Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.     

Coronary stenting using a 6 F. diagnostic catheter: a report of two cases

Standard guiding catheters for coronary interventions may not selectively engage the coronary ostium despite a successful cannulation with a diagnostic catheter of the same curve. This discrepancy is explained by a slight difference in shape between the two catheters (shorter tip of the guiding, absence of tip tapering, etc.). The authors report on the use of 6 F. coronary diagnostic catheters as guiding catheters for coronary angioplasty and stent implantation in two patients with critical stenoses: in the right coronary artery distal to a right internal mammary artery anastomosis in one and in the ostial right coronary artery in the other. In both cases, the use of diagnostic catheters was the key to success despite the vessel orifice being unfavourable for the use of different types of guiding catheters.     

Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial

Objective To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated.Design Randomised controlled trial.Setting Tertiary hospital in Australia.Participants 755 medical and surgical patients: 379 allocated to catheter replacement only when clinically indicated and 376 allocated to routine care of catheter (control group).Main outcome measure A composite measure of catheter failure resulting from phlebitis or infiltration.Results Catheters were removed because of phlebitis or infiltration from 123 of 376 (33%) patients in the control group compared with 143 of 379 (38%) patients in the intervention group; the difference was not significant (relative risk 1.15, 95% confidence interval 0.95 to 1.40). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups (relative risk 0.98, 0.78 to 1.24). Infusion related costs were higher in the control group (mean $A41.02; £19.71; €24.80; $38.55) than intervention group ($A36.40). The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group).Conclusion Replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. Larger trials are needed to test this finding using phlebitis alone as a more clinically meaningful outcome.Registration number Australian New Zealand Clinical Trials Registry ACTRN12605000147684.     

Pseudomonas Cepacia Septicemia Associated with Intravenous Therapy

Four cases of Pseudomonas cepacia septicemia were found in one hospital in 1971. Two were related to severe phlebitis of the arms due to intravenous catheters, a third to an infected central venous pressure catheter. The infections resolved after the catheters were removed in these three cases.Prophylactic antibiotics may play a partial role in predisposing to this kind of infection. Ps. cepacia may be a more common pathogen than previously recognized. Its antibiotic sensitivity pattern distinguishes it from other members of the Pseudomonas family. Nosocomial infection with this bacteria has been traced to quaternary ammonium solutions but the source of infections in the present cases was not found.     

Systemic administration of autologous,alloactivated helper-enriched lymphocytes to patients with metastatic melanoma of the lung

Summary A phase I study was carried out to test the feasibility and toxicity of infusing large numbers of autologous, alloactivated helper lymphocytes into patients with metastatic melanoma. Patient peripheral blood lymphocytes (Pt-PBL) obtained by lymphopheresis and expressing the helper phenotype BT5/9 were separated and stimulated for 48 or 72 h with a pool of PBL from four to six healthy donors. Patients were then infused with such activated lymphocytes over a 2–3 h period. A total of 4 phereses and infusions (2/week for 2 weeks) were carried out for each cycle in each patient. Of the five patients treated, two received a second round of infusions. Infusion of autologous PBL stimulated in vitro for 48 h caused chills, fever, headache, and increased blood pressure. All symptoms disappeared in 2–3 h and were easily controlled by appropriate therapy. When lymphocytes were given after 72 h of allostimulation, no or very mild toxicity was observed. Serum chemistry, coagulation, autoimmunity, and urine analysis showed no gross abnormalities during therapy or follow-up of the patients. Immunological parameters (OKT4/OKT8 ratio, NK activity and cytotoxic T cell activity to autologous melanoma) were evaluated before starting the therapy, during its course and during the 3 to 6 months follow-up. The OKT4/OKT8 ratio increased significantly but transiently soon after the first course of infusions in one of the two patients tested. NK activity increased after 75–100 days in the three patients tested and in one of them it was high even after 180 days. No correlation between NK activity and prognosis was apparent. Cytotoxicity to autologous tumor was assessed in two patients, only one of whom exhibited an increased activity from 75 to 180 days, which was associated with a prognosis better than that of the negative patient. Five patients were treated: two had progressive disease, two had stable disease for 5 and 6 months, respectively. In the first of these patients, a new cycle of lymphocyte infusions was carried out which caused a measurable reduction of lung tumor nodules whose growth, however, resumed 4 months later. This patient died 14 months after the onset of therapy. The fifth patient had a partial regression of pulmonary and intracranial metastases after therapy, but eventually died 3 months later. These results indicate that infusion of a high numbers of autologous, allostimulated helper PBL is a feasible and safe procedure, which could therefore be used in future studies of adoptive immunotherapy of cancer.     

