Uso y complicaciones del cateterismo urinario en salas de cuidados moderados de un hospital universitario

Introducción: El cateterismo urinario es un procedimiento frecuente y en ocasiones es utilizado por fuera de las indicaciones aceptadas para el mismo. Esto aumenta el riesgo de complicaciones vinculadas a su uso, por lo que pueden ser prevenibles. El objetivo del estudio es conocer las características del uso de cateterismo urinario en pacientes ingresados en salas de cuidados moderados de un hospital universitario del tercer nivel de atención, determinar la frecuencia, duración e indicaciones más frecuentes, así como evaluar la presencia de complicaciones asociadas al mismo Metodología: Estudio de corte transversal, realizado en salas de cuidados moderados de un hospital terciario y universitario de Montevideo, Uruguay, el 21 de diciembre de 2022. Se incluyeron pacientes hospitalizados que presentaban o presentaron catéter vesical en la presente internación y se completó la recolección de variables mediante la revisión de la historia clínica. Resultados: De 155 pacientes ingresados en salas de cuidados moderados, a 26 (16,7%) les fue colocado un catéter urinario. La mediana de edad fue 61 años, 80% eran de sexo masculino. La mediana de internación fue de 22 días. En todos los pacientes se utilizó sonda vesical y el 54% fue colocado en el Departamento de Emergencia. En el 46% de los pacientes no se encontró indicación escrita de colocación en la historia clínica. En 50% de los casos no está especificado el motivo de indicación de sonda vesical, mientras que las indicaciones identificadas más frecuentes fueron el control de diuresis (27%) y la desobstrucción de vía urinaria baja (23%). La duración de cateterismo fue de una mediana de 13,5 días, mientras que el 27% de los pacientes la usaron más de 30 días. 35% de los pacientes presentaron complicaciones vinculadas a la sonda vesical, en su mayoría no infecciosas (27%) y 15% presentaron infección urinaria. Estos pacientes tuvieron una duración de cateterismo mayor a los que no presentaron complicaciones (23 vs 10 días, p=0,411). Conclusiones: El catéter vesical fue utilizado en un porcentaje no despreciable de pacientes ingresados en salas de cuidados moderados, de forma prolongada y frecuentemente sin indicación precisa, lo cual expone a un riesgo aumentado de complicaciones vinculadas.

Introduction: Urinary catheterization is a frequent procedure and is sometimes used outside of its accepted indications. This increases the risk of complications related to its use, so they may be preventable. The objective of this study is to know the characteristics of the use of urinary catheterization in patients admitted to moderate care wards of a tertiary care university hospital, to determine the frequency, duration and most frequent indications, as well as to evaluate the presence of associated complications. Methodology: Cross-sectional study, carried out in moderate care wards of a tertiary care and university hospital in Montevideo, Uruguay, on December 21, 2022. Hospitalized patients who present or presented a bladder catheter during the present hospitalization were included, and the collection of variables was completed by reviewing the medical history. Results: Of 155 patients admitted to moderate care wards, 26 (16.7%) had a urinary catheter placed. The median age was 61 years, 80% were male. The median hospitalization was 22 days. In all patients a bladder catheter was used and 54% were placed in the Emergency Department. In 46% of the patients, no written indication for placement was found in the clinical history. In 50% of cases, the reason for indicating the bladder catheter is not specified, while the most frequent indications identified were diuresis control (27%) and lower urinary tract obstruction (23%). The duration of catheterization was a median of 13.5 days, while 27% of the patients used it for more than 30 days. 35% of the patients presented complications related to the bladder catheter, mostly non-infectious (27%) and 15% presented urinary tract infection. These patients had a longer duration of catheterization than those without complications (23 vs 10 days, p=0,411). Conclusions: The bladder catheter was used in a non-negligible percentage of patients admitted to moderate care wards, for a long time and often without a precise indication, which exposes them to an increased risk of related complications.

