peripheral vasoconstriction and the localisation of an peripheral vein renders more difficult, one possibility is a venae section to get safe access. Concerning the amount of preclinical infusion controverse opinions exist. Our evaluation could not give an satisfactory statement because of a differing high incidence of mass bleeding in the groups with low (< 1000 ml) and high (> 2000 ml) preclinical infusion. The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. Especially in those injuries, that are directly associated with the development of early death, i.e. intracranial bleeding, massive hemorrhage from thoracic and intraabdominal lesions these regimens on scene improved survival significantly (Fig 1) (Trunkey 1983). Nevertheless it is still discussed whether a longer rescue time is then justified to intensify on scene therapy. Recent publications demonstrate for instance that infusion therapy beginning on scene is not always necessary and sometimes especially in severe hemorrhagic shock can even aggrevate bleeding (Bickell 1989, Bickell 1991, Bickell 1993, Crawford 1991, Gross 1988, Stern 1993). On the other hand the value of on scene intubation and ventilation and chest tubing in these patients is critically discussed (Mattox 1989). Most of these studies however have their origin in the USA and are related exclusively to penetrating trauma (knife and gunshot wounds), which is completely different from underlying pathomechanisms (pure hemorrhagic shock). Only one reports of the same experience with blunt trauma (Barone 1986). Thus for severe blunt trauma the question is still open: "field stabilization" or "load and go" (Krausz 1992). A decision that always has to be related to the definite rescue time (Smith 1985). It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF).

Abdominal Injuries↗

PubMed1997

Survey of the use of peripherally inserted central venous catheters in children.

OBJECTIVE: Use of peripherally inserted central venous catheters (PICCs) to provide prolonged intravenous (IV) access in children is increasing. Our goal was to describe the children treated with PICCs in our institution, and to study catheter features such as catheter life, completion of therapy, and complications. Furthermore, we also evaluated PICC use in children completing therapy after discharge from our institution. METHODS: A prospective study of all PICCs inserted at the Children's Hospital and Medical Center (CHMC), a university-affiliated teaching institution, during a period of 18 months (January 1994 to July 1995). RESULTS: A total of 441 PICCs were inserted in 390 patients. Patient age ranged from 0 to 22 years with a mean of 5.4 +/- 6.0 years. No insertion complications occurred. Treatment of infectious disease (46%) was the most frequent reason for PICC insertion. All pediatric medical and surgical services used PICCs. Average catheter life was 13 +/- 12 days. Sixty-one percent of PICCs were used entirely at CHMC, while 39% were also used at home or at an outside hospital. Completion of therapy was achieved in 69% of PICCs. Among children who completed therapy outside our hospital, there was no difference in the rates of occlusion, accidental dislodgment, or infection. One hundred twenty-nine (29%) PICCs were removed for complications. Occlusion (7%), accidental displacement (8%), and suspicion of sepsis (8%) were the most common complications. Only 2% of PICCs had documented catheter-associated sepsis. CONCLUSIONS: PICCs provide reliable and safe access for prolonged IV therapy in neonates and children. The low incidence of complications with PICCs make them an attractive device for prolonged IV access. Similar complication rates with use in and out of hospital suggest that home IV therapy can be safely delivered with PICCs, avoiding expensive hospitalization.

Adolescent↗

PubMed2005

Placement of peripherally inserted central catheters without fluoroscopy in children: initial catheter tip position.

