Endoscopic retrieval of migrated Foley catheter: A clinical case series.

Use of Foley catheter in patients with ileostomy, for the decompression of large bowel distal to stoma or for the administration of large bowel enema through colostomy, either to treat constipation or for bowel preparation prior to colonoscopy, is a common practice. Accidental migration of catheter during bowel irrigation through stoma can take place if it is not secured externally to the skin. We present 2 such cases with intra-colonic migration of Foley catheter that occurred during bowel irrigation and were retrieved endoscopically. To our knowledge, this is the first case report of endoscopic removal of Foley catheter that migrated internally through the stoma.

In vitro comparison of the effectiveness of various antimicrobial locks with taurolidine in the treatment and prevention of catheter-related bloodstream infections in patients receiving parenteral nutrition.

OBJECTIVES: To evaluate the effectiveness of various taurolidine solutions in the prevention and treatment of catheter-related bloodstream infections (CRBSIs) caused by the entire spectrum of microbes in patients receiving parenteral nutrition in a shorter period of time. METHODS: The in vitro method was used to test for eradication of biofilm. Different locks were used: TauroSept (2%), TauroLock (1.35%), TauroLock half concentration, and 3.5% taurolidine and tested on Staphylococcus (S.) epidermidis, S. aureus, S. hominis, methicillin-resistant S. aureus (MRSA), Pseudomonas (P.) aeruginosa (PSAE), multidrug-resistant P. aeruginosa (MR PSAE), vancomycin-resistant enterococci, Klebsiella pneumoniae producing carbapenemase (KPC), Klebsiella pneumoniae producing extended-spectrum beta-lactamase (KLPN ESBL), Candida (C.) albicans, and C. glabrata. Broviac catheters were incubated for growth of each organism and then incubated in lock solutions. Colony forming units (CFUs) were then counted after 30 min, 60 min, and 120 min of incubation. RESULTS: A statistically significant decrease in CFUs was observed after 30 min of taurolidine exposure for S. hominis, PSAE, KLPN ESBL, KLPN KPC, C. albicans, and C. glabrata; after 60 min of exposure for S. epidermidis, PSAE, MR PSAE, KLPN ESBL, KPC, C. albicans, and C. glabrata; and after 120 min of exposure for S. epidermidis, S. hominis, S. aureus, PSAE, MR PSAE, KLPN ESBL, KPC, C. albicans, C. glabrata. CONCLUSIONS: The application of taurolidine is effective in the treatment of CRBSIs. Taurolidine proved to be more effective against Gram-negative microorganisms during a 30-min exposure. Using 0.675% taurolidine is still effective. To achieve the required antimicrobial effect, the catheter must be sanitized for at least 2 h.

Effects of Catheter Tracking Management on Urinary Tract Function and Infection Rates in Patients With Spinal Cord Injury.

