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La prevenzione delle infezioni associate a cateteri venoso centrali (CVC)
Luisa Leone, Settore Documentazione, SIDBAE, ISS
Referente: Prof. G. Donelli
Anni: 2000-2008
Lingua: Inglese, Italiano
Base dati: PUBMED
N. Record: 23
Quesito 9
Poiché la deposizione di fibrina e la formazione di trombi sulla superficie interna dei
CVC possono favorire la colonizzazione microbica, è raccomandabile il lavaggio
(flushing) dei CVC con anticoagulanti quali eparina Warfarin, etc.?
Strategia di ricerca
#13 Search ((#3) AND (#11)) AND (#4) Limits: Publication Date from
2000, English, Italian
#12 Search ((#3) AND (#11)) AND (#4)
#11 Search flushing OR flush OR flushes
#4 Search anticoagulant OR anticoagulants
#3 Search Catheterization, Central Venous"[Mesh] OR Central
Venous catheter OR Central Venous catheters OR CVC OR
CVCS OR Central Venous catheterization
06:40:31
23
06:37:54
48
06:35:18
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06:32:46 162878
04:34:27 13798
1: J Am Assoc Lab Anim Sci. 2007 May;46(3):58-60.
Use of a low-concentration heparin solution to extend the life of central venous
catheters in African green monkeys (Chlorocebus aethiops).
Gamble CS, Jacobsen KO, Leffel EK, Pitt ML.
1
Veterinary Medicine Division, United States Army Medical Institute of Infectious
Diseases, Fort Districk, MD, USA. [email protected]
Normal hematologic values for African green monkeys have been reported, but these
results are confounded by the effect of chemical restraint (for example,
ketamine), physical restraint, and capture stress. The dual-lumen central venous
catheter, jacket, and tether combination we describe here allows intravenous
fluid administration and repeated blood sampling without the use of anesthesia or
inducing capture-related stress. The use of a low-concentration heparin solution
for catheter maintenance significantly increased the mean patency time, compared
with a saline-only catheter flush solution. Adding a low-concentration heparin
solution creates a suitable system for serial blood collection in the African
green monkey for as long as 25 d.
Publication Types:
Evaluation Studies
PMID: 17487955 [PubMed - indexed for MEDLINE]
2: MMWR Morb Mortal Wkly Rep. 2006 Sep 8;55(35):961-3.
Erratum in:
MMWR Morb Mortal Wkly Rep. 2006 Oct 13;55(40):1100.
Update: Delayed onset Pseudomonas fluorescens bloodstream infections after
exposure to contaminated heparin flush--Michigan and South Dakota, 2005-2006.
Centers for Disease Control and Prevention (CDC).
In March 2005, CDC reported a multistate outbreak of Pseudomonas fluorescens
bloodstream infections associated with use of syringes preloaded with heparin
intravenous catheter flush. The heparin flush became contaminated during
preparation by IV Flush, LLC (Rowlett, Texas). Thirty-six patients in four states
were identified who had been exposed to the contaminated flush and subsequently
experienced P. fluorescens bloodstream infection during December 2004-February
2005. Based on a recommendation by the Food and Drug Administration (FDA), IV
Flush voluntarily recalled the preloaded syringes in late January; on January 31
and February 4, 2005, FDA issued nationwide alerts recommending that consumers
and institutions stop using and return the preloaded syringes to IV Flush or the
distributor (Pinnacle Medical Supply, Rowlett, Texas). Approximately 3 months
after the product was recalled, patients in Michigan and South Dakota were
identified with P. fluorescens bloodstream infections. As of April 2006, a total
of 15 patients in Michigan and 13 in South Dakota had been identified with
delayed onset P. fluorescens bloodstream infections, with occurrences ranging
from 84 to 421 days after their last potential exposure to the contaminated
flush. The patients all had indwelling central venous catheters and received
treatment during October 2005-February 2006 at clinics known to have used the
contaminated flush. This report describes the investigation of these cases, which
determined that these were delayed onset cases of P. fluorescens bloodstream
infection from a past exposure to contaminated flush, and provides
recommendations for ongoing surveillance for delayed P. fluorescens bloodstream
2
infections among similarly exposed patients.
PMID: 16960550 [PubMed - indexed for MEDLINE]
3: Pharmacotherapy. 2006 Sep;26(9):1262-7.
Use of heparin versus lepirudin flushes to prevent withdrawal occlusion of
central venous access devices.
Horne MK, McCloskey DJ, Calis K, Wesley R, Childs R, Kasten-Sportes C.
Department of Laboratory Medicine, W. G. Magnuson Clinical Center, National
Institutes of Health, Bethesda, Maryland 20892, USA. [email protected]
STUDY OBJECTIVE: To determine whether lepirudin flushes are more effective than
heparinized saline in preventing withdrawal occlusion of central venous access
devices. DESIGN: Randomized, double-blind clinical trial. SETTING: Research
institution-tertiary referral center. PATIENTS: Forty-nine adults undergoing bone
marrow transplantation for hematologic malignancies or metastatic solid tumors.
