Patrulla de catéteres: Análisis de la implementación de un equipo de colocación de catéteres percutáneos como estrategia menos invasiva para la terapia intravenosa / Catheter patrol: analysis of the implementation of a percutaneous catheter placement team as a less invasive strategy for intravenous therapy

En el año 2008 se creó el equipo de patrulla de catéteres para la colocación de catéteres percutáneos por punción directa para pacientes pediátricos en el Hospital de Pediatría Juan P. Garrahan, como estrategia para el cumplimiento de la terapia intravenosa. Diseño: Cohorte retrospectiva. Objetivo: evaluar resultados de la implementación de la patrulla de catéteres entre 2009 y 2013. Se analizaron factores asociados a complicaciones. Criterios de inclusión: catéteres colocados en unidades de cuidados intermedios por Enfermería de patrulla de catéteres en niños con edad entre 31 días a 17 años. Resultados: 2121 catéteres, 1,6 catéteres/paciente, edad mediana 6 años (r 1m- 17 años), permanencia mediana 9 días (7-12). Complicaciones más frecuentes: obstrucción 27,19%, desplazamiento 25,94%,ruptura 11,76%, traccionado por el paciente 11,08%, bacteriemia asociada a catéter 1,62 a 2,80 por 1000 días /catéter. La tasa de incidencia de complicaciones en los menores de 1 año fue 39,92 días catéter mientras que en los mayores de 1 año 31,14 días catéter; p=0,002, diámetro en fr y relación con complicaciones: 4fr 12,17 días/catéter, 3fr 24,25 días/catéter y 2fr 42,27dias/catéter, (p=0,000), no hubo diferencias según cantidad de lúmenes. Conclusiones: los resultados de este estudio sugieren que la edad del paciente, el tipo de cuidado y contención inciden en las complicaciones. Los dispositivos de aseguramiento deberán estar acordes a las necesidades y características del niño (AU)

In 2008, the catheter patrol team was created for the placement of percutaneous catheters by direct puncture for pediatric patients at Hospital de Pediatría Juan P. Garrahan, as a strategy to increase compliance with intravenous therapy. Design: Retrospective cohort study. Objective: to evaluate the results of the implementation of a catheter patrol between 2009 and 2013. Factors associated with complications were analyzed. Inclusion criteria: catheters placed in intermediate care units by catheter patrol nurses in children aged 31 days to 17 years. Results: 2121 catheters, 1.6 catheters/patient, median age 6 years (r 1m- 17 years), median stay 9 days (7-12). Most frequent complications: obstruction 27.19%, displacement 25.94%, rupture 11.76%, accidental pull-out by the patient 11.08%, catheter-associated bacteremia 1.62 to 2.80 per 1000 catheter-days. The incidence rate of complications in children under 1 year of age was 39.92 catheter-days while in those older than 1 year it was 31.14 catheter-days (p=0.002). Relationship between fr diameter and complications: 4fr 12.17 catheter-days, 3fr 24.25 catheter-days, and 2fr 42.27 catheter-days (p=0.000); there were no differences according to the number of lumens. Conclusions: the results of this study suggest that the age of the patient, the type of care, and containment have an impact on complications. Securement devices should be in agreement with the needs and characteristics of the child (AU)

A randomized clinical trial comparing Nitrofurazone-coated and uncoated urinary catheters in kidney transplant recipients: Results from a pilot study.

BACKGROUND: Urinary tract infections are frequent complications early after kidney transplantation, and the use of antimicrobial coated catheters in settings other than transplantation has shown promising results for infection prevention. The purpose of this study was to compare the efficacy of Nitrofurazone-coated silicone urinary catheters with non-impregnated silicone urinary catheters in reducing bacteriuria and urinary tract infections in kidney transplant recipients. METHODS: This single-center study, randomized controlled trial at the Hospital do Rim, a tertiary referral center in kidney transplantation, located in São Paulo, Brazil. Subjects involved living donor kidney transplant recipients, and were randomized 1:1 ratio with a computer-generated system to a Nitrofurazone-coated silicone urinary catheter and non-impregnated silicone urinary catheter from March 2013 to December 2014. Patients with asymptomatic bacteriuria or urinary tract infection at baseline, deceased kidney transplant donors, patients with known hypersensitivity to nitrofurantoin, pregnancy, and those refusing to sign the informed consent form were excluded from the study. RESULTS: Two hundred fourteen subjects were randomized and one hundred seventy-six completed the study. There were no differences in the rates of asymptomatic bacteriuria (12.5% in the Nitrofurazone group and 11.4% in the control group, P = 0.99) and urinary tract infection (8% and 6.8%, P = 0.99) and the incidence of side effects was more frequent in the Nitrofurazone-impregnated silicone urinary catheter group (46.6% and 26.1%, P = 0.007). CONCLUSION: The study suggests that there is no beneficial effect of the employment of Nitrofurazone-coated urinary catheter. TRIAL REGISTRATION NUMBER: ISRCTN57888785.