PURPOSE: To determine how often placement of peripherally inserted central catheters (PICCs) without imaging guidance results in an initially correct central venous catheter tip location. MATERIALS AND METHODS: This study was approved by the hospital's institutional review board, which waived the requirement for informed consent. In a children's hospital, 843 PICCs were placed in 698 patients (age range, 0 days to 26 years; mean, 6.9 years) during a 14-month study period. All PICCs were placed by a specialized team of PICC nurses and interventional radiology technologists in an angiography suite with the supervision of pediatric interventional radiologists. All catheters were threaded blindly to a previously estimated length by either a PICC nurse or a pediatric interventional radiologist, according to National Association of Vascular Access Networks guidelines, and the initial PICC tip location was then determined by means of spot fluoroscopy. PICC tips were regarded as central if they resided anywhere within the superior vena cava (SVC). All catheters were then manipulated with intermittent fluoroscopic guidance to achieve a final central position in the distal third of the SVC. A chi2 test was used to compare initial and final PICC tip locations according to patient age, catheter size, accessed vein, and need for radiologist assistance. A t test was used to compare procedure time with and without radiologist assistance. RESULTS: Analysis included 843 consecutively placed pediatric PICCs, of which 723 (85.8%) had a noncentral initial PICC tip position and required additional manipulation. After catheter repositioning performed with intermittent fluoroscopic guidance, a final central PICC tip location was achieved in 760 PICCs (90.2%). CONCLUSION: Pediatric PICC placement without fluoroscopic guidance required catheter manipulation of initial PICC tip position in 723 cases (85.8%). PICC placement with fluoroscopic guidance is highly successful, and the authors believe it is best performed in an angiography suite.

Adolescent↗

PubMedDate not supplied

The efficacy and safety of blood sampling through peripherally inserted central catheter devices in children.

BACKGROUND: The peripherally inserted central catheter (PICC) is commonly used in children for medication and fluid administration. In addition, PICCs are used occasionally for blood sampling as an alternative to venipuncture. Blood sampling from these catheters carries the hypothetical risk of catheter occlusion caused by blood remaining in the catheter, and this practice is not supported by PICC manufacturers. Children often undergo multiple needle punctures, which are associated with pain, anxiety, and dissatisfaction with care. The authors hypothesized that blood sampling through 3-Fr PICC devices is effective and safe for children. METHODS: After placement of a 3-Fr PICC, all the children were sequentially enrolled in one of two groups. The control group included patients that had 3-Fr PICC devices without blood sampling. The blood sampling group included patients with 3-Fr PICC devices through which blood samples were obtained. Demographic data, PICC placement and sampling data, infusate composition, catheter occlusion, mechanical complications, and blood stream infections were recorded. The primary outcome variable was the difference in occlusion rates between the two groups. RESULTS: The analysis included 204 children with 3-Fr PICCs (120 in the blood sampling group and 84 in the control group) who had a mean age, 117.7 +/- 4.9 months. The mean PICC duration was 15.6 +/- 1.0 days. Blood sampling was successful more than 98% of the time from all blood sampling group catheters, with a mean of 4.4 +/- 0.5 samples removed from each catheter. There was a higher occlusion rate in the blood sampling group. However, this result did not reach statistical significance. There were no significant differences between the groups in terms of infection or mechanical complication rates. CONCLUSIONS: Blood sampling is feasible and effective through 3-Fr PICC devices in children. This practice is not associated with a significant increase in occlusion, infection, or mechanical complication rates.

Age Factors↗

PubMed2004

Alteplase for treatment of occluded peripherally inserted central catheters: safety and efficacy in 240 patients.

PURPOSE: Peripherally inserted central catheters (PICCs) have dramatically improved intravenous therapy, but thrombotic occlusion remains a common problem. Despite the popularity of PICCs, there are few prospective data on the use of fibrinolytic agents to salvage these particular devices. The purpose of this study was to evaluate the efficacy and safety of alteplase treatment. MATERIALS AND METHODS: A subgroup analysis was performed from a phase IIIB prospective, multicenter trial of 995 patients evaluating the use of alteplase to restore function in occluded venous catheters. Two hundred forty patients (126 men; mean age, 53.5 years; range, 2-90 y) with occluded single-lumen (n = 104) or double-lumen (n = 136) PICCs were identified and constitute the study population. Dysfunction was defined as the inability to withdraw 3 mL of blood. Alteplase (2 mg/2 mL) was instilled into the dysfunctional lumen and assessed at 30 and 120 minutes. If the lumen remained occluded, a second alteplase dose was instilled and assessed at 30 and 120 minutes. Patency was defined as the ability to withdraw 3 mL blood and infuse 5 mL of saline solution. The primary efficacy endpoint was the cumulative restored patency rate after a maximum of two doses of alteplase. The primary safety endpoint was the incidence of intracranial hemorrhage within 5 days of treatment. Serious adverse events were recorded for 30 days after treatment. RESULTS: The primary efficacy endpoint was 92.9% (95% CI: 88.8%, 95.8%). Cumulative efficacy 30 and 120 minutes after first and second doses were 59.4%, 81.1%, 89.1%, and 92.9%, respectively. The primary safety endpoint was 0.0%. One major hemorrhage was reported: a patient with acute flare of ulcerative colitis experienced hematochezia 3 days after treatment. One serious adverse event (fever) was attributed to study drug. CONCLUSIONS: Treatment with use of a maximum of two doses of alteplase is safe and effective in restoring function to occluded PICCs.