Context: Patients with bone-marrow injuries, such as spinal cord injuries (SCIs), usually have urinary dysfunction, changes to the urethra's anatomical structure, and pathophysiological changes of the urinary system, which can lead to urodynamic changes. If a patient receives improper treatment, repeated infections of the urinary system can easily occur, causing hydronephrosis and damage to renal function. Objective: The study intended to explore the effects of catheter follow-up management for patients with SCIs on the function of the bladder and the urinary tract and on urinary tract infections (UTIs), selecting antibiotics reasonably according to a bacterial culture and drug sensitivity test. Design: The research team designed a randomized controlled trial. Setting: The study took place at the Hebei Cangzhou Hospital of Integrated Traditional Chinese Medicine (TCM)-Western Medicine (WM) in Cangzhou City, Hebei Province, People's Republic of China. Participants: Participants were 92 patients with SCIs who were treated at the hospital between January 2020 and December 2021. Intervention: The research team randomly divided participants into an intervention group (n = 45) and a control group (n = 47). The control group received routine treatment, while the intervention group received catheter follow-up management. Outcome Measures: At baseline and postintervention after six weeks of treatment, the research team: (1) examined participants' bladder function, (2) examine urodynamic indexes including measurement of the maximum bladder volume, maximum urethral closure pressure, maximum urinary flow rate, and maximum detrusor pressure, and (3) assessed participants' QoL using the World Health Organization Quality of Life Questionnaire Abbreviated (WHOQOL-BREF). Results: Improvements in bladder function, urodynamic indexes, QoL, and UTIs occurred in both groups. The intervention group's: (1) total effective rate for bladder function was 91.11%, which was significantly higher than that of the control group (P = .022); (2) maximal bladder volume, urethral closure pressure, and urinary flow rate were 365.59 ± 54.43 ml, 81.19 ± 8.8 cmH2O, and 18.60 ± 2. 43 ml/s, respectively, and were significantly higher than those of the control group (all P = .000); (3) maximal detrusor pressure was 47.48 ± 5.64 cmH2O, which was significantly lower than that of the control group (p=0.000); (4) scores on the WHOQOL-BREF's subdimensions and total score were significantly higher than those in the control group: psychological, 17.92 ± 1.55; physiological, 30.30 ± 1.82; independence, 22.43 ± 1.40; social relations, 16.82 ± 1.32; environment, 21.19 ± 1.85; and total score, 110.02 ±16.64 (all P = .000); (5) incidence of urinary tract infection was 17.78 which was significantly lower than that of the control group (P = .003). The distribution of bacterial species in the UTIs of the intervention and control groups wasn't significantly different (P = .869). The two bacterial groups were Escherichia coli and Enterococcus. Drug sensitivity tests showed that the Escherichia coli were less susceptible to gentamicin, levofloxacin, and piperacillin than to ciprofloxacin, and the Enterococcus were less susceptible to gentamicin, ciprofloxacin, and levofloxacin than to piperacillin. Conclusions: For patients with SCIs, catheter follow-up management can be helpful in restoring the function of the bladder and urinary tract, can improve patients' QoL, and reduce their rate of UTIs. Clinically, medical practitioners should select antibiotics reasonably according to a bacterial culture and drug-sensitivity test.

Alhagi maurorum extract modulates quorum sensing genes and biofilm formation in Proteus mirabilis.

Proteus mirabilis (P. mirabilis) is a frequent cause of catheter-associated urinary tract infections. This study aims to investigate the anti-infective effect of Alhagi maurorum extract (AME), the traditional medicinal plant in the middle east, on the biofilm-forming P. mirabilis isolates. Hydroalcoholic extract and oil of A. maurorum were characterized by HPLC and GC-MS. The antiproliferative, anti-biofilm, and bactericidal activity of AME at various concentrations were assessed by turbidity, crystal violet binding, and agar well diffusion assays, respectively. The AME's effect on adhesion and quorum sensing (QS) were investigated by in vitro adhesion assay on cell culture and agar overlay assay using Janthinobacterium lividum (ATCC 12472) as a biosensor strain. In addition, the expression level of selected genes involved in QS and biofilm regulation were determined by quantitative Real-Time PCR. Furthermore, the bladder phantom model was created to evaluate the assays and investigate the catheter's calcium deposition. The most effective chemical compounds found in AME were tamarixetin, quercetin, and trans-anethole. Although AME did not inhibit swarming motility, it reduced biofilm production and exerted a concentration-dependent anti-adhesive and anti-QS activity against P. mirabilis. AME also downregulated the expression level of selected genes involved in biofilm formation and QS. This study showed that AME as a natural compound reduced biofilm formation of P. mirabilis by targeting virulence factor genes, quorum sensing, and other strategies that include preventing the adhesion of P. mirabilis to the cells. The results suggest that A. maurorum extract might have the potential to be considered for preventing UTIs caused by P. mirabilis.

Preperitoneal Local Anesthesia Technique in Laparoscopic Peritoneal Dialysis Catheter Placement.

