Application of Electrocardiogram Localization during Peripherally Inserted Central Catheter Line Insertion into the Persistent Left Superior Vena Cava of Neonates

Background Most neonates with persistent left superior vena cava (PLSVC) have no clinical symptoms or hemodynamic changes, and this anomaly is only found during cardiac catheterization, pacemaker implantation, or central venous catheterization. Electrocardiogram (ECG) localization is helpful for the application of the peripherally inserted central catheter (PICC) technique in neonates with PLSVC. Objective To explore the characteristic waveforms of the P wave when a PICC under ECG localization is applied in neonates with PLSVC. Study Design The observation and management strategies for the P wave changes during catheter insertion (CI) of two neonates with PLSVC admitted to our institution between January and July 2020, who underwent PICC line insertion, were summarized. Results The characteristic P wave changes in two children with a PICC line inserted via the PLSVC were observed. When a wide inverted P wave appeared on ECG, the catheter was immediately withdrawn by 0.5 cm, a bidirectional P wave gradually appeared and then disappeared. After that, the catheter was further withdrawn by 0.5 cm. After catheterization, the optimal position of the PICC was confirmed by X-ray photography and bedside B-ultrasound. The PICC line was removed as scheduled after indwelling for 18 and 29 days, respectively, in the two cases, and no PICC-related complications occurred during indwelling. Conclusion The characteristic P wave changes on ECG during CI provide important clinical reference values for the application of the PICC technique under ECG localization in neonates with PLSVC. Key Points

28. The Paradox of an Integrated MAT OPAT Program

Background Patients with substance use disorders (SUD), specifically opioid use disorder (OUD) and injection drug use (IDU) utilize healthcare resources for prolonged inpatient treatment of serious infections stemming from their addictions. For a variety of reasons, physicians treating these patients refuse to send these patients home to receive outpatient parenteral antimicrobial therapy (OPAT), and instead keep the patient in the hospital for several weeks or longer to complete treatment for the injection-related infections. Patients who do not have history of IDU are sent home with a PICC line to receive OPAT once they are no longer acutely ill and therefore no longer meet criteria to remain inpatient, which is the established standard of care. Patients with OUD and IDU are not allowed the same standard of care, and furthermore do not receive adequate, if any, therapy for their primary problem and reason for their serious infection – the addiction. Flow chart of the MAT-OPAT process Methods Medication-assisted treatment (MAT) with buprenorphine-naloxone has been approved for treating adults with opioid use disorder as part of a comprehensive treatment program that also includes counseling and behavioral therapy. Until now in our healthcare system there has been no comprehensive and integrated program to safely discharge patients with OUD and IDU to receive OPAT via a PICC line, while simultaneously treating their addiction. We describe the implementation of a MAT-OPAT program. Please refer to the chart included. Results We present a successful case of a 36-year-old male with a history of endocarditis associated with IV drug use and the intervention of the Healthcare System to link the patient to appropriate Infectious disease, behavioral health and medication adherence treatment for opioid abuse. The patient completed the IV antibiotic therapy and remained enrolled in the behavioral health program with a successful outcome. Conclusion MAT-OPAT implementation in large healthcare system with continuous outpatient support that includes Infectious Disease services, behavioral health and drug abuse rehabilitation therapy can be a successful strategy to minimize readmisión, cost and complications in patients with history of IV drug use and infections that require prolonged intravenous antibiotic therapy. Disclosures All Authors: No reported disclosures

234. Dalbavancin versus Outpatient Parenteral Antimicrobial Therapy with Vancomycin for Treatment of Bone and Joint Infections in a Veteran Population

