JVA

The Journal of Vascular Access

2018, Vol. 19(2) 119­–124
© The Author(s) 2017
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
ISSN 1129-7298 ORIGINAL RESEARCH ARTICLE DOI: 10.5301/jva.5000797
journals.sagepub.com/home/jva

Targeting zero catheter-related

bloodstream infections in pediatric intensive
care unit: a retrospective matched case-control study
Daniele G. Biasucci1, Mauro Pittiruti2, Alessandra Taddei3, Enzo Picconi1, Alessandro Pizza1, Davide Celentano1, Marco Piastra1,
Giancarlo Scoppettuolo4, Giorgio Conti1
1
Department of Intensive Care Medicine and Anesthesiology, “A. Gemelli” University Hospital Foundation, Catholic University of the Sacred
Heart, Rome - Italy
2
Department of Surgery, “A. Gemelli” University Hospital Foundation, Catholic University of the Sacred Heart, Rome - Italy
3
Pediatric Surgery Unit, “A. Gemelli” University Hospital Foundation, Catholic University of the Sacred Heart, Rome - Italy
4
Infectious Diseases Unit, “A. Gemelli” University Hospital Foundation, Catholic University of the Sacred Heart, Rome - Italy

ABSTRACT
Introduction: The aim of this study was to evaluate the effectiveness and safety of a new three-component ‘bun-
dle’ for insertion and management of centrally inserted central catheters (CICCs), designed to minimize catheter-
related bloodstream infections (CRBSIs) in critically ill children.
Methods: Our ‘bundle’ has three components: insertion, management, and education. Insertion and manage-
ment recommendations include: skin antisepsis with 2% chlorhexidine; maximal barrier precautions; ultrasound-
guided venipuncture; tunneling of the catheter when a long indwelling time is expected; glue on the exit site;
sutureless securement; use of transparent dressing; chlorhexidine sponge dressing on the 7th day; neutral dis-
placement needle-free connectors. All CICCs were inserted by appropriately trained physicians proficient in a
standardized simulation training program.
Results: We compared CRBSI rate per 1000 catheters-days of CICCs inserted before adoption of our new bundle
with that of CICCs inserted after implementation of the bundle. CICCs inserted after adoption of the bundle re-
mained in place for a mean of 2.2 days longer than those inserted before. We found a drop in CRBSI rate to 10%,
from 15 per 1000 catheters-days to 1.5.
Conclusions: Our data suggest that a bundle aimed at minimizing CR-BSI in critically ill children should incorporate four
practices: (1) ultrasound guidance, which minimizes contamination by reducing the number of attempts and possible
break-down of aseptic technique; (2) tunneling the catheter to obtain exit site in the infra-clavicular area with reduced
bacterial colonization; (3) glue, which seals and protects the exit site; (4) simulation-based education of the staff.
Keywords: Catheter-related bloodstream infections, Ultrasound-guided vascular access, Tunnelled catheters,
Cyanoacrylate glue, Bundles, Catheter-related complications

Introduction variety of reasons. Common indications for CVC use are he-
modynamic monitoring, repeated blood sampling, infusion of
Background and rationale vasoactive medication, fluid replacement, antibiotic adminis-
tration, hemodialysis, and parenteral nutrition. In addition to
Central venous catheters (CVCs) are common and indis- this, today more and more patients are discharged from the
pensable in modern pediatric critical-care medicine for a pediatric intensive care unit (PICU) to the ward requiring a
medium-term or long-term CVC for the ongoing care. CVCs
Accepted: July 10, 2017 provide stable vascular access, but they are also associated
Published online: November 8, 2017 with catheter-related bloodstream infection (CRBSI), which
is still characterized by increased morbidity and attributable
Corresponding author: costs exceeding US$40,000 (1, 2). CRBSIs are multifactorial
Daniele G. Biasucci events with a reported incidence varying between 0.46 and
Neurointensive Care Unit - Shock & Trauma Unit 26.5 infections per 1000 catheter-days (3). Infection rates vary
Dept of Intensive Care Medicine and Anesthesiology with catheter types, indications, insertion sites, dwell times
“A. Gemelli” University Hospital Foundation and patients’ underlying disease (3). Comprehensive inter-
Istituto di Anestesiologia e Rianimazione
Catholic University of the Sacred Heart ventions directed at CRBSI prevention including staff educa-
Largo F. Vito, 1 tion and the use of insertion and maintenance bundles, have
00168, Rome, Italy been associated with significant reductions in infection rates
danieleguerino.biasucci@policlinicogemelli.it in critically ill children (4, 5). However, despite increasing
120 Targeting zero CR-BSI in PICU

