Gregory J. Schears

Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters

PURPOSE This study was conducted to evaluate the performance of a sutureless adhesive-backed device, StatLock, for securement of peripherally inserted central venous catheters (PICCs). Earlier studies have demonstrated that StatLock significantly reduces catheter-related complications when compared to tape. The purpose of this study was to determine whether a sutureless securement device offers an advantage over suture in preventing catheter-related complications. MATERIALS AND METHODS 170 patients requiring PICCs, which were randomized to suture (n = 85) or StatLock (n = 85) securement were prospectively studied. Patients were followed throughout their entire catheter course, and PICC-related complications including dislodgment, infection, occlusion, leakage, and central venous thrombosis were documented. Catheter outcome data were compared to determine if statistically significant differences existed between the suture and StatLock groups. RESULTS The groups had equivalent demographic characteristics and catheter indications. Average securement time with StatLock was significantly shorter (4.7 minutes vs 2.7 minutes;P <.001). Although StatLock was associated with fewer total complications (42 vs 61), this difference did not achieve significance. However, there were significantly fewer PICC-related bloodstream infections in the StatLock group (2 vs 10; P =.032). One securement-related needle-stick injury was documented during suturing of a PICC. CONCLUSION The sutureless anchor pad was beneficial for both patients and health care providers. Further investigation to determine how StatLock helps reduce catheter-related blood stream infections is necessary.

Neurological Injury in Adults Treated With Extracorporeal Membrane Oxygenation

BACKGROUND Extracorporeal membrane oxygenation (ECMO) may be urgently used as a last resort form of life support when all other treatment options for potentially reversible cardiopulmonary injury have failed. OBJECTIVE To examine the range and frequency of neurological injury in ECMO-treated adults. DESIGN Retrospective clinicopathological cohort study. SETTING Mayo Clinic, Rochester, Minnesota. PATIENTS A prospectively collected registry of all patients 15 years or older treated with ECMO for 12 or more hours from January 2002 to April 2010. INTERVENTION Patients were analyzed for potential risk factors for neurological events and death using logistic regression and Cox proportional hazards models. MAIN OUTCOME MEASURES Neurological diagnosis and/or death. RESULTS A total of 87 adults were treated (35 female [40%]; median age, 54 years [interquartile range, 31]; mean duration of ECMO, 91 hours [interquartile range, 100]; overall survival >7 days after ECMO, 52%). Neurological events occurred in 42 patients who received ECMO (50%; 95% confidence interval [CI], 39%-61%). Diagnoses included subarachnoid hemorrhage, ischemic watershed infarctions, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. Death in patients who received ECMO who did not require antecedent cardiopulmonary resuscitation was associated with increased age (odds ratio, 1.24 per decade; 95% CI, 1.03-1.50; P = .02) and lower minimum arterial oxygen pressure (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .03). Although stroke was rarely diagnosed clinically, 9 of 10 brains studied at autopsy demonstrated hypoxic-ischemic and hemorrhagic lesions of vascular origin. CONCLUSION Severe neurological sequelae occur frequently in adult ECMO-treated patients with otherwise reversible cardiopulmonary injury (conservative estimate, 50%) and include a range of potentially fatal neurological diagnoses that may be due to the precipitating event and/or ECMO treatment.

Cecal ligation and double puncture impairs heat shock protein 70 (HSP-70) expression in the lungs of rats.

Induction of the heat shock response may improve outcome from pathophysiological disturbances. This improvement is associated with and believed to result from expression of heat shock protein (HSP)-70. Therefore, we examined the temporal expression of HSP-70 in an animal model of acute respiratory distress syndrome (ARDS) secondary to fecal peritonitis. Specifically, we hypothesize that sepsis in rats impairs pulmonary HSP-70 expression. ARDS was induced in adolescent rats via cecal ligation and double puncture (2CLP). Sham-operated animals served as controls. Lung tissue was collected 0, 3, 6, 16, 24, and 48 h after 2CLP and sham operation. Northern blot hybridization analysis was performed to detect steady-state HSP-70 messenger ribonucleic (mRNA) levels. HSP-70 protein levels were determined via immunoblotting and immunohistochemistry. Mortality after 2CLP was 50% at 24 h and 75% at 48 h. Northern blot hybridization analysis revealed no significant change in steady-state HSP-70 mRNA levels in lung at any time after 2CLP. HSP-70 steady-state mRNA levels increased after sham operation and was higher than values in 2CLP at 6, 16, and 24 h. HSP-70 protein levels did not change over time in either group. Thus, the expression of HSP-70 does not change after 2CLP. Although lack of an increase in protein levels may be adaptive after sham operation, it is not appropriate after 2CLP. Therefore, failed HSP-70 expression represents a form of pulmonary epithelial dysfunction that may contribute to lung injury in sepsis.

