Indications for venous access in oncology - recommendations of national professional societies and current state in the Czech Republic.

BACKGROUND: The aim of the paper is to present the current recommendations and indications of venous access in oncology which reflect and recognize the opinions of national and international professional societies. It focuses exclusively on the indications of intravenous catheter placement for anticancer treatment, such as medium-term and long-term venous accesses. MATERIALS AND METHODS: The survey results obtained from a national questionnaire of 24 oncology centers identified the current situation in the Czech Republic. There were evaluated relevant data on the number of and the criteria for the introduction of venous accesses provided by physicians. Comparisons were made between current oncological practice and recommendations provided by evidence-based medicine. RESULTS: At each center surveyed in the Czech Republic, an average of 130 ports and 80 permanent implanted central catheters are introduced annually. The ports are increasingly indicated, with over a half of the centers surveyed introducing ports to more than 100 patients a year, with four centers introducing a total of 1,600 ports annually. In all centers, the decision for venous access is made by an oncologist. However, most procedures are performed by a doctor of another specialization, most often by a surgeon, a radiologist or an anesthesiologist. More than a half of the indications for venous access placement result from poor peripheral venous system or complications of parenteral therapy, not from comprehensive assessment prior to the initiation of the therapy. CONCLUSION: Based on our findings, we developed general indications and recommendations for venous access to cancer patients which represent the consensus of an interdisciplinary team of specialists, predominantly from the committee of professional societies - the Society for Ports and Permanent Catheters, the Working Group of Nutritional Care in Oncology of the Czech Oncological Society and the Society of Clinical Nutrition and Intensive Metabolic Care. The number of introduced venous access catheters remains insufficient to meet the needs in the Czech Republic, which necessitates increased awareness and possibilities for safe drug administration.

Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial.

OBJECTIVES: In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT. METHODS: This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC. RESULTS: Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006). CONCLUSIONS: LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT.

Holding and Mobility of Pediatric Patients With Transthoracic Intracardiac Catheters.

BACKGROUND: Nursing care of pediatric patients after cardiac surgery consists of close hemodynamic monitoring, often through transthoracic intracardiac catheters, requiring patients to remain on bed rest and limiting holding and mobility. OBJECTIVES: The primary aim of this quality improvement project was to determine the feasibility of safely mobilizing pediatric patients with transthoracic intracardiac catheters out of bed. Once feasibility was established, the secondary aim was to increase the number of days such patients were out of bed. METHODS AND INTERVENTIONS: New standards and procedures were implemented in July 2015 for pediatric patients with transthoracic intracardiac catheters. After initiation of the new policies, complications were tracked prospectively. Nursing documentation of activity and positioning for all patients with transthoracic intracardiac catheters was extracted from electronic health records for 2 fiscal years before and 3 fiscal years after the new policies were implemented. The Cochran-Armitage test for trend was used to determine whether patterns of out-of-bed documentation changed over time. RESULTS: A total of 1358 patients (approximately 250 to 300 patients each fiscal year) had activity and positioning documented while transthoracic intracardiac catheters were in place. The Cochran-Armitage test for trend revealed that out-of-bed documentation significantly increased after the new policies and procedures were initiated (P < .001). No major complications were noted resulting from patient mobility with transthoracic intracardiac catheters. CONCLUSION: Pediatric patients with transthoracic intracardiac catheters can be safely held and mobilized out of bed.

Developing Appropriateness Criteria for Pediatric Vascular Access.