INTERVENTION: Twenty-four patients received heparin and 25 received lepirudin
flushes. The heparin dose was 3 ml of porcine heparin 100 U/ml (300 U) per
catheter lumen at least once/day; the lepirudin dose was 3 ml of lepirudin 100
microg/ml (300 microg) per catheter lumen at least once/day. After 3-4 weeks, all
49 patients received the heparin flushes. MEASUREMENTS AND MAIN RESULTS: Efficacy
was assessed by the frequency with which the patients were treated with alteplase
instillations for withdrawal occlusion of their central venous access devices
during the first 4 months of catheterization. Three (12.5%) patients treated with
heparin alone and five (20%) treated initially with lepirudin required alteplase
instillations for an estimated relative risk with lepirudin versus heparin of 1.6
(95% confidence interval [CI] 0.40-13.86, p=0.70). CONCLUSION: Lepirudin was not
more effective than heparin, which may have been related to the conservative dose
of lepirudin administered. However, higher lepirudin doses are likely to incur an
unacceptable risk of systemic anticoagulation.
Publication Types:
Comparative Study
Randomized Controlled Trial
Research Support, N.I.H., Intramural
PMID: 16945048 [PubMed - indexed for MEDLINE]
4: Haemophilia. 2006 Sep;12(5):548-50.
Inadvertent anticoagulation of a haemophiliac child with routine line flushing.
Lambert C, Deneys V, Pothen D, Vermylen C, Hermans C.
Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc, Brussels,
Belgium.
We report the case of a 3-year-old boy with severe haemophilia A presenting with
3
recurrent haemarthroses despite daily infusions of factor VIII delivered through
a central venous access device (CVAD). Regular rinsing of the CVAD with heparin,
according to a standard protocol, resulted in systemic anticoagulation, as
demonstrated by prolonged thrombin time and therapeutic anti-Xa levels. The
bleeding symptoms resolved after replacing heparin with a normal saline solution.
This case illustrates that heparin administered to maintain CVAD patency should
be used with caution in young haemophiliacs. Prolonged thrombin time should alert
the physician to this possible CVAD complication.
Publication Types:
Case Reports
PMID: 16919088 [PubMed - indexed for MEDLINE]
5: J Infus Nurs. 2006 May-Jun;29(3):129-45.
Technology of flushing vascular access devices.
Hadaway L.
Lynn Hadaway Associates, Inc., USA. [email protected]
Maintenance of catheter lumen patency is an ongoing challenge. Catheter flushing
is the primary nursing intervention used to prevent lumen occlusion from
thrombotic and precipitate causes. The catheter and all devices attached to it
must be regarded as a system in which each component directly affects the others.
The technology of catheter flushing includes the flush solution itself, the
source of these solutions, syringe design, mechanical pumps, needleless injection
systems, and the design of the catheter. Effective catheter flushing is a
combination of a technique and technology that requires an understanding of how
both must work together.
Publication Types:
Review
PMID: 16878855 [PubMed - indexed for MEDLINE]
6: Pediatrics. 2006 Jul;118(1):e212-5. Epub 2006 Jun 19.
Life-threatening sepsis caused by Burkholderia cepacia from contaminated
intravenous flush solutions prepared by a compounding pharmacy in another state.
Held MR, Begier EM, Beardsley DS, Browne FA, Martinello RA, Baltimore RS,
McDonald LC, Jensen B, Hadler JL, Dembry LM.
Department of Pediatrics, Division of Infectious Diseases, Yale University School
of Medicine, New Haven, Connecticut, USA. [email protected]
We report 2 life-threatening cases of Burkholderia cepacia sepsis caused by
infusate contamination during compounding. Bacterial isolates from the patients'
blood cultures and the infusate were indistinguishable by pulsed-field gel
4
electrophoresis. Proper quality controls at a local and national level are
important for ensuring safe delivery of compounded medications to patients in all
settings, including those outside health care facilities.
Publication Types:
Case Reports
PMID: 16785290 [PubMed - indexed for MEDLINE]
7: Pediatr Infect Dis J. 2005 Dec;24(12):1099-103.
Outbreak of Ralstonia pickettii bacteremia in a neonatal intensive care unit.
Kimura AC, Calvet H, Higa JI, Pitt H, Frank C, Padilla G, Arduino M, Vugia DJ.
California Department of Health Services, Gardena, CA, USA. [email protected]
BACKGROUND: Ralstonia pickettii is a Gram-negative bacillus commonly found in
soil and moist environments; however, R. pickettii is rarely isolated from
clinical specimens. In August 2001, a cluster of R. pickettii bacteremia occurred
among neonatal intensive care unit (NICU) infants at a California hospital.