Introdução: O cateterismo urinário é um procedimento frequente e às vezes é usado fora de suas indicações aceitas. Isso aumenta o risco de complicações relacionadas ao seu uso, portanto, podem ser evitáveis. O objetivo deste estudo é conhecer as características do uso do cateterismo urinário em pacientes internados em enfermarias de cuidados moderados de um hospital universitário terciário, determinar a frequência, duração e indicações mais frequentes, bem como avaliar a presença de complicações associadas ao mesmo. Metodologia: Estudo transversal, realizado em quartos de cuidados moderados de um hospital terciário e universitário em Montevidéu, Uruguai, em 21 de dezembro de 2022. Foram incluídos pacientes que apresentaram ou apresentaram sonda vesical durante a internação atual e a coleta de variáveis ​​foi concluída .revisando o histórico médico. Resultados: Dos 155 pacientes admitidos em enfermarias de cuidados moderados, 26 (16,7%) tiveram um cateter urinário colocado. A idade média foi de 61 anos, 80% eram do sexo masculino. A mediana de internação foi de 22 dias. Em todos os doentes foi utilizada sonda vesical e 54% foram internados no Serviço de Urgência. Em 46% dos pacientes, nenhuma indicação escrita para colocação foi encontrada na história clínica. Em 50% dos casos não é especificado o motivo da indicação da sonda vesical, enquanto as indicações mais frequentes identificadas foram controle da diurese (27%) e desobstrução do trato urinário inferior (23%). A duração do cateterismo foi em média de 13,5 dias, enquanto 27% dos pacientes o utilizaram por mais de 30 dias. 35% dos pacientes apresentaram complicações relacionadas ao cateter vesical, em sua maioria não infecciosas (27%) e 15% apresentaram infecção urinária. Esses pacientes tiveram uma duração mais longa de cateterismo do que aqueles sem complicações (23 vs 10 dias, p=0,411). Conclusões: A sonda vesical foi utilizada em percentual não desprezível de pacientes internados em quartos de cuidados moderados, por tempo prolongado e muitas vezes sem indicação precisa, o que os expõe a um risco aumentado de complicações associadas.

Incidência de obstrução em cateteres periféricos intravenosos em adultos e fatores relacionados / Incidence of obstruction in peripheral intravenous catheters in adults and related factors / Incidencia de obstrucción en catéteres intravenosos periféricos en adultos y factores relacionados

Objetivo: analisar a incidência e os fatores relacionados à obstrução de cateter intravenoso periférico em adultos hospitalizados. Método: uma coorte prospectiva, realizada a partir da observação de 203 cateteres, entre fevereiro de 2019 e maio de 2020, em hospital público e de ensino brasileiro. Foram consideradas variáveis clínicas e do cateter. Os dados foram analisados descritivamente e por estatística inferencial. Resultados: o tempo de permanência variou entre um a 15 dias e a obstrução ocorreu em 7,5% das observações. Houve aumento do risco de obstrução em relação ao sexo (RR=0,49 / p=0,186), à idade (RR=1,20/ p=0,732), aos cateteres de maior calibre (RR=0,53/ p=0,250), à inserção no dorso da mão até antebraço (RR=2,33/ p=0,114) e ao tempo do cateter in situ (RR=033/ p=0,433). Conclusão: O cuidado diário e observação do cateter intravenoso periférico são importantes para minimizar o surgimento de complicações locais e sistêmicas e manter a patência do dispositivo.

Objective: to analyze the incidence and factors related to peripheral intravenous catheter obstruction in hospitalized adults. Method: a prospective cohort, based on the observation of 203 catheters, between February 2019 and May 2020, in a Brazilian public teaching hospital. Clinical and catheter variables were taken into account. The data was analyzed descriptively and using inferential statistics. Results: the length of stay ranged from one to 15 days and obstruction occurred in 7.5% of the observations. There was an increased obstruction risk in relation to gender (RR=0.49 / p=0.186), age (RR=1.20/ p=0.732), larger catheters (RR=0.53/ p=0.250), insertion in the back of the hand up to the forearm (RR=2.33/ p=0.114) and the time length the catheter was in situ (RR=033/ p=0.433). Conclusion: Daily care and observation of the peripheral intravenous catheter is important to minimize the appearance of local and systemic complications and maintain the patency of the device.

