TY - JOUR
AU - Huskins, W, Charles
AB - Central venous catheters (CVCs), including nontunneled CVCs, peripherally inserted central catheters (PICCs), and tunneled or implanted central access devices, are commonly used in pediatrics for emergent, short-term, and long-term indications. CVCs may be associated with insertion-related, mechanical, thrombotic, and infection-related complications that, in turn, are associated with higher mobidiity and mortality, and increased healthcare costs [1–6]. These complications may be competing risks because the choice of CVC insertion site affects the risk of thrombotic and infection-related complications differently [7]. These complications are also additive. For example, CVC-associated thrombi increase the risk of infection because biofilms of fibrin, plasma proteins, and cellular elements allow microbes to colonize the catheter more easily [1, 3]. For these reasons, CVC safety must be viewed holistically, with multidisciplinary input and collaboration. It is essential that all clinicians, including infectious diseases physicians, consider the collective adverse events associated with the use CVCs, both infection-related and non infection-related, as they approach use of a CVC in an individual patient. Central Venous Catheter Selection, Insertion Site Choice, and Insertion Procedures CVCs enable emergent resuscitation, urgent administration of lifesaving medications and fluids, and renal replacement during critical illness. They also offer stable long-term access for essential intravenous therapies. Selection of CVC type is typically guided by indications for central access, the integrity of potential access sites, and available resources, including both personnel and equipment. Quickly accessed nontunneled CVC cannulation sites for emergent and urgent indications include the subclavian vein, internal jugular vein, femoral vein, and the umbilical vein (in neonates) [1]. Insertion at these “short-term” CVC sites requires few steps, such as ultrasound assessment, needle insertion, wire deployment, dilation, and catheter placement [7]. Comparisons of subclavian, jugular, and femoral CVC insertion sites in adults demonstrate pros and cons for each site [8, 9]. Complicating interpretation of these data is the fact that much of the evidence comparing insertion-related complications of nontunneled CVC insertion predates use of ultrasound during the insertion procedure. In our practice, we evaluate site risk and benefit for individual patients, taking into consideration both patient-related factors and individual clinician skill and comfort with placement technique. Subclavian CVCs may have a lower incidence of CVC-associated bloodstream infections (CLABSIs) in adults, and some studies have also found a lower rate of thrombosis [8, 10]. However, subclavian CVC placement is associated with up to a 2-fold risk of major insertion-related complications, including pneumothorax, hemorrhage, severe hematoma, and neurologic complications [8]. The internal jugular vein is much easier to visualize with ultrasound compared with the subclavian vein, so it is often favored [11]. In adults, there is some evidence that jugular CVCs may offer an advantage over femoral CVCs for avoiding infection, though data are inconsistent [1, 8, 10]. Compared with femoral CVCs, jugular CVCs have a higher rate of insertion-related complications (misplacement, pneumothorax, arterial dilation) and venous-to-arterial fistula, but femoral CVCs have a higher rate of overall thrombotic complications [8, 12]. The Infectious Diseases Society of America (IDSA) recommends avoiding femoral vein placement in adults [1]. However, in children, the evidence available to date does not support avoiding femoral CVCs compared with jugular CVCs [13, 14]. Although there is some evidence that femoral CVCs may have higher thrombotic risk (which must be weighed against jugular CVC’s higher rate of insertion complications), the anatomic site of CVC placement has not been demonstrated to be a risk factor for pediatric infection-related complications [13, 15–17]. Patients who require urgent but not emergent central venous access are candidates for PICCs. Infectious diseases physicians often play a larger role in PICC catheter selection and insertion because these catheters are used to treat infections that require extended parenteral antibiotic treatment. PICCs may be placed by trained providers at the bedside or in nonsurgical suites, such as