Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study.

BACKGROUND: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications. METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models. RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar. CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.

Complication Rates of Peripherally Inserted Central Catheters in Oncologic Versus Non-Oncologic Patients.

OBJECTIVES: Peripherally inserted central catheters are commonly used in cancer patients and provide vascular access for the administration of chemotherapy, antibiotics, or parenteral nutrition. Besides many advantages, they represent a source of possible complications such as catheter related blood stream infection, catheter occlusion, or thrombosis. In this study, the catheter-related complication rate between oncologic and non-oncologic patients was compared. METHODS: This retrospective cohort-study included 411 patients who underwent their first catheter placement at the Vienna General Hospital-Medical University of Vienna from January 2013 to June 2018. Patient demographics and catheter-related parameters were collected and statistically analyzed using a competing risk model. RESULTS: Mean catheter dwell time was 27.75 days. The overall complication rate was 7.54% (2.72 per 1000 catheter days). Underlying malignant disease (hazard ratio: 0.351, 95% confidence interval [CI]: 0.133-0.929, P = .035) and chemotherapy administration (hazard ratio: 2.837, 95% CI: 1.088-7.394, P = .033) were significantly associated with the occurrence of any kind of complication. Catheter related blood stream infection was observed among 11 (2.68%) patients and again significantly associated with chemotherapy administration (hazard ratio: 4.545, 95% CI: 1.178-17.539; P = .028). Thrombosis was found in 7 (1.70%) patients and occlusion in 13 (3.16%) cases. CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: Choice of venous access is an interdisciplinary decision with emphasis on patient participation. In oncologic patients, our data suggests that the benefits of peripherally inserted central catheters regarding costs, invasiveness, and accessibility might be outweighed by the higher rate of complications associated with the device. This becomes even more important in a community care setting, where standardized handling procedures and patient education play a pivotal role in device safety.

Retrospective evaluation of intravenous catheterization in client-owned lizards at a veterinary teaching hospital: 21 cases (2018-2021).

OBJECTIVE: To assess the prevalence of lizards presenting to a university teaching hospital that had an IV catheter placed, the catheterization sites used, and complications arising with the placement of the catheter both in the short and long term. DESIGN: Retrospective study. SETTING: University teaching hospital. ANIMALS: Twenty-one lizards, including inland bearded dragons (Pogona vitticeps; 15/21), green iguanas (Iguana iguana; 4/21), and veiled chameleons (Chamaeleo calyptratus; 2/21). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 129 lizard consultations performed between September 27, 2018 and September 27, 2021, 21 catheters were placed, resulting in an overall prevalence of 16.3%. Reasons for catheter placement included hospitalization for fluid therapy (10/21 [47.6%]), anesthesia or surgery ± hospitalization (7/21 [33.3%]), computed tomography scan with contrast (2/21 [9.5%]), euthanasia only (1/21 [4.8%]), and CPR only (1/21 [4.8%]). All catheters were placed in the ventral coccygeal vein via a ventral approach. Sedation was used in 6 of 21 (28.6%) of the catheters placed. Seven of the catheters (35%) were used for administration of fluids only, 4 (20%) were used for administering drugs/medications only, and 9 (45%) catheters administered both fluids and drugs/medications. No complications were noticed in any of the lizards that had catheters placed, both in the short and long term. CONCLUSIONS: Based on the retrospective evaluation of medical records at a veterinary teaching hospital, IV catheter placement in lizards is feasible, including in conscious animals, with roughly 1 consultation out of 6 resulting in a catheter placed. The most frequent reason for catheter placement was for administration of fluids.

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization.

INTRODUCTION: To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. MATERIALS AND METHODS: We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. RESULTS: Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. CONCLUSION: Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.

Intraoperative Blood Pressure Monitoring in Obese Patients.

