Ultrasound Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children. (Dodd)

Kantor DB, et al. Ultrasound Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children. Pediatr Crit Care Med. 2016 Dec;17(12):1124-1130.

OBJECTIVE: Peripheral arterial catheterization is a common invasive procedure performed in critically ill children. However, the benefits of using ultrasound guidance for this procedure in critically ill children, especially when used by inexperienced trainees, are unclear. Our aims were to evaluate whether the use of ultrasound guidance for the placement of radial arterial catheters reduced time and improved success when compared with the palpation method and also to determine patient and trainee variables that influence procedure outcomes. Finally, we evaluated whether adoption of ultrasound guidance among trainees comes at the expense of learning landmark-based methods.

DESIGN: Prospective observational cohort.

SETTING: University affiliated PICU.

PATIENTS: A total of 208 procedures performed by 45 trainees in 192 unique patients (1 mo to 20 yr old) were observed.

INTERVENTION: Implementation of ultrasound curriculum.

MEASUREMENTS AND MAIN RESULTS: The main outcome measures were time and number of attempts required for the procedure. Compared with palpation method, ultrasound guidance was associated with reduced procedure time (8.1 ± 5.2 min compared with 16.5 ± 8.8 min; p < 0.001), reduced number of attempts (3.1 ± 2.6 attempts compared with 6.9 ± 4.2 attempts; p < 0.001), and improved first attempt success rate (28% compared with 11%; p = 0.001) even after adjusting for key confounders in multivariate random effects models. The factors most likely to interfere with peripheral arterial catheterization are patient age, patient systolic blood pressure, patient body mass index, degree of fluid overload, and trainee months in fellowship. The use of ultrasound guidance mitigates the influence of each of these factors. We found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods.

CONCLUSIONS: The use of ultrasound guidance by trainees for radial artery catheterization in critically ill children is associated with improved outcomes compared with the palpation method.

Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists: a retrospective single-institution case series. (Betters)

Conrad SA, Grier LR, Scott LK, et al. Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists: a retrospective single-institution case series. Crit Care Med. 2015 May;43(5):1010-5.

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OBJECTIVE: Extracorporeal membrane oxygenation provides support for patients with severe acute cardiopulmonary failure, allowing the application of lung or myocardial rest in anticipation of organ recovery, or as a bridge to long-term support. Advances in technology have improved the safety and ease of application of extracorporeal membrane oxygenation. Percutaneous cannulation is one of these advances and is now preferred over surgical cannulation in most cases. Percutaneous cannulation is increasingly performed by intensivists, cardiologists, interventional radiologists, and related specialties. The objective of this study is to review the experience of percutaneous cannulation by intensivists at a single institution.

DESIGN: A retrospective review of 100 subjects undergoing percutaneous cannulation for extracorporeal membrane oxygenation.

SETTING: Adult ICUs and PICUs at a tertiary academic medical institution.

PATIENTS: Critically ill neonatal, pediatric, and adult subjects with severe respiratory and/or cardiac failure undergoing percutaneous cannulation for extracorporeal membrane oxygenation. Modes of support included venoarterial, venovenous, venovenoarterial, and arteriovenous.

INTERVENTIONS: Percutaneous extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS: Case reports submitted to the Extracorporeal Life Support Organization and hospital records of the subjects were retrospectively reviewed. Subject demographics, type of support, cannulation configuration, types of cannulas, use of imaging modalities, and complications were recorded and summarized. One hundred ninety cannulations with cannula sizes from size 12 to 31F were performed by four intensivists in 100 subjects. Twenty-three were arterial (12-16F) and 167 were venous (12-31F). Preinsertion ultrasound was performed in 93 subjects (93%), fluoroscopic guidance in 79 subjects (85% of nonarteriovenous subjects), and ultrasound-guided insertion was performed in 65 subjects (65%). Two major complications occurred, each associated with mortality. Cannulation was successful in all other subjects (98% of subjects and 99% of cannulations). There were no cases of cannula-related bloodstream infection.

CONCLUSIONS: Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists can be performed with a high rate of success and a low rate of complications when accompanied by imaging support.

Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. (Singh)

O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of
bloodstream infection: a systematic review and meta-analysis*. Crit Care Med.
2014 Jun;42(6):1334-9.

OBJECTIVE: Catheter-related bloodstream infections are associated with significant costs and adverse consequences. Arterial catheters are commonly used in the critical care setting and are among the most heavily manipulated vascular access devices. We sought to evaluate the prevalence of arterial catheter-related bloodstream infection.

DATA SOURCES: PubMed, CinAHL, EMBASE, and Web of Science.

STUDY SELECTION: Included studies reported prevalence rate of catheter-related bloodstream infection for arterial catheters used for critical illness or postoperative monitoring. For the purposes of this study, catheter-related bloodstream infection was defined as positive blood culture collected from an arterial catheter and from the periphery with the same organism in a patient demonstrating systemic signs of sepsis.

DATA EXTRACTION: The study population, site of insertion, antiseptic preparation, catheter days, and prevalence of catheter-related bloodstream infection were abstracted. When data were not available, authors were contacted for further information.

DATA SYNTHESIS: Forty-nine studies met criteria including 222 cases of arterial catheter-related bloodstream infection in 30,841 catheters. Pooled incidence was 3.40/1,000 catheters or 0.96/1,000 catheter days. Prevalence was considerably higher in the subgroup of studies that cultured all catheters (1.26/1,000 catheter days) compared with those studies that cultured only when the arterial catheter was suspected as the source for the catheter-related bloodstream infection (0.70/1,000 catheter days). Pooled data also found a significantly increased risk of infection for femoral site of insertion compared with radial artery for arterial catheter placement (relative risk, 1.93; 95% CI, 1.32-2.84; p = 0.001)

CONCLUSIONS:: Arterial catheters are an underrecognized cause of catheter-related bloodstream infection. Pooled incidence when catheters were systematically cultured and correlated to blood culture results indicated a substantial burden of arterial catheter-related bloodstream infection. Selection of a radial site over a femoral site will help reduce the risk of arterial catheter-related bloodstream infection. Future studies should evaluate technologies applied to preventing central venous catheter-related bloodstream infection to arterial catheters as well.

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Risk factors for peripherally inserted central venous catheter complications in children. (Kiran)

JAMA Pediatr. 2013 May 1;167(5):429-35. PMID: 23549677

IMPORTANCE: Peripherally inserted central venous catheters (PICCs) are prone to infectious, thrombotic, and mechanical complications. These complications are associated with morbidity, so data are needed to inform quality improvement efforts.

OBJECTIVES: To characterize the epidemiology of and to identify risk factors for complications necessitating removal of PICCs in children. DESIGN Cohort study.

SETTING: Johns Hopkins Children’s Center, Baltimore, Maryland.

PARTICIPANTS: Hospitalized children who had a PICC inserted outside of the neonatal intensive care unit (ICU) from January 1, 2003, through December 31, 2009.

MAIN OUTCOME MEASURES: Complications necessitating PICC removal as recorded by the PICC Team.

RESULTS: During the study period, 2574 PICCs were placed in 1807 children. Complications necessitating catheter removal occurred in 534 PICCs (20.8%) during 46 021 catheter-days (11.6 complications per 1000 catheter-days). These included accidental dislodgement (4.6%), infection (4.3%), occlusion (3.7%), local infiltration (3.0%), leakage (1.5%), breakage (1.4%), phlebitis (1.2%), and thrombosis (0.5%). From 2003 to 2009, complications decreased by 15% per year (incidence rate ratio [IRR], 0.85; 95% CI, 0.81-0.89). In adjusted analysis, all noncentral PICC tip locations-midline (IRR 4.59, 95% CI, 3.69-5.69), midclavicular (2.15; 1.54-2.98), and other (3.26; 1.72-6.15)-compared with central tip location were associated with an increased risk of complications. Pediatric ICU exposure and age younger than 1 year were independently associated with complications necessitating PICC removal.

CONCLUSIONS AND RELEVANCE: Noncentral PICC tip locations, younger age, and pediatric ICU exposure were independent risk factors for complications necessitating PICC removal. Despite reductions in PICC complications, further efforts are needed to prevent PICC-associated complications in children.

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