Salvage of infected tunneled hemodialysis catheters using 70% ethanol lock solution: A brief report.

Tunneled hemodialysis catheters are the lifeline to patients on maintenance hemodialysis with failed arteriovenous fistulas. However, thrombosis and infection are the main causes of reduced longevity of these accesses. According to IDSA guidelines, catheter-related infection with Pseudomonas and fungi are absolute indications for catheter removal. Considering the cost and difficulties in catheter replacement, for those in whom all accesses are exhausted, retaining the same catheter may be lifesaving. We would like to present two patients in whom, 70% ethanol instillation was used to eradicate infection with these organisms as confirmed by repeat cultures post procedure. Hemodialysis is being successfully continued through the same catheter.

A collaborative approach intended to reduce the duration of short term urinary catheters in adult patients at a tertiary care medical center also significantly reduced the duration of hospitalization.

BACKGROUND: Urinary tract infections are the leading cause of nosocomial infections in the United States. The major contributing factor is the placement of indwelling urinary catheters. METHODS: Following a chart review of adult patients hospitalized at a tertiary care medical center who required the use of a short-term (≤ 2 weeks) indwelling urinary catheter, a collaborative effort was initiated by an Infectious Diseases physician to develop protocols focused on the clinical service involved for the expeditious removal of short-term indwelling urinary catheters. The protocols relied in part on the standards of practice by pertinent medical/surgical subspecialty societies. Usage of urinary catheters and duration of hospitalization following implementation of the protocols was assessed. RESULTS: Based on a multivariate analysis controlling for demographic variables, comorbidities, medical vs surgical service, and indication for the urinary catheterization, the median duration of catheterization was significantly reduced from 6.7 days to 3.6 days after the protocols were initiated (P < .001), and the median duration of hospitalization was significantly reduced from 9.5 days to 5.9 days (P < .001). No patient had to have the urinary catheter reinserted. CONCLUSIONS: Development of collaborative protocols for the removal of short-term indwelling urinary catheters significantly reduced both the duration of catheterization and the duration of hospitalization.

Impact of the COVID-19 pandemic on subcutaneous venous port-related complications in patients with cancer: a retrospective case-control study.

BACKGROUND: Vascular access in cancer patients is of great importance in order to deliver tumour-specific therapy and continues to be so during exceptional conditions. This study aimed to examine the impact of the coronavirus disease 2019 pandemic on the care and complication rates associated with subcutaneous venous port (PORT) insertion in cancer treatment. METHODS: We retrospectively studied all adult cancer patients that received a PORT in 2020 at a Swedish county hospital, including insertion characteristics and in-dwell complication rates for up to 6 months after implantation; these estimates were compared with historic data. RESULTS: Data from 257 patients, of which 56 were haematological patients, were included and compared with those of 168 patients in the control group. The group characteristics were similar, except for the inclusion of haematological patients in the study group. Insertion characteristics showed a shorter waiting time and higher rates of antibiotic and sedative use during the pandemic. The rates of postoperative haematoma and catheter occlusion during the study period were higher than otherwise. The rates of adverse events related to the PORT in the solid tumour group were comparable to those in the control group (18.4% vs. 14.9%). Patients with haematological malignancies were more likely to experience adverse events (37.5% vs. 18.4%) and deep venous thrombosis (7.1% vs. 1.0%) than those with solid tumours. CONCLUSION: In conclusion, the present findings suggest that PORTs remain a safe venous access system even during a pandemic, indicating a robust vascular access service.

Catheter-Associated Bloodstream Infections among Patients on Hemodialysis: Progress before and during the COVID-19 Pandemic.

Measures implemented to prevent transmission of severe acute respiratory syndrome coronavirus 2 in outpatient dialysis facilities may also help to prevent catheter-associated bloodstream infections in patients receiving hemodialysis. We used United States Renal Data System data to examine rates of antibiotic administration within dialysis facilities and rates of hospital admission for catheter-associated bloodstream infection from March 2018 through November 2020, and rates of hospitalization for sepsis, to address overall changes in hospitalization during the coronavirus disease 2019 (COVID-19) pandemic. Using logistic regression, we estimated year-over-year adjusted odds ratios of these events in 3-month intervals. During the first 6 months of the pandemic, rates of antibiotic administration were between 20% and 21% lower, and rates of hospitalization for catheter-associated bloodstream infection were between 17% and 24% lower than during corresponding periods in 2019, without significant changes in rates of hospitalization for sepsis. However, rates of catheter-associated events also decreased between 2018 and 2019, driven by reductions in facilities operated by a large dialysis provider. These data suggest that significant reductions in catheter-associated infections occurred during the pandemic, superimposed on nonpandemic-related reductions in some facilities before the pandemic. Even after the pandemic, it may be prudent to continue some COVID-19 mitigation measures to prevent catheter-associated bloodstream infections.

Indwelling Pleural Catheters for Malignant Pleural Effusion: A Time for Action.