OBJECTIVES: To describe the methodology undertaken to provide guidance on the appropriateness, as well as inappropriateness, of vascular access device selection, characteristics, and insertion technique for pediatric patients. METHODS: The RAND Corporation-University of California, Los Angeles Appropriateness Method was used. After definition of key terms and scope, a systematic review of the pediatric vascular access literature was undertaken. Clinical scenarios were developed to reflect the common indications for vascular access across pediatric health care. These were sectioned according to (1) device selection, (2) device characteristics, and (3) insertion technique. An interdisciplinary panel of experts (N = 14) consisting of leading experts representing diverse pediatric clinical disciplines including anesthesiology, cardiology and cardiac surgery, critical care and emergency, general surgery, hematology and oncology, hospital medicine, infectious disease, interventional radiology, pharmacology, regional pediatric hospitalist, and vascular access nursing specialties was convened. The scenarios were rated for appropriateness by the panel over 2 rounds (1 [highly inappropriate] to 9 [highly appropriate]). Round 1 ratings were completed anonymously and independently by panel members and classified into 3 levels of appropriateness: appropriate, uncertain, and inappropriate, or disagreement. For round 2, panelists met in-person to discuss the round 1 ratings and independently rerated the indications. All indications were reclassified into 3 levels of appropriateness or disagreement. CONCLUSIONS: The RAND Corporation-University of California, Los Angeles Appropriateness Method provides a rigorous, in-depth and transparent methodology to develop the first appropriateness criteria for the selection of pediatric vascular access devices in a range of patient groups.

Effectiveness of silver alloy-coated silicone urinary catheters in patients with acute traumatic cervical spinal cord injury: Results of a quality improvement initiative.

Patients with acute traumatic cervical spinal cord injury (ATCSCI) have an increased risk of catheter-associated urinary tract infection (CAUTI). The effectiveness of silver alloy-coated silicone urinary catheters (SACC) in preventing CAUTI in ATCSCI is unknown and was the objective of this study. We performed a quality improvement initiative in an attempt to reduce CAUTI in patients undergoing spine surgery at a single quaternary center. Prior to July 2015, all patients received a latex indwelling catheter (LIC). All patients with ATCSCI with limited hand function (AIS A,B, or C) received a SACC. Incidence of CAUTI, microbiology, duration of infection, antibiotic susceptibility, and catheter-associated adverse events were recorded prospectively. We studied 3081 consecutive patients over the three years, of whom 302 (9.8%) had ATCSCI; 63% of ATCSCI patients were ASIA Impairment Scale (AIS) A or B. The overall rate of CAUTI was 19% (585/3081), and was 38% (116/302) in patients with ATCSCI. Of 178 ATCSCI patients with LIC, 100 (56%) developed a CAUTI compared with 28 of 124 (23%) patients with SACC (p < 0.05). Poly-microbial and gram-positive infection was more common in LIC than in SACC (p < 0.05). Median duration of infection was 9 days in SACC group and 12 days in LIC group (p = 0.08). Resistance to trimethoprim (p < 0.001) and ciprofloxacin (p < 0.05) were more common in LIC group. There was no difference in catheter-associated adverse events or length of stay between the groups. This quality improvement initiative illustrates the effectiveness of antiseptic silver alloy-coated silicone urinary catheters in patients with ATCSCI. In our population, the use of SACC reduces the incidence and the complexity of CAUTI.

Efficacy and clinical outcome of the port-a-cath in children: a tertiary care-center experience.

BACKGROUND: Implanted vascular access devices play an essential role in the management of pediatric patients. The objectives of this study were to assess our experience with port-a-cath insertion in pediatric patients, report its complications, and compare open versus percutaneous approaches. METHODS: We performed a retrospective cohort study, including 568 patients who underwent port-a-cath insertion between 2013 and 2019 in our center. We grouped the patients according to the technique of insertion into two groups: group 1 (n = 168) included patients who had the open approach and group 2 (n = 404) included patients who had the percutaneous technique. (p < 0.001). RESULTS: Patients in group 1 were younger (4.10 ± 3.45 years) compared to patients in group 2 (5.47 ± 3.85 years). The main indications of insertion were hematological malignancy 57.74% (n = 328), solid organ malignancy 25.18% (n = 143), pure hematological diseases 5.46% (n = 31), metabolic diseases 2.64% (n = 15), and others for poor vascular access 8.8% (n = 50). The most common site for insertion in group 1 was the left external jugular (n = 136; 82.98%) and the left subclavian in group 2 (n = 203; 50.25%). Two hundred and two patients had a central line before catheter insertion (36.6%). Complications during insertion were comparable between both groups (p = 0.427). The catheter got stuck in 6 patients; all required additional incision and two needed venotomy. The most common reason to remove the catheter was the completion of the treatment (63.69% and 61.14%, in groups 1 and 2, respectively). The duration of the catheter was comparable between the two groups (13.14 ± 14.76 vs. 14.44 ± 14.04 months in group 1 vs.2; p = 0.327). CONCLUSIONS: Open and percutaneous port-a-cath insertions are safe in children with chronic diseases. Port-a-cath improved patients' management, and complications are infrequent. The most common complications are infection and catheter malfunction, which can be managed without catheter removal in some patients.