Background and Objectives: Peritoneal dialysis is an excellent treatment for end-stage renal disease. Peritoneal dialysis is more advantageous if the catheter is positioned laparoscopically with omentopexy. General anesthesia is required for laparoscopic peritoneal dialysis catheter placement. General anesthesia is associated with increased postoperative morbidity and mortality in high-risk patients. In this retrospective study, the results of laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation are presented for end-stage renal disease patients not fit for general anesthesia. Methods: We recruited 13 patients for laparoscopic placement of peritoneal dialysis catheter out of 99 end-stage renal disease patients who presented at a local tertiary hospital. The selection criteria were based on the American Society of Anesthesiologists classification III or above and patients unfit for general anesthesia. Results: Laparoscopic placement of peritoneal dialysis catheter was performed on 99 patients, and 13 patients were unfit for general anesthesia. Laparoscopic placement of peritoneal dialysis catheter and omentopexy were performed on these 13 patients together with capnoperitoneum, under preperitoneal local anesthesia technique and sedation. Three catheters were removed due to exit-site infection. One patient died after 2 years due to cardiac disease. The remaining patients continued with peritoneal dialysis. No omental entrapment, catheter migration, or other complications were encountered. Conclusion: Laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation was successful for high-risk patients unfit for general anesthesia. This technique can be expanded for healthy patients to avoid general anesthesia complications, reduce costs, and speed recovery.

Strategies for intra-amniotic administration of fetal therapy in a rabbit model of intrauterine growth restriction.

Intrauterine growth restriction affects up to 10% of all pregnancies, leading to fetal programming with detrimental consequences for lifelong health. However, no therapeutic strategies have so far been effective to ameliorate these consequences. Our previous study has demonstrated that a single dose of nutrients administered into the amniotic cavity, bypassing the often dysfunctional placenta via intra-amniotic administration, improved survival at birth but not birthweight in an intrauterine growth restriction rabbit model. The aim of this study was to further develop an effective strategy for intra-amniotic fetal therapy in an animal model. Intrauterine growth restriction was induced by selective ligation of uteroplacental vessels on one uterine horn of pregnant rabbits at gestational day 25, and fetuses were delivered by cesarean section on GD30. During the five days of intrauterine growth restriction development, three different methods of intra-amniotic administration were used: continuous intra-amniotic infusion by osmotic pump, multiple intra-amniotic injections, and single fetal intraperitoneal injection. Technical feasibility, capability to systematically reach the fetus, and survival and birthweight of the derived offspring were evaluated for each technique. Continuous intra-amniotic infusion by osmotic pump was not feasible owing to the high occurrence of catheter displacement and amnion rupture, while methods using two intra-amniotic injections and one fetal intraperitoneal injection were technically feasible but compromised fetal survival. Taking into account all the numerous factors affecting intra-amniotic fetal therapy in the intrauterine growth restriction rabbit model, we conclude that an optimal therapeutic strategy with low technical failure and positive fetal impact on both survival and birthweight still needs to be found.

[Catheter-related bloodstream infections in patients receiving central parenteral nutrition: prevalence, associated factors, and treatment]. / Bacteriemia en pacientes con nutrición parenteral central: prevalencia, factores asociados y tratamiento.

INTRODUCTION: Background: catheter-related infection is one of the complications of central parenteral nutrition treatment with the highest morbidity and mortality. Objectives: the primary endpoint of this study was to analyze the prevalence of bloodstream infection in patients with central parenteral nutrition. Secondary objectives included: a) an assessment of whether type of central catheter, duration of parenteral nutrition treatment, body mass index, or being admitted to the intensive care unit are factors associated with the development of bloodstream infection; b) an analysis of the therapeutic approach. Methods: this was a retrospective observational study. All patients who received central parenteral nutrition after surgery between July 2018 and March 2019 were included. The association between the different variables and the development of bloodstream infection was analyzed by logistic regression. Results: the prevalence of bloodstream infection was 7.3 % (95 % CI: 3.9-13.3) (n = 9/123 patients). The duration of central parenteral nutrition was the only variable associated with the development of bloodstream infection (OR = 1.12; 95 % CI:1.05-1.20; p = 0.001). Conclusions: the prevalence of catheter-related bloodstream infection in this study is low, and the duration of central parenteral nutrition seems to be related to its development. However, further studies are needed to identify risk factors that might help reduce this kind of complications.