r­ esearch activity in CRBSI prevention and despite develop- by expert physicians proficient in a standardized simulation-
ment and spread of the above-mentioned insertion and care based training program (6, 7) aimed at obtaining a strict ad-
bundles, the goal of zero infection for critically ill children is herence to our new insertion and care bundle. Furthermore,
still not attainable. all PICU nurses underwent a structured CICC care training
and competency-based evaluation in order to perfectly ad-
Objective here to maintenance practice provided by our bundle (7). All
skills were taught along with evidence-based strategies for
This study was aimed to evaluate effectiveness, safety, the prevention of CRBSI. According to our insertion and care
feasibility and applicability of a new rigorously evidence- bundle (Tab. I), the vein to be punctured was chosen after
based insertion and care bundle adopted and implemented a structured clinically integrated ultrasound assessment of
in our PICU and directed at targeting zero CRBSI in critically all possible options using the Rapid Central Vein Assessment
ill children. (RaCeVA) protocol (8). US preliminary evaluation and US-G
central venipuncture were performed with a Sonosite Micro-
Materials and methods Maxx ultrasound device equipped with a “Hockey Stick” linear
probe (FUJIFILM SonoSite, Inc.). All CICCs in the control group
Study design and setting were placed using a Seldinger technique, whereas all those
in the study group were placed using a micro-introducer and
This is a retrospective matched case-control study that a modified Seldinger technique. The insertion team chose
was conducted in the 8-bed PICU of a large university hos- the optimal vessel based on a goal vessel-to-catheter ratio of
pital in Rome, Italy (“A. Gemelli” University Hospital, Catho- at least of 3:1, which is determined by pre-puncture US as-
lic University of the Sacred Heart) after the approval of the sessment. Policies adopted both in cases and in controls re-
Institutional Review Board (IRB) who waived the need for quired preprocedural hand hygiene; use of maximum sterile
written informed consent. Our PICU is a tertiary referral cen- technique including mask, cap, full gown, and gloves; head-
ter admitting 85 to 100 pediatric critically ill trauma patients to-toe patient draping; and skin antisepsis with 2% chlorhexi-
per year. dine solution, to dry before venipuncture. There was at least
one assistant present, among whose tasks it was to observe
Study population and catheter type for a possible breakdown of sterile technique. Disregarding
the puncture site, in the study group, all CICCs were tun-
Our retrospective matched case-control study included neled to move the exit site to the infraclavicular area. Correct
all consecutive pediatric patients (aged >48 hours up to catheter tip location was confirmed using the technique of
16 years) who were admitted to our PICU from June 1, 2009 intracavitary electrocardiography (EKG) or subcostal echo-
until June 30, 2014. Starting from January 1, 2012 in our in- cardiography, which allows direct or indirect visualization
stitution we adopted and implemented a multicomponent of the catheter’s tip at the cavo-atrial junction. Following
evidence-based insertion and care bundle directed at tar- insertion, only in the study group, the exit site was sealed
geting zero CRBSI and minimizing all other early and late with cyanoacrylate glue allowing the first dressing change
complications (Tab. I). Sixty-four patients who had a new to be performed after 1 week. On the 7th day, a chlorhexi-
centrally inserted central venous catheter (CICC) placed ac- dine-impregnated antimicrobial sponge was also placed at
cording to our new insertion and care bundle during their the exit site in the study group, whilst, in the control group
intensive care unit (ICU) admission on or after January 1, it was placed since insertion. Each CICC was secured with a
2012 and up to June 30, 2014 were included in the study sutureless device and covered with a transparent dressing.
group. Sixty-four patients who had a new CICC placed be- Neutral displacement needle free connectors (NFC) and port
fore the adoption of the new insertion and care bundle, protectors were used at the hubs. In our institution, all CICCs
starting from December 31, 2011 and going back to June 1, undergo daily visual assessments by nursing staff, and cath-
2009, were included as controls. eter dressings are changed approximately every 7 days using
We included tunneled CICCs in the study group according clean or sterile gloves. The entire medical team and the nurs-
to our bundle and non-tunneled CICCs in the control group. ing staff perform daily assessments of ongoing needs for any
Temporary dialysis catheters, “introducer” catheters and all kind of CVC including both CICCs and peripherally inserted
catheters placed in emergency conditions were excluded. central catheter (PICCs).
According to our bundle, in the study group we used 3F, 4F
and 5F 2- or 3-lumen ProPICC CT Power Injectable as off-label Data collection
multipurpose CICCs (MedComp, Inc, Harleysville, PA, USA). In
the control group, short-term pediatric 4F and 5F triple-lu- Our PICU team maintains a prospective database
men or double-lumen catheters made by Vygon (Vygon, Inc., that tracks demographic and outcome data for all admis-
France) were used. sions, which was queried to identify patients who had a
new CICC during their admission to the PICU. All potential
Catheter insertion technique and nursing care cases were manually reviewed to ensure that they met
inclusion/exclusion criteria and to verify date and time of
All CICCs in both groups were inserted at bedside by ap- insertion and removal to ensure accuracy of CICC indwell-
propriately trained physicians using ultrasound guidance ing time. Patients were followed for CICC-related compli-
(US-G). In particular, CICCs of the study group were inserted cations until the catheter was removed or the patient was
Biasucci et al 121

