Research Grant from American Society of Parenteral
and Enteral Nutrition (ASPEN) Rhoads Research Foundation Grant 2015
The saFety of pArenteral nutrition regarding miCrobial growth and vascular catheter-related infection
(The FACT Study). $5,000
The overarching aim of Nicole's project is the investigation of the effect
of parenteral nutrition (PN) on microbial growth and its link to catheter-related blood stream infections
(CRBSI) in patients with a central venous access device (CVAD). This group of patients are vulnerable
to a variety of opportunistic pathogens due to their compromised immune status and are commonly prescribed
PN due to their disease or the side effects of their treatment. The results of this study will provide
information about the safety and efficacy of the clinical practices of PN administration and CVAD practices
which will improve clinical practice and reduce rates of CRBSI in cancer patients and be extrapolated
to acutely unwell hospitalised patients.
Research Grant from Intensive Care Foundation
Mitchell. The Central venous cAtheter SeCurement And Dressing Evaluation: CASCADE Pilot Trial at
The Princess Alexandra Hospital. 2014-5. $12,240
The Central venous Access device SeCurement And
Dressing Effectiveness: the CASCADE study.
This pilot study is a four arm RCT that will assess
the feasibility of different dressing and securement devices for CVLs in adults. It aims to identify
clinically and cost-effective securement and dressing approaches to prevent CVAD failure. This study,
which will be conducted at the Princess Alexandra Hospital ICU, has received funding from the Intensive
Care Foundation and will be submitted to HREC in the near future.
Simonov M, Pittiruti M, Rickard CM, Chopra V. Navigating venous access: a guide
for hospitalists. Journal of Hospital Medicine. 2015. On-line early March.
access is the foundation for safe and effective hospital-based care. Inpatient providers must have a deep
knowledge of the different types of venous access devices (VADs), their relative indications, contraindications,
and appropriateness. However, such knowledge is difficult to come by and usually only gleaned through
years of clinical experience. To bridge this gap, we provide an in-depth summary of the relevant anatomical
considerations, physical characteristics, advantages, and disadvantages of VADs commonly used in the hospital
setting. In doing so, we seek to improve the safety and share the science of vascular access with frontline
clinicians. To aid decision-making, we conclude by operationalizing the available data through algorithms
that outline appropriate vascular access for the hospitalized patient. Journal of Hospital Medicine 2015.
© 2015 Society of Hospital Medicine
Marsh N, Webster J, Flynn J, Mihala G, Fraser
J, Rickard CM. Securement methods for peripheral venous catheters: A randomised controlled
pilot trial. Journal of Vascular Access. 2015. On-line early 4th Feb.
To assess the effectiveness of four securement methods to prevent peripheral intravenous catheter (PIVC)
A single-centre, four-arm, randomised, controlled, non-blinded, superiority
pilot trial was conducted in a tertiary referral hospital in Queensland (Australia), between November
2012 and January 2013. Adult patients, with a PIVC expected to remain in situ for 24 hours and admitted
to general medical or surgical wards, were randomly allocated to standard polyurethane dressing (control,
SPU), tissue adhesive (TA) with an SPU, bordered polyurethane dressing (BPU) or sutureless securement
device (SSD) with an SPU, experimental groups. The primary endpoint was PIVC failure, defined as premature
device removal before the end of therapy because of pain, blockage, leaking, accidental removal and local
or catheter-related bloodstream infection.
PIVCs were used for an average of 2.6
days across all study groups (n = 85). Catheter failure was lowest in the TA group (3/21, 14%) and highest
in the control group (8/21, 38%), with BPU and SSD failure at 5/20 (25%) and 5/23 (22%), respectively.
The adjusted hazard ratio of catheter failure was lowest in the TA group (0.50, 95% CI: 0.13-1.98), and
then the BPU (0.52, 95% CI: 0.15-1.78) and SSD (0.61, 95% CI: 0.20-1.91) groups. No patient was suspected
of a local or catheter-related bloodstream infection.
Current SPU dressings alone
do not prevent many cases of PIVC failure. TA appears promising as an innovative solution, but may not
be suitable for all patients. A larger Australian National Health and Medical Research Council (NHMRC)-funded
trial has commenced.
Ullman A, Keogh S, Marsh N. Routine versus clinically
indicated replacement of peripheral catheters. British Journal of Nursing. 2015. 24(Sup2): S14.