Tunneled dialysis catheter exchange through fibrin sheath crevice vs in situ catheter exchange for the treatment of catheter dysfunction.

Our aim is to evaluate the safety and efficacy of tunneled dialysis catheter (TDC) exchange through fibrin sheath crevice vs in situ catheter exchange in hemodialysis patients with fibrin-sheath-related catheter dysfunction. Patients with fibrin-sheath-related catheter dysfunction who underwent TDC exchange in our center between 2012 January and 2017 December were retrospectively screened. The included patients were divided into the sheath-crevice group (catheter was exchanged through fibrin sheath crevice) and the in situ group (catheter was exchanged in situ). The blood volume, Kt/V values, and complications were assessed as outcomes. Of the 44 included patients, 25 underwent in situ catheter exchange and 19 underwent catheter exchange through the fibrin sheath crevice. The stabilized maximal blood flow during the first hemodialysis after the catheter replacement reached 250 mL/min in all of the included patients. After 3 months, the stabilized maximal blood flow of the in situ group and the sheath-crevice group were 245.3 ± 9.0 and 244.8 ± 10.05 mL/min (P = .963), respectively. However, after 6 months, the stabilized maximal blood flow during hemodialysis (P = .048) and the Kt/V value (P < .001) of the patients in the sheath-crevice group were significantly higher than the in situ group. No severe complication related to the catheter exchange surgery was observed in either group. For patients with TDC dysfunction caused by fibrin sheath, catheter exchange through the fibrin sheath crevice most likely is a safe and effective alternative strategy for in situ catheter exchange.

Current port maintenance strategies are insufficient: View based on actual presentations of implanted ports.

Nursing staff play a crucial role in maintaining a functional port. Nursing guidelines recommend standard maintenance with 10 ml irrigation without consideration for variations among patients and individual nursing staff. The aim of this study is to identify the efficacy of the current maintenance strategy and analyze the correlation between complications and actual port presentations, based on disassembled intravenous ports after removal from patients. We attempt to organize the information and propose a definite maintenance strategy.After treatment completion, or due to complications, 434 implanted intravenous ports were removed from patients. All ports were deconstructed to observe their actual presentations and were then analyzed in conjunction with medical records. The correlation between complications and actual presentations was analyzed.From March 2012 to December 2017, 434 implanted intravenous ports were removed from oncology patients after completion of treatment or catheter related complications. From the view of maintenance related presentations, injection chamber blood clot was highly correlated with chemotherapy completion (P < .001) and malfunction (P = .005), while tip blood clot (P = .043) was related with chemotherapy completion and catheter fibrin (P = .015) was related to malfunction. From the view of structure related presentations, broken catheter integrity was correlated to chemotherapy completion (P = .007), fracture (P < .001), and malfunction (P = .008). Compression groove was related to chemotherapy completion (P = .03) and broken catheter at protruding stud was related to fracture (P = .04), while diaphragm rupture was correlated to chemotherapy completion (P = .048) and malfunction. (P < .001).Current port maintenance is insufficient for ideal port maintenance, whereby maintenance-related presentations, including tip clot, catheter fibrin, and injection chamber blood clot were identified. We propose a recommended maintenance strategy based on our findings. Structure-related presentations, including broken catheter integrity, broken catheter at protruding stud and diaphragm rupture were seen in patients with longer implantation period. Removal of the implanted port may be considered after 5 years if no disease relapse is noted.