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

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

'Button type' bipolar plasma vaporisation of the prostate compared with standard transurethral resection: a systematic review and meta-analysis of short-term outcome studies.

OBJECTIVE: To evaluate the surgical morbidity and effectiveness in improving symptoms of benign prostatic hyperplasia (BPH), comparing 'button-type' bipolar plasma vaporisation (BTPV) vs transurethral resection of the prostate (TURP). METHODS: We conducted a literature search of published articles until November 2014. Only prospective and randomised studies with comparative data between BTPV and conventional TURP (mono- or bipolar) were included in this review. RESULTS: Six articles were selected for the analyses. In the 871 patients evaluated, 522 underwent TURP and 349 BTPV. There was a tendency for a higher transfusion rate in the TURP group, with two BTPV cases (0.006%) and 16 TURP cases (0.032%) requiring transfusions (P = 0.06). The number of complications was similar between the groups (odds ratio 0.33, 95% confidence interval [CI] 0.8-1.31; P = 0.12; I(2) = 86%). When subdivided by severity, 10.7% (14/131) and 14.6% (52/355) of complications were classified as severe (Clavien 3 or 4) in patients who underwent BTPV and TURP, respectively (P = 0.02). The average duration of indwelling catheterisation was significantly less in patients who underwent BTPV (standardised mean difference [SMD] -0.84; 95% CI -1.54 to 0.14; P = 0.02; I(2) = 81%). Both treatments significantly improved symptoms and the postoperative International Prostate Symptom Score was similar in both groups (SMD 0.09, 95% CI -1.56 to 1.73; P = 0.92). CONCLUSION: BTPV is an effective and safe treatment for BPH. The improvement of urinary symptoms and overall complications are comparable to conventional TURP. However, BTVP appears to be associated with a lower rate of major complications and duration of indwelling catheterisation.

Sonda permeabilizadora en el tratamiento de la disfunción obstructiva de las glándulas de meibomio / Permeabilizing probing for the treatment of obstructive meibonian gland dysfunction

El ojo seco constituye una de las principales afecciones de la superficie ocular por la que acuden las personas a la consulta de Oftalmología. El 70 % de los pacientes con este diagnóstico presentan algún signo relacionado con la enfermedad de las glándulas de Meibomio y su control con los tratamientos habituales continúa siendo un problema. Las compresas calientes y los lavados con champú infantil darán alivio temporal, pero por lo general son abandonados por los pacientes. Otro enfoque es la expresión de las glándulas de Meibomio, la cual es molesta y por lo general necesita realizarse más de una vez; de ahí que el sondeo quirúrgico de esta sea una alternativa a utilizar. El sondaje mediante las sondas de Maskin introducidas desde el 2009 constituye una nueva modalidad terapéutica, la cual, de acuerdo con el conocimiento de los autores, no había sido introducida previamente en el país. La no disponibilidad de sondas con este fin en Cuba fue la motivación para diseñarla con el objetivo de permeabilizar los conductos excretores en la disfunción obstructiva de las glándulas de Meibomio (O- MGD), y así implementar esta técnica. Este dispositivo se construyó con medios propios en el taller de prototipos del laboratorio, de acuerdo con las características anatómicas del sistema glandular. Actualmente se usa de manera regular por doctores con resultados alentadores, como en los casos que se presentan.