Adult↗

PubMed2000

Central venous pressure measurements: peripherally inserted catheters versus centrally inserted catheters.

OBJECTIVE: To determine whether central venous pressure measurements taken from a peripherally inserted central catheter (PICC) correlate with those from a centrally inserted central catheter (CICC). DESIGN: A pilot bench study followed by a prospective, non-blinded, clinical comparison. SETTING: A 16-bed medical coronary intensive care unit and a 30-bed surgical intensive care unit at a university hospital. PATIENTS: Seven surgical intensive care unit patients and five medical coronary intensive care unit patients. INTERVENTIONS: During the bench study, a simple manometer system was set up to test the catheters. During the clinical study, measurements of central venous pressure were recorded from patients who had an indwelling CICC and PICC concomitantly. Positions of the catheter tips in the chest were verified by radiography. Paired central venous pressure measurements were taken from 19-gauge dual-lumen PICCs and from 7-Fr, 16-gauge, 18-gauge, and pulmonary artery catheter CICCs, all with continuous pressure infusion devices. MEASUREMENTS AND MAIN RESULTS: Bench work showed that PICCs, because of their longer length and narrower lumen, have a higher inherent resistance, which can be overcome with a continuous infusion device. During the clinical study, three to 12 paired, digital, central venous pressure measurements were recorded from each of 12 patients for a total of 77 data pairs. Measurements were recorded at end-expiration. Mean central venous pressure from the CICCs was 11 + 7 mm Hg, and from the PICCs was 12 + 7 mm Hg. PICC pressure versus CICC pressure correlated (r = 0.99) for all data pairs. Analysis by repeated measures showed PICC central venous pressure more than CICC central venous pressure by 1.0 + 3.2 mm Hg (p = 0.02). CONCLUSIONS: PICCs can be used to measure central venous pressure and to follow trends in a clinical setting when used with a pressure infusion device to overcome the natural resistance of the PICC. Central venous pressure recorded via PICCs is slightly higher, but the difference is clinically insignificant.

Adult↗

PubMed2007

Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia.

OBJECTIVE: This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease. METHODS: A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed. RESULTS: During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each. CONCLUSIONS: Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.

Catheterization, Peripheral↗

PubMed2005

Multiple versus single lumen umbilical venous catheters for newborn infants.

