Reducing Central Venous Catheter Use through Adoption of Guidelines for Peripheral Catheter–based Vasopressor Delivery

Gandotra, Sakshi; Wunsch, Hannah; Bosch, Nicholas A; Walkey, Allan J.; Teja, Bijan

doi:10.1513/annalsats.202212-1060rl

Cited by 5 publications

(3 citation statements)

References 10 publications

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“…A composite outcome was then developed, including 4 serious complications often considered in clinical decision-making regarding whether to place a CVC: arterial cannulation, pneumothorax, CLABSI, and DVT. Although CVCs are often placed for more than 3 days, we chose a 3-day period to estimate the probability of the composite outcome based on published vasopressor dose trajectories to remain conservative in our estimate.…”

Section: Methodsmentioning

confidence: 99%

“…tion, pneumothorax, CLABSI, and DVT. Although CVCs are often placed for more than 3 days, we chose a 3-day period to estimate the probability of the composite outcome based on published vasopressor dose trajectories 13 to remain conservative in our estimate.…”

Section: Key Pointsmentioning

confidence: 99%

“…These findings have important implications for informed consent and clinical practice because they highlight the need for widespread use of up-to-date insertion protocols and for clinicians to carefully consider risks and benefits of CVC use, particularly for delivery of medications traditionally thought to require CVC that may be safely administered peripherally with appropriate protocols for a short period of time. 4,5 Studies examining vasopressor dose trajectories and implementation of peripheral vasopressor delivery protocols have shown that approximately 50% of patients requiring vasopressors can avoid need for CVC, 13,25,26 with extravasation of peripheral vasopressors being uncommon, and tissue injury being very rare with monitored peripheral administration. 4,[26][27][28][29] A recent international survey of ICUs in the US, Australia, the UK, Canada, and Saudi Arabia found that norepinephrine was delivered peripherally in 113 of 132 centers (86%), reducing need for CVCs.…”

Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

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Complication Rates of Central Venous Catheters

Teja,

Bosch,

Diep

et al. 2024

JAMA Intern Med

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ImportanceCentral venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions.ObjectiveTo summarize current rates of CVC-associated complications.Data SourcesMEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023.Study SelectionThis study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded.Data Extraction and SynthesisTwo reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated.Main Outcomes and MeasuresTen prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed.ResultsOf 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters).Conclusions and RelevanceApproximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.

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Section: Methodsmentioning

confidence: 99%

Section: Key Pointsmentioning

confidence: 99%

Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

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Complication Rates of Central Venous Catheters

Teja,

Bosch,

Diep

et al. 2024

JAMA Intern Med

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A Case for the Evidence-Based Use of Peripheral Vasopressors

Munroe

2024

CHEST

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Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections

Spiegel,

Goodwin

2024

J. Clin. Trans. Sci.

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Background: Central venous lines (CVLs) are frequently utilized in critically ill patients and confer a risk of central line-associated bloodstream infections (CLABSIs). CLABSIs are associated with increased mortality, extended hospitalization, and increased costs. Unnecessary CVL utilization contributes to CLABSIs. This initiative sought to implement a clinical decision support system (CDSS) within an electronic health record (EHR) to quantify the prevalence of potentially unnecessary CVLs and improve their timely removal in six adult intensive care units (ICUs). Methods: Intervention components included: (1) evaluating existing CDSS’ effectiveness, (2) clinician education, (3) developing/implementing an EHR-based CDSS to identify potentially unnecessary CVLs, (4) audit/feedback, and (5) reviewing EHR/institutional data to compare rates of removal of potentially unnecessary CVLs, device utilization, and CLABSIs pre- and postimplementation. Data was evaluated with statistical process control charts, chi-square analyses, and incidence rate ratios. Results: Preimplementation, 25.2% of CVLs were potentially removable, and the mean weekly proportion of these CVLs that were removed within 24 hours was 20.0%. Postimplementation, a greater proportion of potentially unnecessary CVLs were removed (29%, p < 0.0001), CVL utilization decreased, and days between CLABSIs increased. The intervention was most effective in ICUs staffed by pulmonary/critical care physicians, who received monthly audit/feedback, where timely CVL removal increased from a mean of 18.0% to 30.5% (p < 0.0001) and days between CLABSIs increased from 17.3 to 25.7. Conclusions: A significant proportion of active CVLs were potentially unnecessary. CDSS implementation, in conjunction with audit and feedback, correlated with a sustained increase in timely CVL removal and an increase in days between CLABSIs.

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Reducing Central Venous Catheter Use through Adoption of Guidelines for Peripheral Catheter–based Vasopressor Delivery

Cited by 5 publications

References 10 publications

Complication Rates of Central Venous Catheters

Complication Rates of Central Venous Catheters

A Case for the Evidence-Based Use of Peripheral Vasopressors

Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections

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