Dry eye is one of the main eye surface diseases that make people go to the ophthalmological service. Seventy percent of patients with such diagnosis present with some type of symptoms related to the meibonian gland disease and its control with the regular treatments remains a problem. Hot pads and washing using shampoo for children give temporary relief, but are generally the patients do not comply with them for a long period of time. Another approach is the meibonian gland expression, which is uncomfortable and the treatment should be repeated more than once. Hence, the surgical probing seems to be a good alternative. Probing with Maskin probes introduced in 2009 is a new therapeutic variant which, according to the authors, had not been practiced in Cuba before. The lack of this type of probes in Cuba was the main incentive for their design in order to create permeabilization of the excretory ducts in the obstructive meibonian gland dysfunction, and to implement this technique. The devise was built with the resources of the lab prototype shop, taking the anatomical characteristics of the glandular system into consideration. The probes are presently used on a regular basis by ophthalmologists with encouraging results as in the reported cases.

Clinical acceptability and ease of use of a safety IV catheter system.

OBJECTIVE: Occupational risk of transmission of bloodborne pathogens represents a major challenge in prevention. Even though preventive recommendations to avoid needlestick injuries among healthcare workers include the use of needle protective devices, its use in developing countries is not a standard practice. This study aimed to measure, on experienced nurses, perception of performance characteristics and activation of the safety feature of a safety closed IV catheter system (BD Pegasus*), called catheter P, versus a non-safety device (BD Intima II † ) called catheter I in healthy volunteers. METHOD: Fifty-two nurses and 205 healthy volunteers participated in a prospective, randomized, controlled study in a simulated setting. Each nurse performed two insertions of each catheter (one in each forearm) in four study volunteers; the order of insertions was randomly assigned. Statistical analyses were performed to compare the performance of the two catheters regarding Overall Perception of Clinical Acceptability and Ease of Use. RESULTS: Overall acceptance of the device performance characteristics was 90% or more. In all cases, catheter P performed at least as well as catheter I. There were no differences in the insertion success rate between the two devices (93.7% vs. 96.2%). Activation of the safety feature of catheter P occurred 99.4%. Subjects' perception of pain was similar for both devices. Overall perception of clinical acceptability and ease of use were judged better for catheter P than for catheter I (p = 0.006, and p < 0.001 respectively). All clinicians strongly agreed that catheter P would protect them from needle stick injuries. CONCLUSIONS: Despite the study limitations, mainly its artificial setting and its inability to blind, the results indicate that the Safety Closed IV Catheter System with its safety feature represents a good alternative for IV catheter insertions that can help reduce the incidence of stick injuries in health care workers.

Duration of temporary catheter use for hemodialysis: an observational, prospective evaluation of renal units in Brazil.

BACKGROUND: For chronic hemodialysis, the ideal permanent vascular access is the arteriovenous fistula (AVF). Temporary catheters should be reserved for acute dialysis needs. The AVF is associated with lower infection rates, better clinical results, and a higher quality of life and survival when compared to temporary catheters. In Brazil, the proportion of patients with temporary catheters for more than 3 months from the beginning of therapy is used as an evaluation of the quality of renal units. The aim of this study is to evaluate factors associated with the time between the beginning of hemodialysis with temporary catheters and the placement of the first arteriovenous fistula in Brazil. METHODS: This is an observational, prospective non-concurrent study using national administrative registries of all patients financed by the public health system who began renal replacement therapy (RRT) between 2000 and 2004 in Brazil. Incident patients were eligible who had hemodialysis for the first time. Patients were excluded who: had hemodialysis reportedly started after the date of death (inconsistent database); were younger than 18 years old; had HIV; had no record of the first dialysis unit; and were dialyzed in units with less than twenty patients. To evaluate individual and renal unit factors associated with the event of interest, the frailty model was used (N = 55,589). RESULTS: Among the 23,824 patients (42.9%) who underwent fistula placement in the period of the study, 18.2% maintained the temporary catheter for more than three months until the fistula creation. The analysis identified five statistically significant factors associated with longer time until first fistula: higher age (Hazard-risk - HR 0.99, 95% CI 0.99-1.00); having hypertension and cardiovascular diseases (HR 0.94, 95% CI 0.9-0.98) as the cause of chronic renal disease; residing in capitals cities (HR 0.92, 95% CI 0.9-0.95) and certain regions in Brazil - South (HR 0.83, 95% CI 0.8-0.87), Midwest (HR 0.88, 95% CI 0.83-0.94), Northeast (HR 0.91, 95% CI 0.88-0.94), or North (HR 0.88, 95% CI 0.83-0.94) and the type of renal unit (public or private). CONCLUSION: Monitoring the provision of arteriovenous fistulas in renal units could improve the care given to patients with end stage renal disease.