TABLE I - Insertion and maintenance bundle adopted in the group of cases

Insertion and maintenance bundle Cases Controls

1. Hand washing and maximal barrier precautions Yes Yes

2. Skin antisepsis with 2% chlorhexidine Yes Yes
3. Ultrasound pre-puncture evaluation through RaCeVA Yes No
4. Ultrasound guided venipuncture Yes Yes
5. Tunneling of the catheter so to obtain an exit site in the infraclavicular area Yes No
6. Sealing of the exit site with glue Yes No
7. Securement with sutureless device Always Inconsistently
8. Coverage with transparent semipermeable dressing Yes No
9. Chlorhexidine-impregnated sponges After the 1st week Since insertion
10. Use of neutral NFC and port protectors Yes Yes
11. Simulation-based standardized training program Yes No

RaCeVA = rapid central vein assessment; NFC = needle free connectors.

dismissed from the PICU. Data collectors were unaware of Results

whether a subject was a case or a control and of the study
hypothesis. We found a significantly higher severity of disease in the
study group as reflected in the 24-hour Pediatric Index Mor-
Outcomes tality II (PIM II) score (p<0.001), invasive ventilator use, and
length of PICU stay (Tab. II).
The primary endpoint was the rate per 1000 catheter- The veins punctured at different sites are specified in
days of CR-BSI for CICCs placed after having adopted and im- Table III, and the overall complications following catheter
plemented, through a simulation-based standardized training placement are outlined in Table IV.
program, a new insertion and care bundle including (a) tun- We collected more than 1150 catheter-days of data, with
nelization, (b) sealing the exit site with glue, and (c) a struc- 648 catheter-days in the study group and 503 catheter-days
tured global use of ultrasound, compared to the standard of in the control group. The groups differed with respect to in-
care. All CICCs were followed until PICU discharge. dwelling time, with catheters of the study group remaining
Secondary endpoints were the overall rate of symptom- in place for a mean of 2.2 days longer than those of the con-
atic catheter-related deep venous thrombosis (CR-DVT), cath- trol group. We found a significant drop in CR-BSI rate from 15
eter occlusion, and accidental dislodgement. per 1000 catheter-days in the control group to 1.5 per 1000
catheter-days in the study group (p<0.05) (Tab. IV).
Diagnosis