INTRODUCCIÓN: Introducción: la infección relacionada con el catéter es una de las complicaciones del tratamiento con nutrición parenteral central (NPC) que generan una mayor morbimortalidad. Objetivos: el objetivo principal fue analizar la prevalencia de la bacteriemia asociada al catéter en pacientes con nutrición parenteral central. Los objetivos secundarios fueron: a) evaluar si el tipo de catéter central, la duración de la nutrición parenteral central, el índice de masa corporal o la estancia en la unidad de cuidados intensivos son factores asociados al desarrollo de bacteriemia; b) analizar el manejo terapéutico de la infección. Material y métodos: se trata de un estudio observacional retrospectivo. Se incluyeron los pacientes que recibieron nutrición parenteral central tras una intervención quirúrgica entre julio de 2018 y marzo de 2019. La asociación de las variables con el desarrollo de la bacteriemia se analizó mediante regresión logística. Resultados: el 7,3 % (IC 95 %: 3,9-13,3) (n = 9/123) de los pacientes desarrollaron bacteriemia relacionada con el catéter. El único factor asociado al desarrollo de la infección fue la duración de la nutrición parenteral central (OR = 1,12; IC 95 %: 1,05-1,20; p = 0,001). Conclusiones: la prevalencia de la bacteriemia relacionada con el catéter en este estudio es baja. La duración del tratamiento con nutrición parenteral central parece estar relacionada con el desarrollo de la bacteriemia. Sin embargo, se necesitan más estudios para identificar factores de riesgo que permitan minimizar este tipo de complicaciones.

Water vapor thermal therapy to alleviate catheter-dependent urinary retention secondary to benign prostatic hyperplasia.

BACKGROUND: Water vapor thermal therapy utilizes convectively delivered thermal energy to target ablation of obstructive prostatic tissue. We report results of this thermal therapy for relief of nonneurogenic complete urinary retention associated with BPH. PATIENTS AND METHODS: We conducted a retrospective analysis of 38 catheter-dependent men with complete urinary retention consecutively enrolled in a registry in two centers: median age 75.5 years and multiple comorbidities, median prostate volume 58.5 cc (23-153), median 2 failed trials without catheter (TWOCs), and median catheter dependency 3 months (0.3-35). The Rezum™ System thermal therapy procedure was performed in an ambulatory surgery center with conscious sedation or an office procedure room with a modified periprostatic block. Water vapor injections were customized to the configuration of the hyperplastic gland, including median lobe and/or enlarged central zone. RESULTS: Of the 38 treated patients, one was lost to follow-up and 26 of 37 (70.3%) voided spontaneously (mean of 1.6 ± 0.8 TWOCs) and were catheter free a median of 26 days (range 4-65) after the procedure; 18 of these 26 (69%) patients discontinued BPH medications. No significant differences in age, prostate volume, number of water vapor injections, or presence of the median lobe were associated with predicting a successful treatment outcome. Duration of follow-up for 20 catheter-free patients was a median of 475 days or 15.8 months (140-804 days); six patients were followed a median of 31.5 days (0-60). Adverse events were infrequent, mild, and resolved quickly including dysuria in five patients (13%), gross hematuria in four (10.5%), and UTIs in two (2.6%) with indwelling catheters. CONCLUSIONS: Water vapor thermal therapy may provide an effective and safe alternative to surgical treatment in this group of catheter-dependent patients in complete urinary retention.

Meta-analysis of epidural analgesia in patients undergoing pancreatoduodenectomy.

Background: The optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non-epidural alternatives (N-EA) in patients undergoing pancreatoduodenectomy. Methods: A systematic review with meta-analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality. Results: Three RCTs and eight cohort studies (25 089 patients) were included. N-EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0-3 after surgery than those receiving intravenous morphine (mean difference (MD) -0·50, 95 per cent c.i. -0·80 to -0·21; P < 0·001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28·5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0·69, 95 per cent c.i. 0·06 to 0·79; P < 0·001), shorter duration of hospital stay (MD -2·69 (95 per cent c.i. -2·76 to -2·62) days; P < 0·001) and lower mortality (OR 0·69, 0·51 to 0 93; P = 0·02) compared with intravenous morphine. Conclusion: EA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.