Airway pressure release ventilation in pediatrics

Objectives The purpose of this study was to determine the effectiveness of airway pressure release ventilation in children. Design Prospective, randomized, crossover clinical trial. Setting This study was conducted in our 33-bed pediatric intensive care unit at The Children’s Hospital of Philadelphia. Patients Patients requiring mechanical ventilatory support and weighing >8 kg were considered for enrollment. Patients were excluded if they required mechanical ventilatory support for >7 days or required >.50 Fio2 for >7 days before enrollment. Patients with documented obstructive airway disease and congenital or acquired heart disease were excluded as well. Interventions Each patient received both volume-controlled synchronized intermittent mechanical ventilation (SIMV) and airway pressure release ventilation (APRV) via the Drager Evita ventilator (Drager, Lubeck, Germany). Measurements were obtained after the patient was stabilized on each ventilation mode. Stabilization was defined as oxygenation, ventilation, hemodynamic variables, and patient comfort within the acceptable range for each patient as determined by the bedside physician. After measurements were obtained on the initial mode of ventilation, the subjects crossed over to the alternative study mode. Stabilization was again achieved, and measurements were repeated. After completion of the second study measurements, patients were placed on the ventilation modality preferred by the bedside clinician and were followed through weaning and extubation. Measurements Vital signs, airway pressures, minute ventilation, Spo2, and ETCO2 were recorded at enrollment and at each study condition. Main Results APRV provided similar ventilation, oxygenation, mean airway pressure, hemodynamics, and patient comfort as SIMV. Inspiratory airway pressures were lower with APRV when compared with SIMV. Conclusions Using APRV in children with mild to moderate lung disease resulted in comparable levels of ventilation and oxygenation at significantly lower inspiratory peak and plateau pressures. Based on these findings, we plan to evaluate APRV in children with significant lung disease.

ECMO Cannulation Controversies and Complications

Advances in extracorporeal life support have expanded indications for use extending beyond patients undergoing cardiac surgery. The approach to cannulation in patients requiring extracorporeal membrane oxygenation should be individualized and based on the specific clinical scenario in which the need arises. Adherence to proper techniques of vessel visualization, exposure, and cannulation along with accurate placement of cannulae will optimize flows and minimize complications in this setting. Patients in need of mechanical circulatory support require input from a multidisciplinary team approach with systematic clinical evaluation to optimize outcome. If hemodynamics do not initially permit the successful separation from mechanical support, then a systematic search for potentially reversible patient and/ or pump related factors should be undertaken. The success of this therapy is predicated on patient selection, a multidisciplinary team approach in the intensive care unit, adherence to precise technical principles, and repeated patient evaluation.

Use of Helium–Oxygen Mixtures to Relieve Upper Airway Obstruction in a Pediatric Population†

Objectives Helium as a component of inspired gas decreases turbulent flow and airway resistance. Helium–oxygen mixtures have been used since the 1930s in the management of patients with upper airway obstruction. The objective of this study was to evaluate the efficacy of helium–oxygen mixtures in relieving upper airway obstruction in a pediatric population.