BACKGROUND: The optimal method for blood pressure monitoring in obese surgical patients remains unknown. Arterial catheters can cause potential complications, and noninvasive oscillometry provides only intermittent values. Finger cuff methods allow continuous noninvasive monitoring. The authors tested the hypothesis that the agreement between finger cuff and intraarterial measurements is better than the agreement between oscillometric and intraarterial measurements. METHODS: This prospective study compared intraarterial (reference method), finger cuff, and oscillometric (upper arm, forearm, and lower leg) blood pressure measurements in 90 obese patients having bariatric surgery using Bland-Altman analysis, four-quadrant plot and concordance analysis (to assess the ability of monitoring methods to follow blood pressure changes), and error grid analysis (to describe the clinical relevance of measurement differences). RESULTS: The difference (mean ± SD) between finger cuff and intraarterial measurements was -1 mmHg (± 11 mmHg) for mean arterial pressure, -7 mmHg (± 14 mmHg) for systolic blood pressure, and 0 mmHg (± 11 mmHg) for diastolic blood pressure. Concordance between changes in finger cuff and intraarterial measurements was 88% (mean arterial pressure), 85% (systolic blood pressure), and 81% (diastolic blood pressure). In error grid analysis comparing finger cuff and intraarterial measurements, the proportions of measurements in risk zones A to E were 77.1%, 21.6%, 0.9%, 0.4%, and 0.0% for mean arterial pressure, respectively, and 89.5%, 9.8%, 0.2%, 0.4%, and 0.2%, respectively, for systolic blood pressure. For mean arterial pressure and diastolic blood pressure, absolute agreement and trending agreement between finger cuff and intraarterial measurements were better than between oscillometric (at each of the three measurement sites) and intraarterial measurements. Forearm performed better than upper arm and lower leg monitoring with regard to absolute agreement and trending agreement with intraarterial monitoring. CONCLUSIONS: The agreement between finger cuff and intraarterial measurements was better than the agreement between oscillometric and intraarterial measurements for mean arterial pressure and diastolic blood pressure in obese patients during surgery. Forearm oscillometry exhibits better measurement performance than upper arm or lower leg oscillometry.

Safety, Efficacy, and Patient Satisfaction with Initial Peripherally Inserted Central Catheters Compared with Usual Intravenous Access in Terminally Ill Cancer Patients: A Randomized Phase II Study.

PURPOSE: The purpose of this study was to investigate whether routine insertion of peripherally inserted central catheter (PICC) at admission to a hospice-palliative care (HPC) unit is acceptable in terms of safety and efficacy and whether it results in superior patient satisfaction compared to usual intravenous (IV) access. MATERIALS AND METHODS: Terminally ill cancer patients were randomly assigned to two arms: routine PICC access and usual IV access arm. The primary endpoint was IV maintenance success rate, defined as the rate of functional IV maintenance until the intended time (discharge, transfer, or death). RESULTS: A total of 66 terminally ill cancer patients were enrolled and randomized to study arms. Among them, 57 patients (routine PICC, 29; usual IV, 28) were analyzed. In the routine PICC arm, mean time to PICC was 0.84 days (range, 0 to 3 days), 27 patients maintained PICC with function until the intended time. In the usual IV arm, 11 patients maintained peripheral IV access until the intended time, and 15 patients underwent PICC insertion. The IV maintenance success rate in the routine PICC arm (27/29, 93.1%) was similar to that in the usual IV arm (26/28, 92.8%, p=0.958). Patient satisfaction at day 5 was better in the routine PICC arm (97%, 'a little comfort' or 'much comfort') compared with the usual IV arm (21%) (p <0.001). CONCLUSION: Routine PICC insertion in terminally ill cancer patients was comparable in safety and efficacy and resulted in superior satisfaction compared with usual IV access. Thus, routine PICC insertion could be considered at admission to the HPC unit.

The Rise of Transradial Artery Access for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes in Australia.