Objetivo: analizar la incidencia y los factores relacionados con la obstrucción del catéter intravenoso periférico en adultos hospitalizados. Método: cohorte prospectiva, realizada mediante la observación de 203 catéteres, entre febrero de 2019 y mayo de 2020, en un hospital escuela público brasileño. Se consideraron variables clínicas y del catéter. Los datos se analizaron de forma descriptiva y mediante estadística inferencial. Resultados: el tiempo de permanencia varió entre uno y 15 días y la obstrucción ocurrió en el 7,5% de las observaciones. Hubo mayor riesgo de obstrucción en relación con el sexo (RR=0,49 / p=0,186), la edad (RR=1,20 / p=0,732), los catéteres de mayor calibre (RR=0,53 / p= 0,250), la inserción en el dorso de la mano hasta el antebrazo (RR=2,33/ p=0,114) y el tiempo del catéter in situ (RR=033/ p=0,433). Conclusión: el cuidado diario y la observación del catéter intravenoso periférico son importantes para minimizar la aparición de complicaciones locales y sistémicas y mantener la permeabilidad del dispositivo.

Assessment of a Protocol for Reducing Indwelling Urinary Catheter Usage: Reduced Infection Without Increased Acute Kidney Injury.

Introduction In 2019, a level one trauma center in St. Louis, Missouri launched a campaign to reduce the use of indwelling urinary catheters (IUC) in the trauma population. Our study assesses whether the campaign achieved the intended effect of reducing catheter-associated urinary tract infection (CAUTI) and whether this came at the cost of increased acute kidney injury (AKI). Methods We examined a cohort of patients from before and after the IUC reduction campaign. We compared days with IUC, UTI, CAUTI, and AKI, both recorded in the registry and based on a direct review of laboratory results. Significance testing is performed with the Student's t-test for continuous variables and Fisher's exact test for categorical variables. For multivariate analysis, multivariate linear regression is used for continuous outcomes, and multivariate logistic regression is used for binary categorical outcomes.  Results On average, the post-campaign cohort was older and more severely injured. There was a modest decrease in IUC usage following the campaign, which was significant when adjusted for common trauma covariates, B=-0.93; p=0.04. There were 10 (0.4%) cases of CAUTI in the pre-intervention group versus 0 post-intervention (p=0.002). Pyuria was significantly lower post-intervention: 118 (40.3%) versus 84 (29.3%), p=0.007. This remained significant on multivariate analysis: odds ratio (OR): 0.52, p=0.008. There were no significant differences in creatinine (Cr) absolute values or temporal trends over the course of admission between the cohorts. There was no increased AKI measured by kidney disease improving global outcomes (KDIGO) criteria. Conclusion The IUC reduction protocol was associated with a significant decrease in CAUTI without a significant increase in AKI.

Magnetic Resonance Angiography Alone Is Insufficient for Diagnosis and Surgical Planning in Children With Moyamoya.

BACKGROUND: The gold standard for evaluation of the severity of moyamoya vasculopathy is the Suzuki grade determined with cerebral catheter angiography (CA). With greater use of magnetic resonance angiography (MRA) it is important to understand if MRA is truly comparable to CA. METHODS: Children with moyamoya were evaluated using the Suzuki score for CA and the modified MRA six-stage Suzuki score to describe the angiographic findings in moyamoya from initial narrowing of the distal internal carotid artery to the "puff of smoke" appearance of the lenticulostriate collaterals and finally to the disappearance of this network of collaterals. Using Cohen kappa we compared Suzuki grade based on CA with MRA in the same patients. RESULTS: A total of 27 children with moyamoya were reviewed. We calculated a weighted Cohen kappa of 0.49 (P < 0.0001), which is a moderate correlation. CONCLUSIONS: We suggest caution in the reliance on MRA for the diagnosis and evaluation of severity of moyamoya in children.

Flow reduction due to arterial catheterization during stroke treatment - A computational study using a distributed compartment model.

The effectiveness of various stroke treatments depends on the anatomical variability of the cerebral vasculature, particularly the collateral blood vessel network. Collaterals at the level of the Circle of Willis and distal collaterals, such as the leptomeningeal arteries, serve as alternative avenues of flow when the primary pathway is obstructed during an ischemic stroke. Stroke treatment typically involves catheterization of the primary pathway, and the potential risk of further flow reduction to the affected brain area during this treatment has not been previously investigated. To address this clinical question, we derived the lumped parameters for catheterized blood vessels and implemented a corresponding distributed compartment (0D) model. This 0D model was validated against an experimental model and benchmark test cases solved using a 1D model. Additionally, we compared various off-center catheter trajectories modeled using a 3D solver to this 0D model. The differences between them were minimal, validating the simplifying assumption of the central catheter placement in the 0D model. The 0D model was then used to simulate blood flows in realistic cerebral arterial networks with different collateralization characteristics. Ischemic strokes were modeled by occlusion of the M1 segment of the middle cerebral artery in these networks. Catheters of different diameters were inserted up to the obstructed segment and flow alterations in the network were calculated. Results showed up to 45% maximum blood flow reduction in the affected brain region. These findings suggest that catheterization during stroke treatment may have a further detrimental effect for some patients with poor collateralization.