METHODS: A case-control study was conducted to determine risk factors for
infection. A case was a NICU patient with R. pickettii bacteremia. Controls were
NICU infants with negative blood cultures drawn during the same time period. A
detailed environmental investigation was also conducted. RESULTS: We identified
18 patients with 19 distinct episodes of R. pickettii bacteremia from July 30
through August 30, 2001. All cases had intravascular access at the time of
bacteremia. Although the case-control study did not implicate any statistically
significant risk factors, the most likely source of the outbreak was the heparin
flush prepared in the hospital pharmacy. This is supported by the following: (1)
the heparin flush was the only substance introduced directly into the bloodstream
of all case infants; (2) the heparin flush was used exclusively by the NICU; and
(3) no further cases were identified after the heparin flush was discontinued.
Cultures of remaining heparin flush and environmental cultures from the NICU were
negative for R. pickettii. CONCLUSIONS: This unusual outbreak of R. pickettii
bacteremia was most likely caused by contaminated heparin flush and ended after
the heparin flush was discontinued.
PMID: 16371873 [PubMed - indexed for MEDLINE]
8: Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002774.
Update of:
Cochrane Database Syst Rev. 2002;(4):CD002774.
Heparin for prolonging peripheral intravenous catheter use in neonates.
Shah PS, Ng E, Sinha AK.
Mount Sinai Hospital, Department of Paediatrics, Rm 775A, 600 University Avenue,
Toronto, Ontario, Canada. [email protected]
5
BACKGROUND: Peripheral intravenous (PIV) catheters are widely used in modern
medical practice. However, mechanical or infectious complications often
necessitate their removal and/or replacement. Heparin has been shown to be
effective in prolonging the patency of peripheral arterial catheters and central
venous catheters, but may result in life threatening complications, especially in
preterm neonates. OBJECTIVES: The primary objective was to determine the
effectiveness of heparin versus placebo or no treatment on duration of PIV
catheter patency, defined as number of hours of catheter use. The secondary
objectives were to assess the effects of heparin on catheter blockage, phlebitis
or thrombophlebitis, catheter related sepsis, and complications including
abnormality of coagulation profile, allergic reactions to heparin, heparin
induced thrombocytopenia, intraventricular/intracranial hemorrhage and mortality.
SEARCH STRATEGY: A literature search was performed using the following databases:
MEDLINE (1966-February 2005), EMBASE (1980-February 2005), CINAHL (1982-February
2005), Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane
Library, Issue 1, 2005), and abstracts from the annual meetings of the Society
for Pediatric Research, American Pediatric Society and Pediatric Academic
Societies published in Pediatric Research (1991-2004). No language restrictions
were applied. SELECTION CRITERIA: Randomized or quasi-randomized trials of
heparin administered as flush or infusion versus placebo or no treatment were
included. Studies which included a neonatal population and reported on at least
one of the outcomes were included. DATA COLLECTION AND ANALYSIS: The
methodological quality of the studies was assessed using criteria for blinding of
randomization, blinding of intervention, completeness of follow-up and blinding
of outcome assessment. Data on relevant outcomes were extracted and the effect
size was estimated by calculating WMD (weighted mean difference, 95%CI), RR
(relative risk, 95% CI) and RD (risk difference, 95% CI). MAIN RESULTS: Ten
eligible studies were identified. Heparin was administered either as a flush
solution, or as an additive to the total parenteral nutrition solution. Five
studies reported data on the duration of use of the first catheter. Two of these
studies found no statistically significant effect of heparin; two studies showed
a statistically significant increase and one study showed a statistically
significant decrease in the duration of PIV catheter use in the heparin group.
The results were not combined for meta-analysis due to significant heterogeneity
of the treatment effect (p < 0.01). In addition, there were marked differences
between the studies in terms of the methodological quality, the dose, the timing,
the route of administration of heparin and the outcomes reported. From a limited
number of studies, there were no significant differences between the heparin and
the placebo/no treatment groups in the risks of infiltration, phlebitis and
intracranial hemorrhage. AUTHORS' CONCLUSIONS: Implications for practice: The
effect of heparin on the duration of peripheral intravenous catheter use varied
across the studies. Because of clinical heterogeneity and heterogeneity in
treatment effect, recommendations for heparin use in neonates with PIV catheters
cannot be made.Implications for research: There are insufficient data concerning
the effect of heparin for prolonging PIV catheter use in neonates. Further
research on the effectiveness, the optimal dose, and the safety of heparin is
required.
Publication Types:
Review
6
PMID: 16235300 [PubMed - indexed for MEDLINE]
9: Infect Control Hosp Epidemiol. 2005 Jun;26(6):520-4.
Comment in:
Infect Control Hosp Epidemiol. 2005 Jun;26(6):511-4.
A randomized, controlled trial of a new vascular catheter flush solution
(minocycline-EDTA) in temporary hemodialysis access.