Factors Influencing Intracavitary Electrocardiographic P-Wave Changes during Central Venous Catheter Placement

Amplitude changes in the P-wave of intracavitary electrocardiography have been used to assess the tip placement of central venous catheters. The research assessed the sensitivity and specificity of this sign in comparison with standard radiographic techniques for tip location, focusing on factors influencing its clinical utility. Both intracavitary electrocardiography guided tip location and X-ray positioning were used to verify catheter tip locations in patients undergoing central venous catheter insertion. Intracavitary electrocardiograms from 1119 patients (of a total 1160 subjects) showed specific amplitude changes in the P-wave. As the results show, compared with X-ray positioning, the sensitivity of electrocardiography-guided tip location was 97.3%, with false negative rate of 2.7%; the specificity was 1, with false positive rate of zero. Univariate analyses indicated that features including age, gender, height, body weight, and heart rate have no statistically significant influence on P-wave amplitude changes (P>0.05). Multivariate logistic regression revealed that catheter insertion routes (OR = 2.280, P = 0.003) and basal P-wave amplitude (OR = 0.553, P = 0.003) have statistically significant impacts on P-wave amplitude changes. As a reliable indicator of tip location, amplitude change in the P-wave has proved of good sensitivity and excellent specificity, and the minor, zero, false positive rate supports the clinical utility of this technique in early recognition of malpositioned tips. A better sensitivity was achieved in placement of centrally inserted central catheters (CICCs) than that of peripherally inserted central catheters (PICCs). In clinical practice, a combination of intracavitary electrocardiography, ultrasonic inspection and the anthropometric measurement method would further improve the accuracy.     

Prostaglandin E1 infusion therapy in dry age-related macular degeneration

OBJECTIVE: The pilot study is intended to show whether prostaglandin E1 (PGE1) infusions are able to stop the gradual vision loss in dry age-related macular degeneration (AMD) and, further, to stabilize or improve visual acuity. METHODS: With PGE1 infusions 11 patients with different forms of dry AMD were treated and compared with a control group of 10 untreated patients with dry AMD. The target parameter was the visual acuity, as determined with the ETDRS logMAR charts. Other examinations performed during the study were tests of contrast vision, colour vision and central visual fields, as well as autofluorescence and fluorescein angiography and multifocal electroretinography. RESULTS: On termination of the infusions, six patients showed an increase in visual acuity by at least one line, an improvement that was seen in eight patients 2 months after the end of the infusion therapy. After 6 months, one patient exhibited an improvement of visual acuity by three lines and three patients an improvement by one line. Five patients were found to show no change of their baseline acuity values after 6 months, while two patients exhibited an impairment by one line. The visual acuity in the dry AMD control group without PGE1 treatment had decreased by 0.8 lines on the average after 6 months. Contrast vision, central visual fields and the multifocal electroretinogram showed improvements on the termination of infusions and up to 2 months later; no substantial change of these parameters, as compared with the baseline findings, was seen 6 months after the termination of infusions. SUMMARY: This pilot study suggests that PGE1 infusions have a stabilizing or improving effect on the visual acuity of patients with dry AMD. Owing to the limitations of a pilot study, these results should, however, be validated in a larger, randomized and blinded study.     

Modified procedure for implantation of subcutaneous central venous access devices in macaques (Macaca mulatta)

A nonhuman primate model comprising adult male rhesus monkeys (Macaca mulatta) with chronically indwelling subcutaneous central venous access devices provides a unique opportunity to determine plasma pharmacokinetics of new drugs such as anticancer and anti- retroviral agents. The central venous access we use is a low-profile, single-septum, titanium port that is attached to a radiopaque, indwelling catheter; the catheter is implanted in an internal jugular vein. A common complication following placement of the venous access device was migration of the catheter tip. We therefore modified the standard procedure by cutting the silicone catheter and introducing the rigid connector to secure the catheter to the vessel at the insertion site (approximately 9 to 13 cm from the distal end of the catheter). Prior to the use of the connector, three of five catheters migrated within 4 weeks after placement. In contrast, all 13 internal jugular catheters with connectors have remained patent without migration of the catheter tip. Therefore, incorporation of the catheter connector appears to have eliminated the problem of catheter migration.     