Antecedentes: La técnica analgésica óptima tras una duodenopancreatectomía permanece en debate. El objetivo de este estudio fue analizar si la analgesia epidural (epidural analgesia, EA) presenta resultados clínicos superiores en comparación con las alternativas no epidurales (non­epidural alternatives, N­EA) en pacientes que se someten a una duodenopancreatectomía. Métodos: Se realizó una revisión sistemática con metaanálisis de acuerdo con las recomendaciones PRISMA. El 28 de agosto de 2018, se realizó una búsqueda en las bases de datos relevantes de la literatura. El objetivo primario fueron las puntuaciones de dolor. Los objetivos secundarios fueron el fracaso del tratamiento de la analgesia inicial, las complicaciones, la duración de la estancia hospitalaria y la mortalidad. Resultados: Se incluyeron tres ensayos aleatorizados y controlados y ocho estudios de cohortes (25.089 pacientes). Las N­EA estudiadas fueron: morfina intravenosa (iv), infiltración continua de la herida, catéteres torácicos paravertebrales bilaterales y morfina intratecal. Los pacientes con EA tuvieron una puntuación de dolor marginalmente más baja en los días postoperatorios 0 a 3 en comparación con la morfina iv (diferencia de medias (MD) = ­ 0,50, i.c. del 95% ­0,80 a ­0,21; P < 0,001) y puntuaciones de dolor similares en comparación con la infiltración continua de la herida. El fallo del tratamiento ocurrió en el 28,5% de los pacientes con EA, principalmente por inestabilidad hemodinámica o control inadecuado del dolor. La EA se asoció con menos complicaciones (razón de oportunidades, odds ratio, OR = 0,69, i.c. del 95% 0,061 a 0,79; P < 0,001), menor duración de la estancia hospitalaria (MD = ­2,69 días, i.c. del 95% ­2,76 a ­2,62; P < 0,001) y menor mortalidad en comparación con la morfina iv (OR = 0,69, i.c. del 95% 0,51 a 0,93; P = 0,01). Conclusión: La EA proporciona puntuaciones de dolor ligeramente más bajas en los primeros días postoperatorios en comparación con la morfina iv y parece asociarse con menos complicaciones, menor duración de la estancia hospitalaria y menor mortalidad.

Trichosanthin attenuates vascular injury-induced neointimal hyperplasia following balloon catheter injury in rats.

Trichosanthin (TCS), isolated from the root tuber of Trichosantheskirilowii, a well-known traditional Chinese medicinal plant, belonging to the Cucurbitaceae family, was found to exhibit numerous biological and pharmacological activities including anti-inflammatory. However, the effects of TCS on arterial injury induced neointimal hyperplasia and inflammatory cell infiltration remains poorly understood. The aim of study was to examine the effectiveness of TCS on arterial injury-mediated inflammatory processes and underlying mechanisms. A balloon-injured carotid artery induced injury in vivo in rats was established as a model of vascular injury. After 1 day TCS at 20, 40, or 80 mg/kg/day was administered intraperitoneally, daily for 14 days. Subsequently, the carotid artery was excised and taken for immunohistochemical staining. Data showed that TCS significantly dose-dependently reduced balloon injury-induced neointima formation in the carotid artery model rat, accompanied by markedly decreased positive expression percentage proliferating cell nuclear antigen (PCNA). In the in vitro study vascular smooth muscle cells (VSMC) were cultured, proliferation stimulated with platelet-derived growth factor-BB (PDGF-BB) (20 ng/ml) and TCS at 1, 2, or 4 µM added. Data demonstrated that TCS inhibited proliferation and cell cycle progression of VSMC induced by PDGF-BB. Further, TCS significantly lowered mRNA expression of cyclinD1, cyclinE1, and c-fos, and protein expression levels of Akt1, Akt2, and mitogen-activated protein kinase MAPK (ERK1) signaling pathway mediated by PDGF-BB. These findings indicate that TCS inhibits vascular neointimal hyperplasia induced by vascular injury in rats by suppression of VSMC proliferation and migration, which may involve inhibition of Akt/MAPK/ERK signal pathway.

Anticoagulants for the prevention and treatment of catheter-related thrombosis in adults and children on parenteral nutrition: a systematic review and critical appraisal.

