Strategies for the removal of short-term indwelling urethral catheters in adults.

BACKGROUND: Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%. This is an update of a Cochrane Review first published in 2005 and last published in 2007. OBJECTIVES: To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting. DATA COLLECTION AND ANALYSIS: Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment. MAIN RESULTS: We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure. Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence). Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence). Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence). Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria. AUTHORS' CONCLUSIONS: There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions. Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.

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

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

Hiding in Plain Sight: Peripheral Intravenous Catheter Infections.

TOPIC: This article presents an overview of the burden of peripheral intravenous catheter infections and current evidence-based recommendations for prevention. CLINICAL RELEVANCE: Peripheral intravenous catheters are ubiquitous in most health care settings, fostering an acceptance of the peripheral intravenous catheter as benign and inevitable. This device, however, is far from benign, with reported failure rates as high as 90% from complications such as infection and phlebitis. Although reported rates of bloodstream infection related to peripheral intravenous catheters are much lower than those attributed to central venous catheters, the exponentially higher use of peripheral intravenous catheters indicates that the absolute number of peripheral venous catheter-related bloodstream infections is likely as high as and may surpass the number of central venous catheter-related bloodstream infections, with significant associated morbidity and mortality. PURPOSE OF PAPER: Sustained improvements in outcomes related to peripheral intravenous catheters will depend on recognition of the root causes of failure and increased commitment to practice patterns consistent with infusion therapy standards of practice, effective education about peripheral intravenous catheters, accurate documentation of all aspects of peripheral intravenous catheter management, and consistent surveillance of patient outcomes related to peripheral intravenous catheters. CONTENT COVERED: This article reviews the significant burden of peripheral intravenous catheter infections, barriers to effective peripheral intravenous catheter management, and current evidence-based recommendations to prevent this source of patient harm.

Clinically indicated replacement of peripheral vascular catheters: is it safe for patients?

Replacing peripheral vascular catheters when clinically indicated rather than routinely has multiple benefits for patients and practitioners. Managing vascular catheters based on clinical indication provides early opportunities for intervention, or catheter removal or replacement. Where clinically indicated, peripheral vascular catheters can be used for a long time, and this is aided by decision-making tools such as the visual infusion phlebitis score and care bundles. Fewer cannulations result in less pain, better patient comfort and a lower risk of infection. For each cannulation avoided, about 20 minutes can be saved for other care activities. Replacing peripheral vascular catheters according to clinical indication can improve patient safety and optimise resource use.

The RESPECT trial-Replacement of peripheral intravenous catheters according to clinical reasons or every 96 hours: A randomized, controlled, non-inferiority trial.

BACKGROUND: Peripheral intravenous catheters are widely used for infusion therapy. To prevent phlebitis, routine catheter replacement at 72 or 96 hours remains widely practiced. OBJECTIVE: To investigate the non-inferiority of clinically indicated peripheral intravenous catheter replacement compared with routine replacement every 96 hours to prevent phlebitis. Phlebitis severity, catheter indwelling time, and other catheter failure types were also compared. SETTING: Multi-center trial in wards at two hospitals in Sao Paulo, Brazil. DESIGN: The REplacement of PEripheral intravenous CaTheters according to clinical signs or every 96 hours (RESPECT) trial was a Randomized, non-blinded, controlled, non-inferiority trial. PARTICIPANTS: 1319 patients were enrolled with the following inclusion criteria: aged ≥18 years, expected peripheral intravenous therapy for ≥96 hours; peripheral intravenous catheters inserted in the selected wards, intensive care units, or surgical centers; and informed consent provided. Exclusion criteria were: bloodstream infection and/or sepsis, neutrophil count of ≤1000/mm3, and simultaneous use of more than one peripheral intravenous catheter. Recruitment occurred within 96 hours of peripheral intravenous catheter insertion. Randomization was performed using a computer-generated, concealed list. METHODS: As intervention, clinically indicated replacement group patients underwent peripheral intravenous catheter removal only at the end of therapy or in the presence of phlebitis, infiltration, occlusion, displacement, accidental removal, or bloodstream infection. Routine 96-h replacement group patients (control) had their catheters replaced every 96-h, unless clinical reasons required earlier replacement. The primary outcome was Phlebitis and the analyses were carried out on intention-to-treat and per-protocol bases. RESULTS: Demographic and clinical variables were similar between groups, with the exception to type of admission (p = 0.025) more frequent in clinically indicated patients and surgical on routine replacement group. Of the 1319 patients, 119 (9.0%) developed phlebitis with no between-group difference (p = 0.162); these patients used 2747 peripheral intravenous catheters, being that 134 presented phlebitis. Phlebitis/1000 catheter-days, was 14.9 in the clinically indicated group and 23.8 in the routine replacement group (p = 0.006). The survival analysis showed no significant between-group difference in the occurrence of the first phlebitis episode. CONCLUSIONS: Clinically indicated peripheral intravenous catheter replacement was not inferior to routine (96 hours) replacement regarding phlebitis occurrence, and was associated with significantly less phlebitis per 1000 days. TRIAL REGISTRATION: Registered with www.clinicaltrials.gov (NCT02568670).