Effect of covalently bound heparin coating on patency and biocompatibility of long-term indwelling catheters in the rat jugular vein

Many physiologic and pharmacologic studies require long-term vascular access for repeated substance infusion and/or blood sample collection. The study reported here was undertaken to determine whether a functionally active heparin coating would improve long-term patency of venous catheters in rats. Uncoated or coated catheters were surgically placed in the jugular vein, and patency was evaluated twice weekly for a total of 30 days. Culturing of blood and catheters, and histologic examination were performed for all rats. All heparin-coated catheters remained patent for the study duration, with patency defined as ability to infuse saline and withdraw a blood sample. Median patency for uncoated catheters was 17.5 days, with a range of three to 30 days. Histologic evaluation of vessels revealed more advanced and severe lesions in rats with uncoated, compared with coated catheters. Furthermore, uncoated catheters had increased association with bacteremia (3/8), compared with coated (0/9) catheters. Taken together, these results indicate that coating catheters with covalently bound heparin molecules can significantly prolong patency and cause less pathologic damage to the catheterized vessel.     

Total nutrition by peripheral vein — the lipid system

A means for providing total nutrition is described in which 10% soybean oil-eggyolk phosphatide-glycerol emulsion (Intralipid) and a solution of 5% dextrose in 5% protein hydrolysate are given simultaneously into a peripheral vein, utilizing two giving sets united by a Y-connector at the needle. No ketonuria occurred, and there were no side effects from the lipid emulsion. Advantages of this system include absence of significant peripheral phlebitis, avoidance of the hazards of caval catheters, and absence of the complications of hypertonic solutions. Disadvantages include restricted forearm movement and frequent regulation of flow-rates.This system was used in 23 patients for periods of 4 to 78 days (mean 16.3 days). Weight gain and healing occurred, and all survived but one patient who died of myocardial infarction following successful surgical closure of an enterocolocutaneous fistula. The lipid system adds another method to the measures available for the management of major nutritional problems.     

The gastrointestinal tract "tastes" nutrients: evidence from the intestinal taste aversion paradigm

To develop and use a behavioral paradigm for assessments of what nutrient properties are detected by intestinal chemoreceptors, we combined features of the "electronic esophagus" preparation (Elizalde G and Sclafani A. Physiol Behav 47: 63-77, 1990) and the conditioned taste aversion protocol (Garcia J and Koelling RA. Psychon Sci 4: 123-124, 1966). In four experiments, separate groups of food-deprived rats with gastric (experiments 1-4) or duodenal (experiment 4) catheters were infused with either carbohydrates (maltodextrin) or fats (corn oil) into their stomachs or small intestines, either while they consumed nonnutritive flavored solutions (experiments 1 and 2) or in the absence of any intake (experiments 3 and 4). For some animals, one of the macronutrient infusions was paired with lithium chloride injections shown to support conventional conditioned aversions. After training, in various oral preference test trials, animals were given opportunities to taste and consume the nonnutritive solutions that had served as oropharyngeal conditioned stimuli as well as the nutrients that had been infused intragastrically, with or without poisoning, but never sampled by mouth. As previously established, preferences for the nonnutritive flavors were enhanced by association with intragastric infusions of macronutrients, with carbohydrates producing the greater preference. On first exposure to the two macronutrients for oral consumption, animals reduced their intake of the nutrient that had been previously poisoned when it was infused into the gastrointestinal tract. These results, along with additional controls, suggest that nutrient tastes detected in the intestines can be recognized centrally based on oropharyngeal gustatory stimulation.     

Human immune response to multiple injections of murine monoclonal IgG

Murine monoclonal antibody infusions in humans should induce a human anti-mouse immunoglobulin (mIgG) immune response, especially if multiple infusions over an extended period of time are necessary for therapeutic efficacy. We have administered multiple infusions of the murine monoclonal antibody T101 to patients with cutaneous T cell lymphoma (CTCL) or chronic lymphocytic leukemia (CLL). Five of 10 CTCL patients, compared with zero of six CLL patients, developed antibodies to mIgG. In those CTCL patients who did not demonstrate anti-mIgG antibodies, we were unable to correlate the lack of response to any of a large number of clinical parameters. Anti-mIgG antibodies were of both the mu and gamma isotypes and were detectable 14 days after the first infusion. Multiple infusions were associated with elevated titers. The anti-idiotypic portion of the anti-mIgG titer steadily increased with each infusion until eventually, in one patient receiving eight weekly infusions, well over one-half the serum anti-mIgG recognized only T101 and not four other murine IgG2AK antibodies tested. To increase our confidence in these findings, four separate assay systems were used to make these determinations. The identification of anti-idiotype antibodies as the dominant species of the immune response to multiple infusions of murine monoclonal antibody has major implications for future work with monoclonal antibodies. Although it has been suggested that human monoclonal antibodies would obviate an immune response, our work implies that such antibodies might still induce anti-idiotype antibodies if multiple infusions are administered.     