Catheter-related bloodstream infection (CRBSI) was de- TABLE II - Characteristics of the population studied
fined using the standard Centers for Disease Control/Na-
tional Healthcare Safety Network reporting definitions (9). Cases Controls
According to Infectious Diseases Society of America (IDSA)
guidelines, CRBSI events were diagnosed isolating the same Mean age (±SD), m 45.88 (±26.01) 78.01 (±50.0)
organism from the catheter and the peripheral blood with Female, % 31.7 47.9
a differential time to positivity of CICC-derived versus Mean weight (±SD), kg 16.2 (±10.0) 26.63 (±18.03)
peripheral blood culture positivity of more than 2 hours Median PICU LOS (IQR), d 12.0 (1.0-26.0) 5.0 (2.0-13.0)
(10, 11). Mean PIM II score (±SD) 8.29 (±2.70) 2.63 (±1.0)
Median ventilation duration 2.0 (.0-12.0) 1.0 (.0-5.5)
Statistics (IQR), d
Organ dysfunction diagnosis (%)
For comparison of normally distributed, continuous data, Cardiac, % 8.3 NR
we used a 2-sided Student’s t-test. For continuous data that Respiratory, % 16.7 NR
failed tests for normal distribution, we reported the medi-
Neurological, % 35 NR
an and used a non-parametric Wilcoxon rank sum test. For
Oncologic, % 13.3 NR
comparison of nominal data, we used a Pearson χ2 test, or
Fisher’s exact test if the expected event rate was fewer than Other, % 26.7 NR
5. A p value <0.05 was considered statistically significant. All
SD = standard deviation; m = months; PICU LOS = pediatric intensive care
data analyses were performed using SPSS statistical software unit length of stay; IQR = interquartile range; d = days; PIM II = Pediatric Index
(IBM, USA). Mortality II score; NR = not reported.
122 Targeting zero CR-BSI in PICU

TABLE III - Punctured veins at different sites TABLE IV - Complication rates from insertion to PICU discharge

Veins Cases Controls Cases Controls

Right internal jugular vein at 0 (0%) 40 (62.5%) Indwelling time (d) Total 648 503
mid-neck, n (%) Mean (±SD) 9.7 ± 3.1 7.5 ± 3.5
Low lateral right internal 2 (3.12%) 11 (17.2%)
jugular vein, n (%) CR-BSI No 1 8
Left internal jugular vein at 0 (0%) 13 (20.3%) per 1000 catheter 1.5 15
mid-neck, n (%) days
Left brachiocephalic vein, n (%) 2 (3.12%) 0 (0%) CR-DVT No 0 1
Right brachiocephalic vein, n (%) 52 (81.25%) 0 (0%) Accidental dislodgements No 0 3
Right axillary vein, n (%) 4 (6.25%) 0 (0%)
Left subclavian vein, n (%) 2 (3.12%) 0 (0%) CR-BSI = catheter-related bloodstream infections; CR-DVT = catheter-related
deep vein thrombosis; PICU = pediatric intensive care unit; SD = standard
Right external jugular vein, n (%) 2 (3.12%) 0 (0%) deviation.