Permanent vascular access in patients with end-stage renal disease, Brazil / Acesso vascular permanente em pacientes renais crônicos terminais no Brasil / Acceso vascular permanente en pacientes renales crónicos terminales en Brasil

OBJECTIVE: To assess factors associated with the establishment of permanent vascular access for patients with end-stage renal disease. METHODS: Cross-sectional study conducted in a nationally representative sample of Brazilian end-stage renal disease patients in dialysis and transplant centers during 2007. The sample comprised only patients who received hemodialysis as a primary therapy modality and reported the type of vascular access for their primary hemodialysis treatment (N=2,276). Data were from the TRS Project - "Economic and Epidemiologic Evaluation of Modalities of Renal Replacement Therapy in Brazil". Multiple logistic regression analysis was used to assess factors associated with the establishment of permanent vascular access in these patients. RESULTS: About 30 percent of the patients studied had an arteriovenous vascular access. The following factors were associated with a lower likelihood of having an arteriovenous vascular access as a primary type of access: time of hemodialysis start since the diagnosis of chronic renal failure < 1 year; shorter dialysis therapy; having no private health insurance; living in the central-western, northeastern and southeastern regions of Brazil; and living in the northern region plus having no private health insurance. In the final model there was found a positive association between the outcome and pre-dialysis care and no were association with socioeconomic and comorbidity variables. CONCLUSIONS: The study results showed that the focus should on pre-dialysis care to increase the establishment of an arteriovenous vascular access before starting hemodialysis in Brazil.

OBJETIVO: Analisar fatores associados à provisão de acesso vascular arteriovenoso no Brasil. MÉTODOS: Estudo transversal, nacionalmente representativo, com pacientes com doença renal crônica terminal acompanhados em serviços de diálise ou em centros transplantadores no ano de 2007. A amostra incluiu apenas pacientes que tiveram a hemodiálise como primeira modalidade de tratamento e que sabiam com que tipo de acesso vascular haviam iniciado o tratamento (N = 2.276). Os dados são oriundos do Projeto TRS - "Avaliação econômico-epidemiológica das modalidades de Terapia Renal Substitutiva no Brasil". Regressão logística múltipla foi utilizada. RESULTADOS: Aproximadamente 30 por cento dos pacientes tinham acesso vascular arteriovenoso. Os fatores associados à baixa probabilidade de ter acesso vascular arteriovenoso como primeiro tipo de acesso foram: tempo de diagnóstico de doença renal crônica anterior à entrada em hemodiálise < 1 ano, menor tempo de tratamento dialítico, não possuir cobertura de plano de saúde, residir na região Centro-Oeste, Nordeste e Sudeste, e residir na região Norte e ao mesmo tempo não possuir cobertura de plano de saúde. No modelo final não foi observada associação do desfecho com variáveis socioeconômicas e comorbidades, mas sim com cuidados pré-diálise. CONCLUSÕES: Os resultados mostram que, para aumentar a provisão de acesso vascular arteriovenoso antes do início da hemodiálise no Brasil, os esforços devem ser focados no cuidado pré-diálise.

OBJETIVO: Analizar factores asociados a la provisión de acceso vascular arteriovenoso en Brasil. MÉTODOS: Estudio transversal, nacionalmente representativo, con pacientes con enfermedad renal crónica terminal acompañados en servicios de diálisis o en centros transplantadores en el año de 2007. La muestra incluyó pacientes que tuvieron la hemodiálisis como primera modalidad de tratamiento y que sabían con que tipo de acceso vascular habían iniciado el tratamiento (N=2.276). Los datos son oriundos del Proyecto TRS - "Evaluación económica-epidemiológica de las modalidades de Terapia renal Sustitutiva en Brasil". Fue utilizada la regresión logística múltiple. RESULTADOS: Aproximadamente 30 por ciento de los pacientes tenían acceso vascular arteriovenoso. Los factores asociados a la baja probabilidad de tener acceso vascular arteriovenoso como primer tipo de acceso fueron: tiempo de diagnóstico de enfermedad renal crónica anterior a la entrada en hemodiálisis < 1 año, menor tiempo de tratamiento dialítico, no poseer cobertura de seguro de salud, residir en la región Centro-Oeste, Noreste y Sureste, y residir en la región Norte y al mismo tiempo no poseer cobertura de seguro de salud. En el modelo final no fue observada asociación del resultado con variables socioeconómicas y co-morbilidades, pero si con cuidados pre-diálisis. CONCLUSIONES: Los resultados muestran que para aumentar la provisión de acceso vascular arteriovenoso antes del inicio de la hemodiálisis en Brasil, los esfuerzos deben ser enfocados en el cuidado pre-diálisis.