Urinary tract candidiasis: report of a case with bilateral ureteral obstruction

A brief review of the literature on urinary tract candidiasis is presented. The presence of Candida albicans in the urine is rather uncommon and most patients have candiduria without any apparent disease. Among the others, three different clinical types of infection are recognized: (1) pyelonephritis, (2) lower urinary tract infection and (3) ureteral obstruction. Of this last type only seven cases were found in the literature; four of the patients died. We add one case in which the patient did very well after the obstruction of the ureters was relieved by means of ureteral catheters and a large urinary output was maintained for several days.     

A clinical and microbiological study of venous catheterization

In a prospective study of 210 intravenous catheters and needles 31 (15%) swabs yielded 34 microbial isolates. Twenty-eight were “non-pathogenic” skin commensals and six were “pathogenic” organisms. Commensals were isolated predominantly from catheters left in situ for only a short time (up to two days) and pathogenic organisms most frequently from specimens left in situ for a longer time. Correlation was not confirmed between colonization and infection, antibiotic therapy or phlebitis. All samples of IV fluids were sterile on culture. Changing the IV catheter at least every two days is recommended.     

康惠尔水胶体透明贴对阿奇霉素引起的静脉炎的预防作用

目的:观察康惠尔水胶体透明贴对使用阿奇霉素引起的静脉炎的疗效与效果。方法:从我院2009年1月-2010年1月的呼吸内科患者中选择100例使用阿奇霉素静脉输液治疗的患者。分为观察组与对照组,每组50名使用阿奇霉素静脉输液治疗的患者。普通组使用普通透明贴,对照组患者使用康惠尔水胶体透明贴。对两组患者进行比对。结果:观察组的50名患者使用普通透明贴,16例未发生静脉炎,发生静脉炎为34例;对照组的50名患者使用康惠尔水胶体透明贴,仅有2例发生静脉炎的患者。对照组与普通组相比,对照组结果好于普通组,P<0.05差距有显著统计学意义。结论:使用康惠尔水胶体透明贴可以有效的减少呼吸内科患者使用阿奇霉素造成的静脉炎发生率。     

Trial of glucose versus fat emulsion in preparation of amphotericin for use in HIV infected patients with candidiasis.

OBJECTIVES--To compare the tolerance, efficacy, and pharmacokinetics of amphotericin deoxycholate (Fungizone) prepared in a parenteral fat emulsion (Intralipid 20%) or glucose in HIV patients with candidiasis. DESIGN--Non-blind randomised controlled trial. SETTING--University hospital; tertiary clinical care. PATIENTS--22 HIV positive patients with oral candidiasis. INTERVENTIONS--Amphotericin 1 mg/kg/day given on four consecutive days as a one hour infusion dissolved in either 5% glucose (amphotericin-glucose) or parenteral fat emulsion at a final concentration of 2 g/l fat emulsion (amphotericin-fat emulsion). MAIN OUTCOME MEASURES--Clinical tolerance (fever, chills, sweats, nausea, arterial pressure, and pulse rate); biological tolerance (serum creatinine, electrolyte, and magnesium values); clinical score of candidiasis; and serum concentrations of amphotericin. RESULTS--11 patients were enrolled in each group. All the amphotericin-fat emulsion infusions were given without serious problem whereas four amphotericin-glucose infusions were stopped because of renal impairment (n = 3) or severe chills (n = 2), or both. For patients completing the amphotericin-glucose treatment creatine concentration increased by 42 mumol/l; four of seven patients had at least one creatinine value > or = 133 mumol/l versus one of 11 receiving amphotericin-fat emulsion. Magnesium concentration fell significantly with amphotericin-glucose but not with amphotericin-fat emulsion. Clinical side effects were noted in 36/38 infusions with amphotericin-glucose but 10/44 with amphotericin-fat emulsion. Oral candidiasis score was reduced similarly in both groups. Serum amphotericin concentrations were significantly lower and the volume of distribution of the drug higher after infusion of amphotericin-fat emulsion than after amphotericin-glucose. CONCLUSIONS--Clinical and renal toxicity of amphotericin are reduced when the drug is prepared in fat emulsion. Preparation is simple and cost effective. Its efficacy is similar to that of conventional amphotericin.     