BACKGROUND: Multiple lumen umbilical venous catheters (ML-UVCs) instead of single lumen UVCs (SL-UVCs) may decrease the need for additional venous lines. Although it seems self-evident that ML-UVCs would reduce the need of additional venous lines, the rates of associated complications might be different. OBJECTIVES: To compare the effectiveness and the safety of ML-UVCs versus SL-UVCs in terms of need of additional vascular access, rates of complications, morbidity and mortality in newborn infants. SEARCH STRATEGY: Randomized and quasi-randomized trials were identified by searching the MEDLINE (1966 - February 2005), EMBASE (1980- February 2005), CINAHL (1982 - February 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004) and Science Direct (subject area: medicine, journal and abstract database; 1967 to February 2005). Literature search also included a manual search of the abstracts of scientific meetings published in Pediatric Research (1990-2004). Additional citations were sought using references in articles retrieved from searches. Subject experts were contacted to identify the unpublished and ongoing studies. SELECTION CRITERIA: Randomized and quasi-randomized controlled clinical trials comparing safety and efficacy of multiple versus single lumen umbilical venous catheter in neonates (both term and preterm) who were in need of umbilical venous catheter insertion for vascular access in first four weeks of life. DATA COLLECTION AND ANALYSIS: Each review author performed data extraction independently and differences were resolved by discussion. The following outcomes were determined: total number of additional peripheral intravenous lines per baby in first week and first four weeks of life, total number of additional percutaneously and surgically placed central venous lines per baby in first four weeks of life, and other safety and efficacy measures. The treatment effect estimators used were RR, RD, and WMD when appropriate along with their 95% CI. If RD was statistically significant, then number needed to treat (NNT) or number needed to harm (NNH) was calculated. MAIN RESULTS: Three studies qualified for inclusion in this review (Khilnani 1991; Loisel 1996; Soupre 1998). There was a decrease in the ML-UVCs group in the number of additional PIVs used in the first week of life [WMD -1.42, (95% CI -1.74, -1.10), p<0.00001, number of infants (n) = 99]. There was no significant effect on the number of additional PIVs used in the first four weeks of life [MD -2.30, (95% CI -6.65, 2.05), n=36]. There was an increase in catheter malfunction in the ML-UVCs group [typical RR 3.69 (95% CI 0.99, 13.81), p=0.05; RD 0.15 (95% CI 0.03, 0.27), p=0.01; NNH was 7, 95% CI 4, 33; n=99]. The following outcomes were not significantly different in the two groups: clinical sepsis, catheter related blood stream infection, catheter-associated thrombosis, complications related to catheter malposition in heart and great vessels, NEC and early neonatal mortality. AUTHORS' CONCLUSIONS: The use of ML-UVCs in comparison to SL-UVCs in neonates is associated with decrease in the usage of PIVs in first week of life, but an increase in catheter malfunctions. As the quality of included randomized studies is poor and the estimates of clinically important complications are imprecise, no firm recommendations can be made regarding the choice of UVC. Adequately powered, properly randomized and properly blinded controlled trials are needed that address the effectiveness and safety of ML-UVCs (double and triple lumen) in comparison to SL-UVCs. These studies should also address the impact of type of catheter material.

Catheterization, Peripheral↗

PubMed2005

Predictors of in-hospital and 30-day complications of peripheral vascular interventions using bivalirudin as the primary anticoagulant: results from the APPROVE Registry.

BACKGROUND: Predictors of complications in peripheral percutaneous interventions (PPI) with bivalirudin as a base anticoagulant have not yet been defined. The Angiomax Peripheral Procedure Registry of Vascular Events (APPROVE) offers a unique opportunity to analyze predictors of complications with bivalirudin in PPI. METHODS: APPROVE was a prospective, open-label, multi-center clinical trial that assessed the feasibility of bivalirudin in renal, iliac and femoral interventions. Bivalirudin was administered intravenously at a dose of 0.75 mg per kg bolus followed by an infusion of 1.75 mg per kg per hour for the duration of the procedure. Glycoprotein (GP) IIb-IIIa inhibitors were permitted at the discretion of the treating physician. Multiple independent variables were included in a Logistic Regression model to determine predictors of the combined endpoints of ischemic (death, amputation, unplanned urgent revascularization at the treated site, myocardial infarction) and major bleeding or major bleeding alone, assessed during hospitalization and at 30 days. RESULTS: Predictors of in-hospital ischemic and major bleed events were congestive heart failure (p = 0.0173) and exchanges to larger sheath size (ELS) (p = 0.0045). The strongest predictor of major bleeding alone at discharge (p = 0.0041) and at 30 days (p = 0.0016) was the number of ELS. Also, female gender (p = 0.08) and low weight (stratified by gender with < 80 kg versus > 92 kg for males and < 62 kg versus > 77 kg for females) (p = 0.096) showed a trend toward predicting major bleeding at 30 days. Of 505 patients in APPROVE, 26 patients required more than one sheath exchange. Of these, 24 were ELS. Despite this small number, these patients accounted for most of the major bleeding events that occurred (11.5% versus 1.7% in-hospital bleeding for the patients with ELS versus single sheath use respectively, and 15.4% versus 3.1% for 30-day bleeding). GP IIb-IIIa inhibitors (n = 22) use and thrombotic lesions (3%) were not predictors of ischemic and/or bleeding complications. CONCLUSION: ELS during PPI is a strong predictor of bleeding events when bivalirudin is used as a base anticoagulant. Female gender and low weight also tend to contribute to major bleeding.