Permanent vascular access in patients with end-stage renal disease, Brazil.

OBJECTIVE: To assess factors associated with the establishment of permanent vascular access for patients with end-stage renal disease. METHODS: Cross-sectional study conducted in a nationally representative sample of Brazilian end-stage renal disease patients in dialysis and transplant centers during 2007. The sample comprised only patients who received hemodialysis as a primary therapy modality and reported the type of vascular access for their primary hemodialysis treatment (N=2,276). Data were from the TRS Project--"Economic and Epidemiologic Evaluation of Modalities of Renal Replacement Therapy in Brazil". Multiple logistic regression analysis was used to assess factors associated with the establishment of permanent vascular access in these patients. RESULTS: About 30% of the patients studied had an arteriovenous vascular access. The following factors were associated with a lower likelihood of having an arteriovenous vascular access as a primary type of access: time of hemodialysis start since the diagnosis of chronic renal failure < 1 year; shorter dialysis therapy; having no private health insurance; living in the central-western, northeastern and southeastern regions of Brazil; and living in the northern region plus having no private health insurance. In the final model there was found a positive association between the outcome and pre-dialysis care and no were association with socioeconomic and comorbidity variables. CONCLUSIONS: The study results showed that the focus should on pre-dialysis care to increase the establishment of an arteriovenous vascular access before starting hemodialysis in Brazil.

Device-associated infection rates in intensive care units of Brazilian hospitals: datos de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales / Tasa de infecciones asociadas a aparatos en unidades de cuidados intensivos de hospitales brasileños: datos de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8 percent or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7 percent of cases, resistant to ceftazidime in 79.3 percent of cases, and resistant to piperacillin-tazobactam in 85.7 percent of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3 percent of cases, resistant to ceftazidime in 75.5 percent of cases, and resistant to imipenem in 27.7 percent of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3 percent (RR 1.79, P = 0.0149) for VAP, 27.8 percent (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7 percent (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an ...

OBJETIVOS: Determinar las tasas de infección asociadas a aparatos (IAA), los perfiles microbiológicos, la resistencia bacteriana, la estancia hospitalaria adicional y la mortalidad atribuible en las unidades de cuidados intensivos (UCI) de tres hospitales brasileños miembros de la Comunidad Científica Internacional de Control de Infecciones Nosocomiales (INICC). MÉTODOS: Se realizó una vigilancia prospectiva de cohorte de las IAA en cinco UCI de tres hospitales urbanos de Brasil, según las definiciones del Sistema Nacional de Vigilancia de Infecciones Nosocomiales de los Centros para el Control y la Prevención de Enfermedades (CDC-NNIS) de los Estados Unidos de América. RESULTADOS: Entre abril de 2003 y febrero de 2006 se hospitalizaron 1 031 pacientes en las cinco UCI estudiadas, con un total de 10 293 días en los que se adquirieron 307 IAA, para una tasa de 29,8 por ciento (29,8 IAA por 1 000 días-UCI). Las tasas fueron: de 20,9 casos por 1 000 días-ventilador en neumonía asociada a respiradores (NAR); de 9,1 por 1 000 días-catéter en infecciones circulatorias asociadas con cateterismo venoso central (IC-CVC); y de 9,6 por 1 000 días-catéter en infecciones urinarias asociadas con el uso de catéteres (IUAC). De las IAA causadas por Staphylococcus aureus, 95 por ciento se debieron a cepas resistentes a la meticilina. De las infecciones causadas por Enterobacteriaceae, 96,7 por ciento fueron resistentes a la ceftriaxona, 79,3 por ciento a la ceftazidima y 85,7 por ciento a la combinación piperacilina-tazobactam. De las IAA causadas por Pseudomonas aeruginosa, 71,3 por ciento resultaron resistentes a la ciprofloxacina, 75,5 por ciento a la ceftazidima y 27,7 por ciento al imipenem. Los pacientes con IAA en las UCI estudiadas presentaron tasas de mortalidad adicional de 15,3 por ciento (riesgo relativo [RR] = 1,79; P = 0,0149) por NAR, 27,8 por ciento (RR = 2,44; P = 0,0004) por IC-CVC y 10,7 por ciento (RR = 1,56; P = 0,2875) por IUAC. ...