A Peritoneal Dialysis Access Quality Improvement Initiative: A Single-Center Experience.

Background:Little evidence exists regarding optimal peritoneal dialysis (PD) access insertion pathways, benchmarking for patency targets, and definitions of access dysfunction.Methods:This quality improvement (QI) project evaluated patients with PD catheters inserted at a single center in Toronto, Canada, following: establishment of PD catheter insertion protocols, a PD access coordinator, PD access operator training, and outcomes reporting. We define primary vs secondary PD catheter dysfunction by presentation before/after initial home PD treatment. We report catheter dysfunction rates, interventions restoring PD catheter patency (interventional radiology [IR] vs advanced laparoscopic [AL]) (embedded vs non-embedded) between 2012 and 2017.Results:A total of 297 first PD catheters were inserted between January 2012 and December 2017. Interventional radiology PD catheters (n = 94) were placed in older patients with greater comorbidities and less prior abdominal surgery than AL-placed catheters. Indications for IR insertion included need for urgent dialysis given resource availability (36.2% [n = 34]) and prohibitive surgical risk (26.6% [n = 25]). Interventional radiology-inserted catheters had overall (primary and secondary) dysfunction rates of 17%. Non-embedded AL catheters had 16.1% overall dysfunction. Embedded AL-inserted PD catheters had a 24.6% overall dysfunction rate. Among all dysfunctional catheters, IR manipulation was successful in 31% (n = 11), and surgical revision was necessary in all unsuccessful cases with either lysis of adhesions or omentopexy to establish patency.Conclusion:Our PD catheter QI initiative involved tracking, outcome reporting, defining PD catheter dysfunction and PD access insertion pathway development, yielding important insights into opportunities for program improvement. Multicenter research initiatives are needed to further improve PD access dysfunction definitions and to establish the best benchmarks for these metrics.

Comparison of programmed intermittent bolus infusion and continuous infusion for postoperative patient-controlled analgesia with thoracic paravertebral block catheter: a randomized, double-blind, controlled trial.

BACKGROUND AND OBJECTIVES: In this randomized, double-blind, controlled study, we hypothesized that programmed intermittent bolus infusion (PIBI) of local anesthetic for continuous paravertebral block (PVB), combined with patient-controlled analgesia (PCA), provided better pain control, better patient satisfaction, and decreased in local anesthetic consumption when compared with a continuous infusion (CI) combined with PCA, after video-assisted thoracoscopic unilateral lung resection surgery. METHODS: Preoperatively, patients undergoing video-assisted thoracoscopic unilateral lung resection surgery received ipsilateral paravertebral catheters inserted at the level of thoracic vertebrae 4 and 5. All the subjects received an initial bolus of 15 mL 0.375% ropivacaine via the catheters. Subjects were randomized to receive 0.2 % ropivacaine 8 mL/h as either PIBI (n=17) or CI (n=17) combined with a PCA pump. The pain scores, frequency of PCA, local anesthetic consumption, patient satisfaction, and the need for rescue analgesia with tramadol were recorded until 48 hours postoperative. RESULTS: The numeric rating scale scores in the PIBI group were significantly lower than the CI group at 4, 8, 12 hours and 4, 8, 12, 24 hours postoperatively, at rest, and during coughing, respectively. PCA local anesthetic consumption (30 mg (20-60 mg) vs 120 mg (70-155 mg), p=0.000) and frequency of PCA use over 48 hours (3 (2-6) vs 12 (7-15.5), p=0.000) was lower in the PIBI group as compared with the CI group. Additionally, the PIBI group showed greater patient satisfaction. The need for tramadol rescue was similar in the two groups. CONCLUSIONS: In PVBs, local anesthetic administered as a PIBI in conjunction with PCA provided superior postoperative analgesia to a CI combined with PCA in patients undergoing video-assisted thoracoscopic unilateral lung resection surgery. CLINICAL TRIAL REGISTRATION: ChiCTR-IOR-17011253.

