Central venous access device Securement and dressing effectiveness: The CASCADE pilot randomised controlled trial in the adult intensive care.

Central venous access devices (CVADs) are a vital medical device for intensive care (ICU) patients; however, complications and failure are common, yet potentially prevented through effective dressings and securement. The objective of this study was to test the feasibility of a randomised controlled trial (RCT) comparing standard care with three dressing and securement products to prevent CVAD failure. Secondary aims included comparing dressing and securement products on CVAD failure, microbial colonisation, and intervention costs. A single-centre pilot RCT of ICU adult patients requiring CVADs for >24 h were randomised to four groups: (i) sutures plus chlorhexidine gluconate (CHG) dressing (standard care); (ii) standard care plus tissue adhesive (TA); (iii) two sutureless stabilisation devices (SSD) plus CHG dressing; (iv) sutures, CHG disc plus integrated securement dressing (ISD). Descriptive statistics assessed feasibility. Incidence rates (IRs) of CVAD failure were reported, with group differences compared using the Fisher exact and log-rank tests. Cox regression explored univariable risks for failure. A substudy examined bacterial colonisation of catheter tips, dressings, and skin. Cost estimates of the intervention were compared. A total of 121 participants were randomised. Study feasibility was established with no withdrawal and moderate staff acceptability; however, recruitment was low at 12%. Overall CVAD failure was seen in 14 of 114 (12%) CVADs (19 per 1000 catheter-days); highest in the SSD group (IR: 27.3 per 1000 catheter-days [95% confidence interval {CI}: 11.4-65.6]), followed by the standard care group (IR: 22.3 per 1000 catheter-days [95% CI: 8.38-59.5]) and TA group (IR: 20.6 per 1000 catheter-days [95% CI: 6.66-64.0]), and lowest in the ISD group (IR: 8.8 per 1000 catheter-days [95% CI: 2.19-35.0]). The majority of complications (11/14, 79%) were suspected central line-associated bloodstream infection (CLABSI), of which only one was laboratory confirmed (standard care group). The cost per patient was lowest in the standard care group by an average difference of AUD $14. A large multisite RCT examining forms of securement and dressing is feasible. ISD is the highest priority to test further as it had the lowest failure rate. ACTRN12615000667516 PROTOCOL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368765.

Mitchell ML ，Ullman AJ ，Takashima M ，Davis C ，Mihala G ，Powell M ，Gibson V ，Zhang L ，Bauer M ，Geoffrey Playford E ，Rickard CM ... -  《Australian Critical Care》

Central venous Access device SeCurement And Dressing Effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial.

Chan RJ ，Northfield S ，Larsen E ，Mihala G ，Ullman A ，Hancock P ，Marsh N ，Gavin N ，Wyld D ，Allworth A ，Russell E ，Choudhury MA ，Flynn J ，Rickard CM ... -  《Trials》

Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review.

To compare the available dressing and securement devices for central venous access devices (CVADs). Systematic review of randomised controlled trials. Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews and of Effects, NHS Economic Evaluation Database, Ovid MEDLINE, CINAHL, EMBASE, clinical trial registries and reference lists of identified trials. Studies evaluated the effects of dressing and securement devices for CVADs. All types of CVADs were included. Outcome measures were CVAD-related bloodstream infection, CVAD tip colonisation, entry and exit site infection, skin colonisation, skin irritation, failed CVAD securement, dressing condition and mortality. We used standard methodological approaches as expected by The Cochrane Collaboration. We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. It is unclear whether there is a difference in the rate of CVAD-related bloodstream infection between securement with gauze and tape and standard polyurethane (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated dressings and standard polyurethane (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93). There is moderate quality evidence that chlorhexidine gluconate-impregnated dressings reduce the frequency of CVAD-related bloodstream infection per 1000 patient days compared with standard polyurethane dressings (RR 0.51, 95% CI 0.33 to 0.78). There is moderate quality evidence that catheter tip colonisation is reduced with chlorhexidine gluconate-impregnated dressings compared with standard polyurethane dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and standard polyurethane are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). Medication-impregnated dressing products reduce the incidence of CVAD-related bloodstream infection relative to all other dressing types. There is some evidence that chlorhexidine gluconate-impregnated dressings, relative to standard polyurethane dressings, reduce CVAD-related bloodstream infection for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of CVAD-related bloodstream infection. Most studies were conducted in intensive care unit settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVADs.

Ullman AJ ，Cooke ML ，Mitchell M ，Lin F ，New K ，Long DA ，Mihala G ，Rickard CM ... -  《-》

Innovative dressing and securement of tunneled central venous access devices in pediatrics: a pilot randomized controlled trial.

Ullman AJ ，Kleidon T ，Gibson V ，McBride CA ，Mihala G ，Cooke M ，Rickard CM ... -  《-》

Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials.

Paediatric central venous access devices (CVADs) are associated with a 25% incidence of failure. Securement and dressing are strategies used to reduce failure and complication; however, innovative technologies have not been evaluated for their effectiveness across device types. The primary aim of this research is to evaluate the feasibility of launching a full-scale randomised controlled efficacy trial across three CVAD types regarding CVAD securement and dressing, using predefined feasibility criteria. Three feasibility randomised, controlled trials are to be undertaken at the Royal Children's Hospital and the Lady Cilento Children's Hospital, Brisbane, Australia. CVAD securement and dressing interventions under examination compare current practice with sutureless securement devices, integrated securement dressings and tissue adhesive. In total, 328 paediatric patients requiring a peripherally inserted central catheter (n=100); non-tunnelled CVAD (n=180) and tunnelled CVAD (n=48) to be inserted will be recruited and randomly allocated to CVAD securement and dressing products. Primary outcomes will be study feasibility measured by eligibility, recruitment, retention, attrition, missing data, parent/staff satisfaction and effect size. CVAD failure and complication (catheter-associated bloodstream infection, local infection, venous thrombosis, occlusion, dislodgement and breakage) will be compared between groups. Ethical approval to conduct the research has been obtained. All dissemination will be undertaken using the CONSORT Statement recommendations. Additionally, the results will be sent to the relevant organisations which lead CVAD focused clinical practice guidelines development. ACTRN12614001327673; ACTRN12615000977572; ACTRN12614000280606.

Ullman AJ ，Kleidon T ，Gibson V ，Long DA ，Williams T ，McBride CA ，Hallahan A ，Mihala G ，Cooke M ，Rickard CM ... -  《-》