Aged↗

PubMed2006

Comparison of laboratory values obtained by phlebotomy versus saline lock devices.

OBJECTIVES: To assess the utility of a peripheral saline lock device (SLD) as an alternative to a second venipuncture for obtaining selected blood samples. METHODS: This prospective study used a comparative design and was conducted in an urban emergency department (ED). Adult patients with an existing SLD in place who required serial phlebotomy were eligible for inclusion in the study. Each subject had blood samples obtained by venipuncture (control) with a Vacutainer adapter according to standard protocols. Within 5 minutes of obtaining the control samples, a sample was obtained from the patients' SLDs; a tourniquet was applied proximal to the intravenous line, a 5-mL waste portion was obtained, and a Vacutainer adapter was placed to draw specimens for testing. Each of the paired samples was analyzed for hematocrit, electrolytes, and cardiac enzymes. The Bland-Altman method was used to analyze the concordance between each pair of measurements. Paired t-tests for each of the eight laboratory tests were used to assess whether the values were statistically different from each other. The 95% limits of agreement around the mean differences were calculated. Differences between SLD aspirates and venipuncture aspirates also were compared with the federal regulatory standards that ensure reliable and accurate laboratory testing. RESULTS: Eighty-one patients were eligible for the study; in 73 (90.1%; 95% confidence interval [CI] = 81.5% to 95.6%) of the patients, the SLD could be aspirated for testing. The paired t-tests indicated that there were no statistically significant differences between the mean values of the two methods of testing. Of the 584 paired values analyzed, 35 (6.0%; 95% CI = 4.3% to 8.2%) exceeded the Bland-Altman limits of agreement, and 43 (7.4%; 95% CI = 5.4% to 9.8%) fell outside the acceptable range determined by the federal regulation of clinical laboratories. Of those values that exceeded the acceptable Bland-Altman limits of agreement, none would have resulted in clinical intervention. CONCLUSIONS: Aspirating blood via an SLD is an acceptable method of obtaining serial laboratory values in a group of stable, consenting adult ED patients.

Adult↗

PubMed2003

A randomized controlled trial evaluating the efficacy of tetracaine gel for pain relief from peripherally inserted central catheters in infants.

BACKGROUND: Insertion of peripherally inserted central catheters (PICC) is a commonly performed procedure in both preterm and term infants. Tetracaine 4% gel (Ametop; Smith & Nephew Inc, St. Laurent, Quebec), a topical anesthetic, although reported to be effective for reducing the pain of venipuncture in neonates, has not been investigated for the management of pain associated with the PICC procedure. PURPOSE: To determine the efficacy of tetracaine gel for managing the pain associated with the PICC procedure in preterm and term infants. METHODS: A double-blind, placebo-controlled, randomized controlled trial (RCT) design was used. Infants undergoing nonurgent PICC insertion were randomized to receive either the treatment (1.0 g of tetracaine 4% gel) or placebo control (1.0 g of eucerin-plus cream) applied to the skin under occlusion for 30 minutes before the procedure. Data on the behavioral (facial expression) and physiologic (heart rate and oxygen saturation) indicators of pain were collected via videotaping and computer monitoring throughout the procedure. Data then were coded and measured by independent observers using the Premature Infant Pain Profile (PIPP; Stevens et al, 1996), and analyzed using descriptive statistics and repeated-measures analyses of variance. RESULTS: Forty-nine infants, gestational age 27 to 41 weeks (mean = 33; SD = 4.2) and age at time of insertion 2 to 85 days (mean = 18; SD = 22.5) participated. No differences were found between the groups at the time of randomization. There were no adverse cardiorespiratory events or local skin reactions in either group. There was a significant within-subjects main effect of time across the procedure (F[48,3] = 11.03; P < 0.0001). There was no significant between-subjects main effect of group (F[48,1] = 0.11; P = 0.74) and no (group x time) interaction (F[48,3] = 0.45; P = 0.72). CONCLUSION: Tetracaine gel was not effective for pain relief for PICC insertion in infants. Its use for pain relief cannot be recommended based on the results of this study. Other pharmacologic, behavioral, and physical interventions should be investigated for safety and relief of procedural pain in this population of infants.