BACKGROUND: Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral nutrition guidelines suggest anticoagulation for the primary prevention of catheter-related thrombosis during long-term parenteral nutrition. We conducted a systematic review of the efficacy, safety and feasibility of anticoagulant use for preventing and treating catheter-related thrombosis during parenteral nutrition. MATERIALS AND METHODS: We searched for interventional and observational studies on adults and children receiving systemic anticoagulants during either short- or long-term parenteral nutrition delivered via central venous access. Primary outcomes were: objectively-confirmed catheter-related thrombosis, pulmonary embolism and bleeding. Secondary outcomes were: heparin-induced thrombocytopenia, prevalence of anticoagulation, and quality of International Normalised Ratio management in vitamin K antagonist-treated patients. RESULTS: We identified 1,199 studies, of which 23 were included. Seven interventional studies of short-term parenteral nutrition (adult population, n=5) were classified as low-quality: in those, intravenous unfractionated heparin did not prevent catheter-related thrombosis if compared to saline. No interventional studies were conducted in patients on long-term parenteral nutrition. Observational data were sparse, rarely focusing on anticoagulation, and overall of low quality. The reported use of anticoagulants was between 22 and 66% in recent multicentre cohorts. DISCUSSION: The amount and quality of data in this area are very suboptimal: most studies are outdated and involved heterogeneous populations. Currently, there is insufficient evidence to allow conclusions to be reached regarding the efficacy and safety of anticoagulants in this setting.

Parenteral approaches in malabsorption: Home parenteral nutrition.

Severe malabsorption of fluids and nutrients leads to intestinal failure (IF) where intravenous supplementation of nutrients and fluids is necessary to maintain health and/or growth. Long-term treatment of IF implies the start of intravenous support in the outpatient setting (home parenteral nutrition, HPN). Although HPN has proven lifesaving for many patients for more than four decades this strategy remains associated with complications that compromise the quality of life. Many problems relate to the presence of the venous access device and concern infections or vascular occlusion due to thrombosis. Patient training remains key to prevent these complications. Also metabolic problems may arise that involve liver function or composition or bone mineralization. While intestinal transplantation remains inferior to HPN as alternative treatment strategy in terms of survival, promising developments include the introduction of hormones that promote intestinal adaptation, mixed lipid emulsions that decrease liver problems and catheter lock solutions that prevent infections.

Endovascular Therapy for Ruptured Cerebral Aneurysms in the Elderly: Poor Accessibility of the Guiding Catheter and Use of Local Anesthesia as the Predictors of Procedure-Related Rupture.

BACKGROUND: Endovascular therapy is favored for ruptured intracranial aneurysms in the elderly. However, poor accessibility to the aneurysm through the parent artery and use of local anesthesia in this age group may predispose to intraprocedural complications. OBJECTIVE: To evaluate whether age-related poor access to the ruptured target aneurysm and use of local anesthesia are associated with increased incidence of procedure-related rupture during endovascular embolization. METHODS: A total of 117 patients with 117 ruptured aneurysms underwent endovascular embolization at a single institution. Correlation of increasing age with poor accessibility of the guiding catheter was analyzed. In addition, the distance from the aneurysm to the guiding catheter was investigated to identify an association with incidence of procedure-related rupture. Correlation of local anesthesia with procedure-related rupture was also evaluated in the multivariable analysis. RESULTS: Increasing age was significantly associated with poor accessibility of the guiding catheter (P = .001, Mann-Whitney U test). Procedure-related rupture occurred in 9 of 117 aneurysms (7.7%). Longer distance between distal aneurysms and low-positioned guiding catheters carried a higher risk of procedure-related rupture than a shorter distance between proximal aneurysms and high-positioned guiding catheters (odds ratio, 19.3; 95% confidence interval, 1.84-201; P = .01, multivariable analysis). Use of local anesthesia was also a significant risk factor of procedure-related rupture by multivariable analysis. CONCLUSION: Increasing age was correlated with poor accessibility of the guiding catheter in endovascular embolization of ruptured intracranial aneurysms. Distally located aneurysms treated through a low-positioned guiding catheter and use of local anesthesia increased the risk of procedure-related rupture.

The unexpected epidural: a case report.