Device-associated infection rates in intensive care units of Brazilian hospitals: findings of the International Nosocomial Infection Control Consortium.

OBJECTIVES: To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, extra length of stay, and attributable mortality in intensive care units (ICUs) in three Brazilian hospitals that are members of the International Nosocomial Infection Control Consortium (INICC). METHODS: Prospective cohort surveillance of DAIs was conducted in five ICUs in three city hospitals in Brazil by applying the definitions of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS). RESULTS: Between April 2003 and February 2006, 1 031 patients hospitalized in five ICUs for an aggregate 10 293 days acquired 307 DAIs, a rate of 29.8% or 29.8 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 20.9 per 1 000 ventilator-days; the rate for central venous catheter-associated bloodstream infections (CVC-BSI) was 9.1 per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 9.6 per 1 000 catheter-days. Ninety-five percent of all Staphylococcus aureus DAIs were caused by methicillin-resistant strains. Infections caused by Enterobacteriaceae were resistant to ceftriaxone in 96.7% of cases, resistant to ceftazidime in 79.3% of cases, and resistant to piperacillin-tazobactam in 85.7% of cases. Pseudomonas aeruginosa DAIs were resistant to ciprofloxacin in 71.3% of cases, resistant to ceftazidime in 75.5% of cases, and resistant to imipenem in 27.7% of cases. Patients with DAIs in the ICUs of the hospitals included in this study presented extra mortality rates of 15.3% (RR 1.79, P = 0.0149) for VAP, 27.8% (RR 2.44, P = 0.0004) for CVC-BSI, and 10.7% (RR 1.56, P = 0.2875) for CAUTI. CONCLUSION: The DAI rates were high in the ICUs of the Brazilian hospitals included in this study. Patient safety can be improved through the implementation of an active infection control program comprising surveillance of DAIs and infection prevention guidelines. These actions should become a priority in every country.

Utilização do acesso venoso central em pacientes entre 0 e 2 anos da Unidade de Terapia Intensiva Neonatal e Pediátrica em Tubarão - SC / Use of central venous access in 0-2 years old patients in a Pediatric Intensive Care Unit in South Brazil

Objetivo: Conhecer as indicações e os fatores relacionados ao procedimento de acesso venoso central em crianças de idade entre 0 e 2 anos internadas na UTINeonatal e Pediátrica do Hospital Nossa Senhora da Conceição (HNSC), na Cidade de Tubarão, Santa Catarina,entre novembro de 2001 e novembro de 2005. Métodos: Estudo observacional, com delineamento transversal, constituído por pacientes com idade entre 0 e 2 anos submetidos ao procedimento de acesso venosocentral e que estiveram internadas na UTI Neonatal e Pediátrica do HNSC entre novembro de 2001 e novembrode 2005. Realizou-se a coleta de dados a partir de prontuários dos pacientes.Resultados: Houve predominância do sexo masculino, 57,7%. A maior proporção dos pacientes tinha idademédia de 2,47 meses. A administração de hidratação endovenosa e drogas foi a principal indicação para o acesso (87,7%), seguida pela indicação de nutrição parenteral em 60%. O cateter com calibre 17G foi o mais utilizado em todos os vasos dissecados, independente da idade. Em 99,2% a via de acesso utilizada foi a dissecçãodo vaso. Dentre os vasos dissecados, a veia basílica foi a mais utilizada, 60,8% das vezes. Óbito foi à causa da retirada do cateter em 30,8% das vezes. Complicações ocorreram em 10,2% dos casos, com predomínio das complicações tardias (7,9%). Conclusão: Os cateteres inseridos em vasos centrais proporcionam um acesso vascular prolongado, com baixo risco de complicações e segurança para o paciente. A veia basílica é uma via segura para se obter um acesso venoso central, com índices de complicaçõesmuito baixos. As taxas de complicações encontradas no presente estudo foram menores que as encontradas naliteratura.