OBJECTIVES: The aim of this study was to evaluate the outcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) via transradial artery access (TRA) or transfemoral artery access (TFA). BACKGROUND: Over the last decade, evidence for the benefit of TRA for PCI has grown, leading to a steady uptake of TRA around the world. Despite this, the topic remains controversial with contrary evidence to suggest no significant benefit over TFA. METHODS: A retrospective study of consecutive ACS patients from 2011 to 2017 who underwent PCI via TRA or TFA. The primary outcome was Major Adverse Cardiovascular Events (MACE), a composite of death, myocardial infarction (MI), target lesion revascularisation (TLR), or coronary artery bypass graft surgery (CABG) at 12 months. Secondary outcomes included Bleeding Academic Research Consortium (BARC) bleeding events scored 2 or higher, haematoma formation, and stent thrombosis, in addition to all individual components of MACE. RESULTS: We treated 3624 patients (77% male), with PCI via TFA (n = 2391) or TRA (n = 1233). Transradial artery access was associated with a reduction in mortality (3% vs 6.3%; p < 0.0001), MI (1.8% vs 3.9%; p=0.0004), CABG (0.6% vs 1.5%; p=0.0205), TLR (1% vs 2.9%; p < 0.0001), large haematoma (0.4% vs 1.8%; p=0.0003), BARC 2 (0.2% vs 1.1%; p=0.0029), and BARC 3 events (0.4% vs 1.0%; p=0.0426). On multivariate Cox regression analysis, TFA, age ≥ 75, prior PCI, use of bare metal stents, cardiogenic shock, cardiac arrest, and multivessel coronary artery disease were associated with an increased risk of MACE. CONCLUSION: Despite the limitations secondary to the observational nature of our study and multiple confounders, our results are in line with results of major trials and, as such, we feel that our results support the use of TRA as the preferred access site in patients undergoing PCI for ACS to improve patient outcomes.

A multidisciplinary approach to VA ECMO cannulation in children.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) supports gas exchange and circulation in critically ill patients. This study describes a multidisciplinary approach to ECMO cannulation using the expertise of pediatric surgery (PS) and interventional radiology (IR). MATERIAL AND METHODS: Pediatric patients (<18 years) undergoing percutaneous cannulation for peripheral veno-arterial (VA) ECMO by PS and IR from April 2017 to May 2018 were included. Cardiac patients and children cannulated by PS alone were excluded. RESULTS: Five patients were included in the series. Median age was 16 [12.5-17] years and 3 were female. Median ECMO arterial and venous catheter sizes were 19 [17-22] Fr and 25 [25-28] Fr, respectively. Both catheters were placed in the common femoral vessels. A 6Fr antegrade distal perfusion cannula (DPC) was also placed in the superficial femoral artery by IR at the time of cannulation. The median time from admission to procedure start was 10 [7-50] hours and the children were on ECMO for a median length of 3.2 [2.3-4.8] days. There were two episodes of bleeding. No patients had loss of limb circulation. CONCLUSION: A multidisciplinary approach to peripheral VA ECMO cannulation is feasible and safe. Maintenance of limb perfusion by percutaneous placement and removal of DPC may be an advantage of this collaborative approach. LEVEL OF EVIDENCE: IV. TYPE OF RESEARCH: Case series.

De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before and after study.