Malignant pleural effusion (MPE) resulting from metastatic spread to the pleura frequently occurs in patients with primary lung, breast, hematological, gastrointestinal, and gynecological cancers. These effusions tend to reaccumulate quickly, and the patient requires increasingly frequent thoracentesis. An indwelling pleural catheter allows for dramatic improvement in quality of life as the patient has the power to ease her/his own suffering by draining the effusion at home when shortness of breath and/or chest pain intensifies. Patients with MPE need home healthcare support to address symptom management related to complications of advanced metastatic cancer and antineoplasm treatment regimens. The financial obstacles for the home healthcare agency are explored by using agency supply costs, per visit costs, and the patient-driven groupings reimbursement mode grouper to estimate reimbursement. Care for a home healthcare patient with MPE costs Medicare approximately $64.50 per day, markedly less than costs for hospitalization and outpatient thoracentesis. Unfortunately, agencies must absorb the cost of vacuum drainage bottles. Whereas a small positive balance of $291 was estimated for the first 30-day posthospital episode, losses were estimated at $1,185 to $1,633 for subsequent 30-day episodes. Absorbing these costs has become extremely difficult as home healthcare agencies are experiencing unprecedented COVID-19 infection control and staffing-related costs.

Indwelling Pleural Catheter (IPC) for the Management of Hepatic Hydrothorax: The Known and the Unknown.

BACKGROUND: Hepatic hydrothorax (HH) is described as pleural effusion secondary to liver cirrhosis after ruling out other etiologies. We aim to assess the efficacy of an indwelling pleural catheter (IPC) placement in refractory HH in this systematic review and meta-analysis. METHODS: A comprehensive search of literature was performed from inception to December 2020. The authors reviewed, selected, and abstracted the data from eligible studies into Covidence, a systematic review software. Cochrane criteria was used to rate each study for the risk of bias. The data abstracted were described using a random-effects model. Heterogeneity was evaluated using the I2 test. RESULTS: Ten studies involving a total of 269 patients were included. The studies were analyzed for the proportion of pleurodesis achieved, the average time to pleurodesis, total complication rate, pleural infection rate, and mortality. A proportion of 47% of the total subjects included achieved spontaneous pleurodesis in an average duration of 104.3 days. The frequency of total complication rate was noted to be 30.36%. The incidence of pleural cavity infection was described to be 12.4% and death resulting from complications of IPC was 3.35%. CONCLUSION: The current management options for the refractory pleural effusion in HH include repeated thoracenteses, transjugular intrahepatic portosystemic shunt, surgical repair of defects in the diaphragm, and liver transplantation. However, the cost, eligibility, and availability can be some of the major concerns with these treatment modalities. With this meta-analysis, we conclude that IPCs can provide an alternative therapeutic option for spontaneous pleurodesis.

Implementation of evidence-based strategies to reduce catheter-associated urinary tract infections among hospitalized, post-surgical adults.

Several catheter-associated urinary tract infection (CAUTI) prevention interventions were successfully implemented and evaluated on a surgical unit in a community-based hospital. Sustainability of CAUTI prevention efforts requires daily communication between multidisciplinary staff. In our hospital, daily report on CAUTI events and indwelling catheters at a hospital-wide, multidisciplinary safety huddle contributed to an enhanced focus on CAUTI-prevention strategies and unit-level reduction in device use days and CAUTI rates.

Implementation of an external female urinary catheter as an alternative to an indwelling urinary catheter.

BACKGROUND: Until recently, there has been a lack of viable alternative to an indwelling urinary catheter for female patients that require precise urine output measurements. With the introduction of external female urinary catheters, we can now substitute this type of device for an indwelling urinary catheter in many patients, decreasing their risk of catheter-associated urinary tract infections. METHODS: In this retrospective study, we analyzed the impact of a hospital-wide implementation of an external female urinary catheter at a large academic medical center. The study included female patients, greater than 18 years of age. We compared a 12-month period before and after device implementation to assess the impact on indwelling urinary catheter utilization and catheter-associated urinary tract infections rate. RESULTS: Data included over 220,000 patient days, over 10,000 external urinary catheter days and 33,000 indwelling urinary catheter days. We found a statistically significant decrease in indwelling urinary catheter utilization following the implementation of the external female urinary catheter, but only in intensive care units. CONCLUSIONS: It is our recommendation that facilities first implement the device in ICUs as this level of care was where we observed the most significant impact.

Safety and Efficacy of Bedside Peritoneal Dialysis Catheter Placement in the COVID-19 Era: Initial Experience at a New York City Hospital.

INTRODUCTION: Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is common in critically ill patients with COVID-19. Unparalleled numbers of patients with AKI and shortage of dialysis machines and operative resources prompted consideration of expanded use of urgent-start peritoneal dialysis (PD) and evaluation of the safety and efficacy of bedside surgical placement of PD catheters. STUDY DESIGN: Bedside, open PD catheter insertions were performed in early April 2020, at a large academic center in New York City. Patients with SARS-CoV-2 infection and AKI and ambulatory patients with chronic kidney disease and impending need for RRT were included. Detailed surgical technique is described. RESULTS: Fourteen catheters were placed at the bedside over 2 weeks, 11 in critically ill COVID-19 patients and three in ambulatory patients. Mean patient age was 61.9 years (43-83), and mean body mass index was 27.1 (20-37.6); four patients had prior abdominal surgery. All catheters were placed successfully without routine radiographic studies or intraoperative complications. One patient (7%) experienced primary nonfunction of the catheter requiring HD. One patient had limited intraperitoneal bleeding while anticoagulated, which was managed by mechanical compression of the abdominal wall and temporarily holding anticoagulation. All other catheters had an adequate function at 3-18 days of follow-up. CONCLUSIONS: Bedside placement of PD catheters is safe and effective in ICU and outpatient clinic settings. Our surgical protocols allowed for optimization of critical hospital resources, minimization of hazardous exposure to healthcare providers and a broader application of urgent-start PD in selected patients. Long-term follow-up is warranted.