Anesthetics, Local↗

PubMed1999

Augmented venous return for minimally invasive open heart surgery with selective caval cannulation.

OBJECTIVE: Minimally invasive open heart surgery involves limited intrathoracic cannulation sites necessitating cardiopulmonary bypass to be initiated via peripheral access using percutaneous cannulae with the tip placed into the right atrial cavity. However, surgery involving the opening of the right heart obliges the surgeon to maintain the end of the cannulae into the vena cavae. The impeded venous return due to the smaller diameter may be alleviated by inserting a centrifugal pump in the venous line. METHODS: Right anterior mini-thoracotomy and exposure of the femoral site were performed before the patient was heparinized. Cannulation of the femoral artery, the inferior vena cava via the femoral vein and the superior vena cava through the mini-thoracotomy was performed and cardiopulmonary bypass was initiated. Venous drainage was augmented with the centrifugal pump. Cardiac arrest was provoked and both vena cavae were snared before performing the intracardiac procedure. RESULTS: Twenty consecutive patients were operated on using this technique (15 males/five females; age: 44.8 +/- 14.3 years; bodyweight: 73.5 +/- 15.1 kg; body surface area: 1.8 +/- 0.2 m2; theoretical blood flow rate: 4.4 +/- 0.5 l/min). The cannula sizes were 21.9 +/- 2.2 Fr for the femoral artery, 26.5 +/- 1.7 Fr for the inferior vena cava and 23.8 +/- 2.5 Fr for the superior vena cava. Venous drainage through the single inferior vena cava cannula was 2.1 +/- 0.6 l/min (48.8 +/- 13.3% of the theoretical flow). Adding the superior vena cava cannula increased the venous flow to 3.1 +/- 0.4 l/min (70.7 +/- 9.6% of the theoretical value, P < 0.005). The use of the centrifugal pump increased the flow to 4.1 +/- 0.6 l/min (93.4 +/- 8.9% of the theoretical flow, P < 0.001) with a mean inlet negative pressure of -69 +/- 10.2 mmHg. The mean bypass time was 64.0 +/- 24.6 min for a mean operative time of 226.3 +/- 61.0 min. Minimum venous saturation was 69.4 +/- 8.5%. CONCLUSIONS: Despite the smaller diameter of the vena cavae compared to the right atrium, and a smaller internal diameter of percutaneous cardiopulmonary bypass cannulae compared to classic ones; the centrifugal pump improves the venous drainage significantly so that minimally invasive open heart procedures can be performed under optimal and safe perfusion conditions.

Adult↗

PubMed1993

Aortic arch versus central venous epinephrine during CPR.

STUDY OBJECTIVE: To determine if delivery of epinephrine to the peripheral arterial system by an aortic arch catheter is more effective than central venous epinephrine administration during cardiac resuscitation. DESIGN: Randomized, nonblinded, controlled trial. TYPE OF PARTICIPANTS: Sixteen mongrel canines (25 to 31 kg). INTERVENTIONS: Animals had aortic arch pressure, and right atrial pressure, superior vena cava infusion, and descending aortic arch infusion catheters placed using fluoroscopy. After ten minutes of ventricular fibrillation, three DC countershocks were delivered over one minute. If unsuccessful, CPR at 120 compressions per minute was begun, and at 60 seconds of CPR, epinephrine (1 mg/50 mL normal saline) was administered either through the superior vena cava or the aortic arch catheter followed by one more minute of CPR. Defibrillation then was attempted and, if unsuccessful, further resuscitative efforts followed advanced cardiac life support guidelines, except route and dose of epinephrine remained the same. MEASUREMENTS AND MAIN RESULTS: Aortic arch pressure, right atrial pressure, and coronary perfusion pressure (diastolic aortic arch pressure minus diastolic right atrial pressure) were recorded continuously. Aortic arch pressure and coronary perfusion pressure increased more rapidly and to a greater magnitude with aortic arch-epinephrine than superior vena cava-epinephrine. Coronary perfusion pressure doubled by ten seconds in seven of eight in the aortic arch-epinephrine group versus none in the superior vena cava-epinephrine group. Aortic arch pressure and coronary perfusion pressure increases consistently plateaued within 60 seconds after aortic arch-epinephrine but not after superior vena cava-epinephrine. Return of spontaneous circulation was faster (P < .05) in the aortic arch-epinephrine group. Maximal coronary perfusion pressure after epinephrine correlated with the coronary perfusion pressure immediately before epinephrine administration in both groups, but more strongly in the aortic arch-epinephrine group (P = .0001). CONCLUSION: For an equivalent dose of epinephrine, aortic arch administration produces a more rapid response and more rapid peak effect than central venous administration. The combination of aortic arch-epinephrine administration and aortic pressure monitoring may be useful when initial standard resuscitative measures have not been successful.