BACKGROUND: Catheter-associated bloodstream infections and urinary tract infections are frequently encountered health care-associated infections. We aimed to reduce inappropriate use of catheters to reduce health care-associated infections. METHODS: In this multicentre, interrupted time-series and before and after study, we introduced a de-implementation strategy with multifaceted interventions in seven hospitals in the Netherlands. Adult patients admitted to internal medicine, gastroenterology, geriatic, oncology, or pulmonology wards, and non-surgical acute admission units, and who had a (central or peripheral) venous or urinary catheter were eligible for inclusion. One of the interventions was that nurses in the participating wards attended educational meetings on appropriate catheter use. Data on catheter use were collected every 2 weeks by the primary research physician during the baseline period (7 months) and intervention period (7 months), which were separated by a 5 month transition period. The primary outcomes were percentages of short peripheral intravenous catheters and urinary catheters used inappropriately on the days of data collection. Indications for catheter use were based on international guidelines. This study is registered with Netherlands Trial Register, NL5438. FINDINGS: Between Sept 1, 2016, and April 1, 2018, we screened 6157 patients for inclusion, of whom 5696 were enrolled: 2650 patients in the baseline group, and 3046 in the intervention group. Inappropriate use of peripheral intravenous catheters occurred in 366 (22·0%, 95% CI 20·0 to 24·0) of 1665 patients in the baseline group and in 275 (14·4%, 12·8 to 16·0) of 1912 patients in the intervention group (incidence rate ratio [IRR] 0·65, 95% CI 0·56 to 0·77, p<0·0001). Time-series analyses showed an absolute reduction in inappropriate use of peripheral intravenous catheters from baseline to intervention periods of 6·65% (95% CI 2·47 to 10·82, p=0·011). Inappropriate use of urinary catheters occurred in 105 (32·4%, 95% CI 27·3 to 37·8) of 324 patients in the baseline group compared with 96 (24·1%, 20·0 to 28·6) of 398 patients in the intervention group (IRR 0·74, 95% CI 0·56 to 0·98, p=0·013). Time-series analyses showed an absolute reduction in inappropriate use of urinary catheters of 6·34% (95% CI -12·46 to 25·13, p=0·524). INTERPRETATION: Our de-implementation strategy reduced inappropriate use of short peripheral intravenous catheters in patients who were not in the intensive care unit. The reduction of inappropriate use of urinary catheters was substantial, yet not statistically significant in time-series analysis due to a small sample size. The strategy appears well suited for broad-scale implementation to reduce health care-associated infections. FUNDING: Netherlands Organisation for Health Research and Development.

Peripherally inserted central venous catheter (PICC) in outpatient and inpatient oncological treatment.

PURPOSE: So far there is little evidence on peripherally inserted central venous catheter (PICC) in radiation oncology patients maintaining the access during the periods of ambulatory and hospital treatment. METHODS: A total of 522 PICC placements in 484 patients were performed between 11/2011 and 07/2016 at the Department of Radiation Oncology and analysed retrospectively for complications and treatment- and patient-related factors during ambulatory and hospital inpatient use. On initial hospitalization, all patients received a multimodal radio-oncological treatment consisting of radiation and intravenous therapy administered via the PICC. RESULTS: A total of 18,292 catheter days were documented. Median follow-up from catheter insertion to their removal was 37 days (1-97). The overall complication rate was 4.1 per 1000 catheter days (n = 75, 14.4%). Complications were similar between the cohort of outpatient 3.6 per 1000 catheter days and the cohort of inpatient 4.8 per 1000 catheter days (OR 0.976; 95% CI [0.598; 1.619]; p = 0.924). Severe bloodstream infections occurred at a rate of 0.60 per 1000 catheter days (n = 11, 2.1%), deep vein thrombosis at a rate of 0.82 per 1.000 catheter days (n = 15, 2.9%) and local inflammation at a rate of 1.26 per 1.000 catheter days (n = 23, 4.4%). Only immunotherapy could be identified as an independent risk factor for complications (OR 5.6; 95% CI [2.4; 13.1]; p < 0.001). CONCLUSION: Using PICC in outpatients is not associated with an elevated risk of complications. Particular attention should be payed to early identification of PICC associated bloodstream infections. Immunotherapy is an independent risk factor for local skin complication.

Cost analysis comparison between peripherally inserted central catheters and implanted chest ports in patients with cancer-A health economic evaluation of the PICCPORT trial.

BACKGROUND: A reliable central venous access device is a cornerstone in the treatment of cancer. Both peripherally inserted central catheters (PICC) and totally implanted chest ports (PORT) are commonly used for the delivery of chemotherapy. Both types of catheter can cause adverse events such as catheter-related deep venous thrombosis (CR-DVT), infection and mechanical complications. METHOD: We conducted a randomized controlled trial including 399 patients with cancer and performed a health economic evaluation investigating the cost related to PICCs and PORTs using several clinically relevant dimensions from a healthcare perspective. The cost was determined using process and cost estimate models. RESULT: PICCs are associated with a higher total cost when compared with PORTs. Combining the costs of all categories, the prize per inserted device was 824.58 EUR for PICC and 662.34 EUR for PORT. When adjusting for total catheter dwell time the price was 6.58 EUR/day for PICC and 3.01 EUR/day for PORT. The difference in CR-DVT was the main contributor to the difference in cost. The daily cost of PICC is approximately twice to that of PORT. CONCLUSION: We have demonstrated that the cost from a healthcare perspective is higher in cancer patients receiving a PICC than to those with a PORT. The difference is driven mainly by the cost related to the management of adverse events. Our findings are relevant to anaesthetists, oncologists and vascular access clinicians and should be considered when choosing vascular access device prior to chemotherapy.