Bleyer AJ, Mason L, Russell G, Raad II, Sherertz RJ.
Department of Internal Medicine, Wake Forest University School of Medicine,
Winston-Salem, North Carolina, USA. [email protected]
BACKGROUND AND OBJECTIVE: We previously demonstrated that minocycline-EDTA was
efficacious at preventing catheter-related bloodstream infections (BSIs) in three
patients with recurrent infections. This study compared heparin with
minocycline-EDTA as flush solutions used among dialysis patients with central
venous catheters, a high-risk group for catheter-related BSI. METHODS: Patients
were enrolled within 72 hours of catheter insertion and randomized to receive
heparin or minocycline-EDTA as a flush after each dialysis session. Each syringe
containing flush solution was wrapped in orange plastic to conceal the type of
solution it contained. Patients were observed for evidence of infection and
catheter thrombosis. After catheters were removed, cultures were performed to
determine whether microbial colonization had occurred. RESULTS: During a 14-month
period, 60 patients were enrolled (30 in each group). The two groups had similar
demographics and underlying diseases. Catheter survival at 90 days was 83% for
the minocycline-EDTA group versus 66% for the heparin group (P = .07).
Significant catheter colonization, a surrogate measure of catheter-related
infection, was significantly more frequent in the heparin group (9 of 14 vs 1 of
11; P = .005). There was only one catheter-related bacteremia and it occurred in
the heparin group. CONCLUSIONS: When compared with heparin, minocycline-EDTA had
a better 90-day catheter survival (P = .07) and a decreased rate of catheter
colonization. This pilot study warrants a larger prospective, randomized trial.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
PMID: 16018426 [PubMed - indexed for MEDLINE]
10: Cancer Treat Rev. 2005 May;31(3):186-96. Epub 2005 Jan 26.
Prophylactic antibiotics for preventing early Gram-positive central venous
catheter infections in oncology patients, a Cochrane systematic review.
van de Wetering MD, van Woensel JB, Kremer LC, Caron HN.
7
Paediatric Oncology Department, Emma Children's Hospital/Academic Medical Centre,
F8-245, Meibergdreef 9, 1105 AD Amsterdam, The Netherlands.
[email protected]
OBJECTIVE: Long-term tunnelled central venous catheters (TCVC) are increasingly
used in oncology patients. Infections are a frequent complication of TCVC, mostly
caused by Gram-positive bacteria. The objective of this review is to evaluate the
efficacy of antibiotics in the prevention of early Gram-positive TCVC infections,
in oncology patients. DATA SOURCES: We searched MEDLINE, EMBASE, and the Cochrane
Controlled Trials Register up to July 2003. REVIEW METHODS: We selected
randomised controlled trials (RCT) evaluating prophylactic antibiotics prior to
insertion of the TCVC, and the combination of an antibiotic and heparin to flush
the TCVC, in paediatric and adult oncology patients. The primary outcome was
documented Gram-positive bacteraemia in patients with a TCVC. All trials
identified were assessed and the data extracted independently by two reviewers.
RESULTS: There were nine trials included. Four trials reported on
vancomycin/teicoplanin prior to insertion of the TCVC compared to no antibiotics.
There was no reduction in the number of Gram-positive TCVC infections with an
Odds ratio of 0.42 (95% confidence interval 0.13-1.31). Five trials studied
flushing of the TCVC with a vancomycin/heparin solution compared to heparin
flushing only. This method decreased the number of TCVC infections significantly
with an Odds ratio of 0.43 (95% CI 0.21-0.87). CONCLUSION: Flushing the TCVC with
a vancomycin/heparin solution reduced the incidence of Gram-positive infections.
Publication Types:
Research Support, Non-U.S. Gov't
Review
PMID: 15944048 [PubMed - indexed for MEDLINE]
11: MMWR Morb Mortal Wkly Rep. 2005 Mar 25;54(11):269-72.
Pseudomonas bloodstream infections associated with a heparin/saline
flush--Missouri, New York, Texas, and Michigan, 2004-2005.
Centers for Disease Control and Prevention (CDC).
On January 26, 2005, CDC was notified of four cases of Pseudomonas fluorescens
bloodstream infection among patients at an oncology clinic in Missouri. All
patients had received a heparin/saline flush to prevent clotting of indwelling,
central venous catheters. The flushes were preloaded in syringes by IV Flush and
distributed by Pinnacle Medical Supply (Rowlett, Texas). On January 31, a
nationwide alert against use of all heparin or saline flushes preloaded in
syringes by IV Flush was issued by the Food and Drug Administration; the company
recalled these products. As of February 15, state and local health departments
and CDC had identified a total of 36 Pseudomonas species infections in patients
in four states who were administered the heparin/saline flushes from multiple
lots. This report describes the ongoing investigation and provides
recommendations for investigation and management of potential cases.