超声引导改良外周静脉导入中心静脉置管术临床应用经验

目的:探讨超声引导下改良的外周静脉导入中心静脉置管术(Peripherally Inserted Central Catheter,PICC)的临床应用。方法:对42例有恶性肿瘤病史需行PICC置管、浅静脉直视下不明显或触摸不到、不适合盲穿患者42例进行超声引导下改良的PICC术。改良方法包括穿刺支架超声引导以及用一次性使用麻醉用针替代Seldinger包内的穿刺针进行,并与23例标准PICC法对比分析穿刺成功率及穿刺并发症发生率。结果:两种方法穿刺成功率均为100%,其中改良PICC患者41例穿刺一次成功,一次成功率为97.6%;标准PICC患者21例穿刺一次成功,一次成功率为91.3%。两种方法一次成功率差异无统计学意义(P0.05)。42例改良患者中发生2例并发症,包括局部水肿1例及导管异位1例;23例标准PICC患者中发生6例并发症,包括局部水肿2例,导管异位1例,静脉炎1例及局部感染2例。两种方法并发症发生率差异有统计学意义(P=0.019)。结论:超声引导下改良的PICC术一次成功率高,并发症少,值得临床推广。     

三种药液湿敷治疗多巴胺所致静脉炎的临床疗效比较

目的：通过三种药液外敷治疗经外周静脉输入或泵入多巴胺所引起的静脉炎的效果比较,总结出效果最佳的药液。方法：选择因长期静脉应用多巴胺,使用外周静脉留置针,并发静脉炎Ⅰ度或Ⅱ度的患者120例,随机分为三组,分别用50%硫酸镁注射液、10%硝酸甘油溶液、10%酚妥拉明溶液湿敷,每组40例,在湿敷后的1天,3天,7天观察静脉炎消退情况。结果：三种药液湿敷后的第3天在治疗效果方面有显著差异,且10%硝酸甘油溶液的治疗效果比较好,优于其它两种药物（P〈0.017）。结论：10%硝酸甘油溶液湿敷对多巴胺所致静脉炎的治疗效果明显,值得临床推广。     

An in vivo comparison of radiofrequency cardiac lesions formed by standard and magnetically steered 4 mm tip catheters

Background. In vivo comparison of cardiac radiofrequency ablation lesions between standard and magnetically steered 4 mm tip catheters has never been reported. Methods. High and low right atrium (RA) free wall, isthmus, right ventricle (RV) free wall and outflow tract lesions were studied macroscopically and microscopically five days after lesion formation in seven pigs. Shape, size, thrombus formation, and ablation parameters were compared. The effect of minimal, medium and high wall contact was assessed by a contact measurement utility for magnetic catheters. Results. All 14 RA free wall lesions were transmural with a similar epicardial and endocardial surface area. In the RV, the epicardial area usually appeared to be smaller than the endocardial area with standard catheters. Isthmus lesions were difficult to assess transmurality. There was no difference in endocardial area: standard 39 mm² (range 16 to 82 mm²) vs. magnetic 36 mm² (range 23 to 111 mm²). If the catheter tip was perpendicular to the tissue, magnetic lesions were more often round or oval, while standard lesions were more often elongated (p<0.05). When the catheter tip was parallel to tissue, lesions always tended to be elongated. Microscopic characteristics were similar. The contact utility was not useful. Average impedance (p<0.0001) and energy delivered (p<0.05) were less with magnetic catheters. Conclusion. Lesions from magnetically steered catheters are transmural of similar size, but with less variability than standard catheter lesions when the tip is perpendicular to the tissue. Magnetic lesions are associated with lower impedance and energy delivery. This suggests a more stable tip-to-tissue contact. (Neth Heart J 2010;18:66–71.)     

Central venous catheters for chemotherapy of solid tumors--our results in the last 5 years

Central venous catheters provide an easy access for intravenous medications. Having a central line in place will relieve a child from the discomfort and danger of multiple regular intravenous lines for chemotherapy. The use of indwelling central venous catheters has become commonplace in the management of children undergoing oncological treatment. There are two types of central lines commonly used. There are Broviac catheters and Port-A-Cath (PAC) catheters. In the last 5 years we inserted 194 catheters in 175 children. We inserted 121 Broviac catheters and 73 PAC catheters. During the follow up of 39382 catheter days 44 complications were observed. In Broviac group the median follow up was 155 days and in PAC group was 230 days. We observed differences in the incidence between two devices. In Broviac group infections were more frequent and in PAC group other complications were more frequent than infections.