A comparative study evaluating the role of adductor canal block catheter versus intraarticular analgesic infusion on knee pain and range of motion in the immediate postoperative period: a prospective multicenter trial.

Postoperative pain after total knee arthroplasty (TKA) is an important determinant of hospital stay and rehabilitation and thereby functional outcome. Adductor canal block (ACB) and intraarticular analgesic infiltration through catheters (IAC) are techniques of multimodal analgesia which have shown to control postoperative pain satisfactorily. The aim of this study is to evaluate the efficacy of ACB versus IAC in reducing immediate postoperative pain and thereby allow early rehabilitation. A multicenter quasi-experimental study was conducted on 511 patients undergoing unilateral primary TKA from March 2016 to April 2017 who either received ACB with catheter (Group I, n = 350 patients) or IAC (Group II, n = 172 patients) for postoperative pain control. All the patients were assessed for severity of pain by Visual Analogue Scale at 8, 24, 48, 72 h postoperatively and knee range of motion (ROM) on the day of discharge. There was no significant difference in pain scores on postoperative day (POD) 0 (1.09 ± 0.30 vs. 0.98 ± 0.46, p = 0.45) and POD 1 (1.21 ± 0.45 vs. 1.00 ± 0.00, p = 0.11) and in mean ROM on the day of discharge between ACB and IAC (88.40° ± 7.96° vs. 88.34° ± 5.74°; p = 0.93) groups. This study shows that both ACB and IAC provide satisfactory postoperative analgesia with sparing of quadriceps function and good knee ROM leading to early rehabilitation and reduced hospital with no advantage of one technique over another.

Peripheral venous access using devices over needles with and without extension: costs and outcomes / Acceso venoso periférico utilizando dispositivos de aguja con y sin extensión: costos y resultados / Acesso venoso periférico utilizando dispositivos sobre agulha com e sem extensão: custos e desfechos

ABSTRACT Objectives: to analyze the mean direct cost and peripheral venous access length outcomes using devices over needle with and without extension. Methods: quantitative, exploratory-descriptive research. Venous punctures and length of the devices were followed. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals by the unit cost of labor, adding to the cost of materials. Results: the total mean direct cost of using devices "with extension" (US$ 9.37) was 2.9 times the cost of using devices "without extension" (US$ 4.50), US$ 7.71 and US$ 2.66, respectively. Totaling 96 hours of stay, the "device over needle with extension" showed a lower occurrence of accidental loss. Conclusions: the use of the "device over needle with extension", despite its higher mean direct cost, was more effective in favoring adequate length of peripheral venous access.

RESUMEN Objetivos: analizar el costo directo promedio y los resultados de permanencia del acceso venoso periférico, utilizando dispositivos de aguja con y sin extensión. Métodos: investigación cuantitativa, exploratoria descriptiva. Se siguieron los pinchazos venosos y el tiempo de permanencia de los dispositivos. El costo directo promedio se calculó multiplicando el tiempo (cronometrado) dedicado por los profesionales de enfermería por el costo unitario de la mano de obra, lo que se suma al costo de los materiales. Resultados: el costo directo promedio total de usar dispositivos "extendidos" (US$ 9,37) fue 2,9 veces el costo de usar dispositivos "no extendidos" (US$ 4,50) de materiales, US$ 7.71 y US$ 2.66, respectivamente. Con un total de 96 horas de estadía, el "dispositivo de aguja extendida" mostró una menor ocurrencia de pérdida accidental. Conclusiones: a pesar del costo directo promedio más alto, el uso de un "dispositivo de aguja extendida" fue más efectivo para favorecer un tiempo de acceso venoso periférico adecuado.