BACKGROUND: We report the peculiar case of a patient with a retained large epidural catheter fragment, incidentally found 12 years after its placement. Our primary aim is to emphasize how the breakage and retention of even exceptionally large portions of this device can go undetected. The patient can be completely asymptomatic and, with no clue that such a foreign body exists, the presentation of its potential complications can be subtle and misleading. To our knowledge, this is the first reported case of the incidental discovery of such a large fragment so many years after its placement. No consensus exists about how to handle this complication, therefore our report adds to the amount of available evidence. CASE PRESENTATION: A 53-year-old caucasian female with a history of diverticulitis requiring multiple hospitalizations underwent laparoscopic sigmoidectomy. The early postoperative period was complicated by peritonitis, demanding an urgent "second-look" exploratory laparoscopy. Nine days post-operatively, a filiform metallic object in the upper-quadrant was noted on x-ray. No epidural had been placed for either one of her recent surgeries. Given the patient's history, the object was initially thought to be a retained surgical sponge. Previous studies, however, showed that the same image was already present preoperatively. Upon further questioning, the patient reported an epidural being placed twelve years before, at the time of her pregnancy. No mention of breakage had been made to her at that time, nor a retained foreign body was ever reported afterwards, despite her many imaging exams. She also never experienced any symptoms. A 15 cm fragment of a wire-reinforced catheter was surgically retrieved under local anesthesia and fluoroscopic guidance. CONCLUSION: Breakage of the epidural catheter with fragment retention is a known complication of this device, possibly leading to devastating sequelae. The fragment can go undetected for years. In this case our finding was incidental and the patient was asymptomatic. However, in the event a neurologic complication arose, the identification of the unknowingly retained epidural as the causative agent could have been difficult and delayed, with potential harm to the patient.

A pilot study to assess adductor canal catheter tip migration in a cadaver model.

An adductor canal catheter may facilitate early ambulation after total knee arthroplasty, but there is concern over preoperative placement since intraoperative migration of catheters may occur from surgical manipulation and result in ineffective analgesia. We hypothesized that catheter type and subcutaneous tunneling may influence tip migration for preoperatively inserted adductor canal catheters. In a male unembalmed human cadaver, 20 catheter insertion trials were divided randomly into one of four groups: flexible epidural catheter either tunneled or not tunneled; or rigid stimulating catheter either tunneled or not tunneled. Intraoperative patient manipulation was simulated by five range-of-motion exercises of the knee. Distance and length measurements were performed by a blinded regional anesthesiologist. Changes in catheter tip to nerve distance (p = 0.225) and length of catheter within the adductor canal (p = 0.467) were not different between the four groups. Two of five non-tunneled stimulating catheters (40 %) were dislodged compared to 0/5 in all other groups (p = 0.187). A cadaver model may be useful for assessing migration of regional anesthesia catheters; catheter type and subcutaneous tunneling may not affect migration of adductor canal catheters based on this preliminary study. However, future studies involving a larger sample size, actual patients, and other catheter types are warranted.

Only high levels of dabigatran attenuate catheter thrombosis in vitro and in rabbits.

In patients with mechanical heart valves, thromboembolic events were more frequent with dabigatran, an oral thrombin inhibitor, than with warfarin. This observation raises the possibility that dabigatran may be less effective than conventional anticoagulants in patients with other blood-contacting devices, such as catheters. To address this, we compared the capacity of dabigatran and/or heparin to inhibit catheter-induced thrombin generation in vitro and to attenuate catheter occlusion in rabbits. Using a catheter-induced thrombin generation assay, concentrations of dabigatran over 100 ng/ml prolonged the lag time and time to peak thrombin, and reduced the peak thrombin concentration and endogenous thrombin potential in a concentration-dependent fashion. Compared with saline in a rabbit model of catheter thrombosis, dabigatran prolonged the mean time to catheter occlusion by 2.9- and 1.9-fold when plasma levels were 173 and 140 ng/ml, respectively; values comparable to median peak levels in humans given dabigatran 150 mg twice daily. In contrast, low-dose dabigatran, which produced a level of 60 ng/ml; a value comparable to the trough level of dabigatran in humans, did not prolong the time to occlusion. Whereas a 70 U/kg bolus of heparin prolonged the mean time to occlusion by 3.4-fold, a 15 U/kg bolus had no effect. When low-dose dabigatran was given in combination with 15 U/kg heparin, the mean time to occlusion was prolonged by 2.7-fold. These findings suggest that only peak levels of dabigatran are sufficient to prevent catheter-induced clotting unless supplemented heparin is given.