Evaluation of clinically indicated removal versus routine replacement of peripheral vascular catheters.

Latest clinical guidelines for peripheral vascular catheters (PVC) recommend that they should be removed only when clinically indicated and not routinely removed and replaced. In 2017, the authors' hospital policy was changed to align with the new recommendations and, between March and July 2019, 500 PVCs were audited at two main sites to evaluate the efficacy of the change. Of the 500 PVCs, 31% (n=155) were in situ for more than 3 days (range 4-22 days). Analysis of the combined data showed an overall prevalence of phlebitis at 8%, but variation in trends looking at each individual site (7% and 9% respectively) with a wide variation for PVCs in situ for more than 7 days. Implementing clinically indicated removal of PVCs has resulted in better patient experience with fewer PVCs for a course of treatment. Implementation has also resulted in cost savings for the Trust with a notable decrease in number of PVCs used.

Implementing Clinical Practice Guidelines for Replacing Peripheral Intravenous Catheters.

BACKGROUND: A community hospital policy of routinely replacing peripheral intravenous catheters (PIVCs) needed updating to the clinical practice guideline (CPG) of clinically indicated replacement. METHODS: Guided by Lean principles, a clinical nurse leader (CNL) led a quality improvement small test of change on a 38-bed medical unit. The impact of the CPG was evaluated using quality, safety, and workflow measures. RESULTS: Nurses managed 469 inpatients, receiving 1033 PIVCs. Routine PIVC replacement declined from 34% to 3% (P < .001). PIVC dwell time ranged from 4 to 20 days and did not increase phlebitis (P = .41) or catheter-related bloodstream infections. Nurses attributed the improvements in workflow (P = .01) and the quality of patient care (94%) to the updated PIVC guideline. CONCLUSIONS: Clinically-indicated PIVC replacement reduced unnecessary catheter insertions, maintained patient safety, improved efficiency, and is being implemented hospital-wide. This project highlights and advances the CNL role in transforming healthcare.

Should the CDC's recommendations for promptly removing unnecessary centrally inserted central catheters be enhanced? Ultrasound-guided peripheral venous cannulation to fully comply.

PURPOSE: In an effort to reduce catheter-related bloodstream infection's incidence rates in an intensive care unit, several evidence-based procedures recommended by the Centers for Disease Control and Prevention for centrally inserted central catheters were implemented. A failure to fully comply with the recommendation for prompt removal of the centrally inserted central catheters was attributed, mainly to the difficulties and inadequacies raised from establishing peripheral venous access. METHODS: The ultrasound-guided peripheral venous cannulation method as a supplementary intervention to the Centers for Disease Control and Prevention's recommendations was incorporated and examined during the subsequent year. RESULTS: A significant reduction on catheter-related bloodstream infection incidence rates out of the expected range was found. Centrally inserted central catheters utilization ratios were reduced by 10.7% (p < 0.05; 58%-47%) and the catheter-related bloodstream infection incidence rate was reduced by 11.7 per thousand device-days (15.9-4.16/1000 centrally inserted central catheters days (2015-2016 group, respectively)). CONCLUSION: The reduction of catheter-related bloodstream infection was higher than that described in the published literature. This probably shows that the combination of the five evidence-based procedures recommended by the Centers for Disease Control and Prevention together with that of ultrasound-guided peripheral venous cannulation method can increase the compliance with the Category IA recommendation for removal or avoidance of unnecessary placement of centrally inserted central catheters and decrease the catheter-related bloodstream infections in a more effective way, by affecting the patients' centrally inserted central catheter exposure.