RESUMO Objetivos: analisar o custo direto médio e os desfechos de permanência de acesso venoso periférico, utilizando dispositivos sobre agulha com e sem extensão. Métodos: pesquisa quantitativa, exploratório-descritiva. Acompanharam-se as punções venosas e o tempo de permanência dos dispositivos. Calculou-se o custo direto médio multiplicando-se o tempo (cronometrado) despendido por profissionais de enfermagem pelo custo unitário da mão de obra, somando-se ao custo dos materiais. Resultados: o custo direto médio total do uso de dispositivo "com extensão" (US$ 9,37) foi 2,9 vezes do que o custo do uso de dispositivo "sem extensão" (US$ 4,50), destacando-se os custos dos materiais, US$ 7,71 e US$ 2,66, respectivamente. Totalizando 96 horas de permanência, o "dispositivo sobre agulha com extensão" apresentou menor ocorrência de perda acidental. Conclusões: o uso do "dispositivo sobre agulha com extensão", apesar do maior custo direto médio, foi mais eficaz para favorecer o adequado tempo de permanência do acesso venoso periférico.

A 25-year study of gastroschisis outcomes in a middle-income country.

BACKGROUND: Survival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management. METHODS: All newborns with gastroschisis treated during the period 1989-2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis. RESULTS: One hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001), delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001), early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p = .27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period. CONCLUSIONS: Gastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: III.

Upper-Extremity Venous Access for Children and Adults in Pediatric Cardiac Catheterization Laboratory.

BACKGROUND: Traditional approaches to pediatric cardiac catheterization have relied on femoral venous access. Upper- extremity venous access may enable cardiac catheterization procedures to be performed safely for diagnostic and interventional catheterizations. The objective of this multicenter study was to demonstrate the feasibility and safety of upper-extremity venous access in a pediatric cardiac catheterization laboratory. METHODS: A retrospective chart review of all patients who underwent cardiac catheterization via upper-extremity vascular access was performed. RESULTS: Eighty-two cardiac catheterizations were attempted via upper-extremity vein on 72 patients. Successful access was obtained in 75 catheterizations (91%) in 67 patients. Median age at catheterization was 18.79 years (interquartile range [IQR], 13.02-32.75 years; n = 75) with a median weight of 59.4 kg (IQR, 43.3-76.5 kg; n = 75). The youngest patient was 4.1 months old, weighing 4.3 kg. Local anesthesia or light sedation was utilized in 46 procedures (61%). Diagnostic right heart catheterization was the most common procedure (n = 65; 87%), with intervention performed via the upper extremity in 8 cases (11%). Median fluoroscopy time was 10.02 min (IQR, 2.87-36.26 min; n = 75), with dose area product/kg of 3.765 µGy•m²/kg (IQR, 0.74-34.12 µGy•m²/kg; n = 64). Median sheath duration time was 48 min (IQR, 19.5-147 min; n = 57) and median total procedure time was 116 min (IQR, 80.5-299 min; n = 65). Median length of stay for outpatient procedures was 5.37 hr (IQR, 4.25-6.92 hr; n = 27). There were no procedural complications. CONCLUSION: Upper-extremity venous access is a useful, feasible, and safe modality for cardiac catheterization in the pediatric cardiac catheterization laboratory.

Direct cost of peripheral catheterization by nurses / Costo directo del paso de catéter central de inserción periférica por enfermeros / Custo direto da passagem de cateter central de inserção periférica por enfermeiros

ABSTRACT Objective: To measure the average direct cost of peripherally inserted central catheterization performed by nurses in a pediatric and neonatal intensive care unit. Method: A quantitative, exploratory-descriptive, single-case study, whose sample consisted of the non-participant observation of 101 peripherally inserted central catheter procedures. The cost was calculated by multiplying the execution time (timed using a chronometer) spent by nursing professionals, participants in the procedure, by the unit cost of direct labor, added to the cost of materials, drugs, and solutions. Results: The average direct cost of the procedure was US$ 326.95 (standard deviation = US$ 84.47), ranging from US$ 99.03 to US$ 530.71, with a median of US$ 326.17. It was impacted by material costs and the direct labor of the nurses. Conclusion: The measurement of the average direct cost of the peripherally inserted central catheter procedure shed light on the financials of consumed resources, indicating possibilities of intervention aiming to increase efficiency in allocating these resources.