interventional radiology. Insertion requires either a compliant patient or sedation. PICCs may be associated with a lower risk of infection compared with short-term CVCs in certain critically ill pediatric populations [18, 19]. However, pediatric data are inconsistent; some studies found that PICCs have a lower risk of infection, whereas others found no difference [15, 18, 20, 21]. Large adult population studies have not consistently shown use of PICCs to have a significant advantage in preventing infection-related complications or in reducing cumulative infection incidence [10, 22, 23]. There is also evidence that PICCs may have a higher risk of thrombotic complications compared with other CVCs, particularly when the catheter-to-vein diameter ratio exceeds 30%–45% [15, 24–26]. PICCs are often left in place longer than subclavian, jugular, or femoral CVCs. This may be why the cumulative incidence of infection has been demonstrated to be similar even if the per-day incidence is lower [20]. Longer duration of use also confounds assessment of their cumulative incidence of non infection-related complications because longer-dwelling catheters are at increased risk of biofilm development, fibrin accumulation, and other factors that increase the likelihood of thrombotic complications [1, 3, 27]. Tunneled or implanted CVCs (ports) are placed in children for a variety of long-term clinical indications such as chemotherapy, long-term parental nutrition, antimicrobial therapy for severe infections (eg, invasive fungal pneumonia, ganciclovir-resistant cytomegalovirus infection, hardware-associated infections if the hardware cannot yet be safely removed), dialysis, or laboratory blood draws in patients with difficult intravenous access. Tunneled CVCs and ports are typically placed in sterile settings, such as operating rooms or interventional radiology suites [7, 15]. These catheters are associated with lower infection and thrombotic risk [1, 10, 22, 28]. For longer-term central access indications, we preferentially use tunneled catheters or ports because of their lower infection and thrombotic risk. In general, placing smaller catheters with fewer lumens is associated with a lower risk of both thrombosis (smaller catheter diameter) and infection (fewer contamination opportunities) [25, 26, 29]. We emphasize choosing the smallest-diameter catheter with the fewest number of lumens possible. CVC insertion bundles have been shown to reduce the risk of infection-related complications. Bundles should include hand hygiene, antiseptic skin preparation, sterile barriers, utilization of a checklist and independent observer, and a CVC insertion cart or kit [1, 10, 30, 31]. Proceduralists should be trained specifically in CVC insertion [32]. Use of ultrasound guidance reduces the number of cannulation attempts and, therefore, insertion-related complications [1, 11, 33]. Reducing insertion-related complications reduces the development of local thrombi and inflammation, thereby reducing infection risk [1, 11, 33]. Routine catheter “re-siting” (moving the same type of catheter to a different site) or “re-wiring” (insertion of a new catheter via exchange over a wire) has not been demonstrated to reduce either thrombotic or infection-related complications. We do not recommend these practices [1]. Prevention of Catheter-Associated Infection-Related Complications Insertion site, tunnel-track, and implanted port-pocket infections are uncommon and usually reflect insertion-related contamination that may be exacerbated by local trauma [1, 7]. In contrast, CLABSIs are common and typically reflect the adequacy of CVC maintenance practices. We have summarized our major recommendations for longitudinal CLABSI prevention in Table 1. Common mechanisms for CLABSI include migration of skin organisms at the insertion site along the exterior surface of the CVC into the vein and direct contamination of the interior surface of the CVC during access [1, 34]. Rarely, infection may also occur by infusion of extrinsically or intrinsically contaminated medications, fluids, or blood products (platelets, plasma). In addition to CVC-associated fibrin and thrombosis, patient and care-related risk factors for CLABSI include cancer or other immunocompromised status, critical illness, cardiovascular disease, a history of CVC infection, longer duration of nontunneled CVC dwell time, gastrostomy tube presence, parenteral nutrition, and blood transfusions [1, 35–38]. We consider