A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound?

The proper location of the tip of a central venous access device plays a crucial role in minimizing the risks potentially associated with its use. Recent guidelines strongly recommend preferring real-time, intra-procedural methods of tip location since they are more accurate, more reliable and more cost-effective than post-procedural methods. Intracavitary electrocardiography and real time ultrasound can both be applied in the neonatal setting, but they offer different advantages or disadvantages depending on the type of central venous access device. Reviewing the evidence currently available about the use of these two methods in neonates, in terms of applicability, feasibility and accuracy, it can be concluded that (a) real time ultrasound is the only acceptable methodology for tip navigation for any central venous access device in neonates, (b) intracavitary electrocardiography is the preferred method of tip location for central catheters inserted by ultrasound-guided cannulation of the internal jugular vein or the brachiocephalic vein, and (c) real time ultrasound is the preferred method of tip location for umbilical venous catheters, epicutaneo-cava catheters, and central catheters inserted by ultrasound-guided cannulation of the common femoral vein.

Focal alveolar hemorrhage following guide-wire progression into the pulmonary arterial circulation during fibrin sheath angioplasty and catheter exchange: Case report.

Central venous catheters are a frequently used vascular access for hemodialysis. Fibrin sheath formation is a common complication and is associated with catheter malfunction. Although fibrin sheath angioplasty with catheter exchange is a frequently employed procedure, it can be associated with mechanical complications. An important technical step in this procedure is progression of the guide-wire into the inferior vena cava. Focal alveolar hemorrhage is a very rare complication of this procedure. We report a case of a 70-year old patient on dual antiplatelet therapy who underwent fibrin sheath angioplasty with guide-wire catheter exchange and experienced focal alveolar hemorrhage presenting as hemoptysis and acute type 1 respiratory failure. Progression of the guide-wire into the pulmonary circulation and antithrombotic therapy played a significant role in the development of this complication. This report aims to call attention to a poorly described and potentially serious yet avoidable complication of fibrin sheath angioplasty with guide-wire catheter exchange.

Central venous catheter-related thrombosis in patients with amyotrophic lateral sclerosis.

BACKGROUND: Central venous catheterization may be required in patients with amyotrophic lateral sclerosis (ALS) for parenteral nutrition, antibiotic treatment, or blood sampling. Different venous access devices can be taken into consideration-centrally inserted central catheters (CICC), peripherally inserted central catheters (PICC), and femorally inserted central catheters (FICCs)-depending on the clinical conditions of the patients. Regardless of the type of access, the presence of paraplegia or tetraplegia is commonly considered a risk factor for catheter-related thrombosis (CRT). METHOD: This retrospective study analyzes the rate of CRT and other non-infectious complications associated with central venous access in a cohort of 115 patients with paraplegia or tetraplegia, most of them affected by ALS (n = 109). RESULTS: In a period of 34 months, from January 2021 to October 2023, we inserted 75 FICCs, 29 CICCs, and 11 PICCs. PICCs were inserted only in patients with preserved motility of the upper limbs. All devices were inserted by trained operators adopting appropriate insertion bundles. We had no immediate or early complication. Though antithrombotic prophylaxis was adopted only in 61.7% of patients, we had no symptomatic CRT. Other non-infectious complications were infrequent (4 out of 115 patients). CONCLUSION: These results suggest (a) that the presence of paraplegia or tetraplegia is not necessarily associated with an increased risk of CRT, (b) that the adoption of well-designed insertion bundles plays a key role in minimizing non-infectious complications, and (c) that the insertion of FICCs by direct cannulation of the superficial femoral vein at mid-thigh in paraplegic/tetraplegic patients may have the same advantages which have been described in the general population.

Impact of Catheter Ablation of Electrical Storm on Survival: A Propensity Score-Matched Analysis.