RESUMEN Objetivo: Medir el costo directo promedio del paso de catéter central de inserción periférica por enfermeras en una unidad de cuidados intensivos pediátrica y neonatal. Método: Investigación cuantitativa, exploratoria-descriptiva, del tipo estudio de caso único, cuya muestra se constituyó de la observación no participante de 101 pasos de catéter central de inserción periférica. El costo se calculó multiplicando el tiempo (cronometrado) de los profesionales de enfermería, participantes en el procedimiento, por el costo unitario de mano de obra directa, sumándose al costo de materiales/medicamentos/soluciones. Resultados: El costo directo medio del procedimiento correspondió a US$ 326,95 (desviación estándar = US$ 84,47), variando entre US$ 99,03 y US$ 530,71, con mediana de US$ 326,17, habiendo sido impactados por los costos con material y mano de obra directa de los enfermeros ejecutantes. Conclusión: La medición del costo directo medio del paso del catéter central de inserción periférica confirió visibilidad financiera a los insumos consumidos, indicando posibilidades de intervención pretendiendo incrementar su eficiencia alocativa.

RESUMO Objetivo: Mensurar o custo direto médio da passagem de cateter central de inserção periférica, por enfermeiros, em uma unidade de terapia intensiva pediátrica e neonatal. Método: Pesquisa quantitativa, exploratório-descritiva, do tipo estudo de caso único, cuja amostra se constituiu da observação não participante de 101 passagens de cateter central de inserção periférica. O custo foi calculado multiplicando-se o tempo (cronometrado) despendido por profissionais de enfermagem, participantes do procedimento, pelo custo unitário da mão de obra direta, somando-se ao custo dos materiais/medicamentos/soluções. Resultados: O custo direto médio do procedimento correspondeu a US$326.95 (desvio-padrão = US$ 84.47), variando entre US$99.03 e US$530.71, com mediana de US$326.17; tendo sido impactado pelos custos com material e mão de obra direta dos enfermeiros executantes. Conclusão: A mensuração do custo direto médio da passagem de cateter central de inserção periférica conferiu visibilidade financeira aos insumos consumidos, indicando possibilidades de intervenção visando o incremento da sua eficiência alocativa.

Incidence of arterial catheter complications: a retrospective study of 35 cats (2010-2014).

OBJECTIVES: The aim of this study was to investigate the incidence of complications associated with arterial catheterization in cats in a veterinary hospital, and to document which factors may increase the incidence of complications. METHODS: Medical records at a referral veterinary hospital were retrospectively reviewed to identify cats that had an arterial catheter placed between January 2010 and October 2014. RESULTS: Thirty-five cats having 38 arterial catheters were included in the study. There was a relatively high incidence of minor complications (23.7%), with the most common being catheter occlusion. The incidence of major arterial catheter complications was low (2.63%). Duration of catheter use was positively correlated to the incidence of complications. There was also a significant correlation between catheters used for intensive care unit monitoring and incidence of complications. All cats with catheter complications survived to discharge. CONCLUSIONS AND RELEVANCE: The low incidence of major arterial catheter complications in this population of cats illustrates that arterial catheterization is a safe monitoring and diagnostic tool. The duration of catheter placement is significantly associated with the incidence of catheter complications.

Prone transradial catheterization for combined single-session endovascular and percutaneous interventions: approach, technical success, safety, and outcomes in 15 patients.