Peripheral Difficult Venous Access in Children

Early identification of DVA is the first step in optimizing patient care. The consensus panel described DVA as a clinical condition in which multiple attempts and/or special interventions are anticipated or required to achieve and maintain peripheral venous access. Special interventions are defined as the use of any technique or hospital resource with the potential to improve peripheral IV insertion success rates. These include traditional methods of enhancing the visibility and palpability of peripheral veins (eg, warming the catheter site to induce vasodilation); advanced visualization technologies such as ultrasound, transillumination, and nearinfrared lighting; and enlisting designated IV specialists and/or hospital staff with extensive experience in starting pediatric IVs. Some children may need more invasive interventions such as intraosseous (IO) infusion, a peripherally inserted central catheter, or a central venous catheter (CVC) to achieve parenteral access. There is a dearth of clinical evidence on the incidence of DVA in pediatric patients. Studies of IV insertion success rates indicate that 5% to 33% of children require more than 2 needle sticks to achieve IV access. Even when interventions such as transillumination and ultrasound are used, up to 15% of children still require more than 2 attempts to establish venous access. A recent prospective analysis of 593 insertion attempts in centers with pediatric hospitalist services showed that successful placement Establishing peripheral intravenous (IV) access in pediatric patients can be challenging. Clinical studies show that only 53% to 76% of children are successfully cannulated on the first attempt. Multiple failed attempts are painful and upsetting for the child and distressing for family members and caregivers, yet there are no guidelines or consensus statements on the recognition and management of this problem. In January 2008, a panel of physicians and nurses specializing in emergency medicine, anesthesia, critical care, and hospital medicine convened to discuss peripheral difficult venous access (DVA) in children. Daniel Rauch, MD, FAAP, and Laura L. Kuensting, MSN(R), RN, CPNP, cochaired the roundtable discussion, which was made possible by a grant from Baxter Healthcare, Inc. The main objectives of the meeting were to estimate the frequency of DVA in pediatric patients; describe its clinical and emotional impact on the patient, the patient’s family, and clinicians; develop terminology that accurately describes the condition; review the factors that help identify children with DVA; and

Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.

BACKGROUND Although an arteriovenous fistula (AVF) is the hemodialysis access of choice, its prevalence continues to be lower than recommended in the United States. We assessed the association between past peripherally inserted central catheters (PICCs) and lack of functioning AVFs. STUDY DESIGN Case-control study. PARTICIPANTS & SETTING Prevalent hemodialysis population in 7 Mayo Clinic outpatient hemodialysis units. Cases were without functioning AVFs and controls were with functioning AVFs on January 31, 2011. PREDICTORS History of PICCs. OUTCOMES Lack of functioning AVFs. RESULTS On January 31, 2011, a total of 425 patients were receiving maintenance hemodialysis, of whom 282 were included in this study. Of these, 120 (42.5%; cases) were dialyzing through a tunneled dialysis catheter or synthetic arteriovenous graft and 162 (57.5%; controls) had a functioning AVF. PICC use was evaluated in both groups and identified in 30% of hemodialysis patients, with 54% of these placed after dialysis therapy initiation. Cases were more likely to be women (52.5% vs 33.3% in the control group; P = 0.001), with smaller mean vein (4.9 vs 5.8 mm; P < 0.001) and artery diameters (4.6 vs 4.9 mm; P = 0.01) than controls. A PICC was identified in 53 (44.2%) cases, but only 32 (19.7%) controls (P < 0.001). We found a strong and independent association between PICC use and lack of a functioning AVF (OR, 3.2; 95% CI, 1.9-5.5; P < 0.001). This association persisted after adjustment for confounders, including upper-extremity vein and artery diameters, sex, and history of central venous catheter (OR, 2.8; 95% CI, 1.5-5.5; P = 0.002). LIMITATIONS Retrospective study, participants mostly white. CONCLUSION PICCs are commonly placed in patients with end-stage renal disease and are a strong independent risk factor for lack of functioning AVFs.

Aspiration in pediatric anesthesia: Is there a higher incidence compared with adults?

Purpose of review Recent data in both adults and children have suggested that the incidence and severity of the pulmonary aspiration of gastric contents has declined. Previous studies have indicated that aspiration is more common in children than in adults. This review will examine the available data to compare the incidence and severity of aspiration in adults and children. Recent findings There are several studies, some of which have been published recently, that have provided an epidemiologic perspective on the problem of aspiration. Summary Based on the available data, aspiration appears to be slightly more common in children than in adults. The difference, however, is less than that previously reported. Morbidity associated with aspiration is rare in all age groups. This is especially true for children.

Ultrasound for vascular access in pediatric patients.

In pediatric patients vascular access is often more difficult than in adults because of the smaller size of the vessels and the inability of the patient to cooperate without deep sedation or general anesthesia. Therefore Ultrasound has already become an invaluable tool for vascular access, but the full potential of ultrasound has yet to be fully realized. Improvements in image quality and a better understanding of optimal insertion techniques continue to help clinicians safely and efficiently place catheters with fewer complications.