Background Dalbavancin is a long-acting lipoglycopeptide with broad gram-positive activity. A long half-life makes it an attractive treatment option for bone and joint infections (BJI). Previous studies have demonstrated efficacy of dalbavancin in the treatment of BJI. Based on these studies, our institution established a protocol for using dalbavancin as an alternative to IV antibiotics via PICC line. Methods Chart review was performed to compare outcomes of patients who were treated with dalbavancin versus vancomycin for BJI from 8/2017 –7/2020. Patients that received two doses of dalbavancin for BJI were compared with patients who received OPAT with vancomycin during the same time period. Patients were excluded if they were bacteremic or received dalbavancin for another indication. Data was collected from the Veterans Health Administration’s Corporate Data Warehouse and retrospective chart review. No statistical analyses were performed due to the descriptive nature of this study. Results A total of 59 patients were included; 25 received dalbavancin and 34 received vancomycin. Relevant differences in baseline characteristics included a higher proportion of patients with osteomyelitis (88% vs 74%) and refractory infection (64% vs 44%) in the dalbavancin group. More patients in the dalbavancin group (38% vs 24%) were readmitted for the same infection within one year, required (29% vs 21%) additional surgical intervention, and had increased CRPH on follow-up labs (32% vs 3%). Dalbavancin use likely expedited discharge in at least 5 cases where vancomycin levels were not therapeutic. No significant adverse effects due to dalbavancin were noted, aside from one patient with an increase in serum creatinine. In the vancomycin group, 8 patients changed antibiotics due to adverse effects or difficulty managing levels and 3 patients had ED visits for PICC line care. Conclusion Dalbavancin may be a safe PICC-sparing treatment for BJI, particularly in cases where compliance is of concern, or there are logistical or tolerability issues with vancomycin. Our findings do raise concern for worse outcomes with dalbavancin, but the small sample size, difference in baseline characteristics between groups and descriptive nature of the study preclude any conclusions from being drawn. Disclosures All Authors: No reported disclosures

256. PICC Complications Are Common Reasons for ED Visits After PJI

Background Peri-prosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA) requiring surgical intervention and prolonged parenteral antibiotics. Often plagued by complications, the purpose of this study was to characterize the postoperative PICC (peripherally-inserted central catheter) line related complications and readmissions. Causes for 90-Day ED Visits after Revision Surgery for PJI. The figure quantifies causes for ED visits after PJI revision surgery with subsequent PICC line placement. Readmissions from ED are highlighted in blue. PICC-specific problems at ED visit. The figure quantifies the specific PICC-line problems that brought patients to the ED. Readmissions from ED are highlighted in blue. Methods We retrospectively queried an institutional database for total hip (THA) and total knee (TKA) arthroplasty patients from January 2015 through December 2020 that developed a PJI and required PICC placement. Patient demographics, comorbidities, readmissions, and emergency department (ED) visits were collected. Results 889 patients (48.3% female) with a mean age of 64.6 years (18.7-95.2) underwent 435 THA and 454 TKA that were revised for PJI. The cohort had 275 (30.9%) 90-day ED visits and 284 readmissions (31.9%). Of ED visits, 51 (18.5%) were PICC-related, with only five (9.8%) leading to readmission for a PICC complication. Average time from discharge to PICC ED visit was 26.2 days (0.3-89.4). The most common reasons for 90-day ED visit after revision and PICC line placement were issues related to the joint replacement or wound site (“MSK”, n=116, 42.2%) and PICC complaints (n=51, 18.5%). A multivariable logistic regression demonstrated that non-Caucasian race (OR 2.24, 95% CI 1.24-4.04, p=0.007) and younger age (OR 0.98, 95% CI 0.95-1.00, p=0.035) were associated with PICC-related ED visits. Malpositioning (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation. Conclusion PICC complications are common after PJI treatment accounting for nearly 20% of 90-day ED visits. Of these, malpositioning and occlusion of the PICC line occupy the vast majority of these complaints. This high level of utilization early in the course of outpatient parenteral antibiotic therapy represents areas of optimization and potential cost containment in the postoperative care of PJI patients. Disclosures William Jiranek, MD, Depuy Synthes (Other Financial or Material Support, Royalty/Licensing) Michael Bolognesi, MD, Heron Therapeutics, Inc. (Consultant)Total Joint Orthopedics, Inc. (Other Financial or Material Support, Royalty/Licensing)Zimmer Biomet Holdings, Inc. (Other Financial or Material Support, Royalty/Licensing) Thorsten Seyler, MD/PhD, Depuy Synthes (Other Financial or Material Support, Resident Educational Support)Extrel Therapeutics (Board Member, Shareholder)Heraeus Medical (Consultant)MiCare Path (Board Member, Shareholder)OREF (Grant/Research Support)Pattern health (Board Member)Restor3D (Other Financial or Material Support, Royalties)Smith+Nephew, Inc. (Grant/Research Support, Speaker’s Bureau)Stryker (Other Financial or Material Support, Resident Educational Support)Total Joint Orthopedics, Inc. (Consultant)Wolters Kluwer Health (Other Financial or Material Support, Royalties)Zimmer Biomet (Grant/Research Support)