PURPOSE: We aimed to report approach, safety, technical success, and clinical outcomes of prone trans- radial access (PTRA) and demonstrate feasibility for procedures requiring simultaneous arterial intervention and prone percutaneous access. METHODS: Fifteen patients underwent PTRA, seven females (47%) and eight males (53%), mean age of 55 years (range, 19-78 years). All patients underwent PTRA for combined transarterial and posterior-approach percutaneous interventions. Variables included sheath size (French, F), type of anesthesia, arterial intervention technical success, posterior-approach percutaneous intervention technical success, estimated blood loss (mL), fluoroscopy and procedure time, complications, and follow-up. RESULTS: Mean sheath size was 4 F (range, 4-6 F; SD = 0.5). Arterial interventions included transarterial embolization of renal (n=6), hepatic (n=2), and pelvic vessels (n=2), diagnostic arteriography (n=4), and embolization of an arteriovenous malformation (n=1). Posterior-approach intervention technical success was 100% (15/15). PTRA technical success was 100% (15/15). Posterior-approach percutaneous interventions included retroperitoneal (n=5) and pelvic (n=1) mass biopsies, nephrostomy tube placement (n=2), cryoablation of pelvic (n=2) and renal (n=1) masses, sclerotherapy of arteriovenous malformations (n=2), foreign body removal from the renal collecting system (n=2), ablation of a renal tumor (n=1), intracavitary injection of pulmonary mycetoma (n=1), and ablation and cementoplasty of a vertebral body tumor (n=1). The biopsies were diagnostic (6/6). There were no minor or major access-site complications. CONCLUSION: PTRA is a safe and feasible method for performing combined arterial and posterior approach percutaneous interventions without the need for repositioning.

An evaluation of management of transferred paediatric burn patients.

The aim of study was to evaluate whether adequate initial management and safe transfer of paediatric burn patients was carried out in our setup. Patients transferred from other hospitals/ cities to Paediatric Surgery Department, Mayo Hospital were evaluated in this prospective study. Data was entered in a proforma. Around 90.4% patients on presentation had discrepancy in their burn percentage calculation. No intravenous fluids were administered to 75.4% patients and 71.1% patients did not have any intravenous access. Foley's catheter was inserted in 2 patients only though 72.8% needed it. No fasciotomy was performed in 10.5% patients needing it. Two patients needed endotracheal intubation but it was not passed, 49.1% patients were transferred by ambulance and 28.9% patients presented with sepsis. The mortality rate was 38.2%. Initial fluid resuscitation was compared with survival and found significant (p=0.000). This shows that initial burn management, transfer system and referral system is full of errors.

Central versus peripheral cannulation of extracorporeal membrane oxygenation support during double lung transplant for pulmonary hypertension.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) has become the standard of cardiopulmonary support during a sequential double lung transplant for pulmonary hypertension. Whether central or peripheral cannulation is the best strategy for these patients remains unknown. Our goal was to determine which is the best strategy by comparing 2 populations of patients. METHODS: We performed a single-centre retrospective study based on an institutional prospective lung transplant database. RESULTS: Between January 2011 and November 2016, 103 patients underwent double lung transplant for pulmonary hypertension. We compared 54 patients who had central ECMO (cECMO group) to 49 patients who had peripheral ECMO (pECMO group). The pECMO group had significantly more bridged patients who received emergency transplants (31% vs 6%, P = 0.001). The incidence of Grade 3 primary graft dysfunction requiring ECMO (14% vs 11%, P = not significant) and of in-hospital mortality (11% vs 14%, P = not significant) was similar between the groups. Groin infections (16% vs 4%, P = 0.031), deep vein thrombosis (27% vs 11%, P = 0.044) and lower limb ischaemia (12% vs 2%, P = 0.031) occurred significantly more often in the pECMO group. The number of chest reopenings for bleeding or infection was similar between the groups. The 3-month, 1-year and 5-year survival rates did not differ between the groups (P = 0.94). CONCLUSIONS: Central or peripheral ECMO produced similar results during double lung transplant for pulmonary hypertension in terms of in-hospital deaths and long-term survival rates. Central ECMO provided satisfactory results without major bleeding provided the patient was weaned from ECMO at the end of the procedure. Despite the rate of groin and lower limb complications, peripheral cannulation remained the preferred solution to bridge the patient to transplant or for postoperative support.