There were no episodes of symptomatic catheter-related a­ ttempts and the risk of hematoma formation, ultrasound
thrombosis, no episodes of occlusion nor accidental dislodge- guidance may indirectly reduce the incidence of CRBSI and
ments in the study group. CR-DVT (14-19). In fact, the adoption of ultrasound guidance
Furthermore, no cases of insertion-related pneumothorax has been shown to have a significant favorable impact, both
or hemothorax were detected in any of the groups. on the risk of catheter contamination and CRBSI and on the
risk of CR-DVT (14).
Discussion Guidelines and some studies place emphasis on site se-
lection (13-18). In fact, it is recommended to avoid femoral
CR-BSI still represents a relevant cause of morbidity and veins and use the subclavian vein, which is associated with
mortality in PICU (1, 2). It has been shown that CR-BSI is a lower risk of CR-BSI (13). Our findings suggest that the prob-
multifactorial but preventable complication (12). We have lem is not the vein but the exit site location of the catheter.
demonstrated that an evidence-based insertion and care CR-BSIs are related to the contamination risk at the exit site.
bundle aimed at reducing risk factors was associated with We should take into account that different areas of the skin
a significant decrease in CR-BSI rate (Tab. IV). Costello and have different degrees of bacterial colonization. Furthermore,
coworkers, in a retrospective interventional study, showed moisture, warmer areas of body, hair distribution, failure of
a reduction in CR-BSI rate from 7.8/1,000 catheter-days to dressing to adhere, are among relevant risk factors. On the
2.3/1,000 catheter-days after a systematic intervention (5). other hand, various studies have demonstrated that when a
In adult patients, Pronovost et al demonstrated that an ev- long indwelling time is expected, tunneled catheters are pre-
idence-based intervention resulted in an effective and sus- ferred because of the lower risk of infection (20-22). When
tained reduction in rates of CR-BSI (13). comparing the incidence of bloodstream infections of tun-
Most recommendations of our bundle (hand washing neled and totally implanted CICCs in children, most studies
and maximal barrier precautions; skin antisepsis with 2% found a lower risk in the implanted group (20-22). Disregard-
chlorhexidine in; coverage with transparent semipermeable ing the puncture site, tunneling the catheter allows to move
dressing and chlorhexidine-impregnated sponges; NFC disin- catheter’s exit site onto the chest, a dry, flat and stable area
fection; removal of nonessential catheters, etc.) are already with lower colonization, where dressing is optimal and the
well known to be effective in reducing infection risk. Four as- risk of infection is low. Moreover, by stopping bacteria spread
pects make our bundle new and original: along the catheter, the tunnel avoids their entrance into the
vein. We used off-label Power Injectable PICCs, which are
1. Ultrasound guidance, which minimizes contamination central catheters usually peripherally inserted, as a multipur-
by reducing the number of attempts and possible break- pose CICC. The PICC is ideal for tunneling because it is longer
down of aseptic technique. than the traditional CICC and can be trimmed, easily tunneled
2. Tunneling the catheter to obtain exit site in the infra-cla- and safely inserted into a central vein using a modified Seld-
vicular area with reduced bacterial colonization when a inger technique via a microintroducer kit. Furthermore, the
long indwelling catheter is expected (>7 days). characteristic of power injectability has the additional advan-
3. Glue, which seals and protects the exit site. tage of tolerating high-pressure injection (up to 300-350 psi)
4. Education and assessment of procedural competence of of contrast media during radiological procedures and allows
the staff, which has been shown to have important impli- delivery of high flows of fluids for resuscitation.
cations for the quality of care. Also sealing the exit site of catheters with cyanoacrylate
glue reduces the risk of extraluminal contamination, presum-
Several guidelines also recommend the use of ultrasound ably by reducing bacterial entrance through the skin breech
to decrease the rate of CR-BSI in adults and children (14-18). (23). Furthermore, the glue reduces bleeding at the exit site and
Facilitating CICC placement by reducing the number of at the puncture site, and by stabilizing the catheter, reducing “in
Biasucci et al 123