PMID: 15788991 [PubMed - indexed for MEDLINE]
8
12: Pediatr Crit Care Med. 2005 Mar;6(2):216-9.
Heparin-induced thrombocytopenia in the pediatric intensive care unit population.
Frost J, Mureebe L, Russo P, Russo J, Tobias JD.
Department of Anesthesiology, University of Missouri, Columbia, USA.
OBJECTIVES: To report the occurrence of heparin-induced thrombocytopenia (HIT),
discuss its pathophysiology, and outline an approach to management in the
pediatric intensive care unit (ICU) patient. DESIGN: Retrospective case reports.
SETTING: Pediatric ICU in a tertiary-care center. Patients and RESULTS: Two
pediatric ICU patients (2 and 6 mos of age) who developed HIT in the pediatric
ICU. One was receiving heparin as a flush solution through a central line and the
other had full heparinization during cardiopulmonary bypass. Both had received
heparin during their neonatal course and developed thrombocytopenia; however, HIT
was not considered as a possible diagnosis. HIT was diagnosed using a
heparin-induced platelet aggregation study. The thrombocytopenia resolved with
the cessation of heparin administration. One of the patients developed a deep
vein thrombosis around a femoral venous catheter. CONCLUSION: Although well
described in the adult literature, there have been a limited number of reports of
HIT in pediatric-aged patients. Given its potential for morbidity, HIT should be
considered in the differential diagnosis of thrombocytopenia in the pediatric ICU
patient.
Publication Types:
Case Reports
PMID: 15730612 [PubMed - indexed for MEDLINE]
13: Blood Purif. 2004;22(5):473-9. Epub 2004 Oct 29.
Natural saline-flush is sufficient to maintain patency of immobilized-urokinase
double-lumen catheter used to provide temporary blood access for hemodialysis.
Kaneko Y, Iwano M, Yoshida H, Kosuge M, Ito S, Narita I, Gejyo F, Suzuki M.
Division of Clinical Nephrology and Rheumatology, Niigata University Graduate
School of Medical and Dental Sciences, Niigata, Japan.
[email protected]
BACKGROUND: Thrombotic occlusion is a frequent complication of central venous
catheters used to provide temporary blood access on hemodialysis therapy.
Heparin-lock is conventionally used to maintain patency of the catheter, but the
necessity of heparin-lock has not been determined yet. METHODS: After the
immobilized-urokinase double-lumen central venous catheter was inserted into 48
Japanese hemodialysis patients, 22 patients randomized to the heparin group
received a 20-ml saline-flush, followed by 2 ml of 1,000 U/ml heparin-lock, and
26 patients randomized to the saline group received only the 20-ml saline-flush
once a day for each lumen. RESULTS: Thrombotic occlusion was observed in only 1
9
out of 22 patients in the heparin group and 1 out of 26 patients in the saline
group. No significant difference of the catheter survival was observed between
the two groups (p = 0.8599). CONCLUSIONS: Natural saline-flush is sufficient for
maintaining the patency of an immobilized-urokinase double-lumen central venous
catheter.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 15523172 [PubMed - indexed for MEDLINE]
14: Pathology. 2004 Apr;36(2):170-3.
Catheter-drawn blood cultures: is withdrawing the heparin lock beneficial?
Everts R, Harding H.
Microbiology Section Medlab Central Palmerston North New Zealand.
[email protected]
AIMS: To assess the potential benefit of withdrawing or flushing away the heparin
lock before collecting blood for culture from a central venous catheter. METHODS:
We compared the contamination rates of 152 pairs of blood samples aspirated from
central venous catheters in afebrile renal dialysis or cancer patients. We also
assessed the antimicrobial effect of 2000 U of heparin in Bactec Plus Aerobic/F
culture bottles inoculated with a volunteer's blood plus one of six common
bloodstream pathogens. RESULTS: There was no significant difference in
contamination rates between first-drawn (26 of 152, 17.1%) and second-drawn (24
of 152, 15.8%) samples. There was no significance difference in yield (58 of 60
[97%] versus 52 of 53 [98%]) or time to flagging positive (16.6 versus 16.7 h)
between the bottles with and without heparin. CONCLUSIONS: Our results do not
support the practice of withdrawing or flushing away the heparin lock before
collecting blood for culture from a central venous catheter.
Publication Types:
Comparative Study
Research Support, Non-U.S. Gov't
PMID: 15203754 [PubMed - indexed for MEDLINE]
15: Oncologist. 2004;9(2):207-16.
Comment in:
Oncologist. 2004;9(5):594-5; author reply 596.
Thrombotic complications of central venous catheters in cancer patients.
Kuter DJ.