Background of the study:
Currently the US Centers for Disease Control and Prevention (CDC)
state that the peripheral intravenous catheters do not need to be replaced more frequently than every
72 to 96 hours to reduce the risk of infection and phlebitis in adults (O'Grady et al., 2011). Of the
200 million peripheral intravenous catheters estimated to be inserted each year in the USA alone, if even
15% are needed for more than three days, then a change to clinically indicated replacement would prevent
up to six million unnecessary intravenous catheter insertions, and would save about two million hours
of staff time and up to US$60 million in health costs each year for that country alone.
this study was conducted (aims):
The study aimed to understand the effect of extension of peripheral
intravenous catheter dwell-time beyond three days with replacement of catheters only for clinical reasons.
It postulated that patients who had peripheral intravenous catheters replaced when clinically indicated
would have equivalent rates of phlebitis and no difference in other complications compared with patients
with catheters removed every third day.
A multicentre, non-blinded, randomised
controlled equivalence trial was undertaken in three university-affiliated hospitals in Queensland, Australia
(Royal Brisbane and Women's Hospital, Herston; Princess Alexandra Hospital, Woolloongabba; and Gold Coast
Hospital, Southport) between May 2008 and September 2009. It recruited adults (18 years) with a
peripheral intravenous catheter of expected use longer than four days and participants were randomly
assigned to receive either clinically indicated intravenous catheter replacement, or third daily routine
From the 3283 patients randomised (5907 catheters) phlebitis
occurred in 7% patients of both the clinically indicated and routine replacement groups. No patient had
a venous (local) infection and groups were equivalent for all-cause bloodstream infections and catheter
colonisation. Only one patient had a catheter-related bloodstream infection and this patient was in the
routine replacement group. Rates of infiltration, occlusion, accidental removal, total infusion failure,
and in-hospital mortality were all equivalent between groups.
Implications for clinicians:
The study demonstrated that peripheral intravenous catheters can be removed as clinically indicated.
The results of the study are consistent with previous smaller randomised controlled trials (Rickard
et al., 2010, Van Donk et al., 2009, Webster et al., 2008, Webster et al., 2007) and a systematic review
that showed no benefit of routine replacement for phlebitis or catheter-related blood stream infections
(Webster et al., 2010).
The CDC guidelines currently recommend clinically indicated treatment in
children (O'Grady et al., 2011). Intravenous catheters are already frequently left in place beyond the
currently recommended 72 to 96 hours typically as the result of a complex clinical judgment, rather than
a policy violation (Schultz and Gallant, 2005, Palese et al., 2011). The CDC itself tempers its 72 to
96 hour replacement recommendations with "if sites for venous access are limited and no evidence of phlebitis
or infection is present, intravenous catheters can be left in place for longer"(O'Grady et al., 2011)
Thus, a change to policies of clinically indicated removal of intravenous catheters might not be very
far from the current real-world approach that occurs despite policies and recommendations.
evidence now suggests that clinically indicated replacement of peripheral intravenous catheters is safe.
Updated intravenous catheter policies (including CDC guidelines for adult patients) should advocate clinically
indicated removal - focussing on monitoring and immediately removing intravenous catheters for complications
or as soon as treatment is complete. Routine intravascular catheter resite involves pain for patients,
staff procedural time, equipment costs and environmental waste.
Rickard CM, Marsh NM,
Webster J, Gavin NC, McGrail MR, Larsen E. Corley A, Long D, Gowardman JR, Murgo M, Fraser JF, Chan
RJ, Wallis MC, Young J, McMillan D, Zhang L, Choudhury MA, Graves N, Playford EG. Intravascular
device administration sets: Replacement after Standard Versus Prolonged use in hospitalised patients.
The RSVP trial: study protocol for a randomised controlled trial. BMJ Open. 2015. Feb; 5(2),
Introduction: Vascular access devices (VADs), such as peripheral or central venous catheters,
are vital across all medical and surgical specialties. To allow therapy or haemodynamic monitoring, VADs
frequently require administration sets (AS) composed of infusion tubing, fluid containers, pressure-monitoring
transducers and/or burettes. While VADs are replaced only when necessary, AS are routinely replaced every
34days in the belief that this reduces infectious complications. Strong evidence supports AS use up to
4days, but there is less evidence for AS use beyond 4days. AS replacement twice weekly increases hospital
costs and workload.
Methods and analysis: This is a pragmatic, multicentre, randomised controlled
trial (RCT) of equivalence design comparing AS replacement at 4 (control) versus 7 (experimental) days.
Randomisation is stratified by site and device, centrally allocated and concealed until enrolment. 6554
adult/paediatric patients with a central venous catheter, peripherally inserted central catheter or peripheral
arterial catheter will be enrolled over 4years. The primary outcome is VAD-related bloodstream infection
(BSI) and secondary outcomes are VAD colonisation, AS colonisation, all-cause BSI, all-cause mortality,
number of AS per patient, VAD time in situ and costs. Relative incidence rates of VAD-BSI per 100 devices
and hazard rates per 1000 device days (95% CIs) will summarise the impact of 7-day relative to 4-day AS
use and test equivalence. Kaplan-Meier survival curves (with log rank Mantel-Cox test) will compare VAD-BSI
over time. Appropriate parametric or non-parametric techniques will be used to compare secondary end points.
p Values of <0.05 will be considered significant.