Aim: Know the signs and the factors related to the procedure of central venous access in children from 0to 2 years old, hospitalized in Neonatal and Pediatric ICU (Intensive Care Unit) of Nossa Senhora da ConceiçãoHospital (HNSC), in Tubarão city, Santa Catarina, from November 2001 to November 2005. Methods: observational study, with cross design,consisting by patients from 0 to 2 years old, submitted to the procedure of central venous access and who werehospitalized in HNSC Neonatal and Pediatric ICU from November 2001 to November 2005. Data collection wasmade from the patient’s medical reports.Results: There was a predominance of male, 57.7%. The largest proportion of the patients had an average age of 2.47 months. The administration of intravenous hydration and drugs was the main indication for the access (87.7%), followed by the indication ofparenteral nutrition in 60%. The catheter with calibre 17G was the most used in all dissected vessels, regardlessof age. In 99.2%, the path of access used was vessel dissection. Among the dissected vessels, the basilic vein was the most used, 60.8% of the situations. Death was why the catheter was withdrawn in 30.8% of the situations. Complications occurred in 10.2% of cases, with predominance of late complications (7.9%). Conclusion: The catheters inserted in central vesselsprovided an extended vascular access, with low risk of complications, and safety for the patient. The basilicvein is a safe path to get to a central venous access with very low rates of complications. The rates of complicationsfound in this study were lower than those ones found in the literature.

Randomized controlled trial of vascular access in newborns in the neonatal intensive care unit.

OBJECTIVE: To compare the effectiveness of two methods of vascular access in newborns. DESIGN: Randomized controlled trial. SETTING: Neonatal intensive care unit in Regional Hospital of Valdivia, Chile. PARTICIPANTS: Seventy-four high-risk newborns. INTERVENTIONS: Peripherally inserted central catheter and peripheral intravenous catheter. MAIN OUTCOME MEASURES: Length of neonatal intensive care unit stay and incidence of sepsis and phlebitis. RESULTS/DATA ANALYSIS: There were no statistically significant differences in the length of the neonatal intensive care unit stay and in the incidence of sepsis between groups. There was a significant higher incidence of phlebitis in the peripheral intravenous catheter group. CONCLUSIONS: Although there was not a significant effect of the kind of catheter on length of neonatal intensive care unit stay, the peripherally inserted central catheter is recommended because of the decreased risk of phlebitis and the decreased number of venipuncture attempts and catheters needed to complete intravenous therapy.

[Effects of the implementation of Universal Access with Explicit Guaranties (AUGE) Plan on the quality of care of patients with terminal renal failure]. / La implementación del Plan de Acceso Universal y Garantías Explícitas (Plan AUGE) ha deteriorado la calidad del tratamiento de pacientes con insuficiencia renal terminal.

BACKGROUND: The implementation of the AUGE plan for renal failure in Chile in August 2002, generated larger waiting list for outpatient care. AIM: To analyze the incidence of terminal renal failure, the proportion of patients that were admitted to hemodialysis using a definitive vascular access and the lapse of use of transitory catheters, before and after the implementation of AUGE in Calama. MATERIAL AND METHODS: Since 1999, in a dialysis center of Calama, all new patients that are admitted to hemodialysis and the type of vascular access they have are registered. Using this registry, the incidence of terminal renal failure and the lapse between the admission to the center and the installation of a definitive vascular access were calculated for the period 2000 to 2005. RESULTS: From January 2000 to December 2003, the incidence of terminal renal failure was stable in 190 +/- 21 patients per million inhabitants (ppmh). It decreased between January and September 2004 to 124 +/- 18.6. Afterwards, it progressively increased to 221 +/- 21 ppmh. In the study period, the proportion of patients admitted to hemodialysis with a definitive access decreased from 63 to 10% (p<0.01) and the mean lapse of transitory catheter use, increased from 32.9 +/- 42.6 to 73.1 +/- 80.4 days (p<0.01). CONCLUSIONS: The implementation of AUGE for chronic renal failure reduced the quality of care of patients admitted to hemodialysis.