10
Hematology/Oncology Unit, Massachusetts General Hospital, Harvard Medical School,
Boston, Massachusetts 02114, USA. [email protected]
Central venous catheters (CVCs), such as the tunneled catheters and the totally
implanted ports, play a major role in general medicine and oncology. Aside from
the complications (pneumothorax, hemorrhage) associated with their initial
insertion, all of these CVCs are associated with the long-term risks of infection
and thrombosis. Despite routine flushing with heparin or saline, 41% of CVCs
result in thrombosis of the blood vessel, and this markedly increases the risk of
infection. Only one-third of these clots are symptomatic. Within days of
insertion, almost all CVCs are coated with a fibrin sheath, and within 30 days,
most CVC-related thrombi arise. Aside from reducing the function of the catheter,
these CVC-related thrombi can cause postphlebitic syndrome in 15%-30% of cases
and pulmonary embolism in 11% (only half of which are symptomatic). Risk factors
for CVC thrombosis include the type of malignancy, type of chemotherapy, type of
CVC, and locations of insertion site and catheter tip, but not inherited
thrombophilic risk factors. Efforts to reduce CVC thrombosis with systemic
prophylactic anticoagulation with low-molecular-weight heparin have failed.
Low-dose warfarin prophylaxis remains controversial; all studies are flawed, with
older studies, but not newer ones, showing benefit. Currently, less than 10% of
patients with CVCs receive any systemic prophylaxis. Although its general use
cannot be recommended, low-dose warfarin may be a low-risk treatment in patients
with good nutrition and adequate hepatic function. Clearly, additional studies
are required to substantiate the prophylactic use of low-dose warfarin. Newer
anticoagulant treatments, such as pentasaccharide and direct thrombin inhibitors,
need to be explored to address this major medical problem.
Publication Types:
Historical Article
Review
PMID: 15047925 [PubMed - indexed for MEDLINE]
16: Support Care Cancer. 2004 Apr;12(4):278-81. Epub 2004 Feb 13.
Retention of lepirudin at the tip of a silicone catheter: a better catheter flush
solution?
Horne MK 3rd, Inkellis E.
Hematology Service, Department of Laboratory Medicine, National Institutes of
Health, Bethesda, MD 20892, USA. [email protected]
Because central venous catheters often become blocked by clot at their tip
despite heparin flushes, a more effective anticoagulant is needed. We hypothesize
that lepirudin, a recently introduced protein anticoagulant, might be more
effective than heparin because of its tendency to adsorb to silicone, a commonly
used catheter material. We preliminarily tested this hypothesis in vitro by
measuring residual lepirudin and heparin activity at the tip of a catheter that
had been submerged in a flowing stream of water for various periods of time. We
11
observed that lepirudin is less readily removed than heparin from the catheter by
fluid washing over it. This "slow-release" property of lepirudin might provide
prolonged protection against clot formation at the catheter tip. A clinical trial
will be necessary, however, to determine whether this property translates into
significant improvement in catheter function.
PMID: 14968353 [PubMed - indexed for MEDLINE]
17: Tumori. 2003 Sep-Oct;89(5):575-6.
Outbreak of infusion-related septicemia by Ralstonia pickettii in the Oncology
Department.
Marroni M, Pasticci MB, Pantosti A, Colozza MA, Stagni G, Tonato M.
Hospital acquired blood stream infection by Ralstonia pickettii in 9 cancer
patients related to the heparin solution contamination used to flush the central
venous catheter.
Publication Types:
Letter
PMID: 14870792 [PubMed - indexed for MEDLINE]
18: J Cancer Res Clin Oncol. 2004 Apr;130(4):235-41. Epub 2004 Feb 4.
Prophylaxis of port system-associated thromboses in advanced oncology patients
using heparin flushing.
Lersch C, Kotowa W, Fung S, Janssen D.
II. Medizinische Klinik der Technischen Universität München, Klinikum Rechts der
Isar, Ismaninger Strasse 22, 81675, Munich, Germany.
[email protected]
PURPOSE: Thromboses occur in connection with the use of venous port systems.
Valid data on the instillation of heparin-based solutions in the lumen of the
port system are lacking. METHODS: One hundred and seventy-three patients with
malignancy from 19 centres who had participated in an observation study of
subcutaneous thromboprophylaxis with dalteparin-Na (Fragmin P/-Forte) were
analysed with a view to flushing the port systems and investigating any related
influence on the occurrence of catheter-associated thromboses. RESULTS: All
catheter-associated thromboses were seen in centres which used either no UFH, or
UFH concentrations of up to 250 IU/ml (8/108; 7.4%). The rate of thrombosis rose
to 10% (6/60) if no high-risk dose of dalteparin was applied subcutaneously. On
the other hand, the rate of catheter-associated thromboses under the high-risk
dose of dalteparin and/or a more highly concentrated instillation fluid, at 0.9%
(1/113), was much lower. One haemorrhage from gastric ulcer occurred under the
highest UFH concentration in the instillation fluid (2,500 IU UFH/ml).
