The ABBA project (Assess Better Before Access): A retrospective cohort study of neonatal intravascular device outcomes

Abstract

BackgroundVenous access devices (VADs) play a vital role within the neonatal intensive care unit. However, there are significant risks associated with the use of VADs, with complications such as infection, thrombosis, device occlusion, and infiltration/extravasation frequently contributing to device-related failures and increasing the risk of significant patient harm or injury. This study aimed to explore the relationships between risk factors and different venous access device complications in the neonatal setting, and then use that evidence to develop an algorithm based on observational data.MethodsThis is a retrospective, single-center cohort study that was conducted in a large 112-bed neonatal intensive care unit in Qatar. We examined venous access device data from January 2016 to December 2018 for all term and preterm neonates. Descriptive statistics were used to summarize the outcomes, which included a mean and its standard deviation or median and an interquartile range for continuous variables regarding normal distribution, and absolute numbers with percentages for discrete variables.ResultsThe authors recorded a total of 23,858 VADs inserted during the study period. Of these, 21,313 (89%) were peripheral intravenous catheters, 689 (3%) were extended dwell-peripheral intravenous catheters, 1,335 (6%) were epicutaneo-caval catheters, and 521 (2%) were umbilical venous catheters. In total, 51,179 catheter days were registered, with 2.17 catheter days reported per patient. Peripheral device dwell times were significantly shorter when compared with central venous catheter devices (P < 0.001), with mean dwell times of 22 days ± 23 h and 236 days ± 183 h, respectively. After insertion, a complication occurred in 11,177 (51%) of peripheral VADs and 221 (12%) of central VADs. The type of device inserted [P < 0.001, hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.50–0.54], reason/indication for intravenous therapy (P < 0.001, HR = 0.85, 95% CI: 0.82–0.87), and the side of insertion of the device (P < 0.001, HR = 1.25, 95% CI: 1.24–1.27) had a significant relationship with outcomes.ConclusionsFour subgroups of VADs were identified (peripheral intravenous catheters, extended dwell-peripheral intravenous devices, epicutaneo-caval catheters, and umbilical venous catheters) with outcome-related differences. Central venous access devices (epicutaneo-caval catheters and umbilical venous catheters) had lower complications compared with peripheral VADs. Proper venous access device selection, early insertion, and early removal approaches remain crucial to preventing venous access device complications. Peripheral intravenous devices should be used carefully and closely watched for early detection of complications.

Comparing conventional and modified Seldinger techniques using a micro-insertion kit for PICC placement in neonates: a retrospective cohort study

“…The patient characteristics were mainly related to weight [≤1,500 g, as per local protocols ( 15 , 20 , 22 )] and difficult intravenous access. The fluid characteristics of the parental nutrition or related medication included a pH of <5 or >9 and an osmolarity of >600 mOsm/L as per local protocols ( 16 , 21 , 23 ). The analysis of the choice of the “vein inserted” data indicated a difference between the conventional and micro-MST study groups in terms of the selected puncture site/inserted vein ( p = 0.011).…”

“… a CLABSI is defined as a laboratory-confirmed bloodstream infection not associated with any other infection site and developing within 48 h of the central line insertion ( 21 ). b CLABSI incidence rate per 1,000 catheter days.…”

“…There was no evidence that inserters chose the micro-MST for younger patients, and the gradual transition to greater use of the micro-MST approach over the study duration did not support this reasoning. It is possible that this observation might reflect greater utility and adherence to the VA route and device selection algorithm used in the study site ( 16 , 21 ). This tool advocates for earlier selection of central vascular routes, such as PICC, when it is anticipated that intravenous therapy will be prolonged and would affect the age at which PICCs were inserted.…”

“…Second, these might be related to limiting the PICC insertion to a dedicated and highly trained group of staff ( 14 ). Third, it could be that the greater attention to vein preservation strategies and vein assessment, as advocated for by the routinely used 5-Rights mnemonic, was instrumental ( 4 , 16 , 21 ). For example, in this study, incorporating a system for routine systematic vein assessment could have aided insertion success and reduced complications by avoiding suboptimal veins.…”

“…During the initial patient assessment, the NeoVAT uses a locally developed mnemonic—the “5 Rights for Vascular Access”—to ensure the selection of the right device for the right vein when administering the right therapy for the right duration and for the right patient ( 4 , 15 , 21 ). This systematic approach used in in-house training programs helped maintain a standardized and patient-centric practice during VA. Evidence-based care bundles of preventative infection control measures for insertion site dressing and dressing changes, catheter-related bloodstream infections (CLABSI) prevention together with a daily consideration of the need for continued VA, and planned removal are implemented and routinely audited.…”