use of catheters impregnated with an antimicrobial (chlorhexidine/silver sulfadiazine or minocycline/rifampin) for pediatric patients at highest risk for CLABSI, for instance, in immunocompromised children who need emergent or urgent central lines during critical illness [37]. Table 1. Summary of Central Venous Catheter–Associated Bloodstream Infection Prevention Strategies Central Venous Catheter–Associated Bloodstream Infection Prevention Strategya . Level of Recommendation . CVC insertion bundle: hand hygiene, antiseptic skin preparation, sterile barriers, utilization of a checklist and independent observer, and a CVC insertion cart or kit Strongly recommended Catheter site care maintenance bundle: dressing inspections, chlorhexidine scrubs, utilizing prepackaged kits Strongly recommended Catheter hub, cap, or tubing maintenance bundle: disinfection of needleless connectors, replacing all elements simultaneously Strongly recommended Chlorhexidine-impregnated sponge dressing Strongly recommended Hand hygiene before maintenance and access Strongly recommended Dressings should be changed at least every 7 days Strongly recommended Daily chlorhexidine baths Strongly recommended Daily CVC need assessment Strongly recommended Intermittent flushes of some type Strongly recommended Alcohol-containing cap protectors Recommendedb Antimicrobial-impregnated catheters Recommended in high-risk patients Catheter “re-siting” or “re-wiring” Not recommended Central Venous Catheter–Associated Bloodstream Infection Prevention Strategya . Level of Recommendation . CVC insertion bundle: hand hygiene, antiseptic skin preparation, sterile barriers, utilization of a checklist and independent observer, and a CVC insertion cart or kit Strongly recommended Catheter site care maintenance bundle: dressing inspections, chlorhexidine scrubs, utilizing prepackaged kits Strongly recommended Catheter hub, cap, or tubing maintenance bundle: disinfection of needleless connectors, replacing all elements simultaneously Strongly recommended Chlorhexidine-impregnated sponge dressing Strongly recommended Hand hygiene before maintenance and access Strongly recommended Dressings should be changed at least every 7 days Strongly recommended Daily chlorhexidine baths Strongly recommended Daily CVC need assessment Strongly recommended Intermittent flushes of some type Strongly recommended Alcohol-containing cap protectors Recommendedb Antimicrobial-impregnated catheters Recommended in high-risk patients Catheter “re-siting” or “re-wiring” Not recommended Abbreviation: CVC, central venous catheter. aBased on the references put forth by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, published literature, and the authors’ opinion and clinical practice [1, 39]. bAssists with disinfection during maintenance/access. Open in new tab Table 1. Summary of Central Venous Catheter–Associated Bloodstream Infection Prevention Strategies Central Venous Catheter–Associated Bloodstream Infection Prevention Strategya . Level of Recommendation . CVC insertion bundle: hand hygiene, antiseptic skin preparation, sterile barriers, utilization of a checklist and independent observer, and a CVC insertion cart or kit Strongly recommended Catheter site care maintenance bundle: dressing inspections, chlorhexidine scrubs, utilizing prepackaged kits Strongly recommended Catheter hub, cap, or tubing maintenance bundle: disinfection of needleless connectors, replacing all elements simultaneously Strongly recommended Chlorhexidine-impregnated sponge dressing Strongly recommended Hand hygiene before maintenance and access Strongly recommended Dressings should be changed at least every 7 days Strongly recommended Daily chlorhexidine baths Strongly recommended Daily CVC need assessment Strongly recommended Intermittent flushes of some type Strongly recommended Alcohol-containing cap protectors Recommendedb Antimicrobial-impregnated catheters Recommended in high-risk patients Catheter “re-siting” or “re-wiring” Not recommended Central Venous Catheter–Associated Bloodstream Infection Prevention Strategya . Level of Recommendation . CVC insertion bundle: hand hygiene, antiseptic skin preparation, sterile barriers, utilization of a checklist and independent observer, and a CVC insertion cart or kit Strongly recommended Catheter site care maintenance bundle: dressing inspections, chlorhexidine scrubs, utilizing prepackaged kits Strongly recommended Catheter hub, cap, or tubing maintenance bundle: disinfection of needleless connectors, replacing all elements simultaneously Strongly recommended Chlorhexidine-impregnated sponge dressing Strongly recommended Hand hygiene before maintenance and access Strongly recommended Dressings should be changed at least every 7 days Strongly recommended Daily chlorhexidine baths Strongly recommended Daily CVC need assessment Strongly recommended Intermittent flushes of some type Strongly recommended Alcohol-containing cap protectors Recommendedb Antimicrobial-impregnated catheters Recommended in high-risk patients Catheter “re-siting” or “re-wiring” Not recommended Abbreviation: CVC, central venous catheter. aBased on the references put forth by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, published literature, and the authors’ opinion and clinical practice [1, 39]. bAssists with disinfection during maintenance/access. Open in new tab CVC maintenance bundles reduce CLABSI incidence [39]. Maintenance bundles target both catheter site care (dressing inspections, chlorhexidine scrubs, utilizing prepackaged kits) and catheter hub, cap, or tubing access changes (disinfection of needleless connectors, replacing all elements simultaneously) [7, 31, 40–43]. Clear occlusive dressings should be used to allow easy visual inspections [44]. Use of a chlorhexidine-impregnated sponge or dressing for nontunneled CVCs (in patients aged >2 months) has been shown to decrease infection risk [42]. Cap protectors that contain alcohol as a disinfectant reduce CLABSI rates. Though cap protectors are not necessarily required as a routine bundle element, they ensure compliance with the recommended careful and adequate cap disinfection during access [45, 46]. We routinely use alcohol-containing cap protectors in our practice because they are a convenient and reliable way to ensure compliance and streamline bedside nursing procedures. Hand hygiene should be completed before any CVC access or maintenance [39]. Education programs to train staff responsible for catheter care should be undertaken [44, 47]. When possible, dressings should be changed at least every 7 days [42]. In numerous studies, daily chlorhexidine baths have been shown to reduce the risk of bloodstream infection [1, 48–50]. The only patients for whom we do not recommend chlorhexidine bathing are premature neonates; for all other children, we recommend that chlorhexidine bathing be included in every prevention program. Antimicrobial and ethanol lock solutions function by preventing the development of biofilms of infectious organisms along catheters. Prophylactic antimicrobial or ethanol locks in patients who have a history of multiple CLABSIs reduce the frequency of recurrence and may also be helpful when attempting to keep previously infected catheters in place [1, 36, 51, 52]. If a specific organism has been identified that has susceptibility to an available antimicrobial lock, we prefer using that antimicrobial lock over an ethanol lock (directing the antimicrobial lock at the known infectious agent). In the case of a history of bloodstream infections caused by multiple or multidrug-resistant organisms, we consider ethanol locks. We also use ethanol locks for secondary prophylaxis in patients with intestinal failure and a history of CLABSI. Importantly, alcohol softens the polyurethane material of most CVCs, which may increase the risk of rupture during high-pressure infusion. Current manufacturer recommendations are that ethanol locks should not be used with polyurethane materials because alcohols soften the polyurethane material of most CVCs, which may increase the risk of rupture during high-pressure infusion. We review the manufacturer’s information for use prior to long-term use of ethanol locks, and carefully weigh the potential risks vs benefits for individual patients. Longer CVC dwell time is associated with a higher risk of infection [1, 3, 27, 35, 52, 53]. Consequently, a key element of CLABSI prevention is for the entire medical team to repeatedly assess the need for the CVC to remain in place and to remove unnecessary CVCs promptly [39, 43]. Good antimicrobial stewardship practices (eg, converting from intravenous antibiotics to oral antibiotics and prescribing the shortest antibiotic course duration necessary) as well as reducing laboratory draws and prioritizing conversion from parenteral to enteral nutrition may hasten CVC removal. Daily CVC need assessment by nursing staff and rounding checklists decrease the total