Ureteral stents: the good the bad and the ugly.

PURPOSE OF REVIEW: Ureteral stents are necessary in the routine practice of an urologist. Choosing the correct stent and being aware of the options available will allow urologists to provide the best possible care for patients and value to the healthcare system. This review seeks to educate urologists regarding improvements in stent technology currently available or in development. RECENT FINDINGS: Research from around the world is underway to discover an ideal stent - one that is comfortable for patients, resists infection and encrustation and is affordable for hospital systems. Stent design alterations and stent coatings are revealing reductions in encrustation and bacterial colonization. Biodegradable stents and magnetic stents are being tested to prevent the discomfort of cystoscopic removal. Intraureteral stents are proving efficacious while eliminating an irritating coil from the bladder and the symptoms associated with it. SUMMARY: The studies highlighted in this review provide encouraging results in the pursuit of the ideal stent while opening discussion around new concepts and further areas of research.

Arteriovenous Access Graft Infection: Standards of Reporting and Implications for Comparative Data Analysis.

There is presently a lack of organization and standardized reporting schema for arteriovenous graft (AVG) infections. The purpose of this article is to evaluate the various types of treatment modalities for access site infections through an analysis of current publications on AVG. Key proposals are made to support standardization in a data-driven manner to make infection reporting more uniform and thereby facilitate more meaningful comparisons between various dialysis modalities and AVG technologies.

A Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda.

BACKGROUND: Enhanced recovery after surgery (ERAS) expedites return to patient baseline and functional status by reducing surgical trauma, stress, and organ dysfunction. Despite the potential benefits of enhanced recovery protocols, limited research has been done in low-resource settings, where 95% of cesarean deliveries are emergent and could possibly benefit from the application of ERAS protocols. METHODS: In a prospective, randomized, single-blind, controlled trial, mothers delivering by emergency cesarean delivery were randomly assigned to either an ERAS or a standard of care (SOC) recovery arm. Patients in the ERAS arm were treated with a modified ERAS protocol that included modified counseling and education, prophylactic antibiotics, antiemetics, normothermia, restrictive fluid administration, and multimodal analgesia. They also received early initiation of mobilization, feeding, and urethral catheter removal. The primary end point was length of hospital stay. The secondary end points were complications and readmission rates. Mean length of stay in the intervention and control arms were compared using t tests. Statistical analyses were performed using STATA version 13 (College Station, TX). RESULTS: A total of 160 patients were enrolled in the study, with 80 randomized to each arm. There was a statistically significant shorter length of stay for the ERAS arm compared to SOC, with a difference of -18.5 hours (P < .001, 95% confidence interval [CI], -23.67, -13.34). The incidence of complications of severe pain and headache was lower in the ERAS arm compared to SOC (P = .001 for both complications). However, pruritus was more common in the ERAS arm compared to SOC (P = .023). CONCLUSIONS: Use of an ERAS protocol for women undergoing emergency cesarean delivery in a low-income setting is feasible and reduces length of hospital stay without generally increasing the complication rate.

Catheter management after benign transurethral prostate surgery: RAND/UCLA Appropriateness Criteria.

OBJECTIVES: To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use. STUDY DESIGN: RAND/UCLA Appropriateness Methodology. METHODS: Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7). RESULTS: Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate. CONCLUSIONS: We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Lumen-apposing metal stents in management of pancreatic fluid collections: The nobody's land of removal timing.

Pancreatic fluid collections (PFCs) develop as a result of damage to the major or peripheral pancreatic ducts, complication due to acute or chronic pancreatitis, trauma or iatrogenic causes. PFCs include pancreatic pseudocysts (PPs) and walled-off necrosis (WON). PFCs usually resolve spontaneously and are asymptomatic, but if they persist, increase in dimension or became symptomatics, therapeutic intervention is required. Available therapeutic interventions include surgical, percutaneous, and endoscopic drainage. The endoscopic approach is nowadays considered the first line-treatment of PFCs due to various advantages when compared with surgical or percutaneous drainage: decreased morbidity, length of hospital stay, and reduced costs. In the last few years, the endoscopic ultrasound (EUS)-guided transmural drainage, initially with plastic stents, gained popularity. More recently, fully covered self-expanding lumen-apposing metal stents (LAMS) have been demonstrated to be both, safe and effective with high clinical and technical success, reducing the risk of perforation, peritoneal leakage, migration and facilitating the drainage of necrotic contents. In the last few years, several studies evaluating the safety and efficacy of LAMS and their differences with plastic stents have been performed, but literature on the removal timing of this device and associated complications is still limited. The aim of this review is to analyze studies reporting information about the retrieval timing of LAMS and the related adverse events.