Complementary mass spectrometric approaches and scanning electron microscopy to study the structural stability of polyurethane tunneled dialysis catheters after exposure to ethanol solutions.

RATIONALE: Ethanol lock is an emerging therapeutic option for preventing and/or controlling catheter-associated infection. A previous study of silicone catheters showed they underwent no polymer degradation when kept in 60% ethanol for 15 days at 37 °C. The stability of the more widely used polyurethane catheters was studied here in the same way. METHODS: A qualitative and quantitative study of the stability of Carbothane® catheters was performed following their immersion at 37 °C in different solvents (0.9% sodium chloride as control medium and 40%, 60%, 95% ethanol solutions) for different periods of time (from 5 min to 15 days) using scanning electron microscopy and complementary mass spectrometry techniques. RESULTS: Electron ionization analysis of the 95% ethanol storage solutions revealed the release of about 45 products (8 of which were major) subdivided into two groups according to their fragmentation patterns. Combining all the mass spectrometric data made it possible to propose structures. Group I (major) originated from the polycarbonate diol component (soft segment) and group II (minor) from the dicyclohexylmethane-4,4'-diisocyanate component (rigid segment). Semi-quantitative gas chromatography/mass spectrometry (GC/MS) analysis showed that no significantly higher release was observed after immersion for 30 min at 37 °C in 40% ethanol (mean ratio = 0.677 ± 0.068) than after immersion in reference 0.9% sodium chloride solution for 15 days (0.837 ± 0.127). CONCLUSIONS: A 30 min-40% (v/v) ethanol solution can be considered as safe for preventing the infectious complications of Carbothane® dialysis catheters, and a 30 min-60% (v/v) ethanol treatment can be occasionally used to eradicate established biofilm.

[Home-based infusion therapy by Broviac catheter after total parenteral nutrition therapy in a patient with a severe skin condition].

In collaboration between the in-hospital nutrition support team and infection control team, we attempted to standardize the management of infusion therapy. We report on a simple and effective at-home infusion therapy, after total parenteral nutrition(TPN)therapy, by using a Broviac catheter in a discharged patient with a severe skin condition. The patient was a man in his 50s who had amyloidosis. Because of dysphagia and complications of the digestive organs, TPN was chosen as the method for nutritional management. At the beginning the patient repeated infection and a trouble of the skin, but the insertion site was managed by the existing standardized manual. However, switching to a Broviac catheter improved the existing disease. Dermatopathy was improved and there was no catheter-related bloodstream infection under the new management method. Furthermore, the patient is now able to feed orally. Patients should be evaluated individually, and for the case that is hard to care with a manual, it is necessary to choose the best possible method.

Assessment of catheter tip contact force resulting in cardiac perforation in swine atria using force sensing technology.

BACKGROUND: Force sensing is a recently developed technology that allows the determination of the contact force (CF) at the tip of the catheter during electrophysiology procedures. Previous studies suggested that the optimal CF for adequate catheter contact ranges between 10 and 40 g. The aim of this study was to determine the CF needed to cause perforation in the swine atria. METHODS AND RESULTS: Pericardial access was obtained at the beginning of the study in a swine model to drain pericardial effusions. Electroanatomic maps of the right atrium (RA) and left atrium (LA) were constructed. Ablation was performed using an irrigated-tip radiofrequency catheter equipped with force-sensing technology (30 W, 30 mL/min, for 30 seconds). Perforations of the LA and RA wall were intentionally performed in different locations with and without radiofrequency ablation. CF values preceding each perforation were recorded. A total of 111 cardiac perforations were achieved in 7 pigs. The overall average CF resulting in perforation was 175.8±60.4 g (range, 77 to 376 g). This was significantly lower after 30 seconds of radiofrequency delivery: 151.8±49.9 g versus 197±61.3 g (P=0.00005). The average value of CF resulting in perforation was not statistically different between the RA and the LA (169.6±61.6 g versus 181.7±59.3 g) (P=0.29). CONCLUSIONS: Perforation of the atrial wall in a swine model can occur over a wide range of CF values. Perforation can occur with a CF as low as 77 g. Ablation reduces the perforating force by 23%.