La implementación del Plan de Acceso Universal y Garantías Explícitas (Plan AUGE) ha deteriorado la calidad del tratamiento de pacientes con insuficiencia renal terminal / Effects of the implementation of Universal Access with Explicit Guaranties (AUGE) Plan on the quality of care of patients with terminal renal failure

Background: The implementation of the AUGE plan for renal failure in Chile in August 2002, generated larger waiting list for outpatient care. Aim: To analyze the incidence of terminal renal failure, the proportion of patients that were admitted to hemodialysis using a definitive vascular access and the lapse of use of transitory catheters, before and after the implementation of AUGE in Calama. Material and Mehtods: Since 1999, in a dialysis center of Calama, all new patients that are admitted to hemodialysis and the type of vascular access they have are registered. Using this registry, the incidence of terminal renal failure and the lapse between the admission to the center and the installation of a definitive vascular access were calculated for the period 2000 to 2005. Results: From January 2000 to December 2003, the incidence of terminal renal failure was stable in 190 ± 21 patients per million inhabitants (ppmh). It decreased between January and September 2004 to 124 ± 18.6. Afterwards, it progressively increased to 221 ± 21 ppmh. In the study period, the proportion of patients admitted to hemodialysis with a definitive access decreased from 63 to 10 percent (p<0.01) and the mean lapse of transitory catheter use, increased from 32.9 ± 42.6 to 73.1 ± 80.4 days (p<0.01). Conclusions: The implementation of AUGE for chronic renal failure reduced the quality of care of patients admitted to hemodialysis.

Assessment of central venous catheter-associated infections using semi-quantitative or quantitative culture methods

Semiquantitative (Maki) and quantitative (Brun-Buisson) culture techniques were employed in the diagnosis of catheter-related bloodstream infections(CRBSI) in patients who have a short-term central venous catheter (inserted for 30 days). The diagnosis of CRBSI was based on the results of semiquantitative and quantitative culture of material from the removed catheters. Catheter tips (118) from 100 patients were evaluated by both methods. Semiquantitative analysis revealed 34 catheters (28.8%) colonized by greater or equal 15 colonyforming units (cfu), while quantitative cultures (34 catheters, 28.8%) showed the growth of greater or equal 103 cfu/mL. Bacteremia was confirmed in four patients by isolating microorganisms of identical species from both catheters and blood samples. Using the semiquantitative culture technique on short-term central venous catheter tips, we have shown that with a cut-off level of greater or equal 15 cfu, the technique had 100.0% sensitivity, specificity of 68.4%, 25.0% positive predictive value (PPV) and 100.0% negative predictive value (NPV), efficiency of 71.4% and a prevalence of 9.5%. The quantitative method, with a cut-off limit of greater or equal 103 cfu/mL, gave identical values: the sensitivity was 100.0%, specificity 68.4%, positive predictive value (PPV) 25.0%, negative predictive value(NPV) 100.0%, efficiency 71.4% and prevalence 9.5%. We concluded that the semiquantitative and quantitative culture methods, evaluated in parallel, for the first time in Brazil, have similar sensitivity and specificity.

Uso de cateteres venosos totalmente implantados para nutrição parenteral: cuidados, tempo de permanência e ocorrência de complicações infecciosas / Long-term central venous catheter for total parenteral nutrition: catheter care, permanence period, and incidence of infections

Cateteres venosos totalmente implantados são utilizados em pacientes com síndrome do intestino curto, para realizar o suporte nutricional parenteral, o qual mantém estes pacientes vivos, pois fornece-lhes nutrientes que são absorvidos pela via digestiva. No entanto, estes cateteres não são isentos de complicações. As infecções relacionadas aos cateteres venosos são as complicações mais temidas e sua incidência varia de 3 por cento a 20 por cento, aumentando em pacientes mais graves. O objetivo do presente estudo é descrever as complicações infecciosas em pacientes recebendo nutrição parenteral por meio de cateteres venosos totalmente implantados. Tais cateteres são utilizados pela Divisão de Nutrição Clínica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, para realizar o suporte nutricional parenteral em pacientes submetidos a ressecções extensas de intestino delgado. Foram avaliadas as complicações infecciosas ocorridas com 21 cateteres, implantados em 16 pacientes. O tempo de permanência dos cateteres foi de 768±664,3 dias (mediana 529 dias) e a taxa de infecção foi de 0,029 infecções/paciente/ano, resultados que se comparam às taxas de infecção observadas em países desenvolvidos. Concluiu-se que os cuidados observados no manuseio destes cateteres foram de fundamental importância para diminuir a incidência de infecção nestes pacientes.