Machine Learning for Detection of Correct Peripherally Inserted Central Catheter Tip Position from Radiology Reports in Infants

Background In critically ill infants, the position of a peripherally inserted central catheter (PICC) must be confirmed frequently, as the tip may move from its original position and run the risk of hyperosmolar vascular damage or extravasation into surrounding spaces. Automated detection of PICC tip position holds great promise for alerting bedside clinicians to noncentral PICCs. Objectives This research seeks to use natural language processing (NLP) and supervised machine learning (ML) techniques to predict PICC tip position based primarily on text analysis of radiograph reports from infants with an upper extremity PICC. Methods Radiographs, containing a PICC line in infants under 6 months of age, were manually classified into 12 anatomical locations based on the radiologist's textual report of the PICC line's tip. After categorization, we performed a 70/30 train/test split and benchmarked the performance of seven different (neural network, support vector machine, the naïve Bayes, decision tree, random forest, AdaBoost, and K-nearest neighbors) supervised ML algorithms. After optimization, we calculated accuracy, precision, and recall of each algorithm's ability to correctly categorize the stated location of the PICC tip. Results A total of 17,337 radiographs met criteria for inclusion and were labeled manually. Interrater agreement was 99.1%. Support vector machines and neural networks yielded accuracies as high as 98% in identifying PICC tips in central versus noncentral position (binary outcome) and accuracies as high as 95% when attempting to categorize the individual anatomical location (12-category outcome). Conclusion Our study shows that ML classifiers can automatically extract the anatomical location of PICC tips from radiology reports. Two ML classifiers, support vector machine (SVM) and a neural network, obtained top accuracies in both binary and multiple category predictions. Implementing these algorithms in a neonatal intensive care unit as a clinical decision support system may help clinicians address PICC line position.

PICC line management among patients with chronic kidney disease

More than 1 million peripherally inserted central catheters (PICC) are placed annually in the US and are used to provide convenient vascular access for a variety of reasons including long term antibiotic treatment, chemotherapy, parenteral nutrition, and blood draws. Although they are relatively easy to place and inexpensive, PICC line use is associated with many complications such as phlebitis/thrombophlebitis, venous thrombosis, catheter-related infection, wound infection, and central vein stenosis. These complications are far more deleterious for patients with chronic kidney disease (CKD) whose lives depend on a functioning hemodialysis access once they reach end stage kidney disease (ESKD). Despite recent guidelines to avoid PICC lines in CKD and ESKD patients, clinical use remains high. There is an ongoing urgency to educate and inform health care providers and the CKD patients themselves in preserving their venous real estate. In this article, we review AV access and PICC line background, complications associated with PICC lines in the CKD population, and recommendations for alternatives to placing a PICC line in this vulnerable patient population.

Bilateral pleural effusion and pneumomediastinum: rare complication resulting from punctured left subclavian vein following insertion of PICC line for total parenteral nutrition

This is a rare case of development of bi-lateral chylous pleural effusion (containing parenteral nutrition material) along with pneumomediastinum due to punctured left subclavian vein following insertion of a peripherally inserted central venous catheter (PICC) line. Parenteral nutrition is usually preferred for patients unable to tolerate enteral feeding. Due to hypertonicity of the total parenteral nutrition material, it is usually administered via internal jugular or subclavian vein which have a rapid blood flow; therefore, resulting in adequate mixing. Literature studies are yet to clearly explain the communications between two pleural cavities; therefore, development of bilateral pleural effusions in association with pneumomediastinum makes this case more intriguing. We present the journey of a 43-year-old woman who required insertion of bilateral chest drains, followed by sternotomy and repair of the left subclavian vein after she was found in hypoxic respiratory failure 2 days following insertion of PICC line into her left subclavian vein.