BACKGROUND: Electrical storm (ES) is a life-threatening condition, associated with substantial early and subacute mortality. Catheter ablation (CA) is a well-established therapy for ES. However, data regarding the impact of CA on the short-term and midterm survival of patients admitted for ES remain unclear. OBJECTIVES: This multicenter study aimed to investigate the impact of CA of ES on survival outcomes, while accounting for key patient characteristics associated with treatment selection. METHODS: A propensity score-matching (PSM) analysis was performed on 780 consecutive patients admitted for ES in 4 tertiary centers. PSM (1:1) based on the main characteristics associated with the use of CA or medical therapy alone was performed, resulting in 2 groups of 288 patients. RESULTS: After PSM, patients who underwent CA (n = 288) and those treated with medical therapy alone (n = 288) did not present any significant differences in the main demographic characteristics, ES presentation, and management. Compared with medical therapy alone, CA was associated with a significantly lower rate of ES recurrence at 1 year (5% vs 26%; P < 0.001). Similarly, CA was associated with a higher 1-year (91% vs 81%; P < 0.001) and 3-year (78% vs 71%; P = 0.017) survival after discharge. In subgroup analyses, effect of ablation therapy remained consistent in patients older than 70 years of age (HR: 0.39; 95% CI: 0.24-0.66), with substantial efficacy in patients with a LVEF <35% (HR: 0.39; 95% CI: 0.27-0.59). CONCLUSIONS: In propensity-matched analyses, this large study shows that CA-based management of patients admitted for ES is associated with a reduction in mortality compared with medical treatment, particularly in patients with a low ejection fraction.

Morphometry of left atrial appendage isthmus and mitral isthmus: implications for atrial fibrillation catheter ablation.

BACKGROUND: Radiofrequency catheter ablation (RFA) targets the left atrial appendage isthmus (LAA isthmus) and mitral isthmus for treatment of atrial fibrillation. However, proximity of left circumflex artery (LCxA) and great cardiac vein (GCV) in the isthmuses poses fatal risks during ablation. METHODS: This study investigated relationships of LCxA and GCV across three lines in the LAA and mitral isthmus, using 15 human cadaveric hearts. Distances between the vessels and the endocardium, myocardium, and perivascular fat thickness were measured. RESULTS: The results showed that LCxA was mostly consistently located in lower atrial segments and GCV was in lower/upper atrial segments, with change of course mainly observed in the middle of the LAA. The LCxA was found as close as 3-5 mm from the lower border of the LAA isthmus in 80% of specimens, at a depth of 2-3 mm within the LAA isthmus, where 1 mm consisted of myocardium and the remainder was fat, which may not provide adequate protection due to the possibility of liquefaction of fat with heat application. The effective myocardial thickness was consistently 1 mm across all cases in both isthmuses. LCxA was 2 mm in second and third sections of LAA isthmus ("careful segment"). LCxA distances from left inferior pulmonary vein opening was 5 to 12 mm, occasionally dangerously close as <1 mm in 16% of cases. CONCLUSION: This study measured LCxA and GCV in the LAA and mitral isthmus across three lines for the first time in the Indian population, aiding surgeons in RFA planning.

Anatomic obstacles in cavotricuspid isthmus detected by modified 2D transthoracic echocardiography and long-term outcomes in radiofrequency ablation of typical atrial flutter.

BACKGROUND: Although radiofrequency ablation of the cavotricuspid isthmus (CTI), responsible for sustaining atrial flutter, is a highly effective procedure, in extended patients' observations following this procedure, more than every tenth becomes unsuccessful. Therefore, this study aimed to provide helpful information about the anatomy of the CTI in transthoracic echocardiography, which can aid in better planning of the CTI radiofrequency ablation in patients with typical atrial flutter. MATERIALS AND METHODS: 56 patients with typical atrial flutter after radiofrequency ablation were evaluated at the end of the 24-month observation period. With substernal modified transthoracic echocardiographic (mTTE) evaluation, we identified four main anatomical obstacles impeding radiofrequency ablation. These obstacles were tricuspid annular plane systolic excursion, cavotricuspid isthmus length, cavotricuspid isthmus morphology, and the presence of a prominent Eustachian ridge/Eustachian valve. All intraprocedural radiofrequency ablation data were collected for analysis and correlated with anatomical data. RESULTS: In the 24-month observation period, freedom from atrial flutter was 67.86%. The mean length of the isthmus was 30.34 ± 6.67 mm. The isthmus morphology in 56 patients was categorized as flat (n = 27; 48.2%), concave (n = 10; 17.85%), and pouch (n = 19, 33.9%). A prominent Eustachian ridge was observed in 23 patients (41.1%). Lack of anatomical obstacles in mTTE evaluation resulted in 100% efficacy, while the presence of at least two obstacles significantly increased the risk of unsuccessful ablation with more than two (OR 12.31 p = 0.01). Generally, 8 mm electrodes were the most effective for non-difficult CTI, while 3.5 mm electrodes used with a 3D system had highest performance for complex CTI. Notably, aging was the only factor that worsened the long-term outcome (OR 1.07 p = 0.044). CONCLUSIONS: Preoperative usage of mTTE evaluation helps predict difficulty in cavotricuspid isthmus radiofrequency ablation, thus allowing better planning of the radiofrequency ablation strategy using the most accurate radiofrequency ablation electrode.