number of CVC-days and are an integral part of our practice [30, 43]. Prevention of Thrombotic Complications The rate of venous thromboembolism is increasing among pediatric patients, in large part due to an increase in the use of CVCs [54]. CVCs are the single most significant risk factor for thrombus formation in children [55, 56]. In addition to high catheter-to-venous ratio, inappropriate catheter tip position may also affect thrombus formation [25, 26, 57]. Thrombi increase the risk of infection and also lead to clinical complications such as embolic stroke, pulmonary embolism, or impaired venous drainage [1, 3, 55, 58, 59]. The use of heparin prophylaxis (infusion or flushes) may reduce the risk of CVC-associated thrombi but is not yet considered as the standard of care for thrombosis prevention except in children who require total parenteral nutrition (in whom it is suggested) [59]. Several pediatric studies have shown conflicting results regarding the benefit of prophylactic anticoagulation [59–63]. The use of anticoagulation, such as heparin infusion, should be individualized based on patient thrombosis vs bleeding risk. Some clinicians also consider prophylactic heparin infusion in very young infants and in higher-risk populations (eg, children with recent cardiac surgery or significant critical illness). For older children with nontunneled CVCs, there is no strong evidence for use of prophylactic heparin flushes compared with normal saline flushes, though there is good evidence that intermittent flushes of some type prevent thrombotic or mechanical blockages [28, 59]. Heparin-bonded catheters are also available in some settings. While these catheters may offer some reduction of thrombotic risk, they have not been found to offer significant advantage compared with heparin flushes nor have they been shown to effectively prevent fibrin-associated infections when compared with antimicrobial-impregnated lines [37, 64]. Local thrombolytic agents, typically alteplase, should be administered to restore central catheter patency in the instance of a suspected catheter-associated fibrin sheath causing occlusion [59, 63]. If mechanical obstruction persists after several administrations, we suggest pursuing imaging studies to evaluate for CVC dislodgment or thrombosis, as well as considering line removal. CONCLUSIONS Most CVC complications are preventable. Prevention is best achieved by taking a holistic view of the risks associated with complications, recognizing that these risks can be both competing and additive, may change over time, and are influenced by CVC indication as well as other host-related factors. We recommend a comprehensive, multidisciplinary strategy to minimize complication risk during the “lifetime” of an individual CVC. This includes a thoughtful patient-centered approach to the choice of CVC type and insertion site, appropriate insertion procedures, careful CVC maintenance practices by the entire medical team, and continuous reassessment of the need for the CVC, with prompt removal when it is no longer necessary. Note Potential conflicts of interest. W. Charles Huskins received a consulting fee and travel expenses from ADMA Biologics for an unrelated project. All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. O’Grady NP , Alexander M , Burns LA , et al. ; Healthcare Infection Control Practices Advisory Committee . Guidelines for the prevention of intravascular catheter-related infections . Clin Infect Dis 2011 ; 52 : e162 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Siempos II , Kopterides P , Tsangaris I , et al. Impact of catheter-related bloodstream infections on the mortality of critically ill patients: a meta-analysis . Crit Care Med 2009 ; 37 : 2283 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Raad II , Luna M , Khalil SA , et al. The relationship between the thrombotic and infectious complications of central venous catheters . JAMA 1994 ; 271 : 1014 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Zimlichman E , Henderson D , Tamir O , et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system . JAMA Intern Med 2013 ; 173 : 2039 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Smith MJ . Catheter-related bloodstream infections in children . Am J Infect Control 2008 ; 36 : S173.e1 – 3 . OpenURL Placeholder Text WorldCat 6. Goudie A , Dynan L , Brady PW , et al. Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer . Pediatrics 2015 ; 136 : 432 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Chesshyre E , Goff Z , Bowen A , Carapetis J . The prevention, diagnosis and management of central venous line infections in children . J Infect 2015 ; 71 Suppl 1 : S59 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Parienti JJ , Mongardon N , Mégarbane B , et al. ; 3SITES Study Group . Intravascular complications of central venous catheterization by insertion site . N Engl J Med 2015 ; 373 : 1220 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Marik PE , Flemmer M , Harrison W . The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis . Crit Care Med 2012 ; 40 : 2479 – 85 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Maki DG , Kluger DM , Crnich CJ . The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies . Mayo Clin Proc 2006 ; 81 : 1159 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Brass P , Hellmich M , Kolodziej L , et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization . Cochrane Database Syst Rev 2015 ; 1 : Cd006962 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 12. Ge X , Cavallazzi R , Li C , et al. Central venous access sites for the prevention of venous thrombosis, stenosis and infection . Cochrane Database Syst Rev 2012 ; Cd004084 . OpenURL Placeholder Text WorldCat 13. Casado-Flores J , Barja J , Martino R , et al. Complications of central venous catheterization in critically ill children . Pediatr Crit Care Med 2001 ; 2 : 57 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Silvetti S , Aloisio T , Cazzaniga A , Ranucci M . Jugular vs femoral vein for central venous catheterization in pediatric cardiac surgery (PRECiSE): study protocol for a randomized controlled trial . Trials 2018 ; 19 : 329 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Derderian SC , Good R , Vuille-Dit-Bille RN , et al. Central venous lines in critically ill children: thrombosis but not infection is site dependent . J Pediatr Surg 2019 ; 54:1740–1743. OpenURL Placeholder Text WorldCat 16. Karapinar B , Cura A . Complications of central venous catheterization in critically ill children . Pediatr Int 2007 ; 49 : 593 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Costello JM , Graham DA , Morrow DF , et al. Risk factors for central line-associated bloodstream infection in a pediatric cardiac intensive care unit . Pediatr Crit Care Med 2009 ; 10 : 453 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Yamaguchi RS , Noritomi DT , Degaspare NV , et al. Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis . Intensive Care Med 2017 ; 43 : 1097 – 104 . Google Scholar Crossref Search ADS PubMed WorldCat 19. Goes-Silva E , Abreu TF , Frota AC , et al. Use of peripherally inserted central catheters to prevent catheter-associated bloodstream infection in children . Infect Control Hosp Epidemiol 2009 ; 30 : 1024 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 20. Al Raiy B , Fakih MG , Bryan-Nomides N , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high-risk short-term central venous catheters . Am J Infect Control 2010 ; 38 : 149 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 21. Hord JD , Lawlor J , Werner E , et al. ; Children’s Hospital Association Childhood Cancer and Blood Disorders Network . Central line associated blood stream infections in pediatric hematology/oncology patients with different types of central lines . Pediatr Blood Cancer 2016 ; 63 : 1603 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 22. Safdar N , Maki DG . Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients . Chest 2005 ; 128 : 489 – 95 . Google Scholar Crossref Search ADS PubMed WorldCat 23. Chopra V , O’Horo JC , Rogers MA , et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis . Infect Control Hosp Epidemiol 2013 ; 34 : 908 – 18 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Chopra V , Anand S , Hickner A , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis . Lancet 2013 ; 382 : 311 – 25 . Google Scholar Crossref Search ADS PubMed WorldCat 25. Sharp R , Cummings M , Fielder A , et al. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study . Int J Nurs Stud 2015 ; 52 : 677 – 85 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Menéndez JJ , Verdú C , Calderón B , et al. Incidence and risk factors of superficial and deep vein thrombosis associated with peripherally inserted central catheters in children . J Thromb Haemost 2016 ; 14 : 2158 – 68 . Google Scholar Crossref Search ADS PubMed WorldCat 27. Advani S , Reich NG , Sengupta A , et al. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit . Clin Infect Dis 2011 ; 52 : 1108 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 28. Randolph AG , Cook DJ , Gonzales CA , Andrew M . Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials . Chest 1998 ; 113 : 165 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Yeung C , May J , Hughes R . Infection rate for single lumen v triple lumen subclavian catheters . Infect Control Hosp Epidemiol 1988 ; 9 : 154 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Berenholtz SM , Pronovost PJ , Lipsett PA , et al. Eliminating catheter-related bloodstream infections in the intensive care unit . Crit Care Med 2004 ; 32 : 2014 – 20 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Miller MR , Niedner MF , Huskins WC , et al. ; National Association of Children’s Hospitals and Related Institutions Pediatric Intensive Care Unit Central Line-Associated Bloodstream Infection Quality Transformation Teams . Reducing PICU central line-associated bloodstream infections: 3-year results . Pediatrics 2011 ; 128 : e1077 – 83 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Frampton GK , Harris P , Cooper K , et al. Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation . Health Technol Assess 2014 ; 18 : 1 – 365 . Google Scholar Crossref Search ADS WorldCat 33. Lamperti M , Caldiroli D , Cortellazzi P , et al. Safety and efficacy of ultrasound assistance during internal jugular vein cannulation in neurosurgical infants . Intensive Care Med 2008 ; 34 : 2100 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Safdar N , Maki DG . The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters . Intensive Care Med 2004 ; 30 : 62 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 35. Wylie MC , Graham DA , Potter-Bynoe G , et al. Risk factors for central line-associated bloodstream infection in pediatric intensive care units . Infect Control Hosp Epidemiol 2010 ; 31 : 1049 – 56 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Oliveira C , Nasr A , Brindle M , Wales PW . Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis . Pediatrics 2012 ; 129 : 318 – 29 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Gilbert RE , Mok Q , Dwan K , et al. ; CATCH Trial Investigators . Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial . Lancet 2016 ; 387 : 1732 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Kramer RD , Rogers MA , Conte M , et al. Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis . Am J Infect Control 2017 ; 45 : 108 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 39. Marschall J , Mermel LA , Fakih M , et al. ; Society for Healthcare Epidemiology of America . Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update . Infect Control Hosp Epidemiol 2014 ; 35 : 753 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 40. Miller MR , Griswold M , Harris JM 2nd , et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts . Pediatrics 2010 ; 125 : 206 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat 41. O’Horo JC , Silva GL , Munoz-Price LS , Safdar N . The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: a meta-analysis . Infect Control Hosp Epidemiol 2012 ; 33 : 257 – 67 . Google Scholar Crossref Search ADS PubMed WorldCat 42. Timsit JF , Schwebel C , Bouadma L , et al. ; Dressing Study Group . Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial . JAMA 2009 ; 301 : 1231 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 43. Pronovost P , Needham D , Berenholtz S , et al. An intervention to decrease catheter-related bloodstream infections in the ICU . N Engl J Med 2006 ; 355 : 2725 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 44. Eggimann P , Harbarth S , Constantin MN , et al. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care . Lancet 2000 ; 355 : 1864 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 45. Menyhay SZ , Maki DG . Preventing central venous catheter-associated bloodstream infections: development of an antiseptic barrier cap for needleless connectors . Am J Infect Control 2008 ; 36 : S174.e1 – 5 . Google Scholar Crossref Search ADS WorldCat 46. Sweet MA , Cumpston A , Briggs F , et al. Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit . Am J Infect Control 2012 ; 40 : 931 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat 47. Coopersmith CM , Rebmann TL , Zack JE , et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit . Crit Care Med 2002 ; 30 : 59 – 64 . Google Scholar Crossref Search ADS PubMed WorldCat 48. Milstone AM , Elward A , Song X , et al. ; Pediatric SCRUB Trial Study Group . Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial . Lancet 2013 ; 381 : 1099 – 106 . Google Scholar Crossref Search ADS PubMed WorldCat 49. Huang SS , Septimus E , Kleinman K , et al. ; CDC Prevention Epicenters Program ; AHRQ DECIDE Network and Healthcare-Associated Infections Program . Targeted versus universal decolonization to prevent ICU infection . N Engl J Med 2013 ; 368 : 2255 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 50. Climo MW , Yokoe DS , Warren DK , et al. Effect of daily chlorhexidine bathing on hospital-acquired infection . N Engl J Med 2013 ; 368 : 533 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 51. Zacharioudakis IM , Zervou FN , Arvanitis M , et al. Antimicrobial lock solutions as a method to prevent central line-associated bloodstream infections: a meta-analysis of randomized controlled trials . Clin Infect Dis 2014 ; 59 : 1741 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 52. Mermel LA , Allon M , Bouza E , et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America . Clin Infect Dis 2009 ; 49 : 1 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 53. Milstone AM , Reich NG , Advani S , et al. Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study . Pediatrics 2013 ; 132 : e1609 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 54. Raffini L , Huang YS , Witmer C , Feudtner C . Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007 . Pediatrics 2009 ; 124 : 1001 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 55. Faustino EV , Spinella PC , Li S , et al. Incidence and acute complications of asymptomatic central venous catheter-related deep venous thrombosis in critically ill children . J Pediatr 2013 ; 162 : 387 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 56. Massicotte MP , Dix D , Monagle P , et al. Central venous catheter related thrombosis in children: analysis of the Canadian Registry of Venous Thromboembolic Complications . J Pediatr 1998 ; 133 : 770 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 57. Gilon D , Schechter D , Rein AJ , et al. Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation . Am Heart J 1998 ; 135 : 457 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 58. Timsit JF , Farkas JC , Boyer JM , et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis . Chest 1998 ; 114 : 207 – 13 . Google Scholar Crossref Search ADS PubMed WorldCat 59. Monagle P , Chan AKC , Goldenberg NA , et al. Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines . Chest 2012 ; 141 : e737 – 801S . Google Scholar Crossref Search ADS WorldCat 60. Shah P , Shah V . Continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters . Cochrane Database Syst Rev 2005 ; Cd002772 . OpenURL Placeholder Text WorldCat 61. Shah PS , Kalyn A , Satodia P , et al. A randomized, controlled trial of heparin versus placebo infusion to prolong the usability of peripherally placed percutaneous central venous catheters (PCVCs) in neonates: the HIP (Heparin Infusion for PCVC) study . Pediatrics 2007 ; 119 : e284 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 62. Abdelkefi A , Torjman L , Ladeb S , et al. Randomized trial of prevention of catheter-related bloodstream infection by continuous infusion of low-dose unfractionated heparin in patients with hematologic and oncologic disease . J Clin Oncol 2005 ; 23 : 7864 – 70 . Google Scholar Crossref Search ADS PubMed WorldCat 63. Chalmers E , Ganesen V , Liesner R , et al. ; British Committee for Standards in Haematology . Guideline on the investigation, management and prevention of venous thrombosis in children . Br J Haematol 2011 ; 154 : 196 – 207 . Google Scholar Crossref Search ADS PubMed WorldCat 64. Carrasco MN , Bueno A , de las Cuevas C , et al. Evaluation of a triple-lumen central venous heparin-coated catheter versus a catheter coated with chlorhexidine and silver sulfadiazine in critically ill patients . Intensive Care Med 2004 ; 30 : 633 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - How We Approach Central Venous Catheter Safety: A Multidisciplinary Perspective
JF - Journal of the Pediatric Infectious Diseases Society
DO - 10.1093/jpids/piz096
DA - 2020-02-28
UR - https://www.deepdyve.com/lp/oxford-university-press/how-we-approach-central-venous-catheter-safety-a-multidisciplinary-6H5Pg1yZBN
SP - 87
VL - 9
IS - 1
DP - DeepDyve
ER -