Animals↗

PubMed1994

PIC lines save money and hasten discharge in the care of children with ruptured appendicitis.

UNLABELLED: With the need for physicians to help control the rising cost of health care, consideration should be made, when appropriate, to shift more expensive inpatient care (IPC) to the less costly home care (HC) setting. The management of ruptured appendicitis (RA) includes appendectomy and intravenous (IV) antibiotics. Although patients' gastrointestinal function often returns by postoperative day 3 to 5, 10 to 12 days of IPC may be required for completion of the IV antibiotics. A new method of IV access, appropriate for pediatric patients and HC, is the PIC line--a peripherally inserted, centrally placed, intermediate-term silastic catheter. The purpose of this study is to compare the use of short plastic cannulas (SPC) and IPC tl PIC lines and HC in the management of patients with RA with respect to cost, length of hospitalization, morbidity, and patient/family acceptance. METHODS: All children under the care of a single surgeon for RA underwent appendectomy and received IV antibiotics. The antibiotics were continued for a minimum of 10 days postoperatively, or until the patient was afebrile and the white blood cell count was less than 10,000/mm3. Group I (n = 8) had IV access via SPC and IPC care. Group II (n = 8) had a PIC line placed and was discharged to HC when intestinal function returned. The two groups were compared for: number of inpatient days (IPD), home care days (HCD), total care days (TCD), inpatient costs (IP$), home care cost (HC$), total care costs (TC$), number of IVs needed (#IV), catheter related complications, patient/family acceptance of the PIC line/HC concept, and overall morbidity. RESULTS: The children with PIC lines (group II) were all discharged to HC by the seventh postoperative day and received an additional 5 days of antibiotics. The children on conventional inpatient therapy (group I) stayed in the hospital an additional 6 days (P = .002). Both groups had equivalent TCD. The children with PIC lines had lower IP$ (P = .002) and significantly lower (40%) TC$ than did IPC patients (P = .004). The children in group I required placement of more than five IV catheters during their hospitalization. In contrast, the PIC lines were successfully placed in group II patients, and no further IV access was necessary (P = .001). There were no complications from the PIC lines. Neither group experienced recurrent infections or required readmission. The patients' and families' acceptance of the PIC line/HC concept was unanimously favorable. CONCLUSION: When compared with SPC/IPC, PIC line/HC is a safe, efficacious, and significantly cost-effective method for the care of the patient with RA. As experience with PIC line/HC grows, it may become the preferred method of treatment for a variety of illnesses that currently require intermediate-length courses of IV therapy and IPC.

Anti-Bacterial Agents↗

PubMedDate not supplied

Experience with 100 consecutive central venous access arm ports placed by interventional radiologists.