CONCLUSION: The results indicate that a concentration between 500 IU UFH/ml and
1,000 IU UFH/ml in the instillation solution, at the same time as high-risk
12
prophylaxis with subcutaneous dalteparin for prevention of catheter-associated
thromboses, is effective in patients with manifest tumour disease. The
instillation of LMWH-based solutions at a concentration of approx 500 anti-Xa
units/ml should be discussed as a pending issue.
Publication Types:
Multicenter Study
Research Support, Non-U.S. Gov't
PMID: 14760527 [PubMed - indexed for MEDLINE]
19: Nursing. 2003 Jan;33(1):28.
Prevent occlusions with these flushing pointers.
Hadaway LC.
Lynn Hadaway Associates, Inc., Milner, Ga., USA.
PMID: 12575675 [PubMed - indexed for MEDLINE]
20: Cochrane Database Syst Rev. 2002;(4):CD002774.
Update in:
Cochrane Database Syst Rev. 2005;(4):CD002774.
Heparin for prolonging peripheral intravenous catheter use in neonates.
Shah PS, Ng E, Sinha AK.
Department of Newborn and Developmental Paediatrics, Sunnybrook and Women's
College Health Sciences Center, 76 Grenville Street, Toronto, Ontario, Canada,
M5S 1B2. [email protected]
BACKGROUND: Peripheral intravenous (PIV) catheters are widely used in modern
medical practice. However, mechanical or infectious complications often
necessitate their removal and/or replacement. Heparin has been shown to be
effective in prolonging the patency of peripheral arterial catheters and central
venous catheters, but may result in life threatening complications, especially in
preterm neonates. OBJECTIVES: The primary objective was to determine the
effectiveness of heparin versus placebo or no treatment on duration of PIV
catheter patency, defined as number of hours of catheter use. The secondary
objectives were to assess the effects of heparin on catheter blockage, phlebitis
or thrombophlebitis, catheter related sepsis, and complications including
abnormality of coagulation profile, allergic reactions to heparin, heparin
induced thrombocytopenia, intraventricular/intracranial hemorrhage and mortality.
SEARCH STRATEGY: A literature search was performed using the following databases:
MEDLINE (1966-December 2001), EMBASE (1980-December 2001), CINAHL (1982-December
2001), Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001),
and abstracts from the annual meetings of the Society for Pediatric Research,
American Pediatric Society and Pediatric Academic Societies published in
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Pediatric Research (1991-2001). No language restrictions were applied. SELECTION
CRITERIA: Randomized or quasi-randomized trials of heparin administered as flush
or infusion versus placebo or no treatment were included. Studies which included
a neonatal population and reported on at least one of the outcomes were included.
DATA COLLECTION AND ANALYSIS: The methodological quality of the studies was
assessed using criteria for blinding of randomization, blinding of intervention,
completeness of follow-up and blinding of outcome assessment. Data on relevant
outcomes were extracted and the effect size was estimated by calculating WMD
(weighted mean difference, 95%CI), RR (relative risk, 95% CI) and RD (risk
difference, 95% CI). MAIN RESULTS: Eight eligible studies were identified.
Heparin was administered either as a flush solution or as an additive to the
total parenteral nutrition solution. Five studies reported data on the duration
of use of the first catheter. Two of these studies found no statistically
significant effect of heparin; two studies showed a statistically significant
increase and one study showed a statistically significant decrease in the
duration of PIV catheter use in the heparin group. The results were not combined
for meta-analysis due to significant heterogeneity of the treatment effect
(p<0.01). In addition, there were marked differences between the studies in terms
of the methodological quality, the dose, the timing, the route of administration
of heparin and the outcomes reported. From a limited number of studies, there
were no significant differences between the heparin and the placebo/no treatment
groups in the risks of infiltration, phlebitis and intracranial hemorrhage.
REVIEWER'S CONCLUSIONS: Implications for practice: The effect of heparin on the
duration of peripheral intravenous catheter use varied across the studies.
Because of clinical heterogeneity and heterogeneity in treatment effect,
recommendations for heparin use in neonates with PIV catheters cannot be made.
Implications for research: There are insufficient data concerning the effect of
heparin for prolonging PIV catheter use in neonates. Further research on the
effectiveness, the optimal dose, and the safety of heparin is required.
Publication Types:
Review
PMID: 12519576 [PubMed - indexed for MEDLINE]
21: J Pediatr Hematol Oncol. 2002 Dec;24(9):710-3.
A prospective double-blind randomized trial of urokinase flushes to prevent
bacteremia resulting from luminal colonization of subcutaneous central venous
catheters.
Aquino VM, Sandler ES, Mustafa MM, Steele JW, Buchanan GR.