and out” movement, the glue may decrease local damage to Disclosures
the endothelium and the risk of thrombosis (23, 24). Financial support: No grants or funding have been received for this
Sutures are no longer recommended and should be study.
avoided since they cause disruption of the skin around the Conflict of interest: None of the authors has financial interest
catheter exit site, causing inflammation and heavy coloniza- related to this study to disclose.
tion (15, 16). Guidelines recommend sutureless devices to
stabilize the catheter (15-18). In the study group, the use of
sutureless devices was systematic compared to the control References
group in which, instead, their use was inconsistent (14 cases
out of 64) (Tab. I). 1. Elward AM, Hollenbeak CS, Warren DK, Fraser VJ. Attributable
cost of nosocomial primary bloodstream infection in pediatric
Our bundle was implemented after a simulation-based intensive care unit patients. Pediatrics. 2005;115(4):868-872.
training program. All medical and nursing staffs were trained 2. Slonim AD, Kurtines HC, Sprague BM, Singh N. The costs associ-
according to evidence-based recommendations of the World ated with nosocomial bloodstream infections in the pediatric
Congress on Vascular Access (WoCoVA) consensus confer- intensive care unit. Pediatr Crit Care Med. 2001;2(2):170-174.
ence (7, 25). Barsuk et al, in a single-center medical ICU, 3. Janum S, Zingg W, Classen V, Afshari A. Bench-to-bedside re-
found that the rate of CRBSI, after a minimum proficiency view: challenges of diagnosis, care and prevention of central
simulation-based training model on standardized checklist, catheter-related bloodstream infections in children. Crit Care.
reduced from 3.2 per 1000 catheter-days to 0.5 per 1000 2013;17(4):238.
catheter-days (26). Simulation-based training on a checklist 4. Stockwell JA. Nosocomial infections in the pediatric intensive
for insertion and care allowed us to maintain strict adherence care unit: affecting the impact on safety and outcome. Pediatr
to our bundle. Crit Care Med. 2007;8(2)(Suppl):S21-S37.
5. Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora
TJ, Laussen PC. Systematic intervention to reduce central line-
Limitations associated bloodstream infection rates in a pediatric cardiac
intensive care unit. Pediatrics. 2008;121(5):915-923.
Our study has several limitations. The first major limitation 6. Davidson IJ, Yoo MC, Biasucci DG, et al. Simulation training
is its retrospective design. Furthermore, because it is a single- for vascular access interventions. J Vasc Access. 2010;11(3):
center study with a small number of collected catheter-days, 181-190.
we had a limited power to detect CR-BSI. Another limitation 7. Lamperti M, Moureau N, Kelly LJ, et al. Competence in
was our ability to identify only symptomatic catheter-related paediatric central venous lines placement. Br J Anaesth.
thrombosis. 2014;112(2):383.
8. Pittiruti M. Ultrasound guided central vascular access in neo-
Strengths nates, infants and children. Curr Drug Targets. 2012;13(7):
961-969.
9. Centers for Disease Control (CDC)/National Healthcare Safety
We studied pediatric admissions to our general medical/ Network (NHSN). Central Line-Associated Bloodstream Infec-
surgical PICU over a 5-year period, which makes our findings tion (CLABSI). Available from: Event. http://www.cdc.gov/
representative of a long period. nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf. Accessed July
29, 2017.
Conclusions 10. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines
for the diagnosis and management of intravascular catheter-
Our findings strongly support a multipurpose strategy, in- related infection: 2009 Update by the Infectious Diseases Soci-
cluding the use of US-G, with specific preventive and educa- ety of America. Clin Infect Dis. 2009;49(1):1-45.
tional measures and the promotion of good practices in order 11. Raad I, Hanna HA, Alakech B, Chatzinikolaou I, Johnson MM,
to reduce the incidence of CRBSI. Tarrand J. Differential time to positivity: a useful method for di-
agnosing catheter-related bloodstream infections. Ann Intern
Despite progress in recent years that has significantly
Med. 2004;140(1):18-25.
reduced CR-BSIs in ICU, the goal of zero infection is still 12. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient
not in range, not for adults, and even less so for children. safety strategies that can be encouraged for adoption now.
We suggest that a bundle should incorporate three prac- Ann Intern Med. 2013;158(5 Pt 2):365-368.
tices: US-G; tunneling the catheter when a long indwelling 13. Pronovost P, Needham D, Berenholtz S, et al. An intervention
time is expected; sealing the exit site with cyanoacrylate to decrease catheter-related bloodstream infections in the
glue. A simulation-based training program is essential and ICU. N Engl J Med. 2006;355(26):2725-2732.
institutional efforts should be focused on promoting and 14. Lamperti M, Bodenham AR, Pittiruti M, et al. International evi-
implementing such educational protocols. Although we had dence-based recommendations on ultrasound-guided vascular
a significant decrease in CR-BSI rate, it was not yet zero. access. Intensive Care Med. 2012;38(7):1105-1117.
To further decrease CR-BSIs, we could possibly develop 15. OGrady NP, Alexander M, Burns LA, et al. Healthcare Infection
Control Practices Advisory Committee. Guidelines for the pre-
an effective audit tool focused on catheter-care practices vention of intravascular catheter-related infections. Am J Infect
and refresher courses on optimal insertion procedures and Control. 2011;39(4)(Suppl 1):S1-S34.
maintenance care. 16. OGrady NP, Alexander M, Burns LA, et al. Healthcare Infection
Further studies are needed to identify all potential risk Control Practices Advisory Committee (HICPAC). Guidelines for
factors of CR-BSI and to develop prevention strategies that the prevention of intravascular catheter-related infections. Clin
can be incorporated in a multi-faceted bundle. Infect Dis. 2011;52(9):e162-e193.
124 Targeting zero CR-BSI in PICU