Peripherally inserted central catheter, midline, and "short" midline in palliative care: Patient-reported outcome measures to assess impact on quality of care.

OBJECTIVES: A prospective, observational study was conducted in our palliative care unit to assess the impact of peripherally inserted central catheters (PICCs), midline, and "short" midline catheters on the quality of care in cancer and non-cancer patients. The secondary objective was to assess pain and distress during vascular access device insertion. METHODS: Patients were recruited if they underwent insertion of a PICC, midline, or "short" midline catheter as part of their standard care. The Palliative care Outcome Scale was used to assess changes in quality of care after vascular access device positioning. A numerical rating scale was used to measure pain intensity during catheter insertion. RESULTS: Of the 90 patients enrolled, 52.2% were male with a mean age of 73.0 ± 13 years. Among these patients, 64.4% patients underwent "short" midline insertion, 26.7% PICC, and 8.9% midline catheter. The patients' mean baseline Palliative care Outcome Scale score was 15.7 ± 5.6. Three days after vascular access device positioning, the patients' mean Palliative care Outcome Scale score was 11.5 ± 5.5 (p < 0.0001). Mean pain score during vascular access device insertion was 1.26 ± 1.63, and mean procedural distress score was 1.78 ± 1.93. CONCLUSION: These findings suggest that medium-term intravenous catheters can have a favorable impact on quality of care and the procedures for these vascular access device insertions are well tolerated. Further research on the performance of different vascular access devices and their appropriateness in palliative care should be encouraged.

Tunnelled central venous access devices in small children: A comparison of open vs. ultrasound-guided percutaneous insertion in children weighing ten kilograms or less.

PURPOSE: Ultrasound-guided (USG) percutaneous insertion of tunnelled central venous access devices (CVADs) has been shown to be safe and effective in adults. However, there have been concerns over the safety of this technique in small children. This paper analyses the safety of USG percutaneous CVAD insertion in the pediatric population weighing ten kilograms or less. METHOD: All surgically inserted CVADs for children weighing ten kilograms or less, between January 2010 and December 2015 at the Children's Hospital at Westmead were retrospectively reviewed. Open and USG percutaneous techniques were compared with intraoperative complications as the primary outcome variable. Secondary outcome measures included conversion to open technique, postoperative complications, operating time and catheter longevity. RESULTS: 232 cases were identified: 96 (41.4%) open, 136 (58.6%) USG percutaneous. Age ranged <1-48 months; weight 0.7-10 kg. CVADs ranged 2Fr-9Fr in size. Eleven USG percutaneous cases required conversion to open. There was no significant difference in intraoperative complication rate between open (11/96, 11.5%) and USG percutaneous (19/136, 14.0%) groups (p = 0.574). There was no significant difference in overall postoperative complications, operative time or catheter longevity. Mechanical blockage was significantly higher in the open group than the USG percutaneous group (21% vs 10%, p = 0.015). CONCLUSION: USG percutaneous CVAD insertion is safe in children weighing ten kilograms or less. Open catheter insertion may be associated with higher rates of post-operative catheter blockage in small children. LEVEL OF EVIDENCE: Level III.

Local and systemic effects of a silver nitrate coated indwelling pleural catheter in an animal model of pleurodesis.

