Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children.

Objective To describe the observed behavior of professionals in two neonatal and pediatric intensive care units regarding the use of central venous catheter insertion bundle, and the clinical and birth profile of neonates and children who received the devices. Method A quantitative descriptive exploratory study was conducted in two intensive care units of a public hospital in Belo Horizonte with neonates and children, between February and September 2016. Results The sample consisted of 59 observed implants of central venous catheter. Most patients were male preterm infants, of cesarean delivery and proper weight according to the gestational age. Among all procedures observed, only three followed all recommendations for the central venous catheter insertion bundle. Incorrect techniques were observed while performing surgical antisepsis and inadequate use of chlorhexidine, an antiseptic. Conclusion The findings highlight the importance of more investment in continuous training of the team on the prevention of bloodstream infection caused by central venous catheter to reduce the number of adverse events related to intravenous therapy.

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Adherence to central venous catheter insertion bundle in neonatal and pediatric units.

RESUMO Objetivo: Descrever o comportamento observado dos profissionais da Unidade de Terapia Intensiva Neonatal e Pediatrica segundo os itens do bundle de insercao de cateter venoso central, bem como o perfil clinico e de nascimento de neonatos e criancas que receberam os dispositivos. Metodo: Estudo descritivo-exploratorio, de abordagem quantitativa, realizado em duas Unidades de Terapia Intensiva de um hospital publico de Belo Horizonte com neonatos e criancas, entre fevereiro e setembro de 2016. Resultados: A amostra foi constituida por 59 oportunidades de observacao de implantes de cateter venoso central. A maior parte dos pacientes era do sexo masculino, com nascimento prematuro, de parto cesareo e com peso adequado para a idade gestacional. Entre todos os procedimentos observados, em apenas tres nao houve ruptura de nenhuma recomendacao do bundle de insercao de cateter venoso central. Destacaramse as tecnicas incorretas na realizacao da antissepsia cirurgica e o uso inadequado do antisseptico clorexidina. Conclusao: Os achados reforcam a importância de maior investimento na educacao permanente da equipe referente as acoes de prevencao de infeccao da corrente sanguinea relacionada a cateter venoso central, a fim de reduzir a ocorrencia de eventos adversos relacionados a terapia intravenosa.

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Adesão ao bundle de inserção de cateter venoso central em unidades neonatais e pediátricas

Background Commonly used ultrasound-guided internal jugular vein (IJV) cannulation techniques, short axis out of plane and long axis in-plane, have significantly reduced complications but failed to eliminate them because of technical difficulties. Objective This article describes a new anteroposterior short axis in-plane technique that combines advantage of in-plane technique to track the needle tip and short axis view of visualizing nearby anatomical structures by placing the probe on the side of the neck, oriented anteroposteriorly, perpendicular to the long axis of neck. This view visualizes IJV and its relationship to the carotid artery in short axis. The puncture needle is passed in-plane anteroposteriorly from the anterior aspect of the neck. Visualizing the needle, carotid artery, and IJV in single frame minimizes complications. Methods A prospective evaluative clinical trial was conducted in patients who require IJV cannulation for various reasons by performers experienced in ultrasound-guided IJV cannulations. The efficacy of the technique is indicated by 3 primary outcome measures: access time, number of attempts and success rate, and safety by secondary outcome measure, which is the incidence of mechanical complications. Results Seventy-five patients were enrolled. The average number of attempts was 1.17 (standard deviation 0.44), the access time was 27.12 s (standard deviation 21.47), and the success rate was 100%. This technique had 12% incidence of posterior venous wall punctures and 2.66% misplacements and no other complications. Conclusion Anteroposterior short axis in-plane technique is relatively novel and could be alternatively used safely and effectively in place of existing techniques for IJV cannulation.

An Alternate In-Plane Technique of Ultrasound-Guided Internal Jugular Vein Cannulation.

Structure elucidation of new acylated anthocyanins is a challenging task because of molecule complexity, sensitivity to light, atmospheric oxygen, pH, and temperature. The type, number, and position of the acyl moieties should be carefully assessed. New anthocyanins acylated with cinnamic acid derivatives attached to the disaccharide sophorose have been recently isolated, purified, and completely identified in our research group. Structure determination was performed by chemical methods, and spectroscopic techniques, including 1 H and 13 C NMR, 2D NMR, and MS. Connection relationships between an aglycone moiety, three sugars, and one and two acyl groups, respectively, for each compound were also confirmed by HMBC and NOESY measurements. Therefore, six structures of cyanidin sophorosides acylated with caffeoyl and p -coumaroyl residues, isolated from Ipomoea cairica (family: Convolvulaceae), were fully elucidated. These acylated anthocyanins showed antioxidant activity and antimutagenicity. Quantitative structure–activity relationship studies of flavonoids and biflavonoids as enzyme inhibitors are discussed, e.g., inhibiting influenza H1N1 virus neuraminidase, and as inhibitors of P-glycoprotein in multidrug resistance.

Natural Acylated Anthocyanins and Other Related Flavonoids: Structure Elucidation of Ipomoea cairica Compounds and QSAR Studies Including Multidrug Resistance

227 IntRoductIon Central venous catheters (CVCs) are commonly utilized to gain vascular access for varied clinical indications. These include administering drugs, renal replacement therapy, total parenteral nutrition, poor peripheral venous access, cardiac catheterization, and transvenous cardiac pacing.[1] Central venous access involves a large bore catheter inserted in internal jugular, subclavian or femoral vein in the neck, and upper chest or groin (femoral) area.[1] The preferred vein for CVCs is the right internal jugular vein (IJV) for its straight course to the right heart and the lowest risk of the venous stenosis and thrombosis.[2‐4] Successful catheter placement requires not only technical expertise but also awareness of the potential complications.[5] Malposition of the catheter is a relatively common complication (5.01%), which results in the malfunction of catheters.[6,7] Misplacement of the superior vena cava (SVC) can lead to the perforation of the cava or the right atrium, which are associated with serious sequelae.[4,5] Multiple literatures are in the form of isolated case reports or small series, which are cumbersome or time‐consuming to access and do not provide pragmatic guidance or solutions to the problem. This article outlines the normal and abnormal anatomy of the central veins in relation to CVCs, mainly for the IJV, similar advantages applying at all sites. In addition, it presents illustrated cases of the malposition and discusses practical management issues, avoiding the misplacement and following complications.

Malposition of Central Venous Catheter: Presentation and Management.

The number of patients requiring chronic hemodialysis via a tunneled cuffed catheter is increasing. The right internal jugular vein (IJV) is generally the preferred site of percutaneous insertion. In certain situations, for example, in patients with a history of multiple access failures, catheterization of the left IJV is an important option. In this report, we present two rare cases of catheter malposition after left IJV catheterization; catheter adjustments, with the help of chest radiographs, resulted in a positive outcome in both cases. These cases exemplify the difficulties associated with left IJV catheterization, of which there are few reports in the published literature.

Lin Wang

Papers

Malposition of Central Venous Catheter: Presentation and Management.

Rare malposition following left jugular vein catheterization: Case reports and a literature review.