17. Loveday HP, Wilson JA, Pratt RJ, et al. UK Department of 22. Nahum E, Levy I, Katz J, et al. Efficacy of subcutaneous tunnel-
Health. epic3: national evidence-based guidelines for prevent- ing for prevention of bacterial colonization of femoral central
ing healthcare-associated infections in NHS hospitals in Eng- venous catheters in critically ill children. Pediatr Infect Dis J.
land. J Hosp Infect. 2014;86(Suppl 1):S1-S70. 2002;21(11):1000-1004.
18. Marschall J, Mermel LA, Fakih M, et al. Strategies to pre- 23. Wilkinson JN, Chikhani M, Mortimer K, Gill SJ. The anti-
vent central line-associated bloodstream infections in acute microbial effect of Histoacryl skin adhesive. Anaesthesia.
care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2008;63(12):1382-1384.
2014;35(07)(Suppl 2):S89-S107. 24. Scoppettuolo G, Dolcetti L, Emoli A, La Greca A, Biasucci DG,
19. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ul- Pittiruti M. Further benefits of cyanoacrylate glue for central
trasound-guided catheterisation of the internal jugular vein: a venous catheterisation. Anaesthesia. 2015;70(6):758.
prospective comparison with the landmark technique in criti- 25. Moureau N, Lamperti M, Kelly LJ, et al. Evidence-based con-
cal care patients. Crit Care. 2006;10(6):R162. sensus on the insertion of central venous access devices:
20. Henneberg SW, Jungersen D, Hole P. Durability of central ve- definition of minimal requirements for training. Br J Anaesth.
nous catheters. A randomized trial in children with malignant 2013;110(3):347-356.
diseases. Paediatr Anaesth. 1996;6(6):449-451. 26. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB.
21. Schwab SJ, Buller GL, McCann RL, Bollinger RR, Stickel DL. Pro- Use of simulation-based education to reduce catheter-­related
spective evaluation of a Dacron cuffed hemodialysis catheter bloodstream infections. Arch Intern Med. 2009;169(15):
for prolonged use. Am J Kidney Dis. 1988;11(2):166-169. 1420-1423.