Ethics and dissemination: Relevant ethical
approvals have been received. CONSORT Statement recommendations will be used to guide preparation of any
publication. Results will be presented at relevant conferences and sent to the major organisations with
clinical practice guidelines for VAD care.
Trial registration number Australian New Zealand
Clinical Trial Registry (ACTRN 12610000505000).
Carr, P. J. and Rippey, J. C. R.
(2015), Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted
central venous catheter. Clinical Case Reports. doi: 10.1002/ccr3.187
We report a case of peripherally inserted central venous catheter (PICC)-associated deep
vein thrombosis (DVT). Ultrasound images and video of subclavian thrombus are presented. PICC line-associated
DVT, particularly in cancer patients is not uncommon. Point-of-care Emergency Department ultrasound can
readily diagnose this complication and device removal is not always necessary.
The use of the peripherally inserted central venous catheters (PICC) for intravenous nutrition
and intravenous therapy developed a new era for vascular access science. Since
the PICC's debut
in the 1970s its popularity has increased exponentially. This is attributed primarily to perceived
safety, ease of insertion, and increased dwell time when compared to other central venous access
devices. PICCs are, however, not without complication, and the relatively high rate of PICC-associated
thrombus is recognized.
Case History: A 40-year-old male with a diagnosis of metastatic cholangiocarcinoma
(malignancy of the bile ducts) presented to a busy metropolitan ED. He had been receiving intravenous
chemotherapy for several weeks, through a 5Fr double lumen power injectable PICC inserted into his
right basilic vein. He presented with right arm swelling, discomfort, and discoloration. Bedside
ultrasound in the emergency department rapidly confirmed our clinical suspicion, and displayed an
acute, completely occlusive PICC-associated thrombus, involving the basilic, axillary, and subclavian
veins. There was no internal jugular or brachiocephalic vein involvement.
Outcome: The patient was
commenced on therapeutic anticoagulation (subcutaneous enoxaparin twice daily). The PICC was
not removed as the patient required intravenous therapy. His symptoms settled entirely within 5 days.
We had the opportunity to review the patient 6 weeks postdiagnosis
of his PICC-associated deep
vein thrombosis (DVT) and repeated the ultrasound examination. This demonstrated complete resolution
of the basilic, axillary, and subclavian thrombus.
Reynolds H, Taraporewella K,
Tower M, Mihala G, Tuffaha H, Fraser JF, Rickard CM. Novel Technologies Can Provide Effective
Dressing and Securement for Peripheral Arterial Catheters: A Pilot Randomised Controlled Trial in the
Operating Theatre and the Intensive Care Unit. Australian Critical Care. 2015. January. On-line
Peripheral arterial catheters are widely used in the care of
intensive care patients for continuous blood pressure monitoring and blood sampling, yet failure - from
dislodgement, accidental removal, and complications of phlebitis, pain, occlusion and infection - is common.
While appropriate methods of dressing and securement are required to reduce these complications that cause
failure, few studies have been conducted in this area.
To determine initial effectiveness
of one dressing and two securement methods versus usual care, in minimising failure in peripheral arterial
catheters. Feasibility objectives were considered successful if 90/120 patients (75%) received the study
intervention and protocol correctly, and had ease and satisfaction scores for the study dressing and securement
devices of 7 on Numerical Rating Scale scores 1-10.
In this single-site, four-arm,
parallel, pilot randomised controlled trial, patients with arterial catheters, inserted in the operating
theatre and admitted to the intensive care unit postoperatively, were randomly assigned to either one
of the three treatment groups (bordered polyurethane dressing (n=30); a sutureless securement device (n=31);
tissue adhesive (n=32)), or a control group (usual practice polyurethane dressing (not bordered) (n=30)).
One hundred and twenty-three patients completed the trial. The primary outcome of catheter
failure was 2/32 (6.3%) for tissue adhesive, 4/30 (13.3%) for bordered polyurethane, 5/31 (16.1%) for
the sutureless securement device, and 6/30 (20%) for the control usual care polyurethane. Feasibility
criteria were fulfilled. Cost analysis suggested that tissue adhesive was the most cost effective.
The pilot trial showed that the novel technologies were at least as effective as the
present method of a polyurethane dressing for dressing and securement of arterial catheters, and may be
cost effective. The trial also provided evidence that a larger, multicentre trial would be feasible.
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