Factors associated with difficult intravenous access in the paediatric emergency department: A prospective cohort study.

OBJECTIVES: Although it is the most performed invasive procedure, peripheral intravenous catheter (PIVC) insertion in children can be difficult. The primary objective of the study was to identify the factors associated with difficult intravenous access (DIVA) in the paediatric ED, including patient, proceduralist and situational factors. METHODS: This was a single-centre prospective observational cohort study conducted over 28 consecutive days. Research assistants observed PIVC insertion attempts for children under 16 years of age and recorded data for variables relating to the patient, proceduralist and event. Univariate logistic regression modelling was performed to identify factors associated with DIVA, defined as unsuccessful PIVC insertion on the first attempt. RESULTS: A total of 134 participants were recruited; 66 were male (49%) with a median age of 5.7 years. Fifty-two (39%) were classified as having DIVA. There was a total of 207 PIVC insertion attempts with two or more attempts needed for 48 children (36%). Patient factors associated with DIVA included age of 3 years or less and limited vein options. Proceduralist factors included gestalt of 50% or less chance of success, use of a larger gauge (smaller bore) PIVC and less PIVC insertion experience. Situational factors included a combative child, higher pain score and loud ambient noise. CONCLUSIONS: The present study identified multiple patient, proceduralist and situational factors that were associated with DIVA in the paediatric ED. Future studies should explore the development and implementation of a package to address DIVA in children, with the patient-centred goals of reducing pain and improving success.

Ultrasound assessment of short peripheral catheter failure.

INTRODUCTION: Short peripheral catheters (SPCs) are affected by a high complication rate that leads to catheter failure. Currently, the Visual Infusion Phlebitis score (VIP) is the most used tool to verify the presence of inflammatory complications (phlebitis and thrombophlebitis). However, ultrasound signs (US) may be an attractive alternative. OBJECTIVE: This study aims to evaluate the sensitivity and specificity of US and VIP score = 1 in identifying and recognizing early signs of SPC failure. The time to positivity for US and VIP scores was assessed as a secondary outcome. METHODS: An observational prospective study was conducted. In each patient, US (subcutaneous edema; fibroblastic sleeve; thrombophlebitis) and VIP of the exit site were performed every 24 h until 96 h after insertion. Compared to catheter failure, Sensitivity, Specificity, and Predictive values in both US and VIP were calculated. RESULTS: Two hundred patients were enrolled. The presence of ultrasonic pattern suggestive of edema at 72 h (p = 0.018), fibroblastic sleeve at 24, 48, 72, and 96 h (p < 0.001), thrombosis at 48 (p < 0.001) and 72 h (p = 0.005), and at least one of an abovementioned US at all checkpoints (p < 0.001) were highly significant predictors of complications. Both US and VIP effectively detect inflammatory events; however, the US showed better sensitivity in overall checkpoints and earlier predictive ability than VIP (1.9 vs 0.47 days). CONCLUSIONS: An ultrasound inflammatory pattern is correlated with SPC failure. An ultrasound protocol-requiring minimal training-is more effective than VIP in recognizing early signs of device failure.

Vaginal dinoprostone versus Foley catheter for induction of labor at term with an unfavorable cervix: an open-label randomized controlled trial.