Purpose/Aim of the study: This study assessed the safety and potential toxicity of a silver nitrate coated indwelling pleural catheter (SNCIPC) designed to create pleurodesis in a large animal model. MATERIALS AND METHODS: Sixteen animals underwent insertion of either a SNCIPC or an uncoated silicone catheter. Half of the animals were sacrificed at day 7 and the others at day 30. Animal weight and assessment of well-being, pleural fluid and blood collection were performed at regular intervals. Pleurodesis was assessed at necropsy and histopathological examination of organs performed. RESULTS: No mortality or significant clinical findings were observed throughout the experiment. SNCIPC treated animals had increased pleural fluid drainage overall (p < 0.001) and specifically on days 1-4. No differences in hemoglobin, white blood cell count or neutrophil counts were detected between groups. No treatment related histological findings were observed in any of the evaluated tissues outside of the treated area. Serum silver levels in SNCIPC catheter treated animals peaked on Day 4 (0.185 µg/mL, 30 day group) then gradually decreased for the remainder of the study period. The highest tissue silver concentrations were noted in the SNCIPC groups in tissues close to the treatment site in addition to the liver (59.8ug/g +/- 8.6 and 73.3ug/g +/- 25). Pleurodesis scores were significantly higher in SNCIPC treated animals for both the 7 day (median 6.5 vs. 1.0, p = 0.029) and 30 day cohorts (median 7.0 vs. 1.5, p = 0.029). CONCLUSIONS: SNCIPC are well tolerated and not associated with any significant signs of toxicity. Silver levels were elevated in local tissues, serum and liver but without evidence of pathological impact. Effective pleurodesis was present by day 7 and more established by day 30. Clinical studies to investigate the safety and efficacy of this device in patients with malignant pleural effusions appear warranted.

Optimal implantation of Ommaya reservoirs for cystic metastatic brain tumors preceding Gamma Knife radiosurgery.

INTRODUCTION: Although Ommaya reservoir implantation is effective in reducing the target volume of cystic brain metastases preceding stereotactic radiosurgery, adequate volume reduction cannot be achieved in some cases, and the factors leading to failure in volume reduction have not been clearly identified. In this study, we investigated the factors leading to failure in volume reduction after use of the Ommaya reservoir. MATERIALS AND METHODS: Between December 2007 and February 2015, 38 consecutive patients with 40 cystic metastases underwent Ommaya reservoir implantation at our institution. The patient characteristics, treatment parameters, and all available clinical and neuroimaging follow-ups were analyzed retrospectively. RESULTS: The rate of volume reduction was significantly related to the location of the tube tip inside the cyst. By placing the tip at or near the center, 58.7% reduction was achieved, whereas reduction of 42.6% and 7.7% occurred with deep and shallow tip placement, respectively (p=0.011). Although there was no additional surgery in the center placement group, additional surgeries were performed in 5 out of the 23 deep and shallow cases due to inadequate volume reduction. No other factors were correlated with successful volume reduction. CONCLUSION: For adequate volume reduction using the Ommaya reservoir in the treatment of cystic brain metastases prior to stereotactic radiosurgery, the tip of the reservoir tube should be placed at the center of the cyst.

Intercorrências em dispositivos intravenosos de longa permanência na oncohematologia pediátrica: estratégias de aperfeiçoamento do manuseio / Complications in long-term intravenous devices in pediatric oncohematology: strategies for improved management