When guidelines conflict: patient safety, quality of life, and CAUTI reduction in patients with spinal cord injury.

The current Medicare payment structure and some of the recent guidelines aimed at reducing catheter-associated urinary tract infections may be generating a financial incentive for the protocolized, systematic removal of indwelling catheters in hospitalized patients-including those with spinal cord injury. This creates a tension with the Consortium for Spinal Cord Medicine's clinical practice guidelines for the management of neurogenic bladder. This article presents a series of cases and a discussion of the implications with regard to patient safety and quality of life.

Opinion: Aortic Graft Infection-Any Guidelines or Just Surgeon's Experience Lines!

Aggressive strategies for thoracic aortic graft infection, including resection of all infected tissues, in situ replacement with a rifampicin-bonded graft, and omental flap installation, resulted in improved survival.

Removal of retrievable inferior vena cava filters before discharge: Is it associated with increased incidence of pulmonary embolism?

BACKGROUND: Severely injured trauma patients are at high risk of developing deep venous thrombosis and pulmonary emboli (PE), and may have contraindications to prophylactic or therapeutic anticoagulation. Retrievable inferior vena cava filters (rIVCFs) are used to act as a mechanical obstruction to prevent PE in high risk populations and those with deep venous thrombosis who cannot be anticoagulated. The removal rate of rIVCFs is variable in trauma centers, including our previous published rate of 50% to 89%/year. Indwelling filters carry a risk of significant morbidity and the success of retrieval decreases as the dwell time increases. We hypothesized that once patients could receive appropriate prophylactic or therapeutic anticoagulation, rIVCF could be removed before hospital discharge without impact on occurrence or recurrence of PE. METHODS: All trauma patients with rIVCF placed and removed between January 2006 and August 2018 were reviewed. We collected data from record review from admission to 6 months postfilter removal, including demographics, filter indication, filter type, dwell time, placement and removal complications, antithrombosis medications, location of venous thromboembolism, complications, and discharge disposition. Exposure of interest was timing of filter removal: before (BEF) or after hospital discharge (AFT). The outcome of interest was whether the patient had a documented PE within 6 months of filter removal. RESULTS: A total of 281 rIVCFs were placed, 218 were eligible for removal, 72.4% (158/218) were retrieved with 63% (100/158) removed before discharge. Mean filter duration was 26 days and 103 days for the before and after groups, respectively. No differences (p > 0.05) were noted in the distribution of demographic and clinical factors except for filter indication (venous thromboembolism indication, 95% in AFT vs. 74% in BEF, p = 0.0043). Postremoval PE rates were 0% BEF and 1% AFT (Fisher's exact test, p = 1.000). CONCLUSION: Our results suggest that removal of rIVCFs before discharge once patients are appropriately anticoagulated is a safe strategy to improve retrieval rates. LEVEL OF EVIDENCE: Therapeutic, level V.

Collaborative, Innovative Quality Improvement Activity: Development of Queensland Ambulance Service Stickers: Drivers, Approaches, Implementation, and Outcomes.

This article discusses the implementation of 3 targeted interventions aimed at reducing infection rates in patients due to prolonged in situ intravascular catheters (IVCs) during their admission to the hospital. These IVCs are inserted by paramedics with Queensland Ambulance Service (QAS) in prehospital settings. The 3 interventions involved were the application of "QAS-IVC" stickers by QAS paramedics to indicate QAS-inserted IVCs, the implementation of mandatory IVC documentation during patient handover, and clinician engagement to provide patient education on IVC infection signs. Audits undertaken in wards reflected that the interventions were apparent and beneficial; this is evident from the limited number of patients having in-dwelling QAS-IVC and increased awareness among medical staff and patients alike. We, however, did not have comparative data to objectively quantify the success of the interventions implemented.