BACKGROUND: Induction of labor with mechanical methods or pharmacological agents is used in about 20-30% of all pregnant women. We specialized in comparing the effectiveness and safety of dinoprostone versus transcervical Foley catheter for induction of labor in term pregnant women with an unfavorable cervix with adequate samples. OBJECTIVE: To compare the effectiveness and safety of dinoprostone versus transcervical Foley catheter for induction of labor in term pregnant women with an unfavorable cervix. STUDY DESIGN: This is a parallel, open-label randomized controlled trial in two maternal centers in Shanghai, China between October 2019 and July 2022. Women with a singleton pregnancy in cephalic presentation at term and an unfavorable cervix (Bishop score < 6) scheduled for induction of labor were eligible. 1,860 women were randomly allocated to cervical ripening with either a dinoprostone vaginal insert (10mg) or a 60cc Foley catheter for up to 24 hours. The primary outcomes were vaginal delivery rate and time to vaginal delivery. Secondary outcomes included time to delivery and maternal and neonatal morbidity. Analysis was done from an intention-to-treat perspective. The trial was registered with the China trial registry (CTR2000038435). RESULTS: The vaginal birth rates were 72.8% (677/930) vs. 69.9% (650/930) in vaginal dinoprostone and Foley catheter, respectively (aRR 1.04, 95% CI 0.98 to 1.10, risk difference: 0.03). Time to vaginal delivery was not significantly different between the two groups (sub-distribution hazard ratio 1.11, 95% CI 0.99-1.24). Vaginal dinoprostone was more likely complicated with hyperstimulation with fetal heart rate changes (5.8% vs. 2.8%, aRR 2.09, 95% CI 1.32-3.31) and placenta abruption (0.9% vs. 0.1%, aRR: 8.04, 95% CI 1.01-64.15), while Foley catheter was more likely complicated with suspected intrapartum infection (5.1% vs. 8.2 %, aRR: 0.62, 95% CI 0.44-0.88) and postpartum infection (1.4% vs. 3.7%, aRR: 0.38, 95% CI 0.20-0.72). The composite of poor neonatal outcomes was not significantly different between the two groups (4.5% vs. 3.8%, aRR 1.21, 95% CI 0.78 to 1.88), while more neonatal asphyxia occurred in the dinoprostone group (1.2% vs. 0.2%, aRR 5.39, 95% CI 1.22 to 23.92). In a subgroup analysis, vaginal dinoprostone decreased vaginal birth rate slightly in multiparous women (90.6% vs. 97.0%, aRR 0.93, 95% CI 0.88 to 0.99). CONCLUSIONS: In term pregnant women with an unfavorable cervix, induction of labor with vaginal dinoprostone or Foley catheter has similar effectiveness. Foley catheter leads to better safety for neonates, while it may result in a higher risk of maternal infection. Furthermore, Foley catheter should be preferred in multiparous women.

Incidence of fatal and non-fatal pulmonary thromboembolism after removal of tunnelled central venous haemodialysis catheters without ultrasound scan and anticoagulation.

BACKGROUND: Catheter related thrombosis is a common complication of tunnelled central venous catheter (TCVC) usage. There are concerns that TCVC removal could dislodge a thrombus to cause pulmonary thromboembolism (PE). The incidence of PE following TCVC removal is unclear and so the aim of this study was to investigate the incidence of PE and whether it is high enough to warrant screening with ultrasound with a view to systemic anticoagulation prior to TCVC removal. METHODS: 1102 consecutive TCVC removals without ultrasound and systemic anticoagulation were included in this retrospective study. Data were extracted from electronic health records. Measures to identify PE events included: deaths, computed tomography pulmonary angiogram (CT-PA), isotope lung perfusion scans and D-dimers blood tests within 7 days of removal. RESULTS: Of the 1102 TCVC removals, the mean age of patients was 56.9 years and 57.3% were male. The primary renal diagnosis for 24.5% of patients was diabetic nephropathy. There were seven deaths following removal, none of which had PE as a contributing cause on review of their clinical history and death certificates. Five CT-PAs and one isotope lung perfusion scan were carried out in the 7 days after TCVC removal and none had a positive finding of PE. Three patient had D-dimers measured in blood within 7 days and none of these patients were subsequently diagnosed with PE. CONCLUSIONS: There was no evidence of fatal or non-fatal PE's occurring in the 7 days following TCVC removal. This would support the practice of removing TCVCs without the need for ultrasound screening and without a period of systemic anticoagulation.

An abysmal conundrum associated with a misplaced dialysis catheter.