PURPOSE: This study reports the authors' experience with long-term follow-up of 100 consecutive peripherally inserted, subcutaneous arm ports for central venous access. MATERIALS AND METHODS: One hundred patients with subcutaneous arm ports inserted by interventional radiologists were retrospectively studied. Data were collected from the patients' medical records and from telephone canvassing. Using each insertion period as an observation, the complication rates per 100 catheter days were determined with 95% confidence intervals (CIs). RESULTS: One hundred subcutaneously implanted ports were placed in 98 patients; three devices (three patients) were lost to follow-up, leaving 97 devices in 95 patients. Total exposure time was 23,842 days (mean, 246 days; range, 2-865 days). Seven infectious and two noninfectious complications occurred with seven (7.2%) devices in six patients (6.3%), yielding 0.038 complications per 100 catheter days at risk (95% CI; 0.011-0.069) and 0.029 infections per 100 catheter days at risk (95% CI; 0.008-0.058). A successful clinical outcome was defined as a functional port at removal, time of death, or at study closure (minimum of 6 months of follow-up), which was not removed because of a complication. This successful outcome was achieved in 91 ports (93.8%). Procedural-related complications, defined as those occurring up to 30 days after insertion, occurred in only one port (thrombophlebitis and catheter tip infection-day 9). All other patients received several months of service from their port. Fifteen devices were placed in 13 patients with HIV for 3,486 days, with a total complication rate of 0.11 per 100 catheter days (95% CI; 0.0-0.28), all of which were infections. Devices in HIV-positive patients were associated with higher total complication (20% vs 4.9%) and infection rates (20% vs 3.7%) than devices in patients without HIV infection. This gives a relative risk 8.17 x (P = .04) greater for infectious complications for devices placed in HIV-infected individuals. CONCLUSIONS: Subcutaneous arm ports placed by interventional radiologists are effective for central venous access with excellent functionality (93.8% achieved a successful long-term outcome) and a very low procedural complication rate. Although infections were more frequent in HIV-infected individuals, these devices are associated with a very low incidence of both immediate and long-term complications, including infection, for all patients.

Adolescent↗

PubMed2003

A needle-free jet-injection system with lidocaine for peripheral intravenous cannula insertion: a randomized controlled trial with cost-effectiveness analysis.

UNLABELLED: Insertion of a peripheral IV cannula is a common, although painful, procedure. We tested the analgesic efficacy, adverse effects, and cost-effectiveness of a needle-free intradermal drug delivery system (Jet) with lidocaine for the insertion of an IV cannula (18-gauge; dorsum of hand). Four-hundred patients were randomly allocated to one of four groups: (a) no treatment, (b) Jet (J-Tip), National Medical Products Inc, CA; $3.0 per device) with 0.5 mL of saline, (3) Jet with 0.5 mL of lidocaine 1%, and (4) Jet with 0.5 mL of lidocaine 2%. Pain was evaluated using a numerical verbal scale (NVS 0-10). A NVS < or =3 was considered as acceptable in this context. Incremental cost-effectiveness ratios were calculated. Without treatment, 42.4% of patients had a NVS < or = 3, 39.3% with saline, 60.7% with 1% lidocaine (relative risk [RR] compared with no treatment, 0.70; 95% confidence interval [CI], 0.53-0.93), and 86.7% with 2% lidocaine (RR, 0.49; 95% CI, 0.38-0.62). Nineteen and one-half percent of patients had a NVS >3 because of Jet treatment, 13.5% had local hyperemia, and 16.9% had minor local bleeding. Of all Jet treatments, 10.5% were technical failures, and there were 17.6% cannula insertion failures (10.1% without treatment [RR, 1.74; 95% CI, 0.92-3.32]). Compared with no treatment, costs to generate one additional patient with a NVS < or =3 were $23 with lidocaine 1% and $10 with lidocaine 2%. On insertion of an IV cannula on the back of the hand, 58% of patients report at least moderate pain. Lidocaine-Jet is analgesic; there is dose-responsiveness. However, Jet treatment is not painless, and costs incurred to achieve one success compared with doing nothing are not negligible. IMPLICATIONS: Insertion of an IV cannula is painful. Four-hundred patients were randomly allocated to test the analgesic efficacy, adverse effects, and cost-effectiveness of the needle-free intradermal drug delivery system (J-Tip); Jet). Jet with lidocaine is effective, but its application is not painless. Costs to achieve one patient with no more than moderate pain (numerical verbal scale < or =3 of 10) on insertion of an IV cannula are $10.

Adolescent↗