Central Venous Catheter Replacement Strategies in Adult Patients With Major Burn Injury

Study Overview
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Brief Summary
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The aim of this project is to answer the following questions: To determine the incidence of catheter related bacteremia (CRB) with three strategies of central venous catheter exchange in critically ill adult patients with major burn and to determine the regimen that will minimize the risk of bacteremia. To determine the incidence rate of catheter colonization in adult patients with major burns. The scientific knowledge to be acquired through this project is of likely benefit to the care of critically ill patients with burns injury as follows: The intention is to improve the outcomes in critically ill patients by minimizing one of the most frequent causes of infection in the Burn Intensive Care Unit, those from central venous catheters. Decreasing infections will decrease morbidity, decrease length of stay, decrease costs, and decrease mortality.

Detailed Description
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Aim: To determine the incidence of catheter-related bacteremia (CRB) with three primary schedules of central venous catheter exchange in adult critically ill patients with major burn injury. Hypothesis: A strategy of catheter exchange according with clinical criteria will result in no more CRB compared with a routine catheter changes without guidewire exchange strategy or frequent guidewire exchange or frequent new-site replacement. Background: The intravenous catheter-related bacteremia (ICRB) is a nosocomial infection affecting patients admitted to intensive care and that leads to increased morbidity. Accumulative incidence rates of ICRB are 5.5 infections per 1000 catheters-day. Several strategies have been proposed to decrease of the rate of ICRB in critically ill patients. However, there is not agreement to recommend a replacement pattern of central venous catheters in adult critically ill patients with major burns as a strategy for the reduction in intravenous catheter-associated bacteremia. Objectives. To compare three strategies of replacement from central venous catheters for the prevention of ICRB. Find out the risk of mechanical complications associated with each strategy of central venous catheter replacement. Method. Randomized, multicenter clinical trial, single blind to compare three strategies for intravenous catheter replacement in patients with major burns: a scheduled wire-guided strategy every six days: second, a scheduled strategy of replacement every six days in a different punction and third, a re-change strategy guided by clinical criteria for suspicion of catheter-associated infection. Primary outcome: catheter colonization rate and rate of intravenous catheter-associated bacteremia. Secondarily, we calculate the incidence rate of colonization of central venous catheter and finally we will analyze the associated complications. This project requires enough patients to show a difference between three intervention groups. A significant decrease in infection rate would be from the current 20 infections per 1000 catheter days to approximately 15 per 1000 catheter days. This would require a minimum of 1000 catheter days per group.

Official Title
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Comparison of Three Strategies for Changing of Central Venous Catheters in Patients With Serious Burns for the Prevention of Catheter-associated Bacteremia: Randomized Clinical Trial

Conditions
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Catheter-related Bloodstream Infection, Complication of Catheter

Intervention / Treatment
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* Device: central venous catheter replacement (Arrowgard Blue plus Quad-Lumen CVC )


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults (> 18 years old) admitted in a Critical Care Burn Center with a total body surface area (TBSA) greater than 20% and/or smoke inhalation injury. Exclusion Criteria: Adults admitted in a Critical Care Burn Center with a Do-Not-Resuscitate (DNAR) order due to severity of injuries.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: scheduled wire-guided every six days<br>scheduled wire-guided every six days and a replacement of the catheter in a different place after 12 days from randomization. | Device: central venous catheter replacement (Arrowgard Blue plus Quad-Lumen CVC )<br>* Routine practices for the type of catheter of each participating Unit will be respected. Multilumen central venous catheter will be used (i.e Arrowgard Blue plus Quad-Lumen CVC set). Impregnated Catheter with antiseptics or with antibiotics will be allowed.The anatomical locations selected for the replacement of central venous catheter are: subclavian vein, internal jugular vein, femoral vein and the change will be addressed according to the randomization. The dressing and maintenance of the catheter will be guided according with the Guides of The Centers for Disease Control and Prevention (CDCs) and a check-in lists will be fill in for each catheter. A pre-defined stratified analysis will be performed according with: type of catheter, participating unit, and insertion site.<br>* Other names: Catheter Related Bacteremia in Burns, CARBB study;|
| Experimental: Scheduled replacement every six days<br>Scheduled replacement every six days in a different location | Device: central venous catheter replacement (Arrowgard Blue plus Quad-Lumen CVC )<br>* Routine practices for the type of catheter of each participating Unit will be respected. Multilumen central venous catheter will be used (i.e Arrowgard Blue plus Quad-Lumen CVC set). Impregnated Catheter with antiseptics or with antibiotics will be allowed.The anatomical locations selected for the replacement of central venous catheter are: subclavian vein, internal jugular vein, femoral vein and the change will be addressed according to the randomization. The dressing and maintenance of the catheter will be guided according with the Guides of The Centers for Disease Control and Prevention (CDCs) and a check-in lists will be fill in for each catheter. A pre-defined stratified analysis will be performed according with: type of catheter, participating unit, and insertion site.<br>* Other names: Catheter Related Bacteremia in Burns, CARBB study;|
| Experimental: replacement guided by clinical criteria<br>re change of catheter strategy guided by clinical suspicious of catheter-related bacteremia and replacement of the catheter in a different location. | Device: central venous catheter replacement (Arrowgard Blue plus Quad-Lumen CVC )<br>* Routine practices for the type of catheter of each participating Unit will be respected. Multilumen central venous catheter will be used (i.e Arrowgard Blue plus Quad-Lumen CVC set). Impregnated Catheter with antiseptics or with antibiotics will be allowed.The anatomical locations selected for the replacement of central venous catheter are: subclavian vein, internal jugular vein, femoral vein and the change will be addressed according to the randomization. The dressing and maintenance of the catheter will be guided according with the Guides of The Centers for Disease Control and Prevention (CDCs) and a check-in lists will be fill in for each catheter. A pre-defined stratified analysis will be performed according with: type of catheter, participating unit, and insertion site.<br>* Other names: Catheter Related Bacteremia in Burns, CARBB study;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Accumulative Incidence rate of catheter-related bacteremia |  | participants will be followed for the duration of Burn Center stay, an expected lenght of stay average of 6 weeks (that represents the mean length of stay average in our BUrn Center in 2011) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Accumulative incidence rate of catheter colonization | From date of randomization until the date of first documented progression or date of adverse event (pneumothorax, hemothorax)or death from any cause, whichever came first, assessed up to 18 months. | participants will be followed for the duration of Burn Center stay, an expected lenght of stay average of 6 weeks (that represents the mean length of stay average in our BUrn Center in 2011) | 
| Mechanical complications of catheter insertion | Neumothorax, hemothorax, arterial puncture, | during the procedure of central catheter insertion | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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burns, catheter related bacteremia,, infection, central venous catheter,, catheter-related bloodstream, adult critically ill patients