No abstract

Central venous catheters (CVCs) are traditionally used for central venous access in the intensive care unit setting. Use of peripherally inserted central catheters (PICCs) now often extends into the intensive care unit. The goal of this review is to compare the use and safety of PICCs vs CVCs in burn patients. This institutional review board-approved cohort review included all burn patients at a single center who received one or more PICCs during a 2-year period. Primary outcome was number of days each line remained in place. Secondary outcomes were catheter-related bloodstream infection (CR-BSI) and thrombotic and technical complications. Thirty-one burn patients had 37 PICCs during the study period. Patients and controls were comparable in terms of age, TBSA burn injury, and ventilator days. The median length of time that each PICC remained in was 8.8 vs 9.3 days for CVCs (P = .77). The CR-BSI rate for PICCs was 0 per 1000 line days, whereas for CVCs, it was 6.6 per 1000 line days (P = .13). No thrombotic complications were attributed to CVCs; one PICC-associated right upper extremity deep vein thrombosis was identified (2.8% rate). No technical complications were identified in either group. The longevity and complications of PICCs in burn patients differs little from CVCs. CVCs may have a higher rate of CR-BSI in burn patients than PICCs. Although PICCs are not adequate for the fluid volumes typically required during burn shock resuscitation, they can provide a safe and effective alternative for central access in the ongoing care of the burn patient.

Frequent occurrence of low antifactor Xa levels observed in this study demonstrated the inadequacy of standard dosing of enoxaparin for VTE prophylaxis in many patients with acute burns. Enoxaparin dose adjustment was associated with a low incidence of VTE events and no bleeding complications.

Altered pharmacokinetics in critically ill patients have been shown to result in inadequate enoxaparin dosing for venous thromboembolism (VTE) prophylaxis. In the burn unit, routine monitoring of antifactor Xa levels was implemented to ensure adequate VTE prophylaxis. The purpose of this study was to examine the appropriateness of enoxaparin dosing for VTE prophylaxis in this specialized patient population. The authors reviewed patients with acute burn injury from June 1, 2009, to October 20, 2009, who had enoxaparin therapy monitored with antifactor Xa levels. Data collection occurred prospectively. Thirty-eight patients received enoxaparin subcutaneously for prophylaxis of VTE and had antifactor Xa levels measured. Thirty (79%) patients had initial antifactor Xa levels less than 0.2 U/ml. Enoxaparin dosages were subsequently increased as needed to achieve antifactor Xa levels of 0.2 to 0.4 U/ml. Eight of 38 patients never achieved goal antifactor Xa level before enoxaparin was discontinued. The median final dose required to achieve an antifactor Xa level within therapeutic range was 50 mg every 12 hours (range 30-70 mg). In linear regression, final enoxaparin dose correlated with TBSA. Two patients had clinically significant thromboembolic events. There were no documented episodes of significant hemorrhage, thrombocytopenia, or heparin-associated allergy. The low antifactor Xa levels observed in this study demonstrate that standard dosing of enoxaparin for VTE prophylaxis is inadequate for patients with acute burns. In these patients, both a higher initial enoxaparin dose and routine monitoring of antifactor Xa levels are recommended.