Introdução: Durante o tratamento ambulatorial da criança ou adolescente com doença oncohematológica são necessárias inúmeras internações hospitalares e o estabelecimento de um acesso venoso vascular de longa permanência se faz necessário para realização do tratamento quimioterápico. Objetivos: Identificar o perfil clínico de crianças/adolescentes com doença oncohematológica e as características dos cateteres utilizados para realização do seu tratamento; Identificar as principais complicações a partir da manipulação destes cateteres; Elaborar fluxograma de Terapia Lock em cateter totalmente implantado; Elaborar rotina de manipulação do cateter totalmente implantado; Aprimorar a ficha de vigilância epidemiológica que contemple os diferentes tipos de procedimentos realizados durante a manipulação dos cateteres; Realizar um curso de manipulação segura de Cateter Totalmente Implantado. Metodologia: Estudo descritivo, com abordagem quantitativa de 78 fichas de vigilância epidemiológica dos cateteres totalmente implantados e dos cateteres epicutâneo; o cenário do estudo foi um ambulatório de oncohematologia pediátrica localizado em um Hospital Federal do município do Rio de Janeiro, os dados foram coletados em agosto 2015. O projeto foi aprovado com o parecer de número: 1.213.979. Resultados: Os dados levantados nos mostraram que as crianças que realizam tratamento hematológico tiveram um ou mais cateteres. Observou-se que n=32 (59%) dos portadores de cateter totalmente implantado eram do sexo masculino, e n=sete (53%) dos portadores de cateter epicutâneo eram do sexo feminino, a idade variava entre 10 a 16 anos, o principal diagnóstico foi leucemia linfoide aguda em ambos. A média de utilização do cateter totalmente implantado foi 303 dias, enquanto do cateter epicutâneo foi 55 dias, o término do tratamento é o principal motivo de retirada de ambos. A falta de preenchimento de informações nas fichas foi limitador desta pesquisa. Conclusão: Conclui-se que os dois dispositivos levantados por esta pesquisa, desde que indicados e manipulados de forma correta, conseguem cumprir com o objetivo proposto que é proporcionar um tratamento ininterrupto e seguro para o paciente. Havia necessidade de padronizar a rotina de manipulação do cateter totalmente implantado afim de que toda a equipe envolvida realizasse as técnicas de forma segura e eficaz reduzindo assim as chances de complicações relacionadas a este dispositivo.

Discontinuation of peri-operative gentamicin use for indwelling urinary catheter manipulation in orthopaedic surgery.

BACKGROUND: Gentamicin has historically been used prior to insertion and removal of indwelling urinary catheters (IDCs) around elective joint replacement surgery to prevent infection; however, this indication is not recognized in the Australian Therapeutic Guidelines: Antibiotic and the paradigm for safe use of gentamicin has shifted. METHODS: The antimicrobial stewardship team of a 500 bed tertiary regional hospital performed a retrospective clinical study of gentamicin IDC prophylaxis around total hip and knee arthroplasties. Results were presented to the orthopaedic surgeons. A literature review identified no guidelines to support gentamicin prophylaxis and only a very low risk of bacteraemia associated with IDC insertion/removal in patients with established bacteriuria. Consensus was reached with the surgeons to discontinue this practice. Subsequent prospective data collection was commenced to determine effectiveness, with weekly feedback to the Department Head of Orthopaedics. RESULTS: Data from 137 operations pre-intervention (6 months) were compared with 205 operations post-intervention (12 months). The median patient age was 72 years in both groups. Following the intervention, reductions in gentamicin use were demonstrated for IDC insertion (59/137 (42%) to 4/205 (2%), P < 0.01) and removal (39/137 (28%) to 6/205 (3%), P < 0.01). No gentamicin use was observed during the final 40 weeks of the post-intervention period. There were no significant differences between the groups for pre-operative bacteriuria, surgical site infections or acute kidney injury. CONCLUSION: A collaborative approach using quality improvement methodology can lead to an evidence-based reappraisal of established practice. Regular rolling audits and timely feedback were useful in sustaining change.

Standards of care for feline urethral catheters in the UK.