A 25-year-old female patient with chronic glomerulonephritis, initiated on haemodialysis presented with high-grade fever, a dysfunctional catheter, low oxygen saturation and unstable blood pressure. Upon evaluation, the patient was febrile with elevated white blood cell counts. She was intubated, started on inotropes and transferred to the intensive care unit. Chest radiography showed that the tunnelled internal jugular dialysis catheter had migrated to the inferior vena cava. Echocardiography and transoesophageal echocardiography showed severe heart dysfunction with a large thrombus attached to the catheter, indicating catheter-related atrial thrombus (CRAT). CT pulmonary angiography revealed blockage of the segmental pulmonary arteries, suggesting pulmonary embolism. Blood and tracheal cultures revealed Methicillin-resistant Staphylococcus aureus (MRSA). The patient was administered appropriate antibiotics and anticoagulants and underwent surgical removal of the thrombus and the catheter. This case demonstrates the risks associated with improper placement of dialysis catheters and highlights the brief management of CRAT.

Catheter Ablation for Atrial Fibrillation in Patients with Significant Mitral Regurgitation: A Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) is commonly associated with cardiac structural abnormalities including mitral regurgitation (MR). Contemporary guidelines recommend consideration of early rhythm control strategies including catheter ablation (CA) for AF. However, the long-term efficacy of CA is highly variable across studies and patient populations, and the effect of coexisting MR on AF recurrence remains unclear. OBJECTIVES: Determine the impact of significant MR defined as ≥ moderate on AF recurrence rate following CA, and whether CA for AF is associated with significant changes in the severity of MR. METHODS: A systematic search of PubMed, EMBASE, Web of Science, and Cochrane databases for all English-language studies published till December 31, 2023 was performed. RESULTS: A total of 17 studies (N= 2624 patients) were retained for meta-analysis. The pooled recurrence proportion of AF post-CA in patients with baseline significant MR was 36% (95% CI 27 %-46%), compared to 27% (14%-41%) in patients without. The pooled hazard ratio (95% CI) for AF recurrence after CA in the presence of significant MR was 2.47 (1.52 - 4.01), p <0.001, Egger's test p-value =0.0583. The pooled proportion of patients who witnessed MR improvement to non-significant (i.e.

A nurse-led multifaceted intervention for the optimal use of indwelling urinary catheters at a tertiary care center: A before-after trial.

BACKGROUND: Few interventional studies of catheter-associated urinary tract infection (CAUTI) have been conducted to optimize indwelling urinary catheter (IUC) use in Japan. METHODS: The nurse-led, before-after study was conducted at a tertiary care center from June 2018 through May 2022. The intervention included 1) the provision of appropriate indications for IUC use, 2) prospective feedback to the primary care providers by ward nurses on unnecessary/inappropriate IUC use with two, separate interventional phases, the first involving intensive care units (ICU) only, the second involving ICU and general wards, and 3) proactive feedback by Infectious diseases physicians in the Infection Control department to the primary care providers regarding IUC discontinuation upon discharge from the ICU. RESULTS: During the first phase involving the implementation of the intervention only in the ICU, the indwelling urinary catheter-device utilization ratio (IUC-DUR) trend in the general wards decreased by 1.5 % (P = 0.01). However, the addition of the intervention to the general wards in the second phase led to a 2 % increase in the trend (P = 0.010). The CAUTI incidence in neither the ICU nor the general wards changed significantly. CONCLUSIONS: Although providing feedback on IUC removal at discharge from the ICU and appropriate indications for urinary catheter insertion can reduce inappropriate urinary catheter use, the nurse-led intervention alone was inadequate for reducing the CAUTI incidence.

Atrial fibrillation rhythm management: a matter of timing.

Rhythm control in patients with atrial fibrillation (AF) has evolved dramatically in the last decades. Several studies have informed us of the benefits of an early rhythm control strategy and primary rhythm control by catheter ablation (CA). Similarly, several studies have investigated the effects of CA in patients with longer AF duration and more comorbidities, especially heart failure. In the current review, we summarize the current evidence on rhythm control at different time points during the disease course of AF [Table 1 and Central illustration].

Cryoballoon ablation using the sheath-in-sheath technique in a patient with a tortuous common iliac vein.

The sheath-in-sheath technique, utilizing a 15Fr cryoballoon delivery sheath inserted into a 25 cm 16Fr sheath, effectively navigates tortuous iliac veins during cryoballoon ablation for atrial fibrillation, ensuring safe delivery and maintaining essential device performance without complications.