Department of Pediatrics, University of Texas Southwestern Medical Center at
Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
[email protected]
PURPOSE: This study was undertaken to determine if central venous catheter
(CVC)-related infection in children with cancer could be prevented by monthly
flushing of the catheter with urokinase. PATIENTS AND METHODS: Between August
1994 and July 1998, 103 patients with cancer were randomized at the time of
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subcutaneous CVC placement to receive monthly flushing of their catheters with
either 5000 IU of urokinase-heparin or heparin alone. Patients subsequently had
blood cultures taken from their CVCs during an episode of fever. RESULTS:
Seventy-four of the 103 patients (72%) enrolled in the study received at least 6
catheter flushes: 40 with urokinase-heparin and 34 with heparin. The median
number of flushes was 9.5 in the urokinase-heparin group and 10.2 in the
heparin-only group (P = 0.62). There were 5 positive blood cultures in the
urokinase-heparin group and seven in patients receiving heparin alone (P = 0.27).
Staphylococcus epidermidis was isolated from the blood of 3 patients receiving
urokinase-heparin and 6 in those receiving heparin alone (P = 0.17). CONCLUSION:
Prophylactic monthly catheter flushes with 5000 IU urokinase did not
significantly decrease the number of documented bacteremic events in children
with cancer who have CVCs.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
PMID: 12468909 [PubMed - indexed for MEDLINE]
22: Arch Intern Med. 2002 Apr 22;162(8):871-8.
Comment in:
Arch Intern Med. 2002 Oct 28;162(19):2253-4.
Intravascular catheter-related infections: new horizons and recent advances.
Raad II, Hanna HA.
Department of Infectious Diseases, Infection Control, and Employee Health, The
University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX
77030, USA. [email protected]
BACKGROUND: Central venous catheters have become essential devices for the
management of critically and chronically ill patients; however, their use is
often complicated by catheter-related bloodstream infections (CRBSIs), many of
which could be prevented. METHODS: This report is based on a literature review of
more than 100 published articles in intravascular catheter-related infections.
This review focuses on the most recent advances in the methods of diagnosis of
CRBSI as they relate to its pathogenesis and on novel preventive techniques and
approaches to management. RESULTS: Catheter-related bloodstream infections may be
diagnosed by different methods, including simultaneous quantitative blood
cultures, with the central blood culture yielding at least 5-fold colony-forming
units greater than the peripheral blood culture, and simultaneous blood cultures,
whereby the catheter-drawn blood culture becomes positive at least 2 hours before
the peripheral blood culture. Novel preventive techniques include the use of
ionic silver, an anticoagulant/antimicrobial flush solution, a new aseptic hub,
and antimicrobial impregnation of catheters and dressings. Management of CRBSIs
should be based on whether the infection is complicated or uncomplicated.
CONCLUSIONS: Novel technologies that have been proved to aid in the diagnosis and
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prevention of CRBSIs should be considered in clinical practice. The management
approach should be based on the type of microorganism causing the infection and
on whether the infection is complicated or uncomplicated.
Publication Types:
Review
PMID: 11966337 [PubMed - indexed for MEDLINE]
23: J Clin Oncol. 2000 Mar;18(6):1269-78.
Prevention of central venous catheter-related infections and thrombotic events in
immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush
solution: A randomized, multicenter, double-blind trial.
Henrickson KJ, Axtell RA, Hoover SM, Kuhn SM, Pritchett J, Kehl SC, Klein JP.
Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of
Wisconsin, Milwaukee, WI 53226, USA. [email protected]
PURPOSE: To determine whether an antibiotic flush solution containing vancomycin,
heparin, and ciprofloxacin (VHC) can prevent the majority of line infections.
PATIENTS AND METHODS: A prospective double-blind study was performed comparing
VHC to vancomycin and heparin (VH) to heparin alone in 126 pediatric oncology
patients. RESULTS: The 153 assessable lines resulted in 36,944 line days studied.
There were 58 blood stream infections (43 gram-positive, 14 gram-negative, and
one fungal). Forty were defined as line infections (31 heparin, three VH, six
VHC). The time to develop a line infection was significantly increased using
either antibiotic flush (VH, P =.011; VHC, P =.036). The rate of total line
infections (VH, P =.004; VHC, P =.005), gram-positive line infections (VH, P =.
028; VHC, P =.022), and gram-negative line infections (VH, P =.006; VHC, P =.003)
was significantly reduced by either VH or VHC. Sixty-two (41%) of the lines
developed 119 occlusion episodes (heparin, 3.99 per 1,000 line days; VHC, 1.75
per 1,000 line days; P =.0005). Neither antibiotic could be detected after
flushing, and no adverse events were detected, including increased incidence of
vancomycin-resistant Enterococcus colonization or disease. CONCLUSION: The use of
either VH or VHC flush solution significantly decreased the complications
associated with the use of tunneled central venous lines in immunocompromised
children and would save significant health care resources.
Publication Types:
Clinical Trial
Comparative Study
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 10715297 [PubMed - indexed for MEDLINE]
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