OBJECTIVES: This study aimed to determine the standards of care for urethral catheters (UCs) placed in male cats for treatment of urethral obstruction (UO). It also assessed whether these standards were influenced by year of graduation of the veterinary surgeon (VS). METHODS: One hundred veterinary practices were randomly selected, and a telephone survey was conducted with a VS in the practice. Regarding the last urethral catheterisation performed for a male cat with UO, the VS was asked about the use of antibiotics while the catheter was in situ, whether a closed urinary collection system was used, whether aseptic skin preparation of the patient was performed and whether aseptic hand preparation was performed. A χ(2) test was used to determine whether there were significant differences in these percentages when considering year of graduation. RESULTS: Twenty-seven percent of VSs did not use antibiotics while the urethral catheter was in place, 44% used closed urinary collection systems, 41% performed aseptic skin preparation of the patient and 60% aseptically prepared their hands and wore sterile gloves. There was a statistically significant (P <0.01) difference in antibiotic usage, closed collection system usage and aseptic hand preparation across graduation year groups. CONCLUSIONS AND RELEVANCE: Non-sterile urethral catheter placement with open urinary drainage and antibiotic prophylaxis is still a widespread practice among VSs; however, more recent graduates are more likely to perform the procedure aseptically with a closed urinary collection system and withholding of antibiotics. There is a need for further education for postgraduate veterinarians in the prevention of catheter-associated urinary tract infections in cats and further research to provide evidence-based guidelines for feline urethral catheter care.

A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection.

OBJECT In a previous report by the same research group (Kestle et al., 2011), compliance with an 11-step protocol was shown to reduce CSF shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. METHODS The new protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Procedures performed up to September 30, 2013, were included (21 months). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 1935 procedures were performed on 1670 patients at 8 HCRN centers. The overall infection rate was 6.0% (95% CI 5.1%-7.2%). Procedure-specific infection rates varied (insertion 5.0%, revision 5.4%, insertion after EVD 8.3%, and insertion after treatment of infection 12.6%). Full compliance with the protocol occurred in 77% of procedures. The infection rate was 5.0% after compliant procedures and 8.7% after noncompliant procedures (p = 0.005). The infection rate when using this new protocol (6.0%, 95% CI 5.1%-7.2%) was similar to the infection rate observed using the authors' old protocol (5.7%, 95% CI 4.6%-7.0%). CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRN centers had a lower infection rate than noncompliant procedures. Implementation of the new protocol (including AICs) was associated with a 6.0% infection rate, similar to the infection rate of 5.7% from the authors' previously reported protocol. Based on the current data, the role of AICs compared with other infection prevention measures is unclear.

Diagnostic accuracy of the Catheter Injection and Aspiration (CINAS) classification for assessing the function of totally implantable venous access devices.

PURPOSE: Intravenous catheters are used for the administration of intravenous therapy and for blood sampling. These devices are considered as well-functioning if both the injection and aspiration are easy. Malfunction is frequently observed and usually vaguely described as occlusion. We developed the CINAS, the Catheter Injection and Aspiration scheme. The CINAS is a catheter function classification tool, which classifies both the injection and the aspiration ability in a uniform way. Each CINAS class consists of a combination of an injection (IN) and an aspiration (AS) code: e.g. IN1AS1 is the CINAS class for a well-functioning catheter. In this series, we aimed to determine the accuracy of the CINAS class reported by nurses, after minimal training, versus a trained researcher, acting as a reference standard. METHODS: Catheter function was assessed during a standard blood sampling procedure through a totally implantable venous access device in a convenience sample of 150 oncology patients. One nurse researcher and 111 oncology nurses both scored the catheter function according to the CINAS classification scheme, independently. Concordance between the scores was calculated. RESULTS: For the 140 catheters scored as well-functioning (IN1AS1 score) by the researcher, 139 or 99.3 % (95 % confidence interval (CI) 96.1-99.9 %) were scored correctly by the nurse participants. Nine out of ten or 90 % (95 % CI 55.5-98.3 %) of malfunctioning catheters (researcher scores different from IN1AS1) were also identified as malfunctioning by the nurse participants and received exactly the same CINAS score in eight cases (80 %, 95 % CI 44.4-97.5 %). The overall accuracy of the CINAS scored by the nurse participants versus the researcher is (139 + 9)/150 or 98.7 % (95 % CI 95.3-99.8 %). CONCLUSIONS: Nurse participants were able to classify the catheter function of totally implantable venous access devices with the